Stigma was initially described by Erving Goffman in 1963. He identified stigma as any characteristic or attribute by which a person was devalued, tainted, or considered shameful or discredited. Subsequent work in this area was influenced by the work of Goffman, and the concept of stigma has been explored in many contexts and cultures. Stigma is strongly influenced by cultural and contextual value systems that differ over time and across contexts. However, most authors agree with Goffman’s basic definition, which identified the main elements of stigma such as labeling, stereotyping, social isolation, prejudice, rejection, ignorance, status loss, low self-esteem, low self-efficacy, marginalization, and discrimination [1,2,3].
Mental health stigma is defined as the disgrace, social disapproval, or social discrediting of individuals with a mental health problem [4, 5]. Literature identifies multiple dimensions or types of mental health-related stigma, including self-stigma, public stigma, professional stigma, and institutional stigma. Self-stigma refers to negative attitudes of an individual to his/her own mental illness and is also referred to as internalized stigma [1, 6]. Self-stigma has been related to poor outcomes, such as failure to access treatment, disempowerment, reduced self-efficacy, and decreased quality of life [7, 8]. Public stigma refers to negative attitudes towards those with mental illness by held by the general public [1, 6], often based on misconceptions, fear, and prejudice. Related to public stigma is perceived stigma which is defined as individual’s beliefs about the attitudes of others towards mental illness. Research has demonstrated the significant impact of public stigma such as discrimination in workplaces and public agencies [8]. Professional stigma occurs when healthcare professionals hold stigmatizing attitudes toward their patients, which are often based on fear or misunderstandings of the causes and symptoms of mental illness, or when professionals themselves experience stigma from the public or other healthcare professionals because of their work and connection with stigmatized individuals [1]. Professional stigma is of particular concern as it may affect the care and treatment a person with mental illness receives [1], including treatment for physical illnesses [8], thereby impacting their well-being and recovery. Finally, institutional stigma refers to an organization’s policies or culture of negative attitudes and beliefs toward stigmatized individuals, such as those with mental health problems [1, 6,7,8,9,10,11,12,13,14]. Such stigma can also be reinforced by legal frameworks, public policy, and professional practices, thereby becoming deeply embedded in society [8].
In the context of mental healthcare, stigma has been identified as a major issue for patients and families. Stigma hinders access to appropriate and professional medical and psychological treatment, and can result in a person’s condition worsening or multiple readmissions [3, 6, 7, 15]. Furthermore, the impact of stigma is so great that patients describe the stigma and prejudice they encounter as almost as bad as the symptoms of their disorder [16], and as a burden on their private and public lives [17]. Stigma also affects patients’ families or relatives and the professionals who work in mental healthcare settings. Therefore, to reduce stigma in mental healthcare and facilitate the development of appropriate services in Indonesia and similar countries or contexts, it is important that the different types of stigma are clarified and understood within the unique value system and culture.
The Republic of Indonesia has the fourth largest population in the world and the third largest in the Asian continent. As estimated in 2020, the Indonesian population comprises 267 million people; approximately 151 million people (around 56.6% of the Indonesian population) live in urban areas and the remainder lives in rural areas [18, 19]. In general, Indonesians follow a traditional way of life that is strongly affected by traditional and religious beliefs. The prevalence of severe mental illness in Indonesia is estimated at 1.7/1000 population, and that of mild mental illness is around 60/1000 population [18]. Stigma is known to be common in such traditional contexts [19, 20]. Therefore, understanding how stigma manifests in this context will help reduce stigma and contribute to developing mental healthcare services in Indonesia and potentially in other similar Asian contexts.
Treatment for mental illness in Indonesia is currently inadequate. The country has the lowest ratio of psychiatrists per capita in the world, and mental healthcare facilities are limited in availability and underdeveloped in terms of quality, human resources, and infrastructure [20,21,22]. This situation, along with low public awareness of mental illness, persisting stigmatizing and traditional beliefs about mental health, and the lack of local professional knowledge in the area, seriously impact the care of patients with mental illness in terms of access to and quality of services. In addition, stigma about mental illness is rarely discussed openly, which results in misunderstanding, prejudice, confusion, and fear. In this context, families often hide or ostracize family members with mental illness because they are reluctant to bring them to public attention or seek help [18, 21, 23].
A recent study found that the experience of stigma among patients with mental illness in Indonesia was pervasive and negatively impacted use of mental health services[24]. The stigmatization of mental illness is manifested by families, community members, mental health professionals and staff, governmental institutions, and the media. Stigmatization is characterized by violence, fear, exclusion, isolation, rejection, blame, discrimination, and devaluation, primarily as a result of general (mis)understandings about mental illness. Until the stigma associated with mental illness is addressed at the national level, Indonesians with mental illness will continue to suffer and face barriers to accessing mental health services [24]. Given Indonesia’s predominantly rural population and traditional way of life, it is particularly important to examine stigma in this context. For example, persisting stigma means that families in traditional societies such as Indonesia and other Asian countries hide those with mental illness because of embarrassment and shame, and are unwilling to access public mental health services [25]. Stigma may also prevent a family from socializing with other community members. In addition, others may blame family members for the person’s illness, meaning patients experience further feelings of shame and guilt [24,25,26,27,28]. It has also been reported that stigma means that health professionals in psychiatric hospitals often do not treat patients with dignity or respect, and do not provide optimal protection for patients who are hospitalized [29].
Despite the prevalence of mental illness and the high levels of stigma toward patients with mental illness, little research has been conducted to clarify the elements, attributes, and features of different types of stigma in the Indonesian culture and value system. A literature review on mental health in Indonesia conducted in PubMed returned 161 studies published between 1949 and 2020. However, only 15 of these studies discussed stigma either directly or in the context of Indonesian mental health services [18, 30,31,32,33,34,35,36,37,38,39,40,41,42,43]. Among these 15 studies, six discussed stigma in general, consequences of stigma (i.e., “pasung” or confinement), attitudes toward mental health, and perceptions of mental health [18, 30, 31, 41,42,43]. Previous investigations of stigma in Indonesia mainly examined personal stigma, with a focus on the perceptions of those with mental illness and their families, how they respond to stigmatization in their lives, and the impact of stigma on access to mental health facilities or treatment [18, 20,21,22,23, 44]. The present study offers a unique perspective given its comprehensive approach to understanding the different types of stigma that exist in Indonesian culture.