MENTAL ILLNESS STIGMA IN AFRICA AND THE ROLE OF CLINICAL PSYCHOLOGISTS.

 MENTAL ILLNESS STIGMA IN AFRICA – Elizabeth Muthoni Njararuhi    

What is Stigma

             Mental health stigma refers to negative beliefs and ill-treatment directed towards people with mental health conditions. This stigma may be expressed in different forms and it originates from problems stemming from people’s attitudes, as well as their behaviour towards mentally ill individuals. It also includes associate stigma that is experienced by individuals who do not have mental health illness but are associated with people with mental health conditions such as their families and their caregivers (Monnapula-Mazabane & Petersen, 2021).

Forms of Stigma.

           Stigma can have different forms. It can be experienced or it can be shown through actions. Experienced stigma can be classified as stigma received from others. It can be in the form of anticipated stigma, perceived stigma, endorsed stigma or enacted stigma. Action-oriented stigma describes who or what gives or is the recipient of stigma which can be categorized as structural stigma, courtesy stigma, public stigma, or provider-based stigma. Stigma against individuals with mental health conditions has been seen to bring more issues and challenges to those affected than the mental health conditions themselves (Girma et al., 2022).

            Public stigma is experienced as individuals with mental illness go out of their homes to the public. There is also structural stigma that occurs due to lack of awareness among members of the public leading to lack of adequate mental health care and treatment services, high cost of treatment, lack of coordination in care. Lack of inclusion in health care policies is also a form of discrimination. Individuals with mental illness also experience courtesy stigma due to fear of being secluded. This results in isolation of not only individuals with mental health conditions but also their family members due to feelings of embarrassment because of the illness of the family member. Self-stigma or internalized stigma are other forms of stigma that make individuals feel ashamed of their illness where they blame themselves. Mental health illness is referred to by labels such as “crazy” instead of mentally ill. (Girma et al., 2022).

            In Ethiopia, people with mental illness were reported to experience discrimination because others saw them as violent and too aggressive. They were referred to as dangerous. There were variations in how each gender was treated. Pity was expressed towards women and not so much towards the men. Women were pitied because of the consideration that the mental illness had negatively impacted their ability to take up the role of taking care of their families. Because of the cultural expectations that the women within the community had, a diagnosis of mental illness was normally kept a secret within the family. They were expected to continue the role of taking responsibility of the family with little support from others. This neglect of their condition exposed them to abandonment, physical abuse and sexual harassment (Girma et al., 2022).

           Individuals with mental illness face stigma more commonly within the family settings, among friends, members of their community like their neighbours, in places of work as well as in public areas. In families, clients have reported being blamed for their illness and not being accepted. They received negative comments and some are called derogatory names. Their families are also stigmatized by others for being associated with the mentally ill individual. Others have to hide details of their illness for fear of losing their jobs. Due to these experiences, most individuals anticipate discrimination and live with the fear of others discovering their condition. They fear being labelled, being excluded and being seen as different. The anticipated discrimination and internalized forms of stigma lead to negative effects to the clients resulting in reduced interest in seeking help even when it is needed. It also leads to low self-esteem causing isolation and withdrawal from society and lack of emotional wellbeing (Koschorke et al., 2021).

Causes of Stigma          

           Stigma is associated with the assumptions that people have about mental illness based on their beliefs and speculations. In Ethiopia for example, some communities believed that mental illness was as a result of evil spirits because the ill disobeyed Gods rule and the episodes of illness were attacks from the devil. Some perceived it as grief after loss. Others described it as an outcome of overthinking, use of drugs and substance and as an illness of the poor (Girma et al., 2022).

           In many African cultures, causes of mental illness are thought to be psycho-cultural issues. People believe that individuals with mental health issues have unacceptable habits that violate taboos, hold socially unacceptable values and attitudes. Others believe it is because of spiritual and religion related factors, difficulties integrating in the society, difficulties in engaging with one’s environment, facing disasters, drug abuse, financial hardships, behavioural issues, cognitive and emotional difficulties, medical conditions and effects of living a stressful life (Girma et al., 2022).

           In Uganda, the same themes of beliefs emerged in explanation of why individuals with mental illness are stigmatized. Most people were reported to believe that individuals with mental illness are weak and lazy, the ill are viewed as suffering because they are being punished, they are shamed and labelled, they are feared and they are abandoned. These negative beliefs were seen in even well-educated medical students showing that people strongly hold on their cultural and religious beliefs about mental illness which affect treatment and help seeking (Asiimwe et al., 2023).

