STIGMA AND MENTAL ILLNESS

Presenter : Dr. Harneet kaurModerator : Prof. B.S.Chavan

INTRODUCTION Stigma is a broad term which is used to

describe the negative and stereotypical thoughts, attitudes, and feelings about people on the basis of the traits of a person, which can include gender, skin color, sexual orientation, religion and mental illness. It has been used to label certain groups of people as less worthy of respect than others.

These attitudes in the community are supported by ignorance, prejudice and discrimination, and are perpetuated when mental illness is represented in an inaccurate way by the media.

There are still attitudes within most societies that view symptoms of psychopathology (i.e., mental illness) as threatening and uncomfortable, and these attitudes frequently foster stigma and discrimination towards people with mental health problems.

Such reactions are common when people are brave enough to admit they have a mental health problem, and they can often lead on to various forms of exclusion or discrimination – either within social circles or within the workplace.

Stigma is therefore used as a negative label to identify people with mental health problems. It, thus, has its roots in fear and misunderstanding.

Many people hold negative opinions towards people with mental health problems because they do not understand the issues involved and because they are relying on myths and misconceptions.

As health professionals, we are committed to ensuring that people with mental health difficulties must enjoy the same rights on an equal basis with everyone without discrimination.

WHAT IS STIGMA? Stigma is a Greek word that in its origins

referred to a type of marking or tattoo that was cut or burned into the skin of criminals, slaves, or traitors in order to visibly identify them as blemished or morally polluted persons. These individuals were to be avoided or shunned, particularly in public places. (Wikipedia)

Sign of disgrace or discredit which sets a person apart from others. (Bryne 2000)

Stigma results from a process whereby

certain individuals and group are unjustifiably rendered shameful, excluded and discriminated against. [WHO 2002]

“a buzz word, arousing more emotional reaction than words like devaluation and discrimination”[Clausen 1981]

In his 1963 book,  Goffman E. Stigma: Notes on the Management of Spoiled Identity. Erving Goffman defines stigma as

The phenomenon whereby an individual with an attribute which is deeply discredited by his/her society is rejected as a result of the attribute. Stigma is a process by which the reaction of others spoils normal identity.

Gullekson (a clinical psychologist in

California) (in Fink & Tasman, 1992) writes about her brother's schizophrenia:

“For me stigma means fear, resulting in a lack of confidence. Stigma is loss, resulting in unresolved mourning issues. Stigma is not having access to resources… Stigma is being invisible or being reviled, resulting in conflict. Stigma is lowered family esteem and intense shame, resulting in decreased self-worth. Stigma is secrecy… Stigma is anger, resulting in distance. Most importantly, stigma is hopelessness, resulting in helplessness.”

CAUSES OF STIGMA

Economic instability – deals with poverty. Lack of information systems – lack of

education to both professionals and to the general public.

Lack of treatment facilities – the presence of inadequate preventive facilities.

Lifestyle – such as smoking and other drug use, and the act being seen as shameful.

Fear – people fear the unknown outcome of the condition; the condition itself and burden of care.

Previous experience – most people have

experience some form of the disease that might be similar to that particular disease that is stigmatized. They may also have seen people die from the condition in a bizarre circumstance due to family/societal neglect.

Medical diagnosis – the medical model implies diagnosis, and diagnosis implies a label that is applied to a ‘patient’. That label may well be associated with undesirable attributes (e.g., ‘mad’ people cannot function properly in society, or can sometimes be violent), and this again will perpetuate the view that people with mental health problems are different and should be treated with caution.

Media -Stigma in the media is especially

harmful because the media plays an important role in shaping and reinforcing community attitudes, i.e., spreading wrong information. For example, cinematic depictions of schizophrenia are often stereotypic and characterized by misinformation about symptoms, causes and treatment. Schizophrenic characters portray violence behavior, carry dangerous act, and commit suicidal and homicidal behaviors.

TYPES OF STIGMA

Self stigma

Enacted stigma

Felt stigma

SELF STIGMA

is where individuals with mental illness feel they are being judged by others, so they feel disgraced, blame and isolate themselves from people. It is one of the most harmful effects of stigma. Self stigma occurs when it alters how the person views himself/herself. The person living with mental illness may mistakenly believe that his/her condition is a sign of personal weakness or that s/he should be able to control it.

Enacted stigma/Discrimination – this is where there is discrimination against individuals living with mental illness or people who have some of the condition or disease in their community.

Felt stigma – the perception or feeling one has towards people with same specific disease or condition which they also have.

PROCESS OF STIGMA The stages in the process of

stigmatization include:

Labeling – the process of stigma begins when individuals with mental illnesses are first identified, marked and labeled, and seen to be different from others.

