**6.1. Promotion self-awareness**

as much as their ability to handle leads to slowing and prolonging the prognosis. At the same time, some of the destructive effects of the disease increase, causing negative attitudes about the process [1, 65, 66]. In summary, stigma on family of person with OCD; adversely affects

Stigma not only affects adults but also youth and children. Since the incidence of OCD is lower in children, there is not much research done on them. Obsessions and compulsions seen in children affect their daily routines, family relationships, friendship relationships, and self-esteem. The self-esteem of children exposed to stigma by their friends is negatively affected. This causes many problems to emerge, in children, as in adults. Reduced self-esteem caused experiencing problems such as having trouble with going to school, not doing homework, not having friendship relationship, closing up, and difficulty to partici-

Stigma also negatively affects children's friendship relationship. The play takes an important place in the child's life. Friends are needed to play games. Exposure to stigma among friends is causing them to move away. The game environment of a child who is away from friends is disappearing. Moreover, friendship relationship improves the level of stress of the child and loneliness. The exposure of the child to stigma causes nervous, angry, and anxious behaviors. The family of the child, whose stress level is increasing, is also negatively affected by this

The family that is exposed to the child's stigma is also exposed to stigmatization. Family stigma causes family relations to be influenced, family members to be affected by the friendship relationship, and the level of family stress to be increased. The fact that the parents try to cope with these stress factors negatively affect their participation in the long treatment process of the child. Such problems caused by stigma are adversely affecting the treatment process in children, as well as in adults. Because of stigma, diminished supportive mechanisms, increased stress, emotional impact of the child, and problem of participation in the

In OCD management, medical perspective is dominant in general sense [70, 71]. However, OCD people continue their lives in society beyond medical drug treatment. Stigma is often referred to as secondary disease [48]. For this reason, it is important to have a biopsychosocial approach to OCD. Occupational therapists use the biopsychosocial and holistic approach for clients. In the following sections, individuals with OCD are referred to as *client.* For occupational therapy, it is important that the clients fulfill his roles, participation in occupations, and social participation and existence as an individual [72]. Occupational therapists do individual and/or community-based interventions to combat self-stigma, professional stigma, and social

game are problematic in the progress of the treatment process [69].

**6. Psychosocial interventions for stigma**

**5.1. Negative consequences of stigma in children with obsessive compulsive** 

family, person with OCD and their relationship.

100 Anxiety Disorders - From Childhood to Adulthood

**disorder**

pate in the treatment.

situation [67, 68].

In mental illness, individuals may not be aware of self-stigmatization. Because of wrong beliefs or thoughts about themselves, they may have difficulty in performing their roles and participating in their daily activities. For this reason, it is important to increase insight and to create individual awareness in reducing stigmatization. Occupational therapists can use cognitive behavioral therapy, psychoeducation, and also photovoice methods to help clients write and express their thoughts and behaviors who have difficulty in verbally expressing in order to provide individual awareness; thus, contributing to the client's occupational identity and avoiding self-stigmatization.

Cognitive behavioral therapy involves changing individuals' misconceptions with the right thinking. In this regard, it is accepted as a direct and permanent method. CBT, which is used in combination with medical treatment in many mental disorders, is highly effective. CBT, the most commonly used method of treating person with OCD, also has a significant role in reducing self-stigmatization [73, 74]. This method, which is widely used in OCD seen in children, helps to prevent the self-stigma that the individual applies to himself [75, 76]. CBT can be done individually or in groups [77]. Reaching of cognitive behavioral treatment is difficult because of the lack of specialized therapists in the field of reaching. Occupational therapists can specialize in this area to help OCD individuals overcome self-regulation. In addition, CBT is cost effective and accessible via the Internet [78].

One of the most important causes of self-stigmatization is having missing or incorrect information about the disease. Also, diagnosis can lead to labeling in individuals. Psychoeducation is one of the most effective and widely used method as CBT. Even brief information reduces the violence and social distance applied to the individual with OCD. The aim of this pyschoeducation is to give information about the individual's illnesses, to reduce the self-labeling, and to raise the inner awareness of the client. In the context of ideal psychoeducation; medical, psychological, and sociological information about the disease should be included, information about treatment and process should be given, strategies for coping should be explained, and practical training should be done. In addition to these contexts, stories of individuals on similar conditions may increase the effectiveness of education. Occupational therapists can provide these trainings in community mental health centers, hospitals, OCD associations, or individuals with OCD who consultate to them [79].

