I’ll get back to part II of Good vs. Evil next time. But before I do, I wanted to share a realization I recently had.
Psychological misinformation and the vilification of stigma
You may have to bear with me on this one. I’m sharing a perspective I have never heard voiced before. All I ever hear are two camps of perspectives. First, the camp I’ve generally been a part of: those against stigma. More or less, waging a crusade against it. And second, those who voice stigmatized beliefs or discriminate based on it. The second camp is much more conceptually diverse, because the range of beliefs can be infinitely broad. Regarding mental health-related stigma, people in the mental health community view themselves as needing to educate people about how stigma is wrong.
Defining Stigma
The World Health Organization defines health stigma as, “… the negative association between a person or group of people who share certain characteristics and a specific disease” (WHO, 2020). Stigma then produces harm through discriminatory action towards those people. When it comes to mental health, this means beliefs about people who have or are viewed as having a particular mental health condition.
With regard to the diagnosis of schizophrenia, for example, Charlene Sunkel, founder of the Global Mental Health Peer Network and co-chair of the Lancet Commission on Ending Stigma and Discrimination in Mental Health, writes, “It is amazing how people react the moment they just hear the word…. They are afraid of you because of this whole false perception that we are dangerous, we are unable to think, unable to work – that we are basically useless.” (WHO, 2024).
This puts the concept into the realm of fact and fiction: here’s what’s correct, and here’s what’s incorrect. If someone is enforcing something incorrect on someone else, – like denying a person with a schizophrenia diagnosis a job because of these misperceptions – then of course we need to correct it.
This all seems obvious, right? So why am I even bringing this up?
Stigma: Psychological Misinformation
Belief 1: Mental health is a normal state
Unfortunately, the definition above contains problematic assumptions. First and foremost is the definition of health or mental health. There is the belief that “health” is a stable norm that everyone has until “disease” sets in. (See my post here.) Mental disease, in turn, is varyingly taken as about how one is feeling, or how one is behaving. And then, the assumption that these issues are due to miswirings in the brain, creating psycho-behavioral events that are separate from the rest of the person, from other people, and from society. The idea that certain emotions are unhealthy is highly problematic and illogical. Addressing this is the basis for many forms of psychotherapy. And the idea that there are unhealthy ways to behave misrepresents socially constructed ideas as individual and medical.
When the mental health community itself is promoting or endorsing this misinformation, such as through putting across socially-constructed diagnoses as biological fact, how you understand the resulting stigma takes on a different light.
For example, in the same news release quoted above, Sir Graham Thornicroft, Professor of Community Psychiatry at King’s College London and other co-chair of the Lancet Commission, describes the following scenario: “Let’s imagine that a person who has depression develops severe pain in their stomach. They go into an emergency department. The doctor looks at the patient’s case records, sees that they have depression, and says, ‘It’s all in your mind’. On this occasion, it’s actually an appendix that’s about to burst, which could be a fatal complication.”
Where is the stigma coming from?
Most definitely, I believe this hypothetical doctor is using prior beliefs to make a big mistake. But where do these beliefs come from? While not directly in the criteria for a depressive episode, such “somatic complaints” are very common for people with this diagnosis. By believing depression is a psychological disorder, and that you can separate mind from body, you get the idea of “psychosomatic” symptoms. The notion that something can be ‘felt’ but not really ‘there’ (“It’s all in your mind.”) Sir Graham’s erring physician is simply following what they’ve been taught.
Whoa… stop right there!
Hold on, you say… aren’t I just doing the same thing that I’m arguing against? Just re-defining which beliefs constitute the stigma?
Belief 2: Mental Health is best looked at as a true-false binary
Thank you for pointing that out! Yes. You’re correct. Which leads to the second assumption: that this is a true-false issue. Psychological science is, ultimately, not about universal human truths. It is about layered, relational systems. At this time, in this setting, these factors interact in these ways to produce this series of cause and effect. You change one of those factors – like, let’s say, the culture of the people involved, or whether this event is taking place in 1925 or 2025 – then that ripples out to change cause and effect across the whole network. This is even true within one person.
