Tuesday, July 15, 2014

Stigma Rhetoric

I have always been skeptical of the value of the stigma concept in advocating for the rights of people with mental illness.  It seems to imply that a person with a mental illness is obvious to everyone and nothing could be further from the truth.  The usual advocacy groups certainly jumped on it and it was later picked up by professional organizations.  My basic problem with the entire argument is that nobody should know that you have a mental health problem anymore than people should know that I have asthma.  It is a problem of medical confidentiality rather than a problem with stigma.  Anyone who thinks that is not the case just needs to consider what prospective employers think about hiring people with back pain, asthma, or any pre-existing condition that potentially impacts their group health insurance coverage.  Any confidential medical condition is potentially stigmatizing and it certainly is nobody else's business.  If people want to disclose that information that is certainly up to them and as I have posted here in many cases it can be a useful public service.  And I do realize that health insurance companies force you to disclose pre-existing conditions using various methods but that does not mean that your employer should know.

The other problem is that there has been broad and systematic discrimination against people with mental illness and addictions at all levels of government and the business community.  These are the people who have access to protected medical information and make decisions about health care based on it.  That discrimination occurs with full knowledge of a diagnosis and often a recommended treatment plan.  Multiple posts here document that problem and yet nobody comes right out and attacks that issue.  If anything social activism with a stigma focus seems to cast a wide discrimination net rather than focusing on the few people and agencies that can make a critical difference.  It  suggests that the general public is the problem and that educating the general public will solve the problem.

This morning a friend of mine posted this link on Facebook and asked me for my impressions of the argument that neuroscientific explanations potentially lead to more stigma.  That is probably what has me fired up.  If you are trained in science, you realize that there are  internal politics but in general that is not the same as the politics of the barbarians at the gate.  The problem is that all types of science from climate science to neuroscience gets co-opted and interpreted by people who don't know what they are talking about.  I think that is illustrated by one of the summary points in this article:

"As this revolution gathers force, we need to be mindful that biogenetic explanations for mental health problems can have troubling implications for the people who suffer them."

I think it should be obvious that there will be "troubling implications" for anyone who is ignorant on either end of a "biogenetic explanation".  Further, it is really impossible to separate allegedly biogenetic explanations from decades of conditioning by governments, businesses, and the media.  Troubling implications start when you realize that your employer's health plan does not have coverage for mental illnesses or addictions and you have a family member that needs that insurance.

What are the take home points about stigma in all of this?

1.  Businesses that discriminate against mental illness by rationing current services and destroying any infrastructure necessary to treat mental health are stigmatizing.  The message is clearly that they can't be bothered to treat these problems seriously by offering much of anything beyond a crisis stay in a hospital and a 10-20 minute "med check" by a "provider or prescriber" in an outpatient clinic every 3 - 6 months.   No research proven modalities to treat mental illness and a severe push to send people with addictions and serious mental illnesses to county detox, jail, or the street.

But even the businesses not involved can get into the act.  Practically every local market has a business some who is offering "crazy deals."  If you doubt it, Google "crazy deals" or the equivalent "insane deals" and see what you come up with.  Don't forget to look at some of the images.

2.  Governments that ration and destroy the mental health infrastructure and collude with rationing by businesses are stigmatizing.  Examples include empowering insurance companies to decide how they can deconstruct the billing and services of mental health providers and clinics to their advantage (the arbitrary insurance company audit),  empowering business to discount services, legitimizing utilization review and prior authorization (tools for arbitrary denials), and allowing for proprietary business guidelines to dictate who can receive treatment and who can not.  What could be more stigmatizing than to have a business suggest that a person is not "dangerous" enough to be treated and use that as a basis for medical decision making?  Why aren't there any rules about admitting only the "dangerous" myocardial infarctions and sending everybody else home?

