During my mental health clinical rotation at Karwan-e-hayat, I encountered a 45 year old female patient with the diagnosis of Obsessive compulsive disorder and depression in her rehabilitative phase. She gave Rs 50/- to the nursing assistant to bring nimco for her which costed Rs 25/-. The nursing assistant returned with the nimco but did not returned the rest Rs 25/- to the patient by saying that no money was left. When the patient reported the incident to the nurse, the nurse did not pay any attention to the patient. In the beginning the nurse said that she don’t have time to talk about it followed by the statements such as “Unlike you, I have too much work to do” and then when the patient went to another nurse, she ignored the patient also by saying that “The nursing assistant would not have been lying. Patients like you come and go from here every day saying these kinds of things. Go and do your work.” The patient went away quietly looking down. Later she verbalized “Nobody takes us seriously as we are mentally ill patients. So we can’t do anything.” Furthermore she said “Does being mentally ill means we are not humans?”
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“Stigma is a Greek word meaning ‘mark’, and is derived from the verb stizein ‘to tattoo’, ‘to prick’, ‘to puncture’. Stigma is usually a mark of disgrace or infamy, which leads to action: discrimination against the stigmatised person” (Arboleda-Fl´orez & Sartorius, 2008, P.69). stigma occurs when leading social group diminishes the qualities of a less influential group”. Stigma in health care is a very common entity for many groups of the community. One of which is psychiatric patients. “People identified as having mental health problems are one of the most marginalised groups in society” (Martin, 2009, p.6)
The above mentioned case is an example of such cases whereby a mentally ill patient was stigmatized in the hospital settings by the health care professional. Many patients and surveys have highlighted this sheer reality that health care professionals themselves display stigmatizing behaviors and practices (Hinshaw, 2007). Moreover, they depict dehumanizing behavior and lowered expectation towards mentally ill. In this case scenario, the health care professional directly passed on stigmatizing comments to the client. According to Hinshaw, (2007), the health care providers sometimes use frequent comments which are hurtful jokes for the clients. They often use judgmental terms for the patients with one another in the presence of the patient, as though the patients were not even present there. This behavior from the side of the health care provider makes the patient doubt their own self, leading towards self-stigmatization (Hinshaw, 2007). This self-stigmatization in turn makes the patients doubt their own self-esteem, lowering their own self-image (Hinshaw, 2007; Link, Struening, Todd, Asmussen, & Phelan, 2001). One of the accounts presented by Hinshaw in 2007 clearly states that a kid has internalized the belief that his grandmother punishes him because of his misbehavior as a child and self-blaming himself for the adult psychiatric episodes which he was having. In this way, public stigma makes the patients think that there is something wrong with them and they don’t deserve to exist in this world. Many mentally ill people want to get settled in the society but are unable to do so because the world stigmatizes them, the health care professionals stigmatize them and then they doubt their own credibility ending up in self-stigmatizing their own selves. According to former U.S. surgeon David satcher’s report on mental illness of 1999, he clearly concluded that stigma “leads to low self-esteem, isolation, and hopelessnessâ€¦, it deprives people of their dignity and interferes with their full participation in society.” (Satcher, 1999) That clearly highlights the effected abilities of the individual on the grounds of mental illness. According to the writer, self-stigma is inevitable. This highlighted effect of self-stigma is clearly evident in the case scenario presented above by the action of the patient herself, which she has looked down and moved away. This lowered self-esteem in turn brings out hopelessness in the clients (Link, Struening, Todd, Asmussen, & Phelan, 2001). Like the client in the given case scenario says that “nobody takes us seriously. We can’t do anything.” That clearly identifies the notion of hopelessness that the patient has no hopes from life and has accepted clear defeat because of the stigma associated with mental illness.
