Schulze 2007

International Review of Psychiatry, April 2007; 19(2): 137–155
Stigma and mental health professionals: A review of the evidence

on an intricate relationship*
BEATE SCHULZE
Department of General and Social Psychiatry, University of Zurich, Zurich, Switzerland
Abstract
In the past decade, mental health professionals have initiated a number of national and international efforts against the
Int Rev Psychiatry Downloaded from informahealthcare.com by CDL-UC Berkeley on 10/28/14
stigma of mental illness. While largely successful in beating stigma and discrimination, these programmes have, in part, been
criticized to be largely uninformed by the lived realities of people with mental illness and their families. Some critics claimed
that anti-stigma efforts led by mental health professionals were in fact a concealed attempt at de-stigmatizing psychiatry itself
as a profession. This paper will attempt to throw light on the various ways in which mental health professionals are
‘entangled’ in anti-stigma activities. It will outline the complex relationships between stigma and the psychiatric profession,
presenting evidence on how its members can simultaneously be stigmatizers, stigma recipients and powerful agents of de-
stigmatization. In exploring the role of mental health professionals as targets of stigma, new findings will be presented on the
role of stigma as a professional stressor in psychiatry. Conclusions will be drawn on how the pursuit of professional self-
interest can be a legitimate goal of anti-stigma programmes. Further, ways in which acknowledging psychiatry’s own agenda
can contribute to both credibility and success of fighting stigma from within psychiatry will be discussed.
For personal use only.
Keywords: Stigma, attitudes, public images, mental health professionals, burnout, psychiatry, anti-stigma programmes
Introduction stigma . . . , introduce or scrutinize disability rights

legislation, and provide and mainstream mental
The stigma of mental illness and discriminatory health care . . . in easily accessible settings’ (World
behaviour ensuing from it have been widely recog- Health Organization, 2005).
nized as serious obstacles to the life chances of people The need to fight stigma and discrimination has
with mental illness, access to mental health services also been acknowledged by the psychiatric profes-
as well as to advances in psychiatric treatment. sion. In fact, many programmes to combat the stigma
(Byrne, 2000; Sartorius, 2004; Schulze & of mental illness were initiated by professional bodies
Angermeyer, 2003). Stigma has further been found of psychiatrists and other health professionals.
to have substantial public health implications: it may Examples include national programmes such as the
exacerbate stress and its health consequences, Changing Minds Campaign by the Royal College of
reinforce differences in socio-economic status Psychiatrists in the UK (Crisp, 2000), the PSYKE-
and associated health risks, delay appropriate help- Campaign in Sweden (Handikappombudsmannen,
seeking, or terminate treatment for treatable 2001) and the national mental health charity SANE
health problems (Link & Phelan, 2006; Weiss Australia (Hocking, 2003), as well as international
& Ramakrishna, 2001). Based on these insights, efforts such as the World Psychiatric Association’s
eliminating stigma has been taken on board as a Global Programme against Stigma and
central target in national and international health Discrimination because of Schizophrenia (Sartorius
policy, such as by the 2005 WHO European & Schulze, 2005; World Psychiatric Association,
Ministerial Conference on Mental Health in 1998). These programmes shared common aims in
Helsinki. The latter produced an Action Plan that seeking to (1) increase the awareness and knowledge
explicitly proposes to ‘instigate activities to counter of mental illness and treatment options, (2) improve
Correspondence: Beate Schulze, MA, Department of General and Social Psychiatry, University of Zurich, Militaerstrasse 8, PO Box 1930, CH-8021, Zurich,
Switzerland. Tel: þ41-44-296 7370. Fax: þ41-44-296 7409. E-mail: beate.schulze@bli.unizh.ch
* An earlier version of this paper was presented as part of the Symposium ‘Off the beaten track. Hidden issues in stigma research’ at the 14th European Congress
of Psychiatry, Nice 4–8 March 2006.
ISSN 0954–0261 print/ISSN 1369–1627 online ß 2007 Informa UK Ltd.
DOI: 10.1080/09540260701278929
138 B. Schulze
public attitudes towards people with mental illness interrelation with stigma, giving an overview of key
and their families and (3) generate action to findings on each of the facets identified.
eliminate discrimination and prejudice. Results will be presented on the ways in which
Many of these anti-stigma initiatives were met with those working in the mental health field may
considerable success in achieving their objectives. (unwittingly) contribute to creating and reinforcing
Outcomes include an increased public awareness and mental health-related stereotypes, as well as to
improvements in attitudes towards mental illness, a dispelling stigma and discrimination. The paper
reduction of barriers to psychiatric treatment as well will further examine published as well as original
as improved stigma management skills and self- data on the ways in which psychiatrists, too, are
esteem among people with mental illness (Corrigan targets of stigmatization. Conclusions will be drawn
& Lundin, 2001; Crisp, Cowan, & Hart, 2004; concerning how pursuing professional self-interest
Sartorius & Schulze, 2005; Schulze, Richter- can be a legitimate goal of anti-stigma programmes
Werling, Matschinger, & Angermeyer, 2003). and acknowledging psychiatry’s own agenda can,
Compared with the situation in the mid-1990s, in essence, contribute to both the credibility and
when most of these anti-stigma programmes were success of fighting stigma from within psychiatry.
initiated, formerly almost exclusively negative social

representations of mental illness have been comple-
Mental health professionals as stigmatizers
mented with new, more realistic dimensions. Thus,
these efforts successfully challenged some of the At the outset, evidence will be presented as to how
central myths about mental health problems such as mental health professionals may contribute to exactly
personal responsibility, untreatability, and a progres- the stereotypes and discrimination they are fighting
sively negative course (Hayward & Bright, 1997). to eliminate in their anti-stigma efforts. This issue
Experience from these anti-stigma programmes only recently received wider attention in research and
clearly shows how psychiatric professionals can professional debates, revealing unexpected, if not
successfully champion processes of social change. surprising findings (Byrne, 2000; Lauber, Nordt,
Despite their clearly recognizable impact, however, Braunschweig, & Rossler, 2006a; Nordt, Rössler,
anti-stigma programmes originating from within the & Lauber, 2006; Sartorius, 2002; Schulze &
psychiatric profession have variously been criticized Angermeyer, 2003). Long neglected in attitude
to actually be a concealed attempt at raising research, it was perhaps a study of stigma from the
the profile of psychiatry itself rather than being perspective of people with schizophrenia that first
predominantly about improving the situation of indicated in which ways attitudes and routine
those suffering from mental health problems. practices of psychiatrists may be experienced as
Critics have challenged the official goals of stigmatizing by those in their care (Schulze &
anti-stigma programmes by maintaining that, in Angermeyer, 2003). Findings on the perceptions of
fact, the latter are about promoting a positive image stigma by people with mental illness will be presented
of psychiatric care and expertise as well as increasing first, followed by evidence from attitude studies
the utilization of mental health services (Pilgrim & and indications of an emerging professional self-
Rogers, 2005), and about reinforcing the view of the awareness with respect to psychiatry’s contributions
‘needy patient’ by claiming that users primarily need to stigma.
professional guidance in coping with or fighting
stigma (Gombos, 2006). Finally, professionally led
Stigma experiences of people with mental illness and
anti-stigma programmes have been contested for
their families
having a blind spot in that they focus on everybody
else’s attitudes but psychiatrists (Chaplin, 2000; A focus group study enquiring stigma perceptions of
Corker, 2001). people with schizophrenia and their families (ibid.)
This paper aims at reviewing the evidence on used a general opening question to elicit situations
the complex interplay between stigma and mental in which those questioned felt misunderstood or
health professionals. To locate relevant studies, the excluded due to the illness. Results revealed that
databases Ovid Medline and PsycINFO, as well as exclusion and discrimination not only occurred in
the academic search machine Google Scholar were the context of social relationships with friends,
scanned for relevant publications, using the search relatives, colleagues or employers, but also in the
terms ‘Stigma* OR Attitudes* OR Media* OR contact with mental health professionals. In fact,
Film*’ in combination with ‘Mental health profes- stigma related to mental health care accounted for
sionals* OR Psychiatrists* OR Psychiatr*’. A sys- nearly one quarter (22.3%) of all stigma experiences
tematic review of the vast body of research on the reported (Figure 1).
issue is beyond the scope of this paper. Rather, In their relationship with mental health profes-
it outlines the different aspects of psychiatry’s sionals, patients felt stigmatized by a lack of interest
Stigma and mental health professionals 139
Social exclusion/Lack of understanding 16.9
Contact with mental health professionals 11.3
Quality of mental health services 11
Limited access to employment 8.9
Assignment of guilt/own responsibility 8.9
Negative media representations 6.8
Lack of knowledge and informa tion 6.2

