and ways of diminishing it

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1 Stigma of mental illness Advanes in APT Psyhiatri (2000), vol. Treatment 6, p. 65(2000), vol. 6, pp Stigma of mental illness and ways of diminishing it Peter Byrne Stigma is defined as a sign of disgrae or disredit, whih sets a person apart from others. The stigma of mental illness, although more often related to ontext than to a person s appearane, remains a powerful negative attribute in all soial relations. Soiologial interest in psyhiatri stigma was given added vigour with the publiation of Stigma Notes on the Management of Spoiled Identity (Goffman, 1963). More reently, psyhiatrists have begun to reexamine the onsequenes of stigma for their patients. In 1989, the Amerian Psyhiatri Assoiation s annual meeting s theme overoming stigma was subsequently published as a olletion of artiles (Fink & Tasman, 1992), and last year saw the launh of the Royal College of Psyhiatrists fiveyear Changing Minds anti-stigma ampaign. What stigma means Beyond any definition, stigma has beome a marker for adverse experienes (see Box 1). First among these is a sense of shame. Mental illness, despite enturies of learning and the Deade of the Brain, is still pereived as an indulgene, a sign of weakness. Self-stigmatisation has been desribed, and there are numerous personal aounts of psyhiatri illness, where shame overrides even the most extreme of symptoms. In two idential UK publi opinion surveys, little hange was reorded over 10 years, with over 80% endorsing the statement that most people are embarrassed by mentally ill people, and about 30% agreeing I am embarrassed by mentally ill persons (Huxley, 1993). The adaptive response to private and publi shame is serey. Commenting on the barriers to the management of depression, Doherty (1997) ites both patients shame in admitting to, and physiians relutane to enquire about, depressive symptoms. Family and friends may endure a stigma by assoiation, the so-alled ourtesy stigma (Goffman, 1963). In one study of 156 parents and spouses of first-admission patients, half reported making efforts to oneal the illness from others (Phelan et al, 1998). Professionals are no different in this regard, and hide psyhiatri illness in themselves or a family member. Serey ats as an obstale to the presentation and treatment of mental illness at all stages. So, unlike physial illness, when soial resoures are mobilised, people with mental disorders are removed from potential supports. Poorer outomes in hroni mental disorders are likely when patients soial networks are redued (Brugha et al, 1993). The question arises as to just what all this shame and serey is about. Negative ultural santion and Box 1. The experiene of stigma Shame Blame Serey The blak sheep of the family role Isolation Soial exlusion Stereotypes Disrimination Peter Byrne is Senior Leturer at East Kent NHS Community Trust (2 Radnor Park Avenue, Kent CT19 5HN). He ompleted all his psyhiatri training in Ireland: in Dublin, Waterford and Cork. He also letures in Film Studies at University College Dublin. He is a former hairman of the Publi Eduation Committee of the Royal College of Psyhiatrists in Ireland, and the urrent ohairman of media projets of the Changing Minds Committee. His researh interests inlude stigma, the media, patient and publi eduation.

