The International Journal of Psychosocial Rehabilitation

Biases towards Individuals with Psychiatric
Disabilities as related to Community Integration

Oudi Singer, M.Ed.
Kent State University

Citation:
Singer, O.  (2001)  Biases towards individuals with psychiatric disabilities as related to
community integration.  International Journal of Psychosocial Rehabilitation. 6, 21-27


Abstract
Work, housing opportunities and community integration (in general) for individuals with psychiatric disabilities or substance related disabilities are significantly severed by societal stigmatic attitudes (Weiner et al., 1988 as cited in Corrigan et al., 2000). Literature continuously demonstrates that discriminative attitudes vary and come from varied directions. As suggested by literature the ill treatment toward the mentally ill comes from health practitioners as much as from the general population (Spiro, McCrea Curnen, Peschel, & James, 1993; Carling, 1995; Michener, 1998; Sheehan, 1982). The purpose of this Current essay is to observe community integration as influenced by client-other relationships. We will look at three elements of integration: therapeutic inequalities, Community acceptance, and job involvement as related to attitudes toward diagnosed individuals within communities. These realms of involvements will be explored deeply for better understanding of the unfortunate trends; so better awareness can be developed in mental health practices.

Introduction
Historically, western attitudes toward people with the label of “mental illness” have been mostly negative. Though one might think that the nature of attitudes have changed over the decades, reality strongly assures that that is not the case (Spiro et al., 1993; Carling, 1995; Michener, 1998 & Heginbotham, 1998).
Such attitudes contribute more to inequalities, segregation, and discrimination than any other. Negative attitudes stand as a barrier to community integration as well as to job retention and job terminations (Carling, 1995; Corrigan et al., 2000). Successful integration is dependent upon cooperation between professionals in psychiatric hospitals, Community services, families, self-help programs, and the recipients of care (Carling, 1995). When biases invade the practices the practice of care, successful integration is at risk (Carling, 1995).
The teachings of care serve as a backbone to health care code of ethics (Corey, Corey& Callahan 1998; Jonsen, 1991 & Spiro et al., 1993). Even with the existence of such teachings there is a growing literature, from the 60’s to present times that portray a different atmosphere in the relationship between health providers and consumers (Green, 1964; Laing, 1965; Sheehan, 1983; Spiro et al., 1993; Adams, 1993; Lown, 1996 & Michener, 1998).
First barrier: Therapeutic inequalities
Thomas Mann once said that we must behave as though the world was created for human beings (Mann cited in Lown, 1996). Mann’s classical quote strongly suggests Humane Etiquette in relationships. Lown expand his discussion when he brings a dialogue he had with a soviet physician. What was the essence of doctoring for her he asked, she replied: “ every time a doctor sees a patient, the patient should feel better as a result” (Lown, 1996, pp.88). The Soviet Physician response is a reflection of the ideal in the health care relationship.
An intensive look into the clients’ literature and reports suggest something else rather than the ideal (Sheehan, 1982; Michener, 1998 & Nehls, 1999). It reveals a great deal of Dissatisfaction of health recipients. Most of the complaints are strictly linked to inequalities within the therapeutic milieu. Some of the complaints include the feeling of being invisible almost non-existent which is a direct product of an unequal relationship (Leete, 1988 as cited in Carling, 1995)
Being invisible
Literature reports that many consumers facing health providers develop a feeling of being invisible, or not important. As suggested by Carling, consumers with mental illness often report a feeling of ‘invisibility’ as they enter the conditioned therapeutic relationships rather than unconditioned ones; they sense that their views and desires do not matter. Esso Leete (Leete, 1988 as cited in Carling, 1995) commented that he can make suggestions, but these are not being taken seriously, even when describing personal experiences these are often seen as delusions.
 
