Stigma and mental health

Question 1

What is Goffman’s social stigma (Ritsher et al. 2003; Ritsher and Phelan, 2004)?

Answer 1

“an attribute, behaviour, or reputation which is socially discrediting in a particular way that causes an individual to be classified by others in an undesirable, rejected stereotype rather than an accepted, normal one.
Discrimination can lead to disadvantages, and lose self-esteem, leading to feelings of shame, a sense of alienation and social withdrawal.”

Question 2

What, in the early 20th century, marked a shift in disorder classification?

Answer 2

> Lunacy Commissioners’ coding schemes:

• shift from anecdotal observation to systematic classification
• > new system:
• aetiology was distinguished from diagnosis
• causes were identified with input from psychiatrist and patients
• professionals sought to establish the medical history of the patient and their family

> Until the 1940s: WHO’s International Classification of diseases

Question 3

What put an end to the Lunacy Commissioners coding schemes in the late 1940s?

Answer 3

British psychiatry moved toward the WHO’s International Classification of diseases

Question 4

What happened in the 20th century until the 1980s regarding disorder classification?

Answer 4

> 1940s: ICD-based system:

• departure from cause and effect dichotomies
• increasing recognition of varied causes of mental distress
• efforts to classify new diagnoses (e.g. depression, personality disorders)
• which were greeted with resistance towards new classification

> Proliferation of disorders:

• aetiological factors reframed as diagnoses, combining source and symptoms of problems (e.g. alcoholism)
• led to wider dissent
• > questions regarding the liability of psychiatric labels and national variation in diagnostic practice

Question 5

What happened from the late 20th century (1980s) to the present, regarding disorder classification?

Answer 5

> Discourse expanded beyond the medical domain
-> Model that encompassed the biophysical, psychological and sociological
- Darian Leader: “Commodification of the psyche” reflected in the explosion of diagnoses
(from 1-2 dozen in early 20th to 360+ in late 20th)

> Superficial states (e.g. shyness) have been apathologized as defining disorders
- due in part to drug companies seeking to secure niche markets for their products

> DSM-5 publication reignited the debate on the ‘ever-widening net’ of disorders that seeks to cast over unhappiness, personal fortune, and troubling conduct

Question 6

Who was David Rosenham?

What did his “Pseudopatient” study, between 1969-72, consist of?

Answer 6

> Harvard-Based psychiatrist
influenced by the work of Laing and Szasz
his experiments questioned the validity of psychiatric diagnosis

> “Pseudopatient” study

• Rosenham and 7 cohorts, none with psychiatric diagnoses
• got admitted to institutions across the US, presenting with only one symptom: hearing a voice
• > they were kept for between 8 and 52 days
• > 7 were diagnosed with schizophrenia
• > not one was judged “sane”

Question 7

What was the response to Rosenham’s “Pseudopatient” study?

Answer 7

> Following its publication (1973), psychiatrists went on the defensive

• to protest their diagnostic competence
• > attempt to medicalise psychiatry

> the study’s impact was reflected in the DSM-III (1980)
- introduced more rigorous diagnoses

BUT
> Patient actions were taken out of context once admitted
> Behaviour was misinterpreted through this diagnosis ‘filter’ and pathologies in line with it

Question 8

What are the consequences of stigma in treatment?

What did the Lewis and Appleby (1988) study show?

Answer 8

> Adverse connotations of labels (e.g. personality disorder, schizophrenia) may elicit hostility in social and clinical attitudes, and treatment
Today, prejudice is commonly disseminated and reinforced by media scandals about dangerous patients

Question 9

What did the Lewis and Appleby (1988) study show, regarding the consequences of stigma in treatment?

Answer 9

• “Patients given a previous diagnosis of personality disorder were seen as more difficult and less deserving of care compared with control subjects who were not.”
• “The personality disorder cases were regarded as manipulative, attention-seeking, annoying, and in control of their suicidal urges and debts.”
• “Personality disorder therefore appears to be an enduring pejorative judgement rather than a clinical diagnoses.”

Question 10

What does stigma research encompasses?
What is it based on and focused on?
What did it include and exclude?

Answer 10

> Encompasses problems of:

• knowledge -> ignorance
• attitudes -> prejudice
• behaviour -> discrimination

> Based on attitude surveys and media representations
Focused on schizophrenia

> Included few intervention studies
Excluded direct participation by service users

Question 11

What are the proposed limitations of stigma research?

Answer 11

1. Few connections between academic writings and legislation concerning disability rights policy
2. Descriptive work
   - on mental illness and stigma
   - overwhelmingly describing attitude surveys or the portrayal of mental illness by the media
   - less is known about effective interventions to reduce stigma
3. Few direct contributions to this literature by service users
4. Underlying pessimism
   - that stigma is deeply historically rooted and difficult to change
5. Stigma theories have de-emphasised cultural factors and paid little attention to issues related to human rights and social structures

Question 12

What did the study of perceived stigma in schizophrenia patients and their families reveal (Thornicroft et al. 2007, 2009)?

Answer 12

Stigma is related to mental health care for nearly a quarter (22.3%) of all stigma experiences reported.

Question 13

Where do most studies about effective interventions to reduce stigma and discrimination originate in?
What are 3 recognised cultural and socioeconomic influences on stigma?

Answer 13

> High-income countries (HICs)

> Cultural and socioeconomic influences on stigma:

1. Notions of “mental illness” and explanatory models
   - e.g. psychiatric syndrome may be attributed to supernatural forces
2. Cultural meanings of impairments and manifestations
   - e.g. stigma’s impact on marital prospects may have a different impact in a different society
3. Concepts of self and personhood
   - e.g. higher levels of family cohesion may offer more support, but also contribute to the more wides spread impact of stigma, across family members and generations

Question 14

What are the factors in stigma?

