Monthly Archives: October 2013

Kathryn Smale – A matter of identity: the costs and comforts of belonging to stigmatised groups

While nursing my disappointment that I’d missed the talk that inspired last week’s blog, “People Who Heal Us: the role of peer support in mental healthcare treatment”, I found myself dwelling on the question posed by Jenelle Clarke. Was it “the principles of CBT or the peer support that had been the most helpful in overcoming social anxiety”?  I was reminded of an article I read recently, entitled:   ‘Water clubs in residential care: Is it the water or the club that enhances health and well-being?’ (Gleibs et al., 2011). This study explored whether the reported benefits of water club membership led to enhanced perceptions of wellbeing due to a reduction in the negative effects of dehydration or the increased social engagement. Interestingly, the beneficial effects of water were only found when delivered in the context of a club, as opposed to in an individual intervention. Social support had a positive effect on quality of life and, intriguingly, it was identification with other club members that mediated this effect.

Warnings against the spiralling consequences of our individualistic society are all too familiar and it is now well established that lack of social contact can have detrimental effects on both physical and mental health. The additional contribution made by the water club study was to propose identity processes as an underlying mechanism. There has been a burgeoning interest in the social identity approach to health in recent years, but, returning to Jenelle’s question, what are the implications for the realm of mental health research and practice?

Perhaps the additional factor in the context of mental health is that of stigma, topically discussed in Amanda Keeling’s IMH blog earlier this month, “Fear and Loathing: Combating the Stigma Against ‘Scary’ Disorders”. If identification with fellow group members indeed underlies the benefits of peer support, what happens when those identities are stigmatised? Much has been done to raise awareness of the barriers to social integration created by stigma and considerable research now documents prejudices against those living with mental health difficulties. Apparently less attention has delved in any detail into the ways identification with stigmatised groups influence recovery.

A notable exception is research by Crabtree and colleagues (Crabtree et al., 2010). This explored self-perceptions of stigma and the implications of identification with a stigmatised group.  According to social identity theory, group membership plays a key role in determining self-esteem (Tajfel & Turner, 1979). Since intergroup comparisons are relative, membership of a stigmatised group has the potential to adversely impact self-esteem.Clearly this has implications for engagement with both clinician-led and peer support groups.  However, the researchers found that the shared identity of stigmatised group members provided the support needed to resist stigma, challenge prejudice and provide a buffer against the negative effect of discrimination. There was a darker side to this finding, though; the protective mechanisms positively affected self-esteem, but simultaneously supressed a negative relationship between self-esteem and social identification.  Underneath the protection afforded, the more individuals identified with their mental health support group, the worse they felt about themselves (Crabtree et al., 2010).

I’m the first to advocate the importance of community and social support and to lament the rise of an individualistic culture. We exist in relationship with one another. Nevertheless, such research does point to the complexities of group dynamics and the need for caution when presenting the mere existence of support groups as a route to improved wellbeing.  How such groups are viewed by participants and the impact of belonging to them needs to be considered, particularly if membership does not alsoprovide increased social support.  Perhaps part of the problem is where our primary identity lies and the tendency to see diagnostic labels as part of an individual’s essential identity. As Amanda pointed out in her blog, “people with mental health problems are people first and foremost”. This makes the fight against stigma all the more urgent. If their fundamental identity and value is secure, more people may avail themselves of the potential benefits of therapeutic groups rather than avoiding the opportunity due to the connotations being part of such a group may confer.

