Stigma Defined: stigma comes from the Greek word stigma that refers to the marks that were placed on slaves in ancient Greece to infer ownership and their inferior social status (Stuart, 2005). The modern meaning of stigma is founded on Goffman’s concept of a “spoiled identity” reflecting a social attitude toward mental illness that is deeply discrediting and places a person in significant social disgrace (Goffman, 1963).
Stigma can be categorized into three types:
- Courtesy Stigma: also called stigma-by-association; where family/community members may share that level of social discreditation and disgrace because of their association with the person suffering from a mental disorder (Goffman, 1963). PSP workplace culture operates very much like a family. For families, courtesy stigma means fear, loss, lowered family-esteem, secrecy, distrust, anger, inability to cope, helplessness, and hopelessness (Gullekson, 1992). Families are often directly blamed for causing the mental illness or harbouring potentially dangerous persons (Lefley, 1992). PSP workplace culture can inadvertently perpetuate stigma by the fears associated with admitting that “one of them” is suffering and needs help. The perceptions of trust the communities, within which the PSP agencies serve, have in their local PSP agencies becomes in question and maintaining that strong-hero public image unfortunately can become the top priority of these PSP agencies.
- Self-Stigma: Beliefs, perspectives, and world-views that individual’s hold, about themselves and the world around them that perpetuate stigmatization. These beliefs and perceptions are characterized by feelings of guilt, shame, inferiority, and the wish for secrecy in regard to their mental illness (Stuart, 2005). It is very common for workers in the helping professions, such as PSP, to be reluctant and unwilling to accept that they themselves require support or need to access formal mental health (Jayasinghe, et. al., 2005). Thus, there is an importance for training PSP peers to be able to recognize the signs and symptoms of distress in themselves and their colleagues, being able to provide effective interventions and supports when they do recognize these signs, and link those showing greater signs of need to the most appropriate next level of care.
- Discrimination: refers to the unfairness and inequitable treatment by others of persons with mental disorders which can lead to the denial of rights and responsibilities of full citizenship (Stuart, 2005). Discrimination can occur at an interpersonal level where a person may desire to distance themselves or exclude themselves from those with mental illness. It can also occur at a structural level where people with mental disorders are overtly or covertly excluded from public life through legal, economic, social, and institutional practices (Fink and Tasman, 1992; Link and Phelan, 2001). For PSP, discrimination can mean losing their job, their friends, their way of life. Discrimination can cause significant barriers for persons suffering with mental disorders from actually accessing the supports and resources they need to get on a path of recovery (Stuart, 2005).
Stigma and discrimination can significantly impede social integration, interfere with the performance of social roles, diminish quality of life, and prevent timely access to treatment, creating a cycle of social disadvantage and disability (Stolzman, 1994). Poverty, social disadvantage, weak social support, and diminished self-esteem are some of the top barriers to recovery (Stuart, 2005).
Mental Health Commission of Canada recognizes six core components for effective stigma reduction:
- Including social contact from a trained speaker who has lived experience with mental illness. Preferably the contact should be in the form of a live speaker on their personal narrative/testimony where the person describes their experience living with mental illness as well as their path of recovery. Other forms can be participants meeting with a person living with mental illness on multiple occasions as an attempt to learn about their story, as well as observing dramatizations such as plays or stand-up comedy routines (Knaak, Hawke & Patten, 2013).
- The use of multiple forms or points of social contacts such as in-person talks, video interviews, multiple first-voice speakers, multiple points of contact between participants and persons with lived experience of a mental illness. It is important to use multiple sources for first-voice speakers as well as using multiple forms such as live speaker and video recordings so that participants can be exposed to different social contact experiences throughout the program as different people learn in different ways and different stories will resonate with different people (Knaak & Patten, 2013, 2014).
- Programs should focus on behaviour change by teaching skills that help PSP know “what to say” and “what to do”. Many PSP lack the confidence and competence in their ability to help those with mental illness which in turn perpetuates stigmatization. Not knowing what to do or say can instill anxiety or fear about interacting with persons with a mental illness which than can lead to a desire for social distance and feelings of hopelessness and helplessness. Therefore, an element of skills training must be included to achieve effective stigma reduction such as role-playing and scenario-based learning to teach context-specific skills and tools (Knaak & Patten, 2014).
- Programs should engage in “myth-busting’ by correcting ‘false beliefs’. Particularly between the association of violence with mental health, appropriate use of language (i.e., refraining from stigmatizing terms such as ‘frequent-flyer’ where-by referring to a person accessing supports frequently as a drain on resources, and false beliefs about certain behaviours such as believing that being too warm and personal towards a person with a mental illness may cause them to want to attach to them in an unhealthy way. Providing facts and information about the prevalence of mental illness is also an important factor to include (Knaak & Patten, 2014).
- Programs should emphasize and demonstrate recovery as a key part of its message. PSP often hold pessimistic beliefs about the likelihood of recovery (Schulze, 2007). Thus, effective anti-stigma programs need to show that recovery is both real and probable through education/training on effective evidence-based treatments, recovery methods/principles and demonstrate what recovery looks like by showing competence and successful living of persons with lived experience of mental illness. It is important that first-voice speakers tell their story from a perspective of recovery rather than illness which helps to discredit stereotypes while demonstrating that persons with mental illness are competent, capable, and can even live full and successful lives. This also helps to combat feelings of helplessness by demonstrating that those who may at some point require formal mental health treatment are actually not helpless and that the outcome is likely to improve with the right supports (Knaak & Patten, 2014).
- Programs should use an enthusiastic facilitator/instructor who models a person-centred approach (i.e., a person first perspective rather than a “pathology” first perspective) to ‘set the tone’ and guide program messaging (Knaak & Patten, 2014).
The Mental Health Commission of Canada recognises these following stages as important criteria for an effective Anti-Stigma program:
- Identifying key learning needs.
- Preparing and planning effectively.
- Getting leadership on board.
- Maximizing participation
- Building the program using the core components for effective stigma reduction.
- Delivering the program in a way that maximizes audience receptivity.
- Maintaining the momentum using best practices and strategies for program sustainability.
- Being aware-of/attending-to external factors and ongoing challenges.