Concepts of Stigma and its relevance in Mental Health

Outline• Introduction• Components of Stigma• Mental health stigma• Types of Stigma• Formation of Stigma• Cycle of Stigma• Origin of stigmatisation•  Psycho-social theories• Reactions to Stigma• Culture and Stigma• Tools to assess stigma• Interventions • Different studies• Conclusion• References

Introduction

The word stigma is of Greek origin.

Originally referred to the brand or scar burned or cut into the body, signifying that the bearer was a slave, or criminal or otherwise set apart from the general society.

The phenomenon whereby an individual with an attribute which is deeply discredited by his/her society is rejected as a result of the attribute (Goffman, 1963)

Contd…Stigma is the result when persons are categorized as being

deviant, or belonging to a stereotyped group, and whereby there exists discriminatory behavior.

Stigma has been associated as major barrier to recovery for people with mental illnesses.

Contd…

According to Merriam Webster’s Dictionary, Stigma is a set of negative and often unfair beliefs that a

society or group of people have about something. According to Oxford dictionary, stigma is a mark of disgrace associated with a particular

circumstance, quality, or person. As for e.g.: “the stigma of mental disorder”

Cited from :http://www.prc-han.org/docs/overcoming_stigma_feb09.pdf

Meaning• Erving Goffman defined stigma as “the process by which the

reaction of others spoils normal identity”.

• Erving Goffman defined stigma as a special kind of gap between virtual social identity and actual social identity

• The 3 forms of stigma as categorized by Goffman The experience of a mental illness (or the imposition of such a

diagnosis); a physical form of deformity or an undesired differentness; or an association with a particular race, religion, belief, etc.

(Goffman, 1990).

Cited from: Thio, Allex,(2001) Deviant Behavior, 6th ed., Allyn & Bacon

ComponentsLink and Phelan (2001) defined stigma in terms of the presence and

convergence of four interrelated components. First, people distinguish and label human differences. Second, members of the dominant cultural group link labeled persons

with certain undesirable attributes. Third, negatively labeled groups or individuals are placed in distinct

and separate categories from the non-stigmatized. Fourth, as a result of the first three components, labelled individuals

experience status loss. Finally, the process of stigma placement, and therefore management, is dependent on the degree of one’s access to social, economic, and political power.

Cited from: Link B Q., Yang L H., Phelan J C., and Collins P. Y.. (2004) Measuring Mental Illness

Stigma, Schizophrenia Bulletin, Vol. 30, No. 3,

Components of Stigma

Link & Phelan components (2001)

 Labelling

Negative stereotypes

Separation of “us” from “them”.

Status loss and discrimination

Cited from: Link, B. & Phelan, J. (2001) Conceptualizing Stigma. Annual Review of Sociology 27(3): 363–85

Mental Health StigmaMental health stigma can be divided into two distinct types: Social stigma is characterized by prejudicial attitudes and discriminating

behaviour directed towards individuals with mental health problems as a result of the psychiatric label they have been given.

Perceived stigma or self-stigma is the internalizing by the mental health sufferer of their perceptions of discrimination (Link, Cullen, Struening & Shrout, 1989), and perceived stigma can significantly affect feelings of shame and lead to poorer treatment outcomes (Perlick, Rosenheck, Clarkin, Sirey et al., 2001).

Cited from Link BG, Cullen FT, Struening E, Shrout P, Dohrenwend BP. 1989. “A modified labeling theory

approach in the area of mental disorders: An empirical assessment.” American Sociological Review 54:100-23.

Perlick D.A, Rosenheck R.A., Clarkin J F, Sirey J A, Salahi J, Struening E L , Link B G(2001) Adverse Effects of Perceived Stigma on Social Adaptation of Persons Diagnosed With Bipolar Affective Disorder, Psychiatric services, Vol. 52 No. 12

Types of Stigma

• Public stigma occurs when health care providers, employers, and the general public develop and sustain negative stereotypes about people with mental illness.

Self-stigma occurs when individuals with mental illness apply negative stereotypes to themselves.

Institutional stigma occurs when assumptions about persons are translated into public policy and funding decisions that discriminate against people with mental illness.

Cited from:

A report on Overcoming Stigmahttp://www.stampoutstigma.org

Cited from: Peterson D, Barnes A., and Duncan C (2008) , Fighting Shadows, Self-stigma and Mental Illness Whawhai Atu te Whakamā Hihira

Component Public stigma Self Stigma

Stereotype Negative belief about a group For example, dangerous, incompetent and weak of character.

