Campaigns that raise awareness, normalise mental health difficulties and encourage people to tell their story enable the underlying sources of stigma to go unchallenged and the status quo to remain
In recent years, public conversation around mental health has been dominated by the topic of stigma, defined as “a strong feeling of disapproval that most people in a society have about something, especially when this is unfair”. Other than occasional mentions of underfunding of services, stigma is the primary focus of the media and of campaigning efforts by charities. In these contexts, stigma is usually framed as incidences such as strangers hurling verbal abuse or workplace bullying.
There is no doubt that these kinds of interactions happen and that they can be hurtful and traumatic. I have experienced this from the public I encounter in my job and also A&E staff during a mental health assessment. I have met people who use residential mental health services who have been verbally abused by the neighbours that live nearby.
However, I believe that this narrow focus on interpersonal stigma distracts from the underlying purveyors of stigma - mental health services and the medical model of distress. Before examining how these entities contribute to creating far more stigma than random bad eggs encountered out and about, we must first ask ourselves a question. Is this an intentional move, and if so who benefits and how?
Critical voices unheard
Some of the most well-funded and best-known mental health charities often receive financial and rhetorical backing from the state. They are regularly consulted on mental health policy in place of survivor groups, despite the latter’s vocal opposition to them. This can result in policy that negatively affects survivors, for example, that which focuses on getting people back into employment now that work is considered ‘a health outcome’. This is the idea that gaining employment represents a vital recovery goal in itself - but it is a blanket assumption that is often made without considering how important or appropriate it is for the individual. It can be argued that fixating debates on interpersonal instances of stigma and amplifying the voices of those that have such stories to tell allows other, more critical voices to fly under the radar.
What’s more, the result of channelling energy into endless ‘awareness raising’ activities is that attention, both of those who do experience mental distress and those who don’t is deliberately directed inwards. We focus on the times we have been wronged or the times we have wronged without asking ourselves what it is about society that enables this to happen, what we could do to change it, or indeed what social policies are making our mental health worse or whether the workplaces we have created are doing so. Because meanwhile, mental health services and benefits are cut or changed at a growing human cost and the concept of wellbeing is redefined to include work as a health outcome. Treatment is homogenised to favour short bursts of Cognitive Behavioural Therapy or even replaced by ‘guided self-help’ resources, which will likely be inadequate and inappropriate for many, not to mention patronising. While we shouldn’t dismiss that reading or telling recovery stories may feel empowering to some people or that CBT may be enough for others, we cannot lose sight of the bigger battle that needs to be fought. If we do, we will continue to suffer and perish.
When policies, like the roll-out of Universal Credit, that have been linked to suicide show no sign of being scrapped, how have we not noticed? Why is there not a bigger uproar about the impact of austerity? Do we simply need more journalism or is there something else at play? I believe that the dominant anti-stigma campaigns also have a role to play here. After all, who wants to be critical of Jane Doe telling her story to inspire or comfort others? Who wants to be critical of someone who calls out the use of vulgar language? Surely these can only be Good Things. But since the things that these campaigns ask of us are easy to do and feel good, they can easily swallow energy, time and money. This leaves little resources or public appetite to tackle anything harder that might actually make life better for swathes of people.
Furthermore, it is no coincidence that the impact of anti-stigma campaigns is almosty impossible to measure or that they rarely include those who have the most stigmatised diagnoses like psychosis and personality disorders, who often experience abuse in secure settings.
The real purveyors of stigma
If our current obsession with tackling interpersonal stigma is a convenient distraction, what or who should anti-stigma efforts focus on? Who is to blame for creating a society where these more visible aspects of stigma are permissible? It is the same mental health services that enforce a ‘medical model’ that dictates that experiences of mental distress can be grouped into separate categories like physical diseases and are just symptoms of ‘chemical imbalances’ in the brain. There is mounting evidence pointing the finger.
In a research article entitled ‘How Clinical Diagnosis Might Exacerbate Stigma’ by Patrick Corrigan, the author outlines how: “First, the label provided by a diagnosis may act as a cue that signals stereotypes. Second, the criteria that define a diagnosis may augment the stereotypes that describe mental illness”. In short, Corrigan demonstrates that evidence suggests that “diagnostic labels such as schizophrenia and psychosis seem to worsen the level of prejudice, even if people were assigned these labels but didn’t exhibit any of the ‘aberrant behaviour’ they would be expected and assumed to exhibit forever by virtue of being labelled in this way”. All this is compounded when one reflects on the infinite plasticity and arbitrariness of diagnosis unforgettably demonstrated by the Rosenhan Study, where researchers pretended to have ‘auditory hallucinations’ to be admitted to a psychiatric hospital. Once they were in, they told staff the hallucinations stopped and that they felt fine but they found themselves diagnosed and medicated. Alternatively, just ask those who have endured the absurdity of accumulating multiple different diagnoses from different professionals.
Diagnostic labels, and the medical model of distress, is rooted in the Diagnostic and Statistical Manual of Mental Disorders (or its European partner in crime the International Classification of Diseases, ICD for short). When one examines the history of the DSM, one finds a truly maddening tale of utter imagination and speculation. ‘Cracked: Why Psychiatry Does More Harm than Good’, a book written by James Davies, contains an excellent critique of the DSM but the chairman of the DSM IV taskforce provides a useful summary himself. In 2010, during an interview with a journalist about the fifth edition, Allen Frances said: “There is no definition of a mental disorder. I mean, you just can’t define it. It’s bullshit”…“These concepts are virtually impossible to define precisely with bright lines at the boundaries.”
Knowing this, how can we fight back? While this is not an exhaustive list, let’s make a menu. We can make a conscious effort to subvert obfuscating narratives and vocally challenge them wherever we encounter them. We can focus on constructing our own way to describe our experiences in a manner that we ourselves find useful. We can take direct action to highlight who is truly responsible for creating and maintaining stigma and we can use the power of our personal and/or professional relationships to influence those we interact with within oppressive systems.
However, it is key to do this in a way that does not invalidate those for whom instances of stigma have come from strangers, or who do find diagnostic labels useful because these experiences are nonetheless real. It is very easy to do this accidentally but activism and solidarity serve no one if it is not compassionate and understanding as well as fierce. Furthermore, it is vital that movements are democratic, have a diversity of tactics which are accessible and can cross boundaries between professionals and survivors, which Psychologists for Social Change continue to strive towards.
Cognitive Dissident is the pseudonym of the author, who is a member of Psychologists for Social Change