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Theory, Research and Treatment of Mental Health Problems - S1 - Coggle…

- - - - Globally, 1 in 8 people (970 million) are living with a mental health condition but 80% of people with mental health and substance use conditions are without affordable mental health care (World Health Organisation, 2019)
        By 2030, it is predicted that mental health problems will be the leading cause of morbidity and mortality worldwide (Mental Health Foundation, 2023)
        In England, 1 in 6 adults report experiencing a common mental health problem such as anxiety or depression during the past week (Baker and Kirk-Wade, 2023)
        The economic cost of mental ill health globally was estimated at US$2.5 trillion per year in 2010, projected to rise to US$6 trillion per year by 2030 (The Lancet, 2020)
        Inequalities in mental health by demographic characteristics such as gender, ethnicity and socioeconomic status
  - - - The Deinstitutionalisation Movement
        
        Pharmacological advances
        
        A recognition of the iatrogenic harms of institutionalisation
        
        Anti-psychiatry and critical psychology
        
        NHS transformation
        
        The shift to community models of care
        
        Three main components of deinstitutionalisation (King’s Fund, 2015) :
        1.Discharge of people in hospital to the community (c.100,000), 2.Diversion from hospital admissions, 3. Setting up of replacement community services
        
        Systematic closure of existing hospitals – mainly 1980s and 1990s
        
        Building of community staffing and resource infrastructure
        
        Introduction of multi-disciplinary clinical teams including psychology, psychiatry, mental health nursing and social work
        
        Planning, design, delivery and funding carried out by a range of organisations working together across healthcare, local authorities, social care and third sector (King’s Fund, 2015)
        
        Has it worked?
        
        Pros:
        
        Deinstitutionalised mental health services are now the gold standard globally
        
        Only 3% of those in contact with secondary mental health services in the UK in 2021-22 had spent time in a psychiatric inpatient setting as part of this contact (NHS Digital, 2022)
        
        Wider accessibility of treatments and services
        
        Cons:
        
        Inequalities and social exclusion remain problematic
        
        Promotion of autonomy and human rights, but at the same time a heightened focus on risk assessment and public protection
        
        Patchwork of provision with variable funding (the ‘Cinderella service’?)
        
        Joined up working remains challenging, e.g., perinatal mental health
  - - - NHS providers report a range of factors contributing to increased service demand
      - This survey was undertaken in March 2019, prior to the pandemic
      - Source: NHS Providers Survey
      - Covid-19 and the rising cost of living
        
        Overall, levels of distress increased at the beginning of Covid-19 before returning to pre-pandemic levels (Sun et al., 2023) but longer-term effects yet to be determined
        
        Significant mental health inequalities remain, for example, the largest increase in mental health problems during UK Covid-19 lockdowns among those experiencing financial difficulties before the pandemic (NatCen, 2021)
        
        Service demand remains high, contextualised by the rising cost of living
        
        Higher levels of young people exiting the labour market due to mental ill health (Institute of Fiscal Studies, 2023)
        
        Some of the impacts on research
        
        Digital interventions and online research
        
        NHS demand and research recruitment
- - - - Anxiety: Exposure therapy (classical conditioning)
      - Depression: Behaviour activation (operant conditioning)
    - - Anxiety: Cognitive Behaviour Therapy or Cognitive Therapy
      - Depression: Cognitive Behaviour Therapy or Cognitive Therapy
    - - Anxiety: Acceptance & Commitment Therapy or Meta-cognitive Therapy
      - Depression: acceptance and commitment therapy, metacognitive therapy or mindfulness-based cognitive therapy
  - - - Animal - snakes, spiders, birds
      - Natural environment - storms, heights, lightning, water
      - Blood-injection-injury - Seeing blood, seeing an injury, receiving an injection, other invasive procedures
      - Public transport, tunnels, lifts, flying, driving, enclosed spaces
      - Other: Vomiting, children’s fears of loud sounds or costumed characters
  - - - In vivo exposure is treatment of choice for specific phobias
      - Exception
      - Blood-injection-injury phobia will require muscle tension, not direct injections due to risk of fainting (interfiers with exposure treatment) (e.g., Ost et al., 1991)
  - - - Early Behaviourist View:
        
