INTRODUCTION

The word stigma, though having various meanings, is defined as an embarrassing sign, a mark of disgrace associated with a particular person. Stigmatization is described as attributing someone in a way that would decrease the person’s reputation because the individual strays away from the general norms of the society. The stigmatized person is attributed a feature that will result in rejection, refraining or dislike by others (1-3).

Individuals with mental illnesses have been reported to be one of the most vulnerable groups for stigmatization and they have been stigmatized and prejudiced by the society more than individuals who have a physical illness (4-7). It has been reported that individuals with mental illnesses are seen by the society as dangerous, frightening, unstable, irresponsible, unpredictable, and having communication problems (1,8-11).

Individuals with mental illnesses suffer social isolation due to stigmatization, and are confronted with housing and career problems. Negative emotions such as introversion, decreased self-confidence, worthlessness, shame and despair emerge in the stigmatized individual. The internalized stigma develops–which is defined as the individual’s acceptance of the negative stereotypes and the resulting withdrawal from the society with the arising negative emotions. As a result, the social engagement, interpersonal and occupational functioning, and quality of life of the stigmatized individuals deteriorate to a great extent (1,7,12,13).

Stigma also affects treatment and care processes of people with mental illnesses. It has been reported that, these individuals express health care seeking behaviors less, their ability to access to health care services and compliance to treatment decreases (9,12,13).

It has been suggested that the stigmatization for mental illnesses is the result of the myths, misunderstandings, and negative stereotypical judgments and attitudes about mental disorders (5). It is also thought that the language and type of expressions are also important in stigmatization (14,15). It has been found that stigmatizing expressions evoke negative emotions and recall characteristics such as dangerousness and unpredictability, and thus, cause more stigmatization and social isolation (15).

In fighting with stigmatization, it is important to take the necessary precautions, in dealing with the beliefs and attitudes of the society, in raising awareness on this subject, and especially in developing an anti-stigmatism attitude. In this respect, it has been emphasized that mental health workers including psychiatrists, psychiatric nurses, psychologists, and social workers bear tremendous responsibility and there is a need for interventions and studies in this field (5,12,16).

There are several studies related to stigmatization in mental disorders in our country (2,12). Considering the importance of stigmatization, there are a few studies abroad on the use of language and expression styles in mental health (15), whereas, in Turkey, there is only the study of Ozmen et al. (17) in which they have investigated which of the terms “mental disease” and “psychiatric disease” is more stigmatizing. To the best of our knowledge, a study addressing the use of stigmatizing language for mental disorders in the general population and in mental health workers has not been found. In our study, it was aimed to comparatively examine the beliefs about mental disorders and the use of stigmatizing and marking language for mental disorders in mental health workers.

METHOD

Ethical committee approval was obtained from the relevant hospital for the study. In our study, it was aimed to assess the expressions used by mental health workers (psychiatrists and residents, psychiatric nurses, psychologists and social workers and paramedics), who work at the Bakirkoy Prof. Dr. Mazhar Osman Mental Health and Neurological Disorders Training and Research Hospital, to describe mental disorders and individuals with mental disorders. We also aimed to evaluate at what extent or how the mental health workers use psychiatric disorder terminology for disdainful, derogatory and/or sarcastic purposes to describe individuals who do not have mental disorders. It was also planned to question the beliefs about mental disorders as a measure of the stigmatization.

Measures

The time period during which the study would be performed was set as June-August 2015. At first the consent form describing the purpose and method of the study was given to the participants, and those who were willing to participate in the study were asked to fill in the forms and send them to the researcher.

Forms used in the study are the sociodemographic data form, the Stigmatizing Language Use for Mental Illnesses Questionnaire and the Beliefs toward Mental Illness (BMI) Scale.

Sociodemographic Data Form: It is a data form prepared by the researchers in accordance with the aims of the study including sociodemographic characteristics such as age, gender, marital status, education level and questions about psychiatric admission and treatment, but did not include name and last name information.

