Sarah El Halabi1†
Ely Fish1
Mahsa Boroon2
Renato de Filippis3†
Samer El Hayek4
Amine Larnaout5
Dorottya Ori6,7†
Mariana Pinto da Costa8
Rodrigo Ramalho9†
Ramdas Ransing10Fajar Raza1
Mohammadreza Shalbafan11*†- 1Westchester Medical Center Psychiatry Department, Valhalla, NY, United States
- 2Department of Psychiatry, School of Medicine, Alborz University of Medical Sciences, Karaj, Iran
- 3Psychiatry Unit, Department of Health Sciences, University Magna Graecia of Catanzaro, Catanzaro, Italy
- 4Medical Department, Erada Center for Treatment and Rehabilitation in Dubai, Dubai, United Arab Emirates
- 5Department of Psychiatry, Razi Hospital, Faculty of Medicine, University of Tunis, El Manar, Tunisia
- 6Institute of Behavioral Sciences, Semmelweis University, Budapest, Hungary
- 7Department of Mental Health, Heim Pal National Pediatric Institute, Budapest, Hungary
- 8Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, United Kingdom
- 9Department of Social and Community Health, University of Auckland, Auckland, New Zealand
- 10Department of Psychiatry, Clinical Neurosciences and Addiction Medicine, All India Institute of Medical Sciences, Guwahati, Assam, India
- 11Mental Health Research Center, Psychosocial Health Research Institute, Department of Psychiatry, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
1 Introduction
Stigma was first defined by Goffman in 1963 as a “spoiled identity that discredits a person in society” (1).
In the mental health context, stigma can be categorized as two-fold, internal stigma and public stigma. Public stigma occurs when members of the public endorse stereotypes about mental illness and act based on these stereotypes. It refers to a group of negative attitudes and beliefs that motivate the public to fear, reject, avoid, and discriminate against people with mental illness (2). Self-stigma is public stigma that is internalized (2). We cite these two types of stigma as a means of simplification, which is not to say that they summarize all forms of stigma, particularly as they pertain to their most-studied outcome of interest to mental health, reduction in help-seeking behavior (3).
The impact of stigma is difficult to overstate. Stigma against mental illness has been noted in multiple studies to be highly prevalent globally (4–6), and the fear of being subject to stigma has been shown to be one of the most significant barriers to accessing mental health care among a variety of populations (7–9). Meaningful methods to combat stigma and improve access to mental health resources are therefore direly needed. In the literature, different forms of art and artistic expression have been the subject of study as one possible means of combatting mental health stigma (10–15). A systematic review showed that interventions co-employing multiple art forms, including documentary, music, radio, and visual arts, are effective in combatting stigma (10). Cinema has generally been shown to be the single most effective art form in combating stigma (10, 11). Theater has also been shown to be effective (12, 13). Music has also been discussed in the literature as a tool for ameliorating stigma in public consciousness (14).
In this opinion article, we bring together perspectives from early career psychiatrists and trainees with various cultural backgrounds practicing in nine different countries, who met through their common work in a global mental health think tank. The authors were further unified by their common interests in discussing stigma against mental illness and some of the available avenues, through art, to combat that stigma on both local and national levels. The authors fall back on their own experiences in their countries of practice, and, with that, also supplement their observations, when necessary, with literature that pertains to these experiences. While the literature in this work might not be all comprehensive, it is meant to reflect on the various experiences of authors in their countries of practice.
2 Stigma in different countries
Authors reported that stigma against people with mental illness persists in their countries of practice, underscoring the global prevalence of this problem. The author from Italy noted that in his country, deep-seated societal misconceptions and prejudices contribute to a climate of fear, shame, and discrimination, discouraging individuals from seeking help for mental health concerns (16–18). He further stated that this stigma not only hinders early intervention and timely treatment but also perpetuates a culture of silence, making it challenging for individuals to openly discuss their mental health struggles (16–18). The author practicing in New Zealand noted that in that country, one in five individuals with mental illness have changed their behavior in some way to avoid discrimination (19). The author from Iran noted that stigma against the mentally ill originates not only from the general Iranian population (20) but also from healthcare workers (21, 22). He noted that internal medicine and cardiology trainees had shown particularly stigmatizing attitudes towards those suffering from mental illness (21).
