Stigma and mental health problems: why psychiatric professionals are the main culprits

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Introduction

The stigma suffered by people identified as experiencing psychiatric problems is often described as more disabling than the actual mental disorder. This article will first offer a definition of stigma and list the specific negative consequences of being identified as a psychiatric patient. The ways that professional psychiatric services inadvertently promote stigma in the patients they serve will then be described.

What is stigma?

A concise definition of stigma is, ‘A sign of disgrace or discredit which sets a person apart from others’ (1). A helpful distinction can be made between two types of stigma, Firstly, the ‘public stigma’ associated with the way that lay people perceive, and react towards, those individuals identified as displaying psychiatric disorders. Secondly, ‘self stigma’ whereby people suffering mental health problems develop awareness of the way they are perceived and begin to concur with these negative evaluations (2), a process that may contribute to the low self-esteem that is prevalent among psychiatric patients.

A more detailed exploration of stigma has proposed a four stage process (3), all elements of which need to be present for someone to be stigmatized:

1. Labelling: the person is put into a category (e.g. ‘mental patient’ or ‘psychotic’) on the basis of a distinguishing characteristic.

2. Stereotyping: an automatic (some might say lazy) process whereby the label is instantly assumed to signify negative attributes.

3. Separation: the emergence of an ‘us and them’ attitude leading to the labelled person being viewed as an outsider.

4. Loss of status/discrimination: the labelled person is denied rights and opportunities within society.

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The consequences of stigma

There is abundant evidence that stigma blights the lives of people with mental health problems, impacting negatively on their self-concept, relationships and work opportunities. Specifically, these negative consequences include:

1. Perceived as a danger to others

Those people unfortunate enough to acquire the label of ‘schizophrenia’ are commonly perceived as dangerous and unpredictable, despite the fact that this group of patients are 14 times more likely to be the victims of violent crime than to commit one (4). The media is guilty of promoting this psychosis stereotype via their propensity to over report stories linking psychosis with violence, both newspapers (5)(6) and television (7) being culpable of these distortions

2. Limited social networks

Partly as a consequence of the psychosis stereotype, people with mental health problems are inclined to have smaller social networks as compared to the general population (8). Around three-quarters of those experiencing psychoses state that they conceal their diagnosis from others and about half report that they struggle to make and keep friends (9).

3. Harassment from others

Surveys by mental health charities suggest that psychiatric patients disproportionately suffer verbal and physical assaults from members of the public (10).

4. Loss of valued roles

Being labelled with a psychiatric disorder appears to negatively impact on success in the work environment. Anticipation of rejection at interview discourages many sufferers from applying for jobs (11), illustrating the perniciousness of self-stigma (see above). A recent international study concluded that 29% of people labelled with a schizophrenia diagnosis were discriminated against in regards to both finding and keeping a job (9). Furthermore, there are reports that a mental health problem might lead to parenting ability being unfairly questioned (11).

Theme
Specific examples
DANGER TO OTHERS
Inflated perception of risk
 
Viewed as unpredictable
 
Media portayal of "psycho" killer
 
Treated like suspected terrorists
SOCIAL ISOLATION
Few friends
 
Don't talk about mental health problems
 
Suffer abuse from others
LOSS OF VALUED ROLES
Abilities underestimated
 
Reluctance to apply for jobs
 
Discriminated against in the workplace
 
Parenting skills unfairly questioned
The Consequences of Stigma

Psychiatric professionals: a potent source of stigma

Paradoxically, psychiatric professionals are, via their clinical and research practices, the most pernicious source of stigma for people suffering mental health problems. Psychiatric staff often inadvertently stigmatise their patients in three broad ways:


1. By insisting that mental health problems are brain diseases

The beliefs that people hold about the causes of mental health problems will significantly influence their attitudes towards those so afflicted. The insistence by traditional psychiatry that so called mental illnesses like depression and schizophrenia are primarily the result of a genetically inherited brain abnormalities provides fertile ground for the emergence of negative ideas about people experiencing emotional difficulties. Thus, a scholarly review of the research evidence (12) reported that bio-genetic explanations of psychiatric problems – the "mental illness is an illness like any other" approach – are far more likely to nurture stigmatising attitudes as compared to explanations based on people’s difficult life experiences.

