Attempt To End Stigma Increases It

Attempt To End Stigma Increases It

by William Schultz, Doctoral Student


Lena Dunham, a well-known actress, recently received attention and praise because of a collection of Instagram photos she publicly posted, which highlighted her emotional and psychological challenges (subsequently referred to as “mental illnesses”; although I think this and other medical terms are misleading, I’ll use them in this post just for clarity sake) and the medications she uses in response to those challenges. Her central message was that there should be “no shame” surrounding mental illnesses or the use of medications.[1] By “shame”, Dunham was referring to the stigma surrounding mental illnesses, which is pervasive and has a variety of negative effects, such as increasing distress and discouraging individuals from seeking help.[2] Due to the widespread, negative effects of stigma, mental health patients, mental health advocacy organizations, mental health professionals, researchers, celebrities, and politicians have communicated their commitment to ending stigma through psychoeducational campaigns.

For example, actress Glenn Close co-founded an organization called “Bring Change 2 Mind” whose purpose is to “end stigma and discrimination surrounding mental illness” through education. The method for combatting stigma endorsed by Dunham and Close appears to rely on explaining mental illnesses as brain diseases. For instance, the “facts” section of the Bring Change 2 Mind website states that “The fact is, a mental illness is a disorder of the brain – your body’s most important organ – and one in four adults experience mental illness in a given year, including depression, bipolar disorder, schizophrenia, and PTSD.”[3]

By asserting that mental illnesses are brain disorders, this approach highlights supposed brain defects as causes of mental illnesses. This, in turn, challenges the stigmatizing belief that mental illnesses are the result of some sort of moral failure or character weakness. The reasoning goes: You wouldn’t blame someone for being diagnosed with a physical disease to which they didn’t contribute. So why would you blame someone for their mental illness, since mental illnesses are really brain disorders to which they didn’t contribute?

This approach to stigma has been identified in research. For example, Corrigan et al. summarized the perspective described above when they wrote, “Moral models yield attributions that mental illness is onset controllable and persons with mental illness are to blame for their symptoms. Biological models are more consistent with attributions that mental illness is uncontrollable at onset.”[4] In other words, moral models suggest that individuals can control the development of their mental illness while biological models suggest they cannot. This is in line with Bring Change 2 Mind’s claim that “Like most diseases of the body…Mental illnesses are no one’s fault.”[5]

It seems to me that identifying and challenging stigma are excellent goals and I praise individuals and groups, like those mentioned above, for their efforts. However, I’m also concerned because I believe there are at least three important problems with this approach.

The first problem is the assertion that mental illnesses are “brain disorders” contradicts the scientific data and some important philosophic considerations underlying that data. To begin, consider what Thomas Insel, until recently the head of the National Institute for Mental Health, wrote near the end of 2015: “The problem is that even though there have been thousands of studies looking for biological markers of mental health problems such as depression or schizophrenia, none has proven clinically actionable. And, in truth, little has been replicable even in a research setting.”[6] Insel’s comments aren’t out of the ordinary. Congruent statements have been made by many mental health experts.[7] In sum: scientific research has not identified reliable biological pathologies causing mental illnesses. And it’s a plausible argument that if we’ve not identified biological pathologies, it’s a stretch to call mental illnesses “brain disorders” or “brain diseases.”

Perhaps it’s true that researchers may someday identify biological pathologies. Even if they don’t, at the least mental illnesses still involve or are mediated by the brain.[8] And as neuroscience continues to progress, it’s likely that more and more precise correlations between mental illnesses and brain structure and function will be discovered. But even these discoveries wouldn’t immediately justify understanding mental illnesses as brain disorders because a change in the brain is not synonymous with a brain disorder. Let me explain:

All mental phenomenon and behaviors are mediated by the brain. That is, everything changes our brain, from our developmental environment to stressful life events, falling in love, studying for an exam, meditating, and participating in psychotherapy.[9] So even if researchers reliably identified brain differences in individuals who experience, for example chronic anxiety, this does not lead to the conclusion that a disordered brain is causing the anxiety. It merely identifies that the brain changes in response to experiences. To illustrate this point, consider a study in which researchers identified that when individuals diagnosed with social anxiety are administered cognitive-behavioral psychotherapy, their distressful symptoms diminished and their brains changed.[10] Crucially, the mechanism involved in changing the brain was not primarily biological but psychological. In other words, it was not an individual’s disordered brain that was causing their symptoms, but their unhelpful beliefs and behaviors related to social situations.

An objection I’ve often heard to this sort of example is that even though the mechanism of change may be psychological, the change still occurs fundamentally at the biological level. This objection opens up a large discussion which I’ve explored elsewhere and can easily lead us off track (if it hasn’t already). [11] But before returning to discussing stigma, I’ll try to briefly explain an important aspect of my reply to this type of reductionist objection:

If fundamentality is what we are after, then mental illnesses aren’t “really” brain disorders but, instead, patterns of quarks (or quantum fields or whatever else physics identifies) interacting in particular ways. In fact, from this type of reductionist perspective, sciences such as “chemistry” and “biology” aren’t real: they’re useful fictions -- epistemological tools with pragmatic explanatory powers that scientists use until our understanding of physics becomes powerful enough to achieve our explanatory goals. So if we want to be scientific about mental illness, then we need to rely not on neuroscientists, psychiatrists, psychologists, and those who’ve experienced mental illness, but on physicists.

