Byrne (2000:65) defines stigma as a ‘Sign of disgrace or discredit that sets a person apart from others’. There are different types of stigma:

  • Felt stigma or self stigma
  • Enacted stigma
  • Courtesy stigma
  • Structural discrimination

A less well known type of stigma Associative Stigma has also been described in the literature. This will be discussed in more detail later in this section. While there is a voluminous amount of literature written about stigma generally, many people start with the work of Erving Goffman who wrote a very influential book in 1963 called Stigma: Notes on the management of a spoiled identity. You can read a summary of the book here. While the book is over 50 years old, the concepts that Goffman describes provided a clear understanding of the processes associated with stigma and how stigmatized individuals manage it. In this section we will be concentrating on 'Courtesy Stigma'.

After engagement with these eLearning materials you will:

  • be able to discuss the different types of mental distress based stigma.
  • be able to discuss how courtesy stigma impacts of family and friends of mental health service users.
  • be able to discuss their role in assisting families to manage courtesy stigma
  • be able to utilise the information and links in this section to source additional information to support their understanding of stigma and courtesy stigma.

Courtesy stigma occurs when the family and friends of people who have a mental health problem are also discriminated against because of the stigma associated with mental distress. You can learn more about courtesy stigma by following the Prezzi presentation below:

Introduction to Courtesy Stigma

Many European countries have introduced national anti-stigma campaigns to tackle the stigma associated with mental illness. Borschmann et al (2014) have completed a scoping review of these initiatives which you can read at the following link.

Find out if there is a national anti stigma campaign in your country. If there is, what are the features of the campaign and if there is any evidence that its aims are being realised? If there isn't an anti stigma campaign in your country explore some of initiatives that are available in other countries, for example See Change in Ireland or Time to Change in the United Kingdom. What are the main features of their campaigns and is there any evidence of their success?

Angermeyer et al (2003) conducted focus groups with relatives of people with a diagnosis of schizophrenia. The findings suggest that the participants experienced direct and indirect incidences of stigma.

In the table below you will see the subjective experiences of stigma as perceived by relatives of people with schizophrenia which are described in Angermeyer et al’s (2003) study. Spend some time reviewing the table and consider the question that follows.

Domain Subjective Stigmatisation Experience
Interpersonal interaction Contact with mental health professionals: (a) Lack of interest (b) Inadequate flow of information (c) Deprivation of lay competence (d) Technical language as a means of excluding relatives
Interpersonal interaction Social exclusion and withdrawal: (a) Lack of interest; curiosity, ridicule and gossip (b) Discriminating comments (c) Concealment of illness
Interpersonal interaction Assignment of guilt
Interpersonal interaction Insecurity, lack of knowledge and fear
Structural discrimination (a) Poor quality of mental health care (b) legislation and laws (c) Financial burden (d) Bureaucratic procedures at official authorities (e) Poor performance of health insurance (f) Lack of crisis support facilities (g) Lack of support for self help groups
Public images of mental health (a) Media representation (mostly negative reports about mental illness) (b) Association of mental illness with violence and aggression (c) Ignorance and lack of information (d) Unequal acceptance of mental and physical illness (e) Incomprehensibility of the illness expereince (f) Rejection of mental health facilities in the community (g) Metaphorical use of word 'schizophrenic' (h) Lack of support for self help groups
Access to social roles (a) Difficult access to work and problems with integration at work (b) Problems maintaining an existing relationship (c) Problems with landlords

(Angermeyer et al, 2003 p 595)

Reflective question: The experiences described in the table above are taken from an article published over 12 years ago. Is there evidence from your current mental health practice that some of these experiences still exist?

Below are references to some research articles about families experiences of stigma associated with mental distress. Follow the links to read the abstracts. You may be able to access the full text depending on local copyright laws. The articles will help you understand the experience of courtesy stigma.

Authors Link to article abstract
Angermeyer et al (2003) Courtesy stigma: A focus group study of relatives of schizophrenia patients
Gonzalez-Torres et al (2007) Stigma and discrimination towards people with schizophrenia and their family members. A qualitative study with focus groups
Werner & Heinik (2008) Stigma by association and Alzheimer's disease
Karnieli-Miller et al (2013) Family members' of persons living with a serious mental illness: experiences and efforts to cope with stigma
Girma et al (2014) Public stigma against family members of people with mental illness: findings from the Gilgel Gibe Field Research Center (GGFRC), Southwest Ethiopia

Reflective question: How can mental health nurses and other professionals help families who feel that they are being stigmatised?

