'Psiquiatría: situación actual y perspectivas de futuro'. Este es el título del simposio internacional que organizamos el 20 de junio de 2016 en la Fundación Ramón Areces con las fundaciones Juan José López-Ibor y Lilly en homenaje al doctor Juan José López-Ibor, fallecido en enero de 2015. Durante esta jornada, expertos internacionales abordaron la profunda crisis que atraviesa la psiquiatría como disciplina científica y especialidad médica. Además, se presentó el libro con el mismo título del simposio, también en recuerdo del doctor López-Ibor.

1. The Stigma of MentalThe Stigma of Mental
Illnesses:Illnesses: Present situation and FuturePresent situation and Future
PerspectivesPerspectives
Prof.R.Srinivasa MurthyProf.R.Srinivasa Murthy
Mental Health Advisor,Mental Health Advisor,
Sri Shankara Cancer Hospital and Research Centre,Sri Shankara Cancer Hospital and Research Centre,
Bengaluru-IndiaBengaluru-India
Email:Email: smurthy030@gmail.comsmurthy030@gmail.com

2. Stigma of Mental Illnesses-Stigma of Mental Illnesses-
Scope of PresentationScope of Presentation
•Understanding StigmaUnderstanding Stigma
•Recent Developments toRecent Developments to
address stigma ofaddress stigma of
mental illnessesmental illnesses
•Personal Experiences toPersonal Experiences to
address stigmaaddress stigma
•Looking ahead……..Looking ahead……..

6. •Global Mental HealthGlobal Mental Health
initiatives to addressinitiatives to address
stigma …….stigma …….

8. Surgeon General`s ReportSurgeon General`s Report
on Mental Health(1999)on Mental Health(1999)
• ““Despite the efficacy of treatmentDespite the efficacy of treatment
options and the many possible ways ofoptions and the many possible ways of
obtaining a treatment choice,obtaining a treatment choice, nearly anearly a
half of all Americans do not seekhalf of all Americans do not seek
treatmenttreatment.Most often, reluctance to.Most often, reluctance to
seek care is an unfortunate outcomeseek care is an unfortunate outcome
of very real barriers.Foremost amongof very real barriers.Foremost among
these is thethese is the stigmastigma attached toattached to
mental illness and to people with amental illness and to people with a
mental illness”mental illness”
CH-3

10. 1010
Needs of People with Mental DisordersNeeds of People with Mental Disorders
Figure
C
H
A
P
T
E
R
T
H
R
E
E
©
2001

11. “This is a wake-up call for us and for
the world. The current situation
paints a dismal picture of neglect and
a severe lack of resources. The
sooner we face up to this reality, the
more prepared we will be to provide
care and cure.”
Dr Benedetto Saraceno
Director
Department of Mental Health and Substance Dependence, WHO
2001

15. April , 2016- World Bank ReportApril , 2016- World Bank Report

19. Indian Journal of Social Psychiatry-Indian Journal of Social Psychiatry-
Special issue on Stigma(2016)Special issue on Stigma(2016)
• Menace of stigma in psychiatryMenace of stigma in psychiatry
• Tranquilising stigma- personal narrativesTranquilising stigma- personal narratives
• Stigma in dual diagnosisStigma in dual diagnosis
• Stigma experienced by patients and care-Stigma experienced by patients and care-
giversgivers
• Stigma scale in HindiStigma scale in Hindi
• Stigma-national and internationalStigma-national and international
perpectivesperpectives

20. World Cultural Psychiatry Research,World Cultural Psychiatry Research,
Special issue (2015)Special issue (2015)
• Free from Pasung in IndonesiaFree from Pasung in Indonesia
• Crossing borders in BrazilCrossing borders in Brazil
• Play it street smart in IndiaPlay it street smart in India
• Just say know with YouthJust say know with Youth
• Visual arts in psychiatryVisual arts in psychiatry
• The Madness HotelThe Madness Hotel
• Art from PakistanArt from Pakistan
• Musical progressions from IndiaMusical progressions from India

29. RadhaRadha

30. Historical DevelopmentsHistorical Developments
• ControlControl-- JailsJails
• ProtectionProtection -- AsylumsAsylums
• CareCare-- MentalMental
HospitalsHospitals
• RightsRights-- CommunityCommunity
carecare
• StigmaStigma--
EmpowermentEmpowerment

31. COMMUNITY PSYCHIATRYCOMMUNITY PSYCHIATRY
“Moral treatment consists in
removing patients from their
residence to some proper
asylums and for this purpose,
a calm retreat in the country
is preferred, for it is found
that continuance at home
aggravate the disease, as the
improper association of ideas
can not be destroyed”.

