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Letter   |    
Combating Stigma by Redefining It
H. Richard Lamb, M.D.
Psychiatric Services 2000; doi: 10.1176/appi.ps.51.3.392
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In Reply: I want to thank Ms. Ganger for her comments about my article. I have no problem with substituting the word discrimination for stigma. However, whatever we call it, I believe it is important to understand its cause. Bigotry, injustice, and intolerance may well be causative, but if we leave it at that, we miss something very important, namely the public's fear of irrational and unpredictable violence.

The average person reacts with fear when he or she hears that an overtly psychotic person has pushed a stranger in front of a subway train or attempted to assassinate the President or a Beatle or tried to crush a stranger's skull with a rock. Such incidents often become high-profile cases and receive extensive publicity. Only a very few mentally ill persons commit such acts, but when they do, they strike fear in the average citizen.

Can we prevent this chain of events? Obviously, we should provide more community mental health care and do it in a way that is more acceptable to persons with severe mental illness. But if one spends time in jails trying to provide treatment to incarcerated mentally ill persons, it soon becomes evident that many persons there will not accept treatment, no matter how it is offered. Moreover, many of these mentally ill persons are very frightening, and mental health professionals often find ways to avoid accepting them for treatment in community settings, especially without the leverage provided by such mechanisms as civil outpatient commitment or outpatient treatment as a condition of probation.

We know that violence among severely mentally ill persons is most common in those who are acutely psychotic, refuse medications, and are substance abusers. Most of these persons are known to us. If we truly want to reduce stigma and discrimination, we will do what needs to be done to treat them.

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