Editorial

Don’t call me nuts: an internationalperspective on the stigma of mental illness

Mental illness strikes with a two-edged sword. Onone side is the psychological distress and psychi-atric disabilities that prevent people from accom-plishing and enjoying life goals. On the other, is thepublic’s reaction to mental illness; a plethora ofprejudicial beliefs, emotions, and behaviors thatcause the public to discriminate against thoselabeled mentally ill. Unfortunately, public preju-dice and self-stigma may provide equally largebarriers to achieving and relishing life opportunit-ies. Psychiatry and the other mental health profes-sions have spent the past century successfullyunderstanding how symptoms and disabilitiesinterfere with personal wellbeing. In the process,they have developed a smorgasbord of evidence-based services to help people deal with the prob-lems of mental illness. The professions, however,have lagged in both their understanding of stigmaand in the development of approaches to erase it.We have lagged behind the development of clinicalinterventions that deal with the disease. Even moretelling, we have lagged behind consumers of mentalhealth services, who have eloquently complainedabout the broad and insidious effects of stigma onmost aspects of their lives.

Almost 100 years ago, Clifford Beers (1) authoredA Mind that Found Itself which, among its manypurposes, highlighted the omnipresent and harmfulaspects of stigma. Just about 30 years ago, JudyChamberlin’s (2) On Our Own argued that stigmaand discrimination can only be overcome whenthose struggling with mental illness, and society’sinjustices against them, regain control over theirlives. Nothing about us without us was the mantrathat was popular among disenfranchised and dis-gruntled consumers of mental health services.

Consumers, family members, and other advo-cacy groups have been tackling stigma for a longtime. What do mental health researchers now bringto the effort? Their efforts could serve twoimportant goals: (i) a more rigorous understandingof stigma and its various ways of harming peoplewith mental illness and (ii) an objective evaluationof approaches meant to erase its impact. Althoughresearch grappling with these goals has exploded

during the past decade, the established researchprograms of two distinguished social scientists areespecially noteworthy. More then 10 years beforeChamberlin published On Our Own, AmerigoFarina conducted experimentally controlled stud-ies on the impact of stigma (3). Among otherfindings, Farina showed that stigma can lead todiscriminatory practices for people with mentalillness in work settings (4), general medical doctor’soffices (5), and the psychiatric hospital (6). BruceLink applied the more ecological concerns ofsociology to research on mental illness stigma inthe 1980s. He showed that stigma was entwinedwith public fear of dangerousness (7) and thatinternalizing stigma can diminish a person’s selfesteem (8).

Their work has been augmented by large pop-ulation studies like those conducted by Pescosolidoet al. in the States (9), and (10) in Germany. Otherrecent research has sought to apply social psycho-logical models to understanding the impact ofstigma and discrimination (11). Common to all ofthese efforts has been an attempt to understandwhat is stigma and how does it impact people withmental illness. Much of the research thus far hasbeen completed on Western samples; as such, it isbiased by Western perceptions of psychology andsociety. Gaining a more complete understanding ofthe effects of stigma requires broadening stigmaresearch into the international arena. The paper byAngermeyer et al. in this issue of Acta is anexcellent example of the kind of work that needs tobe done (12). They applied models developed inearlier research on Western Europeans to samplesof subjects from Novosibirsk Russia and Ulaanba-atar Mongolia. Among the many illustrativeelements of this paper is their effort to transposethe survey into the language and culture ofparticipants. Specific findings can be learned byreading the article; but perhaps most important istheir conclusion that labeling effects are culture-related.

I have just begun a 5-year project that is teachingme similar lessons. Funded by the National Insti-tutes of Health in the USA, our group is examining

Acta Psychiatr Scand 2004: 109: 403–404Printed in UK. All rights reserved

Copyright � Blackwell Munksgaard 2004

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the attitudes of employers in Hong Kong, Beijing,and Chicago towards people with mental illness,alcoholism, and acquired immunodeficiency syn-drome. A significant hurdle at the onset has beentranslating the guide for a set of qualitativeinterviews into Mandarin and Cantonese. Thistask is more than a linguistic translation and back-translation into two languages. It must be equallysensitive to Chinese cultural processes that arelargely absent from America. Guanxi, for example,refers to the Chinese concept of social relatednessthat would likely influence employer decisions.Employers in China are likely to moderate theirattitudes about a person’s disabilities based on whoin one’s clan or neighborhood recommends theperson. As Western researchers, we rely heavily onour Chinese partners to identify cultural processesthat help us to better understand the actions ofemployers.

