STIGMAand Mental Illness

Himalee Abeya

Stigma

"they called me mad, and I called them mad, and damn them, they outvoted me"

- Nathaniel Lee

Defining Stigma

A sign of disgrace or a discrediting attribute which sets a person apart from others and disqualifies from full social acceptance

Goffman, E. (1963) Stigma: Notes on the management of spoiled identity. Penguin, Harmondsworth.

Origins of the term

Greek - ‘stizein’ a mark placed on slaves as a bodily sign designed to

expose some defect in the ‘moral status’ of the signifier

Early Christian times - stigmata denoted signs of holy grace

Later medical metaphor in reference to physical signs of an illness

A Rake's Progress by 18th century English artist William Hogarth.

The concept of Stigma Stigmatization is an interactive social process

What causes the taint and consequent discredit?

In a psychiatric illness, the afflicted person may be perceived as identified with, and not separate from, the illness

Is a person schizophrenic or do they have schizophrenia?

Littlewood, R., Jadhav, S., Ryder, A., (2007) A Cross National Study of the Stigmatization of Severe Psychiatric Illness: Historical Review, Methodological Considerations and Development of the Questionnaire. Transcultural Psychiatry, 44, 171-202

The difference between a normal and a stigmatised person is a question of perspective, not reality

- Erving Goffman

Goffman, E. (1963) Stigma: Notes on the management of spoiled identity. Penguin, Harmondsworth.

“Why is it when we talk to God, we’re said to be praying,but when God talks to us, we’re said to be schizophrenic?”

Theories of Stigmatisation Perception based models

The fundamental step in the generation of stigma is the perception of difference

Perceived differences may then be associated with undesirable traits Stereotypes

dangerousness /unpredictability poor communication unsavoury or bizarre behaviour

Leads to prejudice – therefore disqualified from full acceptance OR stigmatized

Sayce, L. (1998). Stigma, discrimination and social exclusion: what's in a word? Journal of Mental Health, 7, 331–43Smith, M. (2002) Stigma. Advances in Psychiatric Treatment 8, 317- 323

Theories of Stigmatisation

Public stigma

Stereotype Negative belief about a group Prejudice Agreement with belief and/or negative emotional

reaction (e.g., anger, fear) Discrimination Behavior response to prejudice (e.g., avoidance)

Self-stigma

Stereotype Negative belief about the self Prejudice Agreement with belief, negative emotional

reaction (e.g., low self-esteem) Discrimination Behavior response to prejudice (e.g., Loses work)

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

Social – cognitive model

Theories of Stigmatisation

Justification Models Ego / group / system

Normal Cognitive Reaction Model ?Kernal of truth ?promotes stigma Converse more likely to be true

Link, B.G. (1987) Understanding labeling effects in the area of mental disorders: An assessment of the effects of expectations of rejection. American Sociological Review, 52:96-112.

Jost, J. & Banaji, M. (1994) The role of stereotyping in system-justification and the production of false consciousness . British Journal of Social Psychology, 33, 1-27.

“Would you have your sister marry a person with mental illness ?”

Effects of stigma

Negative impact on patients

withholding help avoidance coercive treatment segregated institutions A negative impact on the illness itself

Delay in seeking Rx Creates stress Contributes to noncompliance

Wahl OF. (1999) Mental health consumers' experience of stigma. Schizophr Bull. 25:467–478

Pinfold, V., Byrne, P. Toulmin, H. (2005) Challenging Stigma and Discrimination in Communities: A Focus Group Study Identifying UK Mental Health Service Users’ Main Campaign Priorities International Journal of Social Psychiatry. 51; 128

Nazi propaganda for their “euthanasia” programme: "This person suffering from hereditary defects costs the

community 60,000 Reichsmarks during his lifetime. Fellow German, that is your money, too."

Effects of stigma

Negative impact on the family

Courtesy stigma ‘a particularly difficult and delicate position if they

cannot remove themselves, for they are both marker and marked’

43% to 92% of caregivers report feeling stigmatized can negatively affect their mental health by reducing

their coping effectiveness

Struening, E. L., Perlick, D. A., Link, B.G., et al (2001) The extent to which caregivers believe most people devalue consumers and their families.

Psychiatric Services, 52, 1633-1638.

“Men will always be mad, and those who think they can cure them are the maddest of all.”

