Jun 01, 2009, By: Sarah Benbow, RN, BScN
Societal abuse refers to the disadvantages that a group experience as a result of unjust social structures. People with mental illness are among the most marginalized, oppressed, devalued and stigmatized populations in our society. They experience a range of societal abuses, including barriers to health care, lack of employment, difficulty accessing and maintaining adequate housing, and discrimination. Nurses are in a unique position to address social inequity and societal abuse as advocates for health and well-being. The author addresses the impact of societal abuse and presents ways in which nurses can advocate for people with mental illness.
Nurses have a moral and ethical obligation to advocate for health and well-being on behalf of individual clients and for social justice on a broader level. In their role as advocates, nurses must address systemic issues that oppress marginalized groups, which include those living in poverty, the elderly, people with mental illness, the homeless, visible minorities, children, and people with disabilities.
Societal abuse refers to the disadvantages that people experience as a result of unjust social structures. This form of abuse prevents people from meeting their full potential and their basic human needs. Although the health-care system has come a long way in the treatment of people with mental health issues, they remain among the most marginalized and devalued populations in our society. Societal abuse causes a “cruel injustice…the denial of the mentally ill’s moral entitlements” (Johnstone, 2001, p. 200).
Impacts of Stigma
Generally, people struggling with mental illness are blamed by society for their current situations, with no attention paid to the socio-political context influencing their experiences. Common stereotypes that present people with mental illness as dangerous, volatile, unkempt and worthless are fuelled by the media (Wilson, Nairn, Coverdale, & Panapa, 1999).
Societal stigma has an impact on all facets of life and can have a catastrophic effect on health. Overton and Medina (2008) identified that discrimination, negative attitudes, physical abuse, lack of employment opportunities, substandard housing, homelessness, and barriers to accessing and utilizing health-care services result from stigma related to mental illness.
In a study measuring stigma in the lives of people with mental illness, 47 per cent of participants reported being harassed or abused in public (DePonte, Bird, & Wright, 2000).Through society’s “actions, words or silence,” individuals with mental illness are being told that they are worthless and undeserving of basic human needs (Nicki, 2001). The resulting loss of self-esteem, poorer quality of life and diminished self-worth reflect the negative perceptions of society at large.
Martin, Pescosolido and Tuch (2000) suggested that those who attribute the consequences of societal stigma to an individual’s character flaws have stronger prejudice against people with mental illness than those who acknowledge the impact that socio-political forces have on health.
Unemployment rates among people with mental health challenges are alarmingly high. In research conducted on mental health and housing in Ontario, only 2 of 300 study participants had full-time employment, while approximately 20 per cent were actively seeking employment (Csiernik, Forchuk, Speechley, & Ward-Griffin, 2007).
In another study, Tugwood, McManus, Burke and Forchuk (2007) examined employment issues related to mental illness. Although the employers did not overtly express discrimination, subtle stereotypes were evident during the interview process that would affect hiring practices. One participant talked about the importance of keeping customers “safe” as a reason for not hiring people with mental illness. Such perceptions, which often go uncontested, are disturbing; recovering mental health clients have not committed crimes that would compromise the safety of others.
The ability to get and keep a job offers individuals a sense of meaning and achievement in life, while enhancing social relationships (Buckle, 2004). Being consistently perceived as inadequate, incompetent and even dangerous because of a disability destroys feelings of self-worth. Once negative perceptions are internalized, hope that struggles can be overcome is lost.
Psychiatric clients’ battles are not over once treatment is completed and they are discharged from hospital. Often times, they are barely stable upon discharge and lack adequate community supports but are expected to be completely self-reliant. Those who have had long stays struggle with deinstitutionalization and an inability to take back control of their lives.
The proportion of people faced with mental health challenges is overrepresented in the homeless population (Kim et al., 2007). Homeless people are at a high risk for experiencing multiple negative health sequelae, such as acute and chronic illness (Morris & Strong, 2004), abuse (Miller & Du Mont, 2000), trauma (Stermac & Paradis, 2000) and compromised mental health (Tischler, Rademeyer, & Vostanis, 2007). When clients are discharged from psychiatric hospital directly into shelter, any progress toward recovery they may have achieved is put at risk. Shelters are overcrowded, and residents are frequently exposed to and pressured into the drug and sex trade industries (Forchuk, Russell, Kingston-MacClure, Turner, & Dill, 2006).
Simply having a roof over one’s head is not good enough. Substandard housing places those with mental illness and their families at risk for violence, exposure to drug and sex trades, and health problems caused by environmental hazards.
Thornicroft, Rose and Kassam (2007) indicated that it is common for health professionals to believe stereotypes about mental illness and that resulting negative interactions with clients contribute to stigma. Supporting these findings are reports from clients that stigma poses a significant barrier to health-care access and service (Cosgrove & Flynn, 2005). Unless individuals feel a certain level of trust in those with whom they interact in the health-care system, they will not seek health services.
WHAT CAN NURSES DO?
Nurses have a moral and professional obligation to advocate for social reform and can do so at many levels. At the micro level, nurses can be proactive in client care decision-making. Upon initial interaction with a mental health client it is extremely important that nurses assess for social and community supports. For example, if housing is an issue, they must intervene immediately to prevent discharge from hospital to the streets and shelters (Forchuk et al., 2006). At the intermediate level, nurses can get involved in committees in their work settings that examine issues such as transition protocols or stigma among health-care professionals. At the macro level, nurses can become involved in letter-writing campaigns and other forms of political protests and in educating nursing students and the general public to increase awareness of social injustices.
Deep-seated systemic discrimination and stigma are difficult to eliminate. Protest, education and contact — the strategies used to transform negative attitudes about visible minorities — must be employed to change the public’s perception of people with mental illness (Corrigan, 1998). Nurses can mark mental health awareness weeks by vigorously challenging myths and inaccurate media portrayals.
By engaging in self-reflection and being always mindful of socio-political influences on health, nurses will be in a strong position to ensure their clients get the appropriate therapeutic care and supports they require. Mental health clinical rotations that provide the opportunity to work with clients in and out of hospital should be requirement for nursing students. Face-to-face contact with those with mental health issues and in-depth examinations of societal abuse will help students gain insight. Educators can promote an understanding of social justice issues by making these the focus of political action projects.
The voices of mental health clients need to be heard when decisions are being made about social policy reform. Nurses must push for acceptance of these voices, which are vital in discussions about ways to improve the system. Bringing current nursing research on social justice and mental illness to the attention of politicians and policy-makers is one way to ensure that governments are aware of existing injustices and areas requiring reform. Nurses and nursing organizations, on their own or with others, can lobby to abolish unjust social policy and to seek increased funding for resources and services for mental health clients.
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Sarah Benbow, RN, BScN, is a Mental Health Nurse at London Health Sciences Centre, and an MScN Student at the University of Western Ontario, London, Ontario.