For at least one contributor – practicing in Hungary – a paucity of research on the subject of mental health and stigma is a significant issue in Eastern European countries (23). The author did note, on the positive side, that Hungary recently initiated a national anti-stigma program. A recent research study found that medical practitioners (24) and the general public (25) in Hungary have positive and non-stigmatizing attitudes and behaviors towards patients with mental illness.
Stigma against people with mental illness was noted to be related to a reluctance to seek care in Iran, Lebanon, India, Italy, and the UK. As an example, our author from Lebanon stated that due to cultural stigma people with mental illness are often hesitant to visit mental health professionals and seek psychiatric assistance, resulting in delayed diagnosis and treatment. This reluctance to seek treatment is even more pronounced among men, who are expected to be emotionally strong, and any display of emotional distress is viewed negatively by the community. Similarly, our author from India stated that people with mental illness are reluctant to seek help due to the fear of being judged or discriminated against. People with mental illness often prefer to seek help of non-psychiatrists (e.g. general physician, neurologist) doctor, alternative medicine doctor, and faith healers due to stigma related to mental illness and by extension, psychiatrists.
Stigma may be particularly visible in certain settings. For example, authors from the UK and New Zealand noted the widespread existence of stigma in places of work and education (15, 19).
The reports by our contributors echoed trends in the global literature. Professor Sartorius, former president of the WPA, EPA and the WHO division of mental health, in an article in 2007 wrote that stigma is the central obstacle towards provision of care for people with mental illness (4). Similarly, a systematic review studying stigma in Latin America and the Caribbean found public stigma towards individuals with mental illness as well as stigma from mental health professionals in the community but less so in university settings (6).
3 Stigma in different languages
Many authors pointed out the pervasive use of stigmatizing language by the general public in different countries and languages, when referring to people living with mental illness, including derogatory terms like “crazy”, “nuts” or “unstable”.
In Lebanon people with mental illness may be referred to by the term “Majnoun”, a dismissive expression encapsulating any behavior outside the norms of society. In Portuguese one would state that one “has little monkeys in the attic” or “Has a screw missing” or that they “Do not play with a full deck” to refer to someone with mental illness. In Hungarian, similar words are used to describe mental illness albeit the author refers to diagnostic labels as a more common way of using stigmatized language. As an example, in Hungary, the author noted that stigma manifested itself in the frequent use of disparaging language like “schizophrenic” as opposed to “people with schizophrenia “among medical professionals, despite publication manuals of the APA and AMA recommendations suggesting the use of the latter, more humanizing term (26, 27). Our authors from Iran noted that people with mental illness are compared to the supernatural and described as devils.
On the other hand, authors from the United States of America commented on more widespread issues related to public stigma such as its relationship to race. In America, studies showed that racial and ethnic minority groups often expressed greater public and self-stigma compared to white American groups (28). They noted that similar stigma was frequently encountered in rural populations (29).
4 Arts to address stigma
While all authors highlighted the presence of stigma in their countries, their experience of the use of art in their local hospitals to address stigma differed substantially. Many of the authors cited art as a healing intervention for patients with mental illness, but very few noted specific efforts by their local hospital system to target mental health stigma in the local population. The exceptions were the authors from UK and New Zealand hospitals who noted local art projects such as art installations and utilizing creative arts for health promotion and to combating stigma.
