Wednesday, March 18, 2020

This is the Stigma

Olivia Mohtady

There is a lot of talk about The Stigma surrounding mental health, yet this is something that has not been well-defined within the endless articles, popular memes and psychological literature surrounding the issue. Not only that, but the themes and cliches that are shared and re-shared amongst all this well-meaning media are often patronising and unrepresentative of everyday experiences of mental health and stigma.

In order to fully support people with the range of difficult experiences that can affect the human mind and self, it is important for all of us to consider what barriers individuals might face in terms of changing their circumstances. Understanding and defining stigma is therefore something that should be the forefront of the mission of any leader, health professional, writer, or indeed, human.

The thing about stigma is that it is less often the brash words and actions that are exposed in media stories. It is not a stranger at a dinner party loudly announcing that people with mental illnesses are a waste of space. It is not a manager discovering their employee is depressed by a recent bereavement and instantly firing them. Sure, these acts are highly stigmatic, but such outright insolence is easy to pinpoint and address. Fortunately, society has evolved enough to have laws and social norms that prevent or at least condemn this kind of abrasive discrimination.

Commonplace stigma is not so straightforward. It is subtle, nuanced and frequently disguised by good intentions.

Stigma is an employee struggling to get to work because of an inexplicable sense of dread that they do not think they could even begin to explain to their manager.

It is somebody recently diagnosed with obsessive-compulsive disorder being sent a meme by a close colleague. The picture is captioned ‘We’re all a bit OCD’ and shows a smiling celebrity arranging a line of pencils. The recipient forces themselves to respond with a laughing emoji, feeling bad for the way their heart sinks at their friend’s well-meant attempt at empathy.

Stigma is not somebody standing on a bridge and being urged to “jump” by a bystander. It is somebody crying on a station platform while passers-by pretend not to notice.

Stigma is not a best-selling author revealing that their recent work was produced during an opportune manic episode, to the delight of their fans and the dismay of one critic. It is an aspiring writer, who has never quite finished their book and wonders why their despair does not make them creative too.

Stigma is not a worried family. Stigma is a person who feels their anxieties are not the right fit for their community or culture, who blames their recurring GP visits on “headaches” when asked by loved ones.

Stigma is not just being reluctant to talk about an issue, before deciding to seek support and consequently receiving adequate care. Stigma is really, really wanting to talk about it, trying to talk about it, being sent down the wrong care pathway, not being listened to, receiving an inexplicable diagnosis, sitting on waiting lists, finally being seen for six therapy sessions that cover one percent of the issue, and being discharged back into world that still does not feel safe...stigma is not wanting to talk about it anymore.

Stigma is not a health professional who is denied healthcare. Stigma is a health professional who is burnt-out and stressed, who is urged by those around them to seek help, but who does not have the time or the drive to prioritise their well-being over their patients’ care.

Stigma is not just about mental health. Hannah Jane Parkinson really hit the nail on the head with her article examining the popular analogy of mental illness being like a broken leg. She is right to fault this comparison for its simplicity. The fact is that most illnesses are not like broken legs. Chronic fatigue syndromes, cancers and auto-immune diseases are complex. They have unclear causes and unknown cures. They are widely misunderstood and misrepresented in the media, bestowing an extra emotional burden on the sufferer.

Feeling that one’s diagnosis is the wrong type to merit empathy and understanding from society is an issue that goes within and beyond mental health. What if you did smoke before you got cancer? What if your bipolar depression does not involve periods of intense productivity? What if you are not suicidal or breaking down in the street; just a little sad and listless, all day, everyday? What if it was your choices that led you to develop an addiction? What if your addiction damaged your internal organs?

Stigma in the media is about somebody else and what unreasonable thing they said. Real stigma is about the self. It is about the experiences of illness or sadness that we have been made to feel we cannot share; the care we feel we do not deserve. Crucially, stigma is founded upon the shame we feel about our own suffering.


The origins of shame

“And you know what wickedness is, and shame, and fear. There were days when you peered into yourself, into the secret places of your heart, and what you saw there made you faint with horror.”
Jean-Paul Sartre

To be ashamed is to be human, according to philosophers such as Jean-Paul Sartre. Sartre suggested that we feel shame because we objectify ourselves under the gaze of others, becoming hyper-aware of our shortcomings as a result of imagining ourselves as the subjects of others’ judgements. This leads us to self-stigmatise before anyone has even uttered a word.

Of course, our fellow humans may well be judging us, but the crucial factor is whether we internalise this social stigma, rather than the social stigma in itself.

This is not to say that public or social stigma is not entirely relevant: Self-stigma is related to the prejudices that a person believes could be directed at them by the communities they belong to. The shame a person feels about a mental health issue or illness therefore varies considerably across cultures and gender.

Sir Graham Thornicroft is an expert on stigma in the field of global mental health. His global study on experiences of stigma for individuals with a diagnosis of major depressive disorder is an important demonstration of the dramatic consequences of stigma. The most interesting aspect of this study is how much anticipated stigma caused individuals to censor reaching out or discussing their feelings.

Even where there had been no experiences of stigma, many participants in this study experienced significant anxiety about maintaining their job or relationship if they disclosed their diagnosis. This shows just how far-reaching stigma can be: It is not one personal attack, it is a fundamental collection of attitudes that underlie the very fabric of our lives.

The prevalence of self-stigma and shame in medical contexts has become a growing area of study in psychological literature. Psychologists have begun to identify unhelpful narratives surrounding illness that cause negative attitudes towards the self. For example, framing the approach to an illness as a ‘battle’ only risks the sufferer identifying as a ‘loser’. Drawing an analogy between depression and a broken leg implies there is a simple ‘fix’ to one of the most dynamic human experiences to ever take hold of a person.

The evidence nowadays points to a relationship between the amount of self-stigma felt by a person and how much help they might seek for their mental health difficulties and everyday human experiences. It is therefore imperative to break down stigma as far as we possibly can as we go forward with conversations about illness, mental health and everyday human suffering.  


How we can break through stigma

Shame and stigma are two sides of the same limiting coin, with judgement being at the root of both. We cannot help it if others judge us, but we can learn to show less judgement and more compassion to ourselves and others. This might help begin a cycle of validation and acceptance for a broad spectrum of human suffering, rather than the pigeon-holing and stereotyping that currently exists for the select few problems that are deemed to be worthy of media attention and glorification.

Professor Paul Gilbert offers an important introduction to compassion as an antidote to shame. His strong recommendations for kindness and acceptance in conversations about health and illness suggest that simply sharing our experiences is not enough to break down stigma. Brazen analogies and cliches are only going to undermine problems that need careful validation and support. Normalising despair only sustains the myth that people have to live with it. Announcing a sense of pride in having befallen an unfortunate event or symptom makes no sense in the context of an ashamed society. Clearly, not all illnesses and issues are created equally, so it is unfair to throw them all under umbrella terms and buzzwords.

We need more language, not more labels.


How far we have come

It has become increasingly important for all of us to give due attention to some of the issues highlighted in this blog, especially when it comes to the workplace. More than ever, leaders and managers need to set an example for having conversations around mental health stigma. Staff must be given the voice that they deserve to share their ideas and concerns; with leaders offering an open, empathetic stance as a first course of action.

None of us are perfect here, and how can we be, with so few terms and phrases available to us in this ‘mental health’ context? However, there is a growing body of individuals who are trying to give human suffering the voice it deserves. Journalists are writing, writers are blogging. Instagrammers are posting. Scientists are researching. Health professionals are tirelessly trying to give their patients the compassion and validation they need; to value the discretion sought by the client in the context of their culture or community.

We may not always get it right and our analogies may be very flawed. The point it that many of us are trying. The more conversation there is, the more likely society is to develop a sophisticated vocabulary for pain, shame and sorrow.

This is something to hold onto. Everyday, there are more and more opportunities to join a collective voice: A voice that, with each mighty effort, chips away at these elusive twin demons of shame and stigma.

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