Photovoice methods used for clients are actively involved in reflecting their lives through photography/draw picture and group work. Photovoice methods enable the individual to increase his/her inner awareness and understand the conditions of the disease and the obstacle [80]. Very few studies have focused on photovoice methods to prevent stigmatization and participatory approaches [81]. Nonetheless, the photovoice methods can be used to understand the paradoxical relationship between social stigma and ethical values. Kawa model developed by Iwama is a photovoice occupational therapy model. This model enables the individual to demonstrate a direct relationship with culture [82]. The client describes the situations in which the individual perceives their own life as difficulty or opportunity in his Kawa drawings. For this reason, in occupational therapy, Kawa River model can be used as an evaluation and intervention in providing stigma awareness. Bavaro has used the Model of Human Occupation [MOHO] to deeply understand the client with OCD. He stated that habits, rituals, environment, and an occupational therapy model can be used for evaluation and intervention of an individual's occupational identity and performance [83]. With the MOHO model, occupational therapist can help to client to reconstruct his own occupational identity and find the source of inner motivation.

and activity demands that activities require. The division of activities into tasks, followed by these steps, allows the regulation of the rituals of clients with OCD. However, occupational

Stigma in Obsessive Compulsive Disorder http://dx.doi.org/10.5772/intechopen.83642 103

Sensory processing disorders in childhood may lead to excessive ritual behaviors. Children with tactile hypersensitivity were found to have an OC tendency later in life, and oral and tactile hypersensitivity in adults were associated with obsessions and compulsions. Studies of OCD on sensory processing both in childhood and on adult individuals show that desensitization techniques are effective on obsessions and compulsions [88–90]. In occupational therapy, sensory integration therapy and desensitization techniques in children and adults and the environment they live in have an important role in enabling individuals to cope with symptoms, fulfill their roles, and interact with the environment. These methods are thought

Individuals with OCD are also stigmatizing in their treatment seeking or avoiding treatment seeking because they are stigmatizing [91, 92]. Within this paradox, clients' attainment of treatment and social inclusion are affected [30]. Occupational therapists should encourage individuals to participate in activities and manage health [72]. Encouraging clients with OCD

The concept of occupational justice argues that individuals have activity capacities, needs, and routines in their environments and have the right to use these capacities to maintain their lives and social participation and empowerment social inclusion [93, 94]. Stigma inhibits social inclusion in OCD individuals [47]. In occupational justice framework; occupational balance and occupational deprivation terms have been used. Occupational deprivation refers to the deprivation of the purposeful occupations the clients is doing due to social factors over time; the occupational alienation refers to estrangement, loss control, and sense of isolation due to social or self-conditions, while the clients fulfill their occupations and roles, and the occupational imbalance, in which there is an imbalance between the occupations required by the roles and the time allocated. Occupational deprivation and occupational alienation are inevitable for OCD due to stigma. The stigma in OCD needs to be considered in the context

*For social and professional stigma, occupational therapy interventions can be categorized as providing occupational justice,* 

Community-based psychiatric rehabilitation aims to provide rehabilitation services and sustainable services within the society and culture in which the individual lives. Studies about people with OCD and society can be effective in changing the cultural history of stigmatization. Projects supported by volunteers can also influence the cultural sub-structure of the stigma [95]. Occupational therapists can conduct community-based rehabilitation work and contribute to the social consensus of clients [96]. Community-based rehabilitation practice with an occupational justice conception that will provide social participation and reduce stigma is among the

is an important intervention to remove the negative consequences of the stigma.

therapists teach OCD individuals time management techniques.

to reduce stigmatization.

*community-based rehabilitation, education and support groups.*

of occupational science.

