Open access, freely available online Health in Action The Global Fight against the Stigma of Schizophrenia We must dispel the myths and misunderstandings surrounding this illness Nadia Kadri, Norman Sartorius*

he stigma attached to mental illness is the greatest obstacle Tto the improvement of the lives of people with mental illness and their families [1]. Such stigma results in (1) a lower priority for mental health services, (2) diffi culty getting staff of good quality to work in these services, (3) continuing problems in fi nding employment and housing for people who have had an episode of mental disorder, (4) the social isolation of people who suffer from mental illness and their families, and (5) poorer quality of care for physical illnesses occurring in people diagnosed as having had psychiatric illnesses [1]. These effects of stigma are true for all mental disorders, and in particular, for schizophrenia. The history of the stigmatisation of mental illness is long, but it is probable DOI: 10.1371/journal.pmed.0020136.g001 that intolerance to mental abnormality (and the rejection of people who Figure 1. The Logo of Open the Doors, in Nine Different Languages had it) has become stronger in the past two centuries because of urbanisation and the growing its consequences have been started in as governments, community agents, demands for skills and qualifi cations recent years. Among those well known and health services at all stages of in almost all sectors of employment. are campaigns undertaken in Australia, This, however, is only part of the the United Kingdom, and Sweden—for story: mental illness is also linked to example, “Changing Minds,” an anti- Citation: Kadri N, Sartorius N (2005) The global fi ght stigma campaign, was launched in against the stigma of schizophrenia. PLoS Med 2(7): stigmatisation, discrimination, and e136. intolerance in rural settings and in all 1998 by the United Kingdom Royal College of Psychiatrists (www.rcpsych. Copyright: © 2005 Kadri and Sartorius. This is an countries, regardless of their level of open-access article distributed under the terms industrialisation and sophistication ac.uk/campaigns/cminds/index. of the Creative Commons Attribution License, of labour. Recent studies carried out htm). A major international effort which permits unrestricted use, distribution, and is The Global Programme against reproduction in any medium, provided the original in developing countries confi rm that work is properly cited. this stigma is universal [1]—indeed Stigma and Discrimination Because of it is fair to say that stigma is attached Schizophrenia, launched by the World Nadia Kadri is currently President of the Moroccan Psychiatric Association (WPA) in 1996 Society of Psychiatry and is the Moroccan local to mental illness in different socio- coordinator of the WPA Global Programme against cultural settings throughout the world, [2]. Stigma and Discrimination Because of Schizophrenia. The WPA programme, known Norman Sartorius, previously Director of the Division and that it is growing in strength and of Mental Health of the World Health Organization in its negative consequences. as “Open the Doors” (see www. and President of the WPA, is currently Scientifi c openthedoors.com and Figure 1), Director of the WPA Global Programme against Programmes against Stigma has fi ve important characteristics that Stigma and Discrimination Because of Schizophrenia. A number of programmes to diminish distinguish it from other previously Abbreviation: WPA, World Psychiatric Association developed programmes. First, it is the stigma related to mental illness and Competing Interests: The authors declare that they an international and collaborative have no competing interests. programme. Second, it is conceived The Health in Action section is a forum for individuals as a long-term programme rather *To whom correspondence should be addressed: [email protected] or organizations to highlight their innovative than as a campaign. Third, it involves approaches to a particular health problem. family and patient organisations as well DOI: 10.1371/journal.pmed.0020136

