The Stigma of Mental Illness

StacyL.OvertonandSondraL.Medina
Stigma surrounding major mental illness creates many barriers. People who experience mental illness face discrimination and prejudice when renting homes, applying for jobs, and accessing mental health services. The authors review the current literature regarding stigma and mental illness. They define stigma and review theories that explain its impact. Counselor training is a peak time to identify and begin to mitigate stigma related to people with mental illness. Implications for counselor training are addressed.

Peoplesufferingfrommentalillnessandothermentalhealth problems are among the most stigmatized, discriminated against,marginalized,disadvantagedandvulnerablemembers ofoursociety(Johnstone,2001,p.201).Negativeconnotations and false assumptions connected with mental illness maybeasharmfulasthediseaseitself.Schizophreniamay evokevisionsofviolenceandinabilitytocareforoneself. Depressionmayconjurethoughtsoflazinessandsubstance abuse.Societalstigmasignificantlylimitsopportunitiesthat areavailableforpeoplewithseriousmentalillnesses(Johnstone, 2001).In1999,theSurgeonGeneralsreportpointedtostigma asakeyvariableinunderstandingthecourseofillnessand outcomesforpeoplewhohavebeengivenapsychiatricdiagnoses(Corrigan,Green,Lundin,Kubiak,&Penn,2001). Inthisarticle,wefirstreviewthedefinitionsofmentalillness andstigmaandthenreviewtheliteratureaboutthetheories of stigma and the impact that stigma has on people with mentalillnesses.Usingcurrentresearchasourbasis,wesuggestwaysthatcounselorscanworktomitigatethestigmaof mentalillness.Weconcludewithsuggestionsfordispelling thestigmatizingbeliefsthatcounselorshold.

Defining Mental Illness and Stigma

Conceptsaboutmentalillnesscanbesubjective,anditcan bedifficulttodefine.Oneofthedefinitionslistedformental illnessintheMerriam-Webster Dictionary(1990)ismentallydisordered,mad,orcrazy(p.506). DuringtheMiddle Ages,peoplewithmentalillnesswereconsideredtobeliving examplesoftheweaknessofhumankind.Thecommonbelief wasthatmentalillnesswasaresultofbeingunabletoremain morallystrong.Peoplewithmentalillnesseswerejailedas criminals and, on some occasions, put to death (Corrigan, 2002). In 1974,Thomas Szasz wrote about the myth of mental illness. He stated that physicians used anatomical and pathological methods to help identify physical illness. Therewasproofthattheseillnessesexistedbecauseofhow theyalteredthephysicalbody.Szaszsbeliefwasthatmedical illnesseswerebeingdiscovered,whereaspsychiatricillnesses werebeinginvented.AccordingtoSzasz,psychiatristswere

inventingdiseasesbasedongroupsofcommonsymptoms. Most of the symptoms that accompany mental illness are invisible, leading people who experience these symptoms todoubttheirrealityandtoexperienceisolationwithinthat reality(Glass,1989). Abroaderandmorecurrentdefinitionofmentalillness referstothespectrumofcognitions,emotions,andbehaviorsthatinterferewithinterpersonalrelationshipsaswellas functionsrequiredforwork,athome,andinschool(Johnstone,2001).Thisdefinitiontakesintoaccountamyriadof differentfunctionsandhowtheyaffectapersonsabilityto performthetasksnecessaryfordailyliving.Thisdefinition isalsopresentinthecurrentpsychiatricdiagnosticmanual, theDiagnostic and Statistical Manual of Mental Disorders (4thed.;DSM-IV;AmericanPsychiatricAssociation,1994). Mostofthediagnosticcategoriestakeintoconsiderationthe degreetowhichthesymptomsofamentalillnessimpedea personsdailyfunctioningwhenidentifyingtheseverityofthe diagnosis.Withthisdefinitionasacriterion,Hardcastleand Hardcastle(2003)foundthat30%ofallgeneralpractitioner consultationsinvolvedamentalillness.Theyalsoreported thatoneinfourpeoplehasamentalillnessatsometimein herorhislife. Asisthecasewithmajormentalillness,stigmaisalsoa difficultconcepttodefine.Historically,stigmacomesfrom theGreekwordstigmata,whichreferstoamarkofshame ordiscredit;astain,oranidentifyingmarkorcharacteristic (Merriam-Webster Dictionary,1990,p.506).Stigma,when itisusedinreferencetomentalillness,isamultifacetedconstructthatinvolvesfeelings,attitudes,andbehaviors(Penn &Martin,1998).Thereareseveralcurrenttheoriesaboutthe constructofstigmaandhowitmightbedeconstructedand defined.Thesetheoriesincludesocial identity, self-stigma, andstructural stigma.

Theories of Stigma
Socialidentitytheoryconsidershowpeopleusesocialconstructstojudgeorlabelsomeonewhoisdifferentordisfavored. Societies, or large groups within societies, evaluate

Stacy L. Overton, Connections, Fort Collins, Colorado, and School for Professional Studies, Regis University; Sondra L. Medina, Department of Counseling, Regis University. Correspondence concerning this article should be addressed to Stacy L. Overton, Connections, 525 West Oak Street, Fort Collins, CO 80526 (e-mail: soverton1@aol.com). 2008 by the American Counseling Association. All rights reserved.