As we observed Attitudes in general are based on behavioral observations (Laing, 1967; Kohlenberg & Tsai, 1991; Hayes, Strosahl & Wilson, 1999). Therapeutic communication that is based on behavior alone without a regard to the client inner-experiences may perpetuate the illness in which it supposes to treat (Laing, 1967; Szasz, 1976 & Carling, 1995). When consumers’ inner-experiences are not met, when clients’ autonomy is being compromised, the recipient feels alienated and often identifies with the role of the ‘patient’ as a result and that may also bring to learnt helplessness and hopelessness which are strong barriers to healing and rehabilitation (Laing, 1965; Carling, 1995 & Torrey, 1995).
 
The act of perceiving the client as invisible also projects on the disbelief toward ones condition. Much has been written in the literature about the nature of therapeutic disbelief toward an individual with chronic illness (Bowman, 1991; Thorne, 1993; Lovgren, Engstorm & Norberg, 1996, as cited in Thorne, Nyhlin, & Paterson, 2000). Based on literature reports and the analysis by Thorne, Nyhlin & Paterson The attitudinal patterns of professionals toward individuals reinforce existing dysfunction within the health care relationship. Convincing a disbelieving professional of the seriousness of symptoms creates a context in which the client is viewed, and labeled as complaining, over anxious, or obsessed with the condition (Benner, 1994; Johansson et al, 1996; Malterud, 1992, 1993, as cited Thorne, Nyhlin & Paterson, 2000).
 
Studies continue to show the direct impact of unequal relationship on the feelings of the client. In a study measuring disagreement with general practitioners, groups 4 and 5 complaints were mainly based on poor care from the general practitioner. 10% of the disagreements within these groups (n=29) reported that they felt that the general practitioner didn't take them seriously. Other (12%) reported other forms of complaints such as feeling that the doctor is unsympathetic. The remaining disagreements were related to a rude approach toward the consumers (Annandale & Hunt, 1998).
Medicating over Dialoguing
Current progress in health care technology and research brought great knowledge and improvement in the life of consumers (Callahan, 1990; Spiro et al., 1993). Such advances gave also birth to a great dilemma in health care. With the biological etiology to illnesses there is the growing assumption that psychotropic interventions are the superior solution for curing an illness (Spiro, et al., 1993; Cousins, 1979, Adams, 1993 &Callahan, 1990). Actually Current research shows that a holism within health care approach as reinforcing better outcomes (Cousins, 1979; Adams, 1993& Comer, 1998).
 
Second Barrier: Community lack of Acceptance
At the community level, negative attitudes have become structured into social pattern of segregation, discrimination, and lack of support for mental health services. For people with psychiatric disabilities, these attitudes may result in economic marginality, segregation and repeated relapse (Carling, 1995).
People whose lives have been disrupted by a psychiatric diagnosis and who lose their jobs, homes or status, as students will have great difficulty achieving these opportunities back once they were labeled (Carling, 1995). Since the attitudes are in the core level of society, community centers will have trouble seeing the potential for integration that lies within individual with psychiatric disabilities (Laing, 1967;Zipple et al., 1988).
 
Pattern of community discriminations can manifest themselves in the refusal of landlords to rent an apartment or to offer a job (Carling, 1995). The attitudes can also include minimizing leisure activities for people with psychiatric disabilities, such as insisting that the person with mental disability will use only certain facilities in certain hours in which the staff is present, or not inviting them to social gatherings after work (Carling, 1995).
 
Education: Discrimination in Among Students
A study led by Corrigan and Colleagues revealed an unequal treatment to ward people with several of disabilities (Corrigan et al, 2000). The Community college students (N=152) strongly stigmatize individuals with disabilities unequally; Students viewed people with psychosis, cocaine addictions and other psychiatric disabilities more negatively than people with physical disabilities (Corrigan et al, 2000).
 
This study strongly demonstrates that discrimination towards people with psychiatric disabilities is still a breathing process within community. Since community life offers less and less for individuals with mental illness, blame and avoidance become a reality for our clientele. A study done by Corrigan and colleagues has showed in a comprehensive study that the attitudes of avoidance and blame are strong towards people with cocaine addiction (0.74, 0.80). Blame and avoidance are also strong towards people with psychosis (0.82, 0.64). Such feelings demonstrate that attitudes of sort can be a significant contributor to the creation of a milieu that indulges inequalities and segregation in educational systems (Corrigan et al, 2000; Carling, 1995).
 
