“Irre menschlich Hamburg” – An Example of a Bottom-Up Project

Abstract

This chapter highlights the advantages and importance of bottom-up approaches in the fight against stigma. Where and how does stigmatization occur? Through uneducated neighbours, colleagues or psychiatric services itself? Does the diagnostic process unwillingly foster stigmatization by creating terminological barriers? Is it the case that today’s prejudices against psychiatry reflect its failure of the past? Which concepts of mental health problems can strengthen or weaken prejudices, and which concepts can foster tolerance and sensitivity? What does successful work against stigma look like and what are the necessary prerequisites for such work? How should a field of psychiatry be constituted that allows for the natural transition between life crises and mental health problems that do not reject experiences with alienating terminology and concepts, but instead supports the assimilation of alienating experiences? Questions regarding stigmatization and in opposite regarding tolerance, sensitivity, prevention and hope are profoundly connected with the understanding of health and mental health problems, as well as the proposed concepts of support systems. Stigmatization due to mental health problems is judged as more distressing compared to stigmatization due to innate features or a minority status, given that the stigmatized person often held similar prejudices prior to their mental health problems. Whether people are stigmatized depends on the concept of human being, not merely on the idiosyncrasies of the individual. If a society propagates the picture of a successful, dynamic, eternally youthful person as the unquestioned standard, then any deviation from this can be stigmatized. A field of psychiatry that diagnoses every “deviation from the norm” and that endlessly extends its diagnostic categories is substantially responsible for the expansion of stigmatization.

These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

This chapter highlights the advantages and importance of bottom-up approaches in the fight against stigma. Where and how does stigmatization occur? Through uneducated neighbours, colleagues or psychiatric services itself? Does the diagnostic process unwillingly foster stigmatization by creating terminological barriers? Is it the case that today’s prejudices against psychiatry reflect its failure of the past? Which concepts of mental health problems can strengthen or weaken prejudices, and which concepts can foster tolerance and sensitivity? What does successful work against stigma look like and what are the necessary prerequisites for such work? How should a field of psychiatry be constituted that allows for the natural transition between life crises and mental health problems that do not reject experiences with alienating terminology and concepts, but instead supports the assimilation of alienating experiences? Questions regarding stigmatization and in opposite regarding tolerance, sensitivity, prevention and hope are profoundly connected with the understanding of health and mental health problems, as well as the proposed concepts of support systems. Stigmatization due to mental health problems is judged as more distressing compared to stigmatization due to innate features or a minority status, given that the stigmatized person often held similar prejudices prior to their mental health problems. Whether people are stigmatized depends on the concept of human being, not merely on the idiosyncrasies of the individual. If a society propagates the picture of a successful, dynamic, eternally youthful person as the unquestioned standard, then any deviation from this can be stigmatized. A field of psychiatry that diagnoses every “deviation from the norm” and that endlessly extends its diagnostic categories is substantially responsible for the expansion of stigmatization.

Mental Health Problems and Prejudices

Prejudices against mental health problems are widespread, so the number of people suffering from prejudice is substantial. One-sided media reports, as well as former misjudgements made in psychiatry, serve to maintain negative stereotypes already disproved by scientific findings, e.g. that patients with mental health problems are “dangerous, incurable and unpredictable”, that their personalities are “split” or that “their parents are responsible for the mental health problems”. Patients with a diagnosis of schizophrenia and their families/relatives particularly experience stigmatization (Schulze and Angermeyer 2003). Fear and social withdrawal are possible consequences. Former studies revealed that fear of public stigma or self-stigma barrier mental health service use and relapse prevention (Clement et al. 2015). Prejudices endanger individual therapeutic progress, familial resources as well as ongoing structural developments in psychiatry. It is an excessive demand of the medical field alone to counteract prejudice. There is evidence shown in meta-analyses that medical illness models and analogies enhance rather than reduce fear and social distance towards people with mental health problems (Angermeyer and Schomerus 2012). Experiences within anti-stigma projects attest to these findings: The elimination of prejudices does not occur through reading about it or professional lectures, but through personal encounters and listening to someone’s story. Therefore, to be credible and convincing, counteracting stigmatization has to be a joined effort of patients, relatives and those working in psychiatry. When targeting young people, anti-stigma works also have to have preventative aspects. For example, anti-stigma topics such as psychosis, mania and depression (bipolar disorder) have to be supplemented by topics such as eating disorders, self-harming behaviour and mental health problems through drug and alcohol consumption.

