what are some of the stigma and taboos related to psychological disorder?

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• Published: 18 October 2021

Types of stigma experienced past patients with mental affliction and mental wellness nurses in Indonesia: a qualitative content analysis

• Del Fatma Wati³,
• Netrida Netrida⁴,
• Vetty Priscilla^four,
• Jacqueline Maria Dias¹,
• Mini Sarah Abrahamⁱ,
• Shameran Slewa-Younan⁵ &
• Nabeel Al-Yateem ORCID: orcid.org/0000-0001-5355-8639 ^{1,half dozen}

International Periodical of Mental Health Systems volume 15, Article number:77 (2021) Cite this article

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Abstract

Groundwork

Stigma refers to the discrediting, devaluing, and shaming of a person because of characteristics or attributes that they possess. Generally, stigma leads to negative social experiences such as isolation, rejection, marginalization, and bigotry. If related to a wellness status such equally mental illness, stigma may affect a person'due south illness and treatment course, including access to advisable and professional medical treatment. Stigma has also been reported to bear upon patients' families or relatives, along with professionals who work in mental healthcare settings. Stigma is strongly influenced by cultural and contextual value systems that differ over time and across contexts. All the same, express information is available on how types of stigma are experienced by patients with mental illness and mental health nurses in Indonesia.

Method

We explored the stigma-related experiences of 15 nurses and fifteen patients in Indonesia. The report pattern and assay of interview data were guided by deductive (directed) content analysis.

Results

Five themes emerged. Four themes were patient-related: personal/patients' stigma, public/social stigma, family stigma, and employment stigma. The 5th theme related to stigma toward healthcare professionals working with patients with mental illnesses, which nosotros categorized every bit professional stigma.

Conclusions

This study has achieved a deep agreement of the concept of stigma in the Indonesian context. This understanding is a prerequisite for developing appropriate interventions that accost this miracle and thereby for the evolution of mental wellness services in Indonesia. This study may besides be transferable to other countries that share like cultural backgrounds and attach to traditional and religious value systems.

Groundwork

Stigma was initially described past Erving Goffman in 1963. He identified stigma as any characteristic or attribute by which a person was devalued, tainted, or considered shameful or discredited. Subsequent piece of work in this expanse was influenced by the work of Goffman, and the concept of stigma has been explored in many contexts and cultures. Stigma is strongly influenced by cultural and contextual value systems that differ over time and across contexts. However, almost authors agree with Goffman's basic definition, which identified the principal elements of stigma such equally labeling, stereotyping, social isolation, prejudice, rejection, ignorance, status loss, depression self-esteem, low self-efficacy, marginalization, and discrimination [i,2,iii].

Mental health stigma is defined equally the disgrace, social disapproval, or social discrediting of individuals with a mental wellness trouble [iv, 5]. Literature identifies multiple dimensions or types of mental wellness-related stigma, including self-stigma, public stigma, professional stigma, and institutional stigma. Self-stigma refers to negative attitudes of an individual to his/her own mental illness and is also referred to equally internalized stigma [ane, half-dozen]. Cocky-stigma has been related to poor outcomes, such as failure to access treatment, disempowerment, reduced self-efficacy, and decreased quality of life [7, eight]. Public stigma refers to negative attitudes towards those with mental illness by held by the general public [1, 6], oftentimes based on misconceptions, fear, and prejudice. Related to public stigma is perceived stigma which is defined as individual'due south behavior about the attitudes of others towards mental illness. Research has demonstrated the significant touch on of public stigma such as bigotry in workplaces and public agencies [8]. Professional person stigma occurs when healthcare professionals hold stigmatizing attitudes toward their patients, which are ofttimes based on fear or misunderstandings of the causes and symptoms of mental illness, or when professionals themselves experience stigma from the public or other healthcare professionals because of their work and connection with stigmatized individuals [1]. Professional stigma is of item concern as it may affect the care and treatment a person with mental illness receives [i], including treatment for physical illnesses [8], thereby impacting their well-being and recovery. Finally, institutional stigma refers to an organization'due south policies or civilization of negative attitudes and beliefs toward stigmatized individuals, such as those with mental health problems [1, vi,7,8,9,10,xi,12,xiii,14]. Such stigma tin also be reinforced past legal frameworks, public policy, and professional practices, thereby becoming deeply embedded in order [viii].

In the context of mental healthcare, stigma has been identified as a major issue for patients and families. Stigma hinders access to appropriate and professional medical and psychological treatment, and can result in a person's condition worsening or multiple readmissions [three, 6, 7, 15]. Furthermore, the touch of stigma is so great that patients describe the stigma and prejudice they encounter equally near as bad as the symptoms of their disorder [16], and as a burden on their private and public lives [17]. Stigma as well affects patients' families or relatives and the professionals who work in mental healthcare settings. Therefore, to reduce stigma in mental healthcare and facilitate the evolution of appropriate services in Republic of indonesia and similar countries or contexts, information technology is important that the different types of stigma are clarified and understood within the unique value organisation and civilization.

