Winter W3 - Stigma, Mental Health and Disease

Goffman's "Spoiled Identity"

- A loss of identity and acceptance of a new, stigmatized identity. - Feeling "dehumanized" and "less than human". - Unconscious ownership of the unacceptable attribute.

HIV-related stigma and Medication Adherence

- Avoiding taking medication in public/work - Altering medication schedule - Shame of being seen made it difficult to fill prescriptions - Thought it easier to conceal status before medication treatment - Skip doses to avoid disclosure. - Avoid taking medication at work to avoid being fired.

Stigma - Related Case

- Cheryl, 20, new mother recently experiencing symptoms of PPD. - Confides her feelings to her sister-in-law, and shares the fact that she is taking antidepressants prescribed by her doctor. - Sister-in-law diverts the conversation towards her own health issues with gallbladder disease. - Sister-in-law doesn't shame Cheryl but also does not provide empathy or concern for her symptoms.

Stigma - Model Case

- Cheryl, 20, new mother recently experiencing symptoms of PPD. - Confides her feelings to her sister-in-law, and shares the fact that she is taking antidepressants prescribed by her doctor. - Sister-in-law reacts by telling Cheryl she should be ashamed of taking medication to "escape responsibility". - Later, Cheryl notices sister-in-law whispering about her to a cousin. - Cheryl believes she is a bad mother for feeling sad after having a baby. - Cheryl decides to change her activities and to avoid those family members, and to not share her feelings with anyone else.

Stigma - Contrary Case

- Cheryl, 20, new mother recently experiencing symptoms of PPD. - Confides her feelings to her sister-in-law, and shares the fact that she is taking antidepressants prescribed by her doctor. - Sister-in-law responds with empathy, offering help. - Later, sister-in-law compliments Cheryl's mothering skills to a cousin in Cheryl's presence.

Stigma - Consequences

- Coping by trying to be recognized as normal. - Trying to avoid the stigma by rearranging life activities or withdrawing. - Social isolation, except for others with similar stigmatized conditions and "wise" people (not stigmatized, but associated with the stigma, not judgmental, treat individual as "normal"). - Self-denial of the issue, or not acknowledging or disclosing it. - Low self-esteem, self-efficacy, confidence. - Feelings of shame, fear, hopelessness, depression, anxiety. - Trying to master skills that seem impossible to them because of their condition.

Postpartum depression - Consequences for families

- Depressed mother is less responsive to her infant's cues for hunger, boredom, or interest in stimulation. - Leads to behavior and learning problems into school age. - Has long lasting and adverse effects on the child's cognitive and emotional development.

HIV-related Stigma felt by Women

- Existential Despair: feeling diagnosis as a death sentence. - Internal Stigma: self-blame, shame, self-imposed social isolation, feeling diagnosis as punishment for past behaviour. - Shunning: insensitive treatment, rejection. - Institutional Disregard: staff in hospitals and other institutions treated them with disrespect; staff revealing their status without their consent.

HIV-related Stigma felt by Men Who Have Sex With Men

- Fear of disclosure, avoidance, fear of infection, rejection, discrimination, and judgmental attitudes - Being avoided by men who were HIV negative - Response: Chose not to disclose and social isolation - Social isolation and avoiding relationships

Stigma in Postpartum Depression

- Fear of disclosure, stigmatization, perceived social pressures, shame, and fear of labeling: impeded postpartum women from seeking mental health treatment. - Further perpetuated by social standards set for mothers by Western middle-class women, and by "mother blaming" (blaming the mother for undesirable outcomes independent of her choices).

Felt Stigma

- Fear of stigmatization and discrimination. - Individuals deal with it by choosing not to disclose their HIV-positive status or carefully doing so to specific people, at specific moments.

Berger HIV Stigma Scale

- Focuses on external and internal sources of stigma - Perceived HIV Stigma: actual or potential experiences of diminished social acceptance, opportunity and negative shift in how others perceive the person. - Four Factors of perceived stigma: 1. Personalized Stigma 2. Disclosure concerns 3. Negative self-image 4. Concern with the attitudes of others regarding HIV - Factors correlate to each other: together, form a single construct of the experience of HIV-related stigma.

