Thu 4 Oct 2018

Nurses essays - Part 3

The School of Nursing has a formal contract with Supporting Families in Mental Illness, Taranaki, to provide learning experiences based on the sharing of narratives by those who have experience with mental health and/or addiction issues, on five separate occasions, during the second year of study in the Bachelor of Nursing programme.

Participants share their lived experience in relation to the mental health case study topics, which include depression, psychosis, bipolar affective disorder, alcohol and others drugs and suicide. An array of issues are discussed, including the qualities and attributes of what makes a good nurse, from the perspective of a person receiving care and navigating the ‘system’.

This learning style is unique to the WITT nursing degree and allows us to continuously develop the students’ holistic thinking, as opposed to delivering a segregated mental health paper; this fits with the WITT BN graduate being ‘work ready’, regardless of the context of future employment.

One of the assessments for year 2 students is to write an essay that answers the question, “Is stigma and discrimination still part of society’s behaviour?”; a selection of essays are then forwarded to the Supporting Families team, who award a special prize to the winning essay, which is presented at Graduation.

In the build-up to celebrating Mental Health Awareness week starting next Monday (October 8) WITT News has been sharing a selection of those essays.

This is the third and final instalment and features essays by Sally Bruce and Casaey Trownson.

 

Is stigma and discrimination still part of society’s behaviour? 

By Sally Bruce

This essay aims to explore the prevalence of stigma and discrimination surrounding mental health still present in New Zealand society today with a focus on schizophrenia. This will be achieved by analysis from a micro and macro perspective; the micro perspective includes clinical examples while the macro perspective examines the national and international attitude towards mental health. Relevant ethical, legal, and professional issues will be explored with critical application of pharmacological science and the impact of the therapeutic relationship. Personal reflection of evolving attitudes and beliefs is included, with examination of interventions to reduce stigma, and comparison of clinical findings to peer-reviewed evidence. Finally, cultural safety implications will be discussed.

The word stigma originates from the Greek language and means to brand or tattoo a person; it is something attached to the individual and is associated with negative connotations and attitudes (Te Pou o Te Whakaaro Nui [Te Pou], 2009). Discrimination is commonly born from stigma and is the act of treating a person or group differently and often unfairly for being different (Te Pou, 2009). Stigmatizing attitudes towards those experiencing mental illness may date back to the 13th century, when limited resources meant those unable to live independently were confined with little distinction. This included criminals, those unable to find gainful employment, those with physical disabilities, and those experiencing mental illness (Evans, 2013).

Asylums intended for the ‘treatment’ of those experiencing mental illness began in the 15th century at Bethlehem Hospital in London and soon became popular throughout the Western world (Evans, 2013). Despite advancements in treatments for mental illness, schizophrenia in particular still receives a significant amount of stigma and discrimination. From a macro perspective, this is evident by the need for anti-stigma campaigns, such as the Like Minds, Like Mine programme in New Zealand (Ministry of Health [MoH] & Health Promotion Agency, 2014).

Moreover, Bardwell and Taylor (2013) describe the effects of stigma and discrimination as bad as the illness of schizophrenia itself. This is shown on a micro level as clients encountered in clinical practice often feel distressed rather than relieved by receiving schizophrenia as a diagnosis. These same clients have also reported difficulties in finding long-term housing and employment as a result of the stigma around schizophrenia. This is also evident on a larger scale, as in New Zealand around one third of those with mental illness do not attempt to gain employment due to anticipated discrimination (Thornicroft, Wyllie, Thornicroft, & Mehta, 2014).

Improvement in public attitude towards mental illness began with the United Nations through development of guiding principles for mental illness, including under principle 1.4 the right to freedom from discrimination (United Nations, 1991). The New Zealand Government has had policies addressing mental illness since the 1990’s, with the current MoH (2012) National Plan for Mental Health and Addiction including actively challenging stigma and discrimination as the first guiding principle. This is further reflected in the Code of Conduct for Nurses in principles 1.6 and 1.7, in which nurses must provide care that is free from discrimination and prejudice (New Zealand Nursing Council, 2012).

