PSYCHIATRIC PATIENTS AND THE ATTITUDE OF HEALTH WORKERS IN FEDERAL NEUROPSYCHIATRIC HOSPITAL
CHAPTER TWO
LITERATURE REVIEW
2.1 Theoretical Framework
Attitude is an evaluative disposition towards someone or something (Zimbardo & Leippe, 1991). Attitudes influence behaviour: they serve the dual purpose of guiding behaviour towards various goals and away from adverse outcomes, and they help people to efficiently process complex information about the social world (Baron, 1992). Yet, negative attitudes can be formed without sufficient information i.e. prejudice, thus undermining that critical process of deciphering the world. Stigma is the social devaluation of a person following negative attributions that are based on stereotypes - prejudice based on overgeneralised beliefs (French, 1996 Jones et al., 1984; Pilgrim, 2009). Corrigan and Watson (2002) proposed a stigma concept based on stereotypes, prejudice, and discrimination. While stereotypes represent notions of groups, people who are prejudiced endorse negative stereotypes thereby generating emotional and the consequent behavioural reactions e.g. hatred leading to discriminatory behaviour. The term stigma was originally used by the ancient Greeks to represent the marks that were pricked on slaves to demonstrate ownership and to reflect their inferior social status. The ancient Greek word for prick was ‘stig’ and the resulting mark, a ‘stigma’ (Falk, 2001). Stigmatising attitudes towards mental illnesses were already evident at the time as mental illness was associated with concepts of shame, loss of face, and humiliation for instance in Sophocles’ Ajax and Euripedes’ The Madness of Heracles. The stigma process consists of two fundamental components: the recognition of the differentiating “mark”, and the subsequent devaluation of the bearer (Dovidio, Major & Crocker, 2000).
Sociological theories provide further insight into the dynamics of mental illness stigma. Erving Goffman’s (1967) classic formulation relies on two constructs: the actor and the audience. The actor in this context is someone who might have a mental health problem while the rest of the society personified in neighbours, employers, family members, significant others or institutions constitute the audience. Stigma occurs when a person’s actual social identity falls short of an ideal identity defined by society, such as behavioural expectations in given situations. Hence, anyone who suffers from a ‘gap’ between their actual identity and society’s ideal identity such as a person with mental illness who may demonstrate lapses in social integration is a potential candidate for stigma. Once spotted, such persons are officially tagged (labelled) which works to isolate them; they are subsequently associated with undesirable characteristics and broadly discriminated against as a result (Corrigan & Penn, 1999; Angermeyer & Matschinger, 2003; Martin, Pescosolido & Tuch, 2000). Attitudes towards the individual change to agree with the label; a 'psycho' is dangerous hence he is kept at a distance. The victim is thus pigeonholed and literally disabled: disempowered, depersonalised and rejected (Pilgrim, 2009). Thus, stigma is not just related to the behaviour sometimes demonstrated by persons with mental illness, but to the label itself. With an experiment where label and aberrant behaviour were manipulated, Link (1987) demonstrated that a person labelled ‘mentally ill’ is likely to be stigmatised even in the absence of any aberrant behaviour.
A similar finding is reported in the classic Rosenhan (1973) study whereby eight people without mental health problems presented themselves at various mental hospitals, complaining that they had been hearing voices utter the words “empty,” “hollow,” and “ thud”. They were quickly diagnosed as suffering from schizophrenia, and all eight were hospitalised. Although the pseudo-patients later dropped all their symptoms and behaved normally, they had great difficulty getting rid of the label and gaining release from the hospital. They reported that staff members were authoritarian in their behaviour towards patients, spent limited time interacting with them, and responded curtly and uncaringly to questions. In fact, they generally treated patients as though they were non-persons and invisible. One of the pseudo-patients recounts “A nurse unbuttoned her uniform to adjust her brassiere in the presence of an entire ward of viewing men. One did not have the sense that she was being seductive. Rather, she didn’t notice us.” In addition, the pseudo-patients described feeling powerless, bored, tired, and uninterested.
Labelling defines patients in terms of their illness: ‘mental patients’ or ‘the mentally ill’ - terms that evoke images of chronic psychopathology. Furthermore, as Pilgrim (2009) observed, labelling strips victims of their pre-morbid identity and imposes on them the new stigmatised identity and role which comes to define them over and beyond their other roles, for example parenthood or career. A study of terms used by school children for mental illness revealed 250 different words and phrases, none of which are positive (Rose et al., 2007). Scheff (1966) had posited how through the systematic process of labelling and discrimination, the ‘career’ of mental illness is perpetuated for sufferers. These place restrictions on persons with mental illness which confines them to the world defined for them. Discrimination in a range of spheres tacitly constrains them from returning to conventional roles. Consequently, such individuals may be compelled to interpret their experiences in the light of the prevailing social stereotype of mental illness, and even modify their behaviour to fit the image. Thus, once the label is assigned, justified or not, it becomes a self-fulfilling prophecy that promotes the development of many schizophrenic symptoms (Comer, 2015).
