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July 2010
WPA guidance on how to combat stigmatization of psychiatry and psychiatrists

NORMAN SARTORIUS1, WOLFGANG GAEBEL2, HELEN-ROSE CLEVELAND2, HEATHER STUART3, TSUYOSHI AKIYAMA4, JULIO ARBOLEDA-FLÓREZ3, ANJA E. BAUMANN5, OYE GUREJE6, MIGUEL R. JORGE7, MARIANNE KASTRUP8, YURIKO SUZUKI9, ALLAN TASMAN10

1Association for the Improvement of Mental Health Programmes, Geneva, Switzerland; 2Department of Psychiatry and Psychotherapy, Heinrich-Heine-University Düsseldorf, Germany; 3Queen’s University, Kingston, Canada; 4Department of Psychiatry, Kanto Medical Center, University of Tokyo, Japan; 5World Health Organization Regional Office for Europe, Copenhagen, Denmark; 6Department of Psychiatry, University College Hospital, Ibadan, Nigeria; 7Federal University of Sao Paulo, Brazil; 8Center for Transcultural Psychiatry, Psychiatric Clinic, Rigshospitalet, Copenhagen, Denmark; 9National Institute of Mental Health, Department of Adult Mental Health, Tokyo, Japan; 10Department of Psychiatry and Behavioral Sciences, University of Louisville, KY, USA

In 2009 the WPA President established a Task Force that was to examine available evidence about the stigmatization of psychiatry and psychiatrists and to make recommendations about action that national psychiatric societies and psychiatrists as professionals could do to reduce or prevent the stigmatization of their discipline as well as to prevent its nefarious consequences. This paper presents a summary of the Task Force’s findings and recommendations. The Task Force reviewed the literature concerning the image of psychiatry and psychiatrists in the media and the opinions about psychiatry and psychiatrists of the general public, of students of medicine, of health professionals other than psychiatrists and of persons with mental illness and their families. It also reviewed the evidence about the interventions that have been undertaken to combat stigma and consequent discrimination and made a series of recommendations to the national psychiatric societies and to individual psychiatrists. The Task Force laid emphasis on the formulation of best practices of psychiatry and their application in health services and on the revision of curricula for the training of health personnel. It also recommended that national psychiatric societies establish links with other professional associations, with organizations of patients and their relatives and with the media in order to approach the problems of stigma on a broad front. The Task Force also underlined the role that psychiatrists can play in the prevention of stigmatization of psychiatry, stressing the need to develop a respectful relationship with patients, to strictly observe ethical rules in the practice of psychiatry and to maintain professional competence.

Key words: Stigmatization, psychiatry, psychiatrists, general public, media, medical students, patients and relatives, ethical rules

(World Psychiatry 2010;9)

One of the goals included in the WPA Action Plan 2008-2011, adopted by the WPA General Assembly, is an improvement of the image of psychiatry and psychiatrists in the eyes of health professionals, the general public, health decision makers and students of health professions (1,2). In the pursuance of this goal, the President of the WPA established a Task Force and entrusted it with the development of a guidance on how to combat stigmatization of psychiatry and psychiatrists.

This paper provides a review of the current knowledge in the area and lists a series of recommendations about what can be done to address the problem.

METHODS USED TO REVIEW PUBLISHED EVIDENCE

The Task Force conducted a review of the literature to identify publications dealing with the image of psychiatry, psychiatrists, psychiatric institutions and psychiatric treatment. The search algorithm selected was applied to Social SciSearch/Social Science Citation Index, PsycINFO, Embase, Somed (joint search via the meta-search engine Dimdi, title only) and Medline (titles and abstracts).

The review aimed at providing a comprehensive account of stereotypes of psychiatry and psychiatrists. However, there are several topics related to attitudes towards psychiatry and psychiatrists (e.g., help-seeking behaviour, compli-ance) that could not be included completely, and are thus only contained as far as they appeared to be of relevance for our review.

The search was conducted in July 2009, was not limited to any specific year and identified articles published in English and German. The members of the Task Force contributed suggestions about publications in other languages of which they were aware. The initial search yielded 8,217 articles, of which 7,296 remained after duplicates were excluded. After screening titles and abstracts, we identified 398 papers as potentially relevant. A further review of references identified additional publications. A total of 503 potentially relevant studies were considered in detail and form the basis for this review.