3.  Court systems that treat the mentally ill like they are criminals are stigmatizing.  This includes practically all court systems because as any forensic psychiatrist will tell you, despite the myths about the so-called insanity defense - it is practically impossible for anyone to get off with that defense.  There are significant numbers of people who are incarcerated for minor nonviolent crimes that were the product of mental illness.  Ask yourself if it is more stigmatizing to have a confidential diagnosis of a mental illness or be listed in the paper as being incarcerated or having been convicted of a crime?

4.   The press has a very poor track record in the area of stigma.  It is well known that the press covers psychiatry more than other medical specialties and has a consistently negative view about the specialty.  How would you feel if you had an illness that resulted in you being seen by a physician whose specialty is consistently portrayed negatively in the media.   For the past two years the press has produced nonstop political arguments about a diagnostic manual that is practically little more than a guidebook for billing codes with many of the esoteric codes only of interest to researchers.  One of the main arguments in those articles was that the diagnostic manual led to arbitrary diagnosis and treatment for the benefit of the pharmaceutical industry.  For anyone with a serious mental illness, could there be a more stigmatizing argument?

5.  The entertainment industry never hesitates to make a buck off of mental illness.  The film Halloween is classic example of equating mental illness with an evil so unstoppable that the psychiatrist involved has to pack a .44 magnum.  That same message has been carried forward in recent television shows.  Some of the efforts in this area are so bad that it takes an incredible bias to justify the product as entertainment.

These are all much better examples than suggesting that science somehow stigmatizes people.  The associated problem is the misunderstanding of science.  We all understand that the media needs to sell stories and the truth about science is that it is a process and not the ultimate truth.  Every story about new fads based on an experimental finding that will never be replicated in the absence of a discussion of scientific method is corrosive to the public's confidence in science.  In this case using "chemical imbalance" as a scientific theory is about as ill informed as anyone could be about the neurobiology of mental illness or normal brain functioning.  At that level this story is more about press induced stigma than anything that neuroscience or neurobiology has to say.

The lesson for today is that the brain is not a sack full of neurotransmitters that is balanced or unbalanced.  If you believe that, you can either stay ignorant about the problem and talk about "chemical imbalance" as though it means something, educate yourself about neuroscience (there are many free sites on the Internet) or you can join any number of psychiatry bashing web sites that claim that psychiatrists believe there is a chemical imbalance.  Your first neuroscience assignment is to read about Eric Kandel and why he got the Nobel Prize.

And where does conflict of interest enter into the stigma equation?  In other words who benefits from mental health stigma as an operative social concept?  Advocacy organizations certainly do.  In many cases is it their raison d'ĂȘtre.  Interestingly concern over stigma has prevented some advocacy organizations from dealing effectively with the issue of people with mental illness who are violent.  They considered violence and aggression to be stigmatizing rather than a fact of some mental illnesses.  Professional organizations like the American Psychiatric Association benefit in that it enhances their credibility with the advocacy organizations but any counterattacks on the forces that ration and deny mental health services have been weak and ineffectual.  Those rationing entities including politicians, government agencies, pharmacy benefit managers and managed care companies benefit tremendously.  After all they have added hundreds of billions of dollars to their bottom lines by basically denying or rationing treatment and in many cases denying that there is any problem at all.

Stigma rhetoric makes it seem like this is a problem inherent in our society with no better solution than an enlightened public.  We will not be able to solve it until enough people are enlightened while the rationing schemes continue.

At that level you could say that stigma is a concept that can be spun for everyone, but let's agree that science has nothing to do with it.

George Dawson, MD, DFAPA

Supplementary 1:  I was asked by a reader to summarize the above post.  Here it is:

There are societal wide biases (business, government, legal, entertainment, etc) that stigmatize the mentally ill.  Some aspects of that process involve the distortion of science (e.g. "chemical imbalance theory").

Now what happens if I decide to run an experiment that asks people about how happy they would be if they had a biologically determined mental illness in that culture? Of course they would react strongly because:

a)  They are from a culture that stigmatizes people with significant mental illness.  They know how the various players would react if they found out that a person has a significant mental illness. Mental illness by itself does not produce a stigma. People are stigmatized by other people with biases and clear agendas.

b)  They really don't know what the scientific implications are because they have been hearing about false theories or reading overt propaganda or they don't know enough about the process or implications of science.


