Excellent observations Bawo and Mahesh. "Paternalism" is a good descriptor of a situation where, instead of us walking beside the sufferer, finding solutions, offering encourangement, being their cheerleader, we are expected to stand above and be some remote judge of their mental health status. In true healing, we are beside them and believe in them.

I fully agree that stigma is a big problem in the field of mental health.

I come from a former communist country, Romania, where, until 1989, psychiatry until took care of grave cases (e.g. schizophrenia), whilst depression, anxiety etc. were not recognized as problems. Also, psychology and psychotherapy were either banned (the later) or marginalized.

Now, more than twenty years after, we are finally felling a decrease in the level of stigma directed towards mental patients in general, and, in my opinion, especially against depression.

One interesting aspect, which is very present here, but i do not know if it is also encountered in other countries, is the stigma psychiatrists receive from other doctors. This stigma goes so far that sometimes psychiatrists are not even considered doctors anymore or they are considered second hand doctors, as if somehow they have betrayed their profession because they do not deal with a classic illness for which you can order tests and investigations. On a personal note, this is the biggest difference I see between psychiatry and other specialties, as psychiatry is the last "frontier" where the doctor will not make a diagnosis based on numbers, but on his own opinion of the situation of the patient.

Well I can't give you a straightforward answer to your question, but in my opinion nothing has changed significantly. Thus i conclude that all those efforts put in anti-stigma campaigns yield poor results. See for instance trend analyses from Germany (Angermeyer & Matschinger, 2005; British Journal of Psychiatry, 186, 331-334) and the USA (Pescosolido et al., 2010; American Journal of Psychiatry, 167, 1321-1330), where after a decade of anti-stigma programs stigma has in fact even grown within the general population. See also our own work on these issues.

There are many varied ways to combat stigma in mental health. Some seem to show positive results, others do not. Those that show positive results tend to involve direct personal interaction between people who have experienced severe mental health problems and people who provide their care (or others who have not experienced such symptoms). For example, evidence is starting to emerge from the field of mental health advocacy, particularly peer-advocacy, that appears to show a reduction in institutionalised stigma (e.g. Psychiatric professionals - as Radoi mentions above). Educational programmes are also providing evidence of lasting change in behaviour & attitudes. See recent review by Dalky, West J Nurs Res June 2012 vol. 34 no. 4 520-547.

Personally, I'd like to see organisations avoid using the phrase "1 in 4 people experience a mental health problem at some time in their life", because I believe that if we were all a little more honest about what constitutes a mental health problem, we could all own up to having one at some stage or another...albeit perhaps a mild version. That way, people would be better able to relate to more severe mental health problems, thereby reducing stigma & improving help-seeking at an earlier stage, eventually reducing the wider costs associated with mental health problems that go unchecked and become much more severe than they needed to.

Radoi, psychiatrists in my country deal with stigma everyday. When other doctors have relatives with a mental illness, they want you to see them privately. Once their relative is stable, they never want you to talk about it. We are frequently the butt of jokes at college conferences. Senior doctors frown at their children who are medical doctors taking up psychiatry as a specialty. As Karen said, perhaps admitting we are flawed mentally in some degree at some times would help all of us appreciate individuals with severe illness episodes. Do you think changing diagnostic labels will help reduce stigma?

Dear Bawo James,

In Thailand, we have attempted to reduce stigma among psychiatric patients with many strategies after WHO announced in 2000 for mental illness caring that is "STOP Exclusion, Dare to Care". One is to apply and truly undertake a therapeutic use of self to look after all clients and their major caregivers with mutual understanding. Second, we always use a therapeutic communication technique for building up a professional relationships with them. There are many techniques as a tool for psychiatric nurses to deal with the patients which you may already know about that. Third, we conduct some therapeutic groups for both patients and family members in order to sustain good actions and promote self by giving positive reinforcement. Importantly, we must change or promote a positive mind and positive attitude among relatives who become a major caregiver. Since we can not take care the patients at home and not often we pay a home visit for follow up their symptoms and screening.

Last but not the least, as we are Buddhist, and most Thai patients are Buddhist as well so we can apply the Buddhist teachings into our tasks when I provide any nursing care for the clients. We must have self-awareness or self-understanding prior to care them. Self-awareness helps us to perform our roles as a professional nurse who are ready to care and help them by using ourselves as a therapist who communicate with them with a compassion mind and empathy on their thoughts, emotions, and behaviors. We always focus on multidisciplinary teamwork and work together. When we have a trouble in own life, we have to recognize our own emotions correctly and regulate or balance it prior to talk with the clients.

I think this information can help you to get some ideas. Anyway, thank you very much for your kindly consideration to help those suffering people who really need your helping hands with your healthy hearts in the long run in your county.

With High Regards,

Chantrarat Vongareesawat [Ammy]

RN., MSN., Ph.D in Nursing,

A Lecturer at Psychiatric Nursing Department.

Office: Kuakarun Faculty of Nursing,

Navamindradhiraj University.

131/ 5 Khao Rd.,Vajira-Dusit District,

Bangkok 10300. Thailand.

I think that several name changes would help. But hiding behind a label that doesn't mean anything to 99% of the population doesn't help.

