That was another segment from, The Family Guide To Mental Health Recovery, which you will remember from last weeks lecture on families, care giving and mental illness. And, I think that young man lays out the issues quite nicely. Why is it that we don't talk about mental health. And why is it that, that silence allows us to have individuals and families and communities so ill prepared to deal with issues of mental illness? Well, I think a lot of it has to do with stigma and the roots of stigma are very deep it has been with us a very long time. And in fact, I think you'll see on one of, of the upcoming slides that stigma is so closely associated with mental illness that in a lot of definitions of stigma that is the, the example that they always give stigma against mental illness. I do want to say that I think things are getting better all the time. We can talk openly about mental health issues. We have mental health awareness weeks. We have people stepping forward who are talking about their experiences of mental illness so people can put a face to that and understand that it affects some, it's something that affects a lot of people. And it affects all kinds of people. And that people recover from mental illness. And that these people are, valuable and functioning people in our communities. But at the same time stigma stays with us. So, what we're going to talk about now is what stigma is, how it works, and, and what supports it, because I think that, that is a very important part of understanding how on the other hand we can combat stigma, and make it more possible for people who are dealing with mental illness and mental health problems to live happily in our communities. So, as I already said, stigma is so closely associated with mental illness, that you will commonly see mental illness or mental disorder mentioned in definitions of the, the term. In this definition it talks about stigma as a mark of disgrace. And the list words below, shame, disgrace, dishonor, bad reputation. They all reinforce a stigma is a negative thing that affects how people are seen by others. In this paper by Overton and Medina, there's a flow reference in your inf, in your resource list. They present a common conceptualization of the building blocks for stigma. First there are stereotypes. Ideas that are widely held by people about a particular group of people. For the most part, we think of stereotypes of negative, because they, at the very least, do not take into account the individuality of people, and the diversity within a group. But I think that we can all acknowledge that when we are taking about stereotypes, we are usually taking about negative ideas, about a group of people. Negative stereotypes becomes the basis and the justification for prejudice. Judgments that people make about a group of people that don't rely on evidence and can be highly resistant to evidence that would contradict these negative attitudes. Prejudice turns the negative ideas that are embedded in stereotypes into attitudes that then justify treating that group of people badly and unfairly. Discrimination is the behavioral consequence of holding negative stereotypes in prejudices about a group of people. Discrimination is the actual day to day actions that happen to exclude those people, undermine them and even harm them. Overton and Medina also point to stick my having an influence at different levels. Structural stigma is reflected in systemic discrimination and exclusion. This is stigma that infiltrates all levels of society, so that it affects things like education, housing, employment, etc. Social stigma is reflected in the interactions that people have with each other. Erving Goffman, who we've talked about many times in this course, wrote about stigma, referring to it as creating a spoiled identity. The spoiled identity creates barriers for people who are trying to interact in a social environment, so it has an impact on their relationships with other people. Internalized stigma, which is also sometimes called self stigma, refers to the way that stigma can get inside a person. In my own work about how people create a diagnosis, sorry, create an identity post-diagnosis, I talk a lot about internalized stigma because the ideas about mental illnesses surround all of us also get inside of us and become something that has a profound influence on how people are able to deal with being told that they have a mental illness. Structural stigma against mental illness plays out in terms of people experiencing barriers to things like employment, housing, education, etc. These are barriers like not being accepted into jobs, or school programs, or housing, if people know you have a mental illness. It may also be things like losing a child or place or school, or living situation because of mental illness. And knowing that if you disclosed that you have mental illness, that you won't be able to have any of these things. Structural stigma also affects access to treatment services for mental illness. The unavailability of mental health services, or the unaffordability of mental health services, is something that is possible, because mental illness is not necessarily prioritized in health and social policies. This is one of the ways the stigma has an effect. The media is part of structural stigma. There's an excerpt of the interview with Caroline Kwok that you haven't seen in which she talks about how stigma in East Asia is reinforced by the media because entertainment portrays mental illness in frightening ways and also because the news media reports negatively about mental illness and sensationalizes negative stories about people with mental illnesses. There's little in the way of balance that could be provided by stories about people with mental illnesses who are making positive contributions. That certainly isn't exclusive to East Asia. There are elements of that everywhere, and most people get most of their information about mental illness from the media, as the person in the video clip said. We don't talk about it, and it's not part of standard education. Social stigma, stigma as experience in relationships, in contact with other people, is something that has a huge impact on the experience of people diagnosed with mental illnesses. The research on public stigma shows that while public attitudes are improving in many