IRCS UNUD Journals, Vol. 1 No. 1, February 2017

22

The Construction of Socio-Cultural Stigmatization of Mental Disorders: A Study on the Forms and Factors of Stigma

Bambang Dharwiyanto Putro

Doctorate Program of Cultural Studies, Faculty of Arts, Udayana University, Jalan Pulau Nias Sanglah, Denpasar,80114

Telp/Fax: (0361) 224121, 238521

Abstract The construction of socio-cultural stigmatization on the understanding of mental disorders is particularly interesting to study in the people with mental disorders who received treatment at the Mental Hospital. Mental disorder is a disease caused by the chaos of thoughts, perceptions and behavior in which the individualaare not able to adjust to themselves, other people, society and the environment. By applying the cultural studies viewpoint that is siding with the oppressed, the study aims to determine the forms and factors causing the stigma of people with mental disorders. The research method used is observation, in-depth interviews and life history data collection. The collected data were then analyzed using qualitative descriptive and interpretative. The results showed that the forms of stigma with mental disorders are divided into two, namely the public stigma (stigma derived from the community) and self-stigma (stigma comes from the patient and his own family). The forms of the public stigma include rejection, exclusion, and violence. The self-stigma takes the forms, among others, prejudice, guilt, fear and anger. Factors behind the stigma of mental disorders are external and internal factors. External factors include, among others, the madness is a disgrace, the myth of mental illness, and people's belief regarding the role of dukun. While the internal factors are family knowledge of the etiology of mental disorders, lack of family support and feelings of shame.

Keywords: stigma, mental disorders, mental hospital, public stigma, self-stigma

  • I.    Introduction3

The process of globalization and the rapid growth of information technology have brought an impact on social values and culture of the society. Meanwhile not all people have the same ability to adapt to these changes. As a result, psychiatric disorders have now become a global health problem. More than 450 million people worldwide live with mental disorders. Globally recurrence rates in patients with mental disorders were 50% to 92% due to non-compliance in the treatment or lack of support and living conditions that are vulnerable to increasing stress (Sheewangisaw, 2012: 1-10).

People with mental disorders in Indonesia based on the data of Riskesdas (Health Research Association) in 2007 include severe mental disorders (schizophrenia) figuring 4-6 per 1000 population. Previously the figure of mental disorders (psychosis) in Indonesia was estimated at 1-3 per 1000 population. The results of

Emotional Mental disorder by Riskedas is 11.6%. Previously the psychiatric disorders (neurosis) including anxiety neurosis, obsessive, hysteria, as well as mental health disorders of psychosomatic / psychophysiological as a result of the pressures of life ranged from 20-60 per 1000 population. So is the case with, drug addiction, juvenile delinquency, and alcohol use or dependence and deviations of human behavior (Depkes RI. KMK. No. 1627/Menkes/SK/XI, 2010: 2)

Today many people believe that mental illness is a stain or a result of the sins done by human; that is why the community respond to the patients with fear and try to avoid them. This wrong attitude resulted in that the program failed to reach the target of mental health for the people in general and have not so far received favorable response. Many patients are afraid and do not like to undergo examination by a doctor or a psychiatrist and a psychologist. They became angry, very offended if checked or think that they are not sick and mentally healthy (Kartono, 1989: 25) Patients with mental disorders who are either

have returned to the community, they still get a discriminative treatment of the environment where they are located because their identity has changed along with the doctor's diagnosis as a dangerous individual (Foucault, 1994: 176).Various forms of public attitude mistakes in responding to the presence of people with mental disorders as a result of wrong thinking pattern construction due to the public ignorance. A person with a mental disorder is generally facing with stigma, discrimination and marginalization. Stigma makes a family feel embarrassed and the community members are afraid of people with mental disorders. The implication is that the community will isolate them from their social environment, delay treatment, increase the suffering, slow the healing process, and inhibit the patient back to the community (Suryani, 1999: 16-18).