RESULTS OF THE REVIEW OF KNOWLEDGE

We defined stigma broadly, to encompass the negative stereotypes and prejudicial beliefs that people may hold, as well as discriminatory or inequitable practices that may result. Further, we recognized that stigma and discrimination may occur at the level of the individual, through interpersonal interactions, as well as at the level of social structures by virtue of unfair policies, practices, and laws (3). We first consider the stigmatization of psychiatry (and psychiatric treatments), then the stigmatization of psychiatrists.

The stigmatization of psychiatry

The general public

The public opinion on psychiatric facilities has been consistently negative during the past decades. The image of a "psychiatric hospital" has been typically that of a large-scale institution with a custodial character (4), locked doors, and located on the outskirts of the community (5,6). In a representative survey of German respondents (4), 25% believed that patients were not let out, and 50% believed that straightjackets were still in use.

Some positive changes could be observed during the 1970s, with the development of community mental health care (7). However, community care was also met by resistance from community residents, referred to as the NIMBY (not in my backyard) syndrome. For example, in one study, while 81% of Americans rejected the idea that "the best way to handle the mentally ill is to keep them behind locked doors", significantly fewer (31%) would actually welcome an outpatient mental health centre in their neighborhood (8). Reasons for this resistance included concerns about declining property values, the safety of children, and personal safety (9-12).

Public opinions about psychiatric treatment have been found to be mixed. While some studies revealed that respondents considered psychiatric treatment to be helpful (13-15), in others, respondents expressed concern about the quality and efficacy of treatment (16-18), and in some, respondents considered psychiatric treatment to be harmful (19-21).

Selecting from a range of treatment options, psychotherapy was usually preferred over psychotropic medication (6,20,22-33). However, the framing of the questions seems to influence the results. A forced choice among treatment options seems to yield a preference for psychotherapy, but if the acceptance of a certain kind of treatment is assessed, studies usually find high rates of acceptance for both psychotherapeutic and psychopharmacological treatment (34-37).

The general public tends to overestimate the effectiveness of psychotherapy, recommending it as the only treatment even for conditions such as schizophrenia where scientific evidence suggests that psychopharmacological treatment is indicated (22,38). In contrast, negative effects of psychotropic medications are perceived as severe, whereas the positive effects are underestimated (31,39,40). In some cases, despite agreeing that they are effective, the majority of respondents would not be willing to take psychiatric medications (41).

Five misconceptions about psychotropic medications were found to be prevalent in the general population. They are perceived as being addictive (30,31,39,42-44), a "sedation without curing" (30,38,39,44-46), an "invasion of identity" (39), merely drugging patients (40), and ineffective in preventing relapse (30). These misconceptions are represented also in Africa, where traditional healers are trusted more than Western trained doctors (47,48).

Negative attitudes about electroconvulsive therapy (ECT) were often observed. In an Australian population study, for example, only 7% perceived ECT as helpful, whereas 70% perceived it as harmful (22).

Medical students

Among medical students, results are mixed, sometimes contradictory. While the overall status of psychiatry as a discipline is low, some studies also report positive changes in attitudes, either over the course of time (49,50) or after completion of psychiatric training during medical school (51-71), although improvement in attitudes seems to be transient (72-75). In other studies, no improvement in attitudes was noted (76-83). Despite positive attitudes, the proportion of medical students indicating they would choose psychiatry as a career is often low (84-91).

Perceived low prestige and low respect among other medical disciplines have been among the main reasons mentioned for not choosing psychiatry as a career (49,87,92-111). In a recent survey of US medical students on medical specialties perceived as the object of bashing, psychiatry ranked third (39%) after family medicine and general internal medicine (112).

When there was an attraction to psychiatry, it appeared to be based primarily on its being interesting and intellectually challenging (77,101,110), and providing a career that promises job satisfaction with good prospects (101,113,114). Medical students often do not view psychiatry as an (intellectually) challenging career choice (101,115-117) and see it as a profession with low job satisfaction and limited fulfillment (109). Psychiatry was, however, in other studies, ranked as most attractive as far as intellectual challenge was considered (92,118,119).

A further influential aspect is the impact of students’ families on their attitudes and their decision to aim for a career in psychiatry. Stereotypes such as specializing in psychiatry being "wasted time" are widespread among the families of medical students (94,120), although students do not necessarily feel discouraged by their family (100,104). Nevertheless, this attitude reflects an image of psychiatry as not being "real medicine" (109).