Stereotypes of mental illness

Psycho killer / maniac Indulgent, libidinous Pathetic sad characters Figures of fun Dishonest excuse: hiding behind

‘psychobabble’ or doctors

Negative reaction – there is negative behavior towards

individuals with mental illnesses because their situations are seen as a result of their sinful behavior or a curse from the gods.

Factor type Example Likely to increase prejudice Attribute of stigmatized Gender- Male gender Appearance- Unkempt appearance Behavior -Acute illness episode Financial circumstances- Homelessness Perceived responsibility- Not responsible for actions Perceived severity- History of hospital admission Perceived course- Incurable/“chronic” Perceived treatments- “Needs drugs” to stay well Perceived danger -Criminality or violence 

Shunning – they are shunned, rejected, avoided, and separated from other people, family or community because of their disease state.

Loss of status – these individuals lose their respect, position, dignity, statuses, and even be isolated from the family or community. Some individual’s rights are even trampled upon and are sacked from their work place, school, or even ejected from their place of residence.

How mental illnesses can affect family and friends

It's difficult to be diagnosed with a serious mental illness such as schizophrenia, bipolar disorder, panic disorder, obsessive-compulsive disorder and major depressive disorder. It's also difficult when a loved one is experiencing one of these diseases. When a person is living with a serious mental illness, the whole family may be affected.

Serious mental illnesses often have a biological component. They are not the result of bad parenting. Even still, after the diagnosis it's normal for most of the parents to feel a range of powerful and often unpleasant emotions.

It's not uncommon to feel ashamed, or hurt, or embarrassed by a family member whose behaviors can be difficult to understand and deal with.

Many people also feel anger at the

circumstances and even at the person who has been diagnosed. And though it may not be logical, parents often engage in some degree of self-blame. Such feelings of shame and anger may also go hand-in-hand with feelings of guilt. Grief is also common.

Parents, in particular, often have to readjust their hopes or expectations for the future when their child develops a serious mental illness. If they have a child (whether a minor or an adult) with a serious mental illness, they may find themselves focusing less attention on their other children.

Healthy siblings may feel anxiety and

frustration at the extra responsibilities they are expected to take on.

Relationships can be wonderful but challenging under the best of circumstances. When one partner has a serious mental illness, the situation can become even more complex. Many times, the partner without a diagnosed disorder will assume more responsibilities, at least for the short term. For a person who is already worried about what is happening with his or her partner, having to spend more time maintaining the household or taking care of the children can be especially hard.

It is important for the couple to keep in mind that most people diagnosed with a serious mental illness improve over time, and that a partner's attitude and behavior can make an important contribution to recovery. It helps to maintain an accepting and positive attitude, while holding realistic expectations for the partner with serious mental illness. Participating in specialized family therapy for serious mental illnesses can be very useful.

CONSEQUENCES OF STIGMA

It leads to negative attitude towards professionals who have dedicated their lives to serve and care for those suffering from the condition(s).

Damaging self-belief, i.e., sense of personal worth and self-esteem is affected; the person becomes shameful and unwilling to seek medication attention, or disclose an illness.

Mistaking belief – that mental illness is a curse from the gods, witchcraft, black magic, etc.

It could lead to prejudice; for example, that mental disorders are dangerous.

Financial problems - Loss of job/lack of employment.

Stigma prevent others from caring for the mentally sick .

Keep people from accessing counseling. Divorce Low self esteem

Failing to seek medical attention. Physical violence or harassment. Fewer opportunities for work, school or

social activities or trouble finding housing.

Lack of understanding by family, friends, co-workers or others the patient know.

Stigma hinders efficient and effective recovery from mental health problems.

ROLE OF MEDIA

Mental disorder and violence are closely linked within public mind. A combination of factors promotes this perception. Sensationalized reporting by the media whenever a violent act is committed by a formal mental patient, popular misuse of psychiatric terms psycho or psychopath and exploitation of stock formulas and narrow stereotypes by entertainment industry the public justifies its fear and rejection of people labeled mentally ill and attempts to segregate them in the community.

In this connection it is important to refer

to the unfortunate role which media in our country like cinema TV or press has played in perpetuating the prejudice against mental disorders.

Stigma in the media is especially harmful because the media plays an important role in shaping and reinforcing community attitudes, i.e., spreading wrong information.

For example, cinematic depictions of schizophrenia are often stereotypic and characterized by misinformation about symptoms, causes and treatment.

Schizophrenic characters portray violence behavior, carry dangerous act, and commit suicidal and homicidal behaviors.

Cultural factors/belief system – this about the myth and misunderstanding.

Ignorance/misconceptions – misperceptions about the cause or onset of the disease as a curse from the gods, punishment for one’s sins, witchcraft, black magic, demonic, spirit possession.

TOOLS Discrimination and stigma scale (DISC) (Health Service and Population Research

Department, Institute of Psychiatry, King's College London, May 2013.)

