In Defense of… Stigma?

I recently came across Manhattan Institute fellow Stephen Eide‘s 2020 article In Defense of Stigma in the online magazine National Affairs. It had some… odd… ideas about mental illness stigma, so I thought I would explore some of them. Okay, forget about exploring, I’m going to rant.

The basic argument in the paper is that stigma isn’t the cause of the challenges faced by people with mental illness, so focusing on it isn’t going to change anything. I think there’s a germ of a reasonable argument tucked away in there, but that wasn’t really where the author ended up going with it.

Serious mental illness

The author argued that not every mental illness belongs in the same conversation; instead, he differentiated between conditions he characterized as non-serious, such as anxiety disorders and OCD, and “serious mental illness.”

Serious mental illness (SMI), sometimes referred to as serious and persistent mental illness (SPMI), doesn’t make an appearance in the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders). It lacks a universally accepted definition, but generally refers to mood or psychotic disorders that cause significant functional impairment for a prolonged period of time. The concept is used most often with regards to mental health services, and it has no business being used to delineate whose illness counts and whose doesn’t.

Mentally ill = violent?

The author also argues that the research literature clearly shows that people with serious mental illness are violent. He references DJ Jaffe (a self-made mental health policy lobbyist, not a researcher), whose site Mental Illness Policy Org says right on its about page that people with untreated SMI are violent, so this is clearly not an impartial source. The large MacArthur Violence Risk Assessment Study would say not so fast when it comes to the violence connection; there’s an increase in risk only in very specific populations, including those with high levels of psychopathy, substance abuse, and command hallucinations to harm others.

Less than 1% of gun-related homicides per year in the US are due to mass shootings by mentally ill people (Knoll & Annas, 2016). We crazy folk are far too busy killing ourselves, accounting for the majority of gun deaths. Stephen Eide argued that there is a link between mass shootings and mental illness, adding “The view that mentally ill individuals suffering from paranoia are dangerous is widely accepted by the public.” If we’re going to talk stigma, yeah, stereotypes like that would be it.

There’s little, if any, indication that psychiatric diagnosis has predictive value when it comes to gun violence.  “The lack of prognostic specificity is in large part a matter of simple math. Psychiatric diagnosis is in and of itself not predictive of violence, and even the overwhelming majority of psychiatric patients who fit the profile of recent US mass shooters—gun-owning, angry, paranoid White men—do not commit crimes” (Metzl and MacLeish, 2015).

Responding to mass shootings

Eide wrote that when politicians feel forced to do something following mass shootings, “taking on stigma is one of the safest routes. The public official who fails to denounce stigma risks being accused of accommodating intolerance.”

I’m not sure what news he’s been listening to (presumably Fox News, given the Manhattan Institute link), but does anyone remember when Donald Trump said “Mental illness and hatred pulls the trigger, not the gun” (CNN.com) after mass shootings in 2019?

Criminal justice system

When it comes to diversion programs that route people to mental illness treatment rather than the jail, Eide writes, “There is a contradiction in saying, on the one hand, that mental illness poses no threat whatsoever to society and, on the other hand, saying that someone under indictment deserves leniency for having committed a crime that can be attributed to a mental illness.”

Marginalized populations of all kinds end up disproportionately represented in the critical justice system; that doesn’t mean that crimes are directly caused by the characteristic that relates to the marginalization.

Accessing mental health services

Regarding the possibility that police officers aren’t using employer-provided mental health services due to fear of career repercussions, the author wrote, “But shouldn’t we want police-department supervisors to be informed about patrol officers’ psychiatric conditions?” Unless there’s an impairment that gets in the way of their ability to job their job safely, I would answer with a resounding hell no.

This is important for health professionals as well. Impairment is a problem. Having a diagnosis and receiving treatment do not mean that someone is automatically impaired. When professionals dealing with mental health issues are reluctant to seek treatment, they are more likely to become impaired.

Why don’t people access treatment?

The author writes that factors other than stigma are the primary reasons why some people with mental illness don’t access treatment. What’s particularly interesting there is that he doesn’t quote anyone with a mental illness or research that involved speaking to people with mental illness, and there’s no indication that he’s ever in his lifetime had an actual conversation with a real live crazy person, so perhaps he’s just offering his opinion?

He probably hasn’t heard the story of the Toronto-area man with bipolar who had to crawl out of the ER after ER staff blew off the pain that kept him from walking and blamed it on his bipolar disorder. More recently than Eide’s article was the NHS’s Serenity Intensive Mentoring program, which could involve sending someone to jail for showing up in the emergency department after a suicide attempt. The health care world isn’t exactly rolling out the welcome mat.

Mild mental illness is good?

As for people with “mild” mental illness, apparently, they’re not the government’s problem. What a bunch of pussies, right?

“Mental-health problems that affect otherwise-functional people, such as mild anxiety or obsessive-compulsive disorders among corporate strivers, or depression among artists and writers, might even enhance their functioning.” That’s remarkably ignorant, and it seems like further confirmation that he hasn’t ever spoken to anyone who has a mental illness.

Keep the crazies away

Another gem: “There is undeniable social benefit in stigmatizing erratic behavior in public places; few of us would enjoy living in a community where such behavior was encouraged and pervasive.” Perhaps he would also like to spend in his life in a suburb with white picket fences, white picket people, and not a soul with a disability. Grandma has Alzheimer’s? Not welcome. Grandpa has Parkinson’s? Far too erratic to be acceptable.

The author also argues for “humane discrimination,” and distinguishing between the rights and responsibilities of people who are and are not in possession of their reason. “Schizophrenic individuals are, by and large, not like you and me. Insisting that they are flies in the face of simple observation and all manner of raw data on rates of employment, income levels, and participation in government-benefit programs.”

Had it been 100 years ago, I can imagine he would have been enthusiastically jumping aboard the eugenics train. Sterilize them all! Or better yet, go with the Nazi approach and try to kill them all off. Humane discrimination, right?

So yeah, I’m not impressed. The author is a fellow at the Manhattan Institute, a conservative free-market think tank, and it appears that crazy folk and homeless folk are his targets of choice. Maybe I should start a think tank. The Crazy Institute has a nice ring to it.

Anyway, going back to the germ of a reasonable idea, do you think stigma should be a top priority for mental health advocacy efforts?

References

• Howard, J. (2019). Blaming mass shootings on mental illness is ‘inaccurate’ and stigmatizing,’ experts say. CNN.com.
• Knoll IV, J. L., & Annas, G. D. (2016). Mass shootings and mental illness. In Gun Violence and Mental Illness. American Psychiatric Association Publishing.
• Metzl, J. M., & MacLeish, K. T. (2015). Mental illness, mass shootings, and the politics of American firearms. American Journal of Public Health, 105(2), 240-249.