Stigma
http://www.minddisorders.com/Py-Z/Stigma.html
Definitions
The 1999 report on mental health by the Surgeon General of the
United States was regarded as a landmark document in the United
Kingdom, as well as the United States. This was because of its
straightforward identification of the stigma associated with mental
illness as the chief obstacle to effective treatment of persons with
mental disorders. Stigma(plural, stigmata) is a Greek word
that in its origins referred to a kind of tattoo mark that was cut
or burned into the skin of criminals, slaves, or traitors in order
to visibly identify them as blemished or morally polluted persons.
These individuals were to be avoided or shunned, particularly in
public places. The word was later applied to other personal
attributes that are considered shameful or discrediting.
Social psychologists have distinguished three large classes, or
categories, of stigma:
- Physical deformities. These include
extremes of height and weight and such conditions as albinism
and facial disfigurements or missing limbs. In the developed
countries, this category also includes such signs of aging as
gray hair, wrinkles, and stooped posture.
- Weaknesses or defects of individual
character. This category includes biographical data that are
held to indicate personal moral defect, such as a criminal
record, addiction, divorce, treatment for mental illness,
unemployment, suicide attempts, etc.
- Tribal stigma. This type of stigma refers
to a person's membership in a race, ethnic group, religion, or
(for women) gender that is thought to disqualify all members of
the group.
The nature of stigma
Origins
One explanation for the origin of stigmata is that its roots in
the human being's concern for group survival at earlier times in
their evolutionary journey. According to this theory, stigmatizing
people who were perceived as unable to contribute to the group's
survival, or who were seen as threats to its well-being, were
stigmatized in order to justify being forced out or being isolated.
The group survival theory is also thought to explain why certain
human attributes seem to be universally regarded as stigmata, while
others are specific to certain cultures or periods of history.
Mental illness appears to be a characteristic that has nearly always
led to the stigmatization and exclusion of its victims. The primary
influences on Western culture, the classical philosophical tradition
of Greece and Rome, and the religious traditions of Judaism and
Christianity indicate that mental illness was a feared affliction
that carried a heavy stigma. The classical philosopher's definition
of a human being as a "rational animal" excluded him or her who had
lost the use of reason and was no longer regarded as fully human;
most likely he or she was under a divine curse. This attitude was
summarized in the well-known saying of Lucretius, "Whom the gods
wish to destroy, they first make mad."
In the Bible, both the Old and the New Testaments reflect the
same fear of mental illness. In 1 Samuel 21, there is an account of
David's pretending to be insane in order to get away from the king
of a neighboring territory. "He changed his behavior before [the
king's servants]; he pretended to be mad in their presence. He
scratched marks on the doors of the gate, and let his spittle run
down his beard." The king, who was taken in by an act that certainly
fits the Diagnostic and Statistical Manual of Mental Disorderscriteria
for malingering, quickly sent David on his way. In the New
Testament, one of Jesus' most famous miracles of healing (Mark
5:1-20) is the restoration of sanity to a man so stigmatized by his
village that he was hunkered down in the graveyard (itself a
stigmatized place) outside the village when Jesus met him. Mark's
account also notes that the villagers had tried at different times
to chain or handcuff the man because they were so afraid of him. One
important positive contribution of Biblical heritage, however, is a
sense of religious obligation toward the mentally ill. Among
Christians, the New Testament's account of Jesus' openness to all
kinds of stigmatized people—tax collectors, prostitutes, and
physically deformed people, as well as the mentally ill—became the
basis for the establishment of the first shelters and hospitals for
the mentally ill.