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Overton & Medina peopletodetermineiftheyfitthesocialnorms.Socialidentity isaconceptfirstwrittenaboutbyGoffman(1963).Hediscussedhowstigmatizedpeopleformavirtual social identity whentheybecomedisfavoredordishonoredintheeyesof society,andthentheybecomeoutcasts.Thisappliestopeople withmentalillnessbecause,historically,mentalillnesshas beenviewedasacharacterormoralflaw.Thetermspoiled collective identitywasalsocoinedbyGoffmantodescribe peoplewhowerestigmatizedandwhoseidentityasawhole wasbroughtintoquestion.Individualswhoarenotstigmatized arealsojudgedbysociety.Peoplewithmentalillnessareoften judgedbytheirbehaviors,butthisdoesnotreflecttheirwhole being.Withspoiledcollectiveidentity,thestigmatizedperson isreducedinthemindsofothersfromawholeandnormal person to a tainted, discounted one. Crawford and Brown (2002)agreedthatstigmaariseswhenanactualsocialidentity fallsshortofasocietallydefinedidealidentity. Thesecondtheoryofstigmaisself-stigma.Self-stigmaisan internalevaluationprocesswherebypeoplejudgethemselves. Thisjudgmentcouldbearesultofmessagesreceivedfromsocietalnorms,butultimatelyitistheindividualwhoiscreating thejudgmenttowardhimselforherself.Thisjudgmentdecreases self-esteemasapersontellshim-orherselfthatheorshedoes notfitinorisnotgoodenoughtoliveuptotheexpectationsthat othersimposeonapersonandhisorherenvironment(Blankertz, 2001).Self-efficacyhasanimpactonthebeliefthatonecan perform,and,consequently,confidenceinonesfutureisgreatly reducedwhenself-efficacyispoor(Blankertz,2001;Corrigan, 2004).Individualsmayinternalizeanidentitythatdehumanizes them.Whenindividualsdonotliveuptothesocialnormsregardingtheiridentity,theyhavefeelingsofinferiority,self-hate,and shame(Lenhardt,2004).Corrigan(2002)describedself-stigma asaprivateshamethatdiminishesself-esteemandcausesselfdoubtregardingwhetheronecanliveindependently,holdajob, earnalivelihood,andfindalifemate. StructuralstigmaissimilartoGoffmans(1963)spoiled collectiveidentitybecause itisanexternalevaluation ofa person that is based on societal norms.This theory looks moreindepthattheprocessofstigmathroughoutaculture andhowstigmaworksasasystem.Thetheoryofstructural stigmadepictsthetangiblebarrierscreatedforpeoplewho havementalillness.AccordingtoJohnstone(2001),onethird ofallstatesrestricttherightsofpeoplewithamentalhealth diagnosis to hold elective offices or sit on juries, and one halfofallstatesrestrictthechildcustodyrightsofsomeone withamentalhealthdiagnosis.Structuralstigmadescribes a process that works to deny people with a mental illness their entitlement to things that people who are considered normaltakeforgranted.Peoplewithamentalillnessmay havedifficultyfindingtheirfunctionorasenseofplacein theintersubjectiveworld(Johnstone,2001).Theymightalso bechallengedintheefforttofindempatheticandsupportive relationshipswithothers,happiness,participatorycitizenship, andpeaceofmind. The Stigma Process AccordingtoCorrigan(2004),structuralstigmaisaprocess. Theprocessinvolves(a)therecognitionofcuesthataperson has a mental illness, (b) activation of stereotypes, and (c) prejudiceordiscriminationagainstthatperson. Cues.Acueisasocialcognitiveprocessofrecognizingthat somethingisdifferentaboutaperson.Acuemaytakeseveral forms.A cue may be something physical or observable, for instance,apsychiatricsymptom,adeficitinsocialskills,or a difference in physical appearance.A label or psychiatric diagnosis may also work as a cue, including a nonspecific label.Inmanycases,itdoesnotmatterwhatthediagnosisis aslongasitinvolvesamentalandnotaphysicalaspectofa person;thediagnosisitselfworksasacue(Corrigan,2004). Otherresearchshowsthatsomepsychiatricdiagnosesworkas astrongercuethanothers.Forexample,psychoticdiagnoses havemorestigmaassociatedwiththemthandiagnosesofmood disorders(Granello&Wheaton,2001).Itisunclearifthisis becausemooddisordersaremoreprevalentandacceptablein ourcultureorbecausepsychoticsymptomsareoftenfearedand arefurtherfromthenormforacceptablebehavior. Stereotypes.Afterapersonhasbeencuedthatthereissomethingdifferentaboutanindividual,stereotypesareactivated withinthatpersonsthoughtprocess.Stereotypesaredefined asknowledgestructuresthatarelearnedbymostmembersof asocialgroup(Corrigan,2004;Lenhardt,2004).According toresearch,stereotypesarecollectivelyagreed-uponnotions aboutagroupofpersonsthatareusedtocategorizethesepeople (Krueger,1996).Eventhoughsomeonemayholdstereotypes aboutagroupofpeople,theymaynotbelievethemorendorse theseideals.Whensomeonesanctionsanegativestereotype, heorsheisgeneratingwhatiscalledprejudice. Prejudice.Prejudiceisaresultofcognitiveandaffective responsestostereotypes.Onecommonaffectiveresponseis reflexivedisgust,whichisconsideredadefensiveemotion. Oftendisgustisaccompaniedbyafearofcontaminationbyor anoverwhelmingwishtoavoidwhatisjudgedasunacceptable oroffensive(Brockington,Hall,Levings,&Murphy,1993; Corriganetal.,2001).Aftertheinitialreflexivereaction,a cognitiveandrule-basedprocesstakesover(Pryor,Reeder, Yeadon,&Hesson-McInnis,2004).Therule-basedprocess isbasedonrulesthatemergefromexpectedsocialinteractions.Therule-basedsystemallowstheindividualtomake adjustmentstohisorherreflexiveandsubsequentreactions. Thisprocesscanbeturnedoffandonandmayreplacethe initialresponseofdisgustwithoneofpityorcourtesy.People who have a strong internal motivation to control prejudice that is paired with weak external motivations to control it demonstratelessracebiasonimplicitmeasures(Pryoretal., 2004).Iftherule-basedsystemdoesnotengage,moreemotionsarecreatedasaresultofprejudice.Statementssuchas IhatethemortheyaredangerousandImafraidofthem arecommonexamplesofstrongemotiontowardatargeted group.Prejudicethenleadstodiscrimination.