2.1.2 Stigma Typologies
2.1.2.1 Public Stigma
To be marked as ‘mentally ill’ carries public, internal (self) and associative stigma. Public stigma occurs when the general population endorses stereotypes and decides to discriminate against people labelled ‘mentally ill’ (Corrigan, Druss & Perlick, 2014). It is mostly caused by the stereotypes of people with mental illness as unpredictable, violent, deranged, incompetent or retarded (Atilola & Olayiwola, 2011; Jorm & Griffiths, 2008; Marie & Miles, 2008). With the stereotype of dangerousness and unpredictability, fear becomes the primary impulse to the development of stigma. Hence, Foucault (1978) had suggested that the strongest cultural stereotype of persons with mental illness focuses on the spectre of a homicidal madman - a deranged being who explodes violently, erratically and inexplicably. These stereotypes could also suggest that persons with mental illness are incapable of normal human activity. Aside the stereotype of dangerousness endorsed by 88% of the respondents, a study by the Canadian Mental Health Association (1994) found the most prevalent misconceptions about persons with mental illness to include that: they had a low IQ or were developmentally handicapped (40%), that they could not function, hold a job, or had anything to contribute (32%) and that they lacked the will power or were weak or lazy (24%). This echoes the finding from the pilot study for the World Psychiatric Association (WPA) Programme “Open the Doors” (Stuart & Arboleda-F1orez, 2001a) where 72% of the respondents believed that persons with schizophrenia could not work in regular jobs. Arboleda-Flórez (2001) reports of Michelle, a vivacious 25 year-old office worker who tells about her major disappointment with her family and family friends that simply expected her to have an abortion when she announced that she was pregnant. They assumed that her schizophrenia would incapacitate her to deliver and to care for her baby. They were also afraid that her medications could have teratogenic effects on the baby. She carried her baby to term and is taking care of it despite the opposition of family and friends.
2.1.2.2 Self-stigma
Attitudes toward people with mental illness also have implication for the perceptions they hold about themselves. Self-stigma occurs when persons with mental illness internalise the corresponding prejudice; in acquiescing to the negative profile imposed on them, sufferers become prejudiced towards themselves. It can lead to low self-esteem (Byrne 2001; Ritsher & Phelan, 2004), self-loathing (Larson & Corrigan, 2008), avoidance of social activities (Perlick et al., 2001), depression (Leff & Warner, 2006), a sense of shame, fear and loneliness (Granerud & Severinsson, 2006) which ultimately result in low quality of life. Patients may become captive in their homes because of other villagers’ twitching curtains, whispering about them and cold-shouldering (Crawford & Brown, 2002). It could lead to concealment of psychiatric conditions, living in denial of symptoms, and fear and discouragement from promptly seeking appropriate treatment (Kahng & Mowbray, 2004; Kiefer, 2001). Thus, self-stigma is a major obstacle to the recovery of those with mental illness (Ritsher, Otilingam, & Grajales, 2003).
In addition to not receiving treatment or support, those who hide concealable stigmas may face considerable stressors and psychological challenges in keeping the stigma secret (Pachankis, 2007). Furthermore, because mental health difficulties are often not obvious to the casual observer, the sufferer may be very wary of anything that might give them away (Kermode et al., 2009). They are thus in perpetual conflict. Moreover, if their status inadvertently comes to the fore, for instance through crisis, they subsequently face the arduous task of perpetually ‘mending face’ (Goffman, 1967). Living with such an unsettling internal state, they are less likely to be successful in work, housing, and relationships (Link et al., 1989). In some traditional collectivist cultures, it could lead to defensive (situational) causal attribution for the condition by the sufferer and their family. For instance, they could start purporting that the condition is the handiwork of supernatural forces, or evildoers (Aghukwa, 2009a) which will in turn lead to rejection or discontinuation of orthodox care and seeking help from religious and traditional healers. Thus, self-stigma compounds the effects of stigmatisation. It is considered the most damaging aspect of stigma as internalisation of the stigmatised status could lead mental health service users to believe that they are of less value (Green et al., 2003), incapable of working and independent living (Corrigan & Penn, 1999).
One in four psychiatric patients in Nigeria have experienced high self stigma (Adewuya, Owoeye, Erinfolami & Ola, 2011). In The Last Taboo (Simmie & Nunes, 2001), one of the authors describes his feelings after a bout of major depression: “Stigma was, for me, the most agonizing aspect of my disorder. It cost friendships, career opportunities, and – most importantly – my self-esteem. It wasn’t long before I began internalizing the attitudes of others, viewing myself as a lesser person. Many of those long days in bed during the depression were spent thinking, ‘I’m mentally ill. I’m a manic-depressive. I’m not the same anymore’. I wondered, desperately, if I would ever again work, ever again be ‘normal’. It was a god awful feeling that contributed immensely to the suicidal yearnings that invaded my thoughts.” Exaggerated pessimistic attitudes about prognosis may increase selfstigmatization which could lead to evasion of help-seeking (Bjo¨rkman, Angelman &
Jo¨nsson, 2008; Corrigan et al., 2014).
2.1.2.3 Associative Stigma
Stigma impacts beyond the individual sufferer as relatives could become victims of "courtesy-stigma" (Angermeyer, Schulze & Dietrich, 2003) - being stigmatized because of their association with someone with mental illness. Families report lowered selfesteem and strained relationships with other family members because of stigma (Gray, 2001; Van der Sanden, Bos, Stutterheim, Pryor, & Kok, 2013). Half of the families surveyed by Phelan and colleagues (1998) in the Suffolk County of New York had concealed their relative’s hospitalization from others because of the fear of social rejection. Associative stigma is more widely felt in communitarian cultures because the family represents the centre of the social institution; the burden of the stigma rests more with the family rather than on the individual (Adler, & Mukheji, 1995). While emotions such as pride and shame relate to how personal behaviour reflects on the self in individualistic cultures, they relate mainly to how personal behaviour reflects on others in collectivist cultures (Mesquita, 2001). To protect the integrity of their kinship system and group identity, communitarian cultures may be led to distance themselves from the person with mental illness (Tyler et al., 2008; Abdullah & Brown, 2011). Stigma therefore seems to be a prominent barrier to care seeking in these cultures (Alvidrez, Snowden, & Kaiser, 2008; Conner, Koeske, & Brown, 2009; Mishra et al., 2009).
