Cultural Stigma and Mental Health

Introduction:

The term stigma, especially regarding mental health, is a complex notion. Although most would agree that stigmatization is negative, there is little agreement on what constitutes a stigma. Erving Goffman [1], a very impactful Canadian-American sociologist in the 20th century, defined stigma as ‘[an] attribute that is deeply discrediting.’ But what is a ‘discrediting attribute’ in one culture, ethnic background, and social class may not be so in another. In many cultures, what constitutes a mental illness and how it is manifested can be vastly different. In the modern world, there is an effort to educate those on what mental illness is and the biological factors that contribute to them, but that also has mixed results in the effort to combat stigma.

Generally, people with poor mental health are not viewed well around the world. The implications of poor mental health depend on several factors, however. Is the person suffering from poor mental health able to contribute to society? Can that person work? Can they have a family? Different emphasis is put on various aspects of what it means to have a ‘normal’ life in different cultures. The manifestation of the stigma usually follows whether these individuals can be functional, what kind of support group they have, whether the culture is more etic (having a Western perspective) or emic (a more local or tribal mindset and the social class of the stigmatized individual) [2].

This article presents several perspectives on the stigmatization of mental health in several countries, including North America, South America, Europe, Asia, and Africa. This is by no means an exhaustive review but a short snapshot of how several cultures approach the issue of mental health stigma.

North America: In certain sections of the United States and Canada, the outlook toward mental health has vastly changed from the start of the 21st century. There has been an active movement through many communities to educate the public on mental health issues and encourage those with mental health concerns to own it and get help. When discussing the etic perspective of mental health, the higher and more urban areas of North America and Western Europe are considered the center for the push on trying to provide a better understanding of mental health and to reduce its stigma. As diverse a population as the United States and Canada have, the outlook on mental health is varied. For example, in rural areas in the United States, the prevalence of mental health issues is similar to that of more urban areas, about 19% in 2016. Still, individuals have to go further to seek help physically, are more often uninsured for mental health, and are less informed about mental illnesses [3]. Rural areas have more traditional values and close communities where privacy may be lacking, which contributes to individuals delaying seeking help and bolsters stigmas toward mental health in the community and self-stigma.

Since 2010, the leading cause of death for teens, besides accidents, was suicide. Peers, social pressures, self-stigma, and a lack of knowledge of mental illness contribute to this. Programs like Youth Aware of Mental Health (YAM) have been implemented in several schools around the country to help educate those with mental illness and their peers and help increase help-seeking behavior. Unfortunately, these strategies have had little influence on increasing help-seeking behavior and suicide in youth [4]. This highlights the difficulty in reducing stigma among individuals with mental health issues and getting them help, even in a higher-income Western medicine setting. Education, despite race, age, gender, or stigma, is associated with higher engagement in seeking help [5].

A Canadian study evaluating the stigma of undergraduates, medical students, and psychiatrists and their outlook on mental illness found that having some relationship with an individual with mental health issues and being educated helped reduce stigma [6]. Higher stigma is associated though within racial minority groups in the US, and since these populations tend to be underserved as far as education as well as facilities to treat people with mental illness, the stigma related to mental health issues is high, and help-seeking is low [7]

South and Latin America: The Pan American Health Organization has 35 member states that include most countries in the Caribbean, South, and North America and addresses physical and mental health concerns in cooperation with these member states to supply health services to the populous without fear of becoming destitute. Mental illness is a prevalent issue in the Caribbean and Latin American countries, contributing to 22% of the health issues in that region. Unfortunately, the available resources still have a large gap [8].

In Columbia, stigma toward mental illness, particularly for males, arises with the cultural aspect of machismo. Males are supposed to be strong and the breadwinners of the family. Having a mental illness, especially one that can take away the ability to provide, can be seen as a weakness. Therefore, these individuals avoid seeking help and typically succumb to alcohol abuse. DIADA (Detection and Integrated Care for Depression and Alcohol Use in Primary Care) has been implemented to bring mental health into primary care and help healthcare professionals, staff, and patients better understand mental illness and support the treatment of mental illness [9].

