Challenging stigma and
discrimination
Essential level learning module
Published in September 2009 by Te Pou o Te Whakaaro Nui
The National Centre of Mental Health Research, Information and Workforce Development.
PO Box 108-244, Symonds Street, Auckland, New Zealand.
ISBN 978-1-877537-41-7
2
Web
www.tepou.co.nz/letsgetreal
Email
[email protected]
Challenging stigma and discrimination – Essential level
Learning module – print version
Contents
Introduction ................................................................................................................4
1
Understanding stigma and discrimination........................................................................7
2
The New Zealand context ........................................................................................ 14
3
Strategies to reduce stigma and discrimination............................................................... 18
References and recommended reading ............................................................................... 23
Learning Review Tool ................................................................................................... 26
Individual Professional Development Plan............................................................................ 28
3
Introduction
The Real Skill for challenging stigma and discrimination is:
Every person working in a mental health and addiction treatment service uses strategies to challenge
stigma and discrimination and provides and promotes a valued place for service users.
Performance indicators – essential
By the completion of this module you will be able to:
•
understand the impact of stigma and discrimination on service users, families and whānau, services
and communities
•
understand and acknowledge the impact of language in relation to stigma and discrimination, and
role model using language that is non-judgemental and non-discriminatory
•
recognise and challenge stigma and discrimination.
Preparation
To help you complete this module, please familiarise yourself with the key national strategy and policy
documents that are relevant to your specific area of work (older adult, adult, child and youth, alcohol and
other drugs). For your reference a list of recommended reading is included in this module. It is strongly
recommended that you familiarise yourself with these documents, as they relate to challenging stigma and
discrimination.
In particular, you should be familiar with the following national strategies, policies and other documents.
•
Ministry of Health. (2007). Like Minds, Like Mine National Plan 2007–2013: Programme to
counter stigma and discrimination associated with mental illness. Wellington: Ministry of
Health.
•
Mental Health Foundation. (2004). Respect Costs Nothing: A survey of discrimination faced by
people with experience of mental illness in Aotearoa New Zealand. Auckland: Mental Health
Foundation.
•
Mental Health Commission. (2001). Recovery Competencies for New Zealand Mental Health
Workers. Wellington: Mental Health Commission.
See in particular competency number six (pp. 53–58): “A competent mental health worker
understands discrimination and social exclusion, its impact on service users and how to reduce
it.”
4
•
Mental Health Commission. (1998). A Travel Guide for People on the Journeys Towards
Equality, Respect and Rights for People who Experience Mental Illness. Wellington: Mental
Health Commission.
•
Peterson, Barnes, & Duncan, (2008). Fighting Shadows: Self-stigma and mental illness:
Whawhai atu te whakama hihira. Auckland: Mental Health Foundation.
•
Ministry of Health. (2005). Te Tāhuhu: Improving mental health 2005–2015: The second mental
health and addiction plan. Wellington: Ministry of Health.
Challenging stigma and discrimination – Essential level
Learning module – print version
•
Ministry of Health. (2006). Te Kōkiri: The mental health and addiction action plan 2006–2015.
Wellington: Ministry of Health.
There are several main themes included in this module:
•
developing a personal understanding of the impact of stigma and discrimination
•
recognising personal behaviours that can contribute to the experience of stigma and
discrimination
•
acknowledging the role that mental health and addiction services, and the people who work in
them, have in combating stigma and discrimination and developing strategies to achieve this.
To gain the maximum benefit from this module you are encouraged to think about how the learning
module applies to you and your work context. When you have finished working through this module use
the Learning Review Tool to help you reflect on how you challenge stigma and discrimination. This will
enable you to identify where your strengths are, along with any areas you may need to further explore in
your Individual Professional Development Plan.
Overview
The experience of stigma and discrimination is one of the biggest barriers that people face to recovery.
