Fri 28 Sep 2018

Nurses' essays

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 on October 8 a selection of these essays will be shared each week.

Two of the students whose essays are being published in WITT News have asked that their names not be attached. Those two essays are published below.

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

Essay 1:


Two major factors that impact the quality of life [QOL] for people with mental illness [MI] are stigma and discrimination. These issues are problems that have existed on a global level throughout history (Fernando, 2010). Throughout this essay, a critical analysis will take place on the degree of stigma and discrimination that still exists in society today. The approach to this topic will take a unique direction, as Māori mental health [MH] and the impact of generational trauma will be analysed in respect to New Zealand’s [NZ] unique bicultural society. Māori continue to be significantly over-represented in MH statistics and frequently experience stigma and discrimination from both the public and the healthcare system (O’Brien, 2017). In respect to this, interventions to reduce stigma will be discussed from both a nursing and public perspective, and the effectiveness of these interventions will be considered through the analysis of evidence-based literature.

To analysis stigma and discrimination, it is important to understand these words when applied to MH. Stigma is a judgement that deems an individual to be unworthy or dangerous. People who possess stigmatising beliefs often avoid socially interacting with mental health consumers [MHC] as they believe they are unpredictable or not worthy of respect (Fernando, 2010). When stigmatising beliefs translate into action, this becomes discrimination. Both have the potential to significantly impact a person’s QOL when experiencing MI. Additionally, the existence of stigmatising beliefs can often generate self-stigmatising beliefs. Self- stigma is an internalised, negative connotation based on the attitudes that exist within society (Fernando, 2010).

From a macro perspective, the NZ government has recently recognised the need to reform MH services so that anti-discriminatory care is prioritised. This aim forms the basis for the Ministry of Health’s Mental Health and Addiction Workforce Action Plan. This five-year plan addresses the impact of trauma on the MH of Māori and highlights discrimination and stigma as barriers to recovery.

This is critical for NZ, as trauma-informed care has the potential to comprehend the generational trauma experienced by Māori following colonisation (Ministry of Health, 2018). Interestingly, reducing discrimination for indigenous MHC was not always a priority for NZ. In 2007, the United Nations [UN] presented the Declaration on Rights of Indigenous People. Of all states, NZ was one of four that voted against this declaration. However, since the signing of this declaration, NZ has reversed their position and now acts in support of it (United Nations, 2008).

On a micro level, acknowledging the role of trauma can have a significant impact on the existence of self-stigma. In a Mental Health Foundation (NZ) endorsed study, participants described acknowledging the role of trauma as a predisposing factor for MI and contributed this to self-stigma. This was due to feelings of hopelessness and feeling as if there were too many barriers in place to realise their potential (Peterson, Barnes, & Duncan, 2008). In contrast to this, Bulanda and Byro-Johnson (2016), highlight that recognising the role of trauma on MI could be empowering, decreasing self-stigma. Being given a MI diagnostic label for trauma survivors (including generational trauma) can instil hope and a sense recovery, making MI more manageable by removing any sense of self-blame.

From a nursing perspective, legal issues can create contradicting implications. A legal factor that contributes society’s existing stigmatising beliefs is the Mental Health Act (1992). The Act aims to ensure vulnerable, unwell patients can receive care that reduces the potential for harm being caused to themselves or others. Supporters of this Act believe compulsory treatment can be given in a way that upholds the rights of the MHC and provides treatment through the safest course of action (Burgess, 2012). There are both positive and negative implications associated with this Act. However, unfortunately this Act reinforces the negative undertones that many possess about MHCs, such as that they are unfit to make their own decisions, and pose a threat to public safety (O’Brien, 2017).

 One ethical dilemma that is associated with involuntary treatment is loss of autonomy. For an ethically educated nurse, this loss of patient autonomy could cause moral distress as the nurse is witness to the loss of freedom of the client, but is bound to follow through with treatment due to the legalities of the Act (Eren, 2014). To overcome this, nurses need to conduct their practice with a high degree of professionalism to ensure the wellbeing of the client. Professionalism is an essential component needed to object the stigma and discrimination that exists within society and the healthcare system. The Nursing Council of New Zealand’s [NCNZ] Code of Conduct (2012), states nurses should act in a way that does not discriminate the individuality of a patient. This should be done by acting with integrity, and placing respect for the patient at the forefront of decisions. To do this reflection should take place on how personal beliefs may impact on nursing care.

