STIGMA, MENTAL ILLNESS, AND

CULTURE

Dr. Patricia Sherman

April 3, 2007

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?

Origins of Stigma

• Ancient Greece – means “mark;” marks were placed on slaves to identify their position in the social structure and indicate they were of lesser value

• People have always needed to determine where they are in relation to others

• Reassuring to believe that someone is beneath you in the “pecking order”

Erving Goffman (1963)

• Suggested that stigma had two major components: public one (reaction of general public to people with mental illness) and self-stigma (prejudice that people with mental illness tend to turn towards themselves

• Stigma comes in three forms

–Overt or external deformations

–Deviations in personal traits (mental illness)

–Tribal stigmas – traits of a race, nation, or religion that deviate from the normative race, nationality or religion

• The more visible the stigmatizing mark or condition, the more society believes the individual should be able to control it and the greater the negative impact of not being able to do so

• List ten groups that are stigmatized

• When have you been stigmatized?

• When have you stigmatized someone else?

Response to stigma

• Try to get rid of what is stigmatizing

• Make special efforts to compensate

• Refuse to accept societal norms

Glossary of Terms

• Labeling – the act of giving a name with a social meaning to a state or characteristic

• Deviance – behavior which is socially abnormal and usually regarded as unacceptable

• Primary deviance – the original deviance, which in the context of illness behavior, is that caused by the illness itself

• Secondary deviance – the abnormal behavior which results from the social reaction to the primary deviance

• Stigma – the negative value given to a characteristic which means that a person is spoiled in some way and liable to social rejection

• Stereotyping – the act of labeling a person with one characteristic (often stigmatized) on the basis of their possession of another characteristic

• Discreditable – a state where a person has a stigmatized characteristic, but this is not generally known. There is therefore a potential to be discredited or rejected if the characteristic becomes apparent

• Discredited – the state where the stigmatized condition has become visible

• Enacted stigma – the social rejection that has taken place as a result of being discredited

• Felt stigma – the perceived social rejection of the stigmatized condition

• Complete Attitude Scale for Mental Illness

• What was difficult to answer?

• What do you wish you could have answered differently?

Four components of stigma

• Labeling people with a condition

• Stereotyping people with that condition

• Creating a division – “us” and “them”

• Discriminating against people based on their label

Why is mental illness stigmatized?

• Its name implies it is different from physical illness

• Sounds as if it’s “all in one’s head”

• Some people believe it results from poor choices

• Belief that people with mental illnesses are dangerous and unpredictable, less competent, unable to work, should be institutionalized, can never get better

Some Health and Social Consequences of Stigma

• Mental illness and addiction are common, but only 1/3 of those needing treatment seek it due to fear of discrimination

• People deny painful symptoms and are reluctant to seek help at an early, more treatable stage of illness

• The drop-out rate for psychiatric treatment is high because people do not want to be seen attending psychiatric clinics.

• People with mental illness often hold the same beliefs as society at large and blame themselves for their illness

• The major way people cope with stigma is to withhold information from those who could help them

• Consumers expect to be rejected by the community and, therefore, are reluctant to engage with others

• The effects of stigma and its resultant social withdrawal may have a greater impact on an individual than the illness

• Family members are also harmed by stigma and may be blamed for causing or contributing to the illness

• Community attitudes can negatively affect recovery rate

• Mental health professionals are also often stigmatized, holding a diminished status in the eyes of other health care professionals and making recruitment challenging

• Many mental health professionals share negative attitudes towards people with mental illness

• The diminished attitude towards consumers is applied to self-help and peer-support programs, negatively affecting the number of referrals

• People with mental illness are less likely to be appropriately diagnosed and treated for co-morbid medical conditions

• Institutions, governments, and policy makers contribute to stigma by systematically under-funding mental health services

• Discrimination towards people with mental illness leads to diminished employment opportunities, lack of career advancement, and hostility in the workplace

• Stigma contributes to the persistent under-funding of research and treatment services

• 74% of people with a mental illness reported they had experienced stigma in the last year

• 16% reported stigma in the workplace

• 13% from staff in a health service

(SANE, Australia, 2006)

• The elderly experience the double stigma of being old and mentally ill and are less likely to seek help; their illnesses may not be detected because of the belief that anxiety and depression are a normal part of aging

• Other groups also experience a double or triple stigma – LGBT, people of color, women (“The gay community stigmatizes us for being mentally ill, and the mental health community stigmatizes us for

being gay”)

• Discrimination is experienced through a loss of human rights, including forced treatment, finding or keeping housing, the right to parent, access to loans, immigration, denial of insurance coverage, and over-representation in the criminal justice system

• Adapted from Mood Disorders Society of Canada’s Stigma and Discrimination Research Workshop, Ottowa, ON – 10/2-4/06.

• Complete Family Scale

• Discuss in small groups

• Report out to larger group

Some Facts About Mental Illness and Recovery

• Mental disorders fall along a continuum of severity. Even though mental disorders are widespread in the population, the main burden of illness is concentrated in a much smaller proportion — about 6 percent, or 1 in 17 Americans — who suffer from a serious mental illness. It is estimated that mental illness affects 1 in 5 families in America.

• Most mental illnesses are biologically based brain disorders.  They cannot be overcome through "will power" and are not related to a person's "character" or intelligence.

• The World Health Organization has reported that four of the 10 leading causes of disability in the US and other developed countries are mental disorders. By 2020, Major Depressive illness will be the leading cause of disability in the world for women and children.  

• Mental illnesses usually strike individuals in the prime of their lives, often during adolescence and young adulthood. All ages are susceptible, but the young and the old are especially vulnerable.

