In pursuit of happiness
‘Happiness’ is a concept that I seem to be increasingly encountering. It is the subject of a piece of work that my colleagues in Arts and Society are involved with in collaboration with the Happy Museum Project, an initiative that is encouraging UK museums to support transition to well-being and sustainability in our society.
The Happy Museum Project was born from psychological research suggesting that happiness and well-being are not related to material wealth. On the contrary, an emphasis on material wealth has led to a focus on the short term, causing the majority to feel pressure to “keep up” and leading to more unhappiness. Key to a sustainable notion of well-being, according to the Happy Museum Project, is what they call ‘support learning for resilience’, which encourages learning that is curiosity driven, engaging, informal and fun and can build resilience, creativity and resourcefulness.
Of course this is not a wholly new concept. We’re becoming increasingly familiar with research that shows that over a certain comfort threshold, increased wealth doesn’t correlate with general satisfaction, take Bhutan’s Gross National Happiness index, for example, which was developed in the 1970s. Now the UK government has started to focus on the notion of happiness, with the announcement of the National Wellbeing Project in 2010, which will see them attempt to measure how happy Britons are and use the results to shape government policy.
One area where happiness does not seem to have been a central consideration however is in education. Take the new Ofsted framework, which requires inspectors to place emphasis on behaviour, safety and teaching but makes no mention of emotional wellbeing, sociability and support. The aim here may have been to concentrate on the essentials and perhaps the more quantifiable elements, but this only reinforces the lack of regard with which these qualities are held.
Plans for performance related pay for teachers could be taken as another example of overlooking the importance of happiness. Not only is this measure likely to increase pressure on teachers, making them less happy, but their performance is likely to be measured solely on academic results, as it must be, and not well-being. This is not to say that the two will always be unrelated. For example it seems obvious that if a child is taught in a way that is exciting, fun, collaborative and supportive then they will not only be happier but will be more engaged and therefore attain better results. But this policy risks increasing pressure on students to achieve academically, leading to more teaching to the test and so risking children’s well-being.
Additionally some proponents of performance related pay for teachers base their arguments on economics; a good teacher = a good education (good grades) = a good job = more money. Not only in the current climate is this not necessarily the case, as there are not enough good jobs for high achieving students, but if money doesn’t make us happy then we shouldn’t be thinking only about education in these terms.
So I come back to the Happy Museum Project’s central tenet – our culture must focus on the long-term and sustainable benefits of its actions. Whilst achieving good academic results may lead to happiness in the short term, it can no longer guarantee a child’s future well-being in the face of unemployment, recessions and climate change, although perhaps it can help. My point is not to belittle academic achievement, but to emphasise that like so many things, we just cannot be sure. What we can be sure of is that having confidence, emotional stability and resilience, will help this generation of students to survive this uncertainty and to cope better, if not always be happy.
Talking, doing, and mental health
Complex subjects make for uneasy debate, and mental health is a good example. The Time to change campaign led by Mind and Rethink has done an excellent job of highlighting that although practically everyone will either experience mental health problems or be close to someone who does, the stigma attached to them makes us reluctant to talk about it.
Last night I helped run an RSA Fellows’ workshop at 3space focusing on the role that enterprise can play in addressing mental health challenges. A handful of inspiring projects described their work, and then the group of thirty or so people (mostly RSA Fellows) shared and developed their ideas over the course of the evening. One project, a social enterprise that will provide employers with advice on how to avoid discrimination and ensure the mental health needs of their employees are accommodated, was awarded a provisional Catalyst award of £2,000 at the end of the evening.
For me, though, the most encouraging thing was the care and thought that went into contributions to the many discussions throughout the evening. At one point, an interesting debate emerged on the possibilities of providing support for those diagnosed with bipolar disorder. Mic Starbuck and Andy Gibson (who led the project that was funded) had proposed that generic advice could be produced that would helpful to anyone at the point of diagnosis.
