Electronic Letters to:
|
|
eLetters: Electronic letters published:
-
![[Read eLetter]](/icons/misc/sectionDOWN.gif)
From Perception to Reality, what are you measuring?
- Rahman Haghighat (24 April 2007)
-
The Stigma Scale - authors' reply
- Michael B King, Sokratis Dinos, Scott Weich, Marc Serfaty, Scott Stevens (27 June 2007)
-
There is More to Stigmatization
- Rahman Haghighat (7 September 2007)
|
|
|||
|
Rahman Haghighat, Independent Consultant Psychiatrist Freelance Psychiatrist, London
Send letter to journal:
r.haghighat{at}lycos.com Rahman Haghighat
|
I would like to make the following comments on King et al (2007) stigma scale. The paper frequently states that it is about a scale measuring “the stigma of mental illness” but, in close scrutiny, it measures nothing other than perceived stigmatization by users some in outpatient, in-patient, and crisis settings. There is no evidence this is an objective assessment of stigmatization. Users’ perception of stigma is affected by their mental state, depression, persecutory delusions or hallucinations. These symptoms can help exaggerate participants’ estimate of social stigmatization (including rejection and discrimination directed at them) and is by no means an accurate measure of it. Measurements of more objective perceptions of stigmatization can only be done in users in remission. The reported negative correlation between self-esteem and perceived stigma can be confounded by high rates of both low self-esteem on the one hand (e.g., Axford & Jerrom, 1986; Barrowclough et al, 2003; Blairy et al, 2004) and persecutory ideation and depressive cognition including ‘self-stigmatization’ on the other in people with mental illness. Indeed, low self-esteem is a common symptom in psychiatric conditions such as depressive disorders in which people can perceive more rejection and discrimination than warranted. Overemphasis on this correlation can divert attention from the fact that the correlation has to do more with people’s mental state than objective level of social stigmatization. An instrument can only be called “standardized” if it attends to both reliability and validity. The instrument is not validated so cannot be called standardized on the basis of a mere testretest reliability. The correlation between the ‘stigma scale’ and self-esteem scale is not an indication of validity of the instrument, and though the authors admit this (p 249, 2nd paragraph, p 253 1st paragraph), they end up referring to their instrument as “standardized” and to the correlation as “concurrent validity”. A wide range of people with diverging diagnoses and mental states have been recruited. There is no randomization and no exclusion criteria. Even the ‘perceived stigmatization’ cannot be attributed to a particular category of patients with a given diagnosis or at least to psychiatric users in general, due to lack of randomization and inclusion of arbitrary proportions of participants with different diagnoses. This is likely to cause problems in comparative studies. Also, stigma by definition excludes “positive aspects of mental illness”. This is indeed why the authors decided to reverse the scores of the ‘positive aspects of mental illness’ factor. For this reason, they should have also called the factor negative aspects of mental illness as a high score on this new factor then represents stigmatization and its negative influence on the person. In brief, a scale measuring partly people’s mental state and partly objective social reality is neither valid nor standardizable as it cannot measure what is supposed to measure, i.e., satisfying the fundamental condition of validity. Axford, S. & Jerrom, DW (1986) Self-esteem in Depression: a controlled repertory grid investigation. British Journal of Medical Psychology, 59 (1):61-8 Barrowclough C, Tarrier N, Humphreys L, et al (2003) Self-esteem in schizophrenia: relationships between self-evaluation, family attitudes, and symptomatology. Journal of Abnormal Psychology, 112(1):92-9. Blairy S, Linotte S, Souery D, et al (2004) Social adjustment and self-esteem of bipolar patients: a multicentric study. Journal of Affective Disorders, 79(1-3):97 -103 King, M, Dinos, S, & Shaw, J et al (2007) The Stigma Scale: the development of a standardized measure of the stigma of mental illness, British Journal of Psychiatry, 190: 248- 254 |
|||
|
|
|||
|
Michael B King, Professor of Psychiatry UCL, Sokratis Dinos, Scott Weich, Marc Serfaty, Scott Stevens
Send letter to journal:
m.king{at}medsch.ucl.ac.uk Michael B King, et al.
