476758 2013
ANP47710.1177/0004867413476758ANZJP PerspectivesANZJP Perspectives
Viewpoint Australian & New Zealand Journal of Psychiatry 47(7) 611–612 DOI: 10.1177/0004867413476758
The hidden medical logic of mental health stigma
© The Royal Australian and New Zealand College of Psychiatrists 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav anp.sagepub.com
Thomas Ungar1 and Stephanie Knaak2
Reducing the stigma associated with mental illness has become an area of increased effort and attention (Abbey et al., 2012; Jorm and Kitchener, 2011; Stuart et al., 2012). What remains of primary concern is how and why health care providers, who are otherwise educated, kind and compassionate helpers, are amongst the most stigmatising when dealing with mental illness (Abbey et al., 2012; Lauber et al., 2006; Stuart et al., 2012). While existing research suggests that emphasising biological aspects of mental illness does not reduce stigma and discrimination among the general public (Corrigan and Watson, 2004; Schomerus et al., 2004), we argue that the same cannot be assumed for health professionals. Health professionals are in the specific business of fixing, treating and otherwise controlling biologic disorder. As such, it is both logical and probable that health professionals apply a different set of cognitive interpretations and/or judgements to a medicalised framing of mental illness (Haslam et al., 2007) than does the general public. Informing our argument is the consideration that stigma and discrimination among health care providers can be thought of as a logical by-product (and perhaps even a result) of mind-body dualism. In contrast to what seems to work for the general public, this consideration provides the basis for the hypothesis that presenting physicians with knowledge of the physiological components of mental illness might be an effective strategy for combating stigma among this professional group. The problem of mind-body dualism dates back to Rene Descartes and
refers to the philosophical split between the (non-physical) mind and the (physical) body. It is a problem that comes into play in the very way physicians think about illness and disease (Miresco and Kirmayer, 2006). When presented with a symptom or set of symptoms, for example, physicians will start by using the fundamental schematic categorisation of “Is it functional or is it organic?” If categorised as organic (i.e. in the body) it is assumed to be real, legitimate and material. From the physician’s point of view, this means it is something that can be observed, studied, treated and corrected. Arguably, this reduces stigma and discrimination. However, if categorised as functional (i.e. a problem of the mind, with no physiological correlates), the physician will consider it less real and the patient may be more likely to be stigmatised and discriminated against. Even though we ‘know’ this to be a false dichotomy, namely that mental illness (like most all illness) is inherently bio-psychosocial, this split between the material (body) and the immaterial (mind) nevertheless continues to structure our thinking. It permeates our language, explanatory models, attributions for illness, health care delivery structures, and resulting attitudes and behaviours. As linguistic philosophers Lakoff and Johnson (1980: 3) explain: “Our conceptual system …plays a central role in defining our everyday realities …. but our conceptual model is not something we are normally aware of. In most of the little things we do everyday, we simply think and act more or less automatically along certain lines.”
Anti-stigma efforts towards health care providers may be limited in their effectiveness if they ignore this basic schematic that underpins how physicians understand illness and disease. Research indicates that a more biomedically dominated conception of mental illness does not seem to reduce stigma amongst the general public – mostly because it creates in the public’s mind a perception that mental illness is less under a person’s control, that people with mental illness are more unpredictable, more potentially dangerous, more fundamentally different, and less likely to recover (Corrigan and Watson, 2004; Schomerus et al., 2004; Stuart et al., 2012). However, extending this same conclusion to health care providers may be an error. And that’s because physicians probably think about ‘the biological’ differently than the general public does. For a physician, using biological information to emphasise the ‘bio’ components of a biopsychosocial illness helps to shift the conception of that illness from something ‘merely’ functional to something organic (and therefore real and treatable). From the physician’s point of view, thinking of an illness in organic terms perhaps 1North
York General Hospital and Faculty of Medicine, University of Toronto, Toronto, Canada 2Mental Health Commission of Canada, Calgary, Canada Corresponding author: Stephanie Knaak, Opening Minds, Mental Health Commission of Canada, Suite 800, 10301 Southport Lane SW, Calgary, Alberta T2W 1S7, Canada. Email:
[email protected]
Australian & New Zealand Journal of Psychiatry, 47(7)