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The Stigma of Mental Illness Discrimination. Discriminationisabehavioralresponsetothe emotionsandbeliefsgeneratedbyprejudice.Thereisanemotionalreactionthatcomesfromattachingstigmatosomeoneor something.Fear,forexample,isastrongemotion,andthisreactionleadstoabehavioralresponse.Forinstance,socialdistancing isacommonresponsetofear(Corriganetal.,2001). Amongtheunderpinningsthatsupportdiscriminationagainst mentalillnessarethatbeliefsystemsaredeeplyingrainedand oftenstructurallyreinforcedbysocietalattitudesoffear,ignorance, and intolerance (Johnstone, 2001).The belief systems thatsocietyholdsaboutmentalillnessaresodeep-seatedthat whensomeonehasaninteractionwithamentallyillperson,their cognitiveprocessesoftendistortthesocialrelationship,leading toconsciousandunconsciousbehaviors.Thelensthatpeopleare lookingthroughmakesitbotheasiertoseeandtoignorecertain conditions(Lenhardt,2004). Discriminationinvolvesdifferentaspectsforthemajority groupandforthestigmatizedgroup.Behaviorsexhibitedby themajoritygroupresultinnegativeactiontowardthestigmatizedgroupandpositiveactionforthemajoritygroup.Often, thepositiveactionsimplyreinforcesbeliefsandstereotypes thatwerepreviouslyheldbythemajoritygroup,thuscreating barriersbetweenthegroups.Avoidanceisacommonaction thatamajoritygroupcantake.Withavoidance,thestigmatized groupbecomestheout-group(Blankertz,2001). Avoidanceisoftendefinedasbeingattributivetheactor practiceofkeepingawayfromorwithdrawingfromsomething undesirable(Merriam Webster Dictionary,1990).Avoidance maybeaninstinctualreactiontriggeredbystigma(Pryoret al.,2004).In2001,KurzbanandLearysuggestedthatavoidancemightserveseveraldifferentfunctions,includingsocial exchange,maintenance,andcontagion. Social exchange is based on the idea that people get somethingpositiveoutofsocialinteractions.Ifpeopleare cuedthatsomeonewithamentalillnessisdifferentorisperceivedasbeneaththeminsocialstatus,theyarelesslikelyto interactwiththatperson.Theymightbeconcernedthatthey arebeingcheatedinthesocialexchangeanduseavoidance withsomeonewhotheyperceivewillofferthemlittleorno socialgain. Maintenance of an ideal identity is another reason that avoidance may be used with someone with a mental illness. Establishingasocialidentityorgroupidentityisimportantin establishing a social power structure.The question of stigma ariseswhenapersonsactualsocialidentityfallsshortofsome societally defined ideal identity (Crawford & Brown, 2002). Maintaininganidealidentityisalsoimportanttoreinforcegroup normsandbeliefs.Distancingallowsthegroupwithpowerto exploitsubordinategroupsandmaintaintheiridealidentityasa group.Avoidancehasabasisinblame,andsomeonewhoisbeing avoidedisoftenbeingblamedforhisorherownsocialsituation (Alicke,2000;Crandall&Eshleman,2003). ThelastreasonthatKurzbanandLeary(2001)haveidentifiedasajustificationforusingavoidanceisconcernabout contagion.Oneofthemanymythsofmentalillnessisthat mentalillnessiscontagious.Peopleoftenactasifphysical contactwithorevenproximitytothestigmatizedpersoncan resultinsomesortofcontagion(Pryoretal.,2004).Even thoughthereisnoresearchtosupporttheideathatmental illnessmightbecommunicable,manypeoplestillperceive theideaasatruth.Avoidanceisusefulindealingwiththe socialconsequencethatbeingassociatedorsocializingwith astigmatizedpersonmayinfluenceonessocialstanding.The personsocializingwithsomeonewithmentalillnessmaybe susceptibletothecontagionoffallingintothesocialgroup ofthementallyill(Sadow,Ryder,&Webster,2002). Avoidanceisacommonbehaviorthatresultsfromprejudice.However,thedesiretoavoidguiltmayalsobeamotivatingforceincontrollingprejudicialbehavior(Pryoretal., 2004).Peoplewhoaremotivatedtocontrolinitialprejudicial behaviorsdisplaymoreapproachbehaviortowardthepeople they have stigmatized after they have had time to process. However,therearetimeswhen,evenafterreflection,people stillchooseavoidance.Avoidanceismorecommonwhenthe stigmaisrelatedtocriminalactivity. Discrimination,orspecificbehaviorsofprejudice,hasa longhistoryinthecontextofmentalhealth.Duringthe19th century when people arrived at Ellis Island, officials were givenafewsecondstodecideifimmigrantsexhibitedsigns ofinsanity.Iftheimmigrantswerethoughttobeinsane, theyweresubjectedtotestsbasedonanillustratedguideto signsofinsanity.Thesesignsincludedbehaviorssuchas actinglikeanIrishperson,wheninfacttheindividualwas French.Individualswhoweredeterminedtobeinsanewere sentbacktotheircountryoforigin(Sayce,1998).Discriminationisoneoftheprimaryelementsthathasanimpacton peoplewithmentalillnesses. Effects of Stigma Theprocessofstigmaproducingprejudicialbehaviorcontributes to structural stigma. Specifically as a culture, it is normativebehaviortoperceivepeoplewithmentalillnessas dangerousandviolent.Therearemanyareasinwhichthis cultural norm for prejudicial behavior results in prejudice againstpeoplewithmentalillness.Thefollowingareasareexamplesofthewayinwhichstructuralstigmahasanimpacton peoplewithmentalillness:lackofemploymentopportunities; limitationsonfindingadequateshelter;barrierstoobtaining treatment services, including negative attitudes of mental healthprofessionals;andtheroleofthemediainperpetuating thenegativeimageofpeoplewithmentalillness. Citizens are less likely to hire people who are labeled mentally ill (Bordieri & Drehmer, 1986). Employers often assumethatpeoplewithamentalillnessmaybemorelikely to be absent, dangerous, or unpredictable (Green, Hayes, Dickinson,Whittaker,&Gilheany,2003).Asasortofselffulfillingprophecy,itisnotuncommonforpeoplewhoexperiencesuchstigmatoalsoexperiencemoresomaticsymptoms.

