Addressing psychiatric and psychosocial issues related to children and adolescents
Stigma was first established as a sociological construct by Erving Goffman in the 1960s. Goffman (1963) defined stigma as “the phenomenon whereby an individual with an attribute which is deeply discredited by his/her society is rejected as a result of the attribute” (p. 3). He viewed stigma as a process by which the attitudes and behaviors of others could damage the normal identity of individuals. Within Goffman's social analysis, one of the most discrediting and socially damaging stigmas in 20th-century Western society was mental illness. Approximately 60 years later, young people (age ≤25 years) with mental health problems continue to experience stigma, which undermines the achievement of their life goals (Corrigan, 2016). This stigma leads to discrimination in education, employment, health care, and can ultimately lead to social exclusion (Corrigan et al., 2014). Stigma can result in young people with mental illness being stereotyped as dangerous, chronically impaired, or somehow culpable for their health condition (Kosyluk et al., 2018).
Richerson and Boyd (2005) define culture as “information capable of affecting individuals' behavior that they acquire from other members of their species through teaching, imitation, and other forms of social transmission” (p. 5). This information can take the form of cultural beliefs about the etiology of mental illness (Makanjuola et al., 2016). For example, the biomedical model that emphasizes biological causation of the symptoms of mental illness dominates in Western cultures, whereas psychosocial, supernatural, and spiritual attributions are common in non-Western cultures (Kate et al., 2012; Makanjuola et al., 2016). Cultural beliefs shape perceptions of stigma related to mental illness, and as a consequence, the stigmatizing of people with mental illness has been found to vary across cultures (Rao et al., 2007). Culture also influences the range of social responses that these experiences elicit, which may include forms of treatment (Stone & Finlay, 2008).
Mental Illness Stigma and Young People
Stigma associated with mental health problems is not clearly understood in childhood and adolescence due to a near absence of research in the area up until the start of the 21st century (Heary et al., 2017). Studies that have been performed in recent years provide glimpses into how stigma presents within some populations. For example, we know that stigma begins early in life, as young people report developing stigma toward individuals with mental health problems, including their peers (O'Driscoll et al., 2012; Reavley & Jorm, 2011). Children as young as 7 years old have been found to be able to describe their negative understandings of the word “crazy” and apply it to vignettes about adults with symptoms of mental illness (Spitzer & Cameron, 1995). Young people who themselves experience mental health problems report being more likely to experience a sense of social distance from others (Martin et al., 2007). They identify being subjected to higher levels of victimization in comparison with their peers who do not have mental health issues (Sentenac et al., 2012). They have also reported encountering higher levels of stigma than their peers with other health issues, such as chronic physical illnesses (Kaushik et al., 2016; Sentenac et al., 2010). With such social circumstances, young people with mental health issues are often reluctant to disclose their illness to peers (Kaushik et al., 2016). This reluctance to disclose their illness can increase the risk of young people using alcohol and other drugs as means to cope with the experience of stigma (Kranke et al., 2017). In addition, stigma is also commonly reported as a barrier to young people seeking help and accessing mental health–related services (Clement et al., 2015).
Mental Illness Stigma and Young People Within a Cultural Context
As noted earlier, culture is a crucial factor in understanding variations in stigma experiences (Abdullah & Brown, 2011). Although stigma has been observed to be ubiquitous across cultures (Dovidio et al., 2000), within cultural groups, the beliefs, practices, and outcomes of stigma may differ significantly (Yang, 2007). For some individuals, beliefs about stigma may have little or no similarity with the dominant cultural beliefs of their society (Bracke et al., 2019). Within society, stigmatization of individuals and minority groups based on sociocultural factors can result in discrimination, marginalization, and poorer outcomes across a range of health and psychosocial measures (Carr et al., 2014).
Psychiatric–mental health nurses (PMHNs) can provide care to young people who are members of more than one stigmatized group within society due to social attitudes related to their ethnic minority status and their diagnosis of mental illness (Knesebeck et al., 2017). For young people, this experience of layered stigma can be particularly damaging as they struggle to establish a positive sense of identity and connection within society (Henkel et al., 2008; Knesebeck et al., 2017). It is therefore vital that PMHNs are able to recognize and respond to the multiple ways in which stigma may be present (Papadopoulos et al., 2013). Shepherd (2019) argues that because culture influences how a young person communicates their lived experience of mental illness to a PMHN, “narratives of distress, illness metaphors, and symptom reporting styles” (p. 151) can all be shaped by their culture and cultural identity. PMHNs must therefore be able to demonstrate cultural awareness, establish therapeutic rapport, and provide opportunities to promote recovery (Procter et al., 2017).
The participation of family members in the planning and delivery of care can have a significant impact on the process of personal recovery and can reduce burden experienced among family members (King & Crowe, 2012). Cultural differences regarding mental illness may be associated with increased experiences of shame and stigma within families, which deter help-seeking behaviors among carers, resulting in suboptimal treatment outcomes (Subandi et al., 2020). The experience of shame in turn may lead to family members being secretive about what is happening to their young relative and reducing their level of participation in the community (Poon et al., 2013). Culture also influences role expectations related to the care of a family member (Somasundaram, 2011). Role expectations structure caregivers' beliefs about their obligations and can even influence their sense of well-being during the caregiving experience (Bui et al., 2018; Tan et al., 2012).
Cross-Cultural Mental Health Care Implications
Culture and connections to culture play a key role in personal recovery (Molloy et al., 2019). Although it is impossible for PMHNs to be cognizant of all cultural belief systems related to mental illness, there are models of care that can facilitate engagement with the nuances of a young person's culture and provide the foundations of appropriate care through respectful curiosity. For example, cultural safety can be an effective way for engaging young people within nursing care (Gray et al., 2003). Cultural safety involves an approach to caring for people where there is no denial of their identity or their care needs and a key focus is on the establishment of shared respect, shared meaning, and shared knowledge (Williams, 1999). The approach influences nursing practice through reflection; it requires PMHNs to explore and identify the assumptions surrounding their care (Ramsden, 2002). This approach includes PMHNs reflecting on their own cultural perspectives, and how these may affect the care they provide to young people (Molloy & Grootjans, 2014). Because cultural safety aims to empower young people receiving care, only they can assess its effectiveness. This empowerment gives them the ability to shape their care through contribution to the nursing process, ensuring it connects with their cultural needs and understandings. By using the concept to guide practice, PMHNs can provide care that promotes positive recognition of diversity and is supportive of personal recovery (Gray et al., 2003; Molloy & Grootjans, 2014).
Although the influence of stigma and culture on mental health is widely acknowledged, the empirical literature on how these issues relate to young people is underdeveloped. Given the dearth of evidence to guide practice, there is a need for PMHNs to develop understandings of the ways culture and stigma impact young people. The ideas of cultural safety provide PMHNs with a framework for engagement that can support them in developing this knowledge.
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