Community Social Dysfunction towards People with Mental Disabilities
Social dysfunction and loss of opportunities experienced by individuals with severe mental illness are greatly exacerbated by the societal stigma (Farina, 1998; Carling, 1995; Link, Cullen, Struening & Shtrout, 1989). Research suggests that employers are less likely to hire persons who are labeled mentally ill (Bordieri & Drehmer, 1987; Farina & Felner, 1973& Link, 1987). Inside the community people with mental illnesses have two options regards work: one is to remain unemployed and the other is having an entry level positions with low pay and little chance of advancement (Carling, 1995). At the employers level, some have false expectations related to the performance level of the person with psychiatric disability (Brown & Saura, 1996).
Third Barrier: Work related Issues
When coming to discuss the issue of Job termination few aspects should be considered, one comes from the Employers level, the other from the client domain (Becker et al., 1998; Cook, 1992). Studies report that many of the termination of jobs are the result of employers’ initiation the employer (40%) in comparison to 14% that left the job themselves without another position (Fabian & Wiedefeld, 1989). Some explanations to consumer low tenure in jobs suggest that lack of proper attendance can be the cause (Lagomarcino, 1990 in Becker, 1998). That low attendance is doesn’t exist within a vacuum since some of it is related to client unsatisfactory job experience or poor employer accommodation (Becker, 1998). Becker’s’ study shows that 58% of the terminations were due to problems in interpersonal relationships (Becker, 1998).
 
Conclusion
Successful community integration is strongly dependent upon true collaboration among professionals, community agents, and the state mental facilities. Inequalities in all forms, from the most innocent one (lack of education regarding what is mental illness) to the more severe one (observed discriminations in community, employment, and selective empathy by professionals) lay as barricades that may prevent individuals with mental illness in succeeding within their communities.
Suggestions might include better preparation former to integration. The preparations not only will involve enhancing social skills, and the life skills of people with mental illness but also will educate and enrich community agents with the knowledge prior to the clients’ arrival to community. Even the most competent individual might fail when community agents instead of embracing the knowledge of the nature of the illness and care embraces the knowledge of old stereotypes and myths (Carling, 1995).
 
QRC, quality rehabilitation and counseling must involves better assessment and better interventions regarding vocational counseling in communities and in pre-employment services (such as supported employment). Such understanding is the conclusion that follows current research regarding job terminations among people with mental illnesses participating in supported employment programs (Becker et al, 1998; Cook, 1992; Bond & Dietzen, 1993).
 
Such terminations in jobs suggest that the clients were not prepared properly to employment. Bond & Dietzen (Bond & Dietzen, 1993) have found that consumers lacked job readiness. Cook (Cook, 1992) has found that consumers that terminated their job were unable to do job tasks. Such finding suggests that pre-employment programs must enhance skills in such consumers.

References
Adams, P. (1993). Gesundheit!. Vermont: Healing Art Press.
Annandale & Hunt, 1998. Accounts of disagreements with doctors. Soc. Sci. Med. Vol46 (1). Pp 119-129.
Becker, D.R., Drake, R.E., Bond, G.R., Xie, H., Dain, B.J., & Harrison, K. (1998). Job terminations among persons with severe mental illness participating in supported employment. Community Mental Health Journal. Vol. 34 (1). pp. 71-82.
Bond, G.R., & Dietzen, L. (1993). Predictive Validity and Vocational Assessment: Reframing the Question. In R.L. Glueckauf, L.B. Sechrest, G.R. Bond, & E.C. McDonel (Eds). Improving Assessment in Rehabilitation and Health.
Brown, A.L., & Saura, K.M. (1996). Vocational rehabilitation needs of individuals dually Diagnosed with Substance Abuse and Chronic Mental Illness. Journal of Applied Rehabilitation and Counseling. Vol. 27(3). pp. 3-10.
Callahan, D. (1990). What Kind of Life. Washington D.C.:Georgetown University Press.