Crabtree, J., Haslam, S. A., Postmes, T., & Haslam, C. (2010) Mental health support groups, stigma, and self-esteem: positive and negative implications of group identification. Journal of social issues. 66 (3), pp. 553-569
Gleibs, I.H., Haslam, C., Haslam, S.A., & Jones, J. (2011). Water clubs in residential care: Is it the water or the club that enhances health and well-being? Psychology and Health, 26, 1361-1378.
Tajfel, H., & Turner, J. C. (1979). An integrative theory of intergroup conflict. In W. G. Austin &
S. Worchel (Eds.), The social psychology of intergroup relations (pp. 33 – 47). Monterey, CA:

Kathryn Smale, ESRC PhD student, School of Medicine

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Jenelle Clarke ~ People Who Heal Us: the role of peer support in mental healthcare treatment

As part of the Art in the Asylum exhibition currently underway at Lakeside, I recently attended the Ancient and Modern Mental Healthcare lecture held on 2 October 2013.  Speaking at the lecture were Jules Evans with Dr Arun Chopra and Dr Ben Di Mambro.  All three speakers focused on different aspects of mental healthcare treatment as depicted from Greek philosophy, films, politics and popular culture.  Rather than give a summary of the evening, I would like to instead highlight the question I have been mulling over following the lecture, namely the use of peer support as a treatment for mental distress.

The ideas of peer support started off with Jules Evans giving us an overview of Cognitive Behavioral Therapy (CBT) and explained how it derives from Greek philosophy, particularly stoicism.  His talk was centered on his own personal story of mental health difficulties in his early 20’s as a result of drug use and his recovery from social anxiety through the use of CBT.  Interestingly, rather than the traditional CBT model of individual therapy with a mental health professional, Jules received help from a peer support group that used a computerised CBT course.  There were no clinical practitioners or mental health professionals – just others who also struggled with anxiety helping each other.  This raised the question for me as to whether it was the principles of CBT or the peer support that had been the most helpful in overcoming social anxiety.  Furthermore, in terms of the peer support, what was it specifically that was beneficial?

The importance of peer support in a therapeutic process is not a new concept, least of all in mental health research.  Many others (Lapsley et al., 2002; Corrigan and Phelan, 2004; Hogan et al., 2002; Davidson et al., 1999; Haigh, 2005; Pilgrim et al., 2009) have done an admirable job of highlighting the use and benefits of peer support.  But it does raise some important questions when exploring the use of peer support as a form treatment, either on its own, or in conjunction with another form of therapy.  What mechanisms are actually at work that make it ‘effective’?  What happens when it goes wrong?  What about the role of power, social control, peer pressure and marginalising?  We (and I definitely include myself in this!) often use sweeping statements, such as relationships are central within mental health treatment.  But as I unpack that I am constantly asking myself – what does that actually mean?  What are we saying matters most?  Contact with people?  Contact with certain types of people?  What types?  And so on and so forth…

My point is that as a form of treatment, peer support is not a routinised model of care in the same way as CBT.  Thank goodness!  Yet it does mean that as a mechanism of change, it receives far less scrutiny.  In addition, much of the social support research focuses on the outcomes of support and does not explore the processes at work within these interactions.  For instance Corrigan and Phelan (2004:519) in their study of individuals with a diagnosis of mental illness found that whilst social support seemed to reduce distress symptoms, it is unclear ‘how social support promotes symptom remission’.

As a form of mental healthcare treatment, peer support can play a vital role in recovery.  After all, the old adage carries a lot of truth: it is people who hurt us and people who heal us.  Yet as Haigh (2005) notes, our question should not be so much do the relationships work and is personal change achieved, but rather what do these relationships and interactions actually mean, how are these meanings constructed and how do they play a role in transformative change.  Questioning, challenging and extending our knowledge of peer support is necessary as, for many people, it forms such an important part of personal change.

Jenelle Clarke, ESRC PhD student, School of Sociology and Social Policy,

Corrigan, P.W. and Phelan, S.M. (2004) Social Support and Recovery in People with Serious Mental Illnesses.   Community Mental Health Journal 40(6): pp.513-523.

Davidson, L., Chinman, M., Kloos, B., Weingarten, R., Stayner, D. and Kraemer Tebes, J. (1999) Peer Support Among Individuals With Severe Mental Illness: a review of the evidence. Clinical Psychology: Science and Practice 6(2): pp.165-187.

