Campaign to Combat Stigmatisation, The Royal College of Psychiatrists, London
College Research Unit, Royal College of Psychiatrists, London
Office for National Statistics, London
Correspondence: Professor A. H. Crisp, Changing Minds Campaign, The Royal College of Psychiatrists, 17 Belgrave Square, London SWIX 8PG ; e-mail : stigma{at}rcpsych.ac.uk
Declaration of interest Unconditional funding from Eli Lilly and Co.Ltd.
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ABSTRACT |
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Aims To determine opinions of the British adult population concerning those with mental illnesses as baseline data for a campaign to combat stigmatisation.
Method Survey of adults (n=1737 interviewed ; 65% response) regarding seven types of common mental disorders. Responses evaluated concerned eight specified perceptions.
Results Respondents commonly perceived people with schizophrenia, alcoholism and drug addiction as unpredictable and dangerous. The two latter conditions were also viewed as self-inflicted. People with any of the seven disorders were perceived as hard to talk with. Opinions about effects of treatment and prognosis suggested reasonable knowledge. About half the respondents reported knowing someone with a mental illness.
Conclusions Negative opinions indiscriminately overemphasise social handicaps that can accompany mental disorders. They contribute to social isolation, distress and difficulties in employment faced by sufferers. A campaign against stigma should take account of the differences in opinions about the seven disorders studied.
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INTRODUCTION |
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METHOD |
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The interview
Advance letters were sent to all addresses giving a brief account of the
survey. The interviews were carried out in the last two weeks of July and the
first week of August 1998.
The survey obtained two sets of data. The first set comprised data collected in all Omnibus Surveys concerning household composition, and individual demographic and employment-related variables. The second set contained responses to questions about opinions concerning people with mental illnesses. Questions were asked about eight topics and each was repeated in relation to seven mental disorders which had been chosen as targets in the College's Campaign. The disorders were severe depression, panic attacks, schizophrenia, dementia, eating disorders, alcoholism and drug addiction. Focus groups carried out at the pre-interview stage indicated that the general population has a good understanding of these terms. Topics were derived from the work of Hayward & Bright (1997), who reviewed the literature on stigmatisation of people with mental illnesses. They concluded that there were enduring themes of people with mental illnesses being perceived as : being dangerous, being unpredictable, being difficult to talk with, having only themselves to blame, being able to pull themselves together, having a poor outcome and responding poorly to treatment. Responses were recorded on a five-point scale, the extremes of which bore anchoring statements, for example "dangerous to others-not dangerous to others". This method was chosen because it had worked well in previous surveys by the ONS. Respondents were also asked whether they knew anyone who has or had had a mental illness.
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RESULTS |
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Responses
Table 1 summarises the
findings of the survey. Respondents were regarded as having a negative
opinion if they endorsed either of the two points on the five-point scale on
the negative side of its mid-point.
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Responses differed between the seven disorders, and the differences were most apparent in answers to questions about dangerousness, attribution of blame, ability to pull themselves together, response to treatment and prospect for recovery.
Schizophrenia, alcoholism and drug addiction elicited the most negative opinions. Approximately 70% of respondents rated people with these conditions as dangerous to others and about 80% rated them as unpredictable. People with alcoholism and drug addiction were frequently rated as to blame for their disorders and capable of helping themselves, while people with schizophrenia were rated in this way by only about 7% of respondents.
Approximately 62% of respondents rated people with severe depression as hard to talk to, 19% responded that they could pull themselves together, 23% that they would not eventually recover, and 23% that they are dangerous to others, yet only 16% thought that they would not respond to treatment.
People with eating disorders attracted less negative opinions, but more than one-third of respondents thought that these people could pull themselves together, have only themselves to blame and would be hard to talk to. Around 90% of respondents rated ultimate outcome as good.
There was a common and widespread view that people with any of the disorders in question are hard to talk with (less so for those with panic attacks or eating disorders) and feel differently from others (less so for those with alcohol addiction) ; also that such people are unpredictable (less so for those with eating disorders).
