Elsevier

Psychiatry Research

Volume 210, Issue 3, 30 December 2013, Pages 1136-1146
Psychiatry Research

Self-stigma, perceived discrimination and empowerment among people with a mental illness in six countries: Pan European stigma study

https://doi.org/10.1016/j.psychres.2013.08.013Get rights and content

Abstract

A cross-sectional study including 796 individuals with a psychiatric disorder was conducted in Croatia, Israel, Lithuania, Malta, Romania and Sweden in 2010 aiming to assess correlates of self-stigma. The Internalized Stigma of Mental Illness (ISMI) was used to measure self-stigma, whereas the Boston University Empowerment Scale was used to measure the self-efficacy/self-esteem (SESE) and sense of power/powerlessness (PP). Perceived discrimination and devaluation was measured with the Perceived Devaluation and Discrimination (PDD) Scale. Thirty three percent of participants had moderate-to-high ISMI scores. In multivariable-adjusted analysis, significant ‘predictors’ of high ISMI scores were: age-group of 50–59 years, current employment, lower social contacts, and minimal-to-low SESE and PP scores. Remarkably, no significant association between ISMI and PDD was evident. Furthermore, there was evidence of a significant interaction between SESE and country. Study participants might not be representative to all individuals with mental disorders in countries included in this survey. Our findings indicate that people with psychiatric diseases suffer both self-stigma and perceived discrimination and devaluation. This is one of the very few reports highlighting country differences and diagnosis disparities of self-stigma among individuals with mental illnesses. Between-country differences should be considered and carefully addressed in the process of policy formulation and interventional programs against stigma.

Introduction

Stigma contributes to the hidden burden of various illnesses. With regard to psychiatric disorders, stigma can be both an attribute and cause of the disease and, therefore, it may become a ‘second disease’ involving a critical downward spiral. It is estimated that between 27% (World Health Organization, 2012) and 38% (Wittchen et al., 2011) of the European Union (EU) population is affected by a mental disorder every year.

Overall, stigma can be defined as the ‘social-status loss and discrimination triggered by negative stereotypes that have become linked in a particular society’ (Ritsher and Phelan, 2004). Thus, stigma is a socially constructed concept, which addresses three interacting levels: institutional (structural stigma), interpersonal (social stigma) and individual (self-stigma) (Livingston and Boyd, 2010). Structural stigma occurs at a macro-level and can appear in rules, policies and practices of both public and private entities, since inherent authority enables them to control and limit the rights and chances of persons of minority groups (Corrigan et al., 2004). Conversely, interpersonal stigma occurs at a meso-level. Public or social stigma is the phenomenon of both endorsement and discrimination of the general population or social groups against stigmatized persons (Corrigan et al., 2005, Corrigan and Watson, 2002).

Although obvious discrimination and social exclusion is often reported by people with a mental illness, it is important to consider that the harm caused by stigma is not merely a direct result of the discrimination by others (Lauber, 2008). Rather, stigma operates through the internalization of the public attitudes and beliefs by the stigmatized person.

Thus, internalized stigma, that is self-stigma, can be generally described as the subjective and internal experience of stigma. A concise definition is provided by Ritsher et al. (2003): ‘Internalized stigma is the devaluation, shame, secrecy and withdrawal triggered by applying negative stereotypes to oneself’.

A series of studies have shown that people with a psychiatric disorder who endorse negative stereotypes suffer from a variety of deleterious consequences such as unemployment, income loss, lower self-esteem, self-efficacy, empowerment and less treatment-seeking behavior (Brohan et al., 2010a, Brohan et al., 2010b, Brohan et al., 2011, Sharac et al., 2010, Vauth et al., 2007, Vogel et al., 2007, Wright et al., 2000). In contrast, mentally ill persons, who are aware of the negative labels but do not apply those to themselves, suffer much less or even remain unaffected (Rüsch et al., 2006).

