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Psychiatry stigmatized by low expectations

March 5, 2012
by Dennis Grantham, Editor-in-Chief
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Psychiatrist questions his profession's beliefs about psychiatric disability, seeks “a more inspiring vision”

Some years ago, President George W. Bush made a much-quoted remark about “the soft bigotry of low expectations.” It’s about the idea that our prejudices about others might be observed and judged not only in our outward actions, but in our inmost thoughts and attitudes.

I recalled this remark after hearing a recent discussion involving community psychiatrists and local behavioral health workers and peers at Case Western Reserve University in Cleveland.  The discussion leader, Ken Thompson, MD, suggested that the profession of psychiatry, along with many of those it serves, seems to be the subject of a very distinct stigma or prejudice within society. (Thompson, by the way, is chief medical officer at Recovery Innovations and an associate professor of psychiatry and public health at the University of Pittsburgh.  He served as medical director at the SAMHSA's Center for Mental Health Services from 2007-10.)

Psychiatry’s image problem, Thompson said, stems from “our inability to point to consistently strong results from our traditional approach to treatment—the thought that people’s problems could be solved with a medical intervention—usually a pill.”

“It’s clear," he continued, that “we haven’t been getting all of the gains [in outcome] that we once thought” and that “the standard paradigm of treatment is petering out. There are not so many new pills, new technologies, or new approaches around the corner.” And, while acknowledging that work is ongoing in search of new treatment interventions, he didn’t believe that these would “revolutionize psychiatry anytime soon.”  

While psychiatry shares some woes with all of medicine, notably concerns about high costs and uneven quality, Thompson asserted that psychiatry in particular suffers from the public perception that it “doesn’t really deliver—or expect to deliver” positive outcomes on a consistent basis. It thus suffers its own, self-inflicted form of public prejudice—its own “soft stigma of low expectations.”

The effectiveness and value of traditional medical interventions have long been measured by decreases in morbidity and mortality and, more recently, by more sophisticated measures including “quality of life” or continued ability to contribute to society. Thus, society’s investment of trust (and funding) in medicine reflects a certain confidence, or expectation, that it reaps a return.

But psychiatry has taken a different course, Thompson noted.  Psychiatry’s recent course has been to argue, essentially, that its interventions “reduce the burden” of the mentally ill on society and give them an opportunity to live a better life. “This is not a useful stance.  It’s not a very inspiring vision to society or the public.” What’s worse, he argued was that “this stance has angered those we serve—the notion that we are going lessen the burden that they place on us.”

A culture of disability and dependence

“We psychiatrists exist because psychiatric diagnoses can be disabling and the people we treat can be disabled for life,” Thompson says.  While the possibility of disabling illness is ever present, he believes that possibility too often turns into an expectation of disability. As a result, what he calls “a culture of disability” has resulted, a culture that aims to “stabilize” a mentally ill person not only through treatment, but by getting them qualified for public disability benefits.  As one audience member suggested, “The doctor doesn’t tell us that we should get better.”

Nor, added Thompson, do many psychiatrists psychiatry recognize the potential value of getting those with serious mental illnesses back to work. He reflected that although he worked for years with mentally ill people in Pittsburgh’s impoverished “Hill district,” he never recalled speaking with them about their potential to get jobs. “I thought it was my job to decrease the burden, to keep people out of the hospital,” he lamented.

“We’ve told people for years that since psychiatric illness is worsened by stress, they probably shouldn’t work. And, we’ve worried about the fact that if they get a job and start working, that job might not be a very rewarding one. But one thing we haven’t considered is that unemployment is incredibly stressful, and that even a ‘lousy’ job is better than none at all.”

He also took on assumptions that if mentally ill individuals started working, they might lose their stability and benefits. “How many of you are aware of the fact that disabled people can actually come off of public benefits?  How many of you are aware that disabled people can return to work, keep income they make, and retain access to public benefits, if they’re needed, for up to five years?”  

“It is striking to me that none of us in the field have ever thought to measure the one thing, the one outcome that society wants:  a measure of how we help people getting better, how our work adds to the number of people who can contribute, who can help society carry the load.” 

Pointing to the thesis of Robert Whitaker’s book: Anatomy of an Illness, Thompson stated that “if psychiatry was doing good, people would be coming off disability instead of going on.” Yet people who struggle with mental illness continue to fight the common misconception that they cannot be cannot be what he called “creative, imaginative, and self-directed people—people who can transform their lives.”

How, he wondered, can psychiatry help those it serves aspire to more in their lives? 



That's a pretty skeptical view, which definitely has some merit but doesn't tell the whole story. Yes, there is a tendency to practice harm reduction, but there is also a push in the public sector to provide person-centered care, by developing a plan the patient feels will make their life meaningful. Then, the patient perhaps becomes more motivated to make changes that are needed to achieve their goals. It becomes less about treating symptoms, and more about living life.

One other thought: if psychiatric treatment has such stigma, why in the world is the demand for services sky high??? If it didn't work, I think the customers would simply go away.

This is a response to the story stating that psychiatry and mental health practitioners need to avoiod “the soft bigotry of low expectations.”

I do not believe that "low expectations" are the primary reason that psychiatric treatment fails to return many patients to independent function and employment. The primary determinant of a patient's return to previous level of functioning is their severity of symptoms and response to treatment. For many psychiatric conditions the cause is unknown and treatment options limited.

Many psychiatric disorders (ie--schizophrenia) are defined by loss of function, due to the symptoms of the illness, not by low expectations of practitioners or patients. Psychiatrists are actually quite good at predicting, based on a patient's severity of illness, their level of functioning.

I work at a VA hospital. To my knowledge, I know of no individual who ever gave up his service connected disability, despite the simple majority doing significantly better over time.

No wonder the public doesn't invest much trust.