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In discussions of mental health stigma one thing that is often left out is that mental health stigma is not just a clinical or a social issue, it is also an ethical issue.
It is well known that stigma affects people’s mental health, increases their suffering and denies them opportunities in life. But denying a group of people the possibility to pursue life goals because they are unwell goes against the values of equality, respect for human dignity and non-discrimination. This makes the question of stigma an ethical question that needs to be addressed.
So, one question to pose is on whose shoulders does the ethical responsibility lie?
Stigma has many causes that can be found in how people think of people belonging to stigmatized groups. Such causes include the belief that people with mental disorders are violent or irrational, the belief that they are to blame for their condition and could snap out of it if they really wanted to, the belief that mental disorders are ultimately untreatable and incapacitating and so on.
Because of the complexity of stigma the effort necessary to address it requires action from different parties. Governments and different social institutions have to be involved (including for funding research on stigma), and individuals, including the people affected, need to take action. In addition to this though, a large part of the burden falls on mental health professionals—not only because of their professional ethics but, also, because they are in a privileged position to make a difference.
Physicians are bound by an ethical code that requires of them beneficence, non-maleficence, and respect for patient autonomy and justice. The same holds for other mental health professionals, such as nurses, social workers and mental health counselors whose professional codes of ethics explicitly set these requirements as priorities.
The focus is usually given to the first three of these. However, since the aim of mental health care is to help patients overcome the difficulties associated with their disorders that prevent them from pursuing their life goals, the work of mental health professionals commits them to things that go beyond just clinical work—i.e. taking active action to overcome the injustices that interfere with these aims. Indeed, some mental health professionals have been active in forming initiatives to fight stigma, such as the Royal College of Psychiatrists’ Changing Minds campaign and the World Psychiatric Association’s Global Programme against Stigma and Discrimination because of Schizophrenia. Yet more can and ought to be done.
Public health campaigns that aim to educate the public are common in the fight against stigma. For educational campaigns to be effective as much as possible though the information disseminated must be targeted, given by people that the public trusts and delivered in a manner that is meaningful and relevant to the group addressed. This is one reason why the involvement of mental health professionals in the fight against stigma is pivotal: because they are experts that the public trusts. This allows them to play a significant role in bringing about change by correcting false and commonly held stereotypes. For instance, in the media which for many people are a major, or the only, source of information about mental illness.
The media typically portray people with mental disorders as violent, inept or homeless thus fuelling, or sustaining, both the public’s negative attitudes to mental disorders and the self-stigmatizing attitudes of people suffering from them. But the power of the media coupled with the expert status of mental health professionals can contribute to the fight against stigma. Mental health professionals can use the media to challenge hurtful misrepresentations about the level of ability of people with mental disorders—something which is currently primarily done by grassroots movements and organized protest groups like NAMI’s Stigmabusters email alert program. To be fair, some mental health professionals already do this by occasionally appearing in the media. But more can be achieved by a continuous cooperation between them and different media outlets, for instance, serving as advisors for media content that relates to mental illness.
Mental health professionals can also serve as advocates for the rights of the disadvantaged group at a political level. Because stigma is also a political matter, the fact of stigma and discrimination and the harm they do must be acknowledged at an institutional level in order for a more inclusive legal framework to be put into place that will protect the rights of people living with mental disorders. Since mental health professionals know how the system works, they know the needs of patients, they can address and communicate those needs, and can collaborate with other (health) professionals to promote them, they are in a unique position to advocate for political change.
But the responsibility of mental health professionals does not stop at their patients. Studies show that a large number of mental health professionals hold stigmatizing beliefs and share many of the attitudes of the public when it comes to psychiatric disorders. These attitudes need to be acknowledged as the problem that they are. Mental health professionals need to be educated about them and be helped to identify them because such biases affect therapy and the general medical attention that patients receive.
In general, since mental health professionals are the experts that people suffering from mental illness will turn to first, often at their most vulnerable, their approach and advice must be well-informed on the question of stigma. This need creates the requirement for improving their training. Education about stigmatizing attitudes within and beyond clinical practice, as well as their causes and their effects as social determinants of health should be incorporated into the curriculum of mental health-related studies and training programs.
This highlights that, beyond the central role that mental health professionals need to play in the fight against mental health stigma, a lot more needs to be done if we hope to effectively address it. And, since the ways stigma arises and is sustained are multiple and often not well-understood an interdisciplinary approach seems necessary. Psychologists, psychiatrists, philosophers, sociologists are just some of the researchers from different disciplines that can work together to study the different mechanisms that give rise to stigma and to find ways to mitigate it.
An instance of such work is the Perfect Project at the University of Birmingham where philosophers and psychologists are working on challenging the common association of mental illness to irrationality—an association that has ethical and social ramifications for the people living with mental disorders. Work of this kind on associations frequently made that result in, often unconscious, biases can challenge the alleged grounds that exist for stigma and thus help in the fight against it.
To conclude this very wordy post, if our aim is to create a more inclusive moral framework in which the rights and needs of people living with mental disorders are respected, the people whose job it is to take care of people with mental disorders ought to be at the center of the effort to change stigmatizing attitudes. They need to actively take up the injustice faced by their patients, act as their advocates and promote self-care and independence.
