1RCSI medical student
The most debilitating aspect of mental illness can be coping with the social stigma, says Rowena Almeida.
Royal College of Surgeons in Ireland Student Medical Journal 2012;5: 89-92.
“If mental health becomes more of an everyday issue, that matters to us all, then the stigma attached to getting help can be reduced. While Irish society will continue to experience considerable change and face new challenges ahead, a mentally healthier Irish society will be much better able to cope.”1
-Health Service Executive
Would we accept someone with a mental illness as a close friend?
One-third of the 187 people surveyed in 2009 for St Patrick’s University Hospital answered ‘no’. Close to 52% of these people claimed that a family member had been treated for a mental illness, yet 40% of them still felt that undergoing treatment for mental health is a sign of failure.2 These statistics, although based on a relatively small sample size, highlight the stark reality echoed across surveys. The biggest barrier in the realisation of mental health is ‘stigma’ and the associated discrimination. It is tragic that the distress of mental illness is only partially related to the medical problem. Instead, the most debilitating aspect of mental illness is the reaction and attitudes of others, and often of ourselves.
The World Health Organisation (WHO) defines mental health as “a state of well-being in which every individual realises his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community”.3 Based on this criterion, Hardcastle et al. showed that 30% of all general consultations involve a mental illness, and estimated that one in four people will have a mental illness at some point in their life.4 Therefore, it comes as no surprise that mental illness is a leading cause of disability and is a WHO priority.
Stigma is a socially constructed mark of disapproval, shame or disgrace that causes significant disadvantage through the curtailment of opportunities.5
During the middle ages, mental illness was considered a sign of weakness of character. It is a shameful reality that contemporary societies and cultures continue to endorse this myth.4 Research shows that stigma has detrimental effects on health and well-being, and exacerbates the fear and isolation experienced by the excluded individual.5,6 Thus, addressing the stigma surrounding mental illness is justifiably a crucial step in the management of mental health.
The concept of stigma
Feelings of rejection and marginalisation by the society in which we live is a form of social suffering that is rooted in fear, misunderstanding and misconceptions.7 Goffman conceptualised stigma as a means for society to categorise people on the basis of normative expectations, thereby dividing the ‘normal’ from the ‘deviant’.7 The end result is that these individuals are identified with an attribute that reduces them “from a whole and usual person to a tainted and discredited one”, socially discounting and excluding them.4 The three constructs that fuel stigma towards mental illness are a lack of knowledge (ignorance), negative attitudes (prejudice) and hostile behaviour (discrimination).8 Prejudice – that is, the cognitive and affective response of fear – is influenced by our poor understanding of mental illness. Ignorance, anxiety and the avoidance of people with mental illness ultimately leads to discrimination.
Stigma towards mental illness can be analysed on three levels. First, self-stigma is an internal process whereby people judge themselves based on messages received from societal norms. This internalised identity decreases self-esteem when the person believes that they have failed to meet societal expectations. Corrigan describes this concept as a private shame that raises self-doubt about one’s capacity to live independently, have meaningful relationships or hold a job.4
Second, structural stigma (or public stigma) occurs when the population endorses and implements stereotypes, prejudice and discrimination to deny people with a mental illness their due entitlement in terms of interpersonal relationships, custody rights, employment or participatory citizenship.9
Third, label avoidance is a means by which stigma can harm individuals who have not yet been diagnosed. These individuals do not seek healthcare so as to avoid the label of mental illness. Research suggests that half to two-thirds of individuals who might benefit from psychiatric services opt not to pursue them for fear of stigmatisation and discrimination.9
Stigma towards mental illness in Ireland
Grow, the mental health charity, estimated a sevenfold increase in young adults attending its mental health support group in 2009.2 Given this incidence, it is worrisome that the 2006 National Disability Authority (NDA) survey on ‘Public Attitudes to Disability in Ireland’ found that people had the most negative attitudes towards those with mental health difficulties compared to other disabilities such as physical, intellectual, visual, auditory or long-term illness. While it is encouraging that 94% of Irish people were aware that anyone could be subject to a mental illness, more than half revealed that they would not want people to know they had one.10,11 It is clear that considerable stigma surrounds mental health issues in Ireland. Stigma associated with mental illness is a public health challenge because it has adverse consequences for both the patients and their families that pervades everywhere from schools to the workplace.12 Only 36% agree that children with mental health problems should be in the same school as other children. In the workplace, people would be least comfortable having colleagues with a mental illness in comparison to other disabilities, such as physical or intellectual.10 Moreover, six in 10 adults believe that people with mental health problems should not qualify for important jobs such as being a doctor or a nurse.10 Such negative attitudes towards mental illness can affect the quality of care provided for these patients and is a barrier to their recovery. We need to vanquish the view that people with mental illness are inferior or a threat to society, and instead harbour a positive attitude towards these individuals.13
Considerable effort has been undertaken to overcome stigma. For instance, the priority of the Mental Health Action Plan for Europe (2005) is to “foster awareness of the importance of mental well-being”. Their specific actions include promoting community-based multi-level interventions, involving public awareness campaigns and efforts to make mental health an integral part of public health.1 Targeted outcomes and modest anti-stigma campaigns focused at a well-defined audience are the most successful and sustainable.14 Studies have shown that education-based interventions result in improvements in beliefs about treatments, a decrease in social distance from people with mental disorders and an increased confidence in providing help to someone with a mental disorder.15 Research would also encourage opportunities for social interaction, which in itself is more effective than anti-stigma campaigns. Another approach to combat stigma is to provide mental health services at the community level, such that multidisciplinary facilities for both mental and physical health are available within the same setting.