The Indonesia has the quaternary largest population in the world and the third largest in the Asian continent. As estimated in 2020, the Indonesian population comprises 267 1000000 people; approximately 151 million people (around 56.6% of the Indonesian population) live in urban areas and the remainder lives in rural areas [18, 19]. In general, Indonesians follow a traditional fashion of life that is strongly affected by traditional and religious beliefs. The prevalence of severe mental illness in Republic of indonesia is estimated at 1.7/1000 population, and that of mild mental illness is effectually sixty/chiliad population [18]. Stigma is known to be common in such traditional contexts [19, 20]. Therefore, understanding how stigma manifests in this context will assistance reduce stigma and contribute to developing mental healthcare services in Indonesia and potentially in other similar Asian contexts.

Handling for mental disease in Indonesia is currently inadequate. The country has the everyman ratio of psychiatrists per capita in the earth, and mental healthcare facilities are limited in availability and underdeveloped in terms of quality, man resources, and infrastructure [xx,21,22]. This situation, along with depression public sensation of mental illness, persisting stigmatizing and traditional beliefs about mental health, and the lack of local professional person noesis in the area, seriously bear upon the care of patients with mental illness in terms of access to and quality of services. In addition, stigma most mental illness is rarely discussed openly, which results in misunderstanding, prejudice, defoliation, and fear. In this context, families oftentimes hibernate or ostracize family members with mental illness considering they are reluctant to bring them to public attention or seek assistance [18, 21, 23].

A contempo written report establish that the experience of stigma among patients with mental illness in Republic of indonesia was pervasive and negatively impacted utilise of mental health services[24]. The stigmatization of mental affliction is manifested by families, community members, mental wellness professionals and staff, governmental institutions, and the media. Stigmatization is characterized by violence, fear, exclusion, isolation, rejection, blame, discrimination, and devaluation, primarily equally a result of general (mis)understandings about mental illness. Until the stigma associated with mental illness is addressed at the national level, Indonesians with mental illness will proceed to endure and face barriers to accessing mental health services [24]. Given Indonesia'southward predominantly rural population and traditional way of life, it is peculiarly important to examine stigma in this context. For example, persisting stigma means that families in traditional societies such as Indonesia and other Asian countries hide those with mental illness considering of embarrassment and shame, and are unwilling to access public mental health services [25]. Stigma may also prevent a family from socializing with other community members. In addition, others may blame family members for the person'southward illness, meaning patients experience farther feelings of shame and guilt [24,25,26,27,28]. Information technology has likewise been reported that stigma means that health professionals in psychiatric hospitals often do not treat patients with dignity or respect, and do not provide optimal protection for patients who are hospitalized [29].

Despite the prevalence of mental illness and the high levels of stigma toward patients with mental affliction, little research has been conducted to analyze the elements, attributes, and features of unlike types of stigma in the Indonesian civilization and value arrangement. A literature review on mental health in Indonesia conducted in PubMed returned 161 studies published between 1949 and 2020. However, but 15 of these studies discussed stigma either directly or in the context of Indonesian mental wellness services [18, xxx,31,32,33,34,35,36,37,38,39,twoscore,41,42,43]. Among these xv studies, 6 discussed stigma in general, consequences of stigma (i.e., "pasung" or confinement), attitudes toward mental health, and perceptions of mental health [xviii, thirty, 31, 41,42,43]. Previous investigations of stigma in Republic of indonesia mainly examined personal stigma, with a focus on the perceptions of those with mental disease and their families, how they respond to stigmatization in their lives, and the impact of stigma on admission to mental health facilities or treatment [xviii, 20,21,22,23, 44]. The present study offers a unique perspective given its comprehensive arroyo to understanding the different types of stigma that be in Indonesian culture.

Question guiding this inquiry

This qualitative study explored different types of stigma that affect individuals with mental health conditions in Indonesia, as described past patients and nursing staff. Specifically, we aimed to clarify the elements, attributes, and features of different types of stigma experienced past patients and nursing staff in Indonesia. Exploring these diverse perspectives allowed us to achieve an in-depth understanding of stigma in this context. The results of this study therefore build on existing literature and may inform specific and effective interventions targeting dissimilar types of stigma. Finally, given Indonesia's size and the similarity of its cultural context to other Asian countries, the results of this study may improve our understanding of types of stigma experienced in the wider Asian context.

