The Royal College of Psychiatrists
in Scotland
Briefing paper
Stigma – a harm and safety
issue
The mental health and well-being of populations has been an increasing global
priority since the World Health Organization (WHO) adopted the recommend­
ations of the first major report on the topic in 2002.1 Since then there has been a
focus on the importance of adopting policies and practices which would reduce
stigma and discrimination and aid recovery. The WHO report emphasised the
principles of the United Nations on the protection of persons with mental health
problems and the improvement of mental healthcare, which asserted that there
should be ‘no discrimination on the grounds of mental illness’.2
Yet despite this focus, overall the evidence from the Attitudes to Mental Health in
Scotland: Scottish Social Attitudes Survey 20133 is that attitudes towards mental
health and those with mental health problems have been fairly stable in Scotland
over the past decade. No clear trends towards an overall reduction or increase in
stigmatising attitudes have been detected. We are standing still on this important
health determinant.
Despite advances in care and treatments for mental health problems, stigma
about these conditions still exists. Stigma causes harm and impacts on safety.
What is stigma?
Stigma can be traced back to early Greek society, where stizein was a mark
placed on a slave indicating their place in society and their lower social value.4
This translates to a modern definition of ‘a mark of disgrace associated with a
particular circumstance, quality or person’.5 To stigmatise is essentially to mark
someone as different and treat them accordingly.
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Stigma can be thought of as public stigma, self-stigma and structural stigma.
Stigma can lead to prejudice and discrimination. Prejudice is forming an opinion
before becoming aware of and understanding the relevant facts. Discrimination
is treating someone less positively or appropriately than other people because of
that prejudice.6
Public stigma is a society-level stigma and includes the prejudicial attitudes and
discriminatory behaviours that people hold towards those with mental health
problems. This can include beliefs that people with mental illness can never recover
(leading to hopelessness), that they are violent and dangerous (leading to fear),
that they are weak and could control their illness (leading to blame and anger) or
that they are like children (leading to a belief that they need decisions made for
them).7,8 In turn, these beliefs lead to behaviours such as avoidance, coercion and
colluding that people with mental health problems cannot live independently.
Self-stigma is when people with mental health problems believe what is being
said about their illness or about them publically and agree with this view. This
affects self-esteem, can lead to a belief that there is no point in trying and may
cause people to give up on life goals such as having a job, a long-term relationship
or even seeking help for their condition.
Structural stigma occurs at an infrastructure level – in policy-making, laws and
institutions. It creates environments where people with mental health problems
are denied their human rights, are treated unfairly or where policies do not give
high priority to mental health issues.
What is the extent of the problem and where is
the harm?
1 in 4 people in the UK will have mental health problems in any year.
9 out of 10 people who experience mental health problems have experienced
discrimination at work or in education, from health professionals and from family
members. People often say that the stigma they face can be more damaging to
them than the diagnosis itself.6,9
‘I feel reluctant to admit I’ve got mental health problems; the stigma and
rejection are too hard to face’10
People reported that professionals were dismissive or assumed that physical
health presentations were ‘all in the mind’.11 This can result in reluctance to return
for further visits for healthcare with a knock-on detrimental effect on physical
health. This is especially harmful as people with severe mental illness have a
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reduced life expectancy when compared with those who do not have a severe
mental illness (20 years less for men and 15 years less for women), are more likely
to have physical illness and are less likely to receive interventions.12 Any attitude
which hampers health-seeking behaviour therefore compounds the needs and
risks already experienced.
When common physical illnesses are studied:
Depression is 3 times more likely in those with coronary heart disease, 2–3 times
more likely in people with diabetes and twice as common in people with chronic
obstructive pulmonary disease (COPD, e.g. bronchitis),13,14 moreover someone
with depression is 3.5 times more likely to die after a heart attack,15 is more likely
to have a poor outcome in diabetes16 and someone with depression has 50%
more acute exacerbations in COPD.17,18
There is a complex interplay between physical and mental health involving
many factors. However stigma – both self-stigma and that displayed by health
professionals – can contribute to adverse outcomes. Not recognising mental
health problems reduces the chance of optimally treating both physical and mental
health conditions.
‘I went to my GP with a breast lump ... [he] sent a referral letter stating
“over-anxious patient, had nervous breakdown at age 17” (20 years ago!).
Consequently I was greeted by the specialist with “well, you’re a bit of a
worrier, aren’t you”? Every physical illness I have had for the last 20 years has
first been dismissed as anxiety, depression or stress.’19
Many people will not seek support because of the stigma they expect to face
and the self-stigma of feeling a burden. No one should ever be made to feel
ashamed or embarrassed to tell anyone that they experience mental health
problems. Together, we have a shared responsibility to understand what mental
health stigma and discrimination feels like and drive home the message that
everyone is entitled to and deserving of help and support.6
What can be done about stigma?
Different strategies for tackling stigma are required for the different types of
stigma.
Public stigma
Public stigma can be tackled through protest, education and contact. Each of
these strategies has its part to play depending on the situation.