Stigmatizing Language Use for Mental Illnesses Questionnaire: It is a questionnaire designed by researchers aiming to determine whether some mental disorder and diagnosis terminology are being used by mental health workers in a stigmatizing manner. By giving instructions such as, “Have you ever noticed that you have used the following words in a contemptuous, humiliating, and/or sarcastic way to characterize the other person, other than for a diagnosed patient and other than for a diagnostic purpose? Please indicate which one(s) you have used in this way” and “Do you think the words below are contemptuous, humiliating to the addressee? Please indicate which one(s) is/are”, the participants were required to choose and mark among the 36 terms selected by the researchers and sorted in alphabetical order. The total number of terms selected by the participants was counted and considered for evaluation. The participants were also suggested to write down other terms they use for this purpose. In addition, the participants were asked about the expressions they used to describe mental health problems and the people suffering from mental health problems, and finally 10 different alphabetically ordered expressions describing mental health problems and the people suffering from mental health problems (insanity, insane, psychiatric disorder, psychiatric illness, psychiatric sickness, mental illness, mentally ill, mental disorder, mental sickness, mental problems) were given and participants were asked to rank from the most positive to most negative in terms of stigmatization.

Beliefs Toward Mental Illness (BMI) Scale: The measure questioning participants’ thoughts and beliefs about mental illnesses, contains 21 questions. It is a 6-point Likert-type scale and consists of three subscales (Incurability and Disturbance in Interpersonal Relationships subscale, Dangerousness subscale, and Shame subscale). Turkish validity and reliability study was performed by Bilge and Cam (18).

Statistical Evaluation

SPSS 15.0 software package was used for statistical evaluation. Histogram and Shapiro-Wilks tests were used to evaluate normal distribution of numerical data. In addition to using descriptive statistical methods (mean, standard deviation, median, frequency, minimum, maximum), Mann Whitney U test was used in comparison of two groups of non-normally distributed quantitative variables. Spearman correlation analysis was used to evaluate the relationship between quantitative variables. Statistical significance value was considered as p<0.05.

RESULTS

A total of 103 forms were collected during the determined period and 95 forms were evaluated because 8 incomplete forms were excluded. Of the participants, 51 (53.7%) were adult psychiatrists, 6 (6.3%) pediatric and adolescent psychiatrist, 23 (24.2%) nurses/paramedics and 15 (15.8%) other mental health workers. Of the whole sample, 59 (62.1%) were female, 36 (37.9%) were male and the mean age was 33.38±8.03 years (range 20-64 years). Other sociodemographic characteristics of the participants are shown in Table 1. Sociodemographic characteristics and family history of psychiatric illness were not found to be determinant in terms of stigmatizing attitudes, whereas those who have had psychiatric illness had lower stigmatization scores (p=0.005).

Participants were divided into 2 groups as psychiatrists (n=57, 60.0%) and other mental health workers (n=38, 40.0%) and compared in terms of negative beliefs and use of stigmatizing language about mental illnesses. Based on BMI total and subscale scores, it was found that psychiatrists had less stigmatizing beliefs than other mental health workers (p<0.001). There was no difference between the groups in terms of the use of the stigmatizing language. There was no correlation between the scores of BMI total and subscale scores and the Stigmatizing Language Use for Mental Illnesses Questionnaire. These comparisons are given in Table 2.

The expressions “insane” and “mentally ill” were identified as the most stigmatizing expressions, and “psychiatric disorder” and “mental health problems” were identified as the least stigmatizing expressions by the participants (Table 3). The “dotard/looney” (n=56/36) and the “junkie” (n=43) were considered the most humiliating/degrading expressions by the participants. In addition, the participants stated that “antisocial” (n=49), “narcissist” (n=36) and “personality disorder” (n=33) were the most frequently used words in a contemptuous, insulting, and/or sarcastic way, other than mentioning a diagnosis.

