|THEME SECTION: STIGMA IN PSYCHIATRIC DISORDERS: SYMPOSIUM
|Year : 2016 | Volume
| Issue : 2 | Page : 120-127
Menace of stigma in psychiatry
Sujata Sethi1, Pankaj Sheoran1, Suja Kurian2
1 Department of Psychiatry, PGIMS, Rohtak, Haryana, India
2 Department of Psychiatry, CMC, Vellore, Tamil Nadu, India
|Date of Web Publication||25-Apr-2016|
Dr. Sujata Sethi
122/8, Shivaji Colony, Rohtak - 124 001, Haryana
Source of Support: None, Conflict of Interest: None
Despite major breakthroughs and advances in our knowledge about various psychiatric disorders, stigma toward psychiatry continues to prevail. The stigmatization of people with mental illnesses has been recognized by international agencies such as the World Health Organization and the World Psychiatric Association as an important public health and human rights problem. Individuals with mental illness are devalued and are treated unfairly by others because of their mental health condition. It is not only the general public that views psychiatry and psychiatrists negatively, but medical students, health professionals other than psychiatrists, families of patients and media also have similar views. These negative attitudes not only lead to delay in seeking professional help for the patients but also discriminate against patients and their families, and hinder in the deserved placement of patients in the society. All these further adversely affect the outcome of psychiatric disorders. This symposium addresses these issues as well as measures to combat and prevent stigmatization of patients with psychiatric disorders.
Keywords: Intervention, prevention, psychiatry, stigma
|How to cite this article:|
Sethi S, Sheoran P, Kurian S. Menace of stigma in psychiatry. Indian J Soc Psychiatry 2016;32:120-7
| Introduction|| |
Stigma as an attribute is deeply discrediting and reduces the bearer from a whole individual to a discounted one.
Health-related stigma is a process where social groups are rejected and excluded on the basis of a health condition. It describes a sociocultural process in which social groups are devalued, rejected, and excluded on the basis of a socially discredited health condition. From the origin of medicine and society, certain medical conditions have been associated with stigma. In comparison to other disorders, mental illnesses are more stigmatized, and this is referred to as the ultimate stigma.
According to the World Health Organization consensus statement, “stigma results from a process whereby certain individuals and groups are unjustifiably rendered shameful, excluded, and discriminated against.” Stigma occurs when the mark links the identified person through the attributional process to undesirable characteristics. It includes problems of knowledge, attitude, and behavior.,, Knowledge hereby means that the stereotype includes social knowledge structures that are learned by most members of a social group. Attitude or prejudice involves an evaluative component which yields emotional response like anger or fear. Prejudice leads to behavioral reactions, discrimination, or hostility.
| Dimensions and Causes of Stigma|| |
Six dimensions of stigma have been described:(i) Concealability, i.e., how obvious or detectable a characteristic is to others. (ii) Course which determines whether the difference is lifelong or reversible over time. (iii) Disruptiveness of stigma decides the impact of the condition on interpersonal relationships. (iv) Esthetics means whether the characteristic elicits a reaction of disgust or is perceived as unattractive. (v) Responsibility whereby the individual is perceived as responsible for the cause of difference which is described as the origin. (vi) Peril, i.e., the degree to which the difference induces feelings of threat or danger in others.
Most cited reason for avoiding people with mental illness is their unpredictable behavior and fear of violence. Negative attitude and avoidance of those with mental illness have also been recorded to be secondary to physiological responses causing unpleasant feelings in the individual.
| Types of Stigma|| |
Stigma related to mental illness can be divided into three based on the different ways it manifests at self, public, and structural levels. Perceived stigma or self-stigma is the internalization of perceived feelings of discrimination of the person with the characteristic causing stigma in the community. Individual feels unsure about how normal people identify or receive them. Self-stigma is the subjective process which is characterized by negative feelings about self, maladaptive behavior, identity transformation through individual's experiences, perception, and anticipation of negative responses from the community. Public stigma endorses the prejudice and discrimination against the discriminated group in the society. Structural stigma refers to the rules, policies, and procedures of the institution that restrict opportunities of the stigmatized individuals.
| Consequences of Stigma|| |
Many people with mental illness experience stigma. Stigma experienced and anticipated by those with mental illness and their families leads to delayed help seeking, under treatment, impoverishment, and social marginalization. For individuals with mental illness, it interferes with opportunities for attaining their needs, socialization, and marriage., Stigma produces changes in feelings and behavior for the person affected and for close family members.
