Most patients with mental illness receive as much care from their families as they can provide. The feelings of guilt that the family experiences are correlated to false beliefs which claim that the reason for mental illness is most often connected to the family or to psychological traits of the patient's parents. In the 20th century a prevailing belief amongst experts was that most psychological problems can be attributed to patients' family situations. These theories have been refuted, but they still caused damage that is very hard to repair. The damage is obvious in families that are unable to help patients due to feelings

Families face objective burdens of responsibility and subjective feelings of social exclusion. They are embarrassed by how the affected individual behaves, are under continuous psychological and financial stress which affects their physical and mental health. Guilt can foster either overprotection or hatred, either denial or attempts at correcting »the mistake«. This, of course, leads to stress in a patient's life and can jeopardize treatment and recovery. Families often try to hide that their loved ones got ill. Research reports that the family of a patient with a severe mental disorder often experience the same social exclusion and loss of their social network as the patient does. There is proof to the fact that relatives of these patients experience physical illness, depression, anxiety and other consequences of

Relatives find it hardest to accept structural stigma, namely unfair and unbalanced treatment and rehabilitation in medical and social services, inadequate legislation and thoughtless political decisions that lead to financial crisis and family deprivation. Their most often voiced complaint is poor care quality. They describe being left on their own as far as patient care is concerned and being sent from one institution to another without any apparent concern for their problems. A lack of cooperation between institutions and exclusion of families from the treatment process seem to be two of the more pressing issues (Angermayer et al., 2003). Legislation that protects patients' rights often stops relatives from being informed, even though they need to be. Information can only be distributed by the doctor and only if the patient agrees to it, which can be a problem where mental problems are concerned. Most families try to get the necessary professional help as soon as possible

and adjust their lifestyle so that symptoms and disability can be managed.

and discrimination.

(Gonzales Torres et al., 2007).

prolonged stress (Awad & Voruganti, 2008).

of guilt.

*- My mom was very concerned about my education, she wondered if I'll manage when I grow up.*

*- I live with my parents; they tolerate much more from me than they did before the disease. They don't bother me with their problems.*

*- My family supported me all the way.*

*- No one in the family treated me differently. Not my parents, not my husband. There was no pity.*

Mental illness scares the family, leading to overprotection, which hampers the patient's selfreliance. Before the patient's family reaches a balances that allows adequate help, too much time passes.

*- When I got sick, my family really just didn't understand it at first. They didn't treat me as an equal. It's better now.*

*- Too much care seriously hampers treatment and rehabilitation. It leads to prejudice and hostility.*

*- They treat me differently now. I can't go out Friday and Saturday night, my parents think something'll happen. I'm not allowed to drink or use any drugs...not that I would, but still.*

*- My parents don't think I can take care of myself.*

*- They were embarrassed at first, that I was in the hospital. Mom wouldn't tell her friends or our neighbours. My parents had a lot of trouble accepting things.*

*- My sisters think that I can't be a good parent, so they interfere all the time.*

Families can be counselled and helped to reduce the feelings of exclusion and helplessness. Educating the family on how to manage the illness in family groups which share experience and help each other is an invaluable tool in combating stigma. Patients' relatives organised on national and international levels wield considerable political power that is used in creating, developing and overseeing different mental health services, including psychiatry.

#### **6.4 Self respect damage, self-discrimination, internalised stigma**

A person's lack of success is considered to be his own fault. Victims of prejudice are forced to hide their disabilities, or at least act in a way that enables them to stay in contact with the dominant culture - one that reinforces the fantasy of a strong, unbreakable self that holds dominion over itself and others (Goffman, 1963, Nastran Ule, 1999).

#### **6.4.1 Hiding the illness**

The act of hiding a mental disorder strengthens the vicious circle of prejudice. Psychiatric patients most often choose not to talk about their disorder or diagnosis since they are subject to strong feelings of guilt and shame due to the aforementioned prejudice. They lead a double life in fear of exposing themselves, which leads to avoiding other people, as they are a direct threat to their exposure. They become lonely and, in turn, feel insecure, constantly threatened and inferior. Withdrawing from society, fearing ridicule, the stigmatized become more and more alone (Goffman, 1963). Despite the above stated, patients admitting their disease actually severely limits their chances of being a member of any privileged social groups. Most often admittance means a membership in the vast group of second class citizens and losing the battle for status (Thesen, 2001). Attempts to hide and obscure their condition are a source of continuous stress, which forces patients to expend enormous amounts of energy on their disguises. When it was suggested by professionals that psychiatric hospitals should be established in city and town centres, the patients' wish to be

Stigma and Mental Disorders 49

embarrassment on both sides, meaning not only with those who expect to be stigmatized

*- Sometimes people say that I would be better if I don't get married and have kids. I agree with them*

Patients believe that expected discrimination is far worse than the smaller number of options they actually have. Still, some do not allow themselves to expect discrimination.

*- I went back to work and back to school. It was a little uncomfortable at first, but now it's OK, I almost never feel that way. I still have trouble meeting people, but I don't give up. Sometimes it*

*- I never went back to my old job. My doctor advised me against continuing in this profession, so I*

The psychological cause for self-loathing is internalization of prejudice. Some people accept disdain to be justified and legitimate. They start to act passively, dependently and helplessly as is expected of them. A social quarantine devoid of encouragement and responsibility is formed around the individual. Expectations are reduced (Lysaker et al., 2007). One withdraws and gives up hope and wishes, making himself less emotionally dependent and less likely to speak out – which are all recognised as »negative« symptoms of mental illness. It was proven that people, who identified themselves as being stigmatized, compare poorly to others, who do not feel stigmatized regarding their intellectual capacity. This means that a stigmatized social group actually functions below their intellectual potential, stigma being the reason for their impairment and not only their illness. They feel incapable of functioning as rational, competent and functional individuals, have lower self-esteem and are often

Being a part of a stigmatized group is a barrier to one's success and often means a loss of life opportunities. People with mental disorders are often isolated, unemployed, poor, single and alone (Thessen, 2001).  They may exhibit the same or even worse stigmatizing behaviour as those outside of the group towards their fellow, more stigmatized patients (Zalar, Strbad & Švab, 2007). The individual does not want to be a part

The anger and outrage directed towards the barriers keeping them out of social life is turned on themselves. Self-stigma is exhibited in feelings of shame, exclusion and loss of importance. Still, the consequences of self loathing do not stop there. Patients in its grasp do not argue their rights or interests, thus maintaining the vicious circle of stigma and legitimizing the fact that non-stigmatized people avoid and exclude them (Goffman, 1963). It must be noted at this point that mental illness does not necessarily mean a loss in effectiveness and self-esteem. People react differently to disease and possible disability. Some fight discrimination and abuse and some are indifferent, depending on an individual's personality and the situation.

*- The opinion of others affects me a lot. I can't talk about that.*

*changed careers and finished a course. I didn't want to retire.*

depressed, anxious and hostile (Quinn et al., 2004).

of the disadvantaged group (Goffman, 1963).

*now.*

*- I don't try to make friends.*

*works out, sometimes it doesn't.*

**6.4.3 Self-stigma**

unrecognized was overlooked. Being in the centre is not the interest of the majority of them. The following statements were made by patients who feel that this is the case.

*- I really want people not to know that I've been diagnosed. When somebody asks me how I'm doing, I never tell the truth- that I'm ill and I'm not doing well. Most wouldn't even understand, if I told them that I have schizophrenia.*

*- I don't say to people: I'm sick. I don't say that I'm going to the hospital. It seems smarter to not say anything.*

*- He asked me if I was in the hospital. So I lied.*

*- I'm ashamed of my diagnosis. I must keep it to myself. If it's important I tell people, but not all the time. It's better to stay quiet.*

*- I don't advertise that I'm being treated.*

*- I can't tell people that I've been diagnosed.*

*- When I meet somebody new, I don't say a thing.*

*- I only go to the library, but they noticed and now they look at me different.*

*- I'm not sick, but those who think that I am, avoid me.*

Despite everything, some have decided to admit their illness and risk unforeseeable consequences:

*- My friend said that I'm living in my own world, one that others can't understand. But I think that she's the sick one - always nervous and stressed. On the other hand, my friends at college don't even understand why I've been sent to the hospital. It depends on the person, I guess.*

*- When I was first in the hospital I felt stigmatized, but only because my mom told me all about that. I had trouble fitting in. I noticed later that people don't care much about whether you're in the hospital or not. I told my classmates that I'm being treated. The more you hide it, the harder it gets. It just gets to be another burden. I now tell everyone, because if I don't, I keep having to think about what I told to who. I have lots of friends, so now it's not a problem anymore.*

#### **6.4.2 Anticipated discrimination**

What they have been taught in their childhood and adult lives makes many patients with mental disorders expect discrimination. The general belief, that the mentally ill are dangerous and incompetent, turns on a patient in the moment of his diagnosis. Becoming a part of an inferior group makes him expect discrimination which leads to demoralization.

Negative cultural concepts start to be felt on a personal level. Prejudice works as a selffulfilling prophecy, which means that expectations of discrimination come true sooner or later. The actual identity of an individual is replaced by a »virtual« social identity, one defined by others through stereotyping (Goffman, 1963).

The general social opinion of the mentally ill is largely created by the media. In movies and reports, a negative outcome of treatment, low quality of life and dangerous and incompetent behaviour are attributed to the mentally ill. These myths endanger self-respect and demoralize patients to an extent that doesn't allow them to fight for a better life. The affected individual is taught society's expectations of him and re-identifies himself; starts controlling his own expectations and avoids any confrontation, thus missing almost every opportunity (Angermeyer et al., 2004). Their social networks shrink, leading to poverty and unemployment, which in turn leads to social exclusion (Kroska & Harkness, 2006). Oversensitvity to any communication involving stigma emerges, presenting itself as

unrecognized was overlooked. Being in the centre is not the interest of the majority of them.

*- I really want people not to know that I've been diagnosed. When somebody asks me how I'm doing, I never tell the truth- that I'm ill and I'm not doing well. Most wouldn't even understand, if I told*

*- I don't say to people: I'm sick. I don't say that I'm going to the hospital. It seems smarter to not say*

*- I'm ashamed of my diagnosis. I must keep it to myself. If it's important I tell people, but not all the*

Despite everything, some have decided to admit their illness and risk unforeseeable

*- My friend said that I'm living in my own world, one that others can't understand. But I think that she's the sick one - always nervous and stressed. On the other hand, my friends at college don't even*

*- When I was first in the hospital I felt stigmatized, but only because my mom told me all about that. I had trouble fitting in. I noticed later that people don't care much about whether you're in the hospital or not. I told my classmates that I'm being treated. The more you hide it, the harder it gets. It just gets to be another burden. I now tell everyone, because if I don't, I keep having to think about what I*

What they have been taught in their childhood and adult lives makes many patients with mental disorders expect discrimination. The general belief, that the mentally ill are dangerous and incompetent, turns on a patient in the moment of his diagnosis. Becoming a part of an inferior group makes him expect discrimination which leads to demoralization. Negative cultural concepts start to be felt on a personal level. Prejudice works as a selffulfilling prophecy, which means that expectations of discrimination come true sooner or later. The actual identity of an individual is replaced by a »virtual« social identity, one

The general social opinion of the mentally ill is largely created by the media. In movies and reports, a negative outcome of treatment, low quality of life and dangerous and incompetent behaviour are attributed to the mentally ill. These myths endanger self-respect and demoralize patients to an extent that doesn't allow them to fight for a better life. The affected individual is taught society's expectations of him and re-identifies himself; starts controlling his own expectations and avoids any confrontation, thus missing almost every opportunity (Angermeyer et al., 2004). Their social networks shrink, leading to poverty and unemployment, which in turn leads to social exclusion (Kroska & Harkness, 2006). Oversensitvity to any communication involving stigma emerges, presenting itself as

The following statements were made by patients who feel that this is the case.

