What do you need to feel safe?

I was just reading "Mother of kidnapped Denver girl speaks of daughter's strength" and I couldn't help but think of what I consider "my first mistake" as a mother responsible for making decisions about how to deal with my son's injuries from traumatic abuse---I desperately wanted to make the decisions that would give my son his best chance of a full recovery from his traumatic injuries. I followed the wrong advice. I should have listened to the Police Officer...

My first mistake was listening to the psychiatrist, instead of taking the advice of Seattle Police Homicide Detective, Don Cameron. His voice still echoes in my memory. There is no way to know how things would have been different for my boy had I taken his advice.  My boy has been forced to live a lie because not one of the "mental health professionals" who "treated" him EVER acknowledged his traumatic injuries, or helped him to process his trauma, or even recognize that his symptoms---which were injuries---were not simply dysfunctional "behaviors." The following week, two of these so-called "professionals" actually attempted to get me to agree that my son needed "to be institutionalized for life" within weeks of his seventh birthday. There is no word that describes how I feel about the intellectual dissonance and willful blindness that must be required for people to repeatedly traumatize my son and in effect---blame my son for his injuries---instead of helping him to feel safe, or helping to prosecute the person who harmed him! These people had a duty to help my son; it would have helped him to know how valuable he is as a human being. He was a child who needed to feel safe; needed to know he would be protected from harm, he needed to know he was defended when he was criminally abused---Some had a legal duty---at the time of the crime---their failure to fulfill their legal duty is itself, criminally negligent---as is the failure of those who lied and helped to cover up these criminal failures; some perjured themselves in Superior Court. My boy was seven, he needed to know that people don't get away with beating little boys up and putting them in a closet.

He still does---he still doesn't feel safe.

Why are different lower "legal" standards used in Involuntary Commitment proceedings?

"If the physician presumes to take into consideration in his work whether a life has value or not, the consequences are boundless and the physician becomes the most dangerous man in the state. -DR. CURISTOPH HUPELAND (1762-1836)

I have not been myself since the summer of 2010. More accurately, I have been changed by the events which happened when my son had a crisis. I more fully realized that many things are just not at all how they should be, and that many people do not seem to care that they are not. Crimes were committed in the summer of 2010 which violated my son's civil rights, and when I filed complaints with the appropriate authorities on his behalf no appropriate action was taken. My son was traumatized yet again by unethical "mental health professionals" who are not going to be held legally accounable for committing crimes which caused harm to a person they owe an ethical legal duty to. It is standard for no one to be held accountable when victimizing people with a psychiatric diagnosis. Crimes are not even investigated, at least crimes in which my son was the victim never have been...

Although involuntary treatment commitment proceedings are considered, “civil” as opposed to “criminal,” one should have no doubt that a loss of one’s liberty, the loss of legal and political status without being afforded equal protection under the law, is a violation of one’s Human Rights. The consequences are as detrimental, if not more so, than the consequences for a misdemeanor criminal conviction. For one thing the Court Order can be in effect for the remainder of one’s life. The individual rights protections the law allows a person in a civil commitment proceeding are less than those people charged with crimes can count on. Not unlike a misdemeanor criminal conviction, a Court Order for involuntary treatment alters a person’s legal status and temporarily deprives them of their Liberty. However, in civil commitment proceedings, the person’s lowered status often becomes a permanent legal distinction, and the deprivation of Liberty can also become permanent, through either in- or out-patient commitment.

This begs the question, “Why are different lower "legal" standards used in Involuntary Commitment proceedings?” The Involuntary Treatment statutes deprive people of individual rights protection people charged with felony crimes can take for granted.  

1. The “evidence” required to obtain a Court Order to detain, and/or commit a person can consist of nothing more than hearsay, speculation, gossip and innuendo, it is not required to comply with the Rules of Evidence.  

2. It is alleged or implied in the proceedings that the person has a “brain disease” or genetic defect which will be corrected, or “medically treated.” No evidence is offered; nor is any evidence to support the claim stated or implied even asked for.

