The stigma of mental illness in Asian cultures

Chee Hong Ng

Objective: This article reviews the attitudes towards mental illness and psychiatric
stigma in Asian cultures.
Method: Relevant literature published in English was reviewed.
Results: Psychiatric stigmas in Asian cultures share some common features.
However, response to mental illness has many variations across cultures.
Psychiatric stigma is prevalent and severe in some but not all Asian cultures.
Conclusions: The stigma of mental illness needs to be studied within its sociocul-
tural context in order to understand its origins, meanings and consequences. It may
be relevant to examine the indigenous concepts, experience and implications of psy-
chological problems to address problems in mental health care relating to stigma.
Key words: attitudes, culture, psychiatric stigma.

Australian and New Zealand Journal of Psychiatry 1997; 31:382-390

Historically, mental illness and the treatment of
mental disorders have involved emotional issues [ 11.
Mentally ill people have often evoked negative
responses in societies of various cultures. The nature
of psychiatric stigma is poorly studied despite its
widespread implications. Knowledge of such atti-
tudes is important not only in understanding the
origins and maintenance of disturbed behaviour but
also to those involved in prevention, early interven-
tion and community treatment of psychiatric patients
[ 2 ] .Moreover, funding and recruitment in this field
are determined by the attitudes and awareness of
people in power, including politicians and health
administrators. This paper will deal with the issues of
psychiatric stigma in Asian cultures which are among
the major non-Western traditions and societies.
The term ‘stigma’ is of Greek origin and refers to a
scar burnt or cut into the body, signifying that the
bearer was a slave, a criminal or of other bad moral
status. It is widely used today to mean a ‘mark of dis-
grace or infamy’ in relation to attitudes and percep-
Chee Hong Ng, Senior Registrar in Psychiatry
St Vincent’s Hospital and Community Psychiatric Service,
Fitzroy, Victoria 3065, Australia
Received 29 August 1996; revised 30 October 1996; accepted 5
November 1996.
tion of self or others. Goffman 131 provided a com-
prehensive account of the intrapersonal and interper-
sonal dynamics of stigma. It is a deeply discrediting
attribute causing a ‘spoiled identity’ and damaged
sense of self. Such socially undesired differentness
occurs within a language of relationships between
people. Clausen [4] argued that stigma is a kind of
buzz word which arouses more emotional reaction
than merely to be devalued or negatively regarded.
Those stigmatised are more likely to be rejected,
stereotyped and discriminated against.
Overview of attitudes towards mental
illness
Systematic studies of public attitudes towards
mental illness refer mostly to Western societies. Two
general methods are mainly employed. First, case
history descriptions based on Star (as cited in [ 2 ,
pp.l1-12]) vignettes are used to evoke judgements o f
subjects about the degree of mental illness prcsent.
They also indicate which behavioural features are
likely to be labelled as signs of mental illness. The
second approach uses social distance scales which
measure the degree of contact that one will accept
with the mentally ill. This was conceptualised by
Bogardus [ 5 ] and later refined by Whatley [(,I.

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 C.H. NG
Early major studies established that mental illness
was generally feared by the community. Even though
people were less likely to identify mental illness,
their response were characteristically negative when
labelling was authoritatively assigned [I]. On the
other hand, while severe mental illness with dis-
turbed behaviour was more easily recognised, the
public could not discriminate this from the much
more common milder form of disorders, resulting in
more generalised attitudes (e.g. all psychiatric
patients are violent and disturbed).
Subsequent studies showed results that were rather
conflicting. Medical researchers more frequently
produced positive attitudes while social scientists
obtained more negative attitudes [2]. Brockman et al.
[7] also noted that methodological techniques were
important determinants. Closed-ended interviews
had more positive results and open-ended interviews
or self-response questionnaires had more negative
results.
Reviews by Rabkin [2,8], Segal [9] and Bhugra [I]
on attitudes towards mental illness summarised some
recent findings:
(1) People are currently better informed about
mental illness. The public’s ability to label a broader
range of behaviour as mental illness has also
increased. Although moral issues remain, both
medical and social considerations have become more
prominent. However, even though mental illness
seems to be accepted as an illness like any other,
people’s feelings are not consistently shaped by this
cognitive awareness.