Methods

Study design

This written report used a qualitative design based on deductive (directed) content assay. Content assay is considered a research method or technique also as a data analysis tool [45, 46]. Research using deductive (directed) content assay commonly has prior theoretical noesis every bit the starting point [47], and this study was informed past previous enquiry findings and theories focused on mental health stigma. Bengtsson (2016) outlined the unlike stages of qualitative content assay (e.k., identifying the written report problem, planning information collection methods, and data analysis) and described both "manifest" and "latent" analysis techniques. The nowadays report used a latent analysis technique, whereby we attempted to empathize underlying meanings reflected in the information in the context of extant cognition and theories relevant to the topic nether study. This aided in developing a deeper agreement of individual meanings and experiences of stigma in this context. Using deductive (directed) content assay allowed us to explore meanings related to mental illness stigma constructed by patients with mental illness and nurses, and draw and interpret those meanings. In addition, this study design allowed us to get deep into the data to reveal participants' thoughts and experiences that were close to their realities at that particular place and time.

Study setting and participants

This report was conducted at the largest of Indonesia's 33 psychiatric hospitals. The hospital is located in W Java, which is one of the 34 provinces in Republic of indonesia, and receives patients referred from across the province (urban and rural areas). Due west Java is an ethnically diverse province with a range of inhabitants from diverse ethnicities. Written report participants were fifteen patients (seven males, eight females) and fifteen psychiatric nurses (10 males, five females) recruited purposefully from the infirmary. Although all participants were recruited in the same site, they originated from both urban and rural areas. The bulk of participants were Sundanese, and some were Javanese. Patient participants were aged 21–52 years with mild/moderate symptoms (every bit noted in their medical records). Nurse participants were psychiatric nurses who had graduated from nursing schools with a specialty in mental wellness nursing. These nurses were aged 22–43 years and had 5–xv years of clinical experience in mental health settings. We based our sample size (North = xxx) on a previous study [48], which indicated that 30 participants was sufficient to ensure data saturation.

Our initial contact with participating nurses was made through a coming together and a presentation about this study at the written report hospital. This initial meeting was followed by data collection at a mutually agreed time. We made contact with patient participants after discussion with the hospital healthcare team. Nosotros excluded patients with severe psychosis or severe symptoms of their mental disease. All participants were required to be able to read and write. Information were collected at the infirmary through interviews held in environments that were individual and quiet to facilitate participants' condolement and conviction to speak. All participants signed an informed consent form before their interview and were assured of the anonymity and confidentiality of their data. All data were coded for analysis, and all data (including field notes and memos) were kept deeply by the master investigator.

Data collection

The primary method of data collection was semi-structured interviews. Interview questions were adult based on themes identified during a literature review. Interview questions were not prescriptive, but were used as a guide to explore aspects that were considered vital to sympathize the elements of the different types of mental wellness-related stigma and stigmatization experienced by participants in traditional Indonesian culture and reality. Interviews took from 30 to 45 min for both nurses and patients' participants. Interview questions were phrased to suit participants (i.eastward. nurses and patients). Sample of interview questions is beneath:

For patients:

• In your opinion how does Indonesian gild run into or deal with mentally sick persons?

• How is it to live in Indonesia when yous have a mental health issue?

For nurses:

• In your opinion how does Indonesian gild see or bargain with mentally sick persons?

• How is it to live in Indonesia for someone who have a mental health problems?

• Could yous requite me an idea about your work in a mental wellness hospital?

Additional information were collected via memos, field notes, and a document review. These boosted data collection methods enabled data triangulation, which improved the credibility of the interpretations of the information. The interviewer likewise used memos to record their thoughts and interpretations of the interviews, the enquiry procedure (including questions and gaps), and the analytic progress of the research. Field notes were used to record observations and reflections on the data. We also conducted a document review to collect hard copy and electronic data that were bachelor in the hospital. This mute testify was important in guiding our estimation of participants' experiences, attitudes, and beliefs.

In total, nosotros conducted thirty semi-structured interviews in the Indonesian linguistic communication (Bahasa Republic of indonesia). To ensure the interviews were consequent, all interviews were conducted past two experienced interviewers (MAS and DFW), who were local members of the inquiry team. At the beginning of the interview with each participant, the interviewers introduced themselves and explained the purpose of the study and the confidential nature of the data collected. This gave participants opportunity to ask whatever questions and helped to establish a comfort level before the interview began. The appropriateness of the interview location and timing was verified with participants; the interviewers tried not to take up as well much of their time, and were prepared to provide emotional support to participants when necessary. Earlier their interview started, each participant confirmed that they had read the participant data sheet and were fully informed about the study. The informed consent process was completed before the start of the interview (in Bahasa Indonesia).

All xxx participants attended on the scheduled day of their interview. The interviews were conducted in hospital meeting rooms or nurses' offices. The questions were asked in the order they were presented in the interview protocol. During the interviews, participants were given time to reflect on and consider their responses to ensure they did not feel pressured to respond before they were ready. Participants were given opportunity to ask more questions at the end of the interview. Finally, the interviewers expressed gratitude for participants' fourth dimension and willingness to participate in this written report. Immediately afterwards the interview, the information was summarized, and field notes and memos were checked.