Accordingly, there is generally consent that stigma is not inherent, but rather it develops in a socio-cultural context. From this point of view, the relationship- and context-interconnection of stigma is fundamental of the appreciation and research of the concept (Corrigan and Watson, 2002, Major and O’Brien, 2005). Therefore, it is essential to reduce internalized stigma and its negative effects on various outcomes exploring the underlying processes of internalized stigma, especially considering country and culture differences.

Corrigan et al. (2009) emphasize that self-stigma is not only ‘there’ (or, ‘not there’), but it is a multilevel process with three sequential stages namely the ‘three A’s: stereotype awareness, agreement and application to oneself. Hence, the first step is the awareness of the social stigma. Specifically, this means the picture of the general public and their imaginable behavior towards the stigmatized group to which the person belongs, for instance mentally ill people in general, or someone with depression in particular (Corrigan et al., 2009, Corrigan et al., 2006). Subsequently, the individual either endorses the stereotype, or dissents it. The internalization of the stigma and application to people with psychiatric disorders or depression is referred to as ‘stereotype agreement’. Nonetheless, self-stigma only develops if the third stage is also passed through the application of the stereotype to oneself, which can be denoted as ‘self-concurrence’ (Corrigan et al., 2009). Widespread stereotypes about people with psychiatric disorders include blame, dangerousness, and incompetence (Corrigan et al., 2009).

To date, numerous studies have measured consequences of self-stigma, but such studies have been mostly restricted to one country only and have focused on a specific mental disorder (Livingston and Boyd, 2010). On the face of it, there is an obvious gap in stigma research.

This study aims to explore cultural and national disparities in self-stigma and its association with several key characteristics, which are putative predictors of the occurrence of internalized stigma. These factors include socio-demographic and socioeconomic characteristics, psychiatric disorders, and psychological factors [self-esteem and self-efficacy, which are regarded as mediators of self-stigma (Corrigan et al., 2009)].

Since previous studies have focused on specific countries, the exploration of socio-cultural disparities is central in this paper. Therefore, to the best of our knowledge, this is one of the very few reports aiming to identify country differences of the underlying processes of self-stigma. We hypothesized between-country differences in the levels of self-stigma due to specific socioeconomic and cultural differences in six countries under investigation. This is based on the social dominance theory (SDT). The SDT provides a framework for integrating causes and effects of prejudice and discrimination both on the individual and on the societal level. Fischer et al. (2012) conducted a meta-analysis, focusing on macrocontextual factors, inferring that ‘social dominance orientation (SDO) can be viewed as a general preference for group-based hierarchy that predicts prejudice’. The authors concluded that the aggregate level of social dominance varied considerably between the 27 tested countries. Higher SDO means were significantly related to less democracy, gender empowerment, lower gross national income and lower level of egalitarianism. Hence, group hierarchies are context-specific and shaped by the socialization into a social system (Fischer et al., 2012).

Section snippets

GAMIAN-Europe

A cross-sectional study was conducted by ‘Global Alliance of Mental Illness Advocacy Networks-Europe’ (GAMIAN-Europe, a non-for-profit organization) in six countries in 2010.

Study population

The survey included 796 participants with a psychiatric disorder who were all members of an associative GAMIAN-Europe organization in one of the following six countries: Croatia, Israel, Lithuania, Malta, Romania, and Sweden. In all countries, inclusion criteria were the same and consisted of the following: age of

Results

Overall, 52% of the study participants were women; 15% were ≥60 years old; 33% had a university degree, and; 36% were currently employed (Table 1). There were 200 participants from Lithuania, whereas the other five countries were represented with 101–151 individuals. Overall, 78% of participants reported 3–5 social contacts. About 28% of individuals were diagnosed with psychosis, 24% with depression and 11% with bipolar syndrome. Overall, 22% of study participants did not agree with their

Main findings

The present study examined the association of self-stigma with socio-demographic and socioeconomic characteristics, psychiatric disorders and psychosocial variables in six countries. One third of participants had moderate-to-high ISMI scores. The highest mean ISMI score was evident among Croatian participants, whereas the lowest ISMI score was exhibited among Swedish individuals. Independent determinants of high ISMI scores were: age-group of 50–59 years, current employment status, a lower

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