  1. A fair question is are they stigmatizing against mentally ill patients or are they skeptical about a branch of medicine that remains relatively nonempirical and nonobjective, as well as frequently pseudoscientific? Fibromyalgia is often not covered as well as lupus for the same reason but that has nothing to do with rheumatology stigma, and everything to do with science.

    I always ask this question when psychiatrists bring up stigma. If you were an insurance company executive, what you think of psychiatry, and especially its claim that just about everything that happens in life is a mental illness? Psychiatrists like to talk about empathy, the true test is to be empathic when it doesn't serve your financial interest. Were insurance companies being discriminatory when they wouldn't want to pay for amytal interviews in recovered memory cases? Turns out they were being better scientists than psychiatrists.

    I've said it before and I've said it often, if psychiatry would have listened to the St. Louis group and limited diagnosis to about 15 hard categories, and would have been more skeptic of dubious treatments, we wouldn't have these problems from the public, government and the insurance companies. At least not more than any other branch of medicine.

    I really don't think stigma is the issue unless you want to scour the backwoods for someone who still thinks its 1940. Tony Soprano killed stigma for the most part. No one I know is ashamed of having been in therapy, in fact it is often a point of pride, and I talk about my own therapy without hesitation.

    I'm just not down with the idea that America is a mean, unsophisticated country that fears people who are different. All the evidence I see is that Americans are almost naively tolerant to a fault.

    If psychiatry were really concerned about stigma, they could have been modest and methodical about DSM-5. But they decided to be political and greedy.

    1. Think the diagnostic proliferation DSM argument is a weak one because nobody I know uses all of the diagnoses in the DSM. and the best study of the matter brings them down to the 40-50 range. If you are an addiction psychiatrist like me, that number is reasonable given the number of addiction diagnoses including withdrawal, intoxication, and associated organic brain syndromes. I have spent practically all of my career treating people with the most severe forms of mental illness.

      Against that backdrop, I have seen no science from the insurance industry. They have in fact generated a lot of pseudoscience of their own including numerous proprietary criteria used by hospital case managers to force doctors to discharge people or to deny care. Compared to that psychiatry looks like particle physics.

      The best examples continue to be disputes that have to do with severely ill people not able to function outside of hospitals, suicide risk, and of course addicted patients who are basically told to go somewhere else to get detoxed or given a bottle of lorazepam to do it on their own. How many times can a utilization review company tell you to discharge suicidal patients after they have been readmitted for another suicide attempt? I would imagine that many psychiatrists have a variety of answers for that question.

      I think we are talking about stigma at two different levels. I think it is an active process that correlates with discrimination and not a feature of having a mental illness. A popular comedy show poking fun at psychosis, homicide and ECT is clearly stigmatizing. There are apparently no high thresholds of political correctness that are currently applied to other segments of society where a similar skit would precipitate widespread outrage. No jokes about AIDS or cancer. It is no accident that millions of Americans get the same level of psychiatric care that is available in developing countries – it is by design.

      I don’t think you have to be down with the fact that “America is a mean and unsophisticated country that fears people who are different.” Those are universal problems that can be observed everywhere. When I was a Peace Corps volunteer in Africa, the mentally ill were shunned and ridiculed in the streets. They got the equivalent level of mental health care that many homeless Americans get and that is nothing.

      Human beings have a tendency to circle up the wagons against anyone perceived as different. It gives the illusion of safety and security; at least until a bigger group comes along and decides that they are the outsiders.

    2. If it's 40-50 that's still a lot less than the 200+ in DSM. And the insurance companies don't have the burden of proof, doctors do. I've had my share of spats with insurance companies, and I think they should be obligated to provide more than a few days care for severely ill inpatients (at least give time for the meds to kick in) but I certainly understand where they are coming from. Chiropractors, acupuncturists and all kind of people want a share of the pie and they have to set limits. Otherwise premiums go up or a kid with neuroblastoma has rationed care. Infinite money and utopia are not possibilities.

