EFFECTS OF MENTAL HEALTH STIGMA

Evaluating the Effects of Mental Health Stigma

On Mental Health Patients in the United States, China, and Norway

Olivia Revill

Global Connections

Mr. Falls

2019-2020

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EFFECTS OF MENTAL HEALTH STIGMA

Abstract

An extremely large part of Earth’s population is affected by mental illness.

Although this is so common, these individuals are more often than not, treated unfairly.

This paper was written to highlight mental illness stigma in the United States, China,

and Norway, specifically how the general population of each country perceives mental

illness and how this affects those suffering from mental illness. Each section of this

paper will go into great detail of stigma in each country and provide examples of stigma

in everyday lives. This paper is looking to convince others that, although it may be

difficult, stopping the stigma surrounding mental illness is vital to increasing the quality

of life of those suffering from mental illness.

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EFFECTS OF MENTAL HEALTH STIGMA

Table of Contents

Abstract 2

Table of Contents 3

Introduction 4

Literature Review 6

Limitations 10

Body 11

Conclusion 21

Bibliography 22

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EFFECTS OF MENTAL HEALTH STIGMA

Introduction

Each year, millions of people are affected by mental illness in the United States

alone. According to the National Alliance on Mental Illness or NAMI, 1 in 5 or 19.1% of

adults experience mental illness each year; 1 in 6 or 16.5% of youth aged 6-17

experience it too. In 2018, only 43.3% of adults and 50.6% of youth affected by mental

illness received treatment (NAMI). As defined by the NAMI, mental illness is “a condition

that affects a person’s thinking, feeling, or mood.” Mental illness affects each person in

a different way, but overall the ability of those affected to interact and function in their

societies is greatly damaged. Examples of mental illness can range from depression

and anxiety disorder to schizophrenia and bipolar disorder. When a large number of

people are affected by mental illness, it often causes the general population of the

society to react negatively, most commonly known as stigma.

The ​Chambers Dictionary of Etymology​ defines stigma as “a mark of shame or

disgrace” (Barnhart, 1988; Bennett, 2012). It can even further be described as “any

attribute which discredits and lowers the status of an individual once he is known to

have this attribute” Farina, Holland, & Ring, 1966, p. 421; Bennett 2012). While the word

stigma has only been around for about 400 years, it has occurred in society for much

longer. Throughout time, it has been shown that people who were openly diagnosed

with mental illness were treated very poorly by their communities. Scientists have

discovered holes drilled in thousand-year-old skulls, a method they believed would

“release the evil spirits within the head” (Maher & Maher, 1985; Zilboorg, 1941; Bennett,

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2012). In the Middle Ages, the Catholic Church would accuse the mentally ill of being

witches and would try them as such (Mora, 1992; Zilboorg, 1941; Bennett 2012). Before

the rise of Hitler, American and European eugenic scientists would propose compulsory

sterilization (Black, 2003; Kelves, 1985; Bennett 2012). Even more recently, those

diagnosed were often subject to unnecessary treatment such as lobotomies,

electroconvulsive therapy, exorcisms, and most often, incarceration in insane asylums

(Bennett 2012, Sienaert & Peuskens 2006). Unfortunately today, we still see the

mentally ill being treated unfairly for their conditions. For example, the mentally ill are

often denied job opportunities. They are seen as “unsuitable” for a job and are often

doubted when it comes to making decisions for themselves. This is most common in the

schizophrenic community, whose unemployment rate lies within the 70% to 90% range

(NAMI 2017). It is clear to see why such a large part of those with mental illness wish to

hide and stay untreated. While some countries, such as Norway, may be seen as more

progressive, mentally ill individuals in China and the United States tend to hide their

condition and not seek treatment out of fear of being isolated from their societies and

blocked from certain opportunities. Because of this, their conditions often worsen,

causing stigma surrounding them to grow.

To go into more detail, this paper will discuss the stigma surrounding mental

health in three countries: the United States, China, and Norway. There will be more

detail on how the stigma exists and how it affects the mentally ill population in each

country. The United States, being the author’s country of origin, will serve as a local

connection to the stigma problem. China and Norway are serving as global connections

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in order to see that the stigma problem isn’t just occurring in the United States; It is

occurring all over the world.

