Resolving mental illness stigma: Should we seek normalcy or solidarity?

Summary

Two approaches have emerged to deal with the stigma of mental illness: normalcy, where people with mental illness are framed as ‘just like everyone else’; and solidarity, where the public agrees to stand with those with mental illness regardless of their symptoms. Pros and cons of each approach are considered.

The stigma of mental illness harms people in many ways: prejudice (i.e. endorsing stereotypical beliefs about a group) and discrimination (behaviourally acting against this group based on prejudice) robs people of rightful opportunities, internalising stigma leads to shame, and avoiding stereotypes causes people not to engage in services. Goffman ¹ characterised stigma as ‘undesired differentness’ that results from a mark distinguishing and discrediting an out-group from the majority. People with mental illness are different from the norm and, hence, somehow broken. One way to erase stigma has been to accentuate similarities between people with mental illness and the rest of the population through an appeal to normalcy. Consider this example: ‘Despite her schizophrenia, Norah is just like everyone else.’ Insights from other stigmatised groups suggest, however, that celebrating differentness may better decrease stigma. Consider American society moving away from a 1960s idea of colour-blindness (that all races are the same and, therefore, should not be stigmatised) to the notion of Black Power and appreciation of African heritage. In this case, society's goal was to celebrate differentness by promoting acceptance and solidarity. The relative merits and limitations of normalcy v. solidarity are considered in this editorial.

Diminishing the difference by highlighting normalcy

Goffman ¹ believed stigmatised people can be active agents in diminishing difference through impression management, the strategic effort to minimise others' perceptions of one's self in order to promote individual goals. A review of the organisational psychology literature outlined 30 impression management strategies that included defensive approaches ² that protect one's image by controlling or framing information that might tarnish a person's reputation. Impression management for psychiatric disabilities has largely taken the form of public education programmes seeking to replace notions of the abnormal with the normal. This is done by contrasting myths of serious mental illness with facts that frame the assertions normally.

Myth: People with serious mental illness are dangerous and unpredictable.

Fact: Epidemiological data suggest acts of violence from people with mental illness are very rare.

The normalcy frame is often used in social marketing campaigns addressing stigma. Australia's beyondblue campaign is a collection of public service announcements and internet materials trying to represent depression and anxiety within the normal realm of experience. beyondblue demystifies treatment, framing it as similar to other medical interventions. The campaign has significantly penetrated the Australian population, with more than 60% of Australians recognising the campaign. ³ Campaign awareness is associated with better recognition of illnesses and greater understanding of the benefits of treatments. ³ New Zealand's Like Minds, Like Mine ⁴ and Britain's Time to Change ⁵ campaigns are also well-studied, nationwide social marketing campaigns.

Celebrating the difference and promoting solidarity

Despite the promise of normalcy campaigns, there may be unintended effects; people with mental illness might be expected to keep aspects of their identity secret in or to accentuate their normalcy. There are consequences to suppressing aspects of one's identity that harms a person's mental and physical health, relationships and well-being. ⁶ Conversely, African Americans and women who identify with their stigmatised group report less stress due to prejudice and better self-esteem. ⁷ The issue of public identity for individuals who are gay, lesbian, bisexual and transgender is a bit more complicated because they need to publicly disclose their orientation. Despite the risks, coming out has generally been found to yield improved mental and physical health. ⁸

What does research suggest about identity and coming out for people with mental illness? Some people who identify with their mental illness may show greater pessimism. ⁹ However, effects of illness identity are influenced by perceived legitimacy of mental illness stigma. ¹⁰ Those who identify with mental illness, but also embrace the stigma of their disorder, report less hope and diminished self-esteem. Conversely, those whose sense of self prominently included their mental illness and rejection of the stigma of mental illness not only showed more hope and better self-esteem, but enhanced social functioning as well. Still, the relationship between group identity and prejudice-related stress is complex. For example, research on Latino students in America has shown the connection between identity and stress is worsened when public prejudice against the group is highlighted in one's community. ¹¹

Identity can have positive or negative aspects. People with mental illness may describe themselves negatively in terms of their distress, failures or symptoms. People might try to alter this kind of self-image in psychotherapy, spiritual endeavours or related activity. Mental illness identity can also be viewed positively leading to a sense of pride. ¹² People experience pride in achieving a standard recognised by their culture (e.g. a medal for the runner) or set by themselves (e.g. a personal best race time). Overcoming challenges of mental illness, withstanding related societal stigma and demonstrating a sense of resilience may lead to identity pride.

Pride also emerges from a sense of who one is; ethnic pride is an example. ‘I am Irish American’ does not suggest any accomplishment per se but rather an additional answer to the person's search to understanding, ‘Who am I?’ In this light, mental illness may be an identity in which some individuals might be proud; the recognition that, ‘I am a person with mental illness’, defines much of their daily experience. This kind of identity promotes authenticity and recognition of one's internal conceptualisations in the face of an imposing world. This might take the form of group identification. People with mental illness who more highly identified with the group were less likely to experience harm to self-esteem or self-efficacy as a result of internalised stigma. ¹³

What then becomes the goal of stigma change programmes? Might the public need to acknowledge positive aspects of some people's identity with mental illness and do this by standing in solidarity with them? Solidarity has two meanings here. First, research suggests that people with a stigmatised condition gain strength through association with peers: solidarity in a segment of the world. More broadly, however, is the experience where the majority stands with the group who is publicly out with their stigmatised identity, where they say they are in solidarity with people in recovery.

Implications for research and advocacy

The task that remains for future research and advocacy is to identify when normalcy or solidarity may be most useful for tearing down stigma. Perhaps normalcy messages are valuable to public service campaigns seeking to decrease the stigma of treatment by representing psychotherapy, for example, as ‘just like a visit to the family physician’. Perhaps solidarity is especially poignant for the person struggling with self-stigma, seeking a group of peers with whom to stand proud. There is a second lesson too. Advocates need to be mindful of unintended consequences of anti-stigma campaigns. Framing someone with mental illness as normal, just like everyone else, might worsen self-stigma and undermine the pursuit of empowerment and self-determination. I believe researchers need to partner with advocates to make certain that outcome measures are sensitive to unintended impacts.

Mixed-methods research has begun to examine what a solidarity campaign might look like to address the stigma of mental illness in a college setting. Using community-based participatory research, qualitative interviews with 24 college students suggested benefits and concerns of a solidarity campaign. ¹⁴ Benefits were distinguished into three areas: individual (e.g. sense of identity, pride and support), community (promote awareness, increase visibility, and provide referrals and resources) and social justice (decrease stigma and promote advocacy/activism). Despite these benefits, participants also identified concerns: creating false expectations, implies parts of campus are unsafe, paternalism, and difficulties accommodating mental health challenges. These findings were then used in community-based research led by Active Minds (the US coordinated anti-stigma effort in more than 400 colleges and universities), who conducted a national survey with 990 participants to describe a solidarity campaign. ¹⁵ The resulting Mental Health Unity campaign (www.activeminds.org/cbs-cares-mental-health-information/1033) was rolled out in October of 2014 and includes a pledge ‘to end the silence by providing a safe space for persons to discuss mental health’ and to ‘listen to mental health experiences without judgment’. These findings are a good first step for understanding the potential value of solidarity as an anti-stigma message.