*- I only go to the library, but they noticed and now they look at me different.*

*understand why I've been sent to the hospital. It depends on the person, I guess.*

*told to who. I have lots of friends, so now it's not a problem anymore.*

defined by others through stereotyping (Goffman, 1963).

*them that I have schizophrenia.*

*time. It's better to stay quiet.*

*- He asked me if I was in the hospital. So I lied.*

*- I'm not sick, but those who think that I am, avoid me.*

*- I don't advertise that I'm being treated. - I can't tell people that I've been diagnosed. - When I meet somebody new, I don't say a thing.*

**6.4.2 Anticipated discrimination**

*anything.*

consequences:

embarrassment on both sides, meaning not only with those who expect to be stigmatized but also those who try to cover up their worry for the affected.

*- The opinion of others affects me a lot. I can't talk about that.*

*- Sometimes people say that I would be better if I don't get married and have kids. I agree with them now.*

*- I don't try to make friends.*

Patients believe that expected discrimination is far worse than the smaller number of options they actually have. Still, some do not allow themselves to expect discrimination.

*- I went back to work and back to school. It was a little uncomfortable at first, but now it's OK, I almost never feel that way. I still have trouble meeting people, but I don't give up. Sometimes it works out, sometimes it doesn't.*

*- People had trouble accepting me, but it wasn't me who had a problem, it was them.*

*- I never went back to my old job. My doctor advised me against continuing in this profession, so I changed careers and finished a course. I didn't want to retire.*

#### **6.4.3 Self-stigma**

The psychological cause for self-loathing is internalization of prejudice. Some people accept disdain to be justified and legitimate. They start to act passively, dependently and helplessly as is expected of them. A social quarantine devoid of encouragement and responsibility is formed around the individual. Expectations are reduced (Lysaker et al., 2007). One withdraws and gives up hope and wishes, making himself less emotionally dependent and less likely to speak out – which are all recognised as »negative« symptoms of mental illness. It was proven that people, who identified themselves as being stigmatized, compare poorly to others, who do not feel stigmatized regarding their intellectual capacity. This means that a stigmatized social group actually functions below their intellectual potential, stigma being the reason for their impairment and not only their illness. They feel incapable of functioning as rational, competent and functional individuals, have lower self-esteem and are often depressed, anxious and hostile (Quinn et al., 2004).

Being a part of a stigmatized group is a barrier to one's success and often means a loss of life opportunities. People with mental disorders are often isolated, unemployed, poor, single and alone (Thessen, 2001).  They may exhibit the same or even worse stigmatizing behaviour as those outside of the group towards their fellow, more stigmatized patients (Zalar, Strbad & Švab, 2007). The individual does not want to be a part of the disadvantaged group (Goffman, 1963).

The anger and outrage directed towards the barriers keeping them out of social life is turned on themselves. Self-stigma is exhibited in feelings of shame, exclusion and loss of importance. Still, the consequences of self loathing do not stop there. Patients in its grasp do not argue their rights or interests, thus maintaining the vicious circle of stigma and legitimizing the fact that non-stigmatized people avoid and exclude them (Goffman, 1963).

It must be noted at this point that mental illness does not necessarily mean a loss in effectiveness and self-esteem. People react differently to disease and possible disability. Some fight discrimination and abuse and some are indifferent, depending on an individual's personality and the situation. People who refuse to accept the stereotype feel angry and

Stigma and Mental Disorders 51

groups. Cardiovascular disease is the main cause of death in this group. The paradox here is that with severe physical health problem good mental health is not possible. All physical illness is strongly connected with depression, anxiety and other mental health problems. It follows logically that every physician should be trained in identifying and treating mental health problems, yet psychiatry is mostly treated as unimportant at most medical schools, by the teaching staff and students alike. The average medical student is likely to have the same opinion of mental health problems as the general public. They mostly feel that psychiatry as a branch of medical science is ineffective and unscientific (Feldmann, 2005). The basis for improving the life and treatment quality of patients with mental disorders is improving the education on all levels of the educational system, including lessons on needs,

Compared to others, people with mental disorders have scarce social networks and are more strongly linked to their families and more dependent on them (Thornicroft, 2006:27).  Loneliness is a risk factor for poor recovery. Most patients try to hide their illness from their friends, as they believe hiding is essential for their social survival. They believe that mental illness makes them social lepers and rarely see it as an opportunity to improve on the

*- True friends stay by your side. You can check who your friends really are and start all over again, or*

*- I didn't exactly have a lot of friends. I met new people when I was admitted to the hospital. They're*

But there seems to be much more negative experience. Friends disappear, flat out decline to see the patient and avoid him. Every friendship lost strengthens feelings of loneliness and

*- I had one friend. I went to visit him once. He told me to leave. He avoided me after that, so I did the*

*- When they say: »she's the crazy one«, I know they're making fun of me. Nobody can stop it from*

*- I feel they don't want to be around me. It takes a lot of time for anyone to get through to me, I know*

*- I called my friend and wished her happy holidays, She said she'd come, but she didn't. I think her*

*- Some of my friends, when I told them I was in, didn't come to see me. I don't trust them anymore.*

quality of their existing relationships and, perhaps, finding new ones.

*- My friends stuck around, mostly. Those who didn't, weren't my friends, were they?*

*- My friends listen more, stand by my side and encourage me.*

*- I feel distant. People don't know what to say when I'm around.*

*- I didn't make any new friends after I was admitted.*

*- Nobody ever comes to visit, nobody ever calls me.*

*- People that know treat me differently. If they don't, everything is much easier.*

rights and the reality of life in fringe groups.

**7. Areas of discrimination**

*- We're better friends than before I got ill.*

**7.1 Friendship**

*even improve them.*

*my friends now.*

despair.

*same.*

*that.*

*husband doesn't let her.*

*happening.*

strong, and justifiably so. Sometimes, as members of a marginalized group which has been wronged, they feel even stronger and more assertive than before. Similar to the reaction of the Afro-American culture, they say that anger is the fair response to stigma. This expression of just anger is more likely to happen if the stigmatized individuals connect in a group focusing on improving the situation. People who fail to identify with a group more often treat discriminatory practices with indifference, regardless of their personal experience (Corrigan, 2005).

The only way to resist self loathing is to stand up to discrimination and resist abuse.

*- They avoid me a lot. I don't care.  I don't think I'm stupid.*

*- I broke it off with some of my friends. Not just because of the diagnosis. Though I'm ok with those that I kept being friends with. If I manage to sort myself out, find a job and my family is fine, then nobody can say I'm schizophrenic, I know that.*

*- I think of being diagnosed as an advantage. Me and my family figured it out, what being ill means and we know exactly what to do when I start acting differently, it is the illness that gets worse.*

#### **6.5 Structural discrimination**

Structural discrimination happens on a systematic level, in a way that automatically stops any attempts to acquire a different social status. The mentally ill are pushed to the edge of society, drastically reducing their life options. Being of the edge of society means that any group can be forced into humility, anonymity and silence. Any discussion of equal rights, respecting diversity and understanding is futile if discrimination is built by the general society and the state itself as the ultimate defence against intrusion of marginalized groups, dreamers and the unadjusted into any decision making system. Some countries include special mental illness clauses in their visa application forms. There are countries or states that deny their mentally ill citizens the right to vote, not considering if an individual can manage the illness or not. But the most generally present effect of structural stigma is poor quality of mental health services and their inaccessibility (Angermeyer et al., 2003), basically denying patients their right to treatment and care in an apparently accidental way. The reasons for this can be found in social service management, political decisions and poor legislation. In a cultural environment with strong values on work and income, a patient is stigmatized and cornered. He is unemployed because of not being able to reach the required production norms. As unemployed individual he is labelled twice: being mentally ill and unproductive or even lazy, unable to achieve the socially required criteria to be considered a productive member of the community. The only possible way out of this situation is belonging to a wider community of people who also feel wronged by the prejudice directed towards the mentally ill. Patients who are able to find a way to belong to such a group and identify with it have more self-esteem and are significantly stronger (Corrigan et al., 1999, 2004).

Stronger individuals report better recovery (Anthony, 2000). Those who are politically connected influence the quality of mental health services.

Poor care for the patients' physical health is one of the more serious problems that mental health care faces.  The risk for physical problems such as diabetes, high blood pressure and cardiovascular disease is far greater amongst people with mental disorders than in other

strong, and justifiably so. Sometimes, as members of a marginalized group which has been wronged, they feel even stronger and more assertive than before. Similar to the reaction of the Afro-American culture, they say that anger is the fair response to stigma. This expression of just anger is more likely to happen if the stigmatized individuals connect in a group focusing on improving the situation. People who fail to identify with a group more often treat discriminatory practices with indifference, regardless of their personal experience

*- They avoid me a lot. I don't care.  I don't think*

*- I broke it off with some of my friends. Not just because of the diagnosis. Though I'm ok with those that I kept being friends with. If I manage to sort myself out, find a job and my family is fine, then*

*- I think of being diagnosed as an advantage. Me and my family figured it out, what being ill means and we know exactly what to do when I start acting differently, it is the illness that gets worse.*

Structural discrimination happens on a systematic level, in a way that automatically stops any attempts to acquire a different social status. The mentally ill are pushed to the edge of society, drastically reducing their life options. Being of the edge of society means that any group can be forced into humility, anonymity and silence. Any discussion of equal rights, respecting diversity and understanding is futile if discrimination is built by the general society and the state itself as the ultimate defence against intrusion of marginalized groups, dreamers and the unadjusted into any decision making system. Some countries include special mental illness clauses in their visa application forms. There are countries or states that deny their mentally ill citizens the right to vote, not considering if an individual can manage the illness or not. But the most generally present effect of structural stigma is poor quality of mental health services and their inaccessibility (Angermeyer et al., 2003), basically denying patients their right to treatment and care in an apparently accidental way. The reasons for this can be found in social service management, political decisions and poor legislation. In a cultural environment with strong values on work and income, a patient is stigmatized and cornered. He is unemployed because of not being able to reach the required production norms. As unemployed individual he is labelled twice: being mentally ill and unproductive or even lazy, unable to achieve the socially required criteria to be considered a productive member of the community. The only possible way out of this situation is belonging to a wider community of people who also feel wronged by the prejudice directed towards the mentally ill. Patients who are able to find a way to belong to such a group and identify with it have more self-esteem and are significantly stronger (Corrigan et al., 1999,

Stronger individuals report better recovery (Anthony, 2000). Those who are politically

Poor care for the patients' physical health is one of the more serious problems that mental health care faces.  The risk for physical problems such as diabetes, high blood pressure and cardiovascular disease is far greater amongst people with mental disorders than in other

connected influence the quality of mental health services.

