issue 103 (our 9th year)
issue 103 (our 9th year)
By Graham C.L. Davey Ph.D.
There are still attitudes within most societies that view symptoms of psychopathology as threatening and uncomfortable, and these attitudes frequently foster stigma and discrimination towards people with mental health problems. Such reactions are common when people are brave enough to admit they have a mental health problem, and they can often lead on to various forms of exclusion or discrimination – either within social circles or within the workplace.
What is mental health stigma?
Mental health stigma can be divided into two distinct types: social stigma is characterized by prejudicial attitudes and discriminating behaviour directed towards individuals with mental health problems as a result of the psychiatric label they have been given. In contrast, perceived stigma or self-stigma is the internalizing by the mental health sufferer of their perceptions of discrimination (Link, Cullen, Struening & Shrout, 1989), and perceived stigma can significantly affect feelings of shame and lead to poorer treatment outcomes (Perlick, Rosenheck, Clarkin, Sirey et al., 2001).
In relation to social stigma, studies have suggested that stigmatising attitudes towards people with mental health problems are widespread and commonly held (Crisp, Gelder, Rix, Meltzer et al., 2000; Bryne, 1997; Heginbotham, 1998). In a survey of over 1700 adults in the UK, Crisp et al. (2000) found that (1) the most commonly held belief was that people with mental health problems were dangerous – especially those with schizophrenia, alcoholism and drug dependence, (2) people believed that some mental health problems such as eating disorders and substance abuse were self inflicted, and (3) respondents believed that people with mental health problems were generally hard to talk to. People tended to hold these negative beliefs regardless of their age, regardless of what knowledge they had of mental health problems, and regardless of whether they knew someone who had a mental health problem. More recent studies of attitudes to individuals with a diagnosis of schizophrenia or major depression convey similar findings. In both cases, a significant proportion of members of the public considered that people with mental health problems such as depression or schizophrenia were unpredictable, dangerous and they would be less likely to employ someone with a mental health problem (Wang & Lai, 2008(link is external); Reavley & Jorm, 2011(link is external)).
Who holds stigmatizing beliefs about mental health problems?
Perhaps surprisingly, stigmatizing beliefs about individuals with mental health problems are held by a broad range of individuals within society, regardless of whether they know someone with a mental health problem, have a family member with a mental health problem, or have a good knowledge and experience of mental health problems (Crisp et al., 2000; Moses, 2010(link is external); Wallace, 2010). For example, Moses (2010) found that stigma directed at adolescents with mental health problems came from family members, peers, and teachers. 46% of these adolescents described experiencing stigmatization by family members in the form of unwarranted assumptions (e.g. the sufferer was being manipulative), distrust, avoidance, pity and gossip, 62% experienced stigma from peers which often led to friendshiplosses and social rejection (Connolly, Geller, Marton & Kutcher (1992), and 35% reported stigma perpetrated by teachers and school staff, who expressed fear, dislike, avoidance, and under-estimation of abilities. Mental health stigma is even widespread in the medical profession, at least in part because it is given a low priority during the training of physicians and GPs (Wallace, 2010(link is external)).
What factors cause stigma?
The social stigma associated with mental health problems almost certainly has multiple causes. Throughout history people with mental health problems have been treated differently, excluded and even brutalized. This treatment may come from the misguided views that people with mental health problems may be more violent or unpredictable than people without such problems, or somehow just “different”, but none of these beliefs has any basis in fact (e.g. Swanson, Holzer, Ganju & Jono, 1990). Similarly, early beliefs about the causes of mental health problems, such as demonic or spirit possession, were ‘explanations’ that would almost certainly give rise to reactions of caution, fear and discrimination. Even the medical model of mental health problems is itself an unwitting source of stigmatizing beliefs.
First, the medical model implies that mental health problems are on a par with physical illnesses and may result from medical or physical dysfunction in some way (when many may not be simply reducible to biological or medical causes). This itself implies that people with mental health problems are in some way ‘different’ from ‘normally’ functioning individuals. Secondly, the medical model implies diagnosis, and diagnosis implies a label that is applied to a ‘patient’. That label may well be associated with undesirable attributes (e.g. ‘mad’ people cannot function properly in society, or can sometimes be violent), and this again will perpetuate the view that people with mental health problems are different and should be treated with caution.