612 shifts the locus of control and actually makes it more controllable, less unpredictable, less permanent, less fundamentally different, more recoverable. While there is currently scant research on this particular question, professional experience suggests that disease state and physiologic information on mental illness is welcomed – and appreciated – by health practitioners. Not only this, the presentation of physiologic information about mental illness may often be an instance of transformative learning (Ungar, 2012a) for the health care provider. Arguably, this leads to a reduction in clinical distance and pessimism, which in turn translates into less stigma and discrimination. So what might an anti-stigma intervention for health care providers look like if it is to be informed by the knowledge that mind-body dualism persists in organising how physicians make sense of illness and disease? A logical strategy would be to develop interventions that fundamentally establish for physicians the organic aspects of mental illness. This is not to suggest that biomedical correlates be privileged over and above (or at the expense of) psychosocial factors as well cautioned by Corrigan and Watson (2004). Nor is it to suggest that this strategy be taken at the expense of other ingredients already known to be successful at reducing stigma among health professionals, like contact-based education and a focus on recovery (Abbey et al., 2012; Pettigrew and Tropp, 2008; Stuart et al., 2012). It is, however, to suggest that the organic aspects of mental illness be firmly recognised and contextualised as a key part of the model. One potentially effective technique would be to show physiologic brain science images from persons with depression and/or schizophrenia. This would add organic legitimacy to the
ANZJP Perspectives symptoms, reducing the potential for stigma and discrimination among health care professionals in regards to onset attributions (Corrigan and Watson, 2004). Showing scans from persons in recovery would be equally important, as these would combat ‘offset’ attributions of stigma (i.e. stigma associated with perceptions of recovery). In as much as physicians believe biological conditions to be more modifiable and predictable than functional ones, another possible strategy for combating stigma would be to teach them skills to predictably modify the condition of mental illness. This is an approach that has demonstrated some success in Canada, through the development and delivery of a mental health continuing medical education module and CBIS (Cognitive Behavioural Interpersonal Skills) Manual for family physicians (Weinerman, 2012). In suggesting that health care providers may interpret biologic information about mental illness differently than the general public, we are also making the point that anti-stigma efforts cannot take a ‘one size fits all’ approach. Indeed, different strategies may be required for different types of learners and groups (Ungar, 2012b). The one thing we know for sure is that further research and empirical investigation on these questions is desperately required. Acknowledgements We would like to acknowledge Andrew Szeto, PhD, for his contribution to the development of this paper. His comments and thoughts were invaluable.
Funding This project was made possible through funding from Opening Minds, the antistigma initiative of the Mental Health Commission of Canada. The work of the Mental Health Commission of Canada is supported by a grant from Health Canada. The funding for the SAGE Choice fee was
Australian & New Zealand Journal of Psychiatry, 47(7)
provided by the North York General Hospital Foundation.
Declaration of interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
References Abbey S, Charbonneau M, Tranulis C, et al. (2012) Stigma and discrimination. Canadian Journal of Psychiatry 56: 1–9. Corrigan PW and Watson AC (2004) At issue: stop the stigma: call mental illness a brain disease. Schizophrenia Bulletin 30: 477–479. Haslam N, Ban L and Kaufmann L (2007) Lay conceptions of mental disorder: The folk psychiatry model. Australian Psychologist 42: 129–137. Jorm AF and Kitchener B (2011) Noting a landmark achievement: Mental Health First Aid training reaches 1% of Australian adults. Australian and New Zealand Journal of Psychiatry 45: 808–813. Lakoff G and Johnson M (1980) Metaphors We Live By. Chicago: University of Chicago Press. Lauber C, Nordt C, Braunschweig C, et al. (2006) Do mental health professionals stigmatize their patients? Acta Psychiatrica Scandinavica 113(Suppl. 429): 51–59. Miresco MJ and Kirmayer LJ (2006) The persistence of mind-brain dualism in psychiatric reasoning about clinical scenarios. American Journal of Psychiatry 163: 913–918. Pettigrew T and Tropp LR (2008) How does intergroup contact reduce prejudice? Meta-analytic test of three mediators. European Journal of Social Psychology 38: 922–934. Schomerus G, Schwan C, Holzinger A, et al. (2012) Evolution of public attitudes about mental illness: a systematic review and meta-analysis. Acta Psychiatrica Scandinavica 125: 440–452. Stuart H, Arboleda-Flórez J and Santorius N (2012) Paradigms Lost: Fighting Stigma and the Lessons Learned. New York: Oxford University Press. Ungar T (2012a) Reducing stigma in mental health with transformative learning. CMAJ, letter to the editor 24 April. Available at www.cmaj. ca/content/178/10/1320.full/reply (accessed 8 August 2012). Ungar T (2012b) Health care provider stigma. Presented at: Together Against Stigma: Changing How We See Mental Illness, Ottawa, Canada, 4–6 June 2012. Mental Health Commission of Canada. Weinerman R (2012) New mental health antistigma training for family physicians: Online CME. Presented at: Together Against Stigma: Changing How We See Mental Illness, Ottawa, Canada, 4–6 June 2012. Mental Health Commission of Canada.