Stigma and discrimination stops people from:
•
feeling a part of their community
•
feeling good about themselves and believing in their personal power to recover
•
seeking treatment
•
maintaining wellness
•
participating in work, education and social activities
•
having support and tautoko from loved ones
•
participating in and contributing to their local communities.
Stigma and discrimination are common experiences for people with mental health and addiction
experiences. In a survey conducted in New Zealand in 2004 by the Mental Health Foundation over 84 per
cent of people with lived experiences of mental illness reported they had experienced discrimination. As a
result, people working in mental health and addiction services have significant responsibilities to ensure
two things. Firstly, that they do not contribute to the experiences of discrimination, and secondly that
they continually practice strategies to challenge stigma and counter the effects and impacts of
discrimination. Research has found that the experience of stigma and discrimination occurs not only with
the public or broader society, but also come from families and whānau, loved ones and people working in
services (Mental Health Foundation, 2004; Peterson et al, 2008).
Stigma exists when people are recognised as different, and then labelled and identified as such.
Invariably this process is linked to dominant beliefs about what constitutes common norms and behaviours.
Once populations have been identified as being “other” or “different”, they are often collectively and
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individually subjected to labelling, negative stereotyping, prejudices, isolation, ridicule, loss of status,
loss of dignity and, in some instances, loss of basic human rights (Peterson, et al, 2008). Discrimination is
a term that is often used to describe these acts, which can be conducted by people or institutions and
society.
People working in mental health and addiction services need to be able to effectively:
6
•
understand the negative impact of stigma on each individual (as this will differ), and work
with that person and their family or whānau to reduce this impact
•
identify institutional practices within their own organisations that may be discriminatory, and
address and correct these
•
identify and correct any thoughts, beliefs or behaviours that they have that may contribute to
stigma and discrimination
•
challenge stigmatising attitudes and behaviours when they are encountered.
Challenging stigma and discrimination – Essential level
Learning module – print version
1 Understanding stigma and discrimination
1.1 Please describe what you understand stigma to mean.
1.2 Please describe what you understand discrimination to mean.
The Ministry of Health’s Like Minds, Like Mine campaign uses material from the Mental Health
Commission’s A Travel Guide for People on the Journeys Towards Equality, Respect and Rights for People
who Experience Mental Illness (1998) to explain the concepts of stigma and discrimination which are
summarised below.
Stigma is a mark of shame, disgrace or disapproval. The word stigma comes from an old Greek word,
meaning to brand or tattoo. Stigma is something attached to a person, which can affect them in many
negative ways. People with mental health or addiction experiences often experience stigma as the result
of discriminatory behaviour and the attitudes of others. This is often experienced as branding, and
contributes to negative feelings such as shame, unworthiness, rejection and loneliness. Some people who
experience mental illness or addiction issues do not seek help for fear of it being a mark of social disgrace
or attracting stigmatisation.
Discrimination is the systematic, unfair treatment of people, because they are different. People with
mental illness or addiction issues may be the subject of ridicule, harassment and abuse. Or they may
simply be forgotten, ignored or denied access to the opportunities that most people take for granted.
They may also have to contend on a daily basis with negative stereotyped images of themselves in the
media, literature or conversation. Discrimination can occur from individuals or from the policies and
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practices of services or organisations. Essentially, discrimination is behaviour that says to people with
mental illness or addiction issues that, “we don’t want you here”, “you’re not as good as us”, “you’re not
one of us” and “you are not important and you don’t belong”.
1.3 Please indicate on the scale below if you think stigma and discrimination of people with experience of
mental illness, is a significant issue?
1
No issue
2
3
A minor issue
A moderate issue
4
A major issue
1.4 Explain why you answered question 1.3 the way that you did.
1.5 Stigma and discrimination happens to many people for many different reasons, such as their gender,
ethnicity, sexuality, disability, etc. The impact of stigma or discrimination can have a negative impact
anyone, and for the service user’s recovery this is often very detrimental. If you have been stigmatised or
discriminated against for some reason, indicate below how it made you feel at the time. If you have not
been discriminated against, think about someone that you know in a personal or work capacity who has
been, and indicate their feelings as a result of those experiences.
