Persistent Stigma, Skepticism About Mental Illness Causes Real Harm
Profound misunderstanding about mental illness — its causes, its legitimacy and its treatment — permeate our culture. And the stigma that accompanies this lack of understanding hurts, a lot. Take this example — hardly original or rare.
Imagine a 15-year-old adolescent girl with fairly severe depression. She may be a classmate of your child, or the daughter of a friend. Let's call her Sally.
Sally's not so ill that she needs to be in the hospital, but she’s close. Her family and I — her psychiatrist — are doing our best to get her better as quickly as possible so she can get back to school. She’s been out now for about three days. Why? She literally lacks the capacity to think clearly. It’s all she can do to drag herself out of her bed and run a toothbrush across her teeth.
There’s a big family history of depression so Sally's parents are both familiar with and frightened by her struggles.
“Can you call the school and ask them to give her more time on some work?” the parents ask.
“Sure,” I say, and I get in touch with the school administrator.
“Well,” I’m told by the very well-meaning administrator, “It IS a tough time of year. The other kids are getting through it somehow. I don’t see why she should get special treatment.”
“Because she has the equivalent of the flu,” I say. I like to use analogies at these crossroads.
“But the flu feels awful. Does she have a fever? Because if she does, she shouldn't come to school...”
“No, she doesn’t have a fever,” I say. I try another analogy. “What if she had been in a car accident, God forbid?”
“Well, that’s pretty different, isn’t it?”
“How?” I ask.
“She’d be hurt,” I’m told. “This is an entirely different thing. You’ll need to get her pediatrician to call.”
I ask the pediatrician to call, and I can feel his discomfort over the phone. “I’m not very good at making this case,” he acknowledges. “It’s probably better if you just call them back.”
(I have to wonder whether he'd be so uncomfortable if I were a gastroenterologist asking him to call the school about a patient with ulcerative colitis?)
So, I call the school back, and, to be fair, we usually get the extra time (though sometimes we don't). But what a struggle! I feel like an attorney arguing a case, as if the people I’m talking to think I’m trying to pull a fast one.
But why? Why, in this day and age, does this scenario so stubbornly persist?
I think it's because plenty of people still feel that psychiatric suffering isn't real. And this causes genuine harm. If Sally encounters resistance to the fact that she's suffering, she'll almost certainly be less likely to seek care. If she feels that her non-psychiatric doctors don't take her suffering seriously, then she's going to suffer quietly and dangerously.
There's even evidence that doctors themselves don't believe this type of pain is real — and they sometimes wonder whether depression results from a moral failing.
Looking at the problem from another perspective, consider this anonymous comment I got from a medical student in the psychiatry course I teach: “Dear Dr. Schlozman: The psychiatry course convinces even the biggest skeptics.”
This comment, entirely well meaning, is also deceptively profound. Whenever I contemplate the vexing world of stigma with regard to mental health, I think first of this comment.
Let’s deconstruct what this student is saying.
"The psychiatry course convinced skeptics."
Does the doctor teaching cardiology have to convince skeptics? Does anyone refuse to believe in nephrology? The burdens placed on psychiatric patients stem largely from the skepticism that many in the community, including the medical community, still patently feel and express. Simply put, quite a few health care providers do not believe that many psychiatric illnesses are real. This is despite data-laden policy papers from the Office of the Surgeon General, from the CDC and even from the World Health Organization.
Doctors, policy makers and the general population still have a long way to go toward accepting psychiatric suffering as part of the medical canon.
That’s not to say that we haven’t made huge strides. In fact, one might argue that the increasingly vocal debates that are happening now with regard to psychiatric suffering are happening precisely because we have allowed ourselves to discuss these issues in open forums. To that end, these discussions are absolutely necessary if we’re to move forward.
Culture And Illness
But for individuals, these debates can be extremely painful. Some will argue, for example, that psychiatric suffering is a cultural construct. Well, try telling someone who is paralyzed with depression that he suffers from a cultural construct. Others claim that psychiatric treatments are untested and unproven; try saying that to the millions of people who have benefited from treatment, and then seen their care denied by insurance companies for “lack of proof.”
Here are responses to these ongoing criticisms.
First of all, of course psychiatry is culturally bound. All of medicine is culturally bound. Psychiatry IS very likely tied more closely to the culture in which it exists than are other fields of medicine. That, however, does not at all mean that psychiatric diseases are not real. To the extent that culture shapes brain development, and that brain development in turn affects culture, you really can’t separate cultural experience from psychological experience.
Still, there are constructs for anxiety, psychosis, pathological mood and social relatedness that are impressively consistent across ethnic and cultural boundaries. In other words, despite cultural differences, these diagnoses are consistent and common.
Second, there exist a huge number of studies that demonstrate the effectiveness of psychiatric treatments. These include psychotherapy studies, medication studies and combination treatments. To be sure, we have a great deal more to learn, but needing to learn more doesn’t in any way separate psychiatry from the rest of medicine’s frontiers.
What’s the bottom line? The stigma against mental health hurts.
We know that stigma hurts us economically, stifles us socially, and paralyzes our creative prowess. Most importantly, we know that the stigma hurts us individually. Twenty percent of us will suffer from some form of psychiatric illness in our lifetime. That means that 20 percent of our population will endure unfair and unfound prejudices.
Of course, if you’re reading this post, then you might already agree with what we’re saying. You might also be preparing your rebuttal. That’s how social change happens.
Stigma against mental health is definitely going away. But we could stand for it to go away a lot faster.
Steven Schlozman, M.D. is an assistant professor of psychiatry at Harvard Medical School and a staff child psychiatrist at Massachusetts General Hospital. He is also associate director of The Clay Center for Young Healthy Minds. Please post or ask questions below, or tweet Dr. Schlozman at @zombieautopsies.