Data analysis

We analyzed data using deductive (directed) content analysis. This method was suitable for this study as we aimed to proceeds a deep agreement of the experiences of Indonesian patients with mental illness and mental wellness nurses in relation to the unlike types and categories of mental health stigma reported in the literature. The interviews were analyzed past the Indonesian members of the research team, who then translated important quotations into English language for reporting. Linguistic equivalence was an important consideration during the translation process to ensure the integrity of our findings. The starting time author (MAS) has English every bit his offset language. During this translation procedure, this author (MAS) was assisted by an Indonesian professional person English nursing translator to ensure linguistic equivalence. The translation process focused on verifying that the translation from Indonesian to English was right in terms of words, terms, concepts, and overall meaning. This ensured that the English translations were comprehensible, simply faithful to the interview data obtained from participants.

During the assay process, we read the interview transcripts several times to become familiar with the text. Next, we merged and coded the words, sentences, and paragraphs line-by-line, equally relevant to each other in terms of both the content and context of stigma. Then, parts related to the experiences of the participating patients and nurses regarding types of stigma were extracted and placed in a separate text file. Codes and units of meaning were interpreted in the context of the report and compared in terms of similarities and differences. Finally, abstruse themes were adult reflecting types of stigma consequent with the literature.

Results

Study participants were 15 patients with mental illness (vii men, eight women) who were hospitalized in the participating psychiatric infirmary, and 15 nurses (5 women, 10 men) who worked in the same hospital. Our assay revealed five main themes. Iv themes were related to patients with mental illnesses and loosely classified under the categories of either public or perceived stigma. These themes were 'perceived stigma from a patient perspective', 'public stigma', family 'attitudes', and 'employment bigotry'. The fifth theme, professional stigma, described stigma experienced (or held) by healthcare professionals who worked with patients with mental illnesses. Although these themes reflected the stigma experienced by participants in our report, they were consistent with the types of stigma described in the literature. This was because we used deductive (directed) content analysis, which draws on existing knowledge and theories every bit the starting betoken for the analysis.

Theme 1: perceived stigma from a patient perspective

The theme of personal/patients' stigma was strongly represented in the narratives of all participating patients, simply received picayune attention from participating nurses. Therefore, merely findings related to patients' perspectives are presented. Participants described feelings of shame and isolation from the customs, and indicated that they were viewed as unlike from other "normal" people. They also believed that others thought they were inadequate, and reported suffering insults. A patient described being insulted as making them aback:

Within lodge, there is insult, discredit…They insult me. I am called "crazy," or "former crazy people." Yes, I take been insulted. It is from friends and the community too. I cannot do anything. I am sad and ashamed, my heart cries without tears. I promise that God helps me... (Participant four)

Participants as well indicated that they were labeled as a "mentally ill person." One patient reported that this labeling was part of their suffering.

If in the community, people run into me [they say], "whew a professor'due south patient." People say "wuhh wuhh" (encounter lowly), "the patient of physician R, wuhhh (low)." Yes, they practise look downwardly. If I visit my professor, my label is not for recovery. Moreover, they make a label for me as the professor's patient; it means that I am a mentally ill person. They consider me like that… (Participant 7)

Participating patients also believed that they were rejected, avoided, and discriminated confronting because they had a mental illness. Further, they reported that community members rejected them because society held wrong assumptions about mental illness. One participant reported:

Yes, they (patients) are rejected, similar that. They actually tin be accepted again by their community, just they (the community) don't take. I as well need to change. So, nosotros are "crazy" depend on us. There are yet wrong assumptions in the customs near mentally ill people. Yes...probably, only few of them, I run across, who can exist accepting. (Participant 2)

Some other participant described how they had been discriminated against by others.

…All the problems are considering the problem cannot be solved by our family members. I experience that there is discrimination…Other people treat us as unequal with people who take concrete illness. Yes, they [general people] practice discriminate… (Participant 5)

Theme 2: public stigma

Public/social stigma was an issue highlighted by both groups of participants. Therefore, this theme is discussed from both patients' and nurses' perspectives.

Patients' perspectives

Support from customs members or other social back up is essential for improving outcomes for people with mental illness. However, most patients felt they lacked this social support.

…I do not have support…I don't take support at all. I practise non know why information technology is like that sir. My community, my sister and other people practise not provide support, no [support]. They only care [about] themselves. No, I practise not have support from other people when in this hospital. They but want me to go to witchcraft, get to a shaman. (Participant xi)

Of particular concern, some participants reported forms of customs violence towards those with mental affliction. Participating patients described experiencing violence from people in the community. One patient shared their experience of being hit and tied by other people in their community.

