Does the Stigma of Mental Illness Contribute to Suicidality? The Role of Public and Individual Stigma

Table of Contents

Introduction
Prerequisites of mental illness stigmatization in the society
Social mechanism of mental illness stigmatization
The social basis of stigma
Scientific approaches to the stigmatization of mental illnesses
Sociological data on mental illness stigmatization
Phenomenology of stigmatization process
Family stigmatization

Concepts, policies, and obstacles for the development of psycho- and socio-therapeutic measures for the de-stigmatization of mental patients

Recommendations on general principles of work to mitigate stigmatizing attitudes

References

Abstract

The stigma of mental disorders and discrimination against the mentally ill remain the most persistent obstacle to improving the quality of life of these people. Often, a mental illness is perceived as something frightening, shameful, unreal, contrived, and incurable; mentally ill people are characterized as dangerous, unpredictable, unreliable, unstable, lazy, weak, useless and/or helpless. According to research data, the main problem is that many people with mental disorders are systematically discriminated in most areas of their lives. These forms of social exclusion occur in the family, at work, in private life, and in public activities, in the health and the media, which leads to the formation of a feeling of extreme insecurity, rejection and despair in mental patients and, accordingly, determines the high level of suicide in this categories of the population. This acute problem determines the need to study the root sources of this phenomenon, its social background, the ways to combat this phenomenon (disgraceful for a society of the 21st century), and find ways to improve the situation.

Introduction

The stigmatization of mentally ill patients is traditionally regarded as a relation to mental patients, characterized by discrimination, that is, an attitude that adversely affects patients. Stigma not only worsens their social adaptation and leads to a decrease in the quality of life, but also prevents compliance with the doctor. A large number of patients with relatively low levels of mental disorders suffer from stigmatization to a greater extent than from the manifestations of the disease themselves (Hinshaw, 2007). It should be noted that in different countries stigmatization manifests itself in different ways. Judging by the works devoted to this problem, the greatest stigmatization of mentally ill is observed in Western European society (Evans-Lacko, Brohan, Mojtabai, and Thornicroft 2012). As the authors point out, for its members, even a simple visit to a psychiatrist has become almost a social stigma, whereas in the US it is perfectly natural to talk about a visit to a psychiatrist, about working on oneself under his leadership (Parcesepe and Cabassa 2013). Nevertheless, most Americans do not want to create a family with them (68%), work closely with them (58%), or spend free time with them (56%) (Martin et al. 2000). The social consequences of the stigma are manifested in the difficulties of finding a job for a mentally ill person, the difficulties in obtaining education, obtaining social and medical help, reducing the range of communication, etc. Stigmatized people face a common discriminating attitude, which is often accompanied by strong hostility (Corrigan and Blink 2016). Precisely, because of these problems, destigmatization begins to be considered as not only one of the key aspects of social rehabilitation but also the possibility of treatment in general.

As a result of the stereotypes that have developed in society, a person who has fallen ill with a mental illness experiences shame and a sense of guilt for his condition. Such an attitude of others towards a mentally ill person leads to the development of a complex of inferiority, handicap, and aggravation of the symptoms of the disease. In inhuman conditions, persecuted by society, humiliated and forced to hide from prying eyes, these unhappy people often prefer suicide to life (Carpiniello and Pinna 2017; Martin, Pescosolido, and Tuch 2000; Oexle et al. 2016; Rusch et al. 2014; Xu, Müller, Heekeren et al. 2016). Hopelessness and despair - the main motivations of suicide - can lead to its implementation.

Acknowledgment of the significance of this problem is the fact that destigmatization is one of the leading directions of the WHO mental health program. However, due to the unresolved theoretical issues, educational campaigns aimed at reducing stigma do not always have the desired result. To increase the effectiveness and purposefulness of the destigmatization effects, it is important to study the views and perceptions of the population in the field of psychiatry affecting the stigmatization of the mentally ill, the study of the phenomenon of self-stigmatization of mentally ill patients and the factors contributing to its emergence, as well as the identification of ways of approaches to the development of psycho- and socio-therapeutic measures for the de-stigmatization of mental patients. The practical importance of such studies is to develop the principles of the destigmatization of people with mental disorders.

Prerequisites of mental illness stigmatization in the society

The modern direction of psychiatry is conditioned by deinstitutionalization, the development of a new approach to the treatment of patients, when, in fact, there is a transition from the remaining of patients in psychiatric clinics to their integration into society. The essence of the new approach can be described through the following basic principles: reduction of the number of visits in the clinic and reduction of the duration of hospitalization; assistance to patients should be provided by interdisciplinary teams on an outpatient basis; the assistance provided should be individualized and flexible; integration of medical and social assistance; when rendering assistance to an ill person, it is supposed to rely on the nearest social environment - his friends and relatives. However, despite these changes, the problem, without solving of which obstacles will arise even on the way of a new system of treatment, is stigmatization and discrimination of mentally ill people.

