Stigma within the Service

November 27, 2016

Those of you that personally know me or follow me on twitter will know that the plan for my next post was to discuss the impacts that physical health conditions have on the patient’s mental health. Well…. Slight change of plan following a speech from a ‘Medical Director’ at an event I attended yesterday organised by Sam Barakat which also included talks from mental health activists Jonny Benjamin, Abbie Mitchell and 'thedepressedmedstudent'. Now I usually like to stay calm and away from any confrontation, especially when it comes to medical professionals… because let’s face it, it’s never worked out too well for me in the past.  However, I think after having more training lately particularly focused around stigma I felt like it was time to speak up, time to vocalise my opinion and tackle stigma. There were so many things that I found troubling during the duration of his speech but after watching footage back and taking direct quotes I am going to try and break it down and add my response. As I’m using direct quotes it’s going to be a fairly long post so apologies there, I think I’m just so fuelled to tackle the stigma right now that it’s hard to stop! After listening to the way a medical director spoke about mental illnesses it is incredibly clear to see why so much stigma exists with as many as 1 in 3 people reporting discrimination within mental health services.


The three key things that were discussed by the director were demand and funding of services, social construction of mental illnesses and the role of medication. For clarity direct quotes from the medical director are in red (once you've read them you'll understand why I want to make clear that they are not my words). 



1. The demand and funding of services


"If you take the politicians view they are spending more on health, but what they are spending is about half a per cent, one per cent more. Actually whats going on is that the health services that are available to any individual are shrinking by 3 – 4 % per year which has been going on for about 6 years. So in reality the health service has shrunk by about 20% due to underlying demand increasing with the same money spent. Mental health is one of the things that although its getting more publicity lately than it use to it is always down the queue for cash..."


Right... where to start! In terms of the percentages provided by the medical director I am not sure whether this is the case or not, however given increased demand following population pressures and funding cuts this wouldn't surprise me if it were true. However, whether the statistics are accurate are not the general idea of decreased funding and so called 'shrinking' of services is a terrifying thought. Particularly when you take a moment to think where the majority of funding will be allocated when the budgets are tight, that's right you guessed it the superiority of 'physical health' reigns again. Now I know that makes me sound anti physical health service, suffering myself from a long-term physical condition I can assure you that is definitely not the case, however what does make me frustrated is the clear disparity in the way in which physical and mental illnesses are addressed. According to research carried out by 'The Centre for Economic Performance's - Mental Health Policy Group' in 2012 mental illnesses accounted for almost 40% of morbidity with a 23% overall burden of disease (including premature death), despite this the share in NHS expenditure was only 13% - now I'm no Pythagoras but the maths doesn't seem to add up here. You've also got the added issue that only around 25% of all those with mental illness are in treatment in comparison to the vast majority of those suffering from physical health conditions. 75% of people! Such a huge number when you think about three quarters of all those in emotional pain not receiving the professional help required, that is absolutely devastating! 


" put that into context with what you were saying earlier on about there should be more, it should be easier to get hold of things, waiting lists should be shorter. Well, sorry that's not what people are voting for right now, that's not what politicians think, you don’t have to agree with it but the reality out there is there is not going to be more, there’s going to be less. By all means get upset, organise a demo, write to your MP say there should be more money in the service, I think that’s a losing argument right now."


On to the second point he brought up regarding funding and demand which probably caused me more upset than the first point. Now this is not so much what he said but the tone was incredibly patronising. I will start a little back to front on this one where he suggested that mental health campaigners were essentially fighting a losing battle.. Gahhh just no! It is thanks to the incredible work of large mental health charities and campaigners such as Time to Change, Rethink Mental Illness and Mind that there has been so much progress in mental health awareness and stigma reduction, saying that there is still a very long way to go! However, to go as far to essentially say that no impact is being made is incredibly unreasonable. Also the terming "by all means get upset" like hello we have a reason to be upset and angry about this, this is our lives we are talking about here! It is a part of every aspect of how we go about our day, do not dare give the impression that we do not have the right to be upset. 


