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 Staff housesChurchNeuropathology (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, and 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 Last Accessed http:// 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 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: IGNORANCEPREJUDICEDISCRIMINATION 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,

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 Christs 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, 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 The Definition has not been amended since PHYSICAL SOCIALMENTAL

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 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. Szasz (1973) The Second Sin Thomas 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 / 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? HISTORY RELIGION ZOOLOGY BOTANY MEDICINE SOCIAL IDENTITY Greek civilisation – slaves / criminals World 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 Usually 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

STIGMA 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 (Piagets 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: TIME and EFFORT TIME and EFFORT PERSONAL CHANGE leading to SOCIAL 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 (Piagets 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 dont 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 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 Be the change that you want to see in the world. Mohandas Gandhi