Negative belief about selfFor example, weak of character andincompetent.

Prejudice Agreement with belief and/or negative emotional reactionFor example, anger and fear.

Agreement with belief Negative emotional reaction For example, low self-esteem and lowself-efficacy.

Discrimination Behavioural response to prejudice.For example. Avoidance of work and housing opportunities and withholding help.

Behavioural response to prejudiceFor example, a failure to pursue work and housing opportunities.

Difference between Public Stigma & Self Stigma

Formation of StigmaIn order to understand the relationship between stigma and mental illness,

the origins of stigma must be defined.

Corrigan and Penn, consider stigmas as “negative and erroneous attitudes about these persons”.

Stigmas have their roots in many different areas, and are reinforced in several ways.

Many facets of society must be examined in order to understand fully the impact of stigma on people diagnosed with mental illnesses.

• The media has one of the largest impacts on society’s views of individuals with mental illness.

Contd…

Corrigan and Penn stated that the media portrays people diagnosed with mental illnesses in one of three ways

homicidal maniacs who need to be feared, who have childlike perceptions of the world that should be marveled

they are rebellious free spirits

• The media tends to portray individuals with mental illnesses as violent and law breakers.

• The stigma that individuals diagnosed with mental illnesses face can translate into prejudice and discrimination at a later time.

• These labels and stereotypes reduce their dignity and alienate them from other people.

Contd…Public perception also plays an integral role in the formation

of stigma.

Herrman explained that there is a need for promoting community understanding of mental illness as well as the illness itself.

He suggested that understanding by the public would help those who suffer from mental illnesses to be able to get and maintain a job more easily, help in education, and their health as well as assist in making laws and policies that help people instead of hurting them

Contd…The perceptions can start in youth and continue for life.

The mentally ill can often have as hard a time combating stigma as they do coping with the effects of their illness itself.

It is necessary to understand the effects of stigma. Without looking at the effects, the general public cannot begin to understand what the mentally ill go through on a daily basis.

In general, according to Penn and Martin, the public perceives people with mental illnesses as dangerous. This may play a big part in why the public stigmatizes individuals with mental illnesses.

Cited from: Smith M(2002) Stigma Advances in Psychiatric Treatment, vol. 8, pp. 317–325

Cycle of Stigma Sartorius (2000)

Cycle of Stigma-   Sartorius, 2000

Origins of stigmatisation

• Constitutional originsConstitutional factors interfere with the capacity for 'proper' social

perception and information processing.

After coming across someone disturbed with schizophrenia, people are more likely to think "He was disheveled and odd" or "He was fit and fast". The intuitive response is that people are more likely to think selectively that the person was "disheveled" and "odd".

Contd…

Research shows that the brain weights negative evaluations in preference to positive ones.

Also, the brain, when overloaded with data, is likely to treat repeated examples of the behavior of a single person as independent instances of the behavior of their group, so repeated episodes of violence by one or a few people with mental illness are likely to be interpreted as independent episodes of violence committed by the category of patients with mental illness.

Contd…Psychological origins: Humans, although do not endorse the misfortune of others, are

willing to use 'unfortunate others' to feel happier about themselves.

People in-groups in which reward is equally distributed are less satisfied in comparison with people in-groups that include an unfortunate person, although they are likely to acknowledge the unfairness of the situation.

Further, people subjected to threats, failures and the frustrations of everyday life and those with low self-esteem tend to derogate others in order to built their own self-esteem and feelings of well-being.

Contd…

This phenomenon is similar to someone feeling powerful when he/she considers another less intelligent or beautiful when he/she considers another ugly.

Thus, stigmatizes benefit from the presence of the stigmatized, the latter providing them with psychological dividends: examples they could consider as 'worse' than themselves in order to redress the balance.

On the contrary, people with higher intelligence and higher self-esteem are more likely to hold positive attitudes towards patients with mental illness, probably because they would not need to degrade those with mental illness in order to feel intelligent or positive about themselves.

Contd…Economic origins:The stigmatiser's discourse has economic aspects as well. "I must

avoid danger to survive and compete": to increase one's access to resources, stigmatization of rivals is used as a weapon in socio-economic competition.

Stigmatization is likely to be more intense in more competitive, self-seeking societies, moderated by the ease of availability of resources.

