CHAPTER ONE
1.0 Introduction 1.1
Background to the Study Mental illness is a term used as a general description for persons who exhibit persistent abnormal behavior (Corrigan, et al., 2005). The illness affects adversely the normal condition of the mental, psychological and emotional make up of the affected person, which makes capacity of insight, orientation, judgment, thought, mood and perception very blurred and disoriented (World Health Organization, 2001). It is a health condition that affects how a person feels, thinks, behaves and interacts with other people (Ihaji, et al., 2013).
Mental illness is generally responsible for 14 percent of the world‟s disease burden (WHO, 2013), and this is expected to increase by 15 percent by the year 2020 (Hugo, et al., 2003). According to WHO (2012), an estimated 25 percent of the world population suffer from one form of mental disorder in their lifetime. Mental illness conditions are linked with about one quarter of the disabilities in the world (Andrews, et al., 1998), and 75% of those affected are found in low income countries. It has also been reported by Kessler, et al., (2001) that in spite the high prevalence of mental health illness in the world, only about 30 to 40 percent of people living with mental illness seek treatment due to the stigma and discrimination. The prevalence of mental illness in Nigeria is approximately 20%, and this shows that with a population of about 174 million in 2013 (World Bank, 2013), about 35.4 million Nigerians might have been suffering from mental illness (Oyewunmi, et al., 2015).
Mental illnesses are of different types and they affect victims in varying degrees of severity. They differ in terms of the etiology, symptoms, prognosis and their therapy (Olubumi, 2009). Some of the major types of mental illnesses include mood disorders, anxiety disorders, personality disorders, psychotic disorders, traumatic related disorders, substance abuse disorders and eating disorders etc. The basic manifestations of mental illness include unremitted deviations in virtually all aspects of social behavior like inappropriate affect, bizarre behavior, language irregularity, poor social skills, mood swings, and alteration in thinking and acting etc. (WHO, 2012). People with psychotic disorders, mood disorders and substance abuse disorders are more likely to be perceived as violent and unpredictable by members of the public and are highly stigmatized compared to people with other mental health disorders (Thornicroft, et al., 2009) .
Members of the public believe that people who have suffered from mental illness are incompetent and dangerous, especially those with psychosis, mood disorders, and drug dependence. Because of this, people show negative attitude towards them. People also believe that mental health conditions like substance abuse and eating disorders are self inflicted by the affected person; therefore, members of the public show less sympathy and negative attitude to people that exhibit such abnormalities (Michaels, et al., 2012) .
Most people in Nigeria attribute mental illness to supernatural powers, wrath from ancestral spirits and gods (Hailemariam, 2015). Lack of knowledge, belief system, superstition, the fear and exclusion of people who are perceived as being different, misconception, lower educational levels, less professional experience by health care professionals, low familiarity with the experience of mental illness have also been identified as factors related to stigmatizing behavior towards people with mental illness (Mainas and Diatri, 2008; Adewuya, et al., 2010; Kluit and Goossens, 2011; Baffoe,
2013; Ahmed, et al., 2014). Nyamongo (2013) added that wars, poverty and natural disasters have influence on mental health and psychosocial well being of the people .
Members of the society may accept stereotypes about mental illness and act on the basis of these stereotypes by blocking mentally sick people‟s access to life chances that define a desirable life; such chances include employment, educational opportunities, satisfactory health care, and safe housing. Members of the public may also discriminate against people living with mental illness by avoiding even basic social contact with them, and by refusing to marry from families who have a mentally sick member (Cifti, et al., 2013). When one comes from a family with a mentally ill person, any deviant behavior one exhibits is attributed to the mental illness found in the family .
Consequently, people living with mental illness gradually internalize the public stereotype and experience diminished self esteem, self efficacy and disempowerment .
This may affect people with mental illness in seeking for treatment (Khan, et al., 2011), recovery from the illness, integrating with other members of the society, and seeking for employment (Stuart, 2008) .
