Mental Health & Prevention 4 (2016) 115123

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Mental Health & Prevention

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Stigma against mental illness: Perspectives of mental health service users

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Namino Ottewell
School of Social Sciences, Waseda University, 16-1, Nishiwaseda, Shinjyuku-ku, Tokyo 1698050, Japan

A R T I C L E I N F O A BS T RAC T

Keywords: This study aimed to understand the perception, management and experience of stigma among people with
Depression mental illness in Japan. Interviews with people with mental illness were conducted and the data were analysed
Schizophrenia using grounded theory approach. The results showed that participants major concerns appeared to obtain or
Stigma keep a job, and being regarded as abnormal. Overall, there were more anities rather than dierences between
Japan
Japan and Western countries, whilst some cultural factors which seem to be related to the dierences are also
discussed.

1. Introduction Kido, Miyamoto, & Kawakami, 2012).

Stigma can be understood as an overarching term referring to
problems of knowledge (ignorance), problems of attitudes (prejudice)
and problems of behaviour (discrimination; Thornicroft, 2006).
Research has shown that people with mental illness often perceive
and experience stigma (Alonso et al., 2009; Lasalvia et al., 2013;
Thornicroft et al., 2009). It also is common for them to employ their
own strategies in order to avoid being stigmatised, such as concealment
of their psychiatric diagnosis or educating others about mental illness
(Chung & Wong, 2004; Ilic et al., 2011). These strategies are
collectively referred to as stigma management.
When exploring stigmatic experiences among people with mental
illness, it also is important to understand how these people perceive
and manage stigma, since these two factors lie behind their stigmatic
experiences. Whilst there are voluminous studies regarding the percep-
tion, management and experience of stigma among those with mental
illness in Western countries, little research has been conducted in
Japan, where mental healthcare is still hospital-based.
Japan has 2.7 psychiatric beds per 1000 population compared to,
for instance, 0.5 in the UK (OECD, 2014). Long-term hospitalisation is
another characteristic of psychiatric care in Japan. In 2012, the average
duration of stay for patients in psychiatric beds was 292 days
(MoHLW, 2013), which is signicantly longer than the average length
of stay of adult patients with mental illness in England in 20112012
(53 days; DoH, 2012). The background of these characteristics of
psychiatric provision in Japan is complex, with one of the possible
reasons being a high proportion of private psychiatric hospitals to
public hospitals (95%; MoHLW, 2012) and stigma against mental
illness in the community (Kurihara et al., 2000; Kurumatani et al.,
2004; Griths et al., 2006; Masuda et al., 2009; Nomura, 2010; Chiba,
There has been a large body of research on stigma against mental
illness in Japan. Ando, Yamaguchi, Aoki, and Thornicroft (2013)
systematically reviewed 19 studies which examined mental-health-
related stigma in Japan. The ndings showed that mental illness was
considerably stigmatised, with schizophrenia being more stigmatised
than depression. Prejudice related to the inabilities, dangerousness and
unpredictability of persons with schizophrenia appeared to be strongly
associated with negative attitudes. The general public often lacked
accurate knowledge about mental illness. Psychiatric sta generally
exhibited less negative attitudes towards patients with schizophrenia
than the general public and physicians, with years of experience in
psychiatric care being negatively correlated with negative attitudes.
With regard to studies other than those included in the review by
Ando et al. (2013), studies using a national or local representative
sample showed that vignettes with severe symptoms, such as halluci-
nations and suicidal thoughts, had more frequently received stigmatis-
ing responses than vignettes with less severe symptoms (Hanzawa,
Nakane, Yoshioka, & Nakane, 2007a, 2007b; Itayama, Takada, &
Tanaka, 2012). A large proportion of laypeople (3650%) believed that
psychiatric hospitals were needed because the majority of the mentally
ill were violent (Zenkaren, 1984, 1998). On the other hand, it was also
found that those who have had contact with mentally ill persons were
more willing to accept those aected than people who have had little or
no contact. In particular, active contact, not passive contact, seemed
the most eective in reducing social distance (Oshima, 1992; Oshima,
Ueda, Yamazaki, & Siiya, 1992; Oshima, Yamazaki, Nakamura, &
Ozawa, 1989). However, this is not always the case. In fact, Taneda,
Morita, and Nakatani (2011) found that respondents who had frequent
contact with those aected had showed greater social distance to them
than respondents who had little contact.

E-mail address: n_ottewell@aoni.waseda.jp.

http://dx.doi.org/10.1016/j.mhp.2016.10.001
Received 26 July 2016; Received in revised form 10 October 2016; Accepted 17 October 2016
Available online 18 October 2016
2212-6570/ 2016 Elsevier GmbH. All rights reserved.