The answers about treatment show that most respondents were optimistic and accurate about prospects for improvement with treatment (note that Table 1 records responses to "would not improve if treated"). The exception is dementia. Responses about eventual recovery were also generally optimistic : only schizophrenia and dementia were frequently rated as "will never recover", and for schizophrenia only one-half of respondents endorsed this response.
There were only minor differences between men and women and in the relationship between opinions and area of residence. The relationship between opinions and area of the country, social class and managerial/supervisory status are complex (further details available from the first author upon request).
Responses to questions about dangerousness differed between respondents over 65 years of age and the rest. A smaller percentage of people in the former group held the opinion that people with schizophrenia, alcoholism or drug addiction are dangerous (the three disorders most commonly associated with dangerousness in the study). This difference was not a feature of the other disorders, such as severe depression (Table 2). The opinions of 16- to 24-year-olds were not significantly different from those of people aged between 25 and 64.
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About one-half of the respondents reported personal knowledge of someone with a mental illness. Table 3 shows responses to questions about dangerousness, being hard to talk to and being able to pull themselves together. The attitudes of those who knew someone with a mental illness did not differ significantly from the rest.
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DISCUSSION |
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The overall opinion that people with eating disorders are very likely to recover is consistent with the tendency to trivialise these conditions. The opinion was held frequently that these disorders, and substance misuse, are self-inflicted. Although this opinion is stigmatising, it has also been held to be a powerful personal and social restraint on the development of alcohol and drug misuse (Johns, 2000). Therefore, as with opinions about dangerousness, any campaign to change attitudes about people affected by substance misuse will have to convey a complex message. For reasons such as those above, a campaign to reduce stigma will need to be long sustained.
Public knowledge
The answers to questions about treatment and the possibility of eventual
recovery also suggest that, in most instances, these stigmatising opinions are
not based on a general lack of knowledge about mental disorder. A large
proportion of respondents said that, with the exception of dementia, patients
would improve with treatment and the proportions expecting eventual recovery
suggest the same conclusion. These findings are in keeping with previous
evidence (Byrne, 1997) that
stigmatising opinions are not always closely related to knowledge. It follows
that campaigns to reduce stigma have to do more than increase knowledge of the
stigmatised conditions.
Most previous research into public opinions has asked about broad concepts such as mental illness. The results of our survey show that the public does differentiate between the seven disorders that we included. The College Campaign will need to deal separately with these disorders, while recognising that there is a general human propensity to stigmatise those who are different (Gilbert, 2000). The survey also indicates that stigmatising attitudes are no less frequent among younger people, suggesting that one important place for any anti-stigma campaign should be within schools.
Those who reported knowing someone with mental illness were no less likely than others to endorse negative statements about the dangerousness of people with schizophrenia, alcoholism or drug addiction. It is claimed (James, 1998) that the effect of contact with a mentally ill person depends on the nature of the contact and the nature of the illness. In the present study, it is possible that opinions about violent behaviour were influenced more by recent dramatic reports of violence in the media than by such varied personal contacts. If this idea is correct, a campaign against stigma has to pay attention to media reporting as well as to providing information to the public.
Communication and empathy
The widely expressed opinion that people with any of the seven mental
disorders are hard to talk to, feel different from the way we do and are
unpredictable is likely to account for some of the social distancing and
isolation that those with mental illness experience. Such social distancing
ensures a continuing lack of familiarity with the realities of sufferers'
experiences and of their illnesses. Such opinions, if also held by health care
workers, may sometimes provide a meaningful starting point for developing
professional competence in the field
(Crisp, 1999). Perceived
difficulties in communication with patients affect professional staff,
including psychiatrists, as well as members of the public. Good communication
with patients requires that professionals listen, and learn about their
patients as people with individual concerns and needs. To achieve this end,
staff need to have sympathetic opinions and to receive appropriate training,
but they also need adequate time. Thus, that part of any anti-stigma campaign
intended to improve communication with patients is necessarily part of a wider
campaign to obtain adequate staffing for all sectors of the health and social
services involved in the care of people with mental disorders.