Financial aspects, such as low pay (49,87,92,99,106,107,109,116,121-124) and lack of government funding (103,125-129), also play a role in forming the image of psychiatry as a discipline. These financial drawbacks have an impact on attitudes of medical students in both clinical and research settings.

Medical students also perceive psychiatry as lacking a solid, authoritative scientific foundation (92,97,101,109,117,119,130-135). This attitude is partly based on uncertainty concerning the nosology and diagnosis of mental illnesses, which is mentioned among the reasons for medical students not to enter psychiatry (109,136,137). The classification of mental disorders in the DSM and ICD categories has been subject to criticism because the majority of these diagnostic categories are not validated by biological criteria (138-141), thus reinforcing the image of psychiatry as not being "real medicine". One aspect of this discussion includes
the question as to whether research using diagnoses that are not validated as inclusion criteria "is equally invalid" (142).

Results concerning medical students’ opinion on psychiatric treatment and its outcome have been mixed. Medical students often viewed psychiatric treatment as ineffective (115,143) and considered psychiatry to be "too slow moving" (133).

Medical students were often less skeptical than the general public towards psychotropic medications (144,145). However, psychotropic drugs were criticized for not targeting the actual cause of the illness (146). Psychotherapy was rated more positively in some instances (147).

Medical students’ attitudes towards ECT have been also mixed. Most of the respondents viewed it as a form of punishment (148,149), only to be used as a last resort (150). In contrast, the majority of medical students in a Nigerian study disagreed with the idea of ECT being misused as a punishment (151). UK students reported no fears of abuse of ECT by psychiatrists, unlike some 30% of their counterparts in Iraq and Egypt (152). Negative attitudes towards ECT may be attributable to mass media and movie depictions (148,153), whereas the UK students were more likely to have observed actual cases treated with ECT (152,154).

Health professionals

Family physicians’ attitudes toward psychiatry have been explored in some studies. Two reasons for non-referral were identified (155): concerns about the effectiveness of psychiatric treatment and stigma for the patient. Psychotropic drugs were often considered necessary, but psychotherapy and combined approaches were also recommended (156,157).

The image of psychiatry from the perspective of psychiatrists has not been studied extensively. A study evaluating how a sample of psychiatrists and pediatricians felt about their specialty found that satisfaction was rated high among psychiatrists (158), with no differences in satisfaction compared with pediatricians. Lambert et al (136), assessing the reasons why doctors left the specialty they had initially chosen, report that the main reasons mentioned by psychiatrists included the specialty’s poor public image, the perceived lack of respect among other doctors, and the perception of under-resourcing. Only 71% of psychiatrists in a British study reported a general willingness to take antipsychotics themselves in the case of a schizophrenic disorder (159).

Student nurses and nurses have been found to have positive attitudes toward psychiatry (160-166). The same applies to pharmacy students (167).

Health professionals’ attitudes towards specific psychiatric treatments appear to coincide with those of the general population and medical students. Thus, depot medication was often perceived as coercive and compromising patient autonomy (168,169), psychotherapy was preferred over antidepressants (170), and psychotropic drugs were often accepted only as a last resort (171). Social workers, however, had a positive attitude towards psychotropic medications (172,173). Only 35% of non-medical mental health professionals reported that they would consider taking antipsychotics themselves in the case of a schizophrenic disorder, whereas 85% would recommend them to relatives (159). Mental health nurses recommended ECT only in cases of extreme depression (174). Involuntary treatment methods elicited strong emotions among nurses (175,176).

Patients and relatives

Among patients who did not comply with a referral to a psychiatrist, the most frequently mentioned reason was the fear of mental illness stigma, rather than negative expectations about the treatment and its quality (177). Patients usually expect that treatment will be helpful (178,179), and most outpatient clients in a community mental health centre were satisfied with the treatment they received (180,181). However, expectations that treatments such as ECT will be painful, and that medications may be administered without their consent are often reported by patients (26,182).