Furthermore, New Zealand has legislation relating to the treatment of those experiencing mental health issues. The Mental Health Act was introduced in 1992 and the purpose of this act was to better define and emphasise the rights of those requiring compulsory mental health treatment (Mental Health Act, 1992; Burgess, 2008). To be under the act, the person must be considered a danger to themselves or others; this is to reduce professional discrimination on the grounds of mental illness and aims to meet ethical guidelines set by the New Zealand Nurses Organisation [NZNO] (2013). These include acting in the client’s best interest (beneficence) and avoiding doing them harm (non-maleficence) (NZNO, 2013).

Removing a person’s autonomy in enactment of the Mental Health Act can be a traumatic experience and should only be executed when the benefits outweigh the costs (Muir-Cochrane, O’Brien, & Wand, 2013). One client met in clinical practice preferred to be under a compulsory treatment order as this meant they had regular access to the treatment they needed, and it removed the barrier of cost to mental health care. However, another client experienced internalised stigma due to the compulsory treatment order and began believing they were incompetent at caring for themselves.

Compulsory treatment almost always includes the use of powerful psychotropic medications as a first line treatment (Clarke & Gordon, 2011). The ethics of this must be considered as antipsychotics in the treatment of schizophrenic symptoms have an extensive list of serious and life-threatening side effects (Te Pou, 2017b). Typical antipsychotics, such as haloperidol, have extra-pyramidal side effects and long-term use can result in tardive dyskinesia (a permanent disorder of movement). Atypical antipsychotics, like quetiapine, are characterised by their high-risk for metabolic side effects, such as insulin resistance, obesity, glucose impairment, and dyslipidaemia (Scigliano & Ronchetti, 2013).

The side effects have been well-documented, but the pathological understanding behind this is not well understood (Clarke & Gordon, 2011; Scigliano & Ronchetti, 2013). Antipsychotics are now known to be dopamine receptor antagonists. While only the D2 receptors are thought to be involved in production of the negative and positive symptoms of schizophrenia, these medications are not selective, and antagonise dopamine receptors throughout the body and brain (Clarke & Gordon, 2011). Furthermore, antipsychotics are thought to act as antagonists on a large number of other receptors, including histamine, serotonin, adrenergic, and muscarinic receptors (Clarke & Gordon, 2011; Scigliano & Ronchetti, 2013). This widespread action contributes to weight gain, insulin resistance, and reduction in glucose uptake (Scigliano & Ronchetti, 2013).

Schizophrenia was also highlighted by Scigliano and Ronchetti (2013) as an independent risk factor for metabolic syndrome. This research found increased glucose, insulin, and cortisol levels in the plasma of participants with untreated schizophrenic symptoms. Scigliano and Ronchetti (2013) suggest this is due to higher levels of noradrenaline, adrenaline, and inflammatory cytokines in these individuals, inducing the metabolic changes. The mechanisms contributing to the increase in metabolic risk factors may therefore by multifactorial, but evidence suggests clinical worsening for those using antipsychotics (Te Pou, 2017b).

This knowledge is important for nurses as they need to be able to educate patients on the potential side effects of medications. Te Pou (2017b) discuss side effects as a main reason for patients not adhering to medication regimens, supported by DiBonaventura, Gabriel, Dupclay, Gupta, and Kim (2012). This study found 86% of participants experienced side effects from antipsychotic medication, and only 42.5% reported complete adherence with medication regimens. Furthermore, given the side effects of medications and the predisposition to physical health problems for those experiencing schizophrenia, this population has high physical health needs (Te Pou, 2017b). However, Clement et al. (2015) found self-stigma and stigma experienced within the healthcare system as leading to reduced help-seeking among this population.

