Open Science Journal of Psychology 2017; 4(2): 17-20 http://www.openscienceonline.com/journal/osjp
The Stigma in the Mental Health Mamoon Zboun Istiklal Hospital, Hashemite University, Jarash, Jordan
Email address
[email protected]
To cite this article Mamoon Zboun. The Stigma in the Mental Health. Open Science Journal of Psychology. Vol. 4, No. 2, 2017, pp. 17-20. Received: July 26, 2017; Accepted: December 26, 2017; Published: February 3, 2018
Abstract The Stigma in the Mental Health Care and demonstrates that many people who would benefit from mental health services option to pursue them or fail to fully participate once they have begun. One of the reasons for this disconnect is the stigma; namely to avoid the label of mental illness and the harm it brings. People decide not to seek or fully participate in care. Stigma yields two kinds of harm that may impede treatment participation: It diminishes self-esteem and robs people of social opportunities. Given the existing literature in this area, recommendations are reviewed for ongoing research that will more comprehensively expand understanding of the stigma– care seeking a link. Implications for the development of ant stigma programs that might promote care seeking and participation are also reviewed.
Keywords Stigma, Mental Illness, Care Seeking, Treatment, Psychological Procedures
1. Introduction 1.1. Past History The pejorative use of the term stigma, reflecting a mark of shame or degradation, is thought to have appeared in the late 16th and early 17th centuries (Simon, 1999), stigma was more broadly used to indicate a tattoo or mark that might have been used for decorative or religious purposes, or for utilitarian reasons, such as a brand placed on criminals or slaves so that they could be identified if they ran away and to indicate their inferior social position (Simon, 1999), The evolution of the term although, negative societal responses to the mentally ill have been global throughout history – a situation that has persisted through changing concepts of mental illness – even through the rise of medical theories and biologically-based explanations for most mental disorders (Mora, 1999), In Stigma: notes on the management of damaged identity, Goffman describes the damaging effects of stigma, which reduces the bearer from a whole person to one that is hopelessly tainted (Goffman, 1968), In Goffman's view, mental illness was one of the most deeply discrediting and socially damaging of all stigmas, such that people with mental illnesses start out with rights and relationships, but end up with little of either (Goffman, 1968), I understand
from this past perspective, stigma is prevalent, pernicious, and resistant to change and, to be successful, anti-stigma programs must be comprehensive and directed to individual, inter-personal, and system-level determinants. 1.2. Present Activities Over the last decade, public health interest in both the liability of mental illness and the hidden liability of mental health related stigma has grown (WHO, 2001), Organizations such as the World Health Organization has recognized stigma as a major public health challenge Growing support for stigma reduction is also evident in the number of government declarations (WHO, 2001), mental health system reviews, and action plans that have high-lighted the disabling effects of stigma and the importance of reducing discrimination (World health association, 2001). Although the quality and effectiveness of mental health treatments and services have improved greatly over the past 50 years, many people who, might benefit from these services choose not to obtain them or do not fully adhere to treatment regimens once they are begun (Guerue, 2006). Stigma is one of several reasons why people make such choices; namely, social– cognitive processes motivate people to avoid the label of mental illness that results when people are associated with mental health care (Guerue, 2006).
18
Mamoon Zboun: The Stigma in the Mental Health
A brief definition of stigma is provided, followed by a more complete description of two specific manifestations that dissuade people from treatment: the threats of diminished self-esteem and of public identification when labeled “mentally ill” (Sartorius, 2005). 1.3 Mental Health Problems and Care Seeking Most clinical and services researchers recognize several interventions as having sufficient empirical evidence to commend them for treatment of specific disorders (American Psychiatric Association, 2008), Two task forces of the American Psychological Association (APA)— on Psychological Intervention Guidelines (2009) and on Promotion and Dissemination of Psychological Procedures (2009)— have developed standards for defining research evidence that describes empirically supported interventions, Division 12 members have summarized these proceedings and similar efforts into a continually evolving set of guidelines and recommendations (American Psychiatric Association, 2008). Few studies which have investigated this aspect of stigma have found that stigma can serve as a means of propagating prejudicial social values. In a review of two case studies on mental illness stigma, Yang et al. (2007) suggested that stigma can be used to enforce social imperatives upon stigmatized individuals, whose trait deviance is perceived as a breach of those social imperatives. Ablon (2002) came to a similar conclusion in her review of medical illness stigma by noting that stigma can be used to bolster broader prejudicial assumptions about the role of sick individuals in society