N. Ottewell Mental Health & Prevention 4 (2016) 115123

As shown above, mental illness are largely stigmatised in Japan. Table 1

Views on mental illness, however, have been gradually changing. This Demographic, diagnostic and employment profile of participants.
is particularly true for depression. As Kitanaka (2012) pointed out,
Men Women
depression became one of the most talked about illnesses in recent n n
Japanese history (p. 2), due to the rapid increase in the number of
people who were diagnosed with depression as a result of excessive Diagnosis
Schizophrenia 8 4
work and took their own lives in the late 1990s.
Depression 2 6
Whilst social attitudes towards mental illness have been the subject
of a large body of research, few studies have focussed upon the Age (years)
experience of stigma among people with mental illness in Japan. It is 2025 0 1
important to understand the personal perspectives of people with 2634 4 7
3544 4 1
mental illness regarding stigma, as this information will contribute to
4554 0 1
suggesting a possible way for reducing stigma. 5564 0 0
This study's objective was to understand the perception, manage- 6574 2 0
ment, and experience of stigma among people with mental illness in
Employment status
Japan. Whilst psychiatric diagnoses include a variety of mental ill-
Job training 4 1
nesses, this study focussed upon schizophrenia and depression speci- Sheltered job 1 0
cally. Indeed, these two illnesses have dierent images among the Employment for people with disabilities/disordersa 3 1
general public (Griths et al., 2006; Pescosolido et al., 2010), and thus Employed (full time) 1 4
the perception, management, and experience of stigma may be Employed (part time) 0 1
Looking after home and family 0 1
dierent between those with schizophrenia and those with depression.
Unemployed 1 2
Comparisons between these two disorders may contribute to a clearer
understanding of mental illness stigma. a
Some companies have a special recruitment policy for people with disabilities/
This study dened perception as what an individual thinks most disorders, including those with mental illness. This is not a sheltered job, and yet people
people believe about the stigmatised group in general and how each who were employed in this recruitment may deal with less complex work than other
workers do, with a lower salary than other workers.
individual believes society views him/her personally because he/she is
a member of the stigmatised group.
1. What images do you think people have of mental illness or people
(LaBel, 2008, p. 414). In addition to this, management was dened
with it?
as strategies for coping with stigma and experience as actually being
2. Have you told your diagnosis to others? Could you tell me why or
stigmatised.
why not?
3. Have the relationships between you and others changed after you
2. Methods told them that you had a diagnosis of mental illness? If so, how have
they changed?
2.1. Participants 4. Have you done something because you did not want to be prejudiced
or discriminated against (for instance, concealing your diagnosis)?
The present study employed qualitative interviews in order to 5. Have you been treated dierently from others in a negative sense?
understand the theoretical relationships between the perception, Have you been told negative things because you have a psychiatric
management, and experience of stigma and what lies behind each diagnosis, or because of others lack of knowledge about mental
element. Following the university's ethical approval, recruitment was illness? If yes, could you tell me how it happened and how you felt
conducted through community activity support centres for psychiatric about it?
patients and psychiatric hospitals in Tokyo. The intent was to recruit 6. Do you think there are any dierences between prejudice and
people with depression and people with schizophrenia. At this end of discrimination against mental illness in the past and those in the
this recruitment, twenty people stated that they wished to participate in present? Do you think people know more about mental illness now
the study. than before?
Table 1 shows the demographic, diagnostic, and employment
prole of the participants. The total population of the participants The participants were also asked to talk freely about their experi-
was equally divided into men (n=10) and women (n=10), of whom 12 ences, feelings, and thoughts concerning stigma against mental illness.
had a diagnosis of schizophrenia, while 8 were diagnosed with Interviews took between approximately 2550 min, with an average
depression. They were all well-functioning psychiatric outpatients, duration of 38 min.
with stable symptoms. The average duration of treatment was 14 years
(ranging from 1 to 40 years). A total of 13 participants experienced
2.3. Data analysis
psychiatric hospitalisation, and the average duration of stay was 8
months (ranging from 1 to 13 months).
Interview data was analysed by employing the grounded theory
All the participants received both an oral and written explanation
approach (Corbin & Strauss, 2008). A recording of each interview was
about the study prior to interviewing, and only those who wished to
transcribed verbatim and read several times. Following this, the
participate voluntarily had an interview. The participants gave a
transcripts were divided into segments, with natural breaks as cut-o
written consent form before interviewing. People that had any pro-
points for coding. Codes and categories were reviewed as the results of
blems with participation were excluded according to the judgement of
the analysis accumulated, and were accepted, modied, discarded, or
mental health professionals.
replaced with new ones. Theoretical relationships between categories
were examined by comparing them with one interview case, contrasting
2.2. Procedure them across interview cases, and by reviewing analysis memoranda.
Through clarifying these relationships, a core category emerged,
Interviews were individual-based and semi-structured. The author namely living with the self that has changed because of mental illness
alone conducted all of the interviews, with all of them being recorded itself and a psychiatric diagnosis label.