It can be said that competition for scarce economic resources intensifies hatred and stigmatization. This again relates to self-interest.

Contd…Nowadays, the expression of discrimination may be dangerous.

A sports team may accuse another team of drug abuse or disgraceful social behavior.

Here, the former is not necessarily projecting one of its own attributes onto the stigmatized; rather, it may project one out of a list of socially objectionable attributes in order to discredit the rival and promote its own opportunities.

Contd…

Evolutionary origins:

 Stigmatization, as a tactic for survival and reproduction, is a

discourse implying a genetic push towards 'discrimination'.

This suggests that genes make humans and animals discriminate in order to avoid dangers, including natural dangers (snakes, heights, darkness), illness (rotten food, those with a contagious disease), mechanical danger (falling objects, those who pose a physical threat) and ideological danger ('deviants', non-conformists and 'psychopaths').

Contd…

Those who are poor bets genetically (carrying genes for a disease), sexually (unattractive, disabled, resourceless), in terms of survival ('social parasites', infected people) and in terms of security ('psychopaths', criminals, exploiters) are avoided and there is competition with potential rivals for resources, all in the service of genetic interest.

Thus, those who are potentially violent because of an underlying mental illness, those who are likely to carry genes for a mental disorder (e.g. manic-depressive illness) and those who are unable to control resources (such as people actively suffering from depression) are stigmatized in the genetic interest of stigmatizes.

Cited from Haghighat R. (2001) A unitary theory of stigmatisation, Pursuit of self-interest and routes to

de-stigmatisation, British Journal of Psychiatry, 178, 207-215

Psycho-social theories

Labelling theoryThe foundations for labeling theory result principally from the

work of two American psychologists, Edwin Lemert and Howard Becker. Labeling theory has emerged as a major sociological approach to understanding mental disorder.

Lemert (1972) argues that studies of deviant behavior need to confront two problems- how deviant behavior originates, and how deviant acts become symbolically attached to certain persons and what the consequences of such attachment are for those individuals. Lemert(1951) came up with the concept of primary and secondary deviance.

Contd…Primary deviance is a situation in which a person who is

“normal” acts differently or strangely, but the behavior is rationalized as atypical by others because it is perceived that this is not the person’s own characteristic.

Secondary deviance refers to a situation in which a person is relegated to a deviant role; i.e., being deviant is thought to be a typical characteristic of that individual.

Contd…

Social factors in mental disorder

Social ClassSocial class has been most consistently and most clearly

demonstrated in various studies to be associated with the disorder.

More specifically, people from the lower classes are more likely than those from other classes to become mentally ill. Surveys on random samples of Americans have consistently found a greater percentage of lower class people suffering from psychiatric symptoms (Dohrenwend, 1975; Strole et al.,1962; Hollingshead and Redlich, 1958; Faris and Dunham,1939).

Contd…

This finding has prompted two conflicting explanationSocial causation- This suggest that lower-class people are more

prone to mental disorder because they are more likely to experience social stress (such as unemployment and divorce); to suffer from psychic frailty, infectious diseases and neurological impairments and to lack quality medical treatment, coping ability and social support. This means that low social status is, through those problems, a cause of mental illness.

Social selection or drift- This suggest that mentally ill people from higher social classes often drift downward into the lower-class neighborhood, helping to increase the rate of mental illness in that neighborhood. This means that the lower-class position is a consequence of mental illness among formerly higher-status people

Contd…

Race and ethnicityMany studies have shown higher rates of psychiatric distress

among American Blacks, Hispanics, and Asians than whites. The explanation for this finding is that minorities experience more social stresses stemming from discrimination, poverty, and cultural conflict(Kessler and Neighbors, 1986; Yamamoto et al.,1983).

On the other hand there are studies showing no significant difference between minorities and Whites. The reason for this is that the minorities group identification, group solidarity, or social network protects them against those social stressors(Kuo and Tsai, 1986; Kessler et al., 1985)

Contd…

The urban environmentA community survey indicates higher rates of mental disorders

in urban areas particularly the inner city, than in rural areas, including the suburbs and small towns (Robbins et al., 1984).

Some community studies also reveal a link between urban living and specific psychiatric problems. Generally urban residents exhibit higher levels of neurotic and personality disorders while the more serious psychotic conditions, especially severe depression, are more prevalent among rural and small- town dwellers(Dohrenwend and Dohrenwend, 1974).

