Reducing the stigma of mental illness
The days of telling your patients to "pull themselves together" should be over. Jim Bolton discusses the various ways in which health professionals can help to reduce the stigma of mental illness at a professional, service, and individual level
Mental health problems are treated as if our thoughts and feelings are separate from our physical bodies. This artificial distinction is reflected in our thinking and language as well as in the provision of health services.
This separation of mind and body contributes to the stigma of mental illness. The description of mental health problems as being "all in the mind" is often followed by the instruction to the patient to "pull yourself together." As a liaison psychiatrist who works in the divide between mental and physical health services, I have many reasons to consider the stigma of mental illness and how it should be tackled.
Mental illness in the general hospital
The artificial divide between physical and mental health services is shown by the high rates of psychological morbidity in general hospitals. Medical and surgical patients have higher rates of anxiety and depression than patients in the wider community, and one third of adult male inpatients drink alcohol in amounts that are hazardous to their health.1 Up to 5% of patients presenting at emergency departments have primary psychiatric problems.2
Having separated the organisation, location, and funding of mental and physical health services in the United Kingdom, we are now struggling to bring them together to meet the psychological needs of general hospital patients. This need is met by liaison psychiatry, which provides psychological care for such patients.3 It also provides important opportunities for combating the stigma of mental illness.
What is stigma?
Stigma marks an individual out as being different and evokes some form of sanction. Illnesses can often be the stigmatising characteristic. However, whereas the stigma of physical conditions such as cancer and epilepsy has declined, mental disorders remain some of the most stigmatised illnesses. Stigmatising beliefs may result in discrimination against people with such illnesses. For people with mental illness, stigma is the largest single obstacle to improving their quality of life.4
Attitudes to mental illness are deeply rooted in society. The concept of mental illness is often associated with fear of the potential threat of patients with such illnesses. Box 1 shows widely held beliefs that contribute to the stigma of mental illness.
Box 1: Stigmatising beliefs about mental illness
- People with mental illnesses are dangerous to others
- Mental illness is feigned or imaginary
- Mental illness reflects a weakness of character
- Disorders are self inflicted
- Outcome is poor
- Disorders are incurable
- It is difficult to communicate with people with mental illnesses
Such beliefs emphasise the difference between "them" and "us." Mental illness can be difficult to understand and empathise with, especially when the illness affects fundamental personal attributes. It is frightening to realise that if somebody else could lose their ability to reason or become altered in their personality, then the same might happen to us. Instead, it is more comforting to consider people with mental illness as different from ourselves. This view ignores the fact that one in four of us will develop some form of mental illness during our lifetime.
Stigmatisation in the medical profession
For effective health care to be delivered, it is crucial that health professionals are not hampered by prejudiced attitudes. The stigmatisation of mental illness among health professionals has been studied less than in the wider population.5 However, personal experience indicates that we should not be complacent: "We've got another nutter for you," is a common opening statement from a junior member of staff when referring a patient to my liaison psychiatry team.
Fear and ignorance of mental illness can result in an insufficient focus on a patient's physical health needs. For example, I have previously been asked to transfer a patient with a past history of schizophrenia from a cardiac care unit to a psychiatric ward, despite the patient's recent myocardial infarction. The belief that mental illness is incurable or self inflicted can also be damaging, leading to patients not being referred for appropriate mental health care.
Senior medical staff often have more realistic attitudes towards mental illness than their junior colleagues.6 This implies that the stigma of mental illness can be reduced by education and experience, and that an examination of attitudes towards mental illness should be included in medical training.5
Psychiatrists themselves share the stigma of mental illness with their patients. Medical students judge psychiatrists to be emotionally unstable and "woolly" thinkers.7 In turn, the practice of psychiatry is often viewed as unscientific, imprecise, and ineffective. Consequently, colleagues who hold these views are less likely to refer patients to mental health services.
Discrimination towards individuals with mental illness can also affect the provision of health services. In the competition for resources in the NHS, mental illness, with its stigmatised image, may lose out to "physical" medicine, with little danger of a public outcry.
Separate legislation concerning mental health may also be discriminating. An alternative would be to replace such legislation with legal measures based on an assessment of a patient's capacity to consent to, or refuse, treatment, which could be applied regardless of whether a condition is judged to be "physical" or "mental."