Stigma is rooted in the structure of society, and also the norms and values that govern everyday life. It causes some groups to be less appreciated, feel shame and social rejection, while the other group feel superior. This problem stems from the stigma and knowledge developed in the community about mental disorders (Irmansyah, 2009: 45-46). Stigma causes the families of patients do not seek treatment that is needed by a sick family member, or the patient will get low-quality services. Stigma is associated with power and domination in society. Stigma is rooted in the structure of society, and also the norms and values that govern everyday life. It causes some groups to be less appreciated, feel shame and social rejection, while the other group feel superior. Generally, this study aims to identify and understand the factual realities in the context of stigma against people with mental disorders who received treatment at the Central Mental Hospital of Bangli. In particular, this study was conducted to obtain a complete and detailed description of the forms of stigma of people with mental disorders and the factors underlying the stigma against people with mental disorders. This research is very important to do as an effort to involve the community with all its components (holistically) in order to build independent consciousness to minimize stigma in

society towards people with mental disorders (destigmatization).

  • II.    Research Methods

The design of this study used qualitative method with an emphasis on emic, ethics, holistic and thick descriptions based on field research conducted intensively on social stigmatization on people with mental disorders and without the measurement or test as prescribed in quantitative methods. The problems of study are examined or analyzed from the perspective / approach of Cultural Studies.

The study was conducted in Bali Provincial Mental Hospital located in Bangli regency. The consideration to choose RSJ Bali Province as the object of the research location was based on the main reason that it is the only Government Mental Hospital located in the province of Bali covering all regencies (nine regencies) in Bali. Until now Regencial and the City hospitals are not yet ready and able to provide inpatient services for psychiatric patients especialy the inpatient hospitalization need longer time. Viewed from the given service model it has a biopsycho-socio-cultural service model and becomes the only referral hospital in the province of Bali in the field of mental health services. In addition, most of the patients had been treated by traditional medicine (household treatment and witchcraft). This means that before getting treatment in a mental hospital, they have had a long and complex behavioral processes of care and treatment as well as the history of previous illness so it is possible that one family member suffering from a mental disorder, know and able to provide information, an explanation regarding the problems in this study.

Primary research instrument is the researcher himself, equipped with an interview guideline. The interview guideline contains a list of open questions that the researcher can conduct interviews freely, widely and deeply. The information extracted is not limited to what is said, but also the meaning of the speech and behavior of informants

Data collection methods used include: 1) observation. Observations are conducted to examine the daily activities carried out by people with mental disorders in the psychiatric hospital,

social relationships ofthe patients with the staff and medical practitioners (psychiatrists, doctors, nurses, and other officers) and their family behavior;2) in-depth interview.The depth interview aims to gather information from informants about the attitudes, experiences, and to elicitate things hidden within the patients (overt - covert behavior) related to research problems;3) the individual's life history. This method is used in an attempt to obtain information about the stigmatization of patients with mental disorders and to know how they make adjustments to the social and cultural factors that influence the process as well as the meaning of stigmatization; 4) document studies. In addition to interview technique, this study also uses documentation technique by examining some documents related to the research problems to obtain a variety of secondary data; and 5) The data analysis method. The data were analyzed qualitative- descriptively and interpretatively. The data obtained need to be scrutinized and classified on the basis of cultural assumptions and with a flexible, reflective, and objective attitudes (Endraswara, 2003: 15).

  • III.    Results and discussion

    • 3.1    Results

      Forms of Stigma on Mental Disorder Patients

Based on the facts obtained in this study it was found that the forms of stigma on people with mental disorders are divided into two, namely the public stigma (stigma from the community) and self-stigma (stigma comes from the patient and his own family). The forms of public stigma are, among others, rejection, exclusion, and violence. As for The self-stigma takes the forms, among others, of prejudice, guilt, fear and anger. More clear explanation will be described as follows.

Factors Affecting the Occurrence of Stigma in the Patients with Mental Disorders

Based on the facts obtained in this study, the factors that influence the occurrence of stigma of people with mental disorders are divided into two, namely 1) external factors, consisting of insanity is a disgrace, the myth of mental illness, public confidence in the role of shaman (balian‘healer’) ; and 2) The internal factors, including the family knowledge of the etiology

(cause) of mental disorders, lack of family support, and feelings of shame.

