STIGMA AND

EMPOWERMENT

Dr N YoganathanMBBS, DPM, Full Member Group Analytic Society

(London), Convenor of Median GroupsConsultant Psychiatrist

Dr J WillisAssistant Registrar, University of Surrey, UK

OUTLINE OF PRESENTATION

• Introduction: changes in mental health care provision in the UK

• Conceptual aspects of stigma and interactive session

• Stigma and empowerment: from mental illness to mental health

• Conclusions

RUNWELL HOSPITAL 1937-2001Staff houses Church Neuropathology (MRC) (Professor

Corsellis)

RUNWELL HOSPITAL 200?

STAFF HOUSE AREA TO BECOME NEW MEDIUM/LOW SECURE HOSPITAL

CHURCH

CHANGES IN MENTAL HEALTH CARE

Anti-stigma campaign by the Royal College of Psychiatry and the Department of Health, UK,1998-2003

www.changingminds.co.uk and www.stigma.org/everyfamily

MH units in District General Hospitals/OP clinics/Day Hospitals/Community Psychiatric Service

Community Mental Health Teams/Crisis and Home Treatment Teams/Assessment Units

Rapid increase in Medium/Low Secure Forensic Psychiatric Care Units

High incidence of mental illness in prisons

(a) Getting worse (b) No change (c) Getting better

PLEASE ANSWER QUESTION 5 OF YOUR QUESTIONAIRE NOW

Public attitudes towards mental illness in the UK between 1993 and 2003

STIGMA IN MENTAL ILLNESS

People with mental disorders continue to experience prejudice and discrimination in every area of their lives, from finding somewhere to live to getting a job.

RCP http://www.rcpsych.ac.uk/ Last Accessed 18.05.07

Many people with serious mental illness are challenged doubly. On the one hand, they struggle with the symptoms and disabilities that result from the disease. On the other, they are challenged by the stereotypes and prejudice that result from misconceptions about mental illness.

Corrigan PW & Watson AC ‘Understanding the impact of stigma on people with mental illness’ World Psychiatry. 2002 February 1(1): 16–20.

STIGMA AND MENTAL ILLNESS

• Externally imposed• Self imposed

• Perceived• Actual

• E.g. Stigma by/in the family; Stigma by professionals; user involvement

• E.g. Gamian research re. specific conditions

PLEASE ANSWER QUESTIONS 6 AND 7 NOW

STIGMATISATION

• Problems of knowledge (ignorance)• Problems of attitudes (prejudices)• Problems of behaviour (discrimination) Thornicroft G et al. ‘Stigma: ignorance, prejudice or

discrimination?’ BMJ (2007) 190:192-193

IGNORANCE PREJUDICE DISCRIMINATION

PLEASE ANSWER QUESTION 8 ON YOUR QUESTIONNAIRE

ADDRESSING STIGMA IN MENTAL ILLNESS

• Protest

• Education

• Contact

• e. g. MIND

• e.g. 5-year campaign by RCP and Dept of Health

• e.g. Community care, groups

From Corrigan, P. & Penn, D. L. (1999) ‘Lessons from social psychology on discrediting psychiatric stigma’. American Psychologist 54, 765 -776.

http://www.askoxford.com/results/?view=dict&freesearch=empowerment&branch=13842570&textsearchtype=exact 16.09.07

stigma   • noun (pl. stigmas or especially in sense 2 stigmata /stigmaat) 1 a mark or sign of disgrace or discredit. 2 (stigmata) (in Christian tradition) marks corresponding to those left on Christ’s body by the Crucifixion, said to have been impressed by divine favour on the bodies of St Francis of Assisi and others. 3 Medicine a visible sign or characteristic of a disease. 4 Botany the part of a pistil that receives the pollen during pollination.   — ORIGIN Greek, ‘a mark made by a pointed instrument, a dot’. 

