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CHAPTER THIRTEEN RECOMMENDATIONS FOR THE FUTURE DEVELOPMENT OF ACTIONS TO ADDRESS THE STIGMA AND DISCRIMINATION EXPERIENCED BY PEOPLE WITH MENTAL HEALTH PROBLEMS

Introduction

13.1 The third aim of the evaluation was to make recommendations for the future direction of work in Scotland to address the stigma and discrimination experienced by people with mental health problems. To inform the development of these recommendations participants in phases 1 and 2 of the evaluation were asked to provide their perspectives on the future direction for anti-stigma and discrimination work. In addition in the final phase of the evaluation, interviews were held with representatives from a range of sectors and spheres where future anti-stigma and discrimination activity may have substantial impact (see Annex 3). These sectors were selected because of their role as employers of people who may have experienced or experience mental health problems, and also as providers of 'goods and services' (in the broadest sense) with a responsibility to ensure that these services are provided in ways that are not discriminatory. The range of perspectives both from phase 3 and the earlier phases are discussed in Chapter 11. This final section of the report takes the analysis a stage further to draw out implications for the future.

The future context

13.2 Consideration of the future direction of work to address the stigma and discrimination experienced by people with mental health problems is particularly timely given the dynamic policy context in Scotland. In 2006 and 2007, a number of initiatives have emerged which both set the policy context for change and also support the continuing cultural shift that challenging stigma and discrimination needs. The Scottish Parliament's Equal Opportunities Committee report published at the end of 2006, for example, placed an emphasis on the social model of disability (Scottish Parliament, 2006). The report recommends that disability equalities issues are mainstreamed to address discrimination. It also proposes a co-ordinated and long term strategic campaign, modelled on 'see me', to tackle negative attitudes towards disabled people. Specifically in relation to mental health, Delivering for Mental Health makes a commitment to addressing the inequality and social exclusion of people with mental health problems (Scottish Executive, 2006b). Following the May 2007 election, the Scottish Government published Better Health Better Care (Scottish Government 2007a) which included the commitment to set up a Ministerial Task Force on Heath Inequalities to look at health and inequality. The Task Force reported in June 2008. The National Programme's discussion paper on the future direction for the mental health improvement in Scotland, Towards a Mentally Flourishing Scotland, reflects the concerns underpinning the work of the Task Force to address inequalities (Scottish Government, 2007b). The discussion paper includes among its target groups those exposed to multiple sources of discrimination. At a UK level, the Equalities and Human Rights Commission creates a new legislative framework for addressing discrimination across the equalities 'strands'.

13.3 This refocusing on inequality and discrimination suggests that now is an opportune moment not only to reflect on the future strategic direction for 'see me', but also to locate action to tackle the stigma and discrimination experienced by people with mental health problems within a broader based framework.

13.4 Whilst recognising the valuable and significant contribution made by 'see me' in establishing a foundation for anti-stigma work, the findings from the evaluation indicate that in order to make further progress in challenging and addressing the stigma and discrimination people with mental health problems experience, the next phase of such work requires a new model with much stronger connections to the wider agenda of inequalities and discrimination and that makes explicit the roles and contributions of other players at policy and service level.

13.5 The new model proposed is elaborated below in more detail to consider:

• Broadening the understanding of the processes that underpin the stigma and discrimination experienced by people with mental health problems and ways for addressing these processes
• Implications for roles and responsibilities across sectors and across levels
• The focus for action.

Broadening the understanding of stigma and discrimination

13.6 The work of 'see me' has revealed the complex dynamics that underpin stigmatising attitudes and discriminatory processes as well as the outcomes of these processes as they affect people with mental health problems. Research by 'see me' and by other agencies such as the Scottish Recovery Network help to illustrate how these attitudes and behaviours expose people with mental health problems to social and economic exclusion, and how, in turn, exclusion and disadvantage are detrimental to mental health and well-being, creating negative cycles that are self reinforcing.

13.7 The conclusions drawn from the evaluation, set out in Chapter 12, suggest the need for approaches that differentiate more sharply between the processes resulting in stigmatising attitudes and those processes resulting in discriminatory behaviour and that can discern how these play out at the level of individual attitudes and behaviours and at the level of institutional cultures and practices. This indicates the need for a 'bundle' of approaches to address both stigma and discrimination at different levels simultaneously, rather than sequentially or separately.

13.8 This work can be pursued within a broader inequalities and human rights framework. Promoting fairness and equality for people who experience mental health problems means seeking to address the stigma and discrimination experienced by individuals and by groups of individuals, and also tackling the wider structural mechanisms of stigma and discrimination that may unequally impact on people with mental health problems, for example discrimination that operates through poverty or worklessness.

