Stigma of Mental Illness: Where Can Public Policy Step In?

Patrick Corrigan, PsyD is Director of the National Consortium on Stigma and Empowerment (NCSE) and Distinguished Professor of Psychology at the Illinois Institute of Technology. Prior to this position, Corrigan spent fourteen years as a professor of Psychiatry and Executive Director of the Center for Psychiatric Rehabilitation at the University of Chicago. Corrigan is a licensed clinical psychologist setting up and providing services for people with serious mental illnesses and their families for more than 30 years.  

Given your decades of experience and status as a well-respected expert in the field of stigma research, how do you view the core mission of your work?

My core mission is to provide advocates the knowledge they need to undermine the discrimination that goes along with having a mental illness. At the end of the day, changing attitudes is not sufficient. You need to change behavior.

Why should public policy researchers and practitioners concern themselves with the stigma of mental illness?

To be frank, there is a lot of money in it. Governments are spending a tremendous amount of money. In the last 10 years, Canada, Australia, New Zealand, the UK, the EU, and the United States (however less so) have devoted millions of dollars to addressing stigma. Since governments are beginning to put some money into it, we want to make sure they are doing it right, because we know they are quite capable of doing it wrong. There is a desire to do all of this easy stuff that not only does not help, but might make things worse. So we need to collect evidence about what works, and what does not work. The other issue is the social justice issue.

What types of policies and/or programs are effective and ineffective in addressing the stigma of mental illness?

We have pretty strong feelings about what we should and shouldn’t invest in. Education is terribly overrated. There are population studies that suggest the world population is much more knowledgeable about mental illness being a brain disorder. Yet the stigma of mental illness for depression is no different, and for schizophrenia, it has actually become worse in the last 15 years. The idea that mental illness is a brain disorder actually tends to rebound and lead to worse attitudes about people with mental illness. We tend to blame them less for the mental illness, but we also tend to believe they do not recover, and if I as an employer believe that you are not going to get any better, I’m not going to hire you.

Then there is what I call the numbskull idea of “changing words” – i.e. calling it something other than schizophrenia. There have been some examples like leprosy is now Hansen’s disease, mania is bipolar disorder, and mental retardation is intellectual disability. There is little research that suggests that it has made any difference. Labels represent difference. So whether I call you bipolar or I call you manic, you are still different than I am, and it is the difference that is fundamentally stigma.

While I’m on my high horse, the other things I’m not really keen on are public service announcements and public service campaigns. First, the research would suggest that while people might remember the campaigns, they have limited impact on actual behavior. The other thing I’m concerned about is that we miss the grassroots nature of stigma change. It’s a problem of people in the world, and if you turn it into a Madison Avenue sort of thing, it becomes a lot of glitz that the politicians like but doesn’t have any translation to people or their communities like their employers or landlords.

What we think is the approach to invest in, and what we work with governments all around the world on is what we call TLC3: Targeted, Local, Continuous, Credible Contact. The whole thing is based on Contact, so it is based on people with lived experience telling their stories. We think it should be Targeted – I’d like the population to change their attitudes tomorrow but they won’t, so it is much more important that employers be willing to hire people, landlords to rent to them, and primary care providers to provide appropriate care. Local – for example, any idea that comes up in New York has neither influence in Chicago nor in Los Angeles. Continuous – contact needs to occur multiple times to be most effective. Credible – it needs to be in a similar vein out of the same community.

Canada is the one place on earth that is doing it pretty well. Canada pays consumer groups to go around and strategically tell their stories. It’s being done in the United States too. The state of California with their Proposition 63 has consumer groups all across the state trying to roll out programs in a similar vein.

There have been advances over the years with regard to federal antidiscrimination legislation such as the Americans with Disabilities Act of 1990 and Mental Health Parity and Addiction Equity Act of 2008. How is this type of legislation effective in addressing stigma? What is outside of the reach of such federal legislation?