Literature Review

In order to write this paper, many reliable sources were necessary. While they

are all cited at the end of this paper, this section will be used to emphasize the

importance of specific sources and how they each contributed to the project. The author

has gathered many sources ranging from ones talking about mental illness itself to ones

going into more detail about each independent country’s stigma, those being the United

States, China, and Sweden.

In order to find all of the necessary sources for this project, the author has

chosen to divide her research into four categories: origins and facts about mental

illness/stigma, mental illness stigma in the United States, mental illness stigma in China,

and mental illness stigma in Sweden.

Origins and Facts about Mental Illness/Stigma

A large part of the research for this section was gathered from two main sources.

These are the National Alliance on Mental Illness (NAMI) website and an article written

by Cynthia Ann Bennett titled ​The Stigma of Mental Illness as Experience by Mental

Health Professionals as Patients: A Phenomenological Study.

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EFFECTS OF MENTAL HEALTH STIGMA

The NAMI website consists of many pages of information ranging from statistics

on American mental illness to articles written about the mentally ill and the challenges

that they face as a result of stigma. From the NAMI website, the author was able to

gather statistics on how many adults and children in the United States suffer from

mental illness and out of these groups, how many people actually receive treatment,

posing the problem that this paper wishes to address. This website also has provided a

formal definition of mental illness and has provided examples for the author to base the

focus of the project around. An article written by Luna Greenstein, found on the NAMI

website, provided a basic understanding and what she describes as the five

components of stigma giving a good idea of where stigma can originate from all three of

the focus countries.

From Cynthia Bennett’s 301 page study on mental illness stigma, the author of

this paper has chosen to take information from pages 13 through 17. On these pages,

the author was able to find information on the origins of mental illness stigma and

provide examples of how the mentally ill were treated in the past. In her study, Cynthia

Bennett gave examples of how powerful organizations and historical figures treated the

mentally ill and some of the cruel and unusual punishment they were forced to endure.

These examples were used in the introduction of this paper to give a background of the

stigma and provide some reasoning for why those diagnosed with mental illness now

might be afraid to come forward with their conditions. She gives multiple definitions of

the word stigma and uses studies done by other researchers to explain in even more

depth how stigma occurs.

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Mental Illness Stigma in the United States

To write this section of the paper, three main sources were used. These are ​The

Social Obligation to Reduce Stigma in Order to Increase Utilization of Mental Health

Services, Trends In News Media Coverage Of Mental Illness In The United States:

​ nd an interview conducted by the author of this paper with an anonymous

1995-2014, a

source. Two of the three sources provided definitions of stigma and examples, while all

three discussed the impact of stigma on the lives of the mentally ill.

In Melissa Berdell’s ​The Social Obligation to Reduce Stigma in Order to Increase

Utilization of Mental Health Services, ​she explains how recently the media has begun to

focus on mental illness in their stories of violence, going as far to describe them in cruel

ways. This is important to the project because it highlights the media’s involvement in

increasing mental health stigma by changing the public’s opinion of mentally ill

individuals.

Trends In News Media Coverage Of Mental Illness In The United States:

​ ritten by Emma McGinty, Alene Kennedy-Hendricks, Seema Choksy, and

1995-2014, w

Colleen Barry, explain in detail a study conducted to support Berdell’s thoughts. This

study used 400 news stories published between 1995-2014 by popular news companies

to support the idea that the media plays a huge role in increasing stigma. This source

also provides statistics about what percentage of the sources they used discussed

violence, whether it be interpersonal or self-directed.

The interview conducted by the author was done with someone who wished to

remain anonymous but had experience working with the mentally ill. In the interview, the

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interviewee was asked questions about how she would personally define stigma as well

as how she believed that media sources and mental health professionals aid in the

increasing stigma surrounding mental illness. This interview served as a perspective

from inside the mental health field to discuss the harm of stigma to patients and discuss

why stopping the stigma is important.