Insecurity and fear 5.9
Secrecy 4.1
Unequal treatment of mental and physical 4.1

illness
0 5 10 15 20 25%
(% of stigma experiences mentioned)

Figure 1. The 10 most frequent stigma experiences of service users and families (n ¼ 54).
in their person and the history of their mental health self-esteem, which further complicated social
problem. They expressed a general feeling that there interaction and efforts to establish new social
is only one standard psychiatric treatment for every- contacts as a large share of previous social network
one, mainly consisting in ‘experimenting with the type ties had been dissolved.
and dosage of drugs’. Focus group participants further These findings were mirrored in further qualitative
criticized that a psychiatric diagnosis is often given studies on service users’ perceptions of stigma
with a negative prognosis such as ‘You’ve got (Pinfold, Byrne, & Toulmin, 2005; The Royal
schizophrenia, you will be ill for the rest of your life’ or College of Psychiatrists, 2002; Walter, 1998). Here,
‘Your illness means that you will end up committing too, people with schizophrenia highlighted the role of
suicide’. These statements were perceived as disheart- psychiatric labelling as a factor in the stigma process
ening and as reducing patients to their illness-related and described the poor quality of mental health
deficits. In addition, family members noted that, services as discriminatory. Above all, users empha-
during in-patient treatment, patients did not get size a need for out-patient services and a focus on
the personal attention they needed, ‘craving for prevention and rehabilitation rather than mainly on
personal contacts with someone other than their fellow- reducing acute symptoms. In their eyes, adequate
patients’, while doctors and nurses were ‘sticking to psychiatric treatment should involve users in all
work to rule’. relevant decisions and develop a comprehensive
In addition, those questioned feel that providers treatment plan taking into account the difficulties
do not sufficiently inform them about the treatment which those with schizophrenia face outside the
they receive, nor about options for follow-up care hospital, in their everyday lives. In addition, they
in the community. Medication side effects, such feel that providers should be aware of the
as extrapyramidal symptoms and weight gain, potentially stigmatizing effects of their own practice.
further contribute to stigma and discrimination. A questionnaire study also found that people
Users described that these visible signs of the disease with mental illness experience structural discrimina-
(or its treatment) led them to avoid social contacts as tion through disadvantages regarding psychiatric
they were no longer capable of concealing the illness, treatment or rehabilitation measures, though this
and thus dissolved what was perceived as protection aspect of stigma was endorsed less frequently
against a priori devaluation in interaction situations. (Holzinger, Beck, Munk, Weithaas, & Angermeyer,
In addition, side effects adversely affected their 2003).
140 B. Schulze
These results would suggest that psychiatry itself Studies investigated four facets of attitudes:
must be an important target of anti-stigma activities –
1. beliefs about mental illnesses (esp.
a focus that up to the present has only played a
expectations on their prognosis and long-term
marginal, if any, part in fighting stigma. Reasons
outcome, assessments of severity, treatment
for this may be manifold. For one, providers’
recommendations and attitudes to community
motives, treatment philosophies and practices serve
care)
an important function is stabilizing their professional
2. attitudes towards people with mental illness
self-concept as well as personal identity. As a
(esp. the presence of stereotypes and the desire
consequence, they are not routinely reflected in
for social distance)
evaluating treatment effectiveness and quality
3. opinions on the civil rights of those with mental
of care. Rather, expert knowledge and scientific
health problems and their restriction, and
standards are consulted in monitoring professional
4. clinician behaviour in the context of
activity, which may lead to a blind spot with regard to
patient contacts (esp. the use of diagnostic
negative consequences on one’s own action. Results
labels and the content of client-provider
of the above qualitative studies appear to lend
communication).
support to criticisms claiming that such a selective
lack of attention also exists in the context of anti- With regard to beliefs about mental illness, the
stigma efforts. studies reviewed leave us with an inconsistent
picture.
Two studies (Kingdon, Sharma, & Hart, 2004;
Mental health professionals’ attitudes towards people
Lauber, Anthony, Ajdacic-Gross, & Rossler, 2004)
with mental illness
investigated psychiatrists’ views towards psychiatric
The following section gives an overview of studies on treatment in the community, both revealing wide-
provider attitudes towards people with mental illness ranging support for community mental health
and their condition. Indications are discussed as to ideologies.
whether and to what extent stigma perceptions of Four studies investigated treatment recommenda-
service users and families are mirrored in the actual tions and outcome beliefs. Kingdon et al. (2004)
attitudes of psychiatrists and other mental health conducted a mail survey among 2813 members of
professionals. the Royal College of Psychiatrists in the UK. Using
As stated earlier, the attitudes of mental health a specially developed questionnaire on schizophre-
professionals have only recently become a focus of nia and its management, the authors found that
stigma research. The vast majority of the literature on most psychiatrists believe that the illness would
attitudes towards mental health and illness has been improve as the result of psychiatric treatment.
dealing with the general public – aiming to under- Further, many of those questioned took a critical
stand public opinion as part of implementing stance toward dosing antipsychotic medication
psychiatric care in the community (Rossler, above recommended limits and the excessive use
Salize, & Voges, 1995; Wolff, Pathare, Craig, & of polypharmacy. However, despite their optimistic
Leff, 1996), to improve the population’s attitudes treatment beliefs, psychiatrists were ambivalent as to
and mental health literacy (Jorm, 2000; Thompson whether patients would eventually recover.
et al., 2002), as well as to develop evidence-based Magliano et al. (2004a) and Magliano et al.
strategies for changing stereotypical views and (2004b) studied beliefs about schizophrenia among
reducing social distance (Angermeyer, Corrigan, & 190 mental health nurses and 110 psychiatrists in a
Matschinger, 2004; Corrigan et al., 2001; Penn random sample of mental health services in Italy.
et al., 1994). Results reveal that both professional groups are
A recent review this body of research reports 65 equally well informed about schizophrenia and had
population surveys assessing public attitudes over positive treatment expectations. Contrasting these,
the last 15 years (Angermeyer & Dietrich, 2006). however, 40% of the professionals held it comple-
Considering that the authors only included studies tely or partly true that ‘there is little to be done for
based on representative or quota samples of the these patients apart from helping them to live in a
general population that enquired a broad range of peaceful environment’ (Magliano et al., 2004b).
beliefs, the magnitude of research into public attitudes Also, only 2% believed in the complete recovery
can be expected to be significantly larger. By contrast, of schizophrenia patients. On a positive note,
this current review identified only nine surveys of the majority of those questioned supported collab-
mental health professionals’ attitudes. If the same orative treatment relationships, agreeing that
rigorous methodological criteria were applied, their patients should be informed about diagnosis as
number would be reduced to four. Each of these well as treatments and their side effects. From these
studies resulted in several publications. two surveys, it emerges that mental health
professionals, on the whole, hold positive beliefs people with mental illness. Two measures are used
regarding treatment outcomes in schizophrenia. to document these: stereotypical beliefs and the
Other studies, however, found the opposite. desire for social distance, i.e. the readiness to engage
A national survey of 2737 Australian mental health in a range of social relationships with someone
professionals revealed that providers tend to be suffering from a mental health problem.
rather negative about treatment outcomes and Stereotypes were investigated in six studies.
prognosis of schizophrenia and depression Two suggest that psychiatrists tend to reject
(Caldwell & Jorm, 2001). In this, psychiatrists were negative attributes such as dangerousness, individual
found to give the most pessimistic ratings, followed responsibility for the illness (Kingdon et al., 2004)
by GPs, clinical psychologists, and mental health and unpredictability (Magliano et al., 2004b).
nurses. At the same time, all professional groups Compared to mental health nurses, psychiatrists
endorsed the assumption that those with schizophre- were found to hold more positive views (ibid.).
nia and depression would be discriminated against by On the other hand, three studies document that
others (‘most people’) (ibid.; Ücok, Polat, Sartorius, mental health professionals subscribe to negative
Erkoc, & Atkinson, 2004). This may hint at a high stereotypes. In a Swiss study (Lauber et al., 2004;
awareness of stigmatizing attitudes present among Nordt et al., 2006), professionals consistently judged
the public, but also, as in the Perceived Stigma Scale negative characteristics to be more typical of people
by Link, Mirotznik, & Cullen (1991), may be with mental illness than positive ones. Psychiatrists
an indicator of mental health professionals’ own held more negative stereotypical views than any other
attitudes. Pessimistic outcome beliefs were also professional group (nurses, other therapists
evident in a survey among Austrian mental and psychologists). Two descriptive studies further
health professionals (n ¼ 89) and their patients with document the presence of negative opinions. Also in
schizophrenia (n ¼ 24) (Rettenbacher, Burns, Switzerland, Domingo and Baer (2003) report
Kemmler, & Fleischhacker, 2004). Asked to rate experiences from daily practice in vocational rehabi-
the severity of schizophrenia in comparison with litation. They argue that case managers (mainly
serious physical disorders such as diabetes, cancer or social workers) may reinforce negative notions by
epilepsy, professionals were less likely than patients aiming to train their clients for ‘normality’, thus
to judge these physical conditions to be worse than devaluing mental illness. In addition, an overall
schizophrenia. In addition, the study indicates orientation in rehabilitation towards achievement
that professionals hold ambivalent views towards may result in unrealistic expectations, potentially
psychotropic medication: while they perceive phar- leading clients to quit programmes due to feelings of
macotherapy to be helpful for their patients, only resignation. In a survey among their colleagues, they
71.4% of psychiatrists and 35% of non-medical further discerned that the latter tend to ascribe
professionals would be willing to take anti-psychotics unsuccessful attempts at vocational integration pre-
themselves if they were to suffer from schizophrenia. dominantly to their clients’ lack of willpower or
The Italian study (Magliano et al., 2004b) found motivation to work. Research surveying the attitudes
similar indecision as to the benefits of pharmacolo- of Australian mental health nurses towards
gical treatments: they were recommend by most Borderline Personality Disorder (BPD) shows that
professionals, while only 28% believed in their ‘total the majority of them perceived patients with BPD as
usefulness’. Doubts as to the helpfulness of psychi- manipulative, 30% state that they tend to make them
atric treatment methods, in particular regarding the angry (Deans & Meocevic, 2006). Results from the
clinical management of depression, were also Italian attitude survey (Magliano et al., 2004b) signal
expressed by mental health professionals in a Swiss that professionals may endorse the view that people
study (Lauber et al., 2005). with mental illness are dangerous, as 66% of them
Finally, several surveys (Jorm, Korten, Jacomb, agreed that psychiatric hospitals are more similar to
Christensen, & Herman, 1999; Magliano et al., prisons than to hospitals. Lastly, the UK study that
2004b; Nordt et al., 2006) tested the ability to reports psychiatrists’ attitudes to be ‘substantially
recognize depression and schizophrenia in a vignette more favourable’ than those of the general public
study, randomly presenting cases of either illness or a admits ‘individual, but important, exceptions’, such
‘non-case’ of a person in a difficult living situation. as their agreement with the stereotype of unpredict-
The vast majority (74–90%) of mental health ability (Kingdon et al., 2004).
professionals identified the cases correctly. Social distance refers to behavioural intentions
However, Nordt et al. (2006) found that one in ensuing from negative stereotypes (Link & Phelan,
four psychiatrists and clinical psychologists also 2001). These were investigated in three studies, two
considered the ‘non-case’ to be mentally ill. using adapted versions of Link, Phelan, Bresnahan,
A second research focus in studying mental health Stueve, & Pescosolido (1999) social distance scale
professional’s beliefs are their attitudes towards (Lauber et al., 2004; Nordt et al., 2006; Van Dorn,
142 B. Schulze
Swanson, Elbogen, & Swartz, 2005), and one a set of with good practice statements and clinical guidelines
specially devised questions (Ücok et al., 2004). The (APA, 1994), as the authors (Clafferty et al., 2001)
latter found that about half of the psychiatrists point out. This picture is contrasted by the UK study
questioned would rather not visit a patient in his or (Kingdon et al., 2004) which found that clinicians
her home and expressed discomfort when meeting a talked to patients about diagnosis, causation and
patient at a social event. The other two studies indicate family relationships. However, they paid less atten-
that professionals display a similar or even greater tion to financial matters, accommodation and leisure
social distance (in the case of psychiatrists) as com- activities – exactly the kind of everyday-life problems
pared to the general public. Also, one exception to the that many service users are keen to address with their
general support of community care has been observed: psychiatrist (Kilian et al., 2003; Schulze &
psychiatrists showed least disagreement with the Angermeyer, 2003).
statement that the presence of mental health facilities The majority of studies addressed professionals’
has a negative impact on property values in the attitudes in comparison with those of the general
area concerned – alluding to a NIMBY (not in my public (see overview in Table I). Findings reveal a
backyard) phenomenon regarding their attitudes complex picture, with providers holding partly more
(Lauber et al., 2004). positive, similar or more negative opinions. It is

