Psychiatrists suffer from stigma too

Psychiatry is a complex enterprise, requiring the longest training period required of any mental health profession. Yet doctors are playing a declining role in deciding health care policy. It is almost as if while acknowledging they would rather see a doctor than anyone else when seriously ill, lay public and politicians also prefer practically any alternative, other than a physician, when determining who should decide how health care is delivered.

Psychiatrists seem even more marginalised than other medical colleagues in public debate about practice (Jorm et al, 1997a , b ). Witness, for example, the way the media handles the community care controversy. It is rare to hear a psychiatrist interviewed in the media whenever controversies over psychiatric care hit the headlines. This stands in stark contrast to the way representatives of other lobby groups like SANE, the Zito Trust, and Mind dominate public debate in the media on these issues.

Why, and how, have non-psychiatrists come to be the first port of call for information and opinion by the media, instead of clinicians or academics who specialise in this area? After all, while the average psychiatrist working in the NHS has years of training and sees thousands of patients, how in touch the media's favourite mental health pressure group leaders are with medical research and practice is questionable. No one dares to ever ask ‘the emperor's clothes’ question — but exactly who are these ‘spokespersons’ meant to represent — and who nominated them to speak for the public or the average patient?

At best, they are thrown up from within relatively small compaigning groups, but what is the precise relationship between these associations and the typical NHS user? This never gets probed by the media, who are too busy for anything other than a superficial treatment of psychiatry. At worst, the spokespeople themselves single-handedly set up the very organisation they front, perhaps they are basically exploiting an acronym, presented to the media as their sole authority to speak for thousands of patients.

While often personally charismatic, their credentials are never explored in the brief time the media gives to mental health issues, but instead their authority to speak on a wide variety of mental health issues is implictly assumed by interviewers and so in turn by the public.

Whatever their background, the sobering truth is these spokespeople are able to colonise column inches and broadcast studios for themselves, because they have a more media-friendly approach to engaging with public opinion than many senior psychiatrists. The way the media works is that you are seen to be a specialist simply because you have broadcast on these issues before. Increasingly news programmes are reduced to presenters interviewing supposed ‘experts’, who are in fact journalists as well.

This is inevitable as the media prefers naturally to work with others who understand the demands of news packaging. Many mental health organisations have former journalists in senior positions or as chief spokes-people. Their contacts and friendships within the media explain their popularity as choices over psychiatrists, when a talking head is needed to discuss the latest ‘schizophrenic outrage’ or government policy.

Why should psychiatrists care how the media works? Because, all too often, doctors get bulldozed out of the way by a particular policy, due to their habit of getting caught looking in the wrong direction. For example, our North American colleagues, including the supposedly powerful American Medical Association, devoted decades to fighting government involvement in medical practice (The Economist, 6 February 1999). Yet in the end it was corporate managers from health maintenance organisations which proved more effective in undermining physicians' autonomy via a series of measures, including regular performance reviews, guidelines for standard practice and swift ending of contracts if doctors failed to live up to the mark.

Psychiatrists are similarly in grave danger of being ignored while health care debate in the media is increasingly infiltrated by non-medical lobbying organisations, whose views on mental health care are not necessarily sympathetic to, or representative of patients, carers or mental health professionals. Eventually, lack of public credibility will produce a government unafraid to ignore psychiatrists' views (Galliher & Tyree, 1985).

It is complacent for professionals used to wielding authority from the comfort of their institutions to simply scorn the media. The Director of Communications for the Canadian Medical Association noted in the recent past that

“psychiatrists appear to have developed either a psychotic fear of and/or a contempt for the media. Very few will go public on an issue in a proactive, voluntary basis. Psychiatrists tend to go public only as a last resort. Unquestionably psychiatrists have special problems, but they simply must be overcome” (Lamontagne, 1990).

While they may obviously be criticised for distortion, the mass media serve as a filter that selects and presents an unwieldy environment to us in ways we can manage and understand. People learn about the world through media accounts — rather than direct observation. The reason spokespersons for lobbying groups have become the modern face of expertise in the area of mental health, as opposed to psychiatrists, is the media finds these commentators more accessible in various ways. They are often easier to get hold of and are more prepared to fit in with media requirements for an interview at short notice because they give a high priority to media liaison — in fact they see developing a relationship with the media as their main raison d'être.

Psychiatrists, on the other hand, have exhaustive clinical and administrative commitments in a stretched service on top of which they may juggle media demands for an interview. This means they are frequently unavailable when the media needs them. Also the strong tendency for doctors when writing or broadcasting in the popular media to be dominated by self-consciousness concerning their reputation among their peers, means their comments are often designed for consumption by fellow professionals and so pass straight over the heads of the general public (Washington Post, 25 June 1982).

If psychiatrists persist with a negative attitude towards media liaison they will be looking the wrong way when the next threat to their autonomy arrives. While the College is beginning to take press liaison more seriously, with media training days and public campaigns, such as ‘Defeat Depression’, the focus is still on what we can do to help our patients by speaking up for them in the media (Paykel et al, 1997, 1998).

Instead, media lobbying could become a more central role of the College, just as this is given a much higher priority in other mental health organisations. In the USA there is increasing acceptance that mental health clinicians should embrace and incorporate new mass media technologies into practice (Stamm, 1998), and utilise the media ‘proactively’ to take more control of public policy debates (Sullivan et al, 1998; Sorensen et al, 1998).

A major task of public education alongside destigmatising mental illness, should also be to raise community awareness, of what psychiatrists do, and the natural limits to effective practice (Edelman, 1985).

This will actually help improve the clinical reality in which psychiatrists daily work. The very latest study on public attitudes found the role of psychiatrists as a potential source of help for schizophrenia was recommended by only roughly one-third of the German public (Angermeyer et al, 1999).

Epidemiological studies on depression also reveal that only a minority of depressed individuals (about one-quarter to one-third) seek professional help for their distress (Jimenez et al, 1997).

This reluctance to turn to psychiatrists could explain the substantial delay in obtaining effective care for patients with first-episode schizophrenia (Lincoln & McGorry, 1995). Individuals often remain in the community for more than one year with untreated psychotic symptoms (Larsen et al, 1996).

Psychiatrists are currently caught in a cycle. Because of the stigma surrounding psychiatrists, patients delay in coming forward to receive treatment that would have been more effective if applied earlier, and because our authority is less than for our other medical colleagues, patients often ignore our advice (Wilkinson & Daoud, 1998). We therefore frequently appear ineffective (Sharf, 1986), and so are passed over by the media looking for authority figures to talk about mental illness (Rosenberg, 1983; Perr, 1983), which then places expertise on mental health issues, in the minds of the public and journalists, elsewhere than within psychiatry. And so the cycle perpetuates itself.

The image of a profession, in particular the way the media handles it, should not be dismissed out of hand as a trivial or remote issue, in fact it goes to the core of clinical practice (Warden, 1998). Therefore, we should try to learn what high profile mental health lobbying groups have to teach us about how to successfully liaise with the media, rather than resentfully carp about their achievement.