In sixteen years as the director (1977-93) of the World Health Organization's (WHO) division of mental health, Dr Norman Sartorius pinned down stigma as the single largest cause that blocks progress in treating mental health issues. In this interview with White Swan Foundation’s Pavitra Jayaraman, Sartorius, who is also the former president of the World Psychiatric Association, talks about the best methods of weeding out stigma and why both health professionals and the general public need to be sensitized.
What do you think is the biggest hurdle in the progress towards the understanding of mental health?
I think that the greatest hurdle in providing people with mental illnesses with appropriate care and making them live in a community is stigmatization. People who have mental illnesses carry stigma. Their illness marks them in a way that makes people shy away from them afraid of them, see them as being dangerous, or not being human. This attitude makes everything that we want to do for them extremely difficult. So unless one can change the image of a mentally ill person and also change the image of the life that they lead, it is very difficult to make any progress. So I would say that the greatest hurdle to improving mental health care is stigma.
And what role do mental health experts play in this?
Stigma is to a large extent omnipresent, it is everywhere. It is present among the doctors, among the policemen, its present among the general population. They all have a feeling that mentally ill people have no value, that they will never improve, or that they are dangerous and should not be touched or looked at. This attitude makes them all so confused. We know today that people who have mental retardation or people who have depression are ten times less likely to be involved in crimes, than people who do not have mental illnesses. But that is not the general perception because our way of hearing and seeing things is marked by stigma. Unless one can change this, one cannot really build up progress.
What is the best practice to overcome this stigma?
Undoubtedly the most powerful way of diminishing stigma is social contact. Once you have sat together with a person with mental illness and spoken to such a person, you will suddenly discover that he is in no way particularly different from anybody else. Of course when a person has an acute bout of illness he is different from when he doesn’t have such a bout of illness. But that’s true for all illnesses. When a person has a very severe pulmonary illness or a cardiac illness, they are also not quite the same with the illness as they are without. But for most of the time you will not be able to tell the difference. Knowledge does have a certain amount of influence on this perception but does not change things entirely. When you provide people with knowledge, they remember selectively. They remember only things that are in tune with their opinion. So changing this opinion and attitude is probably the first task.
What can an organization like White Swan Foundation do to minimize stigma?
One thing you could try is to employ persons with mental illnesses to be one of your speakers. This is something I have seen. If you go to schools or to enterprises and introduce a person who speaks about his own illness, people will look at him and say, ‘that’s impossible, he speaks so well, how could it be that he is mentally ill or was mentally ill?’ And I think that would be a very positive step for your organization.
Another thing to do is to see the extent to which young people in the health profession can be educated, so that the probability that they themselves are causing stigma will be diminished. Health professionals are not necessarily different from other people. I have seen in recent times that the most useful way of dealing with stigma is not to shoot the general message at everybody, but to send out very specific messages. For example, how you inform a policeman about mental illness is very different from the way you inform a journalist about mental illness, or a doctor about mental illness. So that is the second important feature. First you try to make people with the experience speak about it to others, because that becomes much more believable, second is to orient programs to specific groups of people trying to think of the opportunities in which they see people with mental illness, and what they could do in their own job and their daily life to deal with mental illness.
You also need to look at people who look after the mentally ill, families who look after the mentally ill. They are also at a loss, suddenly they find themselves with a person with a mental illness and they feel terrible about it. They are not sure if they are contributing to this illness, sometimes they feel guilty about it, sometimes they feel ashamed, sometimes they feel afraid, and all these things make their lives miserable. So working with families and caregivers will be another area to make a beginning.
Psychiatry has made a lot of progress, yet there is much progress still to be made. Where does the profession stand as of now?
I think many of the possibilities and knowledge of psychiatric illnesses are not really used very well. The past has brought with it not only stigmatization but also the consequences of stigma. For example, the distribution of resources. In many countries and in many institutions the part that is given to the protection of mental health and to the prevention of mental illness is very small, maybe one or two percent. We know today that at least two fifths of all disability in the world is due to mental illness but if you compare the amount of resources that are being put into the field of psychiatry and the amount of trouble that may be created because diseases are not being treated is a huge distinction. This blocks much of the progress that we could make with the knowledge which have. Much of what we know today is not getting used and it is not given a chance to be useful to the population of people with mental illnesses. That goes particularly for the field of prevention for example, where we know that certain things could be well presented but people shy away from it. Of course one has to remember that much of the prevention of mental disorders is not done by psychiatrists, it is done by other people. To give you an example, there is a fairly high proportion of children who are short sighted and if you do not correct their vision in time, the chances are that they will learn less and they will be considered to be slow and retarded. Their whole life may be affected. They lead a life of a retarded person who’ll be able to learn more if given a chance. But parents in some countries, they don’t want their children to wear glasses because they feel it is making the girl less pretty or making the boy less strong. So they don’t give them glasses. This diminishes the input that they get from the world, diminishes their development, diminishes their growth. It’s a very bad thing and yet it is such a simple measure. And there are numerous similar simple measures that come out of the knowledge of psychiatry. So my feeling is that in psychiatry today, there is a huge disproportion between what we know and how it is applied and much of the knowledge today is not being applied. Regarding the treatment of the mentally ill, I think we’ve made great progress. Some of the people may have to continue the treatment for as long as they live but for the majority, they have episodes of illness which can be treated well if it’s brought to the attention of a qualified person and after that, life will in fact continue without any traces of such an illness. So I would call the current state of psychiatry an era of missed opportunities.
There are a number of mental illnesses for which the causes are yet to be established
Let me take the example of child mental illness. If you look at the causes that are leading to mental illness in a child, you will see that there are several of them. For example, maternal mental illness, paternal criminality, overcrowding, frequent hospitalizations for any physical reason and a number of other factors. When only one of those factors is present, the probability that a child will have a mental illness is not very elevated. When the number of those risk factors increases the probability that the child will fall ill is increasing as well. That is a problem for research but it is also a great hope for what we can do for these children. We cannot change paternal criminality but we can change other things. We can change the way in which the child lives, we can help the mother look after the child better, we can think about ways of protecting the school time of the child. There are many risk factors that lead to mental illness but it doesn’t really matter which one of them we remove, because removal of any one of them will decrease the probability of an illness. Some of them are unmovable, but it doesn’t really matter because we can work with others.
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