This article reviews some of the literature on the effect of stigma on persons who have a mental illness. A major recommendation is to change language referring to physical and mental illness by simply calling them chronic illnesses as neuroscience research suggests an anatomical and physiological base for mental illness, Some suggestions from the literature about combating stigma are presented along with the author’s suggestions about other action to achieve the same result. The purpose of this article is to propose a collection of ideas that could have the effect of reducing stigma associated with mental illness. One proposal is to discontinue the distinction between behavioral and physical illness and that “chromic health condition” be the term used for both as this could change the perception of mental illness and reduce stigma.

•    Mental illness
•    Stigma

Blakely TJ (2017) Combating the Stigma of Mental Illness. J Chronic Dis Manag 2(2): 1014.

Physiological base for mental illness

The rationale for the proposal is that the findings of neuroscience suggest that mental illness is physiological as it arises from neuropathways established by negative emotional or traumatic experiences that are stored in the emotional center of the brain [1]. The knowledge base of neuroscience is extensive and awareness of all its complexities is beyond the scope of this article. However, awareness of basic concepts can make a significant contribution to helping understanding mental illness as a chronic health condition. Neuroscience also produced evidence of neural plasticity that may underlie the brain’s ability to adapt and change in response to the environment [2]. This means that recovery from a mental illness, meaning that it is not a critical factor in a person’s life, is highly likely.

The difference that is inferred by the use of the terms mental illness and physical illness is not all that distinct. The mind which is the mechanism of expression of feeling, thinking and behavior that are characteristic of mental illness is located in the brain. This is a central organ like the heart, lungs and the alimentary canal. It is the neural pathways in the brain that are the source of negative feelings that lead to disorganized thinking and behavior that form the symptoms that may be diagnosed as mental illness. What is really happening is that the anatomy of the brain has stored negative experience so the physiology or function of the brain affects behavior that is characteristic of mental illness. This process doesn’t differ that much from the process of diagnosing a chronic physical illness.

It is quite well established that a close connection exists between chronic behavioral and physical conditions so they should be categorized under a mutual heading. There is considerable stigma associated with mental illness. Stigma also occurs with physical illness, especially by those who think that close proximity with someone who has one means they could “catch” it, or because of the disability associated with some of these illnesses. Park, Faulker and Schaller [3], discussed these attitudes. However, stigma of mental illness is a larger problem. If the words chronic health condition were used with a psychiatric diagnosis, i.e chronic anxiety, be applied to mental disease in the same way it is applied to physical disease, i.e. chronic pulmonary obstructive disorder, the perception of the former could be different.

The literature establishes the relationship between mind and body in a way that supports maladies in both being referenced as chronic conditions. For example, the presence of stress connects the two as it affects both mind and body simultaneously. This is a long standing proposition as [4], traced the history of stress in human existence to the classic era and the proposal by Hippocrates who “equated health to a harmonious balance of the elements and qualities of life and disease to a systematic disharmony of these elements” (p. 1245). These authors also cited Epicurus suggestion “that the mind could be among or influence these healing forces...” (p.1245). They delineated the connections between the brain and the body and described the complexities of a state of homeostasis, or balance in the human system, that requires continuous attention to adapting to whatever stressful situations arise. Adaptation consists of both mental and physical reactions. Cohen [5], also proposed that stress contributes to both behavioral and physical illness. Previously McEwen and Stellar [6], described a model of the relationship between stress and behavior that is a response to the environment that is ….”coupled with physiologic and pathophysiologic responses” (p. 2093). These ideas are supported by neuroscience and further indicate the connection between mind and body, further suggesting that chronicity of illnesses in both makes it appropriate to refer to them as chronic conditions.

Further evidence about the connection between body and mind was provided by De Hert [7], who wrote that individuals with serious mental illness have many physical health problems. According to them 60% of mortality of people with SMI is due to physical illness. Hysing, Elgen, Gillberg [8], concluded that there is an increased risk of emotional problems and psychiatric disorders for children who have a chronic physical illness. Cadman [9], reported a study of children with chronic illness, medical conditions and long term disability and the relationship between these and psychiatric disorders and social adjustment problems. The children with chronic illness and disability were at risk for both psychiatric disorders and social adjustment while those without a disability were at a little less risk for psychiatric disorders and a little greater risk for social adjustment problems. The connection as chronic conditions is apparent.

