Stigma is an attribute, behavior or reputation which is socially discrediting in a particular way. It is a potent, insidious, and negative force which grows like a weed. It strangles the forward movement of psychiatric treatment unless identified, “outted”, extracted by the roots on a daily basis. Those of us working in primary care and psychiatry need to become the “weed-eaters” of stigma.
The power of stigma surrounds us. The 50-year-old businessman with depression who admits to taking 20 years to come for treatment. The ADHD child whose parents simultaneously point the finger at one another when asked about family psychiatric history. The psychiatrist who recalls a “complement” by an esteemed professor in training: “Why are you wasting your talents in the halls of Freud?” The psychiatrist who’s internist friend states: “We know you guys that go into psychiatry are a little crazy yourselves”. Many patients are willing to endure considerable psychic pain to avoid treatment. A high achieving high-school graduate (GPA above 4.0) about to enter university with severe anxiety heaped on more difficult to identify, ADHD-inattentive subtype has compensated for her short attention span, distractibility, and procrastination by being driven by fear. Why has she avoided treatment? “Because if I need treatment I am flawed. Because if I need treatment I am weak. Because my family taught me that these are secrets not to be shared.”
Patients are often ambivalent about treatment. They start treatment, feel better, stop treatment, feel worse, and then wonder why treatment is ineffective. Ambivalent patients and families usually assume they will be the recipient of the “dreaded” prescription. Prescription pad aside! Giving voice to the patient’s ambivalence demands that the patient commit himself to, or against, treatment. “Why not continue as you are? What is so bad about the life you are leading now? You won’t have to explain treatment to others, or keep it a secret. Yet you want to decrease your pain and improve your functioning! Saying “no” to treatment gives you a better chance of saying “yes” when the time is right!” Supporting a patient’s ambivalence often makes it easier for the patient to move forward with treatment. Minimize pharmacologic expectations and maximize patient ownership of the treatment process. Patients worry they will “become a zombie, become dependent on the medicine, not do the work myself, be weaker. If medicine is like a shovel, it does not dig the hole itself…you have to do the digging. If you have severe social anxiety and do not expose yourself to anxiety-provoking situations, medicine alone will not do the job for you.”
A 9-year-old boy diagnosed with ADHD refused to take his stimulant medication “because I did not want it to make me do my homework”. Medicine, he thought, would force him to grip the pencil against his will and complete all of his homework which he desperately did not want to do. Medication refusal often comes up in families where stigma remains the elephant in the room. A child may be asked to take a medication that a parent would not be willing to take. A parent may not show himself in the office because he does not “believe in mental health treatment”. It is often what is unsaid and unseen that is most powerful. Empathizing with the child helps parents see the child’s impossible bind. By identifying stigma in the office, we help patients confront one of the largest obstacles to successful treatment and empower them to work towards physical and mental health.
(Joshua Lowinsky, MD Adolescent and Adult Psychiatrist is a partner at Children’s Resource Group in Indianapolis, a consultant to the Indianapolis Public Schools, and Co-founder of the Primary Care Psychiatry Foundation)