Artist Bobby Baker (whose amazing work my colleague Emma Lindley has blogged about before) responded by making a passionate case for why the variety of experiences of bipolar disorder means that one-size-fits-all advice would be unhelpful. Andy’s response accepted this point, suggesting that the aim should be to reinforce this message through the advice given, and help people connect with others who could share their own stories.
Mindful of time, I moved the discussion on, but in fact my heart had leapt a little. This kind of mutually respectful, passionate debate between people with different but complementary experience is a rare enough thing to make it worth celebrating when it happens. It’s tempting to think of talk as a barrier to action. In fact, good talk is what makes action possible.
As Time to Change shows, one of the biggest barriers to better mental health is resistance to talking about it. As Emma has argued persuasively, we can’t counter discrimination and stigma around mental health in the workplace until we understand what creates and perpetuates them. And as the discussion I described earlier illustrates, the first step in agreeing how to support people with mental health challenges is to recognise and reflect the wide range of personal experiences that accompany them.
This was just one highpoint in a long, energetic evening that saw a huge number of ideas form and develop. As well as the project awarded funding, another group hope to take forward their idea for a social enterprise that would support employers in making better provision for people with mental health difficulties – for instance, resolving insurance issues, or arranging temporary cover for time off.
If you’re interested in the issues I’ve touched on here, the debate will continue online on the Mental health and wellbeing group on the Fellowship social network. I’m also keen to hear people’s views on how we can encourage more discussion and exchange of the kind I’ve described – not only because it’s vitally important to understand people’s experiences of mental health, but also because of how it can help to improve them.
Sam is @iamsamthomas on Twitter. You can follow last night’s event as it unfolded on Storify.
Packing punches with poetry
My social science research training was great in terms of giving me the tools to understand more about how we get to know what there is to know. Philosophy of science can be tricky to get your head round at first, but once you get practical examples to illustrate principles, it’s pretty much logical and consistent.
My first degree, which was in English, was much harder, in that, to do well, one had to learn how to get a ‘feel’ for what writers were trying to express, as well as understanding the mechanics of it all. I had excellent tuition, and was both pushed and supported in learning how to get the most valuable all-round education from critical reading of literature.
Unthinking politicians might easily cast aside the close reading of poetry, regarding it as an unvocational and unnecessary discipline. In fact, such practices can bring far greater appreciation to the details of important aspects of life that the language of policy makes impenetrable.
Photo by Joseph Lindley
Here’s a little example. The Social Brain team has been involved in the development of a proposal about ‘Green Prescribing’. The idea of green prescribing is to bring people into contact with nature in order that their mental and physical health is enhanced. Our proposal builds a rationale for this by referencing evidence from a range of sources, but obviously none of them are literary (that would be weird, right?).
Well, it might be unconventional, but sometimes poetry hits the nail on the head in a way that lengthy strings of referenced prose just can’t. Here’s a poem by Elizabeth Bishop, written in 1927.
To a Tree
Oh, tree outside my window, we are kin,
For you ask nothing of a friend but this:
To lean against the window and peer in
And watch me move about! Sufficient bliss
For me, who stand behind its framework stout,
Full of my tiny tragedies and grotesque grieves,
To lean against the window and peer out,
Admiring infinites’mal leaves.
Bobby Baker – an artist at the RSA
If you have never come across Bobby Baker, I envy you. I envy you because you have ahead of you the delicious joy of discovering her work. She is one of the most widely acclaimed performance artists working today, and has a large and impressive back catalogue of work which, using the most fabulously inventive methods (plenty of cake), makes art out of the everyday.
And, there’s nothing as everyday as mental illness. In 2009, Bobby exhibited her ‘diary drawings’ at the Wellcome Collection. These pictures, drawn daily over a period of eleven years, depicted Bobby’s experiences of mental illness, in real time, as it was happening to her. Throughout this period, incidentally, Bobby continued to work prolifically, raise a family and continue to forge an impressive career.
Despite her international reputation, and long established success as an artist, Bobby herself had no idea how the drawings would be received or what the impact of going public with something so personal would be. Needless to say, they went down a storm, the Wellcome extended the length of the original exhibition, and it has since been touring, going to Portugal, Belgium and Holland.