        Acquisition and extinction of phobic responding is
        
        Automatic, mechanistic
        
        Involves only lower level processes
        
        Strong version of this hard to defend on basis of experimental studies
        
        Example: Kamin Blocking Effect
      - Modern Learning Theory:
        
        Acquisition and extinction of phobic responding involves
        
        The organism developing an expectancy of what the CS signals
        
        This involves higher order cognitive processes
        
        Clinical Implication:
        
        Exposure therapy will be maximally effective when it is set up to maximise the violation of expectancies
        
        ‘Violating expectancy’ is similar to ‘belief testing’ so modern exposure and behavioural experiments are similar
    - - Maintain exposure to feared stimulus - Stop negative reinforcement
      - Track anxiety (it should come down) - Extinction learning (gradual weakening of CS-CR link)
      - Work out precisely what is feared and set up exposure to test that out - Exposure is most effective when there is ‘violation of expectancies’
      - Use a graded hierarchy (start easy and work way up) - Although graded approach is widely used, there is some evidence non-graded is more effective
  - - - Discuss a recent example of the difficulty
      - Conduct a detailed moment-by-moment analysis
        
        ‘What happened next? And then?’
      - Ask about cognitions, emotions, behaviours and physical symptoms
      - Discuss moderators
        
        ‘What makes it better / easier to deal with?’
        
        ‘What makes it worse / more difficult to deal with?’
    - - Establish precisely as possible what the person fears will happen
      - Look out for ‘fear of fear’ (Rachman & Bichard, 1988)
        
        Frightened of feeling so frightened
        
        Could indicate panic cognitions
        
        May indicate: ‘I just don’t want to feel that awful’
      - Underestimates of coping / rescue
        
        Cognitions about not being able to cope with the situation / others will not help or ridicule
      - Cognitive processes
        
        Hypervigilance
    - - Avoidance behaviours
        
        Avoid the feared stimulus completely
      - Escape behaviours
        
        If come into contact with the feared stimulus escape
      - Safety behaviours
        
        A behaviour designed to prevent a feared catastrophe but has the paradoxical effect of maintaining the problem because it prevents the cognition from changing
        
        Questions to elicit safety behaviours:
        
        What did you do to cope?
        
        What did you do to manage your symptoms?
        
        What did you do to keep yourself safe?
  - - - Measures:
        
        Q about any shifts
        
        ‘What made the anxiety go up just then?’
        
        Measure frequently or when shift has occurred
      - Careful observation and questioning:
        
        Look out for safety behaviours
        
        ‘Are you doing anything to control your anxiety?
        
        ‘I noticed that you’ve just done X. What’s the reason for that?’
      - Empathy and encouragement
      - Person with phobia should feel in control
        
        ‘What do you think you could try next?’
    - - What learnt?
        
        ‘What did you find out from doing that?’
        
        ‘Are there any differences between what you thought would happen and what actually happened?’
      - Refining
        
        Often you will need to refine the exposure
        
        If problems or no change:‘How could we do things differently to better find out about X?’
        
        Look out for doubts and‘yes-buts’
        
        ‘What could we do to test out that doubt?’
      - Building on
        
        ‘Are there any ways you could build on this between now and the next session?’
    - - Foa and Kozak (1986): Unlearning - fear representation as cognition - emotion - behaviour triangle model
        
        model is reductive nad outdated, newer model better explains relapse
      - Context dependency and competing representations in memory
        
        fear and non-fear triangle models are each mediated by the environmental context
        
        is cues match the fear context then fear representations will be elicited but if the cues match the non-fear context fear response will not occur
        
        The playing field is not even: If cues in current context do not provide discrimination, original fear representation will be retrieved
      - Reducing context-dependent relapse study:
        
        When dogs were taught conditionned phobie in red room context and non-fear response to CS in green room context, non-fear response is shown in safety context but fear response shown in fear and neutral contexts
        