Over 50% of respondents in a study of the attitudes of 160 Yemeni men justified their reasons for not having a relationship with someone with a mental disability based on the fear that they would be viewed negatively by their peers (Alzubaidi, Baluch & Moafi, 1995). Collectivist aspects of some Asian groups, may, for example, lead to perceptions that disabilities of mental illness reflect flaws of the family (Lauber & Rössler, 2007; Sanchez & Gaw, 2007). Shame is worsened when disabilities suggest lack of conformity to social norms, a Confucian ideal (Kim, Atkinson, & Yang, 1999; Lam, Tsang, Chan, & Corrigan, 2006). As a result, Asians who endorse stigma are less likely to seek services when in need (Miville & Constantine, 2007; Shea & Yeh, 2008).
If a history of mental illness is found in either a potential marriage partner or one of their family members in Nigeria, marriage would generally not proceed. A man whose wife suffers from schizophrenia recalls how mental illness still attracts shame to many families in Nigeria “My wife’s mental illness started after the birth of our fourth child in 1993, at first I thought it was high fever but it degenerated to the point of her making trouble with everybody in the neighbourhood and going nude at times. It has been hard for us, especially me, the husband, because of the costs, work and shame that I have to bear” (Eaton & Tilly-Gyado as cited in Ewhrudjakpor, 2010b, pg. 139). A teacher in Maiduguri, north-eastern Nigeria, vowed that she would never allow any of her offspring to specialize in psychiatry nor marry a psychiatrist because of the age-long cultural belief among the Kanuri people that anyone treating persons with mental illness would likely have one of their offspring suffer from mental ailment (Oyegbile, 2009). Yet, some degree of associative stigma could be observed in individualistic (Western) cultures. Reporting from Canada, Arboleda-Flórez (2001) tells the story of John, a 19-year-old university student, who had to accept the termination of a relationship he had just started with a girl from his neighbourhood. Her parents objected to the relationship and decided to send her to another city for her education partly in an attempt to break up the relationship once they knew that John’s mother’s frequent hospitalizations for the past several years were not due to “diabetes”, but to a manic depressive illness. John described the experience with some resignation, “it seems as if I have to carry the sins of my parents”. Some family members and friends can also experience vicarious stigma - the sense of sadness and helplessness a family member feels when observing a relative being the object of prejudice or discrimination because of mental illness (Corrigan & Miller, 2004).
By association, mental health practice and practitioners could also be stigmatised (Persaud, 2000). A comprehensive review of more than 500 studies showed that the public endorses varied stereotypes about psychiatry and psychiatrists (Sartorius et al., 2010). Psychiatrists were perceived to represent ‘‘the end of the line’’ and were associated with ‘‘mad’’ people or ‘‘asylums’ (Youssef & Deane, 2006). There is anecdotal belief that psychiatrists tend to behave like their clients. Medical students believe that psychiatrists “must be crazy”. They view psychiatric practise as having low status, the public view it as ineffective or possibly harmful, patients view it as failing to target essential problems, and the media view it as a discipline without true scholarship (Corrigna et al., 2014). Psychiatrists are often stereotypically portrayed in the media as libidinous lechers, eccentric buffoons, vindictive, repressive agents of society, or evil minded, and in the case of female psychiatrists, as loveless and unfulfilled women (Gabbard & Gabbard, 1992). Psychiatrists and psychologists are not highly respected or appreciated and do not have the same elevated status as medical practitioners because they work with people with mental illness (Wellington, 1992). The theory of cognitive dissonance (Festinger, 1957) suggests that given a choice, health care professionals would tend to select careers in areas where they hold favourable attitudes. Student psychiatric nurses reported disappointment from their family members on their choice of specialization (Wells, McElwee & Ryan 2000). Yet, antipathy to psychiatry or to its practitioners directly undermines participation in fundamental services the profession provides.
2.1.3 Stigma Causal Factors
Aside stereotypes and labelling, other factors that engender or reinforce stigmatising attitudes as discussed below include: culture (Kermode et al., 2009; Al-krenawi et al., 2009), nature and symptom presentation of illness (Dietrich et al., 2004; Hugo, 2001), diagnosis of mental illness (Meltzer et al., 2000; Crabb, et al., 2012) and psychiatric hospitalisation (Rao et al., 2009;
Link et al., 2004). Others are: explanatory models of causation (Grausgruber et al., 2007; Jorm
& Griffiths, 2008), pessimism regarding prognosis (Aghukwa, 2009a; Paterson 2006), media (mis)representations (D i e t r i c h , 2 0 0 6 ; Dinos et al. 2004) a n d negative government policies (Corrigan & Watson, 2003; Okpi, 2013).
2.1.3.2 Nature and Symptom Presentation of Illness
People could also hold attitudes based on what they have experienced of the attitude object (Hugo, 2001). Hence, a major determinant of stigma is the behaviour of the person with mental illness and the associated disability (Jorm & Griffiths, 2008). Illnesses that present in serious observable deformities or lesions like leprosy or in extremely bizarre psychotic behaviours such as schizophrenia are the most negatively perceived (Mulatu, 1999; Marie & Miles, 2008; Al-krenawi et al., 2009). This would be reinforced in the Nigerian context where symptoms of mental illness are mostly judged on behavioural grounds (Binitie, 1970). Hence, most manifest deviant behaviours attract mental illness labels and equate to psychiatric illness presentation in the involved person. Sometimes persons with a serious mental illness such as schizophrenia also suffer negative symptoms like alogia (poverty of speech), anhedonia (poverty of affect), avolition, and catatonia (motor abnormalities). These can constitute serious hindrance to interaction with others and integration into the society. Bell and colleagues (2008) report that more than half of pharmacy students in a cross-cultural study thought that patients with schizophrenia and severe depression were difficult to talk with which may contribute to their receiving less medication counselling than patients with physical health disorders.
