|Year : 2014 | Volume
| Issue : 5 | Page : 550-557
Felt stigma and self-esteem among psychiatric hospital outdoor and community camp attending patients
Shantna Kumari1, Inderjeet Banerjee1, G Majhi2, Suprakash Chaudhury2, Amool R Singh1, AN Verma1
1 Department of Psychiatric Social Work, RINPAS, Kanke, Ranchi, Jharkhand, India
2 Department of Psychiatry, Pravara Institute of Medical Sciences (Deemed University), Rural Medical College and Pravara's Rural Hospital, Loni, Ahmednagar, Maharashtra, India
|Date of Web Publication||10-Sep-2014|
Department of Psychiatry, Pravara Institute of Medical Sciences (Deemed University), Rural Medical College and Pravara's Rural Hospital, Loni, Ahmednagar - 413 736, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: Self-stigma of people with mental illness is a major obstacle to recovery, limiting opportunities and undermining self-esteem. Aim: The aim of this study is to compare felt stigma and self-esteem in psychiatric patients receiving treatment from hospital outdoor clinic or from Community Outreach Program (COP). Materials and Methods: This cross-sectional study was conducted on psychiatric patients who were on outpatient treatment for at least 6 months, but had never been hospitalized. The study sample included 130 patients receiving outdoor treatment from a Psychiatric Hospital and a matched group of 140 patients receiving treatment from COP of the same hospital. Demographic and clinical details of the patients were recorded on a specially designed proforma. Modified felt stigma scale and Rosenberg self-esteem scale were used to assess stigma and self-esteem, respectively. Results: On the modified felt stigma scale, the mean (±standard deviation [SD]) score of psychiatric hospital outpatients (31.89 ± 6.51) was significantly higher than the scores of patients attending COP (29.20 ± 6.80). On Rosenberg self-esteem scale, mean (±SD) scores of patients with psychosis (17.98 ± 1.69) was significantly lower compared to scores of patients with epilepsy (21.83 ± 1.60). There was no significant correlation between stigma and self-esteem. Conclusion: As psychiatric hospital outpatients have significantly more self-stigma when compared to patients attending community outreach camps, the availability of more community outreach camps along with educating people about psychiatric illnesses may help in lowering stigma of psychiatric disorders.
Keywords: Community and hospital outpatient clinic attendees, felt stigma, self-esteem
|How to cite this article:|
Kumari S, Banerjee I, Majhi G, Chaudhury S, Singh AR, Verma A N. Felt stigma and self-esteem among psychiatric hospital outdoor and community camp attending patients. Med J DY Patil Univ 2014;7:550-7
|How to cite this URL:|
Kumari S, Banerjee I, Majhi G, Chaudhury S, Singh AR, Verma A N. Felt stigma and self-esteem among psychiatric hospital outdoor and community camp attending patients. Med J DY Patil Univ [serial online] 2014 [cited 2019 Aug 22];7:550-7. Available from: http://www.mjdrdypu.org/text.asp?2014/7/5/550/140365
| Introduction|| |
Stigma is conceptualized as: "An attribute that is deeply discrediting," "an undesired differentness," and something that reduces the bearer "from a whole and usual person to a tainted, discounted one."  Stigmatization involves a separation of individuals labeled as different from "us" who are believed to possess negative traits, resulting in negative emotional reactions, discrimination, and status loss for the stigmatized persons. The literature describes three interacting levels of stigma: Social (public or enacted), structural (institutional) and internalized (self or felt) stigma. Internalized stigma exists at the individual level and in the context of mental illness, can be described as a process whereby affected individuals endorse stereotypes about mental illness, anticipate social rejection, consider stereotypes to be self-relevant, and believe they are devalued members of society. Psychosocial processes that lead to stigmatization include labeling, stereotyping, separating, status loss, and discrimination in a context of power imbalance. ,,
Stigma may influence how a psychiatric diagnosis is accepted, whether treatment will be adhered to and how people with mental illness function in the world.  Schizophrenia has been found to be one of the most stigmatizing conditions, and studies reveal four dimensions of stigma: Interpersonal interaction, structural discrimination, public images of mental illness and access to social roles. ,,, Individuals labeled with mental illness believe that most people reject and devalue people with mental illnesses and therefore constrict their social networks and opportunities in anticipation of rejection due to stigma. They may suffer a number of negative outcomes, such as demoralization, isolation, impaired social adaptation, unemployment, income loss, less willing to seek treatment, reduced psychiatric medication adherence, and lowered self-esteem. ,,
In psychology, the term self-esteem is used to describe a person's overall sense of self-worth or personal value. Self-esteem is an important component of psychological health. Low self-esteem increases the susceptibility for development of psychiatric disorders such as depression, eating disorders and substance abuse, and the presence of a psychiatric disorder, in turn, lowers self-esteem. , In patients with psychosis low self-esteem has been implicated in both the development of delusions  and maintenance of psychotic symptoms. 
