The challenge of stigma: lessons from Sir Graham Thornicroft
- Páll Matthíasson
- Jun 1
- 20 min read
Updated: Jun 9
Few psychiatrists have contributed as much to our understanding of mental health stigma as Sir Graham Thornicroft. Over several decades, he has combined clinical experience, academic research, and international advocacy to explore how stigma affects people living with mental health conditions and to identify effective ways of reducing discrimination. As author of Shunned and co-chair of the landmark Lancet Commission on Ending Stigma and Discrimination in Mental Health, Thornicroft has helped shape both the scientific understanding of stigma and practical strategies for tackling it. In this interview, he reflects on the origins of his interest in the subject, the evidence behind anti-stigma interventions, the role of social contact in changing attitudes, and the progress that has been made—and still remains to be made—in creating a more inclusive society for people with mental health conditions.
Professor Sir Graham Thornicroft
Graham Thornicroft is Professor Emeritus of Community Mental Health at King’s College London. He is also an Honorary Consultant Psychiatrist at the South London & Maudsley NHS Foundation Trust. Graham has made significant contributions to the development of mental health policy in England, including chairing the External Reference Group for the National Service Framework for Mental Health, the national mental health plan for England for 1999-2009.
Páll Matthíasson: Sir Graham, you are someone who has thought and written extensively about stigma. This includes the book „Shunned“ in 2006, one of my favorite books (1). You also led the Lancet Commission on ending stigma and discrimination in mental health (2), just to name two important things. Could you tell me a bit about why you came to be interested in this topic?
Sir Graham Thornicroft: Thank you very much for inviting me to have this discussion with you today, Páll. What happened is that I’d been working about 20 years as psychiatrist. I did my training in South London, and I did jobs in hospitals and in the community. I then became a senior doctor. We call it consultant in my country, and I worked in community mental health teams for about 10 years, and over time I had a rather vague feeling of discomfort that there was something about working in the field of mental health that was substantially and qualitatively different from most fields of healthcare or medicine. Gradually, I was able to identify what I thought this was, and I named the problem as stigma. This refers to a wide range of occurrences, processes, impacts, but it has effects on staff and family members, as well as on people with mental health conditions. began to feel that there were many ways in which the field of mental health practice is seen within society, but also within most parts of healthcare, as different and worse or inferior to „real“ healthcare or „real“ medicine. Then my feelings of discomfort changed into a feeling of impatience and anger, and I wanted to understand these issues in more detail, and I really wanted time to sit down and learn everything I could about it. I was then working both at university and in a healthcare provider organization. So I made a ridiculous and absurd proposal. I went to my manages for the university, and my manager in the health service, and said I want to you to pay me for a year, but I will temporarily stop working for you. What I plan to do is to spend this year writing a book about stigma. This is so important because everything in our field is somehow tainted or damaged by this corrosive influence.
And to my amazement they said, okay. So I had this amazing opportunity. I imagined that I would persuade my family to go either to a beach, you know, a far away part of the world in a little hut on a mountain top where I'd have my laptop, and our family would do unusual and wonderful things. And they said, forget it. We've got jobs. We've got schools and university. If you want to write a book, you go ahead and it's nothing to do with us. So I didn't go away. I sat at home and first of all, I read and I read and I read. I wanted to find out everything to do with the initial concept of stigma. How it relates to HIV/AIDS, TB, short stature, visual disfigurement, mental health problems, learning disabilities, sex workers, you know, any type of stigma. But I also wanted to read about what stigma means. And here I went round and round in circles. On the one hand, it's such an important concept, because I think it damages so many aspects of mental health. On the other hand, there are many different theories and models and conceptions of what stigma is, and also people outside of the mental health field tend to think of stigma as such a vague term that you can do nothing about it. So for example, when I made proposals to bodies for stigma research, they basically say „go away, this is so vague, you don't know what you're doing. That's not real research. You know, there's nothing of practical interest here“.
