Author: Hanin Makarem

Editor: Kintan van Leeuwen & Elisah Sauerbier

Culture plays a major role in our lives. It shapes one’s personality, behaviour, mindset, daily activities, beliefs and even physical health. On top of that, culture also influences one's mental health and plays a significant part in how people deal with mental health issues. Mental illnesses can be traced in cultural history as far back as ancient Egypt or the Roman Empire, although in other terms than are now used. When we look at history, mental illnesses were often seen as a personal problem and sometimes even as a religious punishment or demonic possession. These negative judgments and attitudes towards mental illnesses and the people who suffer from them integrated into cultures and were passed on to next generations. Even though psychology has enormously developed in the past years, the stigma around mental health and mental illness still co-exist. This stigma contributes to worsening mental illnesses in various ways. In addition, the cultural stigma surrounding mental health creates a vicious circle that prevents people with mental health problems from seeking help.

What is mental health stigma?

The World Health Organisation defines mental health as “Mental health is a state of well-being in which an individual realises their abilities, can cope with the regular stresses of life, can work productively and is able to contribute to his or her community.”

Several determinants play a key role in determining the level of someone’s mental health. According to WHO, social factors such as poverty are proven to be associated with common mental disorders. 115 studies on common mental disorders and poverty in low and middle-income countries have reported 70% positive association between a variety of poverty measures and common mental disorders (World Health Organization, 2014).

A research from Remes et al. suggested that biological factors, genetics for example, are also related to mental health level. Studies have shown association between depression and brain-driven neurotrophic factor (Remes et al., 2021). Additionally, psychological factors are associated with the level of mental health a person has. Childhood trauma, loss of parents, abuse and neglect are all psychological factors that may contribute to mental illnesses. Mental health disorders are much more common than we think. The government of the Netherlands stated that 350 million people worldwide suffer from depression. Moreover, suicide is the second highest cause of death among 15 to 29-year-olds (Ministerie van Algemene Zaken, 2019). The problem is that most people with mental health illnesses are apprehensive about openly discussing their illness. BBC stated that young people reported that they find it difficult to talk about mental health for a number of reasons. The reasons included not wanting to be treated differently, or the fear of rumours and the fear of people underestimating the illness (BBC, 2018). According to Ministry of General Affairs in the Netherlands, Almost 9 out of 10 people with a mental condition experience stigma and discrimination.

As stated by WHO, Afzal Javed (2021) reported, that the word ‘stigma’ is defined as “a mark of shame, disgrace or disapproval that results in an individual being rejected, discriminated against and excluded from participating in several different areas of society”. When we talk about mental illness stigma, we can define it as depreciating or undervaluing the person with mental illness by the general public. Stigmatised people experience forms of mistreatment at economic, social, legal, and institutional levels. This can even result in discrimination, unfair treatment, denial of rights, and responsibilities towards people who deal with mental illnesses.

A culturally ingrained stigma

Stigmatising mentally ill people is not a modern phenomenon. On the contrary, false judgments about mental illness due to a lack of knowledge about them go back to ancient civilizations. A lack of knowledge about mental illnesses and their cause can lead to speculation and emerge impoverished perceptions, resulting in doctors improvising to explain the unknown causes, or people developing an aversion to others with mental illnesses. The knowledge that is now available about the human brain, by virtue of scientific research, was still a great mystery at the time. From a historical perspective, three main theories around mental illnesses have made their mark on how mental illnesses were treated in society

1. Supernatural theories suggest that mental illnesses are caused by devil possessions, displeasing gods, or curses. 

2. Somatogenic theories attribute mental illnesses to disturbances in physical functioning which result from physical illness or genetic inheritance, brain damage, or imbalance. 

3. Psychogenic theories imply that mental illnesses originate from trauma or stressful experiences.

An example of a traditional explanation for mental illnesses can be traced back to 2700 BC. The Chinese ascribed mental illnesses to an imbalance between the negative and positive bodily forces ‘’Yin and Yang‘’. Traditional Chineses medicine asserted that the nature of all living or not living entities is determined by the intrinsic balance between opposing states, Yin and Yang. Therefore, changes in nature result from imbalance between the Yin and Yang. Such disturbance or changes come in the form of mental or physical illnesses (K.H. Aung et al., 2021). In this example, we can see the correlation between culture and mental health (Farreras, 2022).

Mental illnesses do not discriminate between males and females. All genders are susceptible to mental illnesses. However, statistics show that mental illnesses are more common among females compared to males. The bigger issue is that women have faced more discrimnation and stigma. By the beginning of the 13th century, mentally ill women were regarded as possessed witches. At the peak of the witch craze in Europe many women who suffered from hysteria or epilepsy were condemned as possessed witches and burned alive. Scholars report that witch hunts targeted women because at that time people believed that the uterus and spleen were the source of evil. And for that women were more prone to demonic possessions compared to men (Quintanilla, 2020). 