The purpose of the DISC is to collect information on how having a diagnosis of mental illness influences an individual’s personal and social life. This interview-based instrument collects quantitative and qualitative experiences of discrimination in key areas of everyday life and social participation, including work, marriage, parenting, housing, leisure, and religious activities.

It also considers the extent to which participants limit their involvement in areas of life due to anticipated discrimination. The DISC is designed for use by a trained interviewer and the ratings are those reported by the mental health service user.

Mental illness clinicians attitude scale (MICA) The MICA scale was developed at the Health

Services and Population Research Department, Institute of Psychiatry, King’s College London. The MICA scale is self- administered and usually requires about 5 minutes to complete it. A person’s MICA score is the sum of the scores for the individual items. The scores for each item are summed to produce a single overall score. A high overall score indicates a more negative (stigmatizing) attitude.

Questionnaire on anticipated discrimination (QUAD)

The QUAD is designed to assess the extent to which people with mental health problems anticipate personally experiencing mental health-related discrimination. This 14 item scale can be considered as a comprehensive measure of anticipated discrimination which covers a broad range of contexts in which mental health discrimination may be anticipated. It is suitable for use with adults with mental health problems. The QUAD is a self-complete scale and takes around three minutes to complete.

 IS STIGMA UNIVERSAL?

A striking aspect of stigma about mental disorders is its universality. Stigma has been recognized as important in mental health care in countries with extensive services( stuart and arboleda 2001)

Against the universality of stigma, studies across the globe present different pictures of stigma experiences in different countries and communities. In Ethiopia, 75% of family members are stigmatized.

Urban residents experience more stigma, as well as the older age group (Shibre et al 2001).

In Canada, persons of 60 years and older are more socially distancing (Stuart and arboleda 2001).

Studies from Bangalore, India found that

persons presenting with somatic forms of depression are less stigmatized than those with psychological symptoms (Raghuram R et al 2001).

Persons with depression in London experience restricted disclosure as stigma, while Indian patients experience discrimination in the marital area (Raghuram R et al 2001).

In the recently completed WPA stigma project from India, conducted in four cities with 463 ill persons with schizophrenia and 651 family members, two thirds reported discrimination (Srinivasa murthy et al 2001).

Women were more stigmatized, as well as those living in urban areas.

Males experienced greater discrimination in the job area, while women experienced more problems in the family and social area.

Relatively high experience of subtle

discrimination (decreased love, avoidance, rejection, distance, excessive caution) was reported in the family area. The differing types and areas of stigma emphasize the need to consider the 'local' experiences.

Programmes to fight stigma and discrimination should address the study of local experiences in different groups using qualitative and quantitative methods; the interventions should be group specific and the effort at mental health literacy (Goldney et al 2001) should focus on the understandability of mental phenomena.

 IMPACT AND OUTCOME OF INTERVENTIONS

Stigma is a multifaceted concept, and even well-established measures have their limitations.

These measures are self-report questionnaires, which are at risk of social desirability bias. Mass media interventions may reduce prejudice, but there is insufficient evidence to determine their effects on discrimination.

Social contact is the most effective type of intervention to improve stigma-related knowledge and attitudes in the short term. However, the evidence for longer-term benefit of such social contact to reduce stigma is weak. In view of the magnitude of challenges that result from mental health stigma and discrimination, a concerted effort is needed to fund methodologically strong research that will provide robust evidence to support decisions on investment in interventions to reduce stigma.[Thornicroft et al 2015]

Although contact and education both seem to significantly improve attitudes and behavioral intentions toward people with mental illness, contact seems to yield significantly better change, at least among adults. This is especially evident in studies that used more rigorous research designs, such as RCTs. Mean effect sizes for contact when assessing overall effects as well as effects on attitudes and behavioral intentions were significantly greater than those found for education. Meeting people with serious mental illness seems to do more to challenge stigma than educationally contrasting myths versus facts of mental illness. Face-to-face contact with the person, and not a story mediated by videotape, had the greatest effect.(Corrigan 2010)

Programs like NAMI’s Stigma Busters have

targeted stigmatizing advertisements, news stories, and entertainment through strategic letter-writing campaigns. Anecdotally, these seem to have had some effects—for example, one campaign led the American Broadcasting Company to pull its television drama Wonderland in 2000 after two episodes. The show stoked stereotypic connections between mental illness and violence. Research is needed to determine whether anecdotes like these translate to meaningful impact on stigma in the media.

COPING UP

Three approaches to change

Approaches to changing public stigma have been divided into three paradigms on the basis of a review of social- psychological research related to racial-ethnic and gender minority groups: education, contact, and protest (Corrigan et al 2012)

EDUCATION Educational approaches to stigma

challenge inaccurate stereotypes about mental illnesses, replacing them with factual information.

for example, contrary to the myth that people with mental illnesses are homicidal maniacs, the difference in the rate of homicides by people with serious psychiatric disorders versus the general public is very small.