  • 3.2    Discussion

Forms of Stigma on Mental Disorder Patients Public Stigma

Rejection. A negative assessment against people with mental disorders will lead to rejection, so that individuals and societies will tend to develop feelings of dislike. Besides, the individual / society will develop distrust when they should be involved in social activities or exercising interaction with the rejected. This rejection can or can trigger aggressive attitudes and negative behaviors towards people with psychiatric problems. Movement space for people with mental health problems is very limited, and it is evident from the attitude of the community / neighborhood who impressed "hostile" by way of subtle rejection excluding them (intentionally) in the process of interaction. The attitude of rejection towards people with mental disorders can also be seen from the tendency of families / communities to make mental hospital as a dumping ground for people with mental disorders. After the transfer, the family has never pay visit again, the patient is considered to have become the responsibility of the Psychiatric Hospital officers, while the family do not want to know about the state of the patient. Consequently, it was not suprprising to find patients who have been residents there for more than five to ten years without ever having to know where the address and who are their family. Families and even the community assess that the Mental Hospital has a bad reputation in the community. Stereotypes as a place of exile, gatherers, and confinement for mental patients are attached to it. Consequently the label of sick and the identity status of patient has a strong influence in the stigmatization inthe society.It is clearly visible that the ruling class (in this case the Mental Hospital and the public) tend to give a label to the weak (people with mental disorders) as deviant..Labeling has a positive result for the parties that give a label, namely strengthening the social order and social stability. It is really only limited to two reasons, namely (a) since the party that gives a label is in a strong position while being stamped is in a weak position, (b) by punishing the weak, the stronger party will not

deviate as the weaker party. But it does not mean that the ruling party will not deviate. They deviated more sophisticated and subtle This is due to the fact that the public attention was drawn to the deviation of the weak (people with mental disorders). The attitude that do not want to care, fear, a false assumption, scorn and rejection to the patients with mental disorders are complex problemswhich are labeled by the societyonthe patients of mental disorders. This is what must be changed by the people. A feeling of community that people with mental disorders is something that threatens has also to be clarified so that the behavior of rejection to patients with mental disorders will gradually decline.

Exclusion. Stigma against mental disorders does not only cause negative consequences for the sufferers, but also members of their family. The burden of stigma of mental disorder makes patients and their families choose to hide their condition rather than seek help even stigma makes the family also do not understand the character of family members who are mentally handicapped. Family members that are stigmatized as well as the individuals who suffer from mental disorder itself, often have experience increased emotional distress and social exclusion. Social exclusion of people who have mental disorder problem has brought impacts on behavior, healing and participation in society They also have experienced social isolation that affects all kinds of relationships, whether with friends or family. This exclusion also causes that they do not get a balance of access to information, education, employment, housing and other social opportunities. People who are looking for medical services / treatment of mental disorders tend to be excommunicated and are not socially accepted by the society. Consistent with this, people who have been labeled to have had psychiatric counseling services are rated poorly and treated more negative than those who are not treated. Similarly, if a person who is described to seek help for the state of his mental condition, is judged more emotionally unstable and will lead to conditions more severe psychiatric disorders than individuals who seek treatment for physical illness. People with symptoms of mental disorders are involved in secrecy and withdrawal which can exacerbate their social exclusion,

causing that they are judged, not appreciated even declared as a dangerous man.

Violence. The lack of knowledge of family and community in handling the problem of mental disorders, especially the stigma that is still attached firmly in the realm of society, causing people with mental disorders who do not get access to health services to get improper treatment, such as should keep silence and is locked in the room, is not allowed to go out of the house, their hands or feet are chained, and even their legs are chained in a log with the justification that they would not hurt themselves or hurt / injure others in the vicinity. The implication is that the condition of the patient is even worse. The condition of deprivation victim is reallyin an alarming situation. The family or community intentionally or unintentionally do this action are considered to have committed the omission of what happened to the victims of this violence. The search of the patient's condition resulting from the occurrence of violent behavior experienced by people with mental disorders both before and after discharge from psychiatric hospital care indicated that the patient's family actually did not intend to commit violence. The reason was that they just wanted to save their family members who are ill and for this family this is a justification that people with mental disorders do not endanger themselves and others

Self Stigma

Prejudice. The judgement that mental disorder could not be cured and those who have it may not be able to function normally in society pose a hassle since the people with mental disorders increasingly withdraw, will introvert because of fear of being judged and humiliated that finally made the patient did not want to seek help when symptoms of mental disorders began to be felt. It was also apparent how the emergence of stigma on the patientsthemselves among others, first, the negative prejudices that negatively perceived themselves as incompetent and had considered themselves to be a weak character; the second, on the emotional aspects caused, among others, uconfident or incapable; and thirdly, the aspect of discrimination visible from the failure to continue the works and delays of treatment programs.