Most countries exhibited a national effort to combat stigma albeit through different means. For example, the UK, India, and New Zealand cited governmental efforts to alleviate stigma through the arts. In others, there are civilian-led campaigns. In Hungary for example, the national art festival Psychart24 whose goal was to encourage people with mental illness to paint alongside members of the general population and showcase their work to promote equality. In the US, “This Is My Brave” a storytelling theatre show where individuals with mental illness highlight their stories. In the Spring of 2020, this later developed into BraveTV to bring stories of hope online during the COVID-19 pandemic. In Lebanon, there are localized efforts through various NGOs that encourage the facilitation of community mental health art projects aiming to showcase the artistic work of individuals with mental illness in the community. In Tunisia there was a famous play “Jonoun” centered on the lived experience of a patient with schizophrenia. Furthermore, in the wake of the revolution in Tunisia art has gained greater prominence within the public eye. The question of how culture influences art and its potential to mitigate stigma, both locally and nationally, prompted diverse viewpoints among the authors. This underscores the cultural diversity of the multiple nations from which our authors hail. In the USA focus was primarily on Hollywood’s cinematic depictions of mental illness. In other countries such as Italy and Hungary the relationship between architecture and culture and artworks and culture is instrumental. For example, the artworks of Laocoön and His Sons, the madness of Herakles and Dying Gaul were all cited. In New Zealand, Maori art forms include wood carving, weaving, tattooing, and painting. In Lebanon music, dance and literature are expressions of culture. Despite these varied perspectives, authors generally did not perceive a significant relationship between celebrating culture and mitigating the stigma against mental illness.
5 Conclusions
Mental illness-related stigma still exists throughout the world, but efforts are underway to combat it. These efforts take place at a variety of levels - local, civic, federal - and are as unique as the locales from which they originate. The arts have an important and growing role to play in aiding those who seek to combat the stigma against mental illness throughout the world. The authors hope that by discussing the power of art and its multiple uses throughout the world, especially with regards to its relationship to culture, that readers can be made aware of mental health stigma and the role that art can play in helping to combat it.
Author contributions
SarE: Conceptualization, Data curation, Investigation, Methodology, Writing – original draft, Writing – review & editing. EF: Writing – original draft, Writing – review & editing. MB: Data curation, Writing – review & editing. RF: Conceptualization, Data curation, Writing – review & editing. SamE: Conceptualization, Data curation, Writing – review & editing. AL: Data curation, Writing – review & editing. DO: Data curation, Writing – review & editing. MP: Conceptualization, Data curation, Supervision, Writing – review & editing. RoR: Data curation, Writing – review & editing. RaR: Data curation, Writing – review & editing. FR: Data curation, Writing – review & editing. MS: Conceptualization, Data curation, Methodology, Supervision, Writing – review & editing.
Funding
The author(s) declare that no financial support was received for the research, authorship, and/or publication of this article.
Conflict of interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
The author(s) declared that they were an editorial board member of Frontiers, at the time of submission. This had no impact on the peer review process and the final decision.
Publisher’s note
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References
1. Goffman E. Stigma, notes on the management of a spoiled identity Vol. 2. Englewood Cliffs, NJ: Prcntice Hall. Inc (1963).