        Predictions:
        
        If cues at extinction learning (i.e. treatment) can mimic cues at fear learning, then retrieval advantage for fear learning will be attenuated
        
        If context at extinction learning (i.e. treatment) can mimic likely future contexts, then new, non-fear representation will be retrieved
        
        Clinical Implication:
        
        Carry out exposure treatment in the setting in which the phobia was acquired
        
        This is often not possible
        
        Carry out exposure in the context in which the CS is likely to be encountered in the future
        
        Carry out exposure in multiple contexts to maximise future cue matches
        
        Findings on this are mixed
        
        Mental reinstatement of treatment context
        
        Before encountering CS in a new context, person encouraged to think back to the treatment context
- - - - Discrete period of intense fear or discomfort in which ≥ 4 symptoms develop abruptly
      - Examples of symptoms:
        
        Pounding heart
        
        Trembling
        
        Sensation of shortness of breath
        
        Chest pain
        
        Feeling dizzy
        
        Fear of losing control
    - - Concern about experiencing another
      - Worry about implications of attack or its consequences
      - Significant change in behaviour
  - - - emotion
      - Biases
      - Behaviour
      - Physical
  - - - Racing heart… I’m having a heart attack
      - Dizziness… I’m going to faint
      - Tightness in throat… I’m choking
      - Feeling unreal… I’m going crazy
      - Shortness of breath… I’m going to stop breathing and die
  - - - Improves outcome:
        
        Interoceptive exposure
        
        Cognitive restructuring
      - Reduces improvement:
        
        Relaxation training
      - On average patients see significant decrease in panic by session 6 of this treatment
  - - - Be specific
      - More likely to activate emotion
      - If discuss several examples, can search for moderators
      - Check example will be useful
      - Clear memory? Typical? Level of emotion?
    - - Use one to lead to the other
      - ‘When you felt X what sensations were you aware of?’
      - ‘When you had those sensations, what did you think was happening to you?’
      - Cognition
      - ‘What did you think was happening? What’s the worst that could if…?’
      - ‘If you had not have done X [used safety behaviour], what might have happened?’
      - Ask about images
      - Get a belief rating (0-100 scale) how much believed thought at the time.
    - - ‘What did you do to try to cope?’
      - ‘What did you do to try to manage?’
      - Note that safety behaviours can be cognitive (e.g., distraction) as well as behavioural
  - - - Target a Specific Cognition: e.g. If i am uncertain I will not be able to relax and enjoy myself
        
        Rate their conviction in this cognition
      - Experiment: What can you do to test this belief or conviction? (behavioural)
        
        Measure relaxation at regular intervals
      - Outcome and Learning: What happenned? What did you learn? How convicted are you of the original cognition
        
        Some uncertainty remaining is okay
      - Behavioural Experiments in Panic
        
        Aims: Test out validity of catastrophic misinterpretation belief and provide an alternative, non-catastrophic explanation
        
        Target specific symptoms of cencern (e.g. hyperventilation, fainting, etc)
        
        Record the misinterpretation of the symptom
        
        Devise behavioural experiment to target this misinterpretations - often check with a GP before doing physical experiments
    - - Prepare
        
        Work collaboratively to develop the experiment
        
        Identify key cognition test
        
        Check patient understand the experiment and is willing to participate
      - Expose
        
        Induce target cognition
        
        Rate belief and anxiety regulalry on a standardised scale
      - Test
        
        Perform discomfirmatory procedure
        
        Rate belief and anxiety regularly
        
        Check safety behaviours
      - Summarise
        
        What was learnt?
        
