Mental Health Stigma in the Muslim Community

Mental illness stigma continues to be a major barrier for individuals with mental illness. In this paper, we define constructs that comprise stigma (e.g., attitudes, stereotypes, prejudice, discrimination), discuss the harmful effects (e.g., label avoidance, public stigma, selfstigma) and present factors that may influence them (e.g., concealability). In order to better understand mental health stigma in Muslim community, we focus on intersectional stigma and present literature on the complex relationships among race/ethnicity, gender, class, religion, and health status among Muslims. In addition, we include literature highlighting culturally specific presentations of symptoms and mental health problems. Finally, we offer suggestions for future stigma research in Muslim communities. And We will surely test you with something of fear and hunger and a loss of wealth and lives and fruits, but give good tidings to the patient (Surat AiBaqarah 2:155) Although mental health care has improved significantly over the last decades, many people still choose not to seek treatment or quit prematurely. A number of possible factors contribute to these disparities with stigma being perhaps the most significant. Stigma hurts individuals with mental illness and their communities, creating injustices and sometimes devastating consequences. In this paper, we discuss mental illness stigma and its related constructs, describe the 18 Ayse Ciftci, Nev Jones, and Patrick Corrigan current state of understanding mental illness stigma in Islam, and summarize critical considerations to address stigma in this community. Stigma is defined as “the situation of the individual who is disqualified from full social acceptance” (Goffman, 1963, p. 9). In this paper, we distinguish label avoidance from public stigma. Label avoidance refers to instances in which individuals choose to not seek help for mental health problems in order to avoid negative labels (Corrigan, Roe, & Tsang, 2011). In order to avoid psychiatric labels, individuals may choose to not associate themselves with mental health clinic or professionals avoiding diagnosis by avoiding mental health care. Public stigma is the prejudice and discrimination that blocks individuals’ access to employment, educational opportunities, health care, and housing. Public stigma occurs when members of the general public endorse stereotypes about mental illness and act on the basis of these stereotypes. In order to unpack the stigma process, it is helpful to differentiate key terms that comprise the stigma construct: attitudes, stereotypes, prejudice, and discrimination (Corrigan, Roe, & Tsang, 2011). We form attitudes based on seemingly factual views of the world and our values and emotional reactions to these views. Attitudes can be positive or negative. Stereotypes are attitudes made about individuals based on their assignment to a particular group or category. Stereotypes per se rely on generalizations that are often inaccurate or misleading when applied to particular cases. Prejudice refers to negative affective attitudes toward particular groups and implies agreement with derogatory or pejorative stereotypes. An individual walking by men wearing turbans, for example, might not only assume that they are terrorists (a stereotype) but also feel anger and fear toward them because of their presumed dangerousness (prejudice). Discrimination is the behavioral component of stigma and occurs when people act on the basis of prejudiced attitudes or beliefs. For example, individuals who believe that Muslim men are ‘dangerous’ and untrustworthy might avoid neighborhoods in which Muslim families live, or report these men to airport police for “suspicious” activities. Behavioral discrimination might also occur in subtle forms such as choosing not to sit next to an individual wearing a turban on the train. Both label avoidance and selfstigma are frequently framed as consequences of public stigma (Corrigan et al., 2001). Selfstigma occurs when individuals belonging to a stigmatized group internalize public prejudice and direct it toward themselves. The selfstigma process can be broken down into component parts, including awareness (e.g., are individuals aware of the stereotypes related to the mental illness? ), agreement (e.g., do they agree with the stereotypes? ), application (e.g., do they apply these stereotypes to themselves? ), and harm (e.g., is this stereotyping harming their selfesteem or selfefficacy to use coping skills to fight stigma’s effect? ; Corrigan, Larson, & Kuwabara, 2009). One Mental Health Stigma in the Mental Health Community 19 of the most significant harms resulting from selfstigma is the foreclosure of important life pursuits by individuals who come to believe they should not pursue goals that society thinks such individuals cannot succeed in (Corrigan, Larson, & Rusch, 2009). Factors that Influence or Moderate Stigma Jones and colleagues (1984) propose that