Friday, March 15, 2013

Stigmatization in Psychiatry: For the Discipline and for the Patient

Psychiatry is often labeled the “black sheep” of medicine. The continued inability to pinpoint a singular causal mechanism for mental illness spurs the anti-psychiatry movement to argue for the removal of psychiatry as a sub-specialty from the medical field. The assumption underlying this movement is that all mental illnesses are psychological, despite the clear biological/neurological processes that are proven to be associated with various mental disorders. As such, there is no apparent medical justification for psychiatry to remain within the overarching discipline of medicine. The validity of such an assumption is clearly debatable, but this general attitude is often reflected in the lack of funding support for psychiatric services and the socially-derived moralistic stance toward particular mental disorders, such as substance abuse. This, in turn, has clear implications for the mentally ill patient who by extension may be seen as the “black sheep” of the patient realm. A primary care physician insensitive to the neurological mechanisms of mental disorder may be more prone to dismiss the suffering of the mentally ill patient as purely psychological, or “all in their head.”

Let’s take the mentally ill patient in Guatemala as a case in point. I have worked in the Western Highlands of Guatemala for over six years, and my most recent research venture for my doctoral dissertation examined local psychiatric/psychological concerns and the barriers to mental healthcare in the region. My findings suggest that the mentally ill patient faces both community and institutional stigmatization based, in part, from the disparaging attitudes toward psychiatry as a medical discipline. Of course, there are clear historical and cultural contexts to consider for the foundation of the community level stigmatization. A biological basis for mental illness is a relatively new concept within health belief systems in some of the more “traditional” communities throughout the Highlands. However, biomedical understandings to illness in general are becoming more prominent, and according to my research, those who suffer from mental illness themselves are more likely to prefer biomedical/psychiatric treatments to manage their disorder over previously accepted treatment modalities. Therefore, I want to focus on the role of the institutional/disciplinary stigmatization as manifest in the public healthcare system that appears to reinforce community level discriminatory beliefs toward mental illness.

Psychiatry is an acknowledged discipline within the medical field in Guatemala, yet psychiatric services appear to be the least valued, which directly impacts access to healthcare for the mentally ill. Specifically, mental healthcare in Guatemala is underfunded, poorly staffed, and inaccessible to most Guatemalans, despite a relatively high rate of mental health conditions. Recent national studies indicate that one of every three Guatemalans suffers from a mental illness. However, the Guatemalan government spends less than 1% of their overall health budget on mental health services, [1] and the one public psychiatric hospital is notorious for human rights violations. Indeed, the majority of human rights violations reported to the Attorney for Human Rights Office are in direct reference to this hospital (PDH 2010). These reports indicate safety abuses by personnel, inadequate patient nutrition, insufficient availability of medications, deteriorating equipment, and general inadequate conditions (PDH 2010).

Due to the failure of authorities to adequately respond to such known abuses and the overall shortcomings within the public health system, national health care services are becoming more privatized within Guatemala. While this is a general (and global) trend for all of healthcare, the mentally ill are even further marginalized by this transition. Private for-profit physician services are financially out of reach for the majority of Guatemalans, particularly in impoverished areas found throughout the Highlands. Non-profit non-governmental and faith-based organizations that provide supplemental free/low-cost health services rarely, if ever, address the mental health needs of their service population. The primary mechanisms for healthcare support through these institutions are visiting short-term medical mission groups. The services these groups provide are generally limited to basic medical and/or surgical needs. The most commonly provided services include eye exams and minor ocular procedures, dermatological and gastrointestinal evaluations, and reproductive health procedures such as pap smears, hysterectomies/vasectomies, and IUD placement. Mental health issues and chronic diseases are unlikely to be addressed due to the short-term nature of these visiting groups of medical service providers. 

Yet local political leaders from mayors to sector representatives often say that the available resources for mental illness are sufficient. They indicate they have no control over the private sector, and there are no plans for developing more public services to care for the mentally ill. Local public health centers often provide a space for psychiatry/psychology graduate students completing internships as their labor does not cost the center anything, but it is a rare event for students to want to complete their internship in the region due to the lack of jobs available once done. The implication of this degree of inadequate mental healthcare within both the public and private sectors suggests that the mentally ill patient is not worthy of economic support to alleviate their suffering.

Compounding the lack of financial support for psychiatric services are the institutionally reinforced notions of mental illness as a manifestation of moral disorders as opposed to biological ones. As mentioned previously, mentally ill patients suffering from substance abuse in particular must also contend with moralistic stances that undermine the neurological and physiological processes associated with the disease. Alcoholic and addict individuals are regularly encouraged to seek help in churches or Alcoholics Anonymous (AA) group. Even trained physicians [2] will “prescribe” church attendance and/or AA as treatment for alcoholics and addicts. That is all they need, says a regional public health director who is a trained physician. The director suggests that the primary benefit to both church and AA is the fact that the programming does not cost anything to the State. 

The fact that these “treatment” avenues have been proven to be minimally effective in eliciting behavior change is irrelevant. The use of public funds to support alcohol/drug abuse intervention programs would be considered a misuse of funds. Alcoholic/addict individuals are generally considered perdidos (lost causes) and untrustworthy to change; in essence, black sheep. Yet alcoholic individuals in the region often expressed to me their desire for psychiatric services to address the neurological processes underlying their addiction.

These issues within psychiatric care are not specific to Guatemala. Mental healthcare systems throughout the globe, including in the US, are generally considered underfunded and inadequate to meet the needs of the local population. The debate at the professional level regarding psychiatry’s role within the medical profession dismisses the desires of individuals for appropriate psychiatric services that take into account both the physiological and psychological aspects of mental illness. Unfortunately, until psychiatric services receive more complete visible support (e.g., through adequate funding), the discipline of psychiatry and psychiatric patients themselves will continue to be casted as the “black sheep” of the biomedical world. It is only through understanding local stigmatizing conditions and advocating for comprehensive psychiatric services that the suffering of those with mental illness may be alleviated.

Carla Pezzia
University of Texas at San Antonio

End Notes

1. Developed countries, on average, spend 5-9% of their overall health budget on mental healthcare. These countries, on average, also have less prevalence of mental illness within their population. Guatemala and the US have approximately the same prevalence of mental illness (1 in 3). The US spends approximately 5% of the overall health budget on mental healthcare, and this is still not considered sufficient to address the needs of the population.

2. All medical students in Guatemala, regardless of their specialty, must go through a psychiatry rotation as part of their training.


PDH (Attorney for Human Rights Office). 2010. [Special Report on the Right of Every Person to Receive the Highest Standard of Care for Physical and Mental Health: The Right to Health]. Procurador de los Derechos Humanos, Guatemala.

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