These references demonstrate the connection between the brain and the body and by inference the connection between behavioral and physical chronic conditions. There is bias on the part of some observers toward both categories of illness but more toward behavioral illness. It makes sense to singularize these categories into one, that of chronic condition. The term mental illness, about which there is stigma, would receive a less bias response.

Stigma is defined as a mark of disgrace associated with a particular circumstance, quality, or person. The stigma of mental illness is a common problem. Many people have fear of persons who have a mental illness as they are perceived to be dangerous. This fear creates social distancing that is harmful to persons who have a mental illness as they feel rejected and become isolative [10]. Byrne believes that secrecy is an obstacle to acknowledging and seeking treatment for a mental illness. He added that the media are responsible for erroneous perception of persons who have a mental illness and that the media ultimately will be the agent that reverses these negative ideas [11].

Dubin and Fink [12], wrote about the effect of stigma on psychiatric treatment. For example, electroconvulsive therapy was negated to the point where patients refused it and treatment facilities discontinued it because of the stigma associated with it. They added that the attitudes of non-psychiatric professionals oppose the biological basis of mental illness. Further, persons who have a mental illness are treated differently when hospitalized. They are deprived of a telephone and television and must follow a regimented schedule that no patient in a non-psychiatric hospital has to face. Also the general attitude toward persons who have a mental illness is that they are dangerous which the facts do not support. Finally, families feel guilty because of the negative response of others to a family member who has a mental illness. Also, families and/or parents, especially the mother, are often blamed for a member’s illness when the fact is that the cause of mental illness has not been determined.

Corrigan and Rao [13] define self-stigma that is different from public stigma. Their view is that public stigma is the prejudice and discrimination directed toward a particular group such as persons who have a mental illness. This group is the object of negative stereotypes as they are perceived to be dangerous. These authors describe a stage model of self-stigma in which diminished self-esteem occurs as a response to being devalued. The model has three stages: awareness of public stigma, agreement that public stigma really is true about the group and application that the negative stereotype describes her/himself. They proposed the damage to self-esteem does not occur until the third stage. They further proposed that a consequence is what they label the “why try” effect that interferes with achieving goals. Corrigan [14], discuss this effect and its impact on evidence-based social work practice.

What has been suggested is that merging the terms physical and mental illness together and referring to both as chronic conditions would have the effect of reducing stigma. Another possibility lies in reducing self-stigmatization through positive attachment relationships. Many mental health providers believe that a lack of positive attachment to a primary attachment figure is the basis for later emotional distress that sometimes is diagnosable as a mental illness. These providers also believe that self-esteem is formed through this relationship. It seems reasonable to believe that people who have a mental illness also will more likely self-stigmatize when they did not experience a positive attachment. Some comments about attachment may serve to add to its significant relationship to self-stigmatization.

Graham described developmental experience as the priming of synaptic connections through relationships with caretakers. “It is essential to understand experience dependent maturation of the brain to understand the importance of early attachment experiences to shape the brain and our patterns of relating and to embrace the power of new attachment relationships in therapy to re-wire the memories learned with this part of the brain” [1]. She also wrote: “The brain is a social organ, developed and changed in interactions with other brains”. She added that nurture leads to the formation of synaptic connections influenced by interactions with individuals with whom there is a close relationship. “This means that the very foundations of perception, particularly in regard to relationships, rely on the quality of these earliest interactions with our parents” [1].

What is recommended to reverse self-stigmatization is positive attachment experiences. This applies directly to combating stigma because it prevents attachment to others because prejudice and discrimination. This highlights the importance of mental health providers’ relationship with persons who have a mental illness. A client’s attachment to a mental health professional can change attachment style from insecure to secure [15]. This also means that every effort should be made to encourage attachment relationships with family or significant others. When persons with a mental illness have positive attachment relationships with others who do not respond negatively to the illness it is more likely that they will not self-stigmatize.

The mechanisms of brain plasticity are not yet completely understood but research suggests that changes in the brain occur throughout life and that interventions for emotional stress result in behavior change [2,16,17]. New experiences with new relationships generate changes in neural pathways. Neuroscience has shown that behavior may be learned and improved through experience and that this also changes synapses to form new neural circuits and new memories [18]. The discoveries that recently have occurred can significantly improve understanding of the potential for change in human emotions and behavior. This also can help clients develop hope that they can be relieved of the anxiety and stress associated with the effect of stigma. This suggests that intervention can change brain structure and that people can relearn the effects of trauma and other negative psychosocial experiences [19]. A significant intervention would be successful in combating the effect of stigma on a person who has a mental condition.

