N4205 stigma
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Transcript of N4205 stigma
This is the door to an inpatient psychiatric unit. It is locked at all times. Does this look like a place of healing? Why or why not? What does this environment say about the patients on this unit?
THE
OF MENTAL ILLNESS
Stigma
Families will say this, "Only illness in the world where you never get a covered dish." There is something about having a mental illness where everything falls away, and what you experience is fear and isolation rather than a sense of people coming towards you. (Joyce Burland)
What is stigma?
Original meaning: Bodily signs that indicate something about moral character of the person
What is stigma?
Coined by Goffman (1963) to refer to prejudices related to having a mental illness
In Greek society, stigmatizing attitudes about the mentally ill were already apparent
What is stigma?
As early as the 16th century, “madness” was seen as a “perverted will” and “symptoms of animal instincts”…. “a beast”
What is stigma?
AThe Scarlet Letter
What is stigma?
In The Scarlet Letter by Nathanial Hawthorne, Hester is made to wear an “A”, signifying her identify as an adulteress. The “A” is meant to be a symbol of shame, but instead it becomes a powerful symbol of identity to Hester. The letter’s meaning shifts as time passes. Originally intended to mark Hester as an adulterer, the “A” eventually comes to stand for “Able.” Finally, it becomes indeterminate: the Native Americans who come to watch the Election Day pageant think it marks her as a person of importance and status. The letter helps to point out the ultimate meaninglessness of the community’s system of judgment and punishment. More often than not, a symbol becomes a focal point for critical analysis and debate.
What is stigma?
In The Scarlet Letter, Hester is publicly shamed and forced by the people of Boston to wear a badge of humiliation, but she was not willing to leave the town. Hester’s behavior is premised on her desire to determine her own identity rather than to allow others to determine it for her. To her, running away or removing the letter would be an acknowledgment of society’s power over her: she would be admitting that the letter is a mark of shame and something from which she desires to escape. Instead, Hester stays, refiguring the scarlet letter as a symbol of her own experiences and character. Her past sin is a part of who she is; to pretend that it never happened would mean denying a part of herself. Thus, Hester very determinedly integrates her sin into her life.
What is stigma?
What does the story of The Scarlet Letter teach us about the stigma of mental illness?
What is stigma?
In place for centuries, the custodial, institution-based model of care for those with mental illness contributed to their stigmatization by segregation. The mentally ill were separated from the physically ill, who were treated in local hospitals in their own communities. The decision to send persons with mental illness to far-away institutions, although well intentioned in its origins, dislocated them from their communities. With time, they lost their connections with coworkers, friends, and relatives; ultimately, they lost their personal identity. At a system level, the institutional model also contributed to the banishment of mental illness, and also of psychiatry, from the general stream of medicine. The therapeutic nihilism that for centuries permeated most psychiatric work also contributed to the asylum mentality. The few-and-far-between therapeutic successes helped to reinforce the nihilism, in that the remaining conditions were considered incurable. With time, the stigma associated with mental conditions and mental health patients also extended to those in charge of caring for them, psychiatrists included.
What is stigma?
Labeling theory: Reactions of others of central significance in
experience of mental illness Involves an “exchange of meaning” about
what it means to have a mental illness
What is stigma?
Recognition of a differentiating “mark”
+
Devaluation of the bearer of the “mark”
A relational and social construct
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What is stigma?
This static concept of stigma has been enlarged to encompass a social construct linked to values placed on social identities through a process consisting of 2 fundamental components: the recognition of the differentiating “mark” and the subsequent devaluation of the bearer. Stigma is therefore a relational construct based on attributes.
Consequently, stigmatizing conditions may change with time and among cultures
What is stigma?
Perspective
Reactions
Identity
Develops in a matrix of social relationships and interactions
The way stigma is perceived by the stigmatizer or by the person being stigmatized
Exists along a continuum from the entirely personal to group belongness
Cognitive, affective, and/or behavioral reactions to stigma and its consequences
What is stigma?
Visibility: how obvious the mark is Controllability: whether the mark is
under the bearer’s control Impact: if it instills fear by conveying
an element of danger
What is stigma?
Mental health patients who show visible signs of their conditions because of their
symptoms, or because medication side effects may make appear “different”,
are socially construed as being weak in character or lazy,
who display threatening behaviours usually score high on the dimensions of visability, controllability and impact. By a process of association and class identity, all persons with mental illness are equally stigmatized: regardless of impairment or disability level, the individual patient is lumped into a class, and belonging to that class reinforces the stigma against the individual.
Stigma—a definition
“Beliefs, attitudes and behaviours that result in social rejection or isolation of an individual based on any set of characteristics that are perceived by a group to be undesirable or threatening, regardless of whether exposure to the person with these characteristics would actually cause adverse consequences to others” (Van Dorn, 2005)
Types of stigma
Public Self
Public stigma….