32. COMMUNITY PSYCHIATRYCOMMUNITY PSYCHIATRY
“Hospitals are the only places
where insane persons can be at
once humanly and properly
controlled. Poor houses, converted
into madhouses, cease to effect
the purpose to which they are
established, and instead of being
asylum for the aged, the homeless
etc., are transformed into
perpetual bedlams”.- Dorothea
Lynde Dix, 19th century.

34. Stigma of Mental IllnessesStigma of Mental Illnesses
• Origins of Stigma of mentalOrigins of Stigma of mental
illnessesillnesses
– HistoricalHistorical
– CulturalCultural
– ReligiousReligious
– ViolenceViolence
– Places of carePlaces of care
– LegislationLegislation

35. Stigma of MentalStigma of Mental
IllnessesIllnesses
•Dimensions ofDimensions of
StigmaStigma
–Structural stigmaStructural stigma
–Public StigmaPublic Stigma

36. Stigma of MentalStigma of Mental
IllnessesIllnesses
• Stigma and discrimination hasStigma and discrimination has
implications forimplications for
– Denial of human rightsDenial of human rights
– ServicesServices
– Social inclusionSocial inclusion
– EmploymentEmployment
– HousingHousing
– Criminal justice systemCriminal justice system

37. Stigma of Mental Illnesses-Stigma of Mental Illnesses-
Approaches to fightApproaches to fight
stigmastigma
• Increase awareness of mental healthIncrease awareness of mental health
• Increase knowledge of signs and symptomsIncrease knowledge of signs and symptoms
• Increase help seekingIncrease help seeking
• Reduce negative attitudesReduce negative attitudes
• Increase social toleranceIncrease social tolerance
• Decrease social distanceDecrease social distance
• Increase social participationIncrease social participation
• Reduce discriminatory behavioursReduce discriminatory behaviours
• Reduce self-stigmaReduce self-stigma
• Improving housing optionsImproving housing options
• Create advocacy structuresCreate advocacy structures
• Improve access to educationImprove access to education
• Increase access to employmentIncrease access to employment
• Improve fundingImprove funding
• Changes in legislationChanges in legislation

38. Stigma of Mental Illnesses-Stigma of Mental Illnesses-
recent researchrecent research
• Griffiths et al(2014) Effectiveness of anti-stigmaGriffiths et al(2014) Effectiveness of anti-stigma
efforts-meta analysisefforts-meta analysis
• Henderson et al(2014) Health care settingsHenderson et al(2014) Health care settings
• Lasalvia et al(2015) ASPEN/INDIGO STUDYLasalvia et al(2015) ASPEN/INDIGO STUDY
GROUP- Cross-national variations regarding MDDGROUP- Cross-national variations regarding MDD
• Mehta et al(2015) Effectiveness of programmesMehta et al(2015) Effectiveness of programmes
• Thornicroft et al(2015) Effectiveness ofThornicroft et al(2015) Effectiveness of
programmesprogrammes
• Stuart et al(2012) Paradigms LostStuart et al(2012) Paradigms Lost

40. Paradigms Lost..Paradigms Lost..
Stuart et al,2012Stuart et al,2012
• Paradigm 1: Developed Countries HaveParadigm 1: Developed Countries Have
Eradicated StigmaEradicated Stigma
• Paradigm 2: There Is Little Stigmatization inParadigm 2: There Is Little Stigmatization in
Developing CountriesDeveloping Countries
• Paradigm 3: Stigma Reduction Requires Well-Paradigm 3: Stigma Reduction Requires Well-
Developed PlansDeveloped Plans
• Paradigm 4: Science Is the Best Guide forParadigm 4: Science Is the Best Guide for
ProgrammesProgrammes
• Paradigm 5: Psychiatrists Should LeadParadigm 5: Psychiatrists Should Lead
Antistigma Programmes

41. Paradigms Lost..Paradigms Lost..Stuart et al,2012Stuart et al,2012
• Paradigm 6: Improved Knowledge About MentalParadigm 6: Improved Knowledge About Mental
Illness Will Eradicate StigmaIllness Will Eradicate Stigma
• Paradigm 7: Attitude Change Is the Yardstick ofParadigm 7: Attitude Change Is the Yardstick of
SuccessSuccess
• Paradigm 8: Community Care Is DestigmatizingParadigm 8: Community Care Is Destigmatizing
StigmaStigma
• Paradigm 9: Anti-Stigma Campaigns WorkParadigm 9: Anti-Stigma Campaigns Work
• Paradigm 10: Mental Illnesses Are Like AnyParadigm 10: Mental Illnesses Are Like Any
Other IllnessesOther Illnesses
• Paradigm 11: Stigma Can’t Be BeatenParadigm 11: Stigma Can’t Be Beaten