3. Standard Court Procedures are not followed.

4. A person may be appointed an attorney, however, this does not mean that Effective Assistance of Counsel is provided. Not only are the legal, social and political consequences of a Court Order for Involuntary Treatment  profound; the medical consequences can be lethal.

The obvious detrimental social, political and legal consequences to the person court ordered to Involuntary Treatment really demands that individuals have equal protection under the law. It is ethically, legally and morally indefensible they are allowed much less. It is a civil rights violation. It is a social policy that has “legalized” discrimination against an entire class of people Under Color of Law. It is inhumane to deprive vulnerable people of equal protection under the law. The attempts to justify this social policy by claiming it is in a victim’s “best interest;” or that it is done “for their own good” are juvenile; all things considered, justifying any of this as beneficent or charitable is incomprehensible; truly despicable really.

Medical professionals in theory, police themselves...Doctors (and perhaps, all professions that "police" themselves) seem to do so very ineffectively. While this is a rather broad generalization, I believe there is more than a grain of truth in it...
Part of learning in life and in medicine requires learning from one's own and one another's mistakes; in effect, bearing one another's burdens as well---this reliance upon one another may inhibit one’s ability or willingness to learn how and when one should act in defense of a vulnerable person, and perhaps play a role in having a person held accountable for an error that caused harm to a vulnerable person. The intent and the purpose of accountability is to ensure people are treated with respect and have ethical medical care to protect patients from quackery and unethical practitioners. Performing the ethical duty of policing one’s colleagues more effectively and consistently, would restore and help to effectively preserve the ethical integrity of the evidence base, and the reputation of the medical profession.  

One of the things that I have come to realize, (I have yet to accept it with any grace) is with rare exceptions, basically good people, who were otherwise competent professionals made errors in judgement or behaved in a reckless, abusive or negligent manner when interacting with my son.  For the most part, basically decent people harmed my son. Even more looked the other way; failing their ethical duty to my son. It is of no comfort to me to realise it wasn’t malice or ill intent which motivated their actions; truthfully, the fact that it was simply carelessness or ignorance, has  caused me no small amount of additional sorrow...

I’m at a loss as how to reconcile what I believed and thought was true about people in general, and mental health professionals in particular, with our experiences. The manner in which we were treated, has made it impossible to reconcile how we were treated with the ethical guidelines for medicine, or the principles of social justice. Societal norms of civility and human decency I believed at one time to be "how things are done;" were nowhere to be found in our trek through the mental illness system.  I have spent countless hours doing research looking for answers which could possibly explain any of what happened; and I came across the chapter of a book several weeks ago that offered an explanation of sorts, but is of no comfort at all. I am nonetheless thankful to have found it.  

There is no reason for what we experienced. Reason has nothing to do with good people being wilfully blind; in effect, choosing silent complicity. There is no good reason for continuing to employ people who fail to perform required tasks clearly stated in their job description, when their failure is a crime. The system isn't broken---it's the people who are employed in spite of failing to perform a critical part of their jobs as Paid Public Servants. The fact that is, it's a crime for state employees or contracted providers to not refer complaints to Law Enforcement for investigation when required by law to do so; this seems to be conveniently overlooked; rarely (if ever) prosecuted. Probably because the state is ultimately liable for damages.


I am grateful that I was there to bear witness to how my son was used and abused; more grateful that he survived. I am painfully aware others don't survive; then there are the survivors who have no one to validate their pain, some have no one who listens to them at all. No one should have to bear such burdens alone; no one should be without someone who loves them, validates them, believes them and has confidence in them. Someone who will bear witness for them, should they be too traumatized to tell their own story. My son has been silenced by fear and trauma (de)Voiced by his lived experience; he will be 25 day after tomorrow, silenced by fear.  