Stigmatization in Psychiatry?

Does stigmatization occur with discharge from a psychiatric institution? Or does it occur upon its initial diagnosis? What role do diagnostic labels and self-stigmatization play? When and where stigmatization occurs and who is responsible for it is debatable. Likewise are the models for how and where anti-stigma work needs to begin. According to sociologists, it is unquestioned that stigmatization occurs within psychiatry’s diagnostic processes (Finzen 2001), not between classmates, colleagues or neighbours. Therefore, if psychiatry wants to counteract prejudices, it is only credible if this is done across all levels, publicly as well as internally. To do so, a common language is needed. To preserve and nurture this language was an essential reason for the establishment of the psychosis seminars. Psychosis seminars were established to foster a dialogue between three parties on eyelevel: people with experience of mental health problems, relatives and mental health professionals (Bock and Priebe 2005; Bock et al. 2013; Buck 2002). Furthermore, psychiatry in general and the diagnosing physician in particular are responsible for avoiding stigmatization wherever possible. The culture of trialogue provides the needed authenticity, whilst engaging in assessment sessions as well as public anti-stigma work (Alanen 2001).

If in psychiatric practice diagnoses are handled carefully, whilst efforts are made to achieve a common language and to understand and not only fight symptoms, self-understanding is fostered and thereby individual anti-stigma work delivered. This can be effectively complemented and enhanced through public relations activities. But if in today’s psychiatric practice diagnoses and treatment standards are schematically allocated and symptoms are fought as a foreign matter, with disregard to underlying feelings and conflicts, the risk of distancing patients from their perceptions even further is high and is not in line with contemporary knowledge. Furthermore, a psychiatry which does not include relatives or includes them too late, and which does not offer treatment continuity, also contradicts contemporary best practice and participates in stigmatization by enhancing alienation on all levels instead of decreasing it.

Giving a mental health problem a name is not bad per se. Whilst it can frighten patients to name it, it can also allay their fears (“Rumpelstiltskin effect”). The diagnostic process alone does not determine weal and woe. Other determinants are the verbal context, the associated message and the simultaneously offered or denied relationship. Contrary to the generally limited understanding of illness insight and compliance, for example, Roessler et al. (1999) found that patients with an idiosyncratic illness concept have a higher quality of life. This derives the task for psychiatry: to conceptualize psycho-education more sensitively, more generously and in dialogue with the patient, to think of illness insight not as a one-sided requirement from the patient but as the responsibility of the therapist and to achieve compliance through cooperation, not subordination (Bock et al. 2007). This aim applies to children, adolescents and young “first-episode patients” in particular. Here, the diagnostic process needs to take place with particular caution. A sustainable therapeutic relationship and, as stated before, the use of a common language are prerequisites for the diagnostic process, not the result of such a process. To include parents, relatives and friends from the therapeutic process must be regarded as self-evident best practice.

Can an Anthropological Perspective Effectively Counteract Stigmatization?

It is important to regard mental health problems not only medically and pathologically, but also developmentally and anthropologically, meaning within their psychosocial and political context. The anthropological view shows that the transitions between health and mental health problems are fluent and that symptoms are not only alienating but of functional and/or protective relevance, as well as of profoundly human significance. We must not limit our thinking to the question of whether humanity is becoming increasingly psychologically ill. Instead, we must reflect on the fact that mental health problems are inherently human with just as much intensity. The following overview is meant to further elucidate the anthropological view, as well as potentially help with patient contact (Bock 2012a).