This would minimise segregation in treatment and prevent disruption to everyday life.16 The recent RTÉ documentary Behind the Walls addressed the powerlessness of people receiving mental health services, and it elucidated the importance of a balanced partnership between healthcare professionals and service users as a means of affording the latter active participation with relation to their illness.
Founded in 1996, See Change is a national stigma reduction partnership scheme that hopes to change attitudes towards mental illness by increasing public understanding of mental illness. Their targeted public education activities are designed to provide factual information and suggest strategies for enhancing mental health (Figure 1).17,18 As healthcare professionals, we need to dispel stigma as a necessary part of our training and as a vital component of the treatment of patients in the mental health system.
These Irish initiatives have been positive steps towards changing public attitudes and behaviour towards mental illness. At a time of economic uncertainty, it is fortunate that these programmes exist and promote concerted action against discrimination. Our success lies in eliminating stigma towards mental illness in its entirety so that we can accept people with mental health problems into the community with their differences and all. Or, as Samuel Goldwyn would put it: “You’ve got to take the bitter with the sour”.
- HSE. Mental Health in Ireland: Awareness and Attitudes. 2007.
- Tinsley O. Attitudes survey reveals mental health stigma. Irish Times. October 9, 2009.
- WHO. Mental health: a state of well-being. 2009. Cited September 8, 2010. Available from: http://www.who.int/features/factfiles/mental_health/en/index.html.
- Overton SL, Medina SL. The stigma of mental illness. J Counsel Dev. 2008;86:57-63.
- Martin JM. Stigma and student mental health in higher education. High Educ Res Dev. 2010;29(3):259-74.
- Granello D, Wheaton J. Attitudes of undergraduate students towards persons with physical disabilities and mental illness. J Applied Rehab Counsel. 2001;32(3):9-17.
- Carnevale FA. Revisiting Goffman’s Stigma: the social experience of families with children requiring mechanical ventilation at home. J Child Health Care. 2007;11(1):7-18.
- Arboleda-Florez J. What causes stigma? World Psychiatry. 2002;1(1):25-6.
- Corrigan PW, Wassel A. Understanding and influencing the stigma of mental illness. J Psychosoc Nurs Ment Health Serv. 2008;46(1):42-8.
- NDA. Public Attitudes to Disability in Ireland: Report of Findings. 2007.
- SeeChange. Public Attitudes towards mental illness – A Benchmark Study for See Change. 2010.
- Keon W, Hewstone M, Holmes EA. Rethinking ‘mental health stigma’. Eur J Public Health. 2010;20(2):131-2.
- Chambers M, Guise V, Valimaki M, Botelho MA, Scott A, Staniuliene V et al. Nurses’ attitudes to mental illness: a comparison of a sample of nurses from five European countries. Int J Nurs Stud. 2010;47(3):350-62.
- Evans-Lacko S, London J, Little K, Henderson C, Thornicroft G. Evaluation of a brief anti-stigma campaign in Cambridge: do short-term campaigns work? BMC Public Health. 2010;10:339.
- Evans-Lacko S, Little K, Meltzer H, Rose D, Rhydderch D, Henderson C et al. Development and psychometric properties of the mental health knowledge schedule. Can J Psychiatry. 2010;55(7):440-8.
- Datta A, Frewen J. Stigma of Mental Illness. Updated September 19, 2010. Available from: http://www.imt.ie/features-opinion /2010/09/stigma-of-mental-illness.html.
- See Change. The National Mental Health Stigma Reduction Partnership. 2010. Available from: www.seechange.ie.
- Taking Control of your Mental Health. Shine. 2009.
- See Change: What Can be done? 2010. Available from: http://www.seechange.ie/index.php/stigma-and-discriminatio n/57-what-can-be-done.