I have no understanding for why a psychiatric diagnosis is used as a justification for treating people as if the diagnosis means they are less than human; less than worthy of their Human Rights being preserved or even defended. In truth, it seems to me that if a person is not as able to protect their legal interests temporarily or permanently for any reason, the person would need special consideration to preserve and defend their fundamental Human Rights. Involuntary Treatment statutes lower the standards and allow a much lower standard with less protection for an individual's Human Rights to be used. How is that even ethically or morally justifiable? I know it isn't. I know it is inhumane, that it is discrimination based on *a real or perceived* disability; making it "legal;" but not in reality, since it is unconstitutional, and violates individual rights Under Color of Law. That it uses the same convoluted ignorant reasoning; the same type propaganda, and the same social control tactics that were used to implement Eugenics as a "public health" and "social services" policy in this country is horrifying---Doesn't anyone in America know any American History? Implementing these kind of "beneficent" social service programs which deprive people of their human dignity, their Human Rights, and their freedom for life Under Color of Law has been done before in the US Eugenics Era and in Germany leading up to WWII.

via the New Existentialists:

Eugenics and Psychiatry: A Brief Overview of the History

a couple of excerpts:
"In my casual observations in conversation with colleagues, I find that very few mental health professionals are aware of the historical link between psychiatry and eugenics."

"Has psychiatry today fully exorcised the demons of it’s past? I think not. Children in poverty, especially those on public welfare and in foster care, are much more likely to be drugged with harmful antipsychotic drugs. I see this kind of psychiatric abuse as an extension of the eugenics project, and it needs to stop. Psychiatry is also still used to perpetuate racism. Today, we still see that black men are misdiagnosed with schizophrenia five times more often than white people. It is easier to label a person with madness and force his compliance with antipsychotic drugs than to endure the difficult job of listening to a man who lived with the darkness of a lifetime of victimization by racism. Until we see such patterns disappear from psychiatry practice, I will remain unconvinced that psychiatry has fully escaped the weight of its shameful eugenic legacy."

-- Brent Dean Robbins here

available at Amazon

"IF we want to understand violence as a whole, we cannot leave any of its major manifestations in a fog of half-knowledge. But this is exactly what has happened with an unprecedented occurrence of mass violence, the deliberate killing of large numbers of mental patients, for which psychiatrists were directly responsible. To both the general public and the psychiatric profession, the details and the background are still imperfectly known. This is not only a chapter in the history of violence; it is also a chapter in the history of psychiatry. Silence does not wipe it out, minimizing it does not expunge it. It must be faced. We must try to understand and resolve it." Fredric Wetham, M.D. A SIGN FOR CAIN An Exploration of Human Violence
A SIGN FOR CAIN An Exploration of Human Violence FREDRIC WERTHAM, M.D.Chapter 9 (pdf) http://ow.ly/h5dfY  on Leonard Roy Franks website

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Eugenics photo credit

Inpatient Psychiatric Care Can Adversely Effect Mental Health

this study was partially funded by the NIMH
via Psychiatric Services A Journal of the American Psychiatric Association :

Special Section on Seclusion and Restraint: Patients' Reports of Traumatic or Harmful Experiences Within the Psychiatric Setting

B. Christopher Frueh, Ph.D.; Rebecca G. Knapp, Ph.D.; Karen J. Cusack, Ph.D.; Anouk L. Grubaugh, Ph.D.; Julie A. Sauvageot, M.S.W.; Victoria C. Cousins, B.S.; Eunsil Yim, M.S.; Cynthia S. Robins, Ph.D.; Jeannine Monnier, Ph.D.; Thomas G. Hiers, Ph.D.

Psychiatric Services 2005; doi: 10.1176/appi.ps.56.9.1123

from the discussion a couple of excerpts  :

"This study provides strong empirical support for concerns raised by consumer and advocacy groups about patient safety within psychiatric settings. In a sample of patients with severe mental illness who were served by a public mental health clinic, high rates of lifetime trauma occurring within psychiatric settings were reported, including physical assault (31percent), sexual assault (8 percent)..."