Haigh, R. (2005) The Trouble with Modernisation: we need better relationships, not policies and procedures. Mental Health Review Journal 10(3): pp.3-7.

Lapsley, H., Nikora, L.W. and Black, R. (2002) “Kia Mauri Tau!” Narratives of Recovery from Disabling Mental Health Problems. Report of the University of Waikato Mental Health Narratives Project. Wellington: Mental Health Commission.

Pilgrim, D., Rogers, A. and Bentall, R. (2009) The Centrality of Personal Relationships in the Creation and Amelioration Mental Health Problems: the current interdisciplinary case. Health: an interdisciplinary journal for the social study of health, illness and medicine13(2): pp.235-254.


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Professor Justine Schneider ~ Longest stays in Europe make scarce hospital beds harder to get

(originally posted on the UoN Blog on 17 October 2013)

Professor-Justine-ScAC6707-420x210Why is a leading psychiatrist concerned about not having the resources needed to provide psychiatric care?  Martin Baggaley, South London and Maudsley’s clinical director hit the headlines this week when he stated that too many psychiatric beds had been closed.  It is possible to specify fairly precisely how many beds are sufficient to meet the needs of people with severe mental illness.  After all, the prevalence of mental disorders can be estimated within reasonable parameters, based on nationally representative surveys and mental health services have masses of data about readmission rates and co-morbidity, and clinical commissioning groups should have this information. In fact it is not bed numbers, but the balance of community and hospital provision that is at issue here, and data collated for a European study led by the Institute of Mental Health, Nottingham throw light on this balance.

The UK is a world leader in community care. Whereas some other countries, including Belgium and Malta, rely almost entirely on psychiatric hospitals to provide mental health care, for half a century in the UK we have had a strong bias against hospital admission because of its associated stigma, costs and the risk of institutionalisation that long-term admissions are believed to pose.   Responsive, community-based services were developed to span all levels of complexity, from early intervention in psychosis to home treatment for people in crisis.  These comprehensive services have been adversely affected by the cost improvement plans imposed on all providers.  It’s easy to count beds and I don’t disagree that the numbers have been sharply reduced in recent years.  However, as Martin Baggaley states, the shortage of beds is part of a general reduction in mental health and social care provision, it’s one of a swathe of so-called ‘cost improvements’.

Given the recent history of mental health services, it is not surprising that, of 29 European countries, the UK has the ninth lowest number of psychiatric beds per capita.  But it is remarkable that, according to WHO European Hospital Morbidity Database (2012), people admitted to hospital in the UK with schizophrenia (for instance) on average spend nearly four months as inpatients – twice as long as most other countries in Europe.  We need to understand more about these long-term hospital admissions and why the limited inpatient resource seems to have an exceptionally low throughput.

This is a guest blog by Professor Justine Schneider (pictured above), an expert in mental health service evaluation and dementia care in the University’s School of Sociology and Social Policy. This blog draws on a new report ‘Mental health Systems in the European Union Member States, Status of Mental Health in Populations and Benefits to be Expected from Investments into Mental Health’ by Chiara Samele, Stuart Frew and Norman Urquia, 2013.

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Fear and Loathing: Combating the Stigma Against ‘Scary’ Disorders

By something as a way of a general disclaimer, I will say that this is something of a stream of consciousness, based simply on my own impressions as a member of the public.  By all means feel free to criticise roundly what I’ve said in the comments below.

A decade ago, the Richardson Committee presented their report to the Government recommending a complete overhaul of the English mental health legal framework (pdf).  It was highly progressive, recommending a rights-based framework with an emphasis on patient involvement and autonomy, putting the individual at the heart of the system.  It aimed to combat stigma and social exclusion, and recognised that people with mental health problems are people first and foremost.  Alas, it was not to be.  The Labour government, driven in a large part by the public, dismissed the proposals, and made it clear that their preoccupation for legal reform was the risk people with mental health problems apparently posed to the general public.  It appears very little has changed.