Teaching the general population that mental illnesses are the result of faulty genes and consequent brain aberrations – the theme of many anti-stigma “education” campaigns – encourages a range of stigmatising attitudes towards people with mental health problems. These include: a reluctance to form friendships (13)(14); perceptions of immaturity (15); inflated estimations of dangerousness (14)(16); and a tendency to behave more harshly towards them (17).

Despite the efforts of biological psychiatry to peddle their spurious and stigmatizing, “illness like any other” brand of education, it is reassuring that the general public retain more enlightened views, continuing to believe that mental disorders are usually the consequence of traumatic life events (for example, bereavement, stress and victimization) (18).


2. By perpetuating negative and discriminatory attitudes

Service users and their families view psychiatric professionals as the most potent source of stigma and discrimination for people with mental health problems (19)(20). Those labelled as “schizophrenic” commonly feel that they are not believed by professionals and that complaints about their physical health are not taken seriously (21).

Legislation across the developed world allows people deemed to be suffering from a mental illness to be detained without trial, against their will, and forcibly drugged, despite never having committed a crime and retaining the wherewithal to make their own decisions. As such, many people within the psychiatric system are denied certain civil liberties that are afforded all other citizens (with the possible exception of suspected terrorists!), these restrictive practices often being justified on the basis of dubious assumptions about their dangerousness. By implementing such discriminatory legislation, psychiatric professionals effectively collude with the government of the day to exclude troublesome sections of our community under the guise of treating mental illness (22).


3. By using diagnostic labels

Applying a psychiatric diagnostic label (for example “schizophrenia” or “depression”) to someone suffering emotional distress can promote stigma (23). Specifically, labelling of this sort is associated with a number of disadvantages for the service user including: increased pessimism about the prospect of recovery (24); a greater risk of rejection by others (15); underestimation of the individual’s social skills (18); and an enhanced perception of the seriousness of a person’s difficulties (25).

The “schizophrenia” label seems particularly unhelpful, encouraging inflated estimations of dangerousness and the likelihood of social exclusion (26)

Pernicious labelling of this kind is encouraged by the prominence given to the “clinicians’ bible”, otherwise known as the Diagnostic and Statistical Manual of the American Psychiatric Association, a recently updated 5th edition incorporating 15 more mental disorders than its predecessor (27). Despite compelling evidence (28) that psychiatric diagnoses are virtually meaningless, conveying very little about the causes of someone’s mental health problem nor the interventions that will achieve respite, psychiatric professionals deploy these labels in their routine communications thereby exacerbating the stigma suffered by people already enduring misery and distress.



A follow-up hub will discuss how the stigma associated with mental health problems can be effectively reduced.

References

(1) Byrne, P. (2000). Stigma of mental illness and ways of diminishing it. Advances in Psychiatric Treatment, 6, 65–72.

(2) Corrigan, P.W., Rafacz, J. and Rusch, N. (2011). Examining a progressive model of self-stigma and its impact on people with serious mental illness. Psychiatry Research, 189(3), 339–343.

(3) Link, B.G & Phelan, J.C. (2001). Conceptualizing stigma. Annual Review of Sociology, 27(1), 363-385.

(4) Brekke, J.S., Prindle, C., Bae, S.W. & Long, J.D. (2001). Risks for individuals with schizophrenia who are living in the community. Psychiatric Services, 52, 1358–1366.

(5) Corrigan, P.W., Watson, A.C., Gracia, G., Slopen, N., Rasinki, K. & Hall, L.L. (2005). Newspaper stories as measures of structural stigma. Psychiatric Services, 56(5), 551-556.

(6) Coverdale, J., Nairn, R. & Claasen, D. (2002). Depictions of mental illness in print media: a prospective national sample. Australian and New Zealand Journal of Psychiatry, 36(5), 697-700.

(7) Thornicroft, G. (2006). Shunned: discrimination against people with mental illness. New York: Oxford University Press.

(8) Howard, L., Leese, M. & Thornicroft, G. (2000). Social networks and functional status in patients with psychosis. Acta Psychiatrica Scandinavica, 102(5), 376-385.

(9) Thornicroft, G., Brohan, E., Rose, D., Sartorius, N. & Leese, M. (2009). Global pattern of experienced and anticipated discrimination against people with schizophrenia: a cross-sectional survey. The Lancet, 373(9661), 408–415.

(10) MIND (2007). Another assault: Mind’s campaign for equal access to justice for people with mental health problems. Mind, London.

