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Social Stigma Associated with Mental Illnesses


Stigma refers to a label put on individuals with certain behaviors, illness or characteristics and holding negative attitudes towards these individuals based on their behaviors or characteristics. Social stigma has long been attached to mental illnesses. It is as old as mental illnesses are. Society unknowingly holds strong negative attitudes towards mentally ill people which results into stigma. It is believed by the society that people with mental illnesses are unpredictable, incompetent, break rules and norms of the society, not behave in socially acceptable ways and are involved in crimes. They are also associated with evil sprits and demons and it is believed that mental illness is a punishment of wrong acts committed by the individual and is now bearing the consequences of that, and that he/she deserves it. This stigma is a major threat to, and a challenge for modern psychiatry as it has devastating effects on individuals who have mental illnesses. The magnitude of the problem is very much severe as people with mental illnesses isolate themselves, don�t seek treatment or don�t comply with the treatment regimen, and their self esteem lowers down because of this label of stigma being put on them.
It has been observed that stigma is neither related to the level of education of the society nor with the knowledge about mental illnesses; rather it is related to individual�s beliefs and attitudes, as health care providers also hold negative attitudes about mental illnesses. �The public and health care professionals often have negative attitudes to people with mental illness and will behave accordingly once they are told that a person has an illness about which they have prejudices�. (Sartorius, N., 2002). If health care professionals have negative attitudes towards people with mental illness, how can one expect a positive attitude from the general public? They would obviously be having more intense form of negative attitudes towards these people which bothers them a lot. Kaminski, P. & Harty, C. (2000), believe that �public opinion continues to harbour fear and mistrust towards people with mental health problems�. (p.28). Kenny, J.E. (2001) holds the same view and says �stigma towards mental illness is a reality in our society� society professes to have become more enlightened, but there continues to be a significant lack of acceptance of people who experience mental illness�. (p.20). Stigma towards mental illness is not restricted to a certain region rather it is a worldwide phenomenon. Qidwai, W. and Azam, S.A. (2002) conducted a study in Pakistan and they reported that 74% of their participants reported positive for mental illness stigma and therefore didn�t seek treatment for that. 
Sullivan interpersonal model can best be used to explain the effects of social stigma on an individual�s life with mental illness. According to Sullivan �one�s personality involves more than personal characteristics, particularly how one interacted with others. He thought that inadequate or nonsatisfying relationships produced anxiety, which he saw as the basis for all emotional problems�. (Videbeck, S.L. 2004, p.54). Same is true here; because of stigmatization the patient has inadequate or non satisfying relationship with the society. The patient becomes isolated from the society and according to Sullivan this is the root cause of all emotional problems faced by the stigmatized patient like low self esteem, lack of motivation to seek treatment and lack of job. His interaction with the people around him becomes minimal, and the person becomes confused as a result of not being amalgamated into the society. 
The first effect of this stigma on the patient�s life appears in the form of social isolation. These people use isolation as defense mechanism and they believe that this is the only way they can get rid of the problem. According to Kenny, J.E. (2001), �many individuals with mental illness experience a disruption in their pattern of social interaction, a disruption in both external and internal components�. (p.22). The socialization of these people become minimal and it further aggravates the effect of the disease and poses a threat towards recovery. �The impact of stigma on people with mental health problems can lead to avoidance of social contacts. Stigma deprives people of their dignity and interferes with full participation in the society�. (Granerud & Severonsson, 2003, p.602-603). People who become isolated don�t share their feelings and problems because they feel embarrassment because of stigmatization. Therefore lots of negative feelings develop in their minds and irritate them and because of this they may end up in self harming or suicide. It means we are actually aggravating a problem further instead of treating it. Qidwai, W. and Azam, S.A. (2002), describe the issue in Pakistani context and say that �it is well documented that negative opinions overemphasize social handicaps that accompany mental disorders, leading to social isolation, distress and difficulties in employment�. (p.81). 