(2) Factors in the patients that influence public atti-
tude include: frequency of actual or anticipated
behavioural events; extent to which violence is an
issue; intensity of the behaviour; visibility in the
open community and geographic location; the degree
of unpredictability; and the loss of accountability.
Negative attitudes are most likely to be evoked if the
patient is male, of lower socioeconomic class, of
minority status, violent, unpredictable, showing
incomprehensible behaviour (e.g. hearing voices),
lacking social ties and being treated with somatic
therapies in State hospitals.
(3) Factors in the respondents are also important in
shaping attitudes. Older age, lower socioeconomic
status and lower educational level are associated with
greater intolerance and rejection of the mentally ill.
Among the relatives of patients, the lower the socioe-
conomic class, the greater the feelings of fear and
resentment, whereas the higher the socioeconomic
class, the greater the feelings of shame and guilt. In
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383
determining prevailing attitudes towards psychiatric
patients, the respondent’s motivation for attitude
change appears more important than mere past
contact with them.
(4)Factors in the social context also contribute in
forming community perception. The availability and
accessibility of psychiatric services together with the
level of familiarity with such services in the commu-
nity would influence social acceptability.
Community care (including day hospitals, outpatient
clinics, assertive and crisis community treatment)
instead of hospitalisation may lessen stigma. This is
balanced with the impact on public attitudes from
increasing numbers of acutely and chronically dis-
turbed patients in the community.
( 5 ) Even taking into account the inadequacy of
delivery of mental healthcare services in many coun-
tries, there is still general reluctance in seeking psy-
chiatric care. People would choose friends, family
doctor, relatives or clergymen before resorting to
psychiatric services.
(6) Stigma may be real or perceived (i.e. fear of
stigmatisation by the patient and family). Fear of
rejection, self-doubts, concealment and withdrawal
can be far more significant barriers to full social rein-
tegration than the stigma associated with negative
public attitudes. It also appears that attitudes have at
least several components. Some are a function of
enduring personality traits, some are related to edu-
cational exposure and others are more directly
related to action. These affective, cognitive and
behavioural components of attitudes need to be
assessed and dealt with separately.
Cultural response to mental illness and
stigma
The universality of mental illness across culture is
well acknowledged. However, culture can influence
mental illness in terms of the conception, perception,
experience of symptoms, recognition and labelling,
classification, treatment, and course of mental illness
[lo]. These issues are the concern of cross-cultural
psychiatry where one is mindful of Western ethno-
centric bias in diagnostic classifications of psychi-
atric disorders. Such are usually based on concepts of
normality and deviance which are not culture free,
and are derived from clinical populations selected via
social processes for Western treatment [ I I]. The use
of operationalised diagnostic criteria from outside
the culture (etic) should ideally be combined with
indigenous forms of expression and classification of
384 STIGMA OF MENTAL ILLNESS IN ASIAN CULTURES
distress from within the culture (ernic). Using both
etic and emic approaches would allow methodologi-
cally precise and culturally meaningful comparisons
[lo].
With respect to psychiatric stigma, Fabrega 1121
outlined the different ways psychiatric illnesses are
labelled across nowWestern societies. Stigmatisation
depends on what illnesses look like, how they are
symbolically interpreted and what effects they have
on the sufferer’s social capacities, functions and
identity. By analysing the great traditions of non-
Western societies (i.e. Chinese, Indian and Islamic)
Fabrega identified some common themes on psychi-
atric stigma in these societies:
(1) All illnesses are handled in an integrated psy-
chosomatic or somatopsychic way. As mental disor-
ders are not separated from the physical disorders,
the Western bias about ‘being psychiatric’ or having
symptoms stemming from the psyche is not found.
(2) There is, however, a tendency to medicalise
insanity or madness which mainly refers to psy-
choses and severe behavioural abnormalities.
Heavily somatised psychiatric illnesses like neuroses
merged with general medical illness and are treated
as such.
