Overwhelming intolerance towards mental illnesses is a global problem and has predetermined that countless sufferers simply be denied the professional care and treatment they require and with which they can overcome their condition and lead normal lives. The magnitude of the problem and the urgency of devising strategies for the destigmatisation of mental illnesses can only be fully appreciated within the context of the prevalence of mental illness incidents. On the global level, and as estimated by the World Health Organisation, mental health complaints account for 25% of all visits to general practitioners. Often manifesting themselves in physiological symptoms, mental illnesses are difficult to diagnose and, in more cases than not, are identified only after a vast array of physical tests are conducted for determination of the source of health complaint. In other words, mental health illnesses are diagnosed through a process of elimination (Read and Baker, 1996; Barraclo ugh, 1998). The implication here is that approximately one-quarter of the global population suffers, at one point in their lives or another, from mental health problems. Very few have access to the required professional help and those who do seek help, resort to medical, rather than mental health professionals, often contributing to the further complication of the problem. In brief, and as mentioned, the problem is further complicated simply because diagnosis and treatment by any other than mental health professionals is problematic and inefficient.The diagnosis, treatment and control of mental heath problems are problematic for a variety of reasons, all relating to the stigmatisation of this disease category. Diagnosis, treatment and control are problematic because (1) stigmatisation makes admission of a mental health condition by a patient and/or his/her family difficult; (2) stigmatisation of mental health conditions implies that sufferers visit medical, rather than psych iatric professionals for diagnosis and treatment and the latter do not possess the professional knowledge required to either make an accurate diagnosis or provide an effective treatment programme (Grob, 1994); (3) stigmatisation of mental health illnesses, in numerous countries and cultures, discourages psychiatric specialisation, either among nursing or medical practitioners, with the consequence being a dearth in mental health professionals; (Loza, 2006) (4) stigmatisation of mental health conditions has resulted in the virtual exclusion of mental health services from state healthcare programmes with the consequence being that very few can afford treatment; and (5) the stigmatisation of mental health illnesses has determined that this disease category not be taken seriously or, as seriously as are physiological diseases, with the consequence being that state-run services in do not have the resources needed to provide patients with the necessary treatment (Satcher, 2000).As may be determined from the foregoing discussion, the mentally ill are discriminated against by the very nature of their suffering. The fact that their illness is not understood has not only determined that public health policies and private medical insurance not cover psychiatric treatment but has further ensured that they are openly discriminated against. The mentally ill are ostracised from society to the extent that people fear associating with them, renting housing to them, working with them or providing them with employment opportunities. Stigmatisation, implying discrimination, therefore means that the mentally ill are denied access to resources and opportunities. This only contributes to the increased severity of the condition insofar as isolation and denial of access to opportunities leads to low self-esteem, loneliness and hopelessness (Penn and Martin, 1998; Corrigan and Penn, 1999). The stigmatisation of the mentally ill, or of mental illness in general, represen ts a challenge that must be addressed through the adoption of intervention strategies specifically designed to foster understanding about mental health and promote tolerance towards the mentally ill. Lauber et al. (2004) urges that education be the primary vehicle for the destigmatisation of mental illness. The proposal is valid because it correctly identifies ignorance of mental illness as the root cause of its stigmatisation and the promotion of awareness and knowledge as the solution. While valid, however, the proposal is incomplete because it does not identify the educators nor the content of the educational/awareness-promotion program. From the researcher's perspective, and as shall now be argued, the nursing profession has a fundamental role to ply in the promotion of awareness about mental illness and the successful destigmatisation of mental illnesses is largely dependant on the destigmatisation strategies which nurses will adopt and the extent to which they will eff iciently and effectively carry out this responsibility.