I hope you’ll agree with me that this sort of thinking doesn’t make a lot of sense. At the least, I think it’s important to note that many biological oriented researchers agree that this perspective isn’t comprehensive or functional. For example, Kendler argued “It is possible to study scientific questions from perspectives that are both too basic and too abstract” and this is why he thought it important to reject looking for “big, simple neuropathological explanations for psychiatric disorders” and instead accept that in “ways we can observe but not yet fully understand, subjective, first-person mental phenomena have causal efficacy in the world.”[12] In short: psychosocial factors are crucial to understanding the development of mental illnesses and approaches which emphasize only biological features, such as claiming that mental illnesses are brain disorders, overstate the current evidence and are deeply misguided.

Now that we’ve gotten muddy in that philosophical swamp…I want to return to the subject of combatting stigma and my two other concerns about approaches that emphasize brain deficits. My next concern is straight-forward: a significant body of evidence suggests that emphasizing bio-pathological etiologies of mental illness does not reduce stigma. For instance, Angermeyer et al. used a population-based study design to investigate “the question whether promulgating biogenetic explanations may help reduce the stigma attached to mental illness and, therefore, should be included into anti-stigma messages.” [13] They found that biogenetic explanations are linked to increased stigmatizing attitudes and, as a result, should be avoided in anti-stigma campaigns.

Their findings aren’t unusual. In fact, they’re typical. Similar outcomes are found in numerous studies and meta-analyses.[14] Even recent experimental studies suggest that biogenetic etiologies of mental illnesses increase perceived differentness – such as increased perceived incompetence and unpredictability – and do not reduce stigma as well as explanations which emphasize that mental illnesses may not be discrete diseases.[15]

When I first examined this evidence, I was perplexed. I wondered: if biological etiologies emphasize that individuals are not responsible for their mental illnesses – their genetics, brains, and/or chemical imbalances are – then why do biological etiologies not decrease, and often increase, stigma? Well, in short, the research strongly suggests that the reason is that stigma is not only comprised of responsibility. Schomerus et al. emphasized that while biological etiologies of mental illness are often associated with reduced levels of perceived responsibility and blame, these reduced levels can be “outweighed by the adverse effects mediated by perceived differentness and dangerousness, respectively” and similar findings are common.[16] These increased levels of perceived differentness and dangerousness can contribute to the negative effects of stigma that organizations like Bring Change 2 Mind are attempting to challenge. Thus, it seems to me that there’s good reason to rethink this strategy.

Finally, my third concern surrounding emphasizing brain deficits is that this way of thinking can have significant negative impacts on clinical outcomes. Within the past decade, a new area of research has explored the relationship between an individual’s beliefs regarding the etiology of mental illnesses and her or his treatment preferences and prognostic expectations. The research has consistently found that the greater an individual endorses a biological etiology of mental illness, the greater her or his prognostic pessimism. That is, they expect that their symptoms will persist at greater levels for longer periods of time. The proposed mechanism of this finding is that the greater an individual endorses biological etiologies, the greater she or he endorses “essentialist” views of her or himself – the view that an individual’s emotional and psychological states are largely determined by biological factors and that psychological and social factors are largely or completely impotent.[17] This prognostic pessimism is important because a clients’ expectancies to improve are an important contributor to their improvement – individuals who expect to do better, do better.[18] Thus, factors which contribute to individuals expecting to do worse – such as biological etiologies – can contribute to individuals doing worse.

So, given my concerns, where does this leave us? Unfortunately, with no quick and easy solution. Corrigan, Druss, and Perlick noted that “Advocates need to learn from the complex research on stigma change to implement programs that improve care seeking while not exacerbating other forms of discrimination.”[19] That’s not easy because mental illness and stigma are large, often complicated, subjects. At the least, though, I think it’s important to recognize that there are alternatives to biological etiologies of mental illnesses – such as psychosocial approaches -- which are congruent with the scientific evidence and may avoid promoting stigmatizing attitudes. That is, individuals who experience mental illness may be responding to harmful environments and/or lack the knowledge/resources to manage their lives in more adaptive ways. This perspective doesn’t reduce mental illnesses to brain disorders and it doesn’t imply that we should blame individuals for their mental illnesses. It seems to me that this is an approach worth considering.

[1] Holmes, L. (2016). Lena Dunham shuts down mental illness stereotypes in new photos. Retrieved from http://www.huffingtonpost.com/entry/lena-dunham-mental-illness-instagram_us_56a259b7e4b0d8cc1099cf59

[2] Corrigan, P. W., Druss, B. G., & Perlick, D. A. (2014). The impact of mental illness stigma on seeking and participating in mental health care. Psychological Science in the Public Interest15(2), 37-70.