A specific nursing consideration in NZ is the over-representation of Māori in MH statistics. Prior to colonisation, and the introduction of the biomedical framework, Māori had low rates of MI and used traditional healing practices to treat physical and mental ailments. In the past, the use of traditional healing practices to treat illness was highly discriminated against (Durie, 2009). This can be seen through the introduction of the Tohunga Suppression Act (1907) that criminalised the use of spiritual tohunga practices. Although repealed in 1964, this disregarded the wisdom of Māori and their approach to Māori illnesses. The integration of Māori practices into the mainstream health service is a requirement of the Treaty of Waitangi, as Māori health practices are considered a taonga (Wilson & Haretuku, 2015).

Through analysing the epidemiology of Māori MI, it has been recognised that the Māori population has seen an increase in treatment by 72% in the last sixteen years. This is comparable to 36% for the Pākehā population. Interestingly, this is also noticeable in the rates of access to service of 6.1% of Māori, compared to 3% of non-Māori (Ministry of health, 2017). When analysing these statistics it is important to incorporate social factors that may have contributed to these rates. In a NZ Ministry of Social Development study, changes to socio-economic factor in the last twenty years were associated with significant health determinants. For example, benefit cuts in the late 1990s, increased the equality gap for low socioeconomic New Zealanders. This has resulted in an estimated one million people living in hardship. Changes to society can clearly be associated with increased levels deprivation, exposing the most vulnerable to increased MI risk (Casswell, Huakau, Howden-Chapman & Perry, 2011).

It is also important to consider the role of epigenetics and neurobiology, and how this can impact on a person’s MH. In a review of two studies undertaken on colonised populations, similar results were yielded, suggesting that the existence of generational trauma caused a significant methylation change in the genes that process the body’s stress response (Walters, Mohammed, Evans-Campbell, Beltrán, Chae & Duran, 2011; Verny, 2016). Trauma can also alter the function of the neuroendocrine system, which can have significant impacts on a person’s health. Alterations in cortisol levels and gene methylation changes the body’s adaptive responses and caused overactivation of the sympathetic nervous system. This overactivation, and the neurobiological impacts of stress could significantly alter neurodevelopment, hypothalamic-pituitary-adrenal axis function and the incidence of chronic MI (Walters et al., 2011; Verny, 2016).

Recognising the scientific implications that contribute to the onset of MI is important for destabilising stigmatising beliefs (O’Brien, 2017). Throughout undergraduate nursing study, there has been significant changes in the way MI is viewed. Past perceptions on MHC were based on media portrayals and the sentiments echoed by older family members. This created stigmatising beliefs based on fear and uncertainty, and eventually led to an outright avoidance of MHC.

Even  more damaging, was the views that existed about the Māori MHC population. The perception of this population was influenced by an attitude of victim blaming and non-existent acknowledgement for the role of colonisation. This lead to a complete disregard on the effect trauma on current Māori realities. Reflecting on past views is a confronting process met with guilt and shame. However, through the power of knowledge this shame can be transferred into a proactive commitment to dedicate oneself to safe MH care as a future Registered Nurse.

The most significant professional growth that has taken place during undergraduate nursing study has been through contact-based learning. This evidence-based approach has incorporated classroom sessions with MH consumers and placements within a MH service. Bingham and O’Brien (2018), describe the positive changes that take place surrounding student’s stigmatising beliefs when guided through contact-based experiences. It was recognised that the beliefs held about MHSC contributed to high levels of anxiety in the clinical situation, hindering learning experiences. However, through careful guidance and exposure to lived-experiences, positive changes can be seen in student nurse’s beliefs and attitudes (Bingham & O’Brien, 2018).

An unexpected finding from contact-based intervention was the MHC’s experience of discrimination by the healthcare workforce. Participants in the lived-experience program reported that when this occurred, feelings of helplessness and distrust in the healthcare system developed. An example of this was seen through the reflection from a female client. The client reported that when seeking help for their MI issues they were accused of attention-seeking. This resulted in the client feeling as if they had been shunned from the system and led to them seeking relief from alcohol and drugs. As expected, this resulted in a further deterioration of the client’s MH. It is disappointing to consider that if that client had been treated with dignity and respect, their recovery path would have been more empowering and with greater satisfaction.