"Although the findings do not address causality, there is reason to believe that the experiences documented in this study may have an adverse effect on the mental health of this vulnerable population." (emphasis mine)


Can there really be any doubt that the adverse events and traumatic nature of them has "an adverse effect on the mental health of this vulnerable population?!"   


The study was partially funded by NIMH.  The question that needs to be answered is, "Why is the risk of real harm to a person not part of the discussion about the best interests of those diagnosed as "seriously mentally ill?"  As a society, we sentence vulnerable people to locked psychiatric facilities, where if they are assaulted or abused, they are seldom believed or defended. Far too many are assaulted and abused in psychiatric facilities and experience lasting emotional harm.


Read entire the Psychiatric Services Journal article here.
photo credit

The story of a child's path...

via TheAnnaInstitute.org:

This presentation is about the early childhood of Anna, a young woman sexually abused in early childhood, who spent 17 years in the mental health system diagnosed as schizophrenic, and who took her life at the age of 32. The presentation is given by Anna’s mother, Dr. Ann Jennings, and includes photographs and artwork along with a narrative of Anna’s childhood story based on Anna’s memories, and the memories of her parents, brothers and sisters, and the many people who knew and interacted with her as a young child. Current research findings are presented on the damaging consequences that can occur over the lifetime to children who suffer from traumatic experiences and who are not recognized or helped. The presentation ends with an open discussion. For formal trainings, the presentation is followed by review of a matrix of strategies for prevention, recognition and early intervention in childhood trauma which can be implemented on a grass roots level in collaboration with community organizations and people. Participants compose preliminary action plans to create trauma-informed communities involving local neighborhoods and organizations.

THE PRESENTER DR. ANN JENNINGS

Important Souls

image credit: all-free-download.com

Conceptions and Perceptions of a MadMother

only red links are embedded

I was cruising around on the web and came across "Improving the Quality of Health Care for Mental and Substance-Use Conditions" a book that is this from the Institute of Medicine and the Board on Health Care Services. 

This post is my take on how decision making and stigma are relevant to my experiences as the parent of a child who had severe PTSD as a result of a violent assault when he was three years old. My son is now an adult in his mid-twenties, he was diagnosed with schizophrenia by a TEOSS drug trial investigator and drugged into a state of disability (without Informed Consent) by Jon McClellan,(McClellan's testimony in the US Senate) Jon McClellan  ignored my protests, and actually claimed that he did not need my consent for treatment, he stated repeatedly that I had no say. McClellan is the Medical Director of Child Study and Treatment Center, the only psychiatric facility for kids run by Washington State to this day...

a snippet from "Improving the Quality of Health Care for Mental and Substance-Use Conditions" Chapter 2:

Expectations are rising for consumer decision making in the purchase of health care and selection of treatments.

•

Decision-making ability often is not anticipated or supported and often is challenged.

Decision making ability is more than "challenged;" and the professional perception of a psychiatric patient's decision making in-ability extends to others. Parents and guardians can find that their right to make Informed Consent decisions on behalf of a child is compromised, if not stripped from them altogether without Due Process of Law for not giving a child a neurotoxic teratogenic drug. Mary Anne Godboldo had CPS bring the Police with a Swat Team and a tank come take her 13 year old daughter away from her when she sought a second opinion, and made the decision to withdraw her daughter off of Risperdal. I was told by a psychiatrist who taught many of the psychiatrists who have "treated" my son: "Parents who objected to medical treatment they would see as at best ill informed and at worst impaired themselves."
In effect, parents apparently do not have the right to refuse to drug their children...

I can attest that I was never appropriately informed about the drugs prescribed to my son when he was a minor. I say this in retrospect, after having read the Ethical Guidelines for Informed Consent, and after hundreds of hours of research. I can further attest that my now adult son has never been informed of the serious risks for the drugs he takes on a daily basis; drugs he has been taking for over a decade, since he was 13. 

