If we had a clear idea about the causes of people stigmatising mental illness then it would probably help us to do something about it, and perhaps reduce prejudice and discrimination. Unfortunately, it is not that simple.
The many causes of stigma
Notions that people with mental illness are sometimes unpredictable and perhaps dangerous to know seem to have been present throughout recorded history, and can still be witnessed in less well developed nations.[2,3] The rise of Christianity and the Muslim faith have sometimes been criticised for blaming sufferers and relating illness to sin, but religion is just as likely to have fostered caring attitudes. Some commentators have argued that the Industrial Revolution and The Enlightenment led to a ‘demonisation’ of insanity, but those social changes also led to attempts to understand and treat mental illness. Ultimately, many cultural forces may have contributed to a tendency to see the mentally ill as deficient in some way – whether in terms of their moral strength or their ability to contribute to society – but they also seem to have had at least some positive effects. Attitudes to mental illness are too complex to be simply attributed to one factor alone. It may even be that different factors contribute to varying extents in particular mental problems.
Fear! An additional factor which does not seem to be widely recognised is the general human tendency to be wary and sometimes afraid of the unknown. Human beings have a natural tendency to form bonds in relatively small groups and to be critical and suspicious of those outside the group. A fear of ‘the other’ would be exaggerated by any threat of aggression or violence, and exacerbate a tendency to avoid contact with people with mental illness. And avoidance of any feared stimulus reinforces the fear, because it prevents people getting used to whatever is feared.
These ideas and attitudes seem ingrained in our language, psyche, culture and history, such that it is difficult to see any simple way of banishing stigma. They do however suggest some ways ahead and are in fact in keeping with what we know helps to reduce stigma.
What helps reduce stigma?
Education about mental illness seems to have some benefits, but it is a relatively weak approach.[5,6] The beneficial effects of increased understanding and perhaps reduced fear from attending a lecture, reading a book or watching a film may also be transient at best. Medical students, for example, get quite a lot teaching about mental illness during their training but this seems to do little or nothing to impact upon the stigmatisation of mental illness amongst medical students and doctors. Medical attitudes to the mentally ill seem if anything to be worse than in the general population, perhaps reinforced by a medical ‘machismo’ and tendency to deny their own problems.
Worse, some education may actually be counterproductive. There are suggestions for example that the “Just Say No” campaign against illegal drugs, by educating people that many of these drugs are relatively safe, may have actually encouraged them to try them. There are also hints from a couple of studies that helping people to appreciate the experience of auditory hallucinations, or that schizophrenia has some biological causes, can increase understanding but also increase the distance that people want to maintain between themselves and those with schizophrenia.[8,9]
What seems to work the best, and possibly longest, in keeping with the fear and social distancing idea described above, is contact with people with mental illness. Social contact may help folk to appreciate that those with mental illness are ordinary people – who may just have been unfortunate or unlucky (“there but for the grace of God go I”).
People with mental illness also stigmatise themselves and their condition.[10,11] This “self-stigma” reduces the chances that they will seek treatment or take part in everyday activities and reduces their chances of recovery. By staying in and avoiding social contact they also miss the opportunity to introduce themselves to others and thus reduce stigma. Tackling self-stigma may therefore may be just as important, or even more so, as tackling “other stigma”.
 Rosen G. Madness in society. Routledge & Kegan Paul, London, 1968.
 Murphy JM. Psychiatric labelling in cross-cultural perspective. Science 1976; 191: 1019-28. http://www.ncbi.nlm.nih.gov/pubmed/1251213
 Mental health for sustainable development. UK’s All-Party Parliamentary Group on Global Health and Mental Health, 2014. http://www.appg-globalhealth.org.uk/
 Westerink H. Demonic possession and the historical construction of melancholy and hysteria. History of Psychiatry 2014; 25: 335-49. http://www.ncbi.nlm.nih.gov/pubmed/25114148
 Clement S, et al. Mass media interventions for reducing mental health-related stigma. Cochrane Database Systematic Reviews 2013; 23: CD009453. http://www.ncbi.nlm.nih.gov/pubmed/23881731
 Griffiths KM, Carron-Arthur B, Parsons A, Reid R. Effectiveness of programs for reducing the stigma associated with mental disorders. A meta-analysis of randomized controlled trials. World Psychiatry 2014; 13: 161-75. http://www.ncbi.nlm.nih.gov/pubmed/24890069
 Henderson, C et al. Mental health-related stigma in health care and mental health-care settings. Lancet Psychiatry 2014; 1: 467 – 482.
 Ando S, Clement S, Barley EA, Thornicroft G. The simulation of hallucinations to reduce the stigma of schizophrenia: a systematic review. Schizophrenia Research 2011; 133: 8-16. http://www.ncbi.nlm.nih.gov/pubmed/22005017
 Kvaale EP, Gottdiener WH, Haslam N. Biogenetic explanations and stigma: a meta-analytic review of associations among laypeople. Social Science and Medicine 2013; 96: 95-103. http://www.ncbi.nlm.nih.gov/pubmed/24034956
 Gerlinger G,et al. Personal stigma in schizophrenia spectrum disorders: a systematic review of prevalence rates, correlates, impact and interventions. World Psychiatry 2013; 12: 155-64. http://www.ncbi.nlm.nih.gov/pubmed/23737425
 Clement S, et al. What is the impact of mental health-related stigma on help-seeking? A systematic review of quantitative and qualitative studies. Psychological Medicine 2015; 45: 11-27. http://www.ncbi.nlm.nih.gov/pubmed/24569086