with each participant's agreement. Interview questions were as follows: After these analyses, a theory about the perception, management,

116
N. Ottewell
Fig. 1. Participants perception, management and experience of stigma.
and experience of mental illness stigma based upon the theoretical
relationships between the categories was developed. This theory will be
described in Section 3 in detail. Data analysis was preliminarily
conducted by the author, a social scientist who has been studying the
illness experience of people with mental illness. With this said however,
comments on the results of the analysis and advice for further analysis
were provided by three researchers in order to ensure the validity of the
analysis. These researchers included two social scientists and one
anthropologist, all of who have been studying mental-health-related
themes and have more than ten years of experience as a researcher.
3. Results
Analysis of the interview data revealed that the perception, manage-
ment, and experience of stigma were part of the process of living with
the self that has changed because of mental illness itself and the
psychiatric diagnosis label. Fig. 1 summarises the major ndings of this
study. Briey, the theory derived from the analysis is:
Participants self-perception changed due to experiencing symp-
toms of mental illness and accepting a psychiatric diagnosis; they came
to regard themselves as mentally ill. However, as they were aware of
the negative images of their illness in society, they anticipated stigma
and therefore most of them chose selective disclosure. The choice of
selective disclosure depended on their fear of losing something
important to them and their hope altogether. Underlying their hope
were comparisons between themselves and others in general, or
between themselves in the present and in the past. Participants choice
of selective disclosure led to a variety of responses from others,
including being treated as before, being treated as someone who needs
care, and being treated as not ill but lazy, or as dierent from others.
In the following parts, this theory will be described in more detail,
supported by some quotes from interviews. Quoted participants names
have been altered to preserve anonymity. Changes in self-perception,
however, will not be mentioned here, because these changes are not the
theme of the present study.
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Mental Health & Prevention 4 (2016) 115123
3.1. Perception of stigma
All of the participants were aware of the negatively-distorted images
of mental illness in society; they understood that people generally
regarded those aected by mental illness, particularly schizophrenia, as
dangerous, violent or unpredictable. With this said however, nine
participants believed that there had been favourable changes in social
attitudes towards mental illness. These participants felt that people
now know more than they used to about mental illness, mainly because
of an increase in the number of educational programmes focussing
upon mental health/illness on television, the radio, or articles in the
newspaper. Of these nine participants, one participant stated that the
favourable changes were true for mental illness as a whole, including
schizophrenia. However, others thought that, whereas depression was
well known and understood, schizophrenia remained an unfamiliar
illness for laypeople.
Dierences between social attitudes in large cities and those in
small towns were also found. There were two participants who
mentioned these dierences. One of them, Yya, who was diagnosed
with depression when he was at college, was born in Tokyo, but his
family moved to a small town in the middle of Japan (approximately
300 km away from Tokyo) when he was ve. He lived there until
moving to Tokyo in order to study at a college there. Since then he has
lived in Tokyo for approximately 15 years. He stated:
There's a dierence between the countrysidethe so-called insular
countrysideand a place like Tokyo, whose residents are from
various places. In the countryside, people think that those with
mental illness are completely violent and dangerous. There's a
climate along the lines of, Dont go near that person. This exists in
the area I lived. People [in the area] do not even understand
depression. They say that mental illness emerges because people are
weak-willed, and those who are told so believe itIn Tokyo, it's a
givenit's not rare. There didnt seem to be that bad of an image
regarding things that you frequently hear about like depression and
panic disorders. As might be expected, this isnt the case with
schizophrenia: its image is dierent. But if a person is suering
from depression or a panic disorder, it is my feeling that commu-
nication with people would be normal in Tokyo.
N. Ottewell
Yya's beliefs about attitudes towards mental illness in Tokyo
depended largely upon his experiences with work. He had worked
several jobs after graduating from college. At one of the companies he
was working for, he disclosed his illness to his colleagues and superiors,
who showed understanding and care. He had once disclosed his illness
in a job interview. The employers did not care about it, and hired him
regardless. Colleagues and superiors at this company, who knew that
Yya had been diagnosed with depression, were also sympathetic to
him. Another participant, Mika (diagnosis: depression), is from a small
town in southern Japan (1000 km away from Tokyo) and came to
Tokyo in order to study at a college there. She has lived in Tokyo since
then for about ten years. In her interview, Mika also expressed a
viewpoint similar to Yya's.
3.2. Management of stigma
Once the participants accepted that they were mentally ill, they had
a problem regarding disclosure: whether they should tell others and, if
so, whom. The participants already knew that mental illness was often
viewed negatively by society, and therefore they sensed that disclosing
their illness to others could lead to negative consequences.