Mental Illness Stigma in China

To evaluate the stigma in China, two sources were used titled ​Mental Health in

China: Stigma, Family Obligations, and the Potential of Peer Support, ​written by Shelly

Yu, Sarah Kowitt, Edwin Fisher, and Gongying Li, and ​Levels of stigma among

community mental health staff in Guangzhou, China​, written by Jie Li, Juan Li, Graham

Thornicroft, and Yuanguang Huang.

In ​Mental Health in China: Stigma, Family Obligations, and the Potential of Peer

Support, t​ he authors gave basic statistics on how many people are affected by mental

illness in China and the large percentage that hadn’t received treatment for their

condition. The focus of this source was to discuss how family tied to mental illness. The

authors explained how, in China, being associated with someone with a mental illness

actually subjects them to experiencing stigma as well. This was important in showing

the reason patients fear reaching out to family members.

Levels of stigma among community mental health staff in Guangzhou, China​ was

a study conducted to show how stigma is also present within mental health staff in

China. This study used results from three surveys done within mental health staff: the

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RIBS, the MAKS, and the MICA. The results of these surveys show that there seemed

to be a high level of stigma within the mental health profession giving an idea of how

difficult it may be to receive proper treatment in these conditions.

Mental Illness Stigma in Sweden

Because Norway has had a much more progressive look at mental illness

stigma, the focus of this section is mainly on reform done to the mental health care

system after 1997. For this section, there was really only one used abundantly more

than the others. This is an interview done by NCBI. In this interview, Ben Jones is

speaking with Kjell Magne Bondevik, the former Prime Minister of Norway. They speak

about the impact Prime Minister Bondevik had on his country when he revealed he was

diagnosed with depression. After being so open with his country, many things changed

as far as the health care system and stigma was greatly reduced in the country.

Limitations

As with anything else, this project has limitations. There are four main ideas that

limit this project to what it is, those being: the focus countries, studies done over time,

the focus illnesses, and bias. The author is of high-school age therefore, many

possibilities that are obtainable by professional researchers, are not possible for her.

To keep the project from becoming too broad, the author has chosen to gather

her research from studies done in the United States, China, and Sweden. These

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EFFECTS OF MENTAL HEALTH STIGMA

countries are meant to serve as positive (Sweden), negative (China), and neutral

(United States) examples of mental health stigma in order to show the global effect but

in no way will reflect the author’s personal feelings about each of these countries. The

information gathered for this project will not extend outside the boundaries of these

three countries, but it is possible that other countries may be referenced as

comparisons.

Due to the timeframe of this project, the author is unable to conduct studies over

time. This means that most of the information gathered will be from reliable outside

sources and not by the author herself.

While the National Alliance on Mental Illness (NAMI) provides many examples of

mental illness, the research obtained for this project will be primarily centered around

anxiety disorder, depression, bipolar disorder, and schizophrenia. Disorders such as

ADHD, ADD, PTSD, and any eating disorders will not be discussed.

The author does have a personal connection to someone affected by mental

illness and therefore is subject to bias. Despite this, the author is going to provide

information and research that is not the result of personal bias and encourages the

readers of this paper to also set their personal bias aside in order to look at the bigger

picture.

Body

In order to further analyze stigma in each of the individual countries, there

must first be an understanding as to why stigma occurs in the first place. The National

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Alliance on Mental Illness gives five components that lead to stigma occurring:

responsibility, uncertainty, unpredictability, incompetence, and dangerousness.

According to Luna Greenstein, the author of the article, ​Understanding What Causes

Stigma,​ learning more about the roots of stigma can lead to more understanding of how

to improve the life of the mentally ill.

Before applying these components to specific countries, there must be a full

understanding of what these components exactly mean. Responsibility refers to the idea

that those affected by mental illness have a choice in whether or not their condition

impacts the way they live, which is untrue. Their loved ones may believe that they aren’t

fighting hard enough against their illness causing some tension between them.

