Dr. Andrew Mohanraj

The stigma associated with mental illness remains woven in the fabric of society.

EVERY year, World Mental Health Day falls on Oct 10. This day provides an excellent opportunity to highlight issues concerning mental health and mental disorders.

The World Health Organisation (WHO) describes mental health as “a state of well being in which the individual realises his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community”.

People with mental disorders often suffer in one or more of these areas in life. Mental health or mental well being has become a global concern now. By the year 2020, WHO has projected that depression will be the second leading cause of disability in the world. Today, depression is already ranked fourth.

In addition, the movement of people across the globe has drawn attention to migration mental health. Every year, hundreds of millions of people move across national boundaries throughout the world. The public health importance of this is clear for communicable diseases like typhoid and cholera, but less visible is the importance of the mental health effects of migration.

Human rights issues involving people with mental illness are slowly being recognised and acknowledged, leading to sweeping health reforms in many parts of the world. The role of the media has also warranted close attention in the efforts to not only promote good mental health but also to dispel taboos and misconceptions related to mental disorders.

The stigma

One pervasive obstacle towards greater understanding and inclusion of people with mental disorders has been stigma of mental illness. This stigma can be defined as a negative attitude usually based on prejudice or misinformation, which is triggered by odd behaviour or a history of psychiatric treatment in a person.

This does not stop at the illness or the people suffering from mental disorders, but includes their families across generations, institutions that provide treatment, treatment issues, and even mental health professionals.

Stigma starts a vicious cycle that leads to discrimination, decrease in self esteem, poor treatment, segregation, and sometimes utter neglect.

The appalling conditions of individuals with chronic psychosis across the developing world leaves much to be desired. It is heart-rending to see individuals chained to their beds or caged in small cells built behind houses or thrown into asylums where they are kept in isolation in concrete rooms with a hole in the floor for urine and faeces.

It is shameful that in this era of information revolution, people with mental illness are still abused and tortured by traditional healers in the name of ritual cleansing, all with the full support of family members and society.

Even the most harmless of traditional healers inadvertently interfere with modern treatment of mental illness, and in most cases, delay the sufferer from seeking mental health treatment. This inevitably causes some people to become chronically ill.

Subsequently, families tend to suffer the burden, with the search for treatment consuming meagre resources. This burden of care becomes frustrating, leading to hostility towards the ill family member.

Poor understanding of mental illness does not seem to be the exclusive privilege of uninformed societies. Mental health professionals in so-called progressive societies commonly use words that are stigmatising, like “schizophrenic” or other pejorative terms for mental illness, instead of speaking of the person who is ill.

One of our own senior politicians recently said his detractors should be sent to be treated in Tanjung Rambutan since they were “mad”. Obviously, he thought only people without sanity would oppose him!

It was more shocking that there was not a single voice of protest to this stigmatising statement. Some countries have in the past, reinforced prejudice by proposing forced sterilisation of people with mental illness or mental retardation. Recently, it was discovered that American scientists deliberately infected patients in a mental hospital in Guatemala with syphilis 60 years ago in the name of research, to demonstrate if a certain drug could prevent the sexually transmitted disease!

Communication matters

The mass media across the globe exerts a powerful influence on public attitudes towards mental illness. In 2007, a student at Virginia Tech University in the United States, opened fire with a gun in a dormitory, killing 33 people, including himself. Within hours, an anchorperson for a popular American news network jumped to the conclusion that “there is no way you can plan for a psycho, and that is what we are dealing with here”.

In a society where slurs based on race or physical disabilities are frowned upon, pejorative terms like “psycho” are bandied about without remorse.

Despite such shortcomings, the media has also brought about many positive changes. Media coverage of the Asian tsunami in 2004 brought attention to the psychological effects of disasters and the paucity of mental health services in Aceh, Indonesia. This resulted in funding for community mental health services and reforms that led to, among other developments, the removal of restraints from those who were chained or locked up for being mentally ill.

The media brought attention to the devastation caused by Hurricane Katrina. This helped the closure of decrepit, overcrowded state mental hospitals in New Orleans, and persuaded appalled law makers to initiate reforms, including putting pressure on insurance companies to provide adequate coverage for mental illness.

Suffering in silence

Stigma is a very real problem for those who have mental illness. It can be obvious and direct, such as someone making a negative remark about the mental health condition or treatment. It can also be subtle, when someone assumes that a person with mental illness could be violent or dangerous.

It is important to know that mental illness is not due to some form of personal weakness, but has, in fact, a biological basis and can be treated like any other health condition.

The consequences of stigma can be so devastating that the individual can refuse to seek treatment for fear of rejection or discrimination, and even harassment. Individuals who suffer from mental illness should try to learn to accept their condition and recognise the need to seek treatment and support, while helping to educate others regarding mental illness.

There are several steps that can be undertaken by the individual to help cope with stigma:

1. Get treatment

Proper diagnosis and treatment can provide relief for your symptoms and help you return to your work and personal life, Do not let the worry of being labelled with mental illness prevent you from seeking professional help.

2. Do not let stigma create self-doubt and shame

Come to terms with your illness. Others judge you unfairly due to a lack of understanding of your condition. Feeling ashamed can be self destructive. Seek professional help.

3. Do not equate yourself with your illness

You are not an illness. Do not call yourself a schizophrenic. Instead, say I have schizophrenia.

4. Seek support

Confide in people you trust. You may find understanding, compassion and acceptance. Stay in touch with family and friends, and do not isolate yourself.

Get help at school or college

If your child has a mental illness that affects learning, talk to teachers and school or college authorities about it. Otherwise, their ignorance of the situation may lead to discrimination or isolation of your child.

5. Join a support group

Some local groups like the Malaysian Mental Health Association have programmes that watch for and correct stereotypes and misinformation. They also have carers and users meetings that are very beneficial.

6. Speak out

Educate the public about mental illness. If you come across stigmatising television shows or comic strips or even greeting cards, write a letter of protest or highlight this through the media.

7. Take action

Stigma does not only concern the individual suffering from a mental illness. Neither is challenging it a preserve of psychiatrists and mental health workers. The movement against the stigma associated with mental illness should be a concerted effort.

The extraordinary transformation in ethical, legal, and political responses to the AIDS epidemic or the epidemic of tobacco-related diseases demonstrate that concerted efforts by institutions, professionals, families, and organisations can lead to positive changes in people’s lives. This courageous transformation is yet to take place for those suffering from chronic mental illness, particularly those with chronic psychosis.

It is worthwhile to remember that dementia, which can erase an individual’s sense of identity due to severe cognitive failure, has already benefited from this transformation. It is no longer stigmatised as it used to be some years ago.

If it can happen to dementia, then a transformation could influence how we begin to look at chronic mental illness as well.

Dr Andrew Mohanraj is a Malaysian psychiatrist who set up the Aceh Psychosocial Rehabilitation Programme after the tsunami of 2004. He is also a WHO-recognised consultant on community psychiatry.