Stigma Around Mental Illness: A Factor in the Decline of Mental Health Worldwide

In many societies, the notion of stigma is a pervasive yet unquantifiable force that influences perceptions and behaviors. Stigma is defined by the Oxford dictionary as “a strong feeling of disapproval that most people in a society have about something, and such feelings can pervade every area of society: from interpersonal relationships to gender roles, to education and healthcare” (“Stigma” Oxford). On a basic level, stigma can lead to social isolation or shame, and on a deeper level, stigma can drive people to act in self-sabotaging or harmful ways. In the medical field, illnesses are even plagued by various dimensions of stigma depending on “the nature of an illness, its history, attributed characteristics, and sources of the creation and perpetuation of its stigma” (Ablon 2). Such stigma is especially true for less ‘visible’ conditions, such as mental illnesses like bipolar disorder or depression.  It is important to understand the impact of stigma as a barrier to mental health care and as an invisible variable in the treatment of and efficacy of mental health care practices. Although stigma in and of itself is hard to quantify, it’s impact can be observed based on the collective actions and indicators of societies that disapprove of certain behaviors over others. This paper will investigate how stigma affects the access to and acceptance of mental health care depending on the cultural values of collectivist and individualist societies. Specifically, it will evaluate the differences in stigma as a independent variable across East Asian and Western cultures, and whether the anthropological framework of ‘individualism versus collectivism’ is a useful explanatory tool for mental illness stigmatization patterns. Ultimately, it will show how strong collective attitudes, especially those most prevalent in Asian societies, are linked to  greater stigmas against pursuing mental health care as it threatens the reputation of the shared group identity.

Cross-cultural anthropologists and psychologists study how different cultural and socially-constructed factors influence individual behaviors and decision-making. In order to define and systematized such behaviors, they often focus on characteristics that are pervasive or universal within the studied culture. One framework within this camp involves dividing cultures into two categories: collectivist and individualist. Individualist cultures, such as those of the Western world (United States and Europe), tend to elevate the individual above their social groups, and emphasize personal or individual achievement above group goals. Individuals in such societies are socialized to affirm a strong sense of personal power and autonomy over the self  (Maynard 1). This also means that individuals are more inclined to attribute successes and disappoints to their own efforts, rather than to the joint efforts of their member group. Collectivist cultures, such as those of China and Japan, emphasize the needs of their surrounding societal units, such as family and work groups, above their own individual needs or desires. People in these cultures might sacrifice their own comfort and equilibrium for the greater good of everyone else around them. In order to maintain a balanced group dynamic in such cultures, most individuals in that social unit have a specific role to play and are expected to always act within that role (Maynard 1). As a example, according to Hofstede Insights, an independent data analysis firm that measures various intangible aspects of culture based on six variables, Thailand measured a score of 20 in collectivism, as defined by “an individual’s’ level of long-term commitment to their member ‘group”,  making it a highly collectivist country (Hofstede, “Thailand”). Unlike individualist cultures, collectivist cultures like the Thai consider individual successes and disappointments to be reflections of the entire group identity. This means that any anomaly in the members – for example, due to a mental illness – brings shame to the family and comprises their identity or reputation. Thus, members of collectivist societies will optimize for status quo over individuality. This collectivism makes mental illness and seeking help for such an illness a stigma as doing so threatens the cohesion of the group because it often involves multiple people and draws significant attention (Corey 224).  In individualist cultures, people instead optimize for individual advancement, so something which threatens that ideal, like killing oneself (committing suicide) for example, becomes a stigmatized practice. Alternatively, suicide is actually a honorable practice in some collectivist cultures as it maintain the integrity of the group by eliminating the threat (Pierre 5).  Stigmas, therefore, gain their meaning based on the core values and cultural frameworks of a particular society.

