Article by Thessayist Network

Overwhelming intolerance towards mental illnesses is a global problem and has predetermined that countless sufferers simply be denied the professional care and treatment they require and with which they can overcome their condition and lead normal lives. The magnitude of the problem and the urgency of devising strategies for the destigmatisation of mental illnesses can only be fully appreciated within the context of the prevalence of mental illness incidents. On the global level, and as estimated by the World Health Organisation, mental health complaints account for 25% of all visits to general practitioners. Often manifesting themselves in physiological symptoms, mental illnesses are difficult to diagnose and, in more cases than not, are identified only after a vast array of physical tests are conducted for determination of the source of health complaint. In other words, mental health illnesses are diagnosed through a process of elimination (Read and Baker, 1996; Barraclough, 1998). The implication here is that approximately one-quarter of the global population suffers, at one point in their lives or another, from mental health problems. Very few have access to the required professional help and those who do seek help, resort to medical, rather than mental health professionals, often contributing to the further complication of the problem. In brief, and as mentioned, the problem is further complicated simply because diagnosis and treatment by any other than mental health professionals is problematic and inefficient.The diagnosis, treatment and control of mental heath problems are problematic for a variety of reasons, all relating to the stigmatisation of this disease category. Diagnosis, treatment and control are problematic because (1) stigmatisation makes admission of a mental health condition by a patient and/or his/her family difficult; (2) stigmatisation of mental health conditions implies that sufferers visit medical, rather than psychiatric professionals for diagnosis and treatment and the latter do not possess the professional knowledge required to either make an accurate diagnosis or provide an effective treatment programme (Grob, 1994); (3) stigmatisation of mental health illnesses, in numerous countries and cultures, discourages psychiatric specialisation, either among nursing or medical practitioners, with the consequence being a dearth in mental health professionals; (Loza, 2006) (4) stigmatisation of mental health conditions has resulted in the virtual exclusion of mental health services from state healthcare programmes with the consequence being that very few can afford treatment; and (5) the stigmatisation of mental health illnesses has determined that this disease category not be taken seriously or, as seriously as are physiological diseases, with the consequence being that state-run services in do not have the resources needed to provide patients with the necessary treatment (Satcher, 2000).As may be determined from the foregoing discussion, the mentally ill are discriminated against by the very nature of their suffering. The fact that their illness is not understood has not only determined that public health policies and private medical insurance not cover psychiatric treatment but has further ensured that they are openly discriminated against. The mentally ill are ostracised from society to the extent that people fear associating with them, renting housing to them, working with them or providing them with employment opportunities. Stigmatisation, implying discrimination, therefore means that the mentally ill are denied access to resources and opportunities. This only contributes to the increased severity of the condition insofar as isolation and denial of access to opportunities leads to low self-esteem, loneliness and hopelessness (Penn and Martin, 1998; Corrigan and Penn, 1999). The stigmatisation of the mentally ill, or of mental illness in general, represents a challenge that must be addressed through the adoption of intervention strategies specifically designed to foster understanding about mental health and promote tolerance towards the mentally ill. Lauber et al. (2004) urges that education be the primary vehicle for the destigmatisation of mental illness. The proposal is valid because it correctly identifies ignorance of mental illness as the root cause of its stigmatisation and the promotion of awareness and knowledge as the solution. While valid, however, the proposal is incomplete because it does not identify the educators nor the content of the educational/awareness-promotion program. From the researcher’s perspective, and as shall now be argued, the nursing profession has a fundamental role to ply in the promotion of awareness about mental illness and the successful destigmatisation of mental illnesses is largely dependant on the destigmatisation strategies which nurses will adopt and the extent to which they will efficiently and effectively carry out this responsibility.