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Overton & Medina Itismoreacceptabletotalkaboutstomachachesandfatigue thanonesmentalproblems(Wolport,2001).Anticipationof negativeresponsesfromemployersandfellowemployeescan alsoresultinpeoplewithmentalillnesswithdrawingfromor limitingtheirsocialoroccupationalfunctioning(Alexander &Link,2003).Researchershavefoundthatoncepeoplehave beenlabeledmentally ill,theyaremorelikelytobeunderemployedandtoearnlessthanpeoplewiththesamepsychiatric difficultiesbutwhohavenotbeenidentifiedashavingthem. Thisresearchshowsthatlabelingalonecanaffectemployment opportunitieswithouttakingintoaccountapersonsability, knowledge,education,orqualificationsforaparticularjob (Link,1987). Landlordsmayrespondtopeoplewithmentalillnessina waythatissimilartotheattitudeandbehaviorofemployers. Theyarelesslikelytoleaseapartmentstosomeonewhohas beenlabeledmentally ill(Page,1995).Controllability,asdefinedbyCorrigan,Watson,andOttati(2003),maybethekey toactsofdiscriminationtowardpeoplewithmentalillness. Controllabilityisdefinedastheamountofvolitiononehas inasituation.Forexample,alandlordmayperceiveamental illnessassomethingapersonhascontroloveroraresultof negativebehavior.Thelandlordmaybelievethatthemental illnesscomesfromsomethinginternal,suchaspoormoral character,andbelesslikelytoagreetoalease. Anotherwaythatstigmaaffectspeoplewithamentalillnessisthebarrierstheyfaceinobtainingtreatmentservices. Themostcommonbarriersincludefinancialchallengesregardingpayingfortreatment,entryintotreatment,andnegativeattitudesofmentalhealthprofessionalattitudestoward peoplewithamentalillness(Simmons,2001). Financialbarrierscanmakeaccesstoservicesdifficult.As previouslymentioned,ifanindividualhasamentalillness,he orshemighthaveadifficulttimegettingajobbecauseofthe stigmaimposedonthembyemployers.Theymightalsohave challengesrelatedtotheirsymptomsthatmakeitdifficultto holdajob.Moreover,lackofresourcesandcontinuedbudget cutscanmakeitalmostimpossibleforapersontoreceive comprehensiveservices.Suchfinancialconstraintsalsomean thatmentalhealthcentersareoftenunderstaffedandunderpaid,sothatfrustrationstrickledownandcansometimesbe reflectedintheattitudesofthoseprovidingtheservicesthat arebeingofferedtocommunitymembers. Enteringintotreatmentcanalsobeabarriertoservices.Less than30%ofpeoplewithamentalhealthdiagnosisactually seektreatment,andapproximately40%ofpeoplewhohada seriousdiagnosis(e.g.,schizophrenia)andwhoattemptedto gettreatment,failedtoobtaintreatment(Martin,Pescosolida, &Tuch, 2000). Schumacher, Corrigan, and Dejong (2003) foundthatstigmatizedpeoplewhohadanattributethatwas easilyconcealedfromothers(e.g.,gaymen,someonefroma minorityfaithcommunity,orpeoplewithmentalillness)could avoidnegativeattitudesbyconcealingtheattributeandchoosing nottoseeksupportservices.Theymayevenchoosetodenythis attributeorgroupstatusbynotseekinghelpthroughinstitutions thatidentifytheattributeinthefirstplace,likeacommunity mentalhealthcenter(Corrigan,2004). If a person with mental illness is able to reach out and seekservices,theeffectsofstigmahavebeenshowntoinfluencetheefficacyofhisorhertreatment(Sadowetal.,2002). Peoplewhoareusingservicesandperceivetheirowndevaluationorrejectionfromsocietyhavebeenshowntohavepoor treatmentoutcomes(Jorm,Korten,Jacomb,Christensen,& Henderson,1999).Peoplewithmentalillnessesmayhavea difficulttimeaccessingandusingservices.Theymayperceive supportasminimalbothfromprovidersandfromothersupportsystemssuchasfamilyandfriends.Thisperceivedlack ofsupportoftenresultsinincreasedsymptomsofdepression (Mickelson,2001). Mentalhealthprofessionalsattitudestowardsomeonewith amentalillnesscanbothperpetuatestigmaandcreatenew barrierstoreceivingtreatment.Stigmacanoriginatefromthe verypeopleinthementalhealthfieldwhoareexpectedto offerhelptopersonswithamentalillness.Mostwell-trained professionalsinthementalhealthdisciplinessubscribetothe samestereotypesaboutmentalillnessasthegeneralpublic (Corrigan, 2002). Historically, this has not changed much inthementalhealthfield.Theconceptsreflectedintheway thatprofessionalstalkaboutclientsandconceptualizecases isverysimilartothenegativeideasthathavecharacterized clients over the last 2 centuries. Patients are often thought tobeincompetent.Thisattitudeissimilartohistoricalattitudesaboutpsychiatricpatients(Crawford&Brown,2002). Cook,Jonikas,andRazzano(1995)actuallyfoundthatthe generalpublicheldmoreoptimisticopinionsabouttreatment outcomesforpeoplewithmentalillnessesthanwereheldby mental health professionals. Jorm et al. (1999) suggested thatattitudesheldbymentalhealthprofessionalswereinfluencedbytheprofessionalspersonalworkexperienceswith clientsandbyprevailingattitudesoftheprofessionandthe professionalswithwhomtheyworked.Professionalcontact mayimprovegeneralattitudesaboutmentalillness,butsuch contactwasnothelpfulinchangingnegativeattitudesabout predictingprognosisandlong-termoutcomes(Cooketal., 1995). Sadly, these negative attitudes may be conveyed to clientsandtheirfamiliesandhaveaninfluenceontheirexpectationsofoutcomes(Hugo,2001).Fearisthemostprevalent emotionreportedbymentalhealthprofessionalsregardingthis population.Someothersecondaryemotionsincludedislike, neglect,andanger(Penn&Martin,1998).Fearissuchastrong emotionthatitmayperpetuatestigmabycreatingmorelabels thatinfluenceclientsbehaviorsandsymptoms. Onewayinwhichstructuralstigmaislearnedandperpetuatedisthroughthemedia.Themediaarereportedlythe publicsmostimportantsourceofinformationaboutmental illness(Wilson,Nairn,Coverdale,&Panapa,1999a,1999b). InresearchbyCorrigan,River,etal.(2001),90%ofsurvey respondents reported that they had learned about mental