Regarding specific forms of psychiatric treatment, patients and their relatives harbor the same stereotypes about psychotropic medications as are found in the general public. Thus, these medications are often rejected because they are thought to be addictive (32,183-185), not to target the actual causes of the illness (32), to induce personality changes (179,186) and to suppress normal feelings (184). Some studies show a clear preference for psychotherapy over pharmacological treatment (19,26,187,188) and patients often do not expect psychotropic medication when first beginning treatment (178,179,189). Psychiatric treatment was often seen as being either slow in taking effect or completely ineffective (190). However, compared to the general population, psychiatric patients and their relatives have been found to have slightly more positive attitudes towards psychotropic medications (191-195), and some studies report that satisfaction with this form of treatment is high (196-198). Previously hospitalized patients showed more positive attitudes towards psychiatric treatment (199-201).

While ECT has often been viewed by patients as an effective treatment method (202,203), most patients expected severe side effects (204,205), often leading them to consider it as a treatment of last resort. However, this was not the case in patients who had already undergone ECT (206-208). Similarly, while most patients reported that they were not in favor of compulsory treatment, because it would limit their autonomy, most evaluated their actual experience with compulsory treatment as helpful (197,209-218).

The media

The general depiction of psychiatry in the news and entertainment media is predominantly negative. In a media commentary, psychiatry was portrayed as "a discipline without true scholarship, scientific methods, or effective treatment techniques" (219). Newspapers and movies have often conveyed a negative picture of psychiatric hospitals (220,221). These images were quickly generalized and contributed to the negative image of psychiatry overall (222,223). Modern community mental health centers have been rarely depicted in the media (224).

The depiction of psychiatric treatment is also often negative, with images of ineffective and punitive electroshocks (225), forced confinement, or psychoanalytical treatment (224,226,227) prevailing. The "Hollywood mythology of psychiatry" (228) conveys the idea that successful treatment is not based on medication and gradual progress, but on a single cathartic session. Newspaper reports on psychotropic drugs have been substantially more critical than reports on cardiac drugs, more often emphasizing negative side effects while omitting information on beneficial effects (229,230). Reports on ECT have been frequently discriminatory and biased (231). Several newspapers repeatedly criticized the relationship between psychiatry and the industry (232).

The stigmatization of psychiatrists

The general public

The public image of psychiatrists is largely negative and based on insufficient knowledge about their training, expertise and purpose. For example, it is not widely known that psychiatrists are medical doctors, and the duration of their training is underestimated (6,182,233-235). They are ascribed a low status among physicians (236), academicians (235), and mental health professions (237). Many studies report an insufficient differentiation between the various mental health professions, in particular between psychiatrists and psychologists (233,237,238). Only two studies reported that respondents were able to differentiate between the professions (6,235). Psychiatrists are accused of relying too much on medications (239). In the presence of a mental health problem, help from a confidant (25,27,34) or a family physician (241-242) is often recommended instead of treatment by a psychiatrist. Nevertheless, only a small minority of the general public endorse the stereotype that "psychiatrists are useless" (22,236,237,243).

There are competing stereotypes concerning the professional roles of psychiatrists (244,245). On the one hand, they are often perceived as "agents of repression" whose purpose it is to guarantee conformist behavior (244) and who can "see into people’s minds" (18). It is sometimes suggested that psychiatrists do not really want to understand their patients and are hostile towards them (6,107). On the other hand, psychiatrists are sometimes perceived as oracles, diviners or loving saviors, with exaggerated expectations about treatment success and healing (244).

Another misconception about psychiatrists concerns their role in courts as experts who testify about the mental health of defendants. Their explanations for a defendant’s behaviour are often misunderstood as "creating loopholes for criminals" (246,247). In this context, respondents also expressed low confidence in psychiatrists’ ability to detect legal insanity. Similarly, it has been suggested that the testimony of forensic psychiatrists is not based on professional expertise but motivated by financial interest (219,248,249). Nevertheless, the majority of lawyers and judges rejected the low-competence stereotype (250).

Three additional stereotypes describing psychiatrists can be found in the literature, referring to madness, oddness and abusiveness. Arguably, the most common is that of the psychiatrist who suffers from mental health problems (18,233,239,251). However, we have not found a single study that gave direct empirical evidence that the public actually endorse this stereotype. In a population survey (236), the majority described psychiatrists as helpful and trustworthy, and only a small minority perceived them as quirky or intransparent. But, given the choice between various mental health professionals, the participants in an Australian survey felt least comfortable talking to psychiatrists and rated them highest on perceived oddness (237). Finally, psychiatrists have been viewed as dangerous and manipulative abusers (107,252), who exploit their patients and abuse their power (51), even to the extent of trying to obtain sexual favours.