(3) There exist more supernatural,religious, moral-
istic and magical approaches to illness and behav-
iour. While they may confer strong stigma in some
cultures, they may not in others (e.g. the sufferer may
not be blamed for an external cause and the course is
expected to be brief).
(4) Conditions likely to have stigma attached are
chronic, irreversible and relapsing. These are judged
to be a result of sorcery and spiritual punishment, or
of hereditary and constitutional deficits, or of social
and moral transgressions.
The arbitrary distinction between mind and body is
found to be lacking in Asian cultures. According to
Western views, psychological distress should be
expressed in psychological terms. If this is expressed
in physical complaints (as in many cultures of devel-
oping world), then underlying psychopathology is
implied (i.e. somatisation). Furthermore, an inability
to psychologise distress may be misinterpreted as
alexithymia [ll]. There is failure to understand the
patient’s concept of illness as distinct from disease,
which is a medical concept of pathology. Kleinman
[13] viewed illness as the personal, interpersonal and
cultural reaction to disease. Patients will present
problems in a manner consistent with their percep-
tion, experience and cultural orientation of illness.
Somatisation in Chinese and other non-Western
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societies has been widely written about in the litera-
ture. It is not a culture-specific trait as it is also
common in the West. Numerous explanations have
been proposed denial and suppression of affect; lack
of vocabulary to express emotions; influence of tra-
ditional medicine: avoidance of social stigma; social
learning and expectations: and lack of mind-body
differentiation. However, very few are tested empiri-
cally [14]. Somatisation can also serve various func-
tions: to control interpersonal transactions; to gain
greater access over scarce resources: to empower the
somatiser; or to make sense of life problems. An
example of somatisation is neurasthenia (Shenjing
shuairuo, or weakness of nerves). It is a syndrome of
sleeplessness, physical exhaustion, headache, poor
memory, distractibility and dizziness. It enables
expression of mental distress and labelling of minor
mental illness without bearing the psychiatric stigma
[lo]. It is morally acceptable, a way of legitimising
psychosocial problems and sometimes of gaining
redress for past wrongs [ 111. Important to note is that
somatisation here does not refer to psychodynamic
meanings and it occurs concomitantly with emotion-
al distress. Put simply, it is a style of presenting and
communicating one’s problems. If probed directly,
psychological symptoms are usually present [ 141.
Another common aspect in traditional societies
is the importance of familial orientation, group-
centredness and interdependence, which place high
value on group harmony in place of autonomy and
individualism. According to Kirmayer [ 111: ‘Where
the person is conceived in terms of the family or a
larger social unit... stigma of illness affects the entire
unit and demands a collective response’. As a result,
stigma may be more severe because it is attached to
the family as a whole. On the other hand, the family
shares the problem and attempts to solve it using its
own resources. Although treatment may be delayed,
the family provides crucial support and extended
kinship network [151. There is also evidence that
families in many developing countries have lower
levels of expressed emotion. Furthermore, the lack of
specialisation in social and work roles in non-indus-
trial societies may allow greater acceptance of men-
tally ill persons into less demanding work roles [ 161.
The interactions between these factors and mental
illness have significantprognostic implications. Such
effects are evident most notably in the International
Pilot Study of Schizophrenia which found better
prognosis for schizophrenia in developing countries
D71.
The lack of mind-body distinction, tendency for
 C.H. NG
somatisation and the shame shared by the patient and
family directly impact upon help-seeking behaviour.
Lin et al. [I81 found that Asian subjects frequently
have a pattern characterised by persistent family
involvement, extensive use of traditional healthcare
methods, consultation with community leaders and
reluctance in accepting psychiatric referral which
often lead to extreme delay in contact with mental
health services. This partly reflects the coping strate-
gies used, particularly by the Chinese, including
denial, self-control, passive response and endurance
of one’s problems (ren) and family containment at
home. It is also common for Asian patients to use dif-
ferent forms of healing practices concurrently (e.g.
Western medicine, traditional herbal remedy and
temple worship) without a need to commit to a par-
ticular method.
