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Stern: Stigma and Mental Illness – A Barrier to Health Seeking
 

Stern: Stigma and Mental Illness – A Barrier to Health Seeking

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Wonca Working Party on Mental Health

Wonca Working Party on Mental Health
World mental Health Day

presentation Dr Anthony Stern (USA)
Stigma and Mental Illness – A Barrier to Health Seeking

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  • Emile Durkheim, “The Father of Modern Sociology”

Stern: Stigma and Mental Illness – A Barrier to Health Seeking Stern: Stigma and Mental Illness – A Barrier to Health Seeking Presentation Transcript

  • Stigma and Mental Illness – A Barrier to Health Seeking ANTHONY STERN, M.D. ALBERT EINSTEIN COLLEGE OF MEDICINE ANNUAL WORLD MENTAL HEALTH DAY OCTOBER 10 TH , 2010 MALAGA, SPAIN
  • OVERVIEW
    • I Stigma, Psychiatric Disorders, and Health Seeking
    • II Stigma and Mental Ilness: A Brief History of the Concept
    • III Stigma and Clinical Reality: Three Intertwined Threads
    • IV Conclusion: Fighting the Good Fight against Stigma
  • General Health Care: The Role of Stigma
    • Health Care Facts
    • The Links between Stigma and Health Care
    • Extrapolations:
    • from a fuller understanding of stigma and mental illness
    • from studies of difficulties seeking mental health care
  • One U.K. Example of “Label Avoidance”: 2004 GMS (General Medical Services) Contract
    • Patients often would not grant permission to be enlisted into GP practice SMI registers
    • This has hampered the effort to target primary health care for SMI patients
    • Andre Tyler, Institute of Psychiatry: “Many of those affected with SMI feel there is
    • stigma attached to practice registers and by signing one they will live with this
    • permanent record or label.”
    • David Yeomans, University of Leeds: “People with SMI are often treated differently
    • they are given a mental health label, which is part of the problem in trying to persuade
    • patients to register.”
    • “ Running on Empty: Building Momentum to Improve Well-Being in Severe
    • Mental Illness”, John Abbott et. al., pp. 14-15
  • STIGMA: The Origins of the Concept
    • Emile Durkheim
    • 1858-1917
    • 1895 1893 1912
            • 1897
    • Erving Goffman
    • 1922-1982
            • 1963
    • 1961 1959
  • Goffman’s Concept of Stigma: Undesirable Differentness
    • “ Stigma is the process by which the reaction of others
    • spoils normal identity”
    • The stigmatized person presents evidence of being
    • different in an undesirable way: “he is thus reduced in our
    • minds from a whole and usual person to a tainted,
    • discounted one”
  • Link-Phelan Model of Stigmatization
    • Bruce Link Jo Phelan
    • LABELLING: The identification of differences
    • STEREOTYPING: These differences are viewed as negative because of
    • prevailing beliefs
    • SEPARATING: “Us” and “Them” are disconnected
    • DISCRIMINATION: “They” (those labelled) experience status loss leading to
    • unequal circumstances
  • Link-Phelan Model: The Role of Power
    • “ Access to social, economic and political power”
    • allows the stigmatization process to occur
    • Bruce G. Link and Jo C. Phelan ,
    • "Conceptualizing Stigma", Annual Review of Sociology
    • Volume 27 (2001), pp. 363-385
  •  
  •  
  • Types of Stigma
    • “ received” stigma: prejudice and discrimination
    • “ self-stigma”: internalized feelings of devaluation
    • “ structural” or “institutional” stigma: low service use,
    • inadequate funding for treatment and research
    • “ courtesy” stigma: families, providers, and mental
    • health systems for treatment and research
    • “ public” stigma: diffuse public attitudes
    • “ social ” stigma: public, structural and courtesy
  •  
  •  
  •  
  • Levels of the Stigmatizing Process (Thornicroft, Hinshaw)
    • COGNITION - IGNORANCE AND
    • STEREOTYPING
    • AFFECT - PREJUDICE
    • BEHAVIOR - DISCRIMINATION
    • Patrick Corrigan: www.stigmaandempowerment.org
    •  click on “Publications” and “Resources”
  • October 2004, American Psychologist: “How Stigma Interferes with Mental Health Care”
  • What causes the failure to seek or use care?
    • Corrigan:
    • STIGMA (“SELF-STIGMA” AND
    • “ LABEL AVOIDANCE”)
    • HEALTH ILLITERACY (LACK OF KNOWLEDGE)
    • ABOUT ILLNESS AND ABOUT SERVICES
    • AVAILABILITY AND ACCESSIBILITY
