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Special Issue: Cognition in Neuropsychiatric Disorders
Stigma as a barrier to recovery from mental illness
Otto F. Wahl
University of Hartford, 200 Bloomfield Avenue, West Hartford, CT 06117, USA
Advances in neuroscience, technology and research so-
phistication have greatly increased understanding of
mental illnesses and improved the treatment of these
disorders. However, there are also important psychoso-
cial aspects of mental illness that play a significant role in
recovery from these conditions. One set of these factors
involves the prejudice and discrimination, often referred
to as ‘stigma’, faced by people when others learn that
they have been diagnosed with, and/or treated for, a
mental disorder.
There is a long history of research documenting unfavor-
able public opinions about mental illnesses. There is also
recent research that demonstrates that such negative
attitudes have been slow to change. Pescosolido and her
colleagues [1] used the 2006 General Social Survey to
examine contemporary public attitudes toward mental
illnesses in the USA. Survey results revealed several
widespread negative attitudes about mental illnesses.
For example, 47% of respondents indicated that they would
be unwilling to work on a job with someone with depres-
sion; 62% expressed unwillingness to work with a person
with schizophrenia. In addition, a strong tendency to
associate mental illness with violence was apparent.
One-third indicated a belief that those with major depres-
sion were likely to be violent toward others; 60% expected
violence from someone with schizophrenia. Furthermore,
the researchers found relatively little change when they
compared the 2006 results with those obtained from the
same survey done 10 years earlier. Fear of those with a
psychiatric disorder and a reluctance to engage them in
social activities remained, despite the many known efforts
to improve public understanding that occurred during the
decade between surveys.
It is also noteworthy that scientific progress in under-
standing the possible biological and genetic contributions
to psychiatric disorders does not necessarily lead to a
reduction in the above kinds of response to people with
psychiatric disorders. Phelan [2] noted the possibility that
genetic explanations could maintain social rejection by
strengthening the view that those with psychiatric disor-
ders are ‘defective’ and by decreasing optimism about the
potential for full recovery. Subsequent research has sup-
ported such concerns, revealing more negative than posi-
tive effects on social acceptance with biogenetic models of
mental illness [3,4].
Survey and attitude findings, however, do not capture
the actual experience of people with mental illnesses. An
increasing number of studies have attempted to document
those life experiences, and such studies verify that stigma
is a significant ongoing obstacle to recovery. Surveying
over 1400 people with mental illness diagnoses about their
experiences of stigma, and following up with interviews of
100 of the survey respondents, Wahl [5] found many com-
mon and troubling experiences. Social rejection, for exam-
ple, was a frequently reported occurrence. Individuals with
mental illnesses reported that others avoided them once
their psychiatric disorder or mental health treatment was
disclosed. Friends, they said, stopped calling, neighbors’
visits decreased and social invitations declined, all contrib-
uting to an increased sense of isolation and alienation from
their communities. Furthermore, Thornicroft and his col-
leagues [6] established that these kinds of experience occur
worldwide. Using a standardized survey instrument, these
researchers found consistent stigma experiences across
27 countries. The most common area of problematic
experience involved making and keeping friends, and
negotiating sexual or intimate relationships.
Wahl’s survey respondents also reported being devalued
and diminished once their mental disorder was known.
They described how others no longer placed the same value
on their opinions or their abilities, treated them as less
competent and relegated them to less important roles at
home and work. Strong opinions or emotions were unheed-
ed and instead assumed to be simply manifestations of
cognitive impairment or emotional loss of control as a
result of psychiatric illness. Thornicroft [7] has described
how care providers often discourage those with mental
illnesses from pursuing employment or education with
well-intended protectiveness that nevertheless conveys a
message of pessimism and expected incompetence.
Wahl [5] also noted the experience of what he called
‘indirect stigma’. Individuals with mental illnesses may
not be the object of direct attention or rejection but wit-
nesses to events, statements and depictions that convey
negative attitudes about people with diagnoses such as
their own. Persons with psychiatric disorders are often in
the audience when films, television programs and news
stories portray them as dangerous villains, when mental
illness is presented as a source of humor and ridicule, and
when slang references to ‘nuts’ and ‘psychos’ are tolerated
in ways that slang terms would not be for other serious
disorders [8]. The messages that abound in the community
about mental illness are seldom flattering or encouraging
for those living with such illnesses.