Cross-cultural comparisons of attitudes towards
mental illness are important to identify similarities
and differences between cultures, re-evaluate current
understanding of mental disorders and plan services
[ 191. The World Health Organization Collaborative
Study on Strategies for Extending Mental Health
Care was designed to develop community based
mental health care as part of primary health care in
developing countries [20]. The authors studied com-
munity reactions to mental disorders based on stan-
dardised interviews using case vignettes with key
informants in Raipur Rani (rural India), Shagara
Jebel Awlia (rural Sudan) and Sampaloc (urban
Philippines). Perceptions of mental disorders and
their consequences (gravity, prognosis, marriage
prospects, living at home and work) are presented in
graphic attitude profiles. Rural Indians had more
negative and pessimistic attitudes but was more
likely to use modern health services. In contrast,
urban Philippinos preferred traditional medicine for
psychological problems.
In a different study of a multicultural community,
the attitudes towards mental and physical disabilities
were compared. Attitudes towards 20 disability
groups in 665 health workers of six Australian com-
munities were studied using five-point social dis-
tance scales. The degree of stigma attached to
disabilities by the communities was very similar.
People with AIDS, psychiatric illness and mental
retardation were least accepted. Overall, the German
and Anglo-Australian groups were more accepting
while the Italian, Greek, Chinese and Arabic groups
were less accepting of various disabilities [21].
Further understanding of attitudes in different
migrant communities would be highly relevant in
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385
providing acceptable and accessible mental health
services. Unfortunately, research in this area is
lacking.
Attitudes towards mental illness in specific
Asian cultures
Chinese culture
Based on the concept of Tao and a functional
approach, Chinese medicine focuses on the restora-
tion of balance according to the theories of yin-yang,
five evolutive phases, ching-lo and orientation of chi
(meridian system) [22]. Excess emotions are consid-
ered unhealthy. Confucianism values avoidance of
emotions to preserve social harmony. Psychological
problems are expressed in a somatic organ-based lan-
guage [23]. Although these factors may have inhibit-
ed the development of psychiatry in China, mental
illness was integrated non-judgmentally with other
medical illness. The Chinese never had a preoccupa-
tion with ‘insanity’ as in the West and large asylums
were not built [22]. Historically, the mentally ill
received relatively humane treatment according to
Chinese records [23]. However, there is also evi-
dence that treatment of the mentally ill ranged from
pity and compassion to hersh confinement.
Chinese views on the cause of mental illness are
multi-faceted [24]. It may be regarded as moral trans-
gressions towards ancestors or social norms whereby
the family is also held responsible. Alternatively, it
can be attributed to hereditary or even ancestral
inheritance of misconduct, so that the sufferer and
sometimes even siblings are excluded from marriage
traditionally. Common beliefs also include cosmo-
logical forces, wrath of gods and ancestors, posses-
sion by spirits, demons and foxes, hormones, diet,
brain dysfunction, or even political ideology.
It is likely that strong psychiatric stigma is attached
to the family because of the burden of intense shame
and guilt they carry. Mental illness tarnishes family
honour, name and ancestors. Origin of psychiatric
stigma is partly in the fear of the Chinese family
exposing its own shame to outsiders. The stronger
the wish to conceal its ‘disgrace’ from being
exposed, the more intense the psychiatric stigma
~41.
As a result, denial and somatisation are often used
to relieve the family of stigma. Herbs, special diets
and traditional medicines are sought and there is
strong resistance and extreme delay in seeking psy-
chiatric help. Minor mental illnesses are treated as
386 STIGMA OF MENTAL ILLNESS IN ASIAN CULTURES
physical illnesses by physicians. For the severe
mental illnesses, the Chinese family undergo two
stages of help-seeking behaviour. The prediagnosis
stage is often protracted and characterised by family
concern, protectiveness, use of intrafamilial
resources and finally seeking outside help. The post-
labelling stage leads to despair and loss of tolerance,
followed by a series of hospitalisations and ending
with scapegoating and rejection [24].
