Document4

This article was downloaded by: [Democritus University of Thrace]On: 13 February 2014, At: 04:46Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954 Registeredoffice: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK

Journal of Social Work Practice:Psychotherapeutic Approaches inHealth, Welfare and the CommunityPublication details, including instructions for authors andsubscription information:http://www.tandfonline.com/loi/cjsw20

AN ANTISTIGMA APPROACH TOWORKING WITH PERSONS WITH SEVEREMENTAL DISABILITY: SEEKING REALCHANGE THROUGH NARRATIVE CHANGEDavid C. Kondrat a & Barbra Teater ba Utah State University , Department of Sociology, Social Work &Anthropology , 0730 Old Main Logan, UT 843220730 E-mail:b University of Bath , Claverton Downs , Bath, BA2 7AY E-mail:Published online: 10 Mar 2009.

To cite this article: David C. Kondrat & Barbra Teater (2009) AN ANTISTIGMA APPROACH TOWORKING WITH PERSONS WITH SEVERE MENTAL DISABILITY: SEEKING REAL CHANGE THROUGHNARRATIVE CHANGE, Journal of Social Work Practice: Psychotherapeutic Approaches in Health,Welfare and the Community, 23:1, 35-47, DOI: 10.1080/02650530902723308

To link to this article: http://dx.doi.org/10.1080/02650530902723308

PLEASE SCROLL DOWN FOR ARTICLE

Taylor & Francis makes every effort to ensure the accuracy of all the information (theContent) contained in the publications on our platform. However, Taylor & Francis,our agents, and our licensors make no representations or warranties whatsoever as tothe accuracy, completeness, or suitability for any purpose of the Content. Any opinionsand views expressed in this publication are the opinions and views of the authors,and are not the views of or endorsed by Taylor & Francis. The accuracy of the Contentshould not be relied upon and should be independently verified with primary sourcesof information. Taylor and Francis shall not be liable for any losses, actions, claims,proceedings, demands, costs, expenses, damages, and other liabilities whatsoever orhowsoever caused arising directly or indirectly in connection with, in relation to or arisingout of the use of the Content.

This article may be used for research, teaching, and private study purposes. Anysubstantial or systematic reproduction, redistribution, reselling, loan, sub-licensing,systematic supply, or distribution in any form to anyone is expressly forbidden. Terms &

Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions

Dow

nloa

ded

by [D

emoc

ritus

Univ

ersity

of T

hrac

e] at

04:46

13 Fe

brua

ry 20

14

David C. Kondrat & Barbra Teater

AN ANTI-STIGMA APPROACH TO

WORKING WITH PERSONS WITH SEVERE

MENTAL DISABILITY: SEEKING REAL

CHANGE THROUGH NARRATIVE CHANGE

Self-stigma is the process whereby individuals expect to be discriminated against by societyand in turn hold prejudicial beliefs about themselves. Self-stigma is particularly difficult forpersons with severe mental disability (SMD) as they often experience stigma from the publicand, thus, allow the public stigma to foster self-stigma. Public and self-stigma are theorisedto be comprised of stereotypes, prejudice and discrimination. This paper proposes that inorder to decrease self-stigma among persons with SMD, social work and mental healthpractitioners need to intervene on an individual and/or societal level to dispute stereotypes,prevent prejudices and combat discrimination. We propose an individual-level, anti-stigmaapproach utilising social constructivism, adaptive systems theory and narrative therapy toempower persons with SMD to reconstruct their sense of self that is free from stigma.

Keywords self-stigma; severe mental disability; social constructivism;adaptive systems theory; narrative therapy; empowerment

Stigma represents a significant problem for persons living with severe mental disability(SMD), such as schizophrenia, bi-polar disorder, borderline personality disorder andsocial phobia, and can be experienced through either public stigma or self-stigma(Rusch et al., 2006; Watson et al., 2007). Public stigma represents the negativereactions and discrimination persons with SMD receive from other members ofsociety, and self-stigma is experienced when persons with SMD expect to bediscriminated against by society and in turn hold prejudicial beliefs about themselves(Corrigan & Watson, 2002). Public stigma often surfaces through discriminatory actsfrom outside sources, such as a landlord who refuses to lease a housing unit to aperson with SMD, or an employer who refuses to hire a person with SMD. Self-stigma occurs when persons deny themselves opportunities, refuse to seek services towhich they are entitled or disallow themselves a voice regarding the care they receivethrough mental health services (Corrigan & Watson, 2002). Self-stigma can be quitedamaging for persons with SMD as the discrimination and devaluation they experienceare often the result of their psychiatrically labelled status (Link, 1982), which issocially constructed, and can lead to persons with SMD interpreting their label (orSMD) through stereotypes prevalent in society, thus, resulting in self-stigmatisation.