      I agree with you that stigma is worse in other parts of the world. However, one of your original points was that Hollywood contributes to stigma. I completely disagree. Academy Award winning films like Ordinary People and A Beautiful Mind have been very psychiatry friendly. The Sopranos, of course, was a major social force in destigmatizing psychotherapy for men. For every example in the entertainment industry of a "psycho killer" I can give you multiple examples of sympathetic portraits of mental illness and psychiatrists. There are certainly movies and shows about psychiatrists as dupes ("House of Games", which btw is a great movie, or ineffective intellectuals "Frazier" but its hard to argue that these characters are not somewhat based on the kind of people we know.

    3. I am not sure where you practice or how much stigma there used to be in the past, but from what I have seen, it is alive and well.

      I agree that I don't think anyone cares if someone goes to talk someone now and then, and those I know on antidepressants seem happy to share what they think would be helpful for others because they think it is helping them.

      But still, the currently healthy look down on anyone with mental health issues. For the milder forms, you're either weak, just get over it or take a med, in either case quit whining; it isn't like it is cancer or something. For the more severe forms, if it is biological, I am sorry you were born with it but you're unpredictable, are you dependable?

      OK, that was somewhat harsh, but the Corporate, middle class environments I am in are harsh. Anything less than Attila the Hum is concerned weak and anything less than the perfect family on tv advertisements is flawed.

      And, these are observations from someone that isn't mentally ill. I can only imagine what they endure.

  2. I like your blog, and hope you won't assume I'm antipsychiatry and reject out of hand. There is plenty of serious mental illness in my family and not much help, like you blog about.

    The reason I posted is because I am frustrated to keep hearing this revisionist history about chemical imbalances. I learned about chemical imbalances from brochures in the waiting room of my psychiatrists' offices thru the years and INPATIENT in the handouts that were given out to patients in their folders they get when they check in. Nothing was mentioned that it was an analogy - it was stated as a fact (probably with accompanying wiggle language that was deliberately downplayed). I don't recall being told this idea of chemical imbalances to my face by a psychiatrist, but the info was everywhere else. I do go to bipolar disorder support groups on line (the more social ones, not the ones where people list the 5 medications they take etc) and virtually everyone who takes medication says they have a chemical imbalance, and when other, more informed people (some take meds, some do not) try to explain, people get defensive and lock up. SOMEBODY taught them about chemical imbalances, and they still believe it strongly. I am pretty darned sure it wasn't all NAMI brochures pushing this idea of chemical imbalances. There weren't any NAMI brochures in my folders, it was all photocopied handouts except maybe an advance directive brochure in more recent years.

    I also think it's unfair to write, 'if you want to know, go read up on all this neuroscience stuff,' because the truth is, when patients are on antipsychotics, they have no hope of understanding it, and most people with serious mental illness did not get much education. It's true they probably don't read your website. I hope you don't beat your patients over their heads with your intellectual superiority. I doubt that you do, and think it's probably frrustration talking.

    I have posted about this before, and I wonder if psychiatrists go out and sit in their waiting room and look in the brochures, read the handouts that go into patients' folders etc. I know Dr. Hassman does, because he posts the sort of helpful worksheets a person would find in their folder on his website.

    1. Dr. Hassman does? I don't think I've ever seen one on his website or anything remotely similar to what you would find in a doctor's office.

  3. If I have anything that I want to hand a patient - I have read it beforehand. That is why I handout MedlinePlus medication information and not the standard stuff. Even then, there are people here who have criticized me for not providing more intellectually advanced information and those people were not professionals. As you probably know it is impossible to please all of the people.

    It is good to hear that you make the distinction between pamphlets in the waiting room and psychiatrists. From my perspective I have entire series of psychopharmacology texts written for psychiatrists and not a single one talks about "chemical imbalance" in any of their editions over the past 30 years.