I would actually like to see someone try a change in the other direction: name things for what they are: bipolar disorder used to have a very clear name; now it is called something that doesn't mean anything, even to a lot of non psychiatric doctors who have not heard of the change (although i do have to say that it is their fault for not keeping up...).

What I am trying to see is that for people to accept mental illness, they need to understand it. I am not saying it will be easy or it will be fast (I actually estimate that it will require several generations), but seeing as people are most afraid of what they do not understand, I cannot see the reason of us trying to make them understand even less by using complicated names for otherwise clear affections (where is the case of course).

Thank you for the answer, Bawo.

Dear Bawo,

Concerning your question if a different label of mental disorders could reduce stigma, as fas as I know, in Japan or South Korea they changed the label of schizophrenia. I'm not quite sure how it is called now, but you should certainly adress this question to a stigma researcher from there (or consult the respective literature).

I realize your question about stigma is an important one, but my main take on recent mental health interventions in general is that they are superficial at best and ineffective over time, because most of them are pharmacologial in approach. Until we as a mental health field begin seriously addressing the root causes of mental illness (i.e., polypharmacy, substance abuse, heavy metal toxicity, food sensititivities, nutritional deficincies, dehyrdration, PTSD, etc.) and address those causes head-on current modalities will continue to drain the healthcare coffers, fill the prisons, and otherwise standby as we watch an explosion of chronic mental illness in the general population. To me, that is where the stigma rests: we need to be honest about what causes mental illness instead of wasting enormous resources on that which does not heal the patient.

In my opinion, the current strategies to combat the stigma of mental illness is not effective because the patients are still treated with disdain and ridiculed. They are forever labeled as a "crazy person" but no one wants to help them to understand what is wrong with them and what can be done to correct their problem. Another problem we face with the mental health care system is that the marketplace that controls mental health care is concerned primarily with profit, and only secondarily with patients or with quality of care. The marketplace is the wrong solution for problems related to mental health, smoking, and obesity because these conditions are highly profitable. The Hippocratic Oath charges physicians to "do no harm," but practitioners (family and/or psychiatrists) do harm by omission if they do not advise on prevention. Unfortunately, treating a disease is reimbursable but preventing it is not.

While I have yet to transition into the field of mental health, through my studies and observations, I am compelled to answer your question: No, I do not feel as if the current strategies to combat stigma amongst mental illness are effective. I think “terminology” has a huge bearing on stigmatizing. When a majority of people hear/view the conjoining of the terms mental AND illness, they assume the person is “sick” in his/her head. Even as providers of service to the mentally ill, are we not also somewhat guilty of assigning such labels as well? Do we state that we are working with a “schizophrenic” or a “person who has schizophrenia?” Innately, we would want to ward ourselves of any “illnesses” that may infect us. Needless to say, when we label others with “illnesses,” do we really expect others who lack the professional/educational knowledge to desire to be anywhere in close proximity to them? While I have noticed the shift in address from patient to client, client to consumer, and the like; there still exists the stigma amongst persons with mental illnesses, commencing at labeling and trickling down to treatment.

Good comments, all, Patrina. I have been in the education, research, and clinical side of the broader healthcare field for over 35 years. My opinion is that there is stigma resulting from a field that overall has not been very effective in healing the patient, though best efforts with an arbitrarily narrow set of tools are not without robust intent.

As I mentioned above, we continue to deny that schizophrenia, for instance, is a resulting set of behaviors that are consequent to easily found and treated underlying causes, and continue to follow the failed allopathic approach of trying to control behaviors through side effect laden drugs. It just does not work beyond a short-lived timeset, ever.

Address heavy metal accumulations and, in those with that difficulty, along with appropriate counseling (there is the mental component needing counseling, always), and the patient is made well. For others it is severe vitamin deficiencies or a combination of that and food sensitivities (the cell signalling disorders resulting from a processed diet where the individual is virtually starving for organic, bioavailable nutrients is common today), when appropriately addressed always find long term healing.

Others yet from polypharmacy, this great malfeasance of an entire profession, needs our urgent attention. More drugs are never the answer. Our readers may wonder aloud what this has to do with stigma, but these are the stigma that lingers...until we get honest about the causes of the over medicalized "diseases" we treat, we will continue taking the brunt of the skeptics. Taking a drug for a mental illness? How barbaric--a neater "lobotomy", that.

Dear Max,

You have to be kidding:

"As I mentioned above, we continue to deny that schizophrenia, for instance, is a resulting set of behaviors that are consequent to easily found and treated underlying causes"

If it would be that simple then you'd earn a Nobel prize a long time ago. You should consult the literature before you write down such things. We did not find any requisite causal risk factor that adequately explains schizophrenia. If you did so, then you should probably publish your results.

In my opinion changing the names of the diagnosis will not change the stigma. We will simply substitute a new name for the old one and would still feel negative about whatever that denotes mental illness. Awareness, education and exposure are some of the ways that help to combat stigma. However these are not enough, until these measures are also coupled with great deal of compassion

Michael, I am well aware of the literature and have long been concerned at its propensity to diagnose at the symptomatic level without an investigation of causal factors--and hence, the rarity of achieving homeostasis and healing in our patients. Yes, the causal factors are more difficult to find, but they are there.