Impacts on achieving essential life goals, particularly obtaining competitive employment and living safely and independently
Fosters criminalization People with mental illness are dealt with by the
police, courts and jails, instead of mental health system Related to inadequate funding for the mental health system
and “get tough”, policies People with S&S of mental illness are more likely than others
to be arrested (Teplin, 1984) People with mental illness tend to spend more time
incarcerated than people without mental illness (Steadman, McCarty and Morrissey, 1989)
Impacts utilization of health care system
Those affected by self-stigma experience…
Social isolation: people restrict their social networks in
anticipation of rejection Loss of self-esteem:
people believe that they are less valuable as people
Limited prospects for recovery
Other consequences of stigma include…
Impaired social adaptation Social isolation, exclusion from friendships Access to employment blocked
Non-adherence to medication treatment
Models of stigma
Cognitive models: stigma related processes formed and maintained at the psychological level. Stereotype:
Knowledge structures learned by most members of a social group; represent collectively agreed on ideas about groups people
Of mental illness: dangerousness, incompetence, character weakness
Prejudice Endorsement of negative stereotype, experience negative
emotional reactions Discrimination
Behavioural reaction, often angry, leading to hostile discrimination such as withholding care, or fearful, leading to discriminatory avoidance
Models of stigma
Motivational models: explain WHY people stigmatize, or the function it serves, although it is an incomplete picture Ego-justification
Stigma avoids potential threat to one’s physical or psychological self, by avoiding a socially perceived threat
Stigma rationalizes negative group based attitudes and discrimination
Group or system-justification: not satisfactory explanations
Models of stigma
Institutional models: Definition: rules, policies, and procedures
of private and public institutions in positions of power that intentionally restrict the rights and opportunities of the group affected
Examples: Legislation restricting rights and opportunities
of people with mental illness
Models of Stigma
Structural models: Relates to the effect rather than the intent
of an action, rule or law Group goals are not accomplished because
they seem to clash with dominant ideologies that maintain the status quo E.g.cost-effectiveness: funding for mental
health programs, insurance parity
Stigma and violence
Stigma
Those diagnosed with schizophrenia are particularly subject to negative attitudes and distancing behaviour Schizophrenia is seen to be associated with
dangerousness, violence and unpredictability
Majority express preference for social distancing-rates have increased over past 40 years
Fewer negative attitudes about depression
Van Dorn, Swanson, Elbogen, and Swartz (2005)
Research question What are the differences in how mental
health stakeholders (patients, families, clinicians) view people with schizophrenia as compared with general public?
What are the differences in desire for social distance?
Results
Little difference between stakeholder groups in desire for social distance
Family members and clinicians are less likely to see person as violent
Service users most strongly believed the person likely or very likely to be violent
All groups likely to endorse a biomedical model of causality
Family members and service users more likely than clinicians to endorse stressful circumstances as a cause
Significant association between belief that the person was likely to be violent and desire for social distance
Conclusions
Negative attitudes evident even in groups with close association to persons with schizophrenia
People’s beliefs about cause and treatment effectiveness seem to affect perceptions of potential for violence, thus reducing desire for social distance
Changing public stigma
Protest strategies Anecdotal evidence suggests that protest can
be effective as a punishing consequence to decrease the likelihood that people will repeat the behaviour
Asking people to suppress their prejudice about a group can promote a backlash and worsen attitudes as a result (Corrigan, etal 2001)
Educational approaches Produces short term improvements in attitudes
(Corrigan etal), those with greater prejudice are less likely to benefit from education
Changing public stigma
Interpersonal contact Most promising results Contact with promoted greater
improvement in attitudes than protest, education and controls
Improvements seem to be most pronounced when contact is with a person who moderately disconfirms stereotype (Reinke, etal 2004)
Targeted stigma change
Anti-stigma programs are more successful when they target specific groups of people rather than the general public
Specific prejudicial attitudes and discriminatory behaviours need to be targeted Behaviours are more likely to change when
strategies target attitudes that correspond to the behaviour
Power groups must be challenged in the setting in which they might discriminate
Targeted stigma change
Targets Landlords who fail to lease or make reasonable
accommodation Employers who fail to hire or make reasonable
accommodation Health care providers who withhold some services or
are unnecessarily coercive Criminal justice personnel who are unnecessarily
coercive and who fail to use mental health services Policy makers who allocate insufficient resources,
interpret regulations in an “unfriendly” manner The media who perpetually disseminate stigmatizing
images
Erasing public stigma—structural change
Affirmative actions: government approved activities focused on redressing historical disparities Prohibition of discrimination Requiring “reasonable accommodation”
Making changes to the work environment to assist the person to work
Fair housing
Food for thought
What is the relationship between how North Americans understand the etiology of psychosis and the experience of stigma? If psychosis was viewed as being caused by
social factors, would there be any difference in the experience of stigma?
More food for thought
Are psychiatric diagnoses a part of the problem or part of the solution? Do some aspects of anti-stigma campaigns
have a potentially negative impact on service users because they frame most psychosocial problems as a psychiatric diagnosis?
There’s a sea of dandelions, beautiful dandelions. What a beauty! Somewhere we were taught that dandelions are ugly, they’re weeds. Where did we get this stigma about the dandelions? And it just struck me how a lot of life can have stigma attached to it, just like mental illness. (Ruth Detweiler)
Arboleda-Florez, J. (2003). Considerations on the stigma of mental illness (Editorial). Canadian Journal of Psychiatry, 48 (10), 645-650.
Corrigan, P., Green, A., Lundin, R., Kubiak, M., & Penn, D. (2001). Familiarity with and social distance from people who have serious mental illness. Psychiatric Services, 52 (7), 953-958.
Corrigan, P., Kerr, A., & Knudsen, L. (2005). The stigma of mental illness: explanatory models and methods for change. Applied and Preventative Psychology, 11, 179-190.
Jarvis, G. (2007). The social causes of psychosis in North American Psychiatry: a review of a disappearing literature. The Canadian Journal of Psychiatry, 52 (5), 287-294.
Additional References
Additional References 2
Pilgrim, D. & Rogers, A. (2005). Psychiatrists as social engineers: a study of an anti-stigma campaign. Social Science and Medicine, 61, 2546-2556.
Rusch, N., Angermeyer, M., & Corrigan, P. (2005). Mental illness stigma: concepts, consequences, and initiatives to reduce stigma. European Psychiatry, (20), 529-539.
Van Dorn, R., Swanson, J., Elbogen, E., & Swartz, M. (2005). A comparison of stigmatizing attitudes toward persons with schizophrenia in four stakeholder groups: perceived likelihood go violence and desire for social distance. Psychiatry, 68 (2), 152-163.