Myth busted June 2012
People living with mental illness often describe the associated stigma as being more debilitating than the illness itself. [1,2] Stigma involves the labelling and stereotyping of persons living with mental illness as being "different" or having "undesirable" characteristics. Those who experience stigma face discrimination as well as a loss of status and power to change their situation.  Stigma in mental health has a long and storied past, and we don’t have to look too far back in Canada’s history to find a time when a diagnosis of mental illness meant being sent away and locked up for life. Removing people from the community in this way contributed greatly to stigma, as the public came to associate all mental illness with its most extreme forms,[5,6] labelling the diagnosed as crazy, mad, or lunatics. Unfortunately, this stigma remains a problem to this day.
As the discipline of psychiatry (literally, the medical treatment of the mind) matured, an understanding of the biological elements of some mental illnesses began to take hold. Starting in the 1950s, medications were developed that could help to alleviate the symptoms of some mental illnesses.4 It was thought a biological understanding would reduce stigma, since it’s not fair to blame someone for a diagnosis of a disease that’s beyond their control.
Despite good intentions, evidence actually shows that anti-stigma campaigns emphasizing the biological nature of mental illness have not been effective, and have often made the problem worse.[7,8,9,10,11]
A DISEASE LIKE ANY OTHER?
Various anti-stigma initiatives have advocated for an understanding of mental illness as a biological process: "a disease like any other". During the late 1990s, both the Canadian Mental Health Association and the National Alliance on Mental Illness in the United States, framed mental illnesses as brain disorders in their anti-stigma campaigns.[13,14]
A U.S. study showed that although the public adopted a more biological conception of mental illness in 2006 as compared to 1996, the changes in attitude were not associated with reduced stigma. Although knowledge about mental illness increased over that period, attitudes of intolerance worsened. A German investigation came to similar conclusions, finding an increase in the desire for social distance from people with schizophrenia in 2001 as compared to 1990, coincident with increasing public acceptance of the biological causes of mental illness.
So why aren’t mental illnesses diseases like any other? The evidence shows us that while the public may assign less blame to individuals for their biologically-determined mental illness, the very idea that their actions may be beyond their conscious control can create fear of their unpredictability and thus the perception that those with mental illnesses are dangerous,[8,9,10,11,15] leading to avoidance.[7,11,16,17,18] Biological explanations can also instil an ‘us vs. them’ attitude, defining individuals with mental illness as fundamentally different. For example, a 2008 survey of Canadians found that:
- 42% would no longer socialize with a friend diagnosed with mental illness;
- 55% wouldn’t marry someone who suffered from mental illness;
- 25% were afraid of being around someone who suffers from mental illness; and
- 50% would not tell friends or coworkers that a family member was suffering from mental illness.
Similarly, mental illnesses are seen as less responsive to treatment  and more persistent and serious  when framed as biological diseases. This framing may suggest that people with mental illnesses will never recover, which contributes to stigmatizing attitudes.
IT’S NOT THE BIO-BIO-BIO MODEL
So how do we work towards reducing the stigma of mental illness? Despite the recent emphasis on the biological model, research continues to support a bio-psycho-social model, where varied environmental factors interact with life experience and genetic susceptibility to result in mental illness. Science is broadening our understanding of the significant interaction between genes and the environment, demonstrating that many environmental variables, such as one’s early childhood environment, play a large role in determining how genes are expressed.[24,25]
Additionally, factors such as chronic stress, living in an urban area, immigration, traumatic life events, and illicit drug use all can increase one’s vulnerability to mental illness. Presenting mental illness in the context of these psychological and social stressors normalizes symptoms, creating a healthier public perception of mental illness.[21,27] A good example of this in practice is how the Canadian Forces frame mental illness, which refers to depression and post-traumatic stress resulting from war as mental "wounds" and operational stress injuries. The international literature also shows that contact-based education—which involves individuals with lived experience of mental illness sharing their personal stories of illness, stigma and recovery—is one of the most promising practices for reducing stigma.[29,30]
Mental illness results from the interplay of genetic, biological, psychological and environmental factors, a concept well accepted and broadly described by the bio-psycho-social model. Anti-stigma initiatives should emphasize the well-researched psychological and social contributors to mental illness in addition to biological factors. This framing provides an accurate and less stigmatizing explanation of the causes of mental illness. Recognizing that people can and do recover is perhaps the most important way to end the stigmatizing ‘us vs. them’ attitudes and behaviours too often experienced by people living with mental illnesses. Working to change these attitudes will help to improve equity and quality of life for people living with mental illness and their family members.
This issue of Mythbusters is based on an article by the 2012 Mythbusters Award recipient, Dr. Joanna Cheek. This award was co-sponsored by the Mental Health Commission of Canada. Dr. Cheek is a 5th year psychiatry resident at the University of British Columbia, training in Victoria, BC.
1. Kirby, M. & Keon, W. (2006). Out of the Shadows at Last. Report of the Standing Senate Committee on social Affairs, Science and Technology.
2. Mental Health Commission of Canada. (2009). Toward recovery and well-being: A framework for a mental health strategy for Canada. Retrieved from http://www.mentalhealthcommission.ca/SiteCollectionDocuments/boarddocs/15507_MHCC_EN_final.pdf
3. Link, B. & Phelan, J. (2006). Stigma and its Public Health Implications. Lancet, 367, 528-529.
4. Kirby, M. (2004). Mental Health, Mental Illness and Addiction: Overview of Policies and Programs in Canada, Report 1. The Honourable Michael J.L. Kirby, Chair, The Honourable Wilbert Kenon, Deputy Chair, Senate Standing Committee on Social Sciences and Technology.
5. Arboleda-Florez, J. (2003). Considerations on the stigma of mental illness. The Canadian Journal of Psychiatry, 48(10), 645-650.