The Dutch study of the early 1950s is illustrative (do no have the reference with me, but is well known), which first inferred genetic origins (when it's declared genetic, it "explains everything", it seems). But later it was found that deprivation, nutritional deficiencies, heavy metal toxicities (yes,the plagues were more about lead toxicty and weakened immunology of the population than about rats or fleas or viruses), and a host of other factors relevant to WWII, including PSTD, than genetics.

Actually, though, my greater concern is the bi-polar diagnosis, which so often involves the factors I mentioned but rarely mention in the clinical reports. I've taught a good number of clinicians who diagnose and treat these disorders and it is a rare clinician that is checking the factors I mentioned. Hence, an ongoing condition that rarely is healed. I say, search all known underlying contributors, address those and then see what's left over. In my experience, a much healthier, more engaged individual whose own prognosis is "I finally got my life back" is the outcome.

But I will provide another example of where we fall far short as a profession, and that is in the area of Alzheimer's diagnoses and treatment. Here, we find an older adult population where hearing impairment incidence ranges from 45% to 66% (ages 65-90), and where the market penetration of hearing technology is about 20-25%. Yet, the battery for testing of memory and cognitive awareness (typically concluded at the screening level with a verbal test remiscent of the MMSE at 60-65dBSPL @ 3') without so much as a hearing evaluation and correction for those with hearing loss (one metastudy came up with a 92% HL incidence in those diagnosed with AD) and the individual (because they failed the "auditory test" of the MMSE) is prescribed a medication that was brought to market on the fallaceous Amyloid Plaque/Tau theory. Now, I realize this is a large subject to attempt to address in this short space on a busy schedule. But it is intended to be food for thought. We know that un-/under corrected HL causes cognitive and psychosocial behaviors that are impossible to clinically separate from the more organic contributors of AD. The question is why, in the year 2012, we are still disregarding the auditory component in AD diagnosis when it constitutes the proverbial elephant in the living room? Well, for one, the rate of AD diagnoses would plummet, the pharmaceutical model would be exposed as unreliable, and vested interests would take a sizable loss.

As far as a Nobel Prize, any such may come post-humously to the professional who finally brings this more comprehensive approach to the fore in a more enlightened age, but probably not while such is in direct conflict with multibillion dollar interests. But I still say that we have the knowledge base, the tools, and the resources to heal these people. The knowledge base is scattered between a wide range of specialties, the funding of course to address the wide range of considerations is not found in the current reimbursement codes nor in the diagnostic batteries, and the need for a team of allied professionals presents its own practical limitations. But still, at the research and education level, we should be working to bring these modalities together for future beneficiaries of such an approach to healthcare. Inconvenient considerations do not an easy discussion make, I'm afraid, but they beg the question, nonetheless.

Indeed Max, your contributions are quite radical. Perhaps the causal factors you identify would not only implicate mental ill health but physical illnesses as well. Is anything being done about GM foods and renal problems? Like Michael has said if the interventions you suggest have been shown to be consistent in achieving results then standard treatments would have been thrown of the window by now.

In Nigeria, lay persons conceive mental illnesses poorly. You are either restless and poorly co-ordinated or quiet and self absorbed. They rarely grasp diagnostic concepts and it is difficult to implement anti-stigma efforts for a disease that is poorly understood. Ignorance breeds discrimination and stigma

What can be done then? Do we accept that stigma would not go away, but we can only minimize it? Do we reward individuals who have a positive attitude towards the mentally ill? Are patients who are poorly adherent fuelling the fear and consequent stigma? Are persons with mental illness ashamed of associating with others with more severe illness?

A lot of questions. But we need solutions to be culture specific and adapt as society evolves

Great to hear from you, Bawo.

Logic would tell us that if the answers were in front of us like that that we would be doing them, but in reality it matters much whether or not those answers are put to use to the ones who stand to lose or gain, respectively. As it is now, vested interests are tied to the allopathic, compartmentalized approaches of the day that do not work. So, enormous funds are spent for modalities that produce few good results. In fact, the term healing has all but disappeared in modern medicine, supplanted with managing, where the perpetually ill are a conduit of money changing hands, and the healed--often on their own and outside the system--are perceived as the inconvenient adversary.

Yes, the body and mind are one, and what is a mental illness is also a physical one, and vice versa. Studies show, for instance, that up to 77% of depression is caused by inflammation (we find bipolar people wrought with inflammation). So I say, why not address the underlying cause of inflammation (i.e., unhealed injury, unresolved infection, diet, chronic dehydration, diabetes mellitus 2, synovitis, heavy metals, medication effects, substance abuse, sleeplessness) instead of reaching for the Rx pad and adding new problems with the SSRI/SNRIs, etc.? The former solution saves a lot of money, and the latter keeps them coming back so that a perpetual conduit of money continues to change hands. Now, I do not subscribe to a conspiracy of sorts happening here. It is simply ignorance and a lack of incentive (because the money is not behind the efficacious answers to disease, but instead behind the big-money solutions that bring mere temporary relief)---and the economic dynamics behind the whole affair.

