Stigma in mental illness: the role of the antipsychiatry movement in the evolution of psychiatry

This week we hear from our vice-president, Hadis!

Patients with mental disorders have an increased risk of developing, and dying from, somatic disorders.1 One of the reasons for this unearths the deep-rooted stigma towards mental health and illness. Patients with mental illness often report feeling devalued and rejected by health professionals in the somatic healthcare system.2,3 Increasing evidence shows that disparities in health care provision contribute to poor health outcomes for those with mental illness;4 For example the existence of mental illness in women with breast cancer is associated with a higher mortality rate than those without.5

Stigma has been defined as existing when:

“elements of labelling, stereotyping, separation, status loss, and discrimination occur together in a power situation that allows them”.6

Stigma may thus be self-inflicted, restricting individuals in reaching out for help, or external (public stigma) that restricts open discussions and implementation of effective community programmes that address mental illness. Stigma therefore bears a major influence on mental healthcare structure and outcomes.

The roots of this stigma may be better explored in the exploration of the movement known as ‘antipsychiatry’. This emerged as an international movement during the 1960s, not as a reflection of the science of the time but more as a political mirror of the turbulence of the period.7 The psychiatric specialty, from the antipsychiatry point of view, was seen as the work of a group of individuals with legal power to institutionalise vulnerable individuals; the existence of mental illness itself was contested. To probe these concerns, Thomas Sheff8 coined ‘labelling theory’- individuals are ‘labelled’ as deviant as their behaviour does not align with what is accepted to be societal norm. Sheff argues that “most chronic illness is, at least in part, a social role”.

During this period of anti-psychiatry’s gain in momentum, this did indeed reflect the mindset of psychiatry at the time that saw heredity as the cause of mental illness.7 There was furthermore a certain pessimism as to the ability to restore patients to ‘sanity’, as well as the adoption of a custodial approach to mental healthcare that relied on the use of physical restraints.

In a way, the antipsychiatry movement brought to life the concerns over the power wielded by psychiatrists over people’s lives, the lack of a humane approach and undue medicalisation of psychiatry. Advocating for respect of the basic rights of mentally unwell individuals therefore became all the more important for psychiatry to consider, ironically as a result of the antipsychiatry movement. However, at the same time, the radical attitudes of antipsychiatry led to attacks on the speciality as a medical discipline, in the process weakening the social awareness of the importance of medical and institutional care for those with mental illness.

After the 1970s, the movement became increasingly less influential,7 despite the ongoing efforts of high-profile celebrities in their affiliation with Scientology, well-known for its opposition to psychiatry and psychoactive medications. Fronted by the likes of Tom Cruise, public comments that reflected the core of the antipsychiatry movement in denying the existence of mental illness, chemical imbalances, psychiatry as a science, meanwhile attacking those seeking psychiatric help contributed to keeping the stigma against mental health alive. However, the attenuation of the movement’s influence developed partly as a result of the reductionistic and politicised understanding of psychiatry, but also as a result of the advances in psychiatry, neurobiology and efficacy of available treatments.

Furthermore, understanding and acceptance of psychiatry is steadily improving, with all-important improvements in community participation and engagement with mental health services. It has been suggested that the more exposure and familiarity one has with psychiatry, the lower is the stigma towards the specialty and those associated with it.9 This has been shown in literature in the context of medical education; the attitudes and perceptions fostered among medical students with greater exposure to mentally unwell patients in clinical practice is hopeful for breaking down the stigma within the profession itself.9

In summary, many of the antipsychiatry concepts, albeit exaggerated and overstated, may have helped set psychiatry on a better path to careful consideration of the impact of the specialty on patients’ lives and the ongoing stigma that mental illness still attracts globally. Continued work, in the education of both healthcare professionals as well as the public, will prove integral to continued destigmatisation of this all-important area of our professional, and likely our personal, lives.

References:

1. Walker ER, McGee RE, Druss BG. Mortality in mental disorders and global disease burden implications: a systematic review and meta-analysis. JAMA Psychiatry. [Online]. 2015 [Accessed 2021 Oct 02]; 72(4):334-41. Available from: https://www.ncbi.nlm.nih.gov/pubmed/23372832/

2. Nash M. Diagnostic overshadowing: a potential barrier to physical health care for mental health service users. Ment Health Pract. [Online]. 2013 [Accessed 2021 Oct 02];17(4):22–26. Available from: https://dx.doi.org/10.7748%2Fmhp2013.12.17.4.22.e862

3. Knaak S, Mantler E, Szeto A. Mental illness-related stigma in healthcare: Barriers to access and care and evidence-based solutions. Healthc Manage Forum.[Online]. 2017 [Accessed 2021 Oct 03]; 30(2):111-116. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28929889/

4. Sølvhøj IN, Kusier AO, Pedersen PV, Nielsen MBD. Somatic health care professionals' stigmatization of patients with mental disorder: a scoping review. BMC Psychiatry. [Online]. 2021 [Accessed 2021 Oct 02]; 21(1):443. Available from: Somatic health care professionals' stigmatization of patients with mental disorder: a scoping review - PubMed (nih.gov)

5. Mitchell AJ, Pereira IE, Yadegarfar M, Pepereke S, Mugadza V, Stubbs B. Breast cancer screening in women with mental illness: comparative meta-analysis of mammography uptake. Br J Psychiatry. [Online]. 2014 [Accessed 2021 Oct 02]; 205(6):428-35. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25452600/

6. Link BG, Phelan JC. Conceptualizing stigma. Annu Rev Sociol. [Online]. 2001 [Accessed 2021 Oct 02]; 27(1):363–385. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8424966/#CR12

7. Pajević I, Hasanović M. Antipsychiatry as the stigma. Psychiatr Danub. [Online]. 2017 [Accessed 2021 Oct 03];29(Suppl 5):890-894. Available from: Antipsychiatry as the Stigma - PubMed (nih.gov)

8. Scheff T. The labelling theory of mental illness. American sociological review [Online]. 1974 [Accessed 2021 Oct 02]; 39(3):444-452. Available from: scheff.pdf (leeclarke.com)

9. Eksteen HC, Becker PJ, Lippi G. Stigmatization towards the mentally ill: Perceptions of psychiatrists, pre-clinical and post-clinical rotation medical students. Int J Soc Psychiatry. [Online]. 2017 [Accessed 2021 Oct 02]; 63(8):782-791. Available from: Stigmatization towards the mentally ill: Perceptions of psychiatrists, pre-clinical and post-clinical rotation medical students - PubMed (nih.gov)