43. Strategies to FightStrategies to Fight
Stigma…..Stigma…..
• Deviancy model to NormalcyDeviancy model to Normalcy
modelmodel
• Example ofExample of HIV/AIDSHIV/AIDS
movement:movement:
– Expert to PeopleExpert to People
– Hopelessness to hopefulnessHopelessness to hopefulness
– Rights of the peopleRights of the people
– Consumer advocacyConsumer advocacy

44. Stigma of Mental Illnesses-Stigma of Mental Illnesses-
conclusiondsconclusionds
• Stigma has multifacetedStigma has multifaceted
origins and consequences;origins and consequences;
and hence interventions tooand hence interventions too
need to occur at theseneed to occur at these
multiple levels withmultiple levels with
concerted co‑ordinationconcerted co‑ordination..

45. Stigma of Mental IllnessesStigma of Mental Illnesses
conclusiondsconclusionds
•Programmes toProgrammes to
address stigma shouldaddress stigma should
be planned on a long-be planned on a long-
term perspectives ofterm perspectives of
at least 10 yearsat least 10 years

46. Stigma of Mental IllnessesStigma of Mental Illnesses
conclusiondsconclusionds
•Programmes shouldProgrammes should
be addressed tobe addressed to
local needs andlocal needs and
experiencesexperiences

47. Stigma of Mental IllnessesStigma of Mental Illnesses
conclusiondsconclusionds
•Contact programmesContact programmes
are important way ofare important way of
addressing the stigmaaddressing the stigma
in the communityin the community

48. Stigma of Mental IllnessesStigma of Mental Illnesses
conclusiondsconclusionds
•There is need to shiftThere is need to shift
the public dialoguethe public dialogue
from ‘deviancy’ tofrom ‘deviancy’ to
‘normalcy’‘normalcy’

49. Stigma of Mental IllnessesStigma of Mental Illnesses
conclusiondsconclusionds
• Making mental health skillsMaking mental health skills
as part of day to day life is aas part of day to day life is a
good way to move fromgood way to move from
deviancy to normalcydeviancy to normalcy
• Eg: Emotional first aidEg: Emotional first aid
approachapproach

52. Personal experiences………Personal experiences………
• Community mental health initiativesCommunity mental health initiatives
–Integration of mental health withIntegration of mental health with
general health caregeneral health care
–Disaster mental health careDisaster mental health care
–Families of the intellectuallyFamilies of the intellectually
disableddisabled

53. Personal experiences………Personal experiences………
• Cancer and Emotional HealthCancer and Emotional Health
–Referral modelReferral model
–Training of the medical careTraining of the medical care
providersproviders
–Self care of patients and caregiversSelf care of patients and caregivers

56. Personal experiences………Personal experiences………
• Dialogue with opinion makersDialogue with opinion makers
about including mental healthabout including mental health
skills in their personalskills in their personal
portfolio…………portfolio…………

57. LookingLooking
ahead………..ahead………..
• Firstly, in countries with no organized mentalFirstly, in countries with no organized mental
health care and limited resources for mentalhealth care and limited resources for mental
health care,health care, leading to ‘restraint/chaining’ of theleading to ‘restraint/chaining’ of the
persons diagnosed with mental disorders,( eg. Somalia,persons diagnosed with mental disorders,( eg. Somalia,
South Sudan, Congo) the immediate need for essentialSouth Sudan, Congo) the immediate need for essential
mental health care. The availability of care, recovery ofmental health care. The availability of care, recovery of
patients with care and reintegration of ill persons wouldpatients with care and reintegration of ill persons would
take away the fear and desire to criminalise the illtake away the fear and desire to criminalise the ill
persons and exclude them. The approach of integratingpersons and exclude them. The approach of integrating
mental health care with general health care, which hasmental health care with general health care, which has
been the recommendation of World Health Organizationbeen the recommendation of World Health Organization
since 1975, is the most feasiblesince 1975, is the most feasible

58. LookingLooking
ahead………..ahead………..
• Secondly,Secondly, to open theto open the
psychiatric institution to thepsychiatric institution to the
community,community, make the centresmake the centres
treatment centres and combinetreatment centres and combine
these efforts with communitythese efforts with community
mental health caremental health care

59. Looking ahead………..Looking ahead………..
• Thirdly,Thirdly, the need for early identification,the need for early identification,
regular treatment, reintegration, all essential forregular treatment, reintegration, all essential for
the community to destigmatise the ill persons isthe community to destigmatise the ill persons is
to organise care for the persons with mentalto organise care for the persons with mental
disorders , along with the other medicaldisorders , along with the other medical
conditions.conditions. This is ‘providing mental health careThis is ‘providing mental health care
as part of primary healthas part of primary health
care’(WHO,2001,2013). This method has beencare’(WHO,2001,2013). This method has been
shown to be feasible but unfortunately enoughshown to be feasible but unfortunately enough
resources have not been invested to ‘scale upresources have not been invested to ‘scale up
the services’ .the services’ .