This is of particular importance for those experiencing schizophrenia, as the only New Zealand study to examine mortality rates for psychotic disorders found this population had a death rate three times higher than the general population (Cunningham, Peterson, Sarfati, Stanley, & Collings, 2014). This same study concluded this mortality rate has not decreased over time, despite the advances in both pharmaceutical and psychosocial treatments (Cunningham et al., 2014). The therapeutic relationship between client and nurse is therefore essential and only effective when the attitude is non-judgmental, and the client feels safe to disclose information without experiencing discrimination from the nurse (Foster, 2013).

Thornicroft et al. (2014) found 16% of psychiatric service users in New Zealand experienced at least a moderate amount of discrimination from mental health staff. Previous negative experiences may lead to reduced help-seeking and act as a barrier to engagement (Foster, 2013). This was noticed in clinical practice as many clients were hesitant to engage with new clinicians, and for those without a regular GP, they did not want to go to the doctor. Inconsistency in the health professionals involved in all aspects of healthcare makes the development of therapeutic relationships difficult. However, the therapeutic relationship sits at the heart of the recovery framework for these at-risk clients, as it is through this mechanism the health needs of clients can be met (Foster, 2013).

This is emphasized by the Let’s Get Real framework, which highlights six core values underpinning mental health and addiction practice. The six core values are respect for the service user, provision of human rights, commitment to quality services, belief in recovery, the importance of communities, and positive relationships (MoH, 2008). Although these have been developed for use within the mental health and addictions services, it is the personal belief of the student that these are core values that should underpin all healthcare. Furthermore, lived experience of mental illness for the student makes compassion and empathy for these individuals relatively easier, and reaffirms the importance of actively challenging stigma and discrimination within society.

The nursing journey of the student has highlighted how stigma and discrimination is still prominent in society. Even with exposure to serious mental illness and theoretical knowledge gained through case studies, surprisingly little was understood on a personal level by the student about schizophrenia, emphasising how this group is still excluded from society (Bardwell & Taylor, 2013). However, nursing includes confronting personal attitudes and beliefs (Te Pou, 2017a). Schizophrenia as an essay focus was outside of the comfort zone of the student, but in writing of the essay, has challenged preconceived ideas about this mental illness, furthering development of personal and professional attitudes and values that align with the Let’s Get Real values (MoH, 2008).

Although these values and beliefs have developed as a result of the personal nursing journey, this has been influenced by changing attitudes within the profession. The Like Minds, Like Mine campaign has been running since 1997, and through this campaign, public attitudes towards those with mental illness have shown improvement (MoH & Health Promotion Agency, 2014). In target populations, including those aged 15-44 and non-European ethnicities, surveys have shown significant improvement in attitudes within New Zealand (Phoenix Research, 2011). This seems to be supported by reality, as those aged 21 and below have always had exposure to a nationwide anti-stigma campaign, and personal experience with this population would indicate more lenient views towards mental illness than older age groups.

However, experience within clinical practice shows how prevalent stigma and discrimination is, especially for those with schizophrenia. Research conducted by Thornicroft et al. (2014) still found a massive 89% of participants with experience of mental illness reported some discrimination in the previous year due to their illness. This research included 1135 participants who had used psychiatric services within New Zealand and used the recognised Discrimination and Stigma Scale (DISC-12) to measure experienced and anticipated discrimination. This was a peer-reviewed piece of research conducted by previously published authors. However, a limitation of the study was the limited response from those of Asian ethnicity and those aged 16-24 years (Thornicroft et al., 2014).

Furthermore, such research may not take into account differing values and beliefs regarding healthcare. Te Pou (2017a) describe how the client-nurse relationship should be founded on an understanding of context and values, as the position of the client may be very different to the position of the nurse. It is therefore essential to establish early in the relationship the cultural and spiritual beliefs of the client that may influence effective delivery of services. Richardson, McEldowney and Puckey (2015) discuss the building of this relationship through communication as the basis of a culturally safe environment for the client. The recognition of cultural identity is an important part of culturally safe care and has been shown as a prerequisite for positive mental health, particularly among indigenous populations worldwide (Te Pou, 2010).