Discrimination within the MH system significantly contributes to disengagement from the service and poor MH outcomes. Because of this, positive health experiences greatly rely on the nurse-patient relationship. Clients with past negative experiences with the healthcare system, are more likely to hold self- protective barriers, effecting verbal and non-verbal communication (Sewell, 2009). Leininger’s (1991) Transcultural Care Theory states nurse-client relationships should be based respect for the individuality of the client. For effective communication, nurses should have an appreciation for the client’s needs and the barriers that exist in that person’s health care journey.

Eliminating stigma has been identified as a priority to improve the quality of life for MH service users. Recently, there has been a drive to raise awareness about the stigma and discrimination faced by MH consumers (Ministry of Health, 2018). One public awareness program is Mike King’s internationally acclaimed Nutters Club. This movement is based on peer support and the sharing of personal life stories. By utilising social media, Mike King and guests invite discussion about the journey of MI and barriers to recovery. By sharing stories from ordinary New Zealanders, this health promotion model is striving to raise awareness, remove fear and address the stigma that surrounds the MI recovery process (The Key to Life, 2016).

In a study undertaken by Livingston, Tugwell, Korf-Uzan, Cianfrone and Coniglio (2012), a similar campaign was evaluated for effectiveness of stigma reduction on the Canadian population. Interestingly, following analysis of surveys undertaken prior [T1] and post [T2] exposure to the campaign, the desired outcome of the campaign was not achieved. When the attitudes towards MI were compared from T1 and T2 surveys, there was no changes in stigmatising beliefs. Although levels of stigma remained unchanged, respondents reported that the campaign has inspired discussion about MI within social circles. In this way, it could be concluded that social campaigns could create a greater awareness of MI, instead of a reduction of stigma (Livingston et al., 2012). As attitudes towards MI are influenced by multiple factors, it would be of interest to conduct further research on NZ’s response to public awareness campaigns.

Equally important as awareness, is the importance of offering a culturally safe environment so clients feel comfortable to access MH services. This should include showing acceptance towards NZ’s bicultural health practices. When working within a biomedical framework it is easy to dismiss the validity of traditional healing practices and alternative medicine. This is because some disregard this form of medicine as non-evidence based and discriminate its use (Wintrob, 2009). In recent years, there has been a resurgence in traditional Māori health practices within the MH system. From this there has been a growth in the understanding of cultural safety and the effectiveness of treating Māori illness with a Māori worldview (Wilson & Hickey, 2015). Through recognising the need for Māori psychotherapy in practice, nurses strive to offer a safe space for the recovery from generational trauma (Rigby, 2017).

The stigma and discrimination that people experience, and especially Māori, when accessing MH services still exist despite the great drive from society to change this. Although, progress has been made in recent years, it is more of a question of has NZ become more tolerant and accepting, rather than removed stigma and discrimination? As discussed in this essay, Māori continue to be over-represented in the majority of MH statistics, and experience a high level of stigma. It will take a combined effort from both healthcare services and society to overcome this. However, by gaining an understanding on the generational trauma that exists for Māori, progress can be made to create a society that treats all with greater respect and understanding.


Bulanda, J., & Byro-Johnson, T. (2016). A trauma-informed model for empowerment programs targeting vulnerable youth. Child & Adolescent Social Work Journal, 33(4), 303-312. DOI:10.1007/s10560-015-0427-z.

Burgess, M. (2012). A guide to the law for nurses and midwives (4th ed.).

Auckland, New Zealand: Pearson Education New Zealand.

Carrolli, P., Casswell, S., Huakau, J., Howden-Chapman, P., & Perry, P. (2011).

The widening gap: Perceptions of poverty and income inequalities and implications for health and social outcomes. Retrieved from work/publications-resources/journals-and-magazines/social-policy- journal/spj37/08-carroll-et-al.pdf.

Durie, M. (2009). Māori knowledge and medical science. In M. Incayawar, R. Wintrob, L. Bouchard, & G. Bartocci (Eds.), Psychiatrists and traditional healers: Unwitting partners in global mental health (pp. 237 – 248). Oxford, United Kingdom: Wiley Blackwell.