There were two major methods which the participants used when
reacting to the problem: (i) disclosing their illness to specic people
and (ii) disclosing their illness to almost everyone. Although there were
a few participants who chose the second method (indiscriminate
disclosure) or educating others about mental illness as a coping
strategy, the ndings pertaining to these are not mentioned here.
Instead, the focus of the ndings is on selective disclosure, which was
the most frequently employed method of disclosure among the
participants.
3.2.1. Disclosing the changes to specic people
All of the participants, except for four, told their families that they
had received a psychiatric diagnosis. Outside of their families, most of
the participants (17/20) chose the people to whom they disclosed their
illness. They hid it from their friends who were not very close, relatives,
neighbours, colleagues, superiors at work, and so forth. They did so
because they wanted to be regarded as normal, or as someone without
mental illness, and to be treated in the same way as normal people by
others. These participants were aware of how people would regard
them, if they knew that the participants were mentally ill.
In the case of Sakura, who had a diagnosis of schizophrenia and was
working a part-time job at the time of her interview (she did not
disclose her illness to anyone at work), her family knew that she was ill;
indeed, she wanted to be treated as someone with mental illness by her
family members, since otherwise they would not allow her to continue
to work only part-time. Her own honest feeling was that she did not
want to work, even at a part-time job, as she did not believe that she
had recovered enough and it was hard for her to work. However, her
family was having a hard time making ends meet, which left her no
choice other than to nd a job. She told the author that she used her
mental illness as an excuse for not working full-time, but at the same
time, she also stated that she hoped to be regarded as normal by other
people.
I want to be ill and I dont want to be ill. I can make an excuse to my
family if Im ill, but seken [people] dont think of me as normal if
Im ill. I want to make an excuse, but I also want people to regard
me as normal.
By normal, she meant being able to work as people without mental
illness generally do. This notion was shared by some of the participants
who used the words normal and average (n=5), although certain
other participants used these words to refer to behaving as people
generally do or not being dierent from people lacking mental illness
in their nature (n=5). Although not all of the participants used the
words normal and average, it seemed that those who did not use
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Mental Health & Prevention 4 (2016) 115123
these words were also concerned about being regarded as abnormal by
others.
Many of the participants who chose to disclose their illness only to a
small number of people had experience with concealing their illness
when applying for a job and/or while at work (11/17). This was
partially for practical reasons; they feared that they would otherwise
not be able to obtain a job or that they might be demoted or dismissed.
However, their expectation of how they wanted other people to
regard and treat them and/or how they wanted to be also played an
important role in choosing the way they dealt with the problem of
disclosure. They did not want to be regarded as less than average or
negatively deviant; instead, they wanted to be viewed and treated as
someone who can work in the same way as people without mental
illness generally do, or to be regarded and treated as someone who can
work as they used to. They also wished to be thought of and treated as
someone who acts normally (for instance, someone who does not act
in a violent way).
Their expectations were based on their comparisons between
themselves and others in general and/or between themselves in the
past and present. Broadly speaking, there were two patterns in their
thoughts, both of which developed from these comparisons. In terms of
the rst pattern, while they accepted that they had changed physically,
psychologically and/or cognitively, they thought that other aspects had
not changed or there were only small changes. With regard to the
second pattern, they thought that their other aspects had also changed
after they became ill. For the participants, other aspects mostly meant
their ability to work. When adhering to the rst pattern, it was
common for the participants to think that their ability to work had not
changed or had only slightly changed, although they admitted that they
did have a mental illness. Due to the fact that they did not think that
they had problems with working as people generally do and with
working as they used to, they concealed their illness when applying for
a job or when they were in the workplace. They believed that they could
work in the same way as other people do and as they did before; they
also wanted to be regarded and treated as such.
Two participants (one was unemployed and another was participat-
ing in job training at the time of the interview), however, wanted to be
regarded and treated as someone without mental illness at work, while
they thought that it might be dicult for them to work as people
without mental illness generally do or as they used to. Ritsu, who was
diagnosed with schizophrenia and was in his forties at the time of his
interview, had worked several regular jobs in his twenties. Although he
had not yet been diagnosed with schizophrenia when working at these
jobs, he thought that he had already had symptoms of schizophrenia at
that time, as he had been hearing voices, but had still managed to work.
He wanted to have a regular job again and regarded the job training he
was receiving at the time of his interview as preparation for having a
regular job in the near future. When asked whether he was going to
disclose his illness when applying for a regular job, he stated:
Ritsu: Id have a strong desire to do so [applying for a job without
disclosing his illness], one more time. While it's true that physically,
mentally, and so on, things are dierent than when I was in my
twenties, since Id worked at three places then, I really want to try
having a regular job, even if it's too much Id like to give it a tryI
cant leave this [feeling] behind
Interviewer: You are saying that you want to search for a job
without disclosing [your psychiatric illness] because you dont want
to be seen from the beginning as someone with a disorder?