A further attitudinal dimension studied are profes- striking, though, that nearly three quarters of the
sionals’ views concerning the acceptance of restric- relevant publications report that beliefs of mental
tions to the civil rights of people with mental illness. health providers do not differ from those of the
Restrictions assessed include exclusion from the right population, or are even more negative (Table II).
to vote, withdrawal of the driving licence, and This contradicts the hypotheses of most studies that
limitations to the ability to get married or have had expected more favourable attitudes due to
children (Magliano et al., 2004b; Nordt et al., 2006; professionals’ knowledge about mental disorders
Zogg et al., 2003). Findings concur in concluding and their daily contact with those suffering from
that mental health professionals show little approval them (e.g. Lauber et al., 2004). Furthermore,
of these limitations on patients’ civil rights. There is professionals come off better than the public mainly
one exception, however: the possibility of involuntary with regard to attitudes towards psychiatric treat-
admission and treatment is supported by the majority ment and patients’ civil rights, whereas they appear
of those working in the mental health sector (Lepping generally in line with negative public views concern-
et al., 2004; Nordt et al., 2006; Zogg et al., 2003). ing explicit components of the stigma process such as
Beliefs on this restriction, then, were studied in stereotypes and social distance, that have a significant
relation to vignettes depicting individuals in partic- negative impact on the lives of those with mental
ular circumstances, such as representing a danger to illness beyond the treatment context. Unfortunately,
self and others. Moreover, professionals not directly positive views such as mental health professionals’
involved in the legal procedures related to these better knowledge about mental illness and their
measures, such as psychologists and social workers, support for individual rights do not act as a
and those who had suffered from mental health protective factor against stigma, as they are neither
problems themselves, were less likely to be in favour associated with fewer stereotypes nor a greater
of taking action against patients’ will. (ibid.) willingness to closely interact with people with
The fourth facet of research on professionals’ mental illness (Lauber, Nordt, & Rossler, 2006b;
attitudes refers to the behaviour of practitioners in Nordt et al., 2006).
clinical communication. Particular attention is paid Upon first reading, a large share of studies on
to the question as to whether psychiatrists inform mental health professionals’ beliefs about mental
patients of their diagnosis. In the case of schizo- illness hardly produce surprising findings. As one
phrenia, about half of those questioned (43–49%) would expect of people working in the mental health
stated that they did not do so (Ücok et al., 2004), field, they are well-informed about their patients’
unless they were specifically asked (Clafferty et al., illnesses and evaluate their own interventions posi-
2001). If sharing their diagnosis, 15% reported they tively. With respect to other attitudinal components,
would not use the term ‘schizophrenia’, but rather however, findings suggest a less unequivocal picture.
provided a range of confusing terminology such as Corrigan (2002) proposes three criteria for positive
mental breakdown, serious nervous illness, or sick- provider attitudes: (1) focus on recovery, not poor
ness of the mind. (ibid.) Asked for the reasons to prognosis; (2) replacing coercive treatment with
withhold the diagnosis, psychiatrists expressed a collaboration; and (3) support for community-
concern that patients would not understand the based services. He argues that these attitudes were
meaning of the term schizophrenia, or that they conducive to improving mental health outcomes as
expected them to drop out from treatment (Ücok collaborative treatment relationships facilitate better
et al., 2004). This ‘conspiracy of silence’ is not in line use of medications, psychotherapeutic interventions
Table I. Comparison studies between attitudes of mental health professionals and the general public – overview.
Authors Study participants Attitude measures Diagnoses Country
General public (n ¼ 2031) Beliefs about Schizophrenia, Australia

