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The most debilitating aspect of mental illness can be coping with
the social stigma, says ROWENA ALMEIDA.
‘PULL YOURSELF TOGETHER’:
stigma of mental
illness in Ireland
“If mental health becomes more of an everyday
issue, that matters to us all, then the stigma
attached to getting help can be reduced. While
Irish society will continue to experience
considerable change and face new challenges
ahead, a mentally healthier Irish society will be
much better able to cope.”1
Health Service Executive
Introduction
Would we accept someone with a mental illness as a close
friend?
One-third of the 187 people surveyed in 2009 for St Patrick’s
University Hospital answered ‘no’. Close to 52% of these people
claimed that a family member had been treated for a mental
illness, yet 40% of them still felt that undergoing treatment for
mental health is a sign of failure.2 These statistics, although
based on a relatively small sample size, highlight the stark
reality echoed across surveys. The biggest barrier in the
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realisation of mental health is ‘stigma’ and the associated
discrimination. It is tragic that the distress of mental illness is
only partially related to the medical problem. Instead, the most
debilitating aspect of mental illness is the reaction and attitudes
of others, and often of ourselves.
The World Health Organisation (WHO)
defines mental health as “a state of
well-being in which every individual
realises his or her own potential, can
cope with the normal stresses of life, can
work productively and fruitfully, and is
able to make a contribution to her
or his community”.
The World Health Organisation (WHO) defines mental health as
“a state of well-being in which every individual realises his or
her own potential, can cope with the normal stresses of life, can
work productively and fruitfully, and is able to make a
contribution to her or his community”.3 Based on this criterion,
Hardcastle et al. showed that 30% of all general consultations
involve a mental illness, and estimated that one in four people
will have a mental illness at some point in their life.4 Therefore,
it comes as no surprise that mental illness is a leading cause of
disability and is a WHO priority.
Stigma is a socially constructed mark of disapproval, shame or
disgrace that causes significant disadvantage through the
curtailment of opportunities.5
During the middle ages, mental illness was considered a sign of
weakness of character. It is a shameful reality that contemporary
societies and cultures continue to endorse this myth.4 Research
shows that stigma has detrimental effects on health and
well-being, and exacerbates the fear and isolation experienced
by the excluded individual.5,6 Thus, addressing the stigma
surrounding mental illness is justifiably a crucial step in the
management of mental health.
The concept of stigma
Feelings of rejection and marginalisation by the society in which
we live is a form of social suffering that is rooted in fear,
misunderstanding and misconceptions.7 Goffman
conceptualised stigma as a means for society to categorise
people on the basis of normative expectations, thereby dividing
the ‘normal’ from the ‘deviant’.7 The end result is that these
individuals are identified with an attribute that reduces them
“from a whole and usual person to a tainted and discredited
one”, socially discounting and excluding them.4 The three
constructs that fuel stigma towards mental illness are a lack of
knowledge (ignorance), negative attitudes (prejudice) and
hostile behaviour (discrimination).8 Prejudice – that is, the
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cognitive and affective response of fear – is influenced by our
poor understanding of mental illness. Ignorance, anxiety and
the avoidance of people with mental illness ultimately leads to
discrimination.
Stigma towards mental illness can be analysed on three levels.
First, self-stigma is an internal process whereby people judge
themselves based on messages received from societal norms.
This internalised identity decreases self-esteem when the person
believes that they have failed to meet societal expectations.
Corrigan describes this concept as a private shame that raises
self-doubt about one’s capacity to live independently, have
meaningful relationships or hold a job.4
Second, structural stigma (or public stigma) occurs when the
population endorses and implements stereotypes, prejudice and
discrimination to deny people with a mental illness their due
entitlement in terms of interpersonal relationships, custody
rights, employment or participatory citizenship.9
Third, label avoidance is a means by which stigma can harm
individuals who have not yet been diagnosed. These individuals
do not seek healthcare so as to avoid the label of mental illness.
Research suggests that half to two-thirds of individuals who
might benefit from psychiatric services opt not to pursue them
for fear of stigmatisation and discrimination.9
At a time of economic uncertainty, it is
fortunate that these programmes exist
and promote concerted action against
discrimination. Our success lies in
eliminating stigma towards mental
illness in its entirety so that we can
accept people with mental health
problems into the community
with their differences and all.
Stigma towards mental illness in Ireland
Grow, the mental health charity, estimated a sevenfold increase
in young adults attending its mental health support group in
2009.2 Given this incidence, it is worrisome that the 2006
National Disability Authority (NDA) survey on ‘Public Attitudes
to Disability in Ireland’ found that people had the most
negative attitudes towards those with mental health difficulties
compared to other disabilities such as physical, intellectual,
visual, auditory or long-term illness. While it is encouraging that
94% of Irish people were aware that anyone could be subject to
a mental illness, more than half revealed that they would not
want people to know they had one.10,11 It is clear that
considerable stigma surrounds mental health issues in Ireland.