2 APT (2000), vol. 6, p. 66 Byrne myths ombine to ensure sapegoating in the wider ommunity (see Box 1). The reality of disriminatory praties supplies a very real inentive to keep mental health problems a seret. Patients who pursue the serey strategy and withdraw have a more insular support network. Disrimination ours aross every aspet of soial and eonomi existene (Fink & Tasman, 1992; Heller et al, 1996; Read & Reynolds, 1997; Byrne, 1997; Thompson & Thompson, 1997). A ivilisation should be judged by how it treats its mentally ill: disrimination is also about the onditions in whih our patients live, mental health budgets and the priority whih we allow these servies to ahieve. By way of summary, Gullekson (in Fink & Tasman, 1992) writes about her brother s shizophrenia: For me stigma means fear, resulting in a lak of onfidene. Stigma is loss, resulting in unresolved mourning issues. Stigma is not having aess to resoures Stigma is being invisible or being reviled, resulting in onflit. Stigma is lowered family esteem and intense shame, resulting in dereased self-worth. Stigma is serey Stigma is anger, resulting in distane. Most importantly, stigma is hopelessness, resulting in helplessness. Stereotypes Goffman (1963) ommented that the differene between a normal and a stigmatised person was a question of perspetive, not reality. Stigma (like beauty) is in the eye of the beholder, and a body of evidene supports the onept of stereotypes of mental illness (Townsend, 1979; Philo, 1996; Byrne, 1997). Stereotypes are about seletive pereptions that plae people in ategories, exaggerating differenes between groups ( them and us ) in order to obsure differenes within groups (Townsend, 1979). As with raial prejudie, stereotypes make people easier to dismiss, and in so doing, the stigmatiser maintains soial distane. The media perpetuate stigma, giving the publi narrowly foused stories based around stereotypes. On a more positive note, the media are a useful loation to begin the searh for negative representations and adverse attitudes to mental illness, and ultimately the media will be the means of any ampaign that aims to hallenge and replae the stereotypes. Philo (1996) measured violene as the entral element in television representations in 66% of items about mental illness, an interesting figure in that it orresponds with the Royal College of Psyhiatrists 1998 survey, where 70% believed that people with shizophrenia are violent and unpreditable. At the other extreme, people with mental illness are frequently portrayed as vitims, patheti haraters, or the deserving mad (Byrne, 1997). This parallels the experiene of physial disability, where sympathy is a pretext for soial distane the Does he take sugar? strategy. The Royal College of Psyhiatrists survey also reorded onsistently high responses (ranging from 50 79%) in relation to six ommon mental disorders, when the publi was asked whether the sufferer was hard to talk to. Most liniians would instintively enourage empathy not sympathy for their patients. In inema and television, mental illness is the substrate for omedy, more usually laughing at than laughing with the haraters (Byrne, 1997). As part of the them and us strategy, mental disorders have also been onferred with highly harged negative onnotations of self-inflition, an exuse for laziness and riminality. Hyler et al (1991) have written about a number of Hollywood films where the representations of mental illness are of overprivileged, oversexed narissisti parasites. But pull yourself together attitudes are not onfined to fitional sreen representations, with one Northern Ireland general pratitioner writing: Yet they ( neuroti patients ) take up far too muh of our time and energy people omplaining, miserable, depressed, neurotially whining about how unhappy they are, pouring out all their problems in the surgery and dumping them on my doorstep. It would be really unbearable if I was atually listening to them (Farrell, 1999). The proess of stigmatisation The history of stigma, ulturally determined, is desribed elsewhere (Setion 2 of Fink & Tasman, 1992; Warner in Heller et al, 1996). Some soial sientists believed stigma was a funtion of labelling by psyhiatrists, iting benign publi attitudes of self-report studies and the observation that many patients were unaware of stigma: this is not supported by the evidene (Link et al in Fink & Box 2. Stereotypes of mental illness Psyhokiller / mania Indulgent, libidinous Patheti sad haraters Figures of fun Dishonest exuse: hiding behind psyhobabble or dotors

3 Stigma of mental illness APT (2000), vol. 6, p. 67 Tasman, 1992). Mental illness stigma existed long before psyhiatry, although in many instanes the institution of psyhiatry has not helped to redue either stereotyping or disriminatory praties. Further, the ubiquity of stigma and the lak of language to desribe its disourse have served to delay its passing: raism, fatism, ageism, religious bigotry, sexism and homophobia are all reognised desriptions for prejudied beliefs, but there is no word for prejudie against mental illness. One possible remedy to this would be the introdution of the term psyhophobi to desribe any individual who ontinues to hold prejudiial attitudes about mental illness regardless of rational ontrary evidene. Despite inevitable objetions from some, the rise of politially orret language has been a key fator in the suess of ampaigns opposing disrimination based on gender, age, religion, olour, size and physial disability (Thompson & Thompson, 1997). Negative attitudes to people with mental illness start at