STIGMA IN MENTAL HEALTH: A CONCEPT ANALYSIS

LINDA C ARM AN COPEL, PHD, RN PMHCNS, BC, CNE, ANEF, NCC, FAPA

KH AMIS AL-M AM ARI , RN, MS

COLLEGE OF NURSING, V ILLANOVA, PA

Goals & Framework of Concept Analysis

The Goals of the Concept Analysis:

◦ Enhance understanding of the concept for use in research or clinical practice.

◦ Bring the concept closer to being used for research or for clinical practice.

◦ Identify the commonalities and shared experiences of stigma in the mentally ill population.

◦ Increase understanding and conceptual clarity of stigma.

◦ Contribute to instrument development and theory testing.

(Meleis, 2012)

Framework for Concept Analysis: Walker & Avant (2005)

)

The Concept: Stigma

Stigma in mental health is a universal health issue.

The term “stigma” can be traced back to 1700s.

The word “stigma” is derived from the Greek word root which means

“mark,” a brand impressed by an iron.

It also referred to marks branded on cattle or on people who served

as slaves in ancient times in he Orient or in Greece.

Stigma has a negative influence on people’s lives, creating social

distance which interferes with their interactions with people in the

society.

(New Catholic Encyclopedia ,2003)

The Concept: Stigma

Recently, the concept of stigma was introduced into medical

science to describe the discrimination experienced by people

suffering from illnesses, such as HIV/AIDS, obesity, psoriasis, &

mental health disorders.

Stigma disqualifies certain groups from full social acceptance

and the ability to conform to the typical standards of society.

Stigma has a persistent influence on the individual’s health care

problems, as well as on the community, family, and national

political responses to illness.

(Goffman, 1963; New Catholic Encyclopedia, 2003)

The Concept: Stigma

Stigma has a persistent influence on the individual’s health care

problems, as well as on the community, family, and national political

responses to illness.

Stigmatized people suffer from chronic stress, which has additional

negative effects on their physical and mental well being.

There is strong evidence that people with mental illness have less

access to primary health care.

There is evidence that mental health clients receive inferior care for

medical problems. The rates of cardio-vascular disease, obesity, and

diabetes are increasing in people with mental illness.

(Corrigan & Watson, 2002; Bjorkman, Angelman, & Jonsson, 2008; Dehert et. al., 2009; Druss & Bradford, 2000;

Druss & Von Esenwein, 2006; Hatzenbuehler, Phelan, & Link, 2013)

Definition of Stigma

Link and Phelan (2001) defined stigma as a process which occurs

when a person demonstrates noticeable social differences, and

thereby becomes unfairly labeled based on emotional or physical

symptoms or atypical characteristics.

Gary (2005) defined stigma as “a collection of negative attitudes,

beliefs, thoughts, and behaviors that influences the individual, or

the general public, to fear, reject, avoid, be prejudiced, and

discriminate against people with mental disorders” (p.980).

Public Stigma

Public stigma refers to the

attitudes and beliefs of the

general public towards

persons with mental health

challenges or their family

members.

Self-Stigma

Self-stigma is when a

person with mental illness

internalizes stigma and

experiences diminished

self-esteem and self-

efficacy.

Types of Stigma

(Corrigan, Powell, & Rusch, 2012; Watson, 2007).

Double Stigma

Double stigma occurs when

a person with mental illness

concurrently experiences

more than one type of

stigma such as a mental

health diagnosis and a

physical disability.

Stigma by Association

Stigma by association occurs

when negative characteristics

(e.g., psychological distress

and feeling of inferiority) are

attributed to individuals,

family members, care givers,

and healthcare providers

who are in close contact with

stigmatized people.

Types of Stigma

(Corrigan, Powell, & Rusch, 2012; Halter, 2008; Watson, 2007)

Assumptions

There is a link between people’s negative attitudes and stigma

towards clients with mental illness.

The more mentally ill clients believed that they are different

and devalued in the eyes of others, the more self-stigma

occurs.

There is a relationship between stigma and loss of social

identity.

Increased awareness and acceptance of mental illness may

lead to reductions in stigma.

(Corrigan & Watson, 2002; Major & O'Brien, 2005; Minas, Zamzam, Midin, & Cohen, 2011)

Antecedents: The Concept of Stigma

Individual with health problems

Prejudice

Blame

Feelings of rejection

Extreme self-conscious

Fear of others discovering health status

(Berjot & Gillet, 2011 & Hatzenbuehler, Phelan, & Link, 2013)

Characteristics: The Concept of Stigma

Unfavorable attitude from an individual or group

Feeling devalued

Unpleasant personal experience

Perceived negative social norms

(Crocker, 1999; Link & Phelan, 2001;Berjot & Gillet, 2011)

Negative Consequences

Feeling inferior

Negative IPRs

Discrimination

Barriers to health care

Mental health

Physical health

Decrease quality of life

Social isolation

Overall opportunity loss

Positive Consequences

Being assertive by talking

about stigma

Care-Seeking Behaviors

Ongoing participation on

treatment

Active participation in anti-

stigma actions

E.g., media, community

awareness program, etc.