Non-respondents
It may be that some of the 25% of the population who refused at the outset
to be interviewed (i.e. before they knew the content of the enquiry) and
especially the additional 3% later refusing to answer the stigma questions,
were influenced in this by personal sensitivities to self-revelation which
could also be reflected in their attitudes to people with mental
illnesses.
The College Campaign
Despite the five-year Defeat Depression Campaign, mounted jointly by the
Royal Colleges of Psychiatrists and General Practitioners
(Paykel et al, 1997),
which appeared to have some marginal effects on public opinions towards the
illness (Paykel et al,
1998, one-quarter of respondents in the present survey still
endorsed statements that people with severe depression are dangerous to others
and one-fifth that they could pull themselves together. These findings lend
support to the view that health education campaigns are slow to produce
effects. The findings in this survey add to the evidence that it will not be
easy to modify stigmatising opinions. For this reason, in the longer term,
efforts to reduce stigma and its damaging impact on people with mental
illnesses will need to be combined with a campaign to reduce discrimination
against them. The concept of protection against discrimination recognises that
some people are different in certain ways from the majority and that some have
disabilities, but asserts that this minority has equal rights. This important
message can be promulgated even to a population which holds opinions that
people with mental illnesses are different. The Royal College of
Psychiatrists' Campaign is intended to address both issues
(Byrne, 2000 ;
Crisp, 2000).
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CLINICAL IMPLICATIONS AND LIMITATIONS |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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REFERENCES |
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Byrne, P. (2000) Stigma of mental illness and
ways of diminishing it. Advances in Psychiatry
Treatment, 6,
65-72.
Crisp, A. H. (1999) The stigmatization of sufferers with mental disorders. British Journal of General Practice, 49, 3-4.[Medline]
Crisp, A. H. (2000) Changing minds : every
family in the land. An update on the the College's campaign.
Psychiatric Bulletin,
24,
267-268.
Gilbert, P. (2000) Stigmatization as a survival strategy : "skeletons in the cupboard" and the role of shame. In Every Family in the Land : Tackling Prejudice and Discrimination Against People with Mental Illnesses (ed. A. H. Crisp). www.stigma.org.
Hayward, P. & Bright, J. A. (1997) Stigma and mental illness : a review and critique. Journal of Mental Health, 6, 345-354.[CrossRef]
Heginbotham, C. (1998) UK mental health policy can alter the stigma of mental illness. Lancet, 352, 1052-1053.[CrossRef][Medline]
James, A. (1998) Stigma of mental illness : Foreword. Lancet, 352, 1048.[Medline]
Johns, A. (2000) Drug and alcohol addiction. In Every Family in the Land : Tackling Prejudice and Discrimination Against People with Mental Illnesses (ed. A. H. Crisp). www.stigma.org.
Jorm, A. F., Jacomb, P. A., Christensen, H., et al (1999) Attitudes towards people with a mental disorder : a survey of the Australian public and health professionals. Australian and New Zealand Journal of Psychiatry, 33, 77-83.[CrossRef][Medline]
Link, B. G., Struening, E. L., Rahav, M., et al (1997) On stigma and its consequences : evidence from a longitudinal study of men with dual diagnoses of mental illness and substance abuse. Journal of Health and Social Behaviour, 38, 177-190.[Medline]
Paykel, E. S., Tylee, A., Wright, A., et al (1997) The Defeat Depression Campaign : psychiatry in the public arena. American Journal of Psychiatry, 154 (suppl. 6), 59-65.[Abstract]
Paykel, E. S., Hart, D. & Priest, R. G. (1998) Changes in public attitudes to depression during the Defeat Depression Campaign. British Journal of Psychiatry, 173, 519-522.[Abstract]
Porter, R. (1998) Can the stigma of mental illness be changed ? Lancet, 352, 1049-1050.[CrossRef][Medline]
Rabkin, J. G. (1974) Public attitudes toward mental illness : a review of the literature. Schizophrenia Bulletin, 10, 9-33.[Medline]
Received for publication January 5, 2000. Revision received February 24, 2000. Accepted for publication March 24, 2000.