Tackling stigma
Health professionals can take both collective and individual action to challenge the stigma of mental illness at three levels:
- As a professional body
- At a service level
- As individual practitioners
Tackling stigma as a professional body
Changing Minds campaign
In 1998, the Royal College of Psychiatrists launched a five year campaign, "Changing Minds," aimed at reducing the stigma of mental illness. The campaign was informed by a survey of public attitudes towards mental illness8 and includes several initiatives at national and local levels. These include a cinema advertisement, "1 in 4," which emphasises how common mental illness is and has been screened in the United Kingdom before being taken up as an international initiative by the World Health Organization. Information about stigma is also available on the website of the Royal College of Psychiatrists (see below), which has also published a book discussing the stigma of mental illness from the viewpoint of both patients and health professionals.9
Tackling stigma at the service level
Liaison psychiatry
Liaison psychiatry is the public face of mental health services for many patients and health professionals. As a consequence, a psychiatry team working in a general hospital has many opportunities to combat stigma. An effective and responsive team can challenge such beliefs, which will have direct benefits for both psychiatry team and general hospital patients.
My team has often challenged the view that a patient's depression is a response to physical illness and is therefore untreatable. A patient's response to an antidepressant and supportive psychotherapy is often enough evidence to prove otherwise. Such instances also provide an opportunity for informal education about adjustment to physical illness, and the nature of depression. This educational role can be extended if liaison psychiatrists participate in the general postgraduate educational programme at the hospital.
It is vital that liaison psychiatrists speak the same language as other hospital colleagues. The conclusions of a psychiatric assessment should be summarised in an understandable form with a clear management plan. Psychiatric jargon should be avoided (or at least explained).
With adequate resources, a liaison psychiatry team can become integrated into medical and surgical teams, joining ward rounds and outpatient clinics to provide a psychological dimension to patient care. This involvement reinforces the view that the mind and the body are not separable and that comprehensive care depends on meeting all of a patient's health needs.
For many patients, their meeting with a member of the liaison psychiatry team is their first contact with mental health services. This meeting is an opportunity to dispel stereotypes of psychiatry and mental illness. A patient recently commented that not only did I not have a beard and bow tie (although some colleagues do fit the Freudian image), but more importantly I had not labelled her as "mad," with all the frightening connotations that this word held for her.
Tackling stigma at the individual level
Individual practitioners can reduce the stigma and discrimination associated with mental illness in several ways (see box 2).2
Box 2: Ways to reduce the stigma of mental illness
- Examine our own attitudes
- Update our knowledge of mental illness
- Listen to what our patients say about mental illness and its consequences
- Watch out for stigmatising language
- To be an advocate for those with mental illness
- Add political activism to our daily work
- Challenge stigma in the media.
Examine our own attitudes
It is important to examine our own attitudes and to consider how these might affect our clinical practice. Maintaining an up to date knowledge of mental illness leaves less room for stereotyping and prejudice to creep in.
Listen to our patients
Our patients are important in our education about the consequences of mental illness. How has it affected their relationships with family and friends? Is it more difficult for them to find a job? We can be advocates for vulnerable individuals who have to cope with both their illness and the repercussions of stigma.
Mind your language
Make an effort to curb your use of potentially stigmatising language, such as describing patients as if they were their illness. Describing a patient as a "schizophrenic," rather than as someone with schizophrenia, reduces them to a stereotype and robs them of personal identity. You can also challenge others for their stigmatising language and behaviour. For example, I no longer accept a referral for a "nutter" without tactfully pointing out the inappropriateness of such a term. The medical profession should aim to make such terminology as unacceptable as the stereotyping language used for race, disability, and sexual orientation.
Challenging stigmatising language in the media is one way in which individuals can become more active.10 Psychiatrists and psychiatric patients receive more negative press coverage than other medical specialties. Some may see complaining as a role of professional organisations, but remember that newspapers or television companies take complaints more seriously if they receive a lot of them. One letter from an individual can carry as much weight as a collective response from the Royal College of Psychiatrists.
The distinction between the mind and the body is ingrained in our thinking. However, in our medical training we should encourage an integrated biological, psychological, and social view of health care. If we recognise our patients as unique individuals, and not as illnesses, it is harder to stereotype and hold stigmatising attitudes towards mental illness. Liaison psychiatry reintegrates the mind and the body in health services, which is crucial in combating stigma. It is not our patients who should be pulling themselves together: we should look at ourselves.