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The Stigma of Mental Illness illnessfromthemassmedia.Themediacontributestostructuralstigmabecauseitdepictscharacterswithmentalillness asbeingtwo-dimensional.Theaudiencecannotrelatetothe character other than through the limited information that ispresented.Mostmediarepresentationsofmentalillness conjureuptheimageofadangerous,violentindividualwho isalmostalwaysapotentialkiller(Sieff,2003).Characters withmentalillnessesarealsoportrayedinthemediaasbeing simpleandchildlike.Notonlyarethemajorityofcharacters withmentalillnessportrayedasphysicallyviolent(Wilson etal.,1999b),buttheyarealsoportrayedasunpredictable, failures,asocial,incompetent,untrustworthy,andoftenas beingsocialoutcasts.Televisionviewersfindcharacterizationsofindividualswithmentalillnessesinteleviseddramas tobemorecompellingthaninformationfromfactualsources (Wilsonetal.,1999b).Characterswithamentalillnessare depicted with an appearance, sounds, and reactions from other characters to signify danger and unpredictability. Camerashotsandcompare/contrasttechniques(e.g.,highlightingdangerouscharacterswithlighting)arealsousedto underscorethedifferencesbetweencharacterswhoexperiencementalillnessandthosewhodonot.Viewersareoften notevenawareoftheinfluencesthatthesetechniqueshave onthem(Wilsonetal.,1999b). Anotherareaofthemediainwhichmentalillnessisportrayednegativelyisinchildrensmedia.In2003,Wahlreviewed differentformsofchildrensmedia,includingtelevision,films, and cartoons.Wahl determined that the common images of peoplewithmentalillnessintheseformatsdirectedtochildren wereconsistentwithsuchimagesinadultmedia.Mentalillness isshowntobeunattractive,violent,andcriminal.Scheff(1999), oneoftheearlypioneersinstudyingstigma,suggestedthat attitudesofstigmaarefairlywellsetupbyearlychildhood.In fact,heproposedthatchildrenprobablyunderstandtheliteral meaningofcrazyasearlyasfirstgrade.Someoftheothermessagesthatchildrensmediaconveysarethatpeoplewithmental illnessesfailinlife,areridiculedbyothers,areunattractive, andseldombenefitfromtreatment(Wahl,2003). languageshifted.Clientsandpractitionersreferredtoclientsas casesinsteadof persons.Suchlanguageisfoundedinahistory ofoppressinganddehumanizingpeoplewithmentalillness. ThesecondthemethatThesenfoundwaslackoflove.People referredtolonelinessandfeelingunaccepted.Whentheywere askedtoidentifythesefeelings,peoplewithmentalillnesses describedwantingloveintheirlifeandreportedthattheydid notfeelorexperiencethis.ThelastthemethatThesenfoundfor peoplewithmentalillnesseswasthattheyfeltliketheylacked alifeoftheirown.Theyfeltthatothersweremakingchoices andsettinggoalsforthem.Thesethemesreflectanunderlying attitudethatcontributestoalackofself-efficacyforpeople withmentalillness. Self-efficacy can be defined as peoples beliefs about theircapabilitytoachievedesignatedlevelsofperformance. Self-efficacy is influenced by negative cognitions and low self-esteem(Blankertz,2001).Whenpeoplewithamental illnessperceivethattheydonothaveasupportsystemandthat theyaredehumanized,theyhavealowerlevelofself-efficacy. Whenpeoplewithamentalillnessperceivethatpeoplewho constitutetheirsupportsystemsarejudgingthem,thisalso affects their feelings of mastery and makes assessment of functioningdifficult.Stigmaimposedbyotherscreatesthe expectationthatpeoplewithmentalillnessesareunableto liveuptotheresponsibilitiesthatarepartofeverydayliving (Corrigan&Watson,2002). Self-esteem is another area that is affected by stigma. Self-esteemisoftenconfusedwithself-efficacy.Self-esteem isdefinedasapersonsappraisalofhimselforherselfatan emotional level. Stigma can be detrimental to self-esteem. Negative stereotypes associated with the stigma of mental illnesscanhaveaseriousimpactonself-esteem(Blankertz, 2001). Stereotypes are an important part of an underlying beliefsystem,sotheyendureacrossmanydifferentsettings. Thisinfluencesrecoveryaswellasotherareasofoneslife (Sadowetal.,2002).