Bringing it back to the 'waiting list' debate - so he thought that this was not going to change. It is set out by the NHS that for consultant-led mental health services that there should be a waiting time maximum of 18 weeks and fair enough at current there are some major flaws, with some waiting up to 18 months (some even more) for initial treatment for mental health problems to begin under the NHS but there have been steps made to improve this going forward, It is not a 'hopeless' and 'static' state as though he suggested.


The NHS have stated the following "As set out in the Five Year Forward View for Mental Health, NHS England is committed to developing and implementing mental health care pathways – including maximum waiting times for treatment – by 2020/21. Standards are being implemented on a phased basis. Access and waiting times have been introduced for Improved Access to Psychological Therapies (IAPT) and for those experiencing a first episode of psychosis. A standard has been announced for community based eating disorders for children and young people and further pathways are in development."


Though 2020/1 may seem light years away (It will definitely come around fast, I constantly find myself thinking it's still the 90s) but standards are already being put in place, as of April, 2016 the following standards were introduced by the NHS:

  • At least 75% of people referred to an IAPT services should be seen within six weeks but the majority (at least 95%) should be seen by 18 weeks

  • More than 50% of people experiencing a first episode of psychosis will be treated with a NICE-approved care package within two weeks of referral.  

  • At least 15% of adults with depression or anxiety disorders should have access to IAPT services each year, rising to 25% of people by 2020/21.

  • At least 50% of people completing treatment in IAPT services should reach recovery. 



2. Social Construction


You may have to bare with me on this one.... because it most definitely hit a nerve of two with myself and others in the room! So just before I respond to this I wanted to explain briefly what is meant by social construction is before you read any further. Social construction essentially suggests that a thing could not have existed had we not made it ourselves. Now this to me seems largely like victim blaming - which you can see why it hit many nerves in the room! Mental Illness is not the fault of the person it affects, no-one would chose to have a tormented mind and to suggest otherwise is utterly ridiculous. Right on we go...


"Have you heard of social construction? Basically the idea that certain things exist because we believe they exist and we talk about them and we engage with them as social beings in a way, as if they exist. So some people think that mental disorders are objective things that are demonstrated scientifically so they have a sort of reality that it is not just to do with the social interactions around them, but they exist in a way that you could see them somehow. There has never been a mental health problem that you can see on a brain scan. There has been a lot of talk about things like serotonin levels and depression, the evidence has never been terribly good, so you can’t take a blood test and say ok look this person has a mental health problem on a blood test. So establishing that there is an objective scientific reality to mental health problems has always been terribly difficult..."


To some extent this is true, it is not possible to use brain scans alone to diagnose a mental health condition for various reasons such as variation in brain activity among people with the same diagnosis; Psychiatric conditions can look quite different in different individuals; Different psychiatric conditions often share similar symptoms; Similar brain areas are involved in different psychiatric conditions. However it is recognised that mental health conditions such as depression, anxiety, bipolar, schizophrenia originate in the brain and it is becoming increasingly discovered by scientists which areas of the brain are involved in different conditions. For example with 'Post-Traumatic Stress Disorder' there seems to be excessive activity in the amygdala, which is involved in the processing of 'fear', alongside low activity in certain parts of the frontal lobes. It is though due to this overlapping of symptoms across numerous conditions that cause complications when it comes to using brain scans on their own as a means for diagnosis, however this does not mean that there is no place for this within future technological innovation and increased knowledge - after all we did once believe the earth was flat (Stupid analogy sorry - the inner Geography student just came out)!


