Stigmatisation of persons suffering from mental illness is a well researched and documented phenomenon (Overton and Medina 2008). Stigma can be explicit or implicit (Stier and Hinshaw 2007) and mental illness related stigma remains a significant public health concern globally (Pescosolido et al. 2013). Stigmatised views can be found in the general public (Corrigan et al. 2012), healthcare professionals (Schulze 2007) or can be expressed as self stigmatisation (Watson et al. 2007).
In the field of mental health nursing, stigmatisation has far reaching implications for practice (Pinto-Foltz and Logsdon 2009). Stigma can reduce levels of help-seeking behaviour (Henderson, Evans-Lacko and Thornicroft 2013) and also negatively affect patient engagement (Corrigan, Druss and Perlick 2014) which poses a particular challenge for nurses in the field. Stigma can also compound psychological factors that play a role in the mental illness itself. For example, stigma is a moderator of low self-esteem and depression in patients with schizophrenia (Staring et al. 2009).
This literature review critically evaluates research into stigmatisation of mental illness with particular consideration of the prevalence and effects of perceived stigma, stigma in healthcare and self stigma and their effects in terms of health and well-being and the provision of effective treatment and care. There have also been numerous campaigns and interventions to tackle stigma (Dalky 2012) and these are also critically evaluated in terms of their efficacy. These findings are then related to research, public policy and evidence based practice and their potential contribution to professional nursing practice is evaluated.
This literature review was undertaken through a Boolean search of bibliographic databases PubMed and PsychInfo. These databases were selected due to their wide inclusion of articles from peer reviewed journals in the fields of psychology and medicine. The search terms used were “stigma*” and “mental illness” or “mental health” or “mental disorders”. The inclusion criteria were qualitative and quantitative empirical studies as well as literature reviews and meta-studies from North America or Europe. Exclusion criteria were papers older than 15 years, papers not published in English and research where variables other than stigmatisation were the subject of the primary research aim. The abstracts of the papers yielded by the search and that met the inclusion criteria were then reviewed and evaluated using CASP tools (CASP UK 2013) and papers were selected for a more detailed analysis on the basis of their methodological rigour and validity as well as their relevance to mental health nursing practice. Where possible, preference was given to the most recent research.
This section comprises the main literature review and considers the literature and evidence under four main areas: stigmatised views in wider society and among the general public; self-stigma; stigma in health and social care and initiatives to reduce stigma.
Mental illness stigmatisation is characterised by negative views or discrimination based on prejudiced views (Sartorius 2007). Stigmatisation as a social attribution can be explicit, that is conscious and the individual with the stigmatised attitudes has control over this (Stier and Hinshaw 2007). Conversely, it can be implicit where the stigmatisation occurs at a subconscious and intuitive level (ibid).
Stigmatisation can have a profoundly detrimental effect in the lives of individuals with mental illness. The psychosocial effects include isolation as a result of ‘social distancing' by others (Tew et al. 2011). Social distancing refers to avoidant behaviour in relation to those with mental illness (Corrigan et al. 2012). Related to this is the more overt expression of stigma in the form of social rejection (Feldman and Crandall 2007). Both social distancing and rejection will result in people with mental illness having fewer support structures. There are some correlates between social support and outcomes (Corrigan and Phelan 2004). In mental health nursing, facilitating peer-support groups and structures is one possible method by which social support can be strengthened and there is evidence that this reduces stigma and isolation and improves outcomes (Repper and Carter 2011).
Stigma can also affect an individual's employment and consequently their economic wellbeing (Tew et al. 2011. Being employed is positively correlated with better outcomes for people with mental illness (Stuart 2006) and those recovering from serious mental illness place a large degree of importance on employment in relation to their recovery (Dunn, Wewiorski and Rogers 2008). For those individuals who are in employment, stigmatised views may lead them to hide their mental illness from their employer (Krupa et al. 2009) and the stigma may have other consequences in their work life as they may be considered less capable of performing their duties (ibid.). Despite equality legislation in the UK providing statutory protection for people with disabilities (including mental illness), empirical research indicates that stigma still leads to this client group being significantly disadvantaged (Brohan and Thornicroft 2010; Brohan et al. 2010). This is also evidenced in employment statistics where some mental disorders, notably schizophrenia are negatively correlated with employment rates to a significant degree (Marwaha et al. 2007; Seeman 2009). The economic impact of mental health stigma is considerable both for the individual and for wider society (Sharac et al. 2010).