The question is what other actions can be taken to reduce stigma toward persons who have a mental illness? The first thing I have suggested is decide on a term. The words disease and disability seem to conjure up a negative bias response. The word disorder seems strong and rather odd. The word illness has negative connotations for some. It is proposed that the term chronic condition is appropriate. This term has been proposed throughout this article.

One example of the successful use of the term chronic condition in place of mental illness occurred at an agency serving chronically mentally ill clients [20]. Wagner, Austin, Davis [21], developed the Chronic Care Model (CCM) that was designed to change medical service delivery from the concentration on acute care to a program more suitable for persons with chronic illness. Although the CCM focused on chronic physical illness it was successfully adapted to serving adults who had a serious mental illness. An agency demonstration project conceptualized a serious psychiatric condition as a chronic health condition that was treatable and rehabilitative as opposed to a permanent disability. The desired outcome of care was labeled a state of Psychiatric Well Being (PWB). A measurement scale consisting of statements related to social functioning was created to measure PWB. Achievement of a score on the PWB scale indicated a level of recovery from the condition meaning that it did not have a major impact on the life of the client.

[22] Identified seven actions to reduce stigma: 1) know the facts; 2) be aware of your attitudes and behavior; 3) choose your words carefully; 6 7 4) educate others; 5) focus on the positive; 6) support people; and 7) include everyone. In Canada where this organization is located it is unlawful to discriminate against people with mental health and substance abuse problems. Knowing the facts about mental illness, including substance abuse, examining one’s attitudes and beliefs about these issues, challenging those who express erroneous views, being cautious about one’s remarks about these problems and treating people who have a mental condition with respect and dignity are ways of implementing these principles.

The Mayo Clinic Staff [23], described steps persons who have a mental illness can take to combat stigma: 1) get treatment; 2) don’t let stigma create doubt and shame; 3) don’t isolate yourself; 4) don’t equate yourself with your illness; 5) join a support group; 6) get help at school (children); 7) speak out against stigma. These actions may not be appropriate for everyone. It is important to know that persons who are newly diagnosed with a mental illness have many more resources available for treatment and rehabilitation than those who were diagnosed in the past. Medication and case management that includes regular treatment sessions with a mental health professional, result in much earlier positive results. This enables this group to follow the preceding suggestions that could be very helpful in combating stigma. Lai [24], recommend persons with a mental condition interact regularly and normatively with others to demonstrate that mental illness is not the disability about which so many are prejudice. They also perceive that mass media conveys many negative messages about persons who have a mental illness and that a more positive portrayal of these persons would be helpful in combating stigma.

Corrigan and Rao [13], advised that helping persons who self-stigmatize consists of initially making them aware that stigma is a public phenomena and is not a flaw in them. They discussed a group approach to this issue in which discussion occurs about how public attitudes are internalized by those who self-stigmatize. Understanding this process enables these persons to understand how it develops and think differently about themselves as a result. They also pointed out that the National Alliance on Mental Illness has a program has a program “In Our Own Voice” that is available to people. NAMI has chapters in the states that can be contacted for more information. The Internet has other references for ideas about combating stigma that may be consulted by those interested in doing their part to decrease stigma.

There are several other proposals about methods of combating stigma. The proposal that was mentioned in the beginning of this article about merging the terms chronic physical illness and chronic mental illness into simply chronic condition should be considered. There are mental health service agencies available in almost every community in the country. However, few of them are engaged in educational programs for their clients or for the communities in which they are located. Such programs could be very helpful in combating stigma. Program ideas about educating the clients and the community about mental illness and how it is a chronic condition like other chronic conditions could be disseminated in this way.

Mental health agencies have a funding stream through a centralized system. For example, there is a Federally Qualified Health Agency in most counties in the United States. The central agency that funds the local agencies communicates with them regularly with policy statements, newsletters or other means. These methods should focus on presenting correct information about mental illness, especially that all such conditions are treatable and recovery, meaning the illness is not a major factor in a person’s life, is available. New medications and advances in neuroscience about the physiological base of mental illness should be shared with the public. These systems could promote the language change in reference to chronic illness simply by using the term chronic condition repeatedly.

