1. Have you ever
stigmatised or
discriminated
against somebody?
Have you ever been
discriminated
against?

2. What were your
responses to those
questions?
Keep those in mind
while you think
about the following…

3. How do you think
stigma affects those
with mental health
problems?
*
Have you ever seen
doctors or other
medical students
behave or talk in a
stigmatising way?
*
What effect do you
think this might have
on patients?
What do you know about
stigma?
*
Have you ever seen
stigma? What happened?
*
Do you think it is
important to have an
understanding of stigma
as a medical student?
*
Why is mental illness so
stigmatised?

4. Now keep those
questions in mind
while you read this
presentation, and see
if some of your
responses change by
the end.
REMEMBER
Learning medicine
isn’t just about
passing OSCEs…

5. What
is
stigma?
Stigma is defined as a sign
of shame; of being rejected,
shunned or disapproved of
by others.
Stigmatisation in relation
to mental health can take
many forms. These include
name calling, distancing
oneself from somebody who
develops mental illness, or
dismissing their experiences.
Stigma is an opinion or
judgment. When stigma is
acted upon, it becomes
discrimination.

6. Negative attitudes to
people with mental illness
are prevalent in society.
At a young age we learn
through our society to have
certain prejudices that are
carried through into
adulthood.
People with mental illness
are stereotyped; for
example the idea of
schizophrenics as violent
potential killers, or people
suffering from depression
as lazy and self indulgent.
Why does
stigma
happen?

7. Sterotyping makes it easier to
dismiss the experiences of whole
groups of people, creating a ‘them
and us’ mentality.
Negative coverage of mental
illness in the media reinforces
stereotypes, increasing the level of
false negative beliefs about people
with mental illness.
This causes people with mental
illness to become dehumanised
and socially excluded.
This can alter the perception that
someone might have of their self,
leading to further social isolation,
reliance on others and alcohol and
drug abuse.
Why does
stigma
happen?

8. Link and Phelan 2001 proposed
that:
• Human variations are labelled,
which creates distinct groups
of people.
• Labels tie people to negative
attributes in accordance with
society and culture. This causes
stereotyping to occur.
• Labelling creates distinct
groups, allowing an ‘us and
them’ mentality. This
dehumanises the labelled
group.
• Labelling causes discrimination
and loss of social status,
leading to unequal
circumstances
Link BG, Phelan JC. Conceptualizing
Stigma. Annual Review of Sociology 2001;
27: 363-385.
Labelling
and
stigma

9. Stigma socially discredits
a person by assigning a
negative attribute to him
or her. This creates a
negative, undesirable
stereotype.
It is the reaction of
others which spoils
identity.
Erving Goffman, Stigma: Notes on
the Management of Spoiled Identity,
1963
Goffman
1963

10. Goffman describes three
categories of people: the
stigmatised, the normal
and the wise.
The wise are a division
of the normal’ but
understand and
sympathise with the
stigmatised, and
therefore are accepted.
The wise may also bear
stigma from the normal
for being accepted by
the stigmatised. This is
called courtesy stigma,
or stigma by association.
Goffman
1963

11. Research carried out by the
Mental Health Foundation found
that of people who have
experienced mental ill health:
• 56% have experienced stigma
from their family.
• 51% have experienced stigma
from their friends.
• 47% have suffered from
discrimination in the workplace.
• 37% have experienced
discrimination when seeking
employment.
• 44% have experienced stigma
from their GP
• 35% have suffered
discrimination from other
health care professionals
How
common
is stigma?
Figures are taken from
http://www.rethink.org/living_with_mental_illness/ev
eryday_living/stigma_mental_illness/index.html

12. Stigma creates barriers.
People who may be
suffering from mental
illness are reluctant to
access services because of
the negativities associated
with having a diagnosis of
mental illness.
Stigma from healthcare
professionals can lead to
people with mental illness
not being taken seriously,
not being listened to and
not being supported.
It can also lead to a
reluctance to discuss
symptoms of mental health
problems with patients.
Stigma in
healthcare

13. Read the following
accounts of 2
members of the
Patient Voices
group, as they share
their experiences of
living with mental
illness and the
stigma it brings.

