Can our politicians help to reduce stigma and discrimination?

It is no surprise for this journal's readers that stigma and discrimination are both associated with mental health problems. One of our most highly cited papers is an early review of the area by Hayward and Bright which pointed out that based on citations there was an increase in interest in the 1960s, 1970s and 1980s following the introduction of community care and the necessity of moving people out of large hospitals. There was a drop in the 1990s but resurgence in the middle of the last decade. A cursory glance at literature titles in Web of Science shows 193 publications since the turn of the century more than double the highest level in any previous decade.

This journal has also contributed to this renewed interest papers with a special issue edited by Penn and Wykes (Penn & Wykes, 2003) and papers on measurement (Bagley & King, 2005) perceptions of stigma (Kleim et al., 2008) and more recently papers on stigma differences between different groups of individuals showing the within-culture effects that need consideration (Stickney et al., 2012)

Because of the renewed interest we now know that stigma has an impact on families and mental health professionals (Corrigan & Miller, 2004; Ben-Zeev et al., 2012; Kalra, 2012). It is widespread across Europe (Brohan et al., 2010) and the world (Thornicroft et al., 2009) and across various diagnoses (Mond, 2013) stigma and discrimination also affect social networks (Knight et al., 2003) and play a key role in delaying help seeking and treatment (Rusch et al., 2011; Clement et al., 2012) which in turn leads to greater disability and less complete recovery.

Various public health campaigns have been trialled and in the UK a programme of education has been on-going that has shown to have a small influence on the public understanding of mental health issues (Evans-Lacko et al., 2011; Evans-Lacko et al., 2012; Henderson et al., 2012). But most campaigns do not have dramatic effects on early identification of mental ill health so perhaps we need a further boost. This journal published descriptions from people who had experienced or were still experiencing mental ill health describing their responses to a diagnosis of ill health and personal journey to recovery (Bondevik, 2010; Pratchett, 2010; Vonnegut, 2010). These all showed that stigma and self-stigma had an effect on recovery. Celebrities too have discussed their own mental health problems or those of a family and this is thought to be helpful but may bring an extra cost of raising expectations of families about outcomes – “so if Stephen Fry can be successful then why can't everyone with a mental health problem be a success”. The effects of self-stigma in preventing or challenging recovery have been addressed in studies of new treatments (Knight et al., 2006) but these can never compensate completely for discrimination and other effects of stigma. So what will have an effect?

Recently in the UK further interest was fuelled by parliament – an unlikely venue for a public health campaign to begin. This began with a private members bill delivered in the Houses of Parliament. A private members bill is one not launched by the government and it is surprising that this one has obtained so far since this is usually the route taken to raise an issue but for it then not to linger very much in the minds of Members of Parliament (MPs) and certainly not in the public's. But this bill was surprising, if not astonishing, as it is a bill designed to repeal areas of discrimination on the grounds of mental ill health. These discriminations were not even known to most of those with a mental health problem. For instance, if an MP is detained in hospital for six months for a mental health issue then he or she will lose their seat. There is no legislation that would require someone who has a physical impediment that requires long hospital treatment to stand down. The bill repeals this and other areas of discrimination against roles in public life such as serving on a board of education or a company. Repealing areas of discrimination such as discrimination on the grounds of gender is thought to fuel improved attitudes in the populace.

But the effects of this bill were more widespread; it was a catalyst for even more change. During the debate MPs and the House of Lords stood up one by in June, September and November in 2012 and recently (3 February 2013) to report that they had suffered from mental ill health. This produced unprecedented media interest with two MPs giving interviews just about every hour to different media outlets. Even more interesting were the disclosures that accompanied these interviews. Make-up artists and the TV or radio presenters alike praised the MPs for their candour and admitted that either they or a close relative had similar difficulties.

The bill is not just making changes on discrimination in parliament but also changing the rules for jurors and company directors. Currently (and this was a surprise to this author) you cannot be a juror if you admit on the form that you have experienced any mental health problem and this applies even if the mental health problem was some time in the past. The number of people who reply in the affirmative to this question is far fewer than the number of people we would assume receive a summons to attend for jury service and will have or had a mental health issue. Given that many people will try almost anything to wriggle out of jury service clearly those with genuine mental health problems still do not disclose their mental health problems due to feelings of stigma (Corrigan & Matthews, 2003).

The bill has now passed various stages in the House of Commons and now passes to the House of Lords. This may not take too long as they have already debated a similar bill in 2010 and were very much in favour. Therefore, we may now soon have legislation to remove some discriminations. But it has been the process and media support rather than the bill which has had the main effect. The removal of restrictions that prevent people from playing their part in public life will send a wider message to the public about the way in which Parliament wants society as a whole to regard people who are struggling with mental health problems. Maybe I should end with a quote from the September debate

Another clear message I want to send out today is that mental illness is no barrier to making a productive contribution to life – whether it be in public life, family life or in the local community. The more we talk about the issue, the better. It will take time to erase the stigma that is still there around mental illness, but I think we are making great strides and that this Bill is an important step forwards. (Nuttall, Member for Bury North, 14 September 2012 Second Reading; Hansard)

Of course, there are other programmes for improving or reducing stigma such as those for the military (Ben-Zeev et al., 2012) for reducing self-stigma in severe mental illness (Knight 2003, 2006) and for whole populations such as the time to change campaign in the UK (Henderson et al., 2012). We now know that some approaches to stigma reduction may not work (Callard et al., 2012) but perhaps we now do know what might work. These authors do not praise governments easily but the proceedings in the House of Commons has been a wholly laudable process that other countries might consider as a potentially potent way of engaging the public in facing their prejudices and discriminatory processes in the area of mental health. It might be even more potent than the current programmes we have been investigating for the last few years.

Acknowledgement

Til Wykes and Tom Craig would like to acknowledge the support of the NIHR Biomedical Research Centre at the South London and Maudsley NHS Foundation Trust and Til Wykes also acknowledges her NIHR Senior Investigator Award.