Stigma and shame in mental illness: avoiding collusion in art therapy

As we experience a new decade and new global challenges, it is important to re-focus our attention on the needs of our clients and service users. Perhaps now, more than ever before, there is a danger that the vulnerable in society will be overlooked. People diagnosed with mental illnesses often experience a sense of shame, brought on by stigma and prejudice in society, which causes marginalisation, exclusion and a lack of social opportunities. Stigma may also include misconceptions about risks to the public posed by people affected by mental health issues and be heightened by negative portrayal in the media of mental illness. This stigma surrounding a mental health diagnosis is sometimes described by those who experience it as worse than the condition itself (Vigo, 2016, p. 1027), clearly highlighting a need for education (Friedrich et al., 2013) and national campaigns that bring change in our society.

For some people, the diagnosis itself is experienced as ‘insulting, confusing, a further blow to an already crushed sense of self, and a mechanism of discrimination and stigma’ (Morgan, Knight, Bagwash, & Thompson, 2012, p. 92). Attempts to make sense of distress and diagnosis can invite comparison with the self and social ‘ideals’, resulting in feelings of social shame and otherness, when these ‘ideals’ are not met (Johnstone & Boyle et al., 2018, p. 6). For art therapists working within this client group, lack of funding, work conditions, etc. can cause vicarious traumatisation and burnout, as outlined in the article by Elkayam et al. (2020) within this volume.

As art therapists we are committed to supporting our clients and service users as they work through mental health issues; however, the development of interventions to reduce the mental health discrimination and stigma people experience on a daily basis are in their infancy. Using non-medicalised ‘low stigma settings’ (Parkinson & Whiter, 2016, p. 120) such as art therapy groups held in museums and art galleries are an example of how we as art therapists can begin to change stigma around mental illness (Coles & Harrison, 2018; Coles & Jury, 2020; Coles, Harrison, & Todd, 2019).

The principal means for tackling stigma surrounding mental illness has been through public education and awareness mass media campaigns. However, work on unpathologising mental illness has also begun; for example, the British Psychological Society’s publication The Power Threat Meaning (PTM) Framework (Johnstone & Boyle et al., 2018) is an important step forward. The PTM framework can be used to ‘identify broad, provisional, evidence-based patterns of meaning-based threat responses to the negative operation of power, which provide a context for the co-construction of individual narratives, as well as suggesting alternatives to diagnosis’ (Johnstone & Boyle et al., 2018, p. 10).

The Hearing Voices Network seeks to address these stigmatising attitudes and to change the narratives that people who hear voices live by and the attitudes of clinicians that treat them (Romme & Escher, 2000). Voice-hearers are encouraged by this network to seek others who experience voices, and to find ways (not necessarily involving medication) to live with their voices and manage them, with support.

Other national campaigns against stigma attached to mental illness are the Time to Change campaign (https://www.time-to-change.org.uk) launched in 2008, run by two charities – Mind and Rethink Mental Illness, focusing on changing behaviours and reducing prejudice by educating the general public, medical students and employers via mass media marketing campaigns. ‘See Me’ (https://www.seemescotland.org) is a national programme currently running in Scotland aiming to end mental health-related discrimination and stigma by targeting it at its roots, wherever it is experienced, eg at work, at home, in local communities, in education or in health and social care.

Heads Together (https://www.headstogether.org.uk), supported by The Royal Foundation of the Duke and Duchess of Cambridge, is another public campaign, which has recently partnered with the Football Association (May 2019), aiming to generate conversation around mental health, particularly between men. Their focus stems from the recognition that suicide is the most common cause of death for men under 45, aiming to challenge the stigma around mental health and provide support particularly for men who find talking about mental health issues difficult. After all, new and innovative treatments will only be effective if those affected are no longer afraid or too ashamed to ask for help.

Mental health stigma often means that people affected are discriminated against, making it harder for them to obtain housing, jobs and other services. The general population may feel uncomfortable about socialising with people who have been diagnosed with a mental illness and regard them as dangerous, strange, unpredictable and violent (Lauber, Nordt, Braunschweig, & Rossler, 2006). While this may be true for certain disorders, in their acute phase, this is not generally a characteristic of people with mental illness (Lauber et al., 2006), and this erroneous belief leads to social distance and exclusion (Nordt, Miiller, Rossler, & Lauber, 2007). Families or significant others of those affected may also be stigmatised through association (Lauber, Keller, Eichenberger, & Rossler, 2005).

It is important for art therapists and other healthcare professionals to recognise their own power to either ‘affirm or demean’ the self-identities of their clients or service users (Kinsella, 2006, p. 25), by rejecting or upholding stigmatising beliefs or myths about mental illness.

After all, the ‘devalued identity of the “mental patient” may increase and amplify existing experiences of shame, failure, exclusion and marginalisation’ (Johnstone & Boyle et al., 2018, p. 219). It may also lead to self-stigmatisation (ibid., p. 220). Understanding this helps us recognise how stigmatisation can occur on many levels within the healthcare sector, including for example structural, inter-personal and intra-individual (Corrigan, Druss, & Perlick, 2014; Link & Phelan, 2001). Research carried out with healthcare providers has found that stigmatising behaviours and attitudes towards service users with mental illness diagnoses are prevalent across the healthcare spectrum (Knaak, Mantler, & Szeto, 2017).

