This Handbook is about the stigma associated with mental illness and seeking psychological help. Stigma is defined as a mark of shame associated with a specific condition or characteristic (Goffman, Reference Goffman1963). That mark of shame can lead people to do horrible things to others and themselves. As researchers and mental health professionals, we wanted to do something about that. We wanted to disrupt the processes that cause people to fear, intimidate, and shun or avoid others, and drive people to hate themselves for something they have little, if any, control over. One way we knew to do that is through our expertise as researchers. This book is the culmination of our vision to bring together the state-of-the-science regarding stigma and mental health into an accessible resource. We hope that by organizing this material, we might help future researchers, interventionists, and policy makers to effect change in the lives of millions of people throughout the world. Is it a vision too ambitious? Would it be a vision, if it weren’t ambitious?

The field of stigma research has grown dramatically in the past two decades. In a PsychInfo search on May 27, 2021, we found that there were just under 900 books or journal articles related to mental health stigma published between 1890 and 1999. From 2000 to 2021 that number had mushroomed to over 12,000. In other words, publications on mental health stigma over the past 21 years is almost 15 times greater than in the previous 100 years.

Through this Handbook, we aim to summarize the findings on mental health stigma, which, building on Goffman’s Reference Goffman1963 definition, we define as a mark of disgrace or shame related to having a mental illness or seeking psychological help. This comprehensive, single volume covers the most recent research in the field of mental health stigma and provides researchers and practitioners alike with an invaluable resource to drive stigma research and practice into the next decade. Across chapters, the authors present a review of each area including current research findings, describe consensus in the literature, and provide key questions for future research. Best practices in each area, based on the research findings, are presented. The chapters feature authors from a mix of established, expert voices and rising stars in the field who give their answers to the question: What do we know and where should we go from here?

The target readers of the Handbook are researchers, clinicians, educators, undergraduate and graduate students, policy makers, advocacy groups, and professionals seeking information on current mental health stigma trends and how to intervene to reduce stigma. This is an applied research handbook that draws broadly from professionals seeking to understand, address, and eliminate mental health stigma and increase well-being and utilization of mental health services. Those in many disciplines, including psychology, sociology, anthropology, medicine, nursing, counseling, and social work, may be interested in using this book as assigned reading for a graduate student course or for reference in their own research or practice.

What to Expect in the Cambridge Handbook of Stigma and Mental Health

Stigma can serve to maintain discrimination, oppression, and disparities and to reduce compassion and understanding. The authors of the Handbook’s chapters have taken on the task of changing the impact of stigma and the barriers it creates to living our full lives and from reaching our potential by facilitating a deeper understanding of mental health stigma through answering four important questions: “What are the forms of mental health stigma?”; “What are impacts of mental health stigma?”; “How can we develop interventions to reduce mental health stigma across contexts?”; “How can we understand the specific ways that mental health stigma impacts different groups (e.g., racial minorities, veterans)?” As editors of the Handbook, we are extremely happy with the breadth of work covered across the chapters. We hope that you, the reader, will be inspired by this work and the authors, who have invested much of their professional time in understanding mental health stigma.

The Handbook is divided into four sections. Beginning in Part I (Understanding Stigma and Mental Health), chapter authors explore the different types of mental health stigma and address existing psychological models in the field. For example, in Chapter 2 (Theoretical Models to Understand Stigma of Mental Illness) Lindsay Sheehan, Carlo Vittorio Palermo, and Patrick Corrigan clearly lay out different types of mental illness stigma, including public stigma, self-stigma, associative stigma, and structural stigma, and the key theoretical models underlying our understanding into their development and propagation.

