Tuesday, 10 November 2015

Mental Health Stigma Reduces the Opportunities for 'Success'

Mind, Body and Soul
What do we mean when we imply that people with mental health issues are not successful, as it is often done in some of the psychological literature on the effects of depression on agency? A very powerful talk by Dr Victor Pace (Consultant in Palliative Care at the St Christopher's Hospice) inspired me to think about this question again.

The conference "Mind, Body and Soul: An Update on Psychiatric, Philosophical and Legal Aspects of Care of Patients Nearing the End of Life" was hosted by the Royal Society of Medicine on 10th November. Pace talked about the issues emerging in caring for people with severe mental illness who are also terminal patients. He explained very clearly why people with schizophrenia have a higher mortality rate and die twenty years earlier than if they did not have schizophrenia.

The list of factors he mentioned made me think about one notion of success that is quite implicit in our evaluation of our own lives, and other people's lives. The first factor is unemployment. People who are diagnosed with schizophrenia are unlikely to have stable employment in the ten years following the diagnosis, and unemployment means reduced socialisation, loss of control over one's life, dependence on others, and often poverty.

The second factor that was discussed is lack of close relationships. Being socially integrated matters a lot to people with severe mental illness (they would like to have close relationships) and it predicts reduced risk of suicide. But most of people with a diagnosis of schizophrenia (two thirds) lack social integration, and this causes serious disadvantage.

Thirdly, psychosis is the greatest predictor of premature death, not because of suicide, but because of physical illness, such as high incidence of smoking, diabetes, and metabolic syndromes, which are often made worse by antipsychotic drugs. One reason why physical health deteriorates is that people with psychosis access services late (because they feel they may not be taken seriously and have reduced pain sensitivity or pain expression), and often services are ill-equipped to deal with physical health and mental health as a package.

It seems to me that unemployment, lack of close relationships, and physical illness (and their consequences) are part of our pre-theoretical notion of failure. We see the successful agent as productive, socially integrated, able to determine her own path. What is potentially worrying about this identification is the implicit judgement that the agent is responsible for the consequences of her mental health issues. And this would be mistaken, because as Pace showed in his talk, the three factors he mentioned are due to or made much worse by stigma, that is, by the way society regards and treats people with a diagnosis of schizophrenia. The person with psychosis wants to work, make friends, and be well, but there are fewer opportunities for her to do so because she is marginalised.

The risks of marginalisation and of a "them and us" attitude to mental health are some of the issues I tackle in my latest Birmingham Brief.


  1. I'm interested in your suggestion that we make use of a framework of fundamental assumptions about what constitutes failure and success: employment, social integration, and health. I think it's fair to say the current adult mental health system does not just hold individuals responsible for the consequences of their mental health problems, but also for the existence of these problems (including at the genetic level), preferring individualistic approaches to aetiology and treatment to those that emphasise the social origins (such as inequality).

    I don't think it's only mental health that is being increasingly attributed to individual responsibility and choice. Physical health seems to be too. For example, much current media reporting and public health policy focuses on alcohol use, smoking, over-eating and exercise, and thus people are increasingly being held responsible for such serious health concerns as cancers, heart disease and diabetes. With this, individuals are then, perhaps, held responsible for a fundamental measure of personal and subjective success. And are deemed to have failed.

    Certainly with the implication of responsibility (as well as with the illness itself) comes stigma, and a range of intrapsychic impacts (such as changes to self-esteem and an increase in feelings such as shame and guilt), but also interpersonal impacts, such as withdrawal from social contacts. This (mistaken) shift in the locus of responsibility seems to initiate a downward spiral.

    1. Hi Zoë, I agree with you. We tend to attribute personal responsibility to individuals for their physical and mental health, and for their successes and failures (the causal interconnections among these are not fully clear to me yet, and are likely to be complex).

      One aspect of the talk that really resonates with me is the emphasis on the close relationship between physical and mental health which I fear is being neglected in the current discussions on mental health stigma. I feel strongly that medicine should be preoccupied with persons as wholes. I made this point in a recent Birmingham Brief (http://www.birmingham.ac.uk/research/impact/thebirminghambrief/items/2016/01/mental-health-care-revolution-140116.aspx) and in the most recent Philosofa podcast, with Richard Bentall (http://www.philosofa.org/episode-5-is-there-a-clear-line-between-madness-and-sanity/).