Additionally, nurses must be aware of their own cultural beliefs to understand how these may differ from those in their care. The biomedical model of health dominant in Western society means antipsychotic medication is first-line treatment for psychosis (Clarke & Gordon, 2011). However, this may not fit with the beliefs of clients, particularly those of Māori ethnicity, who commonly place high value in communication and language. Treatment focusing purely on tinana (physical) neglects the importance in te ao Māori of hinengaro (mind), wairua (spirit), and whānau (family) (Te Pou, 2010). It is therefore imperative to understand the cultural context of the client when delivering competent care that meets all their needs.

In conclusion, stigma and discrimination towards those with mental illness is still prevalent in society, shown by research and clinical experience (Clement et al., 2015; Thornicroft et al., 2014). However, research also shows improvement in attitudes due to public interventions (Phoenix Research, 2011; Thornicroft et al., 2014). Nurses can act to reduce stigma and discrimination by considering the ethical, legal, and professional context of practice and by engaging in therapeutic relationships with clients. It is also essential to examine personal values and beliefs regarding mental health and addictions as well as cultural safety implications of caring for those with differing values (Te Pou, 2010). Nurses can further reduce stigma and discrimination by supporting nationwide interventions and by actively challenging observed stigma in everyday practice.

 

References

Bardwell, M., & Taylor, R. (2013). Schizophrenic disorders. In R. Elder, K. Evans, & D. Nizette (Eds.), Psychiatric and mental health nursing (3rd ed., pp.264-282). Sydney, Australia: Elsevier.

Burgess, M. (2008). A guide to the law for nurses and midwives (4th ed.) Auckland, New Zealand: Pearson.

Clarke, G., & Gordon, C. (2011). Neurobiology of mental illness. In J. Craft, C. Gordon, & A. Tiziani. (Eds.), Understanding pathophysiology. (pp.1170- 1191). Sydney, Australia: Elsevier.

Clement, S., Schauman, O., Graham, T., Maggioni, F., Evans-Lacko, S., Bezborodovs, N., … Thornicroft, G. (2015). What is the impact of mental health-related stigma on help-seeking? A systematic review of quantitative and qualitative studies. Psychological Medicine, 45(1), 11- 27. doi: 10.1017/S0033291714000129

Cunningham, R., Sarfati, D., Peterson, D., Stanley, J., & Collings, S. (2014). Premature mortality in adults using New Zealand psychiatric services. The New Zealand Medical Journal (Online), 127(1394), 31-41. Retrieved from https://www.nzma.org.nz/journal

DiBonaventura, M., Gabriel, S., Dupclay, L., Gupta, S., & Kim, E. (2012). A patient perspective of the impact of medication side effects on adherence: Results of a cross-sectional nationwide survey of patients with schizophrenia. BMC Psychiatry, 12(20), 1-7. doi: 10.1186/1471- 244X-12-20

Evans, K. (2013). Historical foundations. In R. Elder, K. Evans, & D. Nizette. (Eds.) Psychiatric and mental health nursing (3rd ed., pp.35-53). Sydney, Australia: Elsevier. Foster, K. (2013). Working with consumers. In R. Elder, K. Evans, & D. Nizette (Eds.), Psychiatric and mental health nursing (3rd ed., pp.453-469).

Sydney, Australia: Elsevier. Mental Health (Compulsory Assessment and Treatment) Act 1992 (1992)

Ministry of Health & Health Promotion Agency. (2014). Like minds, like mine national plan 2014-2019: Programme to increase social inclusion and reduce stigma and discrimination for people with experience of mental illness. Wellington, New Zealand: Ministry of Health.

Ministry of Health. (2008). Let’s get real: Real skills for people working in mental health and addiction. Wellington, New Zealand: Author.

Ministry of Health. (2012). Rising to the challenge. The mental health and addiction service development plan 2012-2017. Wellington, New Zealand: Author.

Muir-Cochrane, E., O’Brien, A., & Wand, T. (2013). The Australian and New Zealand politico-legal context. In R. Elder, K. Evans, & D. Nizette. (Eds.) Psychiatric and mental health nursing (3rd ed., pp.54-67). Sydney, Australia: Elsevier.