Jorm et al., 1997; Professional Groups: - Prognosis Depression
Jorm et al., 1999; GPs (n ¼ 827), psychiatrists - Treatment outcomes
Caldwell & Jorm, 2001** (n ¼ 1128) clinical - Helpfulness of treatment
psychologists and mental interventions
health nurses (n ¼ 328) - Discrimination
General public (n ¼ 1737) - Attitudes to community care Schizophrenia UK
Kingdon et al., 2004** Psychiatrists (n ¼ 2813) - Questions about the illness
and its management
General public (n ¼ 1737) - Recognition of the illness Schizophrenia, Switzerland
Lauber et al., 2004; Professional groups: - Stereotypes Depression
Lauber et al., 2006; Psychiatrists (n ¼ 518), - Social Distance
Nordt et al., 2006** nurses (n ¼ 2250), - Beliefs about civil rights
psychologists (n ¼ 67) - Attitudes to community care

and other therapists
(n ¼ 117)
General public (n ¼ 714) Beliefs about Schizophrenia Italy
Magliano et al., 2004b** Professional groups: - Causes
Nurses (n ¼ 190), - Treatment outcomes
psychiatrists (n ¼ 110) - Civil rights
- Ability to perform in social and
occupational roles
General public (n ¼ 59) - Stereotype of violence Schizophrenia North Carolina,
Van Dorn et al., 2005 Professional groups: - Social distance USA
Psychiatrists, psychologists - Causal beliefs

and clinical social
workers (n ¼ 85)
Lay people (n ¼ 389) - Attitudes to involuntary Not specified Germany and
Lepping et al., 2004 Professional groups: admission and treatment England
Psychiatrists (n ¼ 167),
other doctors (n ¼ 54),
nurses (n ¼ 117),
psychologists (n ¼ 36),
social workers (n ¼ 72)
and lawyers (n ¼ 19)
**Representative or random population survey; complete survey of professional organisations or mental health services.
Table II. Comparison studies – summary of results.
Result Times found Type of attitudes concerned
Professionals more positive 6 Patients’ civil rights , prognosis3, attitudes to community care 2,3,
1
than population stereotypes7; helpfulness of psychiatric treatments vs. natural remedies4