[To be continued...]Stigmatisation of Mental Illness in the Arab Middle EastAccording to Arab mental health professionals, among whom one may mention Loza (2006), Sadek (2006) and Okasha (2006), the mental health care system within the Middle East is virtually non-existent. The mental health care system within the Arab Maghreb countries is barely existent; within the Levantine countries inefficient and within the rich Arab Gulf countries, designed for the isolation of sufferers from their communities, rather than their treatment. For a variety of reasons, Egypt stands out as the only Arab country with what can pass as a mental health care system despite its being largely confined to the public sector and therefore, out of the financial reach of the majority (Zidan, 1999).Certainly, there are state mental health care facilities in all of the Arab countries. However, with no exception, these facilities are overpopulated hi gh-security institutions wherein the average patient receives no more than one hour of professional attention a month. Otherwise, a strong regime of drug therapy is administered to patients and, in extreme cases, electrotherapy. As Sadek (2006) notes, the purpose of these institutions is not the treatment of the mentally ill but their isolation from society. Even if mental health professionals intended treatment, the fact is that required resources are simply not available, be it trained mental health nurses, psychologists or psychiatrists.Arab Middle Eastern health professionals have determined that the singular failure of the Arab countries to develop a strong and efficient health care system is directly consequent to the stigmatisation of, and the misunderstandings and misconceptions which surround mental illness (Zidan, 1999; Loza, 2006; Okasha, 2006). The stigmatisation of mental illness has ensured that only a miniscule percentage of the totality of medical students sp ecialises in psychiatry and that hardly any of those who enrol in nursing degrees specialise in mental health nursing (Belal, 2003). There is a significant shortage in mental health professionals and within the medical community, a lack of understanding and awareness of the reality of mental illnesses. The stigmatisation of mental diseases and illness are responsible for this situation.The stigmatisation of mental illnesses in the Middle East is primarily rooted in ancient beliefs and practices. The widespread perception of the mentally ill as being possessed by evil spirits or being, themselves, evil and dangerous to the point of criminal insanity, has never been adequately addressed. Prejudicial beliefs have been allowed to proliferate and have only been fostered by a media which invariably presents mental illness as an outcome of demon possession or criminal insanity, and urges the isolation of the mentally ill from society (Okasha, 2006).Societal attitudes towards mental illnesses are informed by dominant stigmas and not by facts. As earlier mentioned, those suffering from mental illnesses, whether mild depression or severe schizophrenia, are diagnosed as `possessed, with the severity of the condition interpreted as directly relating to the nature of the `possession. This particular stigma is extremely popular among the Bedouin and lower-class urban and rural communities throughout the Arab World and has determined `treatment by religious figures, whether Christian priests or Moslem sheikhs, rather than by mental health professionals (Saleh, 2004).Amongst the middle classes, both urban and rural, all forms of mental illness are discriminated against. They are perceived of retribution for immorality and, therefore, shameful; symptomatic of laziness and weakness of character and therefore resolvable through corrective behavioural approaches. In those few instances where family members acknowledge the illness to be real and realise the necessi ty of professional intervention, they resort to physiological, not psychiatric, treatment (Loza, 2006). There is, in other words, a persistent refusal to take mental illness seriously as determined by stigma and supported by ignorance.Private mental healthcare facilities are available throughout the Arab world and have the resources necessary to diagnose, treat and control mental illnesses. However, they are extremely costly and consequently, not an option for the majority of mental health sufferers (Loza, 2006).The only way to ensure that mental health sufferers in Arab countries receive the professional care they need is through the destigmatisation of mental illnesses. Destigmatisation, as Sadek (2006) argues, will encourage sufferers to seek help and that, in turn will expose the true extent of the demand for mental health treatment and services throughout the Middle East, will reveal the cost of suppressing/ignoring the problem and, accordingly, will encourage the adopt ion of public health policies which adequately address the needs of the mentally ill and provide professionals with the resources necessary for illness control and/or treatment (Okasha, 2006).Several strategies and approaches for the destigmatisation of mental illness have been proposed, with the majority based upon the deep involvement of nursing professionals. Within the context of Arab countries, the destigmatisation of mental illness through the involvement of nursing professionals will confront numerous challenges but if these challenges are overcome, will positively contribute to destigmatisation. Nursing Intervention StrategiesConsidering that the stigmatisation of mental illnesses in the Arab World is rooted in ancient beliefs, traditions and cultural rituals, anthropologists and sociologists have argued that the elimination of these stigmas can only occur within the context of a socio-cultural approach. Saleh (2003) , writing from the perspective of a cultural anthr opologist, insists that the only effective method for the elimination of the stigmas surrounding mental health in the Arab World is through an educational media campaign. As proposed, this campaign will focus on the prejudices surrounding mental illness, expose the ancient roots of these prejudices and effectively illustrate that they are based on