14. Name:
Dr Kenneth Townend PhD
Age:
53
What condition were you diagnosed
with?
Depression due to stroke
When did it all begin?
2004 when i had a stroke and lost my
car/job/hobbies etc
What symptoms did you experience?
Tired all the time. Stressed at anyone,
would throw plates etc. Due to being told
“go in a corner for the rest of my life” by
a hospital consultant.
Where you aware that the symptoms
you were experiencing were not
“normal”, or did they feel “normal” to
you?
I wasn’t aware until i had bereavement
counselling.
Are you aware of anything (such as a
life event, personal trauma, childhood
experience etc) that triggered it all off?
I believe it may have been there a long
time but my 2x strokes bowel cancer in a
5 year period, made it much worse.
How did it affect your personal life,
family, and relationships?
My wife left me.
How was your social life affected?
Unable to go out, could not afford hobbies
never mind do them.
If you were employed, how was this
affected?
Stroke 2004 - spent 12 weeks in hospital,
lost job as a commercial diver working in
20 countries.

15. Most importantly, how did it make
YOU feel?
Stayed in bed all day
How did other people react to your
behaviour/symptoms?
Often did not as never went out.
When did you decide to seek help from
a medical professional?
My GP talking to me, thought that since
the psych road was not for me but maybe
death/bereavement counselling was for
me.
Was there an event that triggered your
desire to seek help?
Shut in the house 24/7 drove me up the
wall.
How helpful were the medical
professionals you saw?
Angry patient wanting answers, i still 6
years down the road know how and why i
had a stroke.
What was the outcome of your seeking
help?
Cope with my lot as i did not smoke drink
and a medical every 6 months before my
stroke as a dive medic.
How did treatment work for you?
Got me to not ditch the old Ken’, but park
him in a safe place where i could still visit
him, but also where i was a new stronger
Ken.

16. How do you feel now?
From 134 tablets a week I had when I
came home, because of Jools, Delia ,
Joanne and Susan [Patient Voices Project]
I am now free of some of the pressures
and able to again stand tall.
What do you think can be done to help
to reduce this stigma, as doctors,
individuals, or society in general?
Listen to my needs as well as others do
not put us in a box.
Do you have any words of wisdom for
the doctors of the future?
Listen to me. I am the expert patient,
whereas you are the doctor
Best wishes
Dr Kenneth Townend PhD

17. Name:
Susan Jane Thornton
Age:
47
What condition were you diagnosed
with?
Bi polar, Cyclothymia:
A persistently unstable mood, involving
many periods of depression and over
elation. This instability usually develops in
late adolescence and follows a chronic
course, although moods maybe within
norms for months at a time.
Mood swings are usually perceived by the
individual as being unrelated to life events.
The diagnosis is difficult to establish
without a prolonged period of observation
or an unusually good account of the
individuals past behaviour.
Cyclothymia frequently fails to come to
medical attention. The essential feature is
a persistent instability of mood involving
numerous periods of deep depression.
When did it all begin?
Early symptoms were recognised in
childhood/adolescence. Overall diagnosis
was revealed in May 2009
What symptoms did you experience?
Difficult making decisions; problems
concentrating;, poor memory recall; guilt;
self criticism; low self esteem; pessimism;
self destructive thinking; continuously
feeling sad; apathy: hopelessness;
helplessness; irritable, quick temper, lack
motivation; social withdrawal; appetite
change; lack of sexual desire; feel neglect;
fatigue or insomnia.
This disorder is common in the relatives of
patients with bi polar disorder and some
individuals with Cyclothymia eventually
develop bi polar disorder themselves. It
may persists throughout adult life, cease
temporary or permanently, or develop
into more server mood swings meeting the
criteria for bipolar disorder or recurrent
depressive disorder in rare cases.