2.1.3.3 Diagnosis of Mental Illness/Psychiatric Hospitalisation
The complexity of stigma dynamics is such that diagnosis of mental illness and psychiatric hospitalisation in themselves could stigmatise (Rao et al., 2009; Crabb et al., 2012). Torrey (1994) had suggested that the stigma associated with diagnosis is worse than dealing with the mental health problem itself. Similarly, the stigma that attends to accessing care for mental health problems has been considered to be a greater barrier to seeking help than the stigma attached to the condition itself (Rost, Smith & Taylor, 1993). Meltzer and colleagues (2000) had noted that openly discussing one’s problems with mental health professionals can attract shame which could even lead to some patients being suicidal. Patients try to contend with these through rejection of the psychiatric explanation of their problems (Sayre, 2000). Although well intentioned in its origins, the asylum mentality that saw to the sectioning of those with mental illness in far away mental hospitals contributed to social distance from them. It structurally helped to define them as different and led to their dislocation from their communities, loss of their community ties, friendships and families. At a more systemic and academic level, institutionalisation meant the banishment of mental illness and psychiatry from the general stream of medicine which helped to reinforce the idea that such patients were incurable (Arboleda-Flórez, 2001).
2.1.3.4 Causal Explanation for Mental Illness
Attribution theories underscore the importance of the causal beliefs people hold for a characteristic or behaviour in determining their responses to the person displaying the characteristic or behaviour (Bag, Yilmaz & Kirpinar, 2006; Jorm & Griffiths, 2008). Research generally reveals an interaction of culture and causal explanations in shaping attitudes towards people with mental illness. For instance, in India, reduced social distance for both depression and psychosis was consistently associated with belief that the problems are caused by personal weakness (Kemode et al., 2009). In contrast, positive association between social distance and viewing mental disorders as a sign of personal weakness has been found in surveys in a number of Western countries including: Australia (Jorm & Griffiths, 2008), US (Martin, Pescosolido, Olafsdottir & McLeod, 2007), the Netherlands (van’t Veer, Kraan, Drosseart & Modde, 2006) and Austria (Grausgruber et al., 2007). While the majority of studies of Western population in a review by Jorm and Oh (2009) indicated negative association between the adoption of childhood adversity/social stressors (psychodynamic) causal explanations and social distance, a study of Turkish population (Ozmen et al, 2004) found a positive association. Furthermore, while all the studies of Western populations in the review by Jorm and Oh (2009) found positive association between biogenetic causal explanation and social distance, America (Martin, Pescosolido, Olafsdottir & McLeod, 2007) and the Netherlands (van’t Veer, Kraan, Drosseart & Modde, 2006) were two exceptions. Further fuelling negative attitude is the pervasive pessimism of prognosis that sees mental illness as incurable (Botha et al. 2006; Paterson 2006; Aghukwa 2009a; Youssef & Deane, 2006). Many Nigerians believe that mental illness is incurable and terminal (Ewhrudjakpor, 2009).
2.1.3.5 Media (Mis)representation of Mental Illness
The grotesque and sensationalistic portrayal of persons with mental illness in the media and in the movies right from the beginning of the industry in the early 1900s is a major source of negative attitudes. Research into the portrayal of mental illness in the media around the world has generally found that negative depictions predominate (Francis, Pirkis, Dunt & Blood, 2001). Wahl and Harman (1989) found that 85.6% of relatives of persons with mental illness identified movies about “mentally ill killers” as the most important contributor to the stigma of the illness. Two mass communication theories: cultivation theory and social cognitive theory ( Stout, Villegas & Jennings, 2004) provide the mechanisms by which the media influences mental illness stigma. The theories describe how the construction and perpetuation of mental illness stigma occur through the media’s social construction of reality. While cultivation theory proposes that repeated exposure to consistent media messages shapes values and perceptions of reality to fit those presented in the media, social cognitive theory on the other hand proposes that, in addition to direct experience, individuals vicariously learn about appropriate behaviour and affective reactions through observation, particularly from media sources.
Common media depictions of persons with mental illness include being dangerous to others, involved with crime, vulnerable and unpredictable. Such depictions stem from sensational reporting of crimes purportedly committed by someone with a mental illness, or from movies in which a popular plot, long exploited by the cinematographic industry, is that of the “psycho- killer” (Byrne, 1998). Characters with mental illness are portrayed in prime time TV shows as rebellious homicidal maniacs with childlike perceptions of the world. They are projected as free spirits that lacked social identity, usually single, unemployed and described negatively with adjectives such as “aggressive” “confused” and “unpredictable” (Wahl, 1995; Farina, 1998). Media misrepresentations of mental illness including in children’s cartoons and in the language employed to deplore misbehaving politicians or public officers can cause, fuel and perpetuate both public and self-stigma (Brown & Crawford, 2002; Seff, 2003; Wahl, 2003; Dietrich et al., 2006). S i n c e m uch of the public image of severe mental illness is informed by the mass media (Torrey 1994; Wahl 1995), the type of information provided by the media will be crucial in forming attitudes. Disturbingly however, media depiction of mental illness and persons with mental illness are typically inaccurate and overwhelmingly negative (Alexander & Link, 2003; Wahl, 1992).