Impacts of Stigma

          According to Koschorke et al. (2021), training on mental health treatment and cultural beliefs defer in most African countries. Defining what mental illness is in each community and being able to identify and treat it was found to be an area affected by stigmatizing beliefs. Some of these beliefs led to downplaying or disregarding mental illness. Another belief that was reported to be stigmatizing was that mental illness is hereditary. For example, in Tunisia mental illness was said to be running in certain families. Other people believed that mental illness does not have a cure and treatment would be ineffective.

            When clients with mental illness seek treatment, in some cases they are received with fear as they are seen as rough and likely to harm others. They are referred to with stigmatizing labels such as “psycho”. In other cases, they are segregated and treated in different areas from other clients which is a stigmatizing process in itself. In other places they label patient files to indicate that they are psychiatric clients. Lack of qualified staff and lack of psychiatric medication is also stigmatizing because mental health should also be included as other treatments are. The stigma in healthcare facilities is a barrier to seeking treatment for clients (Koschorke et al., 2021). Stigma delays reaching out for help and treatment. Other people take long to seek treatment as they first try herbal treatment and religious interventions. Inaccessibility of treatment facilities also result in delays in treatment (Girma et al., 2022).

          Stigma does not only affect individuals with mental illness. It also affects healthcare providers, policy makers, and communities (Girma et al., 2022). Adepoju (2020) reported that fewer doctors in Nigeria chose psychiatry as a specialization because it was associated with stigma. Stigma has been noted as one of the key factors affecting mental health awareness and wellness as well as the mental health care practice as a whole. It is followed closely by other factors such as low awareness and the view that mental health conditions are untreatable. The challenges affect both people with mental illness as well as mental health practitioners. Research has shown that stigma is not only experienced within the community and families but also in treatment centres among healthcare providers (Koschorke et al., 2021).

          In their study, Koschorke et al. (2021) found that the root cause of stigma in treatment institutions were beliefs, stereotypes and misconceptions about mental illness and people with mental illness held by caregivers. Some of the stereotypes were that clients with mental illness were dangerous, violent aggressive and could not control themselves. This has proven to be a major barrier to providing effective services to the people who need them. Attitudes and behaviours of treatment and care provider can also be stigmatizing in cases where they received inadequate training.

            The scarcity of resources and mental health treatment facilities contribute to inaccessibility of treatment causing a barrier to treatment. There are other barriers that cause stigma such as attitudinal barriers where lack of awareness and stigma prevent conversation on mental health and association with individuals with mental illness in the community. Thus, due to stigma, some individuals will prefer religious intervention for treatment instead of medical methods. Economic barriers affect individuals with mental health issues because treatment is inaccessible and expensive (Aguwa et al., 2022).

        In most African countries, physical barriers affect the clients because treatment facilities are not well distributed throughout but instead are mainly located in urban areas. There are also political barriers whereby due to stigma, the government and policy makers neglect mental health leading to little interest in policies and inadequate allocation of funds towards mental health. Infrastructural barriers where there’s shortage of trained personnel to provide adequate services also poses a great challenge (Aguwa et al., 2022).

WHAT IS THE THERAPIST’S ROLE IN ADDRESSING STIGMA – Simon D.M. Karanja

History of addressing Stigma in Mental health 

         Generally speaking, the stigma that surrounds mental health has been as a consequence of ignorance since the beginning of the study and treatment of mental illness. This ignorance has led to considerable fear and extreme stigma surrounding mental health disorders. Many of the past imagery and ideas surrounding mental health have stood the test of time, and remain stuck in many people’s imaginations. Many people with psychological disorders were incarcerated in asylums, while yet in many third world communities these individuals have experienced even worse conditions and subject to severe and, often, completely useless treatment, while being considered defective or beyond help (Moore, 2021). This narrative has perpetuated in certain communities through the mechanisms of cultural beliefs and narratives used to provide or construct reasoning, and crude understanding of odd phenomena among the people, within and outside said communities. 

          Over the years however, mental health has made some progress in reducing this stigma around the world. In the 1960s psychiatry was finally considered a science which allowed for psychiatric patients to gain treatment in hospitals rather than asylums, reducing the taboo associated with conversations on mental health. In the 1970s, research outside the lab became the main focus of the field which allowed scientists to engage people in real-world settings, which provided the public with some insight into what the field was all about. By the 1980s, mental health research was established as a viable academic career, an acceptance into the academic community that helped further improve the outward view of mental health, and provide the understanding of mental health as a complex issue involving social, psychological and biological factors. In the 1990s, researchers demonstrated the true prevalence of mental health disorders and as a result, mental health was finally recognized as something that impacts all humans rather than just a small section of society (Moore, 2021).