Every state has a health or mental health department, or a department that combines the two. There is a communication pathway between state and county offices where local programs are coordinated. It is proposed that the state departments could use this system to emphasize appropriate and helpful information about mental illness to all county agencies. For example, the state with which this author is familiar is divided into regions. Some highly populated counties stand alone while in several situations multiple counties are joined. Most regions have a central office that provides all services directly. There is at least one county that contracts with local agencies to provide specific services. There is an association of directors of public mental health agencies. This board is a vehicle through which information about mental health could be passed in cooperation with the state department.

Another community system that plans and funds social services that often include mental health care is United Way. This system is generally guided by influential members of the community who advise on policy and operations. The United Way planning group could appoint a task force to study the best way to establish a community system the main focus of which would be on educating the community about mental illness. This task force also could study and make recommendations for employment of people who have a mental illness.

Local agencies are where programming based on incoming information is coordinated. Here is where the action takes place, as clients are directly involved as recipients of services. It is proposed that these agencies develop psycho-education programs in which clients are given information about mental illness especially directed at combating self-stigmatization. Similar psycho-education programs could be offered by these agencies at sites different from that where services are provided so agencies and their personnel would be seen as involved as members of the larger community. These agencies also could organize a speakers’ bureau to give talks at various clubs, organization, associations and business groups that are seeking speakers for their meetings.

Local newspapers could be invited to have stories about these activities. Local radio and TV outlets might also be interested in broadcasting information about these events that would bring attention to the topic of mental illness that would encourage more general conversation among community members about the topic.

Leadership has to be provided by national membership organizations of professionals that regularly interact with persons who have a mental illness. The American Medical Association the American Bar Association, the American Nurses Association and the Visiting Nurse Association could focus attention on education of their members about mental illness. This is especially recommended for non-psychiatric medical personnel who oppose the biological base of mental illness.

It also is suggested that the curricula of Schools of Social Work include information about mental illness and the damaging effect of stigma on persons who have such an illness. Emphasis should be placed on recovery and strategies to achieve it.

These are some additional suggestions about what individuals can do to combat stigma. This is not an exhaustive list as many other ideas may occur to people as they think about this issue. The initial action is to learn as much as possible about what mental illness really is as an adjustment to very difficult circumstances that usually have involved rejection, indifference and neglect. These negative experiences form neural pathways that influence feeling, thinking and behavior.

If you are a professional mental health worker equip yourself with correct information about mental illness so you can influence the system from the inside to develop programs that combat stigma. If you are a non-psychiatric physician or health services provider learn the anatomical and physiological aspects of mental illness as this will make a difference in how you relate to persons who have a mental illness.

Learn about recovery from mental illness. It is not a permanent disability as with appropriate treatment recovery, meaning the illness ceases to be a major factor in a person’s life is possible and even likely. As you learn more about mental illness you will become more empathic with them and will express this positive feeling in your contacts with them and others. Don’t differentiate chronic physical illness from chronic mental illness. Just refer to both as chronic conditions with no reference to type.

Those persons who read this article could write their federal senator or representative and ask for sponsorship of legislation that would require dissemination of this information. Personal contact or telephone calls also are effective. Letters to state mental health boards also are helpful. Also contact county government individuals, especially those that serve on the board of the mental health agency, and request them to consider programs for clients and the community that combat stigma.

Mental health agencies often are seeking board members who are interested in policy formulation and implementation of service programs. You can find a way of becoming involved in the mental health system as a volunteer. Most United Way programs have a volunteer placement program. You can become a speaker advocate to combat stigma. Business associations always are seeking speakers at their meetings.

It is apparent that stigma has an effect on persons who have a mental illness. It also is apparent that something could be done to combat stigma. However, any action is going to have to be taken by individuals, including mental health professionals, who do whatever they can to make this effort successful. The recommendations that follow are directed at those persons, especially those who read this article. When one knows what must be done common sense will dictate that it becomes a responsibility to do it.

Hopefully reading this article has influenced you to take some action no matter how small it might be as every effort will have some effect on successfully diminishing stigma and making the lives of persons who have a mental illness easier.

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