Ritsu: That tooyes, I dont want people to think that I have a
disorder. Id like to choose a workplace that will let me work just
like ordinary people, without discrimination.
As he stated, he sensed that it might be dicult for him to have a
regular job because of his changes, although he did not mention
whether he regarded these changes as a result of his illness. His
statements suggest that he wants to be treated the same way as people
N. Ottewell
without mental illness are, at least at work, despite his recognition of
the changes. He made a comparison between himself in the past, who
already had the illness but managed to hold regular jobs, and himself in
the present, who still has the illness as before and is participating in job
training. It seemed that his evaluation of himself in the past was higher
than that of himself in the present, and that he wanted to be the same
as himself in the past again.
Whilst the participants often chose to conceal their diagnosis, they
also revealed it to a small number of people. In most cases, the people
to whom the participants disclosed their illness were those who were
close to them (mostly friends). When they revealed their illness to those
who were close to them, they either wanted these people to accept
them, and to accept the fact that they suer from mental illness, or
expected that these people would accept them and their illness because
of their close relationships. When they disclosed their illness to people
who were not very close to them, such as colleagues and superiors at
work, there were particular reasons for it, including a necessity for
rescheduling work in order to receive regular treatment.
Whomever they chose to reveal their illness to, disclosure of mental
illness could be a problem for some of the participants because of their
diagnosis (n=10). This was the case only for the participants with
schizophrenia. These participants thought that they would not be very
reluctant to tell others about their diagnosis if their diagnosis was not
schizophrenia, but depression instead. They believed that depression
had become more accepted and understood by people, as the number
of people diagnosed with depression has been increasing. On the other
hand, they believed that people did not usually know what schizo-
phrenia was like, or if they did have a view, they regarded those aected
by it as dangerous and violent. In contrast, none of the participants
diagnosed with depression considered that their diagnosis itself
mattered. For all the participants with depression, except for one, it
was the fact that depression was a mental illness which made them
consider whether they should disclose it to others or not. They were
aware that people were often prejudiced against people with mental
illness, regardless of their diagnosis. All of the participants diagnosed
with depression thought that they would not have disclosed their
diagnosis to others if it was schizophrenia.
3.3. Experiences of stigma
The choice to disclose or conceal their illness led to a range of
responses from others. These responses can be classied into three
patterns: (a) they were regarded and/or treated as before and/or as
someone without mental illness, (b) they were regarded as having
changed physically, psychologically and/or cognitively and treated as
before or as someone who needed care and (c) they were regarded as
having changed in other aspects as well, as someone who was also
dierent from others in other aspects, or regarded as unchanged and
treated as someone who could not work or behave as people without
mental illness generally do, or treated as someone who had problems
with their personality. It should be noted, however, that these are
perceived consequences, as reported by the participants. Their percep-
tions could be biased for a variety of reasons, including cognitive biases
related to the symptoms of mental illness.
With regard to the rst pattern, others did not realise that the
participants had a mental illness because they concealed it. As a result,
others attitudes towards them did not change, and these participants
were treated as before. In terms of the second pattern, as was expected
from the participants who disclosed their illness to those close to them,
these people understood that they suered from mental illness and
needed care.
The third pattern is described in detail here, as this pattern is
directly related to stigmatic experiences. Of the 20 participants, there
were 15 participants who had this type of experience. In these cases,
there were two types: (i) the participants thought that they had
changed physically, psychologically and/or cognitively, and yet people
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Mental Health & Prevention 4 (2016) 115123
thought that other aspects of them had also changed or felt that the
participants were dierent from others in other aspects as well because
they have mental illness; moreover, (ii) they thought that they had
changed, but people regarded them as unchanged.
The rst type of experience was the most frequently found, with 10
people (7 with schizophrenia and 3 with depression) reporting it. It was
common that their colleagues and superiors or interviewers for jobs
thought that the participants could not or should not work as they used
to, or as people without mental illness generally do, due to their mental
illness. For example, Souta, who was diagnosed with schizophrenia and
had continued to conceal his illness at work until he suered a relapse,
stated:
[After the relapse] Even though I didnt want to, since the caretaker
at the group home said, Souta, itd be best if you tell your boss
about your illness, I came to feel that itd be better to do so, so I set
up a time to talk with my boss. Then, he said that people who had a
mental disorder or had a disability identication booklet would
have to work part-time while being looked after by the person in
charge or full-time regular employees. Id worked very hard as a
full-time regular employee, but since this happened, I was demoted
to the level of a part-time worker. I was no longer able to do any of
the jobs Id been assigned and that Id been glad to have done. I
thought I could do them, but they no longer let me. It was really like
I was only an assistant. I just ended up doing monotonous work,
despite having worked so hard. I thought that there was nothing
that could be done, that the world is harsh, and worked while being
dissatised.
