parity of professional and public respect: tackling stigma and discrimination claire henderson...
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Parity of Professional and Public respect: Tackling stigma and discrimination
Claire Henderson
Health Service and Population Research Department, King’s College London Institute of Psychiatry, Psychology and
Neuroscience
Acknowledgements• Graham Thornicroft, Paul McCrone, Diana Rose, Morven
Leese, Sara Evans-Lacko, Elizabeth Corker, Elly Lewis-Holmes, Kirsty Little, Jillian London, Danielle Rhydderch, Clare Flach, Guy Shefer, Robert Goulden, Steve Wright, Mirella Genziani, Ann Law, Ruth Stuart, King’s College London Institute of Psychiatry, Psychology and Neuroscience
• TTC Central Management Team, LEAP, Mind, Rethink Mental Illness
• Big Lottery, Comic Relief, Department of Health• Jo Noblett, Hannah Parke, Sarah Clement, Alison Caffrey,
Oliver Gale Grant, Beate Schulze, Benjamin Druss• Dr Christine Rivers, Head of Equality and Human Rights,
Oxleas NHS Foundation Trust
Content
• Stigma in healthcare- experiences of using and working in the NHS
• How do we change it?
Manifestations of stigma: a four level model
Structural discrimination e.g. legislation and policy
Institutional stigma and discrimination/ organisational culture
Interpersonal stigma: knowledge, attitudes, behaviour
Target: Self stigma
Structural discrimination
• Lack of parity between physical and mental health care
• Lack of emphasis on mental health in professionals’ curricula
• Human rights violations• Reduced life expectancy
Organisational culture
‘the ward manager said “Oh you’ve come to see the nutter.”’
A Consultant Liaison Psychiatrist
‘The general problem that we have in the ED here, which we didn't have with or I have not had with other EDs, is as soon as they [the patients] present with mental health, they[the ED staff] are not interested.’
A psychiatric nurse
Interpersonal stigma (1) Knowledge problems
Mental health professionals• specific diagnoses i.e. substance misuse
disorders and EUPD & self harm
Health professionals• More knowledge about most mental health
problems would be useful
(2) Attitude problems
Mental health professionals compared to the general public:• Often more pessimistic re prognosis and experience of
stigma• Similar desire for social distance but ‘should’ and ‘would’
intentions are closer than those of other health professionals
• More supportive of civil rights and community care• More supportive of coercionHealth professionals• more like general public• Responsive to contact based education- Knaak et al
Discrimination Top 10: life areas 2008 and 2014- Viewpoint Survey
2008 2014
1 Being shunned (57.9%) 1 Being shunned (47.2%) (-10.7%) Signif
2= Friends (53.3%) 2 Family (43.3%) (-9.8%) Signif
2= Family (53.1%) 3 Friends (39.7%) (-13.6%) Signif
4 Social life (43.2%) 4 Mental health staff (31.6%) (-2.7%)
5 Mental health staff (34.3%) 5 Social life (29.6%) (-13.6%) Signif
6 Dating (30.9%) 6 Physical health staff (28.0%) (-1.6%)
7 Physical health staff (29.6%) 7 Benefits (23.4%) (+4.4%)
8 Neighbours (25.1%) 8 Neighbours (20.0%) (-5.1%) Signif
9 Finding a job (24.2%) 9 Safety (18.2%) (-1.4%)
10 Privacy (21.6%) 10 Keeping a job (15.6%) (-1.3%)
Discrimination: mental health care• Privacy: correspondence • Diagnostic overshadowing• Verbal abuse• Lack of involvement, respect, ignoring early
relapse• Focus on symptoms vs the person, medication,
and risk• Therapeutic pessimism• Coercion• Involuntary disclosure due to medication side
effects
Discrimination: physical health care• Privacy: correspondence • Diagnostic overshadowing• Verbal abuse• Unnecessary/unhelpful use of security• Avoidance and consequent neglect• Isolation on ward• Inadequate pain relief• Not giving prescribed psychotropic medication• Transplant selection decisions• Poor history taking for liaison psychiatry referral
Health Professionals’ stigma: Why? (1)
Pre professional socialisation – stigma by age 7-8Pre-specialty socialisation- medical school• Lack of parity not challenged• ‘Treatments don’t work, patients don’t get
better’• Not proper medicine
Health professionals’ stigma: Why? (2)Intra-specialty processes:Clinical biasBurnout → blame of service users and routine role enactmentStress can shift what drives behaviour from professional values to stereotypesLack of reflection / advocacy assumptionLived experience is not automatically enough: discounting versus attitude change towards the group
What can we do about it? (1) Improve knowledge and skills to care for specific service user groups
• mental physical interface • EUPD, self harm• Substance misuse
What can we do about it? (2) Maintain professional values/ don’t allow negative attitudes to flourish
• Reflection on automatic thoughts- stereotypes can’t be unlearned but personal beliefs can override
• Prevent/reduce stress and burnout• Repeated positive contact to counteract
clinical bias
What can we do about it? (3) Discrimination perceived, experienced and anticipated by
service users: Mental health services• Minimise practices experienced as discriminatory-
apply personal recovery model• Identify, acknowledge and respond to
discrimination: perceived/anticipated/experienced• Family intervention• Safeguarding• Equality Act • Human Rights Act FREDA principles : fairness,
respect, equality, dignity, autonomy
What can we do about it? (3) Discrimination perceived, experienced and anticipated by
service users: Health services• Stop practice based on negative assumptions
(not credible/violent/worth treating/won’t follow treatment etc.)
• Apply Equality Act – accommodations needed for parity of care
• Human Rights Act FREDA principles : fairness, respect, equality, dignity, autonomy
What can we do about it? (4) Reducing the impact of stigma on oneself
• Seek help and be responsible about professionalism• Try to avoid self stigmatisation- this
is common, you are not a failure, this may help you become a better professional
What can we do about it? (5) Colleagues
Foster a culture where staff with lived experience can be open about their experiences • state visible commitment to end mental health stigma• positively value lived experience as an asset• actively recruit people with lived experience • encourage help seeking• make arrangements where staff need medical
treatment whilst working for the same trustAvoid assumptions – about capability, relapse vs work related unhappiness, reason for being off sick, etc.
Stigma in healthcare, and how do we change it?
• Apply the evidence base from:anti stigma interventions- contact based
educationprofessional education- training by
professional peers
• Organisational culture change to value professionals’ own lived experience
While we wait for organisational change:
Vaclav Havel…realised that "resistance" in its original insurgent and militant sense was impossible in the central Europe of the day. He therefore proposed living "as if" he were a citizen of a free society, "as if" lying and cowardice were not mandatory patriotic duties, "as if" his government had signed (which it actually had) the various treaties and agreements that enshrine universal human rights. He called this tactic the "power of the powerless" because, even when disagreement is almost forbidden, a state that insists on actually compelling assent can be relatively easily made to look stupid.
At around the same time…Professor EP Thompson proposed that we live "as if" a free and independent Europe already existed.
Christopher Hitchens, Letters to a young contrarian, 2001
The exercise of power is determined by thousands of interactions between the world of the powerful and that of the powerless, all
the more so because these worlds are never divided by a sharp line: everyone has a small part of himself in both.