Section I also addresses key aspects related to stigma often missed or only briefly addressed in previous books that heavily focused on the stigma related to having a mental illness, missing significant work that has been done to broaden our understanding of the importance of help-seeking stigma. In Chapter 3 (Disentangling Mental Illness and Help-Seeking Stigmas) Rachel E. Brenner, Maddie M. Egli, and Joseph H. Hammer present a theoretical model that distinguishes between four stigmas related to mental illness and help seeking: (a) public stigma of mental illness, (b) public stigma of seeking help, (c) self-stigma of mental illness, and (d) self-stigma of seeking help. They discuss their most common measurements and how these different stigmas are related to each other and to mental health and help-seeking outcomes. In turn, in Chapter 4 (Measurement of Mental Illness Stigma and Discrimination) Elaine Brohan, Maria Milenov, Ioannis Bakolis, Sara Evans-Lacko, Brandon A. Kohrt, and Graham Thornicroft present up-to-date discussion of the measurement of mental illness stigma and discrimination, highlighting the importance of scale design, local and cross-cultural use, and present suggested directions for future measurement research.

In Part II (Impact of Stigma on Mental Health), authors summarize the current empirical knowledge of mental health stigma. This section includes both reviews and new meta-analyses of the research on mental illness stigma and help-seeking stigma. These reviews focus on the correlates and outcomes associated with mental health stigma, such as psychological well-being and distress, attitudes toward and intentions to seeking psychological help, and other psychological and behavioral outcomes. For example, in Chapter 5 (Time Trends in Public Stigma) Georg Schomerus and Matthias C. Angermeyer report on changes in cultural conceptions of mental illness over the past decade. Their works shows increasing divides between “severe” and “less severe” types of mental illness and provides needed focus for anti-stigma efforts.

Building on this discussion of the changes in the perceptions of stigma over time, Section II also presents recent findings from two meta-analyses examining the effects of self-stigma (how people internalize stigma). In Chapter 6 (Consequences of the Self-Stigma of Mental Illness), Jennifer E. Boyd, Manuel Muñoz López, Clara González-Sanguino, J. Irene Harris, and Isaiah T. Sampson review the key findings of the two meta-analyses and present key similarities and differences in the findings over time. They also start our discussion, taken up further in Section III of the Handbook, on the need to understand the effects of self-stigma on people with a variety of intersectional identities. Then, in Chapter 7 (Self-Stigma of Seeking Help: A Meta-Analysis), Daniel G. Lannin and Jacqueline Bible provide a first-of-its-kind systematic review and meta-analysis on 145 studies into the consequences of help-seeking self-stigma. This key chapter provides compelling evidence into the effects of help-seeking self-stigma on help-seeking attitudes and intentions, decisions to seek online help-seeking information, and future help-seeking behaviors.

A growing research body has also started to distinguish important stigmas unique from mental illness stigma. In Chapter 8 (Stigma and Suicide), Philip J. Batterham, Alison L. Calear, and Ella Kurz discuss the unique measurement, associated demographics and cultural factors, and impacts of suicide stigma (influence on suicidality, depression, and help-seeking) for people with suicide ideation, people who have attempted suicide, and people bereaved by suicide. The authors also provide future directions into understanding the processes by which suicide stigma emerges and how to reduce suicide stigma and prevent suicide. In addition, in Chapter 9 (Intellectual Disability Stigma: The State of the Evidence) Shirli Werner and Katrina Scior discuss research on intellectual disability stigma. Examining the recent work in the area, they discuss the unique aspects of public stigma, professional stigma, self-stigma, and family/affiliate stigma associated with intellectual disabilities and report on stigma change interventions and directions for future research.