So I tried to identify some firm handles I could grasp in the field. The best I came across was work in the field of social psychology, particularly the handbook of social psychology, by Professor Susan Fiske. She conceptualized stigma in relation to aspects of knowledge, attitudes and behaviour. So it was K – A – B. – in my view the three different key elements of stigmatisation. And the more I thought about it, the more sense that made to me. Among, for example, the general public, for example, many people who know really not very much about mental health conditions, and what they do know is mostly wrong, so they have not just incomplete but incorrect information. Secondly, the attitudes, that are the affective, the emotional reactions of people towards others with mental health conditions, which are occasionally compassionate or empathetic, but much more often fearful, confused, frightened, avoidant, and negative. The behavioural component means - what do people actually do? Do you employ somebody if you're an employer, if they disclose a condition? What do you do if you're in a romantic relationship, and the other person says that they've had a history or a current experience or mental health condition? Do you want to continue the relationship? Somebody might want to become a friend? You find that they have a diagnosis? What do you do? And it seemed to me that of the three, the knowledge, attitude, behavioural elements, behaviour was most important, because by and large, these are negative forms of behaviour. So I'd call the knowledge element misunderstanding. The affective element is prejudice. But the behavioural element, which I call discrimination, is actually the most important. Do you get the job? Do you get the place in college? Do you get into the football team? Do you get to join the choir? Do you keep in touch with your family? Do your friends abandon you when you have a diagnosis? So that's what I really wrote about in that book, Shunned. I suppose that my work in this field began with that initial conceptualisation.
Very interesting. Thank you. And you've already covered two follow up questions that I had about stigma and discrimination and the three components of stigma. But so, it might sound like a naive question, but why do you think, apart from the sense of injustice, being aware of and fighting stigma is important?
Well, there's a sort of academic answer, and there's a sort of personal answer. I start with the personal. On the one hand, one could say this is an area of inequality and diversity or a lack of social justice and so on. But, you know, there are many, many areas which show lack of justice. Why should I pick this one? And I think probably the real reason, is that when I was three years old, my mother became severely depressed. I remember a little bit from that time, not very much. But what actually happened is that she was working as a nurse, a district nurse, we now say community nurse. She became severely depressed and suicidal. She had anti-depressants from her GP, but they didn't work, following which she had ECT. Interestingly, she had ECT as a day patient, she wasn't admitted to hospital. She was taken by ambulance to hospital every day, had ECT, slept a bit and came home again in the afternoon. After only six treatments, she got completely better. She told me that her doctor said to her; „well, my dear, you've been very unwell, but you´ll never become depressed again“. I wouldn´t say that to any of my patients, as I really can’t predict the future, but he had given her that reassurance, and it turned out to be true. So I think that's a significant part of why I chose to dedicate my career to mental health. Mum told me later that when she was unwell some of her friends had left her, some family members had been harsh, if not critical, and spoken of a lack of moral fibre. They said, „ pull yourself together,“ or „don't, don't dwell on your misfortunes“, this type of thing. So I think that´s it in part, it was a personal experience. The second reason for my focus on stigma was that I saw what happened in the lives of many of the patients I was treating who found it very difficult to even get a job of any type, let alone a decent job. Quite often, the people who had jobs or were studying lost they would lose their positions when they became unwell, not because they'd lost the capability to do their jobs, but because the people in their organisations or in their colleges assumed that mental illness meant they'd lost capacity and productivity forever, or they'd be unreliable and so forth. So I saw people being systematically socially excluded because of a diagnosis, and that seemed to be wrong, so I wanted to do something about it.
Thank you, and thank you for sharing that personal story as well. It's quite powerful. Can I ask you; you wrote that book on stigma, and you led a Lancet commission on fighting stigma. But would you say that we are on the right track now? Is stigma being reduced, and can we eradicate it?