Educational strategies have included public service announcements, books, flyers, movies, videos, Web pages, podcasts, virtual reality, and other audiovisual aids (finkelstein,2008).

Some benefits of educational interventions include their low cost and broad reach.

CONTACT A second strategy for reducing stigma is

interpersonal contact with members of the stigmatized group. Individuals of the general population who meet and interact with people with mental illnesses are likely to lessen their levels of prejudice.

Social-psychological research has identified factors that seem to moderate contact effects (Alport G 1954), including one-to-one contact so that people who engage with one another can learn of similar interests and potentially cultivate a friendship, contact that includes a common goal , and interactions with a person who moderately disconfirms prevailing stereotypes.

PROTEST

Social activism, or protest, is the third form of stigma change we examined. Protest strategies highlight the injustices of various forms of stigma and chastise offenders for their stereotypes and discrimination.

“SHAME ON THEM FOR PERPETUATE THE IDEA THAT PEOPLE WITH MENTAL ILLNESS ARE JUST ‘BIG KIDS’ UNABLE TO CARE FOR THEMSELVES.”

There is anecdotal evidence suggesting that

protest can reduce harmful media representations (Wahl o 1995).

However, some research implies protest campaigns that ask people to suppress prejudice can produce an unintended “rebound” in which prejudices about a group remain unchanged or actually become worse.

In one set of studies, Macrae and colleagues found that research participants directed to suppress stereotypes about skinheads showed greater stereotype activation and increased distance from members of that group.

COMBATTING STIGMA

Education involves replacing misperceptions with actual facts.

Contact needs to be targeted. Rather than focusing on the population as a

whole, contact is more effective when targeting key groups, typically people in positions of power like employers, landlords, healthcare providers, legislators, and media outlets.

Targeting stigma not only suggests the ‘who’ of strategic contact but also the corresponding ‘what’; what needs to be changed. These are affirming behaviors that seek to increase employer hires and landlord leases and the provision of quality health services to people with mental illness.

Local contact programmes are more effective.

‘Local’ has several meanings but may include geopolitical and diversity factors.

Sociopolitical factors within more narrowly defined areas are also important. Large cities will include neighborhoods of differing socioeconomic status that are likely to influence target-group interests.

for example, employers in impoverished parts of a city will require different contact than peers located in wealthy suburbs.

In addition, rural and urban resources differ

calling for distinct contact programmes. Given research on health and healthcare disparities, consideration of ethnicity and religious background is additionally important for crafting local programmes.

Contacts must be credible The contact person should be similar to the

target. This could mean employers, landlords, healthcare providers and police officers with mental illness present to other employers, landlords, healthcare providers and police officers.

Messages like “The person in recovery can

be successful” and “people with mental illness recover!” needs to be provided by a member of the target group.

For example, employers should tell peers that the person will be a good worker.

Contact ‘partnerships’ are a good solution, combining consumers with representatives of the target group; think of the compelling civic group meeting where a person with mental illness talks about her recovery followed by the boss who discusses the success resulting from having hired her.

Contact must be continuous. One-time contact may have some

positive effects but these are likely to be fleeting. Contact must occur multiple times with the quality of contact varying over time. This calls for different consumer and target partners, messages, venues and opportunities.

It also reminds advocates that stigma change is not easily accomplished and requires not only ongoing efforts, but continual quality assessment of those efforts.

Partnership with skilled investigators like

Clement et al helps achieve this goal. Continuous and local priorities also call for participatory action research, investigations that are equally directed by advocates and researchers.

Proper training of healthcare staff .

There are difficulties in communication with patients affect professional staff, including psychiatrists, as well as members of the public.

Good communication with patients requires

that professionals listen, and learn about their patients as people with individual concerns and needs.

To achieve this end, staff need to have sympathetic opinions and to receive appropriate training, but they also need adequate time.

Thus, that part of any anti-stigma campaign intended to improve communication with patients is necessarily part of a wider campaign to obtain adequate staffing for all sectors of the health and social services involved in the care of people with mental disorders.

KEY REFERENCES

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Corrigan PW. Research and the elimination of the stigma of mental illness. The British Journal of Psychiatry. 2012 Jul 1;201(1):7–8.

Dalky HF. Mental illness stigma reduction interventions: review of intervention trials. West J Nurs Res. 2012 Jun;34(4):520–47.

Fink PJ. Stigma and Mental Illness. American Psychiatric Pub; 1992. 266 p.

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Goffman E. Stigma: Notes on the Management of Spoiled Identity. Simon and Schuster; 2009. 164 p.

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