(11) Read, J. and Baker, S. (1996). Not Just Sticks and Stones: A survey of the Stigma, Taboos and Discrimination Experienced by People with Mental Health Problems. London: MIND

(12) Read, J., Haslam, N., Sayce, L. & Davies, E. (2006). Prejudice and schizophrenia: a review of the ‘mental illness is an illness like any other’ approach. Acta Psychiatrica Scandinavica, 114(5), 303–318.

(13) Golding, S.L., Becker, E., Sherman, S. & Rapparpot, J. (1975). The Behavioural Expectations Scale: assessment of expectations for interaction with the mentally ill. Journal of Consulting and Clinical Psychology, 43, 109.

(14) Read, J. and Harre, N. (2001). The role of biological and genetic causal beliefs in the stigmatisation of ‘mental’ patients. Journal of Mental Health, 10, 223 – 235.

(15) Sarbin, T. and Mancuso, J. (1970). Failure of a moral enterprise. Journal of Consulting and Clinical Psychology, 35, 159–173.

(16) Walker, I and Read, J. (2002). The differential effectiveness of psycho-social and bio-genetic causal explanations in reducing negative attitudes towards ‘mental illness’. Psychiatry, 65, 313–325.

(17) Mehta, S. and Farina, A. (1997). Is being ‘sick’ really better? Effect of the disease view of mental disorder on stigma. Journal of Social and Clinical Psychology, 16, 405-419.

(18) Read, J and Haslam, N. (2004). “Public opinion: bad things happen and can drive you crazy.” In J. Read, L.R. Mosher & R.Bentall (eds.) Models of Madness: Psychological, Social and Biological Approaches to Schizophrenia. Routledge.

(19) Walter, G. (1998). The attitude of health professionals towards carers and individuals with mental illness. Australian Psychiatry, 6, 70–72.

(20) Pinfold, V., Thornicroft, G, Huxley, P. & Farmer, P. (2005). Active ingredients in anti-stigma programmes in mental health. International Review of Psychiatry, 17(2), 123 – 131.

(21) Gonzalez-Torres, M., Oraa, R., Aristegui, M., Fernandez-Rivas, A. & Guimon, J. (2007). Stigma and discrimination towards people with schizophrenia and their family members. Social Psychiatry and Psychiatric Epidemiology, 42(1), 14-23.

(22) Summerfield, D. (2001). “Does psychiatry stigmatize?” Journal of the RoyalSociety of Medicine, 94, 148 – 149.

(23) Sartorius, N. (2002). Iatrogenic stigma of mental illness: begins with behaviour and attitudes of medical professionals, especially psychiatrists. British Medical Journal, 324, 1470–1471.

(24) Angermeyer, M. and Matschinger, H. (1996) The effects of labelling on the lay theory regarding schizophrenic disorders. Social Psychiatry and Psychiatric Epidemiology, 31, 316–320.

(25) Cormack, S. and Furnham, A. (1998). Psychiatric labelling, sex role stereotypes and beliefs about the mentally ill. International Journal of Social Psychiatry, 44, 235–247.

(26) Angermeyer, M. & Matschinger, H. (2003). The stigma of mental illness: effects of labelling on public attitudes toward people with mental disorder. Acta Psychiatrica Scandinavia, 108(4), 304-309.

(27) American Psychiatric Association (2013). The Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

(28) Bentall, R.P. (2009). Doctoring the Mind: Why psychiatric treatments fail. Penguin Books.

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Comments 13 comments

Harold A. Maio 2 years ago

"Stigma", no matter who offers it, is a victimizer's word. You employed it, you are a victimizer.


gsidley profile image

gsidley 2 years ago from Lancashire, England Author

I'm not sure what point you're trying to make. Are you suggesting that if we stop using the term "stigma" the negative consequences of being labelled as mentally ill by western psychiatric systems - the deleterious effects of which have been widely documented - would somehow evaporate?