I mentioned inflammation. A drug ( a TNF alpha blocker) that I do not believe ever came to market (because it costs a projected price of $8000 [US] per daily dose) claims to reduce inflammation in demented individuals in as little as a half hour. Memory is reportedly restored to remakably higher levels as a result of suppression of the proinflammatory cytokines---now, I can only imagine how much money investors poured into this project--$800 million? 1.2 billion? You can imagine the economic stakeholders' incentive for someone to come along with a humber study showing that EPA-DHA combined with a short-chain pectin does nearly the same thing for a tiny fraction the cost. CRP, Gelactin-3, and A1C scores plummet with the inexpensive approach, and we observe improved mental scores, as well.

So, the march goes on--may never get a Nobel prize, but we see many getting well after years of wandering in the allopathic wilderness of pharmacology and disregard of what is bringing on the schizophrenia/bipolar/serve depression/anxiety/manic (pick a label) mental health disorders that plague them. I say, go gentle, go natural, go counseling, go diet and hydration, and watch our patients blossom. The big money is not in it, but the results are there for anyone th...

One more thing, Bowa, I am well aware of many chronic illnesses that result from GMOs. I would have to look at the findings of any studies implicating GMOs specifically in renal disease--I do recall a GM soy causing cancer and other conditions. Perhaps that is to what you refer. But again, the big money will be in suppressing or ignoring these challenges to the public health, just as it was to the early microwave oven research in the late 1980s that found that microwaving food caused increases of cancer. In truth there is a lot of suppression of the larger trends affecting human health, and though polite society will consider that a radical concept we in the research community need to face these questions fearlessly and honestly.

Indeed, in our work we find developmental autism, acquired schizophrenia, and other abnormalities merely variations on a theme--often arising from identical underlying factors. Trait personality, age of onset (of the causal factor), familial (including genetic), and environmental (the social and physical) provide the tapestry that differentiates individuals.

At one point while training a group of interns, one of them remarked that I see "health in a simpler light than most do". Yes, I see only seven subsets of underlying causes, often hard to detect because they are often subclinical (chronic dehyrdration is mostly subclinical, as are chronic micronutrient deficiencies), and therefore go ignored both in research in practice--both funded by the same vested interests. Think what would happen if all of a sudden it was found that addresing these seven underlying (often subclinical) causes were found to shrink most cancer tumors (they do). Hundreds of thousands of people would be thrown out of work. Investments would crash, the entire economy would be shaken. By virtue of a multitude of self-interests, such a simple solution to the pandemic diseases of the world would not be allowed any more than Leonardo DaVinci's thesis that the Earth revolved around the Sun could be allowed, because it crashed into the accepted dogma of the day. But, that is the why you won't find the $800 million (US) projects filling the gaps in the literature on Chartrand's Thesis that addresing underlying causes resolves serious chronic diseases like cancer, diabetes mellitus II, fibromyalgia, multiple sclerosis, ALS, and host of other "uncurables"--even autism, dsylexia, ADHD at the developmental level.

So, much about little goes on.

Some strategies are effective. See the work of Anthony Jorm and Mental health First Aid. This is about reducing stigma and self-stigma through information. Some useful references:

Anderson, R. J. & Pierce, D. 2012. Assumptions associated with mental health literacy training: Insights from initiatives in rural Australia. Advances in Mental Health, 10.

Corrigan, P. W. & Kleinlein, P. 2005. The impact of mental illness stigma. On the stigma of mental illness: Practical strategies for research and social change. Washington, DC: American Psychological Association.

Jorm, A. F. 2000. Mental health literacy: Public knowledge and beliefs about mental disorders. British Journal of Psychiatry, 177, 396-401.

Kelly, C. M. & Jorm, A. F. 2007. Stigma and mood disorders. Current Opinion in Psychiatry, 20, 13-16.

Thanks, Teresa for bringing us back to the original topic.

In my humble opinion, every country can improve their own style to fight stigma. We can use trans-cultural approach, coz stigma is depended from social culture itself

Society is based on norms. There where always be something or someone or some action that will be stigmatized as abnormal. Even if we lived in a society where difference was accepted as the normal and that anti-stigma was the ultimate ideal... those who do not fit in with our new utopia (those who are intolerant etc) will in turn be outcast in someway - most likely as criminals.

Do norms = social cohesion of a select group of people or just continually cause an unstable system where ideal cannot be reached?

This is not to say that since it is "a part of" or as inevitable as "good and evil" that we shouldn't try to do something about it.

To answer the question we need to understand the function of stigma itself. What purpose does it fill? From that point I believe we can move towards change.

(I think part of the answer is that mental health and difference provoke a fear of the unknown, a fear of a loss of self, a perceived threat on the nature of existence)

From my perspective the problem to solve stigma to mental illness lies in solving our own intolerance (which is dificult) and to solve the intolerance from each of our own societies (which is even more dificult). As I interpretate Nathan closing remark, we fear the difference. Therefore in order to avoid discrimination of patients with mental health problems we must educate the general population to be tolerant and to explain what we know and don´t know about mental illness, I assume that more relevant information leads to better understanding and this will improve our tolerance.

Good question Nathan. What is the purpose or function of stigma? Does it serve to protect the individual or group from harm? (real or imagined). I believe that dangerousness is one construct that engenders stigma the most. Like Teresa has said information could be our most effective tool.