These cultural frameworks manifest in all socio-dynamics, such as the way that family members care for their loved ones, all the way up to how governments pass policies related to healthcare, and are defined by generational and historical values embedded in the society. In an individualistic culture like the United States, certain values such as autonomy and unalienable rights to pursue freedom means that individuals see life as their own individual design and a direct product of their own efforts. This is the ideal that the Founding Fathers established in the founding documents and ensured that individuals rights’ to life, liberty, and the pursuit of happiness were protected. In collectivist cultures, notions of interconnectedness are so strong that language and vernaculars have been conceived to reflect it. In Filipino culture, for example, the concept of “Kapwa” which does not have an English equivalent, means ‘togetherness’, a “shared identity” or “brotherhood” (Louie 46).  The value systems across individualist and collectivist cultures define was is acceptable and ideal, versus what is frowned upon and stigmatized. Ultimately, individuals behave and operate within their cultural context which provide broad social guidelines for the trade-offs that influence the choices they make.

Complications in Culture

In strong collectivist cultures, any anomalies, like someone suffering from a mental illness, is exponentially more stressful as it implies the joint identity of the group. For example, a person who breaks the status quo of the group, due to their mental health condition and related ‘abnormal’ behaviors, can be perceived as the ‘other’ and disconnected from the group. Othering is defined as” any action by which an individual or group becomes mentally classified in somebody’s mind as ‘not one of us’” (James 2011). This psychological tactic is a trademark of collectivist societies, such as many East Asian cultures, and causes individuals to optimize for the good of the group, even if it means self-harm.  In China, for example, the teachings and philosophies of Confucianism discourage “open displays of emotions in order to maintain social harmony and to avoid any exposure of personal weakness”. In the context of mental health, those suffering from mental illness, therefore, may avoid seeking help due to the stigma of being perceived as weak and unfit to uphold the strength of the group (Corey 224).  An example of this in practice is evidence through a study called Breaking the Silence: A Study of Depression Among Asian American Women by The National Asian Women’s Health Organization (NAWHO), which found that cultural values are impacting Asian-American women’s sense of autonomy over their life decisions. One specific finding was that Asian-American women choose to remain silent and ignore the subject of depression if they are experiencing symptoms of the illness, or witness depression in their immediate family. Although the study relates to Asian-Americans rather than East Asian nationals, it is still clear how the findings of the study have roots in the common culture. Another study by the American Psychological Association, showed that Asian Americans are three times less likely than White Americans to seek mental health treatment (Kurasaki 205). Another study from 2011 showed that Asian Americans typically avoid mental health services because “opting to utilize such services requires admitting the existence of any health problem and may cause shame to the family if personal issues become public” (Augsberger 8). This means that mental illness is especially stigmatizing, as it reflects poorly on family lineage and can influence beliefs about the reputation of the group to which they belong.  One study involving adult Korean Americans reported that the group members had greater stigmatizations about mental health and believed that “seeking treatment would bring shame to their family if they were to reveal their mental illness” (Jang, Chiriboga and Okazaki 2009). There is a clear familial and collectivist pull which drives decision making to optimize for the good of the group and avoid public shame or ostracization due to exposure of any ‘difference’.  This causes Asians to avoid admitting to and seeking help for mental conditions at higher rates than their White counterparts.

One possible counterargument that arises from mental health service utilization is whether lower use is actually reflective of lower need within people from a similar genetic makeup. For any health illness, it is important to remain open and balanced to the understanding of what is due to environmental versus genetic predisposition.  Although epidemiological research has been conducted on the matter, the results remain largely inconclusive t be able to draw the line. One paramount study found that immediate biological relatives of patients with schizophrenia have a 10% risk of developing the disorder, as compared with 1% in the overall general population (Gejman 50).  However, further epidemiological research on the linkages of mental disorders among Asians and Asian Americans is required to triangulate this issue.

