Living with Mental Illness in a Globalised World

Combating Stigma and Barriers to Healthcare

Ugo Ikwuka

• Publisher: Routledge
• Year: 2021
• Print ISBN: 9780367698294
• eBook ISBN: 9781000382884
• Topic: Medicine
• Subtopic: Psychiatry & Mental Health

Living with Mental Illness in a Globalised World systematically examines the manifold contributions to the burdens of living with mental illness in a developing and globalised world. It explores the stigma of mental illness, the burden of which compares to the symptoms of and is sometimes considered more disabling than the illness itself.

The book starts by reviewing the socio-psychological and cultural processes that contribute to stigma and providing evidence-based interventions to combat it. Chapters critically investigate the ideological and instrumental barriers to mental healthcare and establish that determining the conceptualisations of mental illness helps to unravel the reasons for the underutilisation of mental health services. A compelling case is made for a complementary healthcare model and bottom-up approach that is sensitive to the spiritual and cultural needs of the people.

The text's specific examination of mental healthcare in African countries makes it a timely piece for assisting mental health professionals in understanding the inequities in care that Black Asian and Minority Ethnic groups face and how to improve mental healthcare and delivery to these groups.

Part I

Attitudes towards Mental Illness

Introduction

Mental illness remains highly stigmatised worldwide (Morris et al., 2018). The form and nature may differ across cultures, but stigmatisation of mental illness is present in all societies and all classes of people. In almost all settings, whether social or professional, persons suffering from mental disorders will most certainly endure bigotry, ostracism, prejudice, a diminished social and economic standing, a lowered self-esteem and self-worth (Corrigan & Rao, 2012; Markowitz, 2014; Wu, Chang, Chen, Wang, & Lin, 2015). The burden of the stigma of mental illness has been compared to that of the symptoms and is considered arguably more disabling (Coker, 2005; Feldman & Crandall, 2007; Hinshaw & Stier, 2008), thus constituting double jeopardy for sufferers.

Research interest in the role of stigma in mental health has heightened as mental health-related problems have been accentuated in the public consciousness by celebrities and global leaders alike. Culture influences the experience, expression, and determinants of stigma, and the effectiveness of different approaches to stigma reduction (Al-Krenawi, Graham, Al-Bedah, Kadri, & Sehwail, 2009). Any meaningful intervention to combat stigma, therefore needs to take into consideration the cultural context. However, an unmet need for further research into the phenomenon has been noted, especially in the developing world where mental illness is suffered against the background of destitution and sub-standard care (Bhugra, 2006; Yang, 2007).

Rather than keeping a captive clientele in hospitals, deinstitutionalisation policies – a process that involves replacing long-stay psychiatric hospitals with less isolated community mental health services has become the major strategic response of national governments to coping with mental illness. The policy is supported by the strong evidence of ‘institutionalism’ – the development of disabilities as a consequence of social isolation and institutional care in remote asylums (Thornicroft & Tansella, 2002).

Consequently, the role of the community in the prevention of mental illness and care of afflicted persons has become acknowledged as the most appropriate basis for the development of community mental health programmes (Dessoki & Hifnawy, 2009). As deinstitutionalisation equally entails initiatives for public education on the recognition and prevention of mental conditions and the promotion of mental health in the population (Arboleda-Flórez, 2001), the knowledge of public attitudes to mental illness and its treatment becomes crucial to the realisation of successful community-based programmes.

The World Psychiatric Association (2002) acknowledged that the assessment of the community attitude to mental illness, and surveys of target groups with defined attributes are required to implement effective educational and anti-stigma programmes. The first part of this study robustly responds to the foregoing with a systematic account of stigma processes, types, determinants, consequences, and prevalence. The section concludes with evidence-based stigma reduction interventions.

1The Socio-psychological Processes of Stigma

Attitudes are evaluative dispositions that can influence behaviour (Zimbardo & Leippe, 1991). They can help people to process complex information about the world around them. However, when formed with prejudice, attitudes can undermine that critical process of making sense of the world. For instance, they can lead to stigmatising and socially devaluing a person. Corrigan and Watson (2002) proposed a stigma concept based on stereotypes, prejudice, and discrimination. While stereotypes represent notions of groups, people who are prejudiced endorse negative stereotypes thereby generating emotional (e.g., hatred) and consequent behavioural (e.g., discrimination) reactions. Thus, attitudes always involve cognitions, emotions, and behaviours.