What happened?
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Your or their feelings
Challenging stigma and discrimination – Essential level
Learning module – print version
It will be clear that the feelings and emotional impact of stigma and discrimination are characterised by
negative, unconstructive and ultimately harmful emotions. The following quote from a service user taken
from Peterson et al (2008, p.34) reflects this “after being told what you have, you begin to feel shame,
fear, confusion... You have a sense of loss... You start to isolate yourself from others and eventually from
society”.
1.6 Stigma and discrimination occurs in many contexts and in many different ways. Sometimes it is
expressed overtly in the form of personal verbal abuse and other times through the denial of access to
community resources or activities, to decision making about ones own life or to usual cultural practices.
Thinking about service users you work with, describe below the different ways in which they have
experienced stigma and discrimination.
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1.7 Describe the impact these stigmatising and discriminating attitudes and behaviours have had on these
service users.
1.8 When you meet a person for the first time and they ask you what you do for a living, what is your
response?
1.9 Do you make it clear to them that you work in mental health or addiction services?
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Challenging stigma and discrimination – Essential level
Learning module – print version
1.10 If you answered no to question 1.9, why not?
What will be required for you to start doing so?
1.11 If you answered yes to question 1.9, what (if any) are some of the discriminatory comments that are
made to you when you say you work in mental health or addiction services?
What positive responses can you give to these comments?
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1.12 The way that people talk about people with mental illness helps us to understand how they view
service users. Consider the words and labels below, and then add any others that you have heard and
explain what is actually meant. The first one has been done for you.
Word and label
What is actually meant
Raving mad
What the person is saying doesn’t make sense and therefore can be ignored.
Psycho
Lunatic
Junkie
Crack-head
Alky
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Challenging stigma and discrimination – Essential level
Learning module – print version
The above words and labels are discriminatory and are based around a number of assumptions which
suggest a belief and a response to it. Carling (1995) provides the following summary of some of these
commonly held assumptions and the associated beliefs about people with experience of mental illness or
addiction.
Assumption
Belief and response
Evil or bad
Punish
Weak and vulnerable
Protect, institutionalise
Sick
Treat, medicate, hospitalise
Dangerous and unpredictable
Confine, control, supervise and monitor
Incompetent
Assume responsibility
1.13 For the following assumptions about people with mental health and addiction experiences, indicate
what you consider the belief and response to be. Then add some of your own assumptions and their
correlated beliefs and solutions.
Assumption
Belief and response
Able to recover
A person with strengths
Unique
Connected to family or whānau
Able to contribute to community and society
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2 The New Zealand context
New Zealand has had a publicly funded anti-stigma and discrimination campaign since 1997. Known as
Like Minds, Like Mine, the campaign was a result of a Ministry of Health report, commonly referred to as
the Mason Report (Ministry of Health, 1996), in which Judge Ken Mason recommended the government
should fund a public education campaign to reduce discrimination associated with mental illness. The
Mason Report said (Ministry of Health, 1996, p.164):
“...we support a public awareness campaign – it is a must. It is fundamentally wrong that a vulnerable
group in our society should be continually subjected to the comments and actions of those who possess an
outcast mentality… we are optimistic enough to believe that a well informed New Zealand public will
then realise that [people with mental illness] are people whom we should nurture and value”.
The Like Minds, Like Mine campaign has delivered a comprehensive de-stigmatisation programme over the
past ten years. Some of the most well known activities are the television commercials, which have now
been running for some time.
2.1 See if you can complete the following slogans and sayings from the Like Minds, Like Mine television
campaigns? For each one, indicate what you think the key message is.
Slogan
Key message
K_ _ _ _ _ b_ _ _ _ _ _ _ _ j_ _ _ _ me.
W_ _ _ y_ _ _ _ m_ _ _ _ a
d_ _ _ _ _ _ _ _ _.