playshool and endure into early adulthood: one ohort onfirmed the same prejudies on reexamination eight years later (Weiss, 1994). Green et al (1987) measured onsistently negative publi attitudes at five separate points over 22 years. These studies, and that quoted above from Huxley (1993), diretly ontradit a reent laim (stated but unreferened) that publi pereption of psyhiatri disorders will hange: improved understanding of the auses and mehanisms of disease is likely to redue stigma (MGuffin & Martin, 1999). Aepting the low value most ultures attah to mental disorders, are there any qualities in stigmatisers that ould be altered to redue overall levels of stigma? Adorno et al (1950) have hypothesised about the likely make-up of prejudied people: they have an intolerane of ambiguity, rigid authoritarian beliefs and a hostility towards other groups (ethnoentriity). Other studies of the attributes of those who are more likely to produe negative evaluations of stigmatised people found no relation to onventionalism, but did report an assoiation with a ynial world view (Crandall & Cohen, 1994). Knowing someone who has a mental illness is not assoiated with more enlightened attitudes (Wolff et al, 1996a), but Huxley (1993) identifies that the key fator is diret ontat with people who have had helpful treatment for episodes of mental illness. The hallenge, listed in the third setion of Box 3, is to onfront the stigmatiser with his or her irrational beliefs, in addition to enabling diret ontat with one of them. This may seem an unrealisti aim, if the prototype stigmatiser onjures up images of shaven-headed boot-boys, but any list of stigmatisers inludes landlords, employers, insurers, welfare administrators, housing offiers, universities, health are professionals, lawyers, prison workers and teahers. Levels of intervention The starting point for all target groups and at every level is eduation: to date, the Changing Minds ampaign has sueeded in its requests to medial journals to publish artiles on stigma. These artiles, inluding the exellent Lanet series (Lanet, 1998) have provoked disussion within professional irles, and beyond. Psyhiatri Servies and the UKbased Journal of Mental Health have been major forums for researh and debate on this subjet, and more Box 3. Fators whih influene the prejudie of stigmatisers Fator type Example Likely to inrease prejudie Attribute of stigmatised Gender Male gender Appearane Unkempt appearane Behaviour Aute illness episode Finanial irumstanes Homelessness Assumptions about Pereived fous of illness Many defiits the individual s disorder Pereived responsibility Not responsible for ations Pereived severity History of hospital admission Knowledge base about Pereived origin Self-inflited partiular disorder Pereived ourse Inurable/ hroni Pereived treatments Needs drugs to stay well Pereived danger Criminality or violene

4 APT (2000), vol. 6, p. 68 Byrne reently the Psyhiatri Bulletin has featured a number of key artiles. Other professions nursing, oupational therapy and soial work have been writing about these issues for far longer and in greater depth than psyhiatrists. Publiations in the lay press irulate the arguments to a wider audiene. The Internet is already a highly effetive means of distributing information and speifi antistigma initiatives, and readers an aess details of Changing Minds and other ampaigns through and Stigma and its sequelae should ahieve a prominent plae on the urriulum of all health servie professionals and their students. The latter group will be the deision-makers of the next millennium and will either initiate further soial psyhiatry researh or make the same mistakes as their predeessors. Wolff et al (1996a,b) have provided a pratial working model for interventions aimed at various target groups (see Box 4). One aspet of this is to listen to the onerns of the people whose attitudes you wish to hange. Young ouples with hildren have speifi fears that need to be addressed, and in this group, redutions in levels of fear an be ahieved with eduational interventions (Wolff et al, 1996a). Other settings, for example shools, workplaes and welfare servies, will require different information pakages tailored to their needs. The ontent of these interventions should inlude the omponents of established psyhoeduation modules, the stigma disrimination paradigm (a prototype presentation is available at and information speifi to the needs of the target group. Mental health professionals need to move beyond teahing psyhoeduation in isolation (at the lini) to full partiipation in planned programmes of publi eduation (see Box 5). Every intervention must onvine its target group of the importane of stigma/disrimination, hallenge stereotypes in Box 4. Key suggestions for eduational interventions: after Wolff et al (1996a) Speifi target groups, with prior identifiation of their attitudes No evidene of ommunity baklash Flexible publi eduation pakages Small groups work better Several interventions over time exeed the sum of their parts Continuing ontat with the group (keyworker) maintains momentum ourselves and others, and pursue the ongoing task of unravelling the nature of prejudie. These three separate tasks are summarised in the Changing Minds slogan: Stop, think, understand. Closing the knowledge gap is only part of the answer. Stigmatisers, as a rule, are unlikely to volunteer to attend eduational pakages. Even assuming the message reahes all targets, eduation alone annot hange enturies of folklore and prejudie. The arrot of eduation must be aompanied by the stik of hallenges to