Social Isolation, Ethnicity and Psychosis; A Case-control Study
Chapter One
Aims and Objectives of the Study
This study aims to investigate social isolation, ethnicity, and psychosis: a case-control study among the Igbos in Nigeria. The specific objectives are to;
- Examine the extent to which the Igbo people in Nigeria make psychosocial, biological, and supernatural causal attributions for mental illness
- Demonstrate negative attitudes towards persons with mental illness and desire social distance from them
- Evaluate how Igbo people in Nigeria seek spiritual, traditional, and conventional psychiatric treatments for mental illness
- Investigate the interaction among the four dimensions of causal beliefs, attitudes, help-seeking preferences, and barriers
CHAPTER TWO
LITERATURE REVIEW
Social Isolation
Social isolation is a global public health challenge. Social isolation causes substantial health risks, with magnitude comparable to the damaging impact of cigarette smoking on health [1]. Social isolation is a risk factor for infection, inammation, depression, cognitive decline, cardiovascular disease, and all-cause mortality [2-5].Humans are a social species and are designed to depend on one another for survival. Social isolation is a complex phenomenon; thus, it has various denitions in the literature. For example, social isolation has been definrfned as the absence of or a decrease in the number of social interactions, contacts and relationships with other people, particularly family and friends [6]. Social isolation has two dimensions, namely social disconnectedness and loneliness. Social disconnectedness is the objective dimension of social isolation and can be measured by the composition and size of social network and by the frequency of interactions with individuals a person can share meaningful and supportive relations [7]. Loneliness, also known as perceived isolation, is the subjective dimension of social isolation. Loneliness represents the qualitative aspect of personal relationships, and can only be described by the person who experienced it in terms of a deficit between actual and desired quality and quantity of engagement or within the social context.
Social isolation is a global phenomenon with increasing prevalence. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.Prevalence of Social Isolation and Psychometric: Social isolation is a global public health challenge. Social isolation may worsen the prognosis of diabetes. Assessment of social isolation among older diabetic adults is important, and the use of valid and reliable measure is necessary.
Stigma Typologies
Public Stigma
To be marked as ‘mentally ill’ carries public, internal (self) and associative stigma. Public stigma occurs when the general population endorses stereotypes and decides to discriminate against people labelled ‘mentally ill’ (Corrigan, Druss & Perlick, 2014). It is mostly caused by the stereotypes of people with mental illness as unpredictable, violent, deranged, incompetent or retarded (Atilola & Olayiwola, 2011; Jorm & Griffiths, 2008; Marie & Miles, 2008). With the stereotype of dangerousness and unpredictability, fear becomes the primary impulse to the development of stigma. Hence, Foucault (1978) had suggested that the strongest cultural stereotype of persons with mental illness focuses on the spectre of a homicidal madman – a deranged being who explodes violently, erratically and inexplicably. These stereotypes could also suggest that persons with mental illness are incapable of normal human activity. Aside the stereotype of dangerousness endorsed by 88% of the respondents, a study by the Canadian Mental Health Association (1994) found the most prevalent misconceptions about persons with mental illness to include that: they had a low IQ or were developmentally handicapped (40%), that they could not function, hold a job, or had anything to contribute (32%) and that they lacked the will power or were weak or lazy (24%). This echoes the finding from the pilot study for the World Psychiatric Association (WPA) Programme “Open the Doors” (Stuart & Arboleda-F1orez, 2001a) where 72% of the respondents believed that persons with schizophrenia could not work in regular jobs. Arboleda-Flórez (2001) reports of Michelle, a vivacious 25 year-old office worker who tells about her major disappointment with her family and family friends that simply expected her to have an abortion when she announced that she was pregnant. They assumed that her schizophrenia would incapacitate her to deliver and to care for her baby. They were also afraid that her medications could have teratogenic effects on the baby. She carried her baby to term and is taking care of it despite the opposition of family and friends.