D _ _ _ _ _ _ _ _ _ _ _ _ _ is the
b _ _ _ _ _ _ b_ _ _ _ _ _ to
R_ _ _ _ _ _ _.
Are y _ _ prepared _ _ j _ _ _ _?
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Challenging stigma and discrimination – Essential level
Learning module – print version
Respect Costs Nothing (Mental Health Foundation, 2004) presents the findings of the first survey in New
Zealand that asked service users about their experience of discrimination due to their mental illness. In
total, 785 people took part and of these, only 16 per cent reported no experiences of discrimination.
Some of the main findings were as follows.
•
People report discrimination in all aspects of their lives, from employment and housing to
discrimination from friends, family and community. This discrimination results in people
feeling excluded from many activities of daily living (p.7).
•
Discrimination, even when it occurred several years ago, makes a lasting impression and still
impacts on people’s lives today (p.7).
•
59 per cent of the respondents said that they had been discriminated against by family and
friends, and this was the most often reported form of discrimination (p.73).
•
The fear of discrimination (often based on past experience) is as crippling as discrimination
itself (p.7).
•
46 per cent of respondents said that they had not done something (for example, applied for
work, undertaken education and training, formed relationships, accessed mental health
services, got involved in sports and recreation, or had children) due to this fear of
discrimination (pp.85–89).
2.2 Choose three of the areas of discrimination highlighted in Respect Costs Nothing and outline what
implications they have for the work that you do in mental health and addiction services.
Example
I need to consider that the service users I work with may feel concerned or anxious about engaging in a community
activity because of discrimination they believe they may face. This requires that we address it openly together and
develop suitable strategies to help them address their concerns and enable them to engage in the community-based
activity.
First area
Second area
Third area
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2.3 The following quote is taken from Respect Costs Nothing (Mental Health Foundation, 2004, p.104):
“Every time a person with experience of mental illness is limited from playing the best part they can in
society, our society is poorer for it…In each of these cases [of discrimination covered in report], New
Zealand lost”.
In what ways are service users, families and whānau, services and communities disadvantaged as a result
of discrimination?
Service users in New Zealand are disadvantaged in the following ways.
Their families and whānau are disadvantaged in the following ways.
Services and the mental health and addiction sector in New Zealand are disadvantaged in the following
ways.
Our communities are disadvantaged in the following ways.
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Challenging stigma and discrimination – Essential level
Learning module – print version
2.4 In what ways are you, as someone who works within a mental health and addiction service,
disadvantaged?
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3 Strategies to reduce stigma and
discrimination
Throughout this module you have been developing strategies to reduce stigma and discrimination.
Awareness of stigmatising and discriminating attitudes and behaviours is an important first step in being
able to reduce it. In particular, being aware of your own potential to discriminate is important, as various
research indicates that many service users experience stigma and discrimination from mental health and
addiction services (Mental Health Foundation, 2004). Discrimination from services was experienced in the
forms of disrespect, physical abuse, not being taken seriously, being talked about rather than talked to,
being degraded and ill treated, being put down, ridiculed or discouraged, and being treated as
incompetent (Mental Health Foundation, 2004).
3.1 The Māori slogan for the Like Minds, Like Mine campaign “whakaitia te whakawhiu i te tangata” can be
translated as “reduce your potential to discriminate”. What one thing can you do in your work practice
that will reduce your potential to discriminate? Indicate what you will do, how you will do it, how
frequently and when you will start.
What you will do
How you will do it
Frequency
When you will start
Research suggests there are three overarching strategies to reduce stigma and discrimination (Case
Consulting, 2005). They are:
•
education
•
contact
•
protest.
Education is defined as replacing myths about mental illness with correct information; contact as
challenging discriminatory attitudes and behaviour through direct interactions with people with
experience of mental illness; and protest as actions that suppress discriminatory attitudes and behaviours
towards people with mental illness. Everyone involved in mental health and addiction service delivery is
able to use these three strategies.