        Check changes in belief, modify and repeat if necessary
- - - - Five or more symptoms AND At least one of those must be low mood (symptom 1) or loss of interest or enjoyment (symptom 2)
      - All symptoms in same two-week time period during previous month. Symptoms present most of the day, nearly every day. Change from normal functioning
      - Additional (all must be met)
        
        Clinically significant distress or impairment in functioning
        
        Symptoms are not better accounted for by effects of a substance or medical condition
        
        Not better accounted for by another psychiatric disorder
        
        No history of mania or hypomania
      - Symptoms
        
        Low mood
        
        Loss of interest or enjoyment
        
        Changes in appetite or weight
        
        Changes in sleep
        
        Slowed down or restless
        
        Lacking in energy
        
        Worthless or guilty
        
        Difficulties concentrating or making decisions
        
        Suicidal ideation
  - - - Behaviourists are interested in behaviour. Thoughts and feelings are covert behaviours. Behaviourists are just as interested in them as overt behaviours.
      - Timeline of Reward: Short-term contingencies tend to be more controlling of behaviour than longer-term ones (though verbal control of behaviour in humans makes this more complicated and interesting).
      - +ve does not mean enjoyable, only that something is added into the context. -ve does not mean unenjoyable only that something is removed from the antecedent
  - - - Big change in context can mean well-established B-C relationships that have worked in the past – and kept us well – no longer work
      - For example, a behaviour that was previously reinforced, could now result in punishment.
  - - - OC: Change in context/antecedent.
      - Behaviours no longer help with coping due to new context (non-applicable target behaviours). B doesnt bring about C.
      - What once was rewarding may now be punishing.
      - Shift can be physical (e.g. age) - physically unable to perform important behaviours
    - - Reduction in +ve reinforcement of important behaviours
      - Doing less stuff which makes life worth living
      - Refers to important not enjoyable (hygiene, work ethic, etc)
    - - Avoidance = ST loss of anxiety or dread so discourages effective coping (-ve reinforcement)
      - Immediate consequence dictates behaviour even if LT detriments are obvious
  - - - The focus in Behavioural Activation is always on what a behaviour does for a person (its function) not what it looks like (its form)
      - If a behaviour is no longer possible, then: Work with the person to identify what the functions of the behaviour were:
        
        What did it get them out of life?
        
        How did it help them stay well?
      - There will often be many functions for a single behaviour
      - Work with the person to identify alternative behaviours that may serve the same function
        
        Don’t necessarily go for ‘nearest neighbour’ or ‘look like’ behaviours
        
        The new behaviour may look radically different (it’s the function not the form that matters)
        
        It’s unlikely that you’ll find one behaviour that will replace all of the functions of the old behaviour
        
        Often you’ll need several new behaviours to cover all of the functions
  - - - Core Beliefs
        
        Assumptions
        
        Schema activation
        
        Negative automatic thoughts (NATs)
        
        Emotion
        
        Biases
        
        Behaviour
        
        Physical
        
        This leads to continuous negative thoughts that maintain the difficulty through a series of feedback loops.
        
        This ‘schema’ is dormant until activated by a life event that ‘meshes’ with it. When the schema is activated it biases the way information is processed.
        
        …or ‘rules for living’ (e.g., over-prepare for everything or you’ll fail)
        
        we develop beliefs about ourselves, the world and the future. These can take for form of absolutist statements (e.g., ‘I am a failure’)
      - On the basis of early life experiences
  - - - Questioning style in CBT/CT
      - From Socrates who, when asked a question by his pupils, would respond with a question. This helped them work the answer out for themselves
      - In CBT, this questioning style helps people find their own solutions to problems. Which works better than being told what to do.
      - Setting the scene
        
        Ask the person to describe a specific example of the difficulty
        
        Don’t be afraid to ask for lots of detail, but in a gently curious way
        
        Recreate the scene
        
        Exploring behaviours
        
        What did you do?
        
        How did you respond?
        
        Could you tell more about what you did?
        
        What did you do next?
        
        Exploring Thoughts
        
        What was going through your head when that happened?
        
        Were you thinking anything else?
        
        What sense did you make of that?
        
        Can you tell me what you were thinking?
        
        Exploring Feelings
        
        When you thought that, how did it make you feel?
        
        What was that like for you?
        
        Can you tell me a bit more about how that made you feel?
        