Eren, N. (2014). Nurses' attitudes toward ethical issues in psychiatric inpatient settings. Nursing Ethics, 21(3), 359-373.


Fernando, S. (2010). Mental health, race and culture (3rd ed.). London, United Kingdom: Palgrave Macmillan.

Livingston, J., Tugwell, A., Korf-uzan, K., Cianfrone, M., & Coniglio, C. (2013). Evaluation of a campaign to improve awareness and attitudes of young people towards mental health issues. Social Psychiatry and Psychiatric Epidemiology, 48(6), 965-973. doi:10.1007/s00127-012-0617-3.

McClintock, K., Haereroa, M., Brown, T., Baker, M. (2018). Kia hora te marino: Trauma informed care for Māori. Wellington, New Zealand: Te Rau Matati.

Ministry of Health. (2017). Director of Mental Health’s Annual Report for 2016 released. Retrieved 14 August, 2018 from healths-annual-report-2016-released

Ministry of Health. (2018). Mental health and addiction workforce action plan 2017–2021. Retrieved from health-addiction-workforce-action-plan-2017-2021-2nd-edn-apr18.pdf                                                                                                                                             

Nursing Council of New Zealand. (2012). Code of conduct for nurses. Wellington, New Zealand: Author.

O’Brien, A. (2017). Meeting the mental health needs of individuals and their carers. In J. Crisp, C. Taylor, C. Douglas, G. Rebeirio, & D. Walters. (Eds.). Potter & Perry’s fundamentals of nursing (5th ed., pp1467-1489) Sydney, Australia: Elsevier.

Peterson, D., Barnes, A., & Duncan, C. (2008). Fighting shadows: Self-stigma and mental illness: Whawhai atu te whakamā hihira. Auckland, New Zealand: Mental Health Foundation of New Zealand.

Rigby, G. (2017). Therapist and coloniser: Pākehā approaches to Māori historical trauma. Ata: Journal of Psychotherapy Aotearoa New Zealand, 21(2), 119–131. Retrieved from

Sewell, H. (2009). Working with ethnicity, race and culture in mental health: A handbook for practitioners. London, United Kingdom: Jessica Kingsley Publishers.

The Key to Life. (2016). The nutters club. Retrieved 15 August, 2018 from

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Verny, T. (2016). Do genes matter? Journal of Prenatal & Perinatal Psychology & Health, 30(4), 227-255. Retrieved from

Walters, K., Mohammed., Evans-Campbell, T., Beltrán, R., Chae, D., & Duran, B. (2011). Bodies don’t just tell stories, they tell histories: Embodiment of historical trauma among American Indians and Alaska natives. Du Bois Review, 8(1), 179-189. DOI:10.1017/S1742058X1100018X.

Wilson, D., & Haretuku, R. (2015). Te Tiriti o Waitangi/Treaty of Waitangi 1840: Its influence on health practice. In D. Wepa (Eds.), Cultural safety in Aotearoa New Zealand (2nd ed., pp. 79-98). Melbourne, Australia: Cambridge University Press.

Wilson, D., & Hickey, H. (2015). Māori health: Māori and whānau-centred practice. In D. Wepa (Ed.), Cultural safety in Aotearoa New Zealand (2nd ed., pp. 235-251). Melbourne, Australia: Cambridge University Press.

Wintrob, R. (2009). Overview: looking towards the future of shared knowledge and healing practices. In M. Incayawar, R. Wintrob, L. Bouchard, & G. Bartocci (Eds.), Psychiatrists and traditional healers: Unwitting partners in global mental health (pp. 1 – 11). Oxford, United Kingdom: Wiley Blackwell.


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

Essay 2:

 Society is defined as a group bound by geographic location or by common culture whom interact and behave in a mutually acceptable way (Brohan, Slade, Clement, & Thornicroft, 2010; Picco et al, 2017). When a group or individual does not meet the socially defined criteria because of physical or mental illness or disability; age, gender or race, they are defined as such by an accompanying stigma which is then used to justify their exclusion from society, known as discrimination. (Brohan et al, 2010). With the case of mental illness this stigma is particularly pronounced and although other groups experience discrimination, it is well documented that the mentally ill experience some of the worst stigma and isolation of all groups of society (Bardwell & Taylor, 2013; O’Brien, 2017).

