This article has been double-blind peer reviewed
5 key points
1. Stigma can affect many aspects of people’s lives
2. Self-stigma is the process in which people turn stereotypes towards themselves 3. How the general public perceive people with mental health problems depends on their diagnosis 4. Stigma can be a barrier to seeking early treatment, cause relapse and hinder recovery 5. Future research should investigate the experiences of service users and their families to understand and measure the impact of stigma
Stigma can pervade the lives of people with mental health problems in many different ways. According to Corrigan (2004), it “diminishes self-esteem and robs people of social opportunities”. This can include being denied opportunities such as employment or accommodation because of their illness. Stigma in the form of social distancing has been observed when people are unwilling to associate with a person with mental illness. This might include not allowing the person to provide childcare, or declining the offer of a date (Corrigan et al, 2001).
Self-discrimination or internalised discrimination is the process in which people with mental health problems turn the stereotypes about mental illness adopted by the public, towards themselves. They assume they will be rejected socially and so believe they are not valued (Livingston and Boyd, 2010).
Being discriminated against has a huge impact on self-esteem and confidence. This can increase isolation from society and reinforce feelings of exclusion and social withdrawal. The Queensland Alliance for Mental Health (2010) observed that people with mental health problems are “frequently the object of ridicule or derision and are depicted within the media as being violent, impulsive and incompetent”. It also found that the myth surrounding violence has not been dispelled, despite evidence to the contrary.
In light of this, the Department of Health (2004) funded a programme called Shift, which aimed to reduce the discrimination that those with mental ill health face. The DH (undated) found that “many people with mental health problems say that the biggest barrier to getting back on their feet is not the symptoms of illness, but the attitudes of other people”.
Reviewing the literature
EBSCO was used to access the CINAHL, BNI and MEDLINE databases to search for available literature with the keywords “discrimination” and “mental” in article titles. This produced a total of 428 articles. The search was then limited to narrow down the number of results. Limits were applied as follows: Publication date was set between January 2000 and December 2010; Original research studies and journal articles were specified; The age range was limited to over 17 years old.
The refined search resulted in 155 articles.
In order to assess which articles were relevant, further inclusion and exclusion criteria were set. For example, articles that included the general public’s perception and attitudes towards mental health were included, and only primary research articles were used. Twelve articles matched the criteria.
The literature reviewed suggested that the way in which the general public perceive people with mental health problems depends on their diagnosis. Those with schizophrenia are seen as dangerous and unpredictable (Crisp et al, 2000).
People with alcohol and drug addictions are not only seen as dangerous, but the public also blame them for their addiction (Crisp et al, 2005). There still seems to be a general consensus that anyone with mental illness is unreliable, especially in terms of looking after children. Many believe having a mental illness reduces intelligence and the ability to make decisions (Angermeyer and Matschinger, 2005).
Discrimination and stimga have been linked to ignorance and studies show the majority of the public have limited knowledge of mental illness, and the knowledge they do have is often factually incorrect. Many still believe schizophrenia means having a split personality. In addition, many do not understand the difference between mental illness and learning disabilities and there is still a common misconception that those with depression can “snap out of it” (Thornicroft, 2006).
Depression and anxiety disorders do not have the same weight attached to them as psychotic illnesses but they are nonetheless stigmatised. People with depression are often seen as lazy and hard to talk to (Thornicroft, 2006). Public opinions seem to be held across the board, with no significant differences in relation to gender, education level and income. However, there were differences between age groups, with those in their teens or early 20s and those over 50 expressing the most negative attitudes (Alonso et al, 2009; Crisp et al, 2005).
Crisp et al (2005) noted those in the 16-19-year age range had the most negative attitudes towards people with mental illness, particularly towards those with alcohol and drug addiction. These results are surprising considering widespread reports of young people’s alcohol and drug use. These findings reflect a “them” and “us” type of thinking and suggest that many of those who use alcohol and drugs do not consider the possibility that they could become addicted themselves.
There were some indications that public opinion had become more positive, suggesting greater tolerance and understanding towards mental illness than in previous years (Angermeyer and Matschinger, 2005). However, these findings should be interpreted with caution; the DH (2001) found huge discrepancies between the views the public expressed in surveys and the actual behaviour as experienced or witnessed by service users and service providers.
The media have often been accused of sensationalism by portraying mental illness inaccurately in their quest to gain higher ratings. However, the media can also play an important role in reaching out to many different audiences to promote mental health literacy. Celebrities such as Stephen Fry (diagnosed with bipolar disorder) have spoken publicly about their illness and this seems to be effective in reducing stigma (Blenkiron, 2009). Chan and Sireling (2010) described a new phenomenon in which patients are presenting to psychiatrists claiming to have and seeking a diagnosis of bipolar disorder.