Contemporary contexts
The core feature of stigma in the modern world is defined by
social psychologists as the possession of an attribute "that conveys
a devalued social identity within a particular context." Context is
important in assessing the nature and severity of stress that
a person suffers with regard to stigma. Certain attributes, such as
race or sex, affect an individual's interactions with other people
in so many different situations that they have been termed "master
status" attributes. These have become the classic identifying
characteristic of the person who possesses them. Dorothy Sayers'
essay, "Are Women Human?" is not only a witty satire on the way men
used to describe a woman's job or occupation (with constant
reference to feminine qualities), but a keen social analysis of the
problems created by master status attributes for persons who are
stigmatized.
Other forms of devalued social identity are relative to specific
cultures or subcultures. In one social context, a person who is
stigmatized for an attribute devalued by a particular group may find
acceptance in another group that values the particular attribute. A
common example is that of an artistically or athletically talented
child who grows up in a family that values only intellectual
accomplishment. When the youngster is old enough to leave the family
of origin, he or she can find a school or program for other students
who share the same interest. A less marked contrast, but one that is
relevant to the treatment of mental illness, is the cultural
differences with regard to the degree of response to certain
symptoms of mental illness. A study conducted in the early 21st
century assessed the reaction of family members to elderly people
who were diagnosed with Alzheimer's disease (AD). Findings
pointed to considerable variation across racial and ethnic groups.
Asian Americans were most affected by feelings of shame and social
stigma relative to the memory loss of a family member, while African
Americans were the least affected.
One additional complicating feature of stigma is the issue of
overlapping stigmata. Many people belong to several stigmatized
groups or categories, and it is not always easy to determine which
category triggers the unkind or discriminatory treatment
encountered. For example, one study of the inadequate medical
treatment that is offered to most HIV-positive Native Americans
noted that the stigma of Acquired Immune Deficiency Syndrome (AIDS)
provides a strong motivation for not seeking treatment. The study
protocol, however, did not seek to investigate whether young Native
American men are afraid of being stigmatized for their sexual
orientation, their race, their low socioeconomic status, or all
three.
|
We offer a monthly newsletter dealing with
the various issues surrounding infectious diseases. To
find out more click
HERE. |
|
Stigma and mental illness
Stigma and specific disorders
The stigma that is still attached to mental illness in the
developed countries does not represent a simple or straightforward
problem. Public health experts who have studied the stigmatization
of mental illness in recent years have noted that the general
public's perception of mental illness varies, depending on the
nature of the disorder. While in general the stigma of mental
illness in contemporary society is primarily associated with the
second of the three categories of stigma listed above,— supposed
character failings—it also spills over into the first category.
Mental disorders that affect a person's physical
appearance—particularly weight gain—are more heavily stigmatized
than those that do not.
The stigma related to certain types of mental disorders has
declined since the 1950s, most notably in regard to depression and
the anxiety disorders. It is thought that the reason for this change
is that people are more likely nowadays to attribute these disorders
to stress, with which most people can identify. On the other hand,
the stigma associated with psychotic disorders appears to be worse
than it was in the 1950s. Changes in public attitude are also
reflected in age-group patterns in seeking or dropping out of
treatment for mental disorders. One study demonstrated that older
adults being treated for depression were more likely than younger
adults to drop out of treatment because they felt stigmatized. The
difference in behavior is related to public attitudes toward mental
illness that were widespread when the older adults were adolescents.
In 2002, the types of mental disorders that carry the heaviest
stigma fall into the following categories:
- Disorders associated in the popular mind
with violence and/or illegal activity. These include
schizophrenia, mental problems associated with HIV
infection, and substance abuse disorders.
- Disorders in which the patient's behavior
in public may embarrass family members. These include
dementia in the elderly, borderline personality disorder
in adults, and the autistic spectrum disorders in children.
- Disorders treated with medications that
cause weight gain or other visible side effects.