2. Corrigan PW, Penn DL. Lessons from social psychology on discrediting psychiatric stigma. Am Psychol (1999) 54.9:765. doi: 10.1037/0003-066X.54.9.765
3. Schnyder N, Panczak R, Groth N, Schultze-Lutter F. Association between mental health-related stigma and active help-seeking: systematic review and meta-analysis. Br J Psychiatry (2017) 210:261–8:4. doi: 10.1192/bjp.bp.116.189464
4. Sartorius N. Stigma and mental health. Lancet (2007) 370(9590):810–1. doi: 10.1016/S0140-6736(07)61245-8
5. Pescosolido BA, Halpern-Manners A, Luo L, Perry B. Trends in public stigma of mental illness in the US, 1996-2018. JAMA Netw Open (2021) 4(12):. doi: 10.1001/jamanetworkopen.2021.40202
6. Mascayano F, Tapia T, Schilling S, Alvarado R, Tapia E, Lips W, et al. Stigma toward mental illness in Latin America and the Caribbean: a systematic review. Braz J Psychiatry (2016) 38:73–85. doi: 10.1590/1516-4446-2015-1652
7. Torales J, Aveiro-Róbalo TR, Ríos-González C, Barrios I, Almirón-Santacruz J, González-Urbieta I, et al. Discrimination, stigma and mental health: what’s next? Int Rev Psychiatry (Abingdon England) (2023) 35(3-4):242–50. doi: 10.1080/09540261.2023.218621
8. Hankir AK, Northall A, Zaman R. Stigma and mental health challenges in medical students. BMJ Case Rep (2014) 2014:bcr2014205226. doi: 10.1136/bcr-2014-205226
9. Radez J, Reardon T, Creswell C, Lawrence PJ, Evdoka-Burton G, Waite P. Why do children and adolescents (not) seek and access professional help for their mental health problems? A systematic review of quantitative and qualitative studies. Eur Child Adolesc Psychiatry (2021) 30(2):183–211. doi: 10.1007/s00787-019-01469-4
10. Gaiha SM, Salisbury TT, Usmani S, Koschorke M, Raman U, Petticrew M. Effectiveness of arts interventions to reduce mental-health-related stigma among youth: a systematic review and meta-analysis. BMC Psychiatry (2021) 21(1):1–26. doi: 10.1186/s12888-021-03350-8
11. de Filippis R, Kamalzadeh L, Adiukwu FN, Aroui C, Ramalho R, El Halabi S, et al. Mental health-related stigma in movies: a call for action to the cinema industry. Int J Soc Psychiatry (2023) 69(5):1296–8. doi: 10.1177/00207640231152210
12. Twardzicki M. Challenging stigma around mental illness and promoting social inclusion using the performing arts. J R Soc Promotion Health (2008) 128(2):68–72. doi: 10.1177/1466424007087804
13. Eissazade N, Aeini Z, Ababaf R, Shirazi E, Boroon M, Mosavari H, et al. Investigation of a group of Iranian theater artists’ mental health and attitude toward patients with mental disorders. Front Public Health (2022) 10:990815. doi: 10.3389/fpubh.2022.990815
14. Rodgers D. Community music as a vehicle for tackling mental health-related stigma. London Rev Education. (2017) 15(3):474–87. doi: 10.18546/LRE.15.3.10
15. Mehta N, Clement S, Marcus E, Stona AC, Bezborodovs N, Evans-Lacko S, et al. Evidence for effective interventions to reduce mental health-related stigma and discrimination in the medium and long term: systematic review. Br J Psychiatry: J Ment Sci (2015) 207(5):377–84. doi: 10.1192/bjp.bp.114.151944
16. Munizza C, Argentero P, Coppo A, Tibaldi G, Di Giannantonio M, Picci RL, et al. Public beliefs and attitudes towards depression in Italy: a national survey. PloS One (2013) 8(5):e63806. doi: 10.1371/journal.pone.0063806
17. Moro MF, Calamandrei G, Poli R, Di Mattei V, Perra A, Kurotschka PK, et al. The impact of the COVID-19 pandemic on the mental health of healthcare workers in Italy: analyzing the role of individual and workplace-level factors in the reopening phase after lockdown. Front Psychiatry (2022) 13:867080. doi: 10.3389/fpsyt.2022.867080
18. Lanfredi M, Rossi G, Rossi R, Van Bortel T, Thornicroft G, Quinn N, et al. Depression prevention and mental health promotion interventions: is stigma taken into account? An overview of the Italian initiatives. Epidemiol Psychiatr Sci (2013) 22(4):363–74. doi: 10.1017/S2045796013000085
19. Flett JAM, Lucas N, Kingstone S, Stevenson B. Mental distress and discrimination in Aotearoa New Zealand: Results from 2015-2018 Mental Health Monitor and 2018 Health and Lifestyles Survey. Wellington: Te Hiringa Hauora/Health Promotion Agency (2020).
