Dr. Patrick Corrigan is one of the most eminent researchers in the field of mental illness stigma. He recently published an editorial that captures a salient yet relatively under explored tension related to mental illness stigma education and awareness.
Dr. Corrigan suggests that education programs to reduce stigma either emphasize normalcy or solidarity. Normalcy describes universal humanism and attempts to destruct stereotypes by emphasizing commonalities. An example could be social-contact based interventions where patients with lived experience are brought into contact with providers to share their stories. The problem with social-contact based interventions in healthcare, however, is that they work best if providers and patients are working towards common goals and there are diminished power differentials between them. Similarly, those of us who work in healthcare would agree that professional training is essentially experiential learning through social contact. Yes, social contact can be useful if someone who looks like me and talks like me comes in to tell me that I should see beyond their mental illness, however, if there is someone who does not speak the same language as me or are from a different generation, their story will have less impact. Also, if the contact is with someone in a distressed emotional state or during a period of altered mental status, then perhaps contact could actually reinforce negative stereotypes about patients with mental illness.
In contrast, solidarity celebrates difference and reconstructs shame into pride. For example, after a recent series of tragic youth suicides in Woodstock, Ontario, Canada, youth came together under the slogan, “it is ok to not be ok.” Even though solidarity can help bring the issue of stigma out of the shadows, individual comfort with open disclosure varies considerably. While a sense of pride in one’s illness can be inspiring and empowering when they are doing relatively well, there may be more internalization of shame when they are doing poorly. In order for solidarity to foster a respect for mutual difference, it needs to take place in a culture that is open and safe. In some situations, opening the conversation before everyone is ready can actually be painful and produce unhelpful outcomes.
If we know the best educational interventions emphasize social contact, yet social contact can actually reinforce stereotypes, what can we do about it? If we know that solidarity can work for some but not for all, how do we incorporate it? Finding a balance between these two opposing concepts is essential to move mental illness stigma research into the future.
While there are no easy answers, my area of research proposes reconciliation through an interesting idea…the unconscious.
As a stigma researcher and practicing psychiatrist, I have devoted my life to serving the underserved and fighting against stigma. When I took the implicit association test regarding mental illness for the first time, I learned that I moderately associated mental illness with dangerousness. The test measures the strength of associations between different concepts. You can try it for yourself on the Harvard website. I was forced to reflect on some serious questions: how would I feel if my next-door neighbor converted their home into a group home for individuals with severe mental illness? If someone applied to baby-sit my children and I learned they had a history of self-injurious behaviour, would I judge them negatively? The answers did not always make me comfortable.
Maybe we can balance seeing individuals with mental illness as human beings deserving of compassion while accepting responsibility for our unconscious judgments that have a negative impact on their care. Despite our best intentions, many of us unconsciously and automatically label patients with mental illness in a healthcare setting as dangerous and unpredictable (or even time consuming and unfixable), which leads to discriminatory behaviour. For example, well meaning providers can potentially ignore someone in emotional distress while responding to someone else is in physical distress. The system also demonstrates numerous instances where well trained providers with consciously formed professional and egalitarian goals may still erroneously attribute physical complaints to psychosomatic etiologies.
I believe that a shift in stigma eradication initiatives towards promoting conscious awareness of implicit stigma can potentially change our attitudes by fostering a sense of responsibility, rather than guilt. After all, no one is immune from unconscious bias.
Focusing on unconscious processes also opens us to appreciating more nuanced situations when our positive bias towards patients can demonstrate destructive consequences or when our negative bias can promote safety. When I conducted a seminar about implicit stigma with third year medical students in their psychiatry clerkship, the students were assigned to take the implicit association test and many of them asked, “why is psychiatry the only rotation that gives us panic alarms?” Responding to this challenge in a safe, non-judgmental and open manner is essential. Students may demonstrate a “kickback” if their biases are challenged too aggressively, leading to counterproductive outcomes. It is possible to emphasize that awareness of both positive and negative impacts of our unconscious judgments can help produce more humane and compassionate patient care.
In the end, reducing stigma is all about balance. In our current system, the negative consequences of stigma are destructive and require action. The status quo is not acceptable. In order to produce more compassionate healthcare experiences for individuals with mental illness, all of us who work in healthcare must play a role. No one is immune from implicit stigma, but all of us can take responsibility for it.
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