There is conflicting evidence about the quality of
mental health provision in China, which may reflect
attitudes towards psychiatry. Since the Cultural
Revolution there has been increasing awareness of
the importance of mental health care of which the
scope has enlarged [25]. However, both hospital and
community mental health services and rehabilitation
programs remain limited [26]. Mental illness is still
viewed as largely biological by Chinese psychiatrists
who have little interest in psychosocial or family
dynamics [27]. Training in psychiatry is lacking and
doctors and nurses are very reluctant to work in psy-
chiatry due to its low status, social stigma and the
unrewarding nature of caring for only chronic psy-
chotic patients [24]. Studies of attitudes towards
mental illness are few and difficult to compare
[28,291.
Japanese culture
Given its East Asian origin of culture, some attitudes
and behaviour towards mental illness are similar to
those of the Chinese. Psychological distress is fre-
quently expressed in somatic terms and often treated
as disguised diagnoses [30]. It is also linked to psy-
chological weakness (such as lack of willpower to
exercise self-control) or sociomoral concerns (e.g.
modernisation or breakdown of family structure). As
purity is highly valued, the popular belief about the
hereditary and constitutional nature of mental illness
leads to strong stigmatisation. Social discrimination
such as in marriage, business and education is suffered
by the patient as well as the family and relatives [31].
With rapid socioeconomic changes, the family is
changing from an extended to a nuclear structure.
Tolerance towards a mentally ill family member has
decreased and there is increased dependency on
mental hospitals and doctors to care for the patient
[30]. There is also a deep cultural need for group
approval associated with the ‘shame-culture’ in
Japan, leading to the family’s wish to dissociate from
mental illness. Hence, patients are discouraged from
returning to society [3 11. Self-victimisation on the
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part of mentally ill patients as well as economic
factors may further foster the situation.
One study on attitudes towards the mentally ill in
three Japanese communities concluded that most
regarded the mentally ill as psychotic. Negative atti-
tudes were stronger in older and less educated
respondents who were not related to patients. A third
had sympathetic attitudes and less than a third
viewed the mentally ill as dangerous. Mental illness
in the family was regarded as shameful, and most
preferred treatment in mental hospitals although
many also had an optimistic view of recovery from
mental illness [32].
South-East Asian cultures
The attitude, family response and approach
towards mental illness in these cultures resemble
those in East Asia.
Lien and Rice [33] and Lien [34] described how
mental illness is viewed as madness and is consid-
ered untreatable among the Vietnamese. Fear of
one’s mental problems being known to others and the
concealment of distress retlect the strong stigma
attached to patients and their families. Denial makes
them reluctant to accept psychiatric treatment even if
it proves beneficial. They also see accepting treat-
ment as lack of endurance, personality strength and
dignity.
The predominant influences in Burmese culture are
Buddhism and Nat cult (animistic beliefs).
Traditional beliefs lead to families seeking help from
Buddhist priests, indigenous leaders, witch doctors
and ritual practices. Way [35] stated that barriers to
acceptance of mental health programs within the
community included lack of modern conceptions of
mental illness, isolation of mental hospitals and the
prejudice of health professionals towards the mental-
ly ill.
Westermeyer [36] studied the folk concepts of
mental disorder among rural Lao people. Aetiologics
of ba (insanity) relate to spirit, magic, breaking a
taboo, thinking too much and bad blood, which indi-
cate the kind of treatment needed. Folk concepts like
lost mind, brain illness and slow persons are more
descriptive. Aetiologies that connote responsibility
on the sufferer lead to rejection but those that are
ambiguous allow more supportive response from the
community. He also noted that belief systems are
flexible enough to accommodate different treatment
modalities.
In Malaysia, mental illness is still associated with
 C.H. NG
supernatural causes and punishments for past trans-
gression. Traditional and religious healers are usually
sought first; the type depends on one’s ethnicity. In a
study on perception of mental abnormality in a
Malay village, madness (gila) was associated with
physical violence towards others and would result in
permanent banishment [37]. Prejudices are also
strong against psychiatry even among medical pro-
fessionals. However, of the three major ethnic groups
(Malay, Chinese and Indian), the Malays are general-
ly most supportive and less rejecting towards the
mentally ill. Although madness is strongly stigma-
tised, some conditions which are believed to be acute
and reversible in nature such as amok is less so. An
acutely ill person may be physically restrained in a
village but this is only seen as a preventive rather
than a stigmatising measure [38].
