While attending the 28th Annual Rosalynn Carter Symposium on Mental Health Policy at The Carter Center last week, it occurred to me that mental health professionals are some of the worst when it comes to discriminating against people with mental illness.
They do this in insidious and subtle ways, suggesting a patient can’t do the things others without mental illness can do. Like hold down a job, get into independent housing, interact in social situations or even just go back to school and get a degree.
They also do this in more direct ways, by suggesting to their patients applying for a job or going back to school that, “If they don’t ask about mental illness, don’t volunteer that information.” Why not?
Why are mental health professionals helping to contribute to discrimination and stigma about mental illness by making these suggestions?
I had this insight while Graham Thornicroft, Ph.D., a professor of Community Psychiatry at King’s College London, was giving his keynote. He put up a slide that questioned what we mean when we talk about stigma:
What is stigma?
- Problem of knowledge = ignorance
- Problem of attitudes = prejudice
- Problem of behavior = discrimination
Item 1 is really lot less of a problem nowadays than it was 20 years ago. With the advent and widespread use of the Internet, everyone has access to so much information about these concerns.
Items 2 and 3 are what we are really dealing with today when we talk about the “stigma” of mental illness. It’s really a problem of attitudes and behavior, of prejudice and discrimination.
The last place in the world you would expect to find such problems in attitude and behavior are with the very professionals tasked with treatment of mental illness. And yet such prejudice and discrimination is rampant amongst the profession.
Time and time again, I hear stories of therapists and psychiatrists treating people with things like bipolar disorder and schizophrenia telling their patients all the things they can’t do. Instead of being an encouraging support, they are a wet blanket on an individual’s hopes and dreams (yes, people with bipolar disorder and schizophrenia have hopes and dreams just like the rest of us).
Many Professionals Contribute to the Prejudice and Discrimination of Mental Illness
Both healthcare and mental health professionals regularly contribute to reinforcing the prejudice and discrimination that exists for people with mental illness. Perhaps they do so in a paternalistic manner, hoping to spare their patient the pain of rejection or some people’s attitudes in the real world. But patients don’t want paternalism and don’t need to be coddled. They want support, hope and encouragement.
Perhaps the professional honestly believes the patient is simply “too sick” to participate fully in society. But since there’s no objective measure of what this statement is being measured against, it boils down to this — one person’s opinion.
Here’s some of the statements patients have heard uttered from their therapists’ and psychiatrists’ mouths, and my response:
You can’t hold down a job, it requires a regular commitment. While many people in acute psychiatric distress may indeed have troubles going to a job, usually such features are episodic (and less of an issue when a person is stabilized with a treatment regimen that works for them) — not a permanent character trait of that individual. Many employers are more than happy to make allowances for people with mental illness, if only they’re told ahead of time.
You can’t go back to school and get a degree, it’s too stressful. While people with a mental illness should work to avoid stress, the same could be said of everyone. Once a person finds a treatment that works for them, they should have and be encouraged to experience all that the world has to offer — including an education of their choosing.
You can’t live on your own. While some people make benefit from the routine and familiarity of a group home or living at home with their parents, most people with mental illness don’t need the rigid structure and supervision of such places. Virtually anyone can live independently, as long as they are given the support and encouragement to do so.
You can’t become a therapist or doctor. This is the most frustrating form of discrimination I hear from graduate schools. I’m not sure it’s based on reality, but consider this scenario. A graduate school has two equal candidates vying for one slot. One has disclosed a history of mental illness and successful treatment, while the other has not. Which do you believe the graduate program is going to choose?
Anyone with mental illness can do anything they want in life. The key is finding a successful treatment regimen that works for them, whether it’s medication or psychotherapy or some combination of the two.
Instead of encouraging people to not “bring it up if they don’t,” we should all be talking openly and honestly about mental illness. We are a long ways from the dark times when mental illness can’t be discussed. The people who are often holding us back from the light are sometimes the very mental health professionals who are supposed to be helping.
Encouraging people to hide or be ashamed of their mental illness does not help anyone.
21 comments
Good article. I would only add that the most insidious way mental health practitioners discriminate against clients is through lack of counter-transference awareness, as well as lack of support from management to address it in an ethical manner.