My point is simply this: the stigma is so entrenched and embedded within our society, within psychiatry and the public mental health system, that not a single one of the 6 psychiatrists who have prescribed him the drugs in the last 8 years have thought to inform, educate or obtain consent for the drugs they are prescribing. Even worse, none have listened to him. 

Due to the manner he has been treated, my son has no small amount of fear associated with clinics and hospitals, and he doesn't have any reason to trust any of the professionals he knows. I am utterly at a loss to explain or understand how mental health professionals seem to lack any awareness for how he has been traumatized repeatedly by drugs, and inpatient treatment---his PTSD symptoms are so bad when he has to go to appointments; he becomes utterly terrified. 

There is no compassion or any recognition, validation or offer of support or empathy for how he feels. No offer of any actual help to process his traumatic experiences, or any help coming to terms with the profound iatrogenic neurological and emotional injuries he has sustained. No apparent willingness to understand that his lack of trust is valid; Isaac's initial iatrogenic injuries were not inflicted by the professionals he sees now; but he is acutely aware of the cause of his iatrogenic injuries. 

If any professional would bother to open their mind and stop looking at him as a "mental patient;" perhaps simply consider and maybe come to realize, that his perceptions and his fears, even of them, just might be valid. His injuries were caused by the type of treatment they provide him now. I wonder why there is no understanding of that? Or that they need to earn his trust? Without it, there is little chance he will come to feel safe enough for them to be trusted by him. How will they ever be able to actually help him, much less learn what his level of awareness and his abilities are without his being able to trust them? First things first: earn his trust. Stop being willfully blind by refusing to acknowledge his injuries. Stop pretending that his trauma and fears are not valid; all things considered, it's despicable. 

It is as if professionals do not even see him as a human being, and have absolutely no clue at all that what is causing his ongoing lack of trust of them; and is also causing him further trauma, is their unwillingness to even consider his truth. His story of what happened to him and how it hurt him is irrelevant, it seems. 

The most profound negative effect of my son's treatment resulted from the denial of his humanity, the invalidation of him as a person. He was a kid who had problems; eventually he came to believe, he was the problem. Shortly after going to Child Study and Treatment Center, he realized no one was ever going to listen to him, or help him process his trauma; and that is when, "I went into my head because it was the only safe place left." He told me because he trusts me; my hope is someday he will know he can trust other people too.

Almost eight years ago I brought him home and it has only been in the last couple of years that he has shown a little self-confidence. It was obvious to me within the first week he was home that Isaac perceived any and all correction as criticism and condemnation. He was a kid who had problems who eventually felt and believed he was the problem. When a human is traumatized repeatedly and is without escape; they are being tortured. One cannot recover overnight or without trust. I believe my son when he tells me his story. I am grateful he trusts me and his brother; it's a start. He's doing great, all things considered.

via The National Center for Biotechnology Center Bookshelf:

Improving the Quality of Health Care for Mental and Substance-Use Conditions

Quality Chasm Series

Institute of Medicine (US) Committee on Crossing the Quality Chasm: Adaptation to Mental Health and Addictive Disorders.

Washington (DC): National Academies Press (US); 2006.

ISBN-10: 0-309-10044-5

Copyright © 2006, National Academy of Sciences.

Hardcopy Version at National Academies Press

a few excerpts:

Chapter 3

HOW STIGMA AND DISCRIMINATION IMPEDE PATIENT-CENTERED CARE

“Stigma” is defined as the negative labeling and stereotyping of a group of individuals that is based on some observable trait they share and that leads to discrimination against them by individuals or society at large (Corrigan and Penn, 1999; Link and Phelan, 2001). “Stigma” refers to the negative attitudes toward members of a group; “discrimination” refers to the behaviors that result from these attitudes.