Think about it: someone steps on your toe today, you won’t react the same as when you were 3 years old. Depending on your culture, or your social status, or what era you’re living in, there will be many different takes on whether the response you ended up giving represents justice, or assertiveness, or avoidance, or prejudice, or vindictiveness, or psychopathy (or many other potential interpretations).
Stigma scenarios are multifactorial and probabilistic, not true-false
The person making the stigma-based action is subject to all of these complex factors. As is the person they are making it about. The result may be true-false – the doctor’s interpretation either catches the burst appendix or misses it – but their decision-making process is not. It is probabilistic. Day after day, we are forced to make countless probabilistic choices. When do I need to leave to get to work on time? What should I order for lunch? If I go down this street that doesn’t have many people on it, will I get hurt? Is it safe to go near that person on the train who seems not to have showered in weeks, and who is muttering to themselves?
These last two scenarios create a specific problem, that encourages stigma. If I choose avoidance, I’m likely to feel less anxious and have a positive outcome (I’m safe). This, in turn, reinforces the original idea that that street or person was dangerous. Especially for someone viewing this as a true-false situation. Viewing the related stigma as false ignores the validity of this learning, and misses the point.
What then?
Motivational Interviewing: “Rolling with Resistance”
One potential way out of this problem comes from Motivational Interviewing (MI; Miller and Rollnick, originally 1991). MI was originally designed to help people caught up in one of the most ‘stigmatized’ areas: substance misuse. People caught up in this often get viewed as weak, selfish, or simply bad by many people around them, including family and even mental health clinicians. This is why, historically, people have often looked outside of the mental health establishment, such as to the Anonymous communities. What contributes to leading them there is that common mistakes compound on each other to where people get into a battle over who they are. Mental health clinicians enter into this battle and, with the above assumptions, immediately find themselves with an impossible task of saying the person is helpless (it’s the disease, not the person’) and in control (‘you can change’). How can that be?
MI recognized that these are not opposing truths, but synergistic contextual perspectives. This is the heart of their concept of “rolling with resistance.” There are parts of the person’s experience that are automatic reactions (not in control) and there are parts that the person observes before reacting (changeable). These parts are not fixed, but change over situation, time, and learning. By recognizing the validity of the resistance to change alongside the motivation, MI enables the person to understand their situation and how to tackle it differently.
We can do the same with stigma.
Rather than trying to “End stigma,” like that Lancet commission says, we can roll with it. We can recognize the valid perspectives present within the stigma and find ways to work together.
Looking at stigma differently: Back on the train
Think about the example of the person on the train. If we assume that this person is muttering to themselves because of psychosis (itself a complex, socially-mediated probabilistic assumption, but let’s assume they are for now), then we can say a couple of things. Research shows that people who experience psychosis also experience a high level of violence towards them (e.g., Maniglio, 2009). There also is consistent evidence that people who experience psychosis are a bit more likely to act aggressively than the population norm (e.g., Fazel et al., 2009).
Now, rather than trying to argue one or the other, let’s recognize the validity of both. One way of understanding this data is that yes, if I am around that person on the train, they are a cue that this is a situation where someone is more likely to get hurt. But the perpetrator of violence may be more likely to be me.
Ending thoughts
Unfortunately, I’ve never seen this idea of joining the two ideas together tested, so my idea that there is shared variance – that there is a feedback loop here and that the two evidence bases for people getting hurt overlap – is just an idea. Perhaps whether we are strangers or know each other changes the outcome. Perhaps the stigma itself is jointly created from cultural assumptions.
The main point is that we are all trying to work this out together. Everyone has a role in that. Even those who make the mistake of stigmatizing others. By recognizing the wisdom behind their mistakes, maybe we can understand each other better.