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In order to begin this essay it is worth outlining some of the meanings behind the terms 'mental illness' and 'stigma'. Mental illness is a conceptually problematic term as there as different ways of speaking about normal and abnormal behaviour (Pilgrim and Rogers, 1999). It can broadly be described as a type of health problem which affects an individual's thoughts, feelings and the way they interact around other people. It also has a cognitive dimension as it can affect anybody at any time and may be temporary or permanent (Pilgrim, 2005). Scheff (1984) discusses the medicalisation of mental illness, he argues that 'residual deviance' (pg. 36) can refer to the variety of conditions which are held under the umbrella term of mental illness simply because they do not come under any other category, such as criminal. Essentially, any form of unacceptable or deviant behaviour which is not classed in other ways, becomes a form of mental illness. Scheff's approach uses labelling theory to discuss mental health; this is something I will turn to later. Surveys have revealed that the majority of us are acquainted with mental illness and are familiar with it damaging effects either through a friend or relative etc. 15% of us have had a mental health problem ourselves (Layard, 2005). Stigma can be defined as 'the social consequences of negative attributions about a person based upon stereotype. In the case of people with mental health problems, it is presumed that they lack intelligibility and social competence and that they are dangerous' (Pilgrim, 2005, pg 157). Goffman (1963) argued that stigma 'spoils' a person's social identity, it creates a gap between a typical, ordinary social identity which we expect others to have and our real social identity. It disrupts everyday social interaction because 'normal' individuals do not know how to behave with stigmatized individuals and vice versa (pg. 15). Goffman identified three types of stigma, stigma deriving from physical defects or abnormalities, stigma of race and religion and finally 'perceived blemishes of individual character' this includes such things as sexuality, political beliefs and mental health (Goffman, 1963, pg. 14). Goffman's work is very important in discussing the complexities of stigma and discrimination and I plan to use his work throughout this essay. Skinner et al (1995) argue that a hierarchy of stigma exists in which inferior social statuses such as 'prostitute' and 'alcoholic' are ranked. They identified mental illness as being at the bottom of the hierarchy. The stigma of mental illness is different from others because it involves changes in behaviour which attracts negative judgment by others. It makes people wander about an individual's stability and whether they pose a risk to themselves or others (Bury, 2005).
In order to better understand the stigma of mental illness it is necessary to conduct research into the lay views held amongst the public, this includes accounts from people with mental health problems (MHP) who discuss their experiences, and also the views of those without MHP (Pilgrim, 2005). A qualitative study by Dinos et al (2004) which researched the experiences of 46 people with a mental illness revealed that stigma was a major concern to most of the participants. Stigma defines individuals in terms of their mental illness and has the potential to impact on all aspects of life. Goffman (1963) formulated stigma into a 'double perspective', the first is obvious to others and cannot be hidden. He referred to this as 'discrediting'. The second type is 'discreditable' and is not necessarily noticeable to others (pg. 14). With this form the problem is managing personal information, whether this means hiding the fact that they have a mental illness, or hiding the nature and extent of the condition. Dinos et al (2004) found that the management of information was a major problem and 'a potent source of stress, anxiety and further feelings of stigma even in the absence of any direct discrimination' (pg. 176). Some of the patients chose to downplay their illness by telling others it was another type, such as depression. Experiences of stigma were also dependent on the nature of the illness, those with depression and anxiety were more likely to feel stigmatized. While those with schizophrenia and bi-polar disorder were more likely to experience physical and verbal attacks. The effects of stigma can be extremely damaging, individuals may feel 'depersonalized, rejected and disempowered' (Pilgrim, 2005, pg 158). This can lead to isolation and an acceptance of the treatment received as justified. This in turn can cause a further decline in their health (Dinos, et al, 2004).