The only way to resist self loathing is to stand up to discrimination and resist abuse.

(Corrigan, 2005).

*nobody can say I'm schizophrenic, I know that.*

**6.5 Structural discrimination**

*I'm stupid.*

2004).

groups. Cardiovascular disease is the main cause of death in this group. The paradox here is that with severe physical health problem good mental health is not possible. All physical illness is strongly connected with depression, anxiety and other mental health problems. It follows logically that every physician should be trained in identifying and treating mental health problems, yet psychiatry is mostly treated as unimportant at most medical schools, by the teaching staff and students alike. The average medical student is likely to have the same opinion of mental health problems as the general public. They mostly feel that psychiatry as a branch of medical science is ineffective and unscientific (Feldmann, 2005). The basis for improving the life and treatment quality of patients with mental disorders is improving the education on all levels of the educational system, including lessons on needs, rights and the reality of life in fringe groups.

#### **7. Areas of discrimination**

#### **7.1 Friendship**

Compared to others, people with mental disorders have scarce social networks and are more strongly linked to their families and more dependent on them (Thornicroft, 2006:27).  Loneliness is a risk factor for poor recovery. Most patients try to hide their illness from their friends, as they believe hiding is essential for their social survival. They believe that mental illness makes them social lepers and rarely see it as an opportunity to improve on the quality of their existing relationships and, perhaps, finding new ones.

 *- True friends stay by your side. You can check who your friends really are and start all over again, or even improve them.*

*- We're better friends than before I got ill.*

*- My friends listen more, stand by my side and encourage me.*

*- My friends stuck around, mostly. Those who didn't, weren't my friends, were they?*

*- I didn't exactly have a lot of friends. I met new people when I was admitted to the hospital. They're my friends now.*

But there seems to be much more negative experience. Friends disappear, flat out decline to see the patient and avoid him. Every friendship lost strengthens feelings of loneliness and despair.

*- I had one friend. I went to visit him once. He told me to leave. He avoided me after that, so I did the same.*

*- When they say: »she's the crazy one«, I know they're making fun of me. Nobody can stop it from happening.*

*- Some of my friends, when I told them I was in, didn't come to see me. I don't trust them anymore.*

*- I feel distant. People don't know what to say when I'm around.*

*- People that know treat me differently. If they don't, everything is much easier.*

*- I didn't make any new friends after I was admitted.*

*- I feel they don't want to be around me. It takes a lot of time for anyone to get through to me, I know that.*

*- Nobody ever comes to visit, nobody ever calls me.*

*- I called my friend and wished her happy holidays, She said she'd come, but she didn't. I think her husband doesn't let her.*

Stigma and Mental Disorders 53

*- When I was hospitalised, I was handicapped, had no energy. When I went to pick my son up from kindergarten everybody was very correct. I didn't have any bad experiences, none good too; they just*

*- There was some doubt at home, but I went through with it anyway. I'm really happy I had a baby. - My ex-husband tells me I'm not strict enough when the kids are with me. I don't think so, I think he's too strict and they have to let of some steam when they're with me.  Women with mental health disorders are far more likely to be sexually abused. Research states that there are a lot of cases when a patient should be

Several drugs used in psychiatric treatment have a negative effect on libido, erection and

Intercourse is, because of the above mentioned, less likely to happen in psychiatric institution than in other institutions, but it does occur and not rarely. Prohibiting sexual activity is discrimination, yet it must be implemented sometimes in order to stop people acting on basis of their reduced reasoning because of the illness. People with low self-esteem who agree to intercourse they would otherwise reject also need to be protected. Effects of these dilemmas presented themselves through hospital management decisions conflicting over gender separation. In the name of normalization, England implemented mixed wards for a couple of decades, which are being separated again. The reasons for this are numerous reports of abuse and women's dissatisfaction due to a lack of privacy. Closed wards fared the worst in this experiment of gender mixing, as the patients there have a problem controlling their behaviour. Women who experienced abuse before admission often demand their right for privacy very strictly The number of women being treated because of

*- When I got ill, I couldn't perform. My wife cheated on me a lot, she wasn't happy with me.*

traumatic sexual experiences in psychiatric hospitals is not low (Thornicroft, 2006).

Employment discrimination is one of the most often encountered forms of stigma.

prohibited, even though it is a breach of their basic human rights.

 In clinical practice, this means that in closed wards sexual intercourse is usually

*there are five of us when they come over, but they like being here.*

treated both for sexual abuse and illness (Thornicroft, 2006).

ejaculation, which is one of the leading reasons for avoiding use.

*- It's true I don't have any desire to be sexually active since it got sick. - I can't get a woman pregnant. The medicine would harm the kid.*

*- Sexual disorders are another cause of slow self-esteem.*

*- We tried to adopt a child with my wife, but we couldn't.*

*treated me like everyone else.*

everybody else.

**7.4 Sexuality**

*- I have no libido…It's just gone.*

**7.5 Employment**

*- When I still had a job, I lost my best friend when he found out. He never called me again, so I didn't want to call him.*

*- My childhood friend was shocked, when she found out. She was scared of visiting me, so she never did. I'm sad because I lost my best friend.*

*- My friends were shocked. They avoided me.*

#### **7.2 Partnership**

People with mental disorders are much less likely to be in a committed relationship. There are many reasons for this, the most common being low self-esteem and lack of opportunities. Many existing relationships are discontinued due to the severity of the disease, stigma and financial difficulties. On the other hand many couples manage the illness and find new challenges and qualities in their relationships.

*- For me, it's an advantage. She's great.*

Divorce is one of the most stressful events in an average person's life. Most people need to be helped when faced with divorce, the mentally ill especially so. Several cases of patient's being used and manipulated during the separation process have been reported.

*- My boyfriend dumped me the second I was admitted to hospital. He didn't want to be with me anymore.*

*- I was married. My husband left me when I got ill. I had no relationships since.*

*- My husband left me because of my diagnosis.*

*- Once people know you're ill, it's hard to find somebody who's willing to share your life. You can't have kids when you're taking medication.*

*- My husband isn't understating. He had all the power so he had me hospitalized.*

*- He met somebody else, fell in love and that was that.*

*- Nobody wants to have a physical relationship with you once they know you're ill. People are afraid.*

*- Who am I going to get? People see a cripple when they look at me.*

*- When I went to see my girlfriend her mother wouldn't leave us alone. She couldn't trust someone who was in the hospital.*

#### **7.3 Parenting**

Nurturing and caring for a child after giving birth is one of the hardest physical and mental tests for mothers. Sleeplessness, hormonal imbalance, physical stress, financial difficulties, breastfeeding and relationship difficulties can shake even the strongest of women. Those who are sensitive to psychiatric disorders often experience a relapse in the year following birth. Admitting this, there is little evidence to suggest that schizophrenic mothers are unable to take care of their children. Women with mental disorders often lose their children, despite all the facts. This can be attributed to not receiving any assistance when it is most needed. Mothers don't have access to counselling, education or family therapy (Thornicroft, 2006: 38).

Most parents who have some form of mental disorder provide excellent care to their children and are considered good parents, if sufficient support is provided for possible overloads.

*<sup>-</sup> They think they're better than me.*

*- When I still had a job, I lost my best friend when he found out. He never called me again, so I didn't*

*- My childhood friend was shocked, when she found out. She was scared of visiting me, so she never*

People with mental disorders are much less likely to be in a committed relationship. There are many reasons for this, the most common being low self-esteem and lack of opportunities. Many existing relationships are discontinued due to the severity of the disease, stigma and financial difficulties. On the other hand many couples manage the

Divorce is one of the most stressful events in an average person's life. Most people need to be helped when faced with divorce, the mentally ill especially so. Several cases of patient's

*- My boyfriend dumped me the second I was admitted to hospital. He didn't want to be with me*

*- Once people know you're ill, it's hard to find somebody who's willing to share your life. You can't*

*- Nobody wants to have a physical relationship with you once they know you're ill. People are afraid.*

*- When I went to see my girlfriend her mother wouldn't leave us alone. She couldn't trust someone*

Nurturing and caring for a child after giving birth is one of the hardest physical and mental tests for mothers. Sleeplessness, hormonal imbalance, physical stress, financial difficulties, breastfeeding and relationship difficulties can shake even the strongest of women. Those who are sensitive to psychiatric disorders often experience a relapse in the year following birth. Admitting this, there is little evidence to suggest that schizophrenic mothers are unable to take care of their children. Women with mental disorders often lose their children, despite all the facts. This can be attributed to not receiving any assistance when it is most needed. Mothers don't have access to counselling, education or family therapy (Thornicroft,

Most parents who have some form of mental disorder provide excellent care to their children and are considered good parents, if sufficient support is provided for possible

being used and manipulated during the separation process have been reported.

*- I was married. My husband left me when I got ill. I had no relationships since.*

*- My husband isn't understating. He had all the power so he had me hospitalized.*

illness and find new challenges and qualities in their relationships.

*want to call him.*

**7.2 Partnership**

*anymore.*

*did. I'm sad because I lost my best friend. - They think they're better than me.*

*- For me, it's an advantage. She's great.*

*- My husband left me because of my diagnosis.*

*- He met somebody else, fell in love and that was that.*

*- Who am I going to get? People see a cripple when they look at me.*

*have kids when you're taking medication.*

*who was in the hospital.*

**7.3 Parenting**

2006: 38).

overloads.

*- My friends were shocked. They avoided me.*

*- When I was hospitalised, I was handicapped, had no energy. When I went to pick my son up from kindergarten everybody was very correct. I didn't have any bad experiences, none good too; they just treated me like everyone else.*

*- There was some doubt at home, but I went through with it anyway. I'm really happy I had a baby.*

*- My ex-husband tells me I'm not strict enough when the kids are with me. I don't think so, I think he's too strict and they have to let of some steam when they're with me. It's a very small flat and there are five of us when they come over, but they like being here.*

People with severe mental disorders like schizophrenia want children the same as everybody else.

 Women with mental health disorders are far more likely to be sexually abused. Research states that there are a lot of cases when a patient should be treated both for sexual abuse and illness (Thornicroft, 2006).

Several drugs used in psychiatric treatment have a negative effect on libido, erection and ejaculation, which is one of the leading reasons for avoiding use.