Furthermore, the public perception of mental health patients has been negatively portrayed and perpetuated in many East Asian cultures.  For example, generations have perpetuated the Indonesian practice of pasung, which involves shackling people with real or perceived psychological illnesses. Even though pasung was banned in 1977, people with mental health issues in Indonesia are regularly chained with restraints, or placed into metal cells and cages (Minas and Hervita 2). The extreme practices can be perceived an an extension of othering, a common tactic among collectivist groups. By shackling and restraining the outlier, the society creates a clear distinction that they are a distant other which threatened the normality of the group. In an individualist culture, this individual may not be perceived as a threat to the common identity, but rather a lone wolf actor with unique issues.On the spiritual side, many religious rituals have created not only psychological barriers to accessing health care, but actual physical impossibilities. In Indonesia, for example, the mentally ill are believed to be possessed by spirits and capable of supernatural powers, so they are denied access to treatment as a way to harness and capitalize on their powers (Minas and Hervita 2). Instead, religious rituals become the main vehicle of both caring and treatment for the mentally ill. One 2001 study by the Office of the General Surgeon found that Asian Americans prefer informal solutions for their mental health problems, such as seeking the support of friends or family or working out problems on their own, instead of seeking help from mental health professionals, in turn delaying the decision to seek professional help (Maynard 3). The combination of social stigmas and socio-religious practices, although unquantifiable as variables, contribute greatly to the access to, availability, and utilization of mental health care.

Caveats in Western mental health and differences

This is not to say that individualist cultures absolutely welcome mental health treatment without stigma or shame. However, the stigma more often falls on the individual alone, and has less implications for the individuals surrounding group. However, the individualist structure presents many unique problems for the individual and for society, placing greater responsibility on the individual for their weaknesses and shortcomings. Individualist societies, such as the United States, are actually more prone to personality disorders, substance abuse, and clinical depression than are non-Western cultures. Many of these disorders, such as substance abuse and depression stem from the immense pressure to gain individual status and meaning, due to the cultural emphasis on individual success and progression.  This is especially concerning because recent research has shown that strong social support and social ties protects and improves individual mental health, especially regarding chronic stress (Ozbay 36). Strong notions of individualism have also been implicated in suicide. For example, one study found that city districts with rising rates of young adult male suicide also had the largest proportion of people living alone and the lowest proportions of married people, proving the correlation that socially embedded groups had lower rates of suicide in comparison to the socially isolated (Sinyor 30). Another study entitled, “Culture-gene coevolution of individualism-collectivism and the serotonin transporter gene” found a strong association between the degree of collectiveness of a particular nation and the degree to which they were susceptible to developing depression (Chiao 277).  It found that collectivistic nations, such as East Asia, had significantly lower presence of depression than in individualistic countries, such as the United States and Europe. Thus, certain values related to freedom of expression, material well being, and progressive thinking, can in fact be linked to other specific types of mental health complications.

Like religious practices in Indonesia, there are socio-cultural perceptions in individualistic societies which also contributes to the stigmatization of mental health care. According to one study, American and Canadian stigmatizing attitudes are not limited to mental illness, but more generally linked to the disapproval of persons with psychiatric (or ‘invisible’) disabilities significantly more than those with physical illness (Corrigan 34). In many popular cultural references, such as supervillain or mafia films, severe mental illness has been likened to drug addiction, prostitution, and criminality (Corrigan 37). In such cultures which isolate individuals as products of their own design, those with mental illness are perceived by the public to be incapable of controlling their disabilities and responsible for causing them, unlike with physical disabilities (Corrigan 34). While Canada is often lauded for its universal healthcare system, the country lags when it comes to effective mental healthcare provision. One in five Canadians live with a mental illness, but over 60 percent report not seeking treatment out of fear of being stigmatized. Moreover, in the United States, the emphasis on individual contribution, productivity, and success means that a mental health disorder can lead to perceived decreases in productivity and increased stigmatization of such illnesses in the workplace. For example, individuals living with schizophrenia are seven times more likely to be unemployed than the general population, a higher rate than any other group with disabilities in the United States (NAMI). Thus, Americans are disincentivized to report or seek out professional health for their disorders in order to avoid workplace discrimination or limited employment options.  This means that stigma can manifest drastically in both individualist versus collectivist mindsets, but the driving narratives which embolden the stigmas are largely shaped by the differing values and perceptions within the culture. 