So let me start with an interesting fact. I led, as you said, or I co- led a special report for the Lancet called The Lancet Commission (2). And my co-leader is a remarkable woman who's based in South Africa called Charlene Sunkel. She is the person who hears voices. She spent several years in a large institution in South Africa for psychosis, and she, in recent years, has set up a group called The Global mental health peer network (now called aves Mental Health), with people with lived experience in about 30 or 40 countries who act in a peer or mentoring role with each other. She's remarkable in many ways. As a part of this Lancet report, she commissioned a special survey of people with experience of mental health conditions, and we had over 300 people from about 45 countries who responded about their experiences of stigma and its impact. One of the questions asks; „over the past decade, is stigma getting worse or better in your country?“ And about half said it's getting better. So it's actually reducing. I'm aware that in about 15 countries there have been large scale anti-stigma programmes, for example, in Sweden, Denmark, England, Australia, New Zealand and Canada, so far, all high income countries, and some of those have done formal evaluations. There have been detailed evaluations in Sweden, in Canada, in England, partial evaluations in Scotland, in Australia, New Zealand, and in all of those cases, they've shown real progress in stigma reduction. So can you reduce it? Yes. Is there evidence that across the world, stigma may be reducing? Yes. Can we actually eradicate stigma? I don't know yet. The scale of magnitude of the reductions in stigma was something between 10% and 20% according to whether you are measuring knowledge, attitudes or behaviour. For example, would you want to live next door to somebody with mental illness? Would you want to work with somebody with the condition? Would you want to be a partner or married to a person with a mental health condition? For example, we saw consistent reductions in the case of our anti-stigma program in England program over more than 10 years, We've also seen by comparison if the question would be, can you stop stigma in relation to TB or leprosy or epilepsy or HIV? The answer is yes. So the importance of this is that when we started this work, going back nearly 20 years now, there were some people who said, well, stigma is very regrettable. It's a great pity and a shame, but it's a part of human nature. We have in-groups. We have out-groups. We have us and them. And we have, you know, the affiliate group of ourselves, and unfortunately, as a part of human nature, you can't actually change it. But I'm now sure that that is wrong, We can, and I think we should reduce stigma.
Okay, thank you. And how should we go about that? Is that through things like campaigns or other means?
Next I'd like to mention a consequence or a product that followed our Lancet Commission work. Within that commission report, which is a paper of about 50 pages, we made a series of recommendations for different target audiences, and we said we would like to produce a practical toolkit on how to reduce stigma. We wrote that we've produced the evidence. We found over two hundred systematic reviews on stigma reduction The overall signal from this is a simple and clear message: that is the vital importance of social contact. This means that you arrange for ways for people who do have experience of mental health conditions to have contact with people who do not, in a particular structured way and that can reduce stigma. So after we showed that evidence in the Lancet commission, I worked closely with colleagues in the WHO and with the Global Mental Health Peer Network. We produced a special Toolkit, which is called the WHO Mosaic toolkit on ending stigma and discrimination in mental health, which was published in 2024 by the WHO (3). It gives examples of interventions at every level: it could be how a government which would like to run a national program, and Denmark would be a good example. At the other end of the spectrum, it's possible for an individual to take effective action, again using the principle of social contact. So an example would be a man in Leeds, which is a city in the north of England. He wanted to take action. He set up a stall. It's like a table with a poster on it in the entrance to a train station. And he called it a „Human Library. You're not coming to sit down to borrow a book. You're borrowing my time, or I'm borrowing your time. Please do come and sit down.“ So he's sitting there looking like a very reasonable person. The idea is, you sit down for five or 10 minutes and you talk about something to do with mental health. And he then, in the course of the discussion may well make some type of disclosure about having a mental health condition, though it will depend on the nature of the meeting, People then rush off to the trains. So they are not going to sit there for hours, but there is an encounter.