Uncertainty focuses on the long-term picture of the illness. If the situation seems

hopeless, meaning there is no chance for the person’s condition to improve, then

friends and family tend to avoid the affected person. On the contrary, unpredictability

focuses on the short-term picture. Because people with mental illness don’t have much

control over their condition, they are often seen as “erratic” or “unpredictable.” This

causes situations where they may be treated unfairly and avoided. Moreso often, they

are seen as incompetent meaning unable to make rational decisions for themselves. As

a result of this, individuals with mental illness are often prohibited from experiencing the

same rights and opportunities as an average citizen. This includes the right to hold

office, the right to serve on a jury, and even the right to vote. The last component of

stigma is dangerousness. As explained with unpredictability, people with mental illness

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have the possibility to act erratically. As a result, people fear them and avoid them in

every situation possible. (Greenstein, 2016; NAMI 2016)

Understanding those components of stigma makes it a lot easier to understand

why stigma occurs in individual countries. Overall, there is agreeance that stigma

generally comes from a lack of knowledge on the subject.

Stigma in the United States

In the United States, media is crucial to the gaining and application of knowledge

on any given subject. Many Americans use what they would deem as reliable news

sources to gain the information necessary to form their opinions. In the United States,

much of the stigma surrounding mental illness comes from media coverage.

According to Melissa Berdell, author of ​The Social Obligation to Reduce Stigma

in Order to Increase Utilization of Mental Health Services​, recently, the media has

begun reporting more on violent acts committed by people diagnosed with mental

illnesses. They have specifically focused on the danger of the mentally ill and how they

are “extremely harmful to themselves and others” (Berdell, 2016). In 2016, a study was

conducted by a group of researchers in order to examine the role media plays in

increasing the stigma surrounding mental illness. These researchers used a random

sample of 400 news sources discussing mental illness from the years 1995 to 2014.

The sources were gathered using the search terms, “mental illness,” “mental health,”

“mental,” “psych,” “depression,” “schizo,” “bipolar,” “anxiety,” etc. They found that out of

the 400 news stories, 55% of them discussed violence in relation to mental illness while

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only 47% involved treatment. These articles were then split into categories consisting of

ones involving interpersonal violence, 38% of the total stories, and ones involving

self-directed violence, 29% of the total stories. In this case, interpersonal means

violence towards other people and self-directed means either self-harm or suicide.

The amount of these articles that were focused on interpersonal violence is

alarming because according to the researchers, most people affected by a mental

illness never engaged in any act of violence and only 4% of interpersonal violence in the

United States is carried out by mentally ill individuals. Another study conducted by Otto

Wahl and his colleagues focused on news stories that were published by six

high-circulation US newspapers in 1999. He found that over a quarter of the stories

emphasized the dangerousness of the mentally ill and gave examples of violent acts

committed by a mentally ill individual. It was also discovered that his findings were

consistent in media coverage of other nations including Canada, the United Kingdom,

New Zealand, and Spain, showing that media coverage is an issue globally, not just

within the United States (McGinty; Kennedy-Hendricks; Choksy; Barry, 2016; Wahl,

1995) In order to decrease the stigma in the United States, the media needs to focus

less on violent acts committed by the mentally ill. Portraying mentally ill individuals as

“violent” or “dangerous” is a huge way to influence the public’s opinion of them and

cause fear to grow, thus increasing stigma. An anonymous source stated in an interview

conducted by the author, “Oh I mean that is like the first thing that is announced in a

social media source. If anybody does anything, ‘well they were…’ and that’s kinda how

that person is defined.”

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The anonymous interview source also claimed that mental health professionals

can tend to go into situations with some bias. She says that workers who are introduced

to a case usually read the patient file before even introducing themselves to the

individual. Of course the patient file will contain information on the patient’s past

endeavors which can cause some workers to make assumptions about the person

before meeting them. “They will go into treatment with the preconceived notion of what

that person, child, whatever has done in the past without allowing them to experience it

for themselves. So I think that is how they contribute to the stigma,” she says.

While stigma in the United States hasn’t improved a lot, there has been some

reform to the system, typically in the form of a government act. Under the Americans

with Disabilities Act (ADA), it is illegal for private employers to discriminate against job

applicants just because they have some form of disability, which is included with mental

illness (NAMI). The Rehabilitation Act of 1973 or the Rehab Act works in similar ways; it

prevents employers that receive federal funding from discriminating against federal

government workers and employees. The Family Medical Leave Act (FMLA) is

beneficial for a mentally ill individual who frequently needs breaks from situations like

work. This act permits employees of 12 months or more to take up to 12 weeks of

unpaid leave in the event of illness while still keeping job benefits and placements.

