Date: 01/12/21
Author Name: Sadaf Rais
Qualifications: BA (Hons) psychology MA, MPhil (India)
Designation: RCI licensed clinical psychologist, ACRO Mental Health Services.
Word count: 1,665.
Reading time: 7 minutes
Reviewed by: Aishwarya Krishna Priya
STIGMA IN THE MENTAL HEALTH FIELD
Over the years, there has donned an understanding that both mind and body are two interdependent entities, i.e. effect on one has an impact on the other. However, the world we live in still carries a dichotomous stance on how to approach illness, when it occurs in the body and when it affects the mind. Physical illness is considered to be related to the weakness of the immune system, but unfortunately, mental illness is viewed as caused by weakness in the person itself, thus indicating a character flaw. This paves the way for individuals with mental issues to be seen in a negative light (stigma) and hence, are treated undesirably (discrimination).
In India, there happens to be a grave challenge to mental health care as there are 0.3 psychiatrists per 100,000 inhabitants, thus proving a dearth of mental health care professionals (Singh, 2018). This may challenge and lessen the quality of psychiatric/psychological management, as well as burden the medical professionals leading to practice burnout. Evidently, stigma comprises of three constituents, namely, prejudicial attitudes, lack of knowledge and discrimination (Boge, et. al., 2018). Lack of awareness and insufficient information may cause biases and prejudices to develop, leading to judgments and unfair treatment of sufferers. Besides, the services are mostly concentrated in urban sections of the society, which could be one of the causes for a supply-demand gap.
Stigmatization seems to operate on broadly three levels throughout the healthcare sector, namely (Knaak, et. al., 2017):
The structural level includes an investment of resources, quality of care standards, organizational culture,
The interpersonal level involves patient-provider interactions, discriminatory behaviours, negative attitudes, and
The intra-individual level consists of self-stigma, patient reluctance to seek care, provider reluctance to disclose a mental illness and/or seek care.
HOW STIGMA IS DIRECTED TOWARDS SUCH A POPULATION
The notion of “abnormal” or not “right” in the head which gets attached to individuals with mental illness forms a stigma. The agency to cause and get better, both are put in such individual’s control, hence, remarks like “get over it” or “it is just a phase” are thrown casually and insensitively on the person.
According to Jones and colleagues (1984), stigma is a combination of 6 elements namely, concealability i.e. people differentiate and discriminate due to easy visibility of such people, course refers to how the person is going to respond to the treatment, disruptiveness means how well the person is going to manage personal and occupational fronts later after recovery, peril highlights the dangerousness of the mental illness and the afflicted patient in the society he or she inhabits, aesthetics denotes the displeasing nature of the mental illness i.e. people distance themselves from people with mental illness and constantly view them in a negative light and lastly, origin which indicates the source of the mental illness whether biological, psychological or social (Ahmedani, 2011).
The analytical conclusion on how people with mental illness are stigmatized indicates three aspects, namely (Corrigan and Watson, 2002):
Since violence may come in the form of symptoms in some and not all mental illnesses, such people come to fear and hence be placed at the periphery of the society, rendering them marginalized (fear and exclusion).
Their judgment is constantly questioned even after recovery and therefore, decision making is taken out of their hands (authoritarianism).
Over emotional involvement from caregivers or other societal members puts such people in a child-care environment (benevolence).
The resulting discriminatory behaviour towards such people come in the forms of restricting help to them, social avoidance (less interpersonal contact with them and refraining from marrying), forced treatment/medication and mandatory institutionalization (Corrigan and Watson, 2002).
BARRIERS IN MENTAL HEALTH CARE AT THE SOCIETAL LEVEL
Recovery is not a linear process, it goes through ups and downs from time to time. For people with disabilities (mental or physical) have to be reintegrated into society as a final aspect of recovery. However, the field of mental health is still plagued by stigma which introduces a lot of barriers in health care access and reintegration in society.
Factors like lack of mental health literacy, a sense of psychological mindedness and insufficient public display of positive treatment outcomes are a few which may lead to less than efficient availing of such services or facilities and may hinder in a holistic claiming of well-being. In addition, the self-stigma that people with mental illness carry along may put them at the risk of being silent and maintaining the secrecy of their own deteriorating mental health. Besides, loss of self-esteem, social withdrawal, demoralization, not reaching out for help or untimely help-seeking behaviour, and poorer quality of life also acts as a hindrance (Boge, et. al., 2018). Lack of willingness is another barrier that erupts from shame from prejudice towards illness (Bishop, et. al., 2013).
IMPACT OF STIGMA ON PEOPLE WITH MENTAL ILLNESS
Criticism and negative treatment have undoubtedly damaging bearings on people with mental illness. At a personal level, such people may suffer from an ongoing stress cycle, poor well-being and reduced social functioning. They may unintentionally come to behave in a manner that makes them dependent on others for care and supervision creating a lack of faith in themselves. At the occupational front, reduced job opportunities, setting of a belief that such people even after recovery cannot be in full occupational capacity, hence, are provided with lesser vocations/employment opportunities (Boge, et. al., 2018).