Mental Health by the Numbers

Asia is the largest continent in the world in terms of total surface area and population. Despite the recent shifts towards global humanitarian emphases on mental health, mental health is not a high priority in most Asian countries. With a population exceeding 3.5 billion, over 450 million persons are reported to suffer from mental or neurological disorders in the continent, according to the World Health Organization (WHO). The ratio of mental health personnel to population is significantly below the WHO-recommended levels in the majority of the countries of Asia. In China there are about 15,000 psychiatrists for their population of 1.2 billion people, which is a ratio of about 1 to 80,000. In India, there are only 3000 psychiatrists for all 1 billion people, and Indonesia has about 450 psychiatrists for 210 million people spread across 13,000 islands (WHO). The numbers are even more concerning when it comes to health specialization. For example, in Malaysia, there are only seven child psychiatrists in the entire country of 24 million people, and the quality of their training is questionable. This is contrasted with the United States which has 12.5 mental health workers per 100,000 people, and the United Kingdom which has 16 workers per 100,000 people (WHO). It is clear that for lack of cultural importance or lack of interest, mental health remains marginalized in the realm of health care in most countries in Asia. Thus, it can be argued that reduced levels of collectivism and greater individualism correlates with greater emphasis on mental health resources and personnel. Since many individualist cultures happen to be from the Western world, there are vast differences in the mental health utilization practices of Eastern and Western cultures.

This is further proven as some research suggests that greater acclimation and familiarity of Western mental health practices facilitate proactive help-seeking. The National Latino and Asian American Study (NLAAS) study, found that U.S-born Asian Americans were more likely than first generation immigrant Asian Americans to utilize mental health related services, and that third generation Asian Americans with a diagnosed mental illness personally sought services at an even higher rate (Abe-kim 2007).  On the contrary, another study showed that Asian Americans with more conservative and stronger beliefs in traditional Asian values had less receptive attitudes about seeking out help for mental health issues (Kim and Omizo, 2003). Even through generational lessening of one’s allegiance to traditional norms, though as long as they remain deeply rooted, will continue to interfere with treatment-seeking. Thus, the generational dimensions of mental illness stigma as defined by these culturally-relevant frameworks, are translated into decision-making practices.

A large source of the disparity between East and West is also evident in the lack of formalized medical health education. Most medical schools in Asia do not conduct official curriculums or exams in psychiatry, and the ability to diagnose or manage a mental health patient is not a part of the core requirement to become a doctor. This is compared with the average of one year spent learning the discipline in American medical schools. According to the the World Health Organization, the time spent in psychiatry in Asian medical schools varies greatly, from two weeks of psychiatry apprenticeship in most Indian medical schools, to three weeks at the National University of Singapore, and four weeks at the Beijing Medical University (WHO).  Thus, even on the pre-professional level, allocation of resources to the study and growth of mental health resources is largely driven by the cultural priorities that can be understood through cultural-value frameworks.

Recommendations for Improvement

Understanding cultural beliefs and biases and how it impacts health care decisions is a relatively new frontier in medical research. What becomes clear is that culture and social contexts, while not the only determinants, alter the types of mental health services that various groups choose to access or not. According to the Office of the Surgeon General, without striving to understand this context, “many adverse effects can arise such as cultural misunderstandings between patient and clinician, clinician bias, and the factors that deter groups from accessing and utilizing care, thus preventing them from receiving appropriate care” (OSG 2001). The reform in mental health care must be preceded by a foundation of change in training of health professionals in basic primary care mental health. According to the recommendations by the WHO, as long as Asian medical schools keep repeating the same archaic ways of teaching psychiatry, mental health will remain stagnant. The cultural perception and image of mental health, especially in East Asian cultures, must change. Lastly, public education and NGO work in mental health must be boosted to improve the understanding among all of the basics of mental health and mental illness.

