Year : 2020 | Volume
: 2 | Issue : 3 | Page : 181--183
Fighting Stigma 2020: Synopsis of the Presentation of the Yves Pelicier Prize Lecture at the World Congress of Social Psychiatry, Bucharest, October 2019
Former Director, Mental Health Division, World Health Organization; Former President, World Psychiatric Association; President, Association for the Improvement of Mental Health Programmes, Geneva, Switzerland
President, Association for the Improvement of Mental Health Programmes (AMH)
The United Nations has recently recognized the magnitude and severity of mental health problems and included the need to deal with them among its universal development goals. The main obstacle to achieving these goals is the stigma and discrimination because of mental illness which is still prevailing in all parts of the world. The presentation referred to the excellent programs against stigma that have started in some countries but recognized that in most countries of the world stigma of mental illness is still not effectively tackled. The main reason for this is that the paradigms which have been the basis for national efforts to combat stigma are no longer valid so that progress now depends on developing and applying approaches different from those used so far. The presentation examined the current paradigms of fighting stigma and proposed their replacements.
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Sartorius N. Fighting Stigma 2020: Synopsis of the Presentation of the Yves Pelicier Prize Lecture at the World Congress of Social Psychiatry, Bucharest, October 2019.World Soc Psychiatry 2020;2:181-183
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Sartorius N. Fighting Stigma 2020: Synopsis of the Presentation of the Yves Pelicier Prize Lecture at the World Congress of Social Psychiatry, Bucharest, October 2019. World Soc Psychiatry [serial online] 2020 [cited 2021 Apr 22 ];2:181-183
Available from: https://www.worldsocpsychiatry.org/text.asp?2020/2/3/181/304815
There are good news and bad news about stigma related to mental illness. The bad news is that stigma is still attached to mental illness and to all that touches it – mental health services, psychiatrists and mental health workers, psychotropic medications, families of those suffering from mental illness and other people providing care, institutions in which people with mental illness are treated, and any treatment offered to people who have a mental illness.
The good news is that recent years have seen the development of national and regional programs aiming to reduce stigma in many countries – in Australia, Brazil, Canada, the Czech Republic, Denmark, England, Hong Kong, Germany, Ireland, Japan, The Netherlands, New Zealand, Portugal, Scotland, Singapore, and Wales. In addition, in many countries, there were activities against stigma not necessarily reaching the level of national programs., Awareness of the nefarious effects of stigma has also led international organizations to consider undertaking programs which will counteract or prevent stigma: a notable example is the program to reduce the stigma of mental illness within the secretariat of the United Nations. The representatives of ministries of health of various countries who met recently in London and The Netherlands discussed stigma and ways to reducing it. In Europe, this is not an absolute novelty: during the Greek presidency of the European Union, years ago, fighting stigma has been formally identified as one of the enterprises relevant to all countries of the European Union.
In addition to the contribution which these programs made to mental health care in countries in which they were developed, they also produced a vast amount of experience about program development and techniques which are now available for countries interested in developing anti-stigma programs. What is more, the accumulation of experience permits to re-examine the classical paradigms of work against stigma and reformulate them when necessary.
This reformulation of paradigms or the development of new ways of approaching the fight against stigma is of great importance because of the likelihood that the stigma of mental illness will become even more pernicious in the future, for a variety of reasons. These include the growing distance between people outside of their employment setting and the continuous increase of qualifications necessary to be employed making people with mental illness less likely to get a job and therefore lessened in their own eyes and the eyes of others.
Regrettably, it is not only the diminution of social capital which will increase the importance of stigma and its negative effects. The tendency of many governments to restrict budgetary provision for the promotion of mental health and for the prevention of mental illness in parallel with the tendency of “commodification” of medicine will also add to the probability of stigmatization. The latter – the strategy of evaluation of the desirability or value of any action in terms of its economic effects – will result in a restriction of investment into the care of people with mental illness whose treatment is not as likely to bring economic benefits as the investment into the control or treatment of other diseases. Since there often will be no money to use for treatment, the public will believe that there is no effective treatment which will contribute to their rejection of people with mental illness thought to suffer from illnesses which are not amenable to treatment.
These influences on the field of mental health should be examined in light of social changes which are characterizing modern times and will probably also continue to shape the future of humankind. Among them is the disappearance of the classical family with its obligation of mutual help among members; the waning of the communities (protecting and supporting its members) in the process of rapid urbanization; the replacement of previously important pathways to recognition and fame – such as those of scholarly authority, noble descent, and personal courage – by the single criterion of wealth and capacity to augment it; and what has been called “decivilization” the tendency of governments to cease their support of the societies' feeble and vulnerable members such as the elderly, the disabled, and others whom a civilized society keeps alive and in good hands.
Facing an increased probability that the stigma of mental illness will continue to be present and that its importance might grow, it is useful and timely to examine whether the strategies which we have used in the war against stigma should continue to govern action to reduce or prevent the stigma of mental illness and its nefarious consequences.