The role of the media
The role of the media in perpetuating the stigmatization of
mental illness has received increasing attention from public health
researchers, particularly in Great Britain. In 1998, the Royal
College of Psychiatrists launched a five-year campaign intended to
educate the general public about the nature and treatment of mental
illness. Surveys conducted among present and former mental patients
found that they considered media coverage of their disorders to be
strongly biased toward the sensational and the negative. One-third
of patients said that they felt more depressed or anxious as a
result of news stories about the mentally ill, and 22% felt more
withdrawn. The main complaint from mental health professionals, as
well as patients, is that the media presented mentally ill people as
"dangerous time bombs waiting to explode" when in fact 95% of
murders in the United Kingdom are committed by people with no mental
illness. The proportion of homicides committed by the mentally ill
has decreased by 3% per year since 1957, but this statistic goes
unreported. Much the same story of unfair stigmatization in the
media could be told in the United States, as the Surgeon General's
report indicates.
Physicians' attitudes toward mental illness
Physicians' attitudes toward the mentally ill are also
increasingly recognized as part of the problem of stigmatization.
The patronizing attitude of moral superiority toward the mentally
ill in the early 1960s, specifically in mental hospitals, has not
disappeared. This was reported by Erving Goffman in his classic
study. A Canadian insurance executive told a conference of
physicians in May 2000 that they should look in the mirror for a
picture of the ongoing stigmatization of the mentally ill. The
executive was quoted as saying, "Stigma among physicians deters the
detection of mental disorders, defers or pre-empts correct
diagnosis and proper treatment and, by definition, prolongs
suffering." An American physician who specializes in the treatment
of substance addicts cites three reasons for the persistence of
stigmatizing attitudes among his colleagues: their tendency to see
substance abuse as a social issue, rather than a health issue; their
lack of training in detecting substance abuse; and their mistaken
belief that no effective treatments exist. A similar lack of
information about effective treatments characterizes many
psychiatrists' attitudes toward borderline personality disorder.
|
We offer a monthly newsletter dealing with
the various issues surrounding infectious diseases. To
find out more click
HERE. |
|
Stigma as cause of mental illness
It is significant that researchers in the field of social
psychology have moved in recent years to analyzing stigma in terms
of stress. Newer studies in this field now refer to membership in a
stigmatized group as a stressor that increases a person's risk of
developing a mental illness. The physiological and psychological
effects of stress caused by racist behavior, for example, have been
documented in African Americans. Similar studies of obese people
have found that the stigmatization of obesity is the single
most important factor in the psychological problems of these
patients. To give still another example, the high rates of
depression among postmenopausal women have been attributed to the
fact that aging is a much heavier stigma for women than for men in
contemporary society.
Stigma has a secondary effect on rates of mental illness in that
members of stigmatized groups have less access to educational
opportunities, well-paying jobs, and adequate health care. They are
therefore exposed to more environmental stressors in addition to the
stigma itself.
Stigma as effect
Stigma resulting from mental illness has been shown to increase
the likelihood of a patient's relapse. Since a mental disorder is
not as immediately apparent as race, sex, or physical handicaps,
many people with mental disorders undergo considerable strain trying
to conceal their condition from strangers or casual acquaintances.
More seriously, the stigma causes problems in the job market,
leading to stress that is related to lying to a potential employer
and fears of being found out. Erving Goffman reported in the 1960s
that a common way around the dilemma involved taking a job for about
six months after discharge from a mental institution, then quitting
that job and applying for another with a recommendation from the
first employer that did not mention the history of mental illness.
The stigmatization of the patient with mental illness extends to
family members, partly because they are often seen as the source of
the patient's disorder. A recent editorial in the Journal of the
American Medical Associationtells the story of two sets of
parents coping with the stress caused by other people's reactions to
their children's mental illness, and the different responses they
received when the children's disorders were thought to be a physical
problem. The writer also tells of the problems encountered by the
parents of an autistic child. The writer stated that family
excursions were difficult, and continued, "My friend's wife was
reprimanded by strangers for not being able to control her son. The
boy was stared at and ridiculed. The inventive parent, fed up with
the situation, bought a wheelchair to take the child out. The family
was now asked about their child's disability. They were praised for
their tolerance of his physical hardship and for their courage; the
son was commended for his bravery. Same parents, same child,
different view."
