Cultural safety requires nurses to critically reflect upon on their personal values, beliefs, attitudes, biases and cultural identity, as the experience of mental distress is often associated with stigmatising attitudes, prejudice and discrimination. The first section of this chapter outlines the historical, social and political factors that shaped attitudes, the provision of mental health care and mental health nursing. These factors have seen care transition from a biomedical and punitive approach to one focused on recovery and wellbeing. Cultural safety is discussed, including how the concept recognises the impact of colonisation on Māori mental health, systemic racism and discrimination. The social determinants of mental health are examined, followed by a discussion of mental health legislation, under which mental health services operate. Stigma associated with mental distress is examined. A central tenet of cultural safety is to be regardful of difference and to treat people as individuals, particularly when acknowledging the impact of trauma. An overview of trauma-informed care is provided, with an example from clinical practice which analyses application of cultural safety.

Chapter 7 examines interventions that can be implemented to address mental illness stigma. These include individual actions that the person who is stigmatized can engage in to help them cope with or resist stigma and actions that other people are obligated to perform in order to decrease stigma they may endorse or perpetuate unwittingly. These also include structural changes that social institutions and systems must undergo to make social structures less stigmatizing and more supportive of people with mental illness, and social and cultural interventions that increase the belongingness and acceptance of people with mental illness into the community as well as transform social norms to be more supportive of people with mental illness. In addition to using philosophical argumentation, this chapter draws on empirical literature in social psychology that examines what works to reduce and resist stigma.

Chapter 3 analyzes some of the ways that stereotypes harm people’s sense of self and identity. One way is through expressive harm, which is the harm that results from the unwitting and inevitable perpetuation of stereotypes. Stereotypes have a pervasive cultural power that enables them to control people’s thoughts, feelings, behavior, and social interactions even when people actively disavow the stereotype. Other ways that stereotypes harm people’s sense of self and identity are through the internalization of oppressive social scripts, which ascribe motivations and expectations for behavior, and through stereotype threat, in which people inadvertently and paradoxically act in ways that correspond to stereotypes even as they are trying hard to avoid fitting stereotypes. When people with mental illness internalize oppressive social scripts and experience stereotype threat, they incorporate negative stereotypes into aspects of their experience and identity, which damages their identity and sense of self and also diminishes their autonomy.

Chapter 5 assesses harms that people with mental illness experience that are related to how their self is constituted. These include harms of de-individuation and mis-identification, but also, as this chapter focuses on, harms of social exclusion and dehumanization that result from status loss and moral distancing. Dehumanization occurs through both being reduced to a stereotyped trait and being viewed as lesser compared to others. Having a sense of belonging and being accepted as an equal member of a moral/epistemic/social community are important parts of being viewed as and viewing oneself as a full human being; these are also critical for developing and exercising autonomous agency as well as for well-being and flourishing. People with mental illness are often excluded from these communities as a result of public stigma, diminishing their autonomy and well-being. This chapter shows how dehumanization, social exclusion, and belonging uncertainty threaten belongingness and autonomy.

Chapter 1 examines what mental illness stigma is and analyzes the components of mental illness stigma to show how people with mental illness experience stigma in their daily lives. These components include labeling, stereotyping, prejudice, moral distancing, social exclusion, status loss, dehumanization, microaggressions, discrimination, and epistemic injustice. In each case, I use empirical evidence from the social psychology literature on stigma to show ways in which people with mental illness experience these forms of stigma. Next, I look at factors that affect the kind, degree, and scope of stigma associated with mental illness, including beliefs, political values, cultural values, socioeconomic status, education, and gender. Finally, I examine how many people experience compounding stigmas that come from multiple sources.

Chapter 6 examines what makes discrimination and microaggressions (as a form of discrimination) wrongful. Discrimination involves differential treatment where some people are treated in different, unequal, and worse ways compared to others, and where that differential treatment is based on possessing a socially undesirable trait that marks a person as bad and inferior. Discrimination is wrongful because it harms people in a variety of ways, impacting their circumstances, resources and opportunities, options, agency, autonomy, and well-being. It causes material disadvantage and distributive injustice that denies people access to resources and opportunities and prevents them from having the basic goods necessary to participation in society. It also demeans people and leads to unfair subordination, loss of deliberative freedom, and decreased autonomy. This chapter reviews the philosophical literature on discrimination to provide a pluralistic account of the many harms discrimination and microaggressions cause to people with mental illness, which altogether make discrimination wrongful.

Chapter 2 assesses what stereotypes are and explains what makes them both wrongful and harmful. The chapter begins by defining stereotypes, explaining their relationship to prejudice and implicit bias, and showing how they are maintained due to cognitive biases. I examine factors that go into making the judgments involved with stereotyping. Then I analyze what makes stereotypes wrongful, including their rigidity, their falsity, and the way they overgeneralize about a person’s experience so as to erase its nuance and complexity. I look at descriptive and normative components of stereotypes and show that negative stereotypes always make a normative judgment about the badness and inferiority of a person who fits the stereotype.