Stigmatizing attitudes against people with mental illness are not limited to lay members of the public. Mental health care professionals too hold negative feelings towards people with mental illness (Hansson, et al., 2013). According to Horsefall, et al., (2010), people living with mental illness who received treatment in traditional and psychiatric hospitals experienced stigma and discrimination due to forced interventions associated with mental health treatment from psychiatric doctors. This involves the use of coercive forms of treatment like chaining, seclusion, physical restraints, intrusion on the private lives of people with mental illness, forced psychotropic medication, rejection, beating and restrictions (Valimaka, et al., 2001).
The stigma and discrimination against people living with mental illness also affect family members of the affected persons. This is what Goffman (1963) called courtesy stigma or stigma by association (Phelan, et al., 1998). They suffer from the mental condition of their sick member through associating with the sick person. Family members complained that they were blamed for the illness of their member, so that they felt ashamed of having a mentally ill person in the family (Larson and Corrigan, 2008) .
The experience and expectation of stigma may influence people with mental illness and their family members to adopt measures to cope with the threat of discrimination. Some of the people with mental illness may decide to conceal their treatment to avoid being laid off by their employers. Others may choose to restrict or withdraw from their social interaction with people to avoid being identified as persons living with mental illness, while some may select a small group of people to whom they disclose their problems (Larson and Corrigan, 2008). The cost of disclosure, non disclosure, selective disclosure can expose the stigmatized person to lost opportunities to receive support, risk of rejection from members of the public and others may attempt to provide nonstigmatized members with the necessary awareness on the nature of mental illness (Hamilton, et al. 2011) .
Statistics on the distribution of population by sex and type of disability showed that there were 6,624 people living with mental illness in Benue state (NPC, 2009) .
Furthermore, records from the psychiatric unit of the Federal Medical Center Makurdi (FMC Records, 2015) showed that from 2005 to 2015, 112,200 people visited the hospital for treatment of mental illness. At the Benue State University Teaching Hospital Makurdi, 395 in 2013, 44 in 2014 and 643 in 2015 attended the hospital for treatment of mental illnesses (Health Information Management Department BSUTH,
2016). Similarly, a study by Tormusa, (2015), in Benue and Nassarawa states of north central Nigeria revealed that citizens believed that mental illnesses is stigmatized .
According to the study, citizens believed that mental illness cannot be completely cured, and that when a person comes from a family with a history of mental illness, any deviant behavior a member exhibits is linked to the mental illness found in the family, and people think the person has been affected by the mental illness as well .
The WHO (2001) highlighted the harm resulting from stigma and discrimination against people with mental illness. The organization argued that people with mental illness experience isolation, loneliness and rejection from friends, relatives, neighbors and employers. At the global level, efforts have been made to combat stigma and discrimination against people with mental illness. The International Convention on the Rights of Persons with Disabilities requires that signatories to the convention adopt all appropriate legislative and administrative measures for the implementation of the rights stated in the convention. They are also to take steps to abolish laws, regulations, customs and practices that discriminate against the interest of persons with disabilities (UN, 2003) .
Mental illness is also discussed in the World Health Report (2001) entitled, New Understanding, New Hope, which highlights the problem of stigma and discrimination against people with mental illness. The report clearly demonstrated the benefit of working with social net-works in order to accord equal opportunities to all members of the society. The report stressed that the principle of social integration of all persons must be incorporated into all major interventions related to disability issues.
Article 19 of the United Nations Convention on the rights of persons with disabilities indicated that all persons with disabilities have the right to live in the community, and to choose their place of residence. The article further stated that Member State should facilitate the full participation in the community of persons with disabilities (UN, 2003) .
The European human rights particularly included several components that focus on issues that are critical for people with mental disorders. These components included the convention for the protection of human rights and fundamental freedoms like education, employment, social and legal promotion, free movement and non- social discrimination etc (Caldas, et al., 2011). Nigeria is a signatory to the United Nations Convention on People with Disabilities. The country formulated a mental health policy in 1991, which included the following components: advocacy, promotion, prevention, treatment and rehabilitation of people with mental illness .
Given that mental health is an important precursor of human development, the issues of stigma and discrimination need to be properly addressed .
1.2 Statement of the Research Problem The WHO (2013) estimated that the prevalence of mental illness in Nigeria is approximately 20%, this means that with a population of about 174 million in 2013, (World Bank, 2013), about 35.4 million Nigerians are suffering from mental illness (Oyewunmi, et al., 2015). Unfortunately despite this scary statistics, less attention is given to mental health disorders in Nigeria, compared to other diseases like HIV AIDS, Corona, Ebola, tuberculosis. There is also poor awareness of members of the public on mental health issues in Nigeria (WHO-AIMS Report, 2012).