Contd…

Marital StatusSources of social support like families and spouses can help

mitigate the effects of stress and assist in deflecting tendencies toward psychological difficulties (Kandel, Davies, and Ravies 1985; Kessler and Essex 1982; Turner and Marino, 1994).

Conversely, families and spouses can also be the sources of stress, and impaired relationships in this context can be precipitating factors in the onset of abnormal behavior. Situations leading upto divorce and their aftermath, for example, are known to cause increased depression-especially for women (Aseltine and Kessler 1993; Horwitz

Reactions to stigma

• Fear /Rejection-Due to stigma, the typical reaction encountered by someone with a mental illness (and his or her family members) is fear and rejection.

• Denial of Services -Some have been denied adequate housing, loans, health insurance and jobs due to their history of mental illness.

• Acute loss of self esteem -Due to the stigma associated with the illness, many people have found that they lose their self-esteem and have difficulty making friends.

Contd…

• Stigma prevents help seeking & treatment - The stigma attached to mental illness is so pervasive that people who suspect that they might be mentally ill are unwilling to seek help for fear of what others may think. Spouses may be reluctant to define their partners as mentally ill, while families may delay seeking help for their child because of their fears and shame

People with mental illness face discrimination in the workplace. They may lose their job, be the subject of gossip by coworkers and denied promotions.

Consequences of stigma can be devastating and worse than the illness itself

Contd…

• Labeling is common- a label that's almost impossible to ever shed. They believe that once family and friends find out about their illness, they'll be scorned. They may try to hide their symptoms and not stick to treatment regimens.

• Social Withdrawal and distancing - Some people with mental illness become socially isolated, locked out of their community by the shame and embarrassment that stigma triggers.

• Stigma also leads to social distancing, in which people refuse to rent rooms to someone with a mental illness, don't want them as neighbors or co-workers, and won't befriend them.

• Cited from:• Crisp, A., Gelder, M., Rix, S., Meltzer, H., & Rowlands, O. (2000). Stigmatisation of people

with mental illnesses. British Journal of Psychiatry, 177, 4-7.

Culture and Stigma

Fig. 1. Diagram of the mechanisms by which threat influences stigma outcomes. ‘Culture-specific’ threat is shown to overlap partially with ‘tangible’ and ‘symbolic’ threats while also representing a distinct form of threat that leads to stigmatization.

Contd…

Tangible threat. Representations of physical dangerousness comprise one ‘tangible’

threat via perceived peril to one’s physical safety. Corrigan, Edwards, Green, Diwan, and Penn (2001) and Corrigan et al. (2005)

Symbolic threat. In parallel, attributions of responsibility implying an individual’s

volitional role in causing a stigmatizing condition constitute a second threat.

A ‘symbolic’ threat exists in that a lack of restraint by the individual in acquiring mental illness threatens the ethical order of society (Stangor et al., 2000).

Contd…

A ‘symbolic threat to societal order’ proposes that perceiving that one had control over the origin of mental illness leads to blame, which engenders affective (e.g., anger) and behavioral reactions (e.g., punishment) which result in response to the threat that such individuals pose to societal order.

cultural component’ might include the beliefs, values and practices held by a group, which also includes the individual’s role in negotiating values held by social worlds

Cited in Lawrence H, Yang L H, VaughnsV P, Kotabe H, Link B G, Sawe A, Wong G, Phelan J

C(2013) Culture, threat, and mental illness stigma: Identifying culture-specific threat among Chinese-American groups, Social Science & Medicine 88, 56-67

Tools to assess stigma

Perceived Devaluation and Discrimination Scale (Link BG, 1987)

Internalised Stigma of Mental Illness (Ritsher et.al., 2003)Self-stigma of Mental Illness Scale (Corrigan et.al., 2006)Consumer Experiences of Stigma Questionnaire (Wahl OF,

1999)Rejection Experiences Scale (Kessler et. al., 2007)Depression Self-stigma Scale (Kanter et.al., 2008)Self-reported Experiences of Rejection(Link et.al., 1997)Stigma Scale (King et.al., 2007)The Inventory of Stigmatising Experiences (Stuart et.al., 2005)Self-esteem and Stigma Questionnaire(Hayward et.al., 2002)Stigmatisation Scale (Bagley, King, 2005)

Contd…

Discrimination and Stigma Scale (Thornicroft, 2009)Experiences of Discrimination Scale (Thompson, 2004)

Cited from : Brohan E, Slade,M , Clement S, Thornicroft G(2010) Experiences of mental illness stigma,

prejudice and discrimination: a review of measures. BMC Health Services Research

Interventions:

Strategies to change stereotypesEducation:

Replaces stigmatizing attitudes with accurate conceptions about the disorders

Contact:

Challenges public attitudes through direct interactions with mentally ill persons

Protest:

Suppresses stigmatizing attitudes toward mental illness and behaviors that promote these attitudes

WPA Programme “Open the Doors”

• Need for sharing experience and information obtained in the

course of the programmes.