New Zealand Nurses Organisation. (2013). Code of ethics. Retrieved from http://www.nzno.org.nz/Portals/0/publications/Guideline%20-%20Code%20of%20Ethics%20(2010%202013).pdf

New Zealand Nursing Council (2012) Code of conduct. [Brochure]. Wellington, New Zealand: New Zealand Nursing Council.

Phoenix Research. (2011). Impacts of national media campaign to counter stigma and discrimination associated with mental illness. Survey 11: Response to fifth phase of campaign. Auckland, New Zealand: Author.

Richardson, F., McEldowney, R., & Puckey, T. (2015). Cultural safety in mental health. A practice example. In D. Wepa (Ed.). Cultural safety in Aotearoa

New Zealand (2nd ed., pp.159-176). Melbourne, Australia: Cambridge University Press.

Scigliano, G., & Ronchetti, G. (2013). Antipsychotic-induced metabolic and cardiovascular side effects in schizophrenia: A novel mechanistic hypothesis. CNS Drugs, 27(4), 249-257. Retrieved from https://link.springer.com/journal/40263

Te Pou o Te Whakaaro Nui. (2009). Challenging stigma and discrimination.Essential level learning module. Auckland, New Zealand: Author.

Te Pou o Te Whakaaro Nui. (2010). He rongoā kei te korero: Talking therapies for Māori. Wise practice guide for mental health and addiction services. Auckland, New Zealand: Author.

Te Pou o Te Whakaaro Nui. (2017). Engagement essentials. Auckland, New Zealand: Author.

Te Pou o Te Whakaaro Nui. (2017). The physical health of people with mental health conditions and/or addiction: Evidence update December 2017. Auckland, New Zealand: Author.

Thornicroft, C., Wyllie, A., Thornicroft, G., & Mehta, N. (2014). Impact of the “Like Minds, Like Mine” anti-stigma and discrimination campaign in New Zealand on anticipated and experienced discrimination. Australian & New Zealand Journal of Psychiatry, 48(4), 360-370. Retrieved from http://journals.sagepub.com/home/anp

United Nations. (1991). United Nations principles for the protection of persons with mental illness and for the improvement of mental health hare.

Retrieved from http://www.who.int/mental_health/policy/en/UN_Resolution_on_protecti on_of_persons_with_mental_illness.pdf

 

Is Stigma and Discrimination Still a part of Society’s Behaviour? 

By Casey Trownson

 

Stigma and discrimination are still a part of society’s behaviour at a macro, or large-scale level in the form of Structural Stigma, and at a micro, or small-scale level through self-stigma. They may always exist because they stem from a primitive judgement-making neurocircuit (Dahlitz, 2017), but myriad evidence suggests that reduction is possible through face-to-face encounter (Bingham & O’brien, 2017) and self-reflection to challenge own judgements (Monteiro & Fernandes, 2016).

Judgements about social approachability occur though a neurocircuit composed of sensory organs, the thalamus, the amygdala, the hippocampus and the neocortex, which is activated by seeing someone’s face (Bechara & Damasio, 2016). Sensory neurotransmissions are sent to the thalamus for processing, which causes the amygdala to retrieve spatial memories of experience from the hippocampus, and socially-relevant knowledge about the quality of similar past experiences from the neocortex (Dahlitz, 2017). The result of this circuit either informs that the person is approachable, which activates the parasympathetic ventral vagal branch, or the social system (Hall, Whalley, McKirdy, Sprengelmeyer, & Santos, 2014). Or, it informs to not approach to maintain safety, activating the sympathetic nervous system (Dahlitz, 2017). Thus, it is an innate part of human behaviour to make judgements about approachability to promote safety (Dahlitz, 2017).