Beside the need to increase the availability of formal services among East Asian countries, research has pointed to the need for culturally-competent providers who are “able to understand and deliver mental health treatments with similar worldviews and cognitive styles – such as problem perception, coping orientation, and therapy goals, to that of Asian patients” (Zane 2005). Some movements have also begun to discuss treatment programs for Asian Americans that consider cultural implications of mental health. An example of this is the concept of mindfulness, “the psychological process of bringing one’s attention to experiences occurring in the present moment through the practice of meditation” which has roots in Buddhism and other Asian traditions, and has even been growing in Western psychology as a viable treatment for depression, anxiety, and other mental health problems (Oxford). Understanding the impact of culture and bias, especially the common trends among individualist versus collectivist cultures needs to be a central pillar to health care development practices. If the industry is able to understand that collectivist cultures prefer the support of their family members, for example, then mental health care professionals can begin to explore therapy practices that include these social expectations, rather than try to impose individualist/Western solutions. Improving and empowering the field of mental health in collectivist versus individualist cultures can not only be based on increasing the numbers and personnel, but understanding the root causes and cultural practices that inform all health-related decision-making.

Conclusion

For this analysis, it has been demonstrated that mental health patients suffer a degree of stigma all around the world, but the extent to which they will seek help, and to which the society invests in such resources, can be largely understood against the backdrop of the culture value-paradigm of collectivism and individualism. Using the  framework of individualistic and collectivist societies helps to qualitatively identify culture-specific stereotypes and discrimination that comes with the label of a mental illness. Many people with serious mental illness experience a two-fold challenge. On one hand, they suffer from the disabilities that result from the disease. On the other, they are challenged by the discrimination that results from stereotypes about mental illness. In order to avoid bringing shame to the group, anomalies like mental illness are more stigmatized in collectivist societies, because they represent a divergence from the status quo. This is evidenced by the lack of emphasis and available of mental health treatment in Asian countries versus their Western (more individualistic) counterparts. The influence of culture on healthcare, although not extensively studied, cannot be overlooked.  Culture most visibly shape the interaction with the mental health consumer through diagnosis, treatment, and organization and financing of such services. The aim of this study is investigate whether the cross-cultural value paradigm ‘individualism-collectivism’ is a useful explanatory model for mental illness stigma on a cultural level. When reviewing the patterns in decision-making which optimizes the individual or the group, it appears that the more stigmatizing a culture’s mental illness attitudes are, the more likely collectivism effectively explains these attitudes. In contrast, the more receptive to the field of mental illness, the more likely individualism effectively explains attitudes. What becomes clear is that culture and social contexts, while not the only determinants, are strong factors which shape the mental health perceptions within social groups and affect the types of mental health services they use.