Dr. Grohol
I want to start by thanking you for your pioneering work on the internet. Your site helped me back when I was experiencing the worst of my illness, back in the 1990s.
I think that the stigma generated by professionals is partially connected to the scientific mindset. If you’re scientific, you get rigorous and focused. You need to dominate the variables and control conditions. It’s easy to develop “person blindness.”
“Capacity blindness” has another source, I think. If all you do is serve the poor, and people who have high levels of disease burden, it’s easy to start thinking of sad experiences as “normal for them.”
Even the recovery movement fails at building hopeful futures. People of Judy Chamberlin’s era were so focused on liberation from coercive treatment systems. They took recovery as far as they could given their experiences. The recovery process model was left incomplete. It is as though we climb out of our hole, just to hang around the hole’s edges staring at what we barely escaped, contemplating the bits and pieces of the climbing process.
To get beyond recovery you have to be willing to set a goal beyond the hole, and walk away from the hole, doing whatever you must to maintain your footing.
I think all of this is simpler than our mental health system has made it. Yes, we need treatment, but kindness, friendship and family life deliver meaning and hope. You must look for strengths, with due regard for risks and limits.
Thank you for the opportunity to comment.
–Paul Komarek
What is stigma?
Problem of knowledge = ignorance
Problem of attitudes = prejudice
Problem of behavior = discrimination
It is interesting that you call it “stigma,” it is more aptly prejudice and discrimination.
History has shown us vey clearly it was not the “stigma†of Jews. It is also not the stigma of mental illnesses.
If it is indeed the lack of knowledge, first responsibility has to be higher education, and its graduates.
Harold A. Maio, retired Mental Health Editor
We were talking about this today at a Recovery coaching course I’m running. As a student occupational therapist years ago I was taught not to ‘set people up to fail’ by taking on goals ‘beyond their capabilities’ They had to be persuaded to be ‘realistic’.I have come to see how wrong this is. Who are professionals to know what a person’s capabilities are? What damage is caused by encouraging a person to set limits on their hopes and dreams? As I moved into coaching I discovered the power of belief and expectation, and practical, evidenced -based ways to help a person live their hopes, not bury them.
Exactly. Time and time again, resilient and inspiring individuals have shown the world that the human spirit can’t be pigeon-holed into simple, neat categories.
All too often, I find professionals who look at the statistics or what they were taught about mental disorders from a textbook (or even in talking with other professionals), instead of looking at the person sitting right in front of them. People are not labels — they are capabilities waiting to be transformed.
It’s a professional’s job to help in that transformation. Sadly, too many of them don’t see it that way, and act as a weight on their clients instead of being aspirational and energizing.
Was inspired by what you posted! It helps me start to have more faith in some of the professionals within the Mental Health system after a few years of falling in the cracks with just the same type of training that you voiced in your post. To me, it took courage to be able to write what you posted because oftentimes I have seen it with some of the medical professionals I have come in contact, who talk to those of us with mental health issues, as if we are children and try to refrain from encouraging a person when they believe they can handle things.
I’m doing alot better now with my new counselor and am on very, very small amounts of medication. I haven’t been able to be on medication much since 2006 when the doctors decided that I was experiencing too many allergic reactions to different ones they tried me on. I even tried volunteering for a research program; but my body wouldn’t accept the meds offered so I couldn’t finish the last two weeks due to not being able to take medication.
Anyway, I am glad on joined this forum and will continue to read others’ inputs because you have helped me to have faith in humanity again! Thank you!
As someone who was severely abused as a child, and as someone who has been speaking publicly and conducting research on sexual violence, I have encountered nasty attitudes from therapists/social workers, etc on many occasions. I agree they are the worst, but there are also a few good ones.
It took me decades to recover a life for myself, but I never have and never will identify myself as someone with a mental illness. The ones who abused me are ill, and unfairly I have paid a hefty price which included many struggles that kept me from having a decent life. But I have a good life now, and my first novel *Nickels: A Tale of Dissociation* was published a year ago (and was a Lambda Literary Finalist). Among other other issues, the storyline includes the protagonist having both good and bad interactions with therapists, etc. Keep up the good work!