places, it is still the case that much of the general public perceives people diagnosed with mental illnesses as dangerous or unpredictable and therefore to be feared or avoided. Another popular conception is that people with mental illnesses or mental disorders are childlike and need to be taken care of. That they're not capable of being independent. I think you have to understand this in the context of knowing that for many people their primary contact with someone they know has a mental illness is either through media that portrays them in they ways we've just described or perhaps in day to day interactions with the people who are physically mental ill, mentally ill and are acting in ways that are physically strange. Speaker 1: The reality is that most people know someone who's dealing with mental illness and doesn't fit any of those stereotypes. But because stigma makes it unsafe for people to be open about their experience in mental illness, they don't know that. It should be mentioned that there is also an extensive literature that suggests mental health professionals hold stigmatizing attitudes as well... Many studies show that the level of stigma among mental health professionals is equal to that of the general public or even higher. Now why is that? I have two thoughts on it. One is that mental health professions are part of the same social environment as everyone else, so they are exposed to the same negative ideas that fuel public stigma. Another thought I've had, is that even though mental health professionals, have plenty of opportunity to see the diversity of people who are diagnosed with mental illnesses, and they see that it effects people in different ways, because mental health systems, are mostly set up to deal with the most ill, the most disabled, and the most dangerous of people with metal illnesses, the perception of mental health professionals get distorted, because they are mostly dealing with people who It fits the stereotypes. I don't offer this an excuse for those attitudes, just a possible explanation. Social stigma has the kind of consequences that I kind of already mention. Being rejected and being isolated from the other people. There may be lower social status, because people think less of you, but also because you experience barriers that prevent achieving the kind of things, like employment and education, that would increase your social status. Another issue that brings us close to the issue of internalized stigma is that the anticipation of experiencing stigma also makes people reluctant to engage in social interactions and relationships with other people. I have had lots of conversations with clients about who to tell, how to tell, when to tell, if they should tell, what will happen if they tell. Disclosure of a history of mental illness comes with tremendous social risks and many people would rather avoid them. So now, we come to internalized stigma. Internalized stigma occurs when the negative expectations and stereotypes that are attached to mental illness become internalized by a person who is diagnosed with a mental illness. This is something that partly happens because that individual has been socialized in the same social context that makes the rest of the public hold stigmatizing attitudes. And discriminate against people with mental illness. I also believe, however, that the low expectations that the public and mental health professionals can have for people diagnosed with mental illnesses contributes to internalized stigma. If you're surrounded by people who do not believe that you're able to recover from mental illness and return to a full life, then it's difficult to have those beliefs for yourself. In the paper that I'm mentioning here. The one about social construction of disability, I interviewed people who had experienced episodes of mental illness. And they talked about how the way the world saw them after they had an episode of illness, had a profound effect on what they were then able to achieve as individuals... In the same way that low expectations become a prophecy for someone diagnosed with mental illness, discrimination can reenforce low expectations for the individual. If the world treats you like you don't have the right to be a full participant in it, then you may start to believe it as well. You start to see then that there is a cycle between social stigma and an internalized stigma. They, in a sense, feed off of each other. Stigma clearly has consequences for the experience of mental illness. Overton and Medina suggest that it actually influences the course of illness and as someone who has written about how social attitudes contribute to post-diagnosis disability, I'm inclined to agree. Stigma against mental illness also interferes with help seeking behavior. Do you remember how Ellen Saks described in her video that she avoided medication because she believed that if she didn't take it, it meant she wasn't really ill? That's an example of how stigma can get inside someone. We've created social environments in which continuing, continuing to suffer with mental illness is seen as preferable to being associated with it. So people don't take medication. People don't seek out mental health assistance. People won't walk in the door of a mental health center. And that probably means, people get sick who could have been prevented from getting sick, and people get severely ill. Who could have been helped much sooner in the process. Another consequence of stigma is that it has an effect on how people feel about themselves. If you believe in negative things that people are saying about you, it's obviously going to have an effect on your state of mind, your self-esteem and your level of hope for the future. If you're going to combat stigma, you have to understand stigma. You have to understand that it's something that we have all been raised with. It's a very rare situation to be in a place where there is no stigma against mentally illness. So since stigma is something we all learn, its something we all have to unlearn, that's why public education is so important. And because we understand it as something that has an effect at the structural level, the social level and within people, then our thinking about how to eliminate stigma has to be at all of those levels as well. At the structural level, some of the