It's difficult enough to cope with an anxiety disorder without having to cope with other people's ideas of who you are. Yet people with anxiety disorders and other mental conditions continue to be viewed by many Americans as being weak-willed, having a character flaw, or worse-being "crazy," incompetent, or even violent. Such misperceptions are part of the stigma of mental illnesses.

Defined as a mark of shame, disgrace or disapproval that is imposed on people with a mental illness by others, stigma may have many consequences, including rejection by family, broken friendships, low self-esteem or job discrimination. Reversing negative perceptions of anxiety disorders has been a long-term goal of the Anxiety Disorders Association of America. "People with anxiety disorders have in the past been perceived as the 'the worried well,' but this is misleading, anxiety disorders are real illnesses," says Jerilyn Ross, M.A., L.I.C.S.W., President and CEO of the ADAA. "If we say someone is 'just very shy' in social situations or 'is imagining things' when having a panic attack, we stigmatize them as individuals and deny their suffering."

Stigma Hurts
Unfortunately, stigma is still with us in the 21st century. A landmark study by the Indiana Consortium for Mental Health Services Research (ICMHSR) looked at public attitudes toward mental illnesses between 1950-1996 and concluded that, "there is little evidence that the stigma of mental illness has been reduced in contemporary American society." And stigma hurts. That same historical study showed that even in the late '90s, "levels of social rejection remain distressingly high" for people with a mental illness:

•The number of people who associate mental illnesses with antisocial behavior doubled between 1950 and 1996.
•68% would be "definitely" or "probably unwilling" to have someone with a mental illness marry into their family.
• 58% would be "definitely" or "probably unwilling" to work closely on the job with someone with a mental illness.
• 56% would be "definitely" or "probably unwilling" to spend an evening socializing with a person with a mental illness.

But while surveys can be useful in gauging attitudes of society at large, it is the effect of stigma on individual lives that most concerns researchers like Otto F. Wahl, Ph.D., Professor of Psychology at George Mason University in Fairfax, Virginia. "If we are going to truly eradicate stigma, we need to have a more concrete, practical and personalized understanding of its effects-that is, how stigma makes people feel and how it affects treatment and recovery," he says.

Dr. Wahl has collected the experiences of almost 1,400 consumers of mental health services to get a first-hand account of the effect of stigma. The results, compiled in the book Telling is Risky Business: Mental Health Consumers Confront Stigma, demonstrate how deeply some are wounded by stigma (see box, below). For example, the survey revealed that those with a mental illness often or very often avoided telling others that they have a mental illness (47%); worried that others will view them unfavorably (56%); have been treated unfairly (46%); and have been shunned or avoided by others (26%).

In addition to the social effects, stigma can have negative and long-lasting consequences on self-esteem. "Stigma may become internalized, and the individual may come to share the same beliefs as others and view themselves in similarly disparaging ways," says Dr. Wahl. Indeed, stigma can be worse than the illness itself. "There's no doubt many struggle with a double burden-the disabling effects of their condition and the equally disabling effects of prejudice," says Jean Arnold, co-creator of the National Stigma Clearinghouse.

The Role of the Media
The media remain the public's most influential source of information on mental illnesses. Unfortunately, many of the stories and programs we hear and read contain inaccuracies and denigrate those with mental illnesses. "The media, especially television, are a very powerful socializing agent," says Dr. Wahl, who has studied media depiction of mental illnesses. "Because almost every household in America has a television set, everyone-rich, poor, educated, uneducated, urban, rural-gets the same message about mental illnesses. Thus, the negative messages and violent images can become pervasive throughout society."

Negative socialization regarding stigma may begin at an early age. Until 2000, no studies had been published on the mental health content of children's programming. The first, a study of children's television programming in New Zealand and the U.S., concluded "the frequent and casual use of fundamentally disrespectful vocabulary [such as 'nuts,' 'wacko,' and 'freaky' in episodes reviewed] demonstrate for children that such expressions are acceptable or even funny.