Journal of Social Work Practice Vol. 23, No. 1, March 2009, pp. 3547

ISSN 0265-0533 print/ISSN 1465-3885 online 2009 GAPShttp://www.tandf.co.uk/journals DOI: 10.1080/02650530902723308

Dow

nloa

ded

by [D

emoc

ritus

Univ

ersity

of T

hrac

e] at

04:46

13 Fe

brua

ry 20

14

Corrigan and Watson (2002) theorise that public and self-stigma are created bythree key components: (a) stereotypes; (b) prejudice; and (c) discrimination. Thetheory suggests that the negative stereotypes surrounding persons with SMD causeindividuals in society to have negative thoughts about persons with SMD (prejudice), andin turn the individuals in society react negatively towards persons with SMD(discrimination). The stereotypes also affect persons with SMD and are found to decreasetheir self-esteem and self-efficacy (prejudice) (Corrigan & Watson, 2002; Rusch et al.,2006; Watson et al., 2007) and thus, deny themselves opportunities, services, and avoice to which they are entitled (discrimination) (Corrigan & Watson, 2002).

An experience of self-stigma can be described by Gallo (1994), who sufferedfrom SMD, through the following account: I perceived myself, quite accurately,unfortunately, as having a serious mental illness and therefore as having been relegatedto what I called the social garbage heap. Gallo continues to describe how self-stigma affected her thoughts and behaviours:

I tortured myself with the persistent and repetitive thought that people I wouldencounter, even total strangers, did not like me and wished that mentally illpeople did not exist. Thus, I would do things such as standing away from others atbus stops and hiding and cringing in the far corners of subway cars. Thinking ofmyself as garbage, I would even leave the sidewalk in what I thought of asexhibiting the proper deference to those above me in social class. The lattergroup, of course, included all other human beings.

(pp. 407408)

Gallos story highlights how having a mental illness can be destructive to the self.The presence of mental illness and the societal constructed and negative conceptionsof mental illness become self-defining for individuals who carry the label (Link et al.,1989; Scheff, 1999). Research supports this conclusion as self-stigma is found toreduce work participation and income attainment of psychiatrically labelledindividuals (Link, 1982), impact the self-esteem and sense of quality of life ofpersons with SMD (Rosenfield, 1997; Rusch et al., 2006; Watson et al., 2007), leadto decreased medication treatment compliance (Sirey et al., 2001) and an increase indepressive symptoms (Link et al., 1997; Yen et al., 2005).

As pubic and self-stigma are theorised to be comprised of stereotypes, prejudiceand discrimination, an anti-stigma approach to working with persons with SMDshould intervene into at least one of these components to break the cycle of stigmacreation. This paper proposes an anti-stigma approach to working with persons withSMD through the use of empowerment, social constructivism, adaptive systemstheory and narrative therapy. An anti-stigma approach aims to promote a decrease inself-stigma among persons with SMD by providing a theoretical base for social workand mental health practitioners to practise in an anti-stigma manner.

An anti-stigma approach

Empowerment, the use of language, and recovery

The decrease of self-stigma among persons with SMD will begin through anintervention into one of self-stigmas three components: stereotypes, prejudice, or

3 6 J O U R N A L O F S O C I A L W O R K P R A C T I C E

Dow

nloa

ded

by [D

emoc

ritus

Univ

ersity

of T

hrac

e] at

04:46

13 Fe

brua

ry 20

14

discrimination. The theory and practice of empowerment is a valuable tool inpromoting persons with SMD to gain or regain control of their lives, express theirvoice in regard to their wants and needs, challenge assumptions and stereotypes heldby society, and thus, begin to break the cycle of self-stigmatisation negatively affectingthe person. Empowerment is defined as a process involving the creative use of onespersonal resources to gain and use power to control ones life circumstances, achievepersonal goals, and improve relational and communal good (Browne, 1995; Greeneet al., 2005). The lack of empowerment reflects a low self-esteem, learnedhelplessness, and an external locus of control whereas a presence of empowermentreflects a high degree of self-determination, internal locus of control, and self-efficacy(Greene et al., 2005). As self-esteem and self-efficacy are found to be negativelycorrelated with self-stigma, empowering persons with SMD can lead to increased self-esteem, self-determination, and self-efficacy, thus reducing self-stigma.

A critical aspect in empowering persons with SMD is an evaluation of the use oflanguage. The choice of language used when working with persons with SMD canhave an impact on either empowering them or contributing to further stigmatisation.For example, instead of helping persons with SMD, practitioners can collaboratewith persons with SMD. Thus, an evaluation of the language used with persons withSMD is necessary to begin the empowerment process in decreasing self-stigma. Wepropose to shift the social work and mental health aim from treating persons whosuffer from SMD to working collaboratively with persons in recovery from SMD.

Mental health recovery represents a paradigmatic view of persons with mentalillness that is hopeful, and has the belief that individuals can, and do, get better.According to Anthony (1993), mental health recovery does not necessarily mean thatindividuals do not have to experience limitations caused by the illness, but rather areable to cope with the limitations and live a satisfying, hopeful and productive life.Anthony (1993) discusses the recovery process as involving

the development of new meaning and purpose in ones life as one growsbeyond the catastrophic effects of mental illness. Recovery from mental illnessinvolves much more than recovery from the illness itself. People with mentalillness may have to recover from the stigma they have incorporated into their verybeing; from the iatrogenic effects of treatment settings; from lack of recentopportunities for self-determination; from the negative side effects ofunemployment; and from crushed dreams.