However, this neurocircuit is primitive, and since the frontal lobe has surpassed its development, humans can now activate the circuit without face-to-face encounter and visual sensory information, by going straight to hippocampus and neocortex memory recall, through frontal lobe forethought and imagining the person, giving a generalised judgement to inform sympathetic or parasympathetic response (Dahlitz, 2017). This is theorised to form the basis of stigma, which becomes discrimination when the sympathetic nervous system activation drives avoidance or exclusion from social interaction and other opportunities (Hall, Whalley, McKirdy, Sprengelmeyer, & Santos, 2014). This gives the definition of discrimination that is a prejudicial treatment of people, based on preconceived judgement (Wharne, 2011).

Furthermore, stigma and discrimination also have sociological underpinnings. Structural Stigma is restricted access to opportunities and resources for a target group due to institutional policies influenced by conditions of society such as cultural and social norms (Hatzenbuehler, 2016). In the healthcare setting, this dictates what clinical areas are allocated the most funding, or in other words, which areas are allocated less (DeLuca, Clement & Yanos, 2017). This has been found to reign true at a micro-perspective in personal clinical practice, where the medical and surgical sectors are equipped with adequate desktop computers and laptops. In addiction services however, staff were using textbooks to elevate slow and outdated computer monitors to the correct ergonomic height.

A macro example of this includes The Healthcare Reformation of New Zealand, which was defined by the transition from institutionalised care to more community-based care (Scott, 2016). Ideally, this seemed like a breakthrough in healthcare as it aimed to re-integrate mental health service users into society, which theoretically should have functioned to reduce stigma and discrimination. Although, the reality was that it had the opposite effect because while mental health institutions were being closed, other aspects of the reformation such as the costly development of local, regional and cultural mainstream health agencies were occurring at the same time (Scott, 2016). Such a largescale reformation was ill-coordinated, resulting retracted mental health funding, giving lack of support and macro-discrimination from opportunities for mental health service users (Scott, 2016).

Although, while it is easy to blame those in higher positions for the discrimination because of structural stigma, this issue has an ongoing microlevel sociological responsibility with self-stigma. Self-stigma is a personally internalised form of stigma asserted on the self that damages self-esteem and self-efficacy, creating barriers to accessing mental health and addiction services on one’s own initiative (Stanton, Tooth & Champ, 2016). Some barriers include low expectations of services and low motivation to pursue better opportunities for quality of life, giving microlevel discrimination (Stanton, Tooth & Champ, 2016). For example, while funding is more likely to be denied to areas where people are believed to be responsible for their own predicament such as addiction (Skitka & Tetlock, 1992) and people are also still generally more accepting of budget cuts to mental health and addiction services (DeLuca, Clement & Yanos, 2017). This was demonstrated locally following the Health Care Reformation where many questioned the ability of authorities to make sound judgements about funding allocation without first-person contact with those directly affected, but scarcely pursued it (Scott, 2016). Are those who neglect to respond to stigma and discrimination equally as liable for entertaining it as those who actively demonstrate it?

This complex combination of neuro and social sciences that underpin stigma and discrimination have influenced nursing practice by driving a new assertive outreach approach and self-reflection to challenge own judgements. Assertive outreach brings mental health and addiction services to clients, rather than relying on client-initiated secondary or tertiary access (Wharne, 2011), thereby mitigating self-stigma as a barrier to care (Clement et al., 2015). Another of its merits is that it helps nurses to reconsider judgements when discerning ‘otherness’ from ‘risk’, which are easily confused in the secondary setting, through first-person encounter with the client’s social functioning in their community setting (Wharne, 2011). Does the fact that assertive outreach is such a current issue evidence the existence of stigma and discrimination as part of society’s behaviour?

However, effective assertive outreach relies heavily on being done in a culturally competent manner because different ideas of normality and abnormality regarding mental health and addiction exist across different cultures (Short, Sharman & Speedy, 1998). Failure to recognise so may result in offence, creating further barriers to mental health and addiction nursing cares, giving isolation and facilitation of stigma and discrimination (Short, Sharman & Speedy, 1998). The cultural safety implications for nursing those with differing mental health and addiction related beliefs and practices lay in the need for heavier implementation of the Tripartite Cultural Competence Model, cited by Monteiro and Fernandes (2016), which can be analysed through its three constituents; cultural awareness, cultural knowledge, and cultural skills.