media misrepresentations, positive disrimination in the workplae, test ases in the ourts, and legal santion through (for example) the Disability Rights Commission. In this regard, lessons an be learned from AIDS foundations and the gay ommunity, who met the hallenge of initial publi antipathy to AIDS, and who have now ahieved the dual goals of health promotion and major redutions in disriminatory praties (Thompson & Thompson, 1997). Changing psyhiatry first Ask yourself the following questions: ould you give a talk about stigma next week? What have you done to redue stigma and disrimination against your patients? Is stigma on the undergraduate urriulum of your university, or something about whih your trainees have formal teahing? It is not just that psyhiatry has a shameful history in its ontributions to modern-day misoneptions about mental illness (see Box 6), but that it has also failed to address its urrent defiienies. None of the standard British psyhiatry textbooks ites stigma in their indies. There is a dearth of psyhiatri researh on stigma and disrimination, and a perennial resistane to roking the stigma boat. Wolff et al (1996a) desribed their failure to ahieve ethial approval for their study in London, and also desribed staff preoneptions that it would draw attention to the patients problems, making integration loally more diffiult. Many psyhiatrists share the stereotypes desribed above. Lewis & Appleby (1988) reported that Box 5. From psyhoeduation to publi eduation Patient Family Network Advoate group Person Target group Community Soiety

5 Stigma of mental illness APT (2000), vol. 6, p. 69 psyhiatrists reated to vignettes differently if the person had been given the diagnosis of a personality disorder: one labelled, primary diagnoses differed and value judgements (e.g. manipulative, does not merit NHS time, unlikely to improve, likely to annoy ) appeared more frequently. Antipathies to psyhiatry and psyhiatrists are widespread among the medial profession, but perhaps the real issue is that the majority of psyhiatrists fail to hallenge these prejudies. This failure to respond, be it aquiesene or resignation, annot ontinue. The impetus to hallenge ageism did not ome from medial gerontology, but was later hampioned by that speiality. Radial ation within and outside psyhiatry is now required. Dubin & Fink (in Fink & Tasman, 1992) desribe how psyhiatrists perpetuate many onepts underlying biased and stigmatising attitudes, and suggest that the way in whih psyhiatry is strutured maintains the status quo. Eisenberg (1995) has ritiised the highly harged either/or disourse that mental diseases are either biologial/ no one s fault or psyhologial/ aused by parents, spouses or patients. Silene on these issues is no longer tenable: for all aspets of stigma and disriminatory praties, psyhiatrists need to omplain more often and more effetively media overage is a good starting point (Hart & Philipson, 1999). For psyhiatrists, the debate goes beyond stigma. It inludes the quality and struture of existing servies, and the barriers that deny aess to them (Thompson & Thompson, 1997). Compliane is one example where both a onept, and the theories underlying it, are in need of a radial hange in mind set. Brandon (in Read & Reynolds, 1996) has provided a number of suggestions for hange among psyhiatrists, prinipally abandoning the them and us mentality. Crepaz-Keay (in Read & Reynolds, 1996) sums up the (stereotypial) psyhiatrist s reations to advoates: But you re not like my lients or Who do you represent?. Box 6. A history of dumb ideas in psyhiatry Moon (lunati) and womb (hysteria) theories Tehnique of persuasion Epilepti personalities Mental and moral defetives Eugenis (Ernst Rubin) Insulin oma treatment Frontal lobotomy Momism, shizophrenogeni mothers, Shism & Shew families Treatments for homosexuality Pratial stigma management If every psyhiatrist left rehabilitation to the rehabilitation team, there would be no rehabilitation. Equally, if every psyhiatrist leaves the stigma issue to the Changing Minds ampaign, there will be no enduring hange. Psyhiatrists should address stigma as a separate and important marker in its own right. Beause of the nature of stigma, patients are unlikely to bring it diretly to the attention of the mental health team. Cliniians should ask about the nature of adverse experienes, disrimination, the extent of soial networks, self-image, et., and inorporate these issues into the treatment plan. Aknowledging the existene of prejudie is an essential first step, and is no more dangerous than enquiry into suiidal ideation. There may be a speifi fous of adverse experienes (bullying at work or shool, family diffiulties), or ways in whih the patient an alter others reations to him- or herself (see Box 3). The patient needs to onstrut these stigmatising experienes as part of a generalised prejudie in soiety, allowing the possibility of overoming his or her own diffiulties. Alongside this, the liniian will gain in adding to his or her existing knowledge of the patient s soial ontext and learning more about stigma. Shizophrenia presents unique hallenges. Lak of insight is always problemati, but an affetive omponent an be assoiated with denial of symptoms or rejetion of treatment at key points in the illness. The life events model ontains many events that ould be preipitated by stigma-led experienes: losing a job, a home or a friendship. It is about humiliating and devaluating experienes, and these play an important part in relapses of depression. Equally, the entral roles of vulnerability, destabilisation