Pargar: What Is Psychotherapy and How Effective Is It?

Individuals who face conditions or issues in the field of mental health often encounter a phenomenon referred to as the stigma or taint of mental illness. From this perspective, these individuals grapple on one hand with that psychological condition, which may be difficult, anxiety-inducing, energy-draining, and disruptive to their lives, and on the other hand, they face a negative image that they may receive from themselves or others regarding this condition. The aim of this writing is to show that the phenomenon of stigma surrounding a psychological problem or condition is a complex and multi-layered phenomenon. This writing will also try to show that the stigma surrounding psychological conditions cannot be eliminated solely through public or specialized education by psychotherapists, psychiatrists, or psychologists, and more proactive strategies involving the individuals who are dealing with these conditions are necessary. At the same time, this writing also claims that the stigma surrounding mental health conditions is not merely imposed by the individual facing the condition, the general public, or the media, and that mental health practitioners, both in the field of education and in the provision of services, may also hold these negative, biased, and discriminatory attitudes towards some of their clients.

The English term stigma is used to describe a state that discredits individuals dealing with an issue in society or in their own eyes. As Persian equivalents for this term, the words "قبح" (qubh) or "انگ" (ang) are used, though neither is an exact equivalent for stigma. For the sake of consistency, from here on, this writing will mostly use the word "قبح" (qubh) as the equivalent for stigma, although in some instances "انگ" (ang) will also be used.

The examination, analysis, and attempt to reduce the stigma surrounding mental conditions has a long history, dating back at least to a work by Goffman in the early 1960s (Goffman, 1963). In the final years of the twentieth century, numerous definitions of the stigma of mental conditions were proposed, one of which is as follows: stigma surrounding a condition occurs when those suffering from that condition are attributed an identity that is considered by a segment of society to be of low value, worthless, or counter-value (Mak, Poon, Pun & Cheung, 2007). The result of attributing stigma to a person for a condition encompasses a wide range of states, attitudes, and behaviors, which can include: prejudiced attitudes toward the individual, negative emotional reactions to the individual, discriminatory behavior against the individual, and ultimately, even social and legal structures directed against the individual. For example, consider a person who is currently showing clear symptoms of dependence on a specific substance, for instance, their body aches, they have a runny nose, and they appear anxious and restless. Some members of society may view this person as reckless, lacking self-esteem, or devoid of willpower (prejudiced attitude). Others may feel disgust, pity, or even revulsion upon seeing this person or hearing about their condition (negative emotional reaction). The person might lose their job or be unable to get their paperwork processed at an office because of the condition they are grappling with (discriminatory behavior). And finally, social laws may prevent them from accessing certain rights or citizenship benefits (directed social and legal structure).

It is important to note that stigma is not necessarily imposed on a person by others. Individuals who experience stigma or disgrace may also internalize this state and adopt some of those prejudiced attitudes or negative feelings toward themselves. It is quite possible that a person struggling with substance dependence also views themselves as lacking willpower and incapable. They may have strong preferences not to inform their employer or family members about the condition they are in, and may even be reluctant to disclose this condition to their doctor or psychotherapist.

Rusch and colleagues (Rusch, Angermeyer & Corrigan, 2005), based on research conducted in Canada, England, and Germany, have identified two main but relatively independent factors regarding the stigma surrounding those facing mental health problems: the first factor is fear and exclusion. A segment of society may find those facing mental conditions or problems dangerous and fear them, and try to exclude individuals from various domains (such as where they live, where they study, where they work, etc.). From this perspective, any mental health problem is equated with the potential to create danger and nuisance for others. The second factor is an authoritarian approach (Authoritarianism) in dealing with these individuals. This means it is assumed that these individuals lack a correct and comprehensive understanding of the world around them, are not responsible and reliable, and because they feel helpless, they cannot make correct decisions, and therefore, others must make decisions on their behalf.

It is important to note that language plays a significant role in the formation and perpetuation of stigma surrounding mental health conditions. For instance, the term "mental disorder" can easily reinforce the dichotomies of "healthy/unhealthy" or "able/disabled." On the other hand, while when speaking of physical illnesses, the individual is not identified with their illness, it very often happens that such a situation occurs with mental illnesses. For example, we never hear that someone is cancer or is stroke, but rather we hear that someone has cancer or has had a stroke; however, it is very common to hear that someone is an addict, someone is bipolar, or someone is depressed. In many cultures, referring to mental unhealthiness may be used as an insult; perhaps the word "crazy" itself carries a heavily negative connotation in Persian.

The consequences of the existence and presence of stigma surrounding mental health problems

Diverse research conducted over the past three decades in various countries shows that the use of psychotherapy services is on the rise overall. Iranian citizens appear to be no exception to this rule, and we are witnessing a growing interest in counseling and psychotherapy in Iran. However, other studies indicate that the stigma surrounding certain mental problems (such as schizophrenia, bipolar disorder, or borderline personality disorder) has increased during these same years, even in developed countries. Therefore, one cannot easily take the increase in visits to psychotherapists as evidence of a reduction in the stigma surrounding mental health issues. For further explanation, consider this example. People these days engage in more physical activity than a few decades ago, sign up for gyms more often, follow more content related to cooking or healthy eating, and visit nutritionists more frequently. Greater attention to healthy eating, seeking services and education in this area, and increased physical activity do not mean that the stigma of obesity or not having an ideal physique has diminished. It is quite possible that this very stigma is a factor in why people today pay particular attention to these topics and activities.