"...I personally sort of tend to feel that sometimes when I see somebody who has a very severe psychotic episode that they don’t just think it’s a social construct to do with the way that we think about them or talk about them...So there might be mental disorders that are objectively to do with brain disorders but we have to just take it as a hypothesis rather than proven. However, I don't think that there is any doubt that things like anxiety and depression and so on are heavily socially constructed. There is no doubt that what is meant by depression now is a social construct that's to do with what we all share about what we read in the media, what we understand about depression from talking to other people. It is a socially constructed model of depression which is not the same as it might be in another culture or in another time. The majority of people now diagnosed with depression in the 1950s would have never have been diagnosed with any kind of mental disorder at all. So depression and anxiety are social constructs for now, for here in the way that we chose to use those constructs, and that's important when you start talking about whether the health service is underfunded, where should we spend the money,  do we think it's a scandal that children can’t be admitted to psychiatric beds, because actually these are just constructs for now."


My goodness, where do I even begin with this! I was literally on the edge of my chair listening to this, I felt so agitated and just concerned really about the way in which someone in such an authoritative position within a mental health system spoke about certain conditions. This was primarily in the case of depression and anxiety as stated above, but he also made a claim that 'Borderline Personality Disorder' was not real, not an illness, entirely made up - the footage for this cut out so I don't want to dwell on the exact wording as I'm not able to provide a direct quote but gosh seriously if this is how some professionals deem the conditions it really is no wonder why there is so much stigma, especially in regards to personality disorders. 


The fact he seemed to relate having a very severe psychotic episode to not understanding that the condition is 'socially constructed', like what? really? I can tell you now that I am not currently having a psychotic episode and I can comprehend that such conditions are not socially constructed and they are very much real even if you cannot see them. Saying that the majority of mental health conditions do have physical signs such as weight changes, fatigue and physical aches, the list goes on. 


So Depression is a social construct as a result of what we read in the media? Okay so, yes I agree to a certain level that the media has influenced the prevalence of mental health problems, however it is not reading about mental health problems that has done this, it is other factors involved. Similar to my last post, it has been stated that talking about things such as suicide does not increase the risk of a person making an attempt at their life, but instead can actually reduce it by knowing they are not alone and that there is someone who is willing to openly talk about it without fear of judgement. So in my opinion there needs to be more in the media about mental health not less, and by that I definitely don't mean the garbage printed by certain newspapers, or TV programmes on certain channels, but properly researched media through mental health organisations that raise awareness and in doing so reduces stigma and discrimination around them.


When talking about the past and mental health conditions I don't think it's fair to say oh well so and so wouldn't have been diagnosed with this back in these days. Okay, maybe they wouldn't have had a diagnosis, that doesn't meant that it wasn't there, that it didn't exist? If someone had a tumour that hasn't yet been medically detected, does that mean the tumour doesn't really exist? Because hooray for medicine is that's the case, we'd all be immortal (and doctors would be out of a job). It's also difficult when referring back to the 1950s when mental illness was stigmatised even more so than today, to the point it was highly criminalised - so this most definitely led to the reduction in people seeking help. 



As you can imagine this started quite the debate with some interesting Q&A discussion which I have added below:


Jonny Benjamin – "I was just wondering, you were talking about young people in inpatient units, people with eating disorders people with psychosis where do you think they should go if they shouldn’t go into inpatient units?"


Medical Director - "So the first thing we need to think about is, do we think these things are rising or not? And if we do why? Do we think there are more children with psychosis than there use to be? I think probably not, I think psychosis in children is rare."


Jonny Benjamin – "What about eating disorders?"


Medical Director - "I don’t know if eating disorders are becoming more common or why they should."

Abbie Mitchell - "I have a view on what you said depression is, can you explain what you mean?"


Medical Director - "So I’m suggesting that the diagnosis of depression is not a biomedical construct, so it is not an illness that has go objective measurable scientific correlates, it's a word that we use for describing feelings and it's a word which is used in a social context. So some people will never use the word and will attach nothing to it, whereas other people with attach specific meanings to the word depression but they are social meanings that are relevant to your context, but they won’t necessarily be the same as what anyone else means by depression."


