Stigma: An International Briefing Paper Tackling the discrimination, stigma and social exclusion experienced by people with mental health problems and those close to them 8 0 0 2 / 4 4 0 7 2 References 31

[20] Anderson R, Wynne R, and McDaid D, [29] Kelly BD, ‘Structural violence and ‘Housing and employment’, in Mental schizophrenia’. Social Science & Medicine, Health Policy and Practice across Europe: 2005. 61: p. 721–730. The future direction of mental health care, [30] Kelly BD, ‘The power gap: freedom, power Knapp M, et al., eds, 2007. Open University and mental illness’. Social Science & Press: Maidenhead. p. 280-307. Medicine, 2006. 63: p. 2118–2128. [21] Freyhoff G, et al., eds. Included in Society: [31] Link BG, and Phelan JC, ‘Conceptualizing Results and Recommendations of the stigma’. Annual Review of Sociology, 2001. European Research Initiative on Community- 27: p. 363–385. Based Residential Alternatives for Disabled [32] Hastings G, Social Marketing: Why should People, 2004. European Coalition for the devil have all the best tunes?, 2007. Community Living: Brussels. Butterworth-Heinemann: Oxford. [22] Amaddeo F, et al., Reforms in community [33] Marshall M, How effective are different care: the balance between hospital and types of day care service for people with community-based mental health care, in severe mental disorders? Health Evidence Mental Health Policy and Practice across Network Synthesis Report, 2005. World Europe: The future direction of mental Health Organization: Copenhagen. health care, Knapp M, et al., eds, 2007. [34] Sartorius N, and Schulze H, Reducing the Open University Press: Maidenhead. Stigma of Mental Illness: A Report from a p. 235–249. Global Programme of the World Psychiatric [23] Fazel S, and Danesh J, ‘Serious mental Association, 2005. Cambridge University disorder in 23,000 prisoners’. Lancet, 2002. Press: Cambridge. 359: p. 545–550. [35] Sayce L, From psychiatric patient to citizen: [24] Dressing H, and Salize HJ, ‘Forensic overcoming discrimination and social psychiatric assessment in European Union exclusion, 2000. Palgrave: Basingstoke member states’. Acta Psychiatrica and New York. Scandinavica, 2006. 114: p. 282–289. [36] Mental Health Europe, Conclusions and [25] Link BG, ‘Stigma: many mechanisms require recommendations for policy and practice. multi-faceted responses’. Epidemiologia e Resulting from the final conference of MHE’s Psichiatria Sociale, 2001. 10: p. 8–11. Transnational Exchange Project ‘Good [26] Sayce L, ‘Beyond good intentions: Practices for Combating Social Exclusion Contributors Making anti-discrimination strategies of People with Mental Health Problems’, Published by Health Scotland This briefing paper was commissioned by Health Scotland, a World Health Organization Collaborating Centre that work’. Disability & Society, 2003. 2007. Mental Health Europe: Brussels. Edinburgh Office 18(5): p. 625–642. [37] Parker C, ‘Developing mental health policy: Woodburn House, Canaan Lane is taking forward work on stigma and discrimination as Edinburgh EH10 4SG part of the WHO European Region’s Mental Health in [27] Pinfold V, et al., ‘Active ingredients in anti- a human rights perspective’, in Mental Glasgow Office Europe Implementation Plan 2005–2010. It was written stigma programmes in mental health’. Health Policy and Practice across Europe: Elphinstone House, 65 West Regent Street by researchers from the Scottish Development Centre for International Review of Psychiatry, 2005. The future direction of mental health care, Glasgow G2 2AF Mental Health (SDC) (Dr Felicity Callard, SDC Associate 17(2): p. 123–131. Knapp M, et al., eds. 2007. Open University © NHS Health Scotland, 2008 Consultant; Liz Main, SDC Associate Consultant; Fiona ISBN: 1-84485-413-2 Myers, SDC Senior Policy Researcher; Ann-Mari Pynnonen, [28] Couture S, and Penn D, ‘Interpersonal Press: Maidenhead. p. 308–335. Health Scotland is a WHO Collaborating SDC Research Worker) in collaboration with the Institute contact and the stigma of mental illness: a Centre for Health Promotion and Public of Psychiatry at King’s College London (Professor Graham review of the literature’. Journal of Mental Health Development Thornicroft; Professor Rachel Jenkins), Rethink (Dr Vanessa Health, 2003. 12(3): p. 291–305. Designed by Redpath www.redpath.co.uk Pinfold), and Professor Norman Sartorius.

Contents

01 Why focus on the discrimination, stigma and social exclusion experienced by people with mental health problems and those close to them? 02 Where there is discrimination there is injustice and inequality 03 What are discrimination, stigma and social exclusion? 06 How do discrimination, stigma and social exclusion operate? 07 Why tackle discrimination, stigma and social exclusion? 08 How do discrimination, stigma and social exclusion affect people’s day-to-day lives? 10 How to tackle discrimination, stigma and social exclusion 10 What we know about how to reduce discrimination 11 Tactics 11 Influencing public opinion 12 Convincing and advocating 14 Developing projects 15 Using the law 18 Actions can be taken at different levels 18 Actions can be targeted at different groups 19 Actions can focus on particular mental health problems or all people experiencing mental health problems 19 Actions can use different ways of thinking about mental health problems 21 Making it happen 23 Supporting instruments, principles and policies 23 United Nations 23 Council of Europe 24 WHO European Region 24 European Union 24 A call to action 25 Organisations 30 References People like me who have a mental health problem can live full lives. What holds us back is discrimination, it’s other people’s attitudes. It’s time for action. Introduction 1

Why focus on the discrimination, stigma and social exclusion experienced by people with mental health problems and those close to them?

Discrimination, stigma and social exclusion This briefing paper and accompanying Stigma: make it impossible for people with mental A Guidebook for Action have been designed to health problems to participate fully in society. assist people in understanding discrimination, stigma and social exclusion as experienced by Discrimination, stigma and social exclusion people with mental health problems1 – what diminish the societies in which they are they are, why they matter, where they originate allowed to happen. – and in developing strategies and actions to fight them. It is addressed to all those who can At the WHO European Ministerial Conference reduce the discrimination, stigma and social on Mental Health in Helsinki in January 2005, exclusion experienced by people with mental health ministers from every WHO European health problems and by those close to them. Region country signed up to the Mental Health This is all of us. Action Plan and Mental Health Declaration for Europe [1, 2]. They endorsed mental health and Both the briefing paper and Stigma: A mental wellbeing as ‘fundamental to the quality Guidebook for Action were commissioned by of life and productivity of individuals, families, Health Scotland, the World Health Organization communities and nations’. Collaborating Centre taking the lead on stigma and discrimination as part of the WHO A significant factor undermining the mental European Region’s Mental Health in Europe health and well-being of individuals and Implementation Plan 2005–2010. They have communities is discrimination. Tackling the been written by researchers from the Scottish sources of discrimination is therefore an Development Centre for Mental Health in important part of all initiatives aimed at collaboration with the Institute of Psychiatry improving population mental health. For people at King’s College London, Rethink and Professor with mental health problems it is fundamental Norman Sartorius. Both resources draw on to ensuring their participation in society as equal a mapping exercise and appraisal of anti- citizens. Tackling the discrimination, stigma and discrimination and anti-stigma activities taking inequality people with mental health problems place across the WHO European Region. and those close to them experience is therefore identified in the Declaration and Action Plan as a priority for the next decade. This will include protecting human rights, implementing legislation to ensure that those with mental health problems are able to participate fully in society, and establishing partnerships between the various sectors that have an influence on the social inclusion of people with mental health problems. The Declaration and Action Plan emphasises that people with mental health problems and those close to them must be central to all these activities.