When looking at stigma from a macro perspective, an image prevails of how historically people with mental illness were shut away in institutions, often against their will and without their dignity (Bardwell & Taylor, 2013). At this time, discipline, control and custodial care were the hallmarks of mental health nursing which further negatively exposes the treatment of those with mental illness challenges (Jackson & O’Brien, 2013). This sordid history contributes to the stereotyping of mental health clients and plays a key part in cultivating and maintaining stigma. Furthermore, popular movies and other media continue to present the image of those experiencing mental illness as unpredictable, dangerous and deranged (Bardwell & Taylor, 2013).

From a micro perspective an individual who is experiencing mental illness may apply this stigma to themselves in a phenomenon known as self-stigma (O’ Brien, 2017). Self-stigma refers to how an individual with a mental illness is aware of the negative stereotypes associated with their illness, and applies them to themselves (Horsselenberg, van Busschbach, Aleman & Gerdine, 2016). It occurs through a process of internalisation and negatively affects a person’s self-esteem (Horsselenberg et al, 2016), which then becomes a barrier to their seeking health care and severely hinders their recovery (O’Brien, 2017).

The effects of self-stigma were observed when meeting an individual with bi-polar during a Supporting Families session. They shared that they wrote a blog to document their experiences with the goal that it could help others whom had a similar diagnosis. However, when asked if they attended local support groups with the same intention, the individual quickly stated that no, they were not that crazy. This was evidence of self-stigma persisting even though the person had acknowledged their illness and had insight into their diagnosis (Horsselenberg et al, 2016).

Understanding stigma as a barrier to recovery was gained when caring for an elderly Chinese client whom was experiencing major depressive disorder. It is well documented that in traditional Chinese culture mental illness is interpreted as punishment for wrongdoings, therefore shame and exclusion result from a diagnosis (Liu, Hinton, Tran, Hinton, & Barker, 2008; Ramsey, 2010; Tang & Wu, 2012). When attempts were made to discuss mood, the client responded by referring to somatic pain and stated the medications (which were antidepressants) were not helping with their sore knees.

Tang and Wu (2012) explain how in Chinese culture, the family collective protects itself from public shame by concealing their mentally unwell to avoid the stigma affecting them. In this way, recovery can be restricted by an individual or family whom do not access help (Ramsey, 2010). It was understood that for these cultural reasons the client refused to acknowledge their mental illness as a way of protecting their family’s integrity.

Once the client’s cultural beliefs and values were identified, the focus shifted to setting goals surrounding their physical health with the knowledge that appropriate nutrition, exercise and sleep should affect the client’s mood in a positive way (Moyle, 2013). Treating the individual with regard to the stigma within their culture ensured culturally safe care was provided (Richardson, McEldowney & Puckney, 2015).

When after a few weeks the client’s depression showed no improvement despite good adherence to medications, the psychiatrist introduced the option of electroconvulsive therapy (ECT). The stigma surrounding ECT is perhaps one of the most unfortunate legacies of the past where imagery raised at its mention is so disturbing that it is not considered a legitimate treatment (Palmer, 2013). Depicted as the essence of cruelty in many horror movies and historical accounts of maltreatment, ECT is still considered controversial although research shows the treatment has fewer side effects than antidepressant medications (Palmer, 2013), and is often immediately effective whereas medication can take weeks or months to show efficacy (Rosen, Kung & Lapid, 2016).

ECT is performed under general anaesthetic using a muscle relaxant, therefore the resulting seizure has little to no effect on the client (Athanasos, 2013). It is believed the seizure initiates the release of large amounts of the neurotransmitters serotonin, adrenaline and noradrenaline, while also increasing the responsiveness of the neurons to these chemicals, thereby affecting mood (Ministry of Health, 2009). ECT has had particular success in the elderly with a study by Rosen, Kung & Lapid (2016), showing greater long-term benefits and fewer re-hospitalisations following treatment. Furthermore, impaired liver or renal function as a result of ageing means that older people are often unable to take anti-depressant medications due to their side effects (Moyle, 2013; McKenna & Lim, 2014). In this case, the client’s wishes were respected, trust maintained, and pharmacological treatment continued.

