Stigma of Mental Illness:Assessments and Interventions

Presenter: Dr. Praveen

Chairperson: Dr. Nishanth

Introduction

• The word stigma is of Greek origin.

• Originally referred to the brand or scar burned or cut into

the body, signifying that the bearer was a slave, or criminal

or otherwise set apart from the general society.

• The phenomenon whereby an individual with an attribute

which is deeply discredited by his/her society is rejected

as a result of the attribute (Goffman, 1963)

Contd…

• Stigma is the result when persons are categorized as

being deviant, or belonging to a stereotyped group,

and whereby there exists discriminatory behavior.

• Stigma has been associated as major barrier to recovery

for people with mental illnesses.

Contd…

According to Merriam Webster’s dictionary, stigma is a

set of negative and often unfair beliefs that a society or

group of people have about something.

 

According to Oxford dictionary, stigma is a mark of

disgrace associated with a particular circumstance, quality,

or person. As for e.g.: “the stigma of mental disorder”

Meaning• Erving Goffman defined stigma as “the process by which the

reaction of others spoils normal identity”.

• Erving Goffman defined stigma as a special kind of gap between

virtual social identity and actual social identity

• The 3 forms of stigma as categorized by Goffman

The experience of a mental illness (or the imposition of such

a diagnosis);

a physical form of deformity or an undesired differentness;

or an association with a particular race, religion, belief, etc.

(Goffman, 1990).

Components of Stigma

Link & Phelan components (2001) 

Labeling

Negative stereotypes

Separation of “us” from “them”.

Status loss and discrimination

Mental Illness Stigma• Mental illness stigma encompasses three constructs: stereotypes,

prejudice, and discrimination (Corrigan, 2004).

• Stereotypes are a set of beliefs about members of a group and typically

represent society’s shared beliefs about that group

• Prejudice is a negative attitude toward a person or group (e.g. “I don’t

like/don’t want to have contact with someone with mental health

problems”) (Allport, 1979).

• Discrimination is the behavioural aspect of stigma and is presumed to

result from prejudice or stereotypes

Types of Stigma:

• Social stigma is characterized by prejudicial attitudes and

discriminating behavior directed towards individuals with mental

health problems as a result of the psychiatric label they have been

given.

• Perceived stigma or self-stigma is the internalizing by the

mental health sufferer of their perceptions of discrimination (Link,

Cullen, Struening & Shrout, 1989), and perceived stigma can

significantly affect feelings of shame and lead to poorer treatment

outcomes (Perlick, Rosenheck, Clarkin, Sirey et al., 2001).

Difference between Public Stigma & Self Stigma

Component Public stigma Self Stigma

Stereotype Negative belief about a group For example, dangerous, incompetent and weak of character.

Negative belief about selfFor example, weak of character andincompetent.

Prejudice Agreement with belief and/or negative emotional reactionFor example, anger and fear.

Agreement with belief Negative emotional reaction For example, low self-esteem and lowself-efficacy.

Discrimination Behavioral response to prejudice.For example. Avoidance of work and housing opportunities and withholding help.

Behavioral response to prejudiceFor example, a failure to pursue work and housing opportunities.

Tools to Assess Stigma

Jaipur Stigma Questionnaire

• The newly developed tool, JSQ, has the following features:

– It is in Hindi language

– It has 14 statements which touch upon various themes of

stigma

– Each questions has four options to choose from, which if

translated to English, are as follows:

(a) Neither I feel this way nor the society does

(b) I don’t feel this way but the society does

(c)Sometimes I feel this way, and

(d) I totally agree with the statement.

• It has the advantage of identifying whether the given idea is

impacting at the level of stereotypy, prejudice or possible

discrimination.

Jaipur Stigma Questionnaire

Journal of Mental Health & Human Behaviour ,2011;16 (2)

Orientation to Mental Illness Scale

• The tool developed by Prabhu (1983)

• This specific questionnaire is a modified version consisting of 67

items, which was equivalent to the original one in all respects

• The score range falls between 67 to 335 and it requires about

20 – 30 minutes to complete the scale.

• There are no cut off scores given by the author.

• The tool has been used extensively in research within the

Indian context.

• The Alpha co-efficient of the OMI in the present study is

0.93 indicating adequate reliability

• It taps various aspects of orientation to mental illness

providing scores on 13 factors, subsumed under 4

domains.