and restitution fators have a bearing on outome. Pessimism in the profession may also negatively affet patient pereptions here: for years, the hroni soial breakdown syndrome of long-stay patients was seen as an integral part of shizophrenia (Eisenberg, 1995). Given that at least 50% of people with shizophrenia have signifiant soial skills defiits, any programme must inlude improving interpersonal skills. A symptom-foused approah that inludes stigma management an be inorporated into an existing ognitive behavioural model of treatment (Enright, 1997). A omprehensive list of soial obstales to suessful de-institutionalisation has also been desribed (Farina et al, in Fink & Tasman, 1992). With the possible exeption of some patients with Alzheimer s dementia, patients need to know their diagnosis and what the problems are and are likely

6 APT (2000), vol. 6, p. 70 Byrne to be. Just as adverse publi attitudes endure over time, the adverse effet of stigma on individuals well-being persists from entry into treatment up until a year after suessful treatment (Link et al, 1997). Cognitive behavioural therapy (CBT) is now of proven effiay aross the spetrum of mental disorders (Enright, 1997): its ore strategy is disseminating information about the illness. Holmes & River (1998) have outlined a CBT approah to ombating stigma in individuals. Their artile is one of seven similar artiles in the Winter 1998 (vol. 5) issue of Cognitive Behavioural Pratie. The next step in management is to transform the person from patient to advoate. Part of oping with stigma is fighting stigma. A reent Royal College of Psyhiatrists Counil Report lists many different kinds of advoay: self, peer-group, legal, arer and itizen (Royal College of Psyhiatrists, 1999). In joining an advoate group, the dangers of a them and us situation arise. Certainly, not everyone who experienes mental illness needs the ompanionship and validation of others who have had similar experienes. But if the advoate group inludes ontats with partners, friends and families, along with ommunity groups, ivil rights ativists, ampaigners, even (si) mental health professionals, then it will be a valuable experiene. The College, in the same report, issues a formal poliy diretive on advoay, broadly weloming it, and reommending early exposure to it for its trainees. Fisher (1994) identifies empowerment as essential to reovery from hroni disability. The relationship between psyhiatry and the advoay movement is not a oneway street. In the past three years, these are the learning experienes that the author has enountered at advoates meetings: l an arhitet objeting to her work olleagues onstant referenes to a psyhiatri unit they were designing as a nut house or psyho depot l an insurane exeutive, with a remote history of mental illness, hallenging the loading of his insurane poliy by his own firm l a nurse, following an episode of depression, insisting on returning to the intensive are unit and not, as suggested, to a onvalesene ward l a medial student hallenging the Dean to show the same flexibility with mental illness as he had previously shown with physial disability l a teaher with bipolar disorder enouraging the shools board to inlude information on this illness on the urriulum l a footballer insisting his team play the loal psyhiatri unit l a newsagent offering to keep newspaper uttings to failitate a loal initiative on l l l negative media overage of mental health issues a parent s desription of servies as supermarket psyhiatry a man who had reovered from an episode of depression, objeting to a publi eduation ampaign that would inlude shizophrenia and depression together: Why drag depression down to the level of the gutter? a onsultant psyhiatrist, on hearing an artiulate aount of shizophrenia from a woman living with the illness, Then she ouldn t be shizophreni. Future diretions It is diffiult to predit the progress over time of a variety of existing anti-stigma initiatives. Media overage of these interventions will be essential to disseminate positive mental health messages, while hallenging urrent misrepresentations. Regardless of the means (eduation, legal remedies, health servie hanges), the end is to promote soial inlusion and redue disrimination. The nature of that disrimination will hange as the praties of disrimination are suessfully hallenged: the task is to identify prejudie in whatever ontext. Examination of the ahievements of other antidisrimination movements leaves mental illness stigma as one of the last prejudies. A prerequisite must be to ontinue listing disriminatory praties from different perspetives. In some instanes, for example the urrent pratie of psyhiatri assessment of andidates for organ transplantation, psyhiatrists are already part of the disriminatory ulture, and must rely on others to highlight injustie. Double disrimination, the oinidene of mental illness and ethni minority status, is another area where psyhiatry on its own will not effet hange (Browne in Heller et al, 1996). Psyhiatry in these and other areas must ollaborate with other fields in identifying problems and effeting enduring solutions. All available evidene onfirms the value of loal initiatives, and that means your ative partiipation. Whih would be worse the widespread redution of prejudie against people with mental illness without the partiipation of our speiality, or the maintenane, through disinterest, of the status quo? Please send new ideas for ombating stigma to: Liz Cowan, Changing Minds Campaign Administrator, Royal College of Psyhiatrists, 17 Belgrave Square, London SW1X 8PG.