(p. 15)

Recovery involves the reorienting of persons with a mental illness towards a newsense of self that is not saturated with stigmatic notions. Individual accounts (seeDeegen, 1996; Frese, 1997; Leete, 1989; Lovejoy, 1982) and qualitative studies ofrecovery (see Smith, 2000; Spaniol et al., 2002) indicate that the recovery process ispossible and life changing. Further, these studies describe how individuals with amental illness shed their socially constructed sense of self for one that is self-constructed.

To help promote this change from a self defined by stigma to a self that isrecovering, we propose an acknowledgement of the principles of adaptive systems

A N A N T I - S T I G M A A P P R O A C H 3 7

Dow

nloa

ded

by [D

emoc

ritus

Univ

ersity

of T

hrac

e] at

04:46

13 Fe

brua

ry 20

14

theory and the use of two empowerment approaches: (a) social constructivism; and(b) narrative therapy. Adaptive systems theory and social constructivism can provide afoundation for understanding the self-stigma that persons with SMD have developed,and concepts from narrative therapy (White, 1993), which draws fromconstructivism, can be used by practitioners to help persons with SMD make thenarrative turn away from a stigmatic self towards a recovering self. As with adaptivesystems theory and social constructivism, narrative therapy holds that individuals learnabout themselves through their interaction with the larger social environment (Kelley,1996), including information about the stigma that surrounds mental illness. Narrativetherapists also hold that individuals have positive and hopeful experiences that falloutside the personal stories individuals develop, using information from their socialenvironment, about their lives (Freedman & Combs, 1993). We see narrative therapyas one tool to challenge the stigmatic view of individuals, which they received throughtheir interactions with society, and create a change that impacts individuals sense-of-self, life-course and life-chances.

Social constructivism and adaptive systems theory

Social constructivism is a meta-theory interested in examining individuals reality andhow these realities are constructed based on social contexts, interactions with otherindividuals, and perceptions of the world (Berger & Luckman, 1966). Whenconsidering the social constructivist approach, an understanding of individualsfunctioning in society is determined by their interpretation of their experiences withinsociety, culture, and sub-culture, the meaning they ascribe to these experiences, andthe influence of history, policy and economics (Greene & Lee, 2002). Through socialinterchange within an individuals cultural environment, knowledge and meaning arecreated and are influenced and sustained by the various institutions within thatenvironment (Dean, 1993; Witkin, 1995). From these experiences, a reality iscreated and individuals then view future experiences through this reality (Dewees,1999). The dominant members of society, or the individuals who have power withinthat society, determine the dominant values, beliefs, and norms supported by thatsociety. Adhering to and demonstrating the dominant values, beliefs, and norms isconsidered normal and deviation is considered abnormal. Through these socialinteractions within the dominant society, individuals beliefs and value systems areinfluenced, and therefore impacts how individuals process experiences, view theworld and their role in the world. Individuals function and behave according to theirbelief and value system and interpret the world through this structured lens.

In adaptive systems theory, a system is defined as a single unit and can includeorganisms, ecosystems, and social systems, such as human beings, social relationships,families, kinship networks, neighbourhoods, organisations, the civil service, thegovernment, the world or the universe (Allred et al., 2005; Payne, 1991). Adaptivesystems theory seeks to explain how systems develop from a simplistic state tobecome more complex (Siegel, 1999; Stelk, 2006). In explaining this development,the theory holds the following principles: (a) systems process information receivedfrom other systems, which can lead to behaviours that are either adaptive or problem-solving (Allred et al., 2005; Cilliers, 1998); (b) systems develop in a nonlinear matteras the system continually adapts or reacts to changes in other systems (Allred et al.,


Dow

nloa

ded

by [D

emoc

ritus

Univ

ersity

of T

hrac

e] at

04:46

13 Fe

brua

ry 20

14

2005; Stelk, 2006); and (c) systems are self-referencing and participate in sense-making and self-organisation (Allred et al., 2005; Capra, 1996; Cilliers, 1998).

Sense-making and self-organisation are the two principle components in adaptivesystems theory that assist in explaining the nonlinear development of a system. Sense-making involves a system attempting to make sense out of a situation by gatheringinformation and filtering this through the systems perspective (Allred et al., 2005).Similar to social constructivism, a systems perspective is often shaped by priorexperiences in situations and the influence of other systems perspectives (i.e. viewsof the dominant members of society). Self-organisation is often a result of sense-making in that a system alters, adapts or stabilises behaviours based on the sense-making process in relation to the particular situation (Allred et al., 2005; Stelk,2006). Again, as with social constructivism, systems can change or adapt theirbehaviours based on the responses they receive from other systems and the influenceor pressure to behave or respond according to the standards of the other systems.Behaviours during the self-organisation process are not predictable as situations thatrepresent small changes can actually have large effects on a system and vice versa, yetdue to a systems memory of prior situations, changes in behaviour will occur within apredictable range (Allred et al., 2005). Both social constructivism and adaptivesystems theory recognise the influence of the social environment (i.e. systems) onshaping an individuals behaviour and view of themselves within the socialenvironment and in relation to other systems.