OMI Scale

Comparison of Means of Pre, Post and Follow up Assessment for Orientation towards Mental Illness on 4 main domains of OMI scale

The Self-Stigma of Seeking Help (SSOSH; Vogel, Wade, & Haake, 2006)

• Scale is utilized to measure reductions in self-esteem and self-efficacy

that result from receiving the label of a seeker of psychological help

• SSOSH is a 10-item questionnaire, and includes items such as “If I went

to a therapist, I would be less satisfied with myself.”

• Items are rated from 1 (strongly disagree) to 5 (strongly agree)

• Higher scores represent greater self-stigma of seeking psychological

help

• Evidence for the construct validity of the SSOSH includes

correlations with attitudes toward counselling (r = –.63),

intentions to seek counselling (r =–.38), and the public stigma for

seeking help (r ! .48; Vogel et al.,2006).

• Additionally, the SSOSH has been shown to distinguish between

those who seek help and those who do not (Vogel et al.,2006).

• The SSOSH has demonstrated adequate test–retest reliability

over a period of 2 months α=.72) and adequate internal

consistency (α=.89).

Self-Stigma of Mental Illness (SSOMI) Scale

• 10-item scale, developed for the present study to parallel the Self-

Stigma of Seeking Help (SSOSH) Scale

• It is used to measure the reduction in self-esteem and self-

efficacy that results from receiving the label of mental illness.

• Items were generated by replacing references to seeking

psychological help on the SSOSH with references to having a

mental illness

• Items include such statements as “If I had a mental illness, I

would be less satisfied with myself.”

• Items are rated from 1 (strongly disagree) to 5 (strongly

agree), with half of the items reverse scored such that higher

scores represent greater self-stigma associated with mental

illness.

Beliefs about Devaluation-Discrimination (BDD) Scale

• 12-item scale that measures the extent to which a person

believes the general public devalues and discriminates against

those with a mental illness (Link, 1987)

• BDD includes statements such as “Most people would not hire a

former mental patient to take care of their children, even if he or

she had been well for some time.”

• Items are rated on a 6-point Likert scale from 1 (strongly

disagree) to 6 (strongly agree).

• A higher total score indicates greater public stigma toward

mental illness.

• The internal consistency of the measure has been demonstrated

(α=.76; Link, Cullen, Struening, Shrout, & Dohrenwend, 1989).

Internalized Stigma of Mental Illness (ISMI) scale (Ritsher et.al., 2003)

)

• ISMI : 29-item questionnaire measuring self-stigma among

persons with psychiatric disorders.

• 47 translated versions available

• Indian versions available :Hindi , Bengali& Urdu

• Versions for various psychiatric disorders available

(depression, schizophrenia, substance abuse etc.)

• Most commonly reported findings of studies using the

ISMI are that Internalized stigma correlates with higher

depression, lower self esteem, and higher symptom

severity.

Other Tools

• Self-stigma of Mental Illness Scale (Corrigan et.al., 2006)

• Consumer Experiences of Stigma Questionnaire (Wahl OF, 1999)

• Rejection Experiences Scale (Kessler et. al., 2007)

• Self-reported Experiences of Rejection(Link et.al., 1997)

• Stigma Scale (King et.al., 2007)

• The Inventory of Stigmatizing Experiences (Stuart et.al., 2005)

• Self-esteem and Stigma Questionnaire(Hayward et.al., 2002)

• Stigmatization Scale (Bagley, King, 2005)

Strategies and Interventions to Fight Stigma

• There is no simple or single panacea to eliminate stigma

of mental illness

• Roots of stigmatization are quite complex and embedded

in sociocultural norms.

• Media, healthcare, educational system, law enforcement

& legislation plays an important role in sustaining stigma

Stigma Reduction Strategies

Individual Level(Intra & Inter personal)

Treatment Care & SupportCounselingSelf Help groupsCommunity based rehabilitation

Social Level Education ContactProtestAdvocacy

Structural Level(Institutional/Governmental)

Legal & Policy InterventionInstitutional Intervention Right based approach

Contd

Treatment

• The availability of effective treatment for a particular illness

contributes hugely to reduction of stigma

• This has earlier seen in case of TB & leprosy, which are now

considered curable illnesses

• However, similar curative treatment is not available for mental

illnesses

•

• The prospect of improvement in illness with medication gave a ray of

hope to mentally ill patients.