No difference between professionals 9 Social distance1,2,8, stereotypes7,8, attitudes to involuntary treatment9,
and population patients’ civil rights7, perception that mental illness and physical illness
are different7, agreement with informing patients about diagnosis and treatment*7
Professionals more negative 7 Stereotypes1, social distance1, prognosis/treatment outcomes5,6,7,
than population likelihood of discrimination5,6
1
Nordt et al., 2006; 2 Lauber et al., 2004; 3 Kingdon et al., 2004; 4 Jorm et al., 1997; 5
Jorm et al., 1999; 6
Caldwell & Jorm 2001;
7
Magliano et al., 2004b; 8 Van Dorn et al., 2005; 9 Lepping et al., 2004.
* Positive attitude.
as well as rehabilitation services. Measured against than in institutions (Kingdon et al., 2004; Lauber
this yardstick, one could state that mental health et al., 2004). Further, clinicians display a broad
professionals are moving towards empowering awareness of stigmatizing attitudes and discrimina-
notions of the client–provider relationship. They tory behaviour and include challenging them firmly
strongly support service in the community rather on their professional agenda (Jorm et al., 1999;
144 B. Schulze
Sartorius, 1998; Ücok et al., 2004). On the other professionals reinforcing and contributing to nega-
hand, attitude research suggests that many promote tive beliefs and stigma around mental illness. Finally,
an approach that suggests poor prognosis (Caldwell the fact that mental health professionals’ attitudes
& Jorm, 2001; Jorm et al., 1999; Kingdon et al., largely do not differ from negative public conceptions
2004; Rettenbacher et al., 2004) which they may of mental illness suggests a need to include our own
inadvertently convey in the course of client–provider profession as an important target group in anti-
communication, contributing to self-stigma among stigma efforts.
service users (Corrigan, 2002). Also, mental health
professionals seem to share public concerns about
Professional self-awareness
violence and dangerousness (Van Dorn et al., 2005;
Nordt et al., 2006), which becomes reflected in their This being said, mental health professionals are
support for mandatory treatments (Lauber et al., beginning to show an increasing awareness of their
2004; Lepping et al., 2004). potential contribution to creating and perpetuating
Beyond Corrigan’s model, one of the studies the stigma of mental illness. Colleagues observed that
reviewed lends support to concerns about the psychiatrists play a part in stigmatization through the
potentially damaging consequences of psychiatric careless use of diagnostic labels, using treatments
labelling (Nordt et al., 2006). In the case of that produce significant and visible side effects,
schizophrenia, the latter has been shown to elicit giving a negative prognosis, through working in a
beliefs that those affected by the illness are dangerous system that allows involuntary commitment, as well
and unpredictable, which, in turn, resulted in as through insufficient political advocacy for the
negative emotional reactions and an increased rights of the mentally ill and sufficient resources to
desire for social distance (Angermeyer & provide the best treatment (Beales, 2001; Byrne,
Matschinger, 2003). Through their training and 2000; Chaplin, 2000; Corrigan, 2002; Corker, 2001;
indeed their excellent mental health literacy, mental Hocking, 2003; Sartorius, 1998; Sartorius, 2002). In
health professionals may have sharpened their view addition, most authors of the emerging field of
on human suffering, looking at it through the research into provider attitudes identified a need to
diagnostic lens in order to identify familiar criteria be aware of professionals’ own beliefs and their
in somebody’s ailments that will allow them to bring detrimental consequences (cf. Caldwell & Jorm,
forward their specific expertise to help the person 2001; Clafferty et al., 2001; Lauber et al., 2004;
concerned. However, if these labels evoke negative Magliano et al., 2004b).
outcome expectations in the clinician, this is dis- Comments from within psychiatry thus confirm
couraging for both the patient hoping to get better, research results on users’ stigma experiences and
and the practitioner him- or herself, who is striving professionals’ attitudes. Yet, at the same time, they
for therapeutic success, while actually not quite mark the beginning of a critical movement from
believing in it. This negative outlook inherent in within the discipline. In fact, it was already prior to
the helping relationship has been found to contribute the advent of psychiatry-led anti-stigma programmes
to burnout (Maslach, 1982; Schaufeli & Enzmann, that mental health professionals addressed their
1998) – with damaging consequences both for potential to both stigmatize and de-stigmatize
mental health professionals’ health and quality of (Schlosberg, 1993). This first article was soon to be
care. The critical stance taken on the possibility for followed by a proliferation of journal contributions
those with schizophrenia to fully recover, then, could advocating a start to combating stigma from the
also reflect realistic evaluations based on clinical vantage point of psychiatrists’ own practice. This
experience, such as ‘revolving door patients’, lack of nurtures the hope that this movement is gathering
co-operation in treatment, or potentially confronta- momentum and may eventually be mainstreamed
tional and aggressive situations, involving a need to in mental health care.
restrain patients (Reid et al., 1999). These negative In all, based on evidence from different perspec-
aspects of clinical work, however, may bias mental tives, it can be established that mental health
health professionals towards patients’ deficits and professionals contribute to stigmatizing notions of
problems, while longitudinal research on schizophre- mental illness through different aspects of profes-
nia outcomes would support far more positive sional attitudes and behaviours.
evaluations (Harding, 1988).
In sum, findings indicate that, while mental health
Mental health professionals as stigma
providers are well informed about mental illness,
recipients
they nevertheless do not always hold positive
opinions about the conditions and the people they The other side of the coin is that psychiatrists and
treat. Thus, the evidence appears to support service their discipline are also targets of stigma and
users’ and carers’ concern about mental health discrimination. Evidence will be presented from
research on media portrayals, mental health profes- challenges their professional identity, not least as
sionals’ own accounts of encountering stigma, the their work is portrayed as an unworthy vocation
role of stigma as a professional stressor, medical requiring little skill or expertise (Roth Edney, 2004).
students’ attitudes towards psychiatry, on the mar-
ginal position psychiatry occupies when it comes to Ineffective Treatments. In the media, there is also the
the distribution of resources in healthcare, and one frequent suggestion that mental illnesses do not get
recent observation. better with treatment (Wahl, 1995). In particular,
this becomes reflected in debates surrounding the
implementation of community care policies and the
Media representations of psychiatrists and psychiatric
supposed danger posed by patients who have been
treatment
returned to share ‘our urban space’ in their wake
Stereotypes of psychiatrists. ‘Homicidal maniacs and (Barham, 1997). These took particularly ferocious
narcissistic parasites’ (Hyler et al., 1991) – these are dimensions in the UK, where the press gave
just two common stereotypes applied to people extensive coverage to homicides perpetrated by
with mental illness in film and entertainment psychiatric patients and staged these incidents as
media. Further movie images that contribute to evidence for the failure of mental health care in the
the stigmatization of those experiencing mental community. These press reports did not only attack
health problems include the ‘rebellious free spirit, . . . the policies, but held psychiatrists responsible for
seductress, enlightened member of society, . . . being unable to manage the ‘dangerous individuals’
and zoo specimen’ (ibid.). Changing these media in their care, casting them as ‘overpaid incompetents’
representations has been an important goal in most (Ojo, 2002). Apart from calling the effectiveness of
anti-stigma programmes. community-based psychiatry into question, the
Mental health professionals, their treatments and moral panic scenario created by the British media
facilities are hardly viewed more favourably in the further implied that no medical treatment has taken
media. As highlighted in an early analysis of place prior to deinstitutionalization: those leaving the
psychiatry in film (Schneider, 1977), the psychiatrist safety within the asylum walls were not only depicted
has been depicted in widely varying ways – as as a danger to the public, but also as now being left to
madman, as a powerful force for tinkering with the fend for themselves (Cross, 2004), implying that the
soul, and as a wonder worker who cures patients by sort of treatment provided by hospital psychiatrists
uncovering a single traumatic event. Important consisted merely of incarceration and control.
treatment innovations and fundamental changes in Further to being ineffective, psychiatric treatments
the organization of mental health care since the are portrayed as cruel and invasive, not actually
1970s have done little to alter these stereotypical of benefit, if not harmful for the patients. A comedy
representations. With hardly any exceptions, mental series on the BBC, The Full Wax, provides an
health professionals continue to be portrayed in one example of this kind of image. The host of the
or more of the following ways: neurotic, unable to show introduces her next guest as someone who ‘. . .
maintain professional boundaries, drug or alcohol recently joined the ranks of the chronically barking –
addicted, rigid, controlling, ineffectual, mentally ill the good news is that she has been rehabilitated via
themselves, comically inept, uncaring, self-absorbed, the miracle of 450 volts zapping through her brain.’
having ulterior motives, easily tricked and manipu- The woman then appearing is anything but rehabi-
lated, foolish, and idiotic (Rosen, Walter, Politis, & litated, but trembling, distressed and engaging in the
Shortland, 1997; Roth Edney, 2004). most bizarre behaviour (BBC2, 27 April 1993, cited
Beyond doubt, these inaccurate and unflattering in Philo, 1996). A recent review of 106 movies also
stereotypes constitute stigmatization: the label found clinical incompetence as well as professional
‘psychiatrist’ is associated with negative meanings, misconduct in the shape of boundary violations to be
and psychiatrists are portrayed as ‘a breed apart’ typical for the portrayal of psychiatrists and/or
from other doctors. This holds true not only for the therapists (Gharaibeh, 2005).
overall image relayed, but also concerning the
frequency and type of coverage: Psychiatric items Mental health professionals’ function reduced to social
appear more frequently in factual and fictional media control. Regardless of the little appreciation con-
representations and generally get a bad press ceded to psychiatric expertise in the media, mental
compared with other branches of medicine (Lawrie, health professionals are widely portrayed as powerful
2000; Byrne, 2003). In addition, the dominant media agents of social control. Here, their role definition
images of the psychiatric profession misinform the lies again outside the medical profession. Rather
public and undermine the credibility of mental health than as fulfilling a curative function, psychiatrists
care practitioners (Guimon, cited in Freeman et al., are depicted as gatekeepers to ‘normality’ and are
2001). Hence the public image of psychiatrists assigned punitive and custodial responsibilities,
146 B. Schulze
functions that traditionally rest within the legal concerning the effectiveness of psychiatric treat-
system rather than medicine. For example, a political ments. Psychotropic medication, too, has been
cartoon in the British tabloid The Sun (18 March found to be depicted as a means of mind control
1993, cited in Philo, 1996, p. 47) featured a group and chemical restraint rather than a helpful inter-
therapy session in which a psychiatric patient vention (Rosen et al., 1997; Gharaibeh, 2005). In
evaluates the performance of a Conservative politi- this way, the different elements evident in media
cian positively. In the picture, a white-coated depictions of psychiatry are closely intertwined.
psychiatrist is commenting that this patient ‘is our A media analysis of Germany’s tabloid Bild,
saddest case’ (Philo, 1996). This representation (Angermeyer & Schulze, 2001) shows such por-
simultaneously discredits people with mental illness trayals of psychiatry are far from being singular
as not quite capable of adequate judgement and incidents. On the contrary, court and police reports
presents psychiatrists as an authority holding the about crimes involving a mentally ill suspect were
power of definition as to what constitutes reality and found to account for more than half of the overall
what does not. It also suggests a negative outlook on coverage of mental health issues. Rather than
the treatment prospects on the part of the practi- presenting mental illness in a sensationalist style
tioner, ‘sad’ implying hopelessness. While this typical of tabloids, the crimes are reported in the
attitude may be prevalent among some psychiatrists, news column of the paper, imparting them with
this kind of media portrayal devalues psychiatric additional credibility. As the following example
expertise and treatment methods. shows:
In addition, psychiatrists frequently figure in court ‘Son stabbed father to death with 200 knife thrusts.
and police reporting in the news media. In this In Indianapolis, a 37-year-old stabbed his father (76)
context, they are portrayed as experts to consider to death with 200 knife thrusts . . . He believed that
whether the motives of a perpetrator were ‘normal’ or his father had been possessed by the devil. ‘‘I wanted
‘abnormal’. Historically, it was actually in the to free the ghosts from his body.’’ A jury found him
framework of court reports where psychiatrists first
guilty. He will be admitted to a psychiatric hospital

appeared in the media. Originally a forum to
for life’ (BILD, 20 March 1997, cited in Schulze &
enlighten the citizen and advance reason, news-
Angermeyer, 2001, p. 472).
papers, as a rule, did not discuss emotions and
This type of reporting creates the impression that
subjective motives in their reporting, court reports
psychiatry has an essentially custodial function, and
being one of few exceptions (Imhof, 1999).
that contact with psychiatric services constitutes a
This expert role of psychiatrists in assessing the
particularly harsh legal sanction. Hollywood films,
responsibility of offenders for their crime becomes
too, nurture the notion that psychiatric hospitals
apparent from a news story on the BBC in 1993. The
resemble detention centres. To name but one
broadcast station reported a hostage-taking by a
masked gunman in a French nursery school. example, the highly successful movie Terminator 2
In return for their safe release, he demanded commences in a psychiatric hospital where the
£12 million and safe passage away from the scene. heroine of the film is being confined, showing
On BBC News, it was later reported that the French ‘grey-clothed patients being herded by burly atten-
police changed their version of what the man’s dants with billyclubs’ (Wahl, 1995).
motives had been, following psychiatric advice: The above examples of negative media portrayals
Reporter: ‘. . . the police psychiatrist told reporters of psychiatrists and their discipline, however, are not
that they thought in fact the gun-man had not been to detract from the fact that the vast majority of
after money, but was mentally ill and had staged the unfavourable media representations concern people
siege to attract attention to himself. This made him with mental illness, rather than those treating them.
in the eyes of the authorities all the more dangerous’ Although the images conveyed may contribute to
(BBC1, 15 April 1993). decreasing the prestige of the profession, mental
Media reports of this kind associate psychiatry with health professionals still enjoy a relatively high status
social deviance and again emphasize its social control and income in our society, as Wahl (cited in
function. At the same time, the illnesses treated by Freeman et al., 2001) rightly points out.
psychiatrists are imbued with negative meanings: Consequently, the main focus of anti-stigma activ-
rather than as a health problem threatening the ities targeting journalists and the media should
individual concerned and to be managed with remain on improving depictions of people with
modern medical treatments, they are suggested to mental illness, while not ignoring depictions of
be rooted in deviant, criminal behaviour that needs mental health care and its professions. Since the
to be controlled in the interest of society. These latter, though initially directed at the profession,
portrayals draw strong parallels between psychiatry equally inform public attitudes towards the indivi-
and prison, thus once more instilling doubts duals requiring psychiatric treatment.
Stigma experiences of mental health professionals neighbour who wondered ‘So you’re working as a
psychopath, Dr. L.?’
The needs assessment survey at the four German
Stigma is also evident in exchanges with colleagues
centres participating in the WPA Global Programme
from other specialties. The latter are described as
against Stigma (Schulze & Angermeyer, 2003) also
showing little regard for psychiatrists’ therapeutic
questioned mental health professionals’ (n ¼ 27)
skills as ‘anyone can talk a bit with patients’ and
experiences of stigma in focus group discussions.
endorse the belief that psychiatry is at best ‘soft
Qualitative data analysis of verbatim transcripts
medicine’ for those unhappy to deal with somatic
revealed three areas in which those questioned
aspects of their subject or would simply ‘faint at the
described being confronted with stigma and
sight of a drop of blood’. New elective students at an
discrimination:
acute unit were reported to have wondered ‘where
1. in their relationship with friends, family, the straightjackets are’ or to be afraid of psychiatric
colleagues and medical students; patients. Those professionals involved in teaching
2. through feelings of lacking appreciation for their also variously had questions directed at them from
work evoked by stereotypical public images of students as to whether psychiatry was ‘. . . worth all
psychiatry and the money’.