As he stated, he did not think that he had changed in terms of his
ability to deal with his work because of his illness, and that he had no
problems with working as other people do. He concealed his illness,
because he wished to be regarded and treated as other people are.
However, once he disclosed his illness, his superior decided that he
could no longer work as he used to.
Some of the participants also stated that they had experienced
stigma for aspects other than the ability to work. Tomoko, who was
diagnosed with schizophrenia, for example, had been told by one of her
friends that she (the friend) was afraid that Tomoko might suddenly get
violent because she is schizophrenic. Although Tomoko thought that
she had not changed in aspects other than her diagnosis and she still
behaved as before, as people generally do, the friend thought that
Tomoko had also changed in her behaviour or in her nature. The friend
left Tomoko soon after this, and Tomoko lost contact with her. The
experience was not only restricted to this friend, with Tomoko
reporting that she had lost all of her friends since she had been
diagnosed with schizophrenia. Two participants (one participant with
depression and another with schizophrenia) experienced denial of
medical treatment at a general hospital, where they went because of
their physical illness. The medical sta refused to treat them once the
participants said that they had been diagnosed with mental illness.
Concerning the second type, participants thought that they had
changed, but people regarded them as unchanged; this was true for
some of the participants with depression (n=5) and one participant
with schizophrenia. With this type, the people to whom they disclosed
their illness thought that the participants were not ill, but idle, or that
there was a problem with their personality. Five of these participants
received this type of reaction from their family members and the
remaining participant received it from his colleagues. These six
participants stated that their families or colleagues lacked an under-
standing of mental illness. For instance, Sakiko, who was diagnosed
with depression, stated:
My parents say I shouldnt take psychiatric drugs. I often tell them
that my illness would worsen if I didnt take them, but they never
understand. They say Im just weak-willed and self-centred. They
dont admit Im ill.
N. Ottewell
Whilst there were some participants who experienced stigma within
their families, none of the participants experienced rejection from their
families or lost contact with them. Furthermore, in the present study,
none of the participants expressed worries that their families might be
stigmatised because of their illness (although there were two partici-
pants whose families were stigmatised because of their illness, these
participants had not expected this). It appeared that most of the
participants major concerns were obtaining or keeping a job, and being
regarded as abnormal by others.
4. Discussion
This study found that people with mental illness felt negative
images of their illness in society, concealed their illness for fear of
stigma, and often did face stigma when disclosing it. Overall, there
were more anities rather than dierences in the perception, manage-
ment, and experience of stigma between those with depression and
schizophrenia. There was, however, a dierence in management, with
those suering from schizophrenia generally concerned about disclo-
sure because of their schizophrenia diagnosis. Conversely, those with
depression were worried because of their psychiatric diagnosis in
general. This suggests, on one hand, that the concern among those
with schizophrenia reects the general public's attitudes towards this
disorder, while the worry among those with depression signies that,
generally speaking, prejudice against mental illness still remains in
Japan. Another dierence was also found in the aspect of experience;
those with depression more frequently experienced ignorance about
mental illness, particularly within the family. This may be because
these participants behaviours did not seem to be symptomatic to
others, or it may mean that laypeople in Japan often lack proper
understanding of depression (Jorm et al., 2005; Yamazaki, Matoba,
Kikusawa, & Sakano, 2012).
In the following sections, the ndings of this study will be
discussed, separating them into three elements: perception, manage-
ment, and experience of stigma.
4.1. Perception of stigma
Prior quantitative studies have shown that people with mental
illness often feel that most people would devalue, discriminate against,
or reject those aected (Kleim et al., 2008; Rsch, Lieb, Bohus, &
Corrigan, 2006). Although it is not appropriate to compare these
ndings directly to those of the present study because of the metho-
dological dierences, in a broad sense, the ndings of this study
showed that all of the participants were aware of the negative images
of mental illness in society. Indeed, this was consistent with the
ndings of those quantitative studies, thus suggesting a similarity in
the perception of stigma between people with mental illness in Japan
and those in other countries.
Some qualitative studies found that the perception of stigma could
vary between cultures. In most of these studies, participants were those
who were experiencing several dierent cultures in their everyday life,
such as Asian British or African-American people living in the US
(Alvidrez, Snowden, & Kaiser, 2008; Shefer et al., 2012). In contrast,
most of the participants in this study seemed to think that they were
not experiencing dierent cultures on a daily basis, nor did they
compare their perception of stigma between dierent cultures. There
were only two participants who did compare their perception of stigma
between dierent cultures, and they made comparisons between their
home town and Tokyo.