    So when you talk about "revisionist history" - that is my history right there. It has nothing to do with intellectual superiority - it has to do with the technical knowledge required to be a psychiatrist and what I have been studying for over 20 years. As you probably know the knowledge base of psychiatry is a frequent target of the people who hate and ridicule psychiatrists and I hope I am pointing out that it is not intellectual superiority but a serious lack of scholarship on their part to continue to use a term that is not in our technical literature.

  4. " And the insurance companies don't have the burden of proof, doctors do."

    Only if you accept a completely artificial system constructed by insurance companies and their friends in government that shifts the responsibility away from businesses and to the physician. The business after all can just deny payment on the bill with no input at all from a physician. I don't accept for one second that some reviewer who has never seen the patient knows more about them or what they need than I do. In fact, I don't accept that any reviewer who has never worked on an inpatient unit has a clue about what happens there. The contract for insurance is between the patient and the company. The company essentially wants physicians to rubber stamp their business decisions.

    I don't think the world has become psychotherapy friendly on the basis of the Sopranos. As I have repeatedly stated, good luck getting psychotherapy at all in many managed care systems. The last time I looked CMHCs were also eliminating therapists and using managed care methods to administer them. I guess it illustrates that the business process trumps the Hollywood process. I guess we would have to tally up the score on Hollywood but I doubt that they are as flush with as many accurate portrayals you think. But whenever that gets confronted I usually hear the excuse: "This is art - it doesn't have to be accurate."

  5. I don't think most psychotherapy should be covered by insurance, to be honest with you. I realize this puts me at odds with the profession. It would definitely kill my chance to be APA President, a position that seems to require Music Man ethics and the ability to make pseudoscientific promotional claims that antipsychotics given to prodromal patients are "neuroprotective".


    The reason is I think just about every young adult should go to psychotherapy to learn about themselves. I did the last two years of my residency and I found it beneficial. Amazingly, at the time, insurance paid all but 20 dollars a visit. I considered it the biggest perk of my employment since obviously residents didn't make much. I also joked with the psychiatrist who saw me that I couldn't believe how little it was costing me. Had I been a little less conscientious I would have no showed a lot.

    Now for suicidal depression or dangerous behavior yes, it should be covered and not just superficially. I despise insurance companies (or legal limitations on holds) that don't allow enough time for medication to work with suicidal or dangerous or out of control patients.

    If medical insurance were auto insurance, psychotherapy would be a tune up. Guess what happens to your premiums if insurance covers that? Basically it turns into prepayment of medical services.

    Which is the story of why health insurance is so expensive.

  6. I don't think that you can be APA President unless you are a fairly high level academic and you get nominated by the inner circle. I contemplated running on the basis of a petition but like most write ins - I did not think I could practically get enough signatures in the allotted time frame.

    I don't know how you can adequately treat people without psychotherapy. For many conditions it is the treatment of choice. It actually works to keep people functional and it is a necessary default for anyone who does not tolerate medications. I hope you are not buying the cost effective argument. We seem to have unlimited resources for ablative therapy for atrial fibrillation. It seems like treating somebody with depression, PTSD or OCD with specific psychotherapy is at least as "cost-effective."

    I would see psychotherapy as the months of rehab after the crash.

  7. There's also the fact that people who pay for psychotherapy tend to be more motivated and get more out of it. Not paying anything reinforces entitlement. Maybe there should be an insurance co-pay or sliding scale but there's a good psychological reason it should hurt at least a little in the wallet. And you know if insurance is paying in full, the no-show rate goes way up and effort goes way down.

    1. I have heard that used as justification for running inpatient units that were run down and very substandard relative to medical-surgical units as in: "we don't want them getting too comfortable or they will never leave."

      Obviously no similar standard applied to medical surgical patients.

      I think that goal was met a long time ago, even people who realize they need to stay don't want to stay on typical psych units.

  8. Oh, believe me, if I was APA President, I'd probably have to hire my own version of the Secret Service. I realize that my view are not that of the Adironack Club inner circle or much of the membership at large.

    However, my track record would be a lot better than that of the recent past presidents.