In 2001, Nigeria and 20 other member nations of the African Union signed the Abuja declaration that promised to earmark 15 percent of their federal budgets for healthcare .
But WHO-AIMS report (2012) indicated that Nigeria had not made any sufficient progress towards that target. And by 2018, just 3.95% of the Nigeria‟s budget was allocated to funding Ministry of Health, out of which only 3.3% was allocated to mental health; this is no doubt insignificant considering the enormity of mental health problem in Nigeria .
Apart from the problem of funding, there is also the problem of trained personnel. The WHO- AIMS report (2011), estimated that only 3,195 mental health professionals were working in mental health care facilities in the Nigeria, which means there were just over 11 mental health professionals per 100,000 people. Of this number, there were only 42 psychiatrists (0.15 per 100,000) and 20 psychologists (0.07 per 100,000) .
This means there is lack of specialized personnel for mental health care in Nigeria. The report observed further that there is no extant legislation or policy on mental health in Nigeria. The existing Mental Health Policy document in Nigeria was formulated in 1991, and has not been revised. Moreover, Nigeria is still governed by the Lunacy Act, passed in 1958. The law is antiquated and manifestly not in tune with prevailing realities and best practices in mental health treatment. Thus, there is no direct legal framework to protect the rights of people with mental illness against unhealthy practices like involuntary admissions, discrimination which entails denial of employment, housing, etc and the lack of government social safety network to take care of mentally ill persons (Onyemelukwe, 2016). Family and patient associations, non-governmental organizations which focused on counseling, offering social support to people with mental health issues do not exist in Nigeria. There is absence of a coordinating
mechanism to take care of public education and awareness campaigns on mental health and mental disorders in Nigeria (WHO AIMS report, 2012). This means that People with mental illness and their relatives are left to bear the burden of the disease alone .
This is the stark reality of the problems people with mental illness face in Nigeria .
Apart from the problems highlighted above, people with mental illness also suffer a double challenge as a result of their mental illness. First they suffer from symptoms of the disability like hallucinations, delusions, anxiety and mood swings; the symptoms of the disease affect him in engaging in a paid jobs and other aspect of social life. Second, people with mental illness are challenged by the stereotype and prejudice from the public misconceptions about mental illness (Michaels, et al., 2012). Members of the public generally have negative attitude towards people living with mental illness, these negative attitudes are fuelled by public misconception and beliefs about mental illness .
These misconceptions include the belief that people with mental illness are dangerous, unpredictable, worthless, and that the disease is incurable (Abasiubong, et al., 2007). To compound the problem of people with mental illness, members of the public view them as evil and responsible for their mental disorders. People with mental illness that have been treated in the hospitals and have recovered still face tremendous difficulties accessing jobs from employers, housing from landlords and meaningful social interaction from members of the public, because of stigma and discrimination (Jack-Ide and Middleton, 2012) .
A study by Tormusa (2015) among some ethnic groups in Benue and Nassarawa States revealed that stigma and discrimination is prevalent among the Tiv people of Benue State. According to the study, it is believed among the Tiv people that people who have suffered from mental illness cannot get well again, that they have lost the ability to 9 think and act well and cannot be assigned leadership tasks. Another study by Ihaji et al., (2013) among the Tiv people of Benue State shows that mental illness is hereditary in families. However these studies did not consider the views of the people in other ethnic groups in Benue State. There is therefore the need to obtain a broader knowledge about stigma and discrimination among the people in the ethnic groups in the State .
Knowledge about attitude of members of the public will help in developing programs for reducing stigma and discrimination of mental illness .
The major consequence of society‟s stigma is that people with mental illness gradually begin to internalize the stigmatizing attitudes, which tend to erode previously held opinions about themselves. During this process, the stigmatized persons acquire dominant illness identity, this affects their self concept; they adopt coping strategies as a result of the public stigma by concealing their illness and not seeking treatment. As a result of this concealment, a vicious circle of isolation and abandonment is formed, impacting negatively on the domains of life and affecting chances of recovery and integration into normal life (Link, et al,. 1997). However, much attention has been placed by researchers on public attitude towards mental illness while the real experiences of people who suffer from public stigma are not given the desired attention .
