Psychology and Psychiatry: Open access
Open Access

As slavery plagued humanity for many years, somewhere in ancient city of Greece, slaves and criminals were marked by cutting their flesh in order to recognize them for easy recognition of their low worth to society. The word “stigma” is derived “stizen” a Greek word for a “brand impressed by an iron”. Current understanding and use of the concept stigma in the social sciences is based on the work of Erving Goffman. He defined stigma as an “attribute that is deeply discrediting” reducing the bearer “from a whole and usual person to a tainted, discounted one” He differentiated between three types of stigma, associated with physical deformity, flawed individual character (including mental disorder), and membership of an objectionable social group [1]. Gary defined stigma as “a collection of negative attitudes, beliefs, thoughts and behaviors that influences the individual, or the general public, to fear, reject, avoid, be prejudices, and discriminate against people with mental disorders.” There are various types of stigma. The beliefs and attitudes of the general population to persons with psychiatric disorders and their families is called Public stigma. Self-stigma occurs when a mentally ill person internalizes stigma thereby experiencing reduced self-efficacy and self-esteem. Stigma by association refers to negative characteristics attributed to caregivers, family members and healthcare personnel who are in close contact with stigmatized people.

Centuries have passed in removing the belief of the masses that Mental illness is not a result of demonic possession, but a consequence of neurotransmitters imbalance. Yet we are fighting a battle to remove the demon which has grown in the minds of people as they continue to stigmatize mental illness. Recent years has seen a surge in research in the field of stigma in psychiatric disorders, which may be said to be synonymous with study of discrimination faced by persons with psychiatric disorders. As a result, our knowledge of this field has increased exponentially [2-3]. It has been established that as a result of stigma, psychiatric patients suffer discrimination and exclusion at a personal level. Thus, it causes adverse financial, health and societal effects on psychiatric patients, their families and caregivers. In addition, it also has adverse effects on the society [4]. Stigmatizing mentally ill is similar to racism, it is at par with discrimination on basis of creed and wealth, and it is the rust which is rotting the frame of mental health. The negative attitudes toward persons with psychiatric disorders are widespread and prevalent all over the globe. Moreover, stigma affects all patients who are labeled as mentally ill and is not restricted to persons with psychiatric illness who are violent or exhibit bizarre behavior. People even assume that the psychiatric patients also suffer from permanent intellectual disabilities [5-8].

Worldwide initiatives to cease the discrimination and stigmatization against the mentally ill are being undertaken. WHO has outlined International standards to guide countries in framing policies and laws concerning persons with mental illness. Worldwide a national mental health policy was adopted by 62% of nations by the year 2005 [9]. An Action Plan for Mental Health of European nation was agreed to achieve the under mentioned:

• fostering awareness about psychiatric disorders

• tackling inequality, prejudice and dishonor faced by psychiatric patients.

• improving the professional services for the care of psychiatric patients

• improve the training and availability of mental health professionals.

• take advantage of the understanding and experience of psychiatric patients and carers [10-12].

Since the seminal work of Goffman, the stigma concept has been applied to many groups and the literature on various theoretical as well as practical aspects has accumulated. ‘Stigma' is a social construct whereby society imposes discredits upon individuals. The term has been critiqued because it focuses attention (and blame) on individuals and their health difficulties rather than the collective perpetrators of negative attitudes and unfair treatments or behaviors [13]. Link and Phelan's model explains the development of stigma as a result of interaction of different mechanisms viz. labeling; stereotyping; separating ‘us' and ‘them'; status loss; and discrimination, in the background of control to create ‘stigma' [14].

The relatives of persons with psychiatric disorders have an important position in their lives. Regrettably, the family’s position is often damaged. Family members are frequently stigmatized due to their connection to the person with psychiatric disorder. This type of stigma was named as courtesy stigma by Goffman. Courtesy stigma includes the stereotypes of responsibility, disgrace, and contagion; attitudes of the population that hold the patient’s family members to be responsible for their mental illness

Despite advances in psychiatric research clearly pointing to biological and genetic models of psychiatric disorders, dispelling the notion that one of the causes of mental disorders is bad parenting, the belief still persists in the general population. Due to this the family is considered to be culpable for the psychiatric illness of the patient. Consequently, family members feel guilt and embarrassment, but in addition may keep away from community get –togethers, make efforts in concealing the mentally ill person, and may be unfairly treated in matters of jobs and accommodation.

To evade disgrace to the family the psychiatric disorder 25% to 50% of family members believe that the illness of the member should be concealed; 20% to 30% family members reported low self-worth, [15–17] and strained relationships with friends and significant others [16-19] while 10% observed avoidance by friends because of psychiatric disorder of a family member [15]. Avoidance was more when the person with psychiatric disorder was staying with them [15,18]. In one study 25% of 178 family members believed that others reproach them for the psychiatric disorder of their relative [16]. Patients report that stigma and discrimination occurring as a result of their own (or members of their family) was harder to bear that the psychiatric disorder itself. Stigma is all-encompassing. It adversely affects the individual’s ability to continue his academic activities, accommodation, job, insurance and obtain impartial dealing from the legal system [19].

