In the Old Testament, part of Cain’s punishment for his crimes is to be branded, and thus set aside from society: “And the Lord set a mark upon Cain”. As with many Biblical tales, the archetype of the labelled and marginalised outsider has returned in various forms throughout history. Deliberate marking, or stigmatisation, of people who were deemed social outcasts or a risk to others has been carried out for centuries, from the Poor Law Act in England in the 17th century, requiring people in receipt of charity to wear a humiliating badge on their sleeve, to American Civil War deserters in the 1860s being branded on their faces, to deliberate scarring of slaves and prisoners in all societies. Those who suﬀer illness have not escaped this process of labelling and exclusion: far from it. People with leprosy, one of the oldest known human illnesses, have always been stigmatised: in Medieval Europe, they were required to carry a bell so that others could hear them coming and evacuate the streets. Alternatively, they lived in leper colonies, a practice that still continues in some countries today. AIDS is a modern example of a disorder that until very recently carried a lot of stigma and occupied a place in the public consciousness as a frightening and initially silent killer of young, seemingly healthy, individuals. At the peak of their ability to strike fear into people and lead to those aﬀected being stigmatised, the causes of these illnesses were unknown, and they were thought to represent a high risk of contagion to others. We now know the causative agents of leprosy and HIV, and how the infections are spread. Although it is a sad reﬂection on human nature, perhaps a feeling of personal security is a prerequisite for tolerance. People with mental illness are one of the most stigmatised groups in society. These disorders are very misunderstood, and the causes are still largely obscure. It is unlikely that we will ﬁnd a single causative agent, such as a mycobacterium or retrovirus, for any mental illness. Lacking the reassurance of a simple explanation, how can professionals help to combat mental health stigma? Sara Evans-Lacko and colleagues describe the encouraging results of the educational Time to Change campaign in this issue. Anti-stigma campaigners face many challenges, but perhaps the greatest is the www.thelancet.com/psychiatry Vol 1 July 2014
perception of risk by the media and the public. In 2013, popular UK tabloid newspaper The Sun ran the frontpage story “1,200 Killed by mental patients: shock 10-year toll exposes care crisis”. Clearly the ﬁgures quoted need a more nuanced and sensitive analysis than this headline: but it is public perception that determines stigma, not true risk. It is easy to criticise media reporting, but we as psychiatrists also need to take some of the blame: often we are poor communicators of risk, leading us to be seen as an untrustworthy source of information. In this issue, Cathryn Rodway and colleagues report that mental health service users are more likely to be victims of homicide than are the general population, and that a third of the service user victims in their study were killed by other service users, which highlights a need for more accurate risk assessment from mental health services. Most people with a mental illness are not violent and most homicides are committed by someone known to the victim, with random attacks being very rare. These are valuable data, but the evidence needs to be taken out of the pages of medical journals and into the public arena. Among the multitude of diﬃcult communication skills a psychiatrist needs to master, one which is often forgotten is the need to be able to communicate risk honestly and appropriately. Poor explanations, or simply denying risk exists, will only serve to increase the stigmatisation of people with mental illness and distrust in psychiatry. There is a diﬃcult line to tread between making the public aware of a risk, and making them unnecessarily frightened. Professionals might bear in mind the “hazard and outrage formula” developed by Peter Sandman to describe how the public respond to a perceived danger. The formula uses what the public believe to be the chances of an adverse event happening, rather than the real chances of the event. Our role is not just to explain clearly to our individual patients the risks of their illness and associated medications, but also to communicate these risks accurately and clearly to the public. Ultimately, to be transparent and truthful about risk is essential if we are to tackle stigma, which thrives on misunderstanding and ignorance.
Spencer Sutton/Science Photo Library
What we talk about when we talk about risk
See Articles pages 121 and 129
For more on the “Hazard and outrage” formula see http:// www.petersandman.com/ media/ Respondingto CommunityOutrage.pdf
■ The Lancet Psychiatry 95