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Challenging stigma and discrimination – Essential level
Learning module – print version
3.2 Using the above strategies, consider the following scenarios and indicate how you would challenge the
stigmatising attitude or discriminatory behaviour that is present. Think about the purpose and goal of your
intervention. Consider how you would intervene in a way that maintains the dignity of the person you are
working with and that helps them to challenge discrimination too.
Leilani’s story
Leilani is a Samoan woman who is married and has two young children. She was a volunteer, helping children with
their homework three afternoons a week in a local after-school programme. After the birth of her second child she
became suicidal and withdrawn. When this was disclosed to the after-school programme they suggested to Leilani that
she no longer volunteers until she “comes right again and stops being so risky”.
Your response
Heremia’s story
Heremia is a 19 year old Māori man and is currently doing a building apprenticeship. He was well liked by his peers
and was generally viewed as a friendly workmate and hard worker. That was until his workmates started to find his
behaviour very bizarre, and started to tease and exclude him. His employer grew concerned about his suspected binge
drinking and drug use and its affects on his work. He was asked to take leave of absence from work until he had
“pulled himself together and got off the drugs”.
Your response
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Norman’s story
Norman is a 78 year old Pakeha man who has been active for much of his life. He had held a number of prominent
roles on boards of community groups and welfare societies, but in recent times had become increasingly withdrawn
and failed to attend a number of different meetings. While at meetings he would not participate or interact with
others in the group, and he was subsequently asked to stand down from many of these voluntary positions. Norman
previously found membership of these groups important to his sense of purpose and contribution, and he has become
distressed at the frequent requests to relinquish his roles due to his “blues”.
Your response
3.3 Organisations working within the mental health and addiction sector have increased their focus on
ensuring that people with mental health and addiction experiences are not discriminated against. In the
box below, indicate the key principles that inform your organisation’s policies of de-stigmatisation or antidiscrimination. If your organisation does not have a policy, indicate your suggested principles, which could
begin to inform the development of one.
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Challenging stigma and discrimination – Essential level
Learning module – print version
The American Psychological Association (1993) has drawn up guidelines for the use of language in reducing
stigma. These need to be applied both within mental health and addiction services, and in everyday
interactions with service users, their family and whānau, and other members of the community. The
guidelines are:
•
refer to people as people first and add specific characteristics only as required – for example a
person with addiction, not an addict, or a person with dementia, not demented
•
avoid referring to people as their illness
•
avoid extending the nature of the person’s illness with terms such as chronic, persistent or
severely
•
avoid emotionally negative terms such as victim or suffering from
•
emphasise abilities not limitations
•
avoid offensive expressions such as psycho or crazy
•
avoid metaphoric references to illnesses, such as schizophrenic situation
•
refer to people as contributing community members, rather than as a burden or a problem.
3.4 Choose three of these guidelines that you think you could improve your practice in and indicate in the
boxes below the steps you will take in order to do so.
Improvement
Steps to take
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3.5 Reducing stigma and discrimination may at times require challenging peers and colleagues when their
language, attitudes or behaviour is inappropriate. Thinking about a situation where you have observed
stigmatising attitudes or behaviours from a colleague and respond to the following questions.
How did you respond?
In what ways could your response better reduce stigma and discrimination?
What discussions could you have within your team to collectively address stigma and discrimination within
your workplace?
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Challenging stigma and discrimination – Essential level
Learning module – print version
References and recommended reading
American Psychological Association. (1993). Guidelines for Non-handicapping Language. Washington DC:
American Psychological Association.
Case Consulting. (2005). The Power of Contact. Wellington: Case Consulting Ltd.
Carling, P. J. (1995). Return to Community: Building support systems for people with psychiatric
disabilities. New York: The Guilford Press.
Corrigan, P., & Calabrese, J. (2005). Strategies for assessing and diminishing self-stigma. In P. Corrigan
(Ed.), On the Stigma of Mental Illness: Practical strategies for research and social change (p.p.239–256).
Washington: American Psychological Association.
