Stigma and mental health problems: why psychiatric professionals are the main culprits
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.
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).
DANGER TO OTHERS
Inflated perception of risk
Viewed as unpredictable
Media portayal of "psycho" killer
Treated like suspected terrorists
Don't talk about mental health problems
Suffer abuse from others
LOSS OF VALUED ROLES
Reluctance to apply for jobs
Discriminated against in the workplace
Parenting skills unfairly questioned
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.
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(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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