Guilty Feeling. The families suffered from crisis and hard pressure when they found that one

or more members of their family suffered from mental disorders. This pressure will be a source of stress for members in the family. Meanwhile, for families who are prone to stress, of course, would disturb their role as a support system that led to the increasingly unstable mental disorders in the healing process. One of the heavy psychological burden for families with mental disorders is stigmatization. The adverse effects of stigmatization includes guilty feeling on the part of the family that eventually led to the search of helpsfor patients be delayed. Having family members suffering from mental disorders make the family as if it has a bad seed, so that the family feel guilty, embarrassed socially and loss of self esteem. The family in this case often blame themselves for the pain suffered by family members. Guilty feeling does not just come from the family against family members who suffer from mental disorders, but it can also directly descend on people with mental disorders themselves. Guilty feeling can be in the form of belief that the cause of the disturbance suffered resulted from the weakness in the trial / test of life, the punishment of God or the mistakes of the past.

Fear and Anger. Stigma against mental disorders further aggravated the condition of patients. This of course raises a hassle since the people with mental disorders increasingly withdraw, introvert for fear of being judged and humiliated. What is very painful for the patient's psychological condition is when the shadow of fear of being judged, humiliated and ostracized socially causing patients do not want to seek help when symptoms of mental disorders begin to be felt. The internal stigma is extremely detrimental to the psychological condition of the patient. In addition, patients also tend to think that theyare worthless, incapable, unwilling to socialize and feel inferior. Another problem that often arises in the people with mental disorders, especially with cases in people with mental disorders having violent behavior is excessive anger / rage. Disclosure of anger or rage by the patients with mental disorders is an overflow of emotions arising as a reaction to increased anxiety and perceived by the patients as a threat. as well as to create a feeling of relief.

Factors Affecting the Occurrence of Stigma in Mental Disorder Patients

External factors

Madness is a disgrace. Mental illness, is still considered a shameful disease, became an embarrassment to the patient and his family. The implication is that the family tends to try to cover up if there is a family member who suffers from mental disorder. The family is ashame if the "disgrace" of family is spread that becomes discussion of many people. The stigma created by the community towards a patient with mental disorder can also indirectly make the family of mental disorder patient reluctant to provide fast and precise handling, resulting in the patient’s worsening condition. The society calls the most chronic level of mental illness as memory loss of memory, oblique brain or crazy, as well as other abusive designations. When people with mental disorders outpatient or inpatient in a psychiatric hospital, the families should ideally continue to give attention and support in accordance with the instructions of hospital medical team. But the fact is that still many families of patients who do not want to know the condition of their family members who are hospitalized at the Psychiatric Hospital. Many families who rely completely the cure of the patients to health care workers as the sole authority in the field of health.

Myths About Mental Disorder. The occurrence of stigma can not be separated from the background of myths spreading in the community about mental disorder. First, there is an assumption that people with mental disorders occur only on those who have weak soul alone; Second, the assumption that people with mental disordersis closely related with criminal behavior in their lives; Third, the notion that people with mental disorders should be ostracized and exiled in social life; Fourth, the notion that mental disorders can not be cured; Fifth, the assumption that people with mental disorders all have multiple personalities; Sixth, the assumption that people with mental disorders are certainly due to bad parenting; and Seventh, people with mental disorders can not be cured.