Internalization of stigma and loss of self-esteem; however, are not inevitable. Previous research on attributes other than mental illness has found that although stigmatized groups often experience lower self-esteem, this is not always the case. Some reports downplay the importance of stigma, indicating that it is "transitory and does not appear to pose a severe problem" or that former patients "enjoy nearly total acceptance in all but the most intimate relationships." Some people react to stigma by becoming energized and empowered, whereas others remain relatively indifferent and unaffected. ,,
This study aimed to see the difference of felt stigma and self-esteem among patients getting treatment from a psychiatric hospital outpatient department (OPD) and those receiving treatment from Community Outreach Program (COP) provided by the same hospital. In view of findings of few studies that psychiatric hospital treatment is associated with higher felt stigma  it was hypothesized that persons getting treatment from community services will report lower stigma in comparison to persons getting treatment from hospital OPD. Second, we aimed to see the interrelationship of felt stigma and self-esteem among these groups.
| Materials and Methods|| |
The study was carried out at Community Outreach Camps and OPD of Ranchi Institute of Neuropsychiatry and Allied Sciences (RINPAS), Kanke, Ranchi. RINPAS is a postgraduate teaching hospital running courses in Psychiatry, Clinical Psychology, Psychiatric Social Work and Psychiatric Nursing. It is a 500 bed referral center for all acute psychiatric hospitalizations and outdoor patients within its catchment area, which includes patients from state of Jharkhand, Bihar, Orissa, Chhattisgarh and West Bengal. In addition to psychiatry OPD, the hospital also runs medical, ophthalmology and Dental OPD. RINPAS also runs a regular COP once a month at four different locations where patients with psychiatric disorders and epilepsy are treated. A medical team consisting of psychiatrist, physician, psychiatric social worker and trainee psychiatrists, psychiatric social workers, clinical psychologists and psychiatric nurses visit the COP. Patients attending OPD and COP are supplied medicines for 1 month free of cost. Average attendance at psychiatric OPD is about 200/day. The average attendance at outreach program is about 200 at Jonha, 500 at Khunti, 700 at Saraikela and 900 at Hazaribagh. The study protocol was approved by the Institutional Review Board, and ethical clearance was obtained from the Institutional Ethical Committee. Informed consent was obtained after sharing the objectives of the study and reassuring the participants about their anonymity and the confidentiality of information they were providing.
Purposive sampling technique was used for the selection of the sample. For this study, 140 patients were selected from the monthly community outreach camps and 130 patients from the OPD of RINPAS. None of the patients who were approached refused to participate in the study. Psychiatric diagnoses were made as per International Classification of Diseases (ICD-10) Diagnostic Criteria for Research by the consultant psychiatrist. A cross-sectional design was used to examine felt stigma and self-esteem among persons with at least history of 6 months of treatment and never been admitted as an inpatient. Subjects were between the age ranges of 18-45 years and were educated minimum up to primary level. Both male and female subjects were taken for the study. Patients with severe symptoms (since they were not able to complete the proforma), any evidence of organic mental disorder (dementia, delirium, organic amnestic syndrome, etc.) and comorbid substance dependence or major medical disorders (apart from epilepsy) were excluded from the study. For the purpose of analysis, the patients were divided into three groups viz., those with psychotic disorder (schizophrenia, schizoaffective disorder, delusional disorder, acute and transient psychosis, other nonorganic psychosis, mania, depression and bipolar disorder, etc.) epilepsy and others (anxiety disorders, dysthymia, obsessive compulsive disorder, somatoform disorders, substance use disorders, etc.).