…Yes, I was tied and hit. Therefore, I was really angry and I don't desire to meet the people in my community. Nevertheless, if they come up to my home and repent to me, and so, I will come to repent at their homes. Therefore, I yet feel [the need for] revenge because I was tied and hit. (Participant one)

Additionally, participants perceived that many people in the community believed that mental affliction is a communicable affliction, like to some physical illnesses.

...They stay away from sufferers. Sometimes, they are afraid that mental affliction is a contagious illness. People are afraid because of this. Actually, sufferer isn't harmful. If they are embraced, they will exist OK. (Participant v)

Nurses' perspectives

Some nurse participants noted that the general public/wider society lacked consideration and empathy toward those who suffered from mental illness. This lack of consideration and respective lack of appropriate policies ofttimes resulted in homelessness and isolation among people with mental illness.

Our societies still lack intendance...less attending for people with mental illness. Because communities lack care, communities exercise not care. They merely ignore…I am certain, if ten people [met a person] with mental illness, only i or two people volition still want to say hello or interact with them. (Nurse vii)

A lack of social acceptance was reported by participants every bit resulting in people with mental illness being rejected. A nurse described the impact of patients not beingness accepted in their community.

Considering they (patients) could non be accepted in club…lodge cannot accept them. Other people reject them. In addition, their families cannot be accepted by society. Patients cannot be productive anymore; minimal in fulfilling their basic needs. (Nurse 1)

In general, participants reported that community members feared dangers posed past those with mental illness. Participants indicated that people were agape of patients with mental illness because of a perceived tendency for violent behavior or fear of being attacked past a patient. A nurse described how people were often scared and ran away.

They (community members) are afraid, sir…agape…scared…anxious. The lodge is scared. Yes, it is really, true [people] are scared, run away, they are similar that. They (patients) are ignored, they are left, finally [laughs]. Because they (club) are scared, the patients are ignored. (Nurse 1)

Theme 3: family attitudes towards mentally sick patients

Similar to public/social stigma, both participant groups shared their views and experiences of family stigma. Therefore, findings reflecting both patients' and nurses' perspectives are presented.

Patients' perspectives

Family support plays an important office in the recovery of a person with mental illness. Nonetheless, our participants indicated that their family members provided minimal support because of stigma and shame.

They (family unit members) exercise not talk to me. They practise non support me. Sometimes, my parents are ashamed…My father is non proud of me in front of other people. For example, "my son is like this." "See! My son has been like this." What can he tell others? Other parents will say "my child goes to the college in Jayabaya (a university) takes informatics engineering field." My parents do not mention virtually me like that. My father and mother do not do that…They are ashamed. (Participant 10)

Nurses' perspectives

Participating nursing staff described how many families had moved to another location or changed their address because of feelings of shame. They indicated that some families besides denied they had relatives who were treated in the hospital.

Their families disappear considering of shame? The first, their dwelling house (accost) changes. And then, although we get there and nosotros detect the address, they say "I accept no family unit relationship with him, all his family unit members take died." Some patients have been hither since they were immature. Probably, they are the patient's family unit. People who were at dwelling are his family members, only they don't acknowledge him. "Nosotros don't recognize that patient" [the] family unit said. (Nurse 8)

Participants as well indicated that the extended families often reject relatives that suffered from mental illness. This rejection was reported to happen even after a patient'south hospitalization.

Especially for long-time patients, for example, [those who have spent] many years here, it is difficult to go them (families) to take their relatives home. Because they assume that at dwelling, the patient will badger them. They will badger their family's activities. Then, [the] patient is rejected. Mostly they are rejected… (Nurse half dozen)

Theme 4: Employment discrimination

Both nurses and patients commented on the stigma that people with mental illness experience in the context of their employment. The perspectives of both nurses and patients are presented below. Overall, almost participants indicated there was a great deal of stigma related to mental illness in workplaces.

Patients' perspectives

Returning to work afterward treatment was reported as difficult. Many patients were rejected from returning to their old workplace, including a patient that was previously employed in a government role.

…Yes, it is, very oftentimes. Other people do non want to accept a patient to work again in his task…"You are an ex-crazy private." They will say that. I was a authorities employee…The authorities officers will not let me to work once again. (Participant two)

Nurses' perspectives

A nurse described how patients found it hard to find a job because of having a mental affliction label.

…If they have mental hospital label or have stigma from society, then looking for a job, it is difficult for them. I have had a house assistant who has been tearing. Then, she worked at my parents-in-law; I was worried to exit her at dwelling house alone. I asked: "did you hear voices?" She said "yes." I was scared too. Fortunately, she asked to resign. (Nurse two)

Theme 5: professional person stigma

The fifth theme that emerged from the interviews was professional person stigma. Two forms of professional stigma emerged in this report: stigma directed toward mental health nurses, and stigma from healthcare professionals toward their patients with mental illness. Although this type of stigma was mostly present in nurses' narratives, some patients reported experiencing stigma from healthcare professionals; therefore, both nurses' and patients' perspectives are discussed.