3. through a lack of resources for their job
resulting from an inequitable distribution of Public images of psychiatry. Mental health providers
healthcare funds. judged public perceptions as to the content of their
work (‘lock patients up and drug them’) to be
stigmatizing. Those questioned agreed in their
assessment that people generally hold ‘totally out-
Stigma in social relationships. In the first place, dated views’, suggesting that psychiatry mainly treats
mental health professionals describe that their friends ‘dangerous monsters’. These stereotypical represen-
and family show little interest in their work. After an tations of psychiatric treatment are experienced as
initial curiosity and a certain voyeurism (‘Tell me, devaluing the work they do. In some cases, negative
what does actually happen ‘‘in there’’?’) were attitudes were translated into discriminatory behav-
satisfied, acquaintances’ interest soon subsided. iour. For example, several colleagues recounted that
Whereas it was common among respondents’ circle their children were ridiculed by schoolmates as their
of friends to enquire about each other’s working day, mum or dad ‘works in the loony bin’.
providers felt they rarely asked them questions and Psychiatrists also regret that patients do not talk
describe that there quickly is a change of topic should about their (often very positive) experiences with
they start talking about their job on their own psychiatric care. Rather, the latter would prefer to
account. A certain reservation toward those working conceal the fact that they had been in contact with
in psychiatry also became apparent at social gather- mental health services at all for fear of stigmatizing
ings. Had one volunteered one’s profession, others reactions. For the same reasons, many would hesitate
became cautious as they expected psychiatrists to to seek professional help for mental health problems,
immediately analyse their behaviour and to be able to which is also described as a drawback of psychiatric
‘look through them and uncover intimate details’. stigma.
Second, some of those close to them expressed In the eyes of focus group participants, these
worries about their safety at work. Reflecting public images are disseminated and reinforced by the way
stereotype about dangerousness, friends and family psychiatry is portrayed in the media. On the one
voice concerns such as that ‘a patient could take the hand, professionals ascribe this image to film classics
bread knife and stab you’, or wonder whether one such as One Flew over the Cuckoo’s Nest which
were not ‘not afraid of violent attacks’. Alternatively, promotes the view of ‘the evil psychiatrist’. Also,
they suspected that patients’ ‘craziness’ could be they experience psychiatry as being excluded from
‘contagious’. Suggesting that work in psychiatry must predominantly ‘romantic notions’ of medicine on
really be terrible, a young mental health nurse’s television: hospital series were described as showing
parents enquired ‘For how long do you still have to ‘attractive hospitals with attractive staff’, which
work there, dear?’. Moreover, the feeling of having to hardly ever was the case when psychiatry features in
justify themselves for their career choice (e.g. ‘How TV programmes. These accounts of mental health
in heaven’s name can you bear all this!’; ‘You can’t professionals reflect the findings from studies on
really help those people anyway.’) is shared by many media content on mental health issues.
mental health professionals. Ignorance and a lack of
information about what psychiatry entails can also Inequitable distribution of healthcare resources. Mental
provide for comical encounters, as a senior psychia- health professionals reported problems in negotia-
trist describes his first meeting with his new tions with health insurance companies concerning
148 B. Schulze
the coverage of costs for ‘non-medical interventions’ basis of previous research on burnout (Maslach,
such as psychotherapy or a mobile mental Schaufeli, & Leiter, 2001), patient contacts are not at
health nursing service. In the case of the latter, the forefront of stressful experiences in psychiatry.
insurance companies did not have a category to They do not even appear among the ten most fre-
assign to the kind of services provided, as nursing quently mentioned stressors (Figure 2). However,
was associated solely with somatic aspects of patient equally unexpectedly, the stigma of mental illness as
care. By contrast, respondents state that the necessity well as health and social policy decisions feature
of ‘an expensive CT’ is hardly ever questioned. prominently among the factors mentioned in
This situation is seen to result from a general response to an open question as to what aspects of
imbalance of resources in the health sector, where their work psychiatrists perceived as stressful.
psychiatry was perceived to ‘certainly not (be) a Stigma was found to contribute to job stress in
priority’. On the concrete level, this meant that different ways. First of all, clinicians felt that
mental health professionals had to operate on very psychiatry is perceived as a treatment of ‘last
modest budgets – as little as ‘25 EUR per month for resort’, which is expected to help society to solve
occupational therapy with 18 patients’, as one of the management of difficult behaviours or social
those questioned recounts. A lack of funds was circumstances not essentially related to mental illness
judged as both a restriction of therapeutic when all other services have failed to overcome them.
possibilities and as signalling a lack of recognition As a senior doctor working in a psychiatric hospital in
for one’s work. a rural setting explains:
It really stresses me when, as a psychiatrist,
Stigma as a professional stressor I’ve got the feeling that . . . how shall I put it,
that a problem is referred to us that, strictly
The author is currently conducting a study on speaking, isn’t a psychiatric one, but some
professional stressors and resources of psychiatrists other problem. And we are being looked at as
(n ¼ 78) as part of a wider research effort aimed at helpers of last resort. And when we then give
preventing burnout and promoting provider attitudes advice: ‘Well, why don’t you try this, or that’,
of recovery. First results of a qualitative analysis on then our suggestions aren’t taken seriously
the dimensions of job stress in psychiatry revealed either. We are merely the guardians, if all else
surprising findings: other than hypothesized on the fails. These are very unpleasant moments.
Leadership style 94
Problems with workflow and co-ordination 85
Conflicts between professional groups 64
Stressful circumstances 55
Health and social policy 52
Public image of psychiatry 28
Having to co-ordinate multiple tasks 27
High caseload 25
Lack of recognition/positive feedback 25
Time pressure 24
0 20 40 60 80 100
(Number of mentions out of n=720; account for 66.5% of all mentions)
Figure 2. Professional stressors of psychiatrists (n ¼ 78) – the 10 most frequently mentioned factors.
Further facets of psychiatric stigma that were frequently far from being sufficiently equipped with
found to contribute to the job stress of mental the necessary resources, support frequently lagging
health professionals include the unequal treatment of behind the actual need for service provision to the
physical and mental disorders, the fact that physical present day. Funding for psychiatric research is also
complaints of their patients are frequently not taken scarce (Byrne, 1999).
seriously by colleagues in other medical specialties, a Decision-makers appear to enjoy public support
difficulty to discharge patients into the community for their funding priorities. A German survey
after recovery due to resistance among the popula- investigated the general population’s preferences
tion and a lack of adequate services, and a lack of when it comes to the allocation of healthcare
recognition for the psychiatric profession. These resources. While somatic illnesses like cancer or
findings closely mirror the results of the German cardiovascular disease ranked first, depression, schi-
study on providers’ stigma experiences, with the zophrenia and alcoholism were at the bottom of
difference that stigma was not an explicit concern the list (Matschinger & Angermeyer, 2004).
of the present research.
One recent observation

