1. STIGMA IN MENTAL ILLNESS It is dangerous to be different Dr. Adenike Jesusanmi MB:BS, MRCPsych, MSc (University of Manchester)

2. What is stigma? Stigma can be traced back to early Greek society, where stizein was a mark placed on a slave indicating their place in society and their lower social value. This translates to a modern definition of ‘a mark of disgrace associated with a particular circumstance, quality or person’. To stigmatise is essentially to mark someone as different and treat them accordingly.

3. Effects of Stigma Stigma can lead to prejudice and discrimination. Prejudice is forming an opinion before becoming aware of and understanding the relevant facts. Discrimination is treating someone less positively or appropriately than other people because of that prejudice.

4. Public stigma Public stigma is a society-level stigma and includes the prejudicial attitudes and discriminatory behaviours that people hold towards those with mental health problems. This can include beliefs that people with mental illness can – never recover (leading to hopelessness), – that they are violent and dangerous (leading to fear), – that they are weak and could control their illness (leading to blame and anger) or – that they are like children (leading to a belief that they need decisions made for them). In turn, these beliefs lead to behaviours such as avoidance, coercion and colluding that people with mental health problems cannot live independently.

5. Self Stigma Self-stigma is when people with mental health problems believe what is being said about their illness or about them publicly and agree with this view. This affects self-esteem, can lead to a belief that there is no point in trying and may cause people to give up on life goals such as having a job, a long-term relationship or even seeking help for their condition.

6. Structural stigma Structural stigma occurs at an infrastructure level – in policy-making, laws and institutions. It creates environments where people with mental health problems are denied their human rights, are treated unfairly or where policies do not give high priority to mental health issues.

7. Questions for group reflection Public stigma- what negative beliefs about people with mental illness do you know? Do you know any positive beliefs? Reflect on the effects mental illness can have on marriage, parenting, job prospects, and basic human rights in the community. Do you know of any Government policy/ law that negatively affects people that have or have had mental illness?

8. Royal college of Psychiatrists Changing minds campaign (1997-2003) The campaign set out to combat stigma in mental illness A survey of attitudes towards mental illness was taken before and after the campaign. It chose to focus on six of the most common mental disorders

9. Changing minds campaign "People suffering from mental disorders often attract fear, hostility and disapproval, rather than compassion, support and understanding," says Professor Arthur Crisp, Chairman of the Changing Minds Campaign. "Such stigmatisation not only causes people with mental health problems to feel isolated and unhappy, but may also prevent them receiving help and treatment."

10. Prevalence of common mental disorders. Anxiety - affects more than 1 person in 10 Depression - affects 1 person in 4 Schizophrenia - affects 1 person in 100 Dementia - affects 1 person in 5 over 80 Alcohol and drug addiction - affects about 1 person in 3 Eating disorders - affects 1 person in 50

11. 1 in 4" reinforces the message that anyone can suffer from mental illness – "1 in 4 could be your brother, your sister. Could be your wife, your girlfriend... 1 in 4 could be your daughter... 1 in 4 could me... it could be YOU."

12. Research carried out among the general public at the start of the campaign in 1998 showed that stigmatising attitudes were common. In particular: Many people believed that those suffering from depression should "pull themselves together". People with schizophrenia and alcohol addiction were seen as dangerous.

13. Anyone with a mental health problem was considered "difficult to talk to". The results of this baseline survey were released at the launch of the Changing Minds Campaign, on 7th October 1998. The Changing Minds Campaign closed on 7th October 2003, we are aware however that tackling the stigma of mental illness is an enduring task.

14. Lord anti stigma Bill The Bill was voted for in the House of Lords Essentially it was the start of a process to legislate to put an end to archaic laws which interfere with the rights of people with mental health problems. E.g.-from participating in jury service and becoming or remaining a company director. It will also change a law that currently stipulates that MPs themselves will lose their seats if sectioned under the Mental Health Act, regardless of recovery.

15. Examples of combating stigma associated with mental illness in the U.K. Public Stigma- changing minds campaign. T.V. and other adverts by mental health charities. Education programmes on world mental health day. Programmes supporting people with mental health problems at work. Structural stigma- Disability discrimination act and Lord anti stigma Bill.

16. What can be done about stigma? Different strategies for tackling stigma are required for the different types of stigma. Public stigma Public stigma can be tackled through protest, education and contact. Each of these strategies has its part to play depending on the situation.

17. Protest Here an appeal is made to those holding stigmatising perceptions of mental health problems to stop, by using moral arguments. Specific protests can be very effective, such as the joint response of a number of organisations to an article printed in The Sunday Times ‘I’m sorry, he’s not a differently gifted worker – he’s a psycho’. This protest brought an apology from the author who had not intended that his article discriminate against people with mental health problems and withdrawal of the piece from the paper’s website.

18. Education Here the facts about mental health problems are contrasted with the myths. Effects on attitudes can be variable but education is ‘widely endorsed for influencing prejudice and discrimination’.

19. Education The See Me campaign (Scotland’s national campaign against mental health stigma) in partnership with others is using education to tackle discrimination experienced by bus users in one area who also have a mental health problem. This campaign also uses the third method for tackling stigma: contact.

20. Contact Evidence suggests that contact with people with mental health problems who allow stereotypes to be challenged is an effective way of reducing stigma. This can be formal through speaking at meetings or on education programmes or casual through disclosing mental health problems to others. The Canadian programme Opening Minds combined the contact approach with education and was able to show a reduction in stigmatising attitudes over time.

21. Contact Challenging public stigma is most effective when strategies are targeted at people who have frequent interactions with people with mental health problems including health and social care professionals.

22. Contact The See Me campaign has targeting stigma in health and social care as one of its priorities (along with targeting stigma in young people and employment). It is a challenging fact that health and social care agencies have the potential to discriminate against “25%” of the population, often without realising that this is what they are doing.

23. Self-stigma Promotion of recovery-focused approaches to treatment underpins the reduction of self- stigma Tackling self-stigma is about improving self- esteem and challenging the public stereotypes and can involve empowerment, advocacy and group identification

24. Structural stigma It can be seen that the different stigmas are interrelated and this is also the case for structural stigma. Structural stigma is influenced by public opinion and vice versa.

25. Structural stigma Moving towards equal treatment rights for those with mental health problems, achieving parity of esteem between mental and physical health in terms of policy, resource allocation and services is pivotal to tackling structural stigma. After all, there is no health without mental health.

26. Key points 1.‰People can and do recover from mental health problems. 2.‰Mental health stigma may impact negatively on all aspects of a person’s live including health, their place in society and wellbeing. 3.‰ Stigma occurs at a number of levels in any society. 4.‰There is good evidence that stigma can be tackled using a number of complementary strategies. 5.‰Reducing stigma improves health outcomes.‰ 6.People with mental illness have much to contribute to society in general: they can, for example, be a much-loved family member or friend, an employee, a parent, a student, and an educator. 7.With the right support and treatment people with mental 8.health problems can recover and live fulfilling lives.

27. Group reflection Do you believe that there is a stigma associated with mental illness in Nigeria? Is the stigma appropriate or justified? What can YOU do to combat the stigma? How can public stigma be combatted in Nigeria? How can structural stigma be combatted in Nigeria? What will you do different from today?

28. Thank you Any questions?