6. Mulvale, G., Abelson, J., & Goering, P. (2007). Mental health service delivery in Ontario, Canada: how do policy legacies shape prospects for reform? Health Economics, Policy and Law, 2(4), 363-389.
7. Angermeyer, M. & Matschinger, H. (2005). Causal beliefs and attitudes to people with schizophrenia: trend analysis based on data from two population surveys in Germany. British Journal of Psychiatry, 186(3), 331–334.
8. Read, J. & Law, A. (1999). The relationship of causal beliefs and contact with users of mental health services to attitudes to the ‘mentally ill’. International Journal of Social Psychiatry, 45(3), 216–229.
9. Read, J. & Harre, N. (2001). The role of biological and genetic causal beliefs in the stigmatization of ‘mental patients’. Journal of Mental Health, 10(2), 223-235.
10. Walker I. & Read J. (2002). The differential effectiveness of psychosocial and biogenetic causal explanations in reducing negative attitudes toward "mental illness". Psychiatry, 65(4), 313–325.
11. Schnittker, J. (2008), An uncertain revolution: Why the rise of a genetic model of mental illness has not increased tolerance. Social Science & Medicine, 67(9), 1370-1381.
12. Pescosolido, B., Martin, J., Long, J.S., Medina, T., Phelan, J., & Link, B. (2010). "A Disease Like Any Other"? A Decade of Change in Public Reactions to Schizophrenia, Depression, and Alcohol Dependence. The American Journal of Psychiatry, 167(11), 1321-1330.
13. Canadian Mental Health Association. "Brain Illnesses: Anxiety and Depression". Retrieved from http://www.cmha.ca/highschool/brainillnesses.pdf
14. National Alliance on Mental Illness. (1997). NAMI Derides Special Interests for Continued Opposition to Landmark Anti-Discrimination Legislation. NAMI Newsroom. Retrieved from http://www.nami.org/Template.cfm?Section=Press_Release_Archive&template=/contentmanagement/contentdisplay.cfm&ContentID=5548&title=JAMA%20Paper%20Shows%20That%20Mental%20Health%20Parity%20is%20Affordable
15. Jorm, A.F. & Griffiths, K.M. (2008). The public’s stigmatizing attitudes towards people with mental disorders: how important are biomedical conceptualizations? Acta Psychiatrica Scandinavica, 118(4), 315–321.
16. Lauber, C., Nordt, C., Falcato, L., & Rössler, W. (2004). Factors influencing social distance toward people with mental illness. Community Mental Health Journal, 40(3), 265–274.
17. Dietrich, S., Beck, M., Bujantugs, B., Kenzine, D., Matschinger, H., & Angermeyer, MC. (2004). The relationship between public causal beliefs and social distance toward mentally ill people. The Australian and New Zealand Journal of Psychiatry, 38(5), 348-54.
18. Rüsch, N., Todd, A., Bodenhausen, G., & Corrigan, P. (2010). Biogenetic models of psycho-pathology, implicit guilt, and mental illness stigma. Psychiatry Research, 179(3), 328-332.
19. Phelan, J.C. (2002). Genetic bases of mental illness – a cure for stigma? Trends in Neuroscience, 25(8), 430–431.
20. Canadian Medical Association. (2008). Eighth Annual National Report Card on Health Care. Retrieved from http://www.cma.ca/multimedia/CMA/Content_Images/Inside_cma/Annual_Meeting/2008/GC_Bulletin/National_Report_Card_EN.pdf
21. Lam, D.C. & Salkovskis, P.M. (2007). An experimental investigation of the impact of biological and psychological causal explanations on anxious and depressed patients’ perception of a person with panic disorder. Behavior Research & Therapy, 45(2), 405-411.
22. Phelan, J.C. (2005). Geneticization of deviant behavior and consequences for stigma: the case of mental illness. Journal of Health and Social Behaviour, 46(4), 307–322.
23. Sadock, B. & Sadock, V. (2007). Synopsis of Psychiatry (10th Edition). Lippincott: Williams & Wilkins.
24. Rutter, M. (2002). The interplay of nature, nurture, and developmental influences: the challenge ahead for mental health. Archives of General Psychiatry, 59(11), 996–1000.
25. National Scientific Council on the Developing Child. (2010). Early Experiences Can Alter Gene Expression and Affect Long-Term Development: Working Paper No. 10. Retrieved from http://developingchild.harvard.edu/resources/reports_and_working_papers/working_papers/wp10/
26. Austin, J. & Honer, W. (2004). The potential impact of genetic counseling for mental illness. Clinical Genetics, 67(2), 134-142.
27. Mehta, S.I. & Farina, A. (1997). Is being ‘sick’ really better? Effect of the disease view of mental disorder on stigma. Journal of Social and Clinical Psychology, 16(4), 405–419.
28. National Defence and the Canadian Forces. (2009). The current state of mental health care in the Canadian Forces. Ottawa, Canada. Retrieved from http://www.comfec.forces.gc.ca/pa-ap/nr-sp/doc-eng.asp?id=2844
29. Mental Health Commission of Canada. (2012). Changing directions, changing lives. The Mental Health Strategy for Canada, Ottawa, Canada. p.112. Retrieved from http://strategy.mentalhealthcommission.ca/
30. Stuart, H., Koller, M., Christie, R., & Pietrus, M. (2011). Reducing mental health stigma: A case study. Healthcare Quarterly, 14(2), 40-49.
Mythbusters articles are published by the Canadian Health Services Research Foundation (CHSRF) only after review by experts on the topic. CHSRF is an independent, not-for-profit corporation funded through an agreement with the Government of Canada. Interests and views expressed by those who distribute this document may not reflect those of CHSRF. © 2012.