*- I have no libido…It's just gone.*

*- It's true I don't have any desire to be sexually active since it got sick.*

*- I can't get a woman pregnant. The medicine would harm the kid.*

*- When I got ill, I couldn't perform. My wife cheated on me a lot, she wasn't happy with me.*

*- Sexual disorders are another cause of slow self-esteem.*

Intercourse is, because of the above mentioned, less likely to happen in psychiatric institution than in other institutions, but it does occur and not rarely. Prohibiting sexual activity is discrimination, yet it must be implemented sometimes in order to stop people acting on basis of their reduced reasoning because of the illness. People with low self-esteem who agree to intercourse they would otherwise reject also need to be protected. Effects of these dilemmas presented themselves through hospital management decisions conflicting over gender separation. In the name of normalization, England implemented mixed wards for a couple of decades, which are being separated again. The reasons for this are numerous reports of abuse and women's dissatisfaction due to a lack of privacy. Closed wards fared the worst in this experiment of gender mixing, as the patients there have a problem controlling their behaviour. Women who experienced abuse before admission often demand their right for privacy very strictly The number of women being treated because of traumatic sexual experiences in psychiatric hospitals is not low (Thornicroft, 2006).

 In clinical practice, this means that in closed wards sexual intercourse is usually prohibited, even though it is a breach of their basic human rights.

#### **7.5 Employment**

Employment discrimination is one of the most often encountered forms of stigma.

Stigma and Mental Disorders 55

that individuals work in a tolerant environment where they are entitled to support when needed. There are clear guidelines how to organize work for people with mental health disabilities (Corrigan & McCracken, 2005). People with mental disorders need adjusted work hours and support at the work place (Crowther et al., 2001). An organizational culture which respects mental health, diversity and offers support is therefore necessary, as job performance can be significantly improved even with the most severe mental disorders (Thornicroft & Brohan, 2008). Legislation can speed up the process of employing people with mental disorders, but only slightly as employers still see them as a threat, despite the financial stimulation the government offers for their employment. Productivity is the cornerstone of respect in many cultural environments. To get and keep a job is the best path to recovery, on walked also by many people with severe mental illness. There are many

A student with a mental disorder can experience significant difficulties. Their reduced capabilities show themselves as problems with studying, communicating, memory, thinking and sleep which significantly affects their studies. Such students are hard to recognise as most student difficulties are attributed to a lack of motivation and poor working habits. Research of their special needs is very scarce. The astounding diversity of mental disorders and their varied symptoms further complicate the problem. Student may suffer from depression, anxiety, addiction, psychotic disorders or personality disorders. Each and every of these problems requires a different treatment and different types of support. The diagnosis, however, should not be the reason for program adjustment, it should rather be the reduced capabilities caused by the illness and its other effects - including stigmatization. Obstacles that prevent the student from reaching optimal results need to be removed. Specific social skills, for example, in obtaining information can be improved upon by an appropriate mentor. Additional rights can be provided for a student who just finished recovering from a mental illness, such as additional timelines, additional flexibility, adjustment of class attendance requirements, providing additional mentors and tutors, additional lectures arranged for specific problem areas and the option of at-home studying. Counselling, stress control classes, study planning classes and social skill classes should also be considered. Adjusting the study process should not jeopardise its quality, only change its difficulty. It is not expensive to adjust educational programs, the difficulty lies in combating discrimination against the mentally ill in all stages of the educational system (Rickerson et al., 2004). Rights and needs awareness need to be raised among the staff working in

Students who have received sufficient support have proved that education can help control

Students with mental disorders have reported that some teachers try to help them manage their duties, which depends on the sensibility of the teachers themselves, not on school rules.

*- In college my professors became lenient when they found out about my illness, with homework or*

*even tests. One even gave me a solved test and just told me to copy it.*

examples of people who received enough support to recover in this way.

**7.6 Education**

education.

a mental disorder.

*- Learning helps me get through the day.*

*- I got special treatment in high school.*

*- I rarely got a reply to my work applications and I was never accepted. I wrote about my diagnosis in these applications.*

Work is known to improve mental health, helps manage an individual's life and makes a person feel appreciated. Unemployment deprives people of social interaction, reduces their self-esteem, intensifies feelings of incompetence and pushes people into poverty. Research proves that most people with mental disorders possess work capabilities and desire to employ them (Brohan &Thornicroft, 2010). The low employment rate of people with mental disorders can be blamed on discrimination.

Employers expect mentally ill workers to be unproductive and frequently absent. They fear unpredictability and damage to the workplace or the company. Physically disabled people are twice as likely to be employed compared to the mentally disabled. If people with mental disorders get employed, they can expect a lower and less lucrative position, their experience and education not taken into account.

*- This is a big obstacle and big stress. Employer looks at me very carefully, what I speak and what I do.*

Given time, a lot of them give up on finding employment and accept their social status (Wahl, 1999; Link, 1982). Half of available and appropriate positions are terminated or changed to the mentally ill worker's disadvantage because of poor workplace relations (Becker et al., 1998). The most commonly asked question when discussing possible employment with a patient is whether the individual should reveal his diagnosis to his employer. There is no simple answer to that question. It depends on the employer's prejudice and on whether the position is more or less stressful. Hiding the diagnosis might lead to difficulties. If the individual can not perform set tasks or can not handle the stress, the most common response is inefficiency.

*- There was too much overload, I collapsed and had to go away.*

Honesty, on the other hand, might expose the individual to rejection and victimisation.

*- Nobody said I won't get the job because I was sick, they never say "You are schyzophrenic and we don't want you", but it's obvious.*

The most common solution seems to be denying the illness and covering up problems (Stuart, 2004).

Experts who try to lower their patients' or clients' expectations and try to get them to accept social aids or pensions are also an issue.

Adjusting the work to the needs of people with mental health disorders improves their job performance (Waghorn, 2011). This means making the workplace a little more serene, employing people to work from their homes, adjusting the work hours or just making sure

*- I rarely got a reply to my work applications and I was never accepted. I wrote about my diagnosis in*

Work is known to improve mental health, helps manage an individual's life and makes a person feel appreciated. Unemployment deprives people of social interaction, reduces their self-esteem, intensifies feelings of incompetence and pushes people into poverty. Research proves that most people with mental disorders possess work capabilities and desire to employ them (Brohan &Thornicroft, 2010).  They fear unpredictability and damage to the workplace or the company. Physically disabled people are twice as likely to be employed compared to the mentally disabled. If people with mental disorders get employed, they can expect a lower and less lucrative position, their experience

*- This is a big obstacle and big stress. Employer looks at me very carefully, what I speak and what I do. - I was moved to a lower paid work position, and then finally to some unimportant office. Then I quit.*

Given time, a lot of them give up on finding employment and accept their social status (Wahl, 1999; Link, 1982). Half of available and appropriate positions are terminated or changed to the mentally ill worker's disadvantage because of poor workplace relations (Becker et al., 1998). The most commonly asked question when discussing possible employment with a patient is whether the individual should reveal his diagnosis to his employer. There is no simple answer to that question. It depends on the employer's prejudice and on whether the position is more or less stressful. Hiding the diagnosis might lead to difficulties. If the individual can not perform set tasks or can not handle the stress,

Honesty, on the other hand, might expose the individual to rejection and victimisation.

*- Nobody said I won't get the job because I was sick, they never say "You are schyzophrenic and we*

The most common solution seems to be denying the illness and covering up problems

Experts who try to lower their patients' or clients' expectations and try to get them to accept

Adjusting the work to the needs of people with mental health disorders improves their job performance (Waghorn, 2011). This means making the workplace a little more serene, employing people to work from their homes, adjusting the work hours or just making sure

*these applications.*

disorders can be blamed on discrimination.

and education not taken into account.

*- From team leader to worker and finally a cleaner.*

the most common response is inefficiency.

*don't want you", but it's obvious.*

social aids or pensions are also an issue.

(Stuart, 2004).

*- There was too much overload, I collapsed and had to go away.*

*- I want to work, but I am locked up at home. I have nothing to do - They told me to find another job, when they found about my medication*. that individuals work in a tolerant environment where they are entitled to support when needed. There are clear guidelines how to organize work for people with mental health disabilities (Corrigan & McCracken, 2005). People with mental disorders need adjusted work hours and support at the work place (Crowther et al., 2001). An organizational culture which respects mental health, diversity and offers support is therefore necessary, as job performance can be significantly improved even with the most severe mental disorders (Thornicroft & Brohan, 2008). Legislation can speed up the process of employing people with mental disorders, but only slightly as employers still see them as a threat, despite the financial stimulation the government offers for their employment. Productivity is the cornerstone of respect in many cultural environments. To get and keep a job is the best path to recovery, on walked also by many people with severe mental illness. There are many examples of people who received enough support to recover in this way.

#### **7.6 Education**

A student with a mental disorder can experience significant difficulties. Their reduced capabilities show themselves as problems with studying, communicating, memory, thinking and sleep which significantly affects their studies. Such students are hard to recognise as most student difficulties are attributed to a lack of motivation and poor working habits. Research of their special needs is very scarce. The astounding diversity of mental disorders and their varied symptoms further complicate the problem. Student may suffer from depression, anxiety, addiction, psychotic disorders or personality disorders. Each and every of these problems requires a different treatment and different types of support. The diagnosis, however, should not be the reason for program adjustment, it should rather be the reduced capabilities caused by the illness and its other effects - including stigmatization. Obstacles that prevent the student from reaching optimal results need to be removed. Specific social skills, for example, in obtaining information can be improved upon by an appropriate mentor. Additional rights can be provided for a student who just finished recovering from a mental illness, such as additional timelines, additional flexibility, adjustment of class attendance requirements, providing additional mentors and tutors, additional lectures arranged for specific problem areas and the option of at-home studying. Counselling, stress control classes, study planning classes and social skill classes should also be considered. Adjusting the study process should not jeopardise its quality, only change its difficulty. It is not expensive to adjust educational programs, the difficulty lies in combating discrimination against the mentally ill in all stages of the educational system (Rickerson et al., 2004). Rights and needs awareness need to be raised among the staff working in education.

Students who have received sufficient support have proved that education can help control a mental disorder.

*- Learning helps me get through the day.*

Students with mental disorders have reported that some teachers try to help them manage their duties, which depends on the sensibility of the teachers themselves, not on school rules.

*- In college my professors became lenient when they found out about my illness, with homework or even tests. One even gave me a solved test and just told me to copy it. - I got special treatment in high school.*

Stigma and Mental Disorders 57

People with severe mental disorders are poorer than the general population and suffer from disrespectful behaviour, sometimes physical violence and underestimation. It should be noted however, that there are numerous reports of tolerance, cooperation and equal

Reports from Great Britain and the US claim that people with severe mental disorders are being avoided and excluded by in their communities. When the non-government organization ŠENT in Slovenia was establishing group homes, we believed that people who were living in the neighbourhood should not be given prior information concerning the possible (absence of) danger to help them accept the newcomers. We have firmly stated, however, that any event out of the ordinary, even if it's just an unscheduled visit by an ambulance, should be explained to everyone affected. The recommendation (Thornicroft, 2006: 15) that in the earliest stage of creating the community, residents should be notified carries weight, which might be relativised by the right to confidentiality and the fact that half of the world's adult population will be affected by a mental disorder at some point in their life and that three quarters of this population know somebody who suffers from one. Reports given by interviewed people with schizophrenia in INIGO differ significantly. Often the neighbours are those who notice that an individual requires help. The individual affected may perceive this as an intrusion into his autonomy that damages his self-respect.

