My thoughts on there being ‘no stigma’ around mental illness

Last Sunday, the Observer published a piece by Elizabeth Day which appeared to claim that stigma around mental illness no longer existed.

She certainly didn’t sugar the pill.

“I don’t view mental illness as a scary, strange thing or as a form of weakness. Do you? I doubt it.”

“…bandying around the term “stigma” in reference to mental illness is unhelpful…can’t we just ditch the word?”

“…let’s stop saying there’s a stigma attached to it.”

Unsurprisingly, this went down like a sack of lead balloons with the mental health community. Amongst the fervent criticism was a typically evocative piece by Charlotte Walker.

And who can fail to understand the outrage? Research persistently shows that around 90% of people with a mental illness experience the effects of stigma.

However, in a follow-up piece published on her own blog today, Day tries to clarify her ideas. I’ll assume she’s being genuine in this and not resorting to tactical repositioning. She starts by stating that the real message of her piece was that mental illness is no longer a taboo subject (though the word ‘taboo’ is used once and ‘stigma’ is used eight times). She then goes on to assert that she would never deny that people with mental health problems still experience discrimination, but stigma, something different, is largely a thing of the past.

She reminds us of the definitions of stigma that she used in the original piece:

“…a Greek term that referred to the marking – by cutting or burning – of socially undesirable types such as criminals, slaves or traitors.

and

“…the phenomenon whereby an individual with an attribute which is deeply discredited by his/her society is rejected as a result of the attribute”.

It is here, for me, that the confusion and uproar has arisen. Day’s definition of stigma and the way she interprets it, as well as her obvious lack of appreciation of the prevalence of what others see as stigma are both askew with reality.

Day appears to believe that stigma simply denotes the process of society highlighting an intrinsic, internal flaw in someone (though her chosen definitions do not make that clear):

My issue with the term “stigma” is that it makes the condition itself a negative thing. It places the responsibility for bearing it with the person who has depression. It makes depression the mark of an outcast, of a tattooed outsider, rejected by the wider society.

However, we know that stigma it is a rather different beast to that. The now generally accepted conceptualisation of stigma is Thornicroft’s suggestion that it encompasses problems of knowledge (ignorance), attitudes (prejudice) and behaviour (discrimination, which Day sees as something altogether separate) – all of which are external to the person with mental illness. Though the results of stigma can be felt horrendously, the stigma itself comes from someone else and is inflicted upon a sufferer.

And even if we do work with her more narrow definition of stigma as a process whereby people are laden with blame for their conditions, it’s hardly as if society’s image of mental illness is as unblemished as she thinks it is.

“I simply don’t think the majority of right-thinking people believe [that mentally ill people are bad] anymore.”

Though in science and philosophy (areas which Day may be more familiar with than severe mental illness) we may have moved past the notion of mental illness being worthy of moral judgement or reason for scorn, the real world is sadly still rife with punishment and abuse simply for being unwell.
Moreover, appropriating the term stigma for her own ends (whether knowingly or not) was to steal a word belonging to a group of people for whom it  means something powerful and meaningful, who use it to understand their experiences with depth, pain and hopefully strength. This semantic hijacking is disrespectful. Providing a dictionary definition of stigma to justify it does nothing to negate that.

A final thought – whatever the cause of the misunderstanding, wherever the fault lies, there was a certain word missing in Day’s follow-up, a word that can have such healing power – sorry.

Why A+E fees are a despicable idea

With the average time patients spend in A+E rising and ambulances left queuing up outside for hours, it’s no wonder we’re trying to think of ways to ease the deluge of emergency presentations to hospital.

But one particularly bad idea keeps coming back time and time again – the idea of charging people who turn up with ‘inappropriate’ problems.

This morning it was the turn of the Northern Ireland health minister to float the proposal, targeting people who ‘abuse’ the system by having the temerity to turn up under the influence of drugs or alcohol. England is no stranger to the suggestion either.

I want to list the main reasons why this idea is at best misguided and at worst malicious.

Firstly and most importantly any fee for attending A+E, or any health care service for that matter, is a tax on the sick. The NHS was built on the founding principles that health is a right not a privilege and that no one should have to pay one penny more in sickness than would have had to in health. Sickness and disease are burdens to be accepted and borne by society, not cast onto unfortunate individuals.

Some might say that only charging people who ‘abuse’ the system or ‘bring their illnesses on themselves’ abrogates this moral duty. But I don’t think such a group is either easy to define or deserving of such spite.

So many of the patients I see labelled ‘timewasters’ are in reality the most deserving of care. They often have complex social, emotional and medical needs as well as substance misuse problems over which they have very little control. Society has frequently failed outright in providing them education, a safe and happy childhood, housing, employment and a stable emotional life, but instead of holistic intervention and understanding we are now suggesting charging them for seeking help in the only way we ever taught them – with desperation. Such a policy demonstrates nothing but the most basic misunderstanding of our most vulnerable patients.