Sociodemographic and clinical data sheet
The sociodemographic data sheet included age, sex, education, marital status, occupation, religion, domicile, and monthly income. Apart from the diagnosis, clinical variable recorded included the duration of illness and treatment duration.
Felt stigma scale
To assess the felt stigma the stigma scale was used.  This self-report questionnaire, which can be completed in 5-10 min, may help us understand more about the role of stigma of psychiatric illness in research and clinical settings. The scale was modified for use in this region. Of the 28 items of the original scale, 15 items were selected as appropriate to sociocultural aspects of the sample selected for the study (scale is given in Appendix[Additional file 1] ). The scoring was done on three-point scale as strongly agreed, agreed and not agreed. Of the 15 items included for the study, 11 items were positively worded, and 4 were negatively worded. Hence, the score was reversed for negatively worded items. The minimum score that can be obtained was 15 which signified no stigma while the maximum score was 45. Higher scores show higher felt stigma.
Rosenberg self-esteem scale
To assess self-esteem Rosenberg self-esteem scale used.  The scale generally has high reliability: Test-retest correlations are typically in the range of 0.82-0.88, and Cornbach's alpha for various samples are in the range of 0.77-0.88. This is a 10 item scales which is scored on a four point scale, but we modified it to three point scale. For item 1, 2, 4, 6, and 7, the score ranged 3 strongly agree to 1 disagree, and for the rest it reversed as 1 for strongly agree to 3 for disagree. However, the author also suggests that the scoring can be modified as per need of the study. Hence for this study, the score range of the scale was 10-30 with higher scores indicating higher self-esteem.
| Procedure|| |
Sociodemographic and clinical information of participants who fulfilled the inclusion/exclusion criteria was collected using the sociodemographic and clinical data sheet. Participants were selected from the outpatient services and COP of RINPAS. To assess the perceived stigma felt stigma scale was administered. Rosenberg self-esteem scale was administered to assess self-esteem.
The Statistical Package for the Social Sciences (SPSS) 10.0 version was used for statistical analysis. Data of this study is described using, t-test for continuous variables and Chi-square test for categorical variable. Kruskal-Wallis was used to see the group deference of felt stigma and self-esteem according to diagnostic breakup and further Mann-Whitney U-test was administered to see the difference in self-esteem in between these groups. To see the relationship between the variables Carl Pearson correlation was used.
| Results|| |
[Table 1] shows the demographic and clinical characteristic of the OPD and COP patient sample. Both groups were matched for age, sex and marital status, but they differ significantly for caste, religion, monthly income and residence. In COP attending sample, >60% of patients belonged to Tribes and most of them followed Sarna (tribal) religion. >90% of community attending patients resided in a rural area, and 52% are below the poverty line. It is evident that more than 70% of hospital OPD group having psychotic illness while 50% of community camp attending patients were diagnosed with epilepsy and the difference was statistically significant. However, there were no significant differences among the groups for the duration of illness and duration of medical treatment. The level of felt stigma was significantly more in hospital OPD patients in comparison to community camp attending patients, but self-esteem was not significantly different in the two groups [Table 2]. In the total sample, the felt stigma was not found to differ between patients with psychosis, epilepsy patients, and other patients. On the other hand, self-esteem was found to differ significantly between persons with psychosis and epilepsy in the total sample [Table 3] and [Table 4]. However, when the hospital OPD attending patients and community camp attending patients were analyzed separately, felt stigma and self-esteem was not found to significantly differ according to diagnostic breakup [Table 5]. The felt stigma and self-esteem negatively correlate for the whole group (r = −0.057; P = 0.349) and for community attending patients (r = −0.161; P = 0.058) while for hospital OPD patients group the correlation was positive (r = 0.009; P = 0.922). The correlation was not significant for any group.
