The Stigma of Mental Illness in Developing Countries
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The Stigma of Mental Illness in Developing Countries
Seeking treatment for mental illness can be a daunting task. Even in the United States, where medical care is relatively easy to obtain, there is a stigma surrounding mental illness. In my own experience of living in a small, close-knit community, I found it nearly terrifying to talk to my primary care physician about the anxiety and depression I was experiencing. In my town, parking my car at the counseling center was like admitting that I couldn't take care of myself. The common perception in the community was that people need to 'suck it up' and not rely on doctors or therapists to get through life. With this clear and prevalent stigma against mental illness and treatment, it took me years to finally get the help that I needed. This issue of stigma was still on my mind when I started looking for a topic for this research project. I was curious about how non-Western and developing countries viewed the issue and what was being done to help lessen the stigma of mental illness worldwide.
What is Stigma?
In order to take a close look at mental health stigma in cultures around the world, we first need to understand exactly what is meant by 'stigma.' The dictionary definition of stigma is 'a mark of disgrace or infamy; a stain or reproach, as on one's reputation' (Dictionary.com). This is a good place to start, but it does not accurately define the measurable aspects of stigma, which is necessary for researchers to be able to study it. Link et al. (2004) discuss several theoretical perspectives for stigmatization in general and the stigma of mental illness in particular. Most useful for the purposes of this paper is the framework laid out by Link and Phelen (2001) and discussed and elaborated upon by Link et al. (2004) that suggests several interrelated categories: labeling, stereotyping, separating, emotional reactions, status loss, and stigma's dependence on power structure. Labeling is a natural way that humans categorize differences, and many labels (shoe size, favorite foods) are not socially salient. Other labels, such as sexual preference or nationality, are much more relevant. 'Both the selection of salient characteristics and the creation of labels for them are social achievements that need to be understood as essential components of stigma' (Link et al. 2004). In the stereotyping component, the researchers suggest that the labeled differences are linked to negative assumptions about the labeled person or others with similar characteristics. The next aspect of the 'stigma process' is separating, which is the 'us versus them' mindset. Link et al. (2004) suggest that one place the initial conceptual framework about stigma is lacking is in the underrepresentation of emotional reactions: 'We believe that this underrepresentation needs to be corrected, because emotional responses are critical to understanding the behavior of both stigmatizers and people who are recipients of stigmatizing reactions.' Status loss and discrimination can be overt, like refusing employment to someone with a mental illness, but it can also be much more insidious and pervasive. Link et al. (2004) gives the example that considerably less funding exists for schizophrenia research and facilities for schizophrenia treatment are often located in less desirable locations. The final aspect of the stigma framework is its dependence on power structures ' Link et al. (2004) state that this aspect is very important because without social, cultural, economic and political power the concept of stigma would be much less useful.
Now that we understand at least one way in which stigma can be defined, we must next go about looking at the ways stigma is measured. Link et al.(2004) state that there is a considerable lack of study of mental illness stigma in the developing world ' they reviewed a large number of studied conducted worldwide, and found only a few in Asia and Africa, though the researchers did clarify that this might have been because their review was restricted to English language journals. This paper will focus on a few key studies, but it is certain that more study in this area is needed to get an in-depth look at differences between cultures and the relative stigma of mental illness.
Some studies focus on the stigma of the general population towards those with mental illness, while others focus on the opinions of people who suffer from mental illness. One survey I found to be particularly interesting and useful is the World Mental Health Survey, in which subjects with mental health issues were asked about their perceived stigma (Alonso et al. 2008). For this survey, stigma was considered to be present if respondents reported both embarrassment and perceived discrimination related to illness. Among people with significant activity limitations (i.e., at least moderate difficulty with cognition, mobility, self-care, or social), the perceived stigma rate was highest in the Ukraine, with 32.1% of respondents reporting stigma. The lowest rate was 3.2% in Germany. The average rate of perceived stigma in developing countries was 22.1%, compared to 11.7% in developed countries (Alonso et al. 2008, Table 1). The researchers' finding was that perceived stigma associated with mental disorders is universal, but considerably more frequent in developing countries; however, the implications of this finding were not discussed, though they suggest 'it may be of interest to investigate social, cultural and health service characteristics that differentiate countries in which patients feel less excluded from countries in which patients are more likely to report perceived stigma (Alonso et al. 2008:312). The researchers also found that 'perceived stigma is strongly associated with common mental disorders, particularly with comorbid mood and anxiety' (Alonso et al. 2008:306). The implications of this survey are twofold: first, developing and developed countries have different ways of associating stigma with mental illness, although the reasons for this are not clear. Second, people with mental illness are much more likely to perceive stigma relating to illness than, for example, people with chronic physical ailments. Most interesting to me is the fact that the statistics from Alonso et al.'s (2004) study shows that developing countries have nearly double the rate of perceived stigma as developed countries.