The articles within this volume explore a diverse range of issues important for art therapists to consider, as well as innovative ways to reflect back to our clients and service users that they have been seen and heard, eg the article within this volume by Nash (2019) discussing response art. Springham and Huet’s (2020) article explores harm to clients by art therapists and some of the risk factors involved. Ashby (2019) discusses her research into the impact of the work on art therapists employed in NHS learning disability services, the ongoing change processes they experienced, and how these conditions affected their well-being; burnout, which affects physical and psychological functioning, was of concern.

Stigmatising behaviours and beliefs are not limited to mental illness; however, stigmatised attitudes are perhaps more severe for people with psychiatric disabilities, than those with eg physical illnesses and disabilities (Corrigan et al., 2000). Research to understand the impact of a mental health diagnosis on clients/service users is in its infancy and much work needs to be done in order to understand the extent of prejudice that people living with mental illness experience.

However, those who experience a combination of stigmatising conditions, such as a learning disability, which is often accompanied by physical disability, autistic spectrum condition and mental illness, are even more significantly disadvantaged (Bull, 2012; DoH, 2001; Mencap, 2007). People who have learning disabilities, perhaps with a mental illness, but even without, are likely to experience hate crime and stigmatising attitudes even within their own families.

During the Middle Ages disabled people were targets for ridicule and jokes at their expense, and infanticide of disabled children was commonplace until the Victorian era. A state-run system of asylums was set up in 1845 and people with all kinds of disabilities were incarcerated, including those who were deaf, blind, or had epilepsy. They were often treated cruelly in the institutions, but life in the community was as bad. The lifetime segregation of disabled people was campaigned for in the early twentieth century amid eugenic fears that continued for two decades, but the inception of the welfare state began to change attitudes (Barnes, 1991).

Attitudes towards people with learning disabilities (LD) changed with the concept of Social Role Valorisation (Wolfensberger, 1983), which promoted social inclusion for people with LD, creating opportunities for taking on valued social roles in society, and changing views of people with LD as ‘different’. Another change of attitudes towards people with LD was brought about by Goffman (1961), who challenged how people were viewed, and revealed the impact of institutionalisation on patients and staff. Abuses of patients in institutions were uncovered in the years that followed, and public outrage resulted in the Deinstitutionalisation Policy (Hamlin & Oakes, 2008).

This led to significant changes taking place in LD services over the last 40 years as the result of deinstitutionalisation, which fundamentally changed the way people who have LD were cared for, impacting both clients and staff (Mansell, 2006; Skirrow & Hatton, 2007; Thompson & Rose, 2011). Deinstitutionalisation involved the movement of people with LD, and other people with mental illness, away from incarceration in institutions separate from society to being cared for in the community (Hamlin & Oakes, 2008). Global recognition of the need for deinstitutionalisation brought about similar changes in other parts of the world, such as Sweden and the USA, during the same period (Ericsson & Mansell, 1996).

People with LD are likely to experience abuse and neglect in the community, and to be highly vulnerable in society (Peckham, 2007) due to their social skills deficits which place them at risk (Kavale & Forness, 1996; Morrison & Cosden, 1997). Having a learning disability makes it difficult for people to prosecute their abusers and go to court, as they are often considered incapable of being credible witnesses, and capacity to consent is a crucial determinant (Green, 2001; Joyce, 2003; Sanders, Creation, Bird, & Weber, 1997). They often experience hardship and social deprivation, especially if not living in supported accommodation, and struggle to make appropriate and safe friendships; they are likely to experience bullying and harassment, to be unemployed and to struggle with money management, reading and writing (Emerson & Hatton, 2008).

Three healthcare abuse cases were investigated, in Cornwall (Healthcare Commission, 2006), Sutton and Merton (Healthcare Commission, 2007), and forcibly came to the fore with the television revelation of the appalling conditions endured by people with LD in the private sector at Winterbourne View Hospital (Flynn & Citarella, 2013; Plomin, 2013). The learning disability charity Mencap raised their concerns about disparities in healthcare in their ‘Death by Indifference’ report (Mencap, 2007). Hate crime experienced in the community is also not uncommon (Bull, 2012). It is clear that people with learning disabilities and mental health issues are extremely vulnerable within society.

As art therapists, most of us work with vulnerable populations, and have concerns about how they are viewed within society. As an ethical journal, concerned with the well-being and support of clients and service users, we are making every effort to ensure that articles publish in IJAT follow an anti-stigma code. We have enrolled a lived experience advisor to read the articles in IJAT and report back to the editorial board on ways we can improve the language and manner of reporting used in the journal concerning clients and service users. We are also committed to collaboration in all aspects of research and its dissemination, ensuring that clients’ and service users’ voices are heard, and their stories disseminated in a manner that reflects their lived experience.