*- Of course, my neighbours called the ambulance. It's annoying if your neighbours know they can out you away. They just call the ambulance and tell them to take me. When I bought this flat, my own little place, I locked myself in for 14 days straight - I wanted to put it in order. It was my first apartment! In the ghetto, really small, doesn't matter. Then suddenly, cops came to take me away. And I was so happy to get my own flat. It's unpleasant to say the least, when somebody can send you*

*- I live in a small village; my mom-she's the village gossip. She always cares most about what the neighbours will say. I think that's the source of a lot of problems. If I lived alone, there would be none*

*- I was elected house president twice. I told nobody in the building that I was in the hospital. That's*

Patients with mental disorders are most stigmatized by professionals (Lauber et al., 2006, Nordt et al., 2006). Stigma in professional services is one of the main causes of treatment discontinuation amongst patients (Tehrani et al., 1996). Professionals stigmatize the mentally ill for the following reasons. They are pessimistic about their recovery, despite all the scientific evidence to the contrary. The prognosis for most mental disorders is far better than for most recurring physical illnesses. Experts rarely meet recovered patients, only those

*to the hospital anonymously. They just come, handcuff me and take me away.*

*of that. People in my village are always watching me.*

*why they listened to me.*

**7.10 Professionals**

People in a community most often help one another.

*- The neighbours know when I'm in the hospital. My blinds are down. It bothers me, a little.*

*- My neighbours didn't know I was ill for a long time. They know now, they understand.*

*- They encouraged me. In the library, the staff knew what I'm interested in and they helped me.*

treatment.

**7.9 Neighbours**

They frequently experience discrimination and avoidance.

Some further guidelines for educational adjustment can be found here: (http://www.bu.edu/cpr/jobschool).

#### **7.7 Accommodation, communities**

Different social and cultural environments mean different types of care for people with mental disorders. The Slovenian social environment, for instance, sees most patients living in primary families, similar to the Mediterranean countries. In northern and western countries, most patients live on their own (Thornicroft, 2006).

Today numerous patients live in sheltered living arrangements. This form of accommodation offers diverse levels of care and is an alternative to living with relatives. Patients mostly choose to live in such a community when their domestic situation offers no advantage to recovery, when they feel they have no chance of living on their own and when they require help with everyday obligations. These alternative living choices can only work when competent staff is available, one that can recognise and answer the many different needs that people in such a community have. In Slovenia, social institutions are still one of the most common types of long-term accommodation, and however far they are developed, they still seem to face the same problems - an often reported high risk of neglect and inadequate treatment.

*- Looking for an apartment when mentally ill isn't easy. When I did it, I never told anyone I was ill. People don't like people who are...different. It's best to stay unnoticed.*

*- My landlord knows that I'm ill, she's a bit more careful now. I think it's because I didn't tell her much, but she still tries to make conversation and understand me. I know it's a bit awkward for the both of us, but I fell it's ok, it's her house.*

*- My parents think I'm not mature enough to have my own flat, even though I have one. I can cook for myself. Ironing and washing up are still problems, but I'll get help from a therapist so I can look after myself after I'm discharged.*

#### **7.8 Social relations, finances, civil rights**

A person's social life outside the bonds of family and the workplace depend on his social skills, opportunities, rights, resources and his perceived worth in society. The mentally ill can be discriminated against by having no means for day to day recreation, quality time and simple pleasures. The most common reason for this is financial deprivation, usually caused by unemployment and poor pension or social aid, sufficient only for the bare necessities. Most patients desire employment that would improve their financial status. Even if they do manage to find some form of employment they have to deal with management that s not always tolerant. Furthermore, they are most often not sufficiently informed of their rights and subsequently do not enforce them. Others do not want to enforce their rights because they want to enter any relationship on equal grounds. Some accept their inferior status because of their low expectations.

Different social and cultural environments mean different types of care for people with mental disorders. The Slovenian social environment, for instance, sees most patients living in primary families, similar to the Mediterranean countries. In northern and western

Today numerous patients live in sheltered living arrangements. This form of accommodation offers diverse levels of care and is an alternative to living with relatives. Patients mostly choose to live in such a community when their domestic situation offers no advantage to recovery, when they feel they have no chance of living on their own and when they require help with everyday obligations. These alternative living choices can only work when competent staff is available, one that can recognise and answer the many different needs that people in such a community have. In Slovenia, social institutions are still one of the most common types of long-term accommodation, and however far they are developed, they still seem to face the same problems - an often reported high risk of neglect and

*- Looking for an apartment when mentally ill isn't easy. When I did it, I never told anyone I was ill.*

*- My landlord knows that I'm ill, she's a bit more careful now. I think it's because I didn't tell her much, but she still tries to make conversation and understand me. I know it's a bit awkward for the*

*- My parents think I'm not mature enough to have my own flat, even though I have one. I can cook for myself. Ironing and washing up are still problems, but I'll get help from a therapist so I can look*

A person's social life outside the bonds of family and the workplace depend on his social skills, opportunities, rights, resources and his perceived worth in society. The mentally ill can be discriminated against by having no means for day to day recreation, quality time and simple pleasures. The most common reason for this is financial deprivation, usually caused by unemployment and poor pension or social aid, sufficient only for the bare necessities. Most patients desire employment that would improve their financial status. Even if they do manage to find some form of employment they have to deal with management that s not always tolerant. Furthermore, they are most often not sufficiently informed of their rights and subsequently do not enforce them. Others do not want to enforce their rights because they want to enter any relationship on equal grounds. Some accept their inferior status

They frequently experience discrimination and avoidance.

*- Teachers, professors-they all underestimated me.*

(http://www.bu.edu/cpr/jobschool).

**7.7 Accommodation, communities**

inadequate treatment.

*both of us, but I fell it's ok, it's her house.*

**7.8 Social relations, finances, civil rights**

*after myself after I'm discharged.*

because of their low expectations.

*- When I was doing my requalification everybody looked at me funny.*

countries, most patients live on their own (Thornicroft, 2006).

*People don't like people who are...different. It's best to stay unnoticed.*

Some further guidelines for educational adjustment can be found here:

People with severe mental disorders are poorer than the general population and suffer from disrespectful behaviour, sometimes physical violence and underestimation. It should be noted however, that there are numerous reports of tolerance, cooperation and equal treatment.

*- They encouraged me. In the library, the staff knew what I'm interested in and they helped me.*

#### **7.9 Neighbours**

Reports from Great Britain and the US claim that people with severe mental disorders are being avoided and excluded by in their communities. When the non-government organization ŠENT in Slovenia was establishing group homes, we believed that people who were living in the neighbourhood should not be given prior information concerning the possible (absence of) danger to help them accept the newcomers. We have firmly stated, however, that any event out of the ordinary, even if it's just an unscheduled visit by an ambulance, should be explained to everyone affected. The recommendation (Thornicroft, 2006: 15) that in the earliest stage of creating the community, residents should be notified carries weight, which might be relativised by the right to confidentiality and the fact that half of the world's adult population will be affected by a mental disorder at some point in their life and that three quarters of this population know somebody who suffers from one. Reports given by interviewed people with schizophrenia in INIGO differ significantly. Often the neighbours are those who notice that an individual requires help. The individual affected may perceive this as an intrusion into his autonomy that damages his self-respect.

*- Of course, my neighbours called the ambulance. It's annoying if your neighbours know they can out you away. They just call the ambulance and tell them to take me. When I bought this flat, my own little place, I locked myself in for 14 days straight - I wanted to put it in order. It was my first apartment! In the ghetto, really small, doesn't matter. Then suddenly, cops came to take me away. And I was so happy to get my own flat. It's unpleasant to say the least, when somebody can send you to the hospital anonymously. They just come, handcuff me and take me away.*

*- The neighbours know when I'm in the hospital. My blinds are down. It bothers me, a little.*

*- I live in a small village; my mom-she's the village gossip. She always cares most about what the neighbours will say. I think that's the source of a lot of problems. If I lived alone, there would be none of that. People in my village are always watching me.*

People in a community most often help one another.

*- I was elected house president twice. I told nobody in the building that I was in the hospital. That's why they listened to me.*

*- My neighbours didn't know I was ill for a long time.  Stigma in professional services is one of the main causes of treatment discontinuation amongst patients (Tehrani et al., 1996). Professionals stigmatize the mentally ill for the following reasons. They are pessimistic about their recovery, despite all the scientific evidence to the contrary. The prognosis for most mental disorders is far better than for most recurring physical illnesses. Experts rarely meet recovered patients, only those

Stigma and Mental Disorders 59

*- It's hard to say. There's not a lot of freedom, but they expect you to cooperate with everyone, the*

*- Patients in psychiatric hospitals don't have privacy. You can't do anything on your own, just what*

*- I had to sleep on a "temp", in the living room. People were coming to look at me all night long, made*

Protest is the most used strategy to fight injustice, as unsuccessful as it is. People who discriminate are prone to responding with more discrimination when subject to outrage and opposition. They are less likely to cease their behaviour when other opinions are forced on them. Protest can only positively affect media coverage, specifically those reporters who have failed to form a clear opinion on the matter at hand. Protest is a reactive strategy; it attempts to diminish negative attitudes about mental illness, but fails to promote more

The belief that prejudice is irrational inevitably leads to the logical conclusion that it can be fought with reason. If we were only able to understand the whole truth of mental disorders, the people it affects and ourselves we would be able to overcome prejudice and weaken their connection with our emotions easily. This thesis is the ground on which all antistigmatization educational programs are founded, including those that promote meetings between the non-discriminated and the discriminated. Promoting mental illness awareness is by far the most accepted method of combating stigmatization and discrimination. The same method was used in intercultural dialogue campaigns, aimed at reducing racism and homophobia. It was assumed that people could rationally »delete« their prejudice. It was proven that although short educational programs improve relationships and awareness (Roman & Floyd, 1981, Link et al, 1987, Brockington et al., 1993), they only have short-term effects. Their effect on discriminatory behaviour is unproven and there is some doubt as to whether they influence the behaviour itself or merely change the understanding of a problem (Corrigan et al., 2005, Pinfold et al., 2005, Shulze et al., 2003). People understanding more about mental disorders, however, doesn't mean much to stigmatized individuals. The main problem of educational programs seems to be that discussion is always focused on the stigmatized group, not on the group that stigmatizes. Instead of paying attention to prejudiced individuals, objects of their prejudice are being focused on, as Henriques noted in 1984 in his book »Changing the subject«. Following years showed that more than convictions, actual discriminatory behaviour needed to be stopped, which required knowledge of history, institutions, legislation and the cultural traits of the affected

Establishing direct contact with those who recovered from mental illness is another way to educate. Stories and reports by empowered individuals are a strong weapon against

positive attitudes that are supported by facts (Corrigan & Watson, 2002).