In terms of lay views of mental health held amongst the public, these are usually ones of distrust and sometimes hostility. Many people hold stereotypical views of mentally ill people in which psychotic behaviour is expected (Pilgrim, 2005). The influence of the media is important here and is something I will turn to later. Attribution theory (Corrigan et al, 2000 and Bury, 2005) can be used to explain stigma and discriminatory practices. It consists of two aspects, 'controllability' and 'stability' the former refers to the extent to which individuals are responsible for their own mental illness and stability refers to whether the illness can improve over time and to what extent. Studies which use attribution theory reveal that many believe that individuals with MHP are to blame for their illness and do not deserve any sympathy. They believe them to be potentially dangerous and should be avoided. Also, they show no optimism about people reaching recovery (Corrigan, et al, 2000). An example of such a study comes from Weiner and colleagues (cited in Corrigan, 2000), they asked 59 students to rate various disability groups according to aspects of controllability and stability, the results revealed that they viewed mental illness much more severely than other illnesses. The widespread stigmatization of mental illness is rooted historically in 'fear of the unknown, our tendency to attack ridicule or laugh at what we don't understand' (Lalani and London, 2006). Since the deinstitutionalization of mental illness and the introduction of care in the community initiatives, this fear of the 'other' has become much more significant as the boundaries between the 'sane' and 'insane' have become blurred. We have a strong need to distance ourselves from things that we fear, therefore the stigma of mental illness is one of panic and hostility.
Having discussed the stigma of mental illness and the perceptions held amongst the population in a little more depth, this leaves the question of how it is culturally constructed. Thoits (1985) discusses how we learn to act and feel through repeated social interaction. Our emotions are governed by the norms of society which we internalize from an early age. 'We know how we should feel in a variety of circumstances e.g. sad at a funeral lively at a party, happy at a wedding, proud on success, angry at an insult and so on.' (pg. 224). Equally, we recognize when our behaviour may be viewed as inappropriate to others and learn to control it. For example, 'big boys don't cry' and 'keep a stiff upper lip' (pg. 224). We have a shared awareness of how we ought to behave in the social world, therefore anybody who breaks these norms is subject to ridicule. Thoits develops a theory which contrasts with Scheff (1984). She argues that self-labelling processes are significant in mental health, as people assess their own behaviour and seek professional help voluntarily. Scheff on the other hand focuses on the involuntary nature of mental health treatment and how people come to be defined as mentally ill; his concern lies with the institutionalization of mental illness.
The perceptions of people with mental illness held by wider society are ones of devaluation and discrimination (Link cited in Gaebel et al, 2006). When a person is labelled as mentally ill, these conceptions become part of his or her sense of self. Labelling theory is useful in understanding the stigma of mental illness. We react to mental illness is a similar way to crime and the criminal. This approach to deviance focuses on the reaction of others in maintaining and amplifying rule breaking or secondary deviance (Marsh et al, 2000). The labelling process can have a detrimental effect on a person's status and identity. Their old identity is discarded and a new 'master status' label takes its place. In the case of the mentally ill individual, his or her condition comes to define who they are, regardless of the other roles they may have (such as parenthood or their job). Their stigmatized role of mentally ill dominates their existence (Marsh et al, 2000 and Pilgrim, 2005). The negative effects of labelling are very clear, research has suggested that employers are less likely to offer jobs to those who have been labelled mentally ill. They are also less likely to be given housing and more likely to have charges made against them for violent crimes. Some studies however, have indicated that labelling has had positive benefits for the individual (Pilgrim, 2005).