Associative stigma and mental health professionals

Another type of stigma that recieves less attention in the research literature is Associative Stigma. This is where mental health professionals are stigmatised because of their chosen role. Halter (2008:20) describes associative stigma as the process of being stigmatized based on a close association with a person with mental illness, typically a family member—as if the family was somehow tainted by the relationship. Similarly, a mental health care worker may also be stigmatized based on a work relationship.

Reflective exercise: Think back to when you decided to pursue a career in mental health. Do you remember receiving any negative reactions from your family, friends or peers? If so, what comments did they make?

Halter (2002) suggests that many of these negative associations are influenced by the media where mental health professionals such as nurses are depicted as custodians who lack compassion. Halter (2002) references Nurse Ratched a character from the highly successful 1975 film 'One Flew over the Cuckoo's Nest' as being central to shaping many peoples perceptions of psychiatric nurses. In addition, the publics lack of understanding about mental health and distress and about what mental health professionals actually do somehow mystifies the public perception of mental health professionals.

Among mental health professionals, there is also some evidence to suggest that they experience lowered levels of professional esteem when compared to other health professionals (Halter 2008).In addition Verhaeghe and Bracke (2012) found that associative stigma was associated with increased depersonalisation and emotional exhaustion as well as decreased job satisfaction. Worryingly, their research also found that in units where levels of associative stigma are reported, service users also experience increased levels of self-stigma and lower client satisfaction.

Managing associative stigma

Changing people's perceptions is very difficult as they are often ingrained into their consciousness and continually reinforced by the media and other sources. Mental health professionals need to be able to challenge negative stereotypes about their roles and also be able to clearly articulate what it is that they do. Many negative stereotypes exist because there is a perception that they are working with 'mad','crazy' and 'dangerous' individuals. Challenging negative perceptions of the people who use the mental health services is crucial not only to diminish stigma generally but also in reducing associative stigma. Mental health professionals are in a key position to carry out this task. Education, clinical supervision, personal and professional development will also help professionals to remain focused and will help to challenge negative self beliefs which may inadvertently diminish compassion for the people that use the service.

The stigma attached to mental distress can be very disabling for those affected. It is essential that mental health professionals recognise that stigma exists for service users and their families. Professionals should be prepared to work through and help individuals to manage the psychosocial impact of mental distress on their lives. This is especially important when working with families as often their needs are overlooked. Strategies to educate and support families at this time are essential to challenge negative perceptions of mental distress.

Angermeyer M., Schulze B. & Dietrich S. (2003) Courtesy stigma: A focus group study of relatives of schizophrenia patients Social Psychiatry and Psychiatric Epidemiology 38 (10), 593 -602.

Borschmann R., Greenberg N., Jones N. & Henderson R. (2014) Campaigns to reduce mental illness stigma in Europe: a scoping review. Die Psychiatrie - Grundlagen und Perspektiven 11 (1), 43 -50.

Byrne P. (2000) Stigma of mental illness and ways of diminishing it. Advances in Psychiatric Treatment 6, 65 -72.

Girma E., Möller-Leimkühler AM., Müller N.,Dehning S., Froeschl G. & Tesfaye M. (2014) Public stigma against family members of people with mental illness: findings from the Gilgel Gibe Field Research Center (GGFRC), Southwest Ethiopia. BMC International Human Rights 14 (2) Available at accessed on the 8th October 2015.

Goffman E. (1963) Stigma: Notes on the management of a spoiled identity. Penguin Books, London.

González-Torres M., Oraa R., Arístegui M., Fernández-Rivas A., Guimon J.(2007)Stigma and discrimination towards people with schizophrenia and their family members. A qualitative study with focus groups. Social Psychiatry and Psychiatric Epidemiology 42 (1), 14 - 23.

Halter M. (2002) Stigma in psychiatric nursing. Perspectives in Psychiatric Nursing 38 (1), 23 -29.

Halter M. (2008) Perceived characteristics of psychiatric nurses: stigma by association. Archives of Psychiatric Nursing 22 (1) 20 -26.

Karnieli-Miller O., Perlick D., Nelson A., Mattias K., Corrigan P. & Roe D. (2008) Family members' of persons living with a serious mental illness: experiences and efforts to cope with stigma. Journal of Mental Health 22 (3), 254 - 262.

Verhaeghe M. & Bracke P. (2012) Associative stigma among mental health professionals: implications for professional and service user well-being. Journal of Health and Social Behavior 53, 17 -32.

Werner P. & Heinik J. (2008)Stigma by association and Alzheimer's disease. Aging and Mental Health 12 (1), 92 -99.

The European Commission support for the production of this publication does not constitute an endorsement of the contents which reflects the views only of the authors, and the Commission cannot be held responsible for any use which may be made of the information contained therein.