The participants seemed to be most concerned about keeping or
obtaining a job, and being regarded as abnormal. Concerns about
work among people with mental illness have been recorded both in the
quantitative and qualitative literature, including various countries (US:
Jenkins & Carpenter-Song, 2008, 2009; 27 countries, mainly from
Europe: Thornicroft et al., 2009). In this vein, the perception and
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Mental Health & Prevention 4 (2016) 115123
anticipation of stigma among the participants in this study were similar
to those among people with mental illness in other countries.
Worries about the inuence of their illness on their family's
reputation and marriage prospects of family members have also been
recorded among South Asian, black African and black Caribbean people
living in the UK (Shefer et al., 2012), as well as Indian people with
depression (Weiss, Jadhave, Raguram, Vounatous, & Littlewood,
2001). While the participants in this study seemed to regard stigma
as a more personal problem, rather than a problem which can also
aect the people around them; two participants did experience
courtesy stigma (Goman, 1963) because of their illness, thus suggest-
ing that mental illness can also aect people around those with the
illness in Japan.
4.2. Management of stigma
This study's nding that many of the participants chose selective
disclosure in order to avoid stigma was consistent with the ndings of
existing studies. Chen, Lai, and Yang (2013) revealed that decisions
about the disclosure of a mental illness diagnosis among Chinese
psychiatric inpatients living in the US depended upon their trust in the
people who were close to them. This was true for most of the
participants in this study; they chose to disclose their diagnosis to
those who were close to them, and who would understand that they
were ill, except for the cases where they had to disclose it.
In the present study, most participants wanted to avoid being
regarded as abnormal. They seemed to care how others would view
them, and this often led to the concealment of their illness. Concern
about other people's opinions and reactions, and a desire to pass
publicly for normal among people with mental illness have been
described in previous literature (UK; Forrester-Jones & Barnes, 2008;
US; Jenkins & Carpenter-Song, 2009). As such, it is clear that these
views are shared between Japanese people and people in other
countries. However, a cultural factor might have aected the concern
and desire of Japanese participants. Researchers have argued that
Japanese individuals attach great importance to relationships with
others, their interdependency, and trust between themselves and
others compared to the individualism that is dominant in Western
societies (Hamaguchi, 1988; Kimura, 1972). This argument may help
to understand why participants in this study felt concerned about how
others would see them.
4.3. Experienced stigma
In this section, the experiences of the participants will be discussed
in three areas: employment, personal relationships, and healthcare.
These three were found to be the major areas where people with mental
illness experienced discrimination in the qualitative study in Ireland by
Lakeman et al. (2012). Although Lakeman et al. included the fourth
area, business and nance, the present study omitted this, since no
participants reported being stigmatised in said area.
4.3.1. Employment
This was the most common area where the participants had
experienced stigma. They experienced stigma most frequently in the
form of discrimination, including demotion, dismissal or rejection
during a job interview. Concealment of illness in the workplace or at a
job interview was common, as they anticipated stigma even when they
had never experienced it. It was dicult for some people to work while
concealing their illness and they suered a psychological and/or
physical burden, which sometimes led to a relapse of severe symptoms.
Prior studies have shown that people with mental illness often
experience stigma in the area of employment. Quantitative surveys in
England (Gabbidon et al., 2014), New Zealand (Peterson, Pere,
Sheehan, & Surgenor, 2006), and the United States (Baldwin &
Marcus, 2006) found that 2031% reported that they had experienced
N. Ottewell Mental Health & Prevention 4 (2016) 115123

stigma either in the workplace or when attempting to nd a job. In contrast with the nding of the present study, prior studies
International studies including 27 countries also showed that 29% conducted in other countries, including European countries, the United
experienced stigma either when trying to keep or nd a job States and Australia, have shown that healthcare is one of the most
(Thornicroft et al., 2009). Furthermore, qualitative studies have also common areas where people with mental illness reported experiences
shown that employment is one of the most common areas where people of stigma (Buizza et al., 2007; Mestdagh & Hansen, 2014). It is
with mental illness experience stigma (Schulze and Angermeyer, 2003; unknown as to where the dierence between the present study's
Gonzlez-Torres, Oraa, Arstegui, Fernndez-Rivas, & Guimon, 2007; ndings and the ndings of the existing studies comes from. It might
Jenkins & Carpenter-Song, 2009). A qualitative study in Japan be the case that Japanese people with mental illness experience stigma
(Yoshii, 2013) also revealed that participants with mental illness had less frequently in a clinical setting than those with mental illness in
experienced stigma in the workplace. other countries do. However, there is another possibility, namely that
Concrete examples of stigmatic experience in these quantitative and the participants did not focus on their experience with mental or
qualitative studies include dismissal, rejection during a job interview, general health professionals, even if they had been stigmatised by these
diculty in returning to their job after psychiatric hospitalisation, professionals, as they found stigmatic experiences in other areas to be
refusal of promotion, and pejorative stereotyping by colleagues and/or more intense.
superiors. These examples all t with the experience of the participants
in the present study, thus suggesting that practices of stigma in
employment are similar among dierent cultures.