Counseling & Cognitive behavioral therapy

• These strategies have proven effectiveness in HIV/AIDS (WHO 2002) in

decreasing stigma

• There have been very few studies on counseling to reduce stigma for

mental illness

• People with mental illness, cognitive behavioral therapy has been found to

be an effective strategy in dealing with consequences of self

stigma(Corrigan and Calabrese, 2005)

• Hall & Tarrier 2003, found that CBT for schizophrenia patients with low

esteem resulted in enhancement of their self esteem & improved social

dysfunction

Care & Support

• Proper care & support is important for recovery of patients

and help them by providing a network of social support

(Phelen et al, 1998 )

• Care givers at times perpetuate the stigma of mental

illness (Nyblade et al, 2003)

• Family education plays an important role

Rehabilitation • Successful rehabilitation of a person with mental illness is likely

to reduce the stigmatization of mental illness

Self Help Groups & Support Groups• Support groups have an important contribution on personal

identity, self esteem , their coping skills & social integration (Ablon 2002)

• Self help groups are salient sources of support for persons with mental illness

• Their effectiveness was proven for stigma of TB & HIV/AIDS

Education

• Interventions are aimed in improving the awareness of mental

illness in general public

• Educational interventions can be done through presentations,

discussions, audio tapes& films

• Need to encourage an understanding of mental illness that

extends behind the medical disease model

• There is a sharp consensus to include:

– recovery oriented messages

– see the person messages

– Messages on social inclusion/human rights

– Information on high prevalence of mental disorders

(Clement et al 2010)

• Education programs might lead to diminished discrimination

even changes in stereotypes were not observed

• Social marketing techniques have produced benefits in few

countries in terms of stigma reduction (Jorm et al 2005)

Contact

• Contact refers to all interactions between the public and person

affected

• It can either direct& face to face or indirect (media)

• Contact strategies can engage entire nation in case of prominent

public figure sharing personal experience

• Several studies and reviews demonstrate that contact

interventions are associated with improved attitudes (Corrigen &

Penn 1999)

• These studies further showed change in the attitudes led to

change in behavior

• Contact has been seen as an effective and promising strategy

• A combination strategy of education and contact may be a better

strategy

• However, it is time consuming and cost in effective

Protest

• Protest interventions may contain two messages

– Addressing inaccurate representation if mental illness

– Negative beliefs about mental illness

• Protest interventions could generate short term effects on

attitude change but they have serious limitations (Corrigen &

Penn 1989)

• There is considerable evidence to show protest can change

some behavior significantly (Wahl 1995)

Advocacy

• Advocacy program work towards providing an enabling

environment, influencing the govt to change the policies and

discriminatory laws

• Numerous advocacy are active for various mental illness

• No studies to prove the effectiveness of advocacy in reduction

of mental stigma

Structural Interventions

• Institutional/organizational level aims to modify stigma through

development of new policies within the organization

• Sartorius argues that stigmatization by medical professionals is

often ignored

• Discriminatory acts on part of professional may vary from

inappropriate comments to breach patients confidentiality , from

treatment delay to refusal of treatment (Foreman et al 2003)

• Legal & policy interventions focus on enforcing the protection

of rights of people affected by stigmatizing illness

• Smith 2002 proposed a rights based approach that counter

stigma & discrimination

Need to Address Stigma in Special Population

• Double discrimination which is a coincidence of mental illness & ethnic

minority status is an are where psychiatry must collaborate with other

fields in identifying the problems& enduring solutions

• Women with schizophrenia& broken marriage are stigmatized in both

the ways (Thara et al 2003)

• Diseases like ADHD & learning disorders may be a source of stigma in

children

• Certain legislative & policy decisions are aimed with children with

disability e.g. national trust act

• Sarvasiksha Abbiyan 2002 is an effort by Govt of India specifically

focused on education in children with disabilities & special needs

Current Initiatives to Reduce Stigma

• Over the last 10 years, stigma toward mental disorders has been

acknowledged as a barrier to mental health treatment and

recovery.

• In 1999, the Surgeon General called for approaches to overcome

stigma as a priority for the new millennium.

• In April 2002, President George W. Bush launched The New

Freedom Commission on Mental Health.

• In 2003, the U.S. Department of Health and Human Services

Substance Abuse and Mental Health Service Administration

(SAMHSA)published the first semi-annual memorandum

discussing purpose, current anti-stigma programs, and research

efforts.