Medical students and health professionals

Medical students often report overhearing negative, disparaging remarks about psychiatrists by teachers in medical school and during clerkship (112,120). Based on the notion that "psychiatrists must be crazy because they are able to deal with crazy people" (244) or that "working with crazy people will make you crazy" (120), medical students sometimes perceive psychiatrists as more emotionally unstable or neurotic than other health professionals (65,94,97,253). Medical students may also see psychiatrists as peculiar, fuzzy, confused thinkers who are complex and difficult to understand (79,94,253,254).

Within the medical community, the status of psychiatrists is usually described as low. Some authors suggest that there is a "lack of respect among the medical community" (120), which stereotypes psychiatrists as "unsure, ineffective, useless and incomprehensible" (244). This perception of psychiatrists as "not real doctors" is also reflected in the fact that referral letters from family physicians to psychiatrists rarely contain information about physical symptoms (255). Nevertheless, medical doctors acknowledge that psychiatrists can help people with mental disorders and possess relevant expertise (256). They also report that they value and desire the advice of consultant psychiatrists (257-259), although they do not want to have them as treatment providers on a long-term basis (250,261). Despite these positive attitudes, 35% of non-psychiatric doctors see psychiatrists as less emotionally stable than other physicians, and 51% as neurotic (256).

On the other hand, psychiatrists rated themselves as more introspective, less authoritarian, more cultured and mature than their medical colleagues and 77% disagreed with the idea that they were more neurotic. Psychiatrists are, however, well-aware of their negative image (246,256,262).

Psychiatrists appear to be generally well accepted by other mental health professionals (263,264). Psychologists, nurses and social workers rated psychiatrists as equal to other professional groups in competence, although they consistently evaluated them as less warm (265).

Patients and relatives

Attitudes of patients and their relatives are ambivalent. Satisfaction with psychiatrists’ performance tends to be high (196,198), with attitudes becoming more positive during hospitalization (161). An often expressed concern is about the time pressures that exist within psychiatric care facilities and the associated lack of time for intensive conversations (196,266-269). Some patients have described psychiatrists as controlling (267) and some relatives have perceived them as arrogant (268). Strehlow and Piesiur-Strehlow (270) found that lack of knowledge about the expertise of psychiatrists and negative attitudes led parents to choose psychiatrists only as a last resort for their children with mental health problems.

The media

Many of the stereotypes that are prevalent among the general public can also be found in the way psychiatrists are portrayed in the media. For example, psychiatrists are depicted as unhelpful, not providing effective therapy (128,224), and unable to explain or predict their patients’ behaviour (271). Furthermore, derogatory and colloquial terms for psychiatrists are frequently used (107). The depiction of a malicious, controlling psychiatrist (272), a functionary of the oppressive state (227), was typical for the first half of the last century (228). In the ensuing years, different subtypes of psychiatrists have evolved. For example, Schneider (273) differentiated Dr. Dippy, Dr. Wonderful and Dr. Evil, representing the stereotypes of the mad psychiatrist, the superhealer and the exploitative, boundary-violating psychiatrist. A similar classification has been proposed on the basis of a movie analysis (226). Typically, positive attributes of psychiatrists include them always being available to their patients (228). A review of American movies (274) found that psychiatrists were depicted as helpful and friendly in about one half, and as malicious and boundary-violating in the other half, of the analyzed movies.

INTERVENTIONS TO COMBAT THE STIGMATIZATION OF PSYCHIATRY AND PSYCHIATRISTS

Our review of the literature on the stigmatization of psychiatry and psychiatrists revealed a scarcity of research on the development and evaluation of interventions to combat stigma. The results of these few studies are presented separately for the stigma toward psychiatry and that toward psychiatrists. 

Interventions to combat the stigmatization of psychiatry

Concerning the stigma towards psychiatric treatment, there is some evidence that improving people’s knowledge about mental disorders during a "mental health first aid course" improves concordance with generally recommended therapies (275). There is also some evidence that attitudes towards community-based facilities could be improved by providing information about mental disorders and their treatment as well as contact with persons who suffer from those disorders (276). Battaglia et al (277) found that a presentation given by a psychiatrist on mental health issues for high school students not only improved knowledge about mental health, but also improved help-seeking attitudes and appreciation of psychiatrists, possibly due to greater familiarity.