Next, in Part III (Stigma and Mental Health in Specific Contexts), authors focus on mental health stigma in specific contexts, discussing implications across culture, gender, age, religion, and sexual orientation. A key factor, often overlooked in mental health stigma research, is the role of intersecting stigmatized identities. People who experience mental illness and consider seeking professional help can also be part of other stigmatized groups. However, current mental health stigma research often ignores the potential effects of discrimination from multiple sources or assumes that stigmatization leads to additive effects on health outcomes. In Chapter 10 (The Intersection of Mental Health Stigma and Marginalized Identities), Courtney Andrysiak, Jennifer Cherry, Jessica Salmonsen, and Lauren Mizock discuss the qualitatively different ways that stigmatized social group identities and structural inequalities can intersect for each person, depending on their visible and invisible identities. Authors of the next two chapters then, specifically, discuss the state of knowledge and future needs in understanding intersectionality of stigmatized identities in ethnic minority populations (Chapter 11, Stigma and Mental Health in Ethnic Minority Populations, Lonnie R. Snowden, Genevieve Graaf, Latocia Keyes, and Amanda Ryan) and among LGBTQ+ populations (Chapter 12, Mental Health Stigma among LGBTQ+ Populations, Carlos A. Vidales and Ashley J. Macbeth).

Building on this, Chapters 13–17 focus on how mental health stigma emerges and plays out for different populations including across cultural groups (Chapter 13, Unpacking Cultural Influences on Stigma of People with Mental Illness between Group-Oriented and Individual-Oriented Cultures, Ben C. L. Yu and Winnie W. S. Mak); for men (Chapter 14, All the World’s a Stage: Men, Masculinity, and Mental Health Stigma, Stephen R. Wester); within the military (Chapter 15, Understanding and Reducing the Stigma of Mental Health Problems and of Treatment among Military Personnel, Thomas W. Britt and Zachary P. Klinefelter); across age cohorts (Chapter 16, Stigma of Seeking Mental Health Services and Related Constructs in Older versus Younger Adults, Corey S. Mackenzie, Nicole Del Rosario, and Melissa Krook); and for individuals from different religious backgrounds (Chapter 17, Stigma and Mental Health in the Abrahamic Religious Traditions, Lily A. Mathison, Russell Jackson, and Nathaniel G. Wade).

In Part IV (Reducing Stigma to Promote Mental Health), the authors provide a synthesis of what we know about the ways to reduce mental health stigma. Specifically, authors review commonly used interventions for both individuals and society and focus on cutting-edge interventions and their effectiveness for helping to increase service utilization. For example, in Chapter 18 (Interventions to Reduce Mental Illness Stigma and Discrimination at the Person-Level for Individuals and Small Groups) Sarah J. Parry, Elaine Brohan, Petra C. Gronholm, and Graham Thornicroft provide the current state of support for social contact and educational anti-mental illness stigma interventions. They also discuss the need to focus on specific target groups and provide the evidence currently known for three such groups – healthcare professionals, police, and students – and low- and middle-income countries (LMIC). In Chapter 19 (Population-Based Interventions to Reduce the Stigma of Mental Illness), Gaia Sampogna, Andrea Fiorillo, Lisa Giannelli, and Claire Henderson expand this discussion to review the population-level approaches to reduce mental illness stigma by presenting some of the recent population-level anti-stigma programs, evaluations of the programs that have been completed, and considerations for population efforts in terms of methods and content.

Subsequently, in Chapter 20 (Interventions to Reduce Help-Seeking Stigma for Mental Health Conditions) Jane Sungmin Hahn, Lina-Jolien Peter, Vanessa Juergensen, Georg Schomerus, and Sarah Evans-Lacko focus on systematic reviews of the interventions to reduce help-seeking stigma (i.e., remove the barriers to seeking help) including discussions of improving mental health literacy, psychoeducation, contact, and resource sharing and recent focus on online help-seeking interventions. Andrew J. Seidman, in Chapter 21 (Self-Affirmation Interventions to Reduce Mental Health Stigma), and Patrick J. Heath, in Chapter 22 (Mindfulness and Self-Compassion Interventions to Address Mental Health Stigma), provide the theoretical and empirical support for two newer and innovative approaches that diversify how we may be able to reduce help-seeking stigma that have been receiving important attention.