The ancient Greeks originally used the term stigma to represent the marks that were pricked on slaves to demonstrate ownership and to reflect their inferior social status. ‘Stig’ is the ancient Greek word for ‘prick’ and the resulting mark is ‘stigma’. Thus, the stigma process consists of two fundamental components: the recognition of the differentiating ‘mark’ and the subsequent devaluation of the bearer. Sociological theories provide further insight into the dynamics of mental illness stigma. Erving Goffman’s (1967) classic formulation relies on two constructs: the actor and the audience. The actor in this context is someone who might have a mental health problem, while the rest of the society: neighbours, employers, family members, significant others, or institutions constitute the audience. Stigma occurs when a person’s actual social identity falls short of the ideal identity defined by society, such as behavioural expectations in given situations. Hence, a person with mental illness who may demonstrate lapses in social integration is a potential candidate for stigma.

Once spotted, such persons are labelled - formally tagged, which effectively isolates them. Subsequently, they are associated with undesirable characteristics, and broadly discriminated against as a result. Attitudes towards them change to agree with the label -a ‘psycho’ is dangerous; hence he is given a distance. Through a systematic, ongoing process of labelling and discrimination, the ‘career’ of mental illness is perpetuated for victims as the process effectively restricts and confines them to the world defined for them (Scheff, 1966). Discrimination in a range of spheres tacitly constrains them from returning to conventional roles. The victim is thus literally disabled: disempowered and depersonalised.

Consequently, such individuals may be compelled to interpret their experiences in the light of the prevailing social stereotype of mental illness and even modify their behaviour to fit the image. Thus, once the label is assigned, justified or not, it can become a self-fulfilling prophecy that promotes the development of psychiatric symptoms. Below, a survivor of schizophrenia relays this experience:

Like any worthwhile endeavour, becoming a schizophrenic requires a long period of rigorous training. My training for this unique calling began in earnest when I was six years old. At that time, my somewhat befuddled mother took me to the University of Washington to be examined by psychiatrists in order to find out what was wrong with me. These psychiatrists told my mother: “We don’t know exactly what is wrong with your son, but whatever it is, it is very serious. We recommend that you have him committed immediately or else he will be completely psychotic within less than a year.” My mother did not have me committed since she realised that such a course of action will be extremely damaging to me. But after that ominous prophecy my parents began to view and treat me as if I were either insane or at least in the process of becoming that way. Once, when my mother caught me playing with some vile muck I had mixed up – I was seven at the time – she gravely told me, “They have people put away in mental institutions for doing things like that.” Fear was written all over my mother’s face as she told me this…. The slightest odd behaviour on my part was enough to send my parents into paroxysms of apprehension. My parents’ apprehension in turn made me fear I was going insane…. My fate had been sealed not by my genes, but by the attitudes, beliefs, and expectations of my parents…. I find it extremely difficult to condemn my parents for behaving as if I were going insane when the psychiatric authorities told them that this was an absolute certainty.

(Modrow, 2003, pp. 1–3).

Thus, the judgments of others can turn innocuous miscues into pathological symptoms, thereby reinforcing the belief that some factors of mental illness could be socially constructed. Scheff (1966) was convinced that traditional approaches to understanding mental health and illness have a narrow and incomplete focus. He contests the reductionist approach with genetic and biochemical investigations that focus somewhat exclusively on dynamic systems within the individual, while social processes and the social system in which the individual is involved tend to be undermined or at best relegated to a subsidiary role.

As demonstrated in the classic Rosenhan (1973) study, a person labelled ‘mentally ill’ is likely to be stigmatised even in the absence of any aberrant behaviour. In the study, eight people without mental health problems presented themselves at various psychiatric hospitals, complaining that they had been hearing voices utter the words ‘empty’, ‘hollow’, and ‘thud’. They were quickly diagnosed as suffering from schizophrenia, and all eight were hospitalised. Although the false patients later dropped all their symptoms and behaved normally, they had great difficulty getting rid of the label and gaining release from the hospital. They reported that staff members were authoritarian in their behaviour towards patients, spent limited time interacting with them, and responded curtly and uncaringly to questions. In fact, they generally treated patients as though they were non-persons and invisible. One of the ‘patients’ recalls that a nurse unbuttoned her uniform to adjust her brassiere in the presence of an entire ward of viewing men. There was not the sense that she was being seductive (as cited in Comer, 2015).