Firstly, there is a necessity for cultural self-awareness involving self-reflection and analysis of own cultural beliefs, practices and prejudices, especially since some may not even consider that their mental health and addiction related beliefs are stigmatised (Monteiro & Fernandes, 2016). Secondly, a sound knowledge of other existing cultural perceptions about mental health and addiction must be developed (Monteiro & Fernandes, 2016). This can be achieved through exploring literature, practical experience, or, simply asking the individual. After all, the individual bearer is the expert of their own culture (Spence, 2015). Thirdly, there is a need to demonstrate sound cross-cultural skills to make meaningful interaction, despite discrepancies in mental health and addiction related beliefs and practices (Monteiro & Fernandes, 2016).

Here, the constituents combine to allow for a compare and contrast model to challenge one’s own judgement by daring to see the world of mental health and addiction wearing another’s cultural lens (Spencer, 2015). The interrelated significance of this model lay in the fact that mental health and addiction service users want their service translated into a cultural context that they understand, giving the nurse the power to choose how existing beliefs, like stigma, impact on patient-nurse communication (Short, Sharman & Speedy, 1998).

While on one hand, both the neurocircuit previously explained and Wharne (2011) suggest there is potential for an inhibitory impact on communication, where stigmatised belief of either party drives social avoidance, giving communication barriers and exclusion from service. On the other hand, conscious and honest recognition of stigmatised beliefs can become the construct for powerful and effective patient-nurse communication because it allows for action plans to be put in place, which ensure that the stigmatised beliefs do not result in communication breakdowns and discrimination from opportunities of service (Billingsley & Corey, 2018). This is known as therapeutic use of self, in which many recognise the importance of self-examination of personality, insights, culture and judgements, but true meaning and depth lay in translating self-examination into practice (Taylor, Lee, Kielhofner & Ketkar, 2009).

On that note, it should be asked what the culture of the nursing profession communicates about mental health and addiction related stigma and discrimination, and the impact of this. The Mental Health Compulsory Assessment and Treatment Act (1992) will be used as a vessel to illustrate that ethical, legal and professional issues of the nursing culture tend to each either facilitate or inhibit stigma and discrimination. From an ethical perspective, the Act can be seen to entertain stigma, where it is argued that it is an insult to the principles of justice and autonomy to enact for perceived risk, rather than actual need (O’Brien, 2018). Is this not simply a less blatant form of institutionalisation giving rise to stigma and discrimination? Especially when self-autonomy is a not only a principle of the Treaty of Waitangi, but also a patient right and nursing responsibility as Crown Agents (Nursing Council of New Zealand, 2011). Alternatively, legal perspective argues that the Act inhibits stigma where the person concerned is physically seen at all substantial points of the process. Firstly, an eligible applicant must have physically seen the person no longer than three days before making the application (Mental Health Compulsory Assessment and Treatment Act, 1992 s 8A). Secondly, the practitioner issuing the certificate accompanying the application must also have personally examined the person (Mental Health Compulsory Assessment and Treatment Act, 1992 s 8B). Thirdly, when an application is received, the person must immediately be seen by a psychiatrist for assessment examination (Mental Health Compulsory Assessment and Treatment Act, 1992 s 3b). And finally, the person, not the application alone, must be personally seen by a judge (Mental Health Compulsory Assessment and Treatment Act, 1992 s 18). This is supported by the neuroscience of face-to-face encounter that consummates sound judgement.

Similarly, professional conduct should in theory have an inhibitory impact on stigma and discrimination, where principle 1.7 of the Code of Conduct for Nurses (2012) discourages prejudicing cares given, and principle 3.3 encourages upholding the health consumer’s right to participate in decision-making about their cares (Nursing Council of New Zealand, 2012). However, adherence to law under the Act has been personally seen to overshadow said aspects of ethical and professional conduct by removing self-autonomy and subjecting the person to a treatment to which not only may they not consent, but also differs to that of which a mentally sound or compliant person would receive. This inconsistency communicates confusing ideas about the impact of nursing culture on stigma and discrimination. However, it is the recognition of agents that facilitate and inhibit stigma and discrimination that drive higher cognitive processes like the response to their existence (Dahlitz, 2017).