Stigma - Antecedents

- Interpersonal relationships. - Perceived social norms of mental illness as deviant. - Labelled person accepts the devaluation associated with the label, internalizes the stigma. - Internalization is the MAIN characteristic of stigma, differentiates it from related concepts. - Coping mechanisms are overcome, and the person accepts the label, as a maladaptive response.

Defining attribute that differentiates Stigma from related concepts (prejudice and discrimination)

- Labelled person accepts the devaluation associated with the label, internalizes the stigma. - INTERNALIZATION.

Empirical Referents of Stigma - Measurement Tools (3)

- Measured via self-report. - Instruments: a. Mental Health Consumer' Experience of Stigma b. Link's Devaluation Discrimination c. Internalized Stigma of Mental Illness

Health-related Stigma

- Often diseases/conditions believed to be under the individual's control, or seen as the consequence of unacceptable social behaviour are stigmatized. - i.e. HIV/AIDS, mental illness, alcoholism-related illness, obesity, etc.

Stigma - Objectives of Nursing Care

- Patient/family acceptance of illness. - Development of realistic working definition of illness in patient's own words. - Incorporation of patient's beliefs, expectations, treatment, prognosis, support resources.

HIV-related Stigma felt by Older Adults

- Rejection, fear of infection, shame, negative self image, and social isolation - "felt radioactive", were discriminated by the physician. - Concealment and disclosure concerns - Relationships and hope of support - Age-related stigma e.g., "older people should know better"

Courtesy Stigma

- Stigma caused by an association with an individual living with a stigmatizing condition. - Experienced by participant's children, via avoidance by friends and family for fear of infection.

Enacted Stigma

- Suffering actual discrimination in the forms of rejection, verbal insults, ostracism. - Being avoided for fear of infection, judgement, inability to understand why would family choose to stay close to them.

HIV-related Stigma felt by Individuals living in rural communities

- Suggest that stigma is worse - Themes: social rejection, specific directives while living with another, differential treatment - Being kept from holding small children. - Shame of status and conflict over disclosure - Stigma affected adherence to medical appointments: wearing a hat to avoid being recognized, not bringing children who could read to the clinic.

Steps in Postpartum Depression

- Terror - Dying of self - Struggling to survive - Regaining control

Stigma - Definition

- Universal and multidimensional concept: all cultures and stages of life. - A social construct: society governs which attributes are acceptable and unacceptable. - When one person is labelled deviant and the other is validated as normal. - Loss or lack of a certain quality, leading to feelings of inadequacy and shame.

Stigma - Attributes

- Unpleasant personal experience, permanency. - Perceived unfavourable attitude from another, label attachment. - Discredit by others for being viewed as deviant/inferior from the norm. - Self-identifying with the stigmatized attribute. - Discrimination by others when attempting to assume a normative role.

Health consequences of stigma related to mental illness

- Unrecognized stigma is a barrier to understanding patient behavior and providing individualized, empathic care. - Stigma is an obstacle to mental health treatment: patients avoid seeking treatment for fear of being stigmatized. - Stigma causes withdrawal and social exclusion, impairs life domains, especially interpersonal relationships, employment, housing, and illness recovery. - Delay in treatment seeking prolongs symptoms and extends the course of illness.

HIV-related Stigma - Black vs. White individuals

1. Black individuals living with HIV were more concerned with discrimination and being judged in terms of their morals. 2. White individuals living with HIV were more concerned with rejection.

HIV-related Stigma felt by Low Income People (4 domains)

1. Confronting blame and stereotypes of HIV - Self-blame for having contracted HIV. - Blame from family, friends, strangers, HCPs - Stereotypes: unacceptable behaviour or sexual orientation leading to HIV-positive status. 2. Encountering fear of contagion - Unfounded fear others have of contracting HIV via casual contact. - HCPs also displayed fear of contagion, sometimes very severe. 3. Negotiating disclosure of a stigmatized role - Concerns about disclosure, fear of rejection. - Avoiding medical care for fear of disclosure. 4. Renegotiating social contracts - Finding safe environments and avoiding unsafe places (where judgmental people would possibly be).