Not all persons who have a mental illness are dangerous. A smaller proportion are dangerous to others. Violence is not even commoner among the mentally ill compared to apparently healthy populations.

The next question is, how much do we as professionals believe this fact?

I believe that prejudice is bad for both patients and professionals ,Os should be better prepared to deal with patients this not be learned in life and also in university education.

I believe that even with a maximum education regarding mental health etc of the varying degrees it can present in the population (ex: undiagnosed, nonvisible disabilities, absence of outward signs in some cases etc) the stigma/fear concept will still exist (hence, why it still exists "in the field") because we are dealing with a deeper philosophical phenomenon of our existence at the root.

On another tangent - part of the issue specifically regarding professionals is that we are part of the larger society and use many of the same discourses, semantics etc when we communicate. We don't have adequate words to accurately represent mental illnesses and what does exist is heavy in historical rhetoric. (We could also go into the issues of translation between different languages and misrepresentation due to incommensurability, culturally-specific disorders etc)

We could also discuss issues with the DSM itself and its greater influences on how mental health is defined and viewed.

Essentially, stigma reflects unequal power relations which results in the exclusion of certain individuals and groups to decision making processes and access to services and resources. Stigma is a process of devaluing and dehumanizing attributes of individuals or groups. It is this discrimination that makes it clearly a human rights issue and in my view, a human rights framework to address stigma could be more successful than the predominant view of "understanding mental illness will reduce stigma".

References to people with psychiatric labels as "flawed" or "ill" individuals drives stigma. It is time to refer to people that live with psychosocial disabilities. It is the interaction of the person with the social barriers in society that results in the psychosocial disability. It is the obligation of all families, communities and state structures to respect the dignity and rights of people with psychosocial disabilities and to provide reasonable accommodation and support. Just as the physically disabled person in a wheelchair can expect lifts and ramps, the blind braille, the deaf sign language, so too can the person with psychosocial disability expect support through understanding, tolerance and if they choose, pharmacological assistance. We need a paradigm shift where people with psychosocial disabilities are fully included and can participate in community life. Barriers need to be removed and the diversity of human life celebrated.

At worst, Stigma and discrimination renders stigmatized people as silent but a human rights paradigm can shift this. Here are the words of the Pan African Network of People with Psychosocial Disabilities Declaration of 2011:

We recognise that people with psychosocial disabilities have been viewed in bad ways, with derogatory words being used to describe us such as mentally disturbed, having unsound minds, idiots, lunatics, imbeciles and many other hurtful labels

We are people first! We have potentials, abilities, talents and each of us can make a great contribution to the world. We in the past, presently and in the future, have, do and will continue to make great contributions if barriers are removed.

We believe in an Africa in which all people are free to be themselves and to be treated with dignity. We are all different, unique and our differences should be appreciated as an issue of diversity. We need all people to embrace this diversity. Diversity is beautiful.

There can be no mental health without our expertise. We are the knowers and yet we remain the untapped resource in mental health care. We are the experts. We want to be listened to and to fully participate in our life decisions. We must be the masters of our life journeys.

We want, like everyone else, to vote. We want to marry, form relationships, have fulfilled family lives, raise children, and be treated as others in the workplace with equal remuneration for equal work.

For as long as others decide for us, we do not have rights. No one can speak for us. We want to speak for ourselves.

We want to be embraced with respect and love.

We are deeply concerned about the extent of suffering experienced by our brothers and sisters on our vast continent. Poverty, human rights violations and psychosocial disability go hand in hand. We know that there can be no dignity where poverty exists. No medicines or sophisticated western technology can eradicate poverty and restore dignity.

The history of psychiatry haunts our present. Our people remain chained and shackled in institutions and by ideas which our colonisers brought to our continent.

We want everyone to acknowledge their participation in calling us names and treating us as lesser beings. These are the barriers to our full enjoyment of life. These barriers are disabling us and these prevent us from fully participating in society.

We wish for a better world in which all people are treated equally, a world where human rights belong to everyone. We invite you to walk beside us. We know where we want to go.

I don´t know about public policy, but I am currently writting an article about the expiriences of parents who had their children in the same classroom with a kid with down's syndrome and how it helped then change their view about mental ilness, if you think it can help you I can share it with you

follow up... it is a pre-shcool enviroment so I couldn't come up with a methology that could asses the kids expirience, but if you have any ideas they are welcomed

What about looking at time spent playing together? It is late now and my brain power is diminished- but I am sure that I have seen studies that have used measures of time spent playing together, based on the premise that "play" is an indication of acceptance, as an indicator.......

Thanx Annie, the problem is that the kid with down's just left the school to go to a "special school", some of the parents read my blog where I was discussing pros and cons of sending kids wid mild inteligence deficit to special schools and they contacted me a few weeks ago becouse they wanted me to writte about their expiriences... what I found interesting is that parents say that through their kids, who had no social preconceptions about mental disease, they learnt a lot about it. As far as I can see, kids were aware that their classmate was different, but no more different than the other classmate that was the only ginger in the class.

Stigma around mental illness must be attacked by a SAMHSA/CMHS leadership calling to the attention of c/s/x, peers, MH/SA stakeholders. It is pervasive. As long as the c/s/x is internalizing the stigma, there will be self-hate and hate. Education, training and a public health marketing campaign similar to what Vanguard Communications, the NEC, DBSA, MHA, SAMHSA/CMHS and others are undertaking works. Weave informed trauma and a person-centered recovery with hope, resiliency and wellness solutions.

