Responding to mental health’s mind–body problem

To the Editor

In their recent article in the Australian and New Zealand Journal of Psychiatry, Ungar and Knaak (2013) present a useful analysis of how stigma evidenced by health professionals towards mental health problems may be contributed to by a basic tendency for mind–body dualism in thinking about human experience and behaviour. In the absence of a clear organic cause of most mental health problems, they that propose health professionals in non-psychiatric settings may find it less easy to conceptualise functional mental disorders as real problems, potentially fostering dismissive and blaming attitudes. However, while acknowledging the illusory nature of the mind–body dichotomy, Ungar and Knaak do not suggest that we help health professionals adopt less simplistic understandings of mental health, but rather that we operate within this dualistic perspective, by educating professionals about the organic aspects of mental disorders.

If mind–body dualism influences the thinking of health professionals, enhancing the tangibility of mental distress by portraying it as organic is unlikely to resolve this problem. Specialist mental health professionals are already readily accepting of functional mental disorders as real, yet we often find ourselves discussing whether presenting issues are illness-related versus merely behavioural or personality-related. This suggests that even though we have extended an organic disease model to mental distress, mind–body dualism persists in our thinking, and we have merely shifted where our boundary between illness-related and person-related lies.

A potential cost of this is to reinforce dichotomised views of personal responsibility for distress, encouraging sympathy for illness at the cost of blame for non-illness difficulties. Notably, blaming attitudes among specialist mental health professionals appear most prevalent towards persons with personality disorders and substance use disorders (Markham and Trower, 2003; Rao et al., 2009), highlighting that negative attitudes may be most common where disease-like explanations fit less well as complete conceptualisations of difficulties. The parallel cost of dualist conceptualisations of locus of control for illness is in reinforcing a traditional sick role for those accepted as ill, in which the patient becomes a passive recipient of treatment – in conflict with prevailing views that accepting personal responsibility for self-management is important in promoting personal recovery (Andresen et al., 2003).

Although direct contact with targets of stigma has been helpful in reducing stereotypes within the broader community, stigmatised attitudes remain common among mental health professionals (Schulze, 2007), suggesting that exposure and application of an illness model is not enough. Indeed, the disease model widely used within psychiatry is often criticised for promoting pessimistic stereotypes. Instead, recognising the personal and social contexts of people’s difficulties provides opportunities for promoting more empathic understandings of difficulties, humanising experience in a way which is likely to be helpful in combatting stigma. Hence, conceptualising distress in terms of interactions between biological, emotional, cognitive, behavioural and environmental factors would seem a more helpful way to respond to the poor fit of mental distress with the mind–body split. In this way, we may gain by reinforcing health professionals’ capacity for more sophisticated thinking about the people they see, rather than risking collusion with a simplistic mind–body dualism.