1 The term ‘mental health problem’ is used throughout the briefing paper to include the experiences covered by the terms ‘mental illness’, ‘mental disorders’ and ‘mental ill-health’. 2 Injustice and inequality

Where there is discrimination there is injustice and inequality

The United Nations Charter, to which all They would have their views and contributions States within the WHO European Region taken as seriously as any one else’s. They would are signatories, recognises: not be afraid of the reactions they might face when disclosing their experience of mental ‘the inherent dignity, worth, and equal health problems. and inalienable rights of all members of the human family.’ Discrimination on the basis that someone has or has had a mental health problem often overlaps Discrimination against people with mental with discrimination on other grounds, for example, health problems and against those close to them discrimination against those living in poverty and therefore runs directly counter to the Charter. those from certain ethnic backgrounds. It is therefore vital that those fighting any kind of People with mental disorders around discrimination work together. the world are exposed to a wide range of human rights violations. The stigma they face means they are often ostracised from society and fail to receive the care they require… Everyone has human rights and must be valued for his or her self-worth. States and international organisations have a duty to uphold and protect these rights. Human Rights and Equality of Opportunity Consultation Report, Bamford Review of Mental Health and Learning Disability, Northern Ireland, 2007.

Negative discrimination is unacceptable on any ground, whether, for example, based on gender, age or ethnic background. This includes discrimination on the basis that someone has, or in the past has had, a mental health problem. Fighting the discrimination experienced by people with mental health problems and by those close to them is central to working towards a socially just society. In such a society, people who have been diagnosed with a mental health problem would be able to participate fully – as other citizens do – in social and economic life. Definitions 3

What are discrimination, stigma and social exclusion?

As terms, discrimination, stigma and social … through blaming people for their mental exclusion can mean different things in different health problems … shaming people for their contexts. We use these three terms to mean mental health problems … not wanting to the following: get close to them … fearing them … calling Discrimination means unfair treatment. More them names … talking behind their back … specifically, it involves making any distinction, laughing about them … people thinking they exclusion, restriction or preference that: have nothing in common with people with mental health problems … considering mental ‘has the purpose or effect of nullifying health problems embarrassing or disgraceful or impairing the recognition, enjoyment … thinking people with mental health or exercise by all persons, on an equal problems are childlike … thinking they footing, of all rights and freedoms’ are unintelligent … and in other ways. (UN Human Rights Committee, General comment 18(37)). My mental condition is no longer the problem for me. It is others’ Discrimination covers unintentional as well as perceptions of me that’s the difficulty. intentional discrimination. Some laws can Without knowing it, or even meaning intentionally discriminate by removing the rights of to, it is the general public’s perception people with mental health problems, for example of my condition which is what really to vote or drive. An example of unintentional causes me pain and embarrassment2 . discrimination would be when insurance companies charge all people with a particular The term stigma was used by the sociologist mental health problem higher premiums through Erving Goffman in the 1960s to refer to mistakenly assuming that they are all a higher risk. ‘an attribute that is deeply discrediting’. The attribute – whether it actually exists Policies, laws, public and privately owned or is presumed to exist – reduces the organisations and individuals can all, in different person ‘from a whole and usual person ways, discriminate against people with mental to a tainted, discounted one’ [5]. health problems. It has even been argued that discrimination against people with mental The stigmatising phrase ‘a schizophrenic’, for health problems is so far reaching that it example, reduces the person to an illness. It could be called ‘structural discrimination’ [3]. makes it easier for the person using this phrase Structural discrimination refers to the prejudice to maintain a distance from someone thought and discrimination that occurs not just between of as not fully human. In comparison, the individuals but at the level of organisations non-stigmatising phrase ‘a person with and institutions. schizophrenia’ recognises the person beyond the medical diagnosis. Stigma involves people making unfair moral judgments about other people [4]. Negative judgments and labels can be attached to mental health problems in a wide variety of ways:

2 All first person quotations in this resource are from people with experience of mental health problems and draw on research projects undertaken by Rethink, the Scottish Recovery Network, ‘see me’ and Professor Graham Thornicroft. 4 Definitions

Stigma allows people to distance themselves Making sure that people with mental health from people whom they stigmatise. This results in problems can take part equally in society is isolation and rejection for those people who are therefore not just about reducing the poverty stigmatised; it also reinforces the power that the that many experience. What people also require person who stigmatises has over those people. is access to a range of social and economic opportunities, respect from others, and the People with mental health problems frequently recovery of a sense of hope. internalise negative beliefs and feelings about their status and worth – even if they have not I was just twenty years old when directly experienced discrimination. This has my consultant psychiatrist told me been called self-stigma [6]. Self-stigma can result I would never work again. It is soul in a loss of self-belief and self-confidence and destroying to be told by a professional, feelings of worthlessness. This makes it far more someone I looked up to and who was difficult for people to challenge discriminatory there to help, that you won’t work or attitudes and behaviour within society at large, achieve anything in life. and can also make the symptoms of their mental health problems worse. It is clear from these descriptions that discrimination, stigma and social exclusion Social exclusion means a person is prevented are linked processes creating a cycle of injustice from taking part to the extent that he or she (see Figure 1). People holding stigmatising would like in the normal activities undertaken attitudes will frequently discriminate against by others in their society [7]. For a person with people with mental health problems, and this a mental health problem, social exclusion can discrimination can result in social exclusion. result from a variety of factors: Social exclusion can also intensify stigma: the more that a particular group is socially ‘lack of status, … joblessness, … lack of excluded, the greater the stigma that can be opportunities to establish a family, … small or associated with that group – homeless people non-existent social networks, … compounding with mental health problems, for example. race or other discriminations, … repeated rejection and consequent restriction of hope and expectation’ [8]. The cycle of injustice 5

Figure 1 – The cycle of injustice

Certain differences (or imagined differences) are labelled or pointed out. They are given negative associations. Stigma e.g. ‘Schizophrenics are violent’.

People with those differences are isolated, rejected and unable to participate and contribute in the way that everyone else is able to. Social Exclusion The person with schizophrenia is unable to get a job, is cut off from participating fully in society; the People with those differences symptoms of schizophrenia become (‘them’) are separated out from harder to deal with. everyone else (‘us’). Discrimination e.g. ‘I don’t want to have anything to do with a schizophrenic: I won’t hire him’. 6 Operation

How do discrimination, stigma and social exclusion operate?

Various models have been developed to Different kinds of actions are required to understand how discrimination, stigma challenge each of these three sources of and social exclusion operate. disadvantage. It cannot be assumed that tackling one will on its own reduce the impact Most of these distinguish between people’s of the other two factors. attitudes and their behaviour towards people with mental health problems. One way has been There are different ways in which individuals and to describe discrimination, stigma and social organisations can act to combat discrimination, exclusion as being caused by three overlapping stigma and social exclusion. While some will factors [9]: want to argue for improved laws to ensure that • Ignorance: the problem of knowledge. Most where unjust behaviour occurs it is challenged, people do not know very much about mental others will want to provide opportunities for health problems, and much of what they do more contact between people with mental know – or think they know – is inaccurate. health problems and other people in order • Prejudice: the problem of negative to reduce fear and prejudice. attitudes. People fear and avoid other people with mental health problems; people with There is no place within society where it is mental health problems anticipate fear and not possible to contribute to the fight against avoidance from other people. discrimination, stigma and social exclusion. • Behaviour: the problem of discrimination. People act towards people with mental health problems in ways that are unjust and unfair. Why tackle the problem? 7

Why tackle discrimination, stigma and social exclusion?

