Stigma and Depression                                             (April 2005)

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Dr Clifford Haley works as a consultant psychiatrist with the North Eastern Health Board. In February 2005, he delivered a lecture in Donegal Town to launch the new Aware support group there. As part of the Aware Monthly Lecture Series for 2005, Dr Haley visited Dublin that April to speak about stigma. The following notes are taken from that lecture.

Contents

1. What is stigma?
2. Why do we stigmatise?
3. Stigmatising myths
4. Personal experiences
5. Effects on the individual
6. Challenging stigma
7. Q&A section

Stigma: What is it?
Stigma is defined in the dictionary as 'a sign of disgrace or discredit which sets a person apart from others'. It is also a social idea that defines people in terms of a characteristic that devalues them as a person.

There are many ways in which a person can be stigmatised:
- Self-stigmatisation
- Stigmatisation by the community
- Stigmatisation by association.

The issue of stigma is important in psychiatry for a number of reasons: it affects everyone who suffers from mental illness; it affects the provision of services (we are all familiar with the mental health services being described as the 'Cinderella service'); and, finally, it is an issue that we can all do something about.

Scale of the problem
In a survey in 2004, 41 out of 46 patients described feelings of stigma. 80% of people say that individuals are 'embarrassed' by the mentally ill.

Why do we stigmatise?
Sadly, stigmatisation is actually a natural part of the human condition. When one is faced with something unknown, the natural reaction is ‘fight or flight’. In such a scenario, we make decisions rapidly, making general assumptions about what’s going on and filling in any blanks in our knowledge with other information which we do not actually know to be true. We sometimes tend to fill in these blanks based on previous stereotypes: for instance, some people who have negative experiences of politicians may, even when faced with a ‘good’ politician, find themselves ‘tarring’ him or her with the same brush. Therefore, this perception of the ‘good’ politician is based on filling in the blanks with information gleaned from other situations rather than basing it on the entire facts before us now.

The pathway to stigma leads on from negative stereotypes. All too often, those who experience mental illness are seen as an outside group: they are not like us. This may have its roots in the Asylum Model of mental health care: while the asylums were initially set up as sanctuaries for those who could not cope with every day life because of their illness, they in many ways only served to further isolate these people from society. They removed mental illness from everyday experience and institutionalised it.

Stigmatising Myths
There are a number of myths about mental illness which also add to the stigma:
- Mental illness can often be seen as a punishment.
- Possession – mental illness is sometimes, incorrectly seen as badness within the person coming out.
- Mental illness is sometimes equated with violence and aggression.
- It can also be equated with stupidity. (In fact, some of the most brilliant people in history were mentally ill.)
- There is also a false belief that mental illness always lasts forever.

Perpetuating the myths
A lack of information, education and understanding means that many of the myths about mental illness remain. The media also has a part to play in perpetuating some of these myths, and all of this leads to an increasing sense of guilt and shame amongst those who experience mental illness.

People’s Experience of Stigma in Mental Illness
Stigma can affect any sufferer no matter what form of mental health problem they experience:

"Schizophrenic is the worst diagnosis because I’ve heard it in the papers and on TV... they are really mad people, very dangerous to society, they’ve no control, so obviously I came under that category."

"Well I’m too worried about telling people I’m on medication. There are very, very few people I tell about the ECT... I don’t want to talk about it because I hate it and it's horrible... if they hear about it they’d think I was really mad."

"I regret not going to the hospital. I listened to too many people and I suddenly thought I was going to be labelled as a loony."

"It hurts... my two little nephews were there and wouldn’t come near me... don’t know why, they must have been able to sense something... you feel bad, it makes you feel even worse."

"I feel that if I survive it I’ve been through a very privileged experience and that I can actually make something of it... people I’ve met who’ve had mental health problems, I feel privileged to have met, from all walks of life that I would never have encountered."

Effects of stigma on the individual
- Shame
- Blame
- Secrecy
- Isolation
- Social exclusion
- Discrimination

A previous survey showed that 47% of respondents who experience mental illness were physically or verbally abused in public. 34% had been sacked or had to change jobs. 24% were refused insurance, and 50% felt they were unfairly treated by health services.

The family and society
83% of family members who responded in a Swedish survey in 2002, reported that they had experienced the burden of stigma. It was also found that there was 29% unemployment among sufferers: 63% of voluntary organisations had to delay opening new facilities due to local opposition and 37% of MPs felt that depression is not an illness.

Challenging Stigma: What can we do?
Individually, we should be aware of stereotypes and labels, and we should make a concerted effort to avoid them.

On a professional level, there is a need to improve listening skills and share knowledge. Sharing is what we do with equals.

In society, we can push for less social exclusions by working for improved employment opportunities for those who experience mental illness. There is also a need for legislation which gives people back their rights.

There are many campaigns and organisations specifically targeted at breaking down the myths which surround mental ill-health, and in doing so, challenging the stigma:
- See Me, Scotland
- Stigma.org
- Like Minds, Like Mine
- Beyond Blue
- Mental Health Media's 'Open Up Toolkit'
- Open the Doors

The UK-based Changing Minds campaign which ran from 1998-2003 addressed six types of mental illness, and targeted doctors, young people, the workplace, the media and the general public. As part of this campaign, a report into stigma within the medical profession was published; the website was advertised on the Tube; 'One in Four', a two-minute film, was produced and shown in cinemas and on TV. A book entitled 'Every Family in the Land' was distributed to every household in the country and over 100 articles were published in newspapers across the UK. Results of the campaign showed that there was a small but significant reduction in negative opinion.

Questions & Answers
Dr Haley was asked by a member of the audience if there is anything individual sufferers can do to help in the fight against stigma. He suggested that interested sufferers might become involved in advocacy, as they have a good understanding of what it is like coming from outside of the services. Aware is a member of GAMIAN Europe, a European-wide advocacy body, so anyone interested in more information can check out their website. 

Another attendee on the evening asked Dr Haley about the role of the GP in combating stigma. He replied that GPs have a very important role, as they are the first point of contact within the health services. Whether that first contact is positive or negative can define the pathway into the services for the individual involved. Dr Haley also suggested that GP training and education around the area of mental health is extremely important and should be increased.

Stigma in the workplace also cropped up as an area of concern. Aware has a corporate pen appeal which is a discreet but effective way of creating awareness in workplaces throughout Ireland, both of depressive illness and also of the supports that Aware offers. The organisation also offers information talks to companies across the country in a bid to educate the workforce about the nature and effects of depressive illness and to help break down the stigma which still exists.

Conclusions
- Stigma is a cause of suffering and distress to people with mental illness and those closest to them.
- Everyone can fall into the trap of stigmatising other people.
- Challenging stigma is an important job for all those interested in the field of mental illness.