I deliberately chose a tendentious title for this essay – misleadingly metaphorical rather than literal – to highlight, as one of my recent posts outlines, my alarm stemming from reading research on stigma.
With many others, I had assumed that treating psychiatric disorders as “a disease like any other” (i.e., like any other general medical condition) would ameliorate stigma. This biological perspective reflects a longstanding trend away from moralizing toward medicalizing mental illness – in Karl Menninger’s words, transforming “sin” into “sickness.”
Research on attitudes toward mental illness
In believing that we would thereby ameliorate stigma, we were wrong. My previous post was inspired by Erlend Kvaale and colleagues’ synthesis of extensive research that yielded surprising findings. Although construing mental illnesses as brain disorders decreases blame of the mentally ill person, it does not reduce stigma (i.e., social distancing). Moreover, this reframing can be harmful: It increases pessimism about prognosis, and it also risks increasing perceived dangerousness.
Reading further research on this question made me aware that I failed to appreciate an important facet of this problem that should have been obvious to me: The “brain disorder” reframing is associated with patients’ increasing reliance on medication in relation to psychotherapy; moreover, this reliance is abetted by consumer-directed advertising campaigns by drug companies. Two additional studies illustrate.
Bernice Pescosolido and colleagues examined changes in attitudes about mental illness over a 10-year period (1996-2006) in a representative national sample in the U.S. They asked participants to read clinical vignettes describing symptoms of schizophrenia, depression and alcohol dependence (without using the diagnostic labels). Then they asked participants to indicate:
- If they viewed the person’s problems as a mental illness;
- If they thought the problems were biological (i.e., genetic or biochemical) versus being due to character or the way the person was raised;
- If the person should seek treatment; and
- Most directly related to stigma, if they would seek social distance or would consider the person to be dangerous.
The findings of the study are instructive: Over the 10-year period in the sample as a whole, there was an increase in attributing these mental illnesses to a neurobiological cause. Consistent with this attribution, there was a parallel increase in endorsement of medical treatment (e.g., medication and care by a psychiatrist).
Yet, despite the increasing acceptance of a biological view of illness and treatment, there remained a high level of stigma that did not decrease over time. The majority of respondents would not want to work closely or socialize with the ill person and believed the person to be potentially violent. Some aspects of stigma actually had increased.
Furthermore, an examination of individual differences among participants showed that holding a neurobiological conception did not decrease stigma in any respect. On the contrary, the biological view increased the odds of a stigmatizing reaction in some respects (i.e., preferring not to work with a person with schizophrenia, believing persons with depression to be more dangerous).
Accordingly, a major educational effort has succeeded in persuading the public that mental illness is a neurobiological condition and that medical treatment is needed; yet the authors conclude,
“An overreliance on the neurobiological causes of mental illness and substance use disorders is at best ineffective and at worst potentially stigmatizing.”
Research among college students and attitudes toward mental health services
Corey Mackenzie and colleagues’ study also is disconcerting. These researchers examined changes in U.S. college students’ attitudes toward mental health services over a 40-year period (1968-2008). Overall, they found that students’ attitudes toward seeking help had become substantially more negative over this long period. This finding is noteworthy because accepting the biological nature of mental illness has been associated with an increase in seeking treatment with medication. The authors attribute their findings to the fact that many items in their measure pertain to talk therapy, and they note that the rise in use of medication has been accompanied by a decline in patients seeking psychotherapy.
Mackenzie and colleagues conclude, “It may be that attitudes toward seeking specialty mental health care, and especially psychotherapy, are becoming increasingly negative as a result of public education and pharmacological marketing efforts to convince the public that mental disorders have a neurobiological etiology that require biological treatments such as antidepressant medication.” They refer to previous evidence that “the focus of these marketing and educational efforts has had no effect, or perhaps a negative effect, on attitudes toward people with mental disorders,” and they conclude quite reasonably that these efforts “may be having a similar negative effect on attitudes toward seeking non-biological treatments for mental disorders.”
I hope the research I have reviewed in these two posts will be as disconcerting to professional and lay readers as it is to me. At best, our well-intentioned efforts to reduce stigma by emphasizing the biological basis of mental illness have been ineffective except insofar as they alleviate blame of the ill individual. At worst, these efforts have increased stigma in some respects and might be deterring patients from seeking psychotherapeutic treatments – either as alternatives to medication or in combination with medication. We must do something different. I will address this challenge in my next post, “Can public education decrease stigma?”
Editor’s note: Check out the first post in Dr. Allen’s series about brain disorders and stigma.
Kvaale, E.P., Haslam, N., & Gottdiener, W.H. (2013). The ‘side effects’ of medicalization: A meta-analytic review of how biogenetic explanations affect stigma. Clinical Psychology Review, 33, 782-794.
Mackenzie, C.S., Erickson, J., Deane, F.P., & Wright, M. (2014). Changes in attitudes toward seeking mental health services: A 40-year cross-temporal meta-analysis. Clinical Psychology Review, 34, 99-106.
Menninger, K.A. (1973). Whatever became of sin? New York: Hawthorn Books.
Pescosolido, B.A., Martin, J.K., Long, J.S., Medina, T.R., Phelan, J.C., Link, B.G. (2010). “A disease like any other?” A decade of change in public reactions to schizophrenia, depression and alcohol dependence. American Journal of Psychiatry, 167, 1321-1330.