Medical students’ attitudes towards psychiatry
The author subscribes to Science Direct contents
Medical students’ views of psychiatry are frequently
alerts for a range of topics including psychiatry,
studied as an indicator of the discipline’s position
public health, applied psychology, organizational
within medicine. Research reveals that they regard
behaviour, and human resource management. All
psychiatry as more interesting and intellectually
of these are detected by the spam filter of her
challenging than other medical specialties, but also
e-mail provider, which indicates a spam probability
as lacking a scientific foundation and not being
of 0–25% for these messages, with the exception of
enjoyable. Students also believed that psychiatric
contents alerts on psychiatry, which are consistently
patients were ‘not easy to like’ (Mahli et al., 2003;
rated to be spam with a 25–75% risk. Being unaware

Sivakumar, Wilkinson, & Toone, 1986). This is not
of the algorithms that generate these spam probabil-
surprising if one considers that medical students
ities, this may be due to pure chance.
were found to share many negative stereotypes about
Notwithstanding whether it is intended or not, this
mentally ill people with the general population, partly
filtering effectively disadvantages psychiatric publica-
holding even less favourable views (Rossler et al.,
tions on the knowledge market.
1996). As a result, they consider psychiatry distinctly
This whole range of evidence indicates that mental
and consistently less attractive than other career
health professionals are equally likely to be at the
options (ibid.; Feifel, Moutier, & Swerdlow, 1999).
receiving end of stigma as they are to contribute to
They are indications that students’ attitudes even
negative stereotypes of mental illness.
worsen after they start practising as doctors.
(Sivakumar et al., 1986). Findings from the US
further point to an erosion in the attitudes that new Mental health professionals as
students hold towards psychiatry over the past two de-stigmatizers
decades. (Feifel et al., 1999).
Having established that psychiatric professionals can
be both perpetrators and victims of stigmatizing
Distribution of resources in healthcare behaviours, the question remains to be clarified as to
Research further documents that psychiatry is whether and in which ways they can act as de-
structurally disadvantaged through an unequal dis- stigmatizers of mental illness and those suffering
tribution of resources in healthcare, confirming from them. Their claim to expert knowledge which is
mental health professional’s assessment. Mental recognized at the societal level as well as their social
health programmes have been found to receive low standing as part of the medical profession puts them
priority in the allocation of healthcare and prevention in a privileged position to affect social change. This
funds. Budgets do not nearly reflect the magnitude section outlines the steps mental health professionals
and public health relevance of mental disorders, must take to be credible agents of de-stigmatization.
which are responsible for a major proportion of the Examining our own attitudes and attempting to
disability in the world (Murray & Lopez, 1996; increase tolerance are the stepping stones for
Sartorius, 1998). Historically, the closure of asylums reviewing and changing professional behaviours that
has, in part, been considered a welcome cost-cutting may stigmatize others as well as for managing stigma
exercise at a time of exploding welfare budgets directed at mental health care (Sartorius, 1998).
(Cross, 2004). Especially in the early days, the How then, can this be accomplished? Five steps
emerging community mental health facilities were will be outlined below.
150 B. Schulze
Step 1. Increasing awareness of stigmatizing allowing professionals to notice small steps towards
aspects of clinical practice social integration and judge them as an indication of
progress.
Effectively combating stigma begins with increasing
Enhancing psychiatrists’ skills for effective client–
awareness of stigmatizing aspects in clinical practice
provider communication and co-operative clinical
and attempting to act as de-stigmatizers in the day-
decision-making should be a further focus of
to-day contact with patients, families, and other
psychiatry’s anti-stigma efforts (Hamann, Leucht, &
professionals.
Kissling, 2003). De-stigmatizing providers should
Acting in a de-stigmatizing fashion begins with
being conscious of the power of diagnosis and of the resist the conventional argument that psychiatry is a
labelling process. This includes careful deliberation ‘special case’ when it comes to clinical decisions,
whether to reveal or conceal potentially damaging where patients’ lack of insight requires more directive
information on initial symptoms that are not visible approaches. While there certainly are situations in
for lay people, but recognized by the psychiatrist, to which involuntary measures are required in the best
other parties outside the client–provider relationship interest of those with mental illness, these should
indeed remain a treatment of last resort and not form
(Schlosberg, 1993; Sartorius, 1998). Providers may

wish to develop a strategy of selective disclosure a key message of what psychiatric care is all about.
depending on the receiver of the information, the Ideally, both parties in the therapeutic relationship
timing of disclosure and the expected consequences enter these difficult situations well-prepared, for
of relaying sensitive information of this kind in each example through jointly developing psychiatric
individual case. It goes without saying this should be advance directives (Amering, Stastny, & Hopper,
done in close co-operation with the patients, 2005). Collaborative treatment philosophies must
respecting their ownership of information relating become a crucial ingredient of good psychiatric
to their condition. practice, not least as the quality of therapeutic
Holding de-stigmatizing provider attitudes further relationships predicts outcome (Corrigan, 2002;
implies that professionals work towards demytholo- Priebe & McCabe, 2006).
gizing mental illness by refuting fatalistic notions Sharing professional power more than hitherto
concerning prognosis and treatment. Updating with service users and families does not imply that
clinical knowledge with new research findings can psychiatric expertise is loosing in value. On the
help to overcome a tendency to cynicism towards contrary, both mental illnesses and the consequences
one’s clients which may evolve from a paternalistic of the stigma associated with them have a detrimental
outlook on the helping relationship. Having recent effect on the well-being and self-concept of
study results readily available also allows profes- people with mental health problems. Additionally,
sionals to give scientific explanations, both in their the vast majority of patients is turning to psychiatrists
contact with patients and the wider public, and to in the hope for help towards leading a meaningful
decide on the kind of effective psychotropic medica- life despite and with their condition. Those with
tion with the lowest of profile of side effects. Using severe mental illnesses are undoubtedly most in
evidence-based treatment becomes all the more urgent need of professional support and advice on
important as lay people apparently focus on visible managing stigma and discrimination individually
aspects of social disability in forming their attitudes (Rossler, Lauber, Sartorius, & Munk-Jorgensen,
about severe mental illness (Gaebel, Zaske, & 2006).
Baumann, 2006). A last facet of de-stigmatizing psychiatric practice
As a logical consequence of rejecting negative is building constructive working relationships in
outcome beliefs, providers should work towards multi-professional teams as well as with colleagues
changing the focus of attention in clinical work, from other specialties and relevant partners in the
research and teaching from symptoms and psycho- community. This form of positive personal contact is
pathology to a search for ways to improve the lives likely to work against stereotypes of psychiatrists and
of those with mental illness (Sartorius, 1998). their patients in medicine and society, and to
This includes defining the integration of patients contribute to mainstreaming psychiatry in general
back into regular activities in a regular setting as an healthcare, thus gradually de-stigmatizing the referral
inherent treatment aim (Schlosberg, 1993). Here, it to mental health services (Penn & Couture, 2003).
will be important to resist the ‘normality-trap’ which In sum, mental health professionals should
may hamper successful rehabilitation by defining always be aware that, in their therapeutic role, they
unrealistic goals (Domingo & Baer, 2003). Shifting can either stigmatize more or destigmatize their
the treatment focus ‘from curing to caring’ may patients. Consideration should be taken in the overall
prove a helpful strategy in this regard that could also approach that the benefits to a patient always
positively affect perceptions of therapeutic success by outweigh his or her losses (Schlosberg, 1993).
Step 2. Meaningful user and family involvement the media are already beginning to bear fruit. First
indications of positive moves in the portrayals of the
Secondly, it is important to involve service users and
mental health practitioners are becoming apparent in
family members in anti-stigma programmes from the
the cinema, with the most recent films portraying
outset. For one, they are experts by experience when
people with mental illness as real characters and even
it comes to mental-health related stigma. Further, if
introducing a positive stereotype of mental ill people
psychiatrists reserved the expert role in communicat-
as hero or role model (Rosen et al., 1997). There is
ing with the public for themselves, they would indeed
also a bright point with regard to the movie images of
reinforce stereotypes as this would convey the
psychiatrists, who, as shown in a recent analysis of
message that those with mental illnesses are not
American movies, were depicted as friendly in two-
capable of speaking for themselves or what they have
thirds of the films studied (Gharaibeh, 2005).
to say is of little value (Wahl, 2001). Moreover, anti-
Actively campaigning for mentally ill people’s
stigma programmes solely based on mental health
rights also entails that professional bodies should
professionals’ accounts may be successful in improv-
seek to involve their colleagues ‘on the ground’ more
ing mental health literacy of the population (Paykel,
strongly in programmes to fight stigma. Not only do
Hart, & Priest, 1998; Jorm et al., 2000), but they