Great article! In my opinion, however, lack of knowledge (ignorance) is still a problem. While there is a lot of information on the Internet, etc, this information is often misunderstood and the general public still has many misconceptions about those with mental illness (as in they are all dangerous, etc). We still have so much work to do to increase knowledge, and change attitudes and behavior.
Great article overall. What you did not touch upon is how the use of pharmaceuticals contributes to the stigma. The metamessage of taking a psychotropic medication is that the human is organically inept and that by taking a medication his/her functionality will be improved or corrected. I understand that there is not a single piece of research that confirms that any human has organic chemical imbalance and that the use of psychotropics or other self-medication efforts actually causes the chemical imbalances. Psychotropics in many forms provide a tranquilization effect that limits a person’s emotions and functionality.
Thanks John for bringing up such an important topic that is sadly routinely in shadow.
I’ve written rather extensively about this topic. My own experience as both (now – ex) patient and a mental health professional allows for some interesting and sometimes uncomfortable insights into the mental health system in the United States. I find that there is often deep denial among professionals that this goes on. That bias and prejudice exists among the very people who purport to be the helpers.
This bias and prejudice starting kind of hitting me over the head as I started interacting with professionals online. I could change my hat at will…either speak as a “patient” or a “professional.” I found that I was well-respected and engaged as an equal when I put my “professional” hat on. I also found that I could say exactly the same thing with my “patient” hat on and be immediately dismissed…I started experimenting with changing hats…what I discovered wasn’t pretty.
If anyone is interested this is the most comprehensive piece I’ve written on the subject: Bridging Patient-Professional Divide http://beyondmeds.com/bridging/
I don’t think this topic can be covered enough.
My shrink told me I couldn’t have a baby because I have agoraphobia, GAD (Generalized Anxiety Disorder) and panic attacks.
I mean really, who do these people think they are?
If that were the rule, very few of us would have ever been born.
How does my right to pursuit of happiness differ from someone undiagnosed with such problems?
There is nothing wrong with me physically that would prevent me from having children. Luckily, I am very skeptical and do not take the words of “authority” as the last word. In fact, I was offended.
Clearly, some doctors are wrong.
Of course, I can have a baby. Many, with far worse diagnoses than myself, have babies.
Yet I get this attitude often, from more than one psychologist and psychiatrists as well.
We need to trust ourselves and our OWN opinions sometimes. This is certainly one of those times.
Hi Cate:
Well… I agree with your perspective. Anxiety disorders should not prevent you from having a family at all, unless medication or a history of extreme panic attacks could render you and the baby helpless. Some medications can cause conditions in the baby and extreme anxiety can lead to a stressful pregnancy.
In cases of extreme psychosis or hallucinations, it is recommended that these individuals reframe from having children. This is not simply because of the mental illness, but because individuals with chronic, severe, and untreated psychosis or mood swings have trouble caring for themselves and sometimes end up homeless. The baby born into this situation can be terribly neglected. Because we therapists are also advocates in many ways, we sometimes recommend that families and individuals consider how a baby will impact their life and struggle with mental illness.
Mental illness does not stop you from living life in many cases, but there are those few cases that require an altered lifestyle. This is simply for the protection of the person struggling with the mental illness and those attached to the person, including a baby.
I hope this makes sense. It can be hard to wrap your mind around and even accept. If you have been born with the genes that make you vulnerable to severe schizophrenia, you do not want to hear that you should not have a baby or a family. But sometimes due to medication, lack of treatment, and the severity of the illness, this is best. Consider John Forbes Nash, Jr. He was a great genius, but his family life was often stopped by his mental illness. Google him.
When people say this, it makes me wonder if they would say the same thing to someone with a physical disease such as cerebral palsy. I’ve never heard of it, but there seems to be a lot of eugenics-type thinking coming from supposedly professional doctors about people with severe mental illness should kindly weed their genes out of the general population, as if that alone would prevent new people from getting the disease — it’s thinking along the same lines that straight people never produce gay people, and with the same level of prejudice. “Think of the children!” is the rationale given, but I can’t think of people, say, with serious cancer or heart disease being told the same thing, although deaths and disability from cardiovascular disease and cancer far exceed disability from mental illness. This is probably because CVD and cancer are more common, and can be talked about without prejudice.