Understanding stigma is only half of the battle;of equal importance is testing strategies that aremeant to erase its impact. Based on a review ofbasic behavior research on social change related toprejudice and discrimination, Corrigan and Penn(13) identified three broad processes used in anti-stigma programs: protest, education, and contact.Groups protest inaccurate and hostile representa-tions of mental illness as a way to challenge thestigmas they represent. These efforts send twomessages. To the media: STOP reporting inaccur-ate representations of mental illness. To the public:STOP believing negative views about mentalillness. Largely anecdotal evidence suggests thatprotest campaigns have been effective in gettingstigmatizing images of mental illness withdrawn(14). Education provides information so that thepublic can make more informed decisions aboutmental illness. Research has suggested that parti-cipation in education programs on mental illnessled to improved attitudes about persons with theseproblems (15, 16). Stigma is further diminishedwhen members of the general public have contactwith people with mental illness who are able tohold down jobs or live as good neighbors in thecommunity. Research has shown an inverse rela-tionship between having contact with a person withmental illness and endorsing psychiatric stigma(17–19). Hence, opportunities for the public tomeet persons with severe mental illness maydiscount stigma.

Like explanations of stigma, culture is expectedto interact with stigma change approaches. Forexample, the educational message or nature ofcontact will likely vary across individualist vs.collectivist cultures. It is up to researchers todevelop both theoretical models and methodologi-

cal approaches that facilitate the testing of anti-stigma strategies in the International arena.

Acta Psychiatrica ScandinavicaPatrick W. CorriganInvited Guest Editor

References

1. Beers C. A mind that found itself. 1908.2. Chamberlin J. On our own: patient-controlled alternatives to

the mental health system. New York: McGraw-Hill, 1978.3. Farina A, Allen JG, Saul BB. The role of the stigmatized in

affecting social relationships. J Pers 1968;36:169–182.4. Farina A, Felner RD. Employment interviewer reactions to

former mental patients. J Abnorm Psychol 1973;82.5. Farina A, Hagelauer HD, Holzberg JD. Influence of psy-

chiatric history on physicians� response to a new patient.J Consult Clin Psychol 1976;44:499.

6. Koppel I, Farina A. Hospitalization time and psychiatrists�perceptions of mental patients. J Clin Psychol 1971;27:59–61.

7. Link BG, Cullen FT. Contact with the mentally ill andperceptions of how dangerous they are. J Health SocBehav 1986;27:289–302.

8. Link BG, Cullen FT, Frank J et al. The social rejection offormer mental patients: understanding why labels matter.AJS – American Journal of Sociology 1987;92:1461–1500.

9. Pescosolido BA, Monahan J, Link BG et al. The public’sview of the competence, dangerousness, and need for legalcoercion of persons with mental health problem. Am JPublic Health 1999;89:1339–1345.

10. Angermeyer MC, Matschinger H. The stigma of mentalillness: effects of labelling on public attitudes towardspeople with mental disorder. Acta Psychiatr Scand 2003;108:304–309.

11. Corrigan PW, Bodenhausen G, Markowitz F et al. Dem-onstrating translational research for mental health services:an example from stigma research. Ment Health Serv Res2003;5:79–88.

12. Angermeyer MC, Buyantugs L, Kenzine DV, Matschinger

H. Effects of labelling on public attitudes towards peoplewith schizophrenia: are there cultural differences? ActaPsychiatr Scand 2004;109:420–425.

13. Corrigan PW, Penn D. Disease and discrimination: twoparadigms that describe severe mental illness. Journal ofMental Health (UK) 1997;6:355–366.

14. Wahl OF. Media madness: public images of mental illness.New Brunswick, NJ, USA: Rutgers University Press, 1995.

15. Penn DL, Guynan K, Daily T et al. Dispelling the stigma ofschizophrenia: what sort of information is best? SchizophrBull 1994;20:567–578.

16. Corrigan PW, River L, Lundin RK et al. Three strategiesfor changing attributions about severe mental illness.Schizophr Bull 2001;27:187–195.

17. Corrigan PW, Rowan D, Green A et al. Challenging twomental illness stigmas: personal responsibility and dan-gerousness. Schizophr Bull 2002;28:293–310.

18. Pinfold V, Toulmin H, Thornicroft G et al. Reducing psy-chiatric stigma and discrimination: evaluation of educa-tional interventions in UK secondary schools. Br JPsychiatry 2003;182:342–346.

19. Schulze B, Richter-Werling M, Matschinger H et al. Crazy?So what! Effects of a school project on students� attitudestowards people with schizophrenia. Acta Psychiatr Scand2003;107:142–150.

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Editorial