        Exploring physical symptoms
        
        Did you get any physical symptoms? What were they?
        
        When you had that feeling, did you notice anything happening to your body?
        
        Making links
        
        3 more items...
    - - Take the story piece by piece. For each piece Get the chocolate outer-coating:
        
        The situation (What happened?)
        
        The behaviours (What did you / others do?)
      - Also get the fondant centre:
        
        Thoughts
        
        Feelings
        
        Symptoms
- - - - dverse childhood experiences [ACEs]
      - poor housing
      - poverty
      - Adult traumatic events
      - poor working conditions
    - - poverty
      - homelessness
      - incarceration
      - social isolation
      - unemployment
  - - - In SMI N 2/3 of deaths are related to long term phsyical health conditions listed above - This is preventable
      - Younger adults are 5x more likely to have 3< physical health conditions compared to general age-contrlled population
      - Excess premature mortalilty rates are more than 3x more likely to occure in SMI N - this gap is widening over time
      - Associated with a series of modifiable risk factors which are preventable
      - Comorbidity in SMI population aged 15-34 - More common for chronic health problems in early age for SMI N compared to general population where it tends to occur in middle age
        
        Obesity - 3x
        
        asthema - 1.3x
        
        Diabetes - 3.7x
        
        Hypertension 3.2x
        
        Temporal Changes in life expectancy of SMI compared to GP 1980-2010
        
        GP have significantly more stable increase in life expectancy over time
        
        Societal improvements and increase in medicine availability increased GP life expectancy
        
        SMI fluctuate greatly over time and life exectancy on average has decreased
        
        Male life expectancy is always lower however this difference is significantly greater in SMI population
  - - - Proportion of SMI N who smoke: SMoking prevelence massively increases in association with multiple SMI
        
        Drug dependence - SMI 75%, GP 16.9% smokers
        
        Suicide attempts - SMI 67.2, GP 19% smokers
        
        Alcohol dependence (AUDIT 20) - SMI 60.4%, GP 18.8% smokers
        
        ADHD - SMI 45.5%, GP 19.2% smokers
        
        PTSD - SMI 39.6%, GP 18.5% smokers
        
        Eating Disorders - SMI 34.4%, GP 19.3% smokers
      - Outliers - Regardless of SMI comorbidity, societal changes that reduced smoking down to <20% recently have not affected BPD or psychosis
        
        Bipolar - SMI 53.1%, GP 18.8% smokers
        
        Psychotic Disorders - SMI 53.4%, GP 18.8% smokers
        
        SMoking will be overrepresented in this portionof the population - thus stroke and cardiovascular disease is more comon with these diagnoses
      - Scimitar+ Bespoke Smoking Cessation
        
        Absolutely no judgement of stigma - key to stopping anyone from smoking
        
        Program Foundation: started with a systematic reveiw of existing evidence regarding the causes of smoking addiction and how to imrpove smoking cessation methods
        
        This foundation was tailored specifically to help SMI smokers with their cessation programs
        
        Evaluation Methods used exhaled carbon monoxide to test whether people actually had stopped
        
        Intervention:
        
        Delivered by mental health professionals - ensures that the practitioners understand the unique challenges to every-day lives of SMI N
        
        NRT (nicotine replacesment therapy, e.g. patches or gum) is the mainstay of treatment - staves off the acute symptoms of nicotine withdrawal
        
        Nicotine preloading and cut down to quit - preloading involves taking NRT alongside cigarette use to allow a slower cut of nicotine before cessation and get N used to the NRT options
        
        Psychotropic medication management - psychotropic medication dosage must decrease following cessation. Many N prefered the option to decrease dosage (got peope to try out more often)
        
        Planning for quit attempt - what will you do instead of smoking? - What to do when craving appear, how to avoid social factors which encourage smoking.
        