I agree that the language we use when describing mental health issues is important. A positive step, for example, would be to ditch the use of the term "schizophrenia," a pernicious, pseudo-scientific concept that misleadingly implies a unitary disorder with a discrete biological cause.


denise.w.anderson profile image

denise.w.anderson 2 years ago from Bismarck, North Dakota

This is a lot of food for thought. It definitely makes me take a second look at the system which my family has had to access and be a part of for the past twenty years. As a person with a mental illness, and having family members with mental illness, I simply dislike the term "mental illness." It implies that one is "insane" or "crazy" or that they have something wrong upstairs that keeps them from functioning appropriately. It think a much more appropriate term would be "emotional" or "behavioral" disorder. The various mental illnesses play out in such vastly different ways as to leave a person wondering whether the label does any positive good or not. As a society, we are so used to labeling illnesses, that in order to get proper treatment, we have to label and prescribe. In reality, these actions do nothing more than require us to see a different doctor or take a different medication.


gsidley profile image

gsidley 2 years ago from Lancashire, England Author

Thank you for your considered, thoughtful response. In particular, I agree that, sadly, in western societies a medicalized view of human misery and suffering (along with the consequential labeling) is the only currency that enables access to help and support.


Loki67 profile image

Loki67 2 years ago from Clinton, Ut

I would like you to know that I read your article with sincere interest. I have deep respect for the thought you have put into it, and it sounds as though you, or perhaps someone you love has suffered greatly as a result of the way the mental health community currently functions in a general sense.

I would like to qualify my remarks before I begin. Coincidentally, my sister and I both are married to men diagnosed as Bi-polar. We grew up with a mother who was truly clinically depressed, to the point of being non-functioning. I inherited depression, but was diagnosed as having Borderline Personality Disorder at 23yrs. To add to this, as a result of a minor injury I developed a rare nervous system disorder called CRPS-Complex Regional Pain Syndrome. As a result I have a spinal cord nerve stimulator implant, and I take methadone for pain.

There is a reason that I've listed all of this. I didn't mention that I was a paramedic for 25 years. First of all...as a young adult, struggling with many problems from a troubled childhood, I was blessed that a brilliant Psychiatrist took me on. One of the first things he told me was that Psychiatric 'diagnosis' was more for billing purposes, insurance companies require an ICD9 diagnosis. I had experienced in my career predudice aginst BPD patients as they were labeled as 'incurable', and these mental pigmies who put themselves in a position of responsibility for these people in need could not seem to imagine that perhaps PBH was curable, the mental health community simply didn't have the answers or the patience. The Psychiatrist that I saw never gave up on me. For almost two years I sat in his office for one hour without saying a word. He never cut my time short, never got frustrated, and we eventually stumbled on a solution that opened the door just wide enough for me to feel comfortable to be able to force myself to begin to speak. He had a theraputic technique that was unique from anyone that I've ever come across. 10yrs later I was a completely different person in a sense. I say this because I believe that the psychiatric community needs to study more theraputic practices with the goal, and determination of changing peoples lives, what ever their diagnosis. However, as a paramedic I do understand that many ailments from depression, to bi-polar disorder, to the physical problem of CRPS, have origions in brain chemistry imbalance. At the time that I met my husband, he had been a loving husband and father for about twenty years. Unfortunately, his symptoms were very mild when he was young, but as time passed and he went untreated things began to go hawire. He felt the need for personal perfection in a religious sense. Sadly, he was never treated appropriately, and his wife divorced him. He was so depressed when we met that I'm amazed that he had not taken his life. I learned from my sister that I needed to be involved in his treatment. I found him a better Dr and she immediately began a serious change in his medications. Things have gone strait up from there and we havn't looked back. I am protective of him though. I do notice where I might be asked to participate in something, or teach something, and he's not. He's so smart, kind, and an excellent teacher, it frustrates me. I do believe that the knowledge of his 'mental illness' causes descrimination.

The big question is what is the real cause, and what is the solution.

I'm not sure that the medical community will ever do away with diagnoses. It not only is necessary for billing purposes for insurance, but treatment modalities are created around general diagnoses.

When I began my career as a paramedic I quickly discovered that, even as the only paramedic in the room, tho only one assessing, questioning and treating the patient, they were answering my questions over my head to the fireman standing behind me, often at the door. Time and again my patients ignored me and would rather speak to any 'man' in the room. I gave this some thought. I knew that aside from being a very small female, I was soft spoken, and I looked quite young. I knew that I was not going to change the whole of society over nite, so I had a choice, I could carry a chip around on my shoulder, or I could assess some things that I could change to help the situation and hopefully change peoples response to me. Actually, I just made sure that I was very direct when I addressed a patient, I tried to speak up, I made sure that I was professional and knowledgeable. It worked. In no time I was the only person in the room. It also changed the respect others had for me, and ultimately the promotions I received at work.