This type of integration of mental health into primary care has been done in Brazil through the Centers for Psychosocial Care (CAPS). These have replaced most mental health hospitals in Brazil and act as outpatient care centers for mental health. They interact with other care units like Family Health Units, which are generally the first option in receiving mental health care and are composed of Family Health Teams, a multidisciplinary means to treat mental illnesses locally. This decentralization of mental health care has had a limited effect. Health professionals still need to be trained adequately, and the facilities are underfunded [10]. It is a step in the right direction, however. More information and funding must be provided to increase the system’s effectiveness.

Also, the stigma in Brazil is different from Columbia and other Latin American countries. A typical phrase used is ‘Doenca dos nervos.’ This indicates that the manifestation of mental illness is not biological but environmental. The individual is going through hard times from social, work, or family issues that manifest mental illness [11]. This is a typical thought amongst rural and lower-class communities in Brazil.

Europe: Stigma towards mental illness still prevails in England and other European countries. Culturally, the stigma related to mental illness involves the outlook that those with mental health issues “lack self-discipline and will-power,” and those with mental illness are just different and easy to tell apart and should be avoided [12] Since 2007, the campaign Time to Change has been implemented in media towards the public overall. An assessment of the program concluded that it did increase awareness and reduce the stigma across the general population. Still, it strangely did not do much to curb the stigma of mental health professionals towards mental illness [13]. This looks pretty odd, given that health professionals are generally higher income and come into contact with the mentally ill more often than the general public. The stigma there among health professionals is not unlike those in lower-income countries.

In France, individuals with mental illness are often considered violent, dangerous, not curable, and forced to be cured with medication. A survey of 36,000 French citizens saw 75% with similar viewpoints on mental health. Though, there is a delineation between what the French consider an actual mental illness. Those that suffer from depression are viewed as curable and are not seen in such a negative light because ‘normal’ individuals can better relate to those that suffer from depressive symptoms [14]. Unlike in other Western European countries, information on programs to reduce the stigma of the mentally ill is lacking. An internet search on national French anti-stigma programs and similar searches reveals little about how France’s aims, goals, and history of tackling this issue are implemented.

A descriptive study by Von Lersner et al. [15] sought to evaluate the cultural beliefs of native Germans and Turkish immigrants on the cause of mental illness and how that relates to the stigma of social distancing. There were many differences in how Germans and Turkish immigrants felt about mental illness. Germans attributed the cause of mental illness to both biological and psychological factors. In contrast, Turkish immigrants thought that psychological factors influenced mental illness. Also, Germans had more differentiation on the causes of depression and schizophrenia than the Turkish immigrant population and had more sympathy and desire to help those with depression than schizophrenia. The stigma of social distancing was more substantial for schizophrenia in both groups, but the cause differed. Germans who believe that negative traits like being weak or immoral portray more desire to distance themselves from people with schizophrenia socially. However, the increased social distance was only attributed to the Turkish immigrants who believed that mental illness is caused by the supernatural [15].

In Germany, from 2011 to 2014, an extensive campaign to reduce the stigma of mental illness, particularly depression and schizophrenia, was conducted. It was set up to educate the public and dispel erroneous beliefs about mental illnesses. The program was evaluated in 2016 and found that it had little effect on Germans’ views and likeliness to stigmatize those with mental illness [16]. Although the attempt was admirable, it seems a different strategy is needed.

Asia: China is a very industrialized nation. It is one of many countries providing primary healthcare to all its citizens. As of 2020, the World Health Organization estimated that 54 million Chinese citizens suffer from depression and 41 million suffer from some anxiety disorder. In 2002 China introduced the National Mental Health Plan and, in 2003, sought to integrate mental health into China’s overall healthcare system. In 2012, China passed the Mental Health Law to improve services for mental health and ensure patients’ rights. The National Mental Health Working Plan launched in 2015 has sought to provide services and supervision to 80% of those with severe mental health issues such as schizophrenia. A more recent plan, the Healthy China Action Plan, established in 2019, similarly seeks to provide more services to treat 80% of those with depression by 2030.

These all seem like very forward-thinking strategies to approach the mental health issue in China. Still, a lack of thoughtful allocation of funds has created gaps, and there is a severe shortage of trained mental healthcare professionals in the country. China is somewhat unique in the population’s perception of mental illness. Although studies indicate that an individual seeking help can be a functional part of society, there is still a very high stigma towards mental illness when it comes to personal relationships. Many Chinese citizens have expressed that they would not be friends with, involved in social activity, or date someone that has or has had a mental illness [17]. This stigmatization has impacted those seeking help and has contributed to the lack of Chinese people entering the mental health field.

