Stigma is on the rise

Over the last 30 years, stigma research – particularly research addressing mental illness stigma – has been quite successful in shedding light on mechanisms and circumstances of stigma, and how it affects people at multiple levels, from societal structures to internalization in self-stigma. However, to our astonishment, many of the features of stigma that we identified as targets to eliminate are now being used purposefully in populist rhetoric against marginalized groups. This rhetoric applies an “us” vs. “them” assignment to other vulnerable groups, openly labeling, stereotyping and devaluing them in an effort to control and exclude “them”. It thus follows the stigma process laid out by Link and Phelan in 20011 as if it was a playbook, rather than something we need to overcome. A massive societal change seems to unfold, where devaluation and discrimination of entire groups are no longer taboo. As stigma researchers, we cannot help but wonder what the consequences of these changes for people with mental illness will be. At first glance, we look back at palpable improvements. The stigma concept has helped developing and evaluating successful interventions to reduce discrimination2. Mental health problems have to some extent been normalized, and attitudes toward people with mental health problems in general, and with depression in particular, have softened3, 4. However, these past positive trends do not show the entire picture. People with schizophrenia, for example, have not seen any reduction in stigma. On the contrary, over the last 30 years, perceived differentness of people with schizophrenia has increased5, willingness to help these people has declined6, and several studies show a long-term trend of increasing desire for social distance toward these people4, 6. The severe stigma toward substance use disorders has proven remarkably stable4. So, while common mental health problems, including depression, are now more often recognized and normalized, mental disorders that appear to be disturbing, strange or unpredictable such as psychosis, or morally loaded such as substance use disorders7, are subject to constant or even rising stigma. On a broader political stage, stigma is clearly on the rise. People at the intersection of race/ethnic discrimination and mental ill- ness stigma are at particular danger of being targeted, as shown for example by political campaigns in Germany. Following deadly attacks committed by people with both a migration background and psychotic mental illness, there were general demands of “shutting the borders” and “creating registers for people with men- tal illness”. Groups that have made progress in their legal and societal emancipation, such as People of Color, or members of the lesbian, gay, bisexual and transgender community, have reason to fear that any achievements they fought for are being taken away. Election campaigns by populist parties in Europe and the US encourage openly hostile and hateful messages that now resonate with a growing proportion of the population. Stigma research consistently shows that authoritarian values are associated with more stigma towards people with mental disorders8. While a focus on single stigmatized conditions is important and informative, it also carries the risk of missing the “big picture”, since broader trends affect more than one vulnerable group. If race/ethnic discrimination and mental illness stigma converge, we need to examine the overarching mechanisms that are pushing these linked processes forward, to arrive at useful interventions at multiple levels. It has been hypothesized, for example, that economic competi- tion and growing inequality foster a climate of violence, exclusion and toxic masculinity within society, all to the disadvantage of vul- nerable groups9. These trends could also endanger any progress that has been made with regard to attitudes towards depression and other common mental disorders. Both as psychiatrists and as stigma researchers, we cannot ignore these developments. To keep up with our understanding of a changing situation for people with mental illness in a changing societal context, we need to re-enforce the traditionally strong ties between psychiatry and social sciences. This seems even more ur- gent since the funding of science itself, and social science in particular, has also become a contested political battlefield in some countries. The question arises of how the current societal developments are affecting the stigma experienced by people with mental illness. Does an overall sense of insecurity and crisis increase the readiness to discriminate against perceived outgroups, including people with severe mental illness? Questions like this need sound sci- entific answers to inform both psychiatry and the political sphere. We believe that, in order to answer these questions, we need alliances. We need to connect across countries to see similarities and differences in societal trends that affect people with mental illness. Notably, trend studies on public attitudes are mostly conducted in few high-income countries, and the trends we see might be different in other countries. We also need to broaden our perspective by looking at more than one vulnerable group, since overarching trends likely shape stigma experiences. Finally, and probably most importantly, we need to work more closely with people with lived experience. This reflects the advocate’s research imperative: stigma research is valued to the extent that it informs and activates efforts to reduce stigma.