things that we've seen to combat stigma is advocacy by people diagnosed with mental illness and other people. I would include public education in advocacy affects as well I have health policy, health and social policy as the last bullet here, but I actually think it is the most important strategy for dealing with stigma at its structural level. The way the stigma operates in the structure is through the denial of service, basic rights, access to services etcetera. And you can hope for people to shift their attitudes in ways that will make these things more accessible to people diagnosed with mental illnesses, but the reality is that unless mental illness and mental health promotion is clearly made a priority by governments and embedded in health and social policy, it's very difficult to make meaningful change at the structural level. Policy can feel like it's something very far away from most of us but it's in your face everyday. If you ask questions like how far away or close is your closest mental health care facility, what is the policy that covers your access to mental health care? Do you have to pay for it out of pocket or is it covered by employer or is it covered by the state? Can you get a sick leave for your mental illness? Can you get any kind of leave to take care of a relative with mental illness? If you've been diagnosed with a mental illness are you employable? Can you hold a responsible position? Can you have a driver's license? Can you adopt a child? All of these things reveal how health policy, social policy, and organizational policy affect people who are diagnosed with mental illness. And there need to be people, there need to be things in place at all of these levels to make it possible to deal with mental illness. But one of the ways that structural stigma has in effect, is that these things are not in place. Protest, advocacy, and consumer movements can have an influence on that. And if you think about the history of mental health lecture you will remember that we have seen that protest, advocacy, and consumer movements have made important differences at the structural level that have contributed to some of the destigmatizing of mental illness that we've seen in the last several years. Anti-stigma work at the social level has to deal with people, and how they interact with each other. Public and professional education plays an important role here, because there's a level of stigma that is based in the basic lack of understanding about mental health and illness. Increasing mental health literacy of the general public and health professionals has been demonstrated through shift attitudes and the way that people interact with each other. The media plays an important role in this. For example, in Canada we have the Canadian Mental Health Association, The Center for Addiction and Mental Health, The Mood Disorder Association, and the Schizophrenia Society, just to name a few, that are organizations that put out a lot of information and education about mental illness. They are trying to deal with the information gap that can feed stigma against mental illness. There's been a lot of research about the effect that contact has on stigma against mental illness. Basically, we find that if people are able to have contact with people who are diagnosed with mental disorders, it often contributes to more positive attitudes and less stigmas. There are also circumstances of course where it could have the opposite effect. But in an overall sense, it is helpful for many people to understand the diversity of the experience of mental illness and also to recognize that it's not something that it is happening to some unknown group of people somewhere out there. But instead it's something that happens to people that they know and people who are like them. Finally, workplace accommodations and anti-discrimination policies overlap with the structural anti-stigma interventions I just mentioned. They're, these are ways to increase inclusion of people who are diagnosed with mental illnesses, which is important from a human rights perspective, but also has the effect of increasing the capacity for people with mental illnesses to make contributions in our communities, and to be viewed as contributing members of, Of our communities. Finally, there are anti stigma interventions to deal with internalized stigma as well. You hopefully remember that I talked about the importance of dealing with stigma when working with families who are effective with mental illness. And there is similar, and maybe even more pressing need to deal with the potential for internalized stigma, among people who are diagnosed with mental illnesses. Really, when it comes down to it, we have all learned stigma and probably internalized it to some degree. So part of why we need to do public education about mental illness, and school education, and workplace education, is to put in place knowledge, awareness, and attitudes that do not allow that internalized stigma to turn into prejudice and discrimination against others. And hopelessness and low expectations for, For ourselves. There's some work that's been done on cognitive behavioral interventions, for internalized stigma as well. There's some specific psychotherapy methods that are designed to help people work with issues of stigma and replace self stigmatizing ideas with ideas that can better They promote health and well-being. And then at the end here, mutual support empowerment and self advocacy, things like the consumer survival movement but also other kinds of group support in action, can also help with reducing internalized stigma. Working with other people to improve ones own life and the life of others is an empowering experience that can really help people see that being diagnosed with a mental illness is not have to be the end of having a productive and meaningful life We've also seen the same is true with families. One of the reasons that psycho education and support groups have been so successful for, for addressing family issues is that similarly they are dealing with internalized stigma. And working with other family members to help improve each others lives and to support each other is an empowering experience for them as well. Anti stigma intervention goes hand in hand with mental health promotion and that's what we're going to turn to next.