psychiatrists in mental health services and private
have also been shown to be less effective in changing
practice have direct contact with service users and
stereotypes about people with mental illness and the
families, they are the general public’s first access
desire for social distance towards them (Chou &
point to mental health care. Working closely with
Mak, 1998; Phelan, Link, Stueve, & Pescosolido, practitioners could also facilitate the dissemination of
2000). Indeed, they may even increase fear and social anti-stigma messages by counteracting the apparent
distance, since much of the information given refers divide between the biopsychosocial model promoted
to symptoms and illness-related deficits (Meise et al., in most programmes against stigma and the pre-
2000). Service users, then, should not only be dominantly biomedical focus in clinical practice
involved in programmes to fight stigma, but also in (Pilgrim & Rogers, 2005).
the development and evaluation of services

(Sartorius, 1998; Sartorius, 2002).
Step 4. Campaigning for adequate resources for
treatment and research, other professional interests
Step 3. Recognition of challenging stigma and and fighting self-stigma
discrimination as an inherent part of the profession
Once being convinced of the benefits of their
Next, to do something about stigma, psychiatrists are treatment approaches, psychiatrists should make it
encouraged to be active and loud advocates of the their duty to actively support best practices with
mentally ill and stand up against discrimination policy-makers, rather than outwardly accepting
because of mental health problems (Sartorius, 1998). healthcare cuts while silently bemoaning them
As much as they can potently reinforce stereo- (Sartorius, 1998; Sartorius, 2002). As it is psychia-
types, the media can be a powerful tool for those in trists who are responsible for assuring the quality and
the psychiatric professions in advocating a positive structure of mental health services and removing
mental health agenda. For this to be effective, barriers that deny access to them. When it comes to
psychiatrist must adopt a critical, but open attitude securing adequate resources for services and
to the media and seek to establish ongoing co- research, actively pursuing professional goals is in
operation with journalists, rather than limiting the interests of both patients and psychiatrists and so
contact with the media to public relations in crisis should no longer carry the risk of being attacked as a
situations or to solely attacking them for promoting a ‘hidden agenda’ in psychiatry-led anti-stigma efforts.
negative image of psychiatry. Further, if there is some As Ojo (2002) sums it up in a letter to the editor in
truth in the negative depictions of psychiatry in film, the Psychiatric Bulletin: ‘The gloves should come off
it is the hope of those involved in the fight against and psychiatry needs to shout out louder ‘‘more
stigma that mental health professionals, rather than resources and less stigma’’’ (p. 114).
plainly dismissing the images, ‘. . . will reflect Taking such a confident stance requires that
thoughtfully and use this as a stimulus to change psychiatrists actively deal with the stigma directed
their practice’ (Rosen et al., 1997, p. 7). Moreover, at them. While antipathies of psychiatry and psy-
media relations should aim to improve the depictions chiatrists are widespread among the medical profes-
of people with mental illness, not primarily the sions, the real issue is perhaps that the majority of
images of their professions (Wahl, 2001). psychiatrists fail to challenge these prejudices (Byrne,
Contrasting the rather bleak picture with regard to 2000). In a certain sense, the negative consequences
public representations of psychiatry developed ear- of stigma do not differentiate between different
lier, the profession’s attempts to actively engage with groups of stigma recipients. Self-pity and resignation
152 B. Schulze
sometimes appear just as evident among profes- discrimination, such as user and family organiza-
sionals as in their patients. Stigma management for tions, the pursuit of specific interests has been an
psychiatrists is therefore urgently called for. This may inherent part of their strategy. While user represen-
well consist of active and open pursuits of legitimate tatives campaign explicitly for social inclusion, anti-
professional interests. discrimination legislation and the observance of
medical ethics (Geneva Initiative on Psychiatry,
Step 5. Synthesis 2005; Gombos, 2006), family associations promote
advances in effective treatments and call for more
Professionally led anti-stigma programmes have been support in dealing with the burden of care
successful on many levels in many parts of the world. (EUFAMI, 2005).
The World Psychiatric Association’s Global Conceding that fighting stigma also (though not
Programme against Stigma (www.openthe- primarily) benefits the professional project of
doors.com) stands out as a particular success story. psychiatry can indeed by a strong point of profes-
Its achievements encompass an improvement in the sionally led anti-stigma initiatives. Such a move
attitudes of secondary school students (Pinfold et al., would show that mental health professionals take
2003b; Schulze et al., 2003), better co-operation criticisms to their efforts against stigma seriously
with the police and the legal system (Pinfold et al., and use them as an impetus to further improve both
2003a), a change in patterns of media reporting and their anti-stigma work as well as clinical practice – as
improved co-operation with services users and carers they would routinely do in response to criticisms
(Sartorius & Schulze, 2005). Programme success can in the context of their professional and scientific
at least partly be ascribed to the fact that the WPA’s debates.
anti-stigma effort has taken on board many of the Ideally then, psychiatry should simultaneously be
considerations as to how mental health professionals alert to the ways in which it may produce and
can act as de-stigmatizers outlined above from reinforce stigma, and confidently pursue its agenda
the start. Participating professionals have learned
to de-stigmatize the profession and its practice. This

further important lessons in ten years of fighting could result in a win-win situation among all the
stigma, establishing (1) focussed action on priority parties involved in fighting psychiatric stigma. For
areas, (2) a needs-based approach to programme one, it would help to reduce conflicts between the
development and (3) sustaining long-term commit- different stakeholders. Each would follow specific
ment as key ingredients of sustainable change aims, thus recognizing differences between them,
(Sartorius, 2004). and benefit individually. At the same time and in the
first place, however, such an approach allows all
Conclusion parties to bring their expertise and resources together
in working towards their common goal: the fight
This paper has provided an overview of the manifold
against stigma and discrimination attached to mental
ways in which mental health professionals are
health problems and those living with them.
implicated in efforts to fight psychiatric stigma.
There are valid points of criticism, warning of a
blind spot in anti-stigma programmes driven by the
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International Review of Psychiatry, April 2007; 19(2): 137–155

Stigma and mental health professionals: A review of the evidence

Department of General and Social Psychiatry, University of Zurich, Zurich, Switzerland

Introduction stigma . . . , introduce or scrutinize disability rights

initiated, formerly almost exclusively negative social

Social exclusion/Lack of understanding 16.9

Contact with mental health professionals 11.3

Quality of mental health services 11

Limited access to employment 8.9

Assignment of guilt/own responsibility 8.9

Negative media representations 6.8

Lack of knowledge and informa tion 6.2

Insecurity and fear 5.9

Unequal treatment of mental and physical 4.1

(% of stigma experiences mentioned)

(Lauber et al., 2004). positive, similar or more negative opinions. It is

Authors Study participants Attitude measures Diagnoses Country

General public (n ¼ 2031) Beliefs about Schizophrenia, Australia

psychologists (n ¼ 67) - Attitudes to community care

Psychiatrists, psychologists - Causal beliefs

Table II. Comparison studies – summary of results.

Result Times found Type of attitudes concerned

than population stereotypes7; helpfulness of psychiatric treatments vs. natural remedies4

guilty. He will be admitted to a psychiatric hospital

psychiatry and the money’.

Problems with workflow and co-ordination 85

Conflicts between professional groups 64

Health and social policy 52

Public image of psychiatry 28

Having to co-ordinate multiple tasks 27

Lack of recognition/positive feedback 25

(Number of mentions out of n=720; account for 66.5% of all mentions)

One recent observation

rated to be spam with a 25–75% risk. Being unaware

(Schlosberg, 1993; Sartorius, 1998). Providers may

Hart, & Priest, 1998; Jorm et al., 2000), but they

the development and evaluation of services

to de-stigmatize the profession and its practice. This

evaluation by the Swedish Disability Ombudsman).

(2004). What about psychiatrists’ attitude to mentally ill people?

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