Service losers?

I have just been reading some work written by people looking at issues of stigma and discrimination in mental health, some of the material made me think quite a lot about this subject. Not only did the work state the obvious – things we already know such as people with a mental health issue treated differently to others, but it also examined the role of mental health nurses and I couldn’t help but recognise some of these statements were actually true.

Much is written about stigma and discrimination in mental health, particularly regarding service users, patients clients etc. Erving Goffman, in his book Stigma: Notes on the Management of Spoiled Identity (1963), describes stigma as ‘ a special kind of relationship between attribute and stereotype. An attribute that is deeply discrediting, that reduces the bearer from a whole and usual person to a tainted, discounted one. We believe that a person with stigma is not quite human. We tend to impute a wide range of imperfections on the basis of the original one. We may perceive his defensive response to his situation as a direct expression of his defect’. Goffman goes on to point out that stigma is generated in a social situation. It is a reaction by society that spoils a person’s identity by a set of imposed norms that are brought to bear on an encounter.

There are ‘them and us’ distinctions that underpin prejudice and discrimination and pervade mental heath services. People with mental health problems are devalued and, therefore those who work with them are also devalued by association: this is termed ‘courtesy stigma’ (Goffman 1963) or ‘stigma by association’ ( Neuberg et al 1994) The image of the psychiatric nurse compared to that of busy A&E ‘angel’ or life-giving midwife is seen very differently. Psychiatric nurses receive least recognition, affirmation, acknowledgement and validation from their family and friends (Cronin-Stubbs & Brophy 1985) and the psychiatric system as a whole is downgraded to a ‘Cinderella service’.

In an attempt to preserve our status, it might be tempting for mental health nurses to dissociate themselves from the devalued patients, to amplify differences in order to reduce the perceived threat from ‘out-group’ members (Heatherton et al 2003). When out with clients/patients/service users, it is often clearly demonstrated that you have not chosen to be with this person, that you are not a friend, neighbour, relative, but are with a patient AND are just doing your job!

Does this happen?



6 thoughts on “Service losers?

  1. Yes I believe it does. I saw this happen most when I was a student nurse. I was out in the community helping the HCA with the service users who resided in the ‘Group Homes’. The HCA who clearly loved his job and had the upmost respect for his service users would take the service users food shopping, for coffee, days out, a game of Pool, never once would you have seen any discrimination in his behaviour towards the service user. Infact I strived as a student to learn as much as could from him. That was until I got horibbly wrenched away by the service manager who told me quite clearly that it was beneath me as a nurse to be helping the HCA and service users with daily activity’s living.
    She definately came from the ilk of ‘them and us’ and I leanr t as much from how as to how ‘not to be’ as I did from the HCA as to ‘how to be’.
    Hope that makes sense.

  2. I can clearly remember seeing this ‘dissociation’ in practice.

    In in-patient areas the thing that always used to bug me was things like the cup cleaning rituals that used to go on – anything used by the service user was deemed to be almost ‘unclean’ and would need to be ritually cleansed with boiling water before it could be used by a staff member – I could think of loads of “little” examples like that.


  3. Hi Carole

    I really enjoyed your blog, and can relate it to my experience working with older people – we sometimes felt we were a ‘cinderella service within a cinderella service’. However, I’d like to add that I remember when I first came to work here, I noticed that when asked about my job in social situations, the responses changed from a kind of ‘wow, I could never do that, you must be brave, that must be fascinating, I expect you see some interesting things’ etc, as a nurse, to ‘oh’ as a Uni lecturer!


    What Goffman also stated about stigma was “Once a person becomes aware of her or his stigmatised label, self-perceptions are affected and they assimilate the values of the dominant group.”

    Often service users can internalise stigma and think of their selves as they see others view them. Something I saw in my son when he referred to himself as mad, nutter, lost the plot, pshycho etc. Before his first severe episode of psychosis he had already been diagnosed with schiziphrenia and had confided in his friends. Word soon got out and I later discovered someone had said to him that he was mad and so was all of his family!

    So the stigma does not only stop at the service user. Quite a while later I got chatting to one of our neighbours (we were actually at the social club)she started asking me about my son. I explained how gentle and caring he was, to which she replied “But he must flip sometimes!” well actually no, he doesn’t “flip” at all. The worse that would happen is that he withdrew to his room.

    I eventually realised most of the neighbourhood knew of my son’s diagnosis via what my son had confided to his friends, and there were two options open to me. I avoid the subject and say nothing and hope it would go away, or be open and hold my head up. I chose the second option, periodicly people asked after my son and I near on gave them a lecture on stigma, including friends he knew from childhood. Letting them know he wasn’t stupid he was aware of his condition and aware of the stigma. People often ask after him now and genuinely want to know how he is. When my son first had his diagnosis I didn’t tell anyone for over a year, not even in the family. Not because I was ashamed of him, but because of the reaction I expected. And my natural instinct to protect him and defend him. Perhaps I needed to develop my own strategies first, before I could deal with others.

    Now I would say, stigma can only hurt you if you let it. You have to learn how not to let it get too you, much like the childhood saying “Sticks and stones can break your bones, but names can never hurt you”

  5. I very much noticed the “them and us” attitude in the hospital where Mr Man stayed. I’ve written about this before. In truth, some of the patients are obviously more intelligent and talented than the nurses, but nurses treat them with unimaginable disdain. You would have thought that in their line of work they would recognise the fact that mental illness really can affect anyone and that no one is exempt from the possibility of becoming mentally ill – including themselves.

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