The author began the book by addressing the public stigma, which is concerned with the particular assumptions that remain and influence people’s impressions of the mentally ill person’s behavior. Although stigma is the general term for the function, it includes stereotyping, discrimination, social rejection, and shame. It is a persistent, widely harmful social phenomenon that persists even when a mentally ill person does not display any signs of abnormal behavior.
The argument is strengthened by discussing Erving Goffman, the sociologist that had codified the term. Goffman stated that stigma influences people across social categories, despite its intersectional connection with other forms of discrimination. The sociologist believed that stigma made clients with mental illness discredited in daily social interactions. He further explained that discredited interactions are when someone is aware of the individual’s psychiatric history and, as a result, is biased by this awareness. The stigma process, according to him, resulted in people moving away from labeling behaviors to labeling individuals. The labels are then linked to several stereotypes concerning what the person with the title is like and what he or she continues to be like. Hence, even if rational, the person’s future actions are viewed through that label’s lens and therefore discredited or “written off.” Some examples of stereotypes put forth by the author were unpredictable, incompetent, and dangerous.
Microaggressions are defined as subtle communication of prejudice toward individuals based on membership in marginalized social groups, and they include communications that transmit rudeness and insensitivity. The three types of microaggressions include assumptions of inferiority, patronization, and subtle behaviors indicating the fear of mental illness (Yanos, 2018). Patronization, in particular, refers to treating mentally ill people like children and talking down to them in a pseudo-protective way. The study of in-community tolerance for microaggressions revealed that community members most commonly endorsed a willingness to use patronizing. The author mentioned that, although offensive, patronizing microaggression could be well-intentioned due to lack of information and negative stereotypes.
Social rejection is another form of behavior from community members toward a person with a mental health condition. This type of overt behavior is often more severe than microaggressions, and unfortunately, almost just as frequent. The author examined a number of studies that explored the extent to which individuals with mental illness self-report that they have been socially rejected. Findings for this study were mixed as some people reported being shunned and discriminated against by friends and neighbors while others said some friends have been supportive.
Furthermore, the author commented on the difficulty of separating reported and intended behaviors, which is necessary for the understanding of the true perception of mentally ill people by society. A scale “Reported and Intended Behaviour” was used to ask people if, in the future, they would be willing to continue a relationship with a mentally ill friend (Yanos, 2018). The limitations of social desirability bias and character assumptions of the respondent base were taken into account. Nevertheless, it was revealed that between 25 and 73% (depending on the country of origin of a respondent) would not wish to continue the friendship.
Hate crimes are the behavioral expression of the stigma that has the highest severity level applied to them. Hate crimes are criminal offenses against a person or property that may result from an offender’s bias against the victim’s membership in a specific group. This form of stigmatizing behavior does not frequently occur because of its severity and illegal status. However, evidence suggests that people with mental illnesses are at considerably increased risk of being victims of crime instead of the general population (Yanos, 2018). The author believes that this increased risk could be linked to the secondary consequences of the stigma, namely poverty and criminal justice involvement of the targeted groups.
Information provided on the extent to which people with severe mental illness experience hate crimes comes from surveys and official reports. Each of these sources has potential issues with identification and analysis due to the reporting difficulties associated with a sensitive topic. Surveys would need the victim of the crime to give a reason for the perpetrator’s motivation, which is not an easy task unless he made it clear what was his motives. Official reports rely heavily on the crime that has been reported, and many crimes go unreported. In addition, most official hate crime reports do not differentiate mental illness from other “mental” disabilities such as intellectual disability.
The author spoke about the workplace discrimination of people with mental illnesses, which is, unfortunately, a frequent occurrence. One of the participants of the study has recalled a story from her period of working as a psychiatric nursing assistant. After revealing her diagnosis, she was refused an interview for a psychiatric nursing course, despite having sufficient work experience and a suitable degree. At first, the Director of Nursing Studies would not tell her why, but after she met her face-to-face, the director admitted it was because of the diagnosis revelation.
The author communicated a study whose main emphasis was on people with mental illnesses who were employed. Nearly a half reported their experiences with workplace discrimination, including discrediting the person’s professional competence, prejudicial treatment in evaluations, lack of advancement, and being forced out (Yanos, 2018). The findings suggest that even though more blatant acts of discrimination are not acted upon, there are many ways to indicate that a work environment is hostile for a mentally ill employee.