2. Major Format Guidelines 2.1. Significance This is the first nursing study that focuses on the stigma at the mental health in Jordan. The results of this study will be used to design managerial interventions to reduce stigma in the mental health in Jordan. 2.2. Literature Review Existing bodies of research have extensively described why people might to avoid services because of stigma (Rogers, 2003), Future research needs to build on this literature to develop a more cohesive paradigm for understanding the link between stigma and care avoidance (Hinshaw, 2005). Six specific conundrum need to be addressed in this research (Hinshaw, 2005) firstly, determine how varying aspects of person-level stigma interfere with care seeking (Hinshaw, 2005). Two elements of person stigma seem relevant from the literature review provided in this article (Hinshaw, 2005). Some people might not seek treatment to avoid the public harm that results from labels (Hinshaw, 2005). Alternatively, some people with mental illness may avoid the label to escape stigma’s impact on their sense of self, Future research needs to determine the relative impact of these and other kinds of person-level stigma. Second (Deegan, 2007), examine the impact of disease
awareness (Deegan, 2007). Many persons with psychotic disorders are un-aware of the nature of their mental illness or its impact on the breadth of life functioning domains (Corrigan, & Miller, 2004), Six specific conundra need to be addressed in this research (Beadnell, 2007). First, determine how varying aspects of person-level stigma interfere with care seeking (Beadnell, 2007). Two elements of person stigma seem relevant from the literature review provided in this article (Corrigan, & Miller, 2004). Some people might not seek treatment to avoid the public harm that results from labels (Corrigan, & Miller, 2004). Alternatively, some people with mental illness may avoid the label to escape stigma’s impact on their sense of (Corrigan, & Miller, 2004). Future research needs to determine the relative impact of these and other kinds of person-level stigma (Corrigan, & Miller, 2004). Second, examine the impact of disease awareness. Many persons with psychotic disorders are un-aware of the nature of their mental illness or its impact on the breadth of life functioning domains (Fink, 2005). As a result, some persons with mental illness may not realize they belong to a group of people who are stigmatized (Fink, 2005). Hence, they may be relatively immune to person-level stigma (Fink, 2005). Research examining the impact of stigma on care seeking should include awareness as a covariate (Happell, 2005). Negative attitudes about mental illness often underlie stigma, which can cause affected persons to deny symptoms; delay treatment; be excluded from employment, housing, or relationships; and interfere with recovery (CDC, 2010), Understanding attitudes toward mental illness at the state level could help target initiatives to reduce stigma, but statelevel data are scant (CDC, 2010). Often, when a person with a stigmatized trait is unable to perform an action because of the condition, other people view the person as the problem rather than viewing the condition as the problem (CDC, 2010), More recent definitions of stigma focus on the results of stigma—the prejudice, avoidance, rejection and discrimination directed at people believed to have an illness, disorder or other trait perceived to be undesirable (CDC, 2010). Stigma is further diminished when members of the general public have contact with people with mental illness who are able to hold down jobs or live as good neighbors in the community (Corrigan, 2000). Hence, opportunities for the public to meet persons with severe mental illness may discount stigma (Corrigan, 2000). The research question of particular interest here is how attitudes that may change as a result of these antistigma programs increase care seeking for persons in need.
3. Conclusion and Brief Summary This article provides a summary of current stigmareducing interventions, but is limited by the inability to provide clinical recommendations. Clinical recommendations cannot be made until more evidence is available and a rigorous appraisal of the evidence, such as a systematic review, is undertaken. At that time, best practice can be
Open Science Journal of Psychology 2017; 4(2): 17-20
19
identified and implemented with confidence. Research suggests that stigma may impede people from seeking or fully participating in mental health services. In particular, the threat of social disapproval or diminished self esteem that accompanies the label may account for underused services. Advocacy and government groups have strongly endorsed resolving the stigma of mental illness as a way to improve service use. The report of President Bush’s New Freedom Commission highlighted antistigma programs as a primary goal to improve the mental health system (Saad, 2006). A better understanding of the problem of stigma is needed to inform the development of these antistigma programs. Several areas for development of the research agenda were re-viewed in this article. Psychologists who are able to embrace this research agenda will help advocates to better tackle the stigma problem and will significantly advance treatment use in turn.
programs can be evaluated to (a) determine overall program performance, (b) determine if and how the theory accounts or does not account for the observed outcomes, and (c) determine what may have gone wrong and how to best refine and strengthen the program (Sidani & Bradden, 2000). To facilitate mental health treatment, future nursing research should include developing and evaluating theory-based interventions to reduce stigma both on the micro and macro level. Implementation can occur by targeting groups that hold influence over people with mental disorders (e.g., teachers, policymakers, employers, landlords, health care providers, media) and tailoring interventions to these groups (Corrigan, 2000). Testing the effectiveness of theory-based interventions for these targeted groups is helpful to program evaluation, replication, and dispersion of the intervention effect.
4. Implication and Recommendation
[1]
Simon B. Shame, stigma, and mental illness in Ancient Greece. In: Fink PJ, Tasman A, editors. Stigma and mental illness. Washington: American Psychiatric Press; 1999. pp. 29-39.
[2]
Mora G. Stigma during the Medieval and Renaissance periods. In: Fink PJ, Tasman A, editors. Stigma and mental illness. Washington: American Psychiatric Press; 1999. pp. 41-52.