Within a stigmatized group, different personal, social, and economic resources shape the lives and personal power of individual group members and produce substantial variation in the extent to which any given member personally experiences the effects of stigma (Link and Phelan, 2001). Nevertheless, American society as a whole—like that of most if not all countries—has for centuries stigmatized individuals with M/SU illnesses and discriminated against them socially, in employment, and in their efforts to secure such necessities of life as housing (Farina, 1998; Join Together, 2003; SAMHSA, 2000). Although understanding of the causes of mental illnesses has improved among the general population over the past 50 years, stigma continues (Hall et al., 2003; Pescosolido et al., undated) to varying degrees for individuals with different M/SU illnesses. In general, substance-use illnesses are more stigmatized than mental illnesses, and some mental illnesses (e.g., schizophrenia) more than others (e.g., major depression) (Mann and Himelein, 2004; Martin et al., 2000).

Two negative stereotypes in particular stigmatize individuals with M/SU illnesses and affect their ability to receive patient-centered care: (1) misperceptions about the extent to which individuals with various M/SU illnesses are capable of making decisions about their treatment, and (2) erroneous beliefs about the extent to which these individuals pose a danger to themselves or others (Martin et al., 2000).²

Evidence pertaining to the above stereotypes is presented in the next section. In this section, we examine three ways in which these stereotypes threaten the receipt of patient-centered care: (1) by lessening patients' ability to participate in the management of their illness and achieve desired treatment outcomes; (2) by encouraging pessimistic and nontherapeutic attitudes and behaviors among clinicians, making them less likely to foster and support patients' self-management efforts; and (3) by promoting discriminatory public policies that create barriers to patient-centered care and recovery. All three of these effects of stereotyping can contribute to poorer health outcomes (Link and Phelan, 2001). Understanding them can point to ways of remedying them and thereby promoting patient-centered care.

Adverse Effects on Patients' Ability to Manage Their Care and Achieve Desired Health Outcomes

As noted below, the adverse effects of stigma lead down a pathway to diminished health outcomes. The steps along this pathway are depicted in Figure 3.1 and described below.

FIGURE 3-1

The stigma pathway to diminished health outcomes.

Diminished Self-Esteem

Stigma influences not just how individuals with M/SU illnesses are perceived by others, but also how they perceive themselves (Farina, 1998; Link and Phelan, 2001; Wahl, 1999; Wright et al., 2000). Individuals with a mental illness who have greater concerns about or experiences with stigmatization³ have lower self-esteem (Link et al., 2001; Wright et al., 2000), perform more poorly on tasks (Farina, 1998), and have weaker social and leisure relationships and interactions (Perlick et al., 2001), all of which are associated with a greater risk of relapse or no remission (Cronkite et al., 1998; Sherbourne et al., 1995). Among individuals with mental health problems, stigma also is associated with not taking prescribed medications (Sirey et al., 2001) and is a significant reason why some individuals do not seek treatment (SAMHSA, 2004b). Moreover, stigma leads to self-deprecation and compromised feelings of mastery over life circumstances (Wright et al., 2000), and thereby diminishes beliefs and expectations regarding self-determination and the ability to make decisions on one's own behalf. In short, diminished self-esteem correlates with decreased belief in “self-efficacy” (Markowitz, 1998).

Decreased Self-Efficacy

Perceived self-efficacy refers to a person's belief that that he or she is capable of carrying out a course of action to reach a desired goal. Self-efficacy beliefs touch every aspect of peoples' lives—whether they think productively, self-defeatedly, pessimistically, or optimistically; how well they motivate themselves and persevere in the face of adversity; their vulnerability to stress and depression; the life choices they make; the courses of action they pursue; how much effort they will make in pursuing a course of action; and their emotional reactions to the course of events. Self-efficacy also is a critical determinant of how well knowledge and skills are obtained (Pajares, 2002) and an excellent predictor of behavior. Unless people believe they can produce desired events through their actions, they have little incentive to act. Self-efficacy beliefs are constructed from four main sources of information: personal experience of mastery; vicarious experience through others with similar characteristics; verbal persuasion; and physiological capability, strength, and vulnerabilities (Bandura, 1997b).

