Ethics and the stigma of mental illness and addiction

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By Daniel Buchman

Stigma is socially discrediting. It is a complex social and psychological process that is enacted through intersecting individual (e.g., self-stigma), interpersonal (e.g., relationships) and structural (e.g., policies, socio-cultural attitudes, and laws) levels. Sociologists Bruce Link and Jo Phelan state the stigma process involves interrelated elements of separation (i.e., a powerful in-group separates a less-powerful out-group into moral categories of “us and them”), discrimination, status loss, labeling, and stereotyping. Erving Goffman described stigma as a “spoiled identity”, which can remain associated with the person throughout their lives. Some populations tend to be more stigmatized than others, and these groups tend to get sicker, sick more often, and die earlier. Eradicating stigma is of ethical importance.

It is well established that mental illness and addiction are highly stigmatized. People living with mental illnesses are often assumed lazy, unpredictable, and violent, despite research demonstrating otherwise. Addictions are often stigmatized because people in Western societies tend to see substance use in tension with deeply held cultural values of autonomy and self-control – so, people who use substances are likely to be held responsible, blamed, and punished for the consequences of their substance-using behaviours. The use of illegal substances, such as heroin, is more stigmatized than legal substances, such as alcohol. Compare mental illness and addiction with cancer, where people are often not blamed and penalized for developing the disease. Stigma has also led to persistent underfunding of addiction and mental illness research and treatment services.

A wealth of research demonstrates the potential harms of mental illness and addiction stigma, including shame, chronic stress, and social isolation. This can translate into barriers in accessing healthcare, housing, and disclosing symptoms to others. Stigma—and the criminalization of substance use—may cause people to use substances in unsafe ways and discourage people from calling emergency services out of fear of arrest.

Many healthcare professionals hold stigmatizing attitudes toward people living with mental illness and addictions, even though most professionals are well intentioned and want to benefit their patients. People living with mental illness and addiction often report that they feel disrespected by healthcare professionals, experience a lower quality of care, and perceive that they are not taken seriously.

Some scientists, clinicians, policymakers, and consumer groups are advocating for mental illness and addiction to be considered brain diseases as one way to reduce stigma. These groups highlight findings from neuroscience research that suggest a neurobiological basis for these conditions. Advocates argue that a brain disease framing has the potential to reduce stigma and blame because a neurobiological disease is not an individual’s fault. However, some researchers caution that a brain disease framing may inadvertently intensify stigma. These researchers worry that people living with a mental illness or addiction may be considered neurobiologically flawed—a negative marker of deviance attached to the organ most closely linked with personal identity (i.e., the brain). There is a growing body of research on biological explanations of mental illness and addiction that demonstrates this counterintuitive finding.

Changing the mental health landscape

So, how can we reduce stigma? First, we can alter our language. For example, the Canadian Centre on Substance Abuse changed its name to the Canadian Centre on Substance Use and Addiction. The organization stated that avoiding judgmental words (e.g., abuse) could help to reframe discussions about substance use away from morality and criminality toward discussions about health. Additional recommendations include using language that reflects the health nature of these issues, language that promotes recovery, and avoiding slang.  We can also use people-first language. For example, we can say ‘a person living with a diagnosis of schizophrenia’ vs. ‘a schizophrenic’; ‘a person who uses drugs’ vs. ‘an addict’. People are not defined by their diagnosis or condition.

Second, there is some evidence that contact-based educational approaches between people living with mental illness or substance use disorders and more powerful groups (e.g. healthcare professionals) might help reduce stigma by increasing knowledge about these conditions. While the available evidence is promising, more research is needed. We have much to learn from people with lived and living experience of mental illness and addiction.

Reducing stigma at the interpersonal level may only be minimally beneficial. We need to confront stigma in the social structures that reinforce and worsen the stigma of mental illness and addiction, especially for populations who are the least well-off. As a society, we have made great strides in addressing the stigma associated with mental illness and addiction, and there are many anti-stigma efforts underway, but more work needs to be done. With one in five people experiencing a mental illness or an addiction in their lifetime, these issues are common. We don’t talk about it as much as we ought to. If we can eradicate the stigma of mental illness and addiction, it may also have the corresponding benefit of improving health for all.

Daniel Buchman is a Bioethicist at the University Health Network, a Clinician Investigator in the Krembil Brain Institute, an Assistant Professor in the Dalla Lana School of Public Health, and a Member of the University of Toronto Joint Centre for Bioethics.