I didn't use to pay too much attention to stigma. I knew that there was a prejudice against mental illness, but I didn't focus on it. Over time, I assumed, in educated prosperous societies, such stigma would melt away. But now I think differently. I think it is the most deep-seated human bias, deeper than racism and sexism. It transcends all cultures and all historical eras, and it happens so insidiously that we don't even notice it most of the time.

Now it expresses itself again after the tragic killings in Arizona, the attack on a congressman and others by an individual with probable mental illness. Yet almost all of the discussion in the media has had to do with this person being "evil"; the president used that phrase over and over again in his memorial. His actions were evil; but the person was sick. Sick, ill, diseased. Yes, I mean a disease of the body, not a "social construction."  (We'll come back to that problem.)

One of many examples of media-based stigma is a Boston Globe article by the movie critic Wesley Morris, titled "The deep, dark chill of a madman's smirk", where the mugshot of the killer is put aside classic movie evil villain pictures, such as the demonic Joker from a Batman movie. The author goes on to talk, as usual, about the "evil" of a "certain kind of madman." Nothing new here: just more of the deep stigma ingrained in the conventional wisdom, a level of unconscious prejudice that makes Selma seem like Oz.

Stigma against mental illness runs very deep, not just among the general public, but among medical professionals:  Medical students and general physicians have the same level of stigmatic ideas about mental illness as the general population. It even exists among mental health professionals: many mental health professionals hold stigmatizing attitudes towards some conditions, such as schizophrenia or bipolar disorder or substance abuse. One even sees it at work in some PT blogs, such as in a recent posting, which claimed that there is great "tolerance" for mental illness now in the US. Indeed, some progress has been made with some conditions, like depression and anxiety, but even then, this is quite limited. The same blogger decries "medical" attitudes as harmful. I'd say the reverse. I think the knee-jerk criticism of medical approaches is itself a reflection of stigma: We think mental illness must be all bad (I disagree; this is stigma), and we see some good features in what is called mental illness (I agree), so we try to socially construct it away.

Let's not forget that the greatest modern advance against stigma, the "moral therapy" of Philippe Pinel, was a consequence of a rejection of non-biological attitudes about mental illness, and a recognition of the biological basis of severe insanity. This medical viewpoint dovetailed with the French Revolution's new approach to human rights, starting the slow - very slow - process of destigmatization which still has so far to go.

This is not to say that we could have easily treated the individual in Arizona, and thus prevented what happened. But we could have tried.

I've been working on a project about mental illnesses being beneficial for historical leaders, and recently publicly presented my ideas at Yale,  where the student newspaper reported on the topic rather incredulously (along with some out-of-context quotations). The idea just seems "illogical"; race-equality also seemed illogical 100 years ago to most people, 50 years ago to many, and still is so today to some.

We're working, as a culture, on racism and sexism; these previously hidden evils - a good word for them - are increasingly hyaline clear. But who's working on stigma? We know advocacy groups like NAMI are, and rare political figures like Patrick Kennedy. But the media and our cultural commentators are, by all indications, about as aware of this problem as a schoolchild is of trigonometry.

Art imitates reality, they say. Our movie critics and cultural popinjays - and even many of us mental health professionals - haven't begun to fathom what this reality is.

Mood Swings

A psychiatrist surveys the mind and the wider world
Nassir Ghaemi

Nassir Ghaemi, M.D., M.P.H.,

is Professor of Psychiatry at Tufts University School of Medicine, and Director of the Mood Disorders Program at Tufts Medical Center in Boston.

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