There is evidence that self-efficacy is key to individuals' successful self-management of a variety of chronic illnesses and achievement of resulting improvements in health outcomes (Lorig and Holman, 2003; Lorig et al., 2001; Shoor and Lorig, 2002), as well as an important component of recovery from substance use (Samet et al., 1996). Self-efficacy is among the most powerful predictors of favorable posttreatment outcomes among treated alcohol patients (Project MATCH Research Group, 1998). It is also theorized to be a common mechanism in the effectiveness of psychosocial treatments for a variety of mental illnesses (Bandura, 1997a; Mueser et al., 2002).

Impaired Illness Self-Management

Illness self-management encompasses the day-to-day tasks an individual carries out to live successfully with chronic illness(es). Experts in the study of effective illness self-management interventions identify five core skills needed by patients: problem solving, decision making, resource utilization, formation of an effective patient–provider relationship, and taking action. These five skills are necessary to manage the effects of illness in three areas: medical or behavioral health practices, social and interpersonal role functioning, and emotional management (Lorig and Holman, 2003). These skills pertain, for example, to monitoring illness symptoms; using medications appropriately; practicing behaviors conducive to good health in such areas as nutrition, sleep, and exercise; employing stress reduction practices and managing negative emotions; using community resources appropriately; communicating effectively with health care providers; and practicing health-related problem solving and decision making. Self-management support programs for a variety of chronic illnesses, including heart disease, lung disease, stroke, and arthritis, have been shown to reduce pain and disability, lessen fatigue, decrease needed visits to physicians and emergency rooms, and increase self-reported energy and health. These improvements in health outcomes are strongly associated with increased self-efficacy (Bodenheimer et al., 2002a; Lorig and Holman, 2003; Lorig et al., 2001).⁴

Components of illness self-management for individuals with chronic mental illnesses such as schizophrenia and bipolar illness (i.e., psychoeducation, behavioral practices to support taking medications appropriately, relapse prevention, and teaching of coping skills and actions to alleviate symptoms) also have been developed, tested, and found effective in addressing many of the behaviors necessary for patient recovery (Mueser et al., 2002). A standardized approach for illness self-management has been developed and empirically validated by Stanford University (Stanford University School of Medicine, 2005). Illness self-management also is included as one of the six essential components of the Chronic Care Model (Bodenheimer et al., 2002b), which is discussed in Chapter 5 and is achieving improved health outcomes for a variety of physical and mental illnesses.

Weakened Patient Activation and Self-Determination

Self-efficacy and self-management also are related to the concepts of “patient activation” and “patient self-determination.” “Patient activation” refers to the constellation of skills, knowledge, beliefs, and behaviors necessary for an individual to manage a chronic illness successfully (Von Korff et al., 1997). An “activated” patient also is one of the key elements of the Chronic Care Model (Bodenheimer et al., 2002a). Self-determination theory is concerned with individuals' innate inner resources for personality development and behavioral regulation and how these resources are influenced by social contexts so as to affect human motivation (Ryan and Deci, 2000). Research in this area has established the central importance to self-determination of three innate psychological needs: self-perceived competence (self-efficacy, discussed above), autonomy, and relatedness. This research also has shown that people must perceive themselves as competent (self-efficacious) and experience their behavior as volitional if they are to possess intrinsic motivation (Cook, 2004). (emphasis mine)

Whether one is discussing patient self-management, self-activation, or self-determination, the underlying theme is the same: patients' behaviors will be determined by how meaningful a given problem is to them and how capable of resolving the problem they perceive themselves to be. As described above, stigma can adversely affect individuals' self-efficacy beliefs, their ability to manage their M/SU illness, and thereby their recovery. Clinicians, through their clinical expertise and close relationship with their patients, should be vehicles for increasing their clients' beliefs in their self-efficacy. However, not all providers foster their patients' self-efficacy beliefs and support patient decision making—the second way in which stigma obstructs patient-centered care.