Social mechanism of mental illness stigmatization

The social basis of stigma

For the majority of the population, a prejudiced attitude towards the mentally ill is characteristic, which is expressed in a significant social distance to them, ideas about the need to restrict their rights, attributing to them such qualities as aggressiveness, insecurity, incomprehensibility, complexity, and unpredictability.

Such a prejudiced attitude leads to stigmatization - a negative distinguishing by society of an individual or social group) on some basis, followed by a stereotyped set of social reactions to a given individual (or representatives of a given social group). The origins of these reactions are formed on a very real basis - the mental illness does carry a fundamental danger to society, and communication with a mentally ill person is often burdensome and fraught with unpleasant ‘surprises’ for his surroundings. This burden caused by contact or living with a patient with mental illness, leads to a significant emotional stress, which, on the principle of the feedback, negatively affects the patient himself (Ahmedani 2011). There is an opinion that “negative social stigma is a kind of second disease” (Thornicroft et al. 2016). Therefore, the issues of adaptation of the microsocial environment to the patient are just as relevant for overcoming the effects of stigmatization (first of all, suicide), as well as the issues of psychological adaptation of the patient to the reactions of the social environment (which would significantly reduce suicide inclinations).

Scientific approaches to the stigmatization of mental illnesses

Currently, various approaches are proposed that explain the emergence of stigma: the sociological approach is based on “social stereotypes”; a psychological one considers the mechanism of stigmatization psychological defense mechanisms, in particular, “projection” (Haghighat 2011). Other authors offer the concept of “spoiled identity,” the theory of “labels,” and the unitary theory of stigma (Klin and Lemish 2008).

However, much more important for stigmatization is not so much the strangeness of the behavior of the individual as the prejudices historically formed in a particular society, due to the inability to “influence” the patient, the difficulty of adapting to the environment, in most cases, reduced to the notion of danger, shame (sinfulness), and the defectiveness of a person with a mental disorder (Martin, Pescosolido, and Tuch 2000). These ideologems are assimilated in the process of social development of people and become their own outlooks.

The process of negative distinguishing of a mentally ill person (his stigmatization) begins from the moment of informing the society about the fact of establishing the diagnosis of a mental disorder to an individual, or from the manifestations of a violation of his abilities, appearance, behavior, and also the presence of “other” (incomprehensible to others) interests.

The fact of mental illness is perceive by society as highly undesirable. Usually, individuals who have suffered a mental illness, are “labeled” by society with the label “different.” These patients are perceived warily and people try to stay away from them at a certain distance (Hinshaw 2007). Stigma also has a negative effect on the ability to find work or financial support from federal bodies or other government institutions (Shrivastava et al. 2012). It is not by chance that Oexle et al. note that psychiatric patients, in general, and patients suffering from psychosis, in particular, are very stigmatized, and care about them is practically absent in our society. It is important to emphasize that “labeling,” “mockery” can occur even with absolutely normal behavior of patients in remission (Oexle et al. 2016). In this case, the very information that an individual has had some kind of psychotic state in the past, causes or intensifies the social barrier between the individual and the community around him. Moreover, the labeling involves some social restrictions that the patient begins to experience and which, bearing a stressful influence, is expressed in loss of work, rejection by the sexual partner, reduction of social support, and, ultimately, - strong tension and reduction of the ‘border’ of habitual coping of individual and the decline in social status, as well as the destruction of the system of ideas about “Self” (Rossler 2016). Finally, increased stressful environmental influences associated with stigma can exacerbate the existing disease (Corrigan and Blink 2016).

Sociological data on mental illness stigmatization

A few years ago, a sociological survey was conducted. All questions concerned “the person who was treated in a psychiatric hospital.” No other information (how long was therapy, what were the results of treatment, with what diagnosis he was treated, etc.) were not given deliberately. People were asked if such a person could occupy any leading position; whether he can be elected a deputy of the national or local legislature; whether he can work in the law enforcement system; whether he can work with children. A negative answer in the first case was given by 68% of respondents, in the second - 72%, in the third - 80%, in the fourth - 84% of respondents. It should be stressed once again that the respondents did not know whether this hypothetical person is ill or lightly ill, whether continues to be ill or has already recovered. However, none of them tried to clarify anything at all. “He was treated in a psychiatric hospital” - this information seemed to people quite sufficient for categorical judgment (Corrigan et al., 2012).