Finally, in Chapter 23 (What Is Left to Be Done: Key Points, Future Directions, and New Innovations) we integrate and synthesize the chapters toward a broad understanding of both the current state of our understanding of mental health stigma and important future directions. Specifically, we conclude with a discussion of three broad and key lessons learned from the chapters in the Handbook: the expansion of theories to explain stigma, the intersectionality of stigma, and the effectiveness of interventions to reduce stigma. We then provide three broad areas for future work in this area. These include more explorations into the intersectionality of identities and stigma, further development and testing of interventions to reduce different forms of stigma among different people in different contexts, and an encouragement to push the boundaries of our work with creative and innovative research into new areas of exploration.

What You Should Look for as You Read the Following Chapters

Mental health stigma is a major obstacle to health and wellness (Mejia-Lancheros et al., Reference Mejia-Lancheros, Lachaud and Woodhall-Melnik2021). Findings indicate that negative interactions from others, along with largely negative portrayals of mental illness in the media, lower an individual’s self-esteem and self-efficacy (for discussion, see Corrigan, Reference Corrigan2004). Internalized negative perceptions of mental health issues also appear have a negative impact on mental health and “adjustment and growth” (Mak et al., Reference Mak, Poon, Pun and Cheung2007, p. 256). Concerns about stigmatization also interfere both with the decision to seek help and with the continuing use of services (see Corrigan et al., Reference Corrigan, Druss and Perlick2014). In fact, greater stigma has been linked to lower intention to seek counseling for specific problems (Brenner et al., Reference Brenner, Cornish, Heath, Lannin and Losby2019; Hammer & Vogel, Reference Hammer and Vogel2013; Lannin et al., Reference Lannin, Vogel, Brenner and Tucker2015; Pattyn et al., Reference Pattyn, Verhaeghe, Sercu and Bracke2014), lower rates of accessing online information about mental health and counseling services (Lannin et al., Reference Lannin, Vogel, Brenner, Abraham and Heath2016), and decreased use of services over a two-year period (Seidman et al., Reference Seidman, Lannin, Heath and Vogel2019). It has also been linked with poorer follow-through with therapy (Sirey et al., Reference Sirey, Bruce and Alexopoulos2001a), decreased willingness to return for subsequent counseling sessions (Wade et al., Reference Wade, Post, Cornish, Vogel and Tucker2011), and with early termination of treatment (Sirey et al., Reference Sirey, Bruce and Alexopoulos2001b). Accordingly, there is a clear need to better understand the role of mental health stigma in order to develop interventions designed to overcome these stigmas.

To address these needs, we have attempted to put together a cutting-edge examination of the topic. Importantly, the Handbook also offers important and unique understandings into the different types and possible routes of intervention. We can intervene at the individual, community, family, and societal levels to help people make the most informed and healthy choices for themselves. We believe that psychologists and allied health providers will be more effective at helping people overcome the effects of stigma if they are able to focus their efforts at these different levels.

Of course, no one handbook can cover all topics or perspectives, and so we hope that the current discussions inspire your own interests not only in what we cover but also what we have missed. You may ask yourself:

• “Are there topics not investigated in the Handbook that need to addressed?”

• “Are there stigmatized conditions that have not been covered?”

• “Are there consequences of stigma that have been overlooked?”

For example, although we have a chapter focusing on intersectionality of men and masculinity and mental health stigma, we do not have a separate chapter focused on mental health stigma and gender, or more specifically mental health stigma among women. Mental health stigma and gender are briefly discussed in several chapters (e.g., intersectionality; LGBTQ+), but those who identify as cis-gender women are not discussed at length. This might be both understandable and troubling, as cis-gender women are the single most likely group to seek out mental health services, at least in the United States (Kessler et al., Reference Kessler, Demler and Frank2005). As such, while our goal was to highlight not only what has been done and what needs to be addressed, and we believe the authors have done an excellent job of bringing to light a number of directions in which the field needs to go, we also encourage you as the reader to think about these and other topics and areas that have not been covered in an effort to decide what future work is needed. We hope that asking these questions will stimulate and drive more innovative research in the future.