BRITISH JOURNAL OF PSYCHIATRY (2007), 190, 192^193. doi: 10.1192/bjp.bp.106.025791 EDITORIAL AUTHOR’ S P ROOF

Stigma: ignorance, prejudice or discrimination? IGNORANCE: THE PROBLEM OF KNOWLEDGE , DIANA ROSE, ALIYA KASSAM At a time when there is an unprecedented andNORMAN SARTORIUS volume of information in the public domain, the level of accurate knowledge about mental illnesses (sometimes called ‘mental health literacy’) is meagre (Crisp et aletal, 2005). In a population survey in England, for example, most people (55%) believed that the statement ‘someone who cannot be held responsible for his or her Summary The term stigma refers to these processes are undoubtedly complex, own actions’ describes a person who is problems of knowledge (ignorance), academic writings on stigma (which in mentally ill (Department of Health, 2003). the field of mental health have almost en- Most (63%) thought that fewer than 10% attitudes (prejudice) and behaviour tirely focused upon ) have of the population would experience a (discrimination).Most researchinresearch inthis this area made relatively few connections with legis- mental illness at some time in their lives. has been based on attitude surveys, media lation concerning disability rights policy There is evidence that deliberate interven- representations of mentalillness and (Sayce, 2000) or clinical practice. For ex- tions to improve public knowledge about violence, has only focuseduponfocused upon schizo- ample, legislation such as the Americans depression can be successful, and can re- with Disabilities Act of 1990 in the USA duce the effects of stigmatisation. In a cam- phrenia, has excluded direct participation and the Disability Discrimination Act paign in Australia to increase knowledge by service users, and hasincludedhas included few 1995 in the UK are now being applied about depression and its treatment, some intervention studies.However,studies. However, there is to cases involving mental illness (23% states and territories received an intensive, evidence that interventions to improve of all Disability Discrimination Act cases coordinated programme while others did in the UK). Second, most work on men- not. In the former, people more often public knowledge about mentalillness can tal illness and stigma has been descrip- recognised the features of depression, and be effective.The main challengeinchallengeinfutureis futureis tive, overwhelmingly describing attitude were more likely to support help-seeking toidentify whichinterventions willproduce surveys or the portrayal of mental illness for depression or to accept treatment with behaviour change to reduce discrimination by the media. Little is known about counselling and medication (Jorm et aletal,, against people with mentalillness. effective interventions to reduce stigma. 2005).2005). Third, there have been notably few di- A series of government surveys in Declaration of interest G.T. andandG.T. rect contributions to this literature by England between 1993 and 2003 revealed A.K. undertake stigma-related research service users (Chamberlin, 2005). Fourth, a mixed picture. On one hand there are there has been an underlying pessimism some clear improvements: for example, supported by an educational grant from that stigma is deeply historically rooted the proportion thinking that people with Lundbeck UK Ltd. and difficult to change. This has been mental illness can be easily distinguished Stigma is a mark or sign of disgrace usually one of the reasons for the reluctance to from ‘normal people’ fell from 30% to eliciting negative attitudes to its bearer. If use the results of research in designing 20% (Department of Health, 2003). On attached to a person with a and implementing action plans. Fifth, the other hand, views became significantly it can lead to negative discrimination. It is stigma theories have de-emphasised cul- lessless favourable over this decade for several sometimes but not always related to a lack tural factors and paid little attention to items: for example, the proportion believ- of knowledge about the condition that led issues related to human rights and social ing that residents have nothing to fear from to stigmatisation. There is now a volumi- structures.structures. people coming into their neighbourhood to nous literature on stigma (Link & Phelan, Recently there have been early signs obtain mental health services decreased 2001; Corrigan, 2005), but this has largely of a developing focus upon discrimina- from 70% to 55%. An increase in knowl- been limited to attitude surveys rather than tion. This can be seen as the behavioural edge about mental illness thus does not studies establishing an evidence base of ef- consequences of stigma which act to the necessarily improve either attitudes or be- fective interventions (Sartorius & Schulze, disadvantage of people who are stigma- haviour towards people with mental illness. 2005). Stigma can therefore be seen as an tised (Sayce, 2000). The importance of overarching term that contains three ele- discriminatory behaviour has been clear ments: problems of knowledge (ignorance), for many years in terms of the personal PREJUDICE:PREJUDICE:THE THE PROBLEM OF problems of attitudes (prejudice), and pro- experiences of service users, in terms of NEGATIVE ATTITUDES blems of behaviour (discrimination). devastating effects upon personal relation- ships, parenting and childcare, education, Although the term ‘prejudice’ is used to re- SHORTCOMINGS training, work and housing (Thornicroft, fer to many social groups that experience OF WORK ON STIGMA 2006). Indeed, these voices have said that disadvantage, for example minority ethnic the rejecting behaviour of others may bring groups, it is employed rarely in relation to Five key features have limited the useful- greater disadvantage than the primary people with mental illness. The reactions ness of stigma theories. First, although condition itself. of a host majority to act with prejudice in

192

Downloaded from https://www.cambridge.org/core. 26 Sep 2021 at 19:20:29, subject to the Cambridge Core terms of use. STIGMA