|Table 1: Demographic and clinical characteristics of the patients attending hospital OPD and COP|
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|Table 2: Comparison of felt stigma and self-esteem between patients attending hospital OPD and COP|
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|Table 3: Comparison of felt stigma and self-esteem according to diagnostic breakup in the whole group|
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|Table 4: Comparison of self-esteem between diagnostic breakups in the whole group|
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|Table 5: Comparison of felt stigma and self-esteem according to diagnostic breakup in patients attending hospital OPD and COP|
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| Discussion|| |
Stigma affects people adversely. Stigmatization negatively influences the social life and psychological processes of both the patient and their relatives and thereby causes a decrease in their "quality of life."  In addition to poorer social functioning, those with the stigma of mental illness also encounter a significant barrier to obtaining general medical care  and to recovery from mental illness. ,, Studies on stigma and mental illness in the Indian setting have focused both on measurement of stigma and on locally important sociocultural factors shaping stigma. ,, Rural Indians showed significantly higher stigma scores. The overall pattern of differences between rural and urban samples suggests that the former deploy a punitive model toward the severely mentally ill, while the urban group expressed a liberal view of severe mental illness.  A study of stigma related to depression in Bangalore observed that patients reporting somatic symptoms had lower stigma scores than those reporting psychological symptoms. Qualitative analysis revealed that depressive symptoms were perceived as socially disadvantageous as these may affect marriage and social status.  Utilizing databases from London and Bangalore, the authors subsequently compared new patients with a diagnosis of ICD-9 depressive neurosis at both sites and found higher levels of self-perceived stigma in the London sample. 
This study examines the felt stigma and self-esteem among patients attending hospital OPD and COP. Secondly we studied the relation between felt stigma and self-esteem in these groups. Both the groups matched for age, sex, education, marital status, and occupation, duration of illness and treatment duration but significantly differ for caste, religion, domicile, and monthly income. Our study revealed that the majority of the patients felt stigma for their psychiatric illness and psychiatric hospital outpatients felt significantly more stigma than patients attending community camps.
Other studies in which some of the participant receiving services as outdoor or in the community reported a high level of stigma felt by most of the study population. A nationwide survey of 1301 mental health consumers, the majority of respondents tended to try to conceal their disorders and worried a great deal that others would find out about their psychiatric status and treat them unfavorably.  Another study observed that 53% of 1824 persons with serious mental illness reported some experience of discrimination.  A study from Taiwan reported that 25% out of 247 outpatients had high levels of self-stigma.  Among 193 Chinese patients attending a psychiatric outpatient clinic in Hong Kong, 11% indicated that they were neglected by health care professionals and 8% had been avoided by family members. 
There are very few studies, which compare psychiatric hospital outpatients with patients attending community psychiatric services. In one study from Germany, it was hypothesized that patients sent to mental hospitals would feel more stigmatized than would patients assigned to a university hospital. Just opposite to their prediction, findings revealed that university hospital patients perceived more stigmatization. Mental hospital patients were significantly less likely than university hospital patients to believe that most people would devalue and discriminate against mental patients.  A meta-analysis revealed that 7 out of 10 studies did not find a significant relationship of stigma with psychiatric hospitalization; 2 studies found a positive relationship and one reported a negative relationship. 
In this study, when the felt stigma was compared on the basis of diagnostic breakups, no significant differences were found in the whole group and in both hospital outpatients and community camp attending patients. This finding is in agreement with few earlier studies. A comparative study found that a fair proportion of patients with schizophrenia or depression perceived stigma in contrast, the cardiac patients reported very little stigmatization. The study revealed that the diagnostic label of mental illness may render the person vulnerable to stigmatization.  Stigma was a pervasive concern to almost all the patients (n = 46) from the community and day mental health services in North London. People with psychosis, were most likely to report feelings and experiences of stigma and were most affected by them.  In 74 stable outpatients with schizophrenia receiving community care, 70% were worried about being viewed unfavorably because of their psychiatric illness and 58% avoided telling others about it.  The stigma of epilepsy was assessed in >5,000 patients living in 15 countries in Europe. About 51% reported feeling stigmatized, with 18% reporting feeling highly stigmatized.  This finding is in agreement with high stigma in patients with epilepsy in the present study.