Ways to Mitigate Stigma

Mitigating stigma related to people with mental illness is adifficultmission.Reducingthestereotypesaboutandthe prejudicial behavior toward this group could create many opportunitiesforthem.Therearethreeareasofinvolvement thatstigmaresearchershavesuggestedcouldfosterchange tohelpreducestigmarelatedtopeoplewithmentalillness: protest,education,andcontact. Protestisdefinedasacomplaintoranobjection(MerriamWebster Dictionary,1990,p.418).Throughprotest,anattemptismadetosuppressstigmatizingattitudesbydirectly instructingindividualsnottothinkaboutorconsidernegative stereotypes.Protestisusedtodisputeingrainedbeliefsby proposingargumentsorfactsthatdispelthebeliefsystem. Protestisoftenanattempttoappealtomoralindignation (Corrigan,2002).Protestmaybeusedinapubliccampaign

Impact of Stigma on Individuals With Mental Illnesses

The barriers to and negative attitudes toward people with mentalillnessthatresultfromthestigmaprocessaffectthem greatly.They are often compromised in dealing with daily activities.Afterhearingnegativefeedbackandexperiencing anonslaughtofnegativeactions,theybegintoseethemselves inanegativelight.Peoplewhohavebeendiagnosedwitha mentalillnessoftenfindthattheirself-imageandconfidence aresacrificedbylivingunderthepressureandnegativeexpectationsgeneratedbystigma. In2001,Thesendiscoveredthreeattitudethemesinconversationswithclientsandpractitioners.Thefirstthemethat bothclientsandmentalhealthworkersnoticedwasthatthe