Also, Garland noted that in his study, animal-assisted therapy promotes family and individual communication, contributes to participation, and reduces stigmatization of the disease due to this signification and normalization [84]. Occupational therapist can use purposeful occupations such as animal-assisted approaches to increase social participation of the client and to facilitate social relationships.

## **6.2. Coping strategies**

Obsessions and compulsions and related maladaptive behaviors are the most common causes for individuals to social and self-stigma. Management of obsessions and compulsions are thought to diminish the problems encountered in social participation. Occupational therapists play a pivotal role in teaching different coping strategies and in providing effective use of these coping strategies in different environments and conditions with motor learning principles. Coping strategies can be classified relaxation techniques, body awareness, time management, and desensitization.

Relaxation techniques, which have 35.9% of the strategies used in OCD individuals, are frequently used in the management of anxiety disorders resulting in obsessions and compulsions [85, 86]. Relaxation techniques have been reported to cause somatic and cognitive components to relapse in obsessive compulsive disorders [87]. However, there is still a need for more study for OCD. Relaxation techniques control the repetitive rituals of individuals in their participation and therefore suggest that they can be protected from stigma. Occupational therapist specializing in body–mind awareness and relaxation techniques is needed. By promoting mind and body integration with the biopsychosocial approach, increase in body awareness is thought to have a positive effect on clients' own thoughts.

Time is an important concept in the management of obsessions and compulsions seen in OCD. Participation of daily activities or social activities needs requirements for performance patterns. In occupational therapy, performance patterns define roles, habits, and routines. Beyond these performance patterns, there is also requirement for time management. Occupational therapists conduct an activity analysis to reveal the personal, environmental, and activity demands that activities require. The division of activities into tasks, followed by these steps, allows the regulation of the rituals of clients with OCD. However, occupational therapists teach OCD individuals time management techniques.

obstacle [80]. Very few studies have focused on photovoice methods to prevent stigmatization and participatory approaches [81]. Nonetheless, the photovoice methods can be used to understand the paradoxical relationship between social stigma and ethical values. Kawa model developed by Iwama is a photovoice occupational therapy model. This model enables the individual to demonstrate a direct relationship with culture [82]. The client describes the situations in which the individual perceives their own life as difficulty or opportunity in his Kawa drawings. For this reason, in occupational therapy, Kawa River model can be used as an evaluation and intervention in providing stigma awareness. Bavaro has used the Model of Human Occupation [MOHO] to deeply understand the client with OCD. He stated that habits, rituals, environment, and an occupational therapy model can be used for evaluation and intervention of an individual's occupational identity and performance [83]. With the MOHO model, occupational therapist can help to client to reconstruct his own occupational identity

Also, Garland noted that in his study, animal-assisted therapy promotes family and individual communication, contributes to participation, and reduces stigmatization of the disease due to this signification and normalization [84]. Occupational therapist can use purposeful occupations such as animal-assisted approaches to increase social participation of the client

Obsessions and compulsions and related maladaptive behaviors are the most common causes for individuals to social and self-stigma. Management of obsessions and compulsions are thought to diminish the problems encountered in social participation. Occupational therapists play a pivotal role in teaching different coping strategies and in providing effective use of these coping strategies in different environments and conditions with motor learning principles. Coping strategies can be classified relaxation techniques, body awareness, time

Relaxation techniques, which have 35.9% of the strategies used in OCD individuals, are frequently used in the management of anxiety disorders resulting in obsessions and compulsions [85, 86]. Relaxation techniques have been reported to cause somatic and cognitive components to relapse in obsessive compulsive disorders [87]. However, there is still a need for more study for OCD. Relaxation techniques control the repetitive rituals of individuals in their participation and therefore suggest that they can be protected from stigma. Occupational therapist specializing in body–mind awareness and relaxation techniques is needed. By promoting mind and body integration with the biopsychosocial approach, increase in body

Time is an important concept in the management of obsessions and compulsions seen in OCD. Participation of daily activities or social activities needs requirements for performance patterns. In occupational therapy, performance patterns define roles, habits, and routines. Beyond these performance patterns, there is also requirement for time management. Occupational therapists conduct an activity analysis to reveal the personal, environmental,

awareness is thought to have a positive effect on clients' own thoughts.

and find the source of inner motivation.