Anxiety: Ability or Disorder?

Without anxiety, people would be unable to protect themselves from danger. Humanity would be extinct. Anxiety as such does not need to be regarded as a disorder but, at least initially, as a necessary survival strategy. A persons’ proximity to anxiety and his or her need for anxiety vary and are contingent upon that persons’ biography and constitution. Only if anxiety spreads and takes on a life of its own, if it generalizes and uncouples itself from triggers, then it becomes the danger which it pretends to deter. If this happens, it can be helpful to reconstruct the story of one’s anxiety, to reconnect it with precipitating conflicts, to remember possible triggers and moments of true potential danger, to make sense of the anxiety and to thereby tame it.

Compulsions: Prison or Grounding Ritual

Compulsive actions resemble superstitious rituals and religious rites; they are meant to stabilize an increasingly confused inner and outer world. Maybe, given the lack of religious/culturally accepted rites in our society, compulsive actions often take on an alienating character. The fact that compulsions are functional (i.e. that they create coherence) becomes apparent when contemplating the fact that people with psychosis potential sometimes decompensate after “successful” treatment of their compulsions. Similar to anxiety disorders, it is important to retrace the origination process of compulsions, to make sense of them, to stop their internal dynamic and to thereby to ease tension.

Depression: Protection Versus Harmful Dynamic

Initially, depression also appears to have a protective function: The psyche generates a feign death, comparable to an animal that hides until danger has passed. When something bad happens that exceeds our comprehensive faculties, when emotions are conflicting and cannot be sorted, when we feel overwhelmed and ask too much of ourselves and when decisions are pending that cannot be made, it can become necessary to let go. We develop depressive traits to protect ourselves. To emerge, we require time, silence, patience, reflection, consolation, support or encouragement etc. Problematically, depressive phases can develop own psychological, social and somatic dynamics. In other words, one’s psyche, one’s social environment and one’s cerebral metabolism become increasingly sensitive. In a severe depressive episode, one’s sense of time can get lost, to the extent that there seems to be no before or after. Also, one’s black despair can become so insurmountable that death seems like salvation. Help is necessary. In severe depression, a balance between constructive and destructive forces can be found: The thought about dying can be all-encompassing, whilst the simultaneous paralysis can be a protection from its execution. Despair and self-protection balance each other. Suicide risk increases when antidepressants cause behavioural activation, whilst spirits are still low. Medication therefore requires a therapeutic relationship (Bock 2000).

Mania: Escape Forwards, But Where to?

Mania does not equate happiness. Whoever is truly happy and successful in life doesn’t need to become manic. Whoever becomes manic is desperately happy – searching happiness far away from themselves. Mania and depression can promote each other: Whoever stays isolated during mania can drive himself to such profound exhaustion that a lapse into depression becomes ever more likely. Or depression can be experienced as so deep and boundless that only a flight forward into mania seems possible. Therapeutic support can offer other way of self-monitoring. After a while, however, serious (e.g. somatic) internal dynamics can develop. The above-mentioned loss of a sense of time does not cause bottomless despair but monumental recklessness, leading to the risk of self-harm (Koesler and Bock 2005).

Psychosis as Extreme Thin-Skinnedness

Looking at psychoses from an anthropological perspective – with a focus on it being a human continuum – they appear as an extremely permeable state: Inner conflicts and problems rise to the surface and take shape in hallucinations. Conversely, outside influences find their way inside without being filtered, without the chance to be weighed and ordered (paranoid perceptions). If a person becomes “paranoid”, such a state is comparable to the perceptions of a toddler who sees everything in relation to himself or herself and, for example, feels guilty upon a parental argument. For children, this “egocentric” perception is a necessary developmental milestone. For adults, this perception seems inappropriate and out of touch with reality, therefore psychotic. Going through psychosis is comparable to dreaming – without the protection of sleep. In a dream it is safe to think of oneself as a bird; in a psychosis, it is not. There are dreams that bring pleasure and dreams that evoke fear. Similarly, a psychosis has aspects that may also bring pleasure or evoke fear. In a paranoid psychosis, these appear symbolically as a blend of meaningful significance and threat.