When the rare, but tragic events associated with someone having one of the serious mental disorders is sensationalised by the media, they amplify fear while the more important millions of people who live full, productive lives with these disorders are underrepresented. Media portrayals fail to indicate that the percentage of violence that could be attributed to mental illness as a portion of the general violence in the community is small (Monahan, 2009) and they have far less coverage of positive issues such as accomplishments or human rights issues (Coverdate, Naim, & Classen, 2001; Edney, 2004). Duckworth and colleagues (2003) randomly selected 1,740 American newspaper articles that mentioned schizophrenia or cancer between 1996 and 1997 and found that while only 1% of the articles cited cancer in an inaccurate metaphorical sense, there were 28% of such inaccurate citations for schizophrenia.
2.1.4 Consequences of Negative Attitudes toward Mental Illness
2.1.4.1 Social Exclusion
Stigma has the potential to impact on all aspects of life (Schulze et al., 2003). It begets social exclusion which deprives people with mental illness of their basic citizenship rights, happiness and sharing in the ‘commonwealth’ of life (WHO, 2001b; Pilgrim, 2005). It strips people of their dignity and represents a major barrier to effective rehabilitation and reintegration of people with mental illness. Forty years since the beginning of the era of deinstitutionalization, people with Serious and Persistent Mental Illness (SPMI) are still not well integrated into the society (Moldovan, 2007). Stigma can rob people with mental illness of opportunities for obtaining competitive employment, accessing of services and living independently in a safe and comfortable home (Corrigan et al., 2005; Link & Phelan, 2006; Stuart 2006). Hence, stigmatising attitude of the general public but especially of members of key groups such as employers, landlords and primary care physicians can be especially poignant in the lives of people with mental illness.
Sayce and Boradman (2003) note that a major difficulty with rehabilitation in mental disorder is convincing members of the community such as employers or landlords that people can and do recover from mental illness. A total of 69% of people living with a long-term mental illness in the UK reported that they had been put off applying for jobs because of unfair treatment and a similar percentage felt that they had been unfairly treated by family and friends because of their illness. Only 21% of this group are working, and of these, only 13% are actually employed - the lower percentage working than for any other group with long-term illness or impairments (Office of National Statistics, 1995). This corroborates Pilgrim’s (2005) submission that people with mental illness are three times more likely to be unemployed than those with physical disabilities which has more to do with the attitude of employers than lack of willingness on the part of the individual as indicated by the Citizens Advise Bureau CAB, UK (2003). The CAB equally reported that most people with mental illness are unemployed and those who have jobs end up leaving because their employers convince them that they are unable to cope.
2.1.4.2 Structural Discrimination
Some inequities represented by system-level barriers are attributed to structural stigma - process that represents policies of private and governmental institution that intentionally or unintentionally restrict opportunities of people with mental illness (Link & Phelan, 2001). An example of intentional institutional discrimination is state legislation that limits the civil rights of people with mental illness. Studies examining state legislation in the 1980s (Burton, 1990) and 1990s (Hemmens et al., 2002) indicated that as many as 20 states in the US restricted voting, jury duty, elective office, parenting, and marriage rights because of mental illness. Some of the restrictions are informed by the stigmatizing beliefs that people with mental illness are not capable of being full citizens or family members (Pelletier, Davidson, Roelandt, & Daumerie, 2009). On the other hand, research has shown that endorsing stigma is inversely related to resource allocation. People who endorsed the idea that people are to blame for their mental illness were less likely to provide more money to mental health programmes in a government-fund allocation task (Corrigan, Watson, Warpinski, & Gracia, 2004). Attitudes also influence policy decisions regarding the persons with mental illness in terms of their rights (Levey &
Howells, 1994) and planning of psychiatric services (Mino, Kodera & Bebbington, 1990). Legislators who endorse stereotypes of persons with mental illness can block funding for mental health services that may promote independent living and recovery goals (Corrigan et al., 2004).
In the Report on Mental Health issued by the US Surgeon General, the stigma of mental illness was noted for reduced levels of service funding (U.S. Public Health Service, 1999). In spite of being a leading cause of disability, it is observed that mental health receives the least funding in the health budgets of many developing countries. Often, less than 1 per cent of expenditure on health is made on services for psychiatric conditions in African countries (Kleinman, 2009). High premium is placed on infectious disease and maternal and child health as evidenced by high budgetary allocations to these sectors in comparison to mental health services (Ayorinde & Gureje, 2004; Gureje, 2003). Relative to other illnesses, schizophrenia receives low levels of funding for research and treatment facilities for schizophrenia tend to be located in isolated settings or disadvantaged neighbourhoods (Link et al., 2004). In Canada, for instance, mental health research commands less than 5% of all the health research budgets, yet mental illness directly affects 20% of Canadians (Canadian Alliance on Mental Illness and Mental Health, 2000).
People with mental disorders are more likely to be uninsured or underinsured than the general population (Garfield, Zuvekas, Lave, & Donohue, 2011). Health insurance companies openly discriminate against persons who acknowledge that they have had a mental health problem. Life insurance companies, as well as income protection insurance policies make an ordeal out of collecting payments due to temporary disability caused by mental health conditions such as anxiety or depression with many patients seeing their payments denied or their policies discontinued (Arboleda-Flórez, 2001). When structural stigma such as insurance barriers and inadequate systems of community support persist, effective efforts to prevent or treat mental illness is stalled leading to negative socio-economic consequences such as the loss of productive workforce. Structural discrimination can also take place with regard to legal provision as well as the interpretation and administration of laws (Gutierrez-Lobos, 2002). Criminalisation of mental illness occurs when people with mental health problems are dealt with by the police, courts and jails, instead of the mental health system (Watson, Corrigan & Ottati, 2004). Persons with mental illness are more likely to be accused falsely of violent crimes (Sosowsky, 1980; Steadman, 1981) leading to their higher arrest rates (Goodman, 1992; Raymond, 1991).
