stigma and mental illness himalee abeya. stigma " they called me mad, and i called them mad,...
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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
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.
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.
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
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.
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)