PLoS Medicine | www.plosmedicine.org 0597 July 2005 | Volume 2 | Issue 7 | e136 Box 1. Measures Implemented consequences—the participating sites The sites participating in the by Participating Sites have undertaken studies aimed at a programme are learning from each better understanding of the causes other through contacts, visits, and • provision of information about of stigma, its mechanism of action, the exchange of information. In schizophrenia, through the programme’s and the factors that increase or lessen addition, the programme has identifi ed websites, meetings, books, articles in it [3,4]. Participating sites have also certain strategic directives that have health journals, newspapers, lectures, and implemented an array of measures been incorporated into the rules congresses (Box 1) that were selected taking for new programmes. On the basis • introduction of specifi c legislation or into account the country and its of experience, the key documents rules for the behaviour of selected target specifi cities. of the programme—a step-by-step groups (e.g., health staff in emergency guide on programme development services) Principles Guiding and the manual attached to it—are • organisation of artistic and cultural the Interventions constantly updated and improved. activities Work with patients and relatives. Many of these documents are available on the programme’s website (www. • support for the development of A central priority must be to boost openthedoors.com). (physical) health services for people with patients’ (and families’) self-esteem and mental disorders self-respect. This facilitates patients’ socialisation, their active participation Measuring Success, • introduction of anti-stigma activities in the treatment and rehabilitation Overcoming Obstacles into the training of different types of process, and their motivation for better The success of the WPA programme professionals (e.g., psychiatrists, police personal care. is evaluated at country level and offi cers, teachers) Work with members of the health with direct reference to the targets professions. Emphasis has been placed identifi ed by patients and their on the fact that health workers can families as being particularly the programme, from its planning to do a great deal (as individuals) to important for them. This is being its evaluation. Fourth, it emphasises prevent or diminish stigmatisation by: done by focus group explorations the need for sharing experience and (1) helping their patients maintain of the experiences patients information obtained in the course of self-esteem, (2) developing and and families have had since the the programmes among all concerned, implementing the plan of treatment programme in their country began. within and between countries. Finally, together, (3) being constantly aware of Surveys of attitudes before the and perhaps most importantly, the the danger of labelling, which might programme and during its course programme’s targets are selected on harm their patients, (4) ensuring that have been done in some countries the basis of a process of consultation they have respected their patients’ (e.g., Canada) [6–9]. In addition, with people who have schizophrenia priorities rather then placing these there are general indications of and their families rather than on priorities below those of the health the success of the programme, the basis of theoretical constructs. care system, (5) working with families including the increasingly wide use This means that the targets of the (learning from their experience of programme materials, continuing programmes in different countries and providing them with practical collaboration among the sites, the (and even in different regions of the and useful information), and (6) in number of publications and requests same country) vary. It also means that society, acting as advocates and models for presentation of the programme by the forces uniting the programme are of tolerance and acceptance of people both professional and nonprofessional shared convictions about the principal with mental illness [5]. organisations. A detailed description and overall goals of the programme Work with health authorities. of these matters and references to rather than an imposed and artifi cial Emphasis has been placed on the need publications from the participating uniformity of specifi c short-term to re-examine and improve legislation sites are being published [3]. objectives. and procedures governing the health The main obstacle to success is the The WPA programme has already system to avoid its stigmatising fact that changes in attitudes and involved some 18 countries as follows: potential. behaviour take time. Continuous Austria, Brazil, Canada, Chile, Egypt, Work with journalists and other repetition of action and fi nancial Germany, Greece, India, Italy, Japan, media professionals. Journalists have support have to be maintained over Morocco, Poland, Romania, Slovakia, been engaged in fi ghting stigma years—despite the fact that, in the Spain, Turkey, the UK, and the United through better reporting about mental beginning, anti-stigma programmes States. It is likely that other countries, illness and about people with mental often produce only meagre results. for example Zambia and the Czech illness. In Ireland and the Philippines, Maintaining the motivation of all Republic as well as others, will join it in for example, journalists have been led concerned over many years is very the years to come. by the anti-stigma programme to the diffi cult. The programme also formulation of a voluntary code of non- needs the lasting involvement of all What Has the WPA stigmatising reporting. structures of the health system Programme Achieved? Work with the general public. The (and of other social services), which To reach the main goal of the focus here has been on a change in must see the fi ght against stigma as programme—the reduction or behaviour rather than only a change of one of their permanent and essential elimination of stigma and its attitudes. tasks.

PLoS Medicine | www.plosmedicine.org 0598 July 2005 | Volume 2 | Issue 7 | e136 Conclusion of people with mental illness and their 4. World Psychiatric Association (2002) Open families. Finally, each of us, whether The Doors. The Global Programme to Fight In the descriptions of work done the Stigma and Discrimination Because of in the sites participating in the part of a major programme or alone, Schizophrenia 2002 report. Chicago: World can do something to diminish or avoid Psychiatric Association. 92 p. WPA Global Programme against 5. Sartorius N (1998) Stigma: What can Stigma and Discrimination Because stigmatisation by mental illness. It is psychiatrists do about it? Lancet 352: 1058– of Schizophrenia, there are many just as important to ask what we can 1059. do ourselves to diminish stigmatisation 6. Gaebel W, Baumann A, Witte AM, Zaeske H examples of actions that have (2002) Public attitudes towards people with contributed to the lessening of as it is to urge others to do something mental illness in six German cities: Results of about it. a public survey under special consideration stigma or to the prevention of its of schizophrenia. Eur Arch Psychiatry Clin consequences. These examples Neurosci 252: 278–287. underline the three basic principles References 7. Thompson AH, Stuart H, Bland RC, Arboleda- 1. Pickenhagen A, Sartorius N (2002) The WPA Florez J, Warner R, et al. (2002) World that should be kept in mind when global programme to reduce the stigma and Psychiatric Association. Attitudes about fi ghting stigma. discrimination because of schizophrenia. schizophrenia from the pilot site of the WPA First, the fi ght against stigma is Annotated Bibliography. Available: http:⁄⁄www. worldwide campaign against the stigma openthedoors.com/english/media/ of schizophrenia. Soc Psychiatry Psychiatr a priority because stigmatisation is Bibliography.pdf. Accessed 25 March 2005. Epidemiol 37: 475–482. a major obstacle to any progress in 2. Sartorius N (1997) Fighting schizophrenia and 8. Gaebel W, Baumann AE (2003) Interventions the fi eld of mental health. Second, its stigma: A new World Psychiatric Association to reduce the stigma associated with severe educational program. Br J Psychiatry 170: 297. mental illness: Experiences from the Open the programmes against stigma and 3. Sartorius N, Schulze H (2005) Reducing the Doors program in Germany. Can J Psychiatry discrimination should select their stigma of mental illness. A Report from a 48: 657–662. Global Programme of the World Psychiatric 9. Stuart H, Arboleda-Florez J (2001) Community targets and evaluate their success with Association. Cambridge (United Kingdom): attitudes toward people with schizophrenia. the active and concrete involvement Cambridge University Press. In press. Can J Psychiatry 46: 245–252.

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