On the other side of the fence

This image of a boundary fence to a Scottish mental health “Institution” was recently shared with me.

As an “Institution” the British Journal of Psychiatry rejected my “editorial” on Iatrogenic Stigma.  Fortunately, a longer version called  “Window tax” was published in, Mental Health and Social Inclusion, Vol. 16 Iss: 4 pp. 181 – 187

The British Journal of Psychiatry rejected “On the other side of the fence” for the following reasons:

MS ID#: BJP/2012/115832

The strengths of this paper are:

• It discusses an important set of issues ie how far psychiatric staff themselves contribute towards stigma

The limitations of the paper are:

• It takes a rather anecdotal approach eg a colleague of mine recently wrote etc
• The paper does not seek to examine the evidence that stigma more generally, or more specifically within the psychiatric profession, are getting better or worse
• The paper tends to go over old ground somewhat eg in rehearsing definitions of stigma
• The literature review is rather patchy ie citing the Angermeyer review on biological causal explanations of mental illness but not the recent Schomerus paper
• The discussion is rather wide ranging eg referring to ‘herd instinct’ and Kierkergaard etc
• There is a fairly substantial literature on mental health professionals and students comparing their attitudes to those of the general population but this is not fully referred to

The reviewer was Professor Simon Gilbody

The other side of the fence: Iatrogenic stigma.

Abstract:
The stigma of mental illness is a source of real suffering. This article raises concerns that, despite recent campaigns, stigma has not been fully addressed by our profession and that evidence suggests it may have unwittingly contributed to iatrogenic stigma.

Introduction
In Professor Sartorius’s 2002 editorial on iatrogenic stigma of mental illness, he argued against careless use of diagnostic labels and that “psychiatrists and other mental health staff stigmatise patients in other ways”, often having “negative attitudes to people with mental illness.”[1] There were nine replies to this editorial. One of those was by Dr Smith, a psychiatrist and leading campaigner against stigma, who felt that Professor Sartorius was ‘scapegoating’ psychiatry: “of all health professionals psychiatrists are surely the least likely to misuse diagnostic terms” and “21^st century British psychiatry seeks to be open, inclusive and pragmatic and has arguably made more progress in user consultation and involvement than any other medical specialty.”[2]

A professional colleague of mine recently wrote to me following a difficult experience: “I guess if we are to tackle stigma in mental health, we need to start closer to home in our colleagues”.[3] It is now a decade since the debate above took place and one is left wondering where we are now given campaigns to tackle stigma such as ‘Changing Minds,’[4] ‘See Me’[5] and ‘Time to Change’.[6] Is the story of the last ten years a tale of ‘benign professional progress?’[7] Has our profession led us out into the light and free of the dark stain of stigma? Has the biological and genetic paradigm as the prevailing explanation of mental illness helped in this? Do we really have meaningful engagement with users, sufferers, patients, and carers? And if we start closer to home as my colleague suggested, are we more like Sartorius thought, guilty of iatrogenic stigma or more like Dr Smith suggested, unlikely to misuse diagnosis and stigmatise others?

The term stigma refers to a mark that denotes a shameful quality in the individual so marked. Mental illness is widely considered to be such a quality. Goffman, in his classic text, defines stigma as ‘‘an attribute that is deeply discrediting’’ that reduces the stigmatized person ‘‘from a whole and usual person to a tainted, discounted one’’. In Goffman’s view, stigma occurs as a discrepancy between ‘‘virtual social identity’’ (how a person is characterized by society) and ‘‘actual social identity’’ (the attributes really possessed by a person).[8]

Phelan and colleagues proposed three major functions of stigma and prejudice: norm enforcement (keeping people in); exploitation and domination (keeping people down); and disease avoidance (keeping people away).[9] In this article I briefly look at each of these functions of stigma and reflect on where we have got to in the ten years since Sartorius raised concern over ‘iatrogenic stigma.’

The prevailing mainstream understanding has been that mental illness ‘is an illness like any other’ and further that if the causes of mental disorders are attributed to factors outside the individual’s control such as their genes, people’s reactions to those with mental illness will be less negative. Research on stigma, however, seems to find that the ‘illness like any other illness’ model is more likely to lead to stigma than more psychosocial based models.[10] In a recent review Angermeyer and colleagues identified 33 studies that had looked at ‘biogenetic’ explanations of mental illness and public acceptance of mental illness and concluded that biogenetic causal attributions “were not associated with more tolerant attitudes; they were related to stronger rejection in most studies examining schizophrenia.”[11] One explanation of this is that such dominant ‘biogenetic’ explanation creates the image of some phenomenon over which afflicted individuals have no control thereby rendering their behaviour apparently unpredictable and therefore potentially dangerous.

