The topic came up last week and it happens on a recurrent
basis – diagnoses especially psychiatric diagnoses are not good because they
are stigmatizing. I addressed this fairly
comprehensively in a post on this blog 10 years ago, but the persistent antipsychiatry
rhetoric out there is to keep repeating inaccuracies. Since then there has been a comprehensive academic
definition of stigma that makes things clearer.
Before that academic definition the standard dictionary
definition was “a stain or reproach, as on one’s reputation” (1). There is also a medical definition that is
used to designate obvious pathognomonic findings: “visible evidence of disease”
(2) and a long list of signs that apply.
There are additional definitions that do not apply to the specific
situation of how mental illness is stigmatizing. The American Psychiatric
Association has a web
page on stigma and the adverse effects.
The web page does a good job of breaking it down to the public, personal,
and structural levels. Specific evidence-based
interventions are suggested. They typically involve first-hand experience of
persons with mental illnesses.
More sophisticated definitions of stigma are available today. For the purpose of this post I am using one by
Andersen, et al (3) that modifies previous work done by Link and Phelan (4). According to the authors, stigma is a social
process that involves “labelling, negative stereotyping, separation, and power
asymmetry.” (p. 852). They state further
that stigma is not present unless all these criteria are met – specifically stigma
exists “if and only if” all these criteria are present.
Labelling in this case is defined as “social selection
of human differences”. The authors give
an example of associating alcohol use with homelessness and whether it is a
matter of “cognitive efficiency” based on personal experience and
probabilities. The labelling that occurs is a result of these socially observed
differences. Although these labelled associations can be positive, for the definition
of stigma only negative associations are relevant for stigma. That results in the negative stereotyping.
Separation creates a false barrier between the negatively
stereotyped and everyone else. It
suggests that there cannot possibly be any overlap between the characteristics
of the stereotyped and everyone else.
Earlier in their paper, the authors use the example of obesity, where it
is obvious that there are several almost universal stereotypical qualities and
overt discrimination. The same thing is true of ageism, where it is often assumed
that elderly people are universally frail, cognitively impaired, and have negative
personality traits. It is an us versus them mentality that is currently popular
in right wing politics in the US.
Power asymmetry is attributed to the fact that is
takes social, economic, and political power to label and negatively stereotype.
This is inconsistent with the idea that it happens at an individual level and
those individuals together can form a power structure.
The authors cite an example from Link and Phelan: “They
notice that mentally ill patients might label clinicians as e.g. “pill pushers”
and link them to the stereotypes of being cold, paternalistic, and arrogant.
But the clinicians will not, therefore, be a stigmatized group, because this
group of patients simply do not possess the sufficient power to “(…) imbue
their cognitions about staff with serious discriminatory consequences.”
The social and pollical dimensions of the pill pusher
characterization ignores the prevalence factor.
For example, does the number of people with that characterization equal
or exceed the number of people with other common important stigmatizing biases
like obesity or ageism? I doubt it. We
do see an excessive amount of rhetoric directed at psychiatrists that is
largely inaccurate and contrived and it is not without professional, social,
and pollical fallout (5,6). Very few
reasonable people seem wiling to discuss that.
The other reality that is rarely discussed is the fact that doctors are
not powerful and certainly are not trained to use or exert power. Today they are ordered around by middle level
managers with no training in medicine exerting whatever form of administrative
power that they choose.
There are much better examples of stigmatizing processes
that are obvious but never discussed in today’s world. I come back to the entertainment industry at
the top of the list. Apart from movie reviews
psychiatrists have been curiously silent about this process that has gone on
unabated for decades. To cite a recent
obvious example, I would refer anyone to the most recent episode of The Penguin an
HBO series. In season 1 Episode 4, we
see one of the protagonists falsely diagnosed with mental illness to keep her from
disclosing several homicides committed by her father. She is placed in a medieval Arkham asylum
where the patients are shackled by the neck and treated inhumanely. She is eventually baited into committing a
very violent homicide against another patient who is trying to befriend her. The psychiatrists there are portrayed as
indifferent at best and of course using electroconvulsive therapy as a
punishment (there has not been any progress on that issue since One Flew Over
the Cuckoo’s nest in 1975). There may be
people who argue these problems may have existed in 18th and 19th
century asylums – but the problem is this is set in modern times. The Penguin is driving a 2013 Maserati
Quattroporte VI. This episode plays the
familiar stigma as the mentally ill being excessively violent and psychiatrists
as agents of the state conspiring against people, using psychiatric treatments
as punishments, and not caring at all about individual patients.
Right wing politics is a second source of stigmatization on almost
a daily basis. Trump and affiliated MAGA
politicians routinely suggest that mass shooting and gun violence is
attributable to mental illness – even though it clearly correlates with firearm
availability and density. In the case of
undocumented immigrants, they are triply stigmatized as criminals, mentally ill, and invaders of the country when there is no evidence for it.
A final source is a carry over from my previous post. Businesses and healthcare companies actively discriminate
against mental illness despite parity legislation. That should be obvious by the lack of
resources that people face when trying to find treatment for a severe mental
illness. It is easy to find state-of-the-art care and subspeciality care for
any other bodily symptom – but not psychiatric care. Getting an appointment to see a psychiatrist
even in large metropolitan areas is often impossible. Inpatient bed capacity in the United States
is somewhere below the bed capacity of developing countries in the world. The
majority of people with mental illnesses are not treated.
That is my update on stigma.
The only thing that has changed in the last 10 years is the current spin
that a psychiatric diagnosis or treatment is stigma or stigmatizing and of
course it is not at all. As a reminder,
a diagnosis is for the information of the patient and other treating
professionals, it is confidential, and it is used by people who are professionally
obligated to act in the best interest of the patient.
George Dawson, MD, DFAPA
1: Random House. Webster’s College Dictionary. Random House, New York, 1996 :1314.
2: Steadman’s Medical Dictionary. The Williams and Wilkins Company,
Baltimore1976: 1338
3: Andersen MM, Varga
S, Folker AP. On the definition of stigma. J Eval Clin Pract. 2022
Oct;28(5):847-853. doi: 10.1111/jep.13684. Epub 2022 Apr 23. PMID: 35462457;
PMCID: PMC9790447.
4: Link BG, Phelan
JC. Conceptualizing stigma. Annu Rev Sociol. 2001; 27(1):363‐385.
5: Perlis RH, Jones
DS. High-Impact Medical Journals Reflect Negative Sentiment Toward Psychiatry.
NEJM AI. 2023 Dec 11;1(1):AIcs2300066.
6: Bithell C. Why
psychiatry should engage with the media. Advances in psychiatric treatment.
2011 Mar;17(2):82-4.
Photo Credit:
Click on photo to see Wikimedia Commons information about photo and photographer as well as CC license.
No comments:
Post a Comment