Particularly disturbing is the media's perpetuation of the mentally ill as violent and dangerous. "Mental illness is a common theme in movies, television, plays and books," says Ms. Arnold, whose clearinghouse keeps tabs on instances of stigma in the media. "Regrettably, many of those portrayals are extremely negative and skewed toward making people with mental illnesses seem violent." Over 70% of major characters with a mental illness in prime time television dramas are portrayed as violent; more than one fifth are shown as killers. The typical newspaper depiction of individuals with mental illnesses shows them to be psychotic, unemployed, transient, and dangerous-not as happy, productive members of a family or community.

Changing these stereotypes will take time, but Dr. Wahl offers three strategies for the future:
1. educating those responsible for media depictions of mental illnesses, such as screenwriters and news reporters;
2. reaching future writers, editors and producers through training curricula; and
3. engaging in grassroots advocacy to create pressure on media organizations to change media stereotyping.

Making Progress
Not all the news is bad. First, anecdotal and some empirical evidence exists that the media is changing their portrayals of mental illnesses. A 1999 content analysis comparing newspaper coverage of mental illnesses in 1989 and 1999 showed the ratio of negative depictions to positive ones to be 2:1 in 1999, down considerably from a 4:1 ratio in 1989. "However that still means that mental illnesses and people with mental illnesses are being portrayed in a negative light twice as often as a positive one," says Dr. Wahl, one of the study's authors.

Second, on a broader scale, the ICMHSR survey revealed that Americans' understanding of mental illnesses has broadened over the last five decades to encompass a wide range of disorders, including anxiety, depression and substance abuse. The public also sees a combination of factors-life stressors, genetics and chemical imbalances-as the cause of mental illnesses rather than a bad character or bad parenting. "Another positive trend affecting both patients and the public is a hopeful attitude toward recovery, says Jean Arnold. The ICMHSR survey showed that Americans increasingly recognize that mental health problems will improve if treated.

Third, the number of anti-stigma reports, conferences and organizations is on the rise. "There's been more activity on this issue in the last five years than in the previous 20," says Ms. Arnold. "For example, when we started the National Stigma Clearinghouse, there really wasn't any other organization monitoring media coverage of mental illnesses. Now the clearinghouse website has links to 40 different groups that give a high priority to fighting prejudice and discrimination."

Combating Stigma
By its nature, stigma puts people into categories. This conveniently relieves one of the burdens of seeing people as individuals and treating them as such. Thus, fighting stigma is best achieved by personalizing it. This means speaking up about its effects on you as someone with an anxiety disorder, speaking out when you hear incorrect or negative statements, and speaking with others to find common ground for recovery and advocacy efforts (see below, "What You Can Do to Fight Stigma"). "We took this approach in the Clearinghouse," says Ms. Arnold. "For the first time, we gave people a voice and a way to take concrete action. And it's very satisfying indeed to respond to the stigmatizer." Between 1990 and 1996, the Clearinghouse published 64 monthly reports with hundreds of examples of stigma submitted by media watchers. This watchdog function has been taken over by National Alliance of the Mentally Ill's Stigma Alerts program and the National Mental Health Association's Stigma Watch.

Although much of the research conducted on stigma relates to schizophrenia, bipolar disorder and depression, mental health advocates encourage thinking of stigma as an issue that touches all of us. Anxiety disorders, for example, occur very frequently with other psychiatric illnesses, including depression and substance abuse. "Stigma applied to one person or one psychiatric disorder is a stigma applied to everyone with a mental illness," says Ross. "And it's up to each of us to fight it where we can."

For more information on fighting stigma:

•Anxiety Disorders Association of America's Advocacy Center
www.adaa.org

•National Association for the Mentally Ill
www.nami.org

•National Mental Health Association's Stigma Watch
www.nmha.org/newsroom/stigma/index.cfm

•National Mental Health Awareness Campaign
www.nostigma.org

•National Stigma Clearinghouse
http://community-2.webtv.net/stigmanet/STIGMAHOMEPAGE/index.html

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