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STIGMA IN MENTAL HEALTH: A CONCEPT ANALYSIS L I N D A C AR M A N C O P E L , P H D , R N P M H C N S , B C , C N E , AN E F, N C C , FAPA K H AM I S AL - M A M A R I , R N , M S C O L L E G E O F N U R S I N G , V I L L AN O VA , PA Goals & Framework of Concept Analysis The Goals of the Concept Analysis: ◦ Enhance understanding of the concept for use in research or clinical practice. ◦ Bring the concept closer to being used for research or for clinical ) practice. ◦ Identify the commonalities and shared experiences of stigma in the mentally ill population. ◦ Increase understanding and conceptual clarity of stigma. ◦ Contribute to instrument development and theory testing. (Meleis, 2012) Framework for Concept Analysis: Walker & Avant (2005) The Concept: Stigma Stigma in mental health is a universal health issue. The term “stigma” can be traced back to 1700s. The word “stigma” is derived from the Greek word root which means “mark,” a brand impressed by an iron. It also referred to marks branded on cattle or on people who served as slaves in ancient times in he Orient or in Greece. Stigma has a negative influence on people’s lives, creating social distance which interferes with their interactions with people in the society. (New Catholic Encyclopedia ,2003) The Concept: Stigma Recently, the concept of stigma was introduced into medical science to describe the discrimination experienced by people suffering from illnesses, such as HIV/AIDS, obesity, psoriasis, & mental health disorders. Stigma disqualifies certain groups from full social acceptance and the ability to conform to the typical standards of society. Stigma has a persistent influence on the individual’s health care problems, as well as on the community, family, and national political responses to illness. (Goffman, 1963; New Catholic Encyclopedia, 2003) The Concept: Stigma Stigma has a persistent influence on the individual’s health care problems, as well as on the community, family, and national political responses to illness. Stigmatized people suffer from chronic stress, which has additional negative effects on their physical and mental well being. There is strong evidence that people with mental illness have less access to primary health care. There is evidence that mental health clients receive inferior care for medical problems. The rates of cardio-vascular disease, obesity, and diabetes are increasing in people with mental illness. (Corrigan & Watson, 2002; Bjorkman, Angelman, & Jonsson, 2008; Dehert et. al., 2009; Druss & Bradford, 2000; Druss & Von Esenwein, 2006; Hatzenbuehler, Phelan, & Link, 2013) Definition of Stigma Link and Phelan (2001) defined stigma as a process which occurs when a person demonstrates noticeable social differences, and thereby becomes unfairly labeled based on emotional or physical symptoms or atypical characteristics. Gary (2005) defined stigma as “a collection of negative attitudes, beliefs, thoughts, and behaviors that influences the individual, or the general public, to fear, reject, avoid, be prejudiced, and discriminate against people with mental disorders” (p.980). Types of Stigma Public Stigma Self-Stigma Public stigma refers to the Self-stigma is when a attitudes and beliefs of the person with mental illness general public towards internalizes stigma and persons with mental health experiences diminished challenges or their family self-esteem and selfmembers. efficacy. (Corrigan, Powell, & Rusch, 2012; Watson, 2007). Types of Stigma Stigma by Association Double Stigma Stigma by association occurs Double stigma occurs when when negative characteristics a person with mental illness (e.g., psychological distress concurrently experiences and feeling of inferiority) are more than one type of attributed to individuals, stigma such as a mental family members, care givers, health diagnosis and a and healthcare providers physical disability. who are in close contact with stigmatized people. (Corrigan, Powell, & Rusch, 2012; Halter, 2008; Watson, 2007) Assumptions There is a link between people’s negative attitudes and stigma towards clients with mental illness. The more mentally ill clients believed that they are different and devalued in the eyes of others, the more self-stigma occurs. There is a relationship between stigma and loss of social identity. Increased awareness and acceptance of mental illness may lead to reductions in stigma. (Corrigan & Watson, 2002; Major & O'Brien, 2005; Minas, Zamzam, Midin, & Cohen, 2011) Antecedents: The Concept of Stigma Individual with health problems Prejudice Blame Feelings of rejection Extreme self-conscious Fear of others discovering health status (Berjot & Gillet, 2011 & Hatzenbuehler, Phelan, & Link, 2013) Characteristics: The Concept of Stigma Unfavorable attitude from an individual or group Feeling devalued Unpleasant personal experience Perceived negative social norms (Crocker, 1999; Link & Phelan, 2001;Berjot & Gillet, 2011) Concept of Stigma: Consequences Negative Consequences Feeling inferior Negative IPRs Discrimination Barriers to