When we compare the study group on self-esteem they did not differ significantly, but on the basis of diagnostic breakups they differ significantly and the difference was seen between patients with psychosis and epilepsy. Another finding of the study suggests that there is no significant relationship between self-esteem and felt stigma either in whole patients group or in patients attending hospital outdoor and community camp. Previous studies on the relationship between stigma and self-esteem have given contradictory results. One reason for this is that it is often assumed that membership in a stigmatized group has negative consequences for the self-concept. However, this relationship is neither straightforward nor inevitable, and there is evidence suggesting that negative consequences may not necessarily occur. It has been argued that the relationship has not been sufficiently theorized and that a more detailed analysis is called for in order to understand the relationship between stigma and the self. One study critically examined the modified labeling theory, with examples from a study examining perceptions of stigma and their relationship to self-evaluation. The participants did not deny their mental health problems, but their acceptance of labels was critical and pragmatic. Labels were rejected when they were perceived as carrying an unrealistic and negative stereotype. The research illustrates the importance of considering people's subjective understandings of stigmatized conditions and societal reactions in order to understand the relation between stigma and the self. 
Another study also reported that published narratives by persons with serious mental illness eloquently describe the harmful effects of stigma on self-esteem and self-efficacy. However, a more careful review of the research literature suggests a paradox; namely, personal reactions to the stigma of mental illness may result in significant loss in self-esteem for some while others are energized by prejudice and express righteous anger. Added to this complexity is a third group: Persons who neither lose self-esteem nor become righteously angry at stigma, instead seemingly ignoring the effects of public prejudice altogether. The article draws on research from social psychologists on self-stigma in other minority groups to explain this apparent paradox. A situational model of the personal response to mental illness stigma is described based on the collective representations that are primed in that situation, the person's perception of the legitimacy of stigma in the situation, and the person's identification with the larger group of individuals with mental illness. 
On the other hand to determine whether stigma affects the self-esteem of persons in one study 70 patients with serious mental illnesses were assessed. The findings revealed that the stigma associated with mental illness harms the self-esteem of many people who have serious mental illnesses. The authors suggest that an important consequence of reducing stigma would be to improve the self-esteem of people who have mental illnesses.  Markowitz  had reported that for persons with severe mental illness, controlling symptoms, regaining a positive sense of self, dealing with stigma and discrimination, and trying to lead a productive and satisfying life is increasingly referred to as the ongoing process of recovery. Using longitudinal questionnaire data from 610 persons in self-help groups and outpatient treatment they found that there is a reciprocal relationship between symptoms, self-concept, and life satisfaction and stigma.
Finally, in 31 patients with schizophrenia it was reported that a higher level of perceived stigma is associated with a lower level of self-esteem.  In view of the fact that in this study also there was a trend toward a negative correlation of stigma and self-esteem, further research is needed to conceptualize the relationship between stigma and self-esteem.
The findings of this study indicate the urgent need to plan interventions to address felt stigma and lower self-esteem in patients with mental illness. Creating awareness about felt stigma can initiate a dialogue between patients with psychiatric disorders and the rest of the population. Public stigma can be challenged, and the general population may realize the extent to which persons with psychiatric disorders are affected by stigma. Educating the general public about mental disorders may also help reduce the stigma.
Future studies should be conducted in various settings in India across different sociodemographic variables to understand the various facets of internalized stigma. Studies can further expand the scope of their interest by including persons with different psychiatric diagnosis and correlate self-stigma and self-esteem in each group of patients. If the findings of psychiatric patients attending psychiatric hospital OPD having higher levels of stigma compared to patients attending COP is confirmed in future studies then a policy decision to start COP by all mental hospitals needs to be considered. Apart from reducing stigma this will make psychiatric services available nearer to the patient's home.
In this study, a modified felt stigma scale was used, which may compromise the results. Patients with severe symptoms were not included and your results are limited to neurotics, epileptics and psychotics who were stable with outpatient treatment. The OPD sample contained a high proportion of patients with psychosis, while the COP sample had a high proportion of epilepsy patients, which may have affected the results.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]