… because tackling them can and will make Family members, carers and those close to a difference people with mental health problems can also experience stigma and discrimination and It has commonly been thought that there is can internalise damaging feelings of guilt and no way of overcoming discrimination against shame. Reducing discrimination will therefore those with mental health problems. But in fact reduce negative impacts on the physical and action can be taken. mental health of people close to someone with a mental health problem. … because discrimination, stigma and social exclusion are unacceptable … because every member of society will benefit Fighting discrimination, stigma and social exclusion is a moral imperative. Societies in which there is less discrimination, and therefore less marginalisation of various … because tackling them brings numerous groups tend to be more healthy as well as more benefits to individuals with mental health just societies. Research drawing on data from problems, those close to them and wider a number of countries [11] indicates that less society unequal societies do better on a wide range of measures including physical health as well as People with mental health problems describe social outcomes. Changes in legislation, policy the effects of stigma and discrimination as and resource allocation can result in substantial severe, and more difficult to deal with than the improvements in the mental health of all citizens. mental health problem itself [10]. Discrimination Social policies that promote social support and and stigma puts obstacles in the way of people’s inclusion and that prevent social exclusion play recovery, can make the symptoms of the mental an important role in promoting the mental health problem worse, and can prevent people health of everyone [12]. from seeking help when they are in distress. Reducing discrimination, stigma and social Discrimination, stigma and social exclusion exclusion therefore has the potential to have enormous social and economic costs for significantly improve the quality of life of those individuals, their families, and society. The cost with mental health problems. to society includes the loss of the skills and talents of people with mental health problems Once I stopped viewing my illness as because discrimination excludes them from a problem, I stopped being scared contributing and participating [13]. about what other people would think. … Now I can be more open and I’m able to challenge those who are ready to write off others just because they have mental health problems. 8 Day-to-day life

How do discrimination, stigma and social exclusion affect people’s day-to-day lives?

The discrimination, stigma and social exclusion Poverty and debt: In every country where this experienced by people with mental health has been studied, the majority of people with problems and those close to them can occur more severe mental health problems are in virtually every area of life. It is important relatively worse off financially. Discriminatory to identify those areas where these are most behaviour by financial services in relation to likely to occur because only then can we most access to insurance or in response to debt, for effectively prioritise and design actions to example, can make financial difficulties worse. combat their causes and effects. For example: Housing and homelessness: Landlords can be Employment: people with mental health less willing to rent to people with mental health problems tend to have the lowest rates of problems. People with mental health problems participation in the workforce, despite being can experience abuse and harassment from keen to work. European studies of employment neighbours, and be denied any choices over for people with schizophrenia, for example, where they will live. The quality of public report rates of between 10% and 20% [14]. housing that is made available to them may be People with mental health problems experience of comparatively poorer quality. Discrimination both direct discrimination (prejudicial behaviour can also make it much more difficult for people from employers and colleagues) and indirect with mental health problems to stay in their own discrimination (e.g. disincentives which work homes, increasing the risk of homelessness [20]. against the employment of people with mental health problems) [15]. In addition, Institutionalisation: Despite the impetus the employment opportunities that are made towards de-institutionalisation, many people available to people with mental health problems with mental health problems are still placed in can result in segregating or socially excluding large residential institutions – too many of which people from the rest of society. have been found to commit breaches of human rights and dignity. In addition large institutions Physical and mental healthcare: The behaviour may not be able to provide the same kinds of and attitudes of healthcare professionals – in opportunities for social and economic inclusion both physical and mental health care settings – that community-based forms of care and support can be unintentionally discriminatory. This might can provide [21, 22]. include the use of cheaper treatments with more severe side-effects, lowered expectations for Leisure, recreation, education and travel: recovery and discriminatory behaviour towards People with mental health problems may also people with particular mental health problems find they have fewer opportunities to take part [16]. Research indicates that people with mental in education, leisure, sports and social activities. health problems receive much poorer physical People with mental health problems may be health care as well as poorer mental health care, restricted from owning a driving licence, and that this can result in significantly higher travelling or emigrating. mortality and morbidity rates [17, 18]. Day-to-day life 9

Family life: Research indicates that discrimination, To combat the discrimination, stigma and social stigma and social exclusion affect the chances exclusion experienced by people with mental that people with mental health problems have health problems therefore requires concerted to marry and to engage in intimate relationships, action from people and organisations located and their opportunities to have and retain across a variety of fields. custody of their children. Those within the mental health field – whether Civil life: In many countries, people with users of mental health services, their families mental health problems may be denied the or those close to them, health professionals or opportunities to vote, to serve on a jury, hold advocacy organisations – can all act as a force official positions, own property and sign legal for change. Collaboration with others outside contracts. People under ‘guardianship’ (the of the mental health field is also a powerful legal framework within which decisions are tool. There are many people, groups and made on behalf of people judged to lack organisations with whom to collaborate, competence in an area of their life) may for example: lose all their legal rights. • Politicians and policy makers • Administrators Safety: People with mental health problems are • Academics and universities at greater risk of being the victims of violence • Media professionals and of sexual exploitation but also less likely to • Artists and performers be believed if they report that they have been • Businesses victims of crime. • Lawyers • Organisations and advocates concerned Criminal justice system: Individuals with with human rights and with other forms mental health problems are often over- of discrimination and inequality represented in prison populations [23, 24], • International agencies and donors and mental health care within prisons is • Health and social care organisations. often not of high quality.

The media: The media create and sustain discrimination, stigma and social exclusion through repeatedly using negative and inaccurate representations of people with mental health problems and treatments for mental health problems [19]. In television and in film, people with mental health problems tend to be separated out from other people and routinely associated with violence, unpredictability and irresponsibility. 10 How to tackle the problem

How to tackle discrimination, stigma and social exclusion

The mapping exercise and appraisal undertaken types of activity and at different levels (national, to provide background information for this regional, local) will be most effective in producing briefing paper and the Stigma: A Guidebook long-term change [25, 26]. for Action showed the different ways in which countries across the WHO European Region The gaps in the evidence base, however, were tackling discrimination, stigma and social underline how important it is for activities exclusion, reflecting their different cultural, aimed at tackling discrimination, stigma social, economic and political contexts. and social exclusion to build in both research and evaluation if we are to: This underlines the importance of considering • find out about and learn as much as possible two key questions before developing new from other similar activities before starting projects: • understand what worked and what did not • What are the central issues relating to the work in relation to the activity in order to discrimination, stigma and social exclusion contribute to the evidence base and share facing people with mental health problems learning with others. in the particular country, region or local community? Building networks of people with In some cases, there may not be evidence of mental health problems and those close to whether an activity or action works. Absence of them to act as a base for further actions might evidence does not mean that action should not be a priority in one place. In another country, be taken. It is often possible to make a strong proposing a new anti-discrimination law might theoretical or moral case for why action is be more appropriate. necessary (e.g. if new mental health legislation • What are the potential levers or opportunities is required to replace outdated legislation that in the country, region or locality that might does not adequately protect people’s human provide a way forward in fighting stigma and rights). discrimination? Religious leaders, for example, may play a key role in shaping understanding What is becoming clearer is the importance of mental health problems. Existing and effectiveness of involving those who have employment programmes to help people experience of mental health problems, and those back into the workplace might be a strong close to them, at the heart of any anti-stigma or mechanism for fighting social exclusion. anti-discrimination activity. Face-to-face contact with someone who can talk about their What we know about how to experiences of mental health problems reduce discrimination appears to be a key ingredient in breaking While we know that discrimination, stigma and down discrimination and stigma [27, 28]. social exclusion are experienced by people with mental health problems and those close to them, and have theories as to why, we need more research on which actions tackle them most effectively. Experts are increasingly arguing that approaches that combine a number of different How to tackle the problem 11

Tactics Any approach to tackling discrimination, stigma Using the media and social exclusion needs to acknowledge how For example newspapers and journals, radio, TV, big the power differences are between people advertising and film. Examples of approaches with mental health problems and those who include: discriminate against them [29, 30]. Reducing • Social marketing, that is, using marketing discrimination must aim to reduce these principles and techniques to promote changes imbalances in social, economic and political in attitudes to people with mental health power between people with mental health problems [32]. problems and other citizens [31]. Scotland’s national anti-stigma Various tactics used singly or in combination campaign ‘see me’ has used a can be used to begin to achieve change. social marketing approach. www.seemescotland.org.uk Added impact can come from ensuring that activities aimed at tackling inequalities, • Providing the news media with accurate discrimination, social exclusion and human data on recovery rates for mental health rights abuses also include consideration of problems and guidelines for good reporting discrimination and stigma occurring on the on mental health. grounds of mental health problems. Action • Establishing speakers’ bureaux: training people to deal with discrimination should also be with experience of mental health problems to integrated into work promoting mental health talk to the news media and other organisations. and wellbeing and in programmes to prevent • Awarding media prizes for positive and mental health problems developing. innovative representations of mental health problems in film, TV and radio. Influencing public opinion • Complaining about stigmatising The extent and unacceptability of discrimination, representations in the media. stigma and social exclusion against people with mental health problems and those close to BASTA (Bavarian Anti-Stigma-Action) them are often not widely acknowledged or in Germany runs SANE, an e-mail recognised.People are also often unaware of based ‘Stigma Alarm Network’. SANE the impact that discrimination has on wider uses direct mail campaigns to target society – for example, through lost working days. stigmatising TV series, films, newspaper To address this, various approaches have been reports and advertisements. used to influence public opinion. For example: www.openthedoors.de/en/sane.php 12 How to tackle the problem

Exhibitions, festivals, performance art Training and capacity building Using the arts and culture can be a powerful Training courses to increase awareness of mental way of provoking and engaging people who do health problems can also be developed. not readily respond to mental health topics. Mental Health First Aid is a training In Switzerland, the ‘S’gälbe Wägeli’ course, first developed in Australia, with (Yellow Carriages) project works with the objective of improving the public’s the fact that yellow carriages were awareness and understanding of mental historically used to transport people with health. Scotland’s Mental Health First mental health problems to an asylum or Aid course aims to help people: mental hospital. A modern yellow van • preserve life where a person may stops to pick up passengers in various be a danger to themselves or others towns: passengers are asked about the • provide help to prevent a mental associations they have to the van and health problem developing into then explore issues relating to mental a more serious state health problems. A video on mental • promote recovery of good mental health problems runs inside the van. health www.gaelbewaegeli.ch • provide comfort to a person experiencing a mental health The arts and culture can also be used to combat problem. social exclusion. www.healthscotland.org.uk/smhfa/ index.cfm The Kwartiermakers festivals in the Netherlands use the arts and culture Convincing and advocating as vehicles for social integration. One Those with power need to be convinced to take notable event involved a high profile concerted action to combat the discrimination, choreographer creating a piece for stigma and social exclusion experienced by public performance with a dance people with mental health problems. Which company composed largely of people organisations and which individuals need to with a psychiatric history. be convinced will vary according to the political, www.kwartiermakersfestival- economic and cultural context. It is important amsterdam.nl to embed this work in broader equalities and human rights activities.

In 1990, the Ukrainian Psychiatric Association (UPA), a non-governmental organisation (NGO), founded its Experts Commission to offer social and legal assistance to service users and their families. The Commission provides legal assistance, independently monitors How to tackle the problem 13

psychiatric facilities, and regularly Hamlet Trust informs the mass media, legal and law- www.hamlet-trust.org.uk enforcement authorities of the rights of people with mental health problems The Hamlet Trust c/o in Ukraine. Mental Health Foundation www.upa-psychiatry.org.ua 9th Floor, Sea Containers House 20 Upper Ground Communicating with and persuading policy London SE1 9QB makers and administrators United Kingdom In order to put mental health at the heart of tel: +44 (0)20 7803 1160 public policy. This means ensuring both that fax: +44 (0)20 7803 1111 mental health services are committed to social The Hamlet Trust supports the development inclusion as well as convincing a whole range of of community-based and user-led mental services – education, housing, leisure, community health initiatives. Since 1990, it has worked services – to prioritise social inclusion and reduce to establish, support and develop a network discrimination. Activities might include: of member organisations (which now • Running a policy workshop number more than 50 and which are all • Developing a local policy forum non-governmental organisations, or NGOs) • Working to raise social care allowances throughout Central and Eastern Europe or pensions and Central Asia. Hamlet’s aim is that • Working to improve the provision and these organisations are both based in quality of services. their communities and are led by service- users themselves. Active lobbying by the Georgian Association for Mental Health (GAMH) Resource: resulted in the launch of psycho-social Bureau J, and Shears J, Pathways to Policy: rehabilitation programmes in three A toolkit for grassroots involvement in mental psycho-neurological dispensaries and health policy, 2006. Hamlet Trust Toolkits, one psychiatric hospital. Hamlet Trust: London (available for download from website). This toolkit provides a tried-and-tested framework for establishing policy fora that allow people with mental health problems to have a real voice in policy making. It includes training materials that can be applied in a wide variety of contexts. 14 How to tackle the problem

Developing projects Housing, deinstitutionalisation and homelessness Many kinds of projects can be developed Supported housing and appropriate community- and processes put in place to reduce the based residential alternatives can provide the discrimination, stigma and social exclusion foundations for people with severe mental health people with mental health problems currently problems to participate fully in society. experience in many different areas of their lives. For example: In Kyrgyzstan, the Open Society Mental Health Initiative and Habitat for Humanity Employment and the workplace are working in partnership to offer good Workplace projects focus both on the reintegration quality housing and support services to of workers who have experienced stress-related people with mental health problems and illnesses, and supporting the return to work for their families, in order to provide an people with severe mental health problems. alternative to institutionalisation. Research indicates that for people who have experienced severe mental health problems, European Coalition for Community Living supported employment – i.e. real work in (ECCL) integrated work settings, rather than ‘sheltered www.community-living.info workshops’ – appears to be more effective in terms of supporting people to achieve and The ECCL is a Europe-wide initiative working maintain employment [33]. towards the social inclusion of people with disabilities. Broader employment-related programmes Resource: and initiatives can be used to strengthen the Freyhoff G, Parker C, Coué M, and Grieg N, case for – as well as fund – mental health Included in Society: Results and related anti-discrimination activities. Recommendations of the European Research For countries within the EU: Initiative on Community-based Residential Progress: the EU programme for employment Alternatives for Disabled People, 2004. European and social solidarity 2007–2013 Coalition for Community Living: Brussels www.ec.europa.eu/employment_social/ (available for download from the ECCL website). progress/index_en.htm This report provides policy recommendations This is designed to create more and better and case studies in relation to de- jobs, and to offer equal opportunities for institutionalisation and the provision all through modernising social protection, of community-based care and support. combating poverty, and promoting social inclusion, diversity and non-discrimination. How to tackle the problem 15

Involving consumers of mental health services Using the law Involving people who use mental health services Using the law can be a very powerful means can both combat social exclusion and provide of upholding human rights and of combating new perspectives on how services can be discrimination and social exclusion. Legislation organised to improve the quality of life of can include human rights laws and treaties; laws people with mental health problems. to prevent discrimination on grounds of mental health problems or disability; as well as mental Klimaka, an NGO in Athens whose health legislation. work has been listed in Greece’s ‘Best Practices of the Community Support International and country-specific human Framework’, creates opportunities for rights legislation socially excluded groups (including To protect the rights of all citizens, including people with mental health problems, people with experience of mental health homeless people and people who problems. Examples include United Nations have experienced domestic violence) treaties and Council of Europe treaties (see to participate in society rather than page 23 ‘Supporting instruments, principles simply to receive help and services. and policies’ for more detail). 30% of Klimaka’s staff comprise people from the socially excluded National anti-discrimination legislation groups with which they work. National level laws intended to tackle www.klimaka.org.gr and discrimination on the basis of disability in a www.klimaka-cosmos.net range of different areas of social and economic life should ensure that discrimination due to There are increasing opportunities for users mental health problems is adequately targeted. of mental health services to be involved in developing consumer-run services and in carrying The United Kingdom has a Disability out research in relation to mental health care. Equality Duty, which is designed to ensure that all public bodies (including SURE, the Service User Research government, schools and the health Enterprise at the Institute of Psychiatry, sector) put in place actions to promote King’s College London, is a partnership equality for disabled people in every between researchers who are or who area of their work. have been mental health service users www.dotheduty.org and clinical academic staff that aims to involve service users in all aspects of Making organisations responsible for combating research. It also provides training for discrimination can be more powerful than service users to allow them to develop regulations that demand an individual take skills to undertake research. action when discrimination has taken place. www.iop.kcl.ac.uk 16 How to tackle the problem

Laws can also focus on tackling discrimination, (See: Inclusion in Mind: the Local including discrimination on the grounds of mental authority’s role in promoting wellbeing health problems, in particular areas of life, such as and social development: Mental Health access to employment. See, for example, the Irish (Care and Treatment) (Scotland) Act Employment Equality Act 1998. 2003 Sections 25–31 www.scotland.gov.uk/Publications/ Mental health laws 2007/10/18092957/0 Legislation specifically focusing on protecting and promoting the human rights of people with International laws, declarations, conventions, a mental health problem in relation to treatment principles and instruments can be used to fight and care can also be used for making it illegal the abuse and discrimination experienced by to discriminate against someone on the basis people receiving psychiatric treatment and care that they currently have or have had a mental – particularly those undergoing compulsory health problem. treatment or those who are institutionalised.

Republic of Lithuania: Law on Mental Ensuring people know their legal rights Health Care, June 1995 (no I-924) People with mental health problems can only (amended July 2005 No. X-309). Article use the law if they know their rights, so action 3 specifically prohibits discrimination to increase awareness is a key way of tackling against the mentally ill. discrimination. www3.lrs.lt In the Czech Republic, a manual has Mental health laws can be used, as in Scotland, been produced that familiarises people to promote the social inclusion of people with with mental health problems with their a mental health problem. rights (for example when they are in hospital, as well as later care). It is Scotland: Mental Health (Care and produced for people with mental health Treatment) (Scotland) Act, 2003. This problems, rather than for social workers Act includes provisions to promote the or other professionals, to promote social inclusion of people with mental independent decision-making and to health problems. Guidance to help uphold human rights. public authorities to meet their www.mentalhealth-socialinclusion.org/ responsibilities under the legislation good-practices.html underlines the importance of taking an inclusive approach, that is making use of the same services that are available to the rest of the population How to tackle the problem 17

Mental Disability Advocacy Centre (MDAC) WHO-Mind Project (Mental Health www.mdac.info Improvements for Nations Development www.who.int/mental_health/policy/en H-1088 Budapest, Rákóczi út 27/B The WHO-Mind Project provides information H–1088 Budapest sheets on: Hungary • Promoting the rights of people with mental tel: +36 1 413 2730 disabilities. fax: +36 1 413 2739 • Supporting countries to develop human rights email: [email protected] oriented mental health laws. MDAC advances the human rights of children • Supporting countries to establish mechanisms and adults with actual or perceived intellectual to monitor human rights in mental health or psycho-social (mental health) disabilities. facilities. Focusing on Europe and Central Asia, it uses a combination of law and advocacy to promote equality and social integration. World Health Organization focus on Mental Health, Human Rights and Legislation MDAC is challenging guardianship laws (that www.who.int/mental_health/policy/en outline how decisions are made on behalf of people who are judged to lack competence in Resource: an area of their life) in Bulgaria, Croatia, the WHO Resource Book on Mental Health, Human Czech Republic, Georgia, Hungary, Kyrgyzstan, Rights and Legislation, 2005. World Health Russia and Serbia. To do so, MDAC appeals Organization: Geneva (available for download to the UN Convention on the Rights of from their website, above). Persons with Disabilities, countries’ The Resource Book assists countries in ratification of the European Convention drafting, adopting and implementing mental on Human Rights, and their membership health legislation that places the policies and of the Council of Europe (which brings the plans in the context of internationally expectation of compliance with ‘soft law’ accepted human rights standards and good such as Rec No R(99)4 ‘Principles Concerning practices. It includes a Checklist on Mental the Legal Protection of Incapable Adults’). Health Legislation that helps countries From these sources, MDAC has developed assess whether key components are included 29 indicators that capture basic safeguards in legislation, and ensures that the broad necessary for a person-centred guardianship recommendations contained in the Resource system that respects human rights. Book are examined and considered. 18 How to tackle the problem

Actions can be taken at different levels Local level Actions and activities can take place at different Activities might include: levels. – Working with communities (e.g. festivals). • Some actions can take place at more than – Working with particular groups to reduce one level as part of a multi-faceted, multi-level discriminatory and stigmatising practices. programme against discrimination, stigma – Encouraging and supporting consumer and social inclusion. and family led organisations. • Some actions can be targeted at one particular level. Individual/family level Self-stigma can be addressed through support International level groups for people with mental health problems Some actions demand alliances and partnerships and for their families. that extend beyond national boundaries. For example, partnerships across the world between Actions can be targeted at organisations focusing on physical disabilities different groups and those specifically concerned with mental One approach is to focus on the whole health problems were central in bringing about population (for example, Scotland’s national ‘see the recently signed UN Convention on the Rights me’ anti-stigma campaign); another approach is of Persons with Disabilities. to target particular sectors of the population. These approaches can be used in combination. The World Psychiatric Association (WPA) ‘Open the Doors’ Global Programme against Stigma Particular sectors that have been targeted and Discrimination because of Schizophrenia include: applies the learning from actions in particular • Medical staff (including emergency room countries to actions in other participating physicians, medical students, general countries. physicians, psychiatrists, nurses) • Employers National, devolved, and regional level • Community leaders Appropriate activities might include: • Employers • Implementing anti-discrimination laws • Landlords and action plans – and ensuring they are • Police and corrections officers applied to mental health problems as well • Teachers as physical disabilities • Politicians, legislators and administrators • Drawing up and implementing a national • Families of people with mental health problems mental health action plan • Social service workers • Drawing up and implementing a national • Church leaders anti-stigma action plan • School children and students • Providing economic incentives rather than • Media/journalists. disincentives for people ready to return to work. How to tackle the problem 19

In Poland, the Local Action Group from In other contexts, focusing on particular the WPA Open the Doors campaign has conditions might be more effective. For example, worked with psychiatrists and clergy in the WPA ‘Open the Doors’ programme decided an educational programme for clergy. to focus specifically on schizophrenia because it Clerics and monks within the Roman was felt that stigma related to schizophrenia is Catholic Church have sponsored fund- more severe than that related to other mental raising activities to assist in housing health problems [34]. for people with schizophrenia. www.openthedoors.com It is also important to recognise the discrimination experienced by people who are Actions can focus on a particular doubly disadvantaged – for example, refugees or mental health problem or on all migrants with mental health problems, people mental health problems with mental heath problems from different Actions and activities sometimes tackle ethnic communities, people with mental health discrimination and stigma relating to problems who are lesbian, gay or bisexual, or ex- ‘disability’ in general (which includes mental offenders who have a mental health problem. health problems alongside physical disabilities). Other actions can focus on the discrimination Actions can use different ways of and stigma related to all mental health thinking about mental health problems problems, or it can focus specifically on Any action aimed at tackling discrimination, particular health problems. stigma and/or social exclusion will carry with it – either explicitly or implicitly – messages about Anti-discrimination legislation is most powerful what mental health problems are and what a when it uses a very wide definition of disability. world without discrimination against people with mental health problems would look like. The Irish Employment Equality For example, several anti-stigma campaigns Act 1998 states: have emphasised how common mental health problems are – in the hope that if people ‘‘disability’ shall be taken to include acknowledge how many people experience a disability which exists at present, or mental health problems, they will be less fearful which previously existed but no longer of mental health problems. This is only one exists, or which may exist in the future approach; other influential approaches include: or which is imputed to a person’. • The disability rights/social inclusion model This definition recognises that people can • The use of human rights arguments experience discrimination even without • The recovery model having any diagnosis of a mental health • The bio-medical model/brain disease model (in problem, and that people can continue to which mental health problems are understood experience discrimination even when they to be an illness like physical illnesses). no longer have a mental health problem. 20 How to tackle the problem

The disability rights/social inclusion model arguing for increased research and funding for uses a social model of disability. This focuses on treatment – for example for conditions such as the barriers within society that dis-able people. Alzheimer’s disease. Attention is given here to dismantling the obstacles to their full participation in society We do not yet know which messages and models [35]. This has the advantage of emphasising are most effective – and with which groups of people’s rights to particular benefits or supports, people – in reducing discrimination and stigma. rather than seeing benefits as an act of charity A recent EU project on good practices for or pity. This approach is recognised in the UN combating social exclusion of people with Convention on the Rights of Persons with mental health problems found that a recovery Disabilities which states that: model – alongside an approach that acknowledged the combined impact of social, ‘disability results from the interaction between economic, psychological and biological factors persons with impairments and attitudinal and on people’s mental health – was most useful in environmental barriers that hinders their full promoting social inclusion [36]. and effective participation in society on an equal basis with others’. Anti-discrimination and anti-stigma programmes can be enhanced when tactics are used together Human rights arguments centre on a person with and strengthen one another and are further a mental health problem having the same human combined with or embedded within wider work rights as any other person. Programmes that take on social inclusion, equality and human rights. this approach often target discrimination. In Scotland, for example, in addition The recovery model emphasises that every to new mental health legislation, the person with a mental health problem is capable National Programme for Improving of pursuing a meaningful life, and that recovery Mental Health and Wellbeing: might well include acceptance of ongoing • influences public opinion through the symptoms. While recovery is seen as taking national anti-stigma campaign ‘see me’ different forms for different people, the recovery • influences policy and develops projects model underlines the importance of hope, and through its initiatives designed to each person’s ability to take control over their improve and promote mental health own life and to be an active participant in their and wellbeing and prevent mental own health care. health problems developing. www.wellscotland.info/index.html The bio-medical model adopts a view that ‘mental illness is an illness like any other’ or that it is ‘a brain disease’. It relies on science to explain mental health problems as being caused by chemical imbalances or genetic abnormalities. This model can be powerful in Making it happen 21

Making it happen

Allies and collaboration There is a huge amount of work and many • Actions and activities can build on or different activities already going on within strengthen existing initiatives taking place at and across the WHO European Region to fight a national, regional or international level (see discrimination, stigma and social exclusion. Supporting instruments, principles and policies The mapping activity for this briefing paper on page 23 for some international examples). received material on over 34 different activities • Collaboration with other organisations can from 26 countries (out of 53) within the WHO increase the effectiveness of activities. European Region. The recent EU project ‘Good Practices for Combating Social Exclusion of People with Stigma: A Guidebook for Action that Mental Health Problems’ indicated the value accompanies this briefing paper provides of a broad range of interest groups working more detail about the actions that can be together on issues of discrimination and stigma. taken. The following describes some of the www.mentalhealth- key steps for consideration. socialinclusion.org/home.html

Developing a strategy Resources In planning actions it is crucial to identify: • Anti-discrimination and anti-stigma actions • which tactic(s) will be used need and deserve resources – both financial • at which level(s) and in terms of people. • targeted at which group(s) • Resources can come from a variety of • in relation to which mental health problem(s) sources, and not necessarily just from • with which model(s) or message(s) the mental health sector. (see Figure 2 on page 22). • Resources can be financial, but can also include: Timeline – the provision of staff time • Ongoing, multi-level activities are most – contacts with decision makers effective. – access to databases • But this does not mean that everything has – access to technology or other to happen all at once: often smaller activities infrastructure can ignite people’s interest and commitment – the provision of free television slots. to further action. If a clear strategy is in place, smaller, more short-term activities Evaluation can be effective. Research and evaluation need to be built in to • Keeping the momentum going: Consideration activities to add to what we know and so that we must be given to what is needed – in terms of can learn from each other. While many activities ongoing financial resources and the may not have the resources to undertake contributions of individuals and organisations – detailed and rigorous evaluations, projects for the effects of anti-discrimination activities to should be able to identify what the activity is last. Establishing partnerships can improve the trying to change, how it is going to go about chance of an activity being able to continue. changing it, and what change would look like. 22 Making it happen

FIGURE 2: DEVELOPING A STRATEGY TO TACKLE DISCRIMINATION, STIGMA AND SOCIAL EXCLUSION

WHICH TACTIC(S)? AT WHICH LEVEL(S)? TARGETED AT WHICH GROUP(S)?

• Influencing public opinion, e.g. • International • The whole population – Using the media • National/devolved/regional • Sections of the population, e.g. – Exhibitions/festivals • Local – Medical staff – Training/capacity building – Employers • Convincing/ advocating, e.g. • Individual/family – Community leaders – Advocacy – Employers – Persuading policy makers MORE THAN ONE LEVEL – Landlords CAN BE USED. • Developing projects, e.g. – Police/corrections officers – Workplace – Teachers – Housing – Politicians/legislators – De-institutionalisation – Families of people with – Homelessness mental health problems – Involving consumers of – Social service workers mental health services – Church leaders – School children • Using the law, e.g. – Media/journalists – Human rights legislation – National anti-discrimination MORE THAN ONE GROUP legislation CAN BE TARGETED. – Mental health laws – International laws, declarations and conventions – Ensuring people know their legal rights

TACTICS CAN BE COMBINED.

IN RELATION TO WHICH WITH WHICH MODEL(S) MENTAL HEALTH PROBLEM(S)? OR MESSAGE(S)?

• Disability in general (including e.g. mental health problems) • Disability rights/social inclusion • All mental health problems model • Particular mental health • Human rights arguments problems, e.g. • Recovery model – Schizophrenia – Depression • Bio-medical model – Mental health problems in children and young people MORE THAN ONE MODEL AND/OR MESSAGE CAN BE USED. Supporting mechanisms 23

Supporting instruments, principles and policies

Existing international legislation, policy and Notably, the Convention requires States Parties to: human rights principles can assist actions in • foster in all educational settings, including reducing discrimination, stigma and social those from an early age, respect for the rights exclusion on the grounds of mental health of those with disabilities problems. • encourage the media to use appropriate representations of people with disabilities United Nations • conduct awareness raising campaigns United Nations treaties impose legally binding • promote appropriate training for police and obligations on those states that ratify them. prison staff to ensure access to justice for They include: those with disabilities. • Universal Declaration of Human Rights (UDHR) • International Covenant on Civil and Political Council of Europe Rights (ICCPR) Key Council of Europe treaties and guidelines • International Covenant on Economic, Social include: and Cultural Rights (ICESCR) • European Convention on Human Rights. • Convention Against Torture and Other • European Social Charter (which protects a Cruel, Inhuman or Degrading Treatment range of social and economic rights including or Punishment (CAT). the right to work). • European Convention on the Prevention of Of particular relevance is the UN Convention Torture and Inhuman or Degrading Treatment on the Rights of Persons with Disabilities or Punishment. www.un.org/disabilities • REC(2004)10 Guidelines ‘concerning the protection of the human rights and dignity The Convention, which opened for signature of persons with mental disorder’. on 30 March 2007, demands that signatories The Mental Disability Advocacy Centre’s ‘take all appropriate measures to eliminate website provides a comprehensive discrimination on the basis of disability by collection of mental disability rights in any person, organisation or private enterprise’, Europe, including the texts of relevant and to ‘adopt immediate, effective and instruments and summaries of mental appropriate measures … to combat stereotypes, disability cases decided by the European prejudices and harmful practices relating to Court of Human Rights. A good persons with disabilities … in all areas of life’. summary of the legislation required to support mental health policy that protects people’s human rights is provided by Camilla Parker [37]. www.mdac.info 24 Supporting mechanisms

WHO European Region European Union (EU) As well as the WHO Mental Health Declaration In 2005 the European Commission commissioned and Action Plan, other WHO initiatives in Europe its Green paper on ‘Improving the Mental Health also support anti-discrimination work, for of the Population: Towards a strategy on Mental example: Health for the European Union’. Following a consultation period, the European Commission Schools for Health in Europe (SHE) is has announced that a high level conference to be a European network for school health held in June 2008 will inform the development of promotion providing access to a ‘Mental Health Pact’. This will focus specifically information, good practices and on suicide, school education, workplace contacts. The network’s principles of environment, young and elderly people. equity and access seek to ensure that a health-promoting school ‘is genuinely The EU Directive on Employment (2000) social inclusive’ and able to ‘foster the Article 13 requires EU Member States emotional and social development of to pass laws debarring employment every individual, enabling each to attain discrimination on grounds that include his or her full potential free from disability; they are also required to set discrimination’. up institutions that will ensure www.schoolsforhealth.eu enforcement. europa.eu/scadplus/leg/en/s02311.htm

The Lisbon Strategy commits Member States to generating more and better jobs and promoting social cohesion. Member States are expected to invest in education and training and to conduct an active policy for employment.

A call to action Fighting the discrimination, stigma and social or nationwide multi-level campaigns: all have exclusion experienced by people with mental a vital role to play in tackling the injustices health problems and by those close to them currently experienced by people with mental is both a challenge and an imperative if we are health problems and by those close to them. to achieve socially just societies which value, Even small changes add up and lay the protect and promote the rights of all citizens. foundations for bigger changes. What is This may take the form of small local festivals important is that action is taken. More information 25

Places to go for more information

Organisations country) representing families and carers of people living with severe mental health problems. Below are additional organisations, programmes ZeroStigma is EUFAMI’s campaign to replace and resources that are targeted towards fighting prejudice, ignorance and fear of people with the discrimination, stigma and social exclusion of mental health problems with acceptance, people with mental health problems and those knowledge and understanding. close to them. Amnesty International European Observatory on Health Systems www.amnesty.org and Policies 1 Easton Street www.euro.who.int/observatory London WC1X 0DW The European Observatory on Health Systems United Kingdom and Policies supports and promotes evidence- tel: +44 (0)20 7413 5500 based health policy-making through fax: +44 (0)20 7956 1157 comprehensive analysis of the dynamics of health care systems in Europe. Their work on ENUSP (European Network of (Ex-)Users mental health policy addresses the ongoing and Survivors of Psychiatry) move towards community-based care, and how www.enusp.org barriers to system reform may be overcome. Zabel-Krüger-Damm 183 Resource: D–13469 Berlin Knapp M, McDaid D, Mossialos E, Germany Thornicroft G, (eds) Mental Health Policy and tel: +49 30 8596 3706 Practice across Europe: The future direction email: [email protected] of mental health care, 2007. Open University ENUSP is a grassroots umbrella organisation on Press: Maidenhead (available for download a European level that brings together national from the European Observatory website). organisations of (ex-)users and survivors of The book addresses the legal rights of people psychiatry to communicate and to support with mental health problems, the impact of one another in fighting injustice, expulsion and discrimination, stigma and social exclusion, stigma in the members’ respective countries. and approaches to the reform of services across Europe. EUFAMI (European Federation of Associations of Families of People with Mental Illness) Implementis www.eufami.org www.implementis.eu Diestsevest 100 An online resource for mental health advocacy B–3000 Leuven in Europe developed by the International Belgium Longevity Centre-UK working together with tel: +32 16 74 50 40 EUFAMI. It is designed to assist users, carers, fax: +32 16 74 50 49 healthcare professionals and government email: [email protected] policy makers in reviewing existing mental EUFAMI comprises 42 family associations (across health policies and services and lobbying 26 European countries and one non-European for new areas for action. 26 More information