Concept of Stigma: Consequences

(Corrigan, 2004; Link & Phelan, 2001; Hatzenbuehler et al., 2013; Bjorkman et al., 2008;

Schneider et al. 2011; Gary , 2005)

Nursing Practice:

Examine own beliefs and values

Individualized patient care

Conduct research studies

Patients and Families:

Provide support for patients and families

Acceptance of mental illness

Educate patients, families, and communities about

mental health and mental illness

Recommendations

Recommendations

Nursing Education:

Evaluate current education practices and examine how

theoretical and clinical components of curriculum address

stigmatization.

Evaluate whether the time allotted for mental health theory

and clinical education is sufficient to address stigma.

The nursing profession must recognize all specialties area,

including mental health nursing, as equally valuable and

contributing to the health of individuals, families, and

communities.

Current Studies

The majority of studies

address schizophrenia

Mostly qualitative and

descriptive studies

emphasizing on violence,

stereotypes, and

discrimination

Few intervention studies

Proposed Studies

More studies on types of

stigma and what people

encounter

Strategies to address

stigma

The effect of stigma on

families

Nursing education studies

16

Stigma Research

ReferencesBerjot, S., & Gillet, N. (2011). Stress and coping with discrimination and stigmatization. Frontiers in psychology, 2, 33. doi: 10.3389/fpsyg.2011.00033

Corrigan, P. (2004). How Stigma Interferes With Mental Health Care. American Psychologist, 59(7), 614-625.

Corrigan, P. W., Powell, K. J., & Rusch, N. (2012). How does stigma affect work in people with serious mental illnesses? Psychiatric Rehabilitation Journal, 35(5), 381-384. doi:10.1037/h0094497

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

Crocker, J. (1999). Social Stigma and Self-Esteem: Situational Construction of Self-Worth. Journal of Experimental Social Psychology, 35(1), 89-107. doi: http://dx.doi.org/10.1006/jesp.1998.1369

Gary, F. A. (2005). Stigma: barrier to mental health care among ethnic minorities. Issues in Mental Health Nursing, 26(10), 979-999. doi: 10.1080/01612840500280638

Gouthro, T. J. (2009). Recognizing and addressing the stigma associated with mental health nursing: a critical perspective. Issues in Mental Health Nursing, 30(11), 669-676.

Halter, M. J. (2008). Perceived Characteristics of Psychiatric Nurses: Stigma by Association. Archives of Psychiatric Nursing, 22(1), 20.

ReferencesHappell, B. (2007). Appreciating the importance of history: a brief historical overview of mental health, mental health nursing and education in Australia. International Journal of Psychiatric Nursing Research, 12(2), 1439-1445.

Hatzenbuehler, M. L., Phelan, J. C., & Link, B. G. (2013). Stigma as a fundamental cause of population health inequalities. The American Journal of Public , 103(5), 813-821. doi: 10.2105/ajph.2012.301069

Hinshaw, S. P. (2007). The mark of shame : stigma of mental illness and an agenda for change. Oxford ; New York: Oxford University Press.

Link, B. G., & Phelan, J. C. (2001). Conceptualizing stigma. Annual Review of Sociology, 27, 363-385. doi: 10.1146/annurev.soc.27.1.363

Major, B., & O'Brien, L. T. (2005). The social psychology of stigma. Annual Review of Psychology, 56, 393-421. doi: 10.1146/annurev.psych.56.091103.070137

Minas, H., Zamzam, R., Midin, M., & Cohen, A. (2011). Attitudes of Malaysian general hospital staff towards patients with mental illness and diabetes. BMC Public Health, 11, 317. doi: 10.1186/1471-2458-11-317

ReferencesParcesepe, A. M., & Cabassa, L. J. (2012). Public Stigma of Mental Illness in the United States: A Systematic Literature Review. Administration and policy in mental health. doi:10.1007/s10488-012-0430-z.

Parle, S. (2012). How does stigma affect people with mental illness? Nursing Times, 108(28), 12-14.

Ross, C. A., & Goldner, E. M. (2009). Stigma, negative attitudes and discrimination towards mental illness within the nursing profession: a review of the literature. Journal of Psychiatric and Mental Health Nursing, 16(6), 558-567.

Schneider, J., Beeley, C., & Repper, J. (2011). Campaign appears to influence subjective experience of stigma. Journal of Mental Health, 20(1), 89-97. doi: 10.3109/09638237.2010.537403

Walker, L.O.; Avant, K. C., 2005. Strategies for Theory Construction in Nursing, 4th ed. Pearson Prentice Hall, Upper Saddle River, NJ.

Watson, A. C. (2007). Self-Stigma in People With Mental Illness. Schizophrenia Bulletin, 33(6), 1312-1318.

World Health Organization. (2010). Mental Health and Development: Targeting people with mental health conditions as a vulnerable group. Retrieved from: http://whqlibdoc.who.int/publications/2010/9789241563949_eng.pdf?ua=1