For persons with SMD, both societys response to them and their currentenvironmental situations are personally relevant to each individual. Dominantsocietys notion of SMD further disempowers persons living with SMD, as this labeldenotes abnormality by society. According to Scheff (1999), once an individual isdefined as having a SMD, a label, often defined by stereotypes, is attached and theindividual takes on a career as being the label. The individual starts to act inaccordance with her or his past learning about how an individual with SMD should act(i.e. sense-making), and has learned how to be a person with SMD from theinteractions with dominant society and, thus, acts in accordance with the conceptionsof this label (i.e. self-organisation) (Link, 1982). So persons living with SMD have asense of self that is, at least in part, a result of their current environmental situationand constructed by how society views these individuals.

The application of social constructivism and adaptive systems theory

As mentioned, self-stigma degrades the self of persons with mental illness. This viewof self, in part, contributes to a disempowered sense of self and reduces life chances.Therefore, the goal in working with persons with SMD who wish to move towardsrecovery is to assist them in shedding their socially constructed, stigmatic view of self,by interrupting their current sense-making process, and creating an empowered andauthentic sense of self through self-organisation. This further involves shapinginformation from the environment to support this empowered view of self. Moresimply, the goal is to help the individual see their life as, a life lived forwardsrather than one transfixed in various versions of chronicity (Epston, 1993), byworking with the individual and the information she/he receives from the socialenvironment.


Dow

nloa

ded

by [D

emoc

ritus

Univ

ersity

of T

hrac

e] at

04:46

13 Fe

brua

ry 20

14

As Greene and Lee (2002) argue, constructive approaches to social work practiceare empowering approaches and elicit several general guidelines for practice. Theseguidelines will serve as part of the foundation for our constructive approach toworking with persons with SMD, and help position the practitioners working withthis service user population. These guidelines are: (a) the social worker shoulddevelop a truly collaborative and non-hierarchical relationship with service users; (b)the social worker should take a position of curiosity towards service users view ofreality and their problems; (c) the social worker should take a position that the serviceuser, and not the social worker, is an expert on the service users reality andproblems; (d) the social worker should learn and use the service users language ininteractions with the service user; and (e) the service users reality that emerges fromwork with the social worker is co-created through dialogue between the service userand the social worker (pp. 184187).

Although these general guidelines will begin the empowering process, the changesto an individuals process of sense-making and self-organisation will occur incombination with an increase in positive connections and information flow, and achange in cognitive schema (Allred et al., 2005; Stacey, 1996). Meaning creation anddesigning are two tools by which such changes can occur where meaning creationinvolves the individual making sense out of situations encountered within theenvironment, and designing involves creating and building connections between theindividual and other systems in the environment in order to increase the individualsinformation flow. Social work practitioners can assist in a therapeutic dialogue withindividuals to redefine the meaning they give to situations and create connections toother individuals and resources that reinforce the new meanings.

Therapeutic dialogue plays a pivotal role in meaning creation and designing byhelping persons with SMD to challenge their stigmatic and disempowered sense ofself. As Epston (1993) has argued, therapeutic conversations about a problem can havea real affect on the problem. Therapeutic dialogues can have the potential of helpingindividuals move past their problems or keeping individuals entrapped by theirproblems. Therapeutic conversations can move our service users from stigma towardsrecovery. Questions asked by practitioners who work with persons with SMD can be, invitations to alternative experiences to new realities where people canmeaningfully encounter new possibilities and new knowledge (Freedman & Combs,1993, p. 293). Discussing solutions and possibilities with service users provides a wayto help co-create new meanings and an expanded and authentic sense of self forservice users (de Shazer, 1994).

Although these general suggestions provide a foundation and a context for apractitioner interested in applying social constructivist and adaptive systems theoriesto working with persons with SMD, these suggestions are not therapeutic techniques.What are needed are techniques that can challenge service users disempowered andstigmatic sense of self, take advantage of the powerful role that therapeuticconversations can have on co-creating real change in a service users life, and work tochange and challenge the environmental information available to the service user.Narrative therapy provides techniques that can be used by the practitioner throughtherapeutic conversation with service users. Although the following discussion linearlydescribes selected techniques from each approach and highlights the narrative


Dow

nloa

ded

by [D

emoc

ritus

Univ

ersity

of T

hrac

e] at

04:46

13 Fe

brua

ry 20

14

metaphor of narrative therapy (Freedman & Combs, 1993), the reader is encouragedto consider when and how to use these techniques in individual practice with serviceusers to maximise therapeutic change.