Rüsch and colleagues (Rusch, Angermeyer & Corrigan, 2005) divide the harmful external consequences of stigma surrounding mental issues into two main parts. First, this stigma destructively affects the interpersonal relationships of the person facing these issues and causes an overall negative and, of course, inaccurate image of the mental problem to be presented in society or the media. For instance, saying that someone facing bipolar disorder is moody. Second, this stigma can lead to structural discrimination. For example, an employer refusing to hire someone with a history of hospitalization for depression, or a landlord being reluctant to rent their house to a person with schizophrenia.

As mentioned above, the stigma surrounding mental health issues is not merely a matter imposed on a person by others. It is quite possible that the person grappling with these issues themselves holds beliefs of the same biased, negative, and discriminatory nature about themselves. Self-stigma also has a wide range of harmful consequences. On one hand, it creates an incorrect image of mental disorder and mental illness in the person and leads to feelings of despair, hopelessness, and helplessness. These feelings can, in turn, lower the person's self-esteem. On the other hand, self-stigma may prevent the individual from taking steps to receive professional help, thus causing them to endure difficult conditions for a longer period.

The role of psychiatrists, psychotherapists, and mental health counselors in reducing self-stigma is very significant. If the approach of the psychiatrist and psychotherapist is paternalistic and focuses solely on the person's problems, on one hand, the image that the person is identical with their illness or disorder is reinforced, and on the other hand, the view gains importance that a person facing these issues is a helpless and incapable individual who can only overcome their problems by following the orders of a knowledgeable and capable expert. Therefore, it is recommended that professionals involved in mental health and well-being regularly "examine" themselves and be aware of their own attitudes and beliefs, which can sometimes be biased and paternalistic.

In general, efforts to reduce the stigma surrounding mental health issues rest on three pillars: protest, education, and contact.

Protest is a reaction to the "stigmatized" image seen in public speeches, media programs (television, satellite, and the like), and advertisements. The professional and ethical duty of activists who strive to reduce this kind of stigma is to protest whenever a stereotypical and incorrect image of a psychological issue is presented. However, this method is a reactive one. That is, one must first wait for an incorrect image to be presented somewhere and then react to it.

In contrast to protest, education is a more proactive and active approach and plays a significant role in reducing mental health stigma. However, it should be noted that not every type of education leads to stigma reduction. For example, it is clear that an educational program informing about brain cell changes following long-term use of a specific substance cannot necessarily help reduce the stigma surrounding substance use and addiction. To reduce stigma, an educational program must be specifically designed and delivered with the aim of reducing stigma, and one should not expect stigma reduction to be a side effect of the educational program. At the same time, because the stigma surrounding mental health issues is a multi-layered and complex phenomenon, an educational program might even reinforce stigma in another sub-domain. For instance, take a look at the note page published on BBC Persian about the link between depression and loneliness here. While this page conveys up-to-date information to the reader, it uses four images, all of which present a stereotypical and stigmatized understanding of depression and the person facing it. In other words, while the article's text is educating about depression, the article's images reduce depression to despair and reinforce the stigma surrounding depression.

But the most important factor in reducing the stigma surrounding mental health issues is social contact with individuals who grapple with these issues, especially if these individuals are successful people in their field of work or activity. Today in the West, many successful and famous men and women speak about their history of illness or treatment conditions. Just as an example, one can mention Sophie Grégoire Trudeau, the wife of the Canadian Prime Minister, who faced an eating disorder years ago, or Anderson Cooper, the famous CNN anchor, who has spoken about his dyslexia during adolescence. These difficulties did not prevent these individuals and many others from pursuing academic or professional degrees and achieving success in their fields. In contrast, however, it seems that this social connection with successful Persian-speaking individuals who face mental illnesses or conditions in the realm of mental health is very low. We probably all know famous or successful individuals who have struggled with substance use disorder: Farhad Mehrad dedicated one of his albums to his addiction treatment physician, and Dariush Eghbali has spoken openly about this and even established a foundation to help individuals struggling with substance use. However, it is highly unlikely that we know a successful Persian-speaking athlete, actor, politician, artist, scientist, or manager who has openly spoken about their depression, anxiety, bipolar disorder, borderline personality disorder, or schizophrenia. The main reason for this is that one aspect of the stigma surrounding these illnesses and conditions is that—as mentioned above—it portrays the individual as an incapable and naturally unsuccessful person.

For this last reason, programs and roundtables held in public media solely with the presence of experts cannot take a fundamental step towards breaking the stigma surrounding mental health issues. As in any other domain, the presence of those who are "stigmatized" is the most important factor in combating these stigmas.

The stigma surrounding mental health issues is a complex and multi-layered phenomenon that is not only reinforced by society and the media, but mental health professionals and the individual facing these issues themselves may also contribute to it. It is necessary that psychiatrists, psychotherapists, and mental health counselors be sensitive to instances where this stigma is promoted, directly or implicitly, in the media, public lectures, and advertisements, and object to them, and educate about a stigma-free image of mental health issues. However, objection and education can only effectively act to reduce this stigma when accompanied by the presence of individuals who have experienced these issues and the stigma surrounding them. Although the burden of breaking the stigma cannot be placed solely on the shoulders of those who have experienced its negative effects, the absence of these individuals in public programs and the media continues to reinforce that stigmatized image of the unsuccessful and desperate person struggling with mental health issues. Therefore, those mental health professionals who pay attention to the social aspect of the issue must increasingly conduct their activities in the presence of individuals who are the subject of this stigma.

.

---