7 Stigma of mental illness APT (2000), vol. 6, p. 71 Referenes Adorno, T. W., Frenkyl-Brunswik, D. J., Levinson, D. J., et al (1950) The Authorian Personality. New York: Harper and Row. Brugha, T. S., Wing, J. K., Brewin, C. R., et al (1993) The relationship of soial network defiits with defiits in soial funtioning in long-term psyhiatri disorders. Soial Psyhiatry and Psyhiatri Epidemiology, 28, Byrne, P. (1997) Psyhiatri stigma: past, passing and to ome. Journal of the Royal Soiety of Mediine, 90, Crandall, C. S. & Cohen, C. (1994) The personality of the stigmatizer: ultural world view, onventionalism and selfesteem. Journal of Researh in Personality, 28, Doherty, J. P. (1997) Barriers to the diagnosis of depression in primary are. Journal of Clinial Psyhiatry, 58, Eisenberg, L. (1995) The soial onstrution of the human brain. Amerian Journal of Psyhiatry, 152, Enright, SJ. (1997) Cognitive behavioural therapy linial appliations. British Medial Journal, 314, Farrell, L. (1999) That whih does not kill us will make us stronger. Irish Medial News, 21 June, p. 21. Fink, P. J. & Tasman, A. (1992) Stigma and Mental Illness. Washington, DC: Amerian Psyhiatri Press. Fisher, D. B. (1994) Health are reform based on a model of reovery by people with psyhiatri disabilities. Hospital and Community Psyhiatry, 45, Goffman, E. (1963) Stigma: Notes on the Management of Spoiled Identity. Engelwood Cliffs, NJ: Prentie-Hall. Green, D. E, MCormik, I. A, Walkey, F. H, et al (1987) Community attitudes to mental illness in New Zealand twenty-two years on. Soial Siene Mediine, 24, Hart, D. & Philipson, J. (1999) Changing media minds: A pratial guide. Psyhiatri Bulletin, 23, Heller, T., Reynolds, J. & Gomm, R. (1996) Mental Health Matters: A Reader. London: Mamillan. Holmes, P. & River, L. P. (1998) Individual strategies for oping with the stigma of severe mental illness. Cognitive and Behavioral Pratie, 5, Huxley, P. (1993) Loation and stigma: a survey of ommunity attitudes to mental illness: enlightenment and stigma. Journal of Mental Health UK, 2, Hyler, S. E., Gabbard, G. O. & Shneider, I. (1991) Homiidal manias and narissisti parasites: stigmatization of mentally ill persons in the movies. Hospital and Community Psyhiatry, 42, Lanet (1998) Can the stigma of mental illness be hanged? 352, Lewis, G. & Appleby, L. (1988) Personality disorder: the patients psyhiatrists dislike. British Journal of Psyhiatry, 153, Link, B. G., Struening, E. L., Rahav, M., et al (1997) On stigma and its onsequenes: evidene from a longitudinal study of men with dual diagnoses of mental illness and substane abuse. Journal of Health and Soial Behaviour, 38, MGuffin, P. & Martin, N. (1999) Behaviour and genes. British Medial Journal, 319, Phelan, J. C., Bromet, E. J. & Link, B. G. (1998) Psyhiatri illness and family stigma. Shizophrenia Bulletin, 24, Philo, G. (1996) Media and Mental Distress. New York: Addison Wesley Longman. Read, J. & Reynolds, J. (1997) Speaking Our Minds An Anthology. London: MaMillan. Royal College of Psyhiatrists (1999) Patient Advoay. Counil Report CR74. London: Royal College of Psyhiatrists. Thompson, M. & Thompson, T. (1997) Disrimination Against People with Experienes of Mental Illness. Wellington: Mental Health Commission. Townsend, J. (1979) Stereotypes of mental illness: a omparison with ethni stereotypes. Culture, Mediine & Psyhiatry, 24, Weiss, M. F. (1994) Children s attitudes toward the mentally ill: an eight-year longitudinal follow-up. Psyhologial Reports, 74, Wolff, G., Pathare, S., Craig, C., et al (1996a) Publi eduation for ommunity are. A new approah. British Journal of Psyhiatry, 168, ,,, et al (1996b) Community knowledge of mental illness and reation to mentally ill people. British Journal of Psyhiatry, 168, Multiple hoie questions 1. With regard to an individual s experiene of stigma: a he or she an do little to hange the reations of prejudied people b most psyhiatri patients will omplain diretly to their dotors of the effets of stigma on their lives the experiene of self-stigmatisation an be similar to negative automati thoughts or the negative ognitions desribed in depression d patients with either alohol problems or eating disorders are eah more likely to be blamed for their onditions than other patient groups e ourtesy stigma refers to strangers feeling pity for an individual. 