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Edgar Jones is professor of the history of medicine and psychiatry at the Institute of Psychiatry, Psychology and Neuroscience at King’s College London. He is also programme leader for the MSc in War and Psychiatry.
In recent years, severe mental disorders have proved remarkably resistant to attempts to find effective medicines. The therapeutic revolution of the 1950s offered treatments for both psychosis and depression and it was expected that these pioneering drugs would be followed by a succession of innovative products. Although there have been a number of improvements, no step change in medicinal science has transformed the management of mental illness in the last half century. However, an area where it is possible to implement significant change without resorting to expensive research and development is the issue of stigma. Deeply embedded in Western culture is a widespread prejudice against mental illness. Depression, for example, is often interpreted as a sign of personal weakness, whilst psychosis is commonly equated with violent or dangerous behaviour. Society is generally sympathetic to those who have recovered from a severe physical illness and yet those who have suffered from a psychological disorder are rarely given equivalent consideration. Indeed, a worker who discloses a history of mental illness to an employer may find that it has an adverse impact on their career. And yet, self-stigma, judgements that people make about themselves, can often be more damaging than the opinions of others. People with mental illness often feel a sense of shame and disgrace. Self-stigma, or perceived stigma as it is sometimes known, prevents people from seeking or accepting help. For some this delay in receiving treatment may mean that their illness become more severe and may even require a hospital admission with time away from family and work.
The benefits to both individuals and society as a whole of reducing the stigma of mental illness are clear. People will be treated earlier and suffer less distress. Yet stigma, like the discovery of new medicines to treatment mental illness, has proved a tough challenge. A series of educational campaigns has sought to change the beliefs and behaviour of the public: England (‘Changing Minds’ a five-year campaign launched in 1998 by the Royal College of Psychiatrists), Scotland (‘See Me’, 2002); the USA (‘What a Difference a Friend Makes’, 2006), England (‘Time to Change’, 2007-11), and Canada (‘Opening Minds’, 2009).
Drawing on the findings of previous attempts to address stigma, the ‘Time to Change’ campaign sought to design a best practice model that would address attitudes and behaviour. The campaign was well funded (close to £21 million for the four years to 2011), led by major mental health charities, had clear objectives, and was subject to careful evaluation. The results reveal a mixed picture. The positive outcomes included a small reduction in discrimination reported by service users and improved recognition of common mental health problems by employers. However, some initial gains (such as improvements in the attitudes of medical students) proved short lived. Despite best efforts, the campaign had no impact on a range of key issues; there was no improvement in knowledge or behaviour among the general public, nor any reduction in reports from patients of discrimination by mental health professionals.
As well as analysing the results of the campaign, the researchers sought to explain why it had failed to shift public opinion. They found that people without professional knowledge of mental illness had their own culturally-determined explanations for human behaviour that were rooted in their understanding of peoples’ life histories. So well established were these beliefs that they were reluctant to reconsider. People in large towns were convinced that there was a sharp dividing line between mental illness and normality and repelled efforts to change that view.
Stigma of mental illness goes to the root of Western culture and has existed from the Middle Ages when people suffering from psychiatric illness were often interpreted as suffering from demonic possession. Until 1770, the public were allowed to visit the Bethlem Hospital in central London as a form of entertainment, reinforcing prejudice against those suffering from psychosis. To create a quieter, therapeutic environment, self-contained asylums were built in the nineteenth century but this had the effect of marginalising the mentally ill and removing their treatment from mainstream medicine. Only after considerable debate were psychiatric services included within the remit of the National Health Service on its formation in 1948. Hence, we should not under-estimate the effort required to shift beliefs and opinions relating to those with mental illness.
Research shows that the best way to challenge these stereotypes is through first-hand contact with people with experience of mental health problems, though a key factor is knowing a person who has had helpful treatment for episodes of psychological illness. Evidence confirms the value of local initiatives, either in schools, colleges and places of work, including hospitals.
Reducing the level of stigma in the general population will not solve the enduring problem of how to treat severe mental illness but it will temper some of the distress and anguish that accompanies psychiatric disorders. Whilst it requires us to re-examine deeply-held or long-established beliefs, there is no fundamental reason why these cannot be modified as there are benefits not only for patients, employers but also broader society.