Narrative therapy

Narrative therapy provides the practitioners with therapeutic techniques to challengethe way that individuals interpret and make sense of their lives. From a narrativetherapy perspective, individuals attempt to understand their lives by arrangingtheir experiences of events in sequences across time in such a way as to arrive at acoherent account of themselves and the world around them This account can bereferred to as a story or self narrative (White & Epston, 1990, p. 10). Individualsexperience problems when their self-narratives or stories become problem saturated(White & Epston, 1990). Individuals who experience problems that are labelled byprofessionals as problems, such as mental illness, often adopt the dominate societysideas about these labels into their personal narratives (White, 1993). As a result,individuals often ignore aspects of their lives that contradict these societal drivenproblem saturated narratives. In other words, although individuals experience eventsin their lives that stand in opposition to these problem saturated narratives, theseproblem-free times (alternative narratives), do not make their way into individualstelling of their own stories and/or are not acknowledged by significant others in theindividuals life. The goal of narrative therapy, then, is to help individuals broaden, orre-author, their personal stories to account for these forgotten alternative narratives.By re-working the narratives, individuals are empowered to move beyondconstructing societal and stigmatic definitions and are provided with a sense ofpersonal agency over their lives (White, 1993). According to Kelley (1996), narrativetherapy is typified as consisting of two general stages, deconstruction andreconstruction.

Deconstruction. The first step in narrative therapy is to elicit from service users theirproblem saturated stories (Kelley, 1996). In hearing service users stories, thepractitioner asks the service users questions that help to develop a deeper and fullerunderstanding of their perception of the problem and their reality and the meaningthey give to the problem. Although, we as professionals may view service usersproblem as SMD, service users, themselves, define for us what and how they view theproblem and the problems affect on their lives. The practitioner helps the service usebecome aware of their sense-making and self-organising processes.

A central component of deconstructing a service users story is the externalisationof the service users problem (Carr, 1998; White, 1993). Externalising the problem,what White (1993) calls externalising conversations, involves asking the service userquestions in such a way as to separate the problem and the service user. Through theseconversations, the service user is encouraged not to view the problem as intrinsic tothem; rather the problem is objectified and viewed as something separate from theservice user. In essence, externalising conversations help service users, becomeagents rather than patients (Epston, 1993, p. 171) relative to their problem. Forpractitioners working with persons with SMD, this approach means allowing the


Dow

nloa

ded

by [D

emoc

ritus

Univ

ersity

of T

hrac

e] at

04:46

13 Fe

brua

ry 20

14

service user to name the problem rather than artificially defining the problem asmental illness. The stigmatic view of self that has become a pivotal portal throughwhich persons with SMD view themselves must be objectified. For example,problems dealing with unemployment must not be viewed as a personal failing.Ideations of personal failure must be converted into something separate from theservice user, such as societys lack of knowledge about the abilities andaccomplishments of persons with SMD.

As part of these externalising conversations, practitioners ask service usersquestions about the relative influence of the problem on their life and on others intheir social world (Carr, 1998). The practitioner pays attention to how the serviceusers view of self is influenced by the problem and how the service user is co-optedinto these views by the problem (White, 1993). For persons with mental illness, theservice user can be encouraged to describe how societys lack of knowledge, or otherexternalised problem the service user desires, impacts her or his personal stories. Aspart of exploring the relative influence of the problem, service users are askedquestions about their influence over the problem (Carr, 1998), which helps serviceusers see their role in perpetuating their internalised and often unconscious self-stigmatisation. Externalising conversations set the stage for the next general step ofthe narrative therapy process, the reconstruction or re-authoring stage.

Reconstruction. In the reconstruction stage, the service user is encouraged toexplore those subjugated or ignored stories that are left out of the service usersdominate narrative (Kelley, 1996). White and Epston (1990) have referred to theexploration of these subjugated times as exploring unique outcomes. The role of themental health worker is to move the service user from a sense-making that is problembased to one that is empowered, and to work with the service user on developing aself-organising process that is not limited to the negative roles adopted by personswith a SMD. In exploring unique outcomes, the practitioner encourages the serviceuser to consider times when the problem has not been present. By exploring with theservice user these exception times, the service user is encouraged to recoverexperiences at odds with the dominant story (Freedman & Combs, 1993, p. 296).Here the service user may be encouraged to think about when they feel the leaststigmatised or in some form of mental health recovery. Maybe there is an employerthe service user encountered who was particularly kind, or a friend who never actedas if the service user were mentally ill, or how the service user feels fully alive andhuman when writing poetry.

Once these unique times are identified, the practitioner asks questions to broadenthe service users narrative relative to these unique times. The practitioner askslandscape of action and landscape of consciousness questions to help the service userdetail behaviours and thoughts/meanings, respectively, around these unique outcomes(White, 1993). Landscape of action questions ask the service user to map out theevents, sequences, times and plots related to these unique outcomes (Carr, 1998).These questions help service users trace back in time, both recent and distant,preferred life events that stand in opposition to problem-saturated stories (White,1993). Landscape of consciousness questions ask service users to map out the


Dow

nloa

ded

by [D

emoc

ritus

Univ

ersity

of T

hrac

e] at

04:46

13 Fe

brua

ry 20

14

meanings, effects, evaluations, and justifications of these unique outcomes (Carr,1998). (F)ocusing on the meaning of that story helps assure that the story is anexperience that matters (Freedman & Combs, 1993, p. 301). To further explore thelandscape of action and consciousness questions, the practitioner asks experience-of-experience questions, which asks the service user to consider other persons views ofthe unique outcomes (White, 1993). Landscape of action questions, landscape ofconsciousness questions and experience-of-experience questions are used by thepractitioner to help service users develop a complete picture of times when theservice user felt less stigmatised or in mental health recovery. The storyline ofthe narrative should be robust with an extensively, descriptive picture of the uniquetimes.