Nurses' perspectives

Participating nurses described how mental wellness nurses were labeled as "crazy nurses," which captured the stigma directed to nurses working with patients with mental illness. Some nurses shared examples of how non-mental wellness nurse colleagues and the general public used terms that insulted them.

…People say "ohhhhh [information technology is] because you are psychiatric nurse"..."Uhhhhh...yeah, since he works to intendance for the gelo (crazy) people." They say "whew psychiatric nurse." Sometimes this stigma sticks to the nurses from people in our society. Yes…also, we are labeled by our friends (nurses). They are either joking or serious, I do not know. In addition, my friends say: "ihhhhh...whew, psychiatric nurse." Yes, similar, as crazy equally his patients. (Nurses 6)

It was also noted that too as the general public, some healthcare professionals too believed that mental illness was contagious, similar to many physical illnesses.

….Yesterday, at that place was a student who feared to be contaminated by this disease. She is a student from Palangkaraya, Borneo who fears of contamination too. Also fearing beingness contaminated, they [are] disgusted [past] mentally sick patients. Their cloy with mentally ill people is similar to leprous, dingy, disgusting. In reality, mental illness does not spread, right? Then, there is an image (label)..."Don't have relation[ships] with the patients." (Nurse iv)

Patients' perspectives

Participating patients also reported that some healthcare professionals held stigma toward patients with mental illness. They noted this stigma was often manifested in the use of restraint or seclusion. Some nurses and other infirmary staff were reported to physically abuse their patients.

Yes, I was tied. True, it was true. I take to tell yous. My jaws are tied, by Mr. A (a nurse). I was injected, it was pain, right? I don't sympathize, probably his education wasn't loftier enough and then that he didn't sympathise. My need isn't food, but, they but don't care… (Patient 9)

Word

Stigma has significant impacts on patients with mental illness, family members, communities, and healthcare professionals. To appointment, little enquiry has investigated the types of stigma and corresponding impact in the Indonesian context. Stigma is a worldwide concern that influences people's illness trajectory, treatment process, available opportunities, quality of life, and recovery outcomes. Our report sought to investigate the types of stigma experienced by people with mental illness and mental wellness professionals in the Indonesian context. Using a deductive approach (directed content analysis), our findings on the examples of stigma reported were loosely centred effectually public and perceived stigma, consistent with the types of stigma previously reported in the literature [1, 6,7,8,9,10,eleven,12,13,14]. Nonetheless, we identified features of these types of stigma in the Indonesian context, and our study therefore makes a direct contribution to the literature. As described in previous studies [7, 8], stigma is a brunt for patients with mental disease that tin can be intrapersonal (self-stigma), interpersonal or in relationships with other people, and structural or discriminatory stigma relating to exclusionary policies and other aspects of life or systems. Our participants shared their experiences of different types of stigma, along with the corresponding elements, attributes, and features within the unique Indonesian culture and value system.

Perceived stigma from a patient perspective

Many participants described feelings of shame and being rejected and isolated from society, which resulted in feelings of powerlessness. A plausible explanation for this is that patients had internalized stigma (self-stigma) because of negative attitudes and beliefs toward them. Other studies reported that around twoscore% of people with severe mental illness had high levels of self-stigma [11, 13]. Cocky-stigma exists when an individual believes negative stereotypes about mental affliction and people with mental illness, and feels that these stereotypes apply to them [fourteen]. In addition, most lxx% of patients reported moderate to high levels of perceived discrimination, which has been significantly associated with loftier self-stigma [11]. Implicit self-stigma appears to be associated with negative outcomes. Information technology has been noted that patients who internalize stigma do not respond as well to evidence-based interventions as those that do not internalize stigma [14]. Self-stigma has been associated with poor self-esteem, hopelessness, reduced self-efficacy, and disempowerment [9].

Furthermore, our participants' descriptions of these negative feelings indicated they were implicit processes. This means that they were activated automatically and occurred whether or non the individual deliberately endorsed the suggestion that mental illness is shameful. For example, a patient with mental illness or healthcare professionals working with that patient may explicitly disapprove of such stigmatization, but implicitly, they may still experience the shame associated with this stigmatization. Attempts to reduce self-stigma should therefore consider these implicit processes [49]. In improver, our findings indicated that many patients were labeled past others as mentally ill. Participating patients expressed feelings of shame, and spoke most how the characterization of being a "crazy" person made them feel useless and powerless. For patients, hospitalization in a psychiatric hospital can be experienced as disempowering and stigmatizing [xv]. Because cocky-stigma tin can have negative furnishings on an private's life and treatment outcomes, it is important for clinicians to be aware of the existence of self-stigma, and so they can recognize patients' internalized stigma and address this effectively in handling.