*- There is no privacy in the hospital. For any of us, none has it better.*

*- They were always ok with it, when I wanted to be alone.*

environment (Gonzales Torres et al., 2007).

*doctors, parents. No inner peace.*

*they tell you.*

**8.1 Protest**

**8.2 Education**

**8.3 Contact**

*noise. I cried all night.*

**8. Coping with stigma**

in grave need of assistance. Another reason is the need for distance and superiority, in short, power, which can be easily satisfied in any type of institution. Most professionals claim that they do not stigmatize, that problems arise from patients' oversensitivity to what they say. This anticipated discrimination contributes to patient stress. Stigma directed against the professionals themselves is also very much a reality- people often perceive professionals as arrogant and uncomprehending and therefore don't trust. This leads to procrastination in seeking assistance. Research shows that most people with mental disorders never seek treatment (Wittchen et al., 2005). The most stigmatized diagnoses are alcohol addiction, eating disorders, personality disorders, self-harm and schizophrenia. The most stigmatized patient groups are men with financial problems and the homeless. Discriminatory behaviour of staff increases in case it is decided that he mental problem is the patient's own fault, if the patient is admitted frequently, if violent or criminal behaviour is assumed, if it is believed the patient has little chance of recovery or, finally, if the patient is believed to be dishonest. Besides patronizing, double standards are a common type of stigmatization every act is judged according to the patient's diagnosis even when there is no objective reason to do so. For example, a patient being upset with the quality of his treatment could be interpreted as agitated because of the illness, even if his complaints are legitimate. People with mental disorders encounter the same discrimination in every institution, not just the hospital.  Psychiatrists and nurses who see their profession as stressful, hard and unsatisfying lead the public to see apathy, ignorance and poor patient treatment as the way to behave toward people with mental disorders. On the other hand, committed experts who appreciate their choice of profession set an example of respect, hope and the need to cooperate.

*- The court doesn't take me seriously. He raped me long ago, I was in the hospital and I am still here, and he, the criminal, is out.*

*- I feel the gap between staff and patients, between "healthy" and "mad". Outside the hospital, I'm worried my professors will find out about me, because we are a very small study group.*

*- My tooth was extracted in spite of my resistance to do that. The dentist just did it. I'm not in control of my life.*

*- They didn't tell me about the effects and side effects of drugs, an also about the length of my hospitalization. They didn't tell me anything.*

Others don't experience such problems.

*- My gynecologist knew about my illness, but she didn't treat me diferently.She encourages me to have children, but we decided against it, with my husband, since it's a genetic disease.*

#### **7.11 Privacy**

New legislation demands that a patient be accorded his right to privacy. This can not always be done due to current hospital conditions. Living conditions depend on many factors, chief amongst them the budget available and the level of structural stigmatization. Respect for the right to privacy depends on the staff also - some might see the patients'need to be alone as important, others not. Obviously, a closed ward is needed for patients who need to be observed for their and others' safety.

in grave need of assistance. Another reason is the need for distance and superiority, in short, power, which can be easily satisfied in any type of institution. Most professionals claim that they do not stigmatize, that problems arise from patients' oversensitivity to what they say. This anticipated discrimination contributes to patient stress. Stigma directed against the professionals themselves is also very much a reality- people often perceive professionals as arrogant and uncomprehending and therefore don't trust. This leads to procrastination in seeking assistance. Research shows that most people with mental disorders never seek treatment (Wittchen et al., 2005). The most stigmatized diagnoses are alcohol addiction, eating disorders, personality disorders, self-harm and schizophrenia. The most stigmatized patient groups are men with financial problems and the homeless. Discriminatory behaviour of staff increases in case it is decided that he mental problem is the patient's own fault, if the patient is admitted frequently, if violent or criminal behaviour is assumed, if it is believed the patient has little chance of recovery or, finally, if the patient is believed to be dishonest. Besides patronizing, double standards are a common type of stigmatization every act is judged according to the patient's diagnosis even when there is no objective reason to do so. For example, a patient being upset with the quality of his treatment could be interpreted as agitated because of the illness, even if his complaints are legitimate. People with mental disorders encounter the same discrimination in every institution, not just the hospital.  Psychiatrists and nurses who see their profession as stressful, hard and unsatisfying lead the public to see apathy, ignorance and poor patient treatment as the way to behave toward people with mental disorders. On the other hand, committed experts who appreciate their choice of profession set an example of respect, hope and the need to

*- Social services are like that: they decide instead of you, they treat you differently.*

*worried my professors will find out about me, because we are a very small study group.*

*have children, but we decided against it, with my husband, since it's a genetic disease.*

*- The court doesn't take me seriously. He raped me long ago, I was in the hospital and I am still here,*

*- I feel the gap between staff and patients, between "healthy" and "mad". Outside the hospital, I'm*

*- My tooth was extracted in spite of my resistance to do that. The dentist just did it. I'm not in*

*- They didn't tell me about the effects and side effects of drugs, an also about the length of my*

*- My gynecologist knew about my illness, but she didn't treat me diferently.She encourages me to*

New legislation demands that a patient be accorded his right to privacy. This can not always be done due to current hospital conditions. Living conditions depend on many factors, chief amongst them the budget available and the level of structural stigmatization. Respect for the right to privacy depends on the staff also - some might see the patients'need to be alone as important, others not. Obviously, a closed ward is needed for patients who need to be

cooperate.

*and he, the criminal, is out.*

*hospitalization. They didn't tell me anything.*

Others don't experience such problems.

observed for their and others' safety.

*control of my life.*

**7.11 Privacy**

*- There is no privacy in the hospital. For any of us, none has it better.*

*- It's hard to say. There's not a lot of freedom, but they expect you to cooperate with everyone, the doctors, parents. No inner peace.*

*- Patients in psychiatric hospitals don't have privacy. You can't do anything on your own, just what they tell you.*

*- I had to sleep on a "temp", in the living room. People were coming to look at me all night long, made noise. I cried all night.*

*- They were always ok with it, when I wanted to be alone.*

#### **8. Coping with stigma**

#### **8.1 Protest**

Protest is the most used strategy to fight injustice, as unsuccessful as it is. People who discriminate are prone to responding with more discrimination when subject to outrage and opposition. They are less likely to cease their behaviour when other opinions are forced on them. Protest can only positively affect media coverage, specifically those reporters who have failed to form a clear opinion on the matter at hand. Protest is a reactive strategy; it attempts to diminish negative attitudes about mental illness, but fails to promote more positive attitudes that are supported by facts (Corrigan & Watson, 2002).

#### **8.2 Education**

The belief that prejudice is irrational inevitably leads to the logical conclusion that it can be fought with reason. If we were only able to understand the whole truth of mental disorders, the people it affects and ourselves we would be able to overcome prejudice and weaken their connection with our emotions easily. This thesis is the ground on which all antistigmatization educational programs are founded, including those that promote meetings between the non-discriminated and the discriminated. Promoting mental illness awareness is by far the most accepted method of combating stigmatization and discrimination. The same method was used in intercultural dialogue campaigns, aimed at reducing racism and homophobia. It was assumed that people could rationally »delete« their prejudice. It was proven that although short educational programs improve relationships and awareness (Roman & Floyd, 1981, Link et al, 1987, Brockington et al., 1993), they only have short-term effects. Their effect on discriminatory behaviour is unproven and there is some doubt as to whether they influence the behaviour itself or merely change the understanding of a problem (Corrigan et al., 2005, Pinfold et al., 2005, Shulze et al., 2003). People understanding more about mental disorders, however, doesn't mean much to stigmatized individuals. The main problem of educational programs seems to be that discussion is always focused on the stigmatized group, not on the group that stigmatizes. Instead of paying attention to prejudiced individuals, objects of their prejudice are being focused on, as Henriques noted in 1984 in his book »Changing the subject«. Following years showed that more than convictions, actual discriminatory behaviour needed to be stopped, which required knowledge of history, institutions, legislation and the cultural traits of the affected environment (Gonzales Torres et al., 2007).

#### **8.3 Contact**

Establishing direct contact with those who recovered from mental illness is another way to educate. Stories and reports by empowered individuals are a strong weapon against

Stigma and Mental Disorders 61

The stigmatized were, from 1987 onward, repeatedly assessed on rejection, perceived rejection and anticipation. Some measures on coping orientations were taken as well. The stigma on the affected' carers and relatives was measured with different scales from the one

The biggest stigmatization control project was »Open the Doors«, a study and a campaign under the World Psychiatric Association, which got underway in 1996 in 20 different countries around the globe (Thompson et al., 2002; Sartorius & Schulze, 2005). It was meant to combat prejudice and discrimination against schyzophrenia. The first phase consisted of public polls in 6 different countries, the second a wave of social service public education programs. The project enjoyed some success, achieving, for example, a reduction in social exclusion in Germany (Gaebel, 2004). The following years showed that more than convictions, actual discriminatory behaviour needed to be stopped, which required knowledge of history, institutions, legislation and the cultural traits of the affected environment (Gonzales Torres in dr., 2007). One of the larger anti-stigmatization campaigns »Moving People« proved this as during the campaign, from 2002 to 2005, of 30 milion British reached, 17% more started believing that mental illness and violence are correlated, whereas in Scotland the exact opposite was true- the number of people convinced that the mentally ill are prone to violence dropped by 17% . Before the campaign started 40% more people in Scotland believed in this stereotype than in Wales and England. This result proves

The media research gaps were identified by Stout and others (2004). It was nevertheless clear that those who watch a lot of television hold more negative views of individuals with mental illness than those who watch it less (Granello & Pauley2000). Most of the articles on media influence on stigma share the same conclusion - this is outrage on media reports. A lack of differentiation among different media channels and the scarcity of research on children perception is nevertheless obvious. Additional problems include nonrepresentative results – the people studied are primarily college students. A link between media depiction and individuals' perceptions is thus still theoretical at this point. Replication and expansion of research in this area is required, and particular emphasis should be given to identifying links between exposure to media images and subsequent

A major improvement in research was applying qualitative methods , being essential for appreciating the subtle, damaging effects of stigma, for example structural discrimination. The Goffman work described above was the first and still most influential qualitative research on stigma. Major gaps in stigma research still remained: lack of results on structural

The importance of understanding the social context of the stigma is presented in research about attitudinal and structural barriers that prevent people with mental disabilities from

 The connection between mental disorder and physical illness researched proved that the increased frequency of physical diseases in schizophrenia might be on account of factors related to schizophrenia and its treatment, but undoubtedly also results from the unsatisfactory organization of health services, from the attitudes of medical doctors, and the social stigma ascribed to the schizophrenic patients (Leucht et al., 2007). One of the major approaches to overcome low service use, poor adherence rates, and stigma was defining mental disorders as neurobiological medical disease. The 10-year comparison of public endorsement of treatment and prejudice proved that this approach translates into support

of the last developed in Germay (Wancata et al., 2006).