AUTHOR’SAUTHOR’ S PROOFP ROOF

rejecting a minority group usually involve GRAHAM THORNICROFT, PhD, DIANA ROSE, PhD, ALIYA KASSAM, MSc, NORMAN SARTORIUS, PhD, not just negative thoughts but also emotions Institute of Psychiatry,King’s College, London,UK such as anxiety, anger, resentment, hosti- lity, distaste or disgust. In fact, prejudice Correspondence:Correspondence:ProfessorProfessor GrahamThornicroft,HealthGrahamThornicroft,Health Service and Population Research Department, may more strongly predict discrimination Institute of Psychiatry,King’s College London,De CreCrespignyspigny Park,Park,London London SE5 8AF,UK.Tel: +44(0)207 than do stereotypes. 848 0735; fax: +44(0)207 2771462;277 1462; email: g.thornicroft@@iop.kcl.ac.uk Interestingly, there is almost nothing (First received 26 April 2006, final revision 15 September 2006, accepted 27 October 2006) published about emotional reactions to people with mental illness apart from that describing a fear of violence. One fascinat- ing exception to this is work carried out in south-eastern USA, in which students were or behavioural intentions) are congruent illness, and upon adding to our knowledge asked to imagine meeting people who either with actual behaviour, without assessing about interventions that society should did or did not have a diagnosis of schizo- such behaviour directly. Such research has undertake to reduce both stigmatisation phrenia. All three physiological measures generally focused on hypothetical rather and its consequences. of stress (brow muscle tension, palm skin than real situations, neglecting emotions conductance and heart rate) were raised and the social context, thus producing very REFERENCES during imaginary meetings with ‘labelled’ little guidance about interventions that Chamberlin, J. (2005) User/consumer involvement in compared with ‘non-labelled’ individuals. could reduce social rejection. In short, most work on stigma has been beside the point. mental health service delivery. Epidemiologia Psichiatria Such tension also associated with self- Sociale,, 1414,10^14.

reported negative attitudes of stigma to- Corrigan, P. (2005) On the Stigma of Mental Illness.. wards people with schizophrenia. The CONSEQUENCES American Psychological Association. authors concluded that one reason why FOR ACTION Crisp, A., Gelder, M. G., Goddard, E., et aletal (2005) individuals avoid people with mental illness Stigmatization of people with mental illnesses: a follow- is physiological arousal, which is experi- Experience and evidence gained so far indi- up study within the Changing Minds campaign of the Royal College of Psychiatrists.World Psychiatry,, 44,, enced as unpleasant feelings (Graves et aletal,, cates that the time has come to shift the 106^113.106^113. 2005).2005). focus of research and action from stigma Department of Health (2003) Attitudes to Mental to discrimination, Thus, instead of asking Illness 200320 03 Report.DepartmentofHealth.

DISCRIMINATION: an employer whether he or she would hire Graves, R. E., Cassisi, J. E. & Penn, D. L. (2005) THE PROBLEM OF REJECTING a person with mental illness, we should as- Psychophysiological evaluation of stigma towards AND AVOIDANT BEHAVIOUR sess whether he or she actually does. This schizophrenia. Schizophrenia Research,, 7676, 317^327.,317^327. would allow an evaluation of our interven- Jorm, A. F., Christensen, H., & Griffiths, K. M. Attitude and social distance surveys usually tions by measuring whether and how they (2005)(2005) The impact of beyondblue: the national depression initiative on the Australian public’s ask either students or members of the gen- change behaviour towards people with recognition of depression and beliefs about treatments. eral public what they would do in imagin- mental illness, without necessarily assessing Australian and New Zealand Journal of Psychiatry,, 39,, ary situations or what they think ‘most changes of knowledge or feelings. Finally – 248^254. people’ would do, for example, when faced and most importantly – such a shift of focus Link,B.G.&Phelan,J.C.(2001)Link, B. G. & Phelan, J. C. (2001) Conceptualizing with a neighbour or work colleague with would make it possible for people with stigma.stigma. Annual Review of Sociology,, 27,363^385., 363^385. mental illness. Important lessons have mental illness to expect to benefit from re- Sartorius, N. & Schulze, H. (2005) Reducing the flowed from these findings. This work has levant anti-discrimination policies and laws Stigma of Mental Illness. A Report from a Global Programme of the World Psychiatric Association.. emphasised what ‘normal’ people say with- in their country or jurisdiction, on a basis of Cambridge University Press. out exploring the actual experiences of peo- parity with people with physical disabilities Sayce, L. (2000) From Psychiatric Patient to Citizen. ple with mental illness themselves about the (Thornicroft, 2006). In sum, this means Overcoming Discrimination and Social Exclusion..Palgrave. Palgrave. behaviour of normal people toward them. sharpening our focus upon human rights, Thornicroft, G. (2006) Shunned: Discrimination Further, it has been assumed that such upon injustice and discrimination as actu- against People with Mental Illness..Oxford Oxford University statements (usually on knowledge, attitudes ally experienced by people with mental Press.

193

Downloaded from https://www.cambridge.org/core. 26 Sep 2021 at 19:20:29, subject to the Cambridge Core terms of use.