For the question “How do you call people who have mental health problems?”, most frequent answers were “patient” (n=39) and “psychiatric patient”, wheras for the question “What word(s) do you use to describe mental health problems?”, the most frequent responses were “psychiatric illness” (n=16) and “psychiatric disorder” (n=16)”.

DISCUSSION

Stigmatization is considered to be one of the important factors affecting social engagement, disrupting interpersonal and occupational functioning, decreasing quality of life and adversely affecting treatment and care processes of mental health patients (1,7,12,13). Sartorius (19) have emphasized that the stigmatization is the most important obstacle for individuals with mental illness to reach health care.

Many studies in the literature have shown that stigmatizing attitudes towards individuals with mental illness can be seen in mental health workers as well as in general society (20-23). Indeed, in a study, psychiatrists were reported to have more negative stereotypes than the general population and other mental health workers (24). There are several researches related to stigmatization for mental illness in our country (2,12). The review of Cam and Bilge (12), included 59 studies that have been made in our country during 1999-2013. In some of these studies, the stigmatizing attitudes of mental health workers are underlined (25,26). The study of Saillard (26) shows that psychiatrists may have stigmatizing attitudes. In the study of Arkan et al. (2), it is pointed out that the refusing, dismissive and discriminatory attitudes of medical students and healthcare professionals towards individuals with mental illness remain unchanged over the past decade.

In our study, the stigmatizing attitudes of participants to mental illnesses were assessed with BMI. In the study carried out on university students by Unal et al. (27), the mean total score of BMI was determined as 49.70±13.90. In our study, the total score of BMI was found to be 47.29±19.40 in mental health workers other than psychiatrists. This was 35.95±13.10 for psychiatrists, which is lower than both university students who represent the community and other mental health workers. In our study, it was also found that psychiatrists had significantly lower scores than other mental health workers in the global BMI scale and in the subscales of Incurability and Disturbance in Interpersonal Relationships, Dangerousness, and Shame. Therefore, it has been considered that psychiatrists have less stigmatizing attitudes than general public and other mental health workers. This finding conflicts with the findings of Nordt et al. (24), but it is consistent with studies showing that psychiatrists have more positive attitudes towards mental illnesses (28,29).

Although, sociodemographic characteristics such as age, gender, marital status, education level have been reported in the literature to be effective in stigmatizing attitudes (8,24,27,30), in our sample sociodemographic characteristics were not effective on stigmatizing attitudes. It has also been reported that having contact with individuals with mental illness has a positive effect on stigmatizing attitudes (31). In our study, the presence of a family history of psychiatric illness did not affect the stigmatizing attitudes, but it was found that those who have suffered from psychiatric illnesses had less stigmatizing attitudes.

There are a few studies in the literature examining the effects of language and expression patterns used on the stigmatization for mental illnesses (15). Shattell (14) emphasized the importance of language and stated that language should be used thoughtfully and purposefully in order to prevent stigmatization of mental illnesses. She states that in the expression of “mentally ill person”, mental illness precedes the individual and priority is given to the illness rather than to the individual, whereas mental illness is only one of many characteristics of the individual to be treated as a whole. For this reason, she underlines that “bipolars” should be replaced by “individuals with bipolar disorder” or “schizophrenic” by “individuals with schizophrenia” (14). Rüsch et al. (9) also stated that individuals with mental illness are behaved differently from individuals with a physical illness, eg “schizophrenic” term is frequently used rather than “person with schizophrenia”. Szeto et al. (15) reported that although it is known that the use of words such as “crazy” and “nuts” to describe mental disorders and people with mental disorders, is irritating and stigmatizing, they are frequently used. In this study, it was found that such expressions evoke negative emotions and recall features such as dangerousness and unpredictability, thus leading to more stigmatization and social isolation (15).

