Psychiatrists fighting stigma: Doing more harm than good?

Lee was one of the few whose voice was heard. For most, their exclusion was complete. The French philosopher Michel Foucault described the emergence of psychiatry at the end of the 18th century, silencing the voices of the mad and ending dialogue between "reason" and "madness," and establishing the language of psychiatry as a "monologue of reason about madness."

The tide turned, and asylums began to close in the mid-20th century. But stigma and social exclusion remained. Sociologist Irving Goffman wrote his seminal work on stigma, based on research with asylum inmates. Since then, many studies have shown that the public and even mental health professionals hold stigmatizing attitudes towards people with mental illness. These studies have led to calls to eliminate stigma.

Answering the call recently have been psychiatric organizations that have launched high-profile anti-stigma campaigns. Their logic is that if mental illnesses are seen as "brain diseases," for which people with mental illness cannot be blamed, stigma will reduce. But the stigma remains. People deemed mentally ill are still disadvantaged in employment and health care, and die younger. Schizophrenia is the most stigmatized, due to fears of violence, but depression, anorexia nervous and suicidal behaviour are also targets - as is addiction.

Psychiatrists claim that diagnoses are scientific descriptions of diseases, necessary to ensure correct treatment. Many professionals, including some psychiatrists, disagree, arguing that diagnoses are concepts, not diseases, which have acquired spurious solidity. In physical medicine, a disease is identified by physical signs as well as reported symptoms. In psychiatry, there are no physical signs, and the patient's own view is marginalized. Psychiatric diagnoses are simply labels for types of behaviour, adding nothing to the understanding of experience, cause or cure.

Psychiatric diagnosis may in fact itself be to blame for the stigma of mental illness. Sociologists developed labeling theory, stating that negative cultural definitions of mental illness affect treatment outcomes. In their 1991 book From Mental Patient to Person, Peter Barham and Robert Hayward quote one person with mental illness, illustrating the negative effect of labeling: "You wake up every morning and you think, 'Oh God, I'm a schizophrenic!' If the doctor hadn't told me, I'd just have woken up and thought, 'Well, I'm just going through some sort of illness and I'll probably get over it.' But once you get diagnosed you start thinking all sorts from different corners about the illness and it just gets worse and worse."

Negative assumptions are found inside hospitals too. One woman, Kate, shares her experience on the web site of Time to Change, a UK-wide initiative to fight the stigma of mental illness: "My main experience of Mental Health discrimination was actually within the mental health system itself! Nurses and psychiatrists assumed anything I said was not real (because I was mad), expected everyone to conform to the established routine ... and expected to solve people's problems by giving them drugs and labelling them as insane... I have always upheld that if you put ANY human being through enough stress, contradictions and devaluing, they will develop 'symptoms.'"

In a recent article in the New York Times Magazine adapted from his new book Crazy Like Us: The Globalization of the American Psyche, Ethan Watters suggests that "we treat people more harshly when their problem is described in disease terms" and that "a brain made ill through biomedical or genetic abnormalities is more thoroughly broken and permanently abnormal than one made ill though life events."

The Royal College of Psychiatrists in the United Kingdom ran the Changing Minds campaign from 1998 to 2003, aimed to reduce stigma by increasing awareness about mental illness and offering modern understandings of anxiety, depression, anorexia, schizophrenia and personality disorders. But critics saw the campaign as an attempt to increase public take-up of psychiatry, saying the College had ignored evidence that labeling itself causes damage. Similarly, in the United States, psychiatrists have been criticized for campaigning to convince the public that millions more people, even babies and children, are in need of psychiatric help. Removing the stigma of mental illness, they argue, will simply help psychiatrists and drug companies to widen their empire.

Recently, the World Psychiatric Association began to campaign against the stigmatization of psychiatry and psychiatrists. Dr. Norman Sartorius has admitted that diagnoses are problematic, calling for more care in the use of labeling. He argues that diagnoses can be misunderstood by non-medical professionals and especially by the public, where they feed into negative stereotypes.

However, if we take the psychosocial medicine route, currently eclipsed by biomedicine, we move away from categorical diagnoses and start to see each person's unique problems, life history and needs and wishes, and can build solutions around these. People can regain the capacity to help themselves and one another. Those in the best position to re-educate the public and the professionals are the patients and former patients themselves.

Dr. Jan Wallcraft is a Visiting Fellow at the Universities of Hertfordshire and Birmingham in the United Kingdom.

Editorials do not necessarily reflect the views of CAMH.