that campaigns need to be adjusted to social and cultural environments.

perception impact. Simply stated, more precise research is needed.

discrimination, emotional responses of patients and cross cultural approaches.

becoming active participants in the competitive labour market (Stuart, 2006).

stigmatization. (Brockington et al., 1993; Wolf et al., 1996, Corrigan et al., 2001; Happpel et al., 2002, Pinfold et al., 2005). They were proven more successful than educational campaigns, especially in combating fear (Angemayer et al., 2003), yet even these programs only managed to fight stereotyping (Wolf et al, 1996; Thompson et al., 2002), not social distance. Relating to an individual with mental disorder experience does not affect the social nature of stigma. But, even direct contact effects can be relativised, as individuals can consider the one they are talking to, an exception. An informed and competent individual does not affect the reputation of his whole group, except when he is a recognised representative (Oakes et al., 1994). People with mental health problem experience know where to expect stigma in day to day life. Professional representatives of the mentally ill that give speeches at conventions and seminars aren't typical representatives of the group. Similar to professionals, they require frequent public appearances to maintain their status. Their posture is consequently militant, disdainful and they are constantly trying to find mistakes in their healthy colleagues' communication. They demand »appropriate« behaviour, in keeping with the marginalised group's code. Their expectations differ significantly from the bulk of the population's, who try to be polite and careful in order not to jeopardize their position. Most individuals with mental disorders try to demonstrate that they are well adjusted, behaving similar to others. At the same time, they try to convey that they are not the same; that they are at a disadvantage that needs to be accepted as a fact (Goffman, 1963). Most of the discriminated have developed careful and artful forms of communication, which enables them to be at least partially accepted and prevents severe problems.

#### **9. Research on stigma**

Already in 1999 US research on stigma argued that socio-psychological research of ethnic minorities and other group stereotypes should be considered when implementing anti-stigma strategies. It indicates that (a) attempts to suppress stereotypes through protest can result in a rebound effect; (b) education programs may have limited effectiveness because many stereotypes are resilient to change; (c) contact is enhanced by a variety of factors, including equal status, cooperative interaction, and institutional support (Corrigan & Penn, 1999).

In 2004, Link and others identified a variety of mechanisms allowing observation and measurements of key components present in a stigmatization process. These are: labelling, stereotyping, cognitive separating, emotional reactions, status loss, discrimination experiences and discrimination expectations, structural discrimination and behavioural responses to stigma. Structural discrimination was found not to be adequately researched. Strong proof of prevalence of expected discrimination over actual, experienced discrimination was found.  The main limitation of majority of research by then was found to be social desirability bias. People do not want to state openly that they are reluctant to accept people with mental disorders. Opinion measuring scales and Community Attitudes Toward the Mentally ill scales showed major improvement after contact with people with mental disorders (Crisp et al., 2005), which produced incentive to further anti-stigma strategies. The positive influence of contact was also proved by measuring emotional reactions to people with mental disorders (Angermeyer & Matschinger, 1996) and opened a path to research on stigmatizers.

stigmatization. (Brockington et al., 1993; Wolf et al., 1996, Corrigan et al., 2001; Happpel et al., 2002, Pinfold et al., 2005). They were proven more successful than educational campaigns, especially in combating fear (Angemayer et al., 2003), yet even these programs only managed to fight stereotyping (Wolf et al, 1996; Thompson et al., 2002), not social distance. Relating to an individual with mental disorder experience does not affect the social nature of stigma. But, even direct contact effects can be relativised, as individuals can consider the one they are talking to, an exception. An informed and competent individual does not affect the reputation of his whole group, except when he is a recognised representative (Oakes et al., 1994). People with mental health problem experience know where to expect stigma in day to day life. Professional representatives of the mentally ill that give speeches at conventions and seminars aren't typical representatives of the group. Similar to professionals, they require frequent public appearances to maintain their status. Their posture is consequently militant, disdainful and they are constantly trying to find mistakes in their healthy colleagues' communication. They demand »appropriate« behaviour, in keeping with the marginalised group's code. Their expectations differ significantly from the bulk of the population's, who try to be polite and careful in order not to jeopardize their position. Most individuals with mental disorders try to demonstrate that they are well adjusted, behaving similar to others. At the same time, they try to convey that they are not the same; that they are at a disadvantage that needs to be accepted as a fact (Goffman, 1963). Most of the discriminated have developed careful and artful forms of communication, which enables them to be at least partially accepted and prevents severe

Already in 1999 US research on stigma argued that socio-psychological research of ethnic minorities and other group stereotypes should be considered when implementing anti-stigma strategies. It indicates that (a) attempts to suppress stereotypes through protest can result in a rebound effect; (b) education programs may have limited effectiveness because many stereotypes are resilient to change; (c) contact is enhanced by a variety of factors, including equal status, cooperative interaction, and institutional support (Corrigan & Penn, 1999). In 2004, Link and others identified a variety of mechanisms allowing observation and measurements of key components present in a stigmatization process. These are: labelling, stereotyping, cognitive separating, emotional reactions, status loss, discrimination experiences and discrimination expectations, structural discrimination and behavioural responses to stigma. Structural discrimination was found not to be adequately researched. Strong proof of prevalence of expected discrimination over actual, experienced discrimination was found.  The main limitation of majority of research by then was found to be social desirability bias. People do not want to state openly that they are reluctant to accept people with mental disorders. Opinion measuring scales and Community Attitudes Toward the Mentally ill scales showed major improvement after contact with people with mental disorders (Crisp et al., 2005), which produced incentive to further anti-stigma strategies. The positive influence of contact was also proved by measuring emotional reactions to people with mental disorders (Angermeyer &

Matschinger, 1996) and opened a path to research on stigmatizers.

problems.

**9. Research on stigma**

The stigmatized were, from 1987 onward, repeatedly assessed on rejection, perceived rejection and anticipation. Some measures on coping orientations were taken as well. The stigma on the affected' carers and relatives was measured with different scales from the one of the last developed in Germay (Wancata et al., 2006).

The biggest stigmatization control project was »Open the Doors«, a study and a campaign under the World Psychiatric Association, which got underway in 1996 in 20 different countries around the globe (Thompson et al., 2002; Sartorius & Schulze, 2005). It was meant to combat prejudice and discrimination against schyzophrenia. The first phase consisted of public polls in 6 different countries, the second a wave of social service public education programs. The project enjoyed some success, achieving, for example, a reduction in social exclusion in Germany (Gaebel, 2004). The following years showed that more than convictions, actual discriminatory behaviour needed to be stopped, which required knowledge of history, institutions, legislation and the cultural traits of the affected environment (Gonzales Torres in dr., 2007). One of the larger anti-stigmatization campaigns »Moving People« proved this as during the campaign, from 2002 to 2005, of 30 milion British reached, 17% more started believing that mental illness and violence are correlated, whereas in Scotland the exact opposite was true- the number of people convinced that the mentally ill are prone to violence dropped by 17% . Before the campaign started 40% more people in Scotland believed in this stereotype than in Wales and England. This result proves that campaigns need to be adjusted to social and cultural environments.

The media research gaps were identified by Stout and others (2004). It was nevertheless clear that those who watch a lot of television hold more negative views of individuals with mental illness than those who watch it less (Granello & Pauley2000). Most of the articles on media influence on stigma share the same conclusion - this is outrage on media reports. A lack of differentiation among different media channels and the scarcity of research on children perception is nevertheless obvious. Additional problems include nonrepresentative results – the people studied are primarily college students. A link between media depiction and individuals' perceptions is thus still theoretical at this point. Replication and expansion of research in this area is required, and particular emphasis should be given to identifying links between exposure to media images and subsequent perception impact. Simply stated, more precise research is needed.

A major improvement in research was applying qualitative methods , being essential for appreciating the subtle, damaging effects of stigma, for example structural discrimination. The Goffman work described above was the first and still most influential qualitative research on stigma. Major gaps in stigma research still remained: lack of results on structural discrimination, emotional responses of patients and cross cultural approaches.

The importance of understanding the social context of the stigma is presented in research about attitudinal and structural barriers that prevent people with mental disabilities from becoming active participants in the competitive labour market (Stuart, 2006).

 The connection between mental disorder and physical illness researched proved that the increased frequency of physical diseases in schizophrenia might be on account of factors related to schizophrenia and its treatment, but undoubtedly also results from the unsatisfactory organization of health services, from the attitudes of medical doctors, and the social stigma ascribed to the schizophrenic patients (Leucht et al., 2007). One of the major approaches to overcome low service use, poor adherence rates, and stigma was defining mental disorders as neurobiological medical disease. The 10-year comparison of public endorsement of treatment and prejudice proved that this approach translates into support

Stigma and Mental Disorders 63

The INDIGO study is followed by the ASPEN project which is currently underway (2009-11) in 27 countries of the EU. It's goals are ambitious and include the creation of stigma and discrimination assessment scales, creation of detailed analytical European profile of stigma and discrimination as experienced by young people and adults with depression, including both anticipated and expected discrimination and self-stigma. The focus groups research, literature search and interviews were applied to identify best-practice, relevant problems in local environments and presentations of structural stigma and social exclusion (ASPEN,

INDIGO and ASPEN projects are seen as a step forward towards improvement of research

Prejudice can be fought by associating it with the political and social environment. Stigma can not be removed by open protest, explanations or examples - the only solution is a complex social movement aimed toward the better investment in the position of the mentally ill. All stigma reducing interventions need to be adjusted according to local experience and founded on daily observation of problems individuals face. Prejudice that affects the areas of life important to the affected individual needs to be determined (Yang et al., 2007). A set of social and institutional measures needs to be taken, one that encourages tolerance of illness, patients, treatment and symptoms. The anti-stigma movement should be connected with big mental service planning issues- those of psychiatric rehabilitation and community mental health that give some promise to improve the social position and access to care and treatment of people with mental disorders. Community care for people with mental disorders is important, since it provides multi-sectoral programmes of action to

The only way we as individuals can affect stigma is by leading by example, openly opposing derogatory terms and stereotypes. In basic education, schools and teachers should provide also mental health education, care for mental health and wellbeing of pupils and teachers alike. An inclusive school, promoted, can foster tolerance and make possible early recognition of mental disorders. Every educational level needs to prohibit derogatory language directed at the people with mental disorders and consistently view them as individuals, not diagnoses. Changes in educational curricula should include involving mental health service users and

This work is published with the support of the national association for Mental Health ŠENT,

Adorno, T. W. (1950). *The Authoritarian Personality*. Harper and Row,<PHONE_NUMBER>, New York Angermeyer, M. C. & Matschinger, H. (1996). Relatives' beliefs about causes of

schizophrenia. *Acta Psychiatrica Scandinavica*, Vol. 93, No. 3, (march 1996), pp.199–

their carers at all educational levels as experts and teachers in mental health issues.

on attitudes, systems, personal testimonies and discriminative behaviours.

retrieved 7.7.2011on webpage http://mdac.info/aspen).

promote the social inclusion of people with mental illness.