A colleague in Canada, a woman called Stephanie Knaak, produced a nice paper about the conditions under which social contact is more likely to be an effective anti-stigma intervention. So for example, it is where the nature of the meeting between the person or people with and without experience of the condition is on a relatively equal power status. It´s where the nature of the disclosure, which is often a form of structured narrative or story, is likely to moderately disconfirm a stereotype. So that means that you don't say, you know, „I have psychosis. I can hardly think straight, you know, I can't even wash myself“, and the person is in terrible state. No it is the person who said I had these terrible experiences, but then I saw the light, and I founded my IT company, and I'm a multimillionaire and look how things can change. So it's moderately disconfirming a common stereotype, that somebody is shabby and not able to organize themselves and so forth. The narrative by the person with the experience of a condition also needs to focus on recovery and hope. So it's not a narrative of despair and decline, but one of hope and recovery in respect of a person identifying their goals, working with the staff towards realizing the goals. So I think that we've got a lot of evidence, particularly between the Lancet Commission report and this WHO Mosaic Toolkit about what to do, whether you work at a very large scale or at a very small scale.
Okay, thank you. Now, I interviewed a colleague of mine who is running some IPS (individual placement and support) program for people with severe and enduring mental illness. And what he has actually been doing is to collaborate with the arts and creative industries, and he's found that very helpful to tackle stigma. So I just wonder, do you have any thoughts on that angle?
So what we recommended, both in these two main reports, the Lancet Commission report on this and the WHO Mosaic Toolkit report, is that the active ingredient, the social contact principle, is fine in theory, but you have to decide how to implement it in a particular place at a particular time. That means you have to directly contextualize the intervention to the local culture and context. You also may need to make this not just contextually appropriate and acceptable, but more than that, make it actively interesting. So to give an example: I'm doing a project with colleagues in Delhi in India, with the idea of seeing whether we can do stigma reduction work amongst adolescents living in slums in two cities in India. The intervention was deliberately designed together with young people living in the slums. We explained the idea and said: “Shall we have talks or presentions?“. And they said, „that's boring“. So for the younger children, up to about 10 years of age, they did a game called hopscotch. You just jump on one leg and then two legs and one leg and two legs. So they had a hopscotch game. But also on the pavement we have mental health sayings or messages, and it was a fun thing to do. And for the adolescents, they said, they like magic shows. So the event takes place in community hall. There's a magician with a funny hat, and he's got white gloves on. And then you pull a rabbit or a dove out of the hat. And that´s also surrounded by mental health messages.
That team also did an intervention to see whether you could reduce stigma in rural parts of India in Andhra Pradesh. They selected 42 villages, and the intervention consisted of a short play put on by actors in the village square. It's a small group that goes from one place to the next. There is a short play, about parents, and then a young adult child who develops psychosis. After the short play there's a discussion with the local people, and that did have a measurable stigma reduction impact. Now, the advantage of that, because you talk about the media, is that if you're putting on some form of dramatic production, whether it's TV or social media or video or live, then the role players do not necessarily have to disclose if they do or do not have a condition themselves. One of the core problems of the social contact principle is that it depends upon disclosure, then it means actually taking a big risk to say yes, I have a condition … because of stigma itself. You're trying to reduce stigma, but you actually maybe get to face stigma and suffer the impact of stigma if you actually disclose. But if you're playing as an actor in a story about stigma, you can play the part, and then, if you like, in the discussion, depending on whether the discussion is receptive or hostile, you may or may not disclose your own condition.
We've also done work in China with stigma reduction, we found extreme difficulty finding anybody to say that they have a condition and would like to take part in disclosure. We did find two such people in a study we did in Beijing. So then you may have to be more subtle or inventive. In working with the media, an interesting question arises: does it help to have celebrity endorsement or celebrity disclosure? So if you've got a famous actress or a handsome actor, does it help if they say, they've had postnatal depression or bipolar illness? And the answer is, probably. We did a review paper on this question recently, led by my colleague Petra Gronholm. There's not much published research in the field of mental health, but there is more in terms of cancer or hepatitis. It looks like it may make it more speakable for other people. If they're a celebrity, and have already opened up about having bipolar or having a suicide attempt. The problem, though, is that the ‘ordinary person’, if you like, feels that celebrities are rich, they're famous, they insulated, they can afford to make such disclosures. So celebrities alone aren't sufficient from a campaign, but they can help in opening up the topic,
The main users´and relatives´mental health alliance in Iceland, Geðhjálp, is having a series of lunchtime meetings where, different scholars discuss different aspects of stigma, and it's open to the public, and it's got some media attention. And what I find interesting is that there is now a study discussing different levels of stigma based on the type of mental illness that you have. For example, there is very little stigma against ADHD generally in at least Iceland, and I know in the Nordic countries as a whole, depression has gone down in being stigmatized, for example the Norwegian prime minister opened up about his battle with depression. But at the same time, the stigma against drug addiction, the stigma against schizophrenia, shifts very little, and stigma against kind of neurodevelopmental problems like autism, seems to be a struggle as well. So do you have any comments on these different aspects of stigma based on the type of problem?