        Manual and supervision to ensure delivery - particularly during withdrawal/cravings
        
        Results
        
        6 Months Post-quit: SMI Bespoke smoking cessation = 14.2% vs usual care = 6.5% (p=.01)
        
        12 Months Post-quit: SMI bespoke smoking cessation = 15.2% vs usual care = 10.4% (p=.08
        
        Bespoke smoking cessation therapy is twice as likely to make you quit than usual care after 12 months
- - - - If you do the same test again will you get the same results?
    - - Order effects can invalidate the test to different forms are used to test the reliability using slightly different measures of the same DV
    - - Divide the results into two sets do these results correlate properly?
    - - Uses factor analysis to observe item loading to meet assumption that the latent variable is the same across all items
    - - Unlike CA, this allows for differneces in the latent variable
    - - conversely, reliabilty value reflects the degree of unidimensionality
      - e.g. situational judgement tests, usually multidimensional
  - - - Factor Analysis: Is the variance in the items best explained by one or multiple underlying dimensions? - You must fit your data to the model explained through this testing
      - Principle Components analysis:
    - - Reliabilty has been superceded by Test Information Function Testing
  - - - Information is shown as 1-(error). So the X-axis is on a scale centred on 0. 0 = the average trait for the unidimensional scale
      - The Y-axis referes to the concentration of effective information - for a good test the greatest amount of information will be above 0 (little to no effor) and the least will be at both extremes of th X-axis (greater amount of error as further from 0 - This creates the bell curve you are looking for
      - The Extremes of the X-axis (0 +/- the error) is effectively the standard deviation. The variance squared = SD
      - A high peak in the information curve implies that it is reliable for diagnising the DV trait but cannot reliably measure those outside of that condition. Wider curives will be more reliable for a larger proportion of the GP
      - multidimensional tests will result in additional peaks for each dimension the instrument records
  - - - Criterion Validity (concurrent/predictive): Does your measure reflect the real life criteria for a given condition/characteristic (ecological validity within instrument evaluation)
      - Convergent Validity: Testing a new test against an existing test
      - Divergent Validity: make sure it does NOT correlate with things that are constructuarlly relevant
        
        (e.g. overlapping situational judgement tests with reading comprehension or verbal reasoning tests)
        
        You dont want the test to measure anything outside your specific DV
    - - The validity of a test rests on the claims made for it and how each claim can be evidence at different stages - the validity extends to how you use the scores post-testing also
      - Claims of a test but be compared to the evidence used IRL
  - - - Nominal - classification of a trait - grouping operations - central tendency is the mode - qualitative variability
        
        E.g. Diagnosis: clinical interviews, DSM-V/ICD-11 (menu approach), pathology (e.g. postmortem)
      - Ordinal - comparrison level - sorting operations - median - range/interquartile range variability
        
        E.g. screening (PHQ-9 to stratify people into a scale from MDD to not MDD), varying cut scores (mild, moderate or severe), can be linked back to diagnostic criteria
      - Interval - difference, affinity - comparison to a standard operation - arithemetic mean - deviation variability
        
        E.g. symptom severity (only through item response theory), If monotonic (oves in one direction) and additive.
      - Ratio - magnitude/amount - ratio operation - geometric/harmonic mean - coefficient of variable/standardised range
    - - True Score Model - CTT
        
        a "true score" exists
        
        It can be defined by an "ideal" judge consensus
        
        Measurement error is the only source of variation
      - Latent Variable Model - IRT
        
        Abilities/traits cannot be directly measured
        
        Only quantified via indicators given my tests
        
        ability/trait varies randomly across a distribution (often normal) along with random measurement error
      - CTT vs IRT - DIfferent but not mutually exclusive
        
        CTT test scores are the summed item scores in a given instrument
        
        Emphasis on test reliability (e.g. CA) over information
        
        Resulting scores are ordinal not interval
        
        IRT =/= conventional factor analysis
        
        think of it as pre-parameterisation of a latent variable model
        
        responses are explained by the latent trait not the other way around
        
        Assumes that the level of the latent trait in N predicts the prbability of a response catergory (true or false)
    - - a=discrimination
        
        analogous to loading in factor analysis
        
        A regression slope
        
        measure of the degree to which a test/item can differentiate between respondents of different abilities/traits
      - b=difficulty (commonality in trait not abliity evaluation
        
        the level of a trait required for a 50% probablilty of a certain response (e.g. correct response)
        