stigma is moderated by six factors: concealability, course, disruptiveness, aesthetic qualities, origin, and peril. Concealability refers to the relative apparency of a stigmatizing attribute. Skin color is often visible, whereas mental illness can often be concealed. While highly visible stigmas lead to immediate discrimination, concealable stigmas have other negative consequences. Although a stigma such as mental illness can be hidden in some circumstances, management of information about it— who to disclose to, who not to, how to keep records hidden— may lead to high levels of social stress and strained social interactions (Beatty & Kirby, 2004; Clair, Beatty, & MacLean, 2005; Joachim & Acorn, 2000). Discrimination stemming from visible stigmas may be easier to identify and legally prosecute than discrimination based on invisible attributes (Stefan, 2000). Of the other dimensions articulated by Jones and colleagues, course and peril have emerged as important influences on the degree of stigma and its negative behavioral consequences (Jorm & Griffiths, 2008; Keller, 2005; Link et al., 1999). In recent years, a number of researchers have also begun to explore the influence of different explanatory models or causal beliefs regarding the origins and nature of mental illness (Phelan, 2005; Rusch et al., 2010; Schomerus et al., 2012; Schomerus, Matschinger, & Angermeyer, 2013). With respect to selfstigma, Corrigan and Watson (2002) suggest that group identification and perceived legitimacy of public stigma influence selfstigma. This leads to a paradox: individuals who are aware of public stigma may view these attitudes as legitimate (resulting in low selfesteem) or not legitimate (resulting in intact selfesteem), and react with shame, indifference, or righteous anger, depending on their level of identification with their ingroup. Perceptions of legitimacy is influenced by several factors including negative social feedback and personal values that may protect against selfstigma. Rusch and colleagues (2009, 2010) examined the influence of ingroup perception, perceived legitimacy of discrimination, responses to stigma, and causal attributions. Entitativity is “the perception of the ingroup as a coherent unit” (Rusch et al., 2009, p. 320). For example, individuals may have low entitativity about the ‘group of people’ waiting in a grocery checkout line versus those who attend their mosque. Findings suggested that individuals with high group value (higher group identification and entitativity) and lower perceived legiti20 Ayse Ciftci, Nev Jones, and Patrick Corrigan macy are more resilient to stigma. Group identification can be a critical issue especially dealing with stigma in minority or more collectivist communities. Double Stigma and Intersectionality Stigma impacts individuals of color and minority cultures. Studies conducted within the United States suggest that the experience of mental illness stigma can be more complicated for those from racial and ethnic minority groups. Gary (2005) examined four ethnic groups in the United States (i.e., African Americans, American Indians and Alaska Natives, Asian Americans, and Hispanic Americans) and proposed the concept of “double stigma,” stemming from prejudice and discrimination occasioned by individual’s racial identity and their mental illness. Intersectionality describes the complex relationships between different identities (e.g., race, gender, sexual orientation, class, and disability) and forms of oppression. Effects of interlocking identity axes must be considered simultaneously (Cole, 2009; Collins, 2000, 2007; Hancock, 2007). Oppression associated with race, economic status, disability, and gender operate as an intersecting system, not as unrelated instances of oppression. To use a classic example, middleclass white women are often viewed as relatively asexual pillars of family values, while poor African American women are seen as sexually “promiscuous” (Collins, 2000). An intersectionalist framework proposes that the process and effects of the stigmatization of, for example, a workingclass Muslim woman with depression will differ from that of a middleclass White woman with depression not only in degree (i.e., ‘more’ or additive stigma), but in kind (i.e., qualitatively different stigma with fundamentally different effects on the stigmatized individual). Although the literature on stigma and intersectionality remains small, existing studies underscore the importance of work in this area. On the experimental side, Wirth and Bodenhausen (2007) found that participants reading case studies of men and women with either gendertypical (e.g., women with depression) or genderatypical (e.g., men with depression) psychiatric conditions reacted differently. When cases were gendertypical, participants expressed less sympathy and decreased willingness to provide help or support, relative to cases perceived as genderatypical. In the context of applied scholarship, Collins and colleagues (Collins et