Studies of Stigma in Developing Countries
Lauber and Rossler (2006) conducted a review of literature that summarizes results of research on the stigma of mental illness in developing Asian countries. They state that this research is very important because 'The stigma of mental illness and discrimination against mental patients are believed to be a significant obstacle to development of mental health care and to ensuring quality of life of those suffering from mental illness' (Lauber and Rossler 2006: 158). They provide a clear discussion of how they defined developing and developed countries:
'A developing country is a country with a low-income average, a relatively undeveloped infrastructure and a poor human development index when compared to the global norm'Development entails developing a modern infrastructure (both physical and institutional), and a move away from low value added sectors such as agriculture and natural resource extraction. Developed countries usually have economic systems based on continuous, self-sustaining economic growth' (Lauber and Rossler 2006:160).
This definition helps clarify some of the general differences between developing and developed countries.
Lauber and Rossler's (2006) review of literature found that people in developing countries in Asia are generally afraid of those with mental illness. They also found that many studies reported respondents who felt that mental illness symptoms were a normal reaction to stress; this finding suggests that awareness of mental illness and the need for medical intervention is lacking in these cultures. However, the results of these studies are similar to the results in Western countries (Lauber and Rossler 2006). Another finding of this study was in regards to help-seeking behaviors: it is much more likely for those seeking help for mental illness to rely on family members instead of professional mental health services (Lauber and Rossler 2006). I found it interesting that the researchers suggest the differences in mental health care in developing Asian countries is due not only to 'a different cultural understanding of health and health care,' but also the stigmatizing attitude of health care professionals as well (Lauber and Rossler 2006).
Gureje and Lasebikan (2005) studied the use of treatment services for mental illness in the Yoruba-speaking part of Nigeria through face-to-face interviews with nearly 5,000 adults. They found that fewer than 1 in 10 people with mental health disorders over the past 12 months had received any treatment whatsoever, compared with 25% in the United States (Gureje and Lasebikan 2005). They also found that respondents who did receive treatment were much more likely to be treated in the general medical sector rather than by a mental health specialist; these results are similar to those found in other developing countries as well as developed nations. Another significant finding was that people with mental illness were considerably less likely to use 'complimentary health providers' than those with other non-mental disorders: 'This observation flies in the face of the common belief that traditional healers provide service for a high proportion of persons with mental disorders in developing African countries' (Gureje and Lasebikan 2005:48). The authors suggest that many of the problems with mental health utilization in Nigeria result from its inadequate health service personnel and facilities, financial constraint, as well as 'poor knowledge of and negative attitude to mental illness (both of which are rampant in Nigeria)' (Gureje and Lasebikan 2005:48). This suggests that in addition to the need for better health systems in developing countries, we also need to address the issue of stigma towards mental health treatment.
Another study in 2005 attempted to look at the existing attitudes towards mental illness in the same Yoruba-speaking part of Nigeria. Gureje et al. (2005) studied over 2000 respondents and found widespread stigmatization of mental illness. The researchers found that respondents were often misinformed about the cause of mental illness with 80.8% stating that mental illness could be caused by drug or alcohol abuse, 30.2% claiming possession by evil spirits as a cause, followed by about equal responses of trauma, stress, and genetic inheritance (Gureje et al. 2005; Table 2). The researchers add that only about one-tenth of respondents 'believed that biological factors or brain disease could be the cause of mental illness,' and 9% felt that 'Punishment from God' was a possible cause (Gureje et al. 2005).