Throughout their lifetime, most people go through stable and unstable phases. Situations in which experiencing psychological distress is common include the process of individuation or attachment, the transition from school to work, loss of a job and birth of a child. In these situations, people with psychosis experience react more sensitively than others and therefore develop a psychosis. However, they do not react less humanely. It is therefore important not to declare relapse prevention the absolute goal. Such a stance implies stigmatization. It holds the danger that people not only avoid psychosis and its triggers but life altogether. In turn, this fosters negative symptoms and a post-schizophrenic depression. A detailed translation of psychotic symptoms according to the ICD-10 into a language for people with experience of mental health problems was created in the psychosis seminars and can serve as a basis for a narrative culture in psychiatry (Bock 2012b; Bock et al. 2007).

Borderline: In Between Closeness and Distance

People with a borderline personality disorder struggle through life crossing the borders between reality and dreaming; meanwhile wishes and fears appear irreconcilable or inseparable. The sense for nuances and synchronicities gets lost. Instead, certain needs or feelings are made absolute, whilst others are forcibly blocked out. It is a lifelong task of all human beings, not only of individuals with borderline personality disorders, to strike a balance between wishes and fears, between conflicting priorities such as closeness and distance, adaptation and resistance, attachment and autonomy. However, they experience them in an enhanced way and as existentially threatening. If self-harming behaviour occurs in this context, it is often an attempt to reduce tension, to affirm one’s identity or to influence others. To escape the social, psychological and physical dynamics this ensues, therapeutic support is strongly advised. Anthropologically self-harming behaviour was and continues to be part of many cultures. It occurs, for example, in rituals and ceremonies whilst coming of age. In our culture, however, it has seemingly lost its cultural connection. With some restrictions, borderline personality disorder appears as a prolonged and enhanced adolescence, chronological linked to the transition into adulthood. Dependent on the level of gained internal dynamic, it can lose its impetus later in life.

Life Crises with Multidirectional Internal Dynamics

In contrast to all other living creatures, human beings must wrestle to achieve a sense of self. We can self-doubt – and despair as a result of that doubt; think beyond ourselves and loose ourselves in the process. Life crises present risk and opportunity. Mental health problems can be regarded as existential life crises of particularly thin-skinned people, with the risk of it developing multidirectional internal dynamics (i.e. psychological, social and somatic). These internal dynamics can strongly determine the onset and progress of mental health problems. This can be seen, for example, when cognitive patterns cause patients to spiral deeper into a depression or when the fear of stigmatization fosters social withdrawal and the resulting isolation fuels psychotic hallucinations. Such examples can be continued at will.

Uniting for Tolerance and Sensitivity: Project “Irre menschlich Hamburg”

The possibilities and difficulties of practical anti-stigma work shall be illustrated using the example of the association “Irre menschlich Hamburg e.V.”. It was one of the first anti-stigma projects in Germany and arose from the trialogically organized Hamburg psychosis seminars. Working trialogically is the foundation for the continuing engagement of different target groups in varied contexts and topics, all revolving around psychological health and mental health problems (www.irremenschlich.de). Trialogue forums in general, of which there are now more than 100 in Germany, have proven to be a good training ground for anti-stigma work. Working through mutual prejudices creates a basis for combined efforts to reduce prejudices in the general public. This especially applies for the various advanced education opportunities. “Irre menschlich Hamburg” has a wide spectrum of tasks, and the topics and operating sites are conceptualized broadly. It began with anti-stigma work in the field of education delivering encounter projects in schools: First for the pupil and further on for the teachers as well. The field of anti-stigma campaigns and projects spread further to the university and most importantly to the education of mental health staff to fight stigma in the delivering of psychiatric services: encounter projects for nurses and students of medicine and psychology.

