The Toolkit
STIGMA
What do we mean by stigma?
Stigma occurs when a person or a group of people is subject to labeling, stereotyping, separation, status loss, and/or discrimination. Stigma can be used to exert power over someone based on their identity: race/ethnicity, socioeconomic status, sexual orientation, gender, health status (e.g., HIV, a disability), or mental illness. Sometimes these attributes are visible; others may be concealed but still devalued or despised. People can experience three types of stigma, which often overlap. Stigma may be structural or driven by societal conditions, such as cultural norms, laws, and institutional policies. Stigma may be interpersonal – between people, such as bullying and hate crimes. Stigma can also be “intrapersonal,” as when people internalize negative attitudes towards themselves.
The effects of stigma may show up in surprising ways: clients may apply dismissive stereotypes to themselves or try to “code switch” and conceal aspects of their identity that could trigger stigma. They may have a hard time building trust, believing they can be helped, or following through on advice or treatment.
Surprising Fact!
People who live in high-stigma environments where policies and attitudes target them for social exclusion can experience significant and lingering adverse health effects. Studies of lesbian, gay, and bisexual adults found that long after leaving stigmatized environments, they may continue to experience stress-related biological effects that are similar to traumatic life experiences.
How can stigma affect health equity?
Whatever the source of one’s stigma may be, the stress and disadvantages of being disconnected from society can threaten health. Stigma triggers stress and can exacerbate high blood pressure, cardiovascular disease, and immune system problems. Sexual minorities, Black Americans and ethnic minorities who live in areas with higher levels of prejudice die at younger ages. Stigma can trigger feelings of shame, low-worth, hopelessness, and isolation. It can cause psychological disorders like depression and anxiety and inhibit recovery from mental illness. It can also lead to delays in seeking or continuing medical treatment. Stigma can compound other socio-economic and structural challenges like access to housing, employment, education and health care. Addressing stigma on the interpersonal levels involves a combination of empathy, respect and empowerment.
Actionable Example
WHAT OTHERS HAVE DONE
Develop peer support and mentoring opportunities; foster interactions between stigmatized and non-stigmatized groups
People with mental illness face tremendous stigma and often internalize it as well. A comprehensive mental health program in Los Angeles runs an Anti-Stigma Group that uses Toastmasters to teach public speaking skills. This highly structured, skill-based model gives everyone a role and sets clear expectations, learning objectives and progress metrics. Clients are able to reflect and build pride and confidence while educating the community (including law enforcement and medical professionals) that recovery is possible. This helps reduce the stigma of mental illness for all concerned.
Bibliography
Descriptions of successful, large-scale programs in three countries using evidence-based interventions in education, media literacy, contact, peer services, advocacy, and legislation. From Chapter 4 in Ending Discrimination Against People with Mental and Substance Use Disorders: The Evidence for Stigma Change. (Available from NCBI.)
Empirical Studies of Self-Stigma Reduction Strategies: A Critical Review of the Literature
Review of studies on self-stigma interventions, especially that alter beliefs and attitudes or enhance coping skills and confidence. From the peer-reviewed academic journal Psychiatric Services.
How Does Stigma “Get Under the Skin”?
Research on how stigma and its internalization leads to psychological distress. From the peer- reviewed academic journal Psychological Science.
Stigma as a Fundamental Cause of Population Health Inequalities
Presents research and models on the pervasive role of stigmas in causing and perpetuating health inequities. From the peer-reviewed academic journal American Journal of Public Health.
Stigma, Prejudice and Discrimination Against People with Mental Illness
A broad -- and broadly applicable--overview of stigma related to mental health and links to innovative intervention programs. From the American Psychiatric Association.
Study examining if growing up in highly stigmatizing environments shapes how stigmatized individuals respond to identity-related stress. From the peer-reviewed academic journal Annals of Behavioral Medicine. (Available from NCBI.)
Supporting Patients' Decision-Making Abilities and Preferences
The principles and impact of patient-centered care among people with mental health and substance abuse disorders. From Chapter 3 in Improving the Quality of Health Care for Mental and Substance-Use Conditions: Quality Chasm Series. (Available from NCBI.)
The Oxford Handbook of Stigma, Discrimination and Health
A comprehensive anthology of research on stigma, the health disparities faced by stigmatized groups, and interventions. Available from Google Books.
Understanding Mental Illness Stigma Toward Persons With Multiple Stigmatized Conditions: Implications of Intersectionality Theory
The effects of experiencing multiple stigmas and implications for intervention and research. From the peer-reviewed academic journal Psychiatric Services.
What is the Impact of Self-Stigma? Loss of Self-Respect and the “Why Try” Effect
Research on the complex impacts of self-stigma. From the peer-reviewed academic journal Journal of Mental Health.
Acknowledgements
Dr. Lisa Gennetian
Professor of Public Policy and Early Learning Policy Studies, Duke University
Dr. Rose Lopez
Director, Wellness and Recovery Training and Anti-stigma Group liaison, Pacific Clinical Services, Los Angeles
Dr. Isha Metzger
Professor of Psychology and Director of the Empower Lab, University of Georgia
Amelia Rubenstein
Director of Research and Programs and Jattna Gomez, Director of Equity and Community Engagement, SAFE Center, University of Maryland
Tessa Whitecloud
Former Executive Director, One Just City, Winnipeg, Canada
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