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Lek. Piotr Świtaj
Streszczenie pracy doktorskiej
pt. “Doświadczenie piętna społecznego i dyskryminacji u pacjentów z
rozpoznaniem schizofrenii”.
Summary
Stigmatization of persons receiving psychiatric treatment is considered to be one of
major contemporary challenges in the field of mental health. Social stigmatization and
discrimination contribute to the exclusion of the mentally ill from full participation in social
life and prevent their attainment of important life goals. Moreover, social stigma may
indirectly lead to a deterioration of their clinical status and hamper the process of recovery
through reducing their access to key resources (such as e.g. employment, housing, or medical
care), impairing their co-operation in the treatment and increasing the stress they experience.
In essence, social stigmatization of the mentally ill questions the plenitude of their humanity.
In this sense social stigma is not only of practical importance, but also – as a symptom of
social injustice that needs rectification - constitutes a serious moral challenge to the whole
society.
The concept of social stigma has been applied to a variety of social groups. However,
there is a consensus that stigmatization of the mentally ill is not only particularly dramatic,
but also constitutes a universal phenomenon, since it depends on historical or cultural contexts
to a much lesser degree than many other social categories. The stigma associated with the
experience of schizophrenia is regarded to be particularly painful - on the one hand, due to the
potentially chronic course of the condition and the intensity of clinical and social problems
stemming from it, and on the other hand, because of many common negative social
stereotypes associated with this diagnosis (including the beliefs that people suffering from
schizophrenia are dangerous, unpredictable, have little chance of recovery, are difficult to
communicate with, etc.).
While in recent years there has been a growing interest in the issue of stigmatization of
persons receiving psychiatric treatment, relatively little attention has been paid so far to
subjective aspects of experiencing the stigma of mental illness. Also in Poland social attitudes
toward the mentally ill have been investigated much more often than social rejection
experiences reported by the patients themselves. However, it seems that no other research
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methods can replace the first-hand knowledge obtained from those most directly affected by
stigmatization and discrimination. Studies on the subjective experience of rejection in persons
suffering from mental illness may be a valuable supplementation of public opinion polls, and
knowledge obtained from this source may be useful in the planning and evaluation of antistigmatization campaigns. Social stigmatization and discrimination experiences in patients
with schizophrenia are the main subject of this study.
In the theoretical part of the dissertation basic general assumptions of the
stigmatization concept proposed by Erving Goffman [2005] are presented, and the major
sociological and socio-psychological approaches to the stigma of mental illness are outlined.
The following two currently most important theoretical models of stigmatization of the
mentally ill are discussed in more detail: the sociological model by Link et al. [Link &
Phelan, 2001; Link et al., 2004] and the socio-cognitive model by Corrigan and Watson
[Corrigan, 2000; Corrigan & Watson, 2002]. The next part of the thesis deals with selected
specific issues concerning the mental illness stigma, such as: the structural stigmatization,
transferred stigma, public opinion and social attitudes toward the mentally ill, the role of
media and psychiatric care workers in the process of stigmatization, the origins of stigma,
methods of counteracting stigmatization, and finally, methods of stigma investigation and
measuring. Moreover, major studies conducted so far on the subjective experience of the
stigma of mental illness are overviewed and analyzed in detail.
In the empirical part of the dissertation results of the author’s research are presented
and discussed. The study was concerned firstly, with the subjective experience of social
rejection among patients diagnosed with schizophrenia, and secondly, with its sociodemographic and clinical correlates. To facilitate interpretation of the research findings,
rejection experiences reported by patients with schizophrenia were compared with these of
patients suffering from other mental disorders or somatic diseases.