18. Are you aware of anything (such as a
life event, personal trauma, childhood
experience etc) that triggered it all off?
Events that may have effected/triggered
personal trauma include;
• 5-16yrs-Turblant childhood, father
abusive and had mental health issues.
• 16-19yrs-left school and found “booze
and boys”
• 19-27yrs-Married family, mother
died at 27 also husband left, mother
was the only one that understand and
listened, that meant I didn’t have any
positive reinforcement, be that a
sociable or affectionate figure.
• 27-37yrs-Working full time and
bringing two children up, without any
support of guidance from peers.
• 37-40yrs-stress brought on drug
addiction, taking stimulates to keep up
with daily routine of work and family
life.
• 40-43yrs-total breakdown, lost job
due to inability to sustain a working
life under the conditions. This involved
wrecking the family home, by means of
taking a knife to carpets, curtains,
furniture. All in front of both children
(boys were 11 & 13) Also lashing out
at authority figures, being either locked
up or forced to stay in doors, this was
due to the fact they didn’t understand
the illness that I was going through and
was stigmatised as being an alcoholic.
AS alcohol was my coping mechanism
at the time.
• 43-45yrs-given a diagnosis that I
thought was right for the first time.
Where you aware that the symptoms
you were experiencing were not
“normal”, or did they feel “normal” to
you?
No, initially I knew things weren’t normal,
but could not distinguish between the
norm.

19. How was your social life affected?
After my husband left and had to bring
up too young children by myself, while
working full time, my social life became no
existent. I never had time to myself
brought on pressure, leading to bouts of
depression. The depression became more
intensified, recurring long term sickness
and instability. Which finally lead to a
total and utter breakdown. This involved
both my children, who coped in different
ways.
If you were employed, how was this
affected?
I lost my job after 20 years with a local
authority, at middle management level.
This brought on a severe spiral of
depression. Leading to being arrested and
vandalising property as no one was
listening, I knew I had a problem and
wanted help but at this time, I wasn’t
receiving any due to the stigma of being
perceived as an alcoholic.
Most importantly, how did it make
YOU feel?
From five years till forty three years, I was
misunderstood and never listened to. From
then on, when I had been given a
diagnosis/my label, I was able to take a
stand and understand that instead of
trying to treat it, I able to learn how to
live with it.
How did other people react to your
behaviour/symptoms?
Peers didn’t not understand, again
stigmatised me as nothing but a alcoholic,
without looking deeper into the issue
involved. This means looking at the person
instead of the problem. The person being
able to change and being able to define the
issue (problem) and not the problem
defining the person.

20. When did you decide to seek help from
a medical professional?
I have been trying to seek help from both
medical and professional institutes from a
young age, this being after a parent passed
away and was given no help by any of my
peers, which then brought on the stress of
bringing up a family and holding down a
full time job by myself.
It was only when I had lost my job and
had been binge drinking for over 3 years
and had to go to hospital, in which I was
told if I don’t stop I will not be able to see
my sons grow up, which gave me a
incentive to live and get back on track.
After realising that I need help to get over
this and was given a diagnosis I could
learn to live with, I dealt first my the
alcohol, after 18 months of abstinence I
conditioned myself to have a “on/off
switch”.
This then gave me the confidence to go
and seek out for all help that was out
there, one of the criticisms I have was this
“was trying to find the right help first
time round” and the added factor that
the clinicians did not listen.
Was there an event that triggered your
desire to seek help?
After months of binging and self harm,
my son had to take me to hospital, after
the doctor advising me that I cant carry
on like this, I decided to seek out all the
help and advice I could.
How helpful were the medical
professionals you saw?
At first (again this was over 20 years,
when the establishment was set in their
ways and everyone who had a drinking
problem was categorized anti social and
this was not actually the case) many
people who use drink as a coping
mechanism have mental illness before
starting to abuse instead of the other way
round.