• Today, SAMHSA is a resource for individuals and groups

interested in combating stigma.

•

SAMHSA publishes a quarterly memorandum that reports advances in stigma research and highlights successful stigma-reduction programs

• The National Alliance on Mental Illness (NAMI,2007), the

nation's largest grassroots mental health organization, works to

eliminate the stigma associated with mental disorders.

• NAMI uses protest, personal contact, and community education.

• Stigma Busters is a protest approach used by NAMI to fight

stigma.

• Stigma Busters approaches individuals In Our Own Voice, a

manualized contact and educational program, is designed to

increase mental health knowledge and reduce stigma

• The Carter Centre Mental Health Program offers a broad

approach to combating stigma by supporting. Supporting policy

change ( Palpant, Steimntiz,Bornemann,& Hawkins, 2006).

• Policy change is facilitated through the Mental Health Task Force,

promotion of mental health, illness prevention, and support for

mental illness recovery (Palpant et al., 2006).

• The Depression is Real Campaign was launched in 2006 with

the mission of clarify misconceptions about depression.

• The Depression is Real Campaign utilizes public service

announcements radio, television, and print) to educate the

public about depression and offer hope to those with

depression.

Open the Doors program

• Global approaches to combat stigma toward mental disorders.

• In 1996, the World Psychiatric Association began an initiative –

the Open the Doors program— to combat stigma associated

with schizophrenia and increase mental health knowledge.

• Open the Doors is collaborative, multi-centered, and involves

family and patient organizations.

• Open the Doors encourages action to decrease prejudice and discrimination.

• Outreach is driven from the perspective of those experiencing stigma opposed to established mental health theory that may not have been tested in diverse cultures (Okasha, 2007).

• Open the Doors recognizes cultural, socioeconomic, and demographic differences.

• The program has been adapted for different countries and is available in nine different languages.

WPA Anti-stigma Principles

• Acceptance of difference, not normalization or denial of

difference

• Enable people to believe their own experience, rather than rely

on stereotypes

• Media should follow public opinion

• Though, stigma against psychiatry and psychiatrists are

prevalent, we should not be afraid to defend our profession

WPA – India’s Initiative

• Coordination by NIMHANS under guidance of Prof. R. Srinivasa Murthy

• Use of short films of Dr. Abdul Kalam taking an oath with students

against discrimination in English & Tamil, for educating students in high

school & universities

• Publication of articles on newspaper, distribution of pamphlets &

printing messages on milk packets by Schizophrenia Research

Foundation (SCARF)

• Formation of SHAPES ( Society for Hope, Action, Empathy and Regard

for Schizophrenia) by patients & family members

• One of the more robust evaluations refers to the German

version of the World Psychiatric Association’s Open the Doors

programme

• This is the first study to make use of a longitudinal dataset for

an area based anti-stigma programme

• On January 22, 2002, the Düsseldorf research group previewed

the feature film The White Noise.

• The film portrays a young man with mental illness and his

subjective experiences.

WPA –German Initiative

Social Distance Before and After the Film

Contd..

• Approximately 200 spectators attended the event.

• The film was followed by a podium discussion .

• A questionnaire was distributed among the audience before and

after the film

•

• Of 182 questionnaires distributed, 113 could be used for

evaluation (return rate, 62%).

• On the whole, viewers evaluated the event as positive. Most

viewers (n = 113) believed that they could empathize better

with schizophrenia sufferers as a result of the event and

reported increased understanding.

• Nevertheless, some negative stereotypes were strengthened,

and social distancing increased

• On World Mental Health Day 2006, the Department of Health

launched ‘Action on Stigma’ to tackle discrimination in the

workplace.

• Department of Work and Pension’s Pathways to Work

scheme, developed in conjunction with the National Social

Inclusion Programme.

Key Evaluations of Mental Health Stigma Reduction Programs

Indian Studies

Name of the authors

Year Findings

Thara and Srinivasan

(2000) Marriage, fear of rejection from neighbour and the need to hide the fact from others were some of the more stigmatizing aspects.

Female gender of patient and younger age of the caregiver and patient were related to higher stigma.