Stigma in China

In China, mental health is not a widely popular topic. While it’s truly difficult to get

a one-hundred percent accurate count on how many people are affected by mental

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illness, in the early 2000s, it was estimated that around 17% of the population was

affected by mental illness. Out of this percentage, 92% of those individuals did not

receive any treatment for their condition (Phillips et al. 2009; Yu, Kowitt, Fisher, Li,

2018).

Being diagnosed with mental illness in China causes many of those affected to

be excluded from society. Often they are labeled as, “bu zheng chang,” meaning,

“incapable,” “crazy,” or “unfit.” Being labeled in such a cruel way often leads to job

discrimination and fewer opportunities to make relationships and get married. In order to

prevent being labeled and discriminated against, those affected hide their conditions

(Yu, Kowitt, Fisher, Li, 2018). One patient who was interviewed shared that she’d been

dealing with her depression in secret for the past 20 years. Her family was unaware of

the time she spent in the psychiatric hospital purely because she was afraid of how it

would negatively affect her. Being a business owner, she believed that if her customers

were made aware of her condition that it would drive away business. She was also

afraid that her family and friends would shun her and she would be completely isolated.

Although her condition did have a large impact on her, she was also afraid of her

condition impacting the lives of her loved ones. In China, mental illness is seen as a

genetically transferable trait. They believe that if she had it, without a doubt her son

would have it too. If her community knew of her illness, in the future it may also impact

her son’s chances of getting married and forming social connections (Yu, Kowitt, Fisher,

Li, 2018).

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In China, less than 2.35% of the government’s budget is spent on mental health

care which has led to a lot of issues. Due to the lack of funding, those in need do not

have access to necessary goods and services such as specialized services, trained

physicians, and insurance coverage. (Phillips et al. 2009; Yang et al. 2013; Yu, Kowitt,

Fisher, Li, 2018) It has been proven that having support from loved ones aids in an

individual’s fight against mental illness. Often because it’s so hard to receive help from

the government, patients in China may attempt to turn to family members for support.

This doesn’t always work out in their favor, however. Studies done have revealed that

providing support for an ill family member often has a negative effect on the one helping

as a result of the stigma surrounding mental illness. They experience what is called,

“affiliate stigma,” from their peers and colleagues. This means they experience the

effects of stigma just for being connected to a person with mental illness, exactly what

the patient above was scared of her son experiencing. (Li et al. 2007; Mak and Cheung

2008; Yu, Kowitt, Fisher, Li, 2018). Due to this, those with mental illnesses tend to not

tell anyone about their conditions, out of fear of ruining their lives.

Unfortunately, there seems to be some level of stigma within the staff of mental

health institutions, as well. A study conducted in Guangzhou, China went into depth

about the level of stigma within the institutions. The study was conducted using 214

community mental health staff members from over the course of three months. Surveys

were given to those willing to participate and they were scored using three scales: the

Reported and Intended Behaviour Scale (RIBS), the Mental Health Knowledge

Schedule (MAKS), and the Mental Illness: Clinician’s Attitude Scale (MICA). For the

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RIBS, scores could range from 4 to 20 and a higher score indicated a greater

willingness to interact with people with mental illness. For the MAKS, scores ranged

from 6 to 30, and a higher score indicates more knowledge on mental illness. For the

MICA, scores ranged from 16 to 96 where a lower score indicates less stigma. The

results of those surveys were as follows:

● The average score for the RIBS was 11.97

● The average score for the MAKS was 16.80

● The average score for the MICA was 51.69

(Li, Li, Thornicroft, Huang, 2014) These scores show that, in general, mental health staff

have relatively negative attitudes towards people with mental illnesses or are ill

informed on their conditions. It is unlikely that patients in this environment are seeking

the proper treatment due to the stigma clouding the visions of the workers. Not receiving

proper treatment only worsens the condition of the patients and can lead to more

complications in the future, only making stigma worse.