References

• Ablon, Joan. “The Nature of Stigma and Medical Conditions.” Epilepsy & Behavior, vol. 3, no. 6, 2002, pp. 2–9., doi:10.1016/s1525-5050(02)00543-7.
• Augsberger, Astraea et al. “Factors influencing the underutilization of mental health services among Asian American women with a history of depression and suicide.” BMC health services research vol. 15 542. 8 Dec. 2015, doi:10.1186/s12913-015-1191-7
• Breaking the Silence: a Study of Depression among Asian American Women. National Asian Women’s Health Organization, 2001.
• Chiao, Joan Y., and Katherine D. Blizinsky. “Culture-Gene Coevolution of Individualism-Collectivism and the Serotonin Transporter Gene (5-HTTLPR).” PsycEXTRA Dataset, 2011, doi:10.1037/e634112013-124.
• Corey, Gerald. Theory and Practice of Counseling and Psychotherapy. Cengage Learning, 2017.
• Corrigan, Patrick W, and Amy C Watson. “Understanding the impact of stigma on people with mental illness.” World psychiatry : official journal of the World Psychiatric Association (WPA) vol. 1,1 (2002): 16-20.
• Gejman, Pablo V et al. “The role of genetics in the etiology of schizophrenia.” The Psychiatric clinics of North America vol. 33,1 (2010): 35-66. doi:10.1016/j.psc.2009.12.003
• James. “Othering 101: What Is ‘Othering’?” There Are No Others, 28 Dec. 2011, therearenoothers.wordpress.com/2011/12/28/othering-101-what-is-othering/.
• Jang, Y., Chiriboga, D. A., & Okazaki, S. (2009). “Attitudes toward mental health services: Age group differences in Korean American adults”. Aging & Mental Health, 13, 127– 134.
• Kim, Bryan S. K., and Michael M. Omizo. “Asian Cultural Values, Attitudes toward Seeking Professional Psychological Help, and Willingness to See a Counselor.” The Counseling Psychologist, vol. 31, no. 3, May 2003, pp. 343–361, doi:10.1177/0011000003031003008.
• Kurasaki, Karen S., and Alan K. Koike. “Assessing Psychiatric Prevalence Rates Among Asian Americans.” Asian American Mental Health, 2002, pp. 205–217., doi:10.1007/978-1-4615-0735-2_14.
• Louie, Sam. Asian Honor: Overcoming the Culture of Silence, pp 1-118,. Westbow Press, 2012.
• Maynard, Ashley E. “Introduction: Cultural Learning in Context.” Learning in Cultural Context International and Cultural Psychology Series, pp. 1–7., doi:10.1007/0-387-27550-9_1.
• “Mental Health: Culture, Race, and Ethnicity: A Supplement to Mental Health: A Report of the Surgeon General.” PsycEXTRA Dataset, 2001, doi:10.1037/e647822010-001.
• Minas, Harry, and Hervita, Diatri. “Pasung: Physical Restraint and Confinement of the Mentally Ill in the Community.” International Journal of Mental Health Systems, vol. 2, no. 1, 2008, p. 8., doi:10.1186/1752-4458-2-8.
• “NAMI.” Home, www.nami.org/Blogs/NAMI-Blog/October-2017/Can-Stigma-Prevent-Employment.
• Pierre, Joseph M. “Culturally sanctioned suicide: Euthanasia, seppuku, and terrorist martyrdom.” World journal of psychiatry vol. 5,1 (2015): 4-14. doi:10.5498/wjp.v5.i1.4
• Ozbay, Fatih et al. “Social support and resilience to stress: from neurobiology to clinical practice.” Psychiatry (Edgmont (Pa. : Township)) vol. 4,5 (2007): 35-40.
• Sinyor, Mark et al. “Characterizing suicide in Toronto: an observational study and cluster analysis.” Canadian journal of psychiatry. Revue canadienne de psychiatrie vol. 59,1 (2014): 26-33. doi:10.1177/070674371405900106
• “Stigma” The Oxford Dictionary, 3rd ed., 1997.
• “Thailand.” Hofstede Insights, www.hofstede-insights.com/country/thailand/.
• Yang, Lawrence Hsin, et al. “Recent Advances in Cross-Cultural Measurement in Psychiatric Epidemiology: Utilizing ‘What Matters Most’ to Identify Culture-Specific Aspects of Stigma.” International Journal of Epidemiology, vol. 43, no. 2, Apr. 2014, pp. 494–510. EBSCOhost, doi:10.1093/ije/dyu039.
• Zane, N. , Sue, S. , Chang, J. , Huang, L. , Huang, J. , Lowe, S. , Srinivasan, S. , Chun, K. , Kurasaki, K. and Lee, E. (2005), Beyond ethnic match: Effects of client–therapist cognitive match in problem perception, coping orientation, and therapy goals on treatment outcomes. J. Community Psychol., 33: 569-585. doi:10.1002/jcop.20067