[3]
Goffman E, editor. Stigma: notes on the management of spoiled identity. Englewood Cliffs: Prentice Hall; 1963.
[4]
World Health Organization. Mental health: a call for action by world health ministers. Geneva: World Health Organization; 2001.
[5]
Gureje O, Olley BO, Olusola EO, Kola, World Psychiatry. 2006 Jun; 5 (2): 104-7.
[6]
Sartorius N, Schulze H, editors. Reducing the stigma of mental illness. Cambridge: Cambridge University Press; 2005.
[7]
Yang, L. H., Kleinman, A., Link, B. G., Phelan, J. C., Lee, S., & Good, B. (2007). Culture and stigma: Adding moral experience to stigma theory. Social Science & Medicine, 64 (7), 1524– 1535. http://dx.doi.org/10.1016/j.socscimed.2006.11.013.
[8]
Yang, L., Chen, D., Duan, R., Xia, L., Wang, J., Qurashi, A., Jin, P., Chen, D. (2007). Argonaute 1 regulates the fate of germline stem cells in Drosophila. Development 134 (23): 4265-4272.
[9]
Rogers, E. M. (2003). Diffusions of innovations. (5th ed.). New York: Free Press. 8. Wang, P. S., Angermeyer, M., Borges, G., Bruffaerts, R., Chiu, W. T., De Girolamo, G., & Kessler, R. C. (2007). Delay and failure in treatment seeking after first onset of mental disorders in the World Health Organization's World Mental Health Survey Initiative. World Psychiatry, 6 (3), 177.
The time is developed for nursing to take the lead on this public health concern affecting millions of people. Nurses at all levels can play an active role in reducing stigma. Advocating for change and fair treatment of people with mental disorders should be examined from a social justice framework and can be easily incorporated into daily practice. Nurse scientists and advanced practice nurses can design, evaluate, and implement theory-based stigma-reducing interventions to advance the science. Through continued effort and advances in research, the progress made in eliminating stigma will not only relieve the millions of people and families that suffer but also lead to healthier communities. Although the call by the U.S. Surgeon General and the New Freedom Commission 2007 on Mental Health to reduce stigma has spurred interest in stigma research and prompted new initiatives across the United States, stigma reduction is still in its infancy. Empirical studies that evaluate national stigma programs are nearly absent in the literature and interventions studies are few. Therefore, it is difficult to determine which stigma programs/interventions are effective and how these programs/interventions work to reduce stigma. Programs/interventions (including those for stigma) should be based upon a theoretical framework, informed by pilot work, and targeted to the population of interest (Sidani & Bradden, 2000). Observed studies that evaluate national stigma programs are nearly absent in the literature and interventions studies are few. Therefore, it is difficult to determine which stigma programs/interventions are effective and how these programs/interventions work to reduce stigma. Programs/interventions (including those for stigma) should be based upon a theoretical framework, informed by pilot work, and targeted to the population of interest (Sidani & Bradden, 2000). When a theoretical framework, pilot work, and the population of interest are considered in the program/intervention design (Sidani & Bradden, 2000), researchers can evaluate program outcomes most completely;
References
[10] Corrigan, P. W., & Miller, F. E. (2004). Shame, blame, and contamination: A review of the impact of mental illness stigma on family members. Journal of Mental Health, 13 (6), 537-548. [11] Deegan P. E. (2007, Sept). Healing from self-stigma. ADS Teleconference Training. Retrieved September 26, 2007 from http://www.stopstigma.samhsa.gov/teleconference09262007.h tm
20
Mamoon Zboun: The Stigma in the Mental Health
[12] Happell, B. (2005). Mental health nursing: Challenging stigma and discrimination towards people experiencing a mental illness. International Journal of Mental Health Nursing, 14 (1), 1. [13] Beadnell, B. (2007). Testing mediating mechanisms in theorybased interventions: Contributions to efficacy research. Journal of Adolescent Health, 41, 317-318. [14] CDC. Attitudes Toward Mental Illness—35 States, District of Columbia, and Puerto Rico, 2007. MMWR 2010; 59 (20); 619-625. [15] Corrigan, P. W. (2000). Mental health stigma as social attribution: Implications for research method. [16] President's New Freedom Commission on Mental Health. (2007). Retrieved from http://www.mentalhealthcommission.gov/ on April 15, 2007.
[17] Fink, A. (2005). Conducting research literature reviews: From Internet to paper. Thousand Oaks, CA: Sage. [18] Sidani, S., & Bradden, C. J. (2000). Evaluating nursing interventions: A theory-driven approach. Thousand Oaks, CA: Sage Publications [19] Hinshaw, S. P. (2005). The stigmatization of mental illness in child and parents: Developmental issues, family concerns, and research needs. Journal of Child Psychology and Psychiatry, 46 (7), 714-734. [20] Saad L. (2006). Nurses top list of most honest and ethical professions. Gallup News Service. Retrieved from http://www.calnurses.org/media-center/in-the-news/2006/ december/page.jsp?itemID=29117737.