The results of stigma
The stigmatization of mental disorders has a number of
consequences for the larger society. Patients' refusal to seek
treatment, noncompliance with treatment, and inability to find work
has a high price tag. Disability related to mental illness accounts
for fully 15% of the economic burden caused by alldiseases in
developed countries.
Seeking treatment
Stigmatization of mental illness is an important factor in
preventing persons with mental disorders from asking for help. This
factor affects even mental health services on university campuses;
interviews with Harvard students following a 1995 murder in which a
depressed student killed a classmate, found that students hesitated
to consult mental health professionals because many of their
concerns were treated as disciplinary infractions, rather than
illnesses. The tendency to stigmatize mental disorders as character
faults is as prevalent among educators as among medical
professionals. In addition, studies of large corporations indicate
that employees frequently hesitate to seek treatment for depression
and other stress-related disorders for fear of receiving negative
evaluations of job performance and possible termination. These fears
are especially acute during economic downturns and periods of
corporate downsizing.
Compliance with treatment
Another connection between mental disorders and stigma is the low
rates of treatment compliance among patients. To a large
extent, patient compliance is a direct reflection of the quality of
the doctor-patient relationship. One British study found that
patients with mental disorders were likely to prefer the form of
treatment recommended by psychiatrists with whom they had good
relationships, even if the treatment itself was painful or
difficult. Some patients preferred electroconvulsive therapy(ECT)
to tranquilizers for depression because they had built up trusting
relationships with the doctors who used ECT, and perceived the
doctors who recommended medications as bullying and condescending.
Other reasons for low compliance with treatment regimens are related
to stigmatized side effects. Many patients, particularly women,
discontinue medications that cause weight gain because of the social
stigma attached to obesity in females.
Social and economic consequences
As already mentioned, persons with a history of treatment for
mental disorders frequently encounter prejudice in the job market
and the likelihood of long periods of unemployment; this can result
in lower socioeconomic status, as well as loss of self-esteem. These
problems are not limited to North America. A recent study of mental
health patients in Norway, which is generally considered a
progressive nation, found that the patients had difficulty finding
housing as well as jobs, and were frequently harassed on the street
as well as being socially isolated. In 1990, the Congress of the
U.S. included mental disorders (with a few exceptions for disorders
related to substance abuse and compulsive sexual behaviors) in the
anti-discriminatory provisions of the Americans with Disabilities
Act (ADA). As of 2002, mental disorders constitute the third-largest
category of discrimination claims against employers.
Stigmatization of mental disorders also affects funding for
research into the causes and treatment of mental disorders. Records
of recent Congressional debates indicate that money for mental
health research is still grudgingly apportioned as of 2002.
Future prospects
The stigma of mental illness will not disappear overnight. Slow
changes in attitudes toward other social issues have occurred in the
past three decades, giving hope to the lessening of stigma toward
people with mental illness. However, limitations on indefinite
economic expansion are an reason for concern. As the economic "pie"
has to be divided among a larger number of groups, causing
competition for public funding, persons with mental disorders will
need skilled and committed advocates if their many serious needs are
to receive adequate attention and help.
Resources
BOOKS
Goffman, Erving. Asylums: Essays on the Social Situation of
Mental Patients and Other Inmates.New York: Anchor Books, 1961.
Goffman, Erving. Stigma: Notes on the Management of Spoiled
Identity.New York: Simon and Schuster, Inc.,1963.
PERIODICALS
"AIDS Treatment Eludes Many Indians." AIDS Weekly(December
17, 2001): 10.
Britten, Nicky. "Psychiatry, Stigma, and Resistance:
Psychiatrists Need to Concentrate on Understanding, Not Simply
Compliance." British Medical Journal317 (October 10, 1998):
763-764.