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Protest
Here an appeal is made to those holding stigmatising perceptions of mental health
problems to stop, by using moral arguments. Unfortunately this can be a doubleedged sword and can cause a rebound effect of worsening attitudes.6 However
specific protests can be very effective, such as the joint response of a number
of organisations to an article printed in The Sunday Times ‘I’m sorry, he’s not a
differently gifted worker – he’s a psycho’. This protest brought an apology from
the author who had not intended that his article discriminate against people with
mental health problems and withdrawal of the piece from the paper’s website.20
Education
Here the facts about mental health problems are contrasted with the myths. Effects
on attitudes can be variable but education is ‘widely endorsed for influencing
prejudice and discrimination’.7 The See Me campaign (Scotland’s national campaign
against mental health stigma) in partnership with others is using education to tackle
discrimination experienced by bus users in one area who also have a mental health
problem.21 This campaign also uses the third method for tackling stigma: contact.
Contact
Evidence suggests that contact with people with mental health problems who
allow stereotypes to be challenged is an effective way of reducing stigma. This can
be formal through speaking at meetings or on education programmes or casual
through disclosing mental health problems to others.
The Canadian programme Opening Minds combined the contact approach with
education and was able to show a reduction in stigmatising attitudes over time.22
Challenging public stigma is most effective when strategies are targeted at people
who have frequent interactions with people with mental health problems including
health and social care professionals. The See Me campaign has targeting stigma
in health and social care as one of its priorities (along with targeting stigma in
young people and employment). It is a challenging fact that health and social care
agencies have the potential to discriminate against 25% of the population, often
without realising that this is what they are doing.
Self-stigma
Promotion of recovery-focused approaches to treatment underpins the reduction
of self-stigma and organisations such as the Scottish Recovery Network (www.
scottishrecovery.net) have an important part to play.
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Tackling self-stigma is about improving self-esteem and challenging the public
stereotypes and can involve empowerment, advocacy and group identification,
as well as the use of cognitive–behavioural techniques to challenge negative
stereotypes and thoughts. Miller & Kaiser offer a useful perspective on coping
with stigma.23
Structural stigma
It can be seen that the different stigmas are interrelated and this is also the case for
structural stigma. Structural stigma is influenced by public opinion and vice versa.
Moving towards equal treatment rights for those with mental health problems,
achieving parity of esteem between mental and physical health in terms of policy,
resource allocation and services is pivotal24 to tackling structural stigma. After all,
there is no health without mental health.
Stigma and learning disability
What is a learning disability?
People with learning disabilities have a significant, lifelong condition that started
before adulthood, affected their development and which means they need help to:
‰‰ understand information
‰‰ learn skills
‰‰ cope independently.
But this is only part of a description. It does not capture the whole person who
can be much more – a friend, a family member, a community activist, a student, a
parent, an employee or employer to name just a few roles.25
How does stigma affect those with learning disability?
People with learning disabilities have poorer health than their non-disabled peers;
these differences in health status are, to an extent, avoidable.26 People with learning
disabilities have been shown in research studies to have the poorest health of any
group in Scotland.27 People with learning disabilities also live shorter lives.28,29
The Keys to Life26 identified a number of mediators relating to stigma that cause
these poor outcomes:
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‰‰ discrimination
‰‰ being bullied/harassed
‰‰ violence/abuse
‰‰ communication difficulties
‰‰ multiple adverse life events
‰‰ poverty.
It also stated the following:
‘Poor health can result from social isolation and deprivation. Many people with
learning disabilities have experienced lifelong exclusion resulting from lack of
choice and opportunity as well as experiencing significant barriers to access.
People with learning disabilities are more likely to be exposed to common
causes of poor health such as poverty, poor housing, and lack of employment,
social isolation and discrimination.
‘Many people with learning disabilities have limited verbal communication skills
which impact on others’ ability to understand health needs. Both paid and family
carers play an important role in identifying health needs. Many people with
more severe learning disabilities rely completely on others to communicate
what their health needs are.
‘Communication difficulties are fundamental to explaining many of the barriers
and poorer outcomes people with learning disabilities experience when using
health services. Many healthcare workers have never had training in the kind
of communication methods and techniques that facilitate appropriate access to
services. In addition many healthcare professionals rely on individuals reporting
symptoms and ill-health.’26
Dual diagnoses, dual stigma
People with learning disabilities have a much higher incidence of mental illness.
Rates of illness in a 12-month period are estimated at approx 40%,30 a figure that
is much higher than rates in the general population (approx 27%). For example,
if you have a learning disability you are three times more likely to develop
schizophrenia in your lifetime.
The prevalence of psychiatric disorders is 36% among children with learning
disabilities, compared with 8% among children without learning disabilities.31
This results in a double stigmatisation; that is the dual effect of both having a mental
illness with all its stigma-related challenges plus the significant stigma/inequalities
related to having a learning disability.
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Key points:
‰‰ People can and do recover from mental health problems.