To summarize, I have sincere appreciation and respect for your concerns, and likely experiences. In a world where lables, diagnoses, etc. will always exist, what is the true source of the problem? How can we improve the research and therapy techniques from within the psychiatric community, and what can be done to begin to change societal views?

I truly wish you well.


gsidley profile image

gsidley 2 years ago from Lancashire, England Author

Thank you for your interest, and taking the time to leave a detailed comment.

There is much that I agree with in what you say. Mental health problems can often cause huge amounts of misery and suffering for those afflicted and their relatives. And you're right in pointing out that much of western society adopts diagnostic-driven practices for purposes of insurance, billing etc. Also, people tagged with the "borderline personality disorder" label have often evoked negative, rejecting reactions from professional staff.

However, the points I'd highlight (from 33 years of working as a psychiatric professional in the UK system) are:

1. There is no compelling evidence that mental health problems like depression or schizophrenia are primarily caused by imbalances in brain biochemistry - many psychiatrists even accept this now.

2. Psychiatric diagnoses have no scientific validity and do not predict the course of the problem, nor its effective treatment.

3. Psychiatric diagnoses, despite being virtually meaningless and arbitrary, are associated with increased stigma (as described in the hub).

Thanks again for your interest, it's very much appreciated.


Loki67 profile image

Loki67 2 years ago from Clinton, Ut

Thank you, I have greater understanding of the three points you have just made.


Jules Malleus 2 years ago

I find this article very useful and enlightening.


David Willetts 2 years ago

Great article. Labelling is a really slippery thing, to the extent that we will find ourselves talking about "schizophrenia" and "depression" whilst at the same time saying these things are invalid constructs. For instance, in points 2 and 3 above you make sum it up well, however, in point 1 you refer to "schizophrenia" and "depression" as mental health problems, yet there is no evidence that these terms refer to anything at all (points 2 and 3), which shows just how these terms get in under the radar. There is no evidence that people have things like "schizophrenia" or "depression", as these terms are inventions not discoveries, so we can't use these terms when talking about people without inadvertently supporting the argument in favour of their existence, which has never been demonstrated, in much the same way that the existence of unicorns hasn't been demonstrated - there is no "schizophrenia" of whatever cause, and there is no "depression" of whatever cause. The best we can do is talk about individual distress and what that means to the individual.


gsidley profile image

gsidley 2 years ago from Lancashire, England Author

Jules - I'm pleased you found it of interest. Thank you for reading and commenting.


gsidley profile image

gsidley 2 years ago from Lancashire, England Author

David - I appreciate you taking the time to read and comment.

I agree with everything you say. And the point about my reference to "schizophrenia" and "depression" is a valid one - and perhaps a touch hypocritical of me - although, in my defense, I did prefix the reference in point 1 with "so called mental illnesses" to try to convey the arbitrary nature of these labels.

Thanks again.


tijdeling 24 months ago

I see some points your trying to make, but I think your article can be easily stigmizable as well, especially in the brain disease part. For those of us who have no trauma, but are still severely depressed you seem to dispel us. Nothing is black or white. There are a lot of causes for depression that require different approaches. If you were correct everyone would benefit from therapy and that is just not the case. Likewise the biological approach works for some but not all.


gsidley profile image

gsidley 24 months ago from Lancashire, England Author

tijdeling - Thank you for reading and taking the time to comment.

I fully agree with your assertions that not everyone is helped by therapy and some people benefit from medication. But to describe mental health problems, like depression, as brain diseases is invalid and counterproductive. No direct causative link between brain abnormalities (biochemical or structural) as ever been established despite a huge amount of research - much of it sponsored by the drug companies - aimed at finding such a link.

I'm not proposing that depression is an exclusive consequence of trauma; the level of misery and hopelessness people experience will be the result of a complex interaction of biology (genetics will contribute to the general sensitivity/reactivity of our nervous systems) and a wide range of historical and ongoing life experiences (for example, childhood abuse, emotionally impoverished relationships with care-givers, poverty and social deprivation, victimization, unemployment, bereavement, relationship tensions/break-ups). Each person will have his/her own unique story.

What is clear is that "education" initiatives that claim that mental health problems are primarily caused by brain abnormalities - and many anti-stigma campaign have peddled this notion - are more likely to promote stigma than alleviate it.

Thanks again for your interest.

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