Stigma in society refers to prejudice and discrimination directed at a vulnerable minority group, but related to this is the concept of self-stigma which refers to the internalisation of these negative attitudes (Corrigan and Rao 2012). An empirical study which investigates the link between societal stigma and self stigma (Evans-Lacko et al. 2012). The study of European countries demonstrates that the levels of stigmatised views in society are positively correlated with levels of self-stigma in the individual with mental illness (ibid.). This evidences the fact that stigmatised views in society are internalised by the individual. The mechanism by which self-stigma is mediated is not entirely clear but evidence suggests that stereotype concordance plays a role (Watson et al. 2007).
Stereotypes are societal constructs that view people with mental illness in a certain way (e.g. dangerous or ineffectual) and these are internalised as self-stigma depending on the degree to which the individual is both aware of them and agrees with them (ibid.). Additionally, those with mental illness are affected by what is termed the “perceived legitimacy” of the stereotypes, and the higher this is, the more negatively it impacts on self-esteem. A longitudinal study of individuals with serious mental illnesses (SMI) provides some support for a proposed stage based model of self-stigma (Corrigan, Rafacz and Rüsch 2011). There is an awareness of the stereotype, agreement with the stereotype followed by self application and harm (ibid.). This study used ‘hope' and ‘self esteem' as outcome measures. The authors highlight the link between these measures and behaviours and the negative impact stigma has for these individuals.
The impact of self-stigma is far reaching in the lives of the individual with mental health issues and for nurses involved in their care. The “Why try?” model (Corrigan, Larson and Ruesch 2009) utilises labelling theory which posits that identity and behaviours are affected by the descriptors or classifications applied to them (Moncrieffe and Eyben 2013) and so stigmatised views of mental illness become a ‘self-fulfilling prophecy' (Corrigan and Rao 2012). Individuals may therefore fail to set or strive for certain goals such as employment (Corrigan, Larson and Rüsch 2009). From the perspective of mental health nursing, this self-stigma may consequently have a negative effect on the individual's levels of engagement with services, treatment or care (ibid.) and this is a challenge for those who are involved in the provision of treatment and services.
These negative effects of self-stigma are correlated with poorer outcomes for patients (Rüsch et al. 2010). Self stigma also has a negative effect on help-seeking and engagement which can increase the incidences of hospitalisation (ibid.). Being involuntarily hospitalised under the Mental Health Act (MHA) (Department of Health 2007) may also provoke an emotional response which increases stigma and shame (Rüsch et al. 2014) and entrenched stigma may be a cyclical process which is difficult to counter.
It is important to note that not all individuals with mental health issues, including SMI will internalise stigma. Some individuals simply reject the label or stigmatised views and some are motivated by societal stigmatised views to campaign for justice and change (Corrigan, Druss and Perlick 2014). However, empirical research suggests that over a third (36%) of those with SMI internalise stigma (West et al. 2011) and so challenging stigma by empowering clients and through anti-discriminatory practice (Thompson 2016) should be a priority for mental health professionals including nurses.
Stigmatisation in healthcare may be structural, that is inherent in the healthcare systems themselves or is expressed in views and attitudes held by health or social care professionals. Stigmatised views of mental illness may be reduce the levels of funds and resources allocated to the mental health services which can reduce the levels of care and treatment available and increase the time patients must wait to receive treatment (Thornicroft 2008). Given that early intervention is associated with better outcomes (Berk et al. 2010; Marshall and Rathbone 2011), this poses a challenge for mental health nursing. Additionally, stigmatised views in general healthcare settings can negatively impact the general physical healthcare provided to those with mental illness (Thornicroft 2008). For example, evidence suggests that treatment of those with mental illness in accident and emergency department is of a lower standard than that provided to other patient groups (Thornicroft, Rose and Kassam 2007). Therefore stigmatisation of mental illness can have negative consequences in all fields of nursing, and is not confined to mental health care.
