BOOKS & ELECTRONIC MEDIA

Reducing the stigma of mental illness: a report from a global programme of the World Psychiatric Association

Mitchell G Weiss

Department of Public Health and Epidemiology, Swiss Tropical Institute, Basel, Switzerland (email: mitchell-g.weiss@unibas.ch)

Authors: Norman Sartorius & Hugh Schulze
Publisher: Cambridge University Press, Cambridge, 2005
ISBN: 9780521549431; hardcover; 264 pages; price £30

Stigma has become an ever more frequent answer to many questions about the social burden and psychological suffering associated with major chronic health problems. Mental illnesses figure prominently among them, and this book, focusing on schizophrenia, is concerned with what can and should be done about it. Because population-based programmes for mental health are sorely needed but less common than those for other areas of public health, experience on the practical implications of community contexts of mental illness is most welcome. Recent public health initiatives on mental health have only begun to complement the emphasis on psychiatric treatment services by focusing attention on preventing mental illness and promoting mental health. Stigma has been identified as a hidden aspect of the burden of mental illness. The efforts described in this book have as their objective the relief of this burden, through mobilizing family and community support and appropriate use of existing mental health services.

This global programme against the stigma of schizophrenia that is the subject of the book was initiated by Norman Sartorius in 1996, when he began his three-year term as president of the World Psychiatric Association (WPA), and is continuing under his guidance as its scientific director. The book chronicles the efforts to establish the programme and describes the conceptual framework that was developed to guide action agendas in diverse national and local settings. These agendas are based on a formulation of stigma as a series of dynamic processes affecting persons with schizophrenia, their families, and health systems that care for them. Having previously served as director of WHO's Division of Mental Health for 17 years, and as an outstanding contributor to the field of mental health, Sartorius was uniquely qualified to identify and respond to the pressing needs to relate cross-cutting global interests and local priorities. The WPA initiative to reduce schizophrenia-related stigma appears to have had substantial impact, motivating public health actions to improve the mental health of populations. This effort is arguably as timely today as the international pilot study on schizophrenia, also led by Sartorius, was four decades ago.

The book provides an informative catalogue of strategies and approaches embodied in various anti-stigma programmes throughout the world. These include organizational activities, research, and interventions aimed at those who stigmatize and those who are the targets of stigma. The bulk of the book details such activities from campaigns carried out in 19 countries, each classified at one of four stages of their development. The interventions described focus on priorities and approaches to influence journalists, students, employers and employees, clergy, police and the criminal justice system, family and community groups, and so forth.

To ensure that the lessons of these various country programmes may effectively guide others interested in establishing similar activities, the authors include a chapter that distils the key campaign elements with respect to target groups and the content of interventions. The power and influence of the mass media are an important focus of programme interests, but are recognized by the authors as being two-edged: programme activities typically focus on making appropriate use of the media to counter stigma; however, left on its own, the media may generate more problems than solutions by supporting stereotypes that perpetrate stigma. An afterword, written by Hugh Schulze, a coauthor with expertise in marketing communications who has been involved in the programmes over the past decade, blames the media for misconceptions, "with so many simple-minded messages that lodge in our minds like stones in our shoes."

In an attempt to classify community concepts of stigma, a concluding section discusses four dimensions of stigma, based on focus group data from studies in Germany that are regarded as widely applicable. These dimensions are (i) stigma arising in the context of interpersonal relations; (ii) structural discrimination that limits access to work, insurance, and other opportunities; (iii) public images of mental illness; and (iv) access to social roles. This section and others dealing with the concept of stigma and analysis of cultural differences (Appendix 2) are less carefully developed, however, than the practical content presented in Appendix 1. Although the structure of this concluding section is confusing (with embedded appendixes to appendixes), it nevertheless constitutes a treasure trove of useful guidelines for developing and implementing anti-stigma programmes.

The importance of acknowledging and reducing the stigma of mental illness is an indisputable premise of the book and the WPA global programme, and the broad action agenda that the book presents to stimulate other programmes with similar aims is a major contribution to efforts to improve the mental health of individuals and populations. In the interplay of stigma and disability, however, an exclusive focus on stigma may neglect other aspects of schizophrenia that are also relevant for community mental health. Stigma is not the only barrier to opportunities for people with this disabling disorder, and an exclusive focus on social engineering to eliminate stigma clearly does not constitute a comprehensive public mental health agenda. Though beyond the scope of this book, the need to distinguish the limitations of disability from the impact of stigma is an essential and inescapable task for people with serious mental illness, their families and professional care-givers, as well as for policy-makers.

Notwithstanding this limitation, the activities of the WPA programme and the motivation and guidelines for other anti-stigma campaigns provided in this book are important. Its publication should strengthen needed activities in this area, and for those who would like to involve themselves in this effort, the book will show them how to proceed. It is a valuable resource for mental health professionals and for all who are concerned directly with reducing the hidden burden imposed by the stigma of schizophrenia. The book will also be of use to those involved in other areas of public health, who can draw from the experiences gained in mitigating the stigma of schizophrenia and adapt and apply them to tackling other health problems that are targets of stigma.