CLINICAL HANDBOOK OF SCHIZOPHRENIA

Label Avoidance51. Stigma 535Label avoidance refers to individuals’ concealment of their mental illness to avoid beinglabeled “mentally ill”; this may then cause significant harm in their lives. They may decideto avoid the harm of stigma by hiding their mental illness and “staying in the closet.”Coming out of the closet may have negative impacts on personal relationships, housing,career opportunities, and other life goals. Alternatively, individuals may opt to bypass thestigma altogether by denying their group status and avoiding recovery support of communitymental health centers that tag them with labels. In label avoidance, individualsdecide that hiding their mental illness causes less harm than obtaining the recovery supportthat typically leads to the label of mental illness. This type of label avoidance is themost significant way that stigma impedes mental health care–seeking behaviors.Many individuals avoid disclosure of their mental illness to coworkers, friends, family,and community members to escape negative statements that lead to decreased selfesteem,minimized self-efficacy, and increased shame upon themselves and family members.Within this type of label avoidance, protecting the self and one’s social image from harmoutweighs benefits from receiving support that leads to the mental illness label.Self-StigmaIndividuals with mental illness may endorse and demonstrate self-stigma through harmfulself-thoughts and turning negative behaviors inward. As outlined in Figure 51.1, selfstigmaincludes the same components as public stigma, although the components interactdifferently. First, individuals may hear and believe mental illness stereotypes: “People sayI am incompetent because of my illness, and I believe it.” Second, prejudiced individualsagree with and internalize stereotypes: “Because I am incompetent, I believe that I can’taccomplish anything.” Third, discrimination includes individuals reacting to prejudicewith a behavioral response: “I am incompetent, so I’m not going to apply for that job.”Just like public stigma, self-stigma negatively impacts many aspects of individuals’lives. Specifically, individuals who engage in self-prejudice and self-discrimination avoidtrying to achieve employment, housing, political, educational, relationship, and healthcare goals. By being continually bombarded publicly with stigmatizing images and behaviors,individuals who endorse these notions may have minimal self-esteem, self-efficacy,and confidence, which may lead to a lack of drive to pursue life goals. Moreover, by internalizingstigma, individuals may believe they are less valued in society.Structural StigmaAt the social level, political, economic, and historical forces create stigmatizing social barriersthat restrict life opportunities for individuals with mental illness. Structural stigmacomprises two levels: institutional policies and social structures. Examples of institutionalpolicies, based on prejudice of leaders, include laws and regulations that discriminateagainst individuals with mental illness. For example, some states maintain laws and administrativerules that restrict the rights of individuals with mental illness in the areas ofjury service, voting, holding public office, marriage, parenting, gun ownership, and professionallicensure. Government entities develop these laws and rules based on the labelof mental illness rather than on the severity of disability resulting from the impact of psychiatricsymptoms on functioning.Structural stigma developed historically through economic and political injusticeswrought by prejudice and discrimination. The essential aspect of structural stigma is notthe intent to stigmatize, but rather the effect of keeping individuals with mental illness in