Chapter 4 shows how internalized stigma often results in adaptive preferences that harm a person. When people incorporate aspects of negative stereotypes into their identity, they sometimes develop adaptive preferences by internalizing harmful social norms and beliefs embedded within these stereotypes. I show how people with mental illness often develop goals and desires that are shaped by these beliefs and social norms, which limits what they believe they are capable of, thus reducing their options for action and truncating their agency and autonomy. While adapting desires to one’s circumstances can be positive, as in positive adaptation, it is negative when it is harmful to a person. The adaptive preferences that result from this can be seen as rationality deficits that are oppressive and nonautonomous and that damage well-being and flourishing.

The introduction motivates the book’s arguments by showing how mental illness stigma remains pervasive despite greater awareness of mental health issues and more resources directed at mental health treatment and destigmatization. The forms of mental illness stigma most commonly expressed are stigma against people with severe mental illness who are perceived as homeless, and internalized stigma that people with mental illness project onto themselves. Mental illness stigma arises as a reaction to the violation of social norms of what a human being should be in the Western world in the twenty-first century. I give an account of stigma as the devaluing and discrediting of a person based on possessing a social trait that is seen as violating social norms, constituting a relationship of power. Components of stigma include labeling, stereotyping, prejudice, moral distancing, social exclusion, status loss, dehumanization, microaggressions, discrimination, and epistemic injustice. The chapter ends with a description of the book’s scope, methodology, and chapter outline.

We explore the unique considerations surrounding menopause, periods and contraception for people with intellectual disability (ID), the barriers they face and how to achieve ‘equal outcomes of care’. A complex interplay of communication differences, societal assumptions and stigma, diagnostic overshadowing, physical accessibility challenges, and gaps in healthcare providers’ understanding of ID, create these barriers. Aspiring to achieve equal outcomes of care requires early and adapted communication about menopause, periods and sexual health. Clinicians need to adapt clinical care to embed enquiry about menstruation and menopause and use systematic tracking tools to understand a woman’s periods and associated psychological and behavioural changes and then offer the whole range of treatment options. The responsibility lies with professionals to be aware of the barriers, provide reasonable adjustments to overcome them, and to advocate for equal outcomes around menopause, periods and contraceptive health for people with ID. The chapter includes insight from ‘experts by experience’, and each section provides practical suggestions for professionals working with people with ID.

The Conclusion urges us to consider practices that lead to becoming ‘valuable people’ as something that goes beyond overcoming stigma to changing the evaluations that define what is good. It brings the discussions about values together with a final example of how my interlocutors pursued valued inclusion, by embracing a biomedical model of personhood where people are judged on their minds rather than on their bodies. This draws attention to the wider relevance of questions of entitlement, distribution, and values: wherever my interlocutors went, discussions of values followed.

The research for this chapter was undertaken on the lands of the Wurundjeri people of the Kulin Nations. As is customary in the country in which I live and work, or so-called ‘Australia’ (see Watego, 2021), I acknowledge them as the traditional owners of country, as well as elders past and present. I acknowledge that sovereignty over these lands was never ceded, and that Aboriginal and Torres Strait Islander peoples remain strong in their enduring connections to land, sky, water and culture.

The chapter details the journey of Bethany Yeiser, an individual living with schizophrenia, from her promising academic and musical beginnings to her descent into homelessness and psychosis. Despite facing challenges such as delusions, hallucinations, and homelessness, Bethany eventually found help through involuntary hospitalization, leading to her recovery with the use of clozapine. The narrative highlights the lack of education and support for individuals with schizophrenia, emphasizing the importance of effective treatment and advocacy. Bethany’s experiences have inspired her to establish the CURESZ Foundation to provide education, advocacy, and support for those affected by schizophrenia, promoting hope and recovery for those in need.

This chapter explores the transformative potential of early intervention in schizophrenia, emphasizing its role in improving clinical, functional, and social outcomes. Through the poignant case of “Roger,” a man whose life was marked by untreated psychosis, homelessness, and missed opportunities for care, the chapter illustrates the consequences of delayed treatment and fragmented systems. It reviews epidemiological data, the importance of reducing the duration of untreated psychosis (DUP), and the neurobiological rationale for early-phase treatment. Models such as Coordinated Specialty Care (CSC), EPPIC, and Assertive Community Treatment (ACT) are discussed as effective frameworks for delivering comprehensive, multidisciplinary care. The chapter also addresses barriers to early intervention—including stigma, misdiagnosis, access limitations, and systemic inequities—and advocates for integrated, culturally responsive, and person-centered approaches. Ultimately, it calls for a shift in healthcare systems to prioritize early identification and treatment as a moral and clinical imperative.

This chapter follows the story of Jordon, a young man with schizophrenia who becomes entangled in the criminal justice system due to his untreated illness. The narrative highlights the challenges faced by individuals with severe mental illness, the failures of the mental health system, and the impact of policy and legal structures on their lives. Through the experiences of healthcare professionals and experts in the field, the chapter explores the need for a paradigm shift in the treatment of psychosis, advocating for humane and effective care for individuals across the spectrum of illness severity. The narrative culminates in a call to action to revolutionize the treatment of psychosis in America, emphasizing the importance of understanding, compassion, and evidence-based interventions for those affected by severe mental illness.