This is not an attack in any way on campaigns or organisations who are attempting to try to reduce stigma in Mental Health, simply a point of view. I’m a Clinical Psychologist so I approach issues in relation to mental health with my Clinical Psychologist hat on, I was trained in psychology then Clinical Psychology. I was trained to understand people, then to understand what happens when people experience problems and why they do. People first, then problem. I’m also a person who has experienced the impact of mental health and believes that at any time in the future I may well again. Every day I work with young people who present with a variety of mental health difficulties, from ones which impact only a little on their day to day lives, to ones which dominate every second of their days.
Stigma towards mental health is a huge problem. It can be as damaging as the mental health problem itself. On a daily basis I hear of people being bullied, losing friends and the impact of professionals who maintain the stigma by their own attitudes and approach. A while ago I wrote a blog for Young Minds entitled ‘What do I tell my friends? (it’s copied on this site)’ its title reflects one of the biggest concerns for young people I meet. It takes so much at times to work through mental health problems, it saddens and infuriates me that young people have to dedicate so much energy to overcome and manage the effects of stigma.
A huge issue here is what stigma is. For me and the young people I work with it is a negative evaluation and attitude based on prejudiced beliefs about something, in this case mental health. Recent studies still show that people believe, wrongly, that people who have mental health difficulties are dangerous (as we all know, being a victim is far more likely). I’m not sure we know enough about what the other main negative beliefs are but one I’m pretty sure of is ‘people with mental health difficulties are different to me’. That is a key issue which we have to dispel if we are to reduce stigma in my opinion. This is the heart of the ‘them and us’ dichotomy which is prevalent at the heart of stigmatising beliefs.
The first thing that strikes me about campaigns such as Time to Change is that it is, I think trying to do two things: 1) raise awareness of mental health and 2) reduce stigma of people in relation to mental health. These are 2 very different things.
The approach, 1 in 4 people have a mental health problem in their lives says that mental health ‘problems’ are common. It does raise awareness. What it also implies is that there are 3 people who don’t have a mental health ‘problem’. I’m prepared to be shouted down by people who are more aware than I am of health promotion and other aspects of social health psychology but I do know that one big issue is communicating health/well being based information to people is the message that ‘this is relevant to you’. It also perpetuates, in my opinion the view that there is a difference between people with a mental health problem and those without.
1 in 4 do, whereas 3 in 4 don’t.
There is another option. I work clinically from the point of view that mental health, of all kinds, exists on a continuum. Some people get this immediately, others don’t. A psychiatrist who came to teach us on our Clinical Psychology programme, when I posited this very stance said “there’s no part of me that’s schizophrenic”. Once I’d asked him if he’d had an imaginary friend, ever worried that people were talking about him, worried that his lover was deceiving him he accepted my point.
I challenge people to look at diagnostic criteria for mental health difficulties and find one which seems completely alien to them as a human being. They’re not, they’re aspects of human beings’ life which become more frequent, severe and troubling but they’re not separate in nature to what every person on this planet experiences. What we label as symptoms are things which people experience.
The continuum model suggests that we all exist on a continuum of well being. Rather than yes or no, you have it or you don’t. We all get anxious, I get anxious about going out sometimes but I don’t think for a second that my presentation is the same as someone who is paralysed at the thought of being around other people. We’re on a continuum, they struggle much more than I do (at this moment in time), but we’re not fundamentally different people. Someone who’s struggled with anxiety may well improve massively and may well struggle again as they move up and down the continuum. I could present like they do at some stage of my life and they like me.
The other, more spiky issue is parity, this comes up a lot in stigma debates. Mental health should have parity with physical health. I agree with this wholeheartedly.
- Mental health problems can have as much of an impact as physical health problems.
- Mental health problems are as real as physical health problems.
Who’d disagree with that? But does it mean that for mental health to have parity it must be viewed as the same as physical health? Parity does not require issues to be seen as exactly the same.
My other blog posts examine my view on some of these issues further but I think that there are inherent problems with the stigma debate which uses the term mental illness to communicate the nature of mental health problems. For example, research has shown that saying “schizophrenia is an illness like any other” does not reduce stigma ( see for example Read 2006).
Does saying people are ill reduce stigma? That may be where the Time to Change campaign may be struggling (most worryingly amongst professionals especially). 1 in 4 get ill, that will improve awareness but I can’t see that message reducing stigma.
Some people, myself included, are criticised for saying that mental health problems are not best thought of as illnesses. This in no way means I doubt their severity, their impact and how they can dominate and destroy lives. Why does saying something is an illness make it more real? There are plenty of problems that people experience which are not called illnesses.
I don’t think the illness model assists with stigma. It also conflicts with the continuum model. Simply put, when does a problem become an illness? And then when does the illness become a problem and no longer an illness?
The illness model also has another, unwanted side effect which is often missed. It is not all mental health difficulties which are classed as illnesses by the system. Depression is, psychoses are (including bipolar disorder), eating disorders are, some anxiety difficulties are but that’s about it. Personality disorders are not.
I have worked with many people who have a diagnosis of personality disorder and their distress at times is completely overwhelming. Their distress is real, understandable and genuine. A cursory glance at statistics for people with a diagnosis of personality disorder who take their own lives coldly proves that fact. How is their distress different to someone who has an illness? Anyone in services or anyone who has tried to access support for either themselves or someone they know or care for who has a diagnosis of personality disorder will know how hard it can be to get help. It is getting better, largely down to people with lived experience campaigning so effectively, but it shouldn’t have taken this long.
Why? Because they were seen as people who were not ill in a system that treats illness. That’s not right in my opinion. My argument is not about labels here or diagnosis, or the medical model as such but why the difference? Funding for mental health comes from the NHS mainly, is the illness approach impacting on funding for difficulties which are not seen as illnesses? I don’t know, any evidence I have is anecdotal. It did take a paper entitled ‘Personality Disorder – no longer a diagnosis of exclusion’ ten years ago to highlight the wilful neglect of mental health services towards people who required help. People were excluded from receiving help because they were thought of as not being ill.
Beliefs regarding mental health and the nature of mental health directly impacts on services and the public.
I believe and I don’t think many would genuinely argue that services should treat people in distress, regardless of whether it’s seen as illness or not.
I want what we all want, better services, more services. Services to help anyone who reaches a point where they need help regardless of what we call their distress. I want people, when they have mental health problems to not have to feel ashamed or fear being judged, to be able to focus on working through their difficulties and making their own lives more like what they want them to be.
I know people say that the illness debate is old hat and infuriating but what if it is contributing to stigma? What if debates such as last night’s ‘Should people with mental health difficulties be allowed on TV?’ are a result of a deep pervasive belief system that there is something tangibly different about people with mental health difficulties compared to others?
I’m only asking the question. Maybe it’s time to change our approach to stigma. We do all have to work together to reduce stigma but we have to get our core message right.
What about saying 4 out of 4 people have mental health? For some it becomes very hard to manage their difficulties and they need support, but that could be any one of us, it’s no reflection on them as a person, mental health difficulties can overwhelm anybody.
What if programmes about people experiencing difficulties with mental health showed more of the person, explained about them, their life showed people that they’re no different as a person? Would that help people see that difficulties with mental health can affect any one of us? I can’t help but think it would.
We all have mental health. Anyone can have their lives impacted on by poor mental health, anyone and everyone.
It’s not them and us, it’s us.
Dr Gordon Milson