An interesting discussion. The following comments aim to support new ways of viewing and tackling the problem of stigma and prejudice against mental illness - while repeating some of your arguments. Fostering mental health literacy might be most effective to change stigmatizing people suffering from mental illness. Research on subjective theories - as implicitly mentioned by Teresa - should include lay people and experts. As scientists we should try - as Nathan suggested - to understand the various functions of prejudices and stigmata. Somehow the discussion omits the respect psychiatrists and psychologists enjoy inspite of stigma. So we could resist the temptation of moralizing too much while instead exploring some of the interesting themes you have mentioned: economic aspects, influences of the actual diagnostic systems and manuals, mental health education and limited access to treatment in some areas vs overdiagnosing in other areas.

I agree, Georg, perhaps the dynamics are different in different countries and reimbursement systems, and that may affect public perceptions markedly. In our multidisciplinary practice (to which my research unit is connected) we find that incoming patients enter disillusioned with the pharmaceutical model of mental healthcare, where their problems only get worse over the long-term. Insurance covers the pharmaceutical approach, but much less so and with tremendous limitations in reimbursement when it covers the immensely more effective counseling and alternative medicine approaches.

The public has been trained, in this scenario, to more readily accept the much riskier pharma model and less that which is paid out of pocket. So, while we go back and forth about the existence of stigma and its discouraging effects on patients getting help for mental health problems, my take is that we ought to be discussing how the unified healthcare field can institute better mind/body-body/mind treatments, outcomes data, and cost/benefit analysis.

Every mental health problem, even those whose genesis derived from abuse, deprivation, or otherwise, carries a treatable physical condition---and likewise physical illnesses carry mental components. My take is that once we embrace the more holistic view that outcomes will markedly rise, and a dissillusioned public will begin to view mental health services in more positive light.

Thank you for your thoughtful contribution.

Interesting Georg that you talk about the respect afforded to some metal health clinicians who work with this group. I have just been teaching in China to assist them to set up mental health community services. One of the major problems there is that mental health nurses are paid less than other nurses and have a very lowly status. This kept coming up. It does seem that the stigma has attached here to the health professionals.

On the one hand, as Max pointed out, dynamics are - probably - different in different countries and cultures, at least to a certain extent. So it might be interesting for you, Teresa, to understand the importance of hierarchy and competetivity in the Chinese society or especial subculture you have been living and working in. Perhaps there are other influences to be taken into account which I could not even think of since I am not familiar with rules, values and traditions in China. My experience in migration research is, that some culture specific aspects unfortunately really are culture specific, so - having my own cultural background - I was not aware of them when starting a project.

On the other hand medical doctors and psychologists seem to be considered as more qualified than nurses in most societies. Still there exist further differences of social prestige that are found in many countries. If we accept that in the near future psychiatrists (and psychiatric nurses) will not have exactly the same social status as heart surgeons (and nurses in heart surgery), we could instead of wasting time with disappointment try to improve our diagnostic and therapeutic tools.

Certainly I would be happy to contribute to more cultural sensivity in psychological testing. And sometimes when I feel somewhat discouraged or even depressed I think this could be my own fault. Both helps to see prejudice and stigma as partly harmful but also as definitely interesting and incompletely understood phenomena.

I do make several observations in Sri Lanka, but I am sure these are relevant for most other settings, too:

1. Stigma originates in relation to mental illnesses.

2. Having a mental illness indicates being stupid, unpredictable and odd.

3. Hence people with a mental illness are seen as being mad.

4. If one is mad, others better stay away from that person as much as they can.

5. Stigma gets generalised to other members of the family of the person with the mental illness, his/ her friends and relatives.

6. Then it gets generalised to other health care providers associated with them, psychiatrists, nurses and so on.

7. Then it gets generalised to geographical locations associated with them, psychiatry ward, clinic, towns with mental hospitals and so on.

very insightful, Mahesh. thank you for posting

Just finished reading this article reporting that mental ill health knowledge is positively correlated with negative stigmatizing attitudes (Loch,A.A.,etal.,The more information,the more negative stigma towards schizophrenia:Brazilian general

population and psychiatristscompared.PsychiatryResearch(2012),http://dx.doi.org/10.1016/j.psychres.2012.11.023). Kinda throws a spanner in the works that improving mental health knowledge might be key to reducing stigma. Psychiatrists were more likely to stigmatize compared to lay persons with mental health knowledge and the group without mental health knowledge being least likely. What do you all think?

I think the stigma is harmful for relationship.The people should be aware of estiga to fight lo.Can be eliminated by learning.The health professionals are ordinary people who are not educated to act without stigmatizing the patients will do it.

I agree totally, Bawa. Our practice is set up for patient education as our first order of business. The more the patient knows the more positive they view mental health diagnoses and treatment. Today, in the US we have the added problem of commercialization of mental health (i.e, TV commercials that equate mourning over loss of a loved one with clinical depression) to draw people into the office of physicians who have not been trained in diagnosing and treating clinical mental conditions instead of directing them to a trained and qualified professional who knows such nuances, and who can differentiate causation. Other ads show the very same medication used in off label uses like for "fibromyalgia" or "restless legs". These kinds of oversimplications and commercialization approaches confuse people who need genuine help.