Also in administration, it seemed important to fight discrimination and raise awareness and tolerance, so encounter projects got established for social worker, youth supporters, pastors, probationary services and especially the police, having contact with mentally ill in extreme and acute situations. Also education and information projects in Hamburg businesses began, as well as regular education and training events for journalists and the housing industry. To raise public awareness, activities, e.g. various cultural events, like exhibitions, film screenings and theatre performances, are organized by “Irre menschlich Hamburg”. The development, trial and execution of a curriculum to prepare people with experience of mental health problems for independent anti-stigma work and psychosocial care as peer support worker (EXperienced INvolvement, EX-IN) helped to deliver for all the rising fields and efforts.

Insights into the Work of “Err Human Hamburg”

To give some insight into the broad variety of anti-stigma projects, here a closer look into some activities of Irre menschlich. An overview is presented in (Fig. 25.1).

Anti-stigma in Education: School Projects and Further Development

Irre menschlich provides regular information sessions, materials, classes and prevention projects to Hamburg schools, tailored to all ages and subjects and annually open days for pupil and teachers. A variety of materials like “media suitcases” are developed.

Pioneer Work: Age-Appropriate Information and Personal Encounters

Youth facilities are not only designed to keep young people occupied, and the purpose of schools goes beyond increasing knowledge. Both aspire to provide problem-solving strategies that prepare young people for later life. Anti-stigma work can have direct preventative benefits, especially for young people who have experienced mental health problems directly or indirectly, as it allows teachers, educators and social pedagogues to engage students in discussions about life goals, life crises and personal/professional resources. “Irre menschlich Hamburg” began its anti-stigma work as a result of the strong positive response from schools following the release of the novel “The Begging Queen” (“Die Bettelkönigin”; Stratenwerth and Bock 2001). This urban fairy tale was based on the life of Hamburg artist Hildegard Wohlgemuth. In combination with her school visits, it laid the foundation for many anti-stigma projects. The youth novel “Pias lives…dangerously” (Bock and Kemme 2000) in conjunction with school visits by a former company leader of the German armed forces (role model for the book and now homeless) fulfilled a similar function for junior high students. Over the years a lot of authentic material for all ages and occasions was developed this way. The combination of authentic writing and direct personal encounters appears to best transport the idea of anti-stigma work.

A Lot of Experience and Varied Topics: Educational Policies and Health Policies

Over the past 10 years, “Irre menschlich Hamburg” has completed over 1,000 class projects with Hamburg school students. Core principles are the trialogue and direct personal encounters. Project topics have been continually extended, now including anxiety, psychosis, depression/burnout, self-harming behaviours/borderline personality disorder, eating disorders, psychosis and addiction. The topics gradually align with the experience of school students. Again, the trialogue/the authentic encounter with people with experience of mental health problems proves to be more convincing than conveying technical information or teaching from the moral high ground. The goal “More tolerance in dealing with others and more sensitivity in dealing with oneself” has rehabilitative and preventive aspects.

Experiences of the “Irre menschlich” School Projects

Participant observations, a systematic qualitative analysis of class sessions, and multiple surveys with students, teachers and other participants allow the following conclusions:

• 1. Students hold fewer prejudices than expected. Especially young students relate to people with experience of mental health problems with openness.

• 2. Within class sessions, encounters with psychiatry-experienced people exhibit considerable appeal. The “Irre menschlich Hamburg” material is used in preparation for and after these encounters. If encounters and material are reasonable linked, the project succeeds at its best. If the emphasis is on trialogical encounters, even short class sessions can have lasting effects.

• 3. Materials like the “media suitcases” can be flexibly assembled, dependent on the duration of the class, the students’ ages as well as the qualifications and preferences of the consultant.

