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Correspondence |
Department of Psychiatry and Neurology, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka 431-3192, Japan, and Section of General Psychiatry, Division of Psychological Medicine, Institute of Psychiatry, London, UK. E-mail: ntakei{at}hama-med.ac.jp
Department of Psychiatry and Neurology, Hamamatsu University School of Medicine, Hamamatsu, Japan
Lee et al (2005) reported that in Hong Kong individuals with schizophrenia experience stigma even from family members. This stigma as well as public attitudes towards mental illnesses are serious issues. Mental health professionals are expected to take a supportive stance against such stigmatisation. However, is this always the case?
Practising clinicians may have unconsciously been partly responsible for assigning prejudice to the condition. The terminology routinely used in Japanese clinical practice to describe the characteristics of schizophrenia is somewhat derogatory, e.g. the term jinkaku suijun no teika (a decline in the level of personality) is often used to describe a feature ascribed to the larger domain of negative symptoms. The symptoms checklist used in the official mandatory evaluation of long-term in-patients includes one item regarding ‘the morbid state of personality’; apathy and abulia are assigned the label of ‘residual personality changes’, and no other items are assigned to the category of negative symptoms. These descriptions imply that the affected person’s personality has decayed and, consequently, that the process is irreversible.
There are other expressions often used in Japanese clinical practice that may encourage prejudice: these include jigiteki sokai kan (silly or childish cheerfulness). kekkan jotai (a defective state), hinekure (perverseness) and omoi agari (conceited). The latter two terms were introduced in Japan in 1956 from the original descriptions (Vershrobenheit and Verstiegenheit, respectively) of L. Binswanger (1881-1966) and are still in use.
Demands to eradicate the stigmatisation of people with mental illnesses have never been higher in modern psychiatry (Porter, 1998; Crisp et al, 2000; Corrigan et al, 2001). Caregivers need to be alert to the intrinsic problems that may exist in daily practice. The disclosure of medical records is still uncommon in Japan (Takei, 2001) and standardised diagnostic systems such as the ICD-10 (World Health Organization, 1992) have not been widely used. These practices have fostered reliance on subjective judgement and the use of rather undesirable terminology in clinical practice. Mental health professionals may themselves stigmatise people with schizophrenia and such an unbecoming attitude may not be limited to a particular country.
EDITED BY KIRIAKOS XENITIDIS and COLIN CAMPBELL
REFERENCES
Corrigan, P. W., Edwards, A. B., Green, A., et al
(2001) Prejudice, social distance, and familiarity with
mental illness. Schizophrenia Bulletin,
27, 219
-225.
Crisp, A. H., Gelder, M. G., Rix, S., et al
(2000) Stigmatisation of people with mental illnesses.
British Journal of Psychiatry,
177, 4-7.
Lee, S., Lee, M.T.Y., Chiu, M.Y.L., et al
(2005) Experience of social stigma by people with
schizophrenia in Hong Kong. British Journal of
Psychiatry, 186, 153
-157.
Porter, R. (1998) Can the stigma of mental illness be changed? Lancet, 352, 1049 -1050.[CrossRef][Medline]
Takei, N. (2001) Present status of access to medical records in England – special reference to psychiatry. Seishin Shinkeigaku Zasshi, 103, 15-20.[Medline]
World Health Organization (1992) The ICD–10 Classification of Mental and Behavioural Disorders: Diagnostic Criteria for Research. Geneva: WHO.
Hong Kong Mood Disorders Centre, The Chinese University of Hong Kong, Prince of Wales Hospital, Sha Tin, Hong Kong. E-mail: singlee{at}cuhk.edu.hk
Hong Kong Mood Disorders Centre, The Chinese University of Hong Kong, Hong Kong
Department of Anthropology, Harvard University, USA
Takei et al give salient examples of how psychiatrists and psychiatric treatment contribute to the stigmatisation of individuals with schizophrenia in Japan. We discuss similar and other related instances of such treatment-related stigma in a separate paper (Lee et al, in press).
Compared with stigma in most social situations, treatment-related stigmatisation exhibits two features that render its impact on patients particularly poignant. First, whereas patients can conceal their illness from friends, colleagues or even family members, total secrecy within the psychiatric treatment system is nearly impossible. Nor can they distance themselves from psychiatric treatment without running the risks of being labelled as ‘non-compliant’ or ‘lacking insight’, and having a relapse of illness. Second, patients often experience unconscious stigmatisation by mental health staff. Instances such as those described by Takei et al frequently occur in the course of routine clinical management by psychiatrists and nurses.
However, even when there is no conscious intent to stigmatise, certain institutional practices in psychiatry that cause stigma are examples of structural discrimination (Pincus, 1996). This arises less from personal prejudice than a combination of causes such as poor quality of health services, inadequate budget allocation and neglected rights of patients.
Psychiatrists have routinely blamed negative social attitudes for the stigmatisation of people with schizophrenia. Public health campaigns have sought to reduce the stigma associated with mental illness by increasing public knowledge. Without doubting the benefit of attitudinal shifts among the general population, we believe that programmes aimed at reducing stigma must be informed as well as evaluated by patients’ lived experience of psychiatric treatment. Tackling structural discrimination and the resulting power difference is at the root of such a change.
REFERENCES
Lee, S., Chiu, M. Y. L., Tsang, A., et al (in press) Stigmatizing experience and structural discrimination associated with the treatment of schizophrenia in Hong Kong. Social Science and Medicine, in press.
Pincus, F. L. (1996) Discrimination comes in many forms – individual, institutional, and structural. American Behavioral Scientist, 40, 186 -194.[Abstract]
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