Lupine Publishers | Scholarly Journal Of Psychology And Behavioral Sciences
Abstract
Stigma is one of the barriers that hinder
people with mental illness from successfully engaging in treatment, which
contributes to mental illness having a substantial global burden of disease.
This review article examines the duality of the relationship between mental
health professionals and stigma towards mental illness. Mental health
professionals are subject to associative stigma by virtue of the people with
mental illness whom they work with, which can bring about significant distress
to the mental health professionals. Despite the need for a non-judgemental
attitude for optimal engagement, Health care professionals are not immune from
stigmatizing beliefs of their own. On top and above of anti-stigma initiatives
with the general population in mind, healthcare workers have been prioritized
as a target group for anti-stigma efforts. This is because they have the
Potential to impact others, including both persons with mental illness and the
general public, through the course of their daily work. Before their
professional roles, the training stage might provide the ideal platform to
introduce anti-stigma efforts. This benefits of this might not be immediately
evident, but this has a long-lasting impact with the potential to turn the
wheels of change at the societal level.
Keywords: Social stigma; Mental illness; Medical staff;
Physician patient relations; Nursing staff; Nurse patient relations
Introduction
Persons with mental illness grapple with
stigma and the discrimination that comes along with their mental health
condition. At the public health level, this represents a major concern as it
contributes to the treatment gap which discourages those in need of
professional help from seeking assistance. Looking across the consultation
table, mental health professionals themselves are also subject to associative
stigma from peers who might be working in domains outside of mental health.
This divide comes across as ironic, given the advocacy for an integrative
approach towards mind and body. Mental health professionals work to help those
with mental illness, but are individuals themselves shaped by influences and
personal experience from their immediate surroundings and societal environment
at large. They would also form their own opinions about people with mental
illness, with some of these opinions dating back to even before undergoing
training in their field.
When surveyed in comparison to the general public, mental health professionals
in Australia [1] and America [2] were found to have more positive attitudes
about people with mental health problems. This was also the case for Croatian
medical doctors [3]. However, these results were contrary to the author’s
experience when surveying ward-based doctors and nurses in an acute hospital
about patients with alcohol use disorder [4], which revealed stigma amongst
healthcare workers to be worse than the general public. This article
consolidates literature over the recent two years pertaining to stigma towards
mental illness and healthcare professionals. It considers healthcare
professionals from both perspectives, as the recipients of such stigma and the
personnel concurrently exhibiting discriminatory attitudes.
Mental Health
Professionals Being Stigmatized
Mental health professionals experience
associative stigma, where they are negatively stereotyped because of the people
with mental illness whom they work to help. This has an impact on them, similar
to what their clients and patients would experience. While there might be a
cultural component in associative stigma such that a greater degree of respect
tends to be accorded to mental health professionals in China than the US [5],
examining the manner in which Chinese psychiatrists address the topic of stigma
with psychiatric patients and their relatives [6] might shed light on how this
comes to be the case. As a consequence of stigma, doctors with mental health
concerns might experience reluctance in opening up. Whether at the stage of a
trainee [7] or beyond, disclosing mental illness might cause an individual to
be perceived as “weak” and undermine their professional competence. They are
hence less likely to disclose this in the work setting, to co-workers and
employers alike, and to seek professional assistance for themselves. There is
room for much more to be done to support professionals with mental illness.
Ensuring the presence of medical care with sufficient confidentiality,
occupational health support and back-towork interviews [8] are but some of the
measures with potential to make a difference.
Healthcare Professionals
as Stigmatizers
It is paradoxical to note that healthcare
professionals concurrently exhibit stigmatizing attitudes. The “Inter Nos”
(Latin for “Among Us”) study surveyed attitudes of healthcare professionals
towards mental illness, across multiple centres in Spain, Portugal and Italy
[9]. Hospital-based staff were found to have more stigmatizing responses on
both the Attribution Questionnaire (AQ-27) and The Community Attitudes towards
the Mentally Ill (CAMI), agreeing more readily with restrictive options,
coercion and segregation. In particular, the more discriminatory attitudes and
responses tended to come from nursing assistants as well as staff in
non-clinical and “other clinical” roles. When mental health professionals stigmatize
the persons with mental illness whom they work with, this has the potential to
undermine diagnosis, treatment and successful health outcomes [10]. Right from
the start, this might adversely affect the therapeutic alliance. This in turn
hinders the mental health professionals’ understanding of the service user’s
problem, leading service users to disengage from treatment more readily [11]
which ultimately sets up a vicious cycle as a self-fulfilling prophecy. This
only serves to reinforce the pre-existing negative stereotypes held by the
mental health professional.
Education as a Possible
Means of Addressing the Problem
Before health care professionals assume
their vocational roles, they are, first and foremost, individuals in society
just like every member of the public. Interventions targeted at the general
public would have an impact on them, but yet more can be done during the course
of their professional training. Experiences at the early stages of training can
certainly go a long way in terms of professional development, and others have
advocated for antistigma initiatives to begin at the educational stage. Data
from United States demonstrated the presence of an educational gap [12], such
that psychiatry coursework for pharmacy, nursing and social work students did
not improve stigma towards mental illness. This might seem disheartening, but
the identification of such educational gaps is the first step in allowing them
to be addressed by means of appropriately incorporating anti-stigma training. Following
exposure to the mental health curriculum, improved attitudes towards people
with mental illness were found in medical students from UK [13] and South
Africa [14], as well as nursing students from Turkey [15-17] There might truly
be a role for the revision of curriculum pertaining to mental health, for
anti-stigma programmes to be included as part of the courses. This might turn
out to have a more profound educational impact than factual content found in
textbooks and learnt by rote, about what constitutes mental illness and how
these are treated.
Future Research
From direct contact intervention to
Responding to Experienced and Anticipated Discrimination (READ), there have
been no shortage of ideas on how to tackle stigma through education. However,
the single most effective modality of delivering the anti-stigma message
remains to be seen. Though focused on low- and middle-income countries, a
recent systematic review had difficulty in pinpointing the most effective
anti-stigma intervention [18]. Future head-tohead comparisons of these varying
modalities would help to point the best way forward. Healthcare workers in
particular have many opportunities to come into contact with persons with
mental illness. For the person with mental illness, each interaction can either
work out as a disappointment or a positive encounter. Their influence cannot be
understated, and the impact of stigma in this group warrants anti-stigma
interventions to prioritize this group. It is worthwhile to note the protocol for
a randomized controlled trial in Chile [19] targeting primary healthcare
workers, and to see how this would unfold.
Conclusion
Corrigan & Nieweglowski suggested a
parabolic relationship between familiarity of mental illness and public stigma
[20], where people tend to stigmatize those with mental illness when they were
either unfamiliar or too familiar with them. This proposal does suggest that
too much of exposure might not be a good thing after all, and there exists an
optimal balance in terms of the experience to deliver during training. The need
to address stigma towards mental illness has never been questioned, though the
best methods to do so remain elusive. While the sentiment of the public is
important, this author is a believer of the saying “charity begins at home”.
Mental health professionals and healthcare workers working outside of mental
health domains are two groups that need to be targeted. This is for the
wellbeing of their service users, as well as themselves.
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