However, the lived experiences of mental health service users tell a different story to the findings on public attitudes. In the articles reviewed service users said they experienced stigmatising attitudes and behaviours in many aspects of their lives. Common themes emerged across the articles. Many people felt stigmatised as soon as they were diagnosed with a mental illness, and attributed this to the way in which their illness had been portrayed in the media (Dinos et al, 2004). Receiving a stigmatising label has such a negative effect on people that the Japanese Society of Psychiatry and Neurology - at the demand of the patients’ families group - changed the name of schizophrenia from “mind-split-disease” to “integration disorder” (Sato, 2006).
Many people with mental health problems experienced discrimination when applying for jobs. This included trying to explain gaps in their CV due to episodes of mental ill health. They not only experienced stigma when applying for jobs, but also found that when returning to work colleagues treated them differently, with some experiencing bullying, ridicule and demotion. Service users also faced the dilemma of whether to disclose their illness to friends, family, colleagues or future employers. Many felt they could tell their partner or parents about having a mental illness and still feel supported, but only 12% felt able to tell colleagues (Bos et al, 2009).
Service users reported social discrimination in the community, giving accounts of being physically and verbally attacked by strangers and neighbours, their property being vandalised, or being barred from shops and pubs; those with addictions or psychotic illness tended to experience this more than those with non-psychotic illness. Reports also included examples of being spoken to as if they were stupid or like children, being patronising and, in some instances, having questions addressed to those accompanying them rather than service users themselves (Lyons et al, 2009). Dinos et al (2004) found service users felt a range of emotions surrounding their experiences of discrimination, including anger, depression, fear, anxiety, isolation, guilt, embarrassment and, above all, hurt.
Health and relationships
Service users also encountered discrimination when accessing services such as GPs. They reported professionals as being dismissive or assuming that physical presentations were “all in the mind” (Lyons et al, 2009). This can result in reluctance to return for further visits, which can have a detrimental effect on physical health. This is especially significant, as evidence suggests people with mental illness are at greater risk from physical health problems, including cardiovascular disease, diabetes, obesity and respiratory disease; they also have a higher risk of premature death (Social Exclusion Unit, 2004).
Developing mental illness can also lead to breakdowns in relationships with partners, family and friends. The SEU (2004) reported that a quarter of children had been teased or bullied because of their parents’ mental health problems. Evidence shows rates of comorbidity of drug and alcohol use and psychiatric problems are believed to be rising (SEU, 2004).
Implications for nursing
Stigma can affect many aspects of people’s lives. Even a brief episode of mental illness can have far-reaching effects on wellbeing, disrupting work, families, relationships and social interactions, impacting on the health and wellbeing not just of patients, but also of their families and friends. This can lead to further psychiatric problems such as anxiety and depression.
Stigma can be a barrier to seeking early treatment; often people will not seek professional help until their symptoms have become serious. Others disengage from services or therapeutic interventions or stop taking medication, all of which can cause relapse and hinder recovery.
If mental illness is treated early enough, it can reduce further ill health, and ultimately the risk of suicide. By intervening at the earliest possible opportunity, people may be able to avoid a full episode of mental ill heath, and retain their jobs, relationships or social standing.
The International Council of Nurses (2008) said nurses are fundamental in helping with the “promotion, prevention, care, treatment and rehabilitation of people living with mental health problems and support of their families and communities”. It is therefore imperative to reduce the stigma surrounding mental health and stop these factors impinging on people’s mental wellbeing.
The National Service Framework for Mental Health incorporated standards services must follow to provide consistent quality of care (DH, 1999). These included guidance on “social inclusion, health promotion, tackling stigma and the promotion of opportunities for a normal pattern of daily life”. The DH (2001) concluded that “everyone has mental health needs, whether or not they have a diagnosis of mental illness”. Box 1 features recommendations of ways to help reduce the stigma experienced by mental health service users.
As the media can play an important role in reaching out to many people, it is important to work with and educate them to ensure the portrayal of mental illness is factual, impartial and reliable As those aged under 19 years had particularly negative opinions towards all mental illness, attempts should be made to educate this age group about the issue, particularly on the dangers and effects of substance misuse and addiction In order to plan future services and shape policies further research must be undertaken with people who have direct experience of mental illness to gain more
understanding of the impact stigma has on their lives
The literature confirms the public hold negative beliefs about those with mental health problems. Despite national campaigns, there has not been a significant change in the way the public perceive mental illness. While much research has been carried out to explore the public’s perception of mental illness, future research should explore the experiences of service users and their families, carers or people close to them to understand and measure the impact that stigma has on their lives. This, in turn, could help to shape interventions and policies for improved legislation to help stop the discrimination faced by those with mental illness.
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