With rapid modernisation and growing affluence in
Singapore, its mental health service has been expand-
ed. However, perceptions of mental illness may be
slower to change. Teo [39] reported that 70%of first
admissions to a major psychiatric hospital in
Singapore for mental illness had consulted alterna-
tive ‘healers’ before. Denial of mental illness by the
family results in late presentation. Those with minor
mental illness usually avoid contact with psychiatric
services due to fear of stigmatisation. The negative,
unsympathetic attitude towards the mentally ill is
seen as a major contributing factor to suicide among
Chinese Singaporeans [40].
Indian culture
Concepts of u n d u (severe mental disorder) in
Indian culture are largely influenced by the folk and
Ayruvedic or Indian classical medicine traditions
[41], Folk traditions emphasise supernatural causes,
while Ayruvedic tradition describes mental illness in
terms of humoral imbalance. Other indigenous con-
cepts used include astrology, karma, intense stressors
as well as physical illnesses. Typically, psychiatric
patients have had contact with other healers
(Ayruvedic, folk, temple and homeopathic) prior to
being seen at psychiatric centres. Weiss et af. [411
observed that a medical pluralism exists with respect
to mental disorder where the boundaries between dif-
ferent conceptual models and healing systems
(including the Western approach) are blurred. Thus,
one shifts easily from one conceptual mode to
another and the treatment choices may be made
largely on pragmatic considerations.
Ayruvedic medicine did not regard psychiatric
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387
illness in any special way that is stigmatising [121. In
fact, Ayruvedic practitioners are said to treat the men-
tally ill in a humane and sympathetic manner.
However, perhaps associated with its rigid caste
system, traditional moral and ethical codes of India
suggest evidence of social discrimination towards
mentally ill persons.
Waxler [421 reported that in Sri Lanka, where the
majority are Sinhalese Buddhists and not Tamil
Hindus, psychiatric stigma is not prevalent. Serious
mental illnesses are viewed to be brief and curable.
The patient is not held responsible for his illness and
his identity and credibility does not change. Using
labelling theory, Waxler argues that a favourable atti-
tude towards schizophrenic patients contributes to
their better prognosis.
Various studies using social distance scale have
shown different results with regard to psychiatric
stigma in India. The Vellore study on public attitudes
[43] found 65.3%of respondents objected to marital
alliance with the household of a mental patient. In a
similar study on attitudes of psychiatric patients
themselves, three-quarters were opposed to marital
alliance [44]. Mental illness affects marriage
prospects adversely given the rigid selection of mar-
riage partners which screens out any family history
of mental illness. Families on the whole actively care
for mentally ill patients but due to the burden of prej-
udice, they too eventually reject and abandon them in
mental hospitals. The negative attitudes found in the
World Health Organization Raipur Rani study have
already been mentioned [20].
Poor recruitment to psychiatry has been a serious
problem in developing nations like India. Attitudes of
medical students are important in determining career
choice in psychiatry. One study which looked at the
relationship between attitudes towards psychiatry and
career interest showed some correlation between
favourable attitudes and interest. However, those with
career interests in psychiatry were concerned about
the low career and social status of psychiatry and that
they might be considered as odd by other colleagues
[45]. Undergraduate training remains unsatisfactory
and short postings (e.g. 2 weeks) do not result in any
improvement in attitude [&I. Such negative profes-
sional attitudes found similarly in other Asian soci-
eties may encourage stigma and poor patient care.
Islamic cultures
Medieval Islamic medicine originated from Greek
Galenic humoral tradition and Arabic prophetic
388 STIGMA OF MENTAL ILLNESS IN ASIAN CULTURES
medicine which combined medicine with religious
tradition [12]. In Galenic medicine, insanity was
considered a brain dysfunction due to humoral
imbalance. No moral meaning or shame was
assigned and it was an illness like any other.