Some of the first psychiatric hospitals in the world were created in the Middles East, particularly in Cairo, Damascus, and Baghdad in BCE [18]. The West adopted several scholarly works during this time for over 700 years. Modern-day mental health services in this region are remarkably lacking, though, and stigma is high. Most countries in the region have less than one psychiatrist per 100,000 people. Given the mentally ill’s high social and self-stigma, many do not seek help for their condition.

In the United Arab Emirates, one study showed that only 38% of respondents to a survey said they would seek mental health services for a family member because they either refuse to acknowledge that there is a mental health concern, the stigma towards mental health services, or the belief that the services cannot help the mentally ill individual. A study in Egypt concluded that people in that region believe that the issue of mental illness is socially manifested and not biological. Saudi Arabia is one of the more advanced countries in their attitude toward mental illness and shows more caring to those inflicted and less fear and anger. Israel is not unlike China in that the stigma lies in refusing to have close personal relationships with mentally ill people. The mentally afflicted show a high fear of rejection, and many experienced substandard treatments from health professionals. The high stigma of the mentally ill in this region is likely perpetrated by the lack of mental health education, services, and programs employed to reduce stigma in the area. To implement strategies to help the mentally ill and reduce stigma, consideration for the cultural aspect of the region needs to be taken into account.

Similarly, India has a high rate of stigmatization of the mentally ill. A study on the perspectives of young people in India on mental illness, where 66% of the participants were engaged in health professional training, displayed a lack of knowledge of mental health. Several, 20%, had expressed or would show stigmatizing behavior. Many young people think that mental illness cannot be treated and that people with mental illness are seen as unsafe and reckless [19].

Africa: A comprehensive meta-analysis of several studies on mental health, particularly in the adolescent population, done in 16 sub-Saharan countries, including South Africa (19), Uganda (7), Nigeria (6), Kenya (6), Tanzania (4), Ethiopia (4), Burkina Faso (3), Ghana (3), Zambia (3), Benin (2), Botswana (2), Malawi (2), Namibia (2), Zimbabwe (2), Seychelles (1), Eswatini (1). This analysis observed very high percentages of individuals with mental illness compared to high-income countries. In the general adolescent population in these sub-Saharan countries, approximately 26.9% suffered from depression, 29.8% from anxiety disorders, 40.8% from emotional and behavioral problems, 21.5% from PTSD, and 20.8% had suicidal ideation [20]. Most sub-Saharan countries have not adopted the Western concept that mental illness is biological. They believe these issues stem from the supernatural, like possession or being harassed by evil spirits. This is especially true for individuals with self-stigma in these regions [21].

In contrast to developed countries, these beliefs persist even in the higher-educated population of many African communities. Since many African countries deal with war, poverty, and health issues, mainly HIV, very little attention has been given to mental health concerns. Low and Middle-Income Countries (LAMIC) in Africa dedicate the least money and resources to help the mentally ill, even though mental illness is becoming a more significant issue [22].

Discussion:

Stigma towards mental health is a worldwide issue. It prevents those mentally ill from seeking help in fear of what their family and peers think. It also inhibits these individuals from getting jobs, having a family, and contributing to society meaningfully. Those that stigmatize the mentally ill do so generally out of fear or lack of mental health knowledge. Even when presented with scientific data to suggest that the illness is biological, sometimes that can make the stigma even stronger. Some blame the mentally ill person for being weak-willed or think they have been afflicted by the supernatural and want to ostracize these individuals. But that does not solve the problem or help in any way.

Providing services for the mentally ill is still not a priority in many countries. Places trying to reduce stigma and increase benefits for the mentally ill have met many challenges, such as funding and proper allocation of resources. Also, even health professionals will often stigmatize the mentally ill. These are all roadblocks that need to be addressed. The mentally ill can contribute to society and have meaningful relationships with help from health professionals, family, and peers. This is why programs that aim to reduce stigma are essential, but these interventions must be culturally sensitive. No one suffering from mental illness should do so alone. Governments, schools, communities, and individuals all need to do their part in reducing stigma worldwide.

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