Knowledge of the experiences of internalized stigma can help to develop intervention to help people with mental illnesses overcome the psychological and social effect of public stigma .
Mental health care professionals, both orthodox and traditional, are in constant contact with people with mental illness, because they provide health care services to them. With the constant contact they have with people having mental illness, it is expected that mental healthcare professionals should exhibit a better attitude towards people with 10 mental illness seeking healthcare. However, people with mental illness who have visited health care for treatment complained of prejudice and negative treatment against them by mental healthcare professionals. They have also complained that the attitude of mental health care professionals towards them have exacerbated the stigma that they experienced, through practices such as forceful treatment, chaining, restricting them, avoiding contact with them, and adopting a paternalistic stance towards them (Stuart, et al., 2012). A study on the attitudes of doctors towards people with mental illness in Western Nigeria by Adewuya and Oguntade, (2007), shows that Doctors too have negative attitude towards people with mental illness. The study further reveals that the medical Doctors considered people with mental illness to be unpredictable, dangerous, without self-control and aggressive, similar to the perceived public views in very many countries. The attitude of health care professionals towards people with mental illness is vital, remains a barrier to quality care, treatment and recovery and could affect the quality of mental health services and readiness to provide wholesome interventions for individuals with mental illness. While there is evidence in literature that there is stigma of healthcare professionals, the reasons for their negative attitude towards people with mental illness in Nigeria have not adequately been examined by literature .
In Nigeria, specialist mental health care hospitals are few and located in State capitals, isolated from rural areas and therefore inaccessible to the rural people. Apart from the problem of accessibility, cost of treatment of mental health care is also a major constraint for accessing professional mental health care. Because of theses constraints, most of the people with mental health challenges in the rural areas patronize traditional and mental health care services that are accessible and affordable to them (Coker, et al., 2015). For example in Benue State, Federal Medical Center Makurdi and Benue State University Teaching Hospital Makurdi are all situated in Makurdi, the State capital, far 11 away from people in the rural communities. It was observed that most people accessed traditional heath care for treatment because of the distance to Makurdi. Even at the traditional psychiatric care, people with mental illness are subjected to the most dehumanizing treatment at these treatment centers. An evidence of the bad treatment meted to people with mental illness was presented by Attoh (2013), based on his observation at a mental health healing center at Ogbunike in Anambra state, Nigeria .
Mental patients were chained to the ground, under the trees or in some uncompleted and unroofed structures and were not released from the chains no matter the weather conditions. They were subjected to inhuman treatment like beating with palm-fronds, which are believed to have the power to drive away the demons that cause mental problems. After the beating, “holy” pungent liquids are poured into their eyes and nose, commanding them to sniff it in or else face more beating .
While literature on stigma is available, literature on stigma of traditional mental health care professionals towards people that attend treatment in traditional psychiatric treatment is scanty. In order to effectively provide care for people with mental illness, the attitudes of health professionals towards psychiatric patients are important and needed to be evaluated .
Social stigma does not only affect people with mental illness. It also impact negatively on their family members’ social relationships as well, through what Goffman (1963) refers to as courtesy or associative stigma. Family members associate closely with their relatives who suffer mental illness and are involved in help-seeking and treatment decisions concerning their sick relatives. Family members of people with mental illness stay with them in the same compound take them to the hospital and take care of them 12 when they are sick. Because of their closeness to their sick relative, members of the public direct prejudice against them too .
The prejudice directed against family members of people with mental illness can impose a discrediting negative effect on them, with consequences of social isolation, status loss, discrimination and hiding of their sick relative, which in turn may result to delay in seeking treatment. All of these may result in poor quality of life, depression and increased emotional burden on family members (Ohaeri and Fido, 2001). A study by Catthoor et al., (2015) reveals that family members of people with mental illness reported that they tried to hide the mental illness of their relative always. The family members also reported being excluded from decision making process, being blamed for the affected person’s illness, and being avoided by members of the community. While it is known that family members suffer from prejudice as a result of associative stigma, not much is known about the facilitators and barriers to courtesy stigma and coping strategies among family members. Furthermore, much research have been done on stigma of mental illness, but most of the studies have mainly focused on the individuals with mental illness thus, neglecting the family members who are also affected by this stigma. It can therefore be stated that literature has not focused adequately on the stigma faced by family members of people with mental illness, especially in Benue State. Better understanding of experienced and self-courtesy stigma will reduce and alleviate the psychological distress and isolation that family members often experience, assist members of the public to show more empathy to family members of people with mental illness and help shape public policy in the prevention of stigma in patients and their family members .