People who suffer from mental disorders have no relief even under the roof of a health institute, right from emergency physician to outpatient consultant all of them have a pre-conceived notion about the mentally sick, they act in a solicitous manner in front of them and at times refuse to examine them alone, sometimes they ridicule their illness and consider their suffering tale as a fable. Psychiatric patients say on learning that they have a mental illness, physicians ignore even their concerns about physical health. Discrimination and bias against patients with co-existing psychiatric disorders among doctors is well established. Almost 28% of medical students and 56% of doctors believed that patients with mental illness were not easy to like” [20]. Unfortunately, the attitude of doctors, apart from psychiatrists, towards the mentally ill is often the same as the general population [21-22].

Psychiatrists, themselves, are stigmatized by the population, other doctors and paramedical personnel. “Psychiatrists are looked down upon for not being “real” doctors” [23]. Bias against Psychiatrists exist among doctors, scientists and politicians. It also serves as an obstacle to the free exchange of information about mental illness that can result in improved management of psychiatric disorders, better practices and availability of better funding in the system of mental health [24].

Two forms of stigma have been described (public stigma and selfstigma) both of which impact persons with mental illness negatively. However, the effects they produce are different. Public (social or enacted) stigma results in discrimination and loss of status of the stigmatized person in society. Self (Internalized or felt) stigma exists at the individual level and in the context of psychiatric disorders can be described as a process by which the affected individual accepts stereotypes about mental illness, anticipate social rejection, and believe they are devalued members of society. This leads to reduced selfesteem and unwillingness of the subject to engage in life opportunities [25-26]. Adolescents with psychiatric disorders do not feel normal as they have to take medications, which differentiate them from their peers who are not on medication. Young people desire to be perceived as completely normal. Hence, to protect their self-image they deny and hide the fact that they are taking treatment for a psychiatric disorder [27].

Concerted and continuing efforts at individual, service, national and global level are essential to reduce if not remove stigma towards psychiatric patients, psychiatrists and other mental health professionals. It is essential to scrutinize our own attitude and to judge if it influences our clinical practice [28]. During the training of doctors, due to the structure of the course, an artificial separation is made of “mind” and “body”. This results in an ingrained but erroneous belief that thinking, emotions and feelings are disconnected from our physical body. Moreover, while the pathophysiology of physical illness is understood, that of psychiatric disorders remains unknown. The fact that despite the symptoms of “mental illness” being psychological, the root cause is “physical abnormalities” be it neurodevelopmental of neurochemical, if widely known would remove this artificial separation and probably reduce the stigma.

Providing knowledge and altering the attitudes of the providers of medical care is of paramount importance. Physicians are the interface between Psychiatry and patients and their attitude towards psychiatry will subsequently guide the advances which will be made by their patients.

Provide factual information about psychiatric disorders through print and electronic media. The media should be responsible and accountable. Inaccurate portrayal of persons with psychiatric disorders in the media is common due to which altering stereotypes are difficult.

Highlight, appreciate and recognize the achievements of persons who have psychiatric disorders [19]. People with mental illnesses have made major contributions to diverse fields including the arts and the sciences, from professional sports to entertainment. The support of popular faces like celebrities, athletes and national heroes will help in reducing the stigma.

Do not classify individuals by their disease. Instead of saying, "He's a schizophrenic," say, "He suffers from a psychiatric disorder."

Side effects of psychotropic medications, such as extra pyramidal signs, may be more potent markers of mental illness than the symptoms of the original diagnosis. Improved treatment and care of the mentally ill are central to the fight against stigma and discrimination.

One of the major reasons for stigma is that psychiatric disorders were treated at Mental hospitals and not at general hospitals. Shifting some or all of the mental hospital beds to general hospitals will not only reduce stigma but improve the care of the mentally ill.

The World Psychiatric Association began to campaign against the stigmatization of psychiatry and psychiatrists. Sartorius has admitted that diagnoses are problematic, calling for more care in the use of labeling. He argues that diagnoses can be misunderstood by nonmedical professionals and especially by the public, where they feed into negative stereotypes [29]. Recently some people have even voicing against using the term psychiatry itself. They are of the opinion that the term “psychiatry” itself be changed citing reasons or equating it with the name of the psychiatric disorder. Argument given is say schizophrenia or psychiatric illness; they are one and the same thing. Changing names only lead to more confusion. The need of the hour is awareness.

Stigma of mental illness not only reduces the individual’s self- worth but adversely affects his relationships and opportunities for employment. Providing clear information about the genetic, neurological and biochemical basis of the symptoms of psychiatric disorder will help remove the erroneous beliefs, reservations and bias against it.