In the study of Ozmen et al. (17), in Turkey, the concept of “insanity” and “mental illness” are used in different meanings by general public and the expression of “insanity” has more stigmatizing meaning than the expression of “mental illness”, therefore associated with more dangerousness, leading to more social isolation. It is also possible to find clues about the contribution of the language to the stigmatization in Saillard’s (26) study of psychiatrist views on stigmatization for mental illnesses. For example, some of the psychiatrists who participated in the study mentioned that they had difficulty in wording or writing the term “schizophrenia” because they found it stigmatizing, whereas, some others emphasized the diagnostic term should be clearly spelled out to avoid stigmatization. Similarly, in this study, it has been stated that the diagnosis of schizophrenia, in the same way as emphasized by Shattell (14) and Rüsch et al. (9), has been converted to the term “schizophrenic” in the psychiatrists’ language and thus, the patients are downgraded to the disease, neglecting their individual characteristics (26). The most stigmatizing statements identified by participants were “insane” and “mentally ill”. Participants stated that the statements of “psychiatric disorder” and “mental problems” were less stigmatizing. Therefore it can be considered that the use of less stigmatizing expressions that refer to the disease, not to the patient, may contribute to the prevention of stigmatizing attitudes towards mental illnesses. In our study, it was also found that the participants thought that several psychiatric terms had humiliating/degrading meaning and among these “dotard/looney” and “junkie” were considered the most humiliating/degrading expressions by the participants. In the studies, schizophrenia and alcohol use disorders appear as the most stigmatized mental illnesses (8,25,32,33). Other stigmatized mental illnesses include somatoform disorders and mental retardation (34,35). Besides these, in our study, it was determined that dementia is also among the stigmatized mental diseases. In addition, the participants stated that “antisocial” (n=49), “narcissist” (n=36) and “personality disorder” (n=33) were the most frequently used words in a contemptuous, insulting, and/or sarcastic way, other than mentioning a diagnosis.

In addition, the most frequently used words in a contemptuous, insulting, and/or sarcastic way are antisocial, narcissist, and personality disorder, and this finding is consistent with the findings in the literature that personality disorders are also among the frequently stigmatized mental disorders. Accordingly, Thornicroft et al. (36) pointed out that individuals diagnosed with personality disorders are interpreted by mental health workers as difficult, less deserving, manipulative, interest seeking, and annoying, and the diagnosis was considered as humiliating.

It is emphasized that mental health workers such as psychiatrists, psychiatric nurses, psychologists, social workers bear tremendous responsibility and there is a need for interventions and studies in this field (5,12,16). Sartorius (37) underlines the need for psychiatrists in particular to review their own attitudes. Because in addition to the mentally impaired individuals, their families and relatives (3), the attitude of the psychiatrists also affects, other mental health workers who work with them, and the students and/or residents they educate. It also causes a negative perception towards mental disorders and even the psychiatric profession in the society (38). Avoiding the use of a stigmatizing and marking language and expressions for mental illnesses, acquiring a language that is not excluding the individual characteristics of the patient and putting the emphasis on the disease constitute an important part of the fight with the stigmatization. Accordingly, it is important that at first psychiatrists and then other mental health workers should be aware of the effect of the language they use in their daily practice as well as other factors contributing to the stigmatization, and express the necessary sensibility. We should keep in mind that change starts with us.

The main limitation of our study is that it is conducted at a single institution and with a certain number of mental health workers. This fact both limits the number of the subjects in the sample and does not allow the results of the research to be generalized to cover mental health workers working at other institutions. Another limitation is that the use of the stigmatizing language for mental illnesses was assessed by a questionnaire form prepared by the researchers because of the lack of a measure for this specific subject that have a validity and reliability study.

Stigmatization is an important factor affecting the social engagement, interpersonal and occupational functioning, and the treatment and care processes of individuals with mental illnesses. To fight with stigmatization, it is aimed to increase awareness, to deal with beliefs about mental illnesses and to develop anti-stigmatizing attitudes. Stigmatizing attitudes towards mental illnesses can also be seen in mental health workers. Considering that the language and expressions used are also important in terms of stigmatization, it can be considered that studies and interventions to be made in this field will contribute to reducing the stigmatization.