health care Mental health Physical health Decrease quality of life Social isolation Overall opportunity loss Positive Consequences Being assertive by talking about stigma Care-Seeking Behaviors Ongoing participation on treatment Active participation in antistigma actions E.g., media, community awareness program, etc. (Corrigan, 2004; Link & Phelan, 2001; Hatzenbuehler et al., 2013; Bjorkman et al., 2008; Schneider et al. 2011; Gary , 2005) Recommendations Nursing Practice: Examine own beliefs and values Individualized patient care Conduct research studies Patients and Families: Provide support for patients and families Acceptance of mental illness Educate patients, families, and communities about mental health and mental illness Recommendations Nursing Education: Evaluate current education practices and examine how theoretical and clinical components of curriculum address stigmatization. Evaluate whether the time allotted for mental health theory and clinical education is sufficient to address stigma. The nursing profession must recognize all specialties area, including mental health nursing, as equally valuable and contributing to the health of individuals, families, and communities. Stigma Research Current Studies The majority of studies address schizophrenia Mostly qualitative and descriptive studies emphasizing on violence, stereotypes, and discrimination Few intervention studies Proposed Studies More studies on types of stigma and what people encounter Strategies to address stigma The effect of stigma on families Nursing education studies 16 References Berjot, S., & Gillet, N. (2011). Stress and coping with discrimination and stigmatization. Frontiers in psychology, 2, 33. doi: 10.3389/fpsyg.2011.00033 Corrigan, P. (2004). How Stigma Interferes With Mental Health Care. American Psychologist, 59(7), 614-625. Corrigan, P. W., Powell, K. J., & Rusch, N. (2012). How does stigma affect work in people with serious mental illnesses? Psychiatric Rehabilitation Journal, 35(5), 381-384. doi:10.1037/h0094497 Corrigan, P. W., & Watson, A. C. (2002). Understanding the impact of stigma on people with mental illness. World Psychiatry, 1(1), 16-20. Crocker, J. (1999). Social Stigma and Self-Esteem: Situational Construction of Self-Worth. Journal of Experimental Social Psychology, 35(1), 89-107. doi: http://dx.doi.org/10.1006/jesp.1998.1369 Gary, F. A. (2005). Stigma: barrier to mental health care among ethnic minorities. Issues in Mental Health Nursing, 26(10), 979-999. doi: 10.1080/01612840500280638 Gouthro, T. J. (2009). Recognizing and addressing the stigma associated with mental health nursing: a critical perspective. Issues in Mental Health Nursing, 30(11), 669-676. Halter, M. J. (2008). Perceived Characteristics of Psychiatric Nurses: Stigma by Association. Archives of Psychiatric Nursing, 22(1), 20. References Happell, B. (2007). Appreciating the importance of history: a brief historical overview of mental health, mental health nursing and education in Australia. International Journal of Psychiatric Nursing Research, 12(2), 1439-1445. Hatzenbuehler, M. L., Phelan, J. C., & Link, B. G. (2013). Stigma as a fundamental cause of population health inequalities. The American Journal of Public , 103(5), 813-821. doi: 10.2105/ajph.2012.301069 Hinshaw, S. P. (2007). The mark of shame : stigma of mental illness and an agenda for change. Oxford ; New York: Oxford University Press. Link, B. G., & Phelan, J. C. (2001). Conceptualizing stigma. Annual Review of Sociology, 27, 363-385. doi: 10.1146/annurev.soc.27.1.363 Major, B., & O'Brien, L. T. (2005). The social psychology of stigma. Annual Review of Psychology, 56, 393-421. doi: 10.1146/annurev.psych.56.091103.070137 Minas, H., Zamzam, R., Midin, M., & Cohen, A. (2011). Attitudes of Malaysian general hospital staff towards patients with mental illness and diabetes. BMC Public Health, 11, 317. doi: 10.1186/14712458-11-317 References Parcesepe, A. M., & Cabassa, L. J. (2012). Public Stigma of Mental Illness in the United States: A Systematic Literature Review. Administration and policy in mental health. doi:10.1007/s10488012-0430-z. Parle, S. (2012). How does stigma affect people with mental illness? Nursing Times, 108(28), 12-14. Ross, C. A., & Goldner, E. M. (2009). Stigma, negative attitudes and discrimination towards mental illness within the nursing profession: a review of the literature. Journal of Psychiatric and Mental Health Nursing, 16(6), 558-567. Schneider, J., Beeley, C., & Repper, J. (2011). Campaign appears to influence subjective experience of stigma. Journal of Mental Health, 20(1), 89-97. doi: 10.3109/09638237.2010.537403 Walker, L.O.; Avant, K. C., 2005. Strategies for Theory Construction in Nursing, 4th ed. Pearson Prentice Hall, Upper Saddle River, NJ. Watson, A. C. (2007). Self-Stigma in People With Mental Illness. Schizophrenia Bulletin, 33(6), 1312-1318. World Health Organization. (2010). Mental Health and Development: Targeting people with mental health conditions as a vulnerable group. Retrieved from: http://whqlibdoc.who.int/publications/2010/9789241563949_eng.pdf?ua=1