Forum: Science & Society
Corresponding author: Wahl, O.F. (owahl@hartford.edu).
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Author's personal copy
One consequence of encountering the above messages
and behaviors is that those with psychiatric illnesses may
be reluctant to seek needed treatment [9]. They avoid the
expected rejections by avoiding the treatment that will
expose them to such rejection and devaluation. Research
suggests that perceived stigma is also associated with
lower treatment adherence [10], as people attempt to
distance themselves from the labels that mark them for
social exclusion. Thus, many people are unable to benefit
from the treatment advances that occur. Moreover, many
of those who choose treatment will then worry about what
will happen if others discover their psychiatric status. As
participants in Wahl’s [5] survey indicated, they live with
anxiety about potential rejection, struggle with decisions
about when and to whom to disclose their psychiatric
status, and experience discomfort, shame and loss of
self-esteem as they work to maintain the secret of their
mental illness. As Link [11] noted, they will live with
chronic stress that undermines both their mental and
physical health.
Researchers and advocates have also described the
common experience of discrimination for people with psy-
chiatric diagnoses [5,7,9]. An applicant with a history of a
psychiatric disorder or treatment is less likely to be offered
ajob,berentedanapartment,orbeadmittedtoaprofes-
sional school than someone without such a history. As with
stigma, these kinds of discrimination experience were
reported in all the countries included in Thornicroft’s
studies [6]. Such discrimination, as Link [11] has ob-
served, leads to an unequal distribution of ‘life chances’
and adds the obstacles of unemployment, poverty and even
homelessness to the challenge of recovery. In some places,
there exist official policies that further marginalize citi-
zens with mental illnesses. What has been termed ‘struc-
tural discrimination’, includes limits on obtaining a
driver’s license, passport, or even voting privileges
[7,9,12], making full participation in one’s community
more difficult and undermining a sense of connection or
personal value.
Many with psychiatric disorders also experience an
internal acceptance of negative views about mental illness
and, thus, about themselves, through what has been called
‘self-stigma’ [13]. As members of society who have been
exposed to negative attitudes and representations about
mental illnesses before they became ill, individuals may
already harbor unfavorable appraisals of those whose
ranks they have joined, with their negative self-appraisals
encouraged further by their firsthand experiences of de-
valuation and rejection. Studies suggest that self-stigma is
widespread among those with psychiatric conditions. For
example, Brohan and colleagues [14] found that 42% of
survey respondents with schizophrenia across 14 Europe-
an countries reported moderate or high levels of self-
stigma. Self-stigma has been found to contribute to lowered
self-esteem, treatment avoidance, diminished treatment
adherence and increased risk of psychiatric hospitalization
[13,15].
It is likely, then, that those with psychiatric disorders
may have their efforts toward recovery undermined by
social environments that misunderstand and reject them.
Reluctance to seek or adhere to treatment, interpersonal
isolation, chronic stress induced by expectations of rejec-
tion and discrimination that denies needed employment,
housing and societal privileges, as well as undermining of
self-esteem, may all make successful recovery much less
probable regardless of how effective treatments of basic
symptoms may become.
Certainly, one of the ways to promote recovery is to
expand understanding of the biological and genetic roots
of mental illness and to continue to develop treatment
interventions that free people from severe symptoms that
impair their functioning. However, it is also important to
address, and improve, the personal experiences of people
with psychiatric diagnoses. Reduction of discrimination and
stigma, inclusion, encouragement and empowerment are as
important to recovery from mental illnesses as are the
specific treatments that are emerging from bioscience
research.
References
1 Pescosolido, B.A. et al. (2010) ‘A disease like any other’? A decade of
change in public reactions to schizophrenia, depression, and alcohol
dependence. Am. J. Psychiatry 167, 1321–1330
2 Phelan, J.C. (2002) Genetic bases of mental illness –a cure for stigma?
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3 Phelan, J.C. (2005) Geneticization of deviant behavior and
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4 Rusch, N. et al. (2010) Biogenetic models of psychopathology, implicit
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1364-6613/$ –see front matter ß2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.tics.2011.11.002 Trends in Cognitive Sciences, January 2012, Vol. 16, No. 1
Forum: Science & Society Trends in Cognitive Sciences January 2012, Vol. 16, No. 1
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