Stigma in Norway

Recently, Norway has been considered one of the most progressive countries

when it comes to mental illness stigma and reform. This does not mean their health care

system is perfect, however. In the past, Norway was largely criticized for the amount of

involuntary admissions were recorded. An involuntary admission is when a mentally ill

individual is admitted to a psychiatric hospital nonconsensually but under the order of

the government. Often those admitted were considered a danger to themselves or

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others, but in most cases they were allowed a free lawyer to battle the decision (Wynn,

2018)

Despite this, Norway has hugely reduced mental illness stigma over the years.

According to Norweigan and international studies, 15 to 20% of the population of

Norway experiences some sort of mental illness. Kjell Magne Bondevik was Prime

Minister of Norway from 1997 to 2005. He was widely known for his attempts to reform

mental health care systems and stop the stigma surrounding mental illness. In August of

1998, Bondevik was diagnosed with depression after taking an absence from his role of

Prime Minister. The day after his diagnosis, he was due to give a speech to explain his

absence. Instead of sugar coating and coming up with excuses, he decided to be

truthful and fully explain his condition. He believed that being so open with his people

would help those suffering in silence to come forward with their problems and end the

stigma surrounding mental illness in Norway. After coming forward with his story, he

received around 1,000 letters from Norwegians all across the country saying that him

coming forward with his story has encouraged them to be more open with their

conditions.

Since this time, much mental health reform has come from the Prime Minister

and Parliament. Within this time, the Norwegian government presented an 8-year plan

which would provide 24 billion Norwegian krone, or 4.3 billion USD, to be used for

mental health services. There has also been 75 new mental health institutions added to

Norway’s 18 districts. Along with this, big psychiatric facilities, that were possibly

ineffective in helping patients, have been closed down (Bondevik, Jones 2011). In 1998,

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the Norwegian Parliament also adopted the National Programme for Mental Health

which was focused on increasing public awareness of mental health. Under this

program, patient rights were extended. The general rights added under this act are: “the

right to necessary treatment and care,” “the right to an evaluation of the need for

treatment within a maximum of 30 days,” “the right to an individual plan for treatment

and care,” “the right to a second opinion,” and “the right to choose where to receive

treatment” (Norwegian Ministry of Health and Care Services, 2005).

Another problem with the treatment of the mentally ill in Norway was the

frequency of police involvement with mentally ill individuals “acting out.” According to a

previous psychiatric nurse, Arjen van Dijk, police responded to around 2,000 psychiatric

disturbances per year. Often, the patients were brought in pepper sprayed and

handcuffed, giving off the impression that these individuals were to be feared. In 2005,

van Dijk created a separate ambulance for psychiatric patients where they would be

responded to properly instead of with the unnecessary tactics of the police force. This

ambulance was staffed with two psychiatric nurses and a paramedic. Instead of

immediately taking the patient to the hospital, these staff members take time to get to

know the family and patient and from there decide the best course of action (Pandika,

2014).

Due to this ambulance, Norwegian police were responding to fewer and fewer

psychiatric cases. As a result, community members were witnessing mentally ill

individuals less frequently in such a negative light, preventing the increase of stigma.

Because of the success of this ambulance, cities such as Amsterdam, Netherlands and

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EFFECTS OF MENTAL HEALTH STIGMA

Stockholm, Sweden have adopted their own ambulances, helping to stop the stigma

(Pandika, 2014).

Conclusion

Overall, it is extraordinarily clear why it is so important to stop the stigma

surrounding mental illness. Stigma leads to discrimination and often prevents mentally ill

individuals from having the same opportunities as someone who does not have a

mental illness. Because they are so afraid of being subject to unfair treatment, they

sadly hide their conditions from loved ones. Hiding their illnesses causes their

conditions to get worse which in turn causes an increase in stigma. It is so important to

stop the stigma because as an anonymous source once said, “I think that people

deserve a chance… but they’re somebody’s daughter, they’re somebody’s son, they’re,

you know, somebody’s brother, somebody’s sister and… identify with that before you

identify with their illness and treat them as a human being before you treat them as

someone with a mental illness.”

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