The ways in which the exhibition and the book that came out of it have made an impact are wide reaching. The book won Mind Book of the Year in 2011. People recognised themselves and their own experiences in the images. Those with no experience of mental illness felt a glimmer of understanding as to what it might be like. Practitioners and academics in mental health took notice.
Since that exhibition, Bobby has been as busy as ever, her new piece about what it takes to cultivate mental wellness, Mad Gyms and Kitchens, receiving critical and audience approval.
So, when I put a call out to Fellows of the RSA to find out who has interest, experience or expertise relating to mental health and employment, Bobby Baker responded. As a long-time fan of her work, I was ever so slightly starstruck (and definitely not squealing with glee) to see her name in my inbox. As a keen, and in her words ‘patient’ Fellow, she’s been waiting for the right thing to get involved with, and luckily for me, the challenges I outlined sparked her interest.
Today I met with Bobby Baker to discuss her take on the issues around mental health and work. She has a unique perspective, rich with the insight and wisdom that comes from personal experience. Amongst other things, she told me about a new project she’s working on in which she’ll tell the story of the steps along her journey to get to the extraordinary position of influence and leadership she now occupies. It’s quite a story, and the unique way she has of expressing herself, whether in conversation, in her drawings, or in her performance, is bighearted and expansive. Fortunately for the RSA, she’s as generous with her time and ideas as she is in her artistic expression.
Why Stigma Has Had Its Day
In all honesty, I had never heard of The Society for Curious Thought until last week. It says it exists to foster curiosity and intellectual discovery in pursuit of a better future, which sounds good to me. On closer inspection, it turns out to host an eclectic and fascinating collection of articles and contributions covering arts, science, politics, personal experience, the environment and fiction.
As a result of my call-out last week to Fellows and others about mental health and employment, I was contacted by the Society’s Director, Simon Marriott FRSA, and asked to submit an article further exploring the issues I had written about. I was very pleased to be asked, and my piece, Why Stigma Has Had Its Day has just been published.
My article attempts to summarise an issue adjacent to those I raised last week in my two blog posts about mental health and employment – the problems associated with using ‘stigma’ as a conceptual framework for talking about the social exclusion of people with experience of mental illness.
Here’s a taster:
Discrimination and social exclusion are very real aspects of living with the experience of mental illness and the consequences can be grave: loss of opportunity in education, employment, housing and civic participation. Thirteen years ago, the disability rights campaigner, Liz Sayce did her best to change the way we deal with discrimination against people with experience of mental illness. She wrote an important article explaining why using the notion of ‘stigma’ to describe what is actually discrimination is in itself dangerously marginalising. Disappointingly, no one took very much notice, and these days, ‘stigma’ is still the primary conceptual apparatus used to describe what happens when people who have experienced mental illness are unfairly treated.
Sayce’s key point was that the notion of stigma is problematic because it locates the problem within the person with the mental illness. This has the effect of individualising what is really a social problem. It amounts to a kind of victim blaming. Stigma (literally, mark of shame) carries with it the implication of there being something inherently discreditable about the person being stigmatised. Sayce argues that the ‘mark of shame’ should not be attached to the person with the mental health problem, but rather with the person who is behaving unjustly towards them.
It might be tempting to cast aside such issues as being merely semantic trifles. You might think that anti-stigma campaigners are fighting a good fight, and we all know what we mean when we talk about the stigma of mental illness. In fact, the reasons why discrimination against people with mental health problems continues, may well be partly down to the persistence of a damaging conceptual framework. Conceptual models carry enormous power. The implicit assumptions about where responsibility lies, or whose is the problem, determine to a large degree how we approach the issue as a society.
Discrimination: why mental illness is a special case
I’ve had a great response so far to my post about mental health and employment on Monday, and some important issues have been raised. One of the comments made directly in response to the blog was particularly challenging, and pointed to some important issues which I have tried to tackle in some of my previous work on anti-stigma education.