• Selection of programme’s targets based on consultation with

people who have schizophrenia and their families.

WPA Anti-stigma Principles

Acceptance of difference, not normalisation or denial of difference

Enable people to believe their own experience, rather than rely on stereotypes

Media should follow public opinion

Though, stigma against psychiatry and psychiatrists are prevalent, we should not be afraid to defend our profession

WPA – India’s InitiativeCoordination by NIMHANS under guidance of Prof. R. Srinivasa Murthy

Use of short films of Dr. Abdul Kalam taking an oath with students

against discrimination in English & Tamil, for educating students in high

school & universities

Publication of articles on newspaper, distribution of pamphlets & printing

messages on milk packets by Schizophrenia Research Foundation

(SCARF)

Formation of SHAPES ( Society for Hope, Action, Empathy and Regard

for Schizophrenia) by patients & family members

Different studiesName of the

authors year Findings

Corrigan et al (2002) suggests mechanism for how dangerousness impacts persons with serious mental illness: The public attitude that most persons with serious mental illness are dangerous leads to fear.

Like most sources of fear, people with serious mental illness are avoided.

Citizens are less likely to rent apartments to persons with serious mental illness and are more likely to hospitalize them to protect the public

Weiss et al (2001) In Bangalore the main concerns the sample had were related to marriage-Lowering their own chances of entering a good marriage, but were also concerned with decreasing the chances of one of their relatives.

In the London sample, marriage was of no concern. It was also found that self perceived stigma was much higher in the London sample than in the Bangalore sample.

Contd…

Name of the authors

year Findings

Thara and Srinivasan

(2000) Marriage, fear of rejection from neighbor and the need to hide the fact from others were some of the more stigmatizing aspects.

Female gender of patient and younger age of the caregiver and patient were related to higher stigma.

Srinivasan and Thara

(2001) Psychosocial stressors were most commonly cited, followed by personality defect and heredity

Kohn etal., ( 2004) The stigma, myths and misconceptions surrounding mental disorders have been identified as the major reason for a large number of patients not seeking treatment

Contd…

Name of the authors

year Findings

Ngui etal., (2010) Stigma contributes to much of the

discrimination and human rights violations experienced by people with mental disorders

Loganathan& Murthy,

(2008) A study from NIMHANS found significant differences on stigma among rural and urban patients having schizophrenia.

Urban respondents felt the need to hide their illness and avoided illness histories in job applications, whereas rural respondents experienced more ridicule, shame, and discrimination

Mishra etal., (2009). found more stigma among persons with better insight

Contd…

Name of the authors

year Findings

Charles et.al., (2007) it was found that stigma among patients was associated with male gender, external non stigmatizing beliefs about illness, disease model of illness, total number of causal models, total number of non medical causal beliefs, visiting the temple or other places for cure

Ping Tsao et.al.,

2008 suggest adverse consequences of stigma such as increased social isolation, limited life chances, and decreased access to treatment.

The added burden that stigma imposes on the struggle to recovery can alter behavior, generate anxiety, and ultimately cause isolation from the mainstream culture

Corrigan et. al 2012 both education and contact had positive effects on reducing stigma for adults and adolescents with a mental illness.

Conclusion

Stigma about mental illness can lead people to fear disclosing that they have mental health problems, which may prevent treatment and recovery.

Stigma can result in limited life opportunities.

Stigma poses barriers for public health prevention efforts designed to minimize onset of mental illness and the prevention or worsening of symptoms over time.

Stigma can result in lower prioritization for public resources allocated to mental health services and poorer quality of care delivered to people with mental illness.

Contd…

• Despite general improvement in knowledge about mental

illness, mental disorder continues to receive a great amount of

prejudice, discrimination, and stigma from the public.

• Anti stigma interventions should continue more effectively for

improving knowledge among society & better treatment of

mentally ill.