The People’s Trust about the Role of the Shaman (Balian). In the dynamics of Balinese life, the traditional medical system practiced by healers (shaman) is strongly associated with religious life and customs. Very strong

integration between tradition and religion in public life puts healers as an integral part of people's lives, especially on issues related to public health. Some family members of patients take the family members who experience mental disorder to shaman treatment before finally deciding to undergo treatment and care in the Bangli Mental Hospital of Bali Province. The reason why patient's family try the treatment or care of the patient provided by thebalian is that the treatment at home does not show results, the alleged illness results from noetic causes and want to know the cause of the pain. The families of patients believe that if the pain is caused by noetic causes the cause of the pain is not apparent, not real and without definite form, then it implies that only the shaman who is believed to be someone who has the magical power who is able to drive this cause. Balinese people still believe that Usada treatment (the traditional way of treatment) has many benefits. Although there have been many public health centers (Puskesmas) evenly spread in each district, going to Batra (Traditional Healers) is still an option that can not be dismissed. Diseases for the Balinese is not just a biological phenomenon, but has social, cultural and relegious dimensions

Internal Factor

Family’s Knowledge about Etiology (cause) of Mental Disorders. Until now the family handling against patients with mental disorders has not been satisfactory. The reason is the ignorance of family related to knowledge about the causes (etiology) of mental disorders. Yet on the other hand the family has a duty to make decisions to take appropriate health measures for family members who are sick with the implication of the unfair treatment received by people with mental disorders. Lack of family knowledge can be caused by the stigma that circulates in the surrounding environment.

Absence of Family Support. The stigma created by the community towards people with mental disorders may indirectly make the family or the community around people with mental disorders reluctant to give proper treatment to their family members who are mentally handicapped so that not infrequently the patients who are not handled properly experience and at the same time do violence or uncontrolled acts

disturbing either themselves, their families and the surrounding communities. In this case the family is in a very unprepared circumstances, feeling very sad, disappointed, desperate that the handling of patient is protracted. The family did not immediately bring family members who are mentally handicapped to the professional but tend to hide or conceal the situation from other people or the community. This has resulted in delayed treatment which could deteriorate their mental disoders.

Feeling of Shame. Shame borne by the family is a stigma that is made by the family against family members who suffer from mental disorders. So the assistance of the local environment for treating patients with is ignored. The shame caused families with mental disorders shut themselves off from the environment. Sustainable empowerment becomes very important for people with mental disorders when they are declared clinically cured by physicians, in order to live independent, productive, and confident in the society, free from stigma, discrimination or fear, shame and doubtful. All of these efforts are largely determined by the attitude of caring family members and the surrounding community.

  • IV.    Conclusions

Mental Hospital instead as a safety valve of a diseased condition of the patient, it even strengthens the construction of patient’s stigmatization in the community through the power of discipline. The social body machine develops social stigma (public stigma) consisting of rejection, exclusion, and violence and the power of disciplinary authority over the stigma haunt the patients (self stigma) consisting of prejudice, guilty feeling, fear and anger. Such conditions have implications for the internal and external factors that influence the occurrence of sufferer’s stigma. As for external factors that insanity is a disgrace, the myth of mental illness, and the people's confidence about the role of shaman (healer) and internal factors including a family knowledge of the etiology (cause) of mental disorders, lack of family support, and a sense of shame, all of which perpetuate the reproductive process of mental disorders (insanity), which is a consequence of the

enactment of power strategy and social regulatory in society. Image or the image of Psychiatric Hospital in the community has been so deeply rooted that even if patients were clinically cured, the process of stigmatization and social control in the public sphere remain valid. In this case the sustainable empowerment becomes very important for people with mental disorders when they are declared clinically cured by physicians, in order to live independent, productive, and confidence in the community, free of stigma (destigmatization ), discrimination or fear, embarrassment and hesitation. All of these efforts are largely determined by the attitude of caring family members and the surrounding community.

Acknowledgement

I would like to express my thank to Prof. Dr. Ir. I Nyoman Gde Antara, M. Eng. as the Chairman of the Institute for Research and Community Service Udayana University who has facilated the study. Thanks also to Prof. Dr. A A. Ngurah Anom Kumbara, M.A. who patiently guided the writer as well as open a discussion of critical thinking horizon. My sincere thanks goes also to Kemenristekdikti for the opportunity and trust given in the Doctoral Dissertation Research and funding for the acceleration of the research undertaken.

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