Johann Weyer and Reginald Scot were two Dominican monks who tried to convince people in the mid-to-late-16th century that accused witches were women with mental illnesses and that mental illness was not due to demonic possession but to faulty metabolism and disease, but the Church’s Inquisition banned both of their writings (Farreras, 2022).

In spite of the fact that mental health disorders (MHDs) can affect anyone, especially low and middle-income countries are highly impacted. Factors such as poverty, unemployment, low-quality education, and more, all contribute to increased MHDs numbers in LMICs. According to Javed et al. (2021) 153 low- and middle-income countries (LMICs) where 85% of the world’s population resides and over 80% of the MHDs occur. By 2030, depression will be the third and second highest cause of disease burden in LMICs and middle-income countries.

Why does stigma exist?

Regardless of the progress, development, and growth in the field of psychology, stigma around people with mental illnesses still exists. Research from 2015 argued that mental health stigma appears to be a solid obstacle to treatment access in low-income areas. If psychology is more advanced and science has acquired extensive knowledge about MHDs, then why are mentally ill people still being stigmatised, stereotyped, and discriminated against? In general, stigma arises from misguided stereotypes about people with MHDs. Media outlets play a crucial role in this matter. Media can reinforce stigma in many ways, for instance, negatively portraying mentally ill people as dangerous or harmful around people. Popular movies such as Shutter Island (2010) , Girl, Interrupted (1999), and  Fatal Attraction (1987), have contributed to increasing mental health stigma by wrongly portraying mental illnesses. 

The problem is that individuals do not only face discrimination from society, but also from family members. According to Mascayano et al. (2015), in India, people with schizophrenia have reported high rates of perceived stigma and they have primarily felt that discriminatory attitudes come from the community (46%) and family members (42%). Cross-cultural factors contribute to aggravating the problem. Factors such as perceived shame from an MHDs diagnosis, aspiration to protect the family reputation and personal dignity play a big role when it comes to seeking help for MHDs.

How does it affect people?

Individuals who have MHDs do not only have to deal with the illness and seek proper treatment. On top of that, they have to deal with the consequences of being stigmatised. As a matter of fact, many people with mental illnesses reported that dealing with stigma is harder than dealing with mental illness. They also experience discouraging feelings such as self-doubt, shame, guilt and isolation due to stigma. The adverse effects of stigma include the lack of opportunities for employment and social interaction while these opportunities could actually be progressive in their healing process.

Mental health stigma does not affect people with MHDs only, the problem extends to healthcare professionals and medical students. A. Javed et al. reported that fear of being stigmatised has affected healthcare professionals’ and medical students' willingness to seek help for mental health problems due to the fear of being perceived as less competent, less productive and unsafe to work with (Javed et al., 2021). According to Mayo Clinic, other unfavourable consequences of stigma include bullying, physical violence and harassment. This makes it unsafe for people to talk openly about their mental illness and also makes it difficult to determine who they can and cannot share their story with. In addition, Health insurance doesn't adequately cover the treatment of mental illness (Mayo Clinic, 2017). 

How can we reduce the stigma around mental illnesses?

There are various ways to reduce the stigma associated with MHDs. The WHO advised member countries to invest in developing comprehensive policies to improve population mental health. Raising awareness and spreading knowledge can also contribute to reducing stigma. It is also important to choose your words wisely, for example instead of describing someone as schizophrenic, express their mental issue, for example he/she has schizophrenia. Because people are much more than their illnesses. Choosing empowerment over shaming can also help decrease stigma. While many low to medium income countries implement anti-stigma programs. The problem is most LMICs spend <1% of their health budget on mental health. This percentage is considered very low in comparison to the enormous number of people who need help. Implementing Anti-stigma programs can reduce the stigma. Those programs usually focus on two key interventions targeting mental health professionals and non-mental health professionals such as teachers. This can be very effective because it spreads knowledge and raises awareness among other groups of society (Javed et al., 2021). Closing the mental health treatment gap can also be done by integrating mental health services into primary health care in LMICs where the gap is much bigger compared to western countries.

Finally, there are a number of successful anti-stigma campaigns making a positive impact, such as Make It OK, NAMI, and many more. The Make It OK website has a lot of digital resources such as a guide, knowledge about stigma and more. Make sure to check the websites and extend your knowledge about stigma, its effects and how to reduce it.

LLF aims to contribute in raising awareness over mental health issues, our guide on How to support someone who’s struggling with their mental health, provide useful insights that help you recognize the signs of people struggling with their mental health.