REFERENCES

1.Cam MO, Bilge A, Engin E, Akmese ZB, Turgut EO, Cakir N. Investigating the effectiveness of education of the fight against stigma on mental illness to headmen. Journal of Psychiatric Nursing 2014; 5:129-136. (Turkish) [CrossRef]

2.Arkan B, Bademli K, Duman ZC. Attitudes of health professionals towards mental disorders: studies in Turkey during the last decade. Current Approaches in Psychiatry 2011; 3:214-231. (Turkish)

3.Bilge A, Cam O. The fight against stigma toward mental illness. TAF Preventive Medicine Bulletin 2010; 9:71-78. (Turkish)

4.Ersoy MA, Varan A. Reliability and Validity of the Turkish Version of the Internalized Stigma of Mental Illness Scale. Turk Psikiyatri Derg 2007; 18:163-171. (Turkish)

5.Bostanci N. The Stigma Towards to Individual with Mentally ill Patients and Practices About Reducing this Situation. Dusunen Adam: The Journal of Psychiatry and Neurological Sciences 2005; 18:32-38. (Turkish)

6.Corrigan PW, River LP, Lundin RK, Wasowski KU, Campion J, Mathisen J, Goldstein H, Bergman M, Gagnon C, Kubiak MA. Stigmatizing attributions about mental illness. J Community Psychol 2000; 28:91-102. [CrossRef]

7.Corrigan PW. The impact of stigma on severe mental illness. Cogn Behav Pract 1998; 5:201-222. [CrossRef]

8.Angermeyer MC, Dietrich S. Public beliefs about and attitudes towards people with mental illness: a review of population studies. Acta Psychiatr Scand 2006; 113:163-179. [CrossRef]

9.Rüsch N, Angermeyer MG, Corrigan PW. Mental illness stigma: concepts, consequences, and initiatives to reduce stigma. Eur Psychiatry 2005; 20:529-539. [CrossRef]

10.Angermeyer MC, Schulze B, Dietrich S. Courtesy stigma--a focus group study of relatives of schizophrenia patients. Soc Psychiatry Psychiatr Epidemiol 2003; 38:593-602. [CrossRef]

11.Crisp AH, Gelder MG, Rix S, Meltzer HI, Rowlands OJ. Stigmatisation of people with mental illnesses. Br J Psychiatry 2000; 177:4-7. [CrossRef]

12.Cam O, Bilge A. The process of stigmatization and attitude, belief about mental illness and patient in Turkey: a systematic review. Journal of Psychiatric Nursing 2013; 4:91-101. (Turkish) [CrossRef]

13.Livingston JD, Boyd JE. Correlates and consequences of internalized stigma for people living with mental illness: a systematic review and meta-analysis. Soc Sci Med 2010; 71:2150-2161. [CrossRef]

14.Shattell MM. Stigmatizing language with unintended meanings: “persons with mental illness” or “mentally ill persons”? Issues Ment Health Nurs 2009; 30:199. [CrossRef]

15.Szeto AC, Luong D, Dobson KS. Does labeling matter? An examination of attitudes and perceptions of labels for mental disorders. Soc Psychiatry Psychiatr Epidemiol 2013; 48:659-671. [CrossRef]

16.Byrne P. Stigma of mental illness and ways of diminishing it. Advances in Psychiatric Treatment 2000; 6:65-72. [CrossRef]

17.Ozmen E, Taskin EO, Ozmen D, Demet MM. Which psychiatric label is more stigmatizating? “ruhsal hastalık” or “akil hastaligi”. Turk Psikiyatri Derg 2004; 15:47-55. (Turkish)

18.Bilge A, Cam O. Validity and reliability of Beliefs towards Mental Illness Scale. Anatolian Journal of Psychiatry 2008; 9:91-96. (Turkish)

19.Sartorius N. Fighting stigma: theory and practice. World Psychiatry 2002; 1:26-27.