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Overton & Medina orinindividualdialogue.TheresearchofCoutureandPenn (2003) indicated that the attempt to suppress stereotypes throughprotestcanoftenresultinareboundeffectandgenerallydoesnothaveaneffectonstigma.Accordingtotheseresearchers,theveryattempttokeepunwantedthoughtsoutof themindmightmakethesethoughtsmoreinsistent.In1999, CorriganandPennfoundthatprotestmightbackfire.They conductedastudyinwhichparticipantswereinstructednot tothinkaboutsexandfoundthattheseparticipantsshowed thesameelevationsofphysiologicalarousalasparticipants whoconcentratedonsex.Peoplearemorelikelytobesensitivetostereotype-confirminginformationwhentheyare distractedbyothercognitivetasksorifpsychophysiological arousaldiminishestheircognitiveprocesses.Protest,which attemptstosuppressnegativestereotypesaboutmentalillness,mayactuallybeprimingthesestereotypes(Corrigan &Penn,1999). Educationisanothermethodthathasbeenusedtoattempt tomitigatestigma.Educationisthemeansofconveyingfactual informationtospecificpopulations.Often,educationisused directlytocontradictmythswithfacts.CoutureandPenn(2003) foundthateducationishelpfulforchangingattitudesbuthas littleeffectonsubsequentbehaviors.Educationmayhelpto mitigatestigmaslightlybutdoesnotendureovertime.Belief systemsaresowellingrainedthateducationmaybetoolimited toreduceresilientstigmatizingattitudes(Devine,1995). Contactordirectinteractionisanadditionalwaytomitigate stigma.Thereisanextensivebodyofresearchthatshowsthat interpersonalcontactwithsomeonewithamentalillnessis farmoreeffectiveatmitigatingstigmathaneitherprotestor education.Unlikeeducation,whichchangesattitudesandnot behaviors,contacthasthecapacitytochangeboth. Themorepersonalcontactapersonhaswithastigmatizedgroup,thefewerstigmatizingattitudesheorshewill have(Ingamells,Goodwin,&John,1996).Astotalcontact increases,theperceptionofdangerandattemptstokeepa socialdistancedecrease(Alexander&Link,2003).Research doessupportthatevenminimalcontactwithsomeonewith amentalillnesscanchangestigmatizingbeliefs.Alexander andLinkfoundthatevenveryminimalcontact,eitherprofessionallyorpersonally,willreducestigma.Aslittlecontact asa15-minutevideocandispelmythsaboutmentalillness. People begin to see someone with a diagnosis of mental illnessasanindividualwhoisnotunlikethem.Alexander andLinkalsofoundthatacombinationofpersonalcontact, education,andcooperativecontact,suchasworkingwith someonetowardacommongoal,couldreducestigma.Link andCullen(1986)foundthattherewasnosignificantdifferencebetweenvoluntarycontactandinvoluntarycontact inreducingstigmatizingattitudes. Specifically,contactwiththestigmatizedgroupminimizes theperceptionofgroupdifferences.Whenpeoplehavecontact withsomeonewithamentalillnessandthispersonisperceived tohaveequalstatus,eitherprofessionallyorpersonally,then suchcontactmitigatesstigma(Couture&Penn,2003).One-ononecontactormoreintimateintrapersonalcontactalsoenables contacttoworkmoreeffectively.Cooperativecontactsarealso importantbecauseaspeopleworktogethertowardcommon goals,stereotypesaremoreeasilydisplaced(Corrigan&Penn, 1999). Interaction with someone with a mental illness can changecognitivestructuresandclassificationfromaperception ofthemtothatofus(Corriganetal.,2001). Itispossibleforapersontocomeintocontactwithsomeonewithamentalillnesswhoisconsideredtypicalofastereotypeorwhosebehaviorsomehowreinforcesastereotype. Inthiscase,insteadofmitigatingstigma,contactreinforces it. Stigmatizing beliefs will continue and possibly become worse(Reinke,Corrigan,Leanhard,Lundin,&Kubiak,2004). Mentalhealthprofessionalsmayspecificallystrugglewiththis becausetheyoftenseeclientswhoareconsideredtypicalof astereotype,anddeep-seatedbeliefsaboutmentalillnessare reinforced.Cliniciansareaskedtoexaminetheirownvalues aboutmentalhealth.Corrigan(2004)recommendedthatcounselorsuseempoweringtreatmenttocounteractself-stigmain clients.Ifclinicianslistentotheirclientsandempathizewith theirindividualexperienceswithmentalhealthchallengesand iftheywatchtheirlanguageandavoidbelittlingwordslike complianceandresistance,theymaybeabletocounteract theclientsself-stigma.

Improving Clinician Training to Minimize Stigma

Asourresearchsuggests,mentalhealthpractitionersarenot immune to stigmatizing beliefs. Corrigan (2002) reported thatmostmentalhealthprofessionalssubscribetostereotypes aboutmentalillness,andHugo(2001)foundthatthegeneral publichadmoreoptimisticexpectationsforindividualswith mentalillnessthanmentalhealthprofessionalsdid.Infact,the waythatpractitionersrespondtotheirclientswhoarementally illmaycontributetostigma(Penn&Martin,1998)ormake clientssymptomsworse(Sadowetal.,2002).Therefore,it isimperativetoaddressstigmainthementalhealthfieldand worktodecreasethestigmatizingbeliefsthatpractitioners holdtobetrue.Wesuggestthatcounselorsreceiveeducation aboutstigmaanditsimpactonindividualswithmentalillness,thateducatorsincounselortrainingprogramsworkto increasetheirstudentscapacityforcognitivecomplexity,and thatcounselorsfindopportunitiesfordevelopingegalitarian relationshipswithindividualshavingamentalillness. Bieri (1955) described cognitive complexity as the degree of differentiation among the personal constructs of an individual. In the mental health field, Spengler and Strohmer (1994) reported that counselors with higher levelsofcognitivecomplexitywerelesspronetobiasesin clinical judgment than were counselors with lower levels of cognitive complexity.These biases could also encompassthestigmatizingbeliefswithwhichweareconcerned