Granted that stigma makes some people with mental illness more determined to succeed, the negative impacts can be overwhelming and can persist despite psychiatric treatment and recovery from mental illness. Hence, while symptoms can be devastatingly burdensome for mental health conditions such as schizophrenia, overwhelming evidence indicates that additional distress is caused persons with mental illness by negative attitudes from the general public. Thus, the damaging impact of stigma has been arguably compared to, and even considered worse than that of the symptoms (Coker, 2005; Feldman & Crandall, 2007; Hinshaw & Stier, 2008) thereby constituting a double jeopardy for sufferers. Yet, the burden is worsened in sub-Saharan Africa where sufferers are additionally affected by destitution and face substandard care.
2.1.4.4 Impeding Help-seeking
The prejudice and discrimination that characterise the stigma of mental illness significantly contributes to the disconnect between effective treatments and care seeking (Corrigan et al. 2014). Research has underscored how stigma serves as a barrier to help-seeking for children
(Adler & Wahl, 1998), adolescents (Chandra & Minkovitz, 2007), adults (Vogel, Wade, & Hackler, 2007), and elders (Graham et al., 2003). Stigma impacts care seeking at personal, provider, and system levels. Stigma and discrimination can impede access to care at institutional, community and individual levels as follows: institutional - legislation, funding, and availability of services (Corrigan, Watson, Warpinski & Gracia, 2004; Corrigan, Markowitz & Watson, 2004); community - public attitudes and behaviours (Evans-Lacko, Baum, Danis, Biddle & Goold, 2012); and individual - feeling ashamed to seek help, selfstigmatisation (Rüsch et al., 2009).
Stigma underlies the shame and secrecy associated with suffering from mental illness and the reluctance to self-disclose which inhibits access to care as sufferers are wary of how others will view them once they disclose their disorder (Byrne, 2000; Tanaka et al., 2003; Dinos et al., 2004). Similarly, they attempt to avoid the unfair discrimination and loss of opportunity that comes with stigmatizing labels by avoiding going to clinics or interacting with mental health providers with whom the prejudice is associated (Corrigan, 2004). Patients who are seen by non-psychiatric health workers in general health facilities are apprehensive of referral to psychiatrists or other mental health professionals (Regier et al, 1993; Hartley, Korsea, Bird & Agger, 1998). This arises in most circumstances for reasons that include; patients feeling more comfortable with non-psychiatric workers in general health facilities; and the desire to avoid being labelled mentally ill.
In a study of a rural Australian community (Fuller, Edwards, Procter, & Moss, 2000), the authors report that every person they interviewed concluded that mental health problems were associated with a high degree of stigma, and many suggested that they were associated with fear. A social worker in the study reports that ‘…a lot of people won’t come in (for treatment) because…mental health (has) got that stigma…you know, I’m not a nut case…’ and according to a telephone counsellor in the study: ‘…some are shocked when you … try to give them a referral to a mental health service. Because they may think that’s only for weirdos, people who are mad’. A mental health consumer and advocate in the study similarly declared that: ‘…because of the stigma attached with mental illness…the last thing you want to do is to go into the system and seek help’. The conventional understanding of mental health problems as implying irremediable insanity leads to a fear about what happens to people who become clients within the mental health care system. The telephone counsellor further stated: ‘… [people] see mental health as like the one step on from…[the asylum]…like all the people in the white coats. “I don’t need that sort of thing” ’. The implication is that even when people do recognise their distress, they may avoid formal mental health services, not perceiving them as an appropriate source of help. Owing to stigma, some would still not seek help even when the situation has become critical. The South African Federation of Mental health (2011) revealed that South Africans would rather die than admit to mental illness. Stigma is a powerful inhibitive factor for help-seeking even for battle-hardened soldiers; over 3000 military staff from US Army or Marine Corps units that had served combat duty in Iraq or Afghanistan were anonymously surveyed three to four months after their return. They were assessed for depression, anxiety, or post-traumatic stress disorder (PTSD). Most of the unhealthy soldiers (60-77%) did not seek mental health care mostly due to concerns about possible stigmatisation (Hoge et al., 2004).
It has also been argued that self-stigma is a much more potent stigma that may directly inhibit help seeking since the individual perceives the act of seeking professional help for distress as a threat to their self-worth and as a weakness of character (Vogel & Wade, 2009; Vogel, Wade, & Haake, 2006). Families and relatives that are also stigmatised by association could hide ill relatives and not talk about their condition thus practically foreclosing access to care. Associative stigma could add to the burden of care which could lead to extreme measures such as child abuse, neglect or abandonment with a report alleging that some mothers of children with intellectual disabilities had considered doing away with their children in Nigeria (Abasiubong, Obembe & Ekpo, 2006). Thus, stigma leads to non-utilisation, underutilization or delay in the utilisation of mental health services, living in denial of mental health problems and early termination of mental health treatment. Delay in seeking medical treatment at the onset of illness results in symptoms being aggravated as patients try to cope on their own and the family is so frightened of the consequences of releasing this information (Tanaka et al., 2003).
Studying Arab clients in mental health settings, Al-Krenawi and Graham (2000) noted that stigma may have a particular gendered implication with the potential damage that mental health help-seeking could cause to present and future marital prospects of females including the possibility of divorce or the husband taking on a second polygamous wife. On the other hand, men may associate formal help-seeking with a diminishment of their masculinity and abilities to be strong providers and family leaders. Over 70% of Arab American women victims of domestic violence reported feelings of shame associated with seeking formal social services, and almost this number too reported embarrassment associated with reporting their problem to people outside of their family (Al-Krenawi et al., 2009).