21. What was the outcome of your seeking
help?
Again firstly I was made out to be a
lunatic!!! After my diagnosis, it was like a
revelation. This then gave me the
confidence to move forward and learn
about my label and how to embrace it
positively.
How did treatment work for you?
I’m still here to tell the tale and to re-
educate the clinicians.
How do you feel now?
I feel better in myself and have a more
stable relationship with my children, this
has also had an impact on my social life as
I have both new friends and colleagues to
help me through, but also have gained
more insight into how the patient can help
themselves by helping others in certain
situations like mine.
What do you think can be done to help
to reduce this stigma, as doctors,
individuals, or society in general?
To ask the patients more in-depth
questions not as such relating to the
problem in hand to try get more of an
insight into the overall sphere of the
patient/s involved, this means taking a
more detailed look into the patient’s
history. In some cases maybe speaking to a
relative who has been and witnessed the
patients mental state and/or
deterioration.
In general we could try and combat
overall stigmatisation trough re-education
and pressure groups, to beat, not just
stigma but any sort of discrimination that
involves mental health issues. By focusing
on the “soon to be, new generation of
doctors and councillors of tomorrow” by
getting them at the core, we can not just
educate them into how people may
establish these mental issues but setting a
ground base/work of issues to ignite fuels
of concern and try to stamp it out before
the patient decomposes into a serious
mental state.

22. Do you have any words of wisdom for
the doctors of the future?
• The three C’s; having the Courage to
Challenge Constructively. Patients will
challenge you constructively please take
this as a compliment they will have a
better understanding and both
patient/punter/number/whatever
clinicians want to call us will learn to
negotiate as a team, thus proving to be
more cost effective in the long term.
• We relish our own correctness” I told
you so” crow over other peoples
mistakes and dismiss those who
challenge, those disagree with us, as
arrogant, idiotic or just pain mad, that
is why I am a mentalist activitist !
• Medically activated/enhanced humour,
(straight talking with a hint of witty
banter) this may ease the patient into
giving more than they would normally
digress to your average
doctor/professional.
Is there anything else you would like to
add?
Thank you for asking and remembering
me, I hope this gives you an insight into
how a patient can help, not just with
telling the professional the problem they
may have (self-diagnosis) by giving a
better perspective of an individual with
health problems, if you need to use any of
the above for publication please could you
ask me before hand. I wish you all great
success in your future as ‘The doctors of
tomorrow’
Kind Regards
Susan Jane Thornton

23. LISTEN
(My Journey)
Twenty years, has been and gone,
Nobody listened and it all went wrong.
Time after time, they said I was a
drunk
By no means, I knew I wasn’t a monk.
Over and over,
They called me mad sue,
Bloody hell!
What was I guna do.
Lost my job,
Lost my home,
Lost my integrity too.
So I knocked on door after door,
Until my knuckles were roar.
Stitches, plaster and scalp shaved too
How far was I guna go?
Guess what,
Broken bones and stab wounds too.
You clinicians in there, what are you
going to do,
Please, please listen
If you know what’s best for you.
That’s why you get paid so much for
what you do,
Now I get paid for you to listen,
And listen you will DO!
Hip hip hurray,
You have listened at last.
I now know what you have subjected
me too;
Bi polar, Bi polar,
You clinicians say, by heck you listened
at last to my dismay.
Hip hip hurray I shall be on my way,
Learning to live again
Hip Hip Hurray!
By Susan Jane Thornton
Transcript Scott Howells
Copyright June 2011

24. A good website containing an
overview of stigma aimed at people
suffering with mental health
problems:
www.rethink.org/living_with_mental_i
llness/everyday_living/stigma_mental
_illness/index.html
Journal article providing an overview
of stigma, it’s effects and how it can
be reduced:
Byrne P. Stigma of mental illness
and ways of diminishing it. Advances
in Psychiatric Treatment 2000; 6:
65-72. Available to access online at:
http://apt.rcpsych.org/cgi/content/f
ull/6/1/65
Time to change campaign. Includes
some real life stories from people
with mental health problems.
http://www.time-to-change.org.uk/
The Royal College of Psychiatrists
Fair Deal Campaign.
http://www.rcpsych.ac.uk/campaigns
/fairdeal.aspx
All images courtesy of
Microsoft Office