Public stigma

Public stigma has negative effects on the lives of people with mental illness, and creates barriers to the individual's pursuit of vocational, housing, and healthcare goals [fifty]. In add-on, public stigma affects living, working, and socializing for people with a mental illness [51]. A similar report found that nine out of 10 patients with mental illness had experienced discrimination [52]. Our report too found that both nurse and patient participants reported that people in the community enacted violence toward people with mental illness. For example, considering community members were ashamed and agape of those with mental illness, they commonly subjected people with mental illness to solitude or "pasung" and seclusion or "seklusi" [19]. Confinement/pasung and seclusion/seklusi have a negative touch on on patients with mental illness, and their employ has potential to cause concrete harm and farther psychological trauma [29]. In add-on, many Indonesians adhere to traditional causal beliefs of mental illness, and these beliefs may drive mental health stigma [21, 22, 26, 34, 37]. Given that Republic of indonesia is a developing country, it is likely that these traditional beliefs underling mental health stigma are common beyond rural and urban communities.

Family attitudes

Our findings indicated that stigma related to mental disease also impacted patients' families. This was consistent with Nurjannah et al. [46], who noted that mental health stigma has negative implications on the health and wellbeing of patients and their families. Various impacts on the families of people with mental illness have been documented, including sleep disorders, alterations in interpersonal relationships, worsening of wellbeing, and reduced quality of life [53, 54]. Farther, it has been reported that some families with a relative suffering from mental disease feel shame because other people blame them for being responsible for the illness [24]. A family tin also feel ashamed if people in their community know that they have relative with mental illness. Iii stereotypes associated with family stigma have been described: shame, arraign, and contamination [28]. Our study showed that parents were blamed for their offspring having a mental illness, leading to feelings of shame. It was also noted that family members stayed away from patients when they were in hospital and would not visit them. If nurses conducted habitation visits, family members denied that they had hospitalized relatives. In add-on, we found that family unit members sometimes perpetrated violence towards relatives who had mental illness. For instance, participating patients indicated that families subjected them to pasung/solitude or isolated them in a room (seclusion) because customs members ordered them to do and so, or because they were ashamed or afraid that the patient would be violent [19, 20].

Professional stigma

Another pregnant finding that emerged from participants' narratives was the presence of professional stigma. This blazon of stigma included stigma that nurses held toward patients with mental affliction, as well as their experiences of existence stigmatized by others because of their job. Our participants reported that some nurses and infirmary staff held stigmatized attitudes towards patients, which was consistent with existing literature. This type of stigma is a major business concern for healthcare professionals, specially nurses, as it may result in disparities in healthcare access and treatment, and affect outcomes [55]. A previous report indicated that despite healthcare professionals' attitudes towards mental disease being more positive than those of the general public, paternalistic or negative attitudes were likewise common, especially effectually prognosis and the (supposed) limited possibilities for recovery of people with mental illness [56]. It may likewise be that nurses and other healthcare professionals continue to misunderstand the causes and symptoms of mental affliction, despite considerable experience in this setting. Nurses may as well fear mental illness, particularly if they believe that mental affliction is contagious and tin be transmitted like a contagious physical illness [24]. We speculated that such fear and misunderstanding may be a particular claiming in strongly traditional societies such every bit Indonesia. Our results also showed that nurses felt that they were discriminated against past other (non-mental health) nurses because they worked in a mental hospital. They also felt humiliated when other people chosen them as "crazy" every bit their patients. In addition, our findings indicated that nurses and hospital staff used restraint and seclusion because of fear. This was consistent with a previous study that reported staff may utilise restraint and seclusion when patients are perceived every bit dangerous [57].

Employment discrimination

Having a secure task provides an individual with condition in society. For a patient with mental illness, employment is an important function of recovery. Our findings indicated that patients had experienced stigma in their workplaces, which was consistent with the concept of institutional stigma previously reported. The reports of participants in this written report suggested that many employers in Indonesia still take negative attitudes and discriminate against people with a mental illness. Many participants reported being refused work because they had a mental illness. In addition, some were not accepted back to their previous identify of employment. A previous study found that employment rates for people with severe mental illness were equally low every bit iv% [10]. Discrimination and stigmatizing beliefs and attitudes brand it difficult for people with mental affliction to find employment [58]. A study involving people living with schizophrenia constitute that over one-third anticipated discrimination in job-seeking [11]. Stigma can result in difficulties for people with mental illness entering the competitive workforce. Some employers explicitly express negative attitudes regarding workers with mental illness and may be hesitant to rent them [59]. Having a mental illness may besides limit a person'southward career advocacy, every bit employers are less likely to offer promotion to this grouping [60]. In addition, people with mental affliction reported being passed over for jobs for which they were qualified or fired because of their illness [60]. Our findings showed that although these studies were conducted some time ago, like issues continue to be experienced by people with mental illness.

