It’s a sobering thought that, for many people who use mental health services, other people’s reactions cause more distress than their original problems. And attitudes may even be getting worse. A recent report from the Department of Health found that whereas in 1997, 92% of people questioned agreed that ‘we need to adopt a more tolerant attitude towards people with mental illness’, in 2011 only 86% thought that we need to be more tolerant. Worryingly, young people appeared to be the most prejudiced.
Relatively static attitudes to mental health stand in contrast to the changes there have been in attitudes about ethnicity and sexuality (we currently have a conservative Prime Minister advocating same-sex marriage). It’s even more surprising given the effort that has gone into anti-stigma campaigns. For example you may have seen the recent tube posters or TV ads from the government sponsored Time to Change campaign. So what’s the problem? Perhaps part of the answer is what campaign ads actually say. Or what they don’t.
Traditionally, public education campaigns about mental health have aimed to reduce stigma. The assumption is that stigma is caused by people not recognising that mental health problems are ‘illnesses like any other’. For Time to Change, as our colleague John McGowan recently noted, they are ‘as real as a broken arm’. A key assumption here is that unless distress is seen as part of an illness, people will blame sufferers for their own problems. Much better then to be genuinely sick.
We’re not sure about these underlying assumptions. Firstly, the very idea of stigma is problematic in that it individualises and medicalises what may be an issue of prejudice. We don’t talk about the stigma of being a woman, or of being black; we talk, quite rightly, about sexism and racism.
What about the idea that discriminatory attitudes are based on ignorance? Many anti-stigma campaigns have aimed to increase so-called ‘mental health literacy’– i.e. education about different mental illnesses. Notable examples of this approach have included Every Family in the Land and Defeat Depression, both led by the Royal College of Psychiatrists. Considerable amounts of money have been invested into such campaigns. However, even their advocates have been forced to admit that there has been little effect. If anything, things have got worse. We think that the reason for this lies in the third assumption. Reviewing the evidence, John Read and colleagues found that viewing emotional distress as ‘an illness like any other’ actually increases prejudice and discrimination. For example, in one study based on Stanley Milgram’s famous electric shock obedience experiments, participants who were told that someone had a mental illness opted to give them more electric shocks than if the person’s problems were described in more everyday language*.
*The study’s authors suggest that presenting problems as an ‘illness’ has the effect of making them seem mysterious and unpredictable, the people experiencing the problems as ‘almost another species’.
So if the traditional approach isn’t working, what’s the alternative? In recent years two related approaches have gained ground. The first draws on an idea from the wider disability movement, namely the ‘social model’ of disability. This proposes that, rather than the problem for people with physical disabilities being the actual impairment, most difficulties lie in the way society organises itself. The classic example is putting stairs everywhere. While this model has its limits, these kinds of ideas were influential in the 1995 Disability Discrimination Act, and led to widespread changes, at least in our buildings. Within the mental health field commentators like Liz Saycehave been influential in applying this model. Mad Prideis a colourful example of an approach that says it’s Society’s role to change. This is not simply a romantic notion that we can wish distress away by challenging discrimination. While some people experiencing unusual and exceptional experiences want to be liberated, others may find the experiences distressing and seek some form of help. What both groups agree on is that discrimination is a major problem.
The second approach is what you might call the psychosocial one. There is increasing evidence that even the most severe mental health problems are not the result simply of faulty genes or brain chemicals. They may also be a natural and normal response to the terrible things that can happen to us. As our colleagues John Read and Nick Haslam have put it ‘bad things happen and can drive your crazy’. To many people this is just common sense. Unlike the illness approach, it makes people’s experiences seem more understandable, enabling people to empathise more.
So we have at least two alternatives to the ‘illness like any other’ approach: a focus on ending societal discrimination against people with mental health problems; and viewing distress as a response to negative life experiences. Although Time to Change does not promote a medicalised approach we think it has missed an opportunity to challenge not only our attitudes but something much more fundamental: whether there are people who are ‘normal’ and people who are ‘mentally ill’ , or whether we’re all in this together.
For those unfamiliar with Milgram’s experiment the ‘shocks’ were fake. Those asked to administer them were not made aware of this until after the experiment had concluded.