In order to push these broadened narratives, ones that include the uniqueoutcomes, into the future, the practitioner asks questions about what the future maybe like for the service user given this new knowledge (Carr, 1998). Future orientedquestions allow service users to role-play or rehearse how these unique outcomes willunfold in the future (Freedman & Combs, 1993). Questions about the future shouldbe asked in a tentative way to respect the service users prominent role inconstructing their new narrative (Carr, 1998). As Carr (1998) writes of exploring thepossible future, this is a language of possibilities rather than predefined certainties(p. 496). Here the service users are encouraged to describe what mental healthrecovery means to them and how they will continue to challenge stigmatic and sociallyderived notions of self. This final stage supports Anthonys (1993) definition ofrecovery, which suggests that service users uniquely move forward with life in a waythat brings them the most satisfaction.

Case example

The following case example illustrates a composite of service users from the firstauthors work as a case manager. While the name has been changed, the situation isreal.

John is a 24-year-old male who has been homeless for one year and was referredto a non-profit case management agency by a local homeless shelter. He was hesitantto become involved with the agency because he did not believe he had schizophrenia;he knew what those people were like. He admitted hearing voices, but did nothave a mental illness.

To work from an anti-stigma approach with John, I maintained the principles ofsocial constructivism and empowerment, which involved using positive language thatwould empower versus stigmatise, taking a position of curiosity and acknowledgingthat John is the expert in his situation and experiences, and I followed the theory ofadaptive systems (sense-making and self-organisation) and techniques from narrativetherapy (deconstruction and reconstruction).

Deconstruction was the first step in working with John, which involved Johndescribing his story and his definition of the problem in an attempt to help himbecome aware of his sense-making and self-organising processes. As Johns casemanager, I listened to him describe his life story, his definition of the problem and


Dow

nloa

ded

by [D

emoc

ritus

Univ

ersity

of T

hrac

e] at

04:46

13 Fe

brua

ry 20

14

did not challenge his disbelief that he had schizophrenia. John described his early lifeas normal where his father worked at a local factory and his mother stayed at home.He tried university but could not concentrate on school work and soon left. Thevoices started during Johns first semester at university and a psychiatrist diagnosedJohn with schizophrenia. His parents were initially understanding of his behaviour,however, he refused medication and did not trust his psychiatrist. His parentseventually became scared of his bizarre behaviour and kicked him out of their house.John moved into an apartment, but was evicted after a year as he kept disturbing theneighbours, thus, resulting in John becoming homeless.

Johns sense-making and self-organising processes were fixed on the label ofschizophrenia and the stigma from society associated with such a label. He did notidentify with the label, or the stereotypes from society, but did recognise that voiceswere present and knew that he was not normal!. I had him name his problemfrom his perspective using his own words, which he stated as others. John believedthat other people were scared of him and he thought that others would think he wastoxic. He identified himself with self-stigmatising ideas, and while he did not believehe had a mental illness, he thought others believed he did and, therefore, did notbelieve he was entitled to the same resources and amenities as other members ofsociety, such as housing and employment.

To further understand Johns experience and attempt to externalise the problem,I asked him to describe how the others affect him and his life, and he stated thatothers convinced his parents that he was dangerous, others would not give him achance at employment or a place to live, and that others would not be his friend.John acknowledged that he was able to maintain his own home, work and havefriends, but was hindered from doing so based on the way others viewed him. I askedabout Johns role in the problem and he stated that he was the victim of othershatred. I asked if he played a role in the hatred, yet he did not know because henever gave other people a chance. John began to wonder if keeping a distance fromothers contributed to part of the problem, as this maintained the current stigma hereceived and negative stereotypes by society, and he began to recognise his sense-making process.

After participating in discussions on the definition of the problem and exploringthe influence of the problem on Johns life and his influence over the problem, Johnwanted to get past his problem. I moved onto the reconstruction stage where Iworked with John on changing his sense-making and self-organising processes bytalking about unique times in Johns life when the problem of others was not aproblem (i.e. asking landscape of action, landscape of consciousness, and experience-of-experience questions). John described how at first his parents were helpful as theyincluded him in their lives and allowed him to live with them. To gain a sense of thistime in Johns life, I asked him what life was like before his parents became scared ofhim, and he stated that he helped around the house, as much as he could, and was ableto ignore the voices while he worked at his place of employment. I asked what othersthought of him while he worked and he stated they were not able to tell that he wascrazy. He also talked about how getting his first apartment represented a uniqueexperience as he was able to hold it together just enough to fill out the applicationand meet with the landlord. He stated that it was not until the voices told him to warn