The Nazis thought the same way about the mentally ill, and they and killed/sterilized mentally ill people much as they did the Jews. They would tell you that it was for the best, right? I mean, they were suffering. *shakes my head*
As for John Nash: Dr. John Nash had kids and won the Nobel Prize in Economics. He’s still publishing papers in his field. Good for him! Sure, Nash is disabled, but he’s also had a full life. Why shouldn’t anyone else?
http://www.nobelprize.org/nobel_prizes/economic-sciences/laureates/1994/nash-interview.html
Welcome to the outcome that managed care and the pharmaceutical industries have forced on the system.
Chip away at what clinicians can treat, and then what interventions they can use, and voila, you have the mess we are in now. Now that Obama will be in office for another 4 years and PPACA can be entrenched for the country, let me remind you all that psychiatry will be basically extinct by 2016, that non psychiatrists providers with prescription pads will be the primary treatment providers for more than 75% of mental health care needs, and therapists will have Treatment Plans that will limit therapy visits to less than 10 visits a year.
Welcome to the demise of effective care by the next presidential election. Oh, that is if society lasts to then to appreciate any opportunity for real hope and change. Hey, you who voted for Obama, thank you for your choice! Not that Romney was a real alternative anyway!
And to all of you who laid silent while managed care decimated mental health care interventions, thank you for your silence and lack of advocacy. Sorry I can’t type this in the most overtly sarcastic font one could use!!!
Good Article!
I always tend to look at things critically and consider what other sides of the coin might be useful to bring up. I was thinking more in depth about the statement: “You can’t become a therapist or doctor.”
I wonder if this statement is a bit too broad or black and white and doesn’t cover the gray. Unfortunately, I have seen quite a bit of colleagues and former graduate students enter the field of psychology having had a prior battle with mental illness, trauma, or extreme abuse. Were they the best therapists? No. But they are in the field! Were they capable of getting an education and utilizing their knowledge? Yes. But they couldn’t always offer compassion or true concern because of their experiences. The mere existence of a mental illness should not preclude one from pursuing the field of counseling and psychotherapy.
However, there is a dark side and we don’t talk much about this because we are focused on “anti-stigma.” Anti-stigma for me includes educating people to reality, not skewing the perspective. The dark side includes individuals who:
-Did not successfully complete any type of therapy
-entered therapy and “graduated” as having made progress because they achieved one or two goals
-does not respond well to psychotropic medications such as in the cases of resistant psychotic disorders
-does not believe therapy is required for their issue
In addition, chronic, long standing mental illnesses (like Schizophrenia or Bipolar disorder) or behavioral patterns (such as borderline personality disorder) is also an issue. I have heard of colleagues who do not like to be touched, hugged, or simply called “dear” or “sweetie.” One colleague responded negatively to an elderly woman who called her “dear” at the end of her therapy session. She stormed into my office and criticized the woman for 20min!
I suppose I am saying that realistically there are some issues that preclude some people from entering the field of counseling. EVERYONE is not called to be a therapist! Even if the person has a strong desire to help others, therapy may not be the avenue for them!
We ALL experience trauma, heartache, and psychiatric illnesses. We don’t want to stigmatize or discriminate, but we also want to be open to reality.
Should Jeffrey Dahmer have become a therapist?
Food for thought
Years ago when I was a young attractive college educated working mom in good shape who was in a very bad marriage, I know the PhD psychologist and Psychiatrist only had the best in mind for me when they worked together with my primary doctor to get me to apply for SSDI. But that was the single greatest harm they did to me. Not that they meant to, what they saw in front of them was a terrified young girl on the verge of disapearing. To the rest of the world I was maybe too thin but a bright leader with the world in front of her. Being consistinly told I could not work that I needed to go on SSDI because work was too much for me, I was too sick by professionals was devasating after working my entire life to combat discrimination against my deafness. Coupled with the abuse and memories I took it to heart. Many years later after fighting off multiple psych drugs, their side effects and finding that I can not tolerate anti-depressants in any form I found myself facing a set of far different “professionals”, ones who judged me before even seeing me, I was that middle-age self entitled non-working dependant who was non-compliant. As far as anti-depressants yes they were right(if they would ask past MDs and Pdocs they would have evidence not just my MI word), and yes I was middle age but I was free of work not by any choice of mine. I long ago used up all the “cushion” of trial work months and was pentilized each time I took a full time job and lost it. And lost it I did, mostly because my self esteem is gone. I’m nearing the age people think of retirerment and I’m still trying to get work. I know SSDI is a good thing, and it did help but it came with the statement I wasn’t good enough to work. Thats the part that disabled me, not the deafness, not the MI. They wanted to protect me, but it is not the job of doctors to protect the clients, their job is to support and listen and build a person up so that they can go on with their life, not insulate them form life.
What I needed was a safe place to figure out what to do, I needed to work for the core of myself being. If the message had been instead of “you can’t work,” “you are too sick” but, “you need a break” “You need some time for you”. If back then there had been a way to get out of that system once you were in, a way to get back to work instead of the almost instant discrimination I got from every ER, every doctor, and subsquent mental health workers from seeing the labels and SSDI compound prehaps I would have been able to be a more worthy member of socity today. It is somewhat better in someplaces, strangely, I’ve seen more improvements amoung the attitudes of those working in ER’s and other medical professions than I have amoung those in the mental health field that treats those who are most in need.
As for information/knowledge being out there, yes it is. But it is so intermeshed with mis-information and myths of the media that many people often have the wrong information. Once a prejudice is formed it is very hard to change even with facts, prejudice has more to do with feelings than ideas.
The greatest action/behavior that hurts is silence and inaction. Those who do nothing, see nothing and do not speak up while others are harmed and they know of it. While being abused in a hospital nurses and aids gave me their phone numbers and said if I could excape they would help hide me, but would say nothing to officials for fear of their jobs.
pls excuse the spelling tonight.
I would like to thank you for this article. I experienced a hypo manic episode about 10 years ago due to taking an antidepressant (celexa) for PMDD. I did well on 10 mg. Although it felt as though I would benefit with an increased dosage. This was prescribed by my PCP within one week of the increased dosage I became manic.
I was 34 with no family history or prior shifts in mood regulation.
I was working as an assistant case manager for people living in there own apartments with developmental disabilities and co-occuring mental illness.
I went out on medical leave my direct supervisor went to the hospital and I was not myself very drugged due to being put on antipsychotic drugs – mania and Ativan. I signed a document and was promised employment upon my return.
I was given a fill in spot for 3 wks and told to apply for other positions. I applied for 12 open jobs and provided 2 letters clearing me medically to return to work. These were all jobs that I was qualified for after using my short term disability benefit.
I received no response as they all had to be processed by HR.
I finally applied for a job within the same agency and emailed my resume and letter of interest to the direct manager of that program and bypassed HR.
I was interviewed and hired. It worked as a lateral transfer and for the past ten years have been successful with no problems or complaints and excellent reviews in my personnel file.
I have been working in the division that deals with Major Mental Illness and co-occurring addictions in a residential home that includes a 24 hr. Shift followed by two 8 hour days we are allowed to sleep. From 4pm to 8am this involves single coverage.
I have dealt with some significant behavioral challenges and have more than shown professionalism and competence and have received great feedback from residents- guardians- family members of residents – coworkers- local corrections workers when services are intertwined- as well as police- nursing and psychiatrists.
I now have a total of 26 yrs. experience.
I was ready for a change and applied for a job through Developmental services for an assistant case manager position as I am ready for a change and I am tired of the overnight shift.
I received an immediate call and had an interview with the assistant director of Developmental services as well as the person that would be my immediate supervisor. I had a great interview and both were very interested. Both of the interviewers remembered me from my previous employment there and acknowledged that they were very pleased that I had applied they were aware of my past history when I left 10 yrs earlier.
I was told that I would receive a call If the Director would like to Interview me. This is the standard process and the final interview is basically a formality.
The director of this division was aware of my history as well as it is the same one from 10 yrs.ago.
I still have contacts that have continued to work there and was told by a former colleague that others that had applied did not have the same level of experience/ credentials (much less)
The director said no to me transferring back to that division (pay would have been the same as I receive now) and did not offer further explanation.
I was always in good standing with the director when I worked there in the past and never had any conflicts.
I did not get hired for this position. It simply is not worth trying to make an issue out of this and my contact is a friend as well whom could be at risk for termination and trusted me.
I have not had any psychiatric problems or taken any medications for 10 yrs. I was diagnosed with bi-polar type 3 (symptoms only when undergoing SSRI treatment)
As far as I am concerned there is no way to differentiate bi-polar type 3 from a side effect.
It is simply astounding that after all this time this Director could be so ignorant and continue to stigmatize to the point of not even giving a thought to equal opportunity.
I am through the initial sting and am grateful that I have DBT and CBT skills in order to use as coping techniques with that being said it is so discouraging a very defeating and unfair feeling when I don’t even have a Mental Illness in a traditional sense.
I had a chemically induced reaction. Even if it wasn’t I do not have any symptoms that would interfere with work performance.
This article was definitely very interesting. I have a question. First of all, how can we distinguish between symptoms of any particular disorder and stereotypes about that disorder that contribute to that prejudice? After all, without the DSM-5, how would mental health professionals be able to prescribe the right kind of medication? Of course, I am well aware that medication is only one tool that is used in the recovery process. I am just saying that anxiety and panic attacks have a nasty tendency to limit a persons ability to communicate effectively. However, I totally agree that there is a lot of stigma and discrimination against people in our society today. Unfortunately, though, just because there’s information available doesn’t mean that people bother to access it. That’s the thing about prejudice-it’s part of a persons value system, so people don’t usually bother to question it.
One thing stood out in this piece for me, and that was the part referring to not disclosing a mental disorder/disability when seeking employment. It’s been my experience as a layperson that checking that box indicating I do have it has reduced the number of interviews that I get. Likewise, disclosing my mental disorder (autism) has made me a bit or a target and may have gotten me fired. I cannot prove it, though, so I can’t even go into arbitration. Finding another job has been extremely difficult even in a good job market, so I decided to not disclose the information in this round of submitting job applications. While I have yet to receive an offer, I have been landing an interview for every ten applications I’ve submitted. That’s way better than the 1/25 ratio I saw in my last round of applications. My point is, I can understand why mental health professionals would advise someone to avoid disclosing a mental disorder in a job search. Keeping that information on the down low may actually help someone obtain gainful employment and thus be able to lead an independent life.
I have had an anxiety disorder and intermittent agoraphobia since my late teens. That is some 40 yr. now. I have seen every psychiatrist and psychologist in my area and never really felt they understood me. I would rant, cry and break down at my sessions and they always seemed to be muffling yawns while I talked incessantly.
I never really thought about getting cured from psychiatric visits, till my adult son said ” mom, does anybody get cured seeing a psychiatrist?”…good one. I never got better by seeing them and I had two episodes in the last few years where I encountered them on the street and I said “hi” and they shunned me. These were doctors I had seen for decades. I was literally blown away at their “judgement call” on me.
I told my psychiatrist I thought he was a wet blanket long before I read you use that word here. He clearly takes offense and does his very best to convince me he is being “encouraging” rather than the opposite. He thinks he’s always right. I never seem to win any argument with him.
I’ve been on some type of disability for most of 10 years now. SSDI for 5.5 years. Yes, I do have breakthrough episodes now and then, but I haven’t had to be hospitalized for 5 years. I have been adding new responsibilities to my life, and my psychiatrist isn’t completely against them, but he wants me to take things “One day at a time”, and make progress so slowly. I get excited about new things, and he seems convinced I’m hypomanic so he tries to douse out my excitement with a pail of water (figuratively). This seems to influence my therapist and my husband too. On occasion I do get discouraged and it affects my productivity. But I bounce back on my own, because deep down I’m a very ambitious person. And I really hate this life on disability.
I want an encouraging cheerleader, but are my expectations maybe too much? What level of cheerleader is appropriate for a psychiatrist (and therapist)?
I really needle my psychiatrist sometimes about his wet blanket ways. I don’t want to go too far. I won’t leave him, because he’s such a great doctor otherwise. I’ve been going to him for 10 years. That’s much longer than I’ve stayed with therapists. I’ll admit I have a transference love for him, and he knows it. Sometimes I think he has a similar countertransference, but he works very hard to suppress it. But I can tell anyway. He’s old enough to be my father (around 68). He does act paternalistic towards me. Sometimes I think he’s probably a wet blanket to his children too.