‰‰ Mental health stigma may impact negatively on all aspects of a person’s live
including health and social care.
‰‰ Mental health stigma causes harm and is a patient safety issue.
‰‰ Stigma occurs at a number of levels in any society.
‰‰ There is good evidence that stigma can be tackled using a number of
complementary strategies.
‰‰ Reducing stigma improves health outcomes.
‰‰ People with learning disability have much to contribute to society in general: they
can, for example, be a much-loved family member or friend, an employee, a
parent, a student, and an educator.
‰‰ People with learning disability have poorer health and shorter lives. This is due,
in part, to a number of factors related to stigma.
‰‰ People with learning disability are far more likely to develop mental ill health for
which effective treatments are recognised.
‰‰ Children with learning disability are around four times more likely to develop a
mental health problem.
‰‰ People with learning disability are more likely to be socially isolated and be unable
to secure employment.
‰‰ With the right support and treatment people with learning disability and mental
health problems can recover and live fulfilling lives.
References
1. World Health Organization. The World Health Report. Mental Health, New Understanding, New Hope. WHO, 2001.
2. United Nations General Assembly. The protection of persons with mental illness and the improvement of mental health
care (resolution 46/119). UN, 1991.
3. Scottish Government. Attitudes to Mental Health in Scotland: Scottish Social Attitudes Survey 2013 (http://www.gov.scot/
Publications/2014/11/6698). Scottish Government, 2014.
4. Arboleda-Florez J. What causes stigma? World Psychiatry 2002; 1: 25–6.
5. Oxford Dictionaries. Stigma (http://www.oxforddictionaries.com/definition/english/stigma) accessed 26 Feb 2015).
6. See Me. Undertanding mental health stigma and discrimination. See Me Scotland (https://www.seemescotland.org/
stigma-discrimination/understanding-mental-health-stigma-and-discrimination/).
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8. Mental Health Commission of Canada. Opening Minds Interim Report. MHC Canada, 2013.
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9. Parle S. How does discrimination affect people with mental illness? Nurs Times 2012; 108: 28, 12–14.
10. Office of the Deputy Prime Minister. Mental Health and Social Exclusion. Social Exclusion Unit, 2004.
11. Lyons C, Hopley P, Horrocks J. A decade of stigma and discrimination in mental health: plus ca change, plus c’est la
meme chose. J Psychiatr Ment Health Nurs 2009; 16: 501–7.
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Illness. Scottish Government, 2008.
13. Royal College of Psychiatrists. Whole-Person Care: From Rhetoric to Reality. Achieving parity between mental and physical
health (Occasional Paper OP88). Royal College of Psychiatrists, 2013.
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Mental Health Problems. Mind, 1996.
20. See Me. Our response to the Sunday Times (https://www.seemescotland.org/news/our-response-to-the-sundaytimes/). See Me, 2014.
21. See Me. Stopping discrimination on the buses (https://www.seemescotland.org/news/stopping-discrimination-on-thebuses/). See Me, 2015.
22. Knaak S, Patten S. CBIS Program: Final Evaluation Report. Mental Health Commission of Canada, 2013.
23. Miller CT, Kaiser CR. A theoretical perspective on coping with stigma. J Soc Issues 2001; 57: 73–92.
24. Royal College of Psychiatrists. Achieving parity of esteem between mental and physical health (http://www.rcpsych.
ac.uk/pdf/Parity%20of%20Esteem%20briefing%20Feb%202012.pdf). Royal College of Psychiatrists, 2012.
25. The Scottish Government. The Keys to Life. Improving Quality of Life for People with Learning Disabilities. The Scottish
Government, 2013.
26. Emerson E, Baines S. Health Inequalities & People with Learning Disabilities in the UK: 2010. Improving Health and Lives:
Learning Disabilities Observatory, 2010.
27. NHS Health Scotland. People with Learning Disabilities in Scotland: The Health Needs Assessment Report. NHS Scotland,
2004.
28. Hollins S, Attard M, van Fraunhofer N, McGuigan SM, Sedgwick P. Mortality in people with learning disability: risks
causes, and death certification findings in London. Dev Med Child Neurol 1998; 40: 50–6.
29. McGuigan SM, Hollins S, Attard M. Age specific standardised mortality rates in people with learning disability. J Intellect
Disabil Res 1995; 39: 527–31.
30. Cooper S-A, Smiley E, Morrison J, Williamson A, Allan L. Mental ill-health in adults with intellectual disabilities:
prevalence and associated factors. Br J Psychiatry 2007; 190: 27–35.
31. Emerson E, Hatton, C. The mental health of children and adolescents with intellectual disabilities in Britain. Br J
Psychiatry 2007; 191: 493–99.
The Royal College of Psychiatrists is the leading medical authority on mental health in the UK and is the professional
and educational organisation for doctors specialising in psychiatry. Further information: call 0131 220 2910 or
email Karen Addie at [email protected]. Visit our website where you will find lots of information about
mental health: www.rcpsych.ac.uk.
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© Royal College of Psychiatrists 2015