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The Stigma of Mental Illness (Stoltenberg, 1981). Stoltenberg, McNeill, and Delworth (1998)similarlyfoundthatcounselorswithahigherlevel ofcognitivecomplexitywerebetteratcaseconceptualization,hadahigherlevelofaccurateempathy,andhadbetter skillsofattendingtomulticulturaldynamics.Thissupports thefindingsofFong,Borders,Ethington,andPitts(1997) regarding cognitive complexity: Counselors with higher levelsofcognitivecomplexityhadhigherlevelsofempathy andwerelessoftenjudgmentalaboutpeoplewithmental illness.CoutureandPenn(2003)suggestedthatindividual variablesliketraitempathyandopennesstoexperiencemay influence how contact can minimize stigmatizing beliefs. Cognitivecomplexityisavitalelementincounselorswho wanttoavoidstigma. Althoughcounselingrequiresahighlevelofcognitivecomplexity (Reeve & Heggestad, 2004), most counselor training programsdonotfocusontheacquisitionofcognitiveskilldevelopment(Fongetal.,1997),andstudentsoftenshowminimal gainsincognitivefunctioningoverthecourseoftheirmastersleveltrainingprogram.WhistonandCoker(2000)suggestedthat counseloreducatorsshouldhelpstudentstothinkmorecomplexly andprocessinformationmorequickly.Theyevensuggestedthat thecurriculumincounselortrainingprogramsshouldbemore demandingtoincreasestudentslevelofcognitivecomplexityor thatonlystudentswithhighlevelsofcognitivecomplexitybe admittedtocounselortrainingprograms. Individualsachieveahigherlevelofcognitivecomplexity as they acquire experience in interpreting and anticipating diversepatternsofbehaviorinsocialsituations(Adams-Webber,2003).Thus,educationshouldhelpstudentstoachievea higherlevelofcognitivecomplexitybecausetheyareexposed todiversepatternsofbehaviorandsocialsituationsthrough highereducation.Stoltenberg(1981)outlinedthedevelopmentalstages,intheirincreasingcomplexity,thatcounselors passthrough,andhesuggesteddifferentsupervisorymethods ateachstagethataredesignedtoassiststudentsincreasetheir levelsofcognitivecomplexity.Hesuggestedthatcounselor supervisors use discrimination skills to determine which environmentsaremostsuitedtoaparticularstudentslevel ofdevelopment.Throughtheinteractionswiththesupervisor, the students move through the developmental stages to progress from a stage of dependency, in which they are almosttotallydependentonthesupervisortoofferadidactic situationwithlotsofstructure,toeventuallyreachastageof autonomy,whereinsupervisorsareabletosupportthemand encouragethemtothinkcriticallyaboutsituations.Finally, studentsmayreachastageofmasterywithinthecounseling field(Stoltenberg,1981). Duys and Hedstrom (2000) also encouraged early basic skillstrainingtoenhancecognitivecomplexity.Thisearlybasic skillstrainingcouldalsochallengestigmatizingbeliefsorprovidestudentswiththeopportunityforincreasedcontactonan equalbasiswithanindividualwithmentalillness.Sodowsky, Taffe, and Gutkin (1991) found that increased contact with aculturallydifferentpersoncorrelatedwithhigherlevelsof self-reported multicultural competence, and we suggest that thesamecouldbetruewithmentalillness.Martin(1990)suggestedthatskillstrainingalonedoesnotprovidecounselors withsufficientknowledgeconcerningpurpose,conditions,and contextassociatedwitheffectivecounseling.Curriculumcould becreatedtorequirestudentstovolunteerorinterneitherat amentalhealthfacilityorinotherlessformalsettingswhere theyhavetheopportunityforcontactwithpeoplewhohavea mentalillness.Thiscontactcouldhelpmitigatestigmatizing attitudesandworkasapreventativeprogramforcounselors whoareenteringthefieldofmentalhealth. Finally,peoplewithmentalillnessescouldbeconceptualized as a multicultural population. In the late 1980s and early 1990s, it was common for training programs to add multicultural classes into the curriculum (Hollis &Wantz, 1990).Thesecoursesofferedspecificinformationonworkingwithminoritypopulations,includingethnicminorities, gay and lesbian populations, and people of different ages. Thestigmaandprejudiceexperiencedbyindividualsinsuch populationsarealsoexperiencedbypeoplewhohaveamental illness.Counseloreducatorscouldadvancestandardsofcare for clients with mental illness by defining this population as having multicultural issues. Educators could integrate information into existing classes to train counselors more effectively.Evenifcurriculaalreadytouchontheseissues, counseloreducatorsarechallengedtoreviewandexpandon existingcurriculabecausethesepracticesareimperativein helpingtoreducestigmaintheclassroom.

Conclusion
Stigmaisdebilitatingforpeoplewithmentalillness.It hasanimpactontheiroptionsforlife,theirbeliefsabout themselves, and even the course of their illnesses. We havereviewedtheliteratureandreportedtheprocessof stigmaandsuggestedwaysofmitigatingstigmaforclients whoareexperiencingamentalillness.Finally,wehave suggested ways that clinicians can develop awareness abouttheirownstigmatizingbeliefsandhowclinicians canbetraineddifferentlytominimizethedevelopmentof stigmatizingbeliefs.Werecognizethatmoreresearchis necessarytovalidatethesuggestedchanges.However,we alsorecognizethatchangeisnecessaryifmentalhealth professionals are to address the issue of stigma related tomentalillness.

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