On the medical front, there may be ceasing of medication, dropping out from psychiatric or psychological treatment, lack of a good rapport with the therapist which may cause inefficient therapeutic alliance, an essential component of ineffective management. In addition, there is also evidence that non-mental or physical symptoms aren’t given the required attention from medical professionals, treating those physical symptoms non-seriously as part of mental illness (Knaak, Mantler and Szeto, 2017).
The collateral damage that stigma may produce is known as ‘courtesy stigma’ wherein, the family/friends or significant others get affected as well (Paananen, et. al. 2020).
Moreover, harbouring and directing stigma against mental illness and such afflicted individuals has been found to lower the confidence of patients and their family in the recovery process and that mental illnesses are unreal or untreatable, subsequently feeling hopeless and giving up altogether (Bishop, et. al., 2013). Stigmatizing or labelling negatively has an impact on such individuals as they might start believing the labels put on them and consequently behave in accordance to those thus, strengthening or proving the prevailing stigma, hence, never-ending the vicious cycle.
INTERVENTIONS TO REDUCE STIGMA
Reduction and absolute ceasing of symptoms experience is not the end goal of psychiatric or psychological management, instead, obtaining complete well-being is what it should focus on. Stigma reduction and essentially the cessation are required for the social, psychological, physical, and economic well-being of those affected by mental illness as pointed out by Day, Edgren, and Eshleman (2007). Healthy individuals contribute to a better, improved and informed society to deal in times of crisis and not succumb to the poor plight.
Community-level stigma reducing interventions include increasing awareness via mental health literacy programmes, actively advocating for mental health awareness (Stuart, 2016); intervention programs for mental health professionals and service providers which emphasize on skills of what to say and what to do, along with making use of social contact, encouraging those who are mental illness survivors to present teir lived story through the illness and treatment phases to support and inspire others to seek professional help (Knaak, et. al., 2017).
A joint effort from both the professionals and the survivors is required to break from the vicious cycle of stigma, both at the societal and personal levels.
“It’s a disorder, not a decision.”
REFERENCES
Ahmedani BK. Mental health stigma: society, individuals and profession. Journal of Society, Work Values Ethics. 2011;8(2): 4-1-4-16. Available from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3248273/.
Böge K, Zieger A, Mungee A, Tandon A, Fuchs L. M, Schomerus G, Tam Ta T. M, Dettling M, Bajbouj M, Angermeyer M, Hahn E. Perceived stigmatization and discrimination of people with mental illness: A survey-based study of the general population in five metropolitan cities in India. Indian journal of psychiatry. 2018;60(1), 24–31. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5914258/. doi: 10.4103/psychiatry.IndianJPsychiatry_406_17
Corrigan PW, Watson AC. Understanding the impact of stigma on people with mental illness. World Psychiatry. 2002;1(1):16-20. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1489832/
Day EN, Edgren K, Eshleman A. (2007). Measuring stigma toward mental illness: Development and application of the Mental Illness Stigma scale. Journal of Applied Social Psychology. 2007;37(10), 2191–2219. Available from https://psycnet.apa.org/record/2007-15018-001. doi: 10.1111/j.1559-1816.2007.00255.x
Hof K, Bishop M, Hof DD, Dinsmore JA, Chasek C, Tillman DR. Mental health stigma: impact and interventions. VISTAS. 2013. Available from https://www.counseling.org/knowledge-center/vistas/by-subject2/vistas-professional-development/docs/default-source/vistas/mental-health-stigma---impact-and-interventions.
Knaak S, Mantler E, Szeto A. Mental illness-related stigma in healthcare: Barriers to access and care and evidence-based solutions. Healthcare Management Forum. 2017;30(2):111-116. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5314742/. doi: 10.1177/0840470416679413
Paananen J, Lindholm C, Stevanovic M, Weiste E. Tensions and Paradoxes of Stigma: Discussing Stigma in Mental Health Rehabilitation. International Journal of Environmental Research and Public Health. 2020;17(16). Available from: https://www.mdpi.com/1660-4601/17/16/5943. doi: 10.3390/ijerph17165943
Singh OP. Closing treatment gap of mental disorders in India: Opportunity in new competency-based Medical Council of India curriculum. Indian J Psychiatry. 2018;60(4):375-376. Available from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6278227/. doi: 10.4103/psychiatry.IndianJPsychiatry_458_18
Stuart H. Reducing the stigma of mental illness. Global Mental Health. 2016;3:e17. Available from: https://pubmed.ncbi.nlm.nih.gov/28596886/. doi:10.1017/gmh.2016.11
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