One of the central notions of work against stigma is that it should be done in a well-organized manner, following plans based on data obtained in relevant research. There are three problems with this approach: first, in many places in which it would be possible to do something to reduce stigma, there was no previous research on stigma relevant matters; second, in some instances, research has been done, but its results are of a general nature and do not give guidance for action in a particular locality; third, local research might take time, and when the results are in hand, the willingness of those who would have to carry the program might have disappeared.
The solution to the problem of not having results of locally relevant quantitative research at a time when it would be possible to start a program (e.g., because community leaders or politicians are keen to go ahead or because funds for action can be obtained) is to rely on limited data that can be obtained quickly using qualitative research, for example, ethnographic studies, or simple direct explorations of the experience, attitudes, and motivations of the members of the community in which the program is to be developed.
Another postulate usually employed in the evaluation of success of anti-stigma programs is that the program can be considered as being successful if it led to a change of attitudes of the population to the mentally ill. This postulate fails for two reasons: first, because a change of attitudes of the population does not necessarily lead to action that can help people with a mental illness either during the illness or after it, and second, because the surveys of attitudes are often misleading since they are heavily influenced by the respondents' effort to give answers which are harmonious with prevailing system of values regardless of what they really feel or are ready to do.
The third postulate of work against stigma is that an increase of health literacy will improve attitudes and the behavior of the population. This is rarely true. People who know a great deal about mental illness are often prejudiced and stigmatizing, and those who know nothing or very little about mental illness often help people with mental illness in a selfless and generous way. An important factor affecting the success of health education are prejudices of those who are to be enlightened by knowledge: the rule of selective memory tells us that people remember facts which are in harmony with their prejudice and disregard or forget facts which are not. Thus, before providing facts about mental illness, it is important to know about prejudices and correct them. Providing knowledge once this is done will be useful: providing it before that will reinforce the prejudice and stigmatization. It is thus more appropriate and useful to begin work on health literacy by imparting skills which make it easier to work with people with mental illness (or provide them care): in view of the fact that stigma often carries fear from the person with a mental illness, learning skills which can avert real or imaginary danger is usually easily accepted.
Good intentions and the wish to reduce stigma and make people with mentally ill accepted by the community often find expression in the organization of campaigns, or special events lasting a few days or months. The notion that this will be useful makes people of goodwill invest time and money to organize such interventions. Sometimes, these short-lasting periods of attention to matters concerning mental health and illness are organized once a year for several years. The conviction that this will be useful has in more recent years become weaker and it has become clear that short-lasting campaigns, even if repeated, are not useful unless they are part of a long-term effort in the course of which there are peaks of anti-stigma work performed as part of the routine functioning of the mental health services. If this is not the case, people with mental illness feel even more dejected after the short period (e.g., a mental health week) during which they were shown goodwill and heard about good intention ceases and some other topics receive similar attention.
Another postulate and generally accepted notion is that work against stigma should touch as many persons and communities as possible. Thus, leaders of anti-stigma programs will invest in the production of posters placed in vehicles of public transport or displayed as posters, create and air brief messages during public radio broadcasts, distribute leaflets, and seek other ways to inform the widest possible part of the population. Recent research and experience of major anti-stigma programs showed, however, that these efforts have a very feeble impact and are usually lost in the mass of other information distributed to the general public. Targeting well-defined groups, which are likely to meet and work with mentally ill people, is a far better way of action. For example, working with groups such as policemen, teachers, personnel at reception desks, and midwives allows focusing on specific prejudices and providing information about behavior in particular situations. The effects of such work have been demonstrably successful not only in direct instruction settings but also when the information is provided by way of films, videos, recorded lectures, or discussions.
Thus, in summary, the changes of the postulates of work against stigma would lead to the recommendation that the programs against stigma should be directed at well-defined groups of people and that it should be preceded by an exploration of their views and situations in which they will meet people with mental illness. Work against stigma should not be conducted by campaigns but become a routine part of the program of health services, planned, permanent, and funded like any other vital function of the service. In anti-stigma programs, efforts to increase mental health literacy should follow the acquisition of practical skills enabling people to understand and work with people suffering from mental illness. The goal of anti-stigma programs should be a change of behavior concerning mentally ill people, not only a declaration of changed attitudes. The evaluation of the success of anti-stigma programs should be searched in improvements of laws concerning mental illness, in rates of employment of people with mental illness, in their acceptance in the community, in housing, and opportunities for participation in community life. The ultimate goal of anti-stigma programs should not be that communities tolerate those who are mentally ill but that they include them and treat them as they would any other member of the community.
Stigma remains, for the time being, the main obstacle to the development of mental health services and to the improvement of the fate of people who experience mental illness. It is important to fight against it and use all means possible to prevent it or reduce its consequences. Moreover, it is useful to remember that the first step in all anti-stigma activity was and remains the simple question which we should ask ourselves – Do I accept people with mental illness as I do others? Once the answer to this question is positive, we shall be ready to build programs which will be lasting and effective.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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