Sunday, November 3, 2013

How to Combat Stigma, Part 2

This is part of of a series of posts on how to reduce stigma around mental health. Part 1 is here.

I'm working my way through Anthony Beevor's The Second World War, a one-volume history covering the major military events of World War II. To me, one of the most interesting aspects of the book is how much the author repeatedly describes the psychological effects of stress from war, which affected everyone involved from civilians to front-line soldiers to generals. One particularly striking passage described an infamous incident that occurred in Sicily in August 1943 when General George Patton was visiting hospitalized soldiers [page 498]:
Patton asked a soldier from the 1st Division, a young carpet-layer from Indiana suffering from battle-shock, what his problem was. 'I guess I can't take it,' the soldier replied helplessly. Patton flew into a blind rage, slapped him with his gloves and dragged him out of the tent. He booted him in the rear, shouting: 'You hear me, you gutless bastard. You're going back to the front!' A week later, Patton had another explosion when visiting the 93rd Evacuation Hospital. He even drew his pistol on the victim, threatening to shoot him for cowardice. A British reporter, who happened to be present, heard him say immediately afterwards: 'There's no such thing as shellshock. It's an invention of the Jews!'
I thought about this passage a lot as I was writing this post. In many ways, it does seem that the stigma of having a condition like post-traumatic stress disorder has greatly decreased. No general today would claim that PTSD does not exist or publicly berate a soldier suffering from it. However, the silence and shame surrounding mental conditions continues to be pervasive. There have been numerous articles and reports about the difficulties returning soldiers have in readjusting to civilian life or having access to appropriate treatment. Suicide rates, which used to be lower in the military than in civilian life, are now higher among members of the military.

I have not come across any good studies about evidence-based ways of decreasing stigma related to mental health, so what follows is my own intuition and opinion. I personally do not believe that talking about how common mental illnesses are would do anything to decrease stigma. Just look at the example of obesity, which despite skyrocketing rates, is still something that leads to kids being teased and bullied at school. Likewise, emphasizing that mental illnesses are biologically-based is unlikely to help. Everyone knows that those with intellectual disability have a brain-based condition. However, that did nothing to stop previous terms like "mentally retarded" and "idiot" from becoming pejorative. Below I'll discuss two broad areas that I think can help decrease stigma.

Normalizing the Expression of Emotion

In the U.S., when someone asks "How are you?", the answer is almost always some variation of "I'm okay," no matter what the truth may be. I believe that this cultural taboo against honestly discussing one's emotional states is one of the root causes of stigma. I have had countless patients apologize to me for crying as they describe the stress or trauma in their lives. The perception that it is somehow a weakness to be emotional or to talk about such difficulties leads to shame, which perpetuates stigma. When I ask about a family history of mental illness, one of the most common things I hear is: "I think my ___________ may have _____________, but my family never talked about it." Needless to say, those family members probably never got any sort of treatment for their suffering.

However, in some cultures, the more open expression of emotion seems to help people be more willing to seek treatment, as this CNN report on psychotherapy in Argentina shows. Even in the U.S., there are starting to be efforts to teach children emotional skills, which are increasingly recognized to be as important as intellectual or social skills. I believe that if children (and adults, but it's certainly easier with children) learn that it's acceptable to acknowledge and discuss their own feelings of sadness, anger, frustration, anxiety, etc., then they will have more compassion for others who are in emotional distress.

Of course, this does not address the stigma surrounding serious and chronic mental illnesses. Tellingly, the CNN article linked above contains the following:
One of the soon-to-be psychology graduates is Agustina, 31, who did not want her last name used because her future patients may Google her name.

Every member of Agustina's family goes to some kind of therapy, but, she's quick to add, "It's not that we are completely crazy or something. Nobody has big issues."
So what can be done for those with "big issues"?

Access to Care/Quality Treatments

I believe that as with other conditions like HIV/AIDS or Hansen's disease (a.k.a. leprosy), nothing stigmatizes more than having a group of suffers treated as outcasts and isolated from the rest of society. Having hundreds of thousands of chronically mentally ill people living homeless in the streets and millions more locked up in jails and prisons is terribly stigmatizing. Similarly, having managed care erect roadblocks to patients getting quality psychiatric care is stigmatizing, as it reinforces the idea that mental conditions are second-class citizens compared to purely physical ones. Despite passage of the Mental Health Parity and Addiction Equity Act in 2008, insurers are still unwilling to pay for many treatments.

Unfortunately, this is not going to get better until we as a society come to our senses and implement a better model for mental health treatment. As fellow blogger Dr. George Dawson has pointed out many times on his blog, managed care's focus on cost containment over quality has had a horrendous effect on the ability of clinicians to provide adequate care. Likewise, taxpayers are paying billions to keep mentally ill people locked up, when the same money could be used to much better effect to provide interventions such as stable housing, assertive community treatment, and vocational training.

It does not help that the NIMH continues to emphasize basic biological research above all else, or that the APA does little to challenge the managed care system, accepting it as fait accompli. But hopefully, with enough awareness and activism around these issues, meaningful change will eventually take place, and we as a society will make a bigger dent in the stigma related to mental health.