Answer 14

1. Cultural factors

2. Socioeconomic factors

Question 15

How do socioeconomic factors determine the context in which stigma is enacted and experienced?

Answer 15

> e.g. poverty and access to healthcare

• long associated with outcomes of mental illness
• determine the context in which stigma is enacted and experienced

Question 16

What did Thornicroft et al. (2009) show about the rates of anticipated and experienced discrimination among people with mental illness?
What does it suggests?

Answer 16

“Rates of both anticipated and experienced discrimination are consistently high across countries among people with mental illness”

-> measures like disability discrimination laws might not be effective without interventions to improve self-esteem

Question 17

What’s the current state of anti-stigma campaigns?

Answer 17

> Public Awareness Campaigns
Education = primary target
- for reducing stigma across various age groups or directed at specific communities or professions
Efforts to increase social interaction between people with and without mental illness
Promote responsable media reporting

> Other popular approaches:

• annual events (e.g. Mental Health Awareness Week)
• celebrity advocates
• “real-life” testimony and case studies

Question 18

What did Vanessa Pinfold show by interviewing service users?

Answer 18

> Mental health professionals and the system itself are implicated in creating and perpetuating stigma
-> these 2 factors are necessary targets for anti-stigma initiatives

> “Suggestions for psychiatric reforms included the improvement in doctor’s attitudes”

• ‘listening’ to the patient
• structure of doctor-patient relationships
• increased profile for psychiatry within the medical establishment
• reduced emphasis on the biomedical model (with improved access for psycho-social interventions)

Question 19

What does the “reduced emphasis on the biomedical model”, mentioned by Vanessa Pinfold in her interviews with service users, refer to?
What does it tell us about the impact of stratified/precision making?

Answer 19

Recent focus groups in which service users and carers voiced concerns:

• ongoing advances in fields such as neuropsychiatry could encourage a reductionist view of mental illness amongst both clinicians and the general public
• > ever less attention focused on the person behind the label

=> Within stratified or precision medicine, diagnosis and prescribing could be determined by blood tests and brain scans

Question 20

What did Dr. Beate Schulze notice about stigma within psychiatry itself?

Answer 20

> Blind spot in psychiatry regarding their own contributions on stigma

• stigma acting as a barrier to patient social integration through stereotypical media representation and social prejudice
• > counteracting the therapeutic efforts
• > imbalances in the distribution of resources

> Mental health professionals have concerns about their image and position in the industry
-> specific focus of anti-stigma campaigns

Question 21

What role did mass media campaigns play in stigma?

Answer 21

> Campaigns like Time to Change (UK) and Mental Health Europe have helped long-term reduction in stigma
- especially in relation to prejudice and exclusion

> They help promote help-seeking behaviour, social inclusion and the dismantling of hierarchies and stereotypes

Question 22

What is the Time to Change campaign?

Answer 22

> UK campaign to end stigma and discrimination against people with mental health problems in England
Established in 2007
Run by Mind and Rethink Mental Illness
Funded by: Department of Health, Comic Relief and The Lottery

> Aims to

• empower people with mental health problems or the 3/4 of the population who knows someone with m.h.problems
• to feel confident talking about the issue without facing discrimination

=> Start a dialogue that would lead to behaviour change

Projects:

• national high-profile marketing and media campaign
• Grants scheme to fund grassroots projects, lead by people with mental health problems
• creation of support network
• work with children and young people
• community activity and events

Question 23

What does the mediational model of the role of attitudes in explaining the effects of contact on confidence to change stigma consist of?

Answer 23

Contact changes attitude which gives confidence to challenge stigma
AND contact impacts directly the confidence to challenge stigma

Question 24

How did the Time to Change’s campaign with Anti Stigma Social Marketing work?
What are its results?

Answer 24

> Engaged public via mass media channels, calls to action and social events

• > Modest but significant positive improvements with campaign
• > Association between positive intergroup contact and improved attitudes/willingness to challenge stigma

=> Social contact can be an effective tool
=> Mass media social marketing is most effective on intended behaviour

Question 25

What role do museums play in anti-stigma initiatives?
What did recent exhibitions sought to redress and how?
How does Bethlem’s Museum of the Mind illustrates this change in recent exhibitions?

Answer 25

> Museums enable discussion of difficult histories by acknowledging

• varied perspectives of contributors
• how dominant views emerge for social and political reasons

> Patients traditionally had little voice BUT recent exhibitions have sought to redress this by:
- actively seeking involvement from mental health service users past and present

e. g. Bethlem’s Museum of the Mind
- curated thematically rather than chronologically
- encourages exploration of commonalities in experience rather than linear progression
- the museum’s display and website prominently feature user narratives
- > heavily promotes user involvement

Question 26

What are the principles of the hearing voices network that can help prevent and challenge stigma?

Answer 26

1. Seeing mental distress as human and ultimately understandable
   - view voices, visions, and extreme states of mental disorders as meaningful experiences
   - use human language when describing human experiences
2. Keeping the person in the driving seat
   - allow people to define their own experience
   - support based on need, not diagnosis
   - they need to access a wide range of alternatives to understand and manage their experiences (pros and cons, true choice, collaboration instead of coercion)
3. Supportive communities
   - community-based options can run alongside and as alternatives to psychiatry
   - the approaches must go hand-in-hand with greater awareness of the causal impact of social factors on mental distress (poverty, gender/racial inequalities, unemployment, deprivation, abuse)