Reducing stigma and discrimination: Candidate interventions

What is stigma? The concept of stigma is necessary to develop an understanding of experiences of social exclusion, but it is not sufficient to grasp the whole picture, nor to identify what practical steps need to be taken to promote social inclusion. Stigma consists of three related problems:

Empowerment has been described as the opposite of self-stigmatisation [14]. Policy makers can provide specific financial support for ways in which individuals with mental illness can empower themselves or be empowered. Such specific support might include:

For some people with mental illness, allowance needs to be made at work for their personal requirements. In parallel with the modifications made for people with physical disabilities, people with mental illness-related disabilities may need what are called 'reasonable adjustments' in relation to the anti-discrimination laws. In practice this can include the following measures:

Further, community bodies need to act to promote the social inclusion of people with mental illness. The following initiatives would address discrimination in the workplace and misinformation about mental health issues:

In local communities or health and social care economies initiatives are needed to promote social inclusion of people with mental illness. These are outlined in Table 1.

In national policy a series of changes is necessary that spans government ministries, the non-government and independent sector and service user and professional groups. This is a vision of a long-term attack upon individual and systemic/structural discrimination [6] through a co-ordinated, multi-sectoral programme of action to promote the social inclusion of people with mental illness. Further social marketing approaches, the adaptation of advertising methods for a social good rather than for the consumptions of a commodity, are increasingly often being used [15‐17].

In terms of change needed in mental health systems, several elements are necessary. An example is the development of psychological services designed to support people in or seeking work. Many people with mental illness experience demoralisation, reduced self-esteem, loss of confidence, and sometimes depression [18‐22]. It is therefore likely that support programmes assisting people with mental illness to gain employment will need to assess whether structured psychological treatment is also needed [23‐25]. Second, mental health staff may increasingly see the need to widen their remit from direct treatment provision to also intervening for local populations. Mental health awareness campaigns toward local programmes can be targeted to specific groups [26‐28]. In the anti-stigma network of the World Psychiatric Association (called 'Open the Doors'), for example, such interventions have most often been applied to medical staff, journalists, school children, police, employers and church leaders [29‐33].

Another key target group is healthcare professionals. Consumers surprisingly often relate that their experiences of general healthcare and mental healthcare staff reveal levels of ignorance, prejudice and discrimination that they find deeply distressing. This has been confirmed by studies in Australia, Brazil, Canada, Croatia, England, Malaysia, Spain and Turkey [34‐42]. Based on the principle 'catch them young', several programmes have given anti-stigma interventions to medical students [39, 43‐46]. As is usual in the field of stigma and discrimination, there is more research describing stigma than assessing which interventions are effective. In Japan, one study found that the traditional medical curriculum led to mixed results: students became more accepting of mentally ill people and mental health services, and more optimistic about the outlook with treatment, but there was no impact on their views about how far people with mental illness should have their human rights fully observed [47]. Positive changes in all of these domains were achieved with a one-hour supplementary educational programme [48].

Interestingly, it seems that psychiatrists may not be in the best position to lead such educational programmes. Studies in Switzerland found no overall differences between the general public and psychiatrists in terms of social distance to mentally ill people [49]. Psychiatry itself tries to walk the narrow tightrope between the physical/pharmacological and psychological/social poles [50]. Clinicians who keep contact with people who are unwell, and who selectively stop seeing people who have recovered, may therefore develop a pessimistic view of the outlook for people with mental illnesses [51]. On balance, there is mixed evidence about whether psychiatrists can be seen as stigmatisers or destigmatisers [52]. Mental health nurses have also been found to have both more and less favourable views about people with mental illness than the general public [36]. Interestingly, nurses, like the general population, tend to be more favourable if they have a friend who is mentally ill, i.e. if there is a perceived similarity and equality with the person affected [53].

What, then, should mental health staff do? Direct involvement in the media is a vital route that professionals can use more often, with proper preparation and training. They also need to set their own house in order by promoting information within their training curricula, continuing professional development (continuing medical education) and relicensing/revalidation procedures which ensures that they have accurate information, for example, on recovery [54].

Further, practitioners need in future to pay greater attention to what consumers and family members say about their experiences of discrimination, for example in relation to work or housing. Staff can also work directly with consumers to combat social exclusion, for example by opposing repressive or regressive mental health laws [55]. Third, it is clear that consumer groups increasingly seek to change to the terms of engagement between mental health professionals and consumers, and to move from paternalism to negotiation [14]. Vehicles to support shared decision-making include: crisis plans [56] which seem able to reduce the frequency of compulsory treatment [57], advance directives [58], shared care agreements [59] and consumer-held records [60]. The key fact is that many consumers want direct participation in their own care plans [61].

Going into the public advocacy domain, staff in mental health systems may well develop in future a direct campaigning role. A practical approach is for local and national agencies to set aside their differences and to find common cause. In various areas, such co-ordinating groups are called forums, peak bodies, alliances or consortia. What they have in common is a recognition that what they can achieve together, in political terms, is greater that their individual impact. Core issues able to unite such coalitions are likely to include parity in funding, the use of disability discrimination laws for people with mental illness-related disabilities, and the recognition of international human rights conventions in practice [62‐65]. The actions needed at a national level are summarised in Table 2.

What action is necessary at the international level? Such contributions, so far removed from the everyday lives of people, may be hardly noticeable unless they are very sharply focussed and coherent. Setting international standards for national polices could be one useful intervention. For example the World Health Organisation (WHO) has published standards to guide countries in producing and revising mental health laws [66]. The standards cover advice on:

At present, 25% of countries worldwide do not have mental health legislation and half of those that do enacted their laws over 15 years ago. Generally, lower income countries are more likely to have older legislation [67].

In the European Union, for example, anti discrimination laws are now mandatory under the Article 13 Directive [68]. Such laws must make illegal all discrimination in the workplace on grounds that include disability, and also set up institutions to enforce these laws. The time is therefore right is share experiences between different countries on how successful such laws have been to reduce discrimination against people with mental illness and to understand more clearly what is required both for new legislation elsewhere and for amendments to existing laws that fall short of their original intentions.

International organisations such as the WHO can also contribute towards better care and less discrimination by indicating the need for national mental health policies and by giving guidance on their content. In 2005, for example, only 62% of countries in the world had a mental health policy [67]. In Europe, health ministers have signed a Mental Health Declaration and Action Plan which sets the following priorities: