Recommendations

This critical discourse analysis has revealed some of the hidden stigmatizing assumptions that are embedded in hospital policy. These messages can be counter-acted and the stigma resisted by attempting to reframe the space and roles given to those with mental illness. This can happen in several ways, including empowerment of patients against the hidden messages, increased education about these internalized ideas, explicitly attending to stigma in policy development, and emphasising the role and importance of the therapeutic alliance. The following is a more detailed description of these recommendations.

First, patients need to be aware that they can become empowered and not internalize the hidden stigmatizing messages of paternalism, assumed deviance and social exclusion that are present in their environment. Empowerment towards an achievement of stability and control is part of a strong recovery process (Fisher, 2005). The overarching problem with the mental health care policies I analysed, is that they are too narrow, in a sense that they focus on a small subsection of the patient population. Therefore, these stigmatizing ideas that are being

perpetuated are impacting a larger group, unnecessarily.

As discussed, the role of a “spoiled identity” is core to understanding the difficulty that the mentally ill are facing. The result of self-stigma can cause a deep acceptance of negative perceptions and a hopelessness, which can further marginalize or remove power from the

individual. Negative messages, both explicit and subtle in society, create, and also in effect spoil, the construction of a strong identity among those with mental illness.

The World Health Organization has developed a guide to help evaluate mental health policy (2007). A major goal of mental health care policy is to help, or empower, those with mental illness back into the community as integrated persons (WHO, 2007). One way that empowerment can happen is by changing the treatment environment.

In providing treatment, health care workers are able to influence recovery by encouraging empowering beliefs in individuals with mental illness. To better balance patient and staff safety with the stigmatizing effects of policy, the health care system could work to broaden the

options for treatment, in particular for community-based treatment. For example, alternative treatment places (such as Soteria houses as mentioned earlier) exist in Europe elsewhere and provide a more open and less controlled environment. If the space in which treatment occurs is sufficiently reoriented, then this may decrease stigma by reducing social exclusion and thus limit the perpetuation of negative stereotyping. This will avoid the scenario whereby stigma is perpetuated by hospital policies developed to protect against the potential harms caused by a small minority and end up stigmatizing the entire group.

Second, there is a need for increased education of staff and patients on the stigma of mental illness, as noted by the Mental Health Commission of Canada (2013). In the health care environment of the example presented in this thesis research, staff orientation includes a discussion of one academic journal article on stigma; however, this is most likely not sufficient for mitigating against the effects of stigma inadvertently perpetuated in the hospital

environment. The education needs to be more in-depth, for example including a discussion of paternalism, deviance, and social exclusion. Also, involving people with lived experience of mental illness may help to facilitate social inclusion and reduction in stigma. However, caution should also be taken when involving those with lived experience, as the process can involve reliving traumatic life events. That being said, full disclosure about the potential risks of

participating, without being paternalistic, should be enough preparation for a person to have an ability to make this choice for themselves.

Third, the process by which policies are developed could more effectively incorporate attention to stigma. None of the mental health care policies I examined made reference to the concept of stigma. In addition, the current protocol for policy development within Eastern Health does not include a discussion of stigmatizing language around mental illness. The World Health Organization guidelines emphasise that policy should lessen the impact of stigma within the areas that the policy governs (WHO, 2007). I believe that policy will be strengthened by involving community representatives with a lived experience with mental illness, who could help to research and develop mental health care policies. They would be able to provide much needed insight into the subtle ways that paternalism, social exclusion and ideas of deviance are perpetuated in policy.

Fourth, the relationship between stigma and the therapeutic alliance deserves careful scrutiny. The therapeutic alliance cannot be fully developed if the environment does not foster it. Strengthening communication between staff and patients is important, because unclear or mixed messages impact the formation of a good therapeutic bond. Policies aimed at protecting

staff and patients also portray many elements of stigma that create an unpleasant environment for patients. For example, an over-emphasis on paternalism can create a large disconnect between patients, staff and the goals of treatment. Stigmatizing messages can make patients feel unwelcomed and uncomfortable, and therefore eager to leave. This can lead to the

“revolving door” effect of patients returning for treatment.