Three layers of stigma prevent mental health recovery in Singapore

Internalized stigma, compounded by public, structural, and systemic stigmas pose substantial barriers to recovery among persons with mental illnesses (PMI), according to a recent Singapore study.

Through semi-structured interviews, insights were collected from 17 healthcare professionals who were working in mental health settings. Thematic analysis of their responses revealed three levels of stigma-related factors prevalent in Singapore, namely micro, meso, and macro factors. [BMC Health Serv Res 2022;22:888]

The analysis revealed that micro factors encompassed intrapersonal manifestations of stigma, also called internalized stigma. This included personal feelings of shame and acceptance of negative perceptions or attitudes towards them. In turn, such internalization could lead to the denial of one’s illness, prevent the timely seeking of care, and lower one’s sense of self-worth.

One participating psychologist was quoted in the study: “[S]ome don’t even feel that they deserve friends, they feel that they don’t even deserve treatment. Because they say ‘I have an issue, so what’s the point?’ … I think it’s hard to still explain to people that they are just as ill as anybody with cancer, with diabetes, that they deserve the same treatment.”

These intrapersonal factors are compounded by meso-level stigma-related factors, which refer to the ways in which their community or society look down on them. These include shaming and excluding PMIs, as well as dismissing the very existence of mental health problems. According to the participants, these types of exclusionary behaviours make it even harder for PMIs to help themselves or to deal with their illness.

“[T]hey have to put in extra effort to get school assignment done or do a normal day’s job compared to the average person who doesn’t. So, to them every day is a struggle, every day is a battle … And sometimes they didn’t get applause at the end of the day. All they get [are] all these mixed… sometimes wrong impressions [from] the people that they work with,” said one pharmacist.

Meso-level factors also negatively affected the healthcare professionals themselves, who said that sometimes they felt that their profession was looked down upon by the general public, especially as they compared with other doctors. Other participants also lamented the incorrect general notion that healthcare professionals caring for PMIs were more susceptible to mental health problems, too.

Finally, participants also pointed out the systemic stigma against PMIs, called macro factors. These include large-scale exclusion from employment opportunities, legal recourse, and even the healthcare system. Healthcare has the propensity to assume that symptoms in PMIs are due to their mental condition, rather than a true underlying disease. Some practitioners also tend to turn down PMIs.

Another important macro factor that emerged was the local and cultural values of Singapore, which often attributes mental illnesses to a weak personal constitution or being too sensitive. A strong local culture of shame also discourages patients from seeking help.

“Our study presents an early attempt to examine how stigma influences recovery from the perspective of healthcare professionals, and also showcased important insights on the challenges that stigma poses toward recovery, the findings of which could inform policymakers of ways to improve the recovery of PMI,” the researchers said.