One, it tells the country that that sort of stuff won’t be tolerated. It’s important to realize however that prohibitive laws by themselves are not sufficient for two reasons. Just because the laws are there, doesn’t mean I can’t do it. The other reason is what we would call affirming attitudes and behaviors – what the government calls affirmative action, which is a bit of a “hot potato”.

We would argue that it is not enough to stop hating people. You actually have to promote their rights and opportunities. So the flip side to the Americans with Disabilities Act is really important: the reasonable accommodations aspect, which has more of an affirmative attitudes aspect to it. For example, the whole goal of psych rehab is getting people back to work, and my sense of employers is that, despite doubtless stigma, they don’t want to discriminate against people with mental illness, especially big companies. Even more, they want to know how to hire and provide services with them. So, there is not so much a desire to discriminate against individuals with mental illness as opposed to not knowing how to provide reasonable accommodations.

What do you see as the biggest challenges for addressing the stigma of mental illness?

I think one of the biggest problems with stigma is the two legitimate, competing agendas driving the task, and the two groups come at it with completely different goals. One agenda is what I like to call the “mental health providers agenda”. We know from research that a large amount of people (half to two-thirds) with serious mental illness won’t seek out care. Of the many reasons why, one of them is because of stigma. So one of the goals is to decrease stigma so people are willing to seek care. The other agenda I call more of the “consumer advocates agenda” is that they want stigma to go away because it’s discriminatory and rights are being taken (the right to a job, the right to live independently, and the like).

Here is why they can be at odds. One good example of this is “Beyond Blue” in Australia, targeting more the “mental health providers agenda.”Beyond Blue does these nice ads of people with depression; depression is an illness, a treatable illness. They show a very sad, down, mopey kind of guy that gets treated and is happy again. The good message there is if I’m watching, and I’m depressed, I might go out and get help. The concern we have about this is that when you are sitting there watching, it accentuates the difference – that the depressed guy is different than I am. Anyone who is different than I am is likely to be worse than I am. So we are concerned that things like that exacerbate the discrimination.

Another example is Mental Health First Aid (MHFA). MHFA is a great program for supporting people in getting help. It teaches me to be alert to my friends, family members, and colleagues when they are a little anxious or depressed, and how to provide them with support to get help. The concern we have about it is that the focus is entirely on the illness with no focus on recovery. So I learn again that, fundamentally, people with mental illness are broken, when the rule is that they recover. They stand the same chance of meeting their goals as most anybody does.

A lot of consumer advocates, to begin with, are very suspicious about the mental health system, so they are not supportive of anything that is trying to get more people into the mental health system. They want to make sure people are not robbing them of their rights, so it’s a civil rights agenda. Providers are, rightly so, interested in getting people into treatment. The competing agendas could be a problem.

What are a couple examples of what federal, state, and/or local government could be doing to more successfully address the stigma of mental illness?

A consumer advocate named Judi Chamberlin said it well (though lots of people have said it), “there is nothing about us without us.” So anything that’s being done to promote opportunities for people with mental illness needs to be driven by people with mental illness.

I think another huge public policy issue is the violence and mental illness pairing. Whenever these horribly sad things happen such as Sandy Hook, there is huge confusion about people with mental illness, and the fact that you could have avoided these things if better care were available.People are just looking for a magic wand. For me, the policy issue is off for a couple of reasons. It would be an extremely coercive society if we were going to try and implement some way of trying to identify the “Adam Lanzas” of the world. You look at the high rate of mental illness of us as a society and can see that the police would be really busy. Also, conceptually I think Adam Lanza, while he was mentally ill, 20 percent of the population is mentally ill. It’s an extremely tiny part of the population of people with mental illness that are this violent. Is it so infinitesimal that we understand Adam Lanza better, because he had a serious mental illness, or because he is somehow morally broken to do something this horrendous? One of the problems with our society is that we don’t do well with morality.

Feature Photo: cc/(hurleygurley)