Linking them all together

The issue of the study confirms that stigmatization of mental illness within the Indonesian context, similar to other countries is a complex and multiple dimensional miracle impacting individuals, families, organizations and within the whole society. The outcomes of unlike types of stigma include social disgrace at personal and family level, separation and loss of social integration among families, friends and relatives, status loss and discrimination, homelessness, unemployment, and treatment avoidance. Professional stigma held by nurse professionals toward mental patients develops very much in the aforementioned manner as public stigma. Nurses themselves are also the recipients of stigma because their work and their workplace are seen every bit dangerous or even contagious.

Study limitations

Stigma may limit patients' power to fully disclose their feelings and stigmatization experiences. Therefore, a major limitation of this study was that despite assuring all participants of the anonymity and confidentiality of their information, some participants might not have felt comfy in expressing or discussing hard experiences, and might not have been fully open up and honest in sharing their perceptions or experiences. Therefore, during the interviews, participants might not accept completely disclosed their situation in their responses or withheld data. The small sample size used in this written report (Due north = 30) may also be considered a limitation. However, after our assay of the interviews transcripts, the inquiry team believed that saturation had been reached and no further information drove was necessary. Another major limitation was that this study relied on the researchers' interpretation of the pregnant unsaid in the interview data, which means that some bias persists. To minimize this bias, triangulation was performed using several methods of information drove (interviews, field notes, and writing memos). In add-on, bias might have been introduced in our sample every bit all participants were recruited from a single large referral infirmary. This limits the generalizability of our findings as participants cannot be considered representative of the entire spectrum of mental health settings in Indonesia. Finally, verification of data analysis and interpretation with participants could take been a useful step to farther deepen understanding and increase brownie, this step was not feasible and could not be performed within this report.

Despite these limitations, we believe that our findings are peculiarly relevant for mental health professionals, too as for professionals in other fields where patients and families may be exposed to different kinds of stigmatization. The results of this study may be used to inform research activity in similar settings elsewhere, and contribute to improving practice, instruction, and research in mental health in Republic of indonesia and similar areas. Although generalization is not the intent of qualitative studies per se, it is possible for our results to exist considered in the context of other communities or countries with similar cultural and religious backgrounds. The replication of this study in other mental wellness settings with dissimilar groups of participants may produce different important data.

Determination

In Republic of indonesia and other countries with similar cultural contexts, people adhere to traditional and religious value systems that touch on (positively or negatively) diverse aspects of life, including psychosocial aspects and health. Some of these values take strong roots, and therefore have more effects on vulnerable people, which is of detail importance. Traditional beliefs almost causes of and treatments for mental affliction are prominent in Indonesian civilisation and traditions, and take seeded the persistent existing taboos or stigma that affect the lives and health of patients, families, and relatives. This report achieved a deep understanding of the concept of stigma in the context of mental healthcare in Indonesia; this understanding is a prerequisite for developing appropriate interventions and the development of mental healthcare services in the country.

Availability of information and materials

The datasets used and/or analysed in the present study are available from author MS on reasonable request.

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Acknowledgements

Not applicable

Funding

This study was self-funded.

Author information

Affiliations

1. Academy of Sharjah, Sharjah, UAE

   Muhammad Arsyad Subu, Jacqueline Maria Dias, Mini Sarah Abraham & Nabeel Al-Yateem

2. Universitas Binawan, Jakarta, Indonesia

   Muhammad Arsyad Subu

3. Institute of Health Sciences, Fort De Kock, Republic of indonesia

   Del Fatma Wati

4. Academy of Andalas Padang, Padang, Indonesia

   Netrida Netrida & Vetty Priscilla

5. Western Sydney University, Penrith, Australia

   Shameran Slewa-Younan

6. School of Nursing, Midwifery and Indigenous Health, Charles Sturt University, Orange, NSW, Australia

   Nabeel Al-Yateem

Contributions

MS designed and conceived the study. NA, SSY, DFW, NN, VP,MA and JMD contributed to data analysis/interpretation, drafting of the manuscript, and disquisitional revisions for important intellectual content. All authors read and canonical the final manuscript.

Corresponding author

Correspondence to Nabeel Al-Yateem.

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Subu, K.A., Wati, D.F., Netrida, N. et al. Types of stigma experienced past patients with mental illness and mental health nurses in Indonesia: a qualitative content analysis. Int J Ment Health Syst xv, 77 (2021). https://doi.org/x.1186/s13033-021-00502-x

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• Received: 31 May 2020

• Accustomed: 06 October 2021

• Published: 18 October 2021

• DOI : https://doi.org/10.1186/s13033-021-00502-x

Keywords

• Stigma
• Mental Health
• Indonesia
• Qualitative study
• Content analysis

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