Prior to this encounter, the student had no experience of caring for Asian peoples in a mental health setting and was also challenged by preconceptions about ECT. By learning more about both aspects and examining self-held beliefs, culturally safe care was assured. The New Zealand population of Asian peoples is rapidly growing so having this knowledge will assist in future encounters (appendix 1). Developing the therapeutic relationship required patience and compassion while also ensuring the barriers produced by language and cultural stigma did not affect the calibre of care (Richardson et al, 2015).

Conversely, when on placement in the emergency department (ED), it was noticed staff made little effort to form a therapeutic alliance with those experiencing suicidal ideation. The clients were given a bed, their curtains were closed, and they were left alone for hours waiting for a member of the mental health crisis team. Further research reinforced that this experience of care is unfortunately often the case for those presenting to emergency departments in psychological distress (van Nieuwenhuizen et al, 2013; Shefer, Henderson, Howard, Murray, & Thornicroft, 2014).

Discrimination resulting from mental illness stigma within the medical field is well documented and is referred to as diagnostic overshadowing (Te Pou o te Whakaaro Nui [Te Pou], 2017; Thornicroft et al, 2016). Issues relating to impaired communication or challenging behaviour contribute to the misattribution of symptoms to the individual’s mental illness (Te Pou, 2017), therefore further diagnostic testing does not progress (Wheeler, McKenna & Madell, 2013). Furthermore, due to stereotypes which prevail about the lifestyle habits of people with mental illness, physical health is often disregarded when seeking healthcare.

This discrimination contributes to increased morbidity and mortality among those with a mental illness as discovered in a New Zealand study (Wheeler et al, 2013). It is well understood that long-term use of many antipsychotic and antidepressant medications lead to a condition known as metabolic syndrome, the associated symptoms of which are hypertension, hyperlipidemia, abdominal obesity and insulin resistance. Together these increase the risk of cardiovascular disease, diabetes and stroke (Usher & Foster, 2013). Medical practitioners should be alert to the increased risk factors however this is not always the case (Staveley, Soosay, & O'Brien, 2017).

When examining the professional and ethical breaches caused by diagnostic overshadowing the values of beneficence and non-maleficence are both compromised in this situation. The prevention of future harm is a key aspect of non-maleficence (New Zealand Nurses Organisation [NZNO], 2010), and by ignoring physical symptoms due to the presence of mental illness, justice is also impaired due to the unfair treatment (NZNO, 2010). The Nursing Council of New Zealand (NCNZ) Code of Conduct states in Standard 3.8 that a nurse is required to advocate and influence for the health of vulnerable consumers (NCNZ, 2012), which should occur in all situations where unfair or unsafe treatment occurs. Interestingly, discrimination which results in under-treatment of physical illness is also perhaps linked to the over-treatment of mental illness.

New Zealand currently has the second highest rate of persons receiving compulsory mental health treatment in the world (O’Brien, 2018). Following the Mason Inquiry into mental health in 1996, radical change occurred in mental health care, including the shift of acute services into hospitals and community care with the closing down of mental institutions (Williams, Haarhoff, & Vertongen, 2017). Although the move to community-based or primary care appeared to give individuals more freedom and autonomy, legal restraints under the Mental Health Act (1992) (MHA) mean that many people are required to comply with compulsory treatment without consent (O’Brien, 2018).

The Code of Rights outlines the rights consumers have when receiving health care and the duties providers have (Burgess, 2008). When an individual is placed under the MHA they lose their right to consent to treatment, and many have experience of losing their right to freedom from coercion and discrimination, their right to dignity and their right to be treated with respect (O’Brien, 2018). The stigma which accompanies being placed under an involuntary treatment order contradicts the principles of recovery which requires the individual to have autonomy and self- determination (Gordon, 2013).  Autonomy is essential to the goal of recovery, as individuals need to have a sense of control over how their care progresses and to be involved in the decision-making process (Stanton & Tooth, 2013).