4.4. Limitations
4.3.2. Personal relationships
Whilst the present study contributes new information, it has several
Personal relationships in this study include family, friends, ac-
limitations. First, this study limited participants to people with
quaintances and intimate relationships. Like employment, personal
schizophrenia and those with depression. Mental illnesses include a
relationships were also one of the most common areas where the
variety of other diagnoses, and previous research has shown that the
participants experienced stigma. Loss of friends and being mocked or
perception, management, and the experience of stigma can vary
shunned by their relatives and/or neighbours were reported. Personal
between diagnoses (Bonnington & Rose, 2014; Dinos, Stevens,
relationships were shown by previous studies to be one of the areas
Serfaty, Weich, & King, 2004). Schizophrenia appears to be the most
where people with mental illness experienced stigma most frequently
frequently studied illness in the literature about the perception,
(Elkington et al., 2012; Hansson, Stjernswrd, & Svensson, 2014).
management, or experience of stigma among people with mental
When the participants experienced stigma within the family, the
illness so far, while those with eating disorders, post-traumatic stress
experience was frequently related to ignorance about mental illness;
disorder or dissociative disorders have been under-represented. Future
their families had little knowledge of their illness and simply did not
research will need to include those who have been under-represented.
understand it. Families lack of understanding has also been mentioned
This may lead to a better understanding of specic patterns in the
in existing studies, both quantitative and qualitative (Karidi et al.,
perception, management, and the experience of stigma in people with a
2010; Moses, 2014). Although it was common for the participants with
specic diagnosis.
depression to be regarded as not ill in this study, Gonzlez-Torres et al.
Second, the interview data was analysed by the author alone, which
(2007) found that many of their participants with schizophrenia had
could have led to, at least to some degree, a biased interpretation or a
also experienced this type of stigma. This suggests that people with
more shallow understanding than data analysis by several researchers.
mental illness can be misunderstood as not ill, regardless of their
However, comments and advice from experienced researchers were
diagnosis.
reected in the results of the data analysis, which gives the results more
Whilst there were participants who had experienced stigma within
plausibility. Third, symptom severity and social functioning of the
the family, rejection and avoidance from families were not reported.
participants were judged by mental health professionals, mainly based
Alternatively, some US studies showed that some of the participants
upon their subjective observations of the participants symptom
with mental illness had these experiences (Jenkins & Carpenter-Song,
stability and their behaviour over the last few months prior to inter-
2008; Wahl, 1999). The dierence may be explained by two cultural
views. Validated scales were not used, and thus this study did not
factors: (1) families awareness of self-care and the expectations of the
provide clinical data for the participants.
social role of self-care in families and (2) the ie (family) system, which
Last, the present study focussed upon limited aspects of stigma (the
was established in 1898 and abolished in 1947. According to Munakata
perception, management, and experience of negative stigma) and
(1984), in Japan, families awareness of the need for caring for their
therefore it did not give a comprehensive understanding of their
members is high, and they are socially expected to look after family
perception, management, and experience of stigma. Considering that
members. Thus, families make a great eort to care for their ill relatives
research has shown that the experience of illness has both positive and
and share responsibility. Moreover, in the ie system, where the rst-
negative sides for people living with mental illness (Pitt, Kilbride,
born son succeeds the household and is responsible for all other
Welford, Nothard, & Morrison, 2009), it will be possible to obtain a
members, a relative who is ill is under the responsibility of the head of
deeper understanding of stigma among people with mental illness by
the family and, hence, is looked after within the family. Although the
studying their perception, management, and experience of stigma as a
ie system was abolished, the ndings of the present study suggest that
whole, including the positive aspects.
the culture still remains, and therefore the family is unlikely to reject
family members and lose contact with them in Japan, even if they are
ill.
5. Conclusion
4.3.3. Healthcare
This was an area where only a few participants reported experien- This study found that people with mental illness in Japan felt that
cing stigma. When compared to the areas of employment and personal there existed negative and distorted images of mental illness, concealed
relationships, it appeared that the area of healthcare was not a major their diagnosis, and often experienced stigma when disclosing it. The
issue in terms of their stigmatic experiences. In fact, two participants ndings of this study mirrored those of Western studies, thus suggest-
even stated that they had enjoyed life in hospital; the sta were kind, ing anities in the perception, management, and experience of stigma
they were protected from the outside world, and they made some among those with mental illness across cultures, whilst some dier-
friends there too. ences, such as rejection from the family, were found to exist.

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