I do not know the answer to this question, but I have some thoughts about one aspect of it.
A significant public education effort has been mounted to decrease the stigma associated with mental illnesses by emphasizing their neurobiological basis. We can rightly think of psychiatric conditions as brain disorders with a partly genetic basis. As I have described in “Does reframing mental illnesses as brain disorders reduce stigma?” and “Is psychiatry’s drug addiction increasing the stigma of mental illness?,” this new understanding, assisted by drug companies’ advertising, gradually has taken hold in the public mind.
Yet this hard-won knowledge has not decreased the stigma associated with psychiatric disorders. Although it has ameliorated blame of the individual to some extent, the biological view also has led to more pessimistic prognoses in the public mind and may be fueling perceptions of dangerousness.
These research findings on stigma are especially disconcerting to me; when I educate patients and families, I make the point that psychiatric disorders are “illnesses” in every sense of the word. I make this point – for example, with depression – to help patients be more understanding and less critical of the sheer difficulty they face in recovering. Force of will is not enough; if you’re mentally ill, you cannot just change your mind and be well.
Our emphasis on the biological basis of psychiatric disorders appears to be backfiring. So what do we do? “Sorry, they’re not biological after all.” We cannot go backward; biological treatments are essential for many patients and, with burgeoning knowledge in neuroscience, these treatments hold promise of becoming increasingly effective over the coming years.
Given the research findings on stigma, we cannot make do with a sound bite: “It’s a brain disorder,” implying, it’s not your fault, or your parents’ fault. Blaming the genes or the brain is not helping. We need to understand, not blame.
I see no alternative to aiming for more sophisticated education (one reason why I decided to write a whole book on depression). For starters, we need to make four basic points:
- Brain changes associated with psychiatric disorders are reversible.
- Heredity is not destiny.
- Psychiatric disorders are associated with problems in living.
- Medication is not enough.
One adverse side effect of the “brain disorders” perspective is the (false) implication that the prognosis for recovery is thereby more grim. Of course there are brain changes with psychiatric disorders, just as there are brain changes with college educations. Neuroscience is demonstrating remarkable brain plasticity, not only early in development but also throughout life. Research shows changes in brain functioning associated with medication and with psychotherapy.
Here I am stating the obvious: If brains didn’t change, no one would develop psychiatric disorders, and no one would recover from them; experience would never change. Now we have rapidly developing science and technology to help us understand the neurobiological processes associated with these changes, and this knowledge will help us influence the changes for the better.
Unfortunately, Jo Phelan’s research with a national U.S. sample shows that a genetic explanation for mental illness increases its perceived seriousness and persistence. Moreover, the genetic view extends the stigma from the ill person to the family. Hence, as is true for the brain-disorder view, a genetic explanation increases pessimism about prognosis.
But our fates are not cast in our genes. Research shows that we can rightly speak of genetic “risk” or “vulnerability” for the development of psychiatric disorders. Yet, just as we are learning about brain plasticity, we are appreciating the dynamic nature of genetic influences.
You don’t develop depression because you have “the depression gene.” Multiple genes in interaction – complex networks – are associated with a given psychiatric disorder. Moreover, environmental factors influence gene expression; broadly speaking, for example, early stress can influence the likelihood that genes associated with depression are activated. Thus genes do not act in isolation; they act in concert with other genes and with the environment, including the social environment. To repeat: Heredity is not destiny.
Problems in living
Psychiatric disorders are brain disorders. But how does brain functioning become disordered? Heart disease is a biological illness. How does heart disease develop? We need to think about problems in living. Plainly, health-related behavior plays a significant role in heart disease (e.g., diet and exercise). Stress plays a role in the development of heart disease and psychiatric disorders. Stress is associated with problems in living, including health-related behavior (e.g., being a workaholic, failing to maintain a regular sleep schedule).
Research shows that depression is associated with two kinds of stress: fateful stress (e.g., accidents, victimization) and self-generated stress, which includes stress associated with interpersonal relationships (often mutually generated). Self-generated stress also includes alcohol and drug abuse, which contribute significantly to depression and other psychiatric disorders.
Taking problems in living into account offers hope: We can address these problems and thereby influence our brain functioning.
More than medication
One result of the recent emphasis on “brain disorders” is patients’ increasing reliance on medication and decreasing use of psychotherapy. No doubt, medication can be sufficient for many persons. Yet, if we consider environmental influences over gene expression and the fact that problems in living contribute to brain disorders, we can see that medication is likely to be only part of the solution. For complex and severe psychiatric disorders – for example, developing in the context of a history of problematic relationships – medication alone is likely to be insufficient.
I hold a simple view: Medication relieves symptoms, but psychotherapy promotes new learning. For lasting change, you must learn ways to alleviate and cope with the stress that evokes the symptoms. Moreover, when psychiatric disorders are associated with interpersonal problems, couples and family therapy may be especially important.
As a psychotherapist, my clinical experience convinces me that symptom relief through medication often is essential to enable the patient to benefit from any form of psychotherapy. Moreover, when the psychiatric disorders are especially severe, hospital treatment may be necessary to enable change with medication and psychotherapy.
Can public education reduce stigma?
I have not answered this question. Given the persistence of stigma in the face of massive efforts to increase public knowledge, it is hard to be sanguine about our educational prospects. I am merely addressing the adverse side effects associated with our ill-fated attempt to alleviate stigma by recasting mental illnesses as brain disorders. Perhaps with a bit more complex thinking, we would not translate brain disorders into irreversible conditions.
To reiterate, in educating patients and families, I intend to help them appreciate fully the seriousness of the problems: You cannot simply will yourself out of them or rely on any simple solution. In so doing, I hope to inspire compassion while also emphasizing the capacity for change and recovery.
To me, neuroscience is hopeful: Better understanding will lead to better treatment. But I also protest what I call “biomania,” that is, exclusive reliance on biological understanding to the detriment of appreciating the contribution of problems in living and treatments that address these problems directly. Karl Menninger and his colleagues defined hope as “the positive expectations in a studied situation which go beyond the visible facts.” Perhaps more realistic hope will be one antidote to stigma. But the “studied situation” requires more knowledge than can be contained in a sound bite or a tweet.
Editor’s note: Check out these other posts about brain disorders and stigma by Dr. Allen:
- Is psychiatry’s drug addiction increasing the stigma of mental illness?
- Does reframing mental illnesses as brain disorders reduce stigma?
Allen, J.G. (in press). Biomania: Benefits, risks, and challenges. Smith College Studies in Social Work.
Allen, J.G. (2006). Coping with depression: From catch-22 to hope. Washington, DC: American Psychiatric Publishing.
Menninger, K.A., Mayman, M., & Pruyser, P.W. (1964). The vital balance. New York: Viking.
Phelan, J.C. (2005). Geneticization of deviant behavior and consequences for stigma. Journal of Health and Social Behavior, 46, 307-322.