The BABCP recently lent its support to a confused and misleading media campaign about stigma and mental health. Now it has added to the confusion by publishing an embarrassing case study showcasing the worst kind of failed CBT.
Stigma has a corrosive effect in society, causing exclusion and disadvantage to people who are, in many cases, already disadvantaged in some way. So a well-funded media campaign that promotes stigma should be very worrying.
It is even more worrying when a body like the BABCP, which ought to be thoughtful and responsible in its public statements, sides with those who seek to promote stigma around mental health. Of course, it is not really the BABCP itself that has done this — not really the membership of the Association, who were never asked — only the few academics who run the BABCP have been sucked in.
To understand what they have been sucked into, it helps to understand what stigma is and why it is such a bad thing.
In essence, stigma is when one characteristic of a person is taken as a sign of some other characteristic. For example, if a man walks with a limp and you take that as a sign that he cannot make his own way up stairs, that’s stigma. It is typical of stigma that a slight disability is taken as a sign of much greater disability.
Rational conclusions are not stigma, though. For example, if a man has a broken leg and gets about with crutches, and you take that as a sign that he cannot run to catch a bus, that is a rational conclusion, not stigma.
The effect of stigma is to disrupt relationships, with the result that someone who is stigmatized is treated unfairly. For example, if you stigmatize the man who limps, you might take it upon yourself to be his carer, and lead him to the lift. In that case, stigma has created a false relationship between the two of you, because he does not need you to be his carer. Not seeing him as an equal might then change other aspects of your relationship for the worse, too.
There are, of course, more severe examples. A common one is that when someone has schizophrenia, it might be taken as a sign that he is potentially violent and dangerous. Or when someone has depression, it might be taken as a sign that she is irresponsible and lazy. These false assumptions about people, caused by stigma, can sometimes be much more damaging to the quality of their lives than the original illness.
Stigma causes people to be treated as if they are unequal to the rest of us, less deserving of our respect and trust, and less capable of independence and freedom than they really are. In the case of people who suffer stigma around mental illness, it often leads to false and harmful assumptions about the severity and nature of their condition.
A common characteristic of stigma is that a single attribute is taken as a sign that defines the whole person. For example, the man who walks with a limp might be stigmatized as being “nothing but a cripple”, as if there is nothing more to him than his limp.
Joanne Bramley’s story was presented at an open meeting run by the BABCP in Manchester prior to its conference in July, and then published in the BABCP’s in-house magazine, CBT Today (September 2010, not yet available online at the time of writing).
Events in Joanne’s childhood that she still finds upsetting caused her to suffer from social anxiety ever since. It has meant that she could not participate at college, and it has made it difficult for her to find employment.
In an interview with the Services Manager of the charity Anxiety UK, Joanne was asked what stigma she had encountered because of her disorder. She replied:
I have always felt a great sense of shame and embarrassment…
Instead of answering the question, Joanne simply described her social anxiety! Stigma is when other people take something about you as a sign that you are worse off then you really are, but Joanne does not describe that happening at all.
Clearly, Joanne has never suffered any stigma that she is aware of, or she does not know what the word means. Presumably, the Services Manager who asked the question and the editors of CBT Today do not know what the word means either.
The worst that Joanne can say about other people’s attitudes is:
…social anxiety in particular is not well understood, or even heard of, by some people.
It’s interesting to examine what that means. If social anxiety were well understood by people, how would Joanne’s life be different? The difference would be that she would only have to say that she suffers from social anxiety, and other people would take that as a sign of all kinds of other things about her. They would instantly make assumptions about her disabilities, without having to be told.
So Joanne is complaining that she is not being stigmatized enough for her liking! When people hear she has social anxiety, they are so ignorant that they continue to accept her as a normal person.
Wanting to be stigmatized is part of Joanne’s illness. She would prefer to be the victim of other people’s assumptions, than to have to relate to other people herself:
…to try to explain how it makes you feel to others can be excruciating.
In fact, social anxiety is very easy to explain to people, because every normal person has known what it is like to be shy or nervous at times. They are completely normal feelings. They become a mental illness when they are inappropriate and overwhelming, which they are for Joanne.
Two terrible things have happened in Joanne’s life. The first was that she developed social anxiety. The second was the lifestyle CBT treatment she received for her social anxiety.
Over the years, she had psychotherapy and medication that had no permanent benefits. She remained ill. But then she tried computerized CBT. Interacting with the computer meant that she did not have to relate to a person. The computer program allowed her to redefine her social anxiety as a permanent disability:
I liked the idea of the anonymity of working on a computer as opposed to speaking to a therapist about my problems and having to bring up upsetting events from my past.
By working with the program, Joanne discovered a way to avoid dealing with those events in her past that caused her illness, a way to postpone recovery forever. She has now redefined her whole existence in terms of her social anxiety. It has become her identity, in the same way that the man’s limp became his identity through stigma. She works as a volunteer for Anxiety UK, using the charity for support, and using “CBT skills” to maintain her illness:
In this supportive environment I have been able to put into practise [sic] coping skills which I have learnt from CBT…
The stigma Joanne suffers is that her social anxiety, a treatable and curable condition, is being taken as a sign of permanent disability and exclusion. The false assumptions imposed on Joanne are that she needs permanent support and must permanently struggle with “CBT skills” in order to get by in life, when in reality a competent therapist could cure her in a matter of months.
At last, Joanne has found the stigma she always wanted.