Whacko, cuckoo, "malkop", "waansinnig", loony, nuts, crazy, bananas… the list of negative labels for people living with mental illness is long.
The labelling, discrimination and exclusion of the mentally ill happens all over the world and has occurred throughout history. In ancient Greece, the mentally ill were not allowed out in public and their families were fined if they didn't control them. In the Middle Ages, many mentally ill people were branded as witches or for being possessed by demons, or were "treated" by barbaric methods such as starving and flogging. In South Africa in 1846, the prison colony on Robben Island was converted into a hospital for "lepers, lunatics and other chronically ill patients".
The word "stigma" is derived from the Greek meaning "mark" - which was cut or burnt into the body of a slave, traitor or criminal to publicise that there was something strange or bad about the moral status of the bearer. It signified a "blemished" person who needed to be avoided.
Types of stigma
Studies have shown that the mentally ill are regarded by many as being weak, to blame for their illness or even as dangerous. Local studies have shown that there is a perception that mental illness is due to lack of willpower or faith, and that the mentally ill are dirty and unpredictable.
According to Dr Ulla Botha, a psychiatrist at Stikland Hospital, Cape Town, stigmatisation manifests in different forms including name-calling, physical abuse, talking down, verbal abuse, giving people unequal opportunities and teasing. Victims of stigmatisation may have difficulties finding work and somewhere to live, obtaining life insurance and forming relationships. They may also have low self-esteem, and feel hopeless, worthless and ashamed.
People living with mental illness can also be guilty of stereotyping, prejudice and discrimination, thereby stigmatising themselves. This is referred to as self-stigma. As a result of self-stigma, many people don't seek help or adhere to treatment. The World Health Organisation has recognised stigma as the main barrier to the effective treatment of the mentally ill.
Botha says that many people don't disclose their illnesses for fear that they will be treated differently and looked down upon.
"Some also have the perception that people have depression, for instance, because they did something wrong to deserve it or that their faith isn't strong enough. It is shocking how little people realize that illnesses such as depression, schizophrenia or bipolar disorder are caused by a chemical imbalance in the brain and that it isn't merely a matter of pulling yourself together. The imbalance can only be corrected by means of medication which in some cases needs to be taken daily for long periods."
Botha, who did a thesis on the manifestations of stigma in schizophrenia patients, says that discrimination is at its worst against people with psychotic illnesses such as schizophrenia.
Some medications are also more acceptable than others. Antidepressants have become more acceptable but antipsychotic medications and drugs such as lithium are far less so.
"People don't realise that it isn't always easy to take medication every day, especially if it has bothersome side-effects. Patients often feel that they need to hide it from others. Instead of encouraging people to take their medication and reminding them how important it is to stick to treatment, we sometimes find that ill-informed people convince patients to stop taking their medication.
"The tragedy is that if you've stopped taking medication a couple of times, the medication's ability to stabilise your illness gets weaker and weaker. The more times you relapse, the greater the chance that you will get ill again and the longer you will stay ill."
Experts believe that stigma is derived from prejudice and is the result of fear, apathy and ignorance. We fear what we don't understand. Stigma reduces this fear by encouraging the false belief that mental illness only happens to "other" people who should be separated from the rest of society.
It is believed that knowledge reduces stigma and that fear of mental illness is reduced by compassion and understanding.
Charmaine Hugo, former director of the Mental Health Information Centre, who has done extensive research on stigma and mental illness, says that there are three approaches proposed to combat stigma, namely protest, education and contact:
- Protest involves challenging the media if there is inaccurate reporting of mental illness which perpetuates stigma.
- Education involves providing accurate information about mental illness.
- Contact with people with psychiatric illnesses who lead responsible and productive lives can help to reduce negative stereotypes.
All at life's mercy
There have been several campaigns worldwide to combat stigma against the mentally ill. Locally, the South Africa Society of Psychiatrists (SASOP) provides the media with accurate facts on mental illness, investigates structural disparities and negotiates with medical aids. South African psychiatric interest groups have been involved in a number of anti-stigma initiatives.
"Even though many things have changed over the years, South Africa still has a long way to go to destigmatise psychiatric conditions and to ensure that people are treated optimally," says Botha.
"The public should become aware that mental illness is an illness just like any other, that it is treatable, extremely common and nothing to be ashamed of. We are all at life's mercy and owe each other compassion."
(Ilse Pauw, Health24, updated October 2011)
Botha, U, Koen, L, Niehaus, D. Perceptions of a South African schizophrenia population with regards to community attitudes towards their illness. Social Psychiatry Epidemiology. 2006 41:619-623
Hugo CJ, Metelo-Liquito J, Stein DJ. A critical look at stigma and its impact in psychiatry. 12 th National Psychiatry Congress of the South African Society of Psychiatrists, Somerset West, Sept, 2002.
Hugo, CJ (2003). Mental health literacy and attitudes of human resource practitioners in South Africa. Unpublished Master's thesis, University of Stellenbosch.
Hugo, C, Boschoff, D, Traut, A, Zungu-Dirwayi, N, Stein, D. Community attitudes toward and knowledge of mental illness in South Africa. Social Psychaitry Epidemiology. 2003 38: 715-719
Oosthuizen, P, Scholtz, O, Hugo, C, Richards, B, Emsley, R. Health care discrimination against the mentally ill - a comparison of private health insurance benefits for major depressive disorder and ischaemic heart disease in South Africa. SAMJ 2004, Vol. 94, No. 10
Royal College of Psychiatrists' Changing Minds anti-stigma campaign. Stigma pill box product information leaflet.
To tell or not
My secret life