Stigma and Discrimination in

Healthcare Settings:

Key issues and priorities for action

Improving Physical Health Outcomes of those with Severe and Enduring Mental

Health Problems

 

Wednesday 4th

March 2015

Workshop Aims• To explore stigma and

discrimination as reported by people with lived experience when accessing healthcare settings

• To provide an overview of what we already know in this context

• To discuss potential solutions and actions

See Me 2013-16 Scotland Mental Health Anti-Stigma and

Discrimination Programme

People who experience mental

health problems are more able

to participate in society and live

more fulfilled lives

People who experience mental health

problems will not limit their own lives

and help-seeking behaviour as a

result of self-stigma

Recovery from mental health

problems will be more widely

understood and more people will

believe recovery is possible

Stigma and discrimination will be

reduced in communities and

organisations with a positive impact

on people’s lives

See Me 2013-16 – social movement for change focus for action

National Programme

Media volunteers

Re-focussed social marketing

Media strategy

SMHAFF

Communities Programme

Lived experience participation & leadership

Community champions

Local & thematic change networks

Grants programme site testing

Themes

Human Rights

Health & Social Care

Work & employment

Young people

Health and social care –

Research tells us there is a problem

• It is a significant issue identified by service users.

• There is no consistent difference in attitudes or behaviour described in general health versus mental health settings, although there are some differences in the nature and patterns of stigma

Stigma is prevalent in health settings

Source: Quinn & Gray, 2009

Stigma is prevalent in health settings (cont.)

• Positive and negative attitudes can co-exist in the same individual

• Even where staff express negative attitudes, there is often a willingness or desire for training and education

Source: Quinn & Gray, 2009

Health inequalities and diagnostic overshadowing are present in the NHS• On average, people with mental illness die 5-10

years younger than the general population• People with bipolar disorder have higher levels of

physical morbidity and mortality than the general population

• People with schizophrenia are 3-4 times more likely than general population to develop bowel cancer and have a 52% increased risk of developing breast cancer.

• The risk of depressed patients with coronary heart disease dying in the 2 years after initial assessment is twice as high as it is for non-depressed patients.

(Source: No Health Without Mental Health, Royal College of Psychiatrists

and Academy of Medical Royal Colleges, 2009)

Diagnostic overshadowingHighlighted as a significant problem in A&E in recent qualitative study (16 yes, 5 unsure, 4 no)

“She was discharged and then returned in less than 24 hours… she actually didn’t survive ….the decision was that her behaviour seemed compatible with the pre-existing mental health problem and therefore there was no need to investigate” (Senior A&E Dr)

“I think its sometimes a bit of a shame because …. you automatically put them in a box, Ok, the mental illness, um, without sort of like focussing on the physical pain and what they’re actually going in” (A&E nurse)

Source: van Nieuwenhuizen et al, 2013

Diagnostic overshadowing in A&E – why?Problems obtaining a historyProblems with examination due to agitationEnvironment not appropriate and distressing to patientsClinicians lack of knowledge about mental illnessLabelling and stigma (distracted by diagnosis, frequent attenders, drug and alcohol use)Fear of violence, avoidanceTime pressureLack of parallel working with psychiatry “in one case the involvement of a psychiatrist led to the discovery of a physical illness” Source: van Nieuwenhuizen et al, 2013

% people identifying as having a mental health problem who experienced a positive response about their recovery from health professionals

66%

2006

65%

2013

73%

2008

(Scottish Social Attitudes Survey, 2014)

“The lowest income group were less likely than those in higher income groups to

have received a positive message from professionals about their

recovery”

“No significant reduction in reported discrimination from mental health professionals was found”

34.3% of MH service users surveyed reported discrimination by health care workers in 2008

30.4% of MH service users surveyed reported(not statistically significant) reported discrimination by health care workers in 2011

Time to Change Evaluation

Source: Corker et al, 2013

Mental healthcare professionals’ behaviour might be more resistant to change because:• professional contact selects for people with

the most severe course and outcome (the ‘physician’s bias’);

• contact occurs in the context of an unequal power relationship;

• prejudice against the client group is one aspect of burnout, which is not uncommon among mental health professionals

Why?

Implications?

“The danger of this trend is that people with mental health problems might be deterred from seeking professional help”

“It would be a terrible irony if people were encouraged by T2C to ask for help – only to find that those providing it held prejudicial views”

Dr Claire Henderson, IOP

What can we do?

“We need to find out why we are not seeing such a level of change among health staff. We want to bring people together to discuss that”

Sue Baker, Director, Time to Change

Research suggests that we can do

something about it…

…and also helps us conceptualise what

might make a difference

Mixed methods• The strongest evidence for anti-stigma

interventions in health care settings is for workshops, which have an education and positive contact element

• It is likely that some combination of contact with service users, professional education, “social marketing” to influence attitudes and reform of structural barriers to non-discriminatory practice would be effective

Source: Quinn & Gray, 2009

Social contactBased on evidence informed assumptions that:• where people know someone with

mental health problems they will be less stigmatising

• social contact disconfirms negative attitudes

• needs to be credible • positive and continuous

….so why doesn’t it happen in the mental health service users and professional relationship?

Social contact • Stigma is a deeply embedded

emotional reaction (education not so useful)

• The nature of contact in health and social care settings may be negative, acute and complex

• There is a real power imbalance in the relationship (reinforced by a traditionally disempowering system)

Formalised peer support (hits all the buttons)

Formalised peer support

Challenges and level

the power imbalance

Challenges self-stigma

Enhances

recovery

Challenges direct stigmaChallenges

structural stigma

Changes attitudes

and behaviour

Sustained and

authentic contact

Source: Scottish Government, Evaluation of the

Delivery for Mental Health Peer Support Pilot, 2009

Who is actively challenging stigma?

72% female and 27% male91% white British or Scottish

89% between 26 and 6580% employed (8% retired) (50% public,

13% private, 16% voluntary)

68% have had a mental health problem at some point in their life

88% of these had accessed help from services

(Source: See Me social movement survey, unpublished 2014)

What is their experience of stigma and discrimination?

33% have experienced discrimination as a result of their mh problems

86% have someone close to them who has experienced mh problems

83% have witnessed discrimination towards other people with mh problems

79% have made efforts to improve their own attitudes and/or behaviour

(Source: See Me social movement survey, unpublished 2014)

What motivates them?

• Indignant and appalled at behaviour of healthcare staff, those in workplace and those in authority

• To prevent others experiencing what they have

• People they know have died or suffered because they couldn’t talk about mental health

For discussion…….

Do we know enough about stigma and discrimination in health and social care settings in Scotland to act?

Whose responsibility is it to make change happen?

What are you doing already?

What more could be done?