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Tuesday, 3 April 2012

Is Mental Health Stigma a Useful Concept?

Worldwide, a variety of governments and agencies, including the Mental Health Commission of Canada, have been working to “combat the stigma of mental illness.” On the whole, this seems like a laudable concept. If you go out on the street today and ask people whether they support efforts to reduce stigma, you will have a hard time finding anyone who says “no.”

But ask a second question: “What IS mental illness-related stigma, anyway?” Then you run into the problem.

Lately I’ve been asking this question of mental health professionals and the public. The answers are remarkably vague and wide-ranging. “People think they’re crazy.” “People don’t want to hire those who have mental illness.” “People believe they will take too much time off work.” “People don’t want to have these people as friends.” “They don’t want to rent apartments to them.” "People with mental health problems think badly of themselves." "Actually, I haven't a clue."

In part, these answers can be taken as indicators of the scope of the problem. Stigma isn’t just one thing, it’s a cluster of things. The result, however, is that when two people talk about stigma, there’s a good chance that they are thinking about entirely different phenomena. One person is talking about the problem of housing the homeless, the other is talking about the difficulty in describing one's depression to the relatives.

The wrapping and the contents

Words are often used to bundle phenomena. We notice that our chair doesn’t float into mid-air, that a released pen falls to the floor, and that rain hits the pavement. We group these events under the label "gravity" – a concept that unites various experiences.

A friend gives us a birthday card, they volunteer at the annual fun run, they sponsor a child in another country, and they help out with the dishes after dinner. We begin to think of the word “generous.”

Words like “generous” and “stigma” are like boxes that contain a wide variety of ideas. Over time the boxes themselves begin to seem real, as though they are identifiable things of their own. It becomes easy to assume that we know what they are.

But when I talk about stigma, I am likely thinking about certain items inside that box. When you hear me use the word, you might well be thinking about a different set of items. We can talk about completely different ideas, both thinking that we understand one another and never really communicating. What began as a useful unifying concept becomes a barrier rather than a facilitator to communication.

Why focus on stigma?

Obviously this problem can occur whenever we talk about any concept: intelligence, integrity, criminality, health. Why bother with stigma?

The bundling problem becomes particularly pronounced when the box’s contents are very diverse and relate to one another only loosely, when the contents are never clearly defined, and when people use the box’s label without specifying which contents they are referring to. In these circumstances, the odds of having a discussion that no one really understands go up significantly.

Mental illness stigma fits all three criteria. The term covers a broad array of phenomena.  It is seldom well-defined, even in lengthy discussions of its effects.  And when people discuss any of the phenomena packed within the box, they usually use the term itself rather than spelling out which bit they are referring to.

As an example, the Mental Health Commission of Canada recently launched an anti-stigma campaign called “Opening Minds.” Read their News Release to see if you could figure out what stigma means if you did not already think you know.

To be fair, the news release is quite a brief document. The Commission provides a slightly deeper treatment of the subject here, and includes a definition of stigma:

"Stigma is made up of two parts: negative and unfavorable attitudes, and negative behaviours that result from those attitudes. People living with a mental illness often experience stigma through:

  • Inequality in employment, housing, educational and other opportunities which the rest of us take for granted.
  • Loss of friends and family members (the social and support network).
  • Self-stigma created when someone with a mental illness believes the negative messages."

Stigma, then, is the practice of discrimination, the loss of valued others, and a self-perception problem. Well, yes, all of these can be effects. But then when we talk about stigma and don't define which bit we mean, how do people know what we are talking about?

Who cares?

If we take the problem of stigma seriously, we'll want to target our efforts carefully and define our goals. But when we use a mushy catch-all term we run the risk of racing off to solve the problem without clearly defining the outcome we seek. Our very thinking can become mushy.

In a "Fact Sheet" about stigma, the commission uses remarkably imprecise language and some questionable epidemiology. One of its key messages is "Mental illness is an illness like any other." Meaningless on the surface, it lumps an enormous variety of difficulties under one label, then equates it to physical illness. Is this helpful, or does it simply encourage precisely the kind of overgeneralized reductionism that we are trying to overcome? Some research suggests that stigma actually increases the more that people equate mental illness with physical illness.

Chopping Up Stigma

Am I saying that mental illness stigma doesn't exist? Of course not. It does, and it can be a significant problem.

What I am arguing is that lumping all attitudes, behaviours, and reactions to all mental health problems under one catch-all term is unhelpful, creates more confusion than it is worth, and makes it very unlikely that our efforts will pay off.

Rather than brushing the whole idea under the carpet, then, or treating it as a "motherhood and apple pie" kind of issue, perhaps we need to unpack the term and do away with the wrapping. We need to distinguish between various types of stigma and see different solutions - ranging from depathologizing unpleasant emotion to building affordable housing. Blunting the impact with a vague term is likely only to result in large expenditures with few results. This would be a shame.

1 comment:

  1. Great healthy news you have shared on mental health. Thank you for taking such type healthy point to discuss here.