I think it is now obvious knowledge that giving information, and more information, is not the way to change the attitudes/ behaviours of people. I will read that article and get back to you, Bawo James.

Dr. Jafar Bolhari sent his thoughts as a message to me. He has kindly allowed me to post it.

I do not agree with some comments on the stigma of mental illness. As a 64 year old psychiatrist working in a university in Tehran, Iran, I have had more than 25 years working experience with mentally ill patients. In particular, I do not agree with the statements from Mahesh Rajasuriya. My comments to each statement he made is provided below.

1. Stigma originates in relation to mental illnesses...No, stigma originates in other peoples minds!

2. Having a mental illness indicates being stupid, unpredictable and odd...Others think so!

3. Hence people with a mental illness are seen as being mad...Others try to show they are mad and themselves are not(a narcissistic feeling) !

4. If one is mad, others better stay away from that person as much as they can...Some people do, but not everyone!

5. Stigma gets generalized to other members of the family of the person with the mental illness, his/ her friends and relatives...If we reject the ill person and send him to a mental hospital YES, but it is better we do not do so, and help the family for medical and humanistic therapy.

6. Then it gets generalized to other health care providers associated with them, psychiatrists, nurses and so on...When we provide home care/ therapy nobody is informed about the ill person!

7. Then it gets generalized to geographical locations associated with them, psychiatry ward, clinic, towns with mental hospitals and so on...Yes this is a rationale for developing community and home care for mentally ill patients and closing the mental hospital. This have been done in Italy over 30 years ago and has started in Iran and many countries for many years.

My dear colleagues, the best and low cost way for destigmatization in the world is closing mental hospitals and avoiding to hospitalization and provide home and community care even for severely mentally ill and disturbed one.

With bests,

Jafar Bolhari

Of course, I do agree with Dr. Bolhari. Everything I said above do exist in the mind of people.

However by hiding the mentally ill from the society, and not addressing how we think, which we should do , in my opinion, we make it worse!

Don't we?

We should support community care for other reasons, not to hide discrimination.

Thank you dear Mahesh, so we have same view for stigma, but not on solving this problem. In my openion and based on many literatures decentralizing the hospital care, visiting mentally ill patients in the general hospital or polyclinic or health centres, developing home care/ services, helping people by telephone/ internet counseling, supporting self help group/ peer group for sever mental ill individuals and many other strategies, all are not hiding the mentally ill from the society/ community, but it just is working in the community with patients and family, and is starting a reentry program (CRP: community reentry program by Professor Liberman- UCLA).

Thank you.

But I thought you said "When we provide home care/ therapy nobody is informed about the ill person!" in response to my comment "6. Then it gets generalized to other health care providers associated with them, psychiatrists, nurses and so on."

We see them at home not to hide their status of health. That should not be a reason. Perhaps it is just a desirable or a neutral side effect!

Excellent points--we have found that once a condition has become the subject of reimbursements, paperwork, and interprofessional involved that most patients accept their condition as a "label" (i.e., "I'm bipolar", "I'm clinically depressed", "I'm schizophrenic"). They may not realize that these are temporary conditions symptomatic of abberant behaviors and that, at some point if the mental health professional does their work well, they are no longer these labels. As I have stated above and in other discussions, we have to be ever diligent in searching for underlying causes for the patient's condition and address those so that there is actual "healing" from the condition. It is the institutionalization or imbedment or expectation of reimbursement once the patient is "finally in the system" that the stigma begins for them. Ours is a mission to make sure they are healed, and that they know that, and that the institution and "system" knows that. Otherwise, the financial rewards are to keep them stigmatized.

I think Bawo makes an important point that not only people who suffer from mental illness but those who treat them suffer from stigma. In the UK and I suspect other countries those who treat people with mental health problems are often spoken of in a covertly hostile way. Those who bear the message of suffering are sometimes dismissed or attacked because it is a message that people do not want to hear. In particular, people do not want to hear that the suffering of mental illness is complex and may be difficult to cure. the offering of simple or simplistic solutions for example medicine or therapies that are claimed to be simple (as CBT sometimes is) can make the professional more popular among funders. Conversely explaining the complexity or the difficulty of cure or the possibility that others or society may be responsible for the suffering we call mental illness may make the practitioner less popular and indeed stigmatised.

I think we reduce stigma by engaging with people with mental illness in a true dialogue not presuming that we know what is best for them. They do have the expertise of experience and that should be recognised for what it is (no more no less). I am not a political correctness fan so I do not worry too much about terminology. A good guide is to ask people what they would like to be called or failing that whether we would like the descriptions to be applied to ourselves.

When I am a passenger, I prefer not to be called a customer. Here in the UK peole hate being called "Service Users".

It seems like this conversation is taking a really wonderful turn. A turn that is calling for a serious shift in our thinking.

As mental health professionals we want our system to be prominent, revered and important. Probably at the expense of the well-being of the patient.