Corrigan, P., & Kleinlein, P. (2005). The impact of mental illness stigma. In P. Corrigan (Ed.), On the
Stigma of Mental Illness: Practical strategies for research and social change (p.p.11–14). Washington,
American Psychological Association.
Gendall, P. (2006). New Zealanders’ Attitudes to Mental Illness: Stigma in global context mental health
study. Palmerston North: Department of Marketing, Massey University.
Mental Health Commission. (1998). A Travel Guide for People on the Journeys Towards Equality, Respect
and Rights for People who Experience Mental Illness. Wellington: Mental Health Commission.
Mental Health Commission. (2001). Recovery Competencies for New Zealand Mental Health Workers.
Wellington: Mental Health Commission.
Mental Health Foundation. (2004). Respect Costs Nothing: A survey of discrimination faced by people with
experience of mental illness in Aotearoa New Zealand. Auckland: Mental Health Foundation.
Ministry of Health. (1996). Inquiry under Section 47 of the Health and Disability Services Act 1993 in
Respect of Certain Mental Health Services [The Mason Report]. Wellington: Ministry of Health.
Ministry of Health. (2005). Te Tāhuhu: Improving mental health 2005–2015: The second mental health and
addiction plan. Wellington: Ministry of Health.
Ministry of Health. (2006). Te Kōkiri: The mental health and addiction action plan 2006–2015. Wellington:
Ministry of Health.
23
Ministry of Health. (2007). Like Minds, Like Mine National Plan 2007–2013: Programme to counter stigma
and discrimination associated with mental illness. Wellington: Ministry of Health.
Perkins, R., & Repper, J. (1998). Dilemmas in Community Mental Health Practice: Choice or control.
Oxford: Radcliffe Medical Press Ltd.
Peterson, D., Barnes, A., & Duncan, C. (2008). Fighting Shadows: Self stigma and mental illness: Whawhai
atu te whakama te hihira. Auckland: Mental Health Foundation.
Repper, J., & Perkins, R. (2003). Social Inclusion and Recovery: A model for mental health practice.
Edinburgh: Bailliere Tindal.
Sayce, L. (2000). From Psychiatric Patient to Citizen: Overcoming discrimination and social exclusion.
London: Macmillan.
Social Exclusion Unit. (2004). Mental Health and Social Exclusion. London: Office of the Deputy Prime
Minister.
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Learning module – print version
Challenging stigma and
discrimination –
essential level
Learning Review Tool and
Individual Professional Development Plan
Learning Review Tool
Using the Likert scales below, rate your work in relation to challenging stigma and discrimination.
I understand the meanings of stigma and discrimination
1
2
3
4
Not so much
5
Absolutely I have an understanding of the impacts of stigma and discrimination on service users and their families and
whānau.
1
2
3
4
Very little
understanding
5
Absolutely I can articulate confidently the strategies I bring to my work that reduce stigma and discrimination.
1
2
3
4
Not so confident
5
Absolutely I understand the things I can do to reduce the incidence and experience of stigma and discrimination for
the people that I work with.
1
2
3
4
Not so clearly
Choose your response to one of the above statements, and explain why you made this response.
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Challenging stigma and discrimination – Essential level
Learning module – print version
5
Absolutely What new knowledge or insights have I gained from working through this module?
What are three things that I can put into practice or improve upon as a result?
A
B
C
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Individual Professional Development Plan
Challenging stigma and discrimination (essential level)
One thing I can take personal responsibility for.
Action
Timeframe
Resources
Challenges
What will I do?
When will I do this?
What or who will I need?
What barriers or resistance
will I face?
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Challenging stigma and discrimination – Essential level
Learning module – print version
One thing I can advocate for and work towards.
Action
Timeframe
Resources
Challenges
What will I do?
When will I do this?
What or who will I need?
What barriers or resistance
will I face?
Please retain this Individual Professional Development Plan: challenging stigma and discrimination
(essential level) to contribute to your summary action plan once you have completed all of the
learning modules.
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