[To be continued...]Stigmatisation of Mental Illness in the Arab Middle EastAccording to Arab mental health professionals, among whom one may mention Loza (2006), Sadek (2006) and Okasha (2006), the mental health care system within the Middle East is virtually non-existent. The mental health care system within the Arab Maghreb countries is barely existent; within the Levantine countries inefficient and within the rich Arab Gulf countries, designed for the isolation of sufferers from their communities, rather than their treatment. For a variety of reasons, Egypt stands out as the only Arab country with what can pass as a mental health care system despite its being largely confined to the public sector and therefore, out of the financial reach of the majority (Zidan, 1999).Certainly, there are state mental health care facilities in all of the Arab countries. However, with no exception, these facilities are overpopulated high-security institutions wherein the average patient receives no more than one hour of professional attention a month. Otherwise, a strong regime of drug therapy is administered to patients and, in extreme cases, electrotherapy. As Sadek (2006) notes, the purpose of these institutions is not the treatment of the mentally ill but their isolation from society. Even if mental health professionals intended treatment, the fact is that required resources are simply not available, be it trained mental health nurses, psychologists or psychiatrists.Arab Middle Eastern health professionals have determined that the singular failure of the Arab countries to develop a strong and efficient health care system is directly consequent to the stigmatisation of, and the misunderstandings and misconceptions which surround mental illness (Zidan, 1999; Loza, 2006; Okasha, 2006). The stigmatisation of mental illness has ensured that only a miniscule percentage of the totality of medical students specialises in psychiatry and that hardly any of those who enrol in nursing degrees specialise in mental health nursing (Belal, 2003). There is a significant shortage in mental health professionals and within the medical community, a lack of understanding and awareness of the reality of mental illnesses. The stigmatisation of mental diseases and illness are responsible for this situation.The stigmatisation of mental illnesses in the Middle East is primarily rooted in ancient beliefs and practices. The widespread perception of the mentally ill as being possessed by evil spirits or being, themselves, evil and dangerous to the point of criminal insanity, has never been adequately addressed. Prejudicial beliefs have been allowed to proliferate and have only been fostered by a media which invariably presents mental illness as an outcome of demon possession or criminal insanity, and urges the isolation of the mentally ill from society (Okasha, 2006).Societal attitudes towards mental illnesses are informed by dominant stigmas and not by facts. As earlier mentioned, those suffering from mental illnesses, whether mild depression or severe schizophrenia, are diagnosed as `possessed,’ with the severity of the condition interpreted as directly relating to the nature of the `possession.’ This particular stigma is extremely popular among the Bedouin and lower-class urban and rural communities throughout the Arab World and has determined `treatment’ by religious figures, whether Christian priests or Moslem sheikhs, rather than by mental health professionals (Saleh, 2004).Amongst the middle classes, both urban and rural, all forms of mental illness are discriminated against. They are perceived of retribution for immorality and, therefore, shameful; symptomatic of laziness and weakness of character and therefore resolvable through corrective behavioural approaches. In those few instances where family members acknowledge the illness to be real and realise the necessity of professional intervention, they resort to physiological, not psychiatric, treatment (Loza, 2006). There is, in other words, a persistent refusal to take mental illness seriously as determined by stigma and supported by ignorance.Private mental healthcare facilities are available throughout the Arab world and have the resources necessary to diagnose, treat and control mental illnesses. However, they are extremely costly and consequently, not an option for the majority of mental health sufferers (Loza, 2006).The only way to ensure that mental health sufferers in Arab countries receive the professional care they need is through the destigmatisation of mental illnesses. Destigmatisation, as Sadek (2006) argues, will encourage sufferers to seek help and that, in turn will expose the true extent of the demand for mental health treatment and services throughout the Middle East, will reveal the cost of suppressing/ignoring the problem and, accordingly, will encourage the adoption of public health policies which adequately address the needs of the mentally ill and provide professionals with the resources necessary for illness control and/or treatment (Okasha, 2006).Several strategies and approaches for the destigmatisation of mental illness have been proposed, with the majority based upon the deep involvement of nursing professionals. Within the context of Arab countries, the destigmatisation of mental illness through the involvement of nursing professionals will confront numerous challenges but if these challenges are overcome, will positively contribute to destigmatisation. Nursing Intervention StrategiesConsidering that the stigmatisation of mental illnesses in the Arab World is rooted in ancient beliefs, traditions and cultural rituals, anthropologists and sociologists have argued that the elimination of these stigmas can only occur within the context of a socio-cultural approach. Saleh (2003) , writing from the perspective of a cultural anthropologist, insists that the only effective method for the elimination of the stigmas surrounding mental health in the Arab World is through an educational media campaign. As proposed, this campaign will focus on the prejudices surrounding mental illness, expose the ancient roots of these prejudices and effectively