myths, not facts, and contradict scientific findings and research (Saleh, 2003). A mental illness awareness campaign would probably contribute to deconstruction of prevailing myths about mental illness. More importantly, it could spread awareness regarding the curability/controllability of mental illness and educate public opinion regarding its causes and consequences. However, a critical analysis of this particular proposal reveals that it is limited in scope and hardly has the capacity to change fundamental beliefs about mental illness. Quite simply stated and as further affirmed by Fadel (2001), not only would such a campaign be extremely costly but it could not be sustained for any long periods of time and if ingrained prejudices are to change, long-term solutions are required, not campaigns whose message will probably be forgotten as soon as the campaign itself ends.Nursing intervention comes across as the most viable and effective long-term effective solution to the problem of the stigmatisation of mental illnesses. The position of the nursing professional within the community, as attested to by several researchers, greatly facilitates this task. The nursing professional/practitioner, as opposed to the psychiatrist, is ideally situated to address the stigmatisation of mental illness within the profession, by the mentally ill themselves and by the community. As regards the stigmatisation of mental illness from within the medical profession, several researches have indeed proven that the healthcare community, both medical nurses and doctors, have misconceptions and misunderstandings about mental i llness. A significant percentage of medical doctors and nurses tend to stereotype the mentally ill and regard them as an unwanted burden upon the healthcare system. As Harpell (2005:1) writes, within hospital settings mental health consumers were portrayed as disturbed and aggressive, with strong underlying assumption that they were accessing services at the expense of others more deserving, namely the physically ill and the injured. Writing from the perspective of a mental health nurse, Harpell (2005) maintain ns that the stigmatisation of mental illnesses from within the medical community are symptomatic of the inexplicable disconnect that has developed between the physical and mental health sciences. This disconnect is largely traceable to the stigmatisation of mental illnesses and the underlying assumption that mental illness, or psychiatry, is not a serious branch of medicine and certainly not equal in value to the physiological branch (Swindle et al., 1997). In other w ords, the existing separation between mental and physical healthcare is expressive of the medical communitys stigmatisation of mental illness and only serves to encourage the perpetuation of discrimination against the mentally ill.Krizner (2002) argues that the first step towards the provision of adequate mental healthcare to sufferers is the destigmatisation of mental illness from within the medical community itself. According to Krizner (2002) none are better situated to address the stigmas surrounding mental illnesses from within than are mental healthcare nursing professionals. This argument is based on two assumptions. The first is that nurses work in close association with doctors and are the primary channel of communication between doctors and patients. Therefore, they play a fundamental role in shaping the perception of doctors towards patients and their complaints. The second assumption is that senior nurses are responsible for the training of newly graduated nurses , in addition to which, they play a pivotal role in the training and support of medical intern and residents. Consequently, and as Krizner (2002) argues, educating professional nurses about the implications of mental illness, whether or not that is their chosen speciality, is a fundamental step towards the destigmatisation of mental illnesses from within the medical community, given the positioning and role of nurses therein.Krizners (2002) argument is only valid to a point. Certainly, if nurses are knowledgeable about mental illnesses, they can communicate that knowledge/awareness to medical practitioners and contribute to the destigmatisation of the mental health problems. Generally speaking, however, if nurses are to adequately fulfil this task, it is necessary that the professional nursing training and education programmes be revised to include a solid grounding in mental health, irrespective of whether or not that is the chosen area of specialisation.Even were one to su ppose that professional nursing education and training curriculum were revised to include a thorough grounding in mental health, this still does not emerge as a valid and effective solution insofar as the destigmatisation of mental illness in the Arab World. Quite simply stated, and as expressed by Loza (2006) no more than 10-15% of nurses throughout the Arab World have undergone the required educational and professional training. This has resulted in both a dearth in professional nurses throughout the region and in the entrance of non-professionals into the vocation, implying that they bring their own stigmas regarding mental illnesses along with them. In fact, finding nurses, even non-professionals, willing to work in a mental health setting, or with mentally ill patients is extremely difficult. Therefore the notion that, the destigmatisation of mental illnesses can occurs from within the Arab nursing profession is hardly sound (2006). [To be continued...]
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