Changing the depiction of psychiatry in the media is an important prerequisite for changing public opinion, particularly by promoting realistic expectations about treatment modalities and their success (234,239). Stuart (278) suggests that mental health professionals as well as patients should be more present in the media, in order to provide a more accurate picture of psychiatric treatments and their consumers. Media training for mental health professionals may improve their credibility and the acceptability of their message. A specific intervention that aims at improving the relations between psychiatrists and the media is described by Kutner and Bresin (279). Based on the idea that insecurity in a media interview situation can come across as arrogance, they developed a specific media training program. In workshops with groups of six psychiatry residents, information about the media and its functioning is provided and communication and presentation skills are practiced in role-playing. Even though no formal evaluation was reported, the authors claim positive experiences with the training.

Most interventions aimed at modifying medical students’ attitudes towards psychiatry centered on changes in teaching modalities and the curriculum in medical school. Studies comparing different styles of teaching (e.g., traditional versus problem-based teaching) failed to show an advantage of one method over another (55,67,72). According to a study by Singh et al (67), the acquisition of knowledge, an aware ness of the therapeutic potential of psychiatric interventions and direct patient contact can improve attitudes and enhance psychiatry’s attractiveness as a career choice.

One specific approach to correcting the misperception of psychiatric treatment as ineffective is described by Coodin and Chisholm (280). A psychiatry seminar on recovery in persons with schizophrenia, co-taught by a consumer and a professional, led to more favourable perceptions of treatment for mental illness. Lambert et al (136) argue that tackling the negative image of psychiatry should start in medical school and continue in junior doctor training, in order to retain psychiatrists in their jobs. Moreover, in order to avoid mismatches, they recommend that interested medical students have the opportunity to gain more experience in psychiatric internships before pursuing a long-term career in psychiatry.

Interventions to combat the stigmatization of psychiatrists

We were unable to identify any studies describing interventions specifically targeting the stigmatization and discrimination of psychiatrists. However, there were several recommendations on how to change their negative image, most of which focused on developing a positive relationship with the media. This includes active participation of psychiatrists in the flow of information (233) and provision of expert knowledge on mental health issues (281) and forensic cases (282).

The Quebec Psychiatric Association developed recommendations on how to improve the image of psychiatrists with the help of a communication firm. Their strategies include becoming more visible in the media, responding to public needs and critical events, and increasing the visibility of psychiatrists in the community (283). They further argue that psychiatrists should react publicly to criticism of their profession. Higher visibility and better community orientation are also recommended by Felix (284) and Davidson (285), who suggest that community volunteering is an important approach to better public recognition.

In the interest of reducing stigma within the medical profession, it is recommended to address stigma in psychiatric education (120), providing medical students with a more accurate picture of psychiatry as a discipline and offering positive role models (94,176,286). To form positive relations with trained doctors, consultation-liaison relationships with a psychiatrist are recommended (287). In that regard, it is important that the psychiatrist remains "a physician first and a specialist second", with sound medical knowledge (176,288). Spiessl and Cording (289) suggest an easily accessible psychiatric liaison service for family physicians in
order to reduce delays in referrals. Moreover, they suggest practice-oriented seminars for family physicians, informing them about mental illness but also about psychiatric facilities, as well as continuing education in the context of the psychiatric liaison service.

RECOMMENDATIONS

Our review of the literature on stigmatization of psychiatry and psychiatrists produced only a very small number of articles on research concerning the development and evaluation of interventions aimed at reducing such stigma. The main results indicated the importance of close collaboration with the media. In this regard, the improvement of public relations, the inclusion of psychiatrists in the media as experts on psychiatric issues, as well as workshops for psychiatrists on how to interact with the media, have proven to be effective in reducing the stigma of psychiatry and psychiatrists. Moreover, the media play an important role in providing information and correcting misconceptions about psychiatric treatments, facilities and the job of psychiatrists. The second main result concerns the improvement of the image of psychiatry and psychiatrists through a combination of knowledge and contact with people with mental illness. Specific approaches concerning medical students’ attitudes include addressing stigma and misconceptions about psychiatry during medical training, and improving teaching in psychiatry.

Also on the basis of the experience of its global programme on reducing the stigma and discrimination toward schizophrenia (290-293), the WPA recommends the following actions to combat the stigmatization of psychiatry and psychiatrists.