Exemplary interventions have been developed in response to stigma and discrimination, which evidences their existence in society’s behaviour. A successful local intervention to reduce stigma and discrimination involves the integration of supervised mental health clinical placement in the first year of undergraduate nursing. Not only has this has been researched by Bingham & O’Brien (2017) to produce positive changes in stigmatising attitudes and assumptions by reducing social anxiety, its effectiveness has been personally evidenced at a microlevel, giving the research strength through clear transferability to personal practice.

For example, it used to be believed that people who experience bipolar made incompetent parents, as influenced by the fact that stable parenting is personally valued and another societal belief that people should not pass on the burden of their psychiatric issues by childbearing (Meiser et al., 2007). Interestingly, the opposite was and still is believed about parents experiencing addiction, despite the worldwide macro-view telling otherwise (Kolodny, 2009). In reflection, personally having a parent who experienced addiction, giving a means to face-to-face encounter, most-likely consummated the difference in judgements. After meeting a mother living with bipolar, who bore and raised three healthy children, not only was the personal belief challenged, but completely changed to the point where discussion about parenthood would be encouraged in future mental health and addiction practice because whether planned or not, it is a possibility where careful consideration toward the implications of lifestyle make a positive impact on the experience (Meiser et al., 2007).

However, the meritorious result of this local initiative lacks generalisability to individuals outside of the nursing population, given that the participants were all nursing students. Fortunately, a macro-level anti-stigma and discrimination intervention called the Like Minds Like Mine Campaign (Mental Health Commission, 2014) covers this gap in demographics with a target population that better represents that of New Zealand society. It too has research-based evidence to prove its fruitfulness, where 48% of participants reported definite reduction of stigma and discrimination (Thornicroft, Wyllie, Thornicroft & Mehta, 2013).

So, what does all of this teach about the human experience in a society where stigma and discrimination are a reality? The answer is hope in power of contact with those who experience mental health and addiction to challenge stigmatising beliefs and ill-informed judgements that contribute to discrimination (Ministry of Health, 2015). Thus, the solution has not been under our nose all this time, but above rather, with the eyes in face-to-face encounter, and the brain in self-reflection.

 

References

Bechara, A., & Damasio, H. (2016). Role of amygdala in decision-making. Annals of the New York Academy of Sciences, 985(1), 356-369. doi: 10.1111/j.1749-6632.2003.tb07094.x

Billingsley, K., & Corey, D. (2018). Deconstructing stigma in the therapeutic relationship. In B. Canfield & A. Cunningham (Eds.), Deconstructing stigma in mental health (pp.1-19). Hershey, PA: IGI Global

Bingham, H., & O’Brien, A. (2017). Educational intervention to decrease stigmatising attitudes of undergraduate nurses towards people with mental illness. International Journal of Mental Health Nursing, 26(2), 311-319. doi: 10.1111/inm.12322

Clement, S., Schauman, O., Graham, T., Maggioni, F., Evens-Lacko, S., Bezborodovs, N., Morgan, C., Rusch, N., Brown, J., & Thornicroft, G. (2015). What is the impact of mental health-related stigma on help seeking? A systematic review of quantitative and qualitative studies. Psychological Medicine, 45(1), 11-27. doi: 10.1017/S0033291714000129

Dahlitz, M. (2017). The psychotherapist’s essential guide to the brain. Brisbane, Australia: Dahlitz Media.

DeLuca, J., Clement, T., & Yanos, P. (2017). Does individual stigma predict mental health funding attitudes? Toward an understanding of resource allocation and social climate. The Israel Journal of Psychiatry and Related Sciences, 54(1), 6-17. doi: 10.1023/B:COHM.0000035226.19939.76

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