Whilst research indicates that the attitudes towards persons with mental illness tend to be more positive among mental health professionals when compared to the general population or family members, there are still stigmatised views present in this group (Wahl and Aroesty-Cohen 2010). This stigmatisation is not uniform and varies by country, professional grade and the mental health diagnosis (ibid.). Schizophrenia is particularly stigmatised (Rao et al. 2009) as is borderline personality disorder (Ross and Goldner 2009).
Substance misuse disorders and patients with dual diagnosis are also more likely to be stigmatised by health and social care professionals (Van Boekel et al. 2013). Given the high prevalence of co-morbid substance misuse among those with mental illness (Carra and Johnson 2009; Newton-Howes et al. 2010) this remains a significant obstacle to the provision of effective mental health care. A meta-analytical review of the literature suggests that the stigmatised views encompass perceptions of these service users being violent, manipulative and lacking motivation (Van Boekel et al. 2013) and these factors obstruct the ability to deliver care. These attitudes, which are associated with poor knowledge of substance misuse disorders, negatively impact the service user who become disempowered and consequently have poorer treatment outcomes (ibid.).
It should be noted that many of the negative perceptions of people with mental illness held by healthcare professionals may be based on their previous experiences of caring for these patient groups, rather than as a result of adopting prevailing societal views (Horsfall and Cleary 2010). Therefore both education and strategies for dealing with difficult clinical scenarios are essential in enabling professionals to deliver compassionate and empowering care.
This section considers the range of interventions that have the goal or reducing mental illness stigma. There is a consideration and evaluation of campaigns challenging public stigma as well as interventions designed to tackle self-stigmatisation and stigmatisation among health professionals. In 2009, in the UK, a high profile public health campaign called ‘Time to Change' was launched (Henderson and Thornicroft 2009). The initiative seeks to tackle stigma by increasing social interaction between those with mental illness and those without (ibid.). The campaign's primary goal was to reduce mental health related stigma by 5%. An evaluation one year after the campaign's launch measured the efficacy of the initiative by collating mental health service users' experiences of discrimination as an outcome measure (Henderson et al. 2012). There was a statistically significant reduction in experiences of stigma in relation to friends, family as well as employment finding and retention suggesting this mass media campaign can be effective in tackling stigma (ibid.).
There have been other approaches taken including education and initiatives that actually facilitate the contact between those with mental illness and members of the general public (Corrigan et al. 2012). A meta-study that analysed the results from 72 studies across 14 countries indicate that this social contact is the most effective way of tackling stigmatised views but for adolescents, an educational approach is more effective (ibid.). This would suggest that school based educational interventions would be effective in reducing the levels of public stigma in the future. It is also likely that this may reduce the likelihood of adolescents who later suffer mental illness to internalise stigma.
Addressing self stigmatisation is also a priority for mental health professionals (Corrigan and Rao 2012). One pilot intervention to tackle self-stigma used a group treatment modality that incorporated elements of cognitive behavioural therapy (CBT) and was found to be effective in reducing self-stigma (Lucksted et al. 2011). Given that stigma is a mental construct and its internalisation is a cognitive process (Watson et al. 2007), using CBT to tackle this is an obvious approach to trial and adopt in interventions since CBT analyses cognition and seeks to translate this into behavioural changes, and it has been shown to effective in relation to a variety of mental illness (Horman et al 2012). Another intervention that has had some success integrates an educational component with CBT (Yanos, Roe and Lysaker 2011) and mixed approaches are likely to be efficacious.