102 Anxiety Disorders - From Childhood to Adulthood

and to facilitate social relationships.

management, and desensitization.

**6.2. Coping strategies**

Sensory processing disorders in childhood may lead to excessive ritual behaviors. Children with tactile hypersensitivity were found to have an OC tendency later in life, and oral and tactile hypersensitivity in adults were associated with obsessions and compulsions. Studies of OCD on sensory processing both in childhood and on adult individuals show that desensitization techniques are effective on obsessions and compulsions [88–90]. In occupational therapy, sensory integration therapy and desensitization techniques in children and adults and the environment they live in have an important role in enabling individuals to cope with symptoms, fulfill their roles, and interact with the environment. These methods are thought to reduce stigmatization.

Individuals with OCD are also stigmatizing in their treatment seeking or avoiding treatment seeking because they are stigmatizing [91, 92]. Within this paradox, clients' attainment of treatment and social inclusion are affected [30]. Occupational therapists should encourage individuals to participate in activities and manage health [72]. Encouraging clients with OCD is an important intervention to remove the negative consequences of the stigma.

*For social and professional stigma, occupational therapy interventions can be categorized as providing occupational justice, community-based rehabilitation, education and support groups.*

The concept of occupational justice argues that individuals have activity capacities, needs, and routines in their environments and have the right to use these capacities to maintain their lives and social participation and empowerment social inclusion [93, 94]. Stigma inhibits social inclusion in OCD individuals [47]. In occupational justice framework; occupational balance and occupational deprivation terms have been used. Occupational deprivation refers to the deprivation of the purposeful occupations the clients is doing due to social factors over time; the occupational alienation refers to estrangement, loss control, and sense of isolation due to social or self-conditions, while the clients fulfill their occupations and roles, and the occupational imbalance, in which there is an imbalance between the occupations required by the roles and the time allocated. Occupational deprivation and occupational alienation are inevitable for OCD due to stigma. The stigma in OCD needs to be considered in the context of occupational science.

Community-based psychiatric rehabilitation aims to provide rehabilitation services and sustainable services within the society and culture in which the individual lives. Studies about people with OCD and society can be effective in changing the cultural history of stigmatization. Projects supported by volunteers can also influence the cultural sub-structure of the stigma [95]. Occupational therapists can conduct community-based rehabilitation work and contribute to the social consensus of clients [96]. Community-based rehabilitation practice with an occupational justice conception that will provide social participation and reduce stigma is among the interventions occupational therapists will have [97]. Community participation, social inclusion, and occupational engagement are highly important occupational therapy interventions for reducing stigma and discrimination [98].

Taking social support from family and peers is the way to reduce the social stigma that families are going through. In many countries, support groups have been established for OCD individuals and their families. Bringing together individuals who live in similar conditions allows a group to become less isolated from society [106]. Children learn from their peers. Child or adolescent peer groups are also important in the context of the participation of children [80]. Web-based systems can communicate with social media [103] or virtual-based systems can be effective. The direction of occupational therapists to social support groups and peer support groups is the occupational therapy interventions that promote social integration

Stigma in Obsessive Compulsive Disorder http://dx.doi.org/10.5772/intechopen.83642 105

The best approach to reduce stigma should be a holistic approach and community-based rehabilitation to control clients' symptoms, to protect the clients' occupational identity, to tackle the client and the living environment together, and to raise the awareness of the clients,

Gokcen Akyurek\*, Kubra Sahadet Sezer, Leyla Kaya and Kezban Temucin

disorders. Activitas Nervosa Superior Rediviva. 2013;**55**(1-2):12-18

persons with mental illness. Psychiatric Services. 1999;**50**(11):1407

stigma. Psychiatric Rehabilitation Journal. 2004;**28**(2):113

Department of Occupational Therapy, Faculty of Health Science, Hacettepe University,

[1] Ociskova M, Prasko J, Sedlackova Z. Stigma and self-stigma in patients with anxiety

[2] Corrigan PW, Rowan D, Green A, Lundin R, River P, Uphoff-Wasowski K, et al. Challenging two mental illness stigmas: Personal responsibility and dangerousness. Schizophrenia

[3] Corrigan P. How stigma interferes with mental health care. The American Psychologist.