13.9 There is a need for:

• Continued awareness raising of the specific processes and unacceptable personal and social consequences of stigma and discrimination experienced by people with mental health problems
• Efforts to extend the reach of such awareness raising beyond those sectors which are already sensitised, recognising that this is likely to require different tactics
• Targeting action to benefit those groups who are most likely to be exposed to the deleterious effects of stigma and discrimination
• Greater understanding of the structural processes of discrimination that disadvantage people with mental health problems and a clear identification of the remedial actions required
• A process of embedding such action within 'generic' mechanisms that directly or indirectly address inequality and discrimination. These might include, for example, area-based and organisational equalities and diversity strategies, anti-discrimination training, mental health and well-being strategies and initiatives
• Co-ordination of effort to clarify roles and responsibilities and maximise chances of having a lasting impact
• Commitment to develop the evidence base through research and evaluation.

13.10 The challenge will be to ensure that appropriate consideration of the stigma and discrimination associated with the experience of mental health problems does not get 'lost' by being absorbed into mainstream responsibilities and activities on inequalities and discrimination. A twin track process is therefore proposed to encourage integration into generic structures and processes whilst also ensuring a spotlight continues to be directed onto the stigma and discrimination experienced by people with mental health problems.

Implications for roles and responsibilities

13.11 The complexity of the causes and consequences of stigma and discrimination requires that actions taken need to be collaborative, integrated and co-ordinated. 'see me' has played a key role in kick-starting the process, acting as a flagship to draw attention to the unacceptability of stigma and discrimination and preparing the ground for wider action. In the light of the experience accumulated over the life span of the campaign and in view of other policy developments and service initiatives that have emerged in recent years, there is opportunity to harness these efforts and take concerted action to address stigma and discrimination, with 'see me' playing a clearly defined role, working alongside and in support of other agencies and sectors.

13.12 Moving forward from here will therefore require the active engagement of other agencies, organisations and policy areas to integrate an understanding of the stigma and discrimination experienced by people with mental health problems within their own 'domains' and take responsibility for appropriate remedial action. In the next phase, this is not work that can be undertaken solely by a single body running a campaign for others to 'lift off the shelf'. The campaign would remain one valued part of a wider programme of work, in which 'see me' would play a key role in, supporting others in striving towards common objectives.

13.13 The model of change proposed would utilise various mechanisms working on multiple dimensions:

• Legislation to enforce anti-discrimination practices and to protect rights, including highlighting the role of existing legislation in tackling discrimination as experienced by people with mental health problems
• Supportive policies that translate the principles of legislation into objectives
• Interventions and approaches that remove the barriers faced by people with mental health problems, for example, actions to support access to and retention of employment
• Tools and resources that build capacity and reinforce good practice.

13.14 In addition, future action needs to be multi-layered to comprise developments within and across policies at national level; developments at local level and within organisations and institutions; and developments at the level of individual awareness raising or training.

13.15 As noted in Chapter 12, 'see me''s current aims and objectives are very broad and difficult to translate into measurable terms. To support 'see me''s facilitative role within this model would require greater, shared clarity about the respective roles of 'see me' and other agencies and organisations and how these inter-relate.

Focus for action

13.16 The evaluation findings suggests a need to supplement the valuable 'general population' level work, which would continue to highlight that stigma and discrimination are unacceptable, with a more differentiated, targeted focus. This is likely to require different types of actions, working through and with different stakeholders at a range of levels. It would be important that such work should be informed by the evidence base, to include three main dimensions:

• First, targeting those environments where the greatest 'injury' may be sustained. Key areas identified in the course of the evaluation were employment and employability and the NHS , including mental health services
• Second, targeting action on those groups whose exposure to stigma and discrimination may have an impact on their mental health and well-being. This would include people with mental health problems who may also experience a community sanction because of some aspect of their social identity; people from black and minority ethnic communities, but also, for example, people in poverty
• Third, targeting those groups where the evidence base suggests opportunity for positive change e.g. children and young people; groups such as health professionals, frontline staff in the public and private sectors or the police. A further emerging area is that of self-stigma and discrimination and also 'intimates stigma' - the stigma and discrimination an individual may experience from those closest to them.

Re-thinking the model

13.17 A complex picture has emerged from the analysis of the development and achievements of 'see me' which suggests the value of a tiered model as a way of thinking about the future direction for further action in Scotland to address the stigma and discrimination experienced by people with mental health problems. Drawing on a health improvement model, this approach conceptualises action at three levels: primary level promotion; secondary level prevention; and a tertiary level of more direct action such as recourse to legislation. This model is summarised in Table 13.1 below, which includes implications for roles and responsibilities of different agencies.

13.18 Within this model, there is clearly a continued need to maintain a high level national campaign able to provide a focal point, keep the issue high on the "radar", and act as a resource for people to learn from and draw upon. However, the complexity of the issue suggests that the next stage requires broadening out responsibility, so that the stigma and discrimination experienced by people with mental health problems is more sharply integrated into actions to tackle fundamental sources of inequality.

13.19 As a first step, it is suggested that opportunities are made available to establish a forum for dialogue between different agencies and organisations to further progress this agenda for change. 'see me' has, through its energy and enthusiasm, made visible the experience and impact of the stigma and discrimination experienced by people with mental health problems. To maintain and extend this visibility, the next stage must be to engender this energy throughout the system.

Table 13.1 Tiered approach to addressing the stigma and discrimination experienced by people with mental health problems

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