Stigma and discrimination.

A position paper developed by the Canadian Psychiatric Association 's Stigma- Discrimination Working Group and approved by the CPA's Board of Directors on July >:8, 2011. Introduction Decreasing stigma and discrimination against people with mental illness and their families, and mental health professionals and systems is of the highest priority for Canadian psychiatrists and organized psychiatry. Across the globe, there has been increasing attention to the deleterious effects of stigma and discrimination and calls for psychiatrists to take on key roles in combating stigma and working toward its abolition.'·2 Notwithstanding gains during the past century in decreasing stigma and discrimination based on gender, race, sexual orientation, and religion, and despite an increased openness in dealing with previously taboo medical diagnoses, such as cancer and human immunodeficiency virus-acquired immune deficiency syndrome, stigma and discrimination against people with mental illness and psychiatry remains prevalent. This paper is not only a call to action but also an invitation to individual Canadian psychiatrists and the Canadian Psychiatric Association (CPA) to take a leading role in addressing these crucial issues. What Do We Know About Stigma, Discrimination, and Social Inclusion? Stigma marks a person as different and devalued. Goffman, in his classic work on stigma, noted that stigma diminishes a person "from a whole and usual person to a tainted discounted one."3· p 3 Scambler has summarized Goffman's thinking, noting, "The term stigma conventionally refers to any attribute, trait, or disorder that marks an individual as being unacceptably different from the 'normal' people with whom he Or she routinely interacts, and elicits some form of community sanction."4, p1054 Current understandings of stigma involve a multi-layered process5*: Labelling. The everyday activity of creating categories and classifications is a normal and useful part of modem life. Labelling becomes stigmatizing when it evolves to the steps described below; Stereotyping. A link is created between the labelled individual and a stereotyped, Undesirable social characteristic (for example, "schizophrenics are violent"); Separation. Placing the stereotyped person into a fundamentally different category from the rest of humanity (the "us" and "them" effect, resulting in beliefs such as "I cannot become mentally ill"); Emotional Reaction. The previous cognitive dimensions are accompanied by emotional reactions, The emotional range is not limited to anger, fear, or disgust, but can also involve pity, guilty feelings, or feeling responsible; Discrimination. Discrimination occurs when stigmatization is acted on by concrete behaviours such as exclusion, rejection, or devaluation. Discrimination can take place on a personal level or be enacted through , societal 'and structural inequalities; Power Differential. Discrimination has negative and even devastating consequences when the stigmatized person is in a vulnerable position because of a power differential related to socioeconomic reasons (for example, poverty and little social capital), cultural affiliations (for example, marginalized ethnic groups), or for psychological reasons (for example, fragile selfesteem in depressed patients). The adverse effects of stigma and discrimination on people with mental illness have been well documented1,2 and include delay in seeking treatment, early treatment discontinuation, difficulties obtaining housing and employment, and adverse economic effects.7 Stigma has been described as the "primary barrier" to treatment and recovery.8 Stigma and discrimination are well-documented obstacles to people with lived experience of mental illness receiving adequate general medical care9 and combined are one factor in diminished life expectancy. Life expectancy for people with schizophrenia is lower than the general population by as much as 15 years, and most excess mortality is due to coronary heart disease (both through increased risk factors and suboptimal preventive and curative treatments). …