Dow

nloa

ded

by [D

emoc

ritus

Univ

ersity

of T

hrac

e] at

04:46

13 Fe

brua

ry 20

14

his neighbours about the coming war, that his neighbours began to act differentlytowards him. I asked how he was able to get it together just enough and he describedbeing able to ignore the voices and the information they were giving him. I asked if hecould use work and ignoring his voices to get a place to live. John thought he could.I asked what he thought his future would look like and he stated he would have a smallapartment and have a job just like everyone else. When asked what he would do ifothers became scared of him again, he stated he would show them success, which hehoped would challenge others ideas of him. Over time, John was able to reconnectwith his parents, get a job as a cook at a local restaurant and a small one-bedroomapartment. John also began to see a psychiatrist for help with his voices and decided totake medications. For our last meeting, we had a small party to celebrate Johnssuccess.

Conclusion

We have offered an approach to working with persons with SMD that we believe willmove service users towards the self-realisation of mental health recovery. Theapproach draws on a constructivist and adaptive systems theory understanding ofstigma, theorised to be composed of stereotypes, prejudice and discrimination, andmental health recovery. We believe that self-stigma and recovery are on a continuum;to move towards recovery means moving away from a stigmatic view of self. In orderto help service users on this journey towards recovery, we have suggested principalsof empowerment, constructivist and adaptive systems theory and techniques ofnarrative therapy. The applications of such interventions are seen as puncturing thecycle of stigma creation and feeding the development of self-realisation. Ourcontention is that this anti-stigma approach can be beneficial to any practitionerworking with service users who are mentally ill. The approach can range from simplyempowering a service user through the use of language, understanding the role thatsociety and the environment plays in shaping a service users definition of self (socialconstructivism; adaptive systems theory), or applying therapeutic techniques(narrative therapy) with service users in an attempt to empower them to redefinetheir sense of self.

References

Allred, C. A., Burns, B. J. & Phillips, S. D. (2005) The assertive community treatmentteam as a complex dynamic system of care, Administration and Policy in MentalHealth, vol. 32, no. 3, pp. 211220.

Anthony, W. A. (1993) Recovery from mental illness: the guiding vision of the mentalhealth service system in the 1990s, Psychosocial Rehabilitation Journal, vol. 16,pp. 1123.

Berger, P. L. & Luckman, T. (1966) The Social Construction of Reality, Doubleday, GardenCity, NY.

Browne, C. V. (1995) Empowerment in social work practice with older women, SocialWork, vol. 40, pp. 358364.


Dow

nloa

ded

by [D

emoc

ritus

Univ

ersity

of T

hrac

e] at

04:46

13 Fe

brua

ry 20

14

Capra, F. (1996) The Web of Life, Anchor Books, New York.Carr, A. (1998) Michael Whites narrative therapy, Contemporary Family Therapy, vol. 20,

no. 2, pp. 485503.Cilliers, P. (1998) Complexity and Postmodernism: Understanding Complex Systems, Routledge,

London.Corrigan, P. W. & Watson, A. C. (2002) Understanding the impact of stigma on people

with mental illness, World Psychiatry, vol. 1, no. 1, pp. 1620.Dean, R. G. (1993) Constructivism: an approach to clinical practice, Smith College Studies

in Social Work, vol. 63, no. 2, pp. 127146.Deegen, P. (1996) Recovery is a journey of the heart, Psychiatric Rehabilitation Journal,

vol. 19, no. 3, pp. 9197.De Shazer, S. (1994) Words were Originally Magic, W.W. Norton, New York.Dewees, M. (1999) The application of social constructionist principles to teaching social

work practice in mental health, Journal of Teaching in Social Work, vol. 19, no. 1/2,pp. 3146.

Epston, D. (1993) Internalized discourses versus externalizing discourses, in TherapeuticConversations, eds S. Gilligan & R. Price, W.W. Norton, New York, pp. 161177.

Freedman, J. & Combs, G. (1993) Invitations to new stories: using questions to explorealternative possibilities, in Therapeutic Conversations, eds S. Gilligan & R. Price,W.W. Norton, New York, pp. 291303.

Frese, F. J. (1997) Twelve aspects of coping for persons with serious and persistentmental illness, in Psychological and Social Aspects of Psychiatric Disability, eds R.Spaniol, C. Gagne & M. Koehler, Center for Psychiatric Rehabilitation, Boston,pp. 145155. (Reprinted from Innovations and Research, 1993, vol. 2, no. 3, pp.3946.)

Gallo, K. M. (1994) First person account: self-stigmatization, Schizophrenia Bulletin,vol. 20, no. 2, pp. 407410.

Greene, G. J. & Lee, M. Y. (2002) The social construction of empowerment, inPathways to Power: Readings in Contextual Social Work Practice, eds M. OMelia & K. K.Miley, Allyn & Bacon, Boston, pp. 175201.

Greene, G. J., Lee, M. Y. & Hoffpauir, S. (2005) The languages of empowerment andstrengths in clinical social work: a constructivist perspective, Families in Society,vol. 86, no. 2, pp. 267277.