  • Two Factors That May Influence Whether a Person Who Might Benefit From Mental Health Treatment Actually Seeks It Corrigan, P. (2004). How Stigma Interferes With Mental Health Care. American Psychologist, 59 (7), 614-625. doi:10.1037/0003-066X.59.7.614 © 2004 American Psychological Association
  • U. of Michigan Medical Students
    • Depression, Stigma, and Suicidal Ideation in
    • Medical Students
    • Thomas L. Schwenk, MD; Lindsay Davis, BS; Leslie A.
    • Wimsatt, PhD
    • JAMA 2010; 304(11):1181-1190.
    • "A Disease Like Any Other"? A Decade of Change in
    • Public Reactions to Schizophrenia, Depression,
    • and Alcohol Dependence
    • Am J Psychiatry, Published On-Line (“in advance”)
    • September 15, 2010
    • Bernice A. Pescosolido, Ph.D., Jack K. Martin, Ph.D., J.
    • Scott Long, Ph.D., Tait R. Medina, M.A., Jo C. Phelan,
    • Ph.D., and Bruce G. Link, Ph.D.
  • Optimism, late 1990’s: scientific knowledge will reduce stigma
    • ASSUMPTION:
    • The public understanding of mental illness as a
    • brain disease will decrease community rejection
  • A Comparison of Responses to GSS mental health vignettes, 1996 and 2006
    • the vignettes describe individuals with schizophrenia,
    • major depression, and alcohol dependence
    • 54%  67% attributes major depression to
    • neurobiological causes
    • similar increases in public endorsement of mental
    • health treatment
    • no decrease in stigma, as measured by the desire
    • for social distance and perceived dangerousness
  • Result and Conclusion
    • “ Holding a neurobiological conception of these disorders increased
    • the likelihood of support for treatment but was generally unrelated
    • to stigma. When associated, the effect was to increase, not to decrease,
    • community rejection.”
    • “ An overreliance on the neurobiological causes of mental illness and
    • substance abuse disorders is at best ineffective and at
    • worse potentially stigmatizing.”
    • Research in Eastern Germany, Germany, Turkey, Russia, and
    • Mongolia has revealed similar findings; research in Austria and
    • Australia showed no increase or decrease of stigma
  • The Vicious Cycles of Stigmatization (Sartorius, World Psychiatric Association)
    • affecting individuals
    • affecting families
    • affecting mental health services
    • Reducing the Stigma of Mental Illness ,
    • Google Books, pp. 3-4
  • Fear and Shame: Three Intertwined Causes
    • Stigma
    • Psychiatric Symptoms
    • “ Normal” Psychology
    • (The Human Condition)
  • A Proposed Model
    • SOCIAL STIGMA
    • SELF-STIGMA
    • PSYCHIATRIC 
    • SYMPTOMS
    • SHAME AND FEAR
    • STIGMA 
    • IMPAIRED SYSTEM 
    • LOW
    • SELF-ESTEEM
    • AND AVOIDANT
    • BEHAVIORS 
    • IMPAIRED SELF-CARE
  • SPIRITUAL ROOTS
    • COGNITION (IGNORANCE AND - HEAD STEREOTYPING)
    • AFFECT (PREJUDICE) - HEART
    • BEHAVIOR (DISCRIMINATION) - DEEDS
  • How do we learn…?
    • … to care for each other more fully?
    • … to respect each other more completely?
            • Martin Buber
            • 1878 - 1965
  • Buber: all dialogue depends on the acceptance of otherness
    • “ Genuine conversation, and therefore every actual
    • fulfillment of relation between men <and women>,
    • means acceptance of otherness.”
    • “ Human life and humanity come into being in genuine meetings.”
    • The Knowledge of Man: A Philosophy of the Interhuman , transl. Maurice Friedman and Ronald Gregor Smith (Harper & Row, NY, 1965), p. 69
    • Henri Nouwen
    • 1932 - 1996
    • Mother Teresa
    • 1910-1997
    • “ We treat all people as children of God.”
    • “ We have been created to love and be loved.”
    • “ Be faithful in small things because it is in them that your strength lies.”
    • Exodus 22:21 (New King James version)
    • You shall neither mistreat a stranger nor oppress him,
    • for you were strangers in the land of Egypt.
    • Éxodo 22:21   (Reina-Valera 1960)
    • Y al extranjero no engañarás ni angustiarás,
    • porque extranjeros fuisteis vosotros en la tierra
    • de Egipto.
  • Internet Resources
    • World Psychiatric Association
    • www. openthedoors.com
      • www.worldpsychiatricassociation.org/sections/stigma
      • (over 50 country programs listed)
    • US SAMHSA's Resource Center
    • www.stopstigma.samhsa.gov
    • (over 100 state programs listed)
    • Canada Programs:
    • www.mentalhealthcommission.ca/English/Pages/OpeningMinds
  • Thank you.
    • [email_address]