Corner, L., and J. Bond. "Insight and Perceptions of Risk in
Dementia." The Gerontologist(October 15, 2001): 76.
Farriman, Annabel. "The Stigma of Schizophrenia" British
Medical Journal320 (February 19, 2000): 601.
Leshner, Alan I. "Taking the Stigma Out of Addiction." Family
Practice News30 (August 15, 2000): 30.
Lyons, Declan, and Declan M. McLoughlin. "Psychiatry (Recent
Advances)." British Medical Journal323 (November 24, 2001):
1228-1231.
Maher, Tracy. "Tackling the Stigma of Schizophrenia." Practice
Nurse20 (November 2000): 466-470.
Mahoney, D. "Understanding Racial/Ethnic Variations in Family's
Response to Dementia." The Gerontologist (October 15, 2001):
120.
Myers, A., and J. C. Rosen. "Obesity Stigmatization and Coping:
Relation to Mental Health Symptoms, Body Image, and Self-Esteem."
International Journal of Obesity and Related Metabolic Disorders23
(March 1999): 221-230.
Neil, Janice A. "The Stigma Scale: Measuring Body Image and the
Skin." Plastic Surgical Nursing21 (Summer 2001): 79.
Parker, Gordon, Gemma Gladstone, Kuan Tsee Chee. "Depression in
the Planet's Largest Ethnic Group: The Chinese." American Journal
of Psychiatry158 (June 2001): 857.
Perlick, D. A., R. A. Rosenheck, J. F. Clarkin, and others.
"Stigma as a Barrier to Recovery: Adverse Effects of Perceived
Stigma on Social Adaptation of Persons Diagnosed with Bipolar
Affective Disorder." Psychiatric Services52 (December 2001):
1627-1632.
"Reducing the Stigma of Mental Illness." Lancet357 (April
7, 2001): 1055.
Russell, J. M., and J. A. Mackell. "Bodyweight Gain Associated
with Atypical Antipsychotics: Epidemiology and Therapeutic
Implications." CNS Drugs15 (July 2001): 537-551.
Sirey, Jo Anne, Martha L. Bruce, George S. Alexopoulos, and
others. "Perceived Stigma as a Predictor of Treatment
Discontinuation in Young and Older Outpatients with Depression."
American Journal of Psychiatry158 (March 2001): 479-481.
Smart, L., and D. M. Wegner. "Covering Up What Can't Be Seen:
Concealable Stigma and Mental Control." Journal of Personal and
Social Psychology77 (September 1999): 474-486.
Thesen, J. "Being a Psychiatric Patient in the
Community—Reclassified as the Stigmatized 'Other.'" Scandinavian
Journal of Public Health29 (December 2001): 248-255.
Weissman, Myrna M. "Stigma." Journal of the American Medical
Association285 (January 17, 2001): 261.
Wojcik, Joanne. "Campaign Seeks to Remove Stigma of Mental
Illness." Business Insurance36 (January 21,2002): 1.
Yanos, Philip T., Sarah Rosenfeld, Allan V. Horwitz. "Negative
and Supportive Social Interactions and Quality of Life Among Persons
Diagnosed with Severe Mental Illness." Community Mental Health
Journal37 (October 2001): 405.
ORGANIZATIONS
National Alliance for the Mentally Ill (NAMI). Colonial Place
Three, 2107 Wilson Blvd., Suite 300, Arlington, VA22201. (800)
950-6264. www.nami.org
OTHER
National Institute of Mental Health (NIMH). The Impact of
Mental Illness on Society.NIH Publication No. 01-4586.
<www.nimh.nih.gov/publicat/burden.cfm>.
Office of the Surgeon General. Mental Health: A Report of the
Surgeon General.Washington, D.C.: Government Printing Office,
1999. A copy of the report may be ordered by faxing the
Superintendent of Documents at(202) 512-2250.
Rebecca J. Frey, Ph.D.
|