There is some evidence that people with different diagnostic groups may be stigmatized to a greater or lesser extent. This evidence comes from some large-scale surveys, particularly those by Bernice Pescosolido in the United States. She's done several national surveys, and some international studies as well, suggesting that there is this gradient, usually psychosis and substance use disorder at the top end of the people who are stigmatized against. When we began to plan the English anti-stigma survey (called Time to Change), one of the early questions was, do we take a particular diagnostic group as the focus, or do we rotate them over time? Or do we take several diagnostic groups and forget the others. And we decided not to start cutting up the cake by diagnosis. Now, one part of the reason for that is that early on, after I wrote the book Shunned, I developed a consortium with Professor Norman Sartorius, then at the World Psychiatric Association, and we developed a way of assessing discrimination as rated by people with the condition. First of all, we went to colleagues in 27 countries, and we asked them to take part. We then talked to about 700 people across these countries with a clinical diagnosis of schizophrenia, and we used a structured assessment of their experience of discrimination called DISC. Essentially 90% of those people, said, „yes, we have been discriminated against because of our condition, because of our diagnosis“. We published that in The Lancet. A number of esteemed colleagues said this is completely unsurprising, because schizophrenia is the most stigmatized against condition. So we thanked them for their critical comments and set that up as an empirical question, and we did a further survey. Meanwhile our network had grown and we had over 30 countries represented and we talked to over 1000 people, this time with major depressive disorder. And of those people, 80% said, yes, we've been discriminated against because of our condition. Now, there's a little difference, but not much. It's really very similar. So we didn't find that schizophrenia was much more discriminated against than major depression, which, of course, itself is a serious condition.
There is another interesting element here. I mentioned earlier the survey we undertook a couple of years ago as a part of the Lancet Commission work. And one of the questions said; „which is worse; your experience of having the condition or your experience of having stigma because of the condition?“ And 80% of these people, in about 35 countries, said the stigma is worse than having the condition. And that's, that's one of these research findings that sticks with me, I can't forget it. It seemed to me to be rather impossible to decide where or how you would cut up the diagnostic cake, even if people would understand the diagnostic groups you're referring to. And there is a lot of commonality. Actually, it's actually not clear, is it having a diagnosis that is actually linked to stigma, or is it having had contact with mental health services, which, of course, could leave you without a diagnosis, if it´s a complex case, or maybe many diagnoses over a period of time. Anyway, having had treatment/service, contact/diagnosis, actually enhances the potential for stigmatisation.
In terms of your comment about ADHD and autism and so on, we have a very interesting phenomenon now of some people in my country saying that we have a problem of over- diagnosis. They're saying there is so much interest, particularly with respect to neurodevelopmental disorders, ADHD and autism. People are saying parents are queuing up to have their children assessed. They hope to get more time for exams or special help or some extra dispensation or some educational advantage. There's also claims in my country that people are being registered as being disabled for mental health purposes, and therefore they're not expected to work, and they can get government welfare benefits. Benefits that keep increasing the total government expenditure which it says it can't afford. So we have a major national debate at the moment about under- or over-diagnosis with respect to mental health conditions,.
That´s interesting. Indirectly relevant to this is the discussion in Iceland of an increase in prescribing of antidepressants, and I sense some stigma there. That people are saying on the one hand that not enough people get treatment for depression, but then when they get treatment, the claim is that it is being over-used. So you never know what is right.