illustrate that they are based on myths, not facts, and contradict scientific findings and research (Saleh, 2003). A mental illness awareness campaign would probably contribute to deconstruction of prevailing myths about mental illness. More importantly, it could spread awareness regarding the curability/controllability of mental illness and educate public opinion regarding its causes and consequences. However, a critical analysis of this particular proposal reveals that it is limited in scope and hardly has the capacity to change fundamental beliefs about mental illness. Quite simply stated and as further affirmed by Fadel (2001), not only would such a campaign be extremely costly but it could not be sustained for any long periods of time and if ingrained prejudices are to change, long-term solutions are required, not campaigns whose message will probably be forgotten as soon as the campaign itself ends.Nursing intervention comes across as the most viable and effective long-term effective solution to the problem of the stigmatisation of mental illnesses. The position of the nursing professional within the community, as attested to by several researchers, greatly facilitates this task. The nursing professional/practitioner, as opposed to the psychiatrist, is ideally situated to address the stigmatisation of mental illness within the profession, by the mentally ill themselves and by the community. As regards the stigmatisation of mental illness from within the medical profession, several researches have indeed proven that the healthcare community, both medical nurses and doctors, have misconceptions and misunderstandings about mental illness. A significant percentage of medical doctors and nurses tend to stereotype the mentally ill and regard them as an unwanted burden upon the healthcare system. As Harpell (2005:1) writes, within hospital settings “mental health consumers were portrayed as disturbed and aggressive, with strong underlying assumption that they were accessing services at the expense of others more deserving, namely the physically ill and the injured.” Writing from the perspective of a mental health nurse, Harpell (2005) maintain ns that the stigmatisation of mental illnesses from within the medical community are symptomatic of the inexplicable disconnect that has developed between the physical and mental health sciences. This disconnect is largely traceable to the stigmatisation of mental illnesses and the underlying assumption that mental illness, or psychiatry, is not a serious branch of medicine and certainly not equal in value to the physiological branch (Swindle et al., 1997). In other words, the existing separation between mental and physical healthcare is expressive of the medical community’s stigmatisation of mental illness and only serves to encourage the perpetuation of discrimination against the mentally ill.Krizner (2002) argues that the first step towards the provision of adequate mental healthcare to sufferers is the destigmatisation of mental illness from within the medical community itself. According to Krizner (2002) none are better situated to address the stigmas surrounding mental illnesses from within than are mental healthcare nursing professionals. This argument is based on two assumptions. The first is that nurses work in close association with doctors and are the primary channel of communication between doctors and patients. Therefore, they play a fundamental role in shaping the perception of doctors towards patients and their complaints. The second assumption is that senior nurses are responsible for the training of newly graduated nurses, in addition to which, they play a pivotal role in the training and support of medical intern and residents. Consequently, and as Krizner (2002) argues, educating professional nurses about the implications of mental illness, whether or not that is their chosen speciality, is a fundamental step towards the destigmatisation of mental illnesses from within the medical community, given the positioning and role of nurses therein.Krizner’s (2002) argument is only valid to a point. Certainly, if nurses are knowledgeable about mental illnesses, they can communicate that knowledge/awareness to medical practitioners and contribute to the destigmatisation of the mental health problems. Generally speaking, however, if nurses are to adequately fulfil this task, it is necessary that the professional nursing training and education programmes be revised to include a solid grounding in mental health, irrespective of whether or not that is the chosen area of specialisation.Even were one to suppose that professional nursing education and training curriculum were revised to include a thorough grounding in mental health, this still does not emerge as a valid and effective solution insofar as the destigmatisation of mental illness in the Arab World. Quite simply stated, and as expressed by Loza (2006) no more than 10-15% of nurses throughout the Arab World have undergone the required educational and professional training. This has resulted in both a dearth in professional nurses throughout the region and in the entrance of non-professionals into the vocation, implying that they bring their own stigmas regarding mental illnesses along with them. In fact, finding nurses, even non-professionals, willing to work in a mental health setting, or with mentally ill patients is extremely difficult. Therefore the notion that, the destigmatisation of mental illnesses can occurs from within the Arab nursing profession is hardly sound (2006). [To be continued...]