**10. Conclusion**

**11. Acknowledgment**

Translation: Gregor Cotič.

204, 16000447

**12. References**

Slovenia.

for services but not into a decrease in stigma. Reconfiguring stigma reduction strategies may require providers and advocates to shift to an emphasis on competence and inclusion of patients with mental disorders (Pescosolido et al., 2010).

In Pinfold et al. a review (2005) of relevant literature and the results of the recent Mental Health Awareness in Action (MHAA) programme in England was published to discuss the current evidence base on the active ingredients in effective anti-stigma interventions in mental health. The key active ingredient identified by all intervention groups and workshop facilitators were the testimonies of service users. The statements of service users (consumers) about their experience of mental health problems and of their contact with a range of services had the greatest and most lasting impact on the target audiences in terms of reducing mental health stigma.

Research on stigma and mental disorders has faced several problems: it has made few connections with clinical practice or health policy (for example in relation to help-seeking and access to care); it has been largely descriptive in its use of public attitude surveys or portrayal of mental illness and violence by the media. Few systematic assessments of user experience have been made. The research has been focused on hypothetical rather than real situations, out of context, addressed stigma indirectly rather than directly and has not provided a clear answer on how to intervene to reduce social rejection (Thornicroft et al., 2009). The review of self-stigma research shows lack of longitudinal research in this area and the need for greater attention on disentangling the true nature of the relationship between internalized stigma and other psychosocial variables (Livingston & Boyd, 2010). Public campaigns' efforts to reduce stigma have not been convincing and the field suffers from a lack of applicable solutions (Thornicroft, 2006; Angermeyer et al. 2009; Gaebel et al., 2008)]. The process of destigmatization appears to be a slow one. Data on the economic impact of anti-stigma campaigns is scarce and evaluation is intrinsically difficult (Sharac et al., 2010).

The overall conclusion of research gave some premises that the best course of action to support people with mental illness is empowerment, including a connection with supported employment and job coaching, national policy changes, development of quality services and anti-stigma education of mental health workers. The strongest evidence at present for active ingredients to reduce stigma pertains to direct social contact with people with mental illness and social marketing on the population level (Thornicroft & Brohan, 2008). The research should focus on measures directed at personal stigma of mental illness as it is increasingly being used as a key factor in anti-stigma interventions.

The need to schedule research from public to the affected persons was followed with the introduction of the INDIGO study aimed to describe the nature, direction, and severity of anticipated and experienced discrimination reported by people with schizophrenia. A crosssectional survey in 27 countries was made, in centres affiliated to the INDIGO Research Network, by use of face-to-face interviews with 732 participants with schizophrenia. Discrimination was measured with the newly validated discrimination and stigma scale (DISC), which produces three subscores: positive experienced discrimination; negative experienced discrimination and anticipated discrimination. Rates of both anticipated and experienced discrimination were found to be consistently high among people with schizophrenia, mostly in establishing and keeping friendship, in family relationships and in work places. Almost three thirds of the participants were found to want to conceal their diagnosis (Thornicroft et al., 2009). The theory that contact with mentally ill people reduces stigma and discrimination is not fully supported by latest qualitative INDIGO results (Rose et al., 2011).

for services but not into a decrease in stigma. Reconfiguring stigma reduction strategies may require providers and advocates to shift to an emphasis on competence and inclusion of

In Pinfold et al. a review (2005) of relevant literature and the results of the recent Mental Health Awareness in Action (MHAA) programme in England was published to discuss the current evidence base on the active ingredients in effective anti-stigma interventions in mental health. The key active ingredient identified by all intervention groups and workshop facilitators were the testimonies of service users. The statements of service users (consumers) about their experience of mental health problems and of their contact with a range of services had the greatest and most lasting impact on the target audiences in terms

Research on stigma and mental disorders has faced several problems: it has made few connections with clinical practice or health policy (for example in relation to help-seeking and access to care); it has been largely descriptive in its use of public attitude surveys or portrayal of mental illness and violence by the media. Few systematic assessments of user experience have been made. The research has been focused on hypothetical rather than real situations, out of context, addressed stigma indirectly rather than directly and has not provided a clear answer on how to intervene to reduce social rejection (Thornicroft et al., 2009). The review of self-stigma research shows lack of longitudinal research in this area and the need for greater attention on disentangling the true nature of the relationship between internalized stigma and other psychosocial variables (Livingston & Boyd, 2010). Public campaigns' efforts to reduce stigma have not been convincing and the field suffers from a lack of applicable solutions (Thornicroft, 2006; Angermeyer et al. 2009; Gaebel et al., 2008)]. The process of destigmatization appears to be a slow one. Data on the economic impact of anti-stigma campaigns is scarce and evaluation is intrinsically difficult (Sharac et al., 2010). The overall conclusion of research gave some premises that the best course of action to support people with mental illness is empowerment, including a connection with supported employment and job coaching, national policy changes, development of quality services and anti-stigma education of mental health workers. The strongest evidence at present for active ingredients to reduce stigma pertains to direct social contact with people with mental illness and social marketing on the population level (Thornicroft & Brohan, 2008). The research should focus on measures directed at personal stigma of mental illness as it is increasingly

The need to schedule research from public to the affected persons was followed with the introduction of the INDIGO study aimed to describe the nature, direction, and severity of anticipated and experienced discrimination reported by people with schizophrenia. A crosssectional survey in 27 countries was made, in centres affiliated to the INDIGO Research Network, by use of face-to-face interviews with 732 participants with schizophrenia. Discrimination was measured with the newly validated discrimination and stigma scale (DISC), which produces three subscores: positive experienced discrimination; negative experienced discrimination and anticipated discrimination. Rates of both anticipated and experienced discrimination were found to be consistently high among people with schizophrenia, mostly in establishing and keeping friendship, in family relationships and in work places. Almost three thirds of the participants were found to want to conceal their diagnosis (Thornicroft et al., 2009). The theory that contact with mentally ill people reduces stigma and discrimination is not fully supported by latest qualitative INDIGO results (Rose

patients with mental disorders (Pescosolido et al., 2010).

being used as a key factor in anti-stigma interventions.

et al., 2011).

of reducing mental health stigma.

The INDIGO study is followed by the ASPEN project which is currently underway (2009-11) in 27 countries of the EU. It's goals are ambitious and include the creation of stigma and discrimination assessment scales, creation of detailed analytical European profile of stigma and discrimination as experienced by young people and adults with depression, including both anticipated and expected discrimination and self-stigma. The focus groups research, literature search and interviews were applied to identify best-practice, relevant problems in local environments and presentations of structural stigma and social exclusion (ASPEN, retrieved 7.7.2011on webpage http://mdac.info/aspen).

INDIGO and ASPEN projects are seen as a step forward towards improvement of research on attitudes, systems, personal testimonies and discriminative behaviours.

#### **10. Conclusion**

Prejudice can be fought by associating it with the political and social environment. Stigma can not be removed by open protest, explanations or examples - the only solution is a complex social movement aimed toward the better investment in the position of the mentally ill. All stigma reducing interventions need to be adjusted according to local experience and founded on daily observation of problems individuals face. Prejudice that affects the areas of life important to the affected individual needs to be determined (Yang et al., 2007). A set of social and institutional measures needs to be taken, one that encourages tolerance of illness, patients, treatment and symptoms. The anti-stigma movement should be connected with big mental service planning issues- those of psychiatric rehabilitation and community mental health that give some promise to improve the social position and access to care and treatment of people with mental disorders.

The only way we as individuals can affect stigma is by leading by example, openly opposing derogatory terms and stereotypes. In basic education, schools and teachers should provide also mental health education, care for mental health and wellbeing of pupils and teachers alike. An inclusive school, promoted, can foster tolerance and make possible early recognition of mental disorders. Every educational level needs to prohibit derogatory language directed at the people with mental disorders and consistently view them as individuals, not diagnoses. Changes in educational curricula should include involving mental health service users and their carers at all educational levels as experts and teachers in mental health issues.

#### **11. Acknowledgment**

This work is published with the support of the national association for Mental Health ŠENT, Slovenia.

Translation: Gregor Cotič.

#### **12. References**

Adorno, T. W. (1950). *The Authoritarian Personality*. Harper and Row,<PHONE_NUMBER>, New York Angermeyer, M. C. & Matschinger, H. (1996). Relatives' beliefs about causes of schizophrenia. *Acta Psychiatrica Scandinavica*, Vol. 93, No. 3, (march 1996), pp.199– 204, 16000447

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Goffman, E. (1961). *Asylums. Essays on the Social Situation of Mental Patients and Other*

Goffman, E. (1963). *Stigma: Notes On The Management Of Spoiled Identity.* Pelican Books,

Gonzales Torres, M.A., Oraa, R., Arsegui, M., Fernandez-Rivas, A., & Guimon J. (2007).

Granello, D. H., Pauley, P. S. (2000). Television viewing habits and their relationship to

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Honokonen, T., Henriksson, M., Koiviso, A. M., Stengard, E. & Salokangas, R. K. R.

Kroska, A. & Harkness, S. K. (2006). Stigma Sentiments and Self-Meanings: Exploring the

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towards consumer participation in mental health services and the role of the consumer academic. *International Journal of Mental Health Nursing*, Vol. 11, No. 4,

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**4**

*UK*

Arabinda Narayan Chowdhury

*Northamptonshire Healthcare NHS Foundation Trust, Stuart Road Resource Centre, Corby, Northants NN17 1RJ*

**Culture, Psychiatry and Cultural Competence**

Why the study of culture and its clinical application is important in mental health training and service? Mental health and illness is a set of subjective experience and a social process and thus involves a practice of culture-congruent care. Series of anthropological, sociological and cross-cultural research has clearly demonstrated a very strong ground in favour of this

An individual's cultural background colours every facets of illness, from linguistic or emotional expression (Helman, 2007; Lewis-Fernandez, 1996) to the content of somatic complaints (Goldber & Bridges, 1988) and delusional (Yip, 2003) or hallucinatory experiences (Kim, 2006; Cowen, 2011). Cause, course and outcome of major psychiatric disorders are influenced by cultural factors (Kleinman, 1988; Kirmayer, 2001; Littlewood & Lipsedge, 1997). Wide variations in the prevalence of many psychiatric disorders across geographic regions and ethnocultural groups have been documented (Maercker, 2001). In mental health, dysfunctional behaviour is a key issue in diagnosis, viz. distinction from normal to disordered behaviour. The social and cultural context here is important because identification of abnormal dysfunctional behaviour is basically a social judgement (Kirmayer & Young, 1999). Different cultural and ethnic groups have different perception and practices about health as per their ecocultural adaptation (Weisner, 2002). Social and cultural factors are major determinants of the use of health care services and alternative sources of help. Recent changing global demography demands the recognition and response to cultural diversity in psychiatric practice (intercultural clinical work). Culturally based attitudes and assumptions direct the perspectives that both patient and clinicians constantly