There have been attempts at finding out changes in public perception about those with mental illness over a decade, and it has shown both positive and negative changes. The proportion of people thinking that those with mental illness can be easily distinguished came down, but the proportion of those believing that people do not have anything to fear about others getting help for mental health problems in their neighborhood came down.
| Stigmatization of Psychiatry, Psychiatrists, and Others|| |
Stigma and discrimination may occur at the level of the individual, through interpersonal interactions, as well as at the level of social structures by virtue of unfair policies, practices, and laws.
Stigmatization of psychiatry
The public opinion on psychiatric facilities has been consistently negative. The image of a “psychiatric hospital” has been typically that of a large scale institution with a custodial character, locked doors, and located on the outskirts of the city.,, In a survey by Angenmayer, 25% of the participants believed that patients were not let out, and 50% believed that straitjackets were still in use.
Community care was also met by resistance from community residents, referred to as the not in my backyard syndrome. Reasons for this resistance included concerns about declining property values, the safety of children, and personal safety.,,,
Public opinions about psychiatric treatment have been found to be mixed. While some studies revealed that respondents considered psychiatric treatment to be helpful,, in others, respondents expressed concern about the quality and efficacy of treatment , and in some, respondents considered psychiatric treatment to be harmful.,
The general public tends to overestimate the effectiveness of psychotherapy, recommending it as the only treatment even for conditions such as schizophrenia. In contrast, negative effects of psychotropic medications are perceived as severe, whereas the positive effects are underestimated. The psychotropic medications are considered to be personality altering and making people dependent.
Psychiatry as a career choice ranks quite low. Perceived low prestige and low respect among other medical disciplines have been among the main reasons mentioned for not choosing psychiatry as a career.,,,, Medical students often do not view psychiatry as an intellectually challenging career choice and see it as a profession with low job satisfaction and limited fulfillment.,
A further influential aspect is the impact of students' families on their attitudes and their decision to aim for a career in psychiatry. Stereotypes such as specializing in psychiatry being “wasted time” are widespread among the families of medical students.,
Medical students also perceive psychiatry as lacking a solid, authoritative scientific foundation , and not being “real medicine.”, This attitude is partly based on uncertainty concerning the nosology and diagnosis of mental illnesses, which is mentioned among the reasons for medical students not to take up psychiatry.,
Medical students were often less sceptical than the general public toward psychotropic medication. However, psychotropic drugs were criticized for not targeting the actual cause of the illness.
Family physicians also held negative attitude toward psychiatry. Two reasons identified for nonreferral were: concerns about the effectiveness of psychiatric treatment and stigma for the patient.
Lambert et al. reported that the specialty's poor public image, perceived lack of respect among other doctors, and the perception of under-resourcing were the main reasons for not choosing psychiatry as a career.
Health professionals' attitudes toward specific psychiatric treatments appear to coincide with those of the general population and medical students. Depot medication was often perceived as coercive and compromising patient autonomy, psychotherapy was preferred over antidepressants, and psychotropic drugs were often accepted only as a last resort.
Patients and relatives
The most frequent reason for not seeing a psychiatrist was the fear of mental illness stigma, rather than negative expectations about the treatment and its quality. Patients usually expect that treatment will be helpful. However, expectations that treatments such as electroconvulsive therapy will be painful, and that medications may be administered without their consent are often reported by patients.
Compared to the general population, psychiatric patients and their relatives have been found to have slightly more positive attitudes toward psychotropic medications.,
Stigmatization of psychiatrists
The public image of psychiatrists is largely negative and based on insufficient knowledge about their training, expertise, and purpose. For example, it is not widely known that psychiatrists are medical doctors, and the duration of their training is underestimated. They are ascribed a low status among physicians and academicians.
In the presence of a mental health problem, help from a confidant or a family physician is often recommended instead of treatment by a psychiatrist., They are often perceived as “agents of repression” whose purpose is to guarantee conformist behavior and who can “see into people's minds.”
Another misconception about psychiatrists concerns their role in courts as experts who testify about the mental health of defendants. Their explanations for a defendant's behavior are often misunderstood as “creating loopholes for criminals.”, Similarly, it has been suggested that the testimony of forensic psychiatrists is not based on professional expertise but motivated by financial interest.,
Medical students and health professionals
Medical students often report overhearing negative, disparaging remarks about psychiatrists by teachers in medical school and during internship  and medical students sometimes perceive psychiatrists as more emotionally unstable or neurotic than other health professionals.,
Medical students also see psychiatrists as peculiar, fuzzy, confused thinkers who are complex and difficult to understand. Some suggest that there is a “lack of respect among the medical community,” stereotyping psychiatrists as “unsure, ineffective, useless, and incomprehensible.”,
Patients and relatives
Attitudes of patients and their relatives are ambivalent. Satisfaction with psychiatrists' performance tends to be high, with attitudes becoming more positive during hospitalization., Some patients have described psychiatrists as controlling, and some relatives have perceived them as arrogant., Strehlow and Piesiur-Strehlow found that lack of knowledge about the expertise of psychiatrists and negative attitudes led parents to choose psychiatrists only as a last resort for their children with mental health problems.