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Article by Thessayist Network

IntroductionMental health professionals in the Arab Middle East estimate that at least 60% of the population, age 14 and upwards, suffers mental health problems. Dr. Nasser Loza (2006), owner and director of the largest private mental health hospital in the region, Behman Hospital in Egypt, disagrees with this estimate. Loza (2006) insists that the figure is much higher. In Egypt, Kingdom of Saudi Arabia and Kuwait, for example, both medical and mental health practitioners have estimated the figure at around three-quarters of the above 14 age group and have identified depression as the most prevalent condition (Loza, 2006).Mental health problems, like the vast majority of physiological illnesses, are curable or, at least, controllable. Treatment or control of the problem, however, is primarily dependant upon the acknowledgement of its existence and the subsequent seeking of professional help. Within the Arab Middle East, as is the case with regions, countries and cultures across the world, there exists a persistent unwillingness to admit to the presence of a mental health problem or, at least, to acknowledge its existence to the point of seeking curative treatment. As Professor Loza (2006) explains, despite the fact that there are some very good mental health facilities and professionals in Saudi Arabia and Kuwait, it is incredibly rare for a Saudi or a Kuwaiti national to seek treatment within his home country. The stigma associated with mental health problems makes it virtually impossible for many to tolerate the notion of the social isolation/exclusion that would inevitably result from the acknowledgement of such a problem. Accordingly, when the mental health problem reaches the point where it is debilitating and difficult to conceal, the sufferer’s family only agree to treatment if that treatment is received from outside the home country and anonymously. Needless to say, many cannot afford this treatment option and, so, the vast majority are either left untreated which, as bad as that is, is infinitely preferable to the widely popular practice of self-medication and treatment (Loza, 2006).The stigmatisation of mental health is a formidable obstacle to treatment. Fearing stigmatisation, sufferers are reluctant to admit their condition and seek help. Family, friends, employees and society at large, plays an active role in helping to ensure that this reluctance is maintained and transformed into an outright refusal to admit to the problem and seek treatment. Needless to say, mental health professionals have repeatedly addressed this problem and have outlined strategies for the resolution of the stigma surrounding mental health complaints and conditions, believing that upon the elimination of stigmatisation, access to treatment will be facilitated. A World Health Organisation (2001) White Paper on the stigmatisation of mental health argues that the nursing profession, primarily mental health nurses, must play a more active role in the elimination of the stigma surrounding mental health problems. A critical analysis of the nursing intervention strategies outlined for the confrontation, and the removal of the stigma surrounding mental health illnesses indicates that several of the proposed intervention strategies can play a positive and constructive role in the reduction of the mentioned stigma but that its removal is a long-term process which requires much more than nursing intervention.This research shall argue that nursing intervention strategies can play an invaluable role in the reduction of the stigma surrounding mental health. Within the context of the Middle East, at least, the reduction of the stigma will help sufferers admit to their problem and actively seek treatment. However, upon tracing the background relationship between stigma and disease and the factors determining the stigmatisation of mental disease, it becomes evident that nursing intervention strategies must be expanded to embrace the addressing and education of societies and not just of professionals, sufferers and family members, as has been suggested (World Health Organisation, 2001).The Stigmatisation of Disease”Stigma is a pervasive influence on disease and responses of nations, communities, families and individuals to illness” (Keusch, Wilentz and Kleinman, 2006, p. 526). It has a pervasive influence on disease and the spread of disease because the stigma which surrounds a large array of physiological and psychological diseases actually prohibits victims from expressing their complaints, admitting to the presence of the disorder and/or its symptoms and seeking treatment. The stigmatisation of certain diseases further renders their admission in particular cultures useless. For example, in numerous villages and communities in China and India, HIV and cancer patients are completely ostracised. Their children are prohibited from attending schools; their relatives and family members are dismissed from their place of employment and in more cases than not, village administrators cut of water and power supply to the sufferer’s home, and those of all of his relatives, to drive them out of the area (Keusch, Wilentz and Kleinman, 2006). The stigmatisation of disease actively prevents admission of its presence and/or any of its symptoms. The consequence is not only death from possibly curable, or controllable, diseases, but the uncontrolled spread/transmission of disease. When looked at from that perspective, the cost of stigma to individuals, families, communities and nations is near-incalculable. Conceding to the magnitude of the problem, the Fogarty International Centre, in association with the World Health Organisation, the US National Institute of Health and the Canadian Institute of Health Research organised a landmark international conference entitled “Stigma and Global Health: Developing A Research Agenda” (Michels et al., 2006). The conference’s primary objectives were the development of a research agenda for the identification of the causes of disease stigmatisation and the articulation of effective intervention strategies designed to address and resolve the causes of