Carling, P.J. (1995). Return to Community: Building Support Systems for People with Psychiatric Disabilities. New York: The Guilford Press.

Comer, R.J. (1998). Abnormal Psychology. New York: H. Freeman & Company.
Cook, J.A. (1992). Job Ending Among Youth and Adults With Severe Mental Illness. The Journal of Mental Health Administration. Vol 19. pp 158-169.
Corey, G., Corey, M.S., & Callahan, .P. (1998). Issues and Ethics in The Helping Professions. Boston: Brooks/Cole Publishing Company.
Corrigan, P.W., et al. (2000). Stigmatizing Attributions About Mental Illness. Journal of Community Psychology, Vol. 28, pp.91-102.
Cousins, N. (1979). Anatomy of an Illness. New York: Bantam Books.
Fabian, E., & Wiedefeld, M.F. (1989). Supported Employment for Severely Psychiatrically Disabled Persons: A Descriptive Study. Psychosocial Rehabilitation Journal. 2(13), Pp. 53-60.

Farina, A. (1998). Stigma. In K.T. Mueser& N. Tarrier (Ed.s), Handbook of Social Functioning in Schizophrenia.pp. 247-279). MA: Allyn & Bacon.

Farina, A., & Felner, R.D. (1973). Employment Interviewer Reactions to Former Mental Patients. Journal of Abnormal Psychology. Vol. 82. Pp. 268-272.

Hayes, S.C., Strosahl, K.D. & Wilson, K.G. (1999). Acceptance and Commitment Therapy. New York/ London: The Guilford Press.

Heginbotham, C. (1998). U.K. Mental Health Policy can Alter the Stigma of Mental Illness. The Lancet, Vol 352,Pp. 1052-1053.

Johansson, E.E., Hamberg, K., Lindgren, G., & Westman, G. (1996). “I Have Been Crying my Way”: Quality Analysis of Group of Female Patients’ Consultation Experiences. Family Practice, Vol. 13, pp. 498-503.

Jonsen, A.R. (1990). The New Medicine & The Old Ethics. Massachusetts: Harvard University Press.

Kohlenberg, R.J.& Tsai, M. (1991). FAP: Functional Analytic Psychotherapy. New York and London: Plenum Press.

Laing, R.D. (1965). The Divided- Self. United Kingdom: Penguin Books.

Laing, R.D. (1967). The Politics of Experience and the Bird of Paradise. United Kingdom: Penguin Books.

Link, B.G. (1987). Understanding Labeling Effects in the Area of Mental Disorder: an Assessment of the Effect of Expectations of Rejection. American Sociological Review, Vol 52. pp.96-112.

Lown, B. (1996). The Lost Art of Healing. New York: Ballantine Books:.

Michener, A.J. (1998). Becoming Anna: The Autobiography of a Sixteen-Year-Old. Chicago & London: The University of Chicago Press.

Nehls, N. (1999). Borderline Personality Disorder: The Voice of the Patient. Research in Nursing & Health, Vol 22. pp. 285-293.

Sheehan, S. (1982). Is There no Place on Earth for Me?. New York: Houghton Mifflin Company.
Szasz, T. (1976). Schizophrenia: the Sacred Symbol of Psychiatry. New York: Syracuse University Press.
Spiro, H., McCrea Curnen, M.G., Peschel, E., & James, S.J. (Eds.). (1993). Empathy and the practice of medicine. New Haven/ London: Yale University Press.
Torrey, E.F. (1995). Surviving Schizophrenia. New York: HarperPerennial:
Thorne, S.E., Nyhlin, K.T., & Paterson, B.L. (2000). Attitudes toward patient expertise In chronic illness. International Journal of Nursing Studies,Vol. 37, pp. 303-311.
Zipple, A.M., Carling, P.J., & McDonald, J. (1988). A rehabilitation response to a call for asylum. Schizophrenia Bulletin, Vol. 13, pp. 539-546.

 


Copyright © 2001, Southern Development Group, S.A.  All Rights Reserved.
A Private Non-Profit Agency for the good of all, published in the UK & Honduras