| Intervention|| |
Hence, the stigma related to various walks of psychiatry is pervasive and has become a reason for concern. With advances in our understanding of psychiatric disorders, effective treatment is now possible. But nearly two-third of those with a known mental illness never seek help from a mental health professional. Less than one-fourth of those affected actually receive professional treatment. Stigma is considered to be the most significant barrier to psychiatric patients receiving the care they need.
A lot of work has been done to combat stigma using various strategies. Strategies to combat stigma depend upon the type of stigma, i.e., public stigma or self-stigma. The various approaches to change public stigma include protest, education, and contact.
Strategies make a moral appeal to people to stop holding negative views and not to discriminate against people with mental illness. Anecdotal evidence suggests the efficacy of this method in controlling the portrayal of stigmatizing images of mental illness in media including television, film advertisement, and other forms of media. However, the suppression of attitude has been found to cause a rebound effect so that prejudices about mental illness and patients remain unchanged or become worse. Hence, the method of protest should be used judiciously.,
Watson and Corrigan  suggest various approaches to protest public stigma including letter writing, making phone calls, public denunciation of stigmatizing practice, rallies/marches and sit–ins. The last two methods of protest are quite effective in changing the attitudes of people but require a lot of organization and commitment from the protesters.
Education and contact
Research on adult education strategies has shown that brief education programs lead to significantly improved attitudes about mental illness. Such education programs help people identify the negative stereotypes and myths about mental illness and replace these with factual information. Dharitri et al. demonstrated the effectiveness of a suitably structured education program on the stigmatizing views of a rural and semi-urban community in India. They recommend that sustained efforts are required to bring about a change and to reduce the stigma attached to mental illness. Battaglia et al. reported that a presentation given by a psychiatrist on mental health issues for high school students not only improved knowledge about mental health but also improved help-seeking attitudes and appreciation of psychiatrists, possibly due to greater familiarity. It is also suggested that the educational programs should provide both psychosocial and biological explanations of causation of mental illness to counter negative attitudes.,,
Changing the portraiture of psychiatry in media is important for changing the public opinion, especially by promoting realistic expectation about treatment modalities and their success., This can be effectively done by the frequent public appearance of mental health professionals as well as patients. Kutner and Beresin  suggest that media training of mental health professionals not only improves the relations between psychiatrists and media but also improves their creditability and acceptability. Active participation of psychiatrists in the flow of information and provision of expert knowledge on mental health issues and forensic cases not only develops a positive relationship with the media but also changes the negative image of psychiatrists.,,, The Quebec Psychiatric Association recommends strategies on how to improve the image of psychiatrists. These strategies include becoming more visible in the media, responding to public needs and critical events, and increasing the visibility of psychiatrists in the community. They further argue that psychiatrists should react publicly to criticism of their profession. Higher visibility and better community orientation are also recommended by Felix  and Davidson, who suggest that community volunteering is an important approach to better public recognition.
Modification of attitudes of medical students remains an underworked area. Different styles of teaching (e.g., traditional vs. problem-based teaching) show no advantage of one method over another.,, On the other hand, acquisition of knowledge, awareness of the therapeutic potential of psychiatric interventions, and direct patient contract can improve attitudes and enhance psychiatrists attractiveness as a career choice. Providing medical students with a more accurate picture of psychiatry and offering positive role models can address stigma in psychiatric education.,,, Spiessl and Cording  suggest an easily accessible psychiatric liaison service for family physicians, practice-oriented seminars for family physicians, informing them about mental illness but also about psychiatric facilities, as well as continuing education in the context of the psychiatric liaison service can form positive relations with psychiatrists.
Coodin and Chisholm  recommended that a psychiatry seminar on recovery in persons with schizophrenia, co-taught by a consumer and a professional, lead to more favorable perceptions of treatment for mental illness. Lambert et al. argue that tackling the negative image of psychiatry should start in medical school and continue in junior doctor training in order to retain psychiatrists in their jobs.