Finally, tackling stigma among mental health professionals is of primary importance due to the negative consequences this can have for patient care (Thornicroft 2008). Anti-stigma training for medical students has shown to decrease the prevalence of stigmatised views (Papish et al. 2013) and even brief educational initiatives such as the viewing of anti-discrimination films have shown to reduce the levels of stigma for medical students (Kerby et al. 2008) and this effect would likely be replicated among nursing students. Given the evidence that stigmatised views are prevalent in all areas of nursing (Thornicroft, Rose and Kassam 2007), anti-stigma education should be part of all nursing training. Mental nursing training should itself focus on the importance of a compassionate, person centred approach as a bulwark against stigma (Sercu, Ayala and Bracke 2015).
Research also has an effect on public policy and official care guidelines, although they are also shaped by wider issues such as finances, resources and political opinion. The UK Prime Minister recently pledged that the government would tackle the stigma associated with mental illness (Department for Education 2017). In terms of formal health policy, the mental health strategy for England (Department for Health 2011) explicitly states that fostering positive mental health is the duty of all citizens (patients, families, healthcare and other professionals) as is tackling discrimination and stigma (ibid.). The strategy has six objectives and one of these is that people will experience less mental health related stigma (Department for Health 2011, p. 6). Whilst many facets of the policy document reflect the evidence emerging from the body of research, there is criticism and concern that it will not be effective due to limited resources, especially in a time of austerity (ESRC 2016).
Official public policy is also expressed through NICE guidelines. The issue guidelines specific to mental health service users' experiences and have a specific quality statement on tackling stigma (NICE 2011). The quality statement stipulates that collaborative and inter-professional or inter-agency working is integral to anti-stigma initiatives and professional structures, although there is not precise guidance on how this should be achieved. Generally, NICE guidelines for mental illness advocate person-centred compassionate practice but persistent health inequalities (Lawrence and Kisely 2010) provide evidence that enacting these recommendations effectively is problematic. This makes it even more imperative that the findings from this literature review is reflected in contemporary practice.
Translating the findings of the literature review, educational and contact based initiatives to reduce stigma should be at the centre of evidence based mental health nursing practice (Dalky 2011). The research and evidence indicates that education is more effective in reducing stigma in adolescents (Corrigan et al. 2012) and outreach programmes such as educational schools visits (Pinfold, et al. 2003) have the potential to enhance professional practice in the wider community. Regular ongoing professional training and reflective practice should also help to challenge stigmatised views (Schafer, Wood and Williams 2011)
As well as incorporating evidence based anti-stigma interventions into the practice setting, the research into stigmatisation and mental health, contemporary nursing practice can draw on a number of models of mental health recovery that are inherently anti-stigmatising. This in turn can encourage nurses to develop a personal philosophy of nursing practice that is intrinsically anti-stigmatising, anti-discriminatory and empowering (Thompson 2016). Given that stigmatisation is associated with both diagnosis (Corrigan 2007) and ‘labelling' (Ben-Zeev, Young and Corrigan 2010). Models of nursing such as the tidal modal of mental health recovery (Barker and Buchanan-Barker 2010) can helpfully enhance practice. This approach sees the service user as an individual with an inherent worth, personal strengths and unique history that should be drawn upon to ensure they reach their maximum potential.
This literature review shows that despite a recent interest in mental illness stigma and its prioritisation in mental health care, stigmatised views are still prevalent in the general public, those suffering from mental illness and health professionals themselves. The impact of this stigma is far-reaching and affects all areas of an individual's life from psycho-social well-being to employment prospects. There have been a number of successful contact and educational interventions to tackle stigma by others and approaches that utilise CBT have been effective in tackling self stigma. This evidence should be implemented at scale in general mental health services.
The research into stigmatisation of mental illness should be reflected alongside professional codes of conduct, organisational policies and models of nursing to ensure evidence based practice is being implemented in relation to mental illness stigma. A person centred approach to nursing practice provides a strong basis for addressing stigma and empowering patients and nurses should be aware of the subtleties and various forms that stigmatisation can take in order to empower service users to reach their full potential.
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