2.1.4.5 Impeding Recovery
Stigma is arguably the most important obstacle to the appropriate treatment, rehabilitation, recovery, and the development of effective care and treatment for those suffering from mental illness (Sartorius, 2002; Pitre et al., 2007; Bell et al., 2008). It causes delays in diagnosis (Corrigan et al., 2001) and has also been identified as a primary obstacle to progress in mental health prevention and research (Schomerus & Angermeyer, 2008; Greene-Shortridge et al. 2007; Thornicroft, 2008). People with mental illness receive less medical attention than others (Druss et al., 2001). The fear of madness begets social distancing which undermines the therapeutic efforts of service users and professionals reducing their ability to provide effective care (Foskett, Marriott & Wilson-Rudd, 2004). Using data from the 1990 National Comorbidity Survey in the US, Wang and colleagues (2002) estimated that only 20% of individuals with serious mental illnesses treated in general medical settings and 45.7% of those treated in specialty mental health settings received adequate treatment for their conditions.
Stigma and its attendant discrimination stall recovery and reintegration following a period of illness, and result in lost opportunities for fuller participation in life (Corrigan et al., 2001). Corrigan and colleagues (2004) noted that a major obstacle to the success of programmes, such as Supported Education Programme (SEP) for adults with schizophrenia which helps in the rehabilitation of persons with mental illness, is negative stigmatizing attitudes of the professionals responsible for the daily running of the programmes towards psychiatric disorders and persons with mental illness. In a national survey of users with mental health problems in New Zealand, service users reported discrimination in mental health services which included: failure to provide appropriate services and information, providing disrespectful or inappropriate treatment, failing to respect information from family members, or perpetuating negative stereotypes. They equally reported physical abuse, being talked about rather than to, feeling degraded, or being put down and ridiculed. Some felt abuse was often very subtle and specific to an individual staff member while others reported it as overt and endemic (The Mental Health Foundation of New Zealand, 2003).
Patients with mental illness who perceive devaluation or rejection by others have been shown to have worse outcome (Link et al., 1997). For instance, fear of stigma and lack of understanding of puerperal psychosis by families and healthcare professionals were linked to the finding that women with a severe psychiatric disorder had a 70-fold increased risk of committing postnatal suicide and that mothers with mental illness who kill their children equally do so often as an extension of suicide (Appleby, Mortensen & Faragher, 1998; Craig, 2004; Spinelli, 2004). Consistent with the diathesis-stress model of schizophrenia (Comer, 2015), accentuation of environmental stressors such as job loss, rejection by suitors etc. associated with being stigmatized might equally contribute to relapse. Persistent structural stigma such as insurance barriers and inadequate systems of support lead to degeneration of poorly treated disease, additional disability, injury, or even death (Link & Phelan 2006; Stuart 2005). Limited funding and provider shortages hamper access to care especially for people with more disabling diagnoses such as schizophrenia and bipolar disorder in community mental health settings, particularly in poor and rural areas (Hough, Willging, Altschul, & Adelsheim, 2011).
Stigma can worsen symptoms and increase risk for co-morbid physical disease (Chapman, Perry & Strine, 2005). The rejecting attitudes of the health workers, on the other hand, lead to their inability to detect co-morbid physical illnesses in psychiatric patients and where they are detected, the patients are reluctantly and inappropriately cared for (Aghukwa, 2009a). Stigma could lead to medication non-compliance (Barney, Griffiths, Jorm & Christensen, 2006; Haghighat, 2001). Mkize and Uys (2004) reported how a client defaulted in treatment because of his siblings’ negative reference to his treatment “Take your tablets for madness.” A study of pathways to psychiatric care in Eastern Europe found a preference for ‘mild’ medicines (such as sedatives or hypnotics) which are less taboo to ‘strong’ medicines (such as antidepressants or antipsychotics) with connotations of severe mental illness (Gater et al., 2005).
2.1.5 Pervasiveness of Stigma
The form and nature may differ across cultures but stigmatisation of mental illness is present in all societies and in all classes of people (Levav et al., 2004; Bjo¨rkman, Angelman & Jo¨, 2008; Munro & Baker, 2007). Surveys of North America and Western Europe indicate that stigma is a major concern in the community. A comparison of datasets from 1950 national survey with a 1996 survey did not demonstrate a significant change in the stigmatising attitude of the American public who believe that people who experience psychosis are dangerous (Phelan et al., 2000). Using similar questions and similar study designs, 77% of respondents in Germany (Gaebel et al., 2002) and 75% in Canada (Stuart & Arbodela-Florez, 2001a) would be unwilling to have someone suffering from drug or alcohol dependency, schizophrenia, or depression marry a family member. The stereotype of dangerousness of people with mental illness is equally profound in Germany. Here, labelling also evoked the perception of neediness (Angermeyer et al., 2004). A mental health ‘survivor’ in a Canadian survey reported “I have to lie to my landlord to get a place to live, like tell him you are on disability, if it is not visible or physical, they don’t take you. Even slumlords won’t take you because they don’t want psychiatrically ill people living in their buildings.” ‘Survivors’ in the study reported that they felt ignored, avoided, or treated without respect and sensitivity (People Advocating for Change though Empowerment [P.A.C.E.] Report, 1996).
Sixty-seven per cent of respondents in Australia indicated that people with chronic schizophrenia are unpredictable (Griffiths et al., 2006) while a third of consumers with mental health problems in a New Zealand survey reported having been discriminated against by mental health services (The Mental Health Foundation of New Zealand, 2003). In Italy, where psychiatry has a long history of community treatments, a study conducted 10 years after the promulgation of the 1978 psychiatric reform law found that the general public held negative attitudes toward those with mental illness (Kemali et al., 1989). A study of Greek public attitude towards persons with mental illness found direct association of schizophrenia with criminality (Economou et al., 2005) while a large-scale representative national survey of the British adult population found pervasive negative opinions that exaggerated the handicaps of mental illness (Crisp et al., 2000).