Srinivasan and Thara

(2001) Psychosocial stressors were most commonly cited, followed by personality defect and heredity

Kohn etal., ( 2004) The stigma, myths and misconceptions surrounding mental disorders have been identified as the major reason for a large number of patients not seeking treatment

Contd…

Name of the authors

Year Findings

Loganathan& Murthy,

(2008) A study from NIMHANS found significant differences on stigma among rural and urban patients having schizophrenia.

Urban respondents felt the need to hide their illness and avoided illness histories in job applications, whereas rural respondents experienced more ridicule, shame, and discrimination

Mishra et al., (2009). Found more stigma among persons with better insight

Future Directions • Efforts are necessary to sustain momentum created by WPA

global program

• More focus on intervention towards common & disabling mental

illness

• Further research for clearer understanding of cross cultural

nature of stigma.

• Further research will also guide the most effective or a

combination of strategies to reduce stigma.

Conclusion• Stigma about mental illness can lead people to fear disclosing

that they have mental health problems, which may prevent

treatment and recovery.

• Stigma can result in limited life opportunities.

• Stigma poses barriers for public health prevention efforts

designed to minimize onset of mental illness and the prevention

or worsening of symptoms over time.

Contd…• Stigma can result in lower prioritization for public resources

allocated to mental health services and poorer quality of care

delivered to people with mental illness.

• Despite general improvement in knowledge about mental illness,

mental disorder continues to receive a great amount of

prejudice, discrimination, and stigma from the public.

• Anti stigma interventions should continue more effectively for

improving knowledge among society & better treatment of

mentally ill.

References

• Brohan E, Slade,M , Clement S, Thornicroft G(2010) Experiences of mental illness stigma, prejudice and discrimination: a review of measures. BMC Health Services Research

• Charles, H., Manoranjitham, S.D. & Jacob, K.S. (2007) Stigma and explanatory models among people with schizophrenia and their relatives in Vellore, South India. International Journal of Social Psychiatry, 53, 325 – 332

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

• Corrigan P.W, Morris S. B., Michaels PJ, Rafacz JD, Rüsch N (2012) Challenging the Public Stigma of Mental Illness: A Meta-Analysis of Outcome Studies, Psychiatric Services 63:963–973,

• Crisp, A., Gelder, M., Rix, S., Meltzer, H., & Rowlands, O. (2000). Stigmatisation of people with mental illnesses. British Journal of Psychiatry, 177, 4-7.

• Haghighat R. (2001) A unitary theory of stigmatisation, Pursuit of self-interest and routes to de-stigmatisation, British Journal of Psychiatry, 178, 207-215

• Kohn, R., Saxena, S., etal. (2004) The treatment gap in mental health care. Bulletin of the World Health Organization, 82, 858-866

References

• Lawrence H, Yang L H, VaughnsV P, Kotabe H, Link B G, Sawe A, Wong G, Phelan J C(2013) Culture, threat, and mental illness stigma: Identifying culture-specific threat among Chinese-American groups, Social Science & Medicine 88, 56-67

• Link B Q., Yang L H., Phelan J C., and Collins P. Y.. (2004) Measuring Mental Illness Stigma, Schizophrenia Bulletin, Vol. 30, No. 3,

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• Link, B. & Phelan, J. (2001) Conceptualizing Stigma. Annual Review of Sociology 27(3): 363–85

• Loganathan, S.&Srinivas Murthy, R. (2008) Experiences of stigma and discrimination endured by people suffering from schizophrenia. Indian Journal of Psychiatry, 50(1), 39 – 46

• Mishra, D.K., Alreja, S., Sengar, K.S., etal. (2009) Insight and its relationship with stigma in psychiatric patients. Indian Journal of Psychiatry, 18 (1), 39 – 42

References

• Ngui, E.M., Khasakhala, L., Ndetei, D., etal. (2010) Mental disorders, health inequalities and ethics: A global perspective. International Review of Psychiatry, 22(3), 235 – 244

• Perlick D.A, Rosenheck R.A., Clarkin J F, Sirey J A, Salahi J, Struening E L , Link B G(2001) Adverse Effects of Perceived Stigma on Social Adaptation of Persons Diagnosed With Bipolar Affective Disorder, Psychiatric services, Vol. 52 No. 12

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do Indian families believe in supernatural causes? Social Psychiatry and Psychiatric Epidemiology. 36: 134-140

• Thara R, Srinivasan T. N.(2000) How stigmatizing is schizophrenia in India? International Journal of Social Psychiatry. ;46:135–141

References

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Thank you