Biomedical Scientist - "Sorry to disagree with you but there are plenty of studies that actually show physical change in parts of the brain to show that prolonged depression and manic depression can cause a reduction in neurogenesis, so there are definitely signs that suggest that."


Medical Director - "No I don’t entirely agree. So we’ve got lots of different problems here haven’t we, so if you showed something on a brain scan on somebody who had been depressed for a bit would that demonstrate that depression is an objective illness."


Biomedical Scientist - "define what you mean by a bit…. No health condition even things like diabetes just turns on it is a prolonged system"


*Point brushed over and moved on* 

Abbie Mitchell - "What about things like ECT which targeted the brain, there must have been a reason behind it?"


Medical Director - "It does for some people seem to have an effect, I’m not saying these things don’t have an effect that's different… antidepressants changes the way you feel I’m not disputing that antidepressants change the way that some people feel I’m saying that doesn’t actually prove that there is a biological illness called depression." 

Jodie Goodacre - "Going back to Abbie’s point about social constructs. I have a pain condition that didn’t come up on scans and took months and months and month’s to diagnose but for me that does not make it any less real, so why should that be the case with mental health. Even if you are seeing it as a social construct why should those suffering be any less deserving of treatment, of a hospital bed than others that are deemed to have an illness that is accepted by medicine and science?"


Medical Director - *He responds by discussing social constructs of pain (not what I was asking) and how pain relates to mental health. The point was missed entirely and brushed passed.* 




3.The role of medication


"Big issue, do the drugs work? What do you think of psychiatric drugs? There will people who say this drug works for me and this drug is incredibly important for me and yet somehow they get over prescribed and where does that come from? People get given antidepressants before people really know that the problem is, and is that a bad thing or not because you could say that you have to have a proper diagnosis of a proper illness before someone gives you a drug, but my suggestion to you is that depression is a socially constructed way of talking about feelings, so it’s not a proper biomedical diagnosis anyway. That’s my theory that antidepressants are psychoactive drugs that have interesting effects but what they don’t do is cure an illness called depression."


Now, though I am personally okay to take psychiatric medication I know that many either refuse to take them or hate taking them, so I don't want to get into a 'You should take meds', 'You should not take meds' debate because It is entirely based around the individual in question, around their personal preference, around the drug and condition involved. So instead I am just going to quote what my response on the day was to the medical director.


Jodie Goodacre - " All drugs have the same problem, you’re always going to have to weigh up side effects against the benefits. I take painkillers for a chronic pain condition that doesn’t take away all the pain, it doesn’t change the condition, it is not a cure but it helps me manage the day. Medication is a personal preference which works differently for different people, different drugs work differently so I don’t think it should be a black and white, yes no. Not all medications are used for a ‘cure’ but instead enabling a better life. This is the case in both physical and mental health conditions."


Mental illness may not be entirely understood just yet, but that is not to say that it’s not real and necessary to be treated. I think the fact that people see medication as only being used for a 'cure' is where the issue of medication for mental illnesses had gained stigma. It needs to be understood that it doesn't necessarily make life all happy rainbows and unicorns or suddenly turn a persons life around instantly, it doesn't erase past memories or heal all wounds. What medication does do however is provides the building blocks for this progress to be made, for a person to go about their daily life with greater ease, it is the supporter not the 'solution'. Whilst someone who is on medication may still not be 'cured' or deemed to be living a normal perfect life it can create a greater normal than life without medication. 



Okay, so I am fully aware that this was a blooming long and pretty intense read so I thought a nice little motivational message would be good to finish this off! If you got down this far then I thank you so much for your passion! If you have any personal views on anything that was quoted above then please do drop a message at the bottom of this page, or send me a message through the contact form on the front page - would be so interesting to hear more opinions from you guys! 


Finally I want to say a big thank you to Sam who provided me a copy of the footage from the speech which allowed me to include the direct quotes used above (as my memory is really not all that). 



Sending you all positive vibes















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