These data are also supported by the poll conducted by Kaiser Family Foundation in 2013, the results of which graphically are presented in Appendix A.

S. Timmi conducted an interesting research on psychiatric labels causing harm by stigmatizing mentally ill people, presented in the Appendix B.

Phenomenology of stigmatization process

The stigmatization of a mentally ill person is described as the process of separating an individual from society after the presence of a psychiatric diagnosis, followed by perception by others around him through the prism of stereotyped mental and emotional and behavioral responses based on the category of “mentally ill” (Angermeyer et al. 2017). The authors described this process as a long and multidimensional process, proceeding at the psychological and social levels. The development of stigmatization goes through the following stages: 1. Distinguishing and labeling of a person with a psychiatric diagnosis; 2. Assignment of negative qualities to him in accordance with the existing in the current culture representations of the mentally ill; 3. Referring him to the “category” of the mentally ill, which is opposed to society, and 4. The subsequent decline in the social status of this person. In other words, the stigma is formed first by the definition of the Other, then calling it “unworthy,” and then attributing and suggesting guilt to a person because he is Different (Angermeyer et al. 2017).

The phenomenology of the psychological consequences of stigma for the patients themselves is described in detail by psychiatrists, sociologists, and psychologists. The main emphasis of the researchers is on the study of the guilt and shame that these people feel in connection with the attributes contained in the ‘mythology’ of stigma (Bos et al. 2013). Pinel introduced the concept of “stigma-awareness” (Pinel as cited in Ahmedani 2011) to describe how patients are aware of the impact of their stigma and what psychological consequences it causes. The literature also describes a self-stigmatization process similar to this (Rüsch, Angermeyer, and Corrigan 2005, Thornicroft, Mehta, Clement, Evans-Lacko, Doherty, Rose et al., 2016) – ill person’ awareness of the presence of a psychiatric diagnosis, assimilation and application of myths about his mental illness, followed by distancing himself from potential stigmatizers; this, according to the authors, leads to a decrease in social status, self-evaluation of patients, which, in turn, intensifies stigmatization, i.e., this process is a vicious circle. Self-stigmatization is a series of prohibitions related to social activity that mentally ill impose on their life which as a result is accompanied by a sense of inferiority and social insolvency (Klin and Lemish 2008).

Summarizing the available material, we can conclude that the reaction of a mentally ill person to stigmatization is determined by the same factors as the motivation for stigmatization (the degree of satisfaction with one's life, the hierarchy of values, the generalized image of a mentally ill person), as well as the clinical picture of the disease and the personality structure, is means that one can consider stigmatization and self-stigmatization as a single process. An important point in the psychological study of the stigma of the mentally ill is the identification of the dependence of the consequences of the stigma’ action on one or another nosology.

Family stigmatization

Simultaneously with stigmatization of the patient, there is a process of stigmatization of the family as a whole, as a microsocial group. The stigmatization of the family is manifested both by health workers and by the non-family environment. According to some authors, literature also contributes to the stigmatization, where shame and guilt “envelops” parents who have children with severe mental illnesses, such as schizophrenia, and, in general, reflect public opinion about the role of parents in the mental illness emergence (Baldwin and Marcus 2011). Various anecdotes and misconceptions about mental illnesses further increase the impact of stigmatization not only on the person suffering from mental illness but on the whole family. The stigmatization of the patient's family by the society is aggravated by the fact that the fact that a family member's mental illness essentially maladjust the family. This is due to the following: (a) the situation of chronic stress in family members related to the burden of living with a sick relative; b) a sense of guilt towards the patient, which is amplified by “theoretical grounds” in society and in scientific circles that accuse the family of having a mental illness; c) the tendency of such families to protect themselves from the external environment and the increasing social exclusion over time. Such stigmatized families focus primarily on drug therapy and, in this respect, become its “passive consumers.” The most common reaction of relatives to the described experiences is psychological distancing from the patient, which consists. Precisely. in ignoring him as a person, generating misunderstanding, inadequate attitude to his illness and behavior, hyperopic or dislike, which, in turn, strengthens the sense of guilt and contributes to suicidality (Larson and Corrigan 2008). Thus, the spread of stigmatization to the family of mentally ill person is an additional powerful factor in the formation of feelings of helplessness and despair in the mentally ill and increases the risk of suicide (Corrigan, Michaels, Vega et al. 2012; Evans-Lacko, Brohan, Mojtabai, and Thornicroft 2012; Ritsher, Otilingam, and Grajales 2003).

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