60. Looking ahead………..Looking ahead………..
• Fourthly,Fourthly, for the communities and countriesfor the communities and countries
with well established health and mental healthwith well established health and mental health
care( economically rich countries) there is needcare( economically rich countries) there is need
for educational activities and personal contactfor educational activities and personal contact
with persons with a diagnosis of mentalwith persons with a diagnosis of mental
disordersdisorders. This has been undertaken in a. This has been undertaken in a
number of countries. The challenge for thesenumber of countries. The challenge for these
countries, is to make these programmecountries, is to make these programme
appropriate to the target group and the localappropriate to the target group and the local
context. The other important need is tocontext. The other important need is to
undertake evaluation of such programmes,undertake evaluation of such programmes,
especially over longer periods of time.especially over longer periods of time.

61. Looking ahead………..Looking ahead………..
• Fifthly,Fifthly, to move the dialogueto move the dialogue
from mental disorders to mentalfrom mental disorders to mental
health,health, in a way that people givein a way that people give
mental health a higher priority inmental health a higher priority in
their life and make mental healththeir life and make mental health
skills a part their health kit.skills a part their health kit.

62. EMOTIONAL FIRST AID………..EMOTIONAL FIRST AID………..
• ‘‘We teach our children how to take care of theirWe teach our children how to take care of their
bodies from a very young age and they usuallybodies from a very young age and they usually
learn such lessons well. But ask an adult what youlearn such lessons well. But ask an adult what you
should do to ease the sharp pain of rejection, theshould do to ease the sharp pain of rejection, the
devastating ache of loneliness, or the bitterdevastating ache of loneliness, or the bitter
disappointment of failure and the person woulddisappointment of failure and the person would
know little about how to treat these commonknow little about how to treat these common
psychological injuries. Ask what you should do topsychological injuries. Ask what you should do to
recover from self-esteem or loss and trauma andrecover from self-esteem or loss and trauma and
adults would be equally challenged. Ask how mightadults would be equally challenged. Ask how might
deal with intrusive ruminations or nagging guilt anddeal with intrusive ruminations or nagging guilt and
you are likely to be met with sheepish looks, feetyou are likely to be met with sheepish looks, feet
shuffling and a pointed effort to change the subject’shuffling and a pointed effort to change the subject’
(Guy Winch,2013)(Guy Winch,2013)

63. • The shift in this approach is to move mental health fromThe shift in this approach is to move mental health from
a ‘deviancy model’ to ‘normalcy mode’. When it isa ‘deviancy model’ to ‘normalcy mode’. When it is
presentedpresented not as neutral knowledge/ information,not as neutral knowledge/ information,
but skills that are relevant to the wellbeing ofbut skills that are relevant to the wellbeing of
the individualthe individual , the acceptance of mental health/mental, the acceptance of mental health/mental
disorders will be greater. The vulnerability of all humandisorders will be greater. The vulnerability of all human
beings to mental health issues and a wide range ofbeings to mental health issues and a wide range of
skills( sharing of feelings, listening, taking supports,skills( sharing of feelings, listening, taking supports,
relaxation, mindfulness, exercise, focus of restful sleep,relaxation, mindfulness, exercise, focus of restful sleep,
writing down disturbing feelings, developing mindwriting down disturbing feelings, developing mind
relaxing activities like listening to music, etc ) canrelaxing activities like listening to music, etc ) can
change the way mental health seen as part ofchange the way mental health seen as part of
everyone’s life.everyone’s life.

64. MENTAL HEALTHMENTAL HEALTH
SKILLS….SKILLS….
• The need to identify those mental healthThe need to identify those mental health
skills that matter to ordinary people, andskills that matter to ordinary people, and
to develop methods to help people toto develop methods to help people to
include in their personal lives and giveinclude in their personal lives and give
guidelines when they should seekguidelines when they should seek
professional help. Such an approach isprofessional help. Such an approach is
occurring in the nutrition area and inoccurring in the nutrition area and in
relation to exercise.relation to exercise.

71. What seemsWhat seems
impossible isimpossible is
not reallynot really
always soalways so
M.K. GandhiM.K. Gandhi