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The hidden medical logic of mental health stigma

Australian & New Zealand Journal of Psychiatry, 47(7) Reducing the stigma associated with mental illness has become an area of increased effort and attention (Abbey et al., 2012; Jorm and Kitchener, 2011; Stuart et al., 2012). What remains of primary concern is how and why health care providers, who are otherwise educated, kind and compassionate helpers, are amongst the most stigmatising when dealing with mental illness (Abbey et al., 2012; Lauber et al., 2006; Stuart et al., 2012). While existing research suggests that emphasising biological aspects of mental illness does not reduce stigma and discrimination among the general public (Corrigan and Watson, 2004; Schomerus et al., 2004), we argue that the same cannot be assumed for health professionals. Health professionals are in the specific business of fixing, treating and otherwise controlling biologic disorder. As such, it is both logical and probable that health professionals apply a different set of cognitive interpretations and/or judgements to a medicalised framing of mental illness (Haslam et al., 2007) than does the general public. Informing our argument is the consideration that stigma and discrimination among health care providers can be thought of as a logical by-product (and perhaps even a result) of mind-body dualism. In contrast to what seems to work for the general public, this consideration provides the basis for the hypothesis that presenting physicians with knowledge of the physiological components of mental illness might be an effective strategy for combating stigma among this professional group. The problem of mind-body dualism dates back to Rene Descartes and refers to the philosophical split between the (non-physical) mind and the (physical) body. It is a problem that comes into play in the very way physicians think about illness and disease (Miresco and Kirmayer, 2006). When presented with a symptom or set of symptoms, for example, physicians will start by using the fundamental schematic categorisation of “Is it functional or is it organic?” If categorised as organic (i.e. in the body) it is assumed to be real, legitimate and material. From the physician’s point of view, this means it is something that can be observed, studied, treated and corrected. Arguably, this reduces stigma and discrimination. However, if categorised as functional (i.e. a problem of the mind, with no physiological correlates), the physician will consider it less real and the patient may be more likely to be stigmatised and discriminated against. Even though we ‘know’ this to be a false dichotomy, namely that mental illness (like most all illness) is inherently bio-psychosocial, this split between the material (body) and the immaterial (mind) nevertheless continues to structure our thinking. It permeates our language, explanatory models, attributions for illness, health care delivery structures, and resulting attitudes and behaviours. As linguistic philosophers Lakoff and Johnson (1980: 3) explain: “Our conceptual system ...plays a central role in defining our everyday realities .... but our conceptual model is not something we are normally aware of. In most of the little things we do everyday, we simply think and act more or less automatically along certain lines.” Anti-stigma efforts towards health care providers may be limited in their effectiveness if they ignore this basic schematic that underpins how physicians understand illness and disease. Research indicates that a more biomedically dominated conception of mental illness does not seem to reduce stigma amongst the general public – mostly because it creates in the public’s mind a perception that mental illness is less under a person’s control, that people with mental illness are more unpredictable, more potentially dangerous, more fundamentally different, and less likely to recover (Corrigan and Watson, 2004; Schomerus et al., 2004; Stuart et al., 2012). However, extending this same conclusion to health care providers may be an error. And that’s because physicians probably think about ‘the biological’ differently than the general public does. For a physician, using biological information to emphasise the ‘bio’ components of a biopsychosocial illness helps to shift the conception of that illness from something ‘merely’ functional to something organic (and therefore real and treatable). From the physician’s point of view, thinking of an illness in organic terms perhaps The hidden medical logic of mental health stigma