Editorial

Stigma in mental illness: a continuing concern

Michelle Cleary
Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore

Maureen Deacon
Professor, Mental Health and Learning Disability Department, University of Chester, Warrington Campus, United Kingdom

Debra Jackson
Professor, Faculty of Nursing, Midwifery and Health, University of Technology, Sydney (UTS), Broadway NSW

Sharon Andrew
Department of Acute Care, Faculty of Health and Social Care, Anglia Ruskin University, Chelmsford, United Kingdom

Sally Wai-chi Chan
Professor, Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore

PP: 48 - 50

Article Text

As we live longer in the developed world our chances of experiencing a long-term condition grow, whether it is our own condition or that of someone close to us (Presho, 2008). The contemporary focus on 'survivorship' in cancer care (Bellury et al., 2011) is a good example of our changing experiences of health status. More people are living with cancer, rather than dying prematurely from it, and this has huge systemic ramifications for the individual and their social network. These ramifications include injury to the person's mental health. For example, post-diagnosis, people with cancer are vulnerable to developing debilitating depression (Slovacek et al., 2009).

Deacon (2008) has argued that good mental health is a prerequisite for positive adjustment and effective self-management in the face of developing a long-term condition. Consequently she argues that promoting mental health should be considered as important and routine interventions given by all nurses to all patients. A particularly vulnerable group of patients are those with serious mental illness who also develop a long-term physical condition. There is a complex interplay of bio-psycho-social factors that can impact negatively on their health outcomes and researchers are engaged in trying to understand these dynamic relationships as a pre-cursor to effecting change (Howard et al., 2010). Of critical importance is the stigma of mental illness. This stigma impacts on nurses' willingness to engage in mental and physical health promotion, leading to a systemic failure in person / family-centered care (Horsfall, Cleary & Hunt, 2010).

According to Lauber (2008) "the common understanding of stigma is a severe social disapproval due to believed or actual individual characteristics, beliefs or behaviours that are against norms, be they economic, political, cultural, or social" (p.8). Stigmatizing attitudes exist amongst health professionals including those employed in mental health, which may result from staff working with patients when they are in the most disturbed phase of their illness, despite this not being a typical characteristic of everyday mental illness (Horsfall, et al., 2010). Further, research shows that there are many prejudices and negative attitudes held towards people with a mental illness within the wider community, and that many people regard social interaction with mentally ill people as uncomfortable, viewing the behavior of the individual as potentially dangerous and/or violent (Lauber, 2008). For people living with a mental illness stigmatizing attitudes towards them are a common occurrence, which results in everyday discrimination and disparities. For example, disparities occur in education, housing, job opportunities, income and health care, so whilst stigma on its own is damaging, the discrimination that it can result in can be much worse (Pope, 2011). Discriminating against an individual may produce stigma resulting in social deprivation, such as the refusal of accommodation, which can lead to homelessness, which in turn generates additional stigma (Horsfall et al., 2010). Thus, stigma and discrimination impacts on the individual, and on the health and well-being of their families, and communities. For example, a study of mentally ill parents found that they were reluctant to bring their children for activities outside the home. The parents worried that their children would be stigmatized because of their mental illness. They also had constant worry that their children would be sent to a foster or children's home because of parental mental illness (Chan et al, 2011). This how the impact of stigma not only affected the person living with a mental illness, but also their children and family.

The experience of having a long-term mental health condition brings patients and their families into long-term relationships with health care providers. These relationships demand something different from nurses who may be more accustomed to rapid and task focused interactional contacts that promise quick fixes. Healthcare providers need to build a long term trusting relationship with patients and their families by being with them, listening to their concerns, and providing education, information and social support (Chan, 2011; Cleary et al., 2005). Isolation, shame and secrecy about mental illness could be improved by open discussion with patients and their families, and encouragement for participation in treatment of the illness (Chan, 2009). Taking an open approach means that patients and their families would appreciate that they are not alone. With strong support from healthcare professionals, they would be better placed to build up the courage and confidence required for managing the illness and associated difficulties.

It is also evident that people living with a serious mental illness often have their physical and medical needs overlooked, with their average life span identified as approximately 25years less than that of the general population (Parks & Vreeland, 2007; Pope, 2011). This higher incidence of adverse outcomes has, in part, been linked to the attitude of the healthcare provider (Pope, 2011). The use of derogatory and pejorative terms, which is unacceptable and unprofessional contributes to and perpetuates stigma (Pinfold et al., 2003; Putman, 2008) that in turn, can influence the provision of general care for people with mental illness.

It is incumbent on nurses to set the tone of the work environment and be advocates and speak out in support of all their patients. Nurses are well positioned to ensure a zero tolerance towards discrimination so that people living with a mental illness get access to fair and equitable healthcare, appropriate to their needs. Less visible discrimination can result from the process of 'diagnostic overshadowing' where a diagnosis of mental illness is seen by the health worker as the primary factor at work (Jones, Howard & Thornicroft, 2008). For example, a patient previously treated for severe depression who is now complaining of acute back pain may be offered anti-depressants rather than physical investigations, leading to treatment delay and continued suffering.

It is timely for us all to reflect upon and challenge our values and beliefs and think about how our attitudes may potentially contribute to a range of adverse outcomes for people with a mental illness and those whose well-being has been further threatened by physical health problems. The way we as health professionals work with patients, their families and communities can have a crucial effect on prompt diagnosis, treatment and recovery. Furthermore, development of trusting therapeutic relationships could enhance mental health consumer participation in primary health care strategies such as health care screening, which can not only prevent illness from developing, but assist with early diagnosis and treatment initiation. Interdisciplinary and community partnerships are required to ensure that health care services are appropriate, and target detection, prevention and treatment.

At the end of the day, the solution is basic but socially and organizationally challenging. It requires healthcare providers, including nurses, to advocate for patients and to speak loudly when they see those living with a mental illness receiving suboptimal care from healthcare professionals (Pope, 2011). Quite simply, this is a person / family-centred approach to care that demands the essential nursing skills of empathy, active listening and humility. This will mean, for instance, finding out what is important to a person and their family rather than making assumptions about them.

Nurses play a critical role in building a caring culture and can contribute to promoting mental health literacy, reducing misunderstanding about mental illnesses and social stigma (Chan, 2009; Horsfall et al., 2010). It is important that we reinforce and promote the caring culture. Nurses groups around the world could form united force to advocate for people with mental illness and promote a more accepting and caring culture in their societies.

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