stigma in psychiatry

Introduction
450 million people currently suffer from a mental or neurological disorder, placing these conditions under the leading causes of morbidity and disability worldwide.  Advances in neuroscience, neuro-imaging, genetics and behavioural sciences have greatly improved current understanding and management of these conditions so that most mental and behavioural disorders can be successfully treated.  However, nearly two thirds of those with a known mental disorder never seek help from a health professional, and less than a quarter of those affected actually receive professional treatment.

Stigma is said to be the single most significant barrier to psychiatric patients receiving the care they need. It is a private, public and interpersonal phenomenon that affects every aspect of health care giving and receiving.  The mentally ill are perceived to be dangerous or unpredictable; mental illnesses are viewed as incurable; psychiatric treatments are seen as ineffective or dangerous; treatment centres are thought of as places of horror and abandonment; and mental health professionals are regarded as being mentally abnormal, incompetent, corrupt or evil. Help-seeking behaviour is impeded, psychotropic drugs are viewed with extreme suspicion and rehabilitation is hampered. It impacts negatively on the priority given to mental health, the development and geographical placement of mental health services, the funding made available for research and the attractiveness of the discipline to medical graduates in search of a career. 

Conceptualising stigma
Stigma is derived from a Greek word meaning ‘mark’ which is similar to one meaning ‘to tattoo, prick or puncture’. The original term referred to a sign which was cut or burnt into the body of a slave, traitor or criminal to publicise that there was something unusual or bad about the moral status of the bearer.  It signified a ‘blemished’ person who needed to be avoided, especially in public places.

Current understanding and use of the concept stigma in the social sciences is based on the work of Erving Goffman.  Goffman differentiated between three types of stigma, associated with physical deformity, flawed individual character (including mental disorder), and membership of an objectionable social group. 

The impact and consequences of stigma
Corrigan and Watson describe the impact of stigma as being two-fold, differentiating between public and self-stigma. The former is said to be the reaction of the general public towards the mentally ill, the latter entails the prejudice which the mentally ill internalise.  Both public and self-stigma constitute 3 components: stereotype, prejudice, and discrimination.  Negative beliefs about an individual, group or self (stereotype) may lead to a negative emotional reaction if endorsed (prejudice).  This cognitive and affective response leads in turn to a behavioural reaction (discrimination).

Stigma holds numerous negative consequences for the mentally ill as well as for society as a whole.  Fear of stigma may impede help-seeking, perceived stigma may interfere with adherence to treatment and endorsed stigma may limit the availability of resources and services.  Given that mental illnesses are currently responsible for 12% of the global burden of disease, and expected to reach 15% by the year 2020, society can sorely afford to ignore the cost implications of stigma.

Strategies to tackling stigma
The three approaches proposed to act as change strategies in confronting public stigma are protest, education and contact.

Protest can, for example, be used to dissuade the media from inaccurately representing mental illness and perpetuating negative stereotypes, or to highlight discriminatory behaviours. 

Education programmes involve providing accurate facts and information about mental illness to facilitate informed decision-making.  However, the message and the method of informing needs to be tailored for different diagnoses and target groups. 

Contact with psychiatric patients who lead responsible and productive lives can help to redress stereotypes and reduce negative attitudes. This is particularly so if the contact is regular and takes place in a natural (as opposed to experimental) environment.  However, the quality of the contact is important as bad experiences can increase stigma.

Finally, Norman Sartorius, past president of the WPA, urges mental health professionals to be aware of their own role in the stigmatisation of mental illness and to be actively involved in fighting stigma and discrimination.  A diagnosis of mental illness is in itself stigmatising, and may be a harmful label when used inappropriately.  Side effects of psychotropic medications, such as extrapyramidal signs, may be more potent markers of mental illness than the symptoms of the original diagnosis.   Improved treatment and care of the mentally ill are central to the fight against stigma and discrimination.

Conclusion
Stigma is a negative social process of labelling, discriminating and excluding.  Various theories try to explain the social reasons for stigmatising, some of which explore our evolutionary history and pursuit of genetic self-interest. This may, in some way, explain the power of stigmatisation and emphasise why we should give careful consideration to all the dimensions of this complex phenomenon in order to successfully combat it.  Anti-stigma programmes should acknowledge the multiple facets of stigma, including the role that mental health professionals may play in forming and maintaining the stigma of mental illness.  In the words of the World Health Organization, new understanding has indeed brought new hope and stigma is receiving its due attention on a regional and international level, although much still remains to be done.

“The true solution, of course, to the problem of psychiatric stigmatising, would be the public acceptance,  without shame, of mental disorder.”
(Roy Porter, 2001)

Charmaine Hugo
MHIC
Dept of Psychiatry
University of Stellenbosch
Tel: (021) 938 9229
Fax: (021) 931 4172