• Without treatment the consequences of mental illness for the individual and society are staggering: unnecessary disability, unemployment, substance abuse, homelessness, inappropriate incarceration, suicide, and wasted lives. The economic cost of untreated mental illness is more than 100 billion dollars each year in the United States.

• The best treatments for serious mental illnesses today are highly effective; between 70 and 90 percent of individuals have significant reduction of symptoms and improved quality of life with a combination of pharmacological and psychosocial treatments and supports.

• With appropriate effective medication and a wide range of services tailored to their needs, most people who live with serious mental illnesses can significantly reduce the impact of their illness and find a satisfying measure of achievement and independence.

• Early identification and treatment is of vital importance. By ensuring access to the treatment and recovery supports that are proven effective, recovery is accelerated and the further harm related to the course of illness is minimized.

Mental Illness Across Cultures

• The expression of mental illness in many cultures is in bodily terms – headache, trouble sleeping, fatigue, stomachache, etc.

• Hallucinations and delusions will be culturally relevant

• Need to assess level of acculturation

• Mental illness compounded by immigration experience, conditions leading to immigration, poverty, lack of health insurance, language difficulties, loss of support system, lack of access to traditional healers

• Asian Indians and Pacific Islanders – very few receive treatment (1/6 of those who need it)

• Deep-rooted stigma prevents many from acknowledging their illness

• Stigma extends to families

• Fear of not being able to marry

• Psychiatric illnesses are considered curse from God, punishment for sins in past lives, or manifestations of evil spirits

• Latino/a culture has expectation that people will be able to solve problems on their own

• Serious stigma regarding mental illness

• 75% of family members in Ethiopia report being stigmatized

• Chinese use traditional medicine and healers

• Tend to hide feelings; loss of face

• Emphasis on family involvement

• May use term for sadness that is translated as “congested”

• In traditional Japan, suicide is valorized – it’s a way of maintaining honor by accepting responsibility

• Japanese changing name for schizophrenia from seishi buntetsu byo (split-mind disorder) to togo shiccho sho (loss of coordination disorder)

• African Americans tend to access treatment later – fearful it will make them look weak and not spiritual enough

• Religious preoccupation may not be symptom of mental illness

• In Poland, over 70% indicated that people with mental health disorders are called “crazy,” “loony,” “idiot,” “abnormal”

• 3/5 Scots believed someone with mental illness would not be able to look after children

• Zimbabwe – high rate of depression, especially among women, typically present with multiple physical symptoms

• Many somatic complaints, especially related to the heart and head are metaphors for grief or fear

• Afro-Caribbean immigrants often believe in obeah – a form of witchcraft containing elements of Christianity, animism, and folk medicine

• Based on belief that it is possible to influence the health or well-being of another person from a distance

• Iraqis deny mental illness exists in their country; women will not be able to marry if they are mentally ill

• Kenya – stigma against being a psychiatrist – “Are you alright upstairs?”

• In many parts of the world, spirit possession is common. This may be a way for disadvantaged people to gain status; lose status if symptoms are due to a chemical imbalance

• Could be misdiagnosed as schizophrenia

• The cultures that patients come from shape their mental health and affect the kinds of mental health services they use. Likewise the cultures of the clinicians and the service system affect diagnosis, treatment, and the organization and financing of services

• Complete Scale of Social Distance

• Complete Attitude Towards Seeking Professional Psychological Help

The media• People with mental illness:

–Are homicidal maniacs who need to be feared

–Have childlike perceptions of the world and need to be taken care of, or

–Are responsible for their illness due to weak character and should be blamed

• Show scene from 12 Monkeys

• Show scene from Me, Myself, and Irene

• Discuss

• Newspapers and TV stations can print or broadcast statements about those with mental illness that would not be tolerated if they were said about any other minority group. Stigma insinuates itself into policy decisions, access to care, health insurance, employment discrimination, and in research allocation and priorities.

• 9/11 terrorists characterized as “crazy” or “mad”

• GM Super Bowl ad – robot jumping off bridge

• Wendy’s – multiple personality eating disorder

• Vermont Teddy Bear – “Crazy for You Bear”

• Fox-TV – “Unanimous” – Richard became an outcast after it was discovered he had a psychiatric hospitalization

• Readers’ Digest – “How do crazy people go through the forest?”

Some Ways to Fight Mental Illness Stigma

• Avoid prejudging those with mental illness on the basis of media and societal stereotypes

• Learn more about mental illness

• Learn more about mental illness stigma and discrimination

• Speak up about mental illness stigma

• Listen to people who have experienced mental illness

• Watch your language – talk about people first, then their illness

• Talk openly about mental illness, especially your own or that of a loved one

• Provide support for organizations that fight mental illness stigma

Some Ways to Cope With and End Stigma AS A

CONSUMER

• Get appropriate treatment

• Surround yourself with supportive people

• Make your expectations known

• Don’t equate yourself with your illness

• Share your own experiences

• Monitor the media

• Join an advocacy group

In Our Own Voice (IOOV)

• NAMI initiative in which two trained presenters give personal testimony about their journeys with mental illness

• Listen to PSA’s

Advocacy Websites

• http://community-2.webtv.net/stigmanet/LINKSAntiStigma/

• http://www.stigmaresearch.org/

• http://mentalhealth.samhsa.gov/publications/allpubs/sma06-4176/

• http://www.nami.org/template.cfm?section=fight_stigma

• http://uhaweb.hartford.edu/owahl/resources.htm

• http://www.stampoutstigma.org/

• http://www.mentalhealthstigma.com/

• http://www.adscenter.org/

• Read Kay Redfield Jamison’s statement

Action plan

• What will you do to combat stigma in your professional and/or personal life?– Goal:

• Objective #1• Objective #2• Objective #3