In a study of the attitude of medical students in a south-western Nigerian University towards psychiatric label (Ogunsemi, Odusan, & Olatawura, 2008), a case vignette was presented that ended with a psychiatric label for the experimental group while the control group had the same vignette without the label. The case vignette reads, “Mr AB is a young man who can express his feelings and thoughts among those close to him, although he sometimes gets anxious while talking in a group consisting of strangers. He gets along all right with his family most of the time. Generally, he also gets along with other people. Compared to those of his age, his life can be considered as organised. He is generally an optimistic and happy person. In summary, he establishes a good balance between his social life and study”. For the students in the experimental group, the vignette concluded with the additional label, “This young man has been diagnosed as having mental illness by the doctor who examined him.”

Compared to those in the control group without the attached label, the students in the experimental group, who responded to the questionnaire with the attached psychiatric label, were significantly more unwilling to rent out their houses to the man. They were significantly more unwilling to have him as their next-door neighbour, barber, or hairdresser compared with the control group. They were also not willing to share an office with him or allow their sister to get married to him. They significantly felt that the man would exhaust them both physically and emotionally in their relationship with him compared to those in the control group.

Labelling defines patients in terms of their illness: ‘mental patients’, ‘the mentally ill’, ‘psychotic vagrant’ – terms that evoke images of chronic psychopathology. It strips sufferers of their pre-morbid identity and imposes on them the new stigmatised identity and role which comes to define them over and beyond their other roles such as parent or professional. A study of terms used by school children in England for mental illness revealed 250 different words and phrases, none of which are positive (Rose, Thornicroft, Pinfold, & Kassam, 2007). Similarly, a study that investigated school children’s perception of people with mental illness in south-western Nigeria found the most popular descriptor to be derogatory terms (33%), followed by ‘abnormal appearance and behaviour’ (29.6%) (Ronzoni, Dogra, Omigbodun, Bella, & Atitola, 2010).

As individuals so labelled come to accept the label, they can be ‘rewarded’ for affirming the label by misbehaving to expectation, a process that inadvertently works to reinforce and perpetuate the ‘career’ of mental illness. A classic illustration is the case of Mr Spell. This ostensibly mentally challenged Nigerian spews out letters randomly to ‘spell’ any word. As he does this, the amused audience urges him on after each syllable, and he randomly churns out scores of letters to ‘spell’ a mere four-letter word. As he is excitedly urged on, he feels that he is making sense and the more he ‘performs’. Moreover, his disability means that he lives on the handouts from his audience to whom he is indebted for his survival, and their support largely depends on the extent that he ‘entertains’ them. In fact, if for any reason he fails to misbehave, or his misbehaviour falls short of people’s expectations, he could be punished, not only by being denied the token handouts on which he survives as a destitute vagrant but through direct harassment and victimisation. Today, Mr Spell’s spelling folly has been adapted into music for entertainment, and many of his spelling clips trend on social media.

Indeed, the saying that “every village needs an idiot and every circus a clown” may well pass for Nigerian where it is common for people to create circuses and oblige the ‘madman’ (vagrant sufferer of psychosis) to amuse them with his regressive behaviour. In a case study of south-eastern Nigeria (Ikwuka, 2016), 77% of respondents agreed that people make fun of people with mental illness. As depicted in the Nigerian movie Village Destroyers, a common spectacle is crowding around the ‘madman’ who is obliged to fulfil expectations by dancing weirdly to the mockery tune sung for him. If he dances to expectation, he is ‘rewarded’, for instance, with something to eat, including degraded food. Otherwise, he could be denied such token handouts on which he lives. He could be additionally punished: flogged, kicked about or drenched in wastewater. The situation is reminiscent of the asylum era in Europe when watching people with mental illness became a popular form of amusement, and some asylums even had specially built patient-viewing galleries for the public.

Skinner and colleagues (1995) discern a hierarchy of stigma whereby inferior social statuses like ‘prostitute’ and ‘alcoholic’ are ranked with mental illness at the bottom of the hierarchy. The stigma of mental illness has been referred to as the ‘ultimate stigma’ (Falk, 2001), exceeding those of other conditions and stigmatised groups, including foreigners, immigrants, and those with physical disabilities, because the public perceives it as the most disabling (Economou, Gramandani, Richardson, & Stefanis, 2005; Thompson, Stuart, Bland et al., 2002).

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Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Contents
• Foreword
• Preface
• Acknowledgements
• PART I: Attitudes towards Mental Illness
• PART II: Barriers to Mental Healthcare
• PART III: Pathways to Mental Healthcare: Evolving an Effective Design
• References
• Subject index