Unique challenge in Africa

           However, Africa faces unique challenges with regards to the stigma that surrounds mental health. African countries have competing health and developmental priorities with insufficient funds to address them all, which means mental health care is severely underfunded, contributing to an underappreciation of the disease burden in countries across the continent. Lack of data means that policy makers and the people cannot comprehend the depth of the problem that these countries are facing (WHO, 2022). This means that the lack of awareness continues to echo through these countries and communities, perpetuating the stigma surrounding mental health. This also means that local psychologists are faced with the responsibility of playing a significant role in addressing the ignorance surrounding mental health within Africa.

Some steps psychologists can take

p;    According to Ahad et al. (2023), there are several strategies that have been proposed in the literature to address the stigma surrounding mental health, of which they highlight 5, these include,

• Public awareness campaigns: – Awareness campaigns are a crucial and effective route to addressing misconceptions about mental health, and improving understanding of mental health disorders. Information provided in these settings can dispel myths, reduce stigma and encourage empathy towards affected individuals. Ahad et al. (2023), reference a study by Pinfold et al. (2003) that showed public campaigns using direct social contact with people with mental illness, could significantly improve public attitudes towards mental health. For example, by using video presentations and direct social contact with individuals who had personal experience with mental illness to implement education interventions in schools, facilitated students exposed to such interventions to demonstrate less fear and avoidance of people with mental health problems.
• Cultural competency training for healthcare professionals: – By educating medical healthcare providers with the necessary knowledge and skills to understand and respect their patients’ cultural backgrounds and experiences, stigma can be reduced in healthcare settings. Research shows that healthcare providers who have not undergone cultural competency trainings are more likely to inadvertently contribute to stigma and contribute to patients’ avoidance of help seeking behaviour.
• Peer support programs: – Encouraging individuals with lived experience of mental health disorders to share their stories and experiences, helps normalize mental health issues and challenge stigma. Peer to peer advocacy programs allow people with mental illness to see themselves in a light that may debunk myths and reduce their sense of ‘otherness’ or ‘separateness’ due to their mental illness. Ahad et al. (2023) highlights a study by Pitt et al. (2013) which showed that peer support reduced self-stigma, and improved self-esteem and empowerment among individuals with mental health disorders.

          

• Community-based mental health services: – In order to demystify mental health and available services, it is important to integrate it into primary care and community settings, along with other routine and standard primary care protocols in order to allow mental health to be more accessible and less intimidating, encouraging individuals to seek help when needed. These community-based mental health services have been shown to reduce stigma and discrimination, improving mental health outcomes by introducing a sense of familiarity and normalcy of these services into the community.
• Evidence-based approach: – Finally, it is important to focus on evidence-based approaches when attempting to overcome the barriers created by stigma. Ahad et al. (2023) point to research that discusses education and contact-based interventions. Contact-based interventions involve interactions between people with mental illness and members of the public to challenge negative attitudes and beliefs, while education-based interventions are designed to increase knowledge and awareness around mental illness, reducing negative stereotypes. 

Conclusion

          Ras (2023) discusses the reality of mental health being a socially constructed concept, which means different cultural, religious and ethnic groups have differing ways of conceptualizing it, and in many cases disapproved of the topic in conversation leading to stigma. Many communities in Africa have traditional notions about the origins of mental illness as well as traditional, often detrimental actions for treatment such as exorcisms or isolation rather than the use of evidence-based treatments. In the pursuit of addressing this stigma, Ras (2023) emphasises the importance of considering the role of language when interacting with local communities. By insisting on language used in Western, individualized societies and medical concepts of mental health, we hinder our attempts to integrate mental health into local communities. We instead need to promote collective approaches that focus on communities or groups as beneficiaries (Ras, 2023).

          For many communities there is a fear that therapy many not align with their cultural and/or religious or spiritual beliefs and values, this is why it is also important for evidence-based treatments and interactions to incorporate salient aspects of clients’ cultural identities. One of the ways this can be done is to ensure greater access for individuals from different cultural backgrounds to receive training as mental health providers, or at  the very least emphasize the importance of culturally informed care (Ahmad et a., 2022).

By M.A Elizabeth Muthoni Njararuhi & M.A Simon D.M. Karanja

Reference List

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