What does it mean to reduce the stigma of mental health?

If psychiatry had a buzz-word, it would be stigma. The term is everywhere. Anti-stigma is a constant fixture at medical conferences, on newspaper front-pages and in television bulletins. For good reason too: patients with psychiatric diagnoses have long been marginalised. Even within the medical profession, the UK’s Royal College of Psychiatrists was forced to launch a campaign to dissuade students and doctors from badmouthing the specialty.

But stigma is nebulous. It is difficult to define, hard to grasp and awkward to disentangle from psychiatry’s history. What does it mean to reduce stigma and how might we reconstruct a psychiatry without it?

Recent anti-stigma efforts have been led by brave pioneers disclosing their personal experiences of mental ill-health. Prince Harry, for example, shared his experience of anxiety and anger management followed by his brother, Prince William, who described his own struggle with bereavement. Elsewhere, celebrities recount stories of depression, stress and anxiety, while entire organisations have been founded to dispel taboos. One such organisation, Inside Out, publishes a list of corporate leaders each year who have shared their experiences of mental ill-health.

These courageous acts cement mental health within public discourse. But what if this much–needed attention also comes at a cost? Recent anti-stigma initiatives, especially those championed in the popular media, increasingly pay disproportionate attention to a certain type of mental health condition. Mild manifestations of conditions such as depression and anxiety dominate celebrity advocacy efforts, while cases typically classified as “serious mental illnesses” continue to receive scant attention.

Inside Out’s list of over 90 individuals, for example, doesn’t include a single person with psychosis, despite schizophrenia and substance misuse accounting for over 45 percent of psychiatric hospital admissions. In contrast, burn-out and chronic stress – experiences not formally recognised as psychiatric disorders in doctors’ classification systems – feature multiple times on the list.

Although all efforts to encourage conversation around mental distress should be commended, this worrying trend sees popular mental health narratives abandon our most vulnerable patients. As the editor of Lancet Psychiatry, Niall Boyce has noted, “what [anti-stigma campaigns] risk doing is altering the reality of mental illness to suit public opinion rather than altering public opinion to suit the reality of mental illness.”

Speaking recently on a BBC flagship programme, a journalist embodied exactly this fear. “A lot of mental institutions were closed down because they had electric shock therapy,” she explained, decrying “barbaric treatments you wouldn’t dream of carrying out now.” The studio audience responded with almost unanimous applause, but there was a problem: electro-convulsive therapy is still used by our profession, forming one of the most effective therapies for treatment-resistant depression. However, not deemed palatable to public opinion, it has been virtually written out of the public’s perception of psychiatry.

The medical profession has been equally complicit in the reframing of mental health. At a recent conference I attended, a representative of a local service boasted their Early Intervention in Psychosis clinic no longer used the terms psychosis or schizophrenia in patient literature or consultations. “These terms are stigmatising” we were told, and best avoided.

At another event, software developers described their aspiration for their clinical app and its advocates to look like a “fashion label” rather than a clinical service. Others noted their services excluded individuals with a diagnosis of a serious mental illness, who were instead signposted to traditional services.

The Royal College of General Practitioners recently criticised a app-based services for “cherry-picking” patients with easier-to-treat conditions, but the problem facing psychiatry is even graver. We risk growing an entirely different tree of cherries, directing psychiatry’s newly discovered energy, attention and resources to a different concept of mental illness, while traditional psychiatric services for patients with the most severe conditions wither into the past.

This fear is shared by the former president of the Royal College of Psychiatrists, Professor Simon Wessely. “We don’t need people to be more aware. We can’t deal with the ones who already are aware” he noted. “I’m worried we will overstretch and demoralise our mental health services if all we do is raise awareness.”

Yet concerns go beyond resource limitations; there is also a sense that the broader purpose of psychiatry is being redefined. Increasingly, we talk in metaphors about “mental wellness” rather than specific diagnoses, with the term “mental health” cloaking anything from mild malaise to treatment-resistant psychosis. We talk about reducing stigma but seem to have learnt nothing from previous successes.

Take cancer, once a highly stigmatised illness, which now occupies a more socially acceptable status in public discourse. Its stigma was not dissipated by redefining it or finding an appropriate euphemism, but by thrusting its entire brutal reality into public conversation, allowing marginalised patients to share in the empathy which celebrities and campaigners attracted. As Susan Sontag noted, illness as metaphor does not dispel stigma, it merely entrenches it.

It is also true that when stigma is lifted, it does not lift from all equally. The Guardian journalist Hannah Jane Parkinson notes, “it wasn’t just that certain mental illnesses were acceptable, but certain mental illnesses were acceptable in certain types of people. The conversation needs to be more inclusive when it comes to people whose voices are less loud.”

Our political climate reflects this increasing gulf between the new and traditional faces of mental health. While British politicians idly watch the country’s underfunded prisons become breeding grounds of mental illness, the American President cosies up to a foreign leader who advocates extrajudicial executions of citizens experiencing drug addiction. Both countries increasingly demonise refugees – a group five times more likely to experience mental health conditions than the general population – at the same time as championing celebrity success stories of overcoming burnout, stress and mild anxiety.

Is it not predictable that a society obsessed with individual responsibility, meritocracy and social mobility would focus on individual success stories rather than systematic failures?

I was recently introduced to an African proverb at a conference on psychiatry; “while a tree sways in the wind, a bird cannot perch.” If the West’s contemporary narrative around mental health could be summarised in a phrase, it would state the opposite. Why confront the root problems – mass incarceration, domestic abuse, loneliness, homelessness, drug epidemics, unemployment, social discrimination, child poverty and rising inequality – when we can celebrate the few who have managed to climb to the top of the tree?

Perhaps such recklessness is to be expected from politicians, but doctors should know better. What does it mean for psychiatrists to embrace the sanitisation of their field, adopting euphemisms like “mental wellness,” becoming ashamed of diagnoses like schizophrenia or psychosis, and concealing our most effective treatments from the public? What does it mean to champion socially acceptable celebrity stories of recovery while more unpalatable manifestations of mental illness are side-lined?

The risk is that we displace stigmatised experiences of mental ill-health with more socially acceptable ones. Instead, can we not make space for everyone’s story?

That includes people like Anna Borges, writing about the pressure of portraying a certain narrative of mental illness: “I thought I wasn’t allowed to write about a personal experience until I made it to the mythical other side” she notes. “You hear it all the time: you should have a lesson, a realization, a moral, a triumph. But I might want to die forever.” Or the author of the Living with Schizophrenia blog, who questions whether “people with schizophrenia [will] benefit from reduced stigma when it takes them six weeks to get an appointment to see a psychiatrist?”

Such stories might include the Royal family too, but it’d include Princess Alice as well as Princes William and Harry. The mother of Prince Philip was diagnosed with schizophrenia, admitted to a psychiatric institution and assessed by Sigmund Freud. Such stories need not be laden with pity but heroism; Princess Alice spent her remaining years living in poverty, sheltering Jewish refugees in Nazi-occupied Athens.

Small successes, huge contributions, tiny steps of progress made. Every story is worth telling. While psychiatry should embrace the celebrity advocacy and public awareness from which other areas of healthcare have long benefitted, doing so should not expunge its most vulnerable patients.

Unashamedly sharing all experiences – the unpalatable as well as the came-out-of-it-stronger narratives – may appear to slow the fight against stigma, but it will also make it more robust.

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