• 4. Class sessions over a period of 6 months may be conducted interdisciplinary (e.g. German/history, biology/philosophy/ethics, psychology/art). Teachers, whilst remaining responsible for structuring their classes, may be given advice on how to incorporate the material. This makes the projects economically viable and circumvents detrimental competition with teachers and consultants.

• 5. From a middle school level onwards, students are asked to think about their aspirations and goals in life, about their available resources and possible future conflicts. Discussing mental health problems in this way fosters self-confidence.

• 6. Learning effects are enhanced when students get a chance to organize their own activities. Students have visited an outpatient clinic, organized presents for consultants, written stories, drawn pictures, conducted interviews or discussed the lives of famous artists, scientists or politicians with mental health problems.

• 7. For consultants, being a crisis-experienced “life teacher” has an empowering effect (“It was like a second therapy”).

• 8. The project fosters tolerance in dealing with others and sensitivity in dealing with oneself. Both are dependent on each other and strengthen one another. They are prerequisites for psychological health.

• 9. Within class sessions, worries and conflicts of students are not directly discussed (e.g. having parents with mental health problems). Instead, the sessions are designed to introduce students to the topics of mental health problems. Topics are not dealt with psychologically, but pedagogically, probably to the relief of students who are in distress.

• 10. Through direct personal encounters of people with experience of mental health problems and mental health professionals, students’ awareness is enhanced and the threshold to seek professional help is lowered. This approach is likely to have a greater positive impact on mental health problem prevention than symptom-oriented early diagnoses.

“Life Coaches”: Advanced Education for Teachers

The Institute of Advanced Education for Teachers offers regular courses on “psychological health/mental health problems as a class topic” and “psychological health/mental health problems in school students”. At the yearly meeting of the UNESCO schools in Lübeck/Hamburg in the year 2005, the ideas of “Irre menschlich Hamburg” were well received. In the following year, these schools were encouraged to organize trialogical projects: topics such as inner peace and the protection of one’s inner world were discussed alongside topics such as world peace and environmental protection.

Psychiatry Opens Its Door for Schools (“Psychiatrie Macht Schule”): Collaboration with the University Clinic

Between “Irre menschlich” and the University Medical Center Hamburg-Eppendorf (UKE), a constructive and mutually beneficial cooperation has emerged. “Psychiatrie macht Schule”, an open day held at the UKE, has proven to be especially popular. Each year, more than 1.000 school students take part in approximately 60 trialogical workshops, readings and video lectures at the medical centre. The signature feature of these events is therapists, people with experience of mental health problems and relatives appearing together. Workshops include “Good times – bad times” (Bipolar disorders), “Extreme thin-skinned”, “Hearing voices” (Psychoses) and “What’s up?” (Eating disorders). An accompanying research project currently evaluates these workshops (Dorner et al 2014).

Perspectives on School Projects

In the future, “Irre menschlich Hamburg” and Psychenet intend to establish an ongoing presence at a number of exemplary schools. In particular, the projects aim to incorporate regular information sessions into school curricula, offer courses for teachers that can be tailored quickly upon demand and provide individualized support for students in need (e.g. one-on-one peer support). The projects have shown that trialogical work often makes young people realize that mental health problems can be dealt with in a non-stigmatizing appropriate way and that it can be discussed without having to put themselves in the centre of attention or being forced to take such a place. As such, the project fosters awareness of mental health problems, whilst avoiding the risk of stigmatization or of abusing the role of the teacher. In addition, speaking with consultants and listening to their stories can reduce patients’ anxieties and open up new possibilities for help.

Shaping Attitudes: Fighting Stigma in Society, Work Life and Media

Fascinating Media: “First-Hand Information” for Journalists

“Irre menschlich Hamburg” conveys first-hand information to journalists. Reports about the project were televised on German channels such as ZDF and N3, and members of “Irre menschlich Hamburg” participated in various German talk shows, with the aim of conveying the human side of mental health problems. In addition, the newly designed website and a radio spot that was aired on several youth broadcasts have gotten positive feedback (www.irremenschlich.de).