In the United States, many forms of discrimination against people with mental health conditions are entirely legal. He noted the five main groups of legal rights restricted based on mental illness, including voting, jury duty, holding office, marriage, and parenting. In 1999 an analysis of the state laws in these areas found that 37 of the 50 states had laws restricting voting rights, 44 restricting jury duty, 24 states restricting the ability to hold political office, and 27 restricting marriage (allowing mental illness as grounds for divorce) and 27 states restricting parenting rights. In some cases, the laws stated that persons had to be found incompetent to restrict their rights. However, in most cases, laws did not specify this, and rights were restricted based on a mental illness diagnosis without a reference to incompetence. Finally, the author empathically stated that the restriction of parental rights is the most disturbing of all rights. He defined the idea of “presumptive neglect” as inherently discriminatory since it is based on the inferiority assumption.
Media institutions also engage in the form of structural stigma reflective of their policies and established practices. The author examined the source that studied the extent to which media institutions are systematically biased toward the confirmation of negative stereotypes in their reports about people with mental illnesses. Studies that examine the content of US and Canadian television in the 70s and 80s have found that 70% of TV characters with mental illnesses have been shown to be violent. The same trend continued in popular literature and newspaper stories, intensifying the already existing prejudices.
A newspaper in the UK reported that they had found evidence that modern articles were less likely to use the terms that equate people with their disorders like “schizophrenic.” However, stigmatizing terms such as madman, maniac monster, nutter, psycho, and schizo are still being used and are placed in the headline. The author analyzed a major US tabloid’s content and inferred that the use of such terms is expected. A search in the New Post revealed that they used the term “psycho” in 57 articles, “schizo” in 78 articles, and “madman” in 101 articles during the year (Yanos, 2018). In many of these stories, they used the terms as synonymous with violence, contributing to the harmful pattern once again. The media outlets, in general, are inclined to sensationalize reports that link mental illness to violence and other negative characteristics, as these are often profitable. He emphasizes that many news outlets may focus on negative stories whether or not this helps produce sales and viewership because that is simply done.
Differences in Tolerance for Stigma: Potential Causes
In the final section of the book, the author explains why some people are more accepting of the existing discrimination than others. The key factors include educational level, contact, value-based orientation, and political ideology. Research suggests that the more educated a person is, the less likely they are to endorse negative stereotypes and socially avoid people with mental illness. The more a person gains access to research-based information, the less their beliefs will be influenced by people who are not informed. Although results suggest that providing society with more education about mental illness can reduce stigma, the reduction level is not substantial. Furthermore, some studies have demonstrated that education may only be related to some but not all aspects of the stigma.
Direct contact and personal experience with mentally ill people facilitate access to the authentic perspective, significantly less affected by the prevalent stereotypes. Contact shows the mentally healthy individual understands mentally ill people on a personal level and sees them as independent people with their own talents and strengths. This, however, might not be the case when prejudice is deeply rooted in one’s character and worldview.
Value orientation concerns the complex mix of values attached to the mental illness that has a part in determining whether a person will engage in the stigma. One’s values in this aspect are influenced both by individual attitudes and common cultural norms. The book also examines the link between stigma and race/ethnicity, and national origin. Namely, “tight-knit” immigrant communities with strong collectivist values might be less tolerant of people who “deviate” from expected norms. Individualism and collectivism, and the relationship a person has with their opinion and the opinion of the group also affect the stigma they attach to mental illness.
Finally, a person’s political beliefs might also be a contributing factor to their attitude to the mental health stigma. An individual political perspective is influenced by family members, peers, and other environmental influences from an early age. Researchers focused on two typical practices of political ideology, which include conservativism, which emphasizes tradition and stability, and liberalism, which emphasizes innovation and reform, with moderates sticking to the middle. A sub-type of conservativism, known as right-wing authoritarianism, is considered an indicator of the likely prejudice towards certain groups. Furthermore, research has shown that self-identified conservativism is a persistent predictor of negative stereotypes toward people with a mental health conditions. The author highlighted that most studies on the relationship between political attitudes and stigma simply examined self-reported political identification, demonstrating potentially imperfect sampling.
Yanos, P. (2018). Written off: Mental health stigma and the loss of human potential. Cambridge University Press.