Ending Stigma: With a Cultural Strategy and a New Way of Healing

Editor’s note: Third in a 3-part “Ending Stigma” series | Part II

We have 2 broad cultural pathways for destigmatizing our field. One is following the medical model with its disease-specific biological solutions. The other is by promoting the value of psychosocial healing processes. People sometimes manage psychological healing on their own or with family and friends, while many need a healer as guide. We call our professional healers psychotherapists.

While the medical model is based on pathologizing (i.e., categorizing diseases), the psychosocial model tends to normalize problems. Psychosocial theory may also categorize psychological problems, but its unique destigmatizing remedy is to view problems as part of the human condition. A disease status is thought to remove problems from negative social judgment. Normalizing problems can do the same.

There are weaknesses with both approaches, and we need a more comprehensive strategy. The medical pathway is a narrow solution, while the psychosocial one is far-reaching yet confusing to many. Our field’s destigmatizing efforts have been flawed by their siloed nature. As our textbooks on stigma reflect, we have focused on mental illness separately. We might better end stigma together.

A medical pathway is available to those with presumed biologically based brain diseases. If diseases are indeed blame-free, this model offers absolution from the stigmatized categories of mental illness and addiction. The psychosocial route exists for those without such medical exemption. People suffer from many types of psychological distress, and stigma impacts the entire range, not just disease categories.

Since stigma is broad, our destigmatizing efforts must be equally so. Like a balloon, it cannot be deflated by squeezing one spot. Destigmatizing the pain of those with brain diseases does little for those in non-biological categories. Yet healing with therapy is less surgical and more protracted. It offers freedom from the judgment of stigma, but it is more difficult for the public to understand.

Many people have problems that can benefit from therapy, and yet this remarkably effective service is imbued with stigma and rendered less accessible. Medicalization is potent as it shifts the context from behavioral to medical care. Therapy remains tied to our field and its stigmatized conditions. People avoid therapy and its negative associations. Therapy cannot normalize problems if you do not access it.

Progress depends on a dual focus, therapy and the therapist. The normalizing impact of therapy could be enhanced by reconfiguring primary care to include a core behavioral dimension. Therapy has been isolated as a specialty based on its history and privacy concerns, but isolation impedes access and nurtures stigma. The stigmatizing of the therapist is more insidious and warrants more attention than it has received.

Does everyone in pain want a healer? Medicine, the dominant healing practice, is surely in demand. Psychotherapy, an interpersonal remedy, is less well established. Therapists tend to emphasize being genuine as a person, and some highlight an ability to guide patients through dark times. Yet this does not reassure many who see therapy as an unfamiliar process in which their vulnerabilities are exposed.

We need compelling, trustworthy images about therapy to end stigma. We lack an iconic symbol parallel to the doctor in white coat. Research has reliably measured the impact of the white coat. Patients experience meaningful placebo improvement because the white coat creates positive expectations. Nocebo effects are more likely for therapy. New clients approach with trepidation.

We do not need an iconic counterpart to the white coat. It will suffice if we better attend to the role of public perception in access to care. We must confront the denigration of mental conditions, addictions, and obesity with one voice. Society will better accept all variations of human experience, including its extremes, by understanding how our thoughts, feelings, and behaviors drive our health status.

We can simplify this by learning from primary care. PCPs know the importance of behavior change. Behavior exacerbates or ameliorates every diagnosis. Behavior change is normal. It is universal. Let the challenge of behavior change become our field’s identity. However, we know behavior change is not a painless, antiseptic process. We have all experienced the struggle to change our lives for the better.

This universal struggle remains when we eliminate the stereotypes of stigma. People in a stigma-free society will still know the unavoidable pain of making psychological changes. Yet the process of healing can be demystified and framed as a more familiar process, as learning to change behavior. Some people need more help, perhaps a medication or a healing guide, but it is all part of being human.

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

The views expressed in Perspectives are solely those of the author and do not necessarily reflect the views of Behavioral Healthcare Executive, the Psychiatry & Behavioral Health Learning Network, or other Network authors. Perspectives entries are not medical advice.