Hamlet Trust Health Scotland is Scotland’s health www.hamlet-trust.org.uk improvement agency. Funded by the Scottish The Hamlet Trust c/o Mental Health Foundation Government, it aims to support population 9th Floor, Sea Containers House health improvement and promotion and tackle 20 Upper Ground health inequalities. London SE1 9QB Health Scotland is the WHO Europe Collaborating United Kingdom Centre taking the lead on mental health related tel: +44 (0)20 7803 1160 stigma and discrimination as part of the WHO fax: +44 (0)20 7803 1111 Europe Region’s Mental Health in Europe The Hamlet Trust supports the development of Implementation Plan 2005–2010. community-based and user-led mental health initiatives. Since 1990, it has worked to establish, Mental Health Europe support and develop a network of member www.mhe-sme.org organisations (which now number more than 50 Mental Health Europe and which are all non-governmental organisations, 7 Boulevard Clovis or NGOs) throughout Central & Eastern Europe B–1000 Bruxelles and Central Asia. Hamlet’s aim is that these Belgium organisations are both based in their communities tel: +32 2 280 0468 and are led by service-users themselves. fax: +32 2 280 1604 email: [email protected] Resource: Mental Health Europe (MHE) supports the Bureau J, and Shears J, Pathways to Policy: A emancipation of different groups in the mental toolkit for grassroots involvement in mental health field in order to establish equal positions health policy, 2007. Hamlet Trust Toolkits, Hamlet Trust: London (available for download between the different parties and to ensure that from website). mental health activities and mental health care really meet the needs of the population. It has This toolkit provides a tried-and-tested developed a range of projects centring on social framework for establishing policy fora that allow inclusion and anti-discrimination. people with mental health problems to have a real voice in policy making. It includes training Resource: materials that can be applied in a wide variety www.mentalhealth-socialinclusion.org of contexts. The website reports on the MHE-led EU Project ‘Good practices for combating social exclusion Health Scotland of people with mental health problems’. It www.healthscotland.com includes an online database of best practice Woodburn House for combating social exclusion drawn from Canaan Lane projects in Belgium, Cyprus, Czech Republic, Edinburgh EH10 4SG France, Ireland, Italy, Poland, Slovakia, United Kingdom Slovenia, and the UK. tel: +44 (0)131 536 5500 fax: +44 (0)131 536 5501 email: [email protected] More information 27

The National Programme for Improving Rethink Mental Health and Wellbeing www.rethink.org www.wellscotland.info 5th Floor Royal London House National Programme Team 22–25 Finsbury Square Scottish Government London EC2A 1DX St Andrew’s House United Kingdom Regent Road tel: +44 (0)20 7330 9100 Edinburgh EH1 3DG email: [email protected] United Kingdom Rethink is a UK mental health voluntary tel: +44 (0)131 244 2551 organisation whose work includes activities to email: [email protected] research and tackle stigma and discrimination. Through a number of different initiatives the Resource: National Programme aims to improve the mental www.rethink.org health and wellbeing of everyone in Scotland How can we make mental health education and improve the quality of life and social work?: Example of a successful local mental inclusion of people who experience mental health programme challenging stigma and health problems. discrimination, 2006. Institute of Psychiatry/ Rethink: Surrey (available for download from Open Society Mental Health Initiative the website). www.osmhi.org The report describes the approach taken by one Open Society Institute mental health awareness project in England to Október 6 u 12 reduce discrimination and stigma experienced H–1051 Budapest by people with mental health problems. Hungary +36 1 327 3100 tel: ‘see me’ fax: +36 1 327 3101 www.seemescotland.org.uk The Open Society Mental Health Initiative (MHI) 9–13 Maritime Street aims to ensure that people with mental Edinburgh EH6 6SB disabilities (mental health problems and/or United Kingdom intellectual disabilities) are able to live in the tel: +44 (0)131 624 8945 community and to participate in society with full fax: +44 (0)131 624 8901 respect for their human rights. MHI works in email: [email protected] Central and Eastern Europe and the former Soviet Union, and promotes de-institutionalisation and ‘see me’ is Scotland’s national campaign to end the development of sustainable community- the stigma of mental ill-health. It was launched based services. in October 2002 and is run by an alliance of five organisations. 28 More information

Resource: SMES-EUROPA (Santé Mentale Exclusion Sociale) ‘see me’, A review of the First 4 Years of www.smes-europa.org the Scottish Anti-stigma Campaign, 2008. email: [email protected] ‘see me’: Edinburgh (available for download SMES-EUROPA is a European Network that from the website). addresses social exclusion as a structural The review, available via their website, details phenomenon within society. It works for the way in which evidence and social marketing the mental health and social rehabilitation were brought together to effect change. of homeless people with mental health problems and socially excluded people. Scottish Development Centre for Mental Health www.sdcmh.org.uk Substance Abuse and Mental Health Services 17a Graham Street Administration (SAMHSA) Resource Center to Edinburgh Address Discrimination & Stigma Associated EH6 5QN with Mental Illness (ADS Center) United Kingdom www.stopstigma.samhsa.gov tel: +44 (0)131 555 5959 This is a resource providing information and advice fax: +44 (0)131 555 0285 on fighting the discrimination and stigma email: [email protected] associated with mental health problems. While The Scottish Development Centre for Mental much of its material focuses on an American Health is a Non-Governmental Organisation context, it provides a comprehensive bibliography which undertakes research and development of literature on addressing discrimination and work to support the mental health and well- stigma and other useful resources. being of individuals and communities and Resource: the improvement of services for people with Substance Abuse and Mental Health Services mental health problems. Administration. Developing a Stigma Reduction Initiative, 2006. SAMHSA Pub. No. SMA-4176. Support Project: Promoting the EU Mental Center for Mental Health Services, Substance Health Agenda Abuse and Mental Health Services www.supportproject.eu/AboutSupport.htm Administration: Rockville, MD (available Scottish Development Centre for Mental Health for download from website). (as previous) This resource provides material on how to run The Support Project is a collaborative project anti-stigma and anti-discrimination initiatives. co-funded by the European Commission and led It draws on activities undertaken in eight by the Scottish Development Centre for Mental American states. Health with STAKES and Health Scotland. Together with other projects in the European Union Public Health Programme, the Support Project provides administrative, technical and scientific support to further the mental health priorities of the European Commission. More information 29

World Federation for Mental Health (WFMH) World Psychiatric Association (WPA) Global www.wfmh.org Programme against Stigma and Discrimination 6564 Loisdale Court because of Schizophrenia ‘Open the Doors’ Suite 301 www.openthedoors.com Springfield The ‘Open the Doors’ anti-stigma programme VA 22150-1812 was set up in 1996 by the World Psychiatric USA Association (WPA) as an international tel: +1 703 313 8680 programme to fight the stigma and fax: +1 703 313 8683 discrimination associated with schizophrenia. email: [email protected] The three aims of the programme are to: The WFMH organises World Mental Health Day • Increase the awareness and knowledge of the and promotes the advancement of mental nature of schizophrenia and treatment options. health awareness and advocacy. It works • Improve public attitudes about those who have towards ensuring that public policies and or have had schizophrenia. programmes reflect the crucial importance of • Generate action to eliminate discrimination mental health in the lives of individuals. and prejudice. Countries within the WHO European Region in World Health Organization (WHO) which programmes exist include: Austria, www.euro.who.int/mentalhealth Germany, Greece, Italy, Poland, Romania, WHO Regional Office Slovakia, Spain, Turkey and the United Kingdom. Mental Health Resource: Scherfigsvej 8 Sartorius N, and Schulze H, Reducing the DK–2100 Copenhagen Stigma of Mental Illness: A Report from a Denmark Global Programme of the World Psychiatric tel: +45 39 17 13 91 Association, 2005. Cambridge University fax: +45 39 17 13 18 Press: Cambridge. email: [email protected] The book documents the work of the WPA The Regional Office’s mission is to support Programme, and provides comprehensive Member States in: developing and sustaining details and advice about running various anti- their own health policies, health systems and stigma programmes in countries that are public health programmes, working to prevent economically, politically and culturally diverse. and overcome threats to health, anticipating future challenges, and advocating public health. 30 References

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