The World Health Organization (WHO) has highlighted stigma and the associated discrimination as comprising the “single most important barrier”  facing people with mental health and behavioural issues. The World Psychiatry Association and World Association for Social Psychiatry have joined the WHO in identifying Stigma as a key public health challenge.

As the State Minister for Mental Health, John Molony, said at the launch of the See Change¹ initiative last April, with respect to Stigma in Ireland:

Stigma has no place in Irish society today. It damages people’s lives and can be deeply hurtful and isolating, and is one of the most significant problems encountered by people with mental health problems.

Despite the acknowledged prevalence of mental health problems in society, those who experience them are frequently regarded with suspicion and fear. This Stigma leaves mental health service users suffering from low self-esteem, reduced employment prospects, difficulties in obtaining accommodation and broken relationships.

Stigma in Ireland

A 2002 National Disability Authority (NDA) study - Public Attitudes to Disability - showed that although 82% believed a disabled person should enjoy the same access to employment as non-disabled people, only 55% thought the same should apply for those experiencing a mental health problem. Similarly, only 55% felt a person with a mental health issue should enjoy the same entitlement to fulfilment through relationships as the general public.

The 2007 SLAN report revealed that 52% agreed or strongly agreed with the statement ‘If I was experiencing mental health problems, I wouldn’t want people knowing about it’. HSE Research the same year found one-third of Irish people were scared to talk to those diagnosed with a mental illness.

A recent See Change survey - Public Attitudes Towards Mental Health Problems -  noted that while 94% of Irish people were aware anyone could experience a mental health issue, some 50% indicated they would not want anyone to know they had one. A disturbing intolerance was also evident with 33% believing people with schizophrenia should not be allowed have children.

What is Stigma?

The word Stigma can be traced back to ancient Greece where it denoted the identifying marks imprinted on slaves to designate ownership. The late 16^th and early 17^th centuries saw the term become an indicator of humiliation and degradation.

However, what exactly do we mean by Stigma today?

A key influence in developing the modern meaning of Stigma was Erving Goffman, who developed the concept of `spoiled identity´. Spoiled identity refers to how mental illness is regarded as shameful, often effectively depriving people with a mental health issue of their rights.

Goffman described how `Courtesy Stigma´ - stigma-by-association - can result in family and friends being blamed for the person´s mental health problem or even accused of sheltering a potentially, dangerous person. `Courtesy Stigma´ can also rub off on mental health professionals.

Finally, `Self-Stigma´ occurs when the individual with a mental health problem internalizes feelings of culpability, shame and inadequacy as well as a desire to keep their condition secret.

Negative Consequences

Stigma entails a range of negative consequences. Potential mental health service users may be discouraged from seeking the care and assistance they require, lest other people find out about their condition. It can dissuade people from offering help or being supportive. Mental health service users may be reluctant to follow up on employment opportunities for which they are qualified. Stigma also regularly acts as a barrier to the active participation of mental health services users in the local community.

People with a mental health issue often experience discrimination, which is a natural outcome of Stigma. As John Saunders, the Director of Shine (formerly Schizophrenia Ireland) explains:

Research consistently shows that peoples´ attitudes towards mental health cause unfair treatment, social exclusion and isolation of children and adults who are experiencing mental health problems. Uninformed or distorted ideas can lead to discrimination.

Discrimination can arise at the interpersonal level where mental health service users are excluded or kept at a distance by friends, work colleagues and other members of society with whom they have to interact. It can also occur at the structural level, when mental health service users find it difficult to participate in public life due to explicit or implicit economic, social, cultural, legal and institutional barriers.

The negative consequences of Stigma can have a devastating impact not only on the quality of life of the person with a mental health issue but also their recovery prospects. Many experts argue that mental health Stigma can be more debilitating, constraining and long-lasting than the original mental health issue. Stigma can, therefore, create a cycle of worsening socio-economic prospects and persistent, ongoing mental health problems.

At the broader level, Stigma acts as a break on improvement and reform of the mental health system. As emphasised in the US Surgeon General´s 1999 Report on Mental Health:

Stigma erodes confidence that mental disorders are valid, treatable health conditions… Stigma deters the public from waiting to pay for care and, thus, reduces consumers’ access to resources and opportunities for treatment and social services.

Tackling Stigma

It has been argued that the provision of mental health treatment in psychiatric institutions, which isolate the mental health service user from the community, has played a negative role with respect to Stigma. The development of an effective community mental health system, complete with multi-disciplinary teams, would enable mental health services users receive the support they need with minimal disruption to their everyday life. This would, in turn, minimise their effective exclusion from their local community and curb potential stigmatisation.

An integrated approach to health care, where treatment facilities for both mental and physical ailments are co-located, is key to tackling Stigma. This approach would help break down the segregation in treatment that currently exists, and which contributes to the stigmatisation of mental health service users.

When developing a campaign to combat mental health stigmatisation, mental health service users and their families must be involved at all stages to ensure it covers the most important Stigma and discrimination concerns.

International research has shown that modest and well-focused programmes, targeted at a well-defined audience, are best for tackling Stigma, as they are generally more successful and sustainable. Lessons learned should always be carefully documented for future reference. Furthermore, although the situation with respect to Stigma will naturally vary to some extent between countries, it is important to try and build on what has worked abroad and share experiences with similar initiatives internationally.

At the personal level, it is possible to provide empathetic support to family, friends or colleagues who may be experiencing a mental health problem. However, it is important to avoid being judgmental and trying to force discussion on the issue. It is important to respect the limits of the person with a mental health issue and accept when they express their unwillingness to engage in certain activities such as drinking alcohol.

Of course, Stigma is not the only obstacle impeding mental health service users from participating fully in Ireland´s socio-economic and cultural activities and should not serve as the exclusive focus of our mental health programme. However, given the deep level of ignorance in Ireland regarding mental health problems, it is imperative that every effort is made to confront mental health Stigma and the discrimination which frequently accompanies it.

Notes

1. See Change is a new national partnership scheme to reduce stigma and challenge discrimination associated with mental health problems. For further information on the initiative visit http://www.seechange.ie/

This article by Justin Frewen and Dr. Anna Datta was originally published in the Irish Medical Times.