The commentator suggested that people with experience of mental illness being unable to get secure employment leads to them setting up in self-employment and drew attention to the downsides of this. It sounded to me as though the writer might have had first-hand experience of dealing with a freelancer who had continued to work during an episode of acute mental illness. The “ranting paranoid accusations” sound very difficult to deal with indeed, and it is exactly this sort of troubling behaviour that employers presumably have in mind when they say wouldn’t employ someone with a mental disorder. The response also drew attention to the lack of support available to self-employed individuals experiencing mental health problems and the damage that can be left behind for clients and business partners who “tried to work with them in good faith.”
Interestingly, I had a respondent write to me directly (rather than in the public forum) expressing horror at what they saw as inherent stigma in this analysis. However, despite my interest in reducing prejudice and discrimination against people with mental illness, I do not think that this is an instance of such prejudice. In fact, it very helpfully draws attention to what I see as the real nub of the problem in terms of discrimination and stigma in the context of mental illness.
Discrimination is treating someone unfairly on the basis of characteristics which ought to be irrelevant. We are familiar with the idea that not employing someone because of their gender, race or sexuality is unfair, and amounts to sexism, racism or homophobia. It could be assumed that comparably unfair treatment of a person with a mental illness is the same. However, I think that mental illness is actually a special case, and differs from gender, race, or sexuality in the way in which discrimination functions in relation to it. It is different in that, for individuals who experience it, mental illness is not a constant, unchanging feature. Forgive my massive oversimplification, but at the simplest level, if you are a woman, you are a woman every day – your ‘womanness’ is relatively fixed and definite; likewise with skin colour or sexuality.
If you have a diagnosis of a mental illness, your status is not only likely to be, at some level, contested, but also fluctuating, transient and shifting. There is the issue of the hugely various types of mental illness you may have. Furthermore, no matter what your diagnosis, it is likely that you have had periods of your life when you have been less able to function than others, along with periods of your life when you are entirely able to function. In other words, the way in which the mentally ill part of a person impacts on their life is inconsistent.
What this means is that there are times when it is appropriate and right to treat a person with a mental illness differently to someone who does not have a mental health problem – for example when they are currently in throes of madness ‘proper’. However, a person with a mental illness who is free of symptoms and yet is unfairly treated differentially is therefore being subjected to discrimination in the sense that they are being judged on the grounds of characteristics which ought to be irrelevant.
The result of this is that the idea of ‘stigma’ in relation to mental illness simply does not make sense as a fixed dimension of people’s attitudes. The interaction between the fluctuating, changeable nature of mental illness along with people’s context-specific, plural position taking in relation to it is characterised by too much subtlety and nuance to be rendered simply in terms of stigma.
This is kind of complex, and it’s something people might only really come to understand through personal experience – either of going through some kind of mental illness themselves or by being close to someone who has. Another respondent to my earlier post told me about being a manager of staff with mental health problems and regarding them as “weak willed fools”. It was only after experiencing a breakdown himself that his perspective changed and he seemed clear in his conviction that without this personal experience he would never have shifted his view
There is no substitute for first-hand experience. Indeed, one of the insightful fourteen year olds who participated in some research I did said to me, “You can’t know what it’s like unless you’ve been through it yourself. I could talk to someone with schizophrenia, or whatever, all day long, but I still wouldn’t know what it’s like.” But, that’s not to say our capacity for empathy cannot be enhanced.
I’m convinced that attitudes to mental illness in the workplace can be improved, but that only through greater understanding of personal experiences, including those which have been troubling. Most crucially, the difference between a person with a mental health problem who is currently acutely unwell, and someone with a diagnosis but no impeding symptoms is vital to understand if progress is to be made in managing mental illness and employment.
Mental health at work – everyone’s business
Whose responsibility is it to support people with mental health problems in/to employment? Later this month, the OECD will publish what looks like an important piece of work examining the myths and realities about mental health and work. The issue is a spectacular tangle of grey areas, discrepancies and imprecision.
There’s the matter of looking after the mental health needs of those currently in employment. There’s the challenge of supporting people with long term mental health conditions in getting off benefits and into work both sustainably and without exacerbating their illness. There’s a complex relationship between recovery (which in the case of mental illness is rarely a linear process), therapeutic occupation and the pressure of responsibility.