The next question is how does stigma affects the rehabilitation of the mentally ill patients. How does it affect the coping skills of the mentally ill patients? What are the coping mechanisms of the mentally ill patients which they use in stigma? What are the coping mechanisms of the patients with neurosis who are well aware of the reality and understand this notion of stigma, as opposed to the psychosis patients. According to literature, many a times, the stigma posed is due to many of the bizarre symptoms caused by psychosis and the patients with neuroses also have to take it as they all fall under the category of mental illness for the laymen regardless of psychosis and neurosis (Hinshaw, 2007). According to the ethical principle E of the American psychiatric association, the patients have the right of dignity and respect regardless of any differences; that implies to both psychosis and neurosis (Lowman, 2005). The psychotic patient as mentioned earlier is away from the reality content but they surely understand that they are being treated wrongly. (Levine & Levine, 2009) They are not able to think rationally but surely they are human beings and are witnessing what is going on with them. Many a times we witness that they cry over small things which are going wrong with them. They are witnessing the behavior of the health care provider but are unable to interrelate it to their past experience. Regardless of the psychosis, it is wrong to treat them any bad so how bad can it be for the neurosis client whose reality content is intact and who can rationalize everything that is going on with them and who can interrelate these aspects with their past and then can feel the shame (Hinshaw, 2007). The patient in the above mentioned case scenario would be forced to think if something is wrong with her resulting in feelings of shame and guilt. This guilt in turn takes the patient in the situation of self-stigmatization which leads on to hopelessness which clearly affects the coping mechanism of the individual since if the person would be hopeless towards his illness, the reconstitution would be delayed (Hinshaw, 2007). Stigmatization affects the personal response of the patient which is a vital part of process of coping. The personal responses are individualized and can change over time. Many a times, the strategy which patients use to avoid stigma and to preserve their self-esteem is secrecy, which preserves their self-esteem but isolates the individual from social support (Satcher, 1999; Hinshaw, 2007). stigma has an important part in determining public health consequences by revealing stigmatized individuals to health-harmful conditions, by aggregating stress, declining coping, and by putting a barrior to receiving health care (Link & Phelan, 2006). According to Corrigan and Watson (2002) as cited in hinsaw, 2007 there are many new reasons emerging to justify the reason for some individuals to respond with anger whereas some to nerely ignore the stigma and move on with their lives whilst some internalize the negative message while hurting their self-image. If stigma-related threat is believed to be of greater magnitude than one’s coping responses, several types of voluntary and involuntary reactions can come about, like lowered self-esteem, reduced achievement, and compromised physical health. (Hinshaw, 2007)
Several questions arise Looking upon the behavior of the health care professional such as is the attitude of the nurse justifiable? Would she have had the same stigmatized responsein the case of another pfysically ill patient? If she would have then she is not following the ethical principle E of the American psychological association of respect of people’s right and dignity. This principle clearly states that the regardless of the awareness of the disability, the health care provider has to maintain the respect of the patient. For the violation of this ethical principle, who is responsible? The nurse or the society to see all the mentally ill patients on a single wavelength and stigmatize them. Who is accountable for it? The nurse or the hospital settings or either the society to be accountable for such stigmatization? Would the same behavior have happened in the western settings? If the patient would have sued the in the court, whose statements would be more valued and listened to the nurses’ or the mentally ill client’s who is savaged and stigmatized in the community by the names of irrational and unthinkable. Many accounts of the depressed patients state the fact that they are not been taken seriously while giving some statements because of the stigma associated whereas if some other person of pathological chronic condition gives the same statement, it is taken seriously (Shaw, 1998). In the settings of the above mentioned case scenario, would anyone have had listened to her that her rights are being violated or would this all be given the name of mental illness and let go of?
One more side of stigmatization comes when we tease normal people by the names of the stigmatized people to embarrass them. In everyday life, language patterns indicates an anxiety with mental disorder across all age groups with a host of terms related to mental illness used to scapegoat and humiliate those who violate social norms. They are associated with mentally ill and words like psycho and wacho are used to compare people who go against social norms in the western community (Hinshaw, 2007). Whereas, no literature is to be found for the usage of such words due to the lack of researches in this field. Usage of variants of such terms at young ages signals the pervasiveness of the criticism of persons with mental disorders. Indeed, judgmental tags of “retard” or “crazy” are among the first terms used by children who haven’t even started their schoolings yet to relegate socially rejected friends in the west. (Hinshaw, 2007) Media also plays important role in stigmatizing the mentally ill. Media differs in east and west which directly effects pattern of stigmatizing. “People with psychotic-level disorders, as well as milder disturbances, were portrayed as ignorant, dangerous, dirty, unkind, and unpredictable.” (Hinshaw, 2007, p.118)
The model which could best be incorporated in this is Link and Phelan’s model of stigma. In this model stigma is processed by many different components. First one is on distinguishing and labeling differences(Link & Phelan, 2001). Most of the differences are usually ignored but sometimes they are not overlooked at and thus labeled. In my clinical case scenario, the patient was labeled as mentally ill having no work to do. The second component is on associating human differences with negative attributes(Link & Phelan, 2001). This occurs when the labeled differences are linked to stereotypes and so my patient’s mental illness was stereotyped as workless people. The third component is of on separating us from them which brings the notion of stigmatization(Link & Phelan, 2001). In the above mentioned case scenario also, the patient was referred to as out group as evidenced by the statement “patients like you come and go each day but we have work to do”, clearly defining the notion of us versus them. The last component is status loss and discrimination(Link & Phelan, 2001). In the status loss, patient is connected to undesirable characteristics that reduce his or her status in the eyes of the stigmatizer. In this case, the undesirable characteristic was that mentally ill patients are laid off and redundant where as we are working people so we are higher than them and in this way stigmatized people are put down at the bottom of the hierarchy.
Keeping in view the principles of American psychiatric association, the strategies which I would like to pose in this context is the nurse should look in the matter and confirmed the case with the nursing assistant as well as to the shop from which the nursing assistant got the nimco from. Moreover, nursing assistants should be taught all the rights of the patients so that being a health care provider; they would follow all the ethical principles. On an institutional level, a system should be made in which patients can have some responsible person to take care of these things instead of asking anyone they can get their hands on to.
To conclude, not much research has been done on this issue of mental health and proper awareness does not exist in this society. More researches needs to be done to address this issue as stigma in mental health persists all around the world. Strategies needed to be thought about to remove this factor of stigma. More education sessions about this needs to be done on the clinical side to make the nurses and other health care providers aware of what the rights of the patients are and a check and balance system should be there to acknowledge either those rights have been followed and fulfilled or not.
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