Objectives. The main aims of the study were the following: (1) to assess the
frequency and type of social stigma and discrimination experiences reported by persons
receiving treatment for schizophrenia, (2) to compare schizophrenia patients and those
diagnosed with other mental disorders (recurrent depression, alcohol dependence or drug
dependence) for the frequency of reported rejection experiences, (3) to compare the frequency
of rejection experiences reported by patients diagnosed with schizophrenia or other mental
disorders and by patients with somatic diseases (hematological neoplasms or cardiovascular
diseases), and finally, (4) to evaluate the relationship between the frequency of stigmatization
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experiences reported by schizophrenia patients and their socio-demographic and clinical
characteristics.
Method. Participants in the study were 153 patients with the diagnosis of
schizophrenia (62 treated on the outpatient basis and 91 inpatients). They were examined
using the Consumer Experiences of Stigma Questionnaire (CESQ, Wahl 1999a; 1999b), while
their social functioning was assessed by means of the Global Assessment of Functioning
(GAF) scale (APA 2000), and the subjective quality of life with the extended version of the
Satisfaction with Life Domains Scale (SLDS, Baker & Intagliata 1982; Corten et al. 1994).
Severity of their psychopathological symptoms was assessed using two abbreviated selfreport mental health rating scales: the Frankfurter Befindlichkeits –Skala (FBS, Sűllwold &
Herrlich 1987) and the Paranoid-Depressivitäts-Skala (PD-S, von Zerssen & Koeller 1976),
as well as two psychopathological scales of a complex structure: the Positive and Negative
Syndrome Scale (PANSS, Kay et al. 1987), and the Kliniczna Ocena Zespołów
Schizofrenicznych (KOSS-S, Clinical Assessment of Schizophrenic Syndromes Scale, Wciórka
2004).
The comparative groups included: 31 patients diagnosed with recurrent depressive
disorder, 30 patients with drug dependence, 39 with alcohol dependence, 31 with the
diagnosis of hematological neoplasm, and 33 with cardiovascular disorders. Patients from
these groups were assessed using modified versions of the Consumer Experiences of Stigma
Questionnaire CESQ and Satisfaction with Life Domains Scale (SLDS).
Results. Stigmatization experiences, both indirect (e.g. critical remarks and comments
about the mentally ill, insulting TV broadcasts or newspaper articles) and direct (e.g. being
avoided by others, treated as disabled, or advised to lower the range of life aspirations) turned
out to be frequent among persons with schizophrenia. Only few schizophrenia patients denied
any negative experiences. A vast majority of the subjects are afraid of social rejection and so
they do not disclose the fact of receiving psychiatric treatment to anybody except their close
family. However, this neither protects them from various forms of stigmatization, nor
liberates them from stress and apprehension of being disapproved by others. Specific
instances of discrimination were much less often reported by persons diagnosed with
schizophrenia, and occurred mostly in the context of employment and contacts with the
judicial system. Besides negative, many patients reported also positive experiences in their
interpersonal relations.
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Patients with schizophrenia reported stigma and discrimination experiences just as
often as did alcohol dependent persons and those with recurrent depression, but less often than
drug dependent respondents. As compared to patients with somatic diseases, persons
diagnosed with schizophrenia or other mental disorders more often experience social rejection
and their subjective quality of life is lower.
The experience of social rejection was found to be related to rather few sociodemographic and clinical characteristics of schizophrenia patients. More frequent
stigmatization experiences are associated with poorer quality of life, onset at an earlier age,
and availability of a close social environment (lonely patients less often report stigma
experiences than do those who have family members or close friends in their immediate
environment). No clear-cut relationships were found between stigma and either social
functioning or psychopathological symptoms severity.
Conclusions. Patients with schizophrenia report frequent stigma experiences, but
relatively seldom complain of overt discrimination. The frequency of rejection experiences
reported by patients with the diagnosis of schizophrenia is related to their socio-demographic
and clinical characteristics to a relatively small degree. The subjective experience of mental
illness stigma is much more painful than experiencing the stigma of somatic disease. Drug
dependent persons are victims of a particularly strong stigmatization and discrimination. In
comparison to somatic patients, persons with mental disorders are characterized by lower
subjective quality of life.