Psychological Health and Mental Health Problems in the Working Environment: Specific Projects

Early on, “Irre menschlich Hamburg” began to organize trialogical projects for companies located within Hamburg. Again, the aim was to shape public perception of mental health problems towards a more human view and to foster the willingness of employers to recruit or continually employ people with mental health problems. Topics such as depression/burnout, as well as addiction and psychosis (e.g. in the advanced education course for teachers), were met with a particularly positive response. Together with the rehabilitation committee and the senator for town planning, “Irre menschlich Hamburg” participated in a large education campaign for the Hamburg housing industry. As with the other projects, the aim was to counteract prejudices and to develop new forms of cooperation, so people with mental health problems are able to find housing and sign their own housing contracts. Within the housing industry, more tolerance and sensitivity is also needed. Rare encounters occurred at a large opening event and at the regional advanced education courses.

Anti-stigma Work in Administration and Police Department

Youth Support: Raising Awareness Without Stigmatization

Since prejudices against mental health problems are common amongst young people, those who are at risk of developing mental health problems are quickly stigmatized and ostracized. Self-stigmatization is a frequently observed attempt to pre-empt social exclusion. Within the area of youth support, trialogical education courses with active participation of people with experience of mental health problems and their relatives have existed for many years. A 3-day basic course, which links anthropological understanding, support possibilities and a trialogue discourse, is regularly well attended. A long-term cooperation is planned as well and probationary services as well as unemployment/job-seeking services.

Supporting De-Escalation: Advanced Education for Police Officers

Within the Hamburg police, “Irre menschlich” has taken on a long-term responsibility to educate middle-level civil servants. Courses offer practical units on psychosis, mania and borderline personality disorder. The focus is on combining professional information with direct personal encounters, to correct one-sided views of mental health problems, reduce fears and search for de-escalation strategies. Rare encounters have occurred within this context. For example, at an advanced education course held in connection with the deaths of three people with mental health problems, a trialogical meeting occurred between the following parties: police executives, mental health professionals, people with experience of mental health problems, their relatives and a traumatized police woman, who, in distress, fired one of the fatal shots. Following an initial trial phase, police administration decided to anchor anti-stigma work within their curriculum by adding a training and encounter unit delivered by “Irre menschlich Hamburg”. Its effect on the participants was assessed in 2014 measuring the social distance, causal attributions, emotional reactions, stereotyped attitudes, the assumed effect of different treatment and the prognosis for schizophrenia with questionnaires before and after the training. The results show the tendency of a positive effect of the training. The social distance is reduced, and less negative stereotypes and fear were observed. Besides that participants developed a more differentiated attitude towards effective treatment methods and considered more psychosocial causes of mental disorders, despite the agreement to biological causes, the expectation of anger and pro-social reactions did not change. Altogether a positive effect of the trialogical training could be shown.

Cooperation with Psychenet

For its proposed project Psychenet (Härter et al. 2012; Bock 2011), Hamburg was awarded “Health region of the future” in its subproject 1, and the encounter projects were intensified and extended. In addition, the trialogical education courses were enlarged. The media campaign (posters, film spots for cinemas) was successfully conceptualized trialogically; and people with experience of mental health problems modelled for the posters and wrote the accompanying text (rather than actors). Having gained confidence from this anti-stigma campaign, it was also decided to shoot film spots using people with experience of mental health problems. This project benefitted in particular from the photographer Thomas Rusch. Members of “Irre menschlich Hamburg” were able to influence the character of the anti-stigma campaign significantly.

The Future of “Irre menschlich Hamburg”

Recruitment and New Consultant Training

In the beginning – given its emergence from the psychosis seminars – “Irre menschlich Hamburg” focused on psychoses and bipolar disorders. For a few years now, the project has engaged consultants for many aspects of psychological health and mental health problems. Some of these consultants are recruited from the EX-IN programme. There has been an increasing amount of interest to participate in the project as a consultant. It has become apparent that the consultants benefit from their participation. Not only do they receive an income (for school projects only), they also receive a lot of personal encouragement.