        Analogous to intercepts/cut points in logstic/probit regression
- - - - Self-stigma: The person internalises broader negative stereotypes and applies these to their own identity: awareness, agreement and negative self-perception (Corrigan et al., 2016)
      - Felt stigma: The person is aware of broader labels but does not apply these personally, though they remain aware of the impact of the label on how they are viewed by others
      - Stigma by association (sometimes known as courtesy stigma): family members or significantothers are impacted by being associated with a person who carries a stigmatised attribute.
      - Resistance: a person is aware that they carry what is perceived as a stigmatised attribute but actively rejects the negative stereotypes associated with the label (Thoits, 2011)
    - - Clear evidence for impact of self-stigma on self-esteem, hope and social relationships and emerging evidence for impacts on suicidality, self-isolation, treatment adherence and vocational outcomes among people living with SMI(Yanos et al., 2020)
      - Associated with reduced likelihood of formal help-seeking with larger effects for certain groups: younger adults, males, military background, healthcare professionals, ethnic minorities (Clement et al., 2015)
      - Social exclusion, for example, employment, housing, relationships (MentalHealth Foundation, 2021)
      - Differences in public attitudes
        
        By diagnosis, for example, psychosis and personality disorder vs depression and anxiety
        
        Explanations of illness: biogenetic essentialism
        
        Beliefs about help-seeking
        
        Intersectionality
        
        Over time
        
        Attribution theory
  - - - Interested in how stigma arises and is enacted at the interpersonal level - Mental illness is viewed by Goffman as a ‘discreditable’ characteristic that can result in a ‘spoiled identity’.
      - Holding a discreditable characteristic can lead to experiences of shame and social exclusion - The crucial point made by Goffman is that the process by which certain characteristics become stigmatised is wholly dependent on social interactions
      - Discreditable characteristics represent a departure from social norms: social groups decide which characteristics are stigmatised or not, and how to treat people as a result.
      - To protect their identity from becoming ‘spoiled’, people may use strategies to hide stigmatised characteristics in social interactions to avoid becoming discredited and therefore socially excluded. - Strategies include ‘passing’, ‘covering’ and ‘withdrawal’.
    - - Origin of Labelling: “Stigmatization is entirely contingent on access to social, economicand political power that allows the identification of differentness, theconstruction of stereotypes, the separation of labelled persons intodistinct categories, and the full execution of disapproval, rejection,exclusion and discrimination” (Link and Phelan, 2001, p367)
    - - Majority of theory and research has focusedon the interpersonal (individual and publicstigma) contextualised by a tradition of socialinteractionism. More recently, a shift in focus tothe structural.
      - Structural Stigma
        
        Policies, laws and cultural norms are associated with health inequalities among minority groups across arange of indicators including myocardial infarction, mortality and substance misuse (Hatzenbuehler andLink, 2014)
        
        Pachankis et al. (2015) analysed laws, policies and public attitudes across different countries and found that where these were more restrictive and negative towards sexual minorities.
        
        this led to higher unmethealth needs and concealment of sexual orientation.
        
        Compared to White people, Black people in the UK are 40% more likely to enter mental health services via the police or criminal justice system, less likely to receive psychological treatment, four times morelikely to be detained under the Mental Health Act rather than entering via voluntary treatment routes,
        
        more likely to be subject to seclusion or restraint (Mind, 2019; Mental Health Foundation, 2021)
      - Media Representation
        
        Explanations provided in the media influence public knowledge about mental health and ouremotional responses (McGinty, Webster and Barry, 2013)
        
        Since the 1980s, media representations of mental illness and treatments have shifted from structural to biomedical (Clarke and Gawley,2009)
        
        Journalism focused on violence has decreased over time but remains one of the most widely reported topics (Murphy, Fatoye and Wibberley,2013)
        
        Are representations now becoming more positive?