OED DEFINITIONS

empower  • verb 1 give authority or power to; authorize. 2 give strength and confidence to.   — DERIVATIVES empowerment noun.

WHO DEFINITION OF HEALTH

Health is a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity.

Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19-22 June, 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100)

and entered into force on 7 April 1948.

The Definition has not been The Definition has not been amended since 1948.amended since 1948.

PHYSICAL

SOCIAL MENTAL

A DIDACTIC MODEL OF HEALTH/ILLHEALTH

MEDICINE – BODY / BRAIN

• Normal (health) Abnormal (ill health)

• Symptoms, signs and investigations ‘Normal’ range – within 95%Accurate measurements and statistics

e.g. blood sugar, blood pressure

• ‘Acute’ psychiatry – mostly medicine, which is inevitably a ‘didactic’/scientific process

If you talk to God, you are praying; if God talks to you, you have schizophrenia.If you talk to the dead, you are a spiritualist; if the dead talk to you, you have schizophrenia.After Thomas SzaszAfter Thomas Szasz

Formerly, when religion was strong, science weak, people mistook magic for medicine;now, when science is strong and religion weak, people mistake medicine for magic.Thomas Szasz (1973) The Second Sin Szasz (1973) The Second Sin

LIMITATIONS OF DEFINITIONS/LABELS

A DIALECTICAL MODEL OF HEALTH/ ILL HEALTH

PSYCHIATRY – BODY / MIND

• Difficulties in defining ‘normal’ and ‘abnormal’

• MIND – complex and dynamic (evolving)More than the sum of the parts of the brain

Thoughts / perceptions / emotions / beliefs Values / expectations / toleranceIndividual / family / societySocial norms (mores) / stereotypes

• Rehabilitation psychiatry – medicine and psychology, sociology, anthropology, philosophy, politics, economics etc etc. It is inevitably a dialectical process

WHAT IS STIGMA?

• HISTORY

• RELIGION

• ZOOLOGY

• BOTANY

• MEDICINE

• SOCIAL IDENTITY

Greek civilisation – slaves / criminalsWorld War II – concentration camps

Skin eruptions of crucifixion (stigmata)

Respiratory spiracle of insects

Receptacle for pollen

Symptoms /signs

Markings on face / tattoos / jewellery /mobile phones / designer labels

Greek word (plural is stigmata) meaning ‘mark with a pointed instrument’ Greek word (plural is stigmata) meaning ‘mark with a pointed instrument’ Usually associated with a mark of shame / disgraceUsually associated with a mark of shame / disgrace

OCCURRENCE OF STIGMATISATION

• Age• Race• Religion• Gender• Sexuality• Physical appearance• Disability /disease• Class / caste• Status • Qualifications• Any other?

Everyday situations where stigma can be evident

STIGMASTIGMA

N Yoganathan

&

MENTAL ILLNESS

STIGMA

Dr N Yoganathan MBBS DPM

Member Group Analytic Society (London)

Approved under Section 12 Mental Health Act 1983

Consultant Psychiatrist

&

MENTAL HEALTH

THE DIALECTIC OF STIGMA

ORIGINS OF STIGMA

•In order to avoid social chaos, confusion and discomfort, human beings (and other animals) create strata (pecking order)

•When faced with uncertainty/anxiety/fear etc, it is a natural defensive response, which inevitably lead to ‘assumptions’ that are primitive (Piaget’s concrete operational stage)

•Melanie Klein – paranoid-schizoid position/ splitting

•Stigma – an inevitable by-product of group living

In the animal kingdom, the rule is, eat or be eaten;

in the human kingdom, define or be defined. Thomas Szasz

UNDERSTANDING STIGMA

STIGMA

Splitting

OPENNESS

DIALOGUE

TOLERANCE

EMPATHY (MINDFULNESS)

UNDERSTANDING

Healing

Requires:Requires:

TIMETIME and and EFFORTEFFORT

PERSONAL CHANGEPERSONAL CHANGE leading to leading to SOCIAL CHANGESOCIAL CHANGE

DEALING WITH STIGMA

Effective resolution through a group forum/ dialogue

Melanie Klein – depressive position and reparation

Finding a voice e.g. campaigns, demonstrations

Tolerating ambiguities and change (Piaget’s shift from concrete operational to formal operational)

CONFRONTING STIGMA• Stigma represents a complex, dynamic (interactive) process

• It is part of social evolution (for survival of the adaptable)

• It is exacerbated by the ambiguity caused by our increasingly regulated society

• It is a personal experience which affects us all

• It is an inevitable product of our living in groups

• Dealing with stigma on our own is extremely difficult

• 1:1/small group (parent/family) - - - - large group (society/world)

• ‘Impersonal Fellowship’ and dialogue in groups required to address and confront aspects of stigma e.g. Median Groups

NON-PHARMACOLOGICAL THERAPIES

• Counselling• Art / drama / music / occupational therapy • Anxiety / anger / social skills management• Dynamic psychotherapy (1:1, group)• Cognitive therapy• Cognitive behaviour therapy (CBT)• Cognitive analytical therapy (CAT)• Acceptance commitment therapy (ACT)• Inter-personal therapy (IPT) • Dialectical behaviour therapy (DBT)• Mindfulness behaviour therapy (MBT)• Median Groups

DIALOGUE

Socrates – Platonic dialogues, art of debate by question and answer

Plato – science of first principles, ultimate, clearest form of knowledge, ‘supreme art’

Aristotle – distinguished syllogistic reasoning from dialectic reasoning

Kant – antinomy, contradiction between 2 reasonable beliefs / conclusions, metaphysical / empirical

Hegel – dialectic, triadic movement of thesis / antithesis/ synthesis

Dialogue in groups – levelling, lateralising, multi-personal, multi-polar, multi-dimensional, egalitarian

Duologue and monologue – arguments, binary oppositions, true/false, hierarchical, compartmentalised, didactic

Two monks were once travelling together down a muddy road. A heavy rain was falling. Coming around the bend, they met a lovely girl in a silk kimono and sash, unable to cross the intersection.

“Come on, girl,” said the first monk. Lifting her in his arms, he carried her over the mud.

The second monk did not speak again until that night when they reached a lodging temple. Then he no longer could restrain himself.

“We monks don’t go near females,” he said. “It is dangerous. Why did you do that?”

“I left the girl there,” the first monk said. “Are you still carrying her?”

ZEN STORY

*

HAVE PUBLIC ATTITUDES TOWARDS

MENTAL ILLNESS CHANGED?

“For successful rehabilitation in psychiatry, we need to address the anxieties first of staff, then of relatives/carers and finally patients.” Yoganathan WMHC 2007

PROTEST

EDUCATIONCONTACT

AN HOLISTIC APPROACH

EMPOWERMENT

As human beings, our greatness lies not so much in being able to remake the world – that is the myth of the atomic age – as being able to remake ourselves. Mohandas Gandhi

With the advance of science and technology, people today expect there to be a pill for every ill; in an era of corporate culture and market economy, is it surprising to find we have an ill for every pill?N Yoganathan

SOME PARTING THOUGHTS

Masturbation: primary sexual activity of mankind. In the 19th century, it was a disease; now, it is a cure. . After Thomas Szasz (1973) The Second Sin

Galileo, born 1564, charged with heresy 1616. Publicly pardoned by the Roman Catholic Church 1992

To be truly mindful of others, one must reach a stage of ‘no-mind’ N Yoganathan 2007 ‘Zen, Stigma and Mental Health’

FIN

© Dr N Yoganathan & Dr J Willis September 2007

drnynathan@blueyonder.co.uk j.willis@surrey.ac.uk www.netgroup.org.uk

Be the change that you want to see in the world. Mohandas Gandhi