Stigma and exclusion

Happy New Year and welcome to the January 2012 issue of Advances. Let me introduce myself as the first Trainee Editor of the journal. I joined the editorial team in August and I am thrilled to be on board, particularly at such an exciting time. This month, for the first time, the journal’s content is available free online to all RCPsych members, as part of their College membership. This will allow free and easy access to the wide range of articles and resources that Advances provides. For a journal committed to teaching, training and CPD, this is a significant and timely development. I would like to extend a warm welcome to the trainees and medical student associates who may be reading the journal for the first time.

In this issue, the complex interrelations of sex, gender and mental health are explored in three articles dedicated to the assessment, diagnosis and treatment of gender dysphoria (Eden et al, pp. 2–11; Wylie et al, pp. 12–16; Hakeem, pp. 17–24). Gender dysphoria is often neglected, particularly in teaching and training. This is despite the fact that the general psychiatrist is the main point of entry to specialist services for those experiencing the profoundly disturbing feeling of being of the wrong gender. As well as diagnostic and management concerns, these articles highlight and address a number of other important issues, including the validity of the diagnosis, what might constitute effective treatment, and the effect of stigma and marginalisation of these individuals.

Consideration of the pervasive and detrimental effects of stigma and exclusion on mental health is continued in Sikuade’s celebration of Frantz Fanon (pp. 25–31). A pioneering and forward-thinking psychiatrist in his time and a tireless civil rights campaigner, Fanon was the first psychiatrist to outline the similarities between the effects of racial exclusion and mental illness on an individual’s relationship with society, work echoed by the recent AESOP study (Morgan 2006). This large-scale epidemiological study found a nine-fold increase in the incidence of schizophrenia among African–Caribbeans in the UK, particularly those migrating from countries with a majority Black population. The ongoing study is investigating a variety of proposed factors to explain this striking difference, among them marginalisation and exclusion.

Supervising therapy in personality disorder

My Editor’s pick for the January issue is an article on the effect on staff of patients with personality disorder (Moore, pp. 44–55). Working with these patients can be a difficult experience, particularly without adequate support or supervision. Staff bear the brunt of the anger, frustration and, sometimes, hatred of their patients. Despite this, clinicians must create a nurturing environment, without retaliation, modelling adult relationships and providing stable attachment figures. This is no mean feat and it cannot be achieved without proper supervision and peer support. Navigating the inevitable tensions and dissonance of the situation, and promoting health and recovery, are fundamental to the therapeutic process. In her article, Moore illustrates how to promote and sustain a containing and therapeutic environment not just for the patients but also for the staff caring for them.