Strengthening Preventative Project

Together with the professional “Ersterkrankten” project (“first-episode patients”), “Irre menschlich Hamburg” is aiming to support young people (and their relatives) in current crises. For example, dedicated (former) patients and their relatives might share personal experiences with young people who are searching for help. This can foster mindfulness and lower the threshold to seek professional help. This indirect trialogical approach is likely to have a greater effect on the prevention of mental health problems than early diagnoses.

Peer Support: EXperienced INvolvement (EX-IN), Achieving More Resistance to Stigmatization

“EX-IN” was an EU project set out to develop a curriculum for training people who had gone through psychological crises in order to help other people with similar psychological problems. By now, it has become a flourishing trialogical practice. An increasing number of clinical and subclinical institutions employ peer support worker as so-called recovery companions. The trialogical approach aims to strengthen patients’ self-confidence, resources and quality of life. It aims to support patients during their recovery and offer relief and encouragement to relatives. According to the project experience, peer support has a threefold effect: (1) it strengthens self-efficacy and in result counteracts the risk for self-stigmatization, (2) it changes the perception of mental health problems amongst mental health staff, and (3) it reduces the risk for stigmatization against people with mental health problems in psychiatry. A number of international studies support the beneficial effects of this intervention (e.g. Davidson et al. 2012; Mahlke et al. 2014). As part of Psychenet Hamburg, “twofold peer support” was established in all psychiatric clinics in the Hamburg region, which entails people with experience of mental health problems supporting people in current crises as well as relatives supporting other relatives. A randomized study further evaluates its feasibility and effectiveness, as well as effects on the peer support worker themselves and attitudes of other mental health staff.

Fig. 25.1

Network of the project “Irre menschlich Hamburg e.V.”

Information Box 25.1: Summary

• 1. Top-down anti-stigma campaigns run the risk of transmitting reductionist messages. Narrow medical illness concepts, as often propagated by pharmacological firms and still represented in mental health-care services, are not suited to decrease social distance or the risk of self-stigmatization.

• 2. A fluent transition between health and mental health problems counteracts the risk of (self-)stigmatization (Schomerus et al. 2012; Angermeyer and Schomerus 2012).

• 3. Encounters with individuals with mental health problems can reduce social distance and weaken prejudices.

• 4. Tolerance in dealing with others and oneself are worthwhile aims for prevention projects. Trialogical projects in schools and firms have rehabilitative effects as well as preventative effects.

• 5. Trialogical advanced education courses for journalists, teachers, the police, youth support services, health professions, housing associations, unemployment projects and probationary services reduce prejudices and mutual reservations. They strengthen the qualification of these professions and have an important political function towards inclusion (Bock and Priebe 2005).

• 6. In a clinical context, peer support can reduce the risk for self-stigmatization, whilst increasing self-efficacy and fostering self-help.

• 7. Peer support is likely to change perceptions of mental health problems within psychiatry, thereby minimizing the risk of stigmatization in and through this professional field.

• 8. The trialogical approach operates on multiple levels. Originating from the psychosis seminars/trialogue forums, it is effective for everyday work in psychiatry (e.g. open dialogue, treatment agreements), advanced education courses, congresses, organizations, complaints offices as well as psychiatry politics and immediate anti-stigma work. The ultimate aim is to achieve equitable cooperation between institutions and experts (people with experience of mental health problems, relatives, health professionals).

• 9. Success is more likely for local, long-term trialogical projects than top-down and exclusively medically oriented anti-stigma campaigns.

• 10. A trialogical citizen action committee is able to reach several groups: pupils, teacher journalists, police, pastors, health-care professionals, housing industry and others. With these projects Irre menschlich Hamburg has won a special award of the European unit as best practice model (inno-serv.eu/de/content/irre-menschlich-ev-hamburg).