References:• Brohan E, Slade,M , Clement S, Thornicroft G(2010) Experiences of mental

illness stigma, prejudice and discrimination: a review of measures. BMC Health Services Research

• Charles, H., Manoranjitham, S.D. & Jacob, K.S. (2007) Stigma and explanatory models among people with schizophrenia and their relatives in Vellore, South India. International Journal of Social Psychiatry, 53, 325 – 332

• Corrigan, P.W. & Watson, A.C. (2002) Understanding the impact of stigma on people with mental illness. World Psychiatry, 1(1), 16 – 20

• Corrigan P.W, Morris S. B., Michaels PJ, Rafacz JD, Rüsch N (2012) Challenging the Public Stigma of Mental Illness: A Meta-Analysis of Outcome Studies, Psychiatric Services 63:963–973,

• Crisp, A., Gelder, M., Rix, S., Meltzer, H., & Rowlands, O. (2000). Stigmatisation of people with mental illnesses. British Journal of Psychiatry, 177, 4-7.

• Haghighat R. (2001) A unitary theory of stigmatisation, Pursuit of self-interest and routes to de-stigmatisation, British Journal of Psychiatry, 178, 207-215

• Kohn, R., Saxena, S., etal. (2004) The treatment gap in mental health care. Bulletin of the World Health Organization, 82, 858-866

Contd…

• Lawrence H, Yang L H, VaughnsV P, Kotabe H, Link B G, Sawe A, Wong G, Phelan J C(2013) Culture, threat, and mental illness stigma: Identifying culture-specific threat among Chinese-American groups, Social Science & Medicine 88, 56-67

• Link B Q., Yang L H., Phelan J C., and Collins P. Y.. (2004) Measuring Mental Illness Stigma, Schizophrenia Bulletin, Vol. 30, No. 3,

• Link BG, Cullen FT, Struening E, Shrout P, Dohrenwend BP. (1989) A modified labeling theory approach in the area of mental disorders: An empirical assessment. American Sociological Review 54:100-23.

• Link, B. & Phelan, J. (2001) Conceptualizing Stigma. Annual Review of Sociology 27(3): 363–85

• Loganathan, S.&Srinivas Murthy, R. (2008) Experiences of stigma and discrimination endured by people suffering from schizophrenia. Indian Journal of Psychiatry, 50(1), 39 – 46

• Mishra, D.K., Alreja, S., Sengar, K.S., etal. (2009) Insight and its relationship with stigma in psychiatric patients. Indian Journal of Psychiatry, 18 (1), 39 – 42

Contd…• Ngui, E.M., Khasakhala, L., Ndetei, D., etal. (2010) Mental disorders, health

inequalities and ethics: A global perspective. International Review of Psychiatry, 22(3), 235 – 244

• Perlick D.A, Rosenheck R.A., Clarkin J F, Sirey J A, Salahi J, Struening E L , Link B G(2001) Adverse Effects of Perceived Stigma on Social Adaptation of Persons Diagnosed With Bipolar Affective Disorder, Psychiatric services, Vol. 52 No. 12

• Peterson D, Barnes A., and Duncan C (2008) , Fighting Shadows, Self-stigma and Mental Illness Whawhai Atu te Whakamā Hihira

• Ping Tsao, C.I., Tummala, A., Roberts, L.W. (2008) Stigma inMental Health Care. Academic Psychiatry, 32, 70 - 72

• Smith M(2002) Stigma Advances in Psychiatric Treatment, vol. 8, pp. 317–325• Srinivasan, T.N., Thara, R. (2001). Beliefs about causation of

schizophrenia: do Indian families believe in supernatural causes? Social Psychiatry and Psychiatric Epidemiology. 36: 134-140

• Thara R, Srinivasan T. N.(2000) How stigmatizing is schizophrenia in India? International Journal of Social Psychiatry. ;46:135–141

Contd…

• Thio, Allex,(2001) Deviant Behavior, 6th ed., Allyn & Bacon

• Weiss, M.G.; Jadhav, S.; Raguram, R.; Vounatsou, P.; Littlewood, R., (2001) Psychiatric stigma across cultures: local validation in Bangalore and London. Anthropology and Medicine 8(1):71-87.

Websites: http://www.prchan.org/docs/overcoming_stigma_feb09.pdf http://www.stampoutstigma.org A report on Overcoming Stigma www.openthedoors.com www.likeminds.org.nz www.changingminds.org

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