From thousands of years, debate has been going on among practitioners how to treat mental illness. Several modifications have been done from burning, chaining, locking them in homes and drilling their heads to unchaining and treating them like humans (Foerschner, 2010). But the nurses who work in mental health setting still face the problems in delivering care in a stigma free environment in order to promote the health of mentally ill patients (Stuart, 2009). For such mentally ill clients we need to accept their behavior rather than stigmatization (Angermeyer & Matschinger, 2003). Stigma is a “collection of negative attitudes, beliefs, thoughts, and behaviors that influence the individual, or the general public, to fear, reject, avoid, be prejudiced, and discriminate people” (Gary, 2005). The reason behind selection of this topic is that to accepting mentally ill patient with the intention of promoting their health. In West, stigma to mental illness is properly recognized, equally managed and prevented. Yet, in Eastern cultures, being mentally ill is still seen as a mark of dishonor for family, mental health patients are still stigmatized and socially isolated and supposed as being haunted by evil spirit or jinn (Naeem, Ayub, Javed, Irfan, Haral & Kingdon, 2006). Additionally, mental health is considered to be the most avoided field in Pakistan due to the stigma attached to it (Qasim, 2012).
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Not so long I have being in psychiatric setting where we all were sitting in café having our break together, suddenly a man in brown traditional clothes with leather jacket wearing black goggles ask one of our colleague if he want some tea? he answered “no”, that person sat on nearby table and ask waiter to bring one zinger burger. While noting his getup which was not according to weather and unusual behavior, my colleague abruptly ask our faculty “Ma’am is he mad or what? After hearing those words that patient suddenly pushes his chair and leaves the café.” This is how people unintentionally target psychiatric patient by hitting their self-esteem rather accepting them as a part of society and understand there awkward behavior as a part of their illness. In a society stigma marks a boundary between “normal” and “outsider,” and between “us” and “them” (Link & Phelan, 2001). Question is how we can break this boundary of discrimination which is causing barrier to recovery of mentally ill clients?
The case scenario will now be analyzed on a social cognitive model explains how public and self stigma are formed and maintained. There are 3 components that structure this model are: stereotype, prejudice, and discrimination. Social psychologists see stereotypes as information learned by society (Augoustinos, Ahrens, & Innes, 1994; Esses, Haddock, & Zanna, 1994; Hilton & von Hippel, 1996; Judd & Park, 1993; Krueger, 1996; Mullen, Rozell, & Johnson, 1996). Without thinking we quickly create expectation and impression of people who fit in to a stereotyped group, (Hamilton & Sherman, 1994) just like my colleague label that person as ‘mad’. Prejudice endorse people may show a negative reactions by supporting their learned negative stereotype. (Devine, 1988, 1989, 1995; Hilton & von Hippel, 1996; Krueger, 1996). Prejudice may lead to discriminatory behavior (Weiner, 1995) just like my colleague discriminate that person as one who is not following societal norms and discriminate his behavior from normal to abnormal (for social cognitive model refer appendix fig 1.).
Being stigmatized has several harmful effects on the individual, the immediate family and the community too. At first in the name of honor or embarrassment, the individual and family doesn’t reach the health care provider for treatment options. It also cause non-adherence to effective treatment regimen. Self stigma is another effect resulting in low self esteem, negative self perception and self care when a person internalizes the discriminatory behavior and societal stigmatizing attitude. Lastly stigma has also affects the attitude of health care provider. Study has shown that in hospital setting nurses display punishing attitude and use unacceptable manner for treating them, like unnecessarily retraining them (Pinto-Foltz & Logsdon, 2009).
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To reduce stigma and discrimination against people with mental health disorders the largest ever program was launched in England on Jan 21, 2009, called Time to Change. By referring social cognitive model this program aims to show that change is possible that would bring hope to people who are deleteriously exhausted by discrimination (refer appendix fig 2.) (Henderson & Thornicroft). A few procedures for stigma decrease are accounted in the literature. These interventions and techniques might be used at diverse levels: the intrapersonal, interpersonal, organizational/institutional, group, and governmental/structural (McLeroy et al, 1988; Richard et al, 1996). Firstly, intrapersonal level has always remained a primary focus to change the behavior of an individual. Interventions are done to change the individual’s knowledge, behavior, attitude, self concept, enhancing self esteem, coping skills, strengthening, and financial support. We can carry out these interventions via individual counseling or cognitive behavioral therapy (CBT) and Self help advocacy and support groups (Heijnders & Van Der Meij, 2006). Secondly, intervention at interpersonal level deals with the impact of social gathering and social support on the health of mentally ill client. The interpersonal environment of the patient includes their family, friends and work environment. They intend to build connections between patient and his/her interpersonal environment in order to restore or promote their health. This could be carry out through Care and support by family, Home care teams, and Community-based rehabilitation (Heijnders & Van Der Meij, 2006). Furthermore, the organizational level also being used in order to change the perception of public towards stigma and its effect on individual. This could be accomplished through training programs and institutional changes which increase knowledge of the disease and effect of stigma on the lives of mentally ill clients (Heijnders & Van Der Meij, 2006). Additionally stigma reduction can be intervene at community level whose aim is to increase knowledge about mental illness and stigma attached to it. For stigma reduction campaign, education is often used as a first step and it may combine with the other strategies as well. Educational interventions may include presentations, discussions, simulations, audiotapes, and movies, focusing specific populations (Heijnders & Van Der Meij, 2006). Lastly, on governmental level work can be carried out in order to structure such policy which aims to protect the rights of the people who are suffering from stigmatizing illness (Heijnders & Van Der Meij, 2006). The World Health Organization (WHO) argued that ‘policies on discrimination, access to prevention and care, confidentiality of care and individual’s rights can make a significant impact’ (2002).
In Conclusion it is recommended that client’s dignity and safety should remain paramount at all times. To break the chain of stigma the social cognitive model should be vigilantly applied in psychiatric setting. Patient-centred approach is required, which starts with intrapersonal level, which gives power to affected person to development self esteem and stigma reduction related programs at other levels. “There is nothing either good or bad, but thinking makes it so” (Shakespeare, Hamlet, Act 2 Scene 2).
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