I will discuss ways in which stigma can be addressed below, but it must also be acknowledged here that the media regularly play a role in perpetuating stigmatizing stereotypes of people with mental health problems. The popular press is a branch of the media that is frequently criticized for perpetuating these stereotypes. Blame can also be levelled at the entertainment media. For example, cinematic depictions of schizophrenia are often stereotypic and characterized by misinformation about symptoms, causes and treatment. In an analysis of English-language movies released between 1990-2010 that depicted at least one character with schizophrenia, Owen (2012) found that most schizophrenic characters displayed violent behaviour, one-third of these violent characters engaged in homicidal behaviour, and a quarter committed suicide.
This suggests that negative portrayals of schizophrenia in contemporary movies are common and are sure to reinforce biased beliefs and stigmatizing attitudes towards people with mental health problems. While the media may be getting better at increasing their portrayal of anti-stigmatising material over recent years, studies suggest that there has been no proportional decrease in the news media’s publication of stigmatising articles, suggesting that the media is still a significant source of stigma-relevant misinformation (Thornicroft, Goulden, Shefer, Rhydderch et al., 2013(link is external)).
Why does stigma matter?
Stigma embraces both prejudicial attitudes and discriminating behaviour towards individuals with mental health problems, and the social effects of this include exclusion, poor social support, poorer subjective quality of life, and low self-esteem (Livingston & Boyd, 2010(link is external)). As well as it’s affect on the quality of daily living, stigma also has a detrimental affect on treatment outcomes, and so hinders efficient and effective recovery from mental health problems (Perlick, Rosenheck, Clarkin, Sirey et al., 2001). In particular, self-stigma is correlated with poorer vocational outcomes (employment success) and increased social isolation (Yanos, Roe & Lysaker, 2010(link is external)). These factors alone represent significant reasons for attempting to eradicate mental health stigma and ensure that social inclusion is facilitated and recovery can be efficiently achieved.
How can we eliminate stigma?
We now have a good knowledge of what mental health stigma is and how it affects sufferers, both in terms of their role in society and their route to recovery. It is not surprising, then, that attention has most recently turned to developing ways in which stigma and discrimination can be reduced. As we have already described, people tend to hold these negative beliefs about mental health problems regardless of their age, regardless of what knowledge they have of mental health problems, and regardless of whether they know someone who has a mental health problem. The fact that such negative attitudes appear to be so entrenched suggests that campaigns to change these beliefs will have to be multifaceted, will have to do more than just impart knowledge about mental health problems, and will need to challenge existing negative stereotypes especially as they are portrayed in the general media (Pinfold, Toulmin, Thornicroft, Huxley et al., 2003).
In the UK, the “Time to Change” campaign is one of the biggest programmes attempting to address mental health stigma and is supported by both charities and mental health service providers (http://www.time-to-change.org.uk(link is external)). This programme provides blogs, videos, TV advertisments, and promotional events to help raise awareness of mental health stigma and the detrimental affect this has on mental health sufferers.
However, raising awareness of mental health problems simply by providing information about these problems may not be a simple solution – especially since individuals who are most knowledgeable about mental health problems (e.g. psychiatrists, mental health nurses) regularly hold strong stigmatizing beliefs about mental health themselves! (Schlosberg, 1993; Caldwell & Jorm, 2001). As a consequence, attention has turned towards some methods identified in the social psychology literature for improving inter-group relations and reducing prejudice (Brown, 2010).
These methods aim to promote events encouraging mass participation social contact between individuals with and without mental health problems and to facilitate positive intergroup contact and disclosure of mental health problems (one example is the “Time to Change” Roadshow, which sets up events in prominent town centre locations with high footfall). Analysis of these kinds of inter-group events suggests that they (1) improve attitudes towards people with mental health problems, (2) increase future willingness to disclose mental health problems, and (3) promote behaviours associated with anti-stigma engagement (Evans-Lacko, London, Japhet, Rusch et al., 2012; Thornicroft, Brohan, Kassam & Lewis-Holmes, 2008).