There are underlying problems around the hindering of aspiration and ambition as a result of the onset of mental illness. There’s the confusing business of common mental disorders, such as anxiety and depression, and severe mental disorders, all of which can be chronic, transitory and, very likely, fluctuating in degree of severity.
Dealing with these challenges falls neatly between health and social care provision, the welfare system, and the big bad world of the free market. The very idea of mental illness takes us to extremely uncomfortable places, and the fact that employers don’t really want to know and employees don’t really want to talk about their mental health is only one indication of the deep social stigma that still exists.
So even though we know that the costs of mental ill health are enormous (estimated at as much as 4% of GDP in the EU), it does not seem to be an issue that people outside the mental health sector are engaging with very seriously. Employers and corporations are, so far, not a real partner to the mental health care system.
The government is ploughing money into the Work Programme, which pays specialist providers to get people with long term conditions into work, but without any kind of systematic approach towards employers and the workplace. The fact is that employers do not like the idea of mentally ill staff (only four in ten employers say they would hire someone with a mental disorder) and we cannot simply sidestep or overlook this when trying to encourage people off benefits and into work.
And, although there is overwhelming evidence that employment is an important element of continuous, on-going recovery from mental illness, the mental health care system takes minimal responsibility for the employment status of its patients. Part of the problem here is that so much of the mental health care system is geared up towards severe mental disorders, and a long held lack of expectation of recovery. Once a person falls into the system of mental health care, the path towards becoming a career mental health patient is a lot easier to fall onto than any alternative paths.
The OECD’s report will argue that policy can and must respond more effectively to these challenges, but to do so will require a co-ordinated approach and a multi-level shift. This will require a level of integration that is hard to see emerging from what the coalition is up to.
For example, we know that prevention and early intervention are crucial, so we need to find ways to join up vocational support with first line health care response to mental distress. To make working life compatible with long term mental disorder, there is a need to stop trying to shoehorn people with mental health conditions into inflexible and conventional models of working and encourage employers to accept variations in people’s productivity, and a more diverse and creative view of what it means to get the job done.
Within all of this I’m sure there are real opportunities for social enterprises to play a role in bringing about shifts not only in attitudes to mental health at work, but also in terms of matchmaking people with employers and helping employers to respond proactively to the mental health needs of the workforce. The Social Brain and Enterprise teams at the RSA are currently interested in exploring this area, so if you’re working in this space or have ideas you’d care to share, do get in touch.
What’s up, doc?
On Tuesday the winners of the Mind Media Awards were announced. These awards give recognition to those media channels that handle mental health issues sensitively, appropriately and without stigmatising. BBC1’s Casualty won the accolade in the Drama category, beating off competition from Holby City and a psychological thriller called Exile. Like I said earlier this week, I don’t watch much telly, and I haven’t seen Casualty for years, but when I saw the list of winners, it didn’t surprise me that the programme came out on top. It’s the sort of show I would expect to do all right when it comes to representation of people with mental illnesses.
More of a surprise was the discovery that only days before winning the award, an episode of Casualty was broadcast in which they managed to get in a stigma-inducing blunder. While I was wandering around the National Portrait Gallery with a doctor friend of mine last night, she asked me if I’d seen Saturday’s edition of Casualty, and whether I’d be writing to the BBC to complain about the stigma. I’ve since checked out the offending episode on iPlayer, and, here’s the problem.
In what I assume is an on-going storyline about a doctor with bipolar disorder, the issue of medication during pregnancy has come up. The character in question has recently fallen pregnant, and is reluctant to stop taking the mood stabilising medication, lithium, because of her keenness to maintain a stable mood during her pregnancy. A concerned colleague intervenes with misgivings about the risks of lithium exposure to the unborn baby. The well-informed doctor says she knows the risks, and that a 10% chance of a heart defect amounts a 90% chance of being normal.