Negative health outcomes from HIV-related stigma (6)

1. Mental health issues: decreased social support, rejection, despair, loneliness, decreased self-esteem, isolation; additional psychosocial stress. 2. Medication adherence issues: lack of adherence related to need to conceal the diagnosis; leads to higher risk of morbidity and lower QOL. 3. Accession of healthcare services: neglecting medical appointments due to need to conceal the diagnosis from others in the household. 4. Employment issues: fear of losing employment if employer becomes aware of diagnosis; could further impact SES, insurance. 5. Housing issues: may be forced to relocated if the housing community becomes aware of diagnosis; forgo eligibility for government-assisted housing in attempt to conceal diagnosis. 6. Physical violence and verbal abuse: high risk of experiencing physical violence and verbal abuse; caregivers also at risk; impact on psychosocial support and mental health.

Three types of Stigma (Goffman)

1. Physical deformities: deaf, blind, crippled. 2. Blemishes: undesirable personality traits, such as irrational or criminal behaviour. 3. Tribal Stigma: stigma related to ethnicity or race.

Four factors of manifested HIV-related Stigma (Herek)

1. Prejudice 2. Discouting 3. Discrediting 4. Discrimination

Stigma IS NOT...

1. Prejudice: beliefs in negative stereotypes that result in negative emotional reactions to certain people. 2. Discrimination: decisions and actions informed by prejudicial thoughts.

HIV-related Stigma and Healthcare Providers (4 themes)

1. Referral source stigma: perpetrated by the HCP as indifference, lack of acceptance, making assumptions. 2. Physician stigma: reluctance of HCP to provide care. 3. Stigma from physician specialists: primary care physicians were more likely to refer patients to specialists to avoid providing care; included infectious disease specialists. 4. Stigma perceived by clients: all of the above.

The issue of greatest concern to the stigmatized individual is?

ACCEPTANCE

"Mother Blaming"

Blaming the mother for undesirable outcomes independent of her choices.

Once the condition is gone, a stigmatized person's label disappears. True or False?

False. Once a stigmatized person has been labeled, the label does not disappear despite the absence of the condition

Stigma - Nursing Implications

Nurses must: - Use understanding of stigma and how individuals cope with being stigmatized to enhance and individualize care. - Examine their own beliefs and values and how those interact with the patient. - Always base care on support, acceptance and reassurance and keep an open, non-judgmental communication. - Refer patients to appropriate resources in the community. - Protest inaccurate representations of mental illness and treatment.

Prejudice and Discrimination

PREJUDICE - Prejudice that becomes evident in a decision process, and is observable, measurable, and reportable. - Result of the actions of others, and is linked to the perpetrator (differently to stigma, which is the label internalized by the victim). DISCRIMINATION - Cognitive process that has a behavioural aspect and is considered an antecedent to discrimination. - Involves thoughts or ideas about people that could be exhibited consciously or unconsciously through discriminating behavior. - The endorsement of negative stereotypes that result in negative emotional reactions.

Public vs. Self Stigma

Public: How the public responds to a group when they approve of the prejudicial attitudes towards a group. Self: What members of the stigmatized groups do to internalize the public stigma.

HIV-related Stigma Measurement Tool

Quantitative methods: Berger HIV Stigma Scale Qualitative methods: semi-structured, in-depth interviews Mixed Methods

HIV-related Stigma - Definition

The collection of adverse attitudes, beliefs and actions of others against people living with or affected by HIV, which may result in deleterious internalized beliefs or actions taken by persons living with or affected by HIV infection that may result in negative health outcomes. Manifested through four factors: prejudice, discrimination, discounting, discrediting.

Unrecognized stigma is a barrier to understanding patient behavior and providing individualized, empathic care. True or False?

True.

Stigma in PPD - Nursing Implications

Understand: - Mothers fear disclosing condition. - Stigmatization, perceived social pressures, shame, and fear of being labelled were barriers to seeking help. - Social standards set for mothers and "mother blaming" make disclosure even harder. Act: - Educate public, patients and their families about PPD, and about treatment which is most often successful. - Integrate PPD education into parenting classes. - Avoid stereotypes about motherhood, which include it being a period of joy and bliss.