From intuition- to evidence-based anti-stigma interventions

Corrigan and Watson propose a conceptual framework for the study of the impact of stigma of mental illness which may prove very helpful for both research and planning of anti-stigma interventions. They speak in their paper of mental illness in general. I think that in a next step their model would benefit from the introduction of differentiations for specific mental disorders. Results of population surveys indicate that there are considerable differences with regard to stereotypes: for example, perceived dangerousness poses a particular and even increasing problem for people with schizophrenia, while people with substance use disorders are at the highest risk of being blamed for their disorders (1). These differences are associated with corresponding differences in emotional reactions and the degree of discrimination. For example, the public's desire for social distance appears strongest against people with drug dependence, followed by those with alcohol dependence and schizophrenia, while people with depression and anxiety disorders are met with less rejection (2,3). There may also be some differences with regard to self-stigmatization and stigma coping. To know more about the variation of the stigma components between disorders seems important in order to be able to develop interventions tailored more closely to the actual needs.

In the last paragraph, Corrigan and Watson point out that the research reviewed in their paper examines stigma exclusively at the individual psychological level, mostly ignoring the fact that stigma is inherent in the social structures that make up society. One can only agree with them when they emphasize the need for further research, in view of the extreme scarcity of studies on this subject. The exploration of patients' and relatives' subjective views on stigma by means of focus groups proves to be quite revealing in this respect. Here, a wide range of discriminating experiences due to imbalances and injustices inherent in political decisions and legal regulations are reported (4). As a result of stigma, psychiatry is marginalized in the health care system; less money is allocated to the psychiatric sector than to other medical services. There are laws which directly and overtly discriminate against mentally disordered persons, as well as laws which do not fundamentally differentiate between mentally disordered and somatically ill persons, but where the rules are differently applied, and - in most of the cases - with an adverse result. In addition, legal provisions enacted to protect the rights of mentally disordered persons may include some sections resulting in discrimination (5).

Stimulated by the WPA's Global Program and some other national programs, numerous interventions, all aimed at reducing the stigma of mental illness, have recently been initiated throughout the world. It is my impression that the choice of the actions taken has not unfrequently been guided by personal preferences rather than being based on empirical evidence. Just to give an example: where the stigmatising effect of the psychiatric diagnosis and the fact of being a psychiatric patient is concerned, two opposing strategies can be distinguished: medicalisation and normalisation. Proponents of medicalisation expect to achieve a de-stigmatising effect by integrating psychiatry as much as possible into medicine. They support the application of the medical disease concept to psychiatric disorders and encourage conceiving of mental illness in the same way as of physical illness. They propose a clear delineation between normality and mental illness. Psychiatry is understood as a specialist discipline within medicine. The strategy of 'normalisers' pursues exactly the opposite objective: they distance themselves from medicine. Those favouring this approach avoid calling mental health problems an illness and prefer speaking of a 'crisis'. In their opinion, there is a continuum between normality and mental disorder. They strongly oppose the use of psychiatric diagnoses. Labelling as a psychiatric 'patient' is strictly avoided. Rather, those with mental health problems are called 'clients', 'users', 'psychiatric consumers' (or even 'psychiatric survivors'). Which of the two strategies is more successful in avoiding stigma remains, however, an open question. There is a pressing need for studies evaluating the effects of the various anti-stigma strategies. Corrigan's conceptualisation of the stigma of mental illness may provide a useful framework for such studies.