It has been suggested that the MHA requires review to align both with international human rights law and with the current philosophy of recovery as treatment for mental illness (Gordon, 2013; Gordon & O’Brien, 2014). Focus on the forming of an effective therapeutic alliance to gain consent to treatment has been suggested as an alternative to compulsory treatment and would achieve a reduction in self-stigma (Gordon, 2013). It is encouraging to note the Mental Health Commission (MHC) has a ten-point agenda for change of which reducing the use of the MHA is a goal (MHC, 2018).

Other MHC interventions to reduce societal stigma and discrimination include the long-running Like Minds, Like Mine campaign and the recently established Take the Load Off campaign (MHC, 2018). These projects aim to encourage people to share their experience of mental illness and to educate the public about the high incidence of mental illness in New Zealand (MHC, 2018). These interventions have experienced some success with a study by Thornicroft, Wylie, Thornicroft & Mehta (2013) finding 48% of participants thought discrimination had reduced notably as a result of the Like Minds, Like Mine campaign.

Te Pou has promoted the reduction of seclusion and restraint in mental health nursing to also reduce stigma (Te Pou, 2015). Scott (2016) states that this institutional trauma adds to the initial trauma and places the individual in an even more vulnerable state with compounding self-stigma. In evaluating this project’s achievement, research was found which compared the rate of seclusion episodes in mental health facilities in New Zealand between 2007 and 2014 showed a significant drop in the use of seclusion (Drown, Harding & Marshall, 2018).

Reflection on how personal beliefs and attitudes to mental illness developed saw the examination of limited exposure to mental illness in youth and the influence of media on perceptions. Interventions which have influenced practice on a personal level include aspects of the Bachelor of Nursing course. Through integrated case studies, emphasis is placed on both physical and mental illnesses which resulted in comprehensive knowledge about different illnesses, their treatments and recovery. The opportunity to interact with those with lived experiences during the Supporting Families sessions has proven to be an amazing resource in changing misconceptions and reducing discomfort which arose from them. Invaluable gains in understanding and acceptance of those with mental illness have also been made through the specialist mental health clinical placements. Although initially confronting, the growing knowledge and interest in the speciality have made it an attractive option for the future.

In studies to find what will reduce stigma, social contact between those with mental illness and people without has shown to be the most effective form of stigma intervention (Thornicroft et al, 2016). This method has shown the most potential to initiate behaviour change through the reduction of anxiety and provocation of empathy (Bingham & O’Brien, 2017), however due to the lack of any long-term research it is unknown if this tolerance is sustained over time (Thornicroft et al, 2016).

Stigma and associated discrimination are still very much a part of society’s behaviour and although there has been progress made through various interventions, ongoing education is required to ensure the impact is further reduced. Evidence within this essay has been used to show how stigma negatively effects recovery for those with mental health challenges and also to make recommendation for change. This essay has examined and analysed the effects of discrimination and has evaluated how developing understanding has changed perception on a personal level.


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Bingham, H. & O'Brien, A. (2017). Educational intervention to decrease stigmatization attitudes of undergraduate nurses towards people with mental illness. International Journal of Mental Health

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

Drown, C., Harding, T., & Marshall, R. (2018). Nurse perceptions of the use of seclusion in mental health inpatient facilities: Have attitudes to Māori changed? The Journal of Mental Health Training, Education, and Practice, 13(2), 100-111. Retrieved from

Gordon, S. (2013). The recovery of compulsory assessment and treatment. In J. Dawson, & K. Gleghill (Eds.). New Zealand’s mental health act in practice (pp.268-284). Wellington, New Zealand: Victoria University Press.

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Horsselenberg, E., van Busschbach, J., Aleman, A., & Gerdine, H. (2016). Self- stigma and its relationship with victimization, psychotic symptoms and self-esteem among people with schizophrenia spectrum disorders. PLoS One, 11(10) doi:10.1371/journal.pone.0149763

Jackson, D., & O’Brien, L. (2013). The effective nurse. In R. Elder, K. Evans, & D. Nizette (Eds.). Psychiatric and mental health nursing (3rd ed., pp.3- 13). Sydney, Australia: Elsevier.

Liu, D., Hinton, L., Tran, C., Hinton, D., & Barker, J. (2008). Reexamining the relationships among dementia, stigma, and ageing in immigrant Chinese and Vietnamese family caregivers. Journal of Cross-Cultural Gerontology, 23(3), 283-99. doi:10.1007/s10823-008-9075-5

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