CHAPTER THREE
METHODOLOGY
Research Design
Causal explanatory models influence the symptom presentation of a disorder (Helman, 1990; Weiss, 1996) and have implication for help-seeking behaviours, recommendations for treatment and stigmatising views towards persons with mental illness (Broussard el al., 2010; Muga & Jenkins, 2008; Compton et al., 2018; Carteret, 2011). The trajectory of illness is also influenced by the beliefs patients and doctors hold about course and prognosis (Eisenberg, 1988). Explanatory model, independent of ethnicity, is also associated with treatment satisfaction (Dein, 2002). Hence, dissonance between patients’ and therapists’ explanatory models may affect culturally sensitive clinical practice, satisfaction and treatment compliance. This segment of the study is conducted in two stages; a preliminary exploratory study (Study 1a) precedes the substantive confirmatory study (Study 1b).
CHAPTER FOUR
RESULTS AND DISCUSSIONS
Results
Exploratory Study (1a)
The demographic characteristics of the exploratory study sample are summarised in Table 1.3.
CHAPTER FIVE
SUMMARY CONCLUSION AND RECOMMENDATIONS
Summary
Significantly mixed endorsement of the supernatural, biological and psychosocial causal models was found and it represents a paradigm shift from the earlier predominance of supernatural causal explanations. However, supernatural causal attribution was still made significantly more than biological and psychosocial attributions. The leading endorsement of supernatural causations reflects the enduring traditional religious worldview of the people that shapes the conceptualisation of reality including psychopathology. While increased endorsements of the biopsychosocial models could be considered a reflection of improving mental health literacy based on the general advancement in scientific knowledge, an enabling background was found for these in the culture, the unitary vision of reality and the historical experiences of the people.
Mixed attribution reflects a holistic view of health and healing and provides empirical evidence against any assumption that the people in this region believe solely in the spiritual aetiologies of mental illnesses. Understanding the conceptualisation of illness is key to achieving therapeutic alliance which facilitates treatment adherence and satisfaction. Thus, healthcare professionals in this context must recognise the potential for patients to hold strongly mixed or even contradictory beliefs about their conditions. The finding of a positive relationship between the endorsement of supernatural causations and the endorsement of psychosocial and biological causations strongly reinforces this. This challenges mental healthcare systems and therapists to demonstrate the skills necessary to respond effectively in this context especially as trivialising or pathologising clients’ beliefs could work against therapeutic alliance. To be effective, therapists need to be culturally competent for only then could they appropriately demonstrate empathy and also be in the position to recognise when beliefs are indeed becoming pathological or inimical.
Demographic correlates of the explanatory models were identified for targeted interventions. For instance, those in non-nursing professions were significantly less likely to endorse the biopsychosocial causations compared to those in the nursing profession hence these would benefit from mental health education. Those with low education were significantly less likely to endorse psychosocial causations compared to those with higher education and would therefore benefit from enlightenment campaigns on psychosocial causations
Conclusion
Mixed attribution is a cheering finding in this study as it demonstrates increased endorsement of the scientific (psychosocial and biological) causal models. On the other hand, it reflects the holistic view of health and healing that could inform therapeutic practice in this context since understanding of causal beliefs and perceptions of illness are keys to achieving therapeutic alliance between the healthcare provider and the patient. Yet, the generally greater endorsement of the supernatural model underscores the significance of the spiritual which permeates the people’s word-view including psychopathology. n our study, beliefs about the relationship between evil spirits, devil possession and mental illness carried with them implicit assumptions about moral failings on the part of individuals experiencing psychological distress. It is likely that, within African-descended communities, this finding relates not only to serious mental illnesses which are sometimes linked with violence in the minds of the general public but extends to more common mental disorders. Social psychiatry suggests that cultural beliefs play an important role in shaping societal responses to people with mental illnesses, influencing stereotyping, service provision and help-seeking.
The interaction between faith and kinship/relational structures was a factor in creating and perpetuating interpersonal stigma. The effect might be described in relation to Serrant-Green’s53 ‘screaming silences’ framework. Although originally developed in relation to physical illnesses, evidence from this study and elsewhere suggests the framework (which describes how individuals suffer in silence because of shame, stigma and related absence of discourse within these communities) is applicable to mental illness.