Stigma associated with mental illness is a public health
challenge because it has adverse consequences for both the
patients and their families that pervades everywhere from
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schools to the workplace.12 Only 36% agree that children with
mental health problems should be in the same school as other
children. In the workplace, people would be least comfortable
having colleagues with a mental illness in comparison to other
disabilities, such as physical or intellectual.10 Moreover, six in 10
adults believe that people with mental health problems should
not qualify for important jobs such as being a doctor or a
nurse.10 Such negative attitudes towards mental illness can
affect the quality of care provided for these patients and is a
barrier to their recovery. We need to vanquish the view that
people with mental illness are inferior or a threat to society, and
instead harbour a positive attitude towards these individuals.13
The recent RTÉ documentary Behind
the Walls addressed the powerlessness of
people receiving mental health services,
and it elucidated the importance of
a balanced partnership between
healthcare professionals and service
users as a means of affording the
latter active participation with
relation to their illness.
Combating stigma
Considerable effort has been undertaken to overcome stigma.
For instance, the priority of the Mental Health Action Plan for
Europe (2005) is to “foster awareness of the importance of
mental well-being”. Their specific actions include promoting
community-based multi-level interventions, involving public
awareness campaigns and efforts to make mental health an
integral part of public health.1 Targeted outcomes and modest
anti-stigma campaigns focused at a well-defined audience are
the most successful and sustainable.14 Studies have shown that
education-based interventions result in improvements in beliefs
about treatments, a decrease in social distance from people
with mental disorders and an increased confidence in providing
help to someone with a mental disorder.15 Research would also
encourage opportunities for social interaction, which in itself is
more effective than anti-stigma campaigns. Another approach
to combat stigma is to provide mental health services at the
community level, such that multidisciplinary facilities for both
mental and physical health are available within the same
setting.
This would minimise segregation in treatment and prevent
disruption to everyday life.16 The recent RTÉ documentary
Behind the Walls addressed the powerlessness of people
receiving mental health services, and it elucidated the
importance of a balanced partnership between healthcare
professionals and service users as a means of affording the latter
active participation with relation to their illness.
Founded in 1996, See Change is a national stigma reduction
partnership scheme that hopes to change attitudes towards
mental illness by increasing public understanding of mental
illness. Their targeted public education activities are designed to
provide factual information and suggest strategies for
enhancing mental health (Figure 1).17,18 As healthcare
professionals, we need to dispel stigma as a necessary part of
our training and as a vital component of the treatment of
patients in the mental health system.
These Irish initiatives have been positive steps towards changing
public attitudes and behaviour towards mental illness. At a time
of economic uncertainty, it is fortunate that these programmes
exist and promote concerted action against discrimination. Our
success lies in eliminating stigma towards mental illness in its
entirety so that we can accept people with mental health
problems into the community with their differences and all. Or,
as Samuel Goldwyn would put it: “You’ve got to take the bitter
with the sour”.
Rowena Almeida is an RCSI medical student.
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Education
Talking
openly
Media
Decrease
stigma by
Quality
support and
treatment
Language
Personal
role
FIGURE 1: Strategies to combat stigma towards mental illness as undertaken by See Change. Image courtesy of seechange.ie.19
References
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HSE. Mental Health in Ireland: Awareness and Attitudes. 2007.
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Tinsley O. Attitudes survey reveals mental health stigma. Irish
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3.
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stigma’. Eur J Public Health. 2010;20(2):131-2.
13. Chambers M, Guise V, Valimaki M, Botelho MA, Scott A,
WHO. Mental health: a state of well-being. 2009. Cited
Staniuliene V et al. Nurses’ attitudes to mental illness: a
September 8, 2010. Available from: http://www.who.int/
comparison of a sample of nurses from five European
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Martin JM. Stigma and student mental health in higher
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2010;10:339.
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16. Datta A, Frewen J. Stigma of Mental Illness. Updated
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Arboleda-Florez J. What causes stigma? World Psychiatry.
http://www.imt.ie/features-opinion
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Corrigan PW, Wassel A. Understanding and influencing the
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stigma of mental illness. J Psychosoc Nurs Ment Health Serv.
2008;46(1):42-8.
10. NDA. Public Attitudes to Disability in Ireland: Report of
Findings. 2007.
11. SeeChange. Public Attitudes towards mental illness – A
Benchmark Study for See Change. 2010.
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/2010/09/stigma-of-mental-illness.html.
17. See Change. The National Mental Health Stigma Reduction
Partnership. 2010. Available from: www.seechange.ie.
18. Taking Control of your Mental Health. Shine. 2009.
19. See Change: What Can be done? 2010. Available from:
http://www.seechange.ie/index.php/stigma-and-discriminatio
n/57-what-can-be-done.