Stigma Affects Clinician Attitudes and Behaviors

Because of their scientific knowledge and special relationship with their patients, clinicians have a singular opportunity through their attitudes and practices to promote patient self-esteem, self-efficacy, decision making about treatment, illness self-management practices, and recovery. While many health care professionals exemplify these positive attitudes and related practices in their treatment relationships with their patients, some do not. Testimony to the committee from consumer groups (Bergeson, 2004; Leibfried, 2004) revealed that poor provider support for patients' decision making and illness self-management and pessimistic beliefs about their abilities were serious obstacles to their decision making and recovery. As articulated by one speaker (Bergeson, 2004):

We believe that the majority of physicians and other health care providers must fundamentally change their approach toward their patients, an approach revealed through the use of that “special voice.” Sadly, far too many professionals have a manner of speaking to us as if we are slightly stupid children.

It's that voice that reminds us that we aren't really partners in care with our health care providers. No matter that we may know more about the latest efficacy data on specific medications than our doctors; no matter that we may be following rTMS and vagus nerve studies as treatment options and our nurses haven't even heard of them; no matter that we may be aware of the outcomes of CBT [cognitive behavioral therapy] with bipolar patients, and our talk therapist—who is most frequently a social worker—isn't schooled in the fundamentals of CBT.

It's that voice that reminds us that health care providers still think of themselves as taking care of us, instead of working with us. It's the voice of learned helplessness.

Clinical training in inpatient settings, as opposed to the ambulatory settings in which most individuals receive treatment, provides experience with patients with mental illnesses during their most acutely ill phase and may thus reinforce a view of those with such illnesses as being more disabled than is the case. Moreover, most academic education and training programs for clinicians focus on the cognitive domain of learning, along with some skill development. Few programs have content or instructional strategies targeting the affective or attitudinal domain of learning. Thus it should not be a surprise that clinicians' attitudes may mirror those of society at large and be unchanged by their education (Stuart et al., 2004).

Recognizing the power of terminology to contribute to stigma, the Substance Abuse and Mental Health Services Administration's (SAMHSA) National Treatment Plan Initiative for improving substance abuse health care called for a language audit to identify problems inherent in the terminology used in the field and in public discussions, and for the development of a nonstigmatizing taxonomy to describe alcoholism, drug “addiction,” and available treatments and services (SAMHSA, 2000). A similar process could be beneficial in reducing stigmatizing language used throughout the mental health field.

read it here

Public Conceptions of Mental Illness in 1950 and 1996: What Is Mental Illness and Is It to be Feared?

Jo C. Phelan, Bruce G. Link, Ann Stueve and Bernice A. Pescosolido

Journal of Health and Social Behavior
Vol. 41, No. 2 (Jun., 2000), pp. 188-207
Published by: American Sociological Association

Abstract:

In the 1950s, the public defined mental illness in much narrower and more extreme terms than did psychiatry, and fearful and rejecting attitudes toward people with mental illnesses were common. Several indicators suggest that definitions of mental illness may have broadened and that rejection and negative stereotypes may have decreased since that time. However, lack of comparable data over time prevents us from drawing firm conclusions on these questions. To address this problem, the Mental Health Module of the 1996 General Social Survey repeated a question regarding the meaning of mental illness that was first asked of a nationally representative sample in 1950. A comparison of 1950 and 1996 results shows that conceptions of mental illness have broadened somewhat over this time period to include a greater proportion of non-psychotic disorders, but that perceptions that mentally ill people are violent or frightening substantially increased, rather than decreased. This increase was limited to respondents who viewed mental illness in terms of psychosis. Among such respondents, the proportion who described a mentally ill person as being violent increased by nearly 2 1/2 times between 1950 and 1996. We discuss the possibility that there has been a real move toward acceptance of many forms of mental illness as something that can happen to one of "us," but that people with psychosis remain a "them " who are more feared than they were half a century ago. here