[3] Bring Change 2 Mind (2016). The facts. Retrieved from http://bringchange2mind.org/learn/the-facts/

[4] Corrigan, P. W., River, L. P., Lundin, R. K., Wasowski, K. U., Campion, J., Mathisen, J., Goldstein, H., Bergman, M., Gagnon, C., & Kubiak, M. A. (2000). Stigmatizing attributions about mental illness. Journal of Community Psychology, 28(1), 91-102.

[5] Bring Change 2 Mind (2016). The facts. Retrieved from http://bringchange2mind.org/learn/the-facts/

[6] Insel, T. (2015). A different way of thinking. New Scientist, 227(3035), 5.

[7] Deacon, B. J. (2013). The biomedical model of mental disorder: A critical analysis of its validity, utility, and effects on psychotherapy research. Clinical Psychology Review, 33(7), 846-861; Fuchs, T. (2012). Are Mental Illnesses Diseases of the Brain?. Critical Neuroscience: A Handbook of the Social and Cultural Contexts of Neuroscience, 331-344; Graham, G. (2013). The Disordered Mind: An Introduction to Philosophy of Mind and Mental Illness. New York, NY: Routledge; Miller, G. A. (2010). Mistreating psychology in the decades of the brain. Perspectives on Psychological Science5(6), 716-743.

[8] Fuchs, T. (2011). The brain--A mediating organ. Journal of Consciousness Studies18(7-8), 196-221.

[9] Hunter, N., & Schultz, W. (2016). Brain scan research. Ethical Human Psychology and Psychiatry, 18(1), In press.

[10] Månsson, K. N., Salami, A., Frick, A., Carlbring, P., Andersson, G., Furmark, T., & Boraxbekk, C. J. (2016). Neuroplasticity in response to cognitive behavior therapy for social anxiety disorder. Translational Psychiatry, 6, e727, 1-8.

[11] Schultz, W. (2015). Neuroessentialism: Theoretical and clinical considerations. Journal of Humanistic Psychology, published online before print on December 3, 2015, doi:10.1177/0022167815617296.

[12] Kendler, K. S. (2005). Toward a philosophical structure for psychiatry. The American Journal of Psychiatry162(3), 433-440.

[13] Angermeyer, M. C., Millier, A., Kouki, M., Refaï, T., Schomerus, G., & Toumi, M. (2014). Biogenetic explanations and emotional reactions to people with schizophrenia and major depressive disorder. Psychiatry Research, 220(1), 702-704.

[14] Kvaale, E. P., Gottdiener, W. H., & Haslam, N. (2013). Biogenetic explanations and stigma: A meta-analytic review of associations among laypeople. Social Science & Medicine, 96, 95-103; Schomerus, G., Matschinger, H., & Angermeyer, M. C. (2014). Causal beliefs of the public and social acceptance of persons with mental illness: a comparative analysis of schizophrenia, depression and alcohol dependence. Psychological Medicine, 44(02), 303-314; Speerforck, S., Schomerus, G., Pruess, S., & Angermeyer, M. C. (2014). Different biogenetic causal explanations and attitudes towards persons with major depression, schizophrenia and alcohol dependence: Is the concept of a chemical imbalance beneficial?. Journal of Affective Disorders, 168, 224-228.

[15] Wiesjahn, M., Jung, E., Kremser, J. D., Rief, W., & Lincoln, T. M. (2016). The potential of continuum versus biogenetic beliefs in reducing stigmatization against persons with schizophrenia: An experimental study. Journal of Behavior Therapy and Experimental Psychiatry50, 231-237.

[16] Schomerus, G., Matschinger, H., & Angermeyer, M. C. (2014). Causal beliefs of the public and social acceptance of persons with mental illness: a comparative analysis of schizophrenia, depression and alcohol dependence. Psychological Medicine, 44(02), 303-314.

[17] Schultz, W. (2015). Neuroessentialism: Theoretical and clinical considerations. Journal of Humanistic Psychology, published online before print on December 3, 2015, doi:10.1177/0022167815617296.

[18] Constantino, M. J., Ametrano, R. M., & Greenberg, R. P. (2012). Clinician interventions and participant characteristics that foster adaptive patient expectations for psychotherapy and psychotherapeutic change. Psychotherapy, 49, 557-569.

[19] Corrigan, P. W., Druss, B. G., & Perlick, D. A. (2014). The impact of mental illness stigma on seeking and participating in mental health care. Psychological Science in the Public Interest15(2), 37-70.

4 Comments

  • Al, Excellent point. If I could re-write this article it would include four concerns -- including the concern you point out: that biological etiologies encourage biological treatments (e.g., ssri//neuroleptics) which have a variety of significant, negative side-effects. William

  • This is a very well done and helpful article William. Much appreciated. I would add some other problems with the belief that "mental illnesses" are caused by chemical imbalances, genetic dynamics and brain disorders. That is an extremely cynical belief. It essentially means that the most important faculty you have help you live your life - your mind - is not under your control. Rather you are at the mercy of forces over which you have no control when it comes to your mental state of being. Can't get much more cynical than that. It is also a very harmful belief. Because as you point our, people who subscribe to the Biopsychiatric Belief System are relatively