This is the big mistake. It’s also another example of the clumsy use of statistics thrown in just to suit the current purpose. Like so many things, the real picture concerning the potential risk of taking lithium during pregnancy is much more complex, but some evidence suggests the risk of cardiovascular complications is more like 1 in 200 (compared to 1 in 2000 in the general population). A 0.5% chance is very different from a 10% chance.
This paper from 2008 compiles and examines all of the available evidence on this issue and concludes that lithium should be used in pregnancy without hesitation if needed. However, to make this argument, evidence is assimilated and discussed in such a way that does not lead to a single nice, neat, conclusive percentage of risk.
Okay, so Casualty got their figures wrong. But, why is this stigmatising, I hear you cry. Put yourself in the shoes of a newly pregnant mother who has bipolar illness and is taking lithium. Making the decision as to whether to discontinue treatment is a damned difficult one. You, like any expectant mother, are determined to do everything within your control to protect your unborn child. This includes looking after yourself and avoiding bipolar relapse. You look at the evidence, and see that, taking everything into consideration, the risk to your child of continuing to take lithium is probably lower than the risk of harm if you stop taking it. If people around you have gleaned their knowledge of the topic from Casualty, the chances are that they will hold that view that this is a more irresponsible and negligent choice than it really is.
The friend who told me about Casualty’s gaffe knows a real life doctor, who really has bipolar disorder who recently had to make precisely this choice. She was really upset by this misrepresentation precisely because it made her feel people would think she’d been reckless. Perhaps it’s a small point, but it’s the kind of detail that a drama show with a reputation (and indeed an award) for careful treatment of mental health issues should take more care over.
What is evidence anyway?
The idea of rigour is pretty important when it comes to research. In a previous post I’ve expressed the view that we need to acquire and properly understand evidence before investing a lot of money in rolling out interventions. But, that’s not to say that collecting ‘evidence’ for efficacy and effectiveness is always as rigorous as it might appear.
I’m very interested in anti-stigma mental health education, and I do think it’s important to know that approaches to such education are working well before they are rolled out on any large scale. But, how do you know that they work?
Conventionally, quasi-experimental designs are used in which participants complete attitude surveys before and after taking part in an intervention, and differences in attitude scores are compared. Early in my research career, I constructed a questionnaire designed to measure adolescents’ attitudes to mental illness. I followed a rigorous procedure to do this, interviewing young people in order to generate statements to include on the questionnaire, piloting the questionnaire and conducting factor analysis.
Even though my questionnaire was quite well put together, and appeared to be able to produce valid and reliable results, the process of constructing it caused me to develop a highly critical stance in relation to measuring attitudes in this way.
My feeling was that while an analysis of young people’s responses to the questionnaire may able to indicate general trends and patterns in respondents’ views, the instrument was also reductive. In order to generate material for the questionnaire, I held group discussions with young people. The content of these was rich and complex, with individuals frequently holding contradictory views and occupying ambiguous positions in relation to mental illness. The level of detail, nuance and subtlety which I observed during the focus groups could simply not be captured by a questionnaire using a bipolar response scale.
Another limitation of attitude measurement techniques is that they force responses to be recorded as either positive or negative. It became clear through my discussions with young people that ambivalence and confusion were very genuine features of their understanding, which questionnaires are unable to capture.
Not only that, but using a questionnaire to measure attitudes to something as complex as mental illness is problematic for semantic reasons. Most questionnaires about mental illness, including the one I constructed, rely on people responding to the phrase ‘mental illness’, without knowing how the term is understood by individual respondents. Given that ‘mental illness’ can describe such a vast spectrum of experience, from full blown madness, to fairly mild sadness, it may well be that different respondents are thinking about completely different things as they complete the questionnaire.
This has important implications. A common item on attitude to mental illness questionnaires is ‘people with mental illness are dangerous’. If you are imagining a person in the throes of paranoid psychosis, it’s likely that you’ll answer the question quite differently than if you are imagining someone with postnatal depression or anorexia.