I suggest good books to start with are to read 1. Erving Goffman's books titled 'Asylums'. He gives a poignant account of the lived experiences of a "patients' perspective, and also Stigma: Notes on the Management of Spoiled Identity (1963). We must recognise that stigma is a social construct and as such it is important that we acknowledge the root causes of stigma and how in practice we can support and assist patients as 'individuals' to cope and manage with their circumstances and to meet their basic needs. Without consideration of basic needs (and Maslow provides a good theoretical framework) professionals working in mental health are less able to support and assist family, carers and stakeholders in building a support framework for each individual person with a mental health condition to live with independence and possess the functional skills necessary to be active in their community (s). The essential ingredient is to help the patient help themselves and this may in turn lessen the stigma associated with being perceived as a non functional member of the community by having socially valued roles. Stigma is also perceived in relation to being homeless, unempployed, uneducated etc. it is important to address basis needs and to build resilience within the patient and their support networks. As policy makers are trying to come to grips with the complexity of issues, It must be remembered that deinstitutionalisation needs to be associated with quality services in the community (s) that prople with mental health conditions and the professionals that support these populations co-exist.and resources to support ccommunity support initiatives. People can still remain socially and physically isolated especially in the community.

Isn't is interesting, James, that most good literature on this topic is fairly 'old'?

Mahesh, you are right that relevant literature is fairly old. I think the pull towards providing biological explanations for mental illness took stigma from the front burner. I am surprised that Jeremy pointed out that persons with mental illness despise being called service users. We had begun to embrace that term here in Nigeria. I think paternalism in medicine and worse in psychiatry has limited our ability to think outside the box in finding solutions to stigma. Or as someone said, 'No matter how much perfume a skunk wears, it's still a skunk.' I don't believe however that stigma and mental illness must be bedfellows

Excellent observations Bawo and Mahesh. "Paternalism" is a good descriptor of a situation where, instead of us walking beside the sufferer, finding solutions, offering encourangement, being their cheerleader, we are expected to stand above and be some remote judge of their mental health status. In true healing, we are beside them and believe in them.

Stigma and mental illnesses should not be bedfellows. Nor should be stigma and cancer. And HIV. And being deaf. And being poor. And being different.

Bawo, if I may, can I kindly ask why you said " I don't believe however that stigma and mental illness must be bedfellows"? What I am referring to is your usage of 'mental illness' rather than 'mental illnesses'. We never use a similar term in other specialities, for an example rheumatological illness or gynaecological illness, but instead we say rheumatological illnesses and gynaecological illnesses.

@ Mahesh. Meant to say mental illnesses. Typographical error on my part.

Thank you, Susan--you are most correct on that.

Client, recipient, customer, consumer, service user...they are all labels that single persons out as different from the "normal" healthcare patient; even as research provides more and more evidence of the physiology of these illnesses. However, unlike other major health conditions (heart disease, cancer, diabetes, etc.), the psychosocial aspects of mental illness also need treated for recovery or remission to occur. Historically, however, payer sources (insurance, Medicaid, Medicare, etc.) have not viewed these aspects of treatment as "medically" necessary.

On this point, there may be room for optimism. Mainstream healthcare is looking toward more holistic treatment models as a means of achieving successful outcomes for diabetes, heart disease, etc. When they do, they may be surprised at what can be learned from mental health systems.

I think people have a tendency to depart from the different, which can be fat, ugly, mentally ill patients of cancer, heart disease..The people should be educated to accept others people. Education starts in childhood, but can have good effect in adults too.

Yes, Jacqueline, and especially because most mental illness is undergirded by physical illness. Once we integrate the causes of both, which are one in the same, mental and physical health both become complete subjects. For one without the other is ineffective at best and abrogates that which can really be done to relieve human suffering.

Mental illness stigma suffers because the person can not maintain healthy attachments, the relationship is very dificult.This causes withdrawal and stigma from others, I believe that most of the other diseases.The person with mental illness can attack and harm others and can not work like the others due to his emotional injury.

Jacqueline, this is particularly true of borderline personality and certain victims of medical malfeasance, where underlying causes (addictions, toxicities, sensitivities, dehydration, polypharmacy, dietary deficits, etc.) are totally ignored yet the mental illness is "treated". Many of the manic-depressive group fall under this category of propensity to harm. When we finally understand that physical health and mental health are one in the same in our concern for our patients, and arrange for both to be considered concomitantly, we find our effectiveness as mental health professionals is second to none. Anything less and we remain with the dismal outcomes of current mental health approaches.

In order to reduce negative stigma towards stuttering in students we integrated various curricula into my graduate fluency disorders courses. Examples:

www.researchgate.net/publication/273521110_The_Effects_of_Emotional_Intelligence_Training_in_Graduate_Fluency_Disorders_Classes

www.researchgate.net/publication/230689600_Mitigating_Negative_Stereotyping_of_Stuttering_in_a_Fluency_Disorders_Class?_iepl[viewId]=oOg4qDjdErMJjQVztN2rfxaR&_iepl[profilePublicationItemVariant]=default&_iepl[contexts][0]=prfpi&_iepl[targetEntityId]=PB%3A230689600&_iepl[interactionType]=publicationTitle

Article Mitigating Negative Stereotyping of Stuttering in a Fluency ...

Chapter The Effects of Emotional Intelligence Training in Graduate F...