Moreover, on the basis of the experience of its global program on reducing the stigma and discrimination toward schizophrenia,,,,, the World Psychiatric Association (WPA) recommends the following actions to combat the stigmatization of psychiatry and psychiatrists:
Recommendations to national psychiatric societies
- National psychiatric organizations should define best practices of psychiatry and actively pursue their application in the mental health care system by following ways:
- Publication of appropriate guidelines about best practices
- Introduction of their contents into the medical curricula
- Making training in their use an essential part of postgraduate education in psychiatry
- Existence of best practice guidelines should be made public knowledge
- Ensuring rapid action in instances of human rights violations in the practice or research related to psychiatry and clearly report on the effects of such action
- Regular reporting on scientific achievements and successes in the provision of care for people with mental disorders in communications with governments
- Working toward full transparency of their relationship with health-related industries.
- National Psychiatric Organizations, in collaboration with relevant academic institutions, should revise the curricula for undergraduate and postgraduate medical training
Research shows that medical students have a poor opinion of psychiatry and are reluctant to choose psychiatry as a career. This is partly due to the influence of teachers from other medical disciplines who hold negative views and partly due to the way psychiatry is presented and taught in medical schools in most countries. WPA recommends that following teaching methods could make the subject of psychiatry more attractive:
- Intensified instruction about skills (that can be used in dealing with mental illness as well as in the practice of medicine in general)
- Contact with people who have been treated for their psychiatric illness and recovered
- Involvement of family members as teachers about the routine management of mental illness and impairment in the community
- Exposure to successful community care programs for the mentally ill
- Use of summer schools and exchange programs to increase the attraction of psychiatry, and
- Better integration of the teaching of psychiatry with that of neurosciences and behavioral sciences
- Teaching skills of presentation and communication, especially for work with the media and governmental offices, as these skills are of considerable importance in the development of mental health services as well as in any effort to change the image of psychiatry
- Postgraduate training should also include education about the origins of the stigma of mental illness and about the methods that can be used to combat it.
- National psychiatric societies should work closely and in collaboration with other professional societies, with patient and family associations and with other organizations that can be involved in the provision of mental health care and the rehabilitation of the mentally Following are some of the suggested methods:
- Conducting joint projects (e.g., research on comorbidity of mental and physical disorders)
- Involving patient and family organizations in the production of guidelines and practice standards
- Collaboration with patient and family organizations to make psychiatric services more efficient and user-friendly
- Holding regular meetings with representatives of patient and family organizations and leaders of mental health programs to reduce the number of conflicts and to provide opportunities for contact and collaboration
- Collaboration with schools and teacher associations as well as organizations such as the Rotary club can also be helpful in reducing the stigma of psychiatry.
- National psychiatric societies should seek to establish and maintain sound working relationships with the media.
The role of the media in shaping attitudes of the general public cannot be overstated. Media often holds psychiatry in negative mainly because of incomplete or obsolete knowledge about the discipline. National psychiatric societies should help media in this respect by number of methods such as:
- Providing up-to-date information from time to time
- Developing working relationships with media representatives
- Holding workshops, regular informative bulletins, and press releases
- Involving media representatives in planning services.
Recommendations to leaders of psychiatric services and individual psychiatrists
It is important for the psychiatrists to be aware of the fact that their behavior can contribute to the stigmatization of psychiatry as a discipline and of themselves as its representatives.
Hence, it is recommended that special attention should be paid toward the following:
- Development of a respectful relationship with patients and their families
- Staying up to date with advances in psychiatric research and practice and their implementation in clinical practice
- Observing ethical principles in the provision of care and in the organization of services
- Collaboration with other medical and health workers as well as with other professionals involved in the care for people with mental disorders.
| Problems in the Field of Studies on Stigma|| |
Five problems related to studies in the field of stigma have been identified. Academic work on stigma related to mental illness has made very few connections in the field of legislation on disability. Most of the studies in this field have been descriptive and little is known about effective interventions to reduce the stigma. The third problem described is that direct contributions by service users in this field are very few. The underlying attitude is that stigma is deep rooted and cannot be changed. Another concern about studies on stigma theories is that they have not addressed cultural factors.
| Conclusion|| |
Stigma is a negative social process of labeling, discriminating, and excluding. To combat the menace of stigma, specific interventions must be planned and consumer involvement is must. It requires a sustained, multifaceted, and long-term effort.
Sartorius and Gaebel, past presidents of the WPA, urge mental health professionals to be aware of their own role in the stigmatization of mental illness and to be actively involved in fighting stigma and discrimination.
”The true solution, of course, to the problem of psychiatric stigmatizing, would be the public acceptance, without shame, of mental disorder” (Roy Porter, 2001).
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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