2. The following statements are true about people who hold prejudied attitudes: a knowing someone with mental illness is assoiated with more benign attitudes to people with mental illness b people who do not blame the individual with mental illness are more likely to get involved in anti-stigma initiatives women show more benign behaviours to the stigmatised than men d parents with young hildren tend to show a greater understanding of the links between mental illness and violene e diret ontat with someone who has aute psyhosis helps generate greater understanding later on 3. Regarding researh on the effets of stigma: a the majority of researh has been arried out by psyhiatrists b there has been a marked inrease in stigmarelated publiations over the past 10 years stigma management is a onept first devised by soial workers d telling people they have shizophrenia is assoiated with an inrease in suiidal behaviour e teahing patients about the nature of bipolar disorder redues the number of mani relapses and improves soial funtioning overall.

8 APT (2000), vol. 6, p. 72 Byrne 4. With respet to stigma and the ourse of the illness and its treatment: a soial isolation is assoiated with a longer duration of depression b general pratitioners do not pereive themselves as being involved in the are of their patients with serious mental illness, partiularly if they are Blak Afrian, Blak Caribbean, or male studies of people who had ontat with psyhiatri institutions (USA), ompared to ontrols, show median ages of death of 66 and 76 respetively d measuring the attitudes of health professionals, patients with anorexia were seen as signifiantly less likeable than patients with shizophrenia, and as being responsible for their illness e sine the publiation of Goffman s Stigma in 1963, psyhiatrists have been at the forefront in ampaigns to identify and abolish stigma. 5. Researh on ommunity attitudes to mental illness (Green et al, 1987) show: a little or no hange over 22 years in negative attitudes to mental illness b attitudes to people with individual mental illnesses have shown more understanding as knowledge inreased, alongside phased ommunity are psyhiatrists are held in equally high esteem to dotors d to be an ex-mental patient arries a number of low positive ratings e stereotypial beliefs, suh as dangerous, worthless, weak and foolish, have persisted to the same degree over 22 years. MCQ answers a F a F a F a T a T b F b T b T b T b F T T T T F d T d F d F d T d T e F e F e T e F e T Faulty of General & Community Psyhiatry and The Collegiate Trainees Committee Joint Annual Meeting Sessions to be held on: Royal College of Psyhiatrists 9 th 10 th Marh 2000, Kensington Town Hall, London n n n Community Psyhiatry n Psyhiatry and Primary Care Psyhiatry in the A&E Department n Epidemiologial Studies in Psyhiatry Neuropsyhiatry and Neuropharmaology Also to inlude: THE WILLIAM SARGANT LECTURE Psyhopharmaotherapy in the ontext of ulture and ethniity Professor Keh-Ming Lin, UCLA Shool of Mediine, NIMH Researh Center on the Psyhobiology of Ethniity, USA If you require further details on the above meeting please ontat the Conferene Offie at The Royal College of Psyhiatrists on ext. 168, or by fax on