The roots of stigmatization

Stigma and discrimination of the mentally ill is a complex issue. There is one perspective that I miss in most of the discussions on the topic. Identifying similarities and differences is a general phenomenon in biological systems. Humans as well as all higher animals are always evaluating creatures around them. Males are evaluating other males as well as females and females are evaluating males and females. In the evolutionary development it is apparent that there is a need of evaluation of other creatures around us. Why do we continuously assess others? There are a number of basic issues. Is this somebody to be afraid of, is this a competitor in any respect - competing for mates, competing for status, for resources, is this somebody who will be a burden for you somehow and is this somebody who is disturbing the equilibrium in your group/society? Or is this a possible partner, to mate or to join somehow? This evaluation is a more or less conscious continuously ongoing process and I think this is the basis for the negative stigmatization process finally resulting in discrimination and exclusion of the mentally ill.

So, one important task would be to try to identify which features in people with mental disorders evoke these negative emotions and reactions. It is obvious that a psychotic, badly dressed, bad smelling, aggressive and disturbing person evokes feelings of disgust and fear and runs the risk of discrimination and exclusion. I think we have to find out more precisely what is deviant in a negative way in the appearance and behavior of the many different kinds of mental illnesses and then try to support and as much as possible restore the human dignity of patients suffering from different kinds of disturbances. This we can do through better treatments and better general care in society.

The issue of self-stigmatization is extremely important but has also attracted less attention. Maybe this is as great a problem in the Western world as stigmatization from others. This in turn has probably to do with the cultural perceptions of mental disorders and mental disturbances. This leads into the cultural differences which are observed. Existing research indicates that traditional societies seem to be less stigmatizing and discriminating towards the mentally ill. However, there is stigma even in traditional societies, which is shown in a number of studies. But there are obvious differences regarding stereotypes, prejudices and resulting discrimination. In a recent study of the perception of stigma among family members of individuals with schizophrenia and major affective disorders in rural Ethiopia, only a small proportion "felt that somehow it might be their fault" that their family member had become sick (only 4.5% indicated such a feeling) (1).

How to counteract self-blame and selfstigmatization? The modern society places very much of the responsibility for one's own life on the individual person. Possible ways to counteract self-blame and selfstigmatization would be to increase the knowledge about the causes and the background of mental health problems. The everyday problems people experience are often the effect of a complicated sequence of events for which the individual person is only partly responsible. The responsibility of the individual for his/her own well-being is not unlimited. And, of course, self-stigmatization is also an effect of having a stigmatizing attitude towards others with mental illness. So, it is necessary to work with the general stereotypes and prejudices regarding mental illness in general in society to reduce the risk of both external and self-stigmatization.

Finally I think that the most important way to reduce stigma and discrimination is through improved treatment and care of the mentally ill. The example of epilepsy is encouraging. Since there are effective treatments and these are available for the general population, the perceptions about epilepsy have changed and prejudice and discrimination have decreased considerably. The positive experience of a better community based and integrative care of the mentally retarded is also very promising. When mentally retarded are identified early and given opportunities to develop and to live according to their functional, intellectual and social capacities, their quality of life improves enormously and they are being accepted and included in society in a much more humane way.

So there are a number of promising strategies to combat stigma and discrimination of the mentally ill based on research and experiences from other human ailments causing suffering, stigma and discrimination. The evolutionary basis for assessing and discriminating others, however, means that we have to be very persistent and consequent in our efforts to combat stigma and discrimination.