Kelley, P. (1996) Narrative theory and social work treatment, in Treatment: InterlockingTheoretical Approaches, ed. F. J. Turner, Free Press, New York, pp. 461479.

Leete, E. (1989) How I perceive and manage my illness, Schizophrenia Bulletin, vol. 15,no. 2, pp. 197200.

Link, B. (1982) Mental patient status, work, and income: an examination of the effects ofa psychiatric label, American Sociological Review, vol. 47, pp. 202215.

Link, B. G., Cullen, F. T., Struening, E., Shrout, P. E. & Dohrenwend, B. P. (1989) Amodified labeling theory approach to mental disorders: an empirical assessment,American Sociological Review, vol. 54, pp. 400432.

Link, B. G., Struening, E. L., Rahav, M., Phelan, J. C. & Nuttbrock, L. (1997) Onstigma and its consequences: evidence from a longitudinal study of men with dualdiagnoses of mental illness and substance abuse, Journal of Health and Social Behavior,vol. 38, no. 2, pp. 177190.

Lovejoy, M. (1982) Expectations and the recovery process, Schizophrenia Bulletin, vol. 9,no. 4, pp. 604609.


Dow

nloa

ded

by [D

emoc

ritus

Univ

ersity

of T

hrac

e] at

04:46

13 Fe

brua

ry 20

14

Payne, C. (1991) The systems approach, in Handbook of Theory for Practice Teachers inSocial Work, ed. J. Lishman, Kingsley, London, pp. 2234.

Rosenfield, S. (1997) Labeling mental illness: the effects of received services andperceived stigma on life satisfaction, American Sociological Review, vol. 62,pp. 660672.

Rusch, N., Holzer, A., Hermann, C., Schramm, E., Jacob, G., Bohus, M., Lieb, K. &Corrigan, P. W. (2006) Self-stigma in women with borderline personality disorderand women with social phobia, Journal of Nervous & Mental Disease, vol. 194, no. 10,pp. 766773.

Scheff, T. (1999) Being Mentally Ill, 3rd edn, Adline, Chicago.Siegel, D. J. (1999) The Developing Mind: Toward a Neurobiology of Interpersonal Experience,

Guildford Press, New York.Sirey, J. A., Bruce, M. L., Alexopoulos, G. S., Perlick, D. A., Friedman, S. J. & Meyers, B. S.

(2001) Perceived stigma and patient rated severity of illness as predictors ofantidepressant drug adherence, Psychiatric Services, vol. 52, pp. 16151620.

Smith, M. K. (2000) Recovery from a severe psychiatric disability: findings from aqualitative study, Psychiatric Rehabilitation Journal, vol. 24, no. 2, pp. 149158.

Spaniol, L., Wewiorski, N. J., Gagne, C. & Anthony, W. A. (2002) The process ofrecovery from schizophrenia, International Review of Psychiatry, vol. 14, pp. 327336.

Stacey, R. D. (1996) Complexity and Creativity in Organization, Berrett-Koehler, San Francisco.Stelk, W. J. (2006) Implementing health-care innovations: in search of a theoretical

foundation for a science of implementation, International Journal of Mental Health,vol. 35, no. 2, pp. 3549.

Watson, A. C., Corrigan, P., Larson, J. E. & Sells, M. (2007) Self-stigma in people withmental illness, Schizophrenia Bulletin, vol. 33, pp. 13121318.

White, M. (1993) Deconstruction and therapy, in Therapeutic Conversations, eds S.Gilligan & R. Price, W.W. Norton, New York, pp. 2161.

White, M. & Epston, D. (1990) Narrative Means to Therapeutic Ends, W. W. Norton, New York.Witkin, S. L. (1995) Family social work: a critical constructionist perspective, Journal of

Family Social Work, vol. 1, no. 1, pp. 3345.Yen, C., Chen, C., Lee, Y., Tang, T., Yen, J. & Ko, C. (2005) Self-stigma and its

correlates among outpatients with depressive disorders, Psychiatric Services, vol. 56,no. 5, pp. 599601.

David Kondrat, MSW, PhD., is an assistant professor of social work at Utah State

University. His research interests include mental health stigma, recovery in mental

illness, and direct social work practice. He is particularly interested in how mental

health treatment providers negotiate stigma with their consumers and aide in their

mental health recovery. Address: Utah State University, Department of Sociology, Social

Work, & Anthropology 0730 Old Main Logan, UT 84322-0730. [email: david.kondrat

@usu.edu]

Barbra Teater is a lecturer in the Department of Social & Policy Sciences at the

University of Bath where she teaches social work theories and methods and social work

legislation. Her current research focuses on residential mobility and low-income

housing, social work in the community, and direct social work practice. Barbra and

David are currently co-authoring a book on social work theories and methods. Address:

University of Bath, Claverton Downs, Bath, BA2 7AY. [email: [email protected]]


Dow

nloa

ded

by [D

emoc

ritus

Univ

ersity

of T

hrac

e] at

04:46

13 Fe

brua

ry 20

14

Documents

Document4