Transcript Slide 1

STIGMA
AND
EMPOWERMENT
Dr N Yoganathan
MBBS, DPM, Full Member Group Analytic Society
(London), Convenor of Median Groups
Consultant Psychiatrist
Dr J Willis
Assistant 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 1937-2001
Staff houses
Church
Neuropathology (MRC) (Professor Corsellis)
RUNWELL HOSPITAL 200?
CHURCH
STAFF HOUSE AREA TO BECOME NEW MEDIUM/LOW SECURE HOSPITAL
CHANGES IN MENTAL HEALTH CARE
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
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
PLEASE ANSWER QUESTION 5 OF YOUR QUESTIONAIRE NOW
Public attitudes towards mental illness in the UK between 1993 and 2003
(a) Getting worse
(b) No change
(c) Getting better
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
• E.g. Stigma by/in the
family; Stigma by
professionals; user
involvement
• Perceived
• Actual
• 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
•
e. g.
• Education
•
e.g. 5-year
• Contact
•
MIND
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.
OED DEFINITIONS
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’.
empower
• verb 1 give authority or power to; authorize. 2 give strength and
confidence to.
— DERIVATIVES empowerment noun.
http://www.askoxford.com/results/?view=dict&freesearch=empowerment&branch=13842570&textsearchtype=exact 16.09.07
WHO DEFINITION OF HEALTH
Health is a state of complete
physical, mental and social wellbeing, and not merely the absence of
disease or infirmity.
PHYSICAL
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
amended since 1948.
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
LIMITATIONS OF DEFINITIONS/LABELS
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 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
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 / tolerance
Individual / family / society
Social norms (mores) / stereotypes
• Rehabilitation psychiatry – medicine and psychology,
sociology, anthropology, philosophy, politics, economics
etc etc. It is inevitably a dialectical process
WHAT IS STIGMA?
Greek word (plural is stigmata) meaning ‘mark with a pointed instrument’
Usually associated with a mark of shame / disgrace
• HISTORY
• RELIGION
Greek civilisation – slaves / criminals
World War II – concentration camps
Skin eruptions of crucifixion (stigmata)
• ZOOLOGY
Respiratory spiracle of insects
• BOTANY
Receptacle for pollen
• MEDICINE
Symptoms /signs
• SOCIAL IDENTITY
Markings on face / tattoos / jewellery /
mobile phones / designer labels
OCCURRENCE OF STIGMATISATION
Everyday situations where stigma can be evident
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Age
Race
Religion
Gender
Sexuality
Physical appearance
Disability /disease
Class / caste
Status
Qualifications
Any other?
THE DIALECTIC OF STIGMA
STIGMA
STIGMA
&
&
MENTAL ILLNESS
MENTAL HEALTH
Dr N Yoganathan MBBS DPM
N Yoganathan
Member Group Analytic Society (London)
Approved under Section 12 Mental Health
Act 1983
Consultant Psychiatrist
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
OPENNESS
UNDERSTANDING
DIALOGUE
TOLERANCE
EMPATHY
(MINDFULNESS)
Splitting
Healing
Requires:
TIME and EFFORT
PERSONAL CHANGE leading to SOCIAL CHANGE
DEALING WITH STIGMA
Finding a voice e.g. campaigns, demonstrations
Tolerating ambiguities and change (Piaget’s shift from
concrete operational to formal operational)
Melanie Klein – depressive position and reparation
Effective resolution through a group forum/ dialogue
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
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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, multipolar, multi-dimensional, egalitarian
Duologue and monologue – arguments, binary oppositions,
true/false, hierarchical, compartmentalised, didactic
ZEN STORY
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?”
*
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
AN HOLISTIC APPROACH
PROTEST
EMPOWERMENT
CONTACT
EDUCATION
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
SOME PARTING THOUGHTS
Galileo, born 1564, charged with heresy 1616.
Publicly pardoned by the Roman Catholic Church 1992
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
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
To be truly mindful of others, one must reach a stage
of ‘no-mind’ N Yoganathan 2007 ‘Zen, Stigma and Mental Health’
Be the change that you want to see in the world.
Mohandas Gandhi
FIN
© Dr N Yoganathan & Dr J Willis September 2007
www.netgroup.org.uk
[email protected]
[email protected]