 The University of Manchester recently released a report (pdf) into figures for suicide and homicide amongst people with mental health problems.  Though passed by in most of the media, preoccupied with the sale of Royal Mail, the Sun thought it fit to report it thus:


The issues with this headline are almost too many to list (thought the Independent and the Guardian both do an admirable job).  Most obviously, it is sensationalist, and reports only half of the report, choosing to focus only on the homicides than the suicide rate – which, as Time for Change note, is sadly a much bigger risk to people with psychosocial disabilities; 90% of suicides in the UK are by people with mental health problems.  The debacle of the ASDA ‘mental patient’ halloween costume, and similar offerings from Tesco’s and Amazon, demonstrates that there is still an underlying fear that people with psychosocial disabilities are likely to turn into ‘mad axe murders’ at any given second, and The Sun’s headline does absolutely nothing to dispel this belief, even if the actual article itself was more nuanced and suggested that it was the system that had failed, rather than the individuals themselves being inherently dangerous (though I’m not sure that I’d want to see their ideas of an improved system).  When a 3rd of the population believe that people with mental health problems are likely to be violent, when in actual people with mental health problems account for only 5% of homicides, this kind of reporting is completely irresponsible.

However, in the aftermath of the ASDA debacle, I noticed something that I found slightly troubling.  I can’t claim to have done a rigorous search on this, so this is simply my impression of what I have seen as a member of the public, not as a mental health researcher, but the prominent responses were primiarily from people who had depression.  Rightly, they were angry at being characterised as ‘mad axe murderers’ – but I couldn’t help thinking that, actually, they were not being characterised as so.  While it would be wrong to say there is no stigma around depression, and that we are all open and understanding about it, it is not depression that the general public think of when they think of ‘mad axe murderer’, or the stereotyped mental patient in strait jackets and padded cells.  Depression is not ‘madness’ in the eyes of the general public: it is psychosis, and personality disorders, and it is this group who are damaged by those costumes, and the Sun’s reporting.

However, it is not this group who have been targeted in the campaigning.  The prominent celebrity voices, working hard to normalise mental illness have been Ruby Wax, Stephen Fry, and Alistair Campbell, all who have experienced, or continue to experience, some kind of affect disorders.  Where is the voice for psychosis, or personality disorder?  The latter is still associated with the cold, heartless killers so popular in our detective TV shows, the former perhaps most closely correlated with ‘madness’.  These are seen as unpredictable, ‘scary’ disorders, and it is these which people most closely associate with the ‘psycho killer’ headlines of old, and which were most closely targeted by the ‘mental patient’ costumes, and the Sun headline this week – not depression.  Despite this, however, the voice of these individuals is less prominent.  Wikipedia lists a number of celebrities who are said to have/have had schizophrenia, yet none of them has the same profile as Wax, Fry or Campbell in terms of advocacy for normalisation and open dialogue for the disorder.  The reporting of Stephen Fry’s account of his attempted suicide was, in the main, done sensitively and commended; in contrast, Amanda Byne’s increasingly erratic behaviour has been documented salaciously, in a manner reminiscent of Britney Spears’; her diagnosis with schizophrenia has been greeted with sympathy, but the run up to her committal in a secure facility was covered with both a tone of incredulity and wariness.

The national media has a lot to answer for in terms of how it reports stories around the ‘dangerousness’ of people with mental health problems – but equally the focus on ‘safe’ disorders from campaigns is perhaps missing an important point.  People do not fear people with depression – they fear depression itself, and the campaigns have done a remarkable job opening dialogue and normalising depression.  Now, we need to do the same work with other disorders; fear only goes away with greater understanding, and a greater public discourse around fear of the perceived ‘danger’ of people with mental health problems to others needs to begin.