|
We were puzzled by Rahman Haghighat’s criticism of our development of a stigma scale and would like to respond to his points. First, ours is a self-report measure of perceived stigma and we do not claim otherwise. Perceived stigma is a valuable construct that may have a greater impact on future mental and social well-being (including relationships and occupation) than so-called objective acts of discrimination. This is also true of social support. Second, we agree that the relationship between perceived stigma and low self esteem is potentially confounded by low mood. However our sample contained a heterogeneous group of participants from a range of settings and thus it is unlikely that a sizeable proportion were depressed at the time of the study. In addition, Dr Haghighat overlooks the complexity of any putative association between stigma and depressive symptoms. Perceived stigma may cause or maintain depressive episodes. Third, it is important to avoid invalidating reports of perceived stigma by dismissing them as depressive or paranoid epiphenomena. Fourth, Dr Haghighat claims our instrument has no validity. In fact, as we made clear in our paper, it is based firmly on the views and experiences of people with mental illness who were interviewed in depth in a previous study (Dinos et al. 2004) and thus it has greater validity than many scales used in the mental health field. Fifth, we do not understand Dr Haghighat’s reference to randomisation which has no role here. If he means random selection of people to participate then our method closely approximates to his wish in that potential participants were not selected on any predetermined basis. Naturally participation depends to some degree on participants’ abilities and personal inclinations but that is true whether selected randomly or not. Finally, participants in our earlier qualitative study emphasised that positive outcomes may arise from experiencing mental illness and thus such items were included in our scale. We reversed their scores to indicate that stigma might be greater when such positive aspects were lacking. This is not the same thing as assuming mental illness has only negative aspects. In parallel fashion the opposite of risk is not protection. It is lack of risk. Dinos S, Stevens S, Serfaty M, Weich S, King M. Stigma: the feelings and experiences of 46 people with mental illness. Qualitative study. British Journal of Psychiatry 2004;184:176-181. | |||
|
|
|||
|
Rahman Haghighat, Consultant Freelance Consultant Psychiatrist
Send letter to journal:
r.haghighat{at}lycos.com Rahman Haghighat
|
I thank Michael King and co-authors for responding to my letter regarding their work. I was nevertheless concerned that they did not take on board almost any of the various points I raised. With respect, I think that it is our capacity for self-criticism or accepting others’ criticism that advances science. Their response regrettably further shows their profound misunderstanding of stigmatisation. Therein, they say their paper is about ‘perceived stigma’ and that they have never claimed otherwise. Yet, both in their paper title and the aims section they refer to measurement of the ‘stigma of mental illness’ in general which is an awesomely complex concept with diverse varieties including enacted, expected, perceived, attributed and felt stigmatization (Scambler, 1989, Haghighat, 2001). As such, I find the title and aims sections something of an over-claiming as the rest of the paper, being about perceived stigma, frustrates the reader’s expectation and fails to support the title and aims. The authors make a number of axiomatic comments such as “perceived stigma may cause or maintain depressive episodes” without acknowledging its reverse too: depressive symptoms and persecutory ideations are fertile grounds for over-perceiving stigmatization. Therefore, such perception cannot be used as an accurate and objective measure of social stigmatization. I do not intend to dismiss, as purely “paranoid or depressive epiphenomena”, users’ real and painful experience of rejection and marginalization nor the social reality of stigmatization, rather I wish to emphasize that such perceptions are confounded by the effect of their mental state and cannot be used by investigators as an objective measure of stigmatization. As scientific observers we need to separate real social phenomena stigmatizing people (which need social intervention such as educational, or policy intervention, Haghighat, 2003) from over- perceived stigmatization or self-stigmatization (which needs individual reality orientation, psychotherapy or re-construction of self-esteem). Professor King and co-authors emphasize that not everyone in their sample had depressive disorder, [and so the total ‘perceived stigma’ cannot be partly due to the effect of the mental state]. They surprisingly overlook the mood component (as a dimension and not a diagnosis) prevalent in a large number of psychiatric conditions including schizoaffective disorders, anxiety disorders and personality disorders. Also, persecutory ideations can be seen in almost all psychiatric conditions and are not restricted to depression. Further, the authors do not seem to have noticed the references at the end of my earlier letter, solid evidence for the presence of high rates of low self-esteem in a large number of psychiatric conditions, depression or otherwise. Though low self-esteem can be induced or worsened by social stigmatization it is also a powerful catalyst for over-perceiving such stigmatization. There is no doubt in the enriching quality of a trying life experience such as a mental illness for some people. Nonetheless, people who report positive aspects to their mental illness have not necessarily perceived less stigmatization than those who do not report such positive aspects. On the contrary, they may have been stigmatised tremendously more and are reclaiming the lost sense of personal value, normality and intelligence as a means of withstanding stigmatisation. This phenomenon is called revalorization or reclaiming in which people erect defences to compensate for the intensity of their perceived stigmatisation. Estroff (1982), reporting the narratives of users whom she and her colleagues studied, refers to what she called ‘normalising talk’ by users. The normalising talk attempts to persuade others that the patient is worthwhile, is enriched by the experience of illness, is one of us, and normal. This indeed can be nothing other than reclaiming value and dignity for acutely perceived stigmatization that the authors have misconstrued as evidence of less perceived stigma. “The deaf are intelligent,” “The black are beautiful”. “Schizophrenic means brainy”, proclaimed by the stigmatised, are examples of revalorisation due to stigmatisation that has been extensively exposed in sociological literature (for example, Sacks, 1989) which the authors have missed in their work. Finally, randomisation is required in attitudinal surveys to reduce investigators’ bias in selecting subjects, irrespective of the investigators’ honest wish to be impartial (subjects who are more vocal, more cooperative or who have already expressed ideas about the subject of survey are unconsciously more likely to be approached by key workers, investigators etc.) which inevitably may corroborate investigators’ previously held hypothesis through a biased sample. Estroff, S. E. (1982) Long-term Psychiatric Clients in an American Community: Some Sociocultural Factors in Mental Illness. In Clinically Applied Anthropology (eds N. Chrisman & T. W. Maretzki). Reidel. Haghighat, R. (2001) Stigmatisation of People with Schizophrenia. PhD Dissertation, University of London. Haghighat, R. (2003) A Preventive Strategy for Schizophrenia: from primitive drives to development of a new society. In Intervention for Schizophrenic Disorders, pp. 130-158 (ed. A. Grispini). Giovani Fioriti. Sacks, O. (1989) Seeing Voices. University of California Press. Scambler, G. (1989) Epilepsy. Routledge. |
|||