13 There is therefore a need to carry out a study in the study area to fill the identified gaps in knowledge on the social stigma and discrimination against people living with mental illness .
1.3 Research Questions Derived from the statement of the problem, the following research questions were stated to aid the study: i. What is the attitude of members of the public towards people living with mental illness in Benue State? ii. What is the level of internalized stigma among people living with mental illness in Benue State? iii. Do mental health care professionals also discriminate against people living with mental illness? iv. How do stigma and discrimination affect the family members and relatives of people living with mental illness in Benue State? v. What are the coping strategies employed by people living with mental illness in managing stigma and discrimination? vi. How can the stigma and discrimination against people living with mental illness be reduced in Benue State? 1.4 Objectives of the Study The main objective of this study was to examine the social stigma and discrimination against people living with mental illness. The specific objectives are: 14 i. To determine the attitude of members of the public towards people living with mental illness in Benue State .
ii. To investigate the prevalence of internalized stigma among people with mental illness in Benue State .
iii. To examine the level of discrimination against people living with mental illness by mental health care professionals .
iv. To investigate how stigma and discrimination affect the family members of people living with mental illness in Benue State .
v. To identify the strategies used by people living with mental illness in coping with stigma and discrimination .
vi. To ascertain possible areas of intervention for reducing social stigma attached to people living with mental illness and their families in Benue state .
1.5 Significance of the Study The problem of social stigma and discrimination against people with mental illness and their family members have been the concern of governments, individuals and nongovernmental organizations. However, the goal of reducing social stigma and discrimination has not been achieved because of the attitude of members of the public against people with mental illness. Studies have been conducted on stigma of mental illness among the Tiv people, but studies on social stigma among the ethnic groups in Benue State have not been given attention. Moreover, the experiences of people who suffer from mental illness and their family members have not been given attention. This study therefore examined the attitude of the ethnic groups in Benue State towards people with mental illness, the experiences of people who suffer from mental illness and their family members. The result of this study served both theoretical and practical 15 purposes. Theoretically, the study gave an insight into the social stigma and discrimination prevalent among the ethnic groups in Benue State. The study also brought to fore the experiences of people suffering from mental illness as a result of public stigma, especially those treated at the traditional psychiatric centers. This has no doubt added to literally knowledge on social stigma and discrimination against mental illness .
This study is important to policy formulation because it revealed that the prevalence of elevated internalized stigma among the people living with mental illness who attended traditional health care is more than those who attended orthodox care. This finding is important to policy formulation because further interventions to reduce social stigma should include people receiving traditional psychiatric care .
Furthermore, social advocates, campaigners and activists for the rights of the mentally sick may find the work helpful as the recommendations of the study help them focus their anti stigma campaigns on not just members of the general public but on family members of people living with mental illness as well. Members of the public may be interested in the work because it may help them have a better understanding of stigma against people living with mental illness .
1.6 Scope and Delimitation of the Study The study examined social stigma and discrimination towards people living with mental illness and their family members in Benue State, Nigeria. Specifically, the study examined the attitudes of members of the public in Benue State towards people with mental illness and their family members. The study also determined the prevalence of 16 internalized stigma among people living with mental illness accessing treatment at both orthodox and traditional psychiatric health care centres. The study also determined attitude of healthcare professionals towards people living with mental illness. The scope also included identifying the strategies used by people living with mental illness to cope with stigma and discrimination, and suggesting possible areas of intervention to reduce stigma .
1.7 Justification of the Study The study was carried out to examine social stigma and discrimination against people living with mental illness in Benue State. This study was carried out to provide an understanding of the attitude towards mental illness among the different tribes in Benue State. The study was essential because it served as a baseline for the developing of awareness among members of public and healthcare professionals about stigma and discrimination of mental illness .