stigma (Michels et al., 2006).The Conference identified several diseases whose treatment and control were virtually prohibited by their stigmatisation. While noting that the stigmatisation of physiological diseases such as HIV had potentially drastic effects on communities and nations, insofar as their stigmatisation facilitated their transmission, the Conference noted that no set of diseases suffered from stigmatisation as did mental health ones. It is, thus, that the Conference organisers emphasised the urgency of examining the reasons behind the stigmatisation of mental health problems, the consequences of their stigmatisation upon sufferers and communities and the articulation of corrective strategies designed to resolve the problem (Michels et al., 2006).The Stigmatisation of Mental Health DiseasesEvery society, culture and nation possesses ingrained prejudices against mental health sufferers. Jamison (2006) emphasises that research has effectively proven that the stigmatisation of mental health problems has its roots in ancient beliefs about, and attitudes towards, mental illnesses. As both Link et al. (1999) and Lauber et al (2004) explain, these beliefs and attitudes, passed down from one generation to another over the ages have, in numerous societies, determined the evolution of overt societal prejudices towards mental health sufferers with the predominant attitude being a complete refusal to tolerate mental illnesses and sufferers. Alternately feared and despised, mental health sufferers are generally regarded as either a danger to society or as weak and ineffective personalities who simply do not have what it takes to confront life and survive. Both of these attitudes have lent to deconstructive public opinions about mental health sufferers. The first opinion maintains that as dangers to society, mental health sufferers should simply be locked up. The second opinion quite explicitly states that since mental health sufferers do not have what it takes to live life and survive it, they, as would their families, be better of were they to die (Link et al., 1999; Lauber, 2004; Jamison, 2006). Given the negative public opinion towards mental illnesses, not to mention the unsympathetic attitudes towards sufferers, Link et al. (1999) argue that there is little opportunity or tolerance for open discussions on mental illnesses. In a surprising number of countries, the media is allowed to print and broadcast discriminatory opinions on mental health which would never be tolerated were they made in reference to any other group of people. The ability of the media to do so, whether in the supposedly enlightened West or the Middle East, is not simply an expression of the prevailing deconstructive and negative opinions on mental health but, more importantly, serves to justify intolerance and sustain discrimination.The stigmatisation of the mentally ill is largely a consequence of ignorance about mental health and the various illnesses which it embraces. A research on the stigmatisation of mental illnesses and the strategies which may be deployed to address the various stigmas surrounding the condition maintains that the first step towards destigmatisation is the articulation of the dominant prejudices regarding mental illnesses (World Health Organisation, 2001). Studies on the stigmatisation of mental illnesses reveal that prejudicial attitudes towards the mentally ill stem from a set of erroneous belies. The first is that the whole concept of mental illness is a myth and that psychological problems do not constitute serious illnesses which require treatment (World Health Organisation, 2001). The second is that mental illness is a blanket excuse for laziness and a fundamental unwillingness to work and be a constructive member of society. The third is that mental illness is nothing other than a symptom of character weakness which will only be compounded if `sufferers’ are coddled (Bolton, 2003). Mental illness, in other words, is not taken seriously and insofar as it is defined as an excuse for the unwillingness of some to work and take responsibility for themselves, is not tolerated. Within the context of societies which are intolerant towards mental illnesses, public health policies towards the expression of discrimination towards mental illnesses. Little public funds are allocated to mental illness, access to mental health care is problematic because available resources fall far short of the required, health insurance policies rarely cover mental illness, employees openly discriminate against mental health sufferers and mental illness research occupies the lowest of public priorities (Jamison, 2006). Stigmatisation of mental illness has, in other words, seeped through public policy and determined that sufferers suffer in silence and survive their condition as best as they can, often without access to the professional healthcare they require.The stigmatisation of mental illnesses and the pervasive unwillingness to help mental health sufferers is not confined to any single country or culture. Corrigan et al. (2004) explain that studies and surveys on public opinion towards mental illnesses has revealed that stigmatising attitudes, culminating in discriminatory health policies and employment practices, is a formidable problem throughout the United States and much of Western Europe. Brockington et al. (1993) supports this finding and maintains it to be an immediate outcome of social and communal intolerance towards mental health sufferers. Concurring, Weiner (1995) presents evidence which confirms that discrimination against mental illnesses and mental health sufferers operates on a global level. In fact, while mental health professionals in the United Kingdom may urge for greater societal understanding of mental illnesses and argue the urgency of greater public support, Western societies are infinitely more tolerant of mental health illnesses than are Eastern ones. In Eastern societies such as Asia and the Middle East, there is an overwhelming tendency to equate all forms of mental illness with insanity and to completely ostracise the mentally ill (Weiner, 1995). [To be continued...]

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