Competing perspectives on erasing the stigma of illness: what says the dodo bird?

The dodo bird is an Alice in Wonderland character who, at the end of a race, concludes "Everybody has won and all must have prizes". The dodo bird effect has been used to describe a conundrum resulting from behavior change research that fails to distinguish superiority among discrete strategies for psychotherapeutic change. Research on stigma change may find itself at this point. Advocates have developed and implemented multiple approaches to changing stigma; some of these might be shown to have more beneficial impact than others. The mental health community has been especially active in tackling stigma, so many of the examples herein come from the corresponding body of research. We divide the multiple approaches to stigma change into sets of competing or complementary perspectives and examine both the benefits and the negative unintended consequences of examples. We consider the effects of education versus contact on stigmatizers (public stigma), the stigmatized (self-stigma), and the social sphere in which the two groups engage (structural stigma). Stigma impact varies by targets and outcomes so we examine impact on knowledge versus attitudes at the population versus grassroots levels. Overall, we found that effects of contact seem greater than education for stigmatizers. For the stigmatized, approaches that target eliminating self-stigma may be less beneficial than interventions designed to promote disclosure. Targeting grassroots may yield greater impact than population-based approaches. Increasing knowledge and pity may yield unintended consequences which may undermine life opportunities of people with the illness. Our review highlighted the benefits of competing perspectives in advancing our understanding of stigma change and crafting of more effective anti-stigma interventions.