Health care professionals, along with health care institutions, can play a significant role in combating and reducing stigma. For example, evidence shows that mental illness and substance use services delivered in primary care can reduce stigma and discrimination, as well as human rights violations. Primary care presents a real opportunity to normalize mental  illness and substance use problems because these problems are treated close to clients'  communities by the same health professionals and in the same location as people with other health conditions (WHO & WONCA, 2008).
Given the roles and responsibilities of health professionals, they may be stigmatizers, stigma recipients or powerful agents of de-stigmatization and recovery. Health care practitioners have an opportunity to address key attitudes and behaviours toward people with mental illness and substance use problems and can actively prevent their own prejudice toward them. At the same time, they can ensure that accurate knowledge about mental illness and substance use problems are disseminated and a recovery-based approach is emphasized in the communities they serve, because stigma is often based on misconceptions that lead to blaming clients.

Stigma Concepts and Factors 

Commonly, stigma is defined as negative attitudes (prejudice) and negative behaviour (discrimination)

Stereotypes are efficient knowledge structures that govern understanding of a social group (Augoustinos et al., 1994). They are commonly held standardized and simplified beliefs or conceptions about groups of people based on a learning process and some prior assumptions. The process of labelling people with mental illness and/or substance use problems involves many factors and is multi-determinate over time. The process includes ignorance (Thornicroft et al., 2007) and emotional reactions such as fear, as well as perceived danger (Corrigan, 2002).

Prejudice is an unfavourable opinion or feeling formed beforehand. Some prejudices that are especially problematic include the belief that people with mental illness and substance use problems are dangerous and should be avoided; that they are to blame for their disabilities, which are related to a weak character; that they require authority figures to make decisions for them because they are incompetent; and that they are like children who require parent figures to take care of them (Brockington et al., 1993; Taylor & Dear, 1981).

Discrimination refers to the intentional or unintentional behaviour that acts to the disadvantage of people with mental illness and substance use problems (Sayce, 2000). People with mental disorders are, or can be, particularly vulnerable to abuse and violation of human rights (WHO, 2005). Discrimination against people with these issues takes many forms, affects several fundamental areas of life and is pervasive. Discrimination may occur at an interpersonal level, reflecting a desire for social distance and exclusion. It may also occur at a structural level when people with mental illness and substance use problems are overtly or covertly excluded from public life through a variety of social and institutional means.

There are at least four main types of stigma: public stigma, self-stigma, courtesy stigma and structural stigma (Corrigan, 2004; Goffman, 1963; Stuart, 2005).

  • Public stigma is defined as the public attitudes and beliefs toward people with mental illness and substance use problems and how the public endorses the prejudice and discrimination against them.
  • Self-stigma occurs when members of a stigmatized group internalize public stigma. This judgment decreases self-esteem, self-efficacy and, consequently, confidence in one's future, as the person assumes that he or she does not meet the expectations of others (Link, 2001)
  • Courtesy stigma is defined as the stigma attached to the families or other people who are close to the individual or group that is stigmatized. Courtesy stigma, also known as stigma by association, affects everything and everyone surrounding the person with a mental illness or substance use problem.
  • Structural stigma refers to the way in which policies and practices of private and government institutions intentionally or unintentionally restrict people's opportunities (Corrigan, 2005). The emphasis is on the socio-political forces rather than on processes at the interpersonal level.
Some of the principles that guide the fight against stigma:
  • Stigma around mental health and substance use issues is first a question of human rights violation and social injustice, as well as a public health challenge.
  • Reducing stigma is a shared responsibility—everybody can make a difference. The participation of civil society is essential in achieving the objective of fighting stigma.
  • Changing attitudes about stigma is not enough—it is necessary to also focus on reducing discrimination.
  • Mental health promotion, human rights protection, recovery and wellness should be a Priority to build a sense of promise and hope.
  • Anti-stigma initiatives must be part of a comprehensive long-term process, integrated and co-ordinated with overall mental health promotion and human rights protection strategies.
  • Multi-sectoral approaches, built on existing and new initiatives, are necessary to reduce stigma and prevent negative consequences.
  • Strong political commitment is essential to develop and support comprehensive multisectoral measures and co-ordinated responses.
  • People with mental illness and substance use problems must play a critical role in planning, design, implementation and evaluation of anti-stigma initiatives because they know what it is like to live with mental health and substance use issues and because increasing contact with people who have experienced such issues facilitates a change of attitudes and behaviours among the general population.
  • Specific sub-strategies might be needed to address stigma regarding particular problems.
  • Cultural appropriateness and relevance are necessary to have an impact.
  • Continuous evaluation and research need to be considered.