In September 2013, the supermarket chains Tesco and Asda were forced to apologise following public outcry in the UK against their stereotypical association of mental illness with the weird ghost of Halloween. Asda had produced ‘mental patient fancy dress costume’ with the catchphrase “Everyone will be running away from you in fear in this mental patient fancy dress.” Tesco equally had a costume called ‘Psycho Ward’ on its shelves. Earlier in March 2006, the BBC and other media reported the public outcry against the statue of the Prime Minister Winston Churchill in a straitjacket which was commissioned by the mental health charity ‘Rethink’ and unveiled in the Norwich area to draw attention to and stamp out the stigma surrounding mental health. Churchill was chosen because despite dealing with the symptoms of manic depression throughout his life, he was able to become Prime Minister, lead the country during the World War II and was voted “The Greatest Briton” in a national poll. But the public, including the politician’s family and World War II veterans interpreted the concept as ‘distasteful’, ‘absurd’ and ‘pathetic’ and their complaints eventually led to the removal of the sculpture.
Similarly, a coffee shop run by people with mental health problems in China was forced to shut down due to protests of the local community (Song et al., 2005). Another Chinese study noted that persons with mental illness are always seen as potential sources of social instability because it is feared that they are volatile (Park, Xiao, Worth & Park, 2005). Associative stigma is equally rife in the Chinese collectivist culture where mental illness is highly stigmatizing for the whole family not just the individual afflicted. The emphasis on collective responsibility leads to the belief that mental illness is a family problem. Care-giving is thus retained within the context of the family for as long as possible which results in delay in getting professional help (Ryder, Bean & Dion, 2000). About 80% of Japanese respondents agreed with a landlord’s decision not to rent a house to someone with mental illness (Tanaka et al., 2006). Marriage prospects, fear of rejection by neighbours, and the need to hide the illness from others were among the additional concerns of people with schizophrenia and their caregivers in India (Thara & Srinivasan, 2000). In the Erwadi tragedy in South India in 2001, more than 20 persons with mental illness were burnt to death when a fire swept one of the treatment shelters near the healing mosque where they were chained to their beds (Murthy, 2001).
Earlier studies had claimed that stigmatizing attitude towards persons with mental illness is less evident in traditional non-Western societies such as Africa (Carothers, 1948; Fabrega, 1991; Cheetham & Rzadkowolski, 1980). Cooper and Sartorius (1977) noted the suggestion that social representation of mental diseases in pre-industrialized and threshold countries with less differentiation between mental and physical illnesses as well as a religious dimension in the conceptualization of mental illness have a preventive effect on stigmatization. Disputing this claim however, a renowned African psychiatrist and mental health scholar Oye Gureje reports that it borders on the exotic and reflects an erroneous tendency to present Africa as some sort of El dorado where, unlike in “civilized communities”, no distinction is made between the sane and the insane, with everybody living together in blissful happiness (Gureje, 2007). He went further to articulate the common knowledge that in Africa, patients with mental illness are socially alienated and abused as a result of their illness, often along with their families. Disaffiliated families often abandon and disown their sick members because of societal stigma and shame.
A study of Moroccan families of patients with schizophrenia found that most of the families suffer from stigma and discrimination with a total of 86.7% reporting that they have hard lives because of the illness, and 72% reporting psychological suffering caused by sleep and relationship disturbances and a poor quality of life (Kadri, Manoudi, Berrada & Moussaoui, 2004). An Ethiopian survey revealed a widespread experience of stigma by people with mental illness with three quarters of their family members also experiencing stigma (Shibre et al., 2001). Only a quarter of a Malawian study sample believed that mental illness could be treated outside of the hospital setting (Crabb et al., 2012).
Negative attitude towards people with mental illness is prevalent in Nigerian communities. In a seminal work (Gureje et al., 2005) which investigated community knowledge of and attitude toward mental illness in south-western Nigeria, most of the respondents thought that people with mental illness were mentally retarded, public nuisances, dangerous because of their violent behaviour and could not be treated outside the hospital. Only about a quarter thought that persons with mental illness could work in regular jobs. The five most endorsed personal attributes of persons with mental illness in a survey of doctors in the same south-western Nigeria included: unpredictability, dangerous, lacking self-control, aggressive and dependence. There was equally pessimism of prognosis with only 9% of doctors believing that mental illness could be cured (Adewuya & Oguntade, 2007). More than a third of healthcare providers surveyed in south-southern Nigeria indicated that they would indeed shun or out-rightly reject family members suffering from mental illness (Ewhrudjakpor, 2009). The study equally reported a primitive system of management as in 2006, the state Ministry under which the care of persons with mental illness fell, had successfully gathered vagrants suffering with psychosis and quarantined them with the help of native doctors who were charged with ‘managing’ their decline.
Similarly, in a more recent exercise, against their constitutional right of abode in any part of the country, the Lagos state government in south-western Nigeria gathered some destitute vagrants suffering with psychosis, herded them in a truck, and ‘deported’ them to their states of origin in the eastern part of the country where they were abandoned and some reportedly died after some days (Okpi, 2013; Adeniyi, 2013). Such situations are not helped by the lack of expeditious enactment of enabling laws in Nigeria. For instance, the mental health bill proposed by the Association of Nigerian Psychiatrists is yet to be passed into law. The existing legislation dates back to British colonial laws of 1916 that were later revised as the Lunacy Act in 1958, with the quite stigmatising caption.