Well with many of these issues, there is no simple way of responding, but I´ll make a couple of comments. First there is a colleague called Stefan Leucht in Germany. He published a very interesting paper (4), about how effective mental health treatments really are, compared to otherchronic conditions, Iike asthma, hypertension or diabetes, and finds that on average the effectiveness of mental health treatments is slightly stronger than for a number of common physical long-term conditions. Then there is an important question about whether medication is overused, lets say for depression, because psychological or psychosocial interventions are not available or affordable or accessible? This is true in many countries, not all though. One of the things I´ve done in recent years is that I chaired a guideline developing group for the World Health Organisation, called the MHGap Intervention Guide. These are recommendationsintended for colleagues in low and middle income countries, for example working in primary healthcare, but are also useful anywhere, about treatments for many common or severe mental health conditions. It´s based on a very detailed review of all the evidence, in particular focused questions like, „what´s the best first line medication for treating psychosis“, „what´s the evidence for psychosocial recovery approach for people with psychosis“, and so on. And what we´ve seen, now that we´ve made three editions of this guideline over 15 years is that the recommendations have changed as the evidence has changed. For many mental health conditions there´s now much more evidence in favour of psychological or psychosocial treatments, especially in relation to depression and anxiety. So our recommendations have increasingly stressed these psychological and psychosocial elements. In other words, we made recommendations for medications if the evidence justifies that.
Very interesting. It makes me think of the fact that in 2008 3% of our people with severe and enduring mental illness in Iceland ended up in paid work. Today nearly over 30 and up to 50% do. There´s been no change in medication, this is down to other interventions; IPS, rehabilitation etc. Now I could sit here all day and bombard you with questions, it is like having access to a gold mine, but this must come to an end. But any last words, any advice to colleagues in the Nordic and Baltic countries on how to deal with stigma?
Just a couple of key points. The implications of the evidence for social contact are profound. It means that people like you and me can play a part in stigma reduction but we are not the essential protagonists or active ingredients. The essential active change agents for stigma reduction are people who have experience, now or in the past, of mental illness. If they are then assisted by people like us to lead stigma interventions, that can be effective, at a local level, , at a regional or at a national level. And that means that it´s not just a partnership it is a question of how professionals can actively support the change agents to do their work to best effect.
Thank you very much. □
References
Thornicroft G. Shunned: Discrimination Against People with Mental Illness. Oxford: Oxford University Press; 2006.
Thornicroft G, Sunkel C, Alikhon Aliev A, Baker S, Brohan E, El Chammay R, et al. The Lancet Commission on ending stigma and discrimination in mental health. Lancet. 2022;400(10361):1438–1480. doi:10.1016/S0140-6736(22)01470-2.
World Health Organization Regional Office for Europe. The WHO Mosaic Toolkit to End Stigma and Discrimination in Mental Health. Copenhagen: WHO Regional Office for Europe; 2024. Available from: WHO Mosaic Toolkit
Leucht, S., et al. (2012). "Putting the efficacy of psychiatric and general medicine medication into perspective: review of meta-analyses." The British journal of psychiatry : the journal of mental science 200(2): 97-106.
AUTHOR: Páll Matthíasson
MD PhD FRCPsych FRCP FRCPE, is a consultant psychiatrist at Landspitali - The National University Hospital of Iceland. He graduated in medicine from The University of Iceland, completed his training in adult psychiatry from the Maudsley & Bethlem Hospitals in London and did a PhD in psychopharmacology from the Institute of Psychiatry, University of London. Páll has been director of Mental Health Services at Landspitali, CEO / Director of Landspitali and honorary senior lecturer at the University of Iceland. Currently he is Chairman of The Icelandic Mental Health Commission, a multi-stakeholder advisory group to the Icelandic government on mental health issues. His research interests include treatment-resistant schizophrenia, reducing coercion in psychiatry, burn-out and resilience.
Image by Ólöf Björnsdóttir.