1.8 Limitations of the Study The study had the following limitations. First, the study was carried out in only two orthodox hospitals in Benue State: Benue State University Teaching Hospital Makurdi and Federal Medical Centre Makurdi, and in six traditional psychiatric hospitals in Benue State. Hence, the findings cannot be generalized; this is because the study setting, sample size and particulars of people with mental illness receiving care in the hospital, especially their social class, were not representative of the entire population .
This also means that only people with mental illness receiving care at these health centers were included in the study, if a survey were made of people affected by mental 17 illness not receiving care in hospital, different results could be obtained. Secondly, the study is a cross-sectional study, which is just a snapshot of what took place within the time of the study. A different result could be obtained if the study were longitudinal .
Notwithstanding these limitations, the strength of this present study lies in its large sample size and its ability to study different ethnic groups in Benue State which have brought out varied perspectives in the study of stigmatization of mental illness .
Moreover, the study used a mixed method and this is expected to produce a better result .
1.9 Operational Definition of Terms 1.9.1 Social stigma. For the purpose of this study, social stigma is used to refer to negative behavior of members of the public towards a person with an attribute that violates the norms of the society for example, a person who has mental illness .
1.9.2 Social stigma of mental illness. For the purpose of this study, the social stigma of mental illness refers to a negative perception and reaction against a person who has lost social status as a result of having suffered from mental illness and is thus devalued, and considered inferior by members of the public. Such a person carries the label wherever he or she goes. Such a person is referred to as “mad” “crazy” “lunatic”. The social stigma is manifested when members of the public refuse to associate with them, refuse to give them responsibilities, use of denigrating words against such persons, refusing to marry from families with members who are suffering from mental illness, and refusing to share accommodation with those affected .
18 1.9.3 Discrimination of mental illness. For the purpose of this study, discrimination refers to how people are scorned or treated unfairly in the society because they have mental illness .
1.9.4 Mental illness. Mental illness is here referred to as “ihundugh” in Tiv language and is synonymous to mental disorder and psychiatric disorders. These concepts will be used interchangeably except where otherwise stated. For the purpose of this study, mental illness refers to a disease that affects the mind, mood, brain and behavior of the affected person and involves a change in emotion, thinking and is characterized by awkward and bizarre behavior such as talking to oneself, mood swing, untidy appearance, inappropriate effect and often disruptive behavior which makes the person less acceptable by members of the public .
Mental illness is derogatively known by different names such as craziness, lunacy, madness, abnormality etc. As used in this study, mental illnesses refer to: mood disorders (such as depression or bipolar disorder), personality disorders, psychotic disorders (such as schizophrenia), trauma-related disorders (such as post-traumatic stress disorder) substance abuse disorders. These groups of mental illness are chosen because they are perceived to be aggressive and dangerous and are therefore stigmatized and discriminated more by members of the public more .
1.9.5 Family members. These are also referred to as caregivers or significant others .
These are individuals who are biologically or socially related and who have been living with the person having mental illness for a period of six months or more. They include father, mother, sister, brother, son, daughter and other family members or friends .
19 1.9.6 People living with mental illness or mentally sick persons refers to individual(s) who are 18 years and above and have been diagnosed with mood disorders (such as depression or bipolar disorder), personality disorders, psychotic disorders (such as schizophrenia), trauma-related disorders (such as post-traumatic stress disorder), substance abuse disorders, have been treated for a period of one year or more and recovered and are well enough to engage in an intelligible discussion as adjudged by an orthodox or traditional psychiatric doctor. These groups of mental illness are chosen because the patients are perceived to be aggressive and dangerous and are therefore stigmatized and discriminated against by members of the public .
1.9.7 Public attitude towards people with mental illness. For this study, it refers to negative or positive behavior of members of the community towards people with mental illness .
1.9.8 Internalized stigma of mental illness refers to an endorsement of the negative behavior of members of the public towards people having mental illness .
1.9.9 Stereotypes are defined as negative expectations of members of the public about a person with mental illness .
1.9.10 Prejudice refers to unpleasant emotional affective attitude towards people with mental illness. It implies association with derogatory or pejorative attitude 20
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