Amanda Keeling, PhD Student, School of Law, University of Nottingham,

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Dr Simon Clarke ~ The Visible and the Invisible Nature of Mental Health Prejudice

“What a sad era when it is easier to smash an atom than a prejudice.”
― Albert Einstein

I was recently sent a ‘humorous’ email called the ‘Alberta Mental Health Release Examination’, forwarded as a group email to everyone on a University mailing list for, presumably, light relief. Please have a go at completing it yourself:


Alberta MH Examination 1


Alberta MH Examination


Now, it isn’t clear from the Form whether we are reading a knowing satire on the absurdities of (presumably) arcane psychiatric practices, or the piece is trading on a social stereotype equating mental health difficulties with a lack of intelligence and/or a chronic lack of common sense (Common Sense Deficit Disorder – or CSDD – in the new DSM-V anyone?). If the former, it is rank prejudice of a type that would be considered entirely and rightly unacceptable if, for example, it was aimed at gender or ethnicity; at best, it is very close to the mark. Either way, the fact that such an email can be sent on a group list, without any awareness that the content may be considered inappropriate, tells us a lot about what is, or what is not, considered offensive in our society today.

It’s probably too much of an easy target to use the Conservative Party Conference as an example of unthinking prejudice, but as the remarks in question involve the current Minister for Health, I think we can make an exception here. During his speech, Jeremy Hunt made two rather inappropriate ‘jokes’: the first was about having a seizure (funny topic that), the second about how some people think he needs an operation for his head. Whilst I’m sure many of us would agree that there are certain aspects of Mr Hunt’s intellectual credibility that require closer examination (his association with Rupert Murdoch for one) I consider it quite remarkable that such a senior politician could make light of such serious issues, in such a high profile way. I’m sure Mr Hunt meant no offensive by his remarks, and would probably be shocked if he realised how they have been received by some people. However, it’s the fact that he can make such statements unknowingly, and that they can go relatively unnoticed in the national press, which to me highlights how certain (negative) attitudes towards mental health difficulties have become a cultural norm.

If the Alberta Mental Health Release Examination Form and Jeremy Hunt’s comments were close to the line, then Tesco and Asda blundered over same line in spectacular fashion (think rabid bull on steroids bushwhacking its way across a field). Now I’m sure most people reading this article would have already seen these images, but for those of you who have not seen the ‘Mental Health Patient’ Halloween costume, have a look at this:

Mental Health 'Fancy Dress Costume'

I’m not sure whether it’s the blood-splattered straitjacket, the macabre mask or the meat-cleaver which I find most offensive; all in all, it adds up to one large, sorry mess. The fact that this costume must have passed several chains of command to reach the shop front is astonishing.

Thankfully Asda and Tesco have apologised for the costume and removed it from their stores, which I guess is a cause for hope. As the Centre for Mental Health Blog highlighted last week, a collective group of people were successful in getting it removed within one day. Less cause for hope however was a recent YouGov poll  which indicated that people with mental health difficulties are considered to be the group which experiences the most discrimination in our society. All things considered, it seems we have a long way to go. Einstein would appear to be right: it is truly easier to smash an atom than a prejudice. Unfortunately, the only thing that is being smashed at the moment is the dignity of people with mental health difficulties. The fact that our society is contributing to this smashing should be cause for concern to us all.

Dr Simon Clarke
Clinical Psychologist, PhD student and ex-mental health service user
Nottinghamshire Healthcare NHS Trust and University of Nottingham


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Launch of a new IMH Centre!

So far so good for SoFu!

The official launch of the new IMH Centre for Social Futures (SoFu) will take place on Friday 6 December 2013 with opening speeches from Professor Paul Crawford, SoFu Director, and Professor Mike Cooke CBE, Chief Executive of Nottinghamshire Healthcare NHS Trust, as well as other eminent guest speakers. The launch takes place in the Centre of Advanced Studies on the University of Nottingham’s University Park, from 1.30pm to approx. 6pm, with additional presentations, refreshments, and a drinks reception plus networking. For further information or to register your attendance, please email:

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