Reluctance to treatment has been described the second major effect of stigma. People with mental illness believe that when they seek treatment or admitted to a psychiatric hospital, more people will become aware of their illness and there will be further stigmatization. Secondly, society believes that mental illnesses can�t be treated. This perception inhibits them from seeking treatment which they need. According to Gary, F.A. (2005), stigma is �an inhibiting factor that impedes help seeking behaviors and the quality of treatment and life experienced by individuals with the illness�. (p.988). Same is true to Asia as evidenced by Qidwai, W. and Azam, S.A. (2002) study which says �it has been argued that culturally determinant causal beliefs of mental distress contribute to attitudes towards seeking professional help for psychological problems for Asians�. (p.81). To be very specific to Pakistani context �the culture in itself has complicating, conflicting and sometime confusing influence in help seeking behavior of psychiatric patients�. (Naeem, et.al, 2005, p.156). This is clear from this discussion that stigma further aggravates the illness to many folds and it has deprived millions of patients around the world from getting better treatment.
Lowering of self esteem is another undesirable effect of social stigma. These people feel shame, embarrassment, guilt and very low because of being labeled. They feel that they are something different from the rest of the society that is why they are being abused, cursed and not respected in the society. �Many individuals with mental illness experience lowered self esteem. Over time they exhibit diminished self efficacy and continual lowering of self esteem�. (Gary, F.A. 2005). According to Granerud and Severonsson, (2003), �stigmatization leads to alter self esteem as well as to changes in social situation�. (p.610). Because of stigmatization these individuals feel that they are not productive members of the society, they can�t do certain tasks which other people can do and that they have no value in the society. 
Stigma also affects the employment life of an individual and hence influences the economy of the individual. They avoid going to their respective jobs because of embarrassment. Also we discussed it earlier that they feel less potential than others and believe that they can not work. According to Gary, F.A. (2005), ��individuals with mental illness might avoid employment and elect not to be successful at some task or in a job because of fear of failure, or internalized self stigma which can translate into self abhorrence�. (p.989).� Stigmatization has been associated with decreased employment and housing opportunities��. (Kenny, J.E. 2001, p.23). Mentally ill people themselves are also reluctant to go for employment because of the fear of stigma at workplace. The other thing which needs to be considered is that society believes that people who are mentally ill are incompetent and has less cognitive skills. As a result they are not selected for the jobs. In a country like Pakistan, where healthy individuals are not being selected for jobs, how can mentally ill be employed. This poses a threat to the economy of these individuals and it leads to many other problems like lack of treatment, lack of nutrition and deficits in requirements of daily living secondary to less economy.
Health care team members have the responsibility to care for stigmatized patients and their families to promote their recovery towards good health by minimizing the effects of stigma on them. The root cause of the problem is the society. The society unknowingly blames the mentally ill person, so it needs proper awareness about mental illnesses to end up the stigma. This awareness in the society can be brought through public awareness programmes and by involving media in the spread of knowledge and information about mental illnesses. Everyone of us need to understand that mentally ill people are just like other individuals who have illnesses, and mental illnesses can be treated just like other illnesses. Kenny, J.E. (2001) believes that �the fragmenting and isolating effects of mental illness requires nurses [as well as other health care professionals] to be compassionate in their interaction with these clients to help enhance their feelings of self worth and thereby reduce the impact of stigma�. (p.23). Health team needs to be very therapeutic in their communication with these patients and in no moment let them feel that there is no one in the world who can understand them and their feelings. Health professionals can make them realize that they are not the only one in this world suffering from this problem, rather there are too many with the same problem. We need to realize them that mental illnesses are just like physical illnesses and society�s stigmatization is because of ignorance. These people need to be encouraged to ventilate their feelings and concerns so that they can feel relaxed after catharsis. Arranging meetings with patients having the same problems can help them to know that they are not alone with this problem. In this way they can share their feelings and concerns with each others and can plan solutions for them. �Training in social skills reduces stigmatization�. (Granerud and Severonsson, 2003). By this way they can perform certain tasks and feel that they can do something and they can realize the society too that they are as competent as healthy individuals.
To conclude we can say that stigma associated with mental illnesses is just like a dual diagnosis for mentally ill patients. Its torturing effects are much more severe than the mental illness itself. This is affecting many parts of their lives including but not limited to physical, social, psychological, mental and economical. They have become isolated, their self esteem has gone down and they have lost their jobs because of this stigma. This is a global problem and a major challenge for psychiatry. To help reduce the impact of stigma society needs education and awareness about mental illnesses. The individual patient needs continuous support, reassurance and help to cope with this problem. 


Abdul Qayum
Karachi.