Furthermore, how many illnesses which people ‘bring on themselves’ are we more than happy to treat for free? A broken leg from a skiing accident gets you top notch free orthopaedic care, even though you knew it could happen when you booked the holiday. Smoking for 20 years gives you COPD but there’s still an NHS bed for you if you need it when the winter chest infection season starts. But if you’re difficult to emotionally relate to, you keep coming back and have difficulty following advice, all of a sudden it’s your own fault and you should learn your lesson.

No one turns up to A+E for fun. We need to address the problems of difficult patients more thoroughly, not bat them away with a fine for being so bothersome.

There are numerous secondary reasons why charging people for medical services is counterproductive. People who are genuinely unwell will decide not to turn up for fear of it being labelled inappropriate or expensive, as the US know only too well.

The cost of implementing a system to charge so-called ‘abusers’ of healthcare would in all likelihood cost far more than it would earn, especially bearing in mind the track record of NHS IT projects, and almost by definition would target the very people who are least able to pay the charges anyway. Many also fear it would also represent the thin end of the wedge towards universal charges – something I wouldn’t put past this government.

All in all, a frighteningly frequent proposal which shows just how badly some people understand our more challenging patients and just how little they really want to help them. I hope I never see it suggested again, though I’m completely sure I will.

Dangerous Debates

I like a good public debate, especially when it comes to mental health. I’ve been to a fair few, like the Maudsley Debate on CBT for psychosis, and even spoken at one myself, on the value of diagnosis in psychiatry.

Debates are often called for, much anticipated, and generally held up to be an uncontaminated source of truth and progress in heated times.

I wonder though, whether they’re the universal answer that they’re cracked up to be. I’d never argue against issues being discussed informally on smaller platforms like Twitter, but hosting an official and well publicised event on a grand stage seems to hold quite a propensity to make the issue at hand even less clear.

Firstly, the motion sometimes isn’t fair. I was rather piqued to read the introduction to a debate due to happen in November at the Royal Geographic Society, at which speakers will argue for and against the motion that ‘Psychiatrists and the Pharmaceutical Industry are to Blame for the Current ‘Epidemic’ of Mental Disorders’. It’s a straw man – the assumption has been made that there is an epidemic of psychiatric diagnosing (when in fact, mental health services are too busy to see even the sickest patients enough and are being cut further) and someone is to blame.

The rest of the blurb is obnoxiously biased too, for example ‘Drug pushers. We tend to associate them with the bleak underworld of criminality. But some would argue that there’s another class of drug pushers, just as unscrupulous, who work in the highly respectable fields of psychiatry and the pharmaceutical industry.’

Sir Simon Wessely, speaking against the motion, is one of the best public orators I’ve ever seen but he’s starting from a phenomenally biased position. Unless the motion and backdrop are fair and balanced, a debate can turn into a pointless inquisition and show trial serving only to reinforce the skewed presumptions of the people who set the motion.

Secondly, I just don’t think that some topics are suitable for public debate, either because of the nature of the question or the state of the current answer to that question.

Public debates are not objective. They are rhetorical sniping contests won not by people with the best and most useful answers but by the people who convince the audience, who are themselves hugely biased already, using charisma, ethos, selective information and verbal trickery. The recent demand in a broadsheet newspaper by the so-called ‘Council for Evidence Based Psychiatry’ for a public debate on the harms of psychiatric medication was in my view completely ridiculous – there is no way a complex, lengthy and highly statistical issue like that should be thrown to a few angry academics in front of microphones.

In some cases too, simply having the debate lends credence to one side of the argument that it doesn’t deserve. We wouldn’t have a public debate on vaccination and autism, because we know well enough already what the answer is and we don’t want to give the other side more credit than it deserves. I suppose you could call it meta-debate. Far be it from me to ascribe that to any topic in mental health, but Nick Clegg didn’t seem to fair too well against Nigel Farage. It was over before it even started – Farage had proven that his views were apparently worthy of airtime. The fact he outdid Clegg with panache too was an added bonus for him. The sensible, grown up politicians steered clear of the no-win situation.

To finish, we shouldn’t mistake the result of a debate for closure on an issue either, which seems to be a nagging recent trend. If we can’t make our minds up about an issue after decades of research then there’s no way we’ll get there in one evening.

At the end of the day we just need to remember what a public debate is – a few highly biased people talking in a highly biased way to a highly biased audience about an often highly biased motion. They can be fun, exciting and stimulating, but they run the risk of distorting an argument even further and they certainly aren’t an absolute truth.

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