Recommendations to national psychiatric societies

National psychiatric organizations should define best practices of psychiatry and actively pursue their application in the mental health care system.

In addition to the publication of appropriate guidelines about best practices, psychiatric organizations should find ways to introduce their contents into the medical curricula and make training in their use an essential part of postgraduate education in psychiatry. The fact that best practice guidelines exist and that they are being applied should be public knowledge.

Psychiatric organizations should ensure rapid action in instances of human rights violations in the practice or research related to psychiatry and clearly report on the effects of such action. They should place emphasis on the development of techniques that will facilitate the control of quality of psychiatric practice, and on the wide use of such techniques. They should regularly report on scientific achievements and successes in the provision of care for people with mental disorders in communications with governments. They should work toward full transparency of their relationship with health related industries.

National psychiatric organizations, in collaboration with relevant academic institutions, should revise the curricula for undergraduate and postgraduate medical training.

There is evidence from a number of countries that medical students have a poor opinion of psychiatry and that a decreasing number of them choose psychiatry as a specialty upon graduation. As our review showed, this is in part due to the influence of teachers from other medical disciplines who hold such views and in part to the way in which psychiatry is presented and taught in medical schools in most countries. A variety of teaching methods that could make the subject of psychiatry more attractive exist, but are not widely used. These include the intensified instruction about skills (that can be used in dealing with mental illness as well as in the practice of medicine in general), contact with people who have been treated for their psychiatric illness and recovered, the involvement of family members as teachers about the routine management of mental illness and impairment in the community, exposure to successful community care for the mentally ill, use of summer schools and exchange programs to increase the attraction of psychiatry, and a better integration of the teaching of psychiatry with that of neurosciences and behavioral sciences.

Skills of presentation and communication, for work with the media and governmental offices, are of considerable importance in the development of mental health services as well as in any effort to change the image of psychiatry. At present, these skills are taught only exceptionally. Postgraduate training should also include education about the origins of stigma of mental illness and about the methods that can be used to combat it.

National psychiatric societies should establish closer links and collaboration with other professional societies, with patient and family associations and with other organizations that can be involved in the provision of mental health care and the rehabilitation of the mentally ill.

The image of psychiatry and of psychiatrists depends, to a large extent, on the opinion of other medical specialists and on the perception of the discipline by those who use psychiatric services. Psychiatric societies often have very poor links to other professional societies and to organizations of patients and relatives, with which the relationship is often adversarial. The conduct of joint projects (e.g., research on comorbidity of mental and physical disorders) and collaboration with patient and family organizations in the production of guidelines and practice standards might diminish the gap that currently exists and contribute to the
improvement of the image of psychiatry.

Collaboration with patient and family organizations can also contribute to the effort to make psychiatric services more efficient and user-friendly. The experience that some countries have in this respect (e.g., in the joint selection of an "ombudsman" who can help to resolve problems emerging emerging in mental health services and the introduction of regular meetings of representatives of patient and family organizations and leaders of mental health programs) may reduce the number of conflicts and provide opportunities for contact and collaboration.

Collaboration with schools and teacher associations as well as organizations such as the Rotary Club can also be helpful in reducing the stigma of psychiatry.

National psychiatric societies should seek to establish and maintain sound working relationships with the media.

The role of the media in shaping attitudes of the general public is of increasing importance. The information which media have about the practice of psychiatry is often incomplete or obsolete. National psychiatric societies should consider different ways of providing up-to-date information and developing working relationships with media representatives, including workshops, regular informative bulletins and press releases, the involvement of media representatives in planning services and other ways appropriate for the country.

Recommendations to leaders of psychiatric services and individual psychiatrists

Psychiatrists must be aware that their behaviour can contribute to the stigmatization of psychiatry as a discipline and of themselves as its representatives.

The behaviour of psychiatrists in their clinical practice is of decisive importance for the image of psychiatry and psychiatrists. Its components that need to be given particular attention include: a) the development of a respectful relationship with patients and their relatives; b) staying abreast with advances of psychiatric research and practice and their implementation in clinical practice; c) strict observance of ethical principles in the provision of care and in the organization of services; d) collaboration with other medical specialists and health workers as well as with other professionals involved in the care for people with mental disorders.

Acknowledgements

The authors would like to thank Ms. M. Marekwica, Ms. K. Samjeske and Ms. P. Schlamann for their contributions to the paper and their helpful assistance.

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