—Voltaire

Effects of stigma

Negative impact of stigma on Psychiatric Services

Stigma has been identified as a serious barrier to effective psychiatric services

Lesser resources are allocated to mental health than other areas of medicine in developing countries

Discriminatory policies and practices are prevalent in developed and developing countries alike. e.g. Canada

Norman, S. (1998). Stigma: what can psychiatrists do about it? Lancet, 352; 9133; 1058

Effects of stigma

Positive effects of stigma

Adopt protective strategies and develop resilience

Develop coping strategies Empowerment

Oyserman, D., and J. K. Swim. (2001). Stigma: An insider’s view. Journal of Social Issues 57 (1): 1-14

Cultural variations of stigma Difference in attitudes towards Mental illness

East - attribute an external causation to the illness. Madness is viewed as an affliction; when relieved the person may need care, but the negative labelling of

madness disappeared societies are more cohesive – less extrusion

West - value placed on the autonomous individual;

need to assume personal responsibility for their illness. – less tolerance and support

Littlewood, R., Jadhav, S., Ryder, A., (2007) A Cross National Study of the Stigmatization of Severe Psychiatric Illness: Historical Review, Methodological Considerations and Development of the Questionnaire. Transcultural Psychiatry, 44, 171-202

The Evil Eye: An attributed cause of Mental Illness in Saudi Arabia

عين حسد

Stigma experienced by users of mental health care in a tertiary care hospital setting – a descriptive study Specific objectives

To validate the Stigma Scale for a Sri Lankan setting To describe the nature of stigma experienced and

quantify the intensity of stigma in terms of the Stigma Scale

To describe the patterns of experience of stigma, if any, with relation to the psychiatric morbidity, socio-demographic characteristics and illness factors in

participants

The stigma scale

Developed by Prof Michael King and Sokratis Dinos et al (published in the BJPsych, Feb. 2007) was used in this study.

Measures self stigma in mental health service users. self-report questionnaire, can be completed in 5–10

minutes; It comprises 28 items

The goal of validation was to generate a culturally appropriate translation with semantic and conceptual equivalence to the original

King, M., Dinos, S., Shaw, J. et al (2007) The Stigma Scale: development of a standardised measure of the stigma of mental illness. British Journal of Psychiatry 190, 248-254

The stigma scaleThe scale has three subscales : Discrimination Disclosure Positive aspects

Each item on the scale is given a score from 0 to 4 or 4 to 0, on a five-point Likert scale

e.g.1. I’ve been discriminated against in education because of my

mental health problems

2. Having had mental health problems has made me a more understanding person

3. I worry about telling people I receive psychological treatment

Sample Population Subjects were 323 persons presenting to Psychiatry Clinic and

Psychiatry Ward of the National Hospital of Sri Lanka, Colombo

Inclusion criteria Age between 16 and 70 years Patients who give informed consent Literate Rational on mental state examination: based on

interviewer (the author)’s assessment

Findings from the study….. The findings showed that patients of this population

perceive stigma - overall mean score on the stigma scale was 56.89

of the subscales of the stigma scale, the score was higher for disclosure than for discrimination

Upto 52% were unhappy with the way people behaved with them and spoke to them

20% felt they had been discriminated against by health professionals

Findings from the study…..

54% felt they had not been discriminated against by their employers

61% stated they did not feel embarrassed about there health problems

The only trend observed in relation to the socio-demographic factors was - the level of perceived stigma reduced as the income category increased

Perceived stigma was comparatively more in patients with schizophrenia

Themes in Stigma intervention Rights-based protest: tackling discrimination

Equal opportunities and rights

Normalisation “people with mental illness are just like us” Medicalisation ?

Information, media and social attitudes outcomes of media intervention are often disappointing.

Sir Winston Churchill: used as an anti-stigma icon

SANE - stigma watch

What can be done? The goal is acceptance of difference, not

normalisation or denial of difference.

We should seek to enable people to believe their own experience, rather than rely on stereotypes portrayed in the media

Risks should be acknowledged, but put in context.

The stigma against psychiatry and psychiatrists echoes most of the factors relating to stigma against those with mental illness: we should not be afraid to defend our profession.

“Why would I choose to have an manic-depression? Because I honestly believe that as a result of it I have felt more things more deeply; had more experiences, more intensely; loved more, and been more loved; laughed more often for having cried more often; appreciated more the springs for all the winters; worn death close, and appreciated it-and life-more…”

Prof. Kay Redfield Jamison

(Prof. of Psychiatry, John Hopkins University)