Given community members’ tendency to turn to the church for help in times of trouble, faith leaders’ reports of their lack of expertise in relation to mental illness is an important finding. As reported by respondents, normative cultural beliefs in the existence of evil spirits and demonic possession might influence perceptions of what may (or may not) be evidence of psychiatric illness. Moreover, the Black-majority church’s ‘symbolic centrality and historic multifunctionality might explain the preference for community-level alternatives (such as local pastors or folk practitioners) vs. mainstream sources of help in African-descended communities,55, 56 which could impede affected individuals’ engagement with formal mental health services. The significance of our study is that, as with findings from a north of England sample of Caribbean-origin women,43 these attitudes and help-seeking preferences have persisted among subsequent generations of British-born people of African descent.
Heightened anticipation/experience of negative consequences resulting from a diagnosis of mental illness in the family, which is to be kept behind closed doors, may be partly explained by the collectivist nature of African-descended cultures, and by the ideological stigma attached to family honour or ‘good name’. In this context, mental illness can be seen not solely as negatively impacting the individual but also as ‘contaminating’ the extended family and potentially the entire community. Under these circumstances, our findings indicate that individuals diagnosed with mental illness are likely to experience a triple jeopardy in terms of stigma – rejection by their families, stigma and alienation from their communities and internalized ‘self-stigma’. In consequence, they are at risk of increased social isolation which is both antithetical to recovery from mental illness and increases the likelihood of relapse and hospitalization, which further reinforces stigma.
Our findings suggest that to tackle ethnically based disparities in mental health and to provide appropriate and responsive mental health services that meet the needs of a diverse population, key factors such as race/ethnicity, faith and culture need to be taken into consideration as they all affect how mental illness is perceived, experienced and managed. The analysis of the aforementioned axes of diversity offered a nuanced understanding of stigma associated with mental illness and its effect on help-seeking.
Recommendations
In line with the findings of the study;
- Members of a social network could consequently seek conventional psychiatric care for themselves and for their suffering relatives or influence them to do so. Thus, while they help to get psychiatric care to be better received in this context, they would also continue to provide the highly regarded traditional solidarity in care that appear to be lacking in the seemingly isolating conventional care system
- To make for a responsive mental healthcare system, the study corroborates the call of the WHO (2008) for the integration of mental healthcare into the primary health care system. The study also highlighted demographic groups that would be more likely encumbered either ideologically or materially in accessing conventional psychiatric care hence constituting primary targets for educational and/or infrastructural interventions as applicable. The Nigeria based respondents would be more likely constrained both ideologically and instrumentally in accessing conventional psychiatric care
- The mental healthcare preferences of demographic groups were also highlighted to inform the planning of services; those with low education would more likely opt for the traditional and spiritual treatment pathways compared to those with higher education while the reverse holds for the preference of conventional psychiatric treatment
- Demographic groups that were relatively more identified with negative attitudes and that could therefore benefit from targeted interventions include: those that are not familiar with sufferers of mental illness, those in the older age bracket, the males, the Protestants, and the Nigeria-based respondents. Overall, however, the indispensability of education in improving attitudes was underscored in low education being associated with all the negative attitude constructs while higher education was associated relatively more with the positive attitude constructs.
Suggestions for Further Study
This study also highlighted the determinant impact of mental illness conceptualisations in shaping attitude and help-seeking behaviour. The primacy of mental health education in improving mental illness conceptualisations was underscored in this regard. Carrying out enlightenment campaigns beginning with groups at most risk including those with less education, the Protestants, those not familiar with persons with mental illness and the Nigeria- based respondents will therefore be a resourceful way of immediately giving back to this deprived society that generously responded to this research project. Finally, as perspectives including beliefs, attitudes and socio-economic situations change over time, periodic longitudinal studies would be necessary for the evolution of responsive model(s) of care at every era.
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