It`s Time to Approach Stigma From Another Direction

It may be time to discard the belief that behavioral health conditions like depression and schizophrenia will be less stigmatized once people understand they are disorders of the brain. While people may learn to adopt this view of biological causation, it may not impact stigma. Furthermore, our field is broadly stigmatized. This focus fails to address how stigma cuts off many other people from needed help.

Research suggests we may not be able to reduce negative social attitudes just by promoting a medical model of illness. For example, a study showed that a biological understanding of major disorders did not result in a decrease in stigma. A broad literature review found even when people support professional treatment for mental disorders, stigma endures.

That study ends with a practical suggestion (p. 15): “[F]ear of the stigmatizing effects of treatment can be reduced by providing care in less stigmatizing settings like primary care offices, community centers, and schools.” It may be time to change course. We may need to accept some unwanted conclusions about anti-stigma education. We may need to do more than change attitudes.

Stigma in our field goes beyond mental illness and addiction. Vulnerability is stigmatized as well. Needing to see a psychotherapist is stigmatized. Our field is hampered by more than misconception about severe disorders. Many people are ashamed of their vulnerability, of their personal secrets and feelings. Therapists find people must often overcome these attitudes to get help.

Anti-stigma campaigns are educational. The goal is to help people see certain major psychiatric disorders as being like other medical illnesses. This leaves the bulk of the DSM, presumably conditions without biological causes, out of the discussion. Yet society stigmatizes psychological struggle broadly. While there may be empathy for their plight, the non-biologically afflicted get no anti-stigma tools.

Another confusing aspect of the brain disorder argument is where the line of biological causation is drawn. The case is based more on professional consensus than specific findings. We lack any biological markers or medical cures. Where do other severe disorders like eating disorders belong?  Subtypes like anorexia are quite physically destructive, but evidence of a causal brain disorder is sparse.

People naively think individuals with anorexia should just eat and those with alcohol use disorder simply not drink. Yet ignorance is not the only source of stigma. So too is fear. We fear unusual people, but we also fear exposure of our own failings, weaknesses and peculiarities. Shame fuels stigma, even apart from ignorance. A recent article by a physician is telling. She regrets needing to hide her early history of anorexia to advance her career.

This story is doubly enraging. Why must people still hide personal troubles in our scientifically advanced age, and shouldn’t resiliency be the main message? When does it overshadow the shame of this disorder? Would we not celebrate the resiliency of a cancer survivor? Shame is not just about the origins of a problem. The solution is not more education about brain and behavior.

One might hope more specific evidence about brain disorders will change public attitudes. Yet there is no reason to believe more empirical information will tip the scales and change long-held biases. As an alternative, we might change our institutions by taking the behavioral healthcare field out of the shadows of secrecy and shame. This approach gets at the root cause of the problem.

Stigma involves several misunderstandings about people, but it is also an entrenched component of our culture and society. In our competitive society, people hide weakness. We can say that having a brain disorder is not a sign of weakness, but this does not change broadly held cultural messages and practices. Is there a focal point for more basic social change? Our healthcare practices are central.

As noted earlier, primary care offices are less stigmatized. We might create other healthcare contexts with low stigma, but primary care is a natural (rather than planned) environment for this. Why? We are encouraged to see PCPs routinely for a wide range of concerns. All problems matter, regardless of origin. Unfortunately, PCPs are as uneasy as everyone else discussing behavioral issues. More training?

Better yet, why not move behavioral interventions to primary care? The services of licensed therapists could be relocated, and we could also facilitate recurring comments by PCPs about the importance of thoughts, feelings and behaviors in health. Our field should not be an isolated specialty, a hidden practice, foreign to most people. Psychological wellbeing should be a regular part of a health checkup.

When behavioral health is widely seen as one aspect of health, it will be less important that some problems are more biologically based than others. People warrant care regardless of the source of their suffering. Let us defeat stigma by accepting the full range of human emotional experience. Routine, primary care is the best way to promote behavioral health for all. Let shame die in primary care.

Ed Jones, PhD, is senior vice president for the Institute for Health and Productivity Management.