The interpretation of the answer to such a question is also problematic. If someone agrees with the statement, their response is interpreted as indicating a negative attitude to mental illness. However, although most people with mental health problems are not dangerous, some people with mental illness do sometimes do dangerous things. It is possible that someone may agree with the statement on the grounds that they know this, but that they are generally supportive towards people with mental illness and therefore hold a broadly positive attitude.
So, although it’s important to have some evidence which demonstrates that interventions do what they are supposed to do, it’s also important to be critical about the nature of that evidence. As Einstein said, “not everything that can be counted counts and not everything that counts can be counted”.
The medical model of mental illness: we’re not convinced
A great systematic review has been published in this month’s British Journal of Psychiatry. It has the slightly less than tabloid-friendly title Biogenetic Explanations and Public Acceptance of Mental Illness: Systematic Review of Population Studies, but behind the dense title is a really useful and important piece of work.
Matthias Angermeyer and his colleagues examined 33 studies which looked at the public’s beliefs about the causes of mental illness, in order to find out whether there is a relationship between those beliefs and the degree of tolerance people show towards people with experience of mental illness. This is important, not least because the shape of anti-stigma education and campaigning is determined by the causal model on which it is based.
Historically, the dominant model for public anti-stigma campaigning has been built on the foundations of the biogenetic model of mental illness, in which it is assumed that mental illness comes about primarily as a result of biochemical or genetic deviations.
Anti-stigma efforts have led to simple messages being devised, which are designed to get people to leave their prejudices behind. Under the biogenetic model, the types of messages you end up with are ‘mental illness is an illness just like any other,’ and ‘mental illness is treated with medication’.
Angermeyer’s systematic review concludes that biogenetic explanations for mental illness are correlated with less tolerance of people with mental illness amongst the general public, and therefore, basing anti-stigma work on biogenetically based causal models is an inappropriate means of countering stigma.
This is not at all surprising to me, and you if stop and think about it, it’s no wonder that the public are unconvinced by messages like ‘mental illness is just like any other illness’. The reality is that mental illness(es) are not very much like physical illness(es). We need only to think about the way mental and physical illnesses are diagnosed to realise this.
In general medicine, diagnosis typically proceeds through the identification of signs which indicate the presence of disease. In the case of diabetes, for example, it is possible to determine whether the patient has the condition by measuring their blood glucose level. The patient may have been experiencing symptoms such as feeling thirsty and tired. These symptoms, although they do indicate the possible presence of the illness are not sufficient for a diagnosis of diabetes – the physician relies upon the results of a blood test (a sign) to make a confident diagnosis.
Psychiatric diagnosis does not work like this. Although it is assumed that there is a biological dimension to mental illness, there are no definitive physical indicators of mental illnesses which categorically and objectively confirm the presence or absence of a mental disorder. It isn’t possible to determine, say through measuring their serotonin level, whether a person is suffering from depression; nor is it possible to diagnose psychosis through carrying out a blood test or x-ray. Instead, psychiatric diagnoses are made by way of observation or reporting of ‘symptoms,’ which are nearly always subjective judgements about what people say and do.
The truth is that, whilst it seems there may be some biological and genetic factors in mental illness, the science is not sufficiently advanced to be able to be clear about what they are and how they act. Not only that, but, to a much greater extent than with physical illness, the social and political dimensions in the construction of mental illness are controversial.
Therefore, oversimplified, biogenetically based anti-stigma initiatives are destined to fail because they don’t acknowledge or attend to the true complexity of mental illness. They do little to engage with people’s genuine uncertainty about why mental illnesses come about, and their legitimate fears about the sometimes worrying ways in which mental illnesses affect people’s behaviour.
One of the reasons why anti-stigma work has so far tended to insist on keeping biogenetic explanations at its heart may be to do with psychiatry’s need to assert its scientific credentials in line with other medical specialisms. I particularly applaud Matthias Angermeyer and his colleagues for drawing attention to this possibility in their concluding remarks. In asking whether the insistence on neuroscientific emphases in public education about mental illness is really in the interests of patients, they show a refreshing humility, which should be welcomed by psychiatrists, scientists, and patients.
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