In addition to the misunderstood causes of mental illness, the researchers found that many Nigerians have generally negative views towards people with mental illness: fewer than half of respondents believed that the mentally ill could be treated outside of hospitals, and only ' thought that mentally ill people could work at a regular job. The researchers found that these negative attitudes were equally spread across the socioeconomic spectrum (Gureje et al. 2005). The stigma associated with mental illness in Nigeria is evident in the responses that show 'most respondents were unwilling to have social interactions with someone with mental illness,' including fear of having a conversation with or working with a mentally ill person (Gureje et al. 2005:437). 83% of respondents would be ashamed of people knowing that someone in their family was mentally ill, and only 3.4% responded that they could marry someone with a mental illness (Gureje et al. 2005: Table 4). These results support the findings of the World Mental Health Survey that the stigma of mental illness is considerably higher in developing countries than in developed countries, but the research still does not show any distinct variables that could be identified in order to help reduce the associated stigma.
Griffiths et al. (2006) performed a comparison of stigma in response to mental disorders between Australia and Japan, and found some interesting results. This was the only research I found that used similar methodologies to survey the public in two different cultures. Though both Japan and Australia are developed nations, the cross-cultural comparison is relevant to this study. Griffiths et al. (2006) found a significantly higher proportion of the Japanese respondents held 'stigmatizing attitudes and social distance' towards mental illness. The authors give several possible reasons for this difference. First, conformity is more highly valued in Japan, so people who deviate from the norm because of mental illness would be more negatively impacted. Secondly, the treatment options in the two countries differ: in Japan, long-term institutionalization is common, while in Australia, community and rehabilitation services are emphasized. The implication is that even among developed countries, significant differences in the rates of stigma and the way it affects a society occur; therefore, any push to combat stigma needs to take into account these cultural differences. The authors suggest that this study may 'point to ways in which interventions programs for reducing stigma might be tailored for each country' (Griffiths et al. 2006).
Attempts to Reduce Stigma Associated With Mental Illness
Many countries and cultures have made attempts to reduce the stigma associated with mental illness. Lauber and Rossler (2006) discuss the attempts in some Asian countries to rename schizophrenia in order to reduce the stigma associated with the disease; however, results show that a less pejorative label has little effect on the stigma associated with schizophrenia. Stein and Gureje (2004) suggest the approach of medicalization of suffering, or training healthcare providers to recognize the depression and anxiety that are often related to violence, chronic illness, and poverty ' in order for this to be successful, however, overcoming the stigma related to mental health issues is of primary importance. Lauber and Sartorius (2007) states that work towards reducing the stigma of mental illness is very important as a human rights issue: 'Societal or structural discrimination finds its expression in jurisdiction that restricts the civil rights of people with mental illness in, for example, voting, parenting or serving jury duty, inequities in medical insurance coverage, discrimination in housing and employment, and the reliance on jails, prisons and homeless shelters as the way of disposing of people with mental illness' (103). They discuss the importance of the normalization paradigm in which people with mental disorders are seen as 'similar to and not different from other people' and medicalization, the idea that mental illness is a treatable medical condition rather than a personal defect, in the anti-stigma endeavors (Lauber and Sartorius 2007).
Form (2000) suggests that one important aspect of reducing mental health stigma is to increase what he calls 'mental health literacy' or knowledge about mental health disorders: he outlines several education programs that were widespread in the 80s and 90s in the United States ' the Depression Awareness, Recognition and Treatment Program and the National Depression Screening Day. These programs received widespread media attention, but their effects have not been studied. Form suggests that one good way to help improve mental health literacy is to target specific populations, such as high school students. However, Form's research says little about how these ideas would work in developing countries.
In conclusion, a look at the research on stigma associated with mental illness shows significant differences in developing and developed countries, but the reasons for this are still unclear. I had hoped to conclude this research with a set of key differences between high-stigma and low-stigma cultures, but this information, if it exists, was not found. I believe that research on identifying causes for and reducing incidences of the stigma of mental illness is a very important topic in medical anthropology and one I believe will see continued advancement in research in the future.
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