Although insanity was a private family affair, it was
also a communal responsibility. Ancient Islamic
hospitals included wards for the mentally ill. Dols
[47] described how the harsh conditions of confine-
ment in these hospitals were considered simply nec-
essary to prevent harm to self and others. These
hospitals were accessible to the public and insanity
was accepted like other disabilities.
However, religious and spiritual explanations and
practices were also prominent in Islamic society.
Madness was associated with the Jinn, evil eye, vio-
lation of taboos, personal trauma, inheritance or
God’s will. Care of the insane was the responsibility
of the family and there was ‘resistance to incarcera-
tion of the insane’. The Koran and Islamic laws
strongly advocate supportive and tolerant treatment
of the ‘incompetent’. Such tolerance of a wide range
of normal and abnormal behaviour is a feature of
Islamic society in which the harmless mentally ill
person can be usually contained [471.
The above characteristics are evident in
Horikoshi’s description of an Islamic psychiatric
institution in West Java [48]. Mental illness is
viewed as a result of imbalance of hot and cold sub-
stances and also inadequate religious faith. To
restore humoral imbalance and religious faith, the
patients undergo a process of relaxation therapy,
sleep and diet control, counselling, work therapy
and religious training. Even if treatment fails, men-
tally ill patients return home and live in the com-
munity without any alienation or discrimination.
Their disorderly behaviour is tolerated and some-
times even respected due to their selflessness. To
exclude them from society is to defy God’s will.
Hence, psychiatric stigma seems hardly present in
Islamic society.
Conclusions
Stigma of mental illness can be studied from dif-
ferent perspectives including ancient medical, socio-
cultural, cross-cultural and systematic approaches.
Although the literature frequently refers to stigma,
epidemiological and systematic studies are scarce.
Not surprisingly, the measure of stigma is highly
complex and multifaceted.
The contexts in understanding stigma of mental
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illness in Asian cultures share a number of common
features. Lack of mind-body dualism, somatisation,
medicalisation of psychiatric illnesses, spiritual and
religious beliefs and family orientation are among
these features. Traditional beliefs, religious affilia-
tion, economic factors and level of modernisation in
the society often determine the type of treatment
sought in mental illness. However, explanatory
models and treatment choices are not infrequently
pluralistic.
Response to mental illness has many variations
across cultures. To compare with Western culture is
to look from only one reference point. Attitudes
towards mental illness depend on the type of mental
illness and its effects on social function and identity.
However, the nature and degree of stigma depend on
the conceptualisation and labelling of the illness
within the society. These are influenced by complex
factors associated with culture, religion, values,
social orientation and system. The rapid socio-
economic changes in many Asian countries today
will no doubt exert further effects. Hence, stigma
cannot be studied in isolation and its sociocultural
context needs to be taken into account in order to
understand its origins, meanings and consequences.
The effects and dynamics of stigmatisation in psy-
chiatric illness are extensive. They can be manifested
at different levels including psychological, family,
social, cultural and economic. Self-devaluation,
expressed emotions, family burden, low marriage
prospects, loss of job and status, social discrimina-
tion and lack of mental health resources are only
some important effects. These in turn will affect the
treatment, course and outcome of mental illness.
Given the apparent better prognosis of schizophrenia
in developing countries, the impact of stigma on
outcome warrants further research.
Whether stigma is more prevalent and severe in
Asian cultures is by no means conclusive and cer-
tainly cannot be generalised. Although there is lack
of acceptance of mental illness and psychiatric treat-
ment in many Asian cultures, stigma is only but one
factor. To attribute problems in mental health care to
stigma loosely and indiscriminately does not serve to
address the important issues. It may be more relevant
to examine the indigenous concepts, experience and
implicationsof psychologicalproblems as well as the
socioculturalresponse to mental illness. Such knowl-
edge would bear direct influence on the utilisation of
mental health services, treatment compliance, treat-
ment response, preventive programs and public edu-
cation strategies.
 C.H. NG
Acknowledgement
I would like to acknowledge my colleagues in the
Victorian Transcultural Psychiatry Unit for their
support and assistance.
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