[4] Anthony WA, Blanch A. Supported employment for persons who are psychiatrically disabled: An historical and conceptual perspective. Psychosocial Rehabilitation Journal.

[5] Sturm R, Gresenz CR, Pacula RL, Wells KB. Datapoints: Labor force participation by

[6] Corrigan PW. Target-specific stigma change: A strategy for impacting mental illness

\*Address all correspondence to: gkcnakyrk@gmail.com

of clients and thus reduce stigma [79, 106].

family, and the community.

**Author details**

Ankara, Turkey

**References**

Bulletin. 2002;**28**(2):293-309

2004;**59**(7):614

1987;**11**(2):5

Occupational therapists visit the home where the client lives and make the home assessments. OT can provide OCD management and can make appropriate house arrangements for the client. The family and/or caregiver are informed. For school-aged OCD clients, OTs can visit the school, be informed by interviewing their peers and their teachers and if necessary, make appropriate environmental adjustments to the client. Informing adults and making workplace visits and environmental adaptations for clients with OCD have an important place in interventions that can reduce stigmatization.

Anti-stigma or reducing stigmatization interventions focused on the people with OCD and their families, health professionals, the general public, pupils and teachers, and health professionals. Education about OCD and misbeliefs is the primary aim of most campaigns, followed by the empowerment of people OCD and the prevention of impact of stigmatization [99, 100]. Occupational therapists have an advocacy role to promote social awareness and support the social integration of clients [72]. For OCD, occupational therapists can make these campaigns at a social level, and they can argue with politicians for legal regulations. It is among the responsibilities of occupational therapists to defend the rights of clients and to ensure the participation of clients with OCD in this way.

The media, however, play an important role in determining the attitudes of individuals toward perceptions and stigma and have a growing voice [101]. TV programs and publications have been reported to have positive effects on stigma [102]. A study on media reported that the Monk character, an individual with OCD, reduced stigma against OCD [60]. In the technology world, there are many people who reach through social media and individuals can be encouraged to tell their stories by digital storytelling methods. Thus, stigmatization can be decreased by increasing social awareness [103].

It has been noted that individuals with OCD have avoided treatment seeking because of the stigma they have seen most from their families. More stigma is reported to be applied especially in socio-demographic lower income families [104]. Also, family members living with the patient (such as parents, partners, children and siblings) are involved in daily rituals and undergoing social stigmatization. For this reason, families may encounter inequalities in occupational role performing. It is possible for OCD individuals to have access to treatment and to support their social integration and to provide social inclusion for the OCD individual's family members. The biggest profit from the support groups could have individuals with high levels of self-stigmatization and poor social networks. Such groups might be focused on stigmatization (and thus indirectly on building self-esteem). The biggest profits from the support groups were the high levels of self-stigmatization and poor social networks. Educational activities are of great importance as such groups might be focused on stigmatization (and thus indirectly on building self-esteem), adaptive coping strategies to deal with daily hassles and interpersonal conflicts, and adopting supportive behaviors. These trainings can be made for health professionals for professional stigma, for children and adolescents with OCD [105], or for general public [100].

Taking social support from family and peers is the way to reduce the social stigma that families are going through. In many countries, support groups have been established for OCD individuals and their families. Bringing together individuals who live in similar conditions allows a group to become less isolated from society [106]. Children learn from their peers. Child or adolescent peer groups are also important in the context of the participation of children [80]. Web-based systems can communicate with social media [103] or virtual-based systems can be effective. The direction of occupational therapists to social support groups and peer support groups is the occupational therapy interventions that promote social integration of clients and thus reduce stigma [79, 106].

The best approach to reduce stigma should be a holistic approach and community-based rehabilitation to control clients' symptoms, to protect the clients' occupational identity, to tackle the client and the living environment together, and to raise the awareness of the clients, family, and the community.