20.Hannson L, Jormfeldt H, Svedberg P, Svensson B. Mental health professionals’ attitudes towards people with mental illness: do they differ from attitudes held by people with mental illness? Int J Soc Psychiatry 2013; 59:48-54.

21.Hugo M. Mental health professionals’ attitudes towards people who have experienced a mental health disorder. J Psychiatr Ment Health Nurs 2001; 8:419-425. [CrossRef]

22.Jorm AF, Korten AE, Jacomb PA, Christensen H, Henderson S. Attitudes towards people with a mental disorder: a survey of the Australian public and health professionals. Aust N Z J Psychiatry 1999; 33:77-83. [CrossRef]

23.Rao H, Mahadevappa H, Pillay P, Sessay M, Abraham A, Luty J. A study of stigmatized attitudes towards people with mental health problems among health professionals. J Psychiatr Ment Health Nurs 2009; 16:279-284. [CrossRef]

24.Nordt C, Rössler W, Lauber C. Attitudes of mental health professionals toward people with schizophrenia and major depression. Schizophr Bull 2006; 32:709-714. [CrossRef]

25.Ucok A, Polat A, Sartorius N, Erkoc S, Atakli C. Attitudes of psychiatrists toward patients with schizophrenia. Psychiatr Clin Neurosci 2004; 58:89-91. [CrossRef]

26.Saillard EK. Psychiatrist views on stigmatization toward people with mental illness and recommendations. Turk Psikiyatri Derg 2010; 21:14-24. (Turkish) [CrossRef]

27.Unal S, Hisar F, Celik B, Ozguven Z. Beliefs of university students on mental illness. Dusunen Adam: The Journal of Psychiatry and Neurological Sciences 2010; 23:145-150. (Turkish) [CrossRef]

28.Kingdon D, Sharma T, Hart D. What attitudes do psychiatrists hold towards people with mental illness. BJPsych Bulletin 2004; 28:401-406. [CrossRef]

29.Lauber C, Anthony M, Ajdacic-Gross V, Rössler W. What about psychiatrists’ attitude to mentally ill people? Eur Psychiatry 2004; 19:423-427.

30.Arvaniti A, Samakouri M, Kalamara E, Bochtsou V, Bikos C, Livaditis M. Health service staff’s attitudes towards patients with mental illness. Soc Psychiatry Psychiatr Epidemiol 2009; 44:658-665. [CrossRef]

31.Corrigan PW, Morris SB, Michaels PJ, Rafacz JD, Rüsch N. Challenging the public stigma of mental illness: a meta-analysis of outcome studies. Psychiatr Serv 2012; 63:963-973. [CrossRef]

32.Mann CE, Himelein MJ. Factors associated with stigmatization of persons with mental illness. Psychiatr Serv 2004; 55:185-187. [CrossRef]

33.Corrigan PW, Lurie BD, Goldman HH, Slopen N, Medasani K, Phelan S. How adolescents perceive the stigma of mental illness and alcohol abuse. Psychiatr Serv 2005; 56:544-550. [CrossRef]

34.Chaplin R. Psychiatrists can cause stigma too. Br J Psychiatry 2000; 177:467. [CrossRef]

35.Davidson J. Contesting stigma and contested emotions: personal experience and public perception of specific phobias. Soc Sci Med 2005; 61:2155-2164. [CrossRef]

36.Thornicroft G, Rose D, Mehta N. Discrimination against people with mental illness: what can psychiatrists do? Adv Psychiatr Treat 2010; 16:53-59.

37.Sartorius N. Iatrogenic stigma of mental illness. BMJ 2002; 324:1470-1471. [CrossRef]

38.Walter G, Rosen A. Psychiatric stigma and the role of the psychiatrist. Australas Psychiatry 1997; 5:72-74. [CrossRef]