The main source of information for the general public about mental illness comes from the mass media. The media have come to represent the beliefs and perceptions of wider society and frequently exaggerate events and portray inaccurate stereotypes of people with MHP. 'There is an unquestioning acceptance in the media of the 'rising toll of killings' as a result of community care' (Dunn, 2002). For example, in the Daily Mail (21 February, 2003) the headline '400 care in the community patients living by murder park' was printed after a woman was found dead in East London. After discovering that a large number of care in the community patients lived near the park, the police and the media assumed she was 'murdered by a deranged psychiatric patient living in the community.' Headlines like this are not uncommon and newspapers consistently present the image of the dangerous, unstable, incurable mental patient (Lalani and London, 2006). Other examples of hard-hitting headlines include 'violent, mad. So doc's set him free. New 'community care scandal' (The Sun, 26 February 2005) and 'Bonkers Bruno locked up' (The Sun, 22 September 2003). Philo (1996) found that two thirds of news coverage made associations between mental illness and violence, but media depictions are not consistent with the facts about mental health and violence. Home office statistics indicate that there is little or no correlation between violence and mental illness. In reality, people with MHP are more likely to be the victims of crime than the perpetrators (Dunn, 2002). There is a lot of empirical evidence to suggest that the media informs us about mental illness and that their depictions are 'characteristically inaccurate and unfavourable (Wahl, 1992, pg. 351). Wahl and Roth (cited in Wahl, 1992) found that mentally ill characters in prime time TV shows lacked a social identity. They were usually single, unemployed and described negatively with adjectives like "aggressive" "confused" and "unpredictable" (pg. 345). Many other studies have produced similar results, with dangerousness and violence being the most common traits of people with MHP. Wahl argues that these portrayals must have an effect on our behaviour and attitudes towards mental illness. Many studies have 'demonstrated that repeated exposure to media stereotypes in general influences conceptions of social reality' (pg. 346). He cites research that demonstrates that heavy viewers of television tend to relate the real world to televisions distorted representations. One study asked students to complete a questionnaire about mental health before and after a viewing of "One flew over the cuckoo's nest" those who saw the film had a less positive view of mental illness than those who hadn't seen it (Wahl, 1992). It is clear then that the overall relationship between the media and the mentally ill 'is not in dispute: it is one of sensationalism, exaggeration and fear mongering' (Lalani and London, 2006). It is important however to mention that not all aspects of the media perpetuate negative stereotypes and it can be a useful tool in tackling discrimination and stigma.
For many people living with a mental illness, the cultural attitudes of fear, hostility and ignorance has contributed to experiences of isolation and social exclusion. A report by the Citizens advice Bureau (CAB, 2003) revealed that most people with a MHP are unemployed and that those who did have jobs end up leaving because their employers convince them that they are unable to cope. Jo, a mental health service user discussed her experiences at work in a report to the mind inquiry (Dunn, 2002 pg. 11) when she informed her boss that she had to see a psychiatrist 'his reaction said it all, as soon as mental illness is mentioned people literally back away from you'. Pilgrim (2005) highlights that people with MHP are three time as likely to be unemployed than those with physical disabilities. This is mainly because of the attitudes of employers and not because of a lack of willingness on the part of the individual (CAB, 2003). There also exists a disincentive to work for those who are in receipt of welfare benefits. For many, their income upon finding work would only increase at a small rate, if it all, and they would lose out on any supplementary benefits such as housing benefits. Further to this is the difficulty in having their benefits reinstated should the job not work out (CAB, 2003). Social exclusion is a complicated and often cyclical process. It can affect a person's access to education, social services and health care. Such limited access to one service can have a knock on effect on others. For example, restricted use of education and training opportunities can sustain unemployment further which in turn contributes to the benefit trap and can of course deepen a person's exclusion and cause a further decline in their health (Dunn, 2002). It is clear then that the social exclusion of people with MHP denies them the basic levels of citizenship, happiness and wealth available to everybody else (Pilgrim, 2005).
To conclude, the stigma of mental illness is based on generalizations about insanity. These stereotypes are constructed through feelings of fear and anxiety over things we do not understand and struggle to relate to. There is no doubt that our views of mental illness are completely ungrounded and are transmitted repeatedly through the mass media, thus reinforcing a distorted image in our collective psyche. Stigma is used to identify and expose something abnormal about an individual (Goffman, 1963). However some are critical of the stigma framework and argue that it is too individualistic. If we study the collective discriminatory practices which cause exclusion for many people with mental illness, such as poverty and labour market disadvantage, then strategies for change may be easier to develop (Pilgrim, 2005). Layard (2005) identified mental health as our biggest social problem. It is not just a major health concern, it is a political issue. With such high numbers of people affected my mental illness, the costs to the economy are significant. Tackling stigmatization is an essential step in improving the lives of those affected. This involves inclusion of groups themselves, as only those with the knowledge and experience cans suggest what is right for them.