Keeping people in
Keeping people in refers to the phenomenon of the ‘herd instinct.’ This term describes the tendency to associate with others and follow the group’s behaviour. Consequences of this include: tight definition of the herd, perceived acceptable behaviours for members of the herd, perceived unacceptable behaviours for members of the herd, and consequences for non-conformity. It was the Danish philosopher Kierkegaard who introduced the related idea of ‘authenticity’ and contended that there was public pressure to conform to society, which led to ‘inauthenticity.’[12]  As a profession, we need to be aware that our collective behaviour can be limited by the herd and that this behaviour risks being less ‘authentic’ as a result.

Keeping people down
inabil, including psychiatric stigmatisation, is an exaggerated attribution of ‘other-ness’ to certain individuals or groups. There is an assumption (made by the discriminator) of the existence of fundamental differences between themselves and ‘the other’.

The diagnostic lens, which brings part, but never the whole, into sharp focus, is a stigmatiser in itself. It can lead to a situation where the doctor (and the wider world) may cease to see the whole person, and be easily distracted from what else is going on outside any label. Whilst our profession has made great efforts to tackle stigma, a study by Lauber and colleagues found that nearly three quarters of relevant publications report that beliefs of mental health providers do not differ from those of the population, or are even more negative.[13] This would seem to contradict the belief that mental health providers (including psychiatrists) should have more favourable attitudes due to professionals’ knowledge about mental disorders and their daily contact with those suffering from them. They concluded: “Our findings indicate that, while mental health providers are well informed about mental illness, they nevertheless do not always hold positive opinions about the conditions and the people they treat.” Here we may have a seemingly insoluble problem, as classifications of ‘disorders’ immediately labels a person into a category of ‘otherness.’ Those defining the ‘otherness’ must take care that this is not used to reinforce their own power: for one group to have more, another must have less.

Keeping people away
In the past decade, mental health professionals have initiated a number of national and international efforts against the stigma of mental illness. Although successful in tackling some aspects of stigma and discrimination, these programmes have been criticized for being largely uninformed by the lived realities of people with mental illness and their families.[14] While these initiatives over stigma continue to keep those affected away, it is difficult to see further progress being made.

It is part of conventional psychiatric training that the description of symptoms by the patient (“subjective”) is seen as less valid than the interpretation (“objective”) by the “expert” interviewer. Beveridge however, has recommended that it is time to abandon what he termed the ‘subjective-objective divide’.[15] As far back as the 1930s Harry Stack Sullivan argued that the most important therapeutic factor was the relationship between doctor and patient, leading him to decry those clinicians who adopted a detached and supposedly ‘objective’ approach to the patient.[16] It may be that this persistence of the “doctor knows best” attitude is one of the reasons why psychiatry has had such a limited engagement with the user movement.

Conclusion:
Mainstream medical journals such as the British Medical Journal have for many years now included inputs from scientists, sociologists, journalists, anthropologists, politicians and of course patients.[17] In contrast, as a recent study confirms, psychiatric journals publish more biological studies than internal-medicine journals, with less interest in drawing on wider sources of evidence and information.[18] One area that is desperately under represented is the voice of the patients.

Anti-stigma initiatives need to be careful not to rely solely on biological or genetic concepts of mental illness. The evidence from the systematic reviews described above tells us that ‘biogenetic’ approaches do not solve the problems of discrimination and social exclusion of people with mental illness. Indeed Angermeyer et al concluded “[that at] this stage, promulgating biogenetic causal models of mental illness cannot be regarded as a rational, evidence-based strategy to decrease individual discrimination against people with mental illness, but rather entails a risk of increasing stigma.”11

Medical professionals need to consider their own attitudes and to become aware of them, to involve service users in the development of services, and to stand up against discrimination. Psychiatry suffers from stigma of its own as it is often seen as “other” from the standpoint of the increasingly technological fields of medicine and surgery. This perhaps explains the professions reluctance to embrace the humanities. However, enhanced understanding of what is going on between psychiatrist and patient, and greater openness to more diverse sources of evidence and information, does not preclude a scientific explanation of what is going on in the patient alone, and such scientific explanation does not need to cut off a vulnerable person. In the last ten years the internet has allowed users to open up new paradigms beyond the prevailing ‘biogenetic’ where biography, dignity and the celebration of uniqueness are encouraged. If Psychiatry can overcome its fears and tackle all the heads of stigma, most particularly by truly listening to its patients, it can only be to the benefit of the profession and patients alike.