Our new Bipolar Carers Support Group meetings are held at South Yarra on the first Tuesday of each month commencing at 7:00pm (except January) – see http://bipolarlife.org.au/south-yarra-bp/
Close family and friends (bipolar carers or caregivers) can be a primary source of support for a person with bipolar disorder. Discussions include ways caregivers can take care of themselves, deal with the bipolar disorder and the personal impact it has on them.
Enquiries to email@example.com
If you are over 18 and have bipolar disorder you may be eligible to help us trial new, online self-guided interventions designed to improve quality of life in people who experience bipolar. We are comparing two types of interventions that have been created by international experts which both include videos, exercises, tools, forums and an online coach.
To find out if these interventions are helpful, you would also be asked to complete 4 assessments (which include a telephone and online component) over a 6 month period. You will be reimbursed for participation in these assessments.
If you would like more information about the research or would like to participate go to: www.orbitonline.org
The Grammy-nominated singer writes about the darker side of her creativity
“I don’t like to give credit to anything that’s dark or twisted like bipolar disorder: it’s a dangerous disease, statistics show that 1 In 4 people die from it by taking their own lives. But my doctor tells me that it’s a double edge sword – it’s not a good thing that I have it but I can be thankful because it’s a big part of my creativity”.
I have to take medication regularly and this has had an impact me in a good way, artistically speaking. Before I was on medication the mania was so bad that I couldn’t concentrate, so although I’d feel very creative I could never really finish a piece of work because my mind was moving so fast.
I had so much anger and judgement towards myself for my work not being up to the standard that I expected it to be, so I wouldn’t allow myself to complete anything. And usually when I would be able to complete something would be when I was in a depressive state.
Now that I’m on medication I still get the mania and depression because the medication doesn’t cure it, but it makes it so much more manageable. I can complete all the work that I start and if I am struggling to complete it, it’s really my own psychological things that are getting in the way.
It’s very important for me to do things like talk therapy. That’s where you begin to see the walls that your illness has put up as a way to protect yourself… but of course those walls also keep us from getting to the truth of things. When I’m on tour, one of the lovely things about meeting journalists is that it’s kinda like its own therapy so I can still feel in a secure place.
My doctor said when I’m feeling good, it’s not healthy; it’s mania but could be early stage mania which is hypo-mania, you feel very elated and have many ideas.
What’s dangerous about that is that when you have the type of bipolar I have (Bipolar 1 Rapid Cycling), the early bouts of my mania feel fantastic and then very quickly it stumbles to be very spiralled out; paranoia, fear, even hallucinations at times.
Now I’ll go into what is called “spinning thoughts” that I cannot turn off in my head. until I go to the piano. Then I’m really able to be creative. Although I take the medication which has made a huge impact on my life in a positive way, still, honestly, when I’m a bit sick is when I’m at my most creative.
I didn’t think of my songwriting or music when I received the diagnosis of bipolar, what I thought of was “thank God”, there is an answer to why I have felt the way I have felt for so many years, since childhood.
I was so incredibly ashamed of myself, all growing up and through my 20s I thought I was a bad seed.
Once I heard this bipolar diagnosis it helped me to see that a big part of the illness is having self-hatred and self-doubt, which is why suicide rates for bipolar are so high, so this brought me great comfort.
When I’m in the mindset of either depression or mania, which is what really funnels my creativity, I will complete a song that day.
So I tend to become very obsessive and not leave the piano until I do – however when I come across pieces that I’m working on and I see that I’m struggling to find the lyric… that may take a year to write.
But no change or shift in mood takes me away from that once I start on it. If I’m feeling balanced I will probably leave it alone for a few weeks, and then once I go back I will shift back on the piano, and I will become very vigilant on figuring out that piece.
“When I was diagnosed with Bipolar I thought it was the end of all hope. All I could see is how it destroyed the lives of my relatives. However, a few years on from diagnosis I find that I am doing well.
My life is very similar to how it was before. There are a few positive things that this disorder has given me.
(1) I am more understanding and compassionate to people with mental and emotional struggles
(2) I am now highly motivated to protect myself and stand up for the things I need.
Before Bipolar I tended to put others first even to my own detriment. Bipolar has made me stronger in caring for others AND Myself.”