20. Rezvanifar F, Shariat SV, Amini H, Rasoulian M, Shalbafan M. A scoping review of questionnaires on stigma of mental illness in Persian. Iranian J Psychiatry Clin Psychol (2020) 26(2):240–56. doi: 10.32598/ijpcp.26.2.2619.1
21. Movahedi S, Shariat SV, Shalbafan M. Attitude of Iranian medical specialty trainees toward providing health care services to patients with mental disorders. Front Psychiatry (2022) 13:961538. doi: 10.3389/fpsyt.2022.961538
22. Pokharel A, Philip S, Khound M, El Hayek S, de Filippis R, Ransing R, et al. Mental illness stigma among perinatal women in low-and middle-income countries: early career psychiatrists’ perspective. Front Psychiatry (2023) 14:1283715. doi: 10.3389/fpsyt.2023.1283715
23. Winkler P, Krupchanka D, Roberts T, Kondratova L, Machů V, Höschl C, et al. A blind spot on the global mental health map: a scoping review of 25 years’ development of mental health care for people with severe mental illnesses in central and eastern Europe. Lancet Psychiatry (2017) 4(8):634–42. doi: 10.1016/S2215-0366(17)30135-9
24. Őri D, Vass E, Vajsz K, Vincze K, Sztancsik V, Szemán-Nagy A, et al. Psychometric validation of the Reported and Intended Behaviour Scale (RIBS) in Hungary with a particular focus on ‘Don’t know’ responses and further scoring recommendations. BMC Public Health (2023) 23:1773. doi: 10.1186/s12889-023-16707-3
25. Őri D, Szocsics P, Molnár T, Ralovich FV, Huszár Z, Bene Á, et al. Stigma towards mental illness and help-seeking behaviors among adult and child psychiatrists in Hungary: A cross-sectional study. PloS One (2022) 17(6):e0269802. doi: 10.1371/journal.pone.0269802
27. Iverson C, Association AM. AMA manual of style: a guide for authors and editors. New York (2007).
28. Misra S, Jackson VW, Chong J, Choe K, Tay C, Wong J, et al. Systematic review of cultural aspects of stigma and mental illness among racial and ethnic minority groups in the United States: Implications for interventions. Am J Community Psychol (2021) 68(3-4):486–512. doi: 10.1002/ajcp.12516
Keywords: psychiatry, art, social stigma, discrimination, mental disorders
Citation: El Halabi S, Fish E, Boroon M, de Filippis R, El Hayek S, Larnaout A, Ori D, Pinto da Costa M, Ramalho R, Ransing R, Raza F and Shalbafan M (2024) The role of arts in moderating mental health-related stigma: views of early career psychiatrists and trainees from different parts of the world. Front. Psychiatry 15:1293142. doi: 10.3389/fpsyt.2024.1293142
Received: 12 September 2023; Accepted: 29 January 2024;
Published: 20 February 2024.
Edited by:
Carlos Sequeira, University of Porto, PortugalReviewed by:
José Carlos Carvalho, Escola Superior de Enfermagem do Porto, PortugalClaudia Tavares, Fluminense Federal University, Brazil
Copyright © 2024 El Halabi, Fish, Boroon, de Filippis, El Hayek, Larnaout, Ori, Pinto da Costa, Ramalho, Ransing, Raza and Shalbafan. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Mohammadreza Shalbafan, shalbafan.mr@iums.ac.ir
†ORCID: Sarah El Halabi, orcid.org/0000-0003-2012-6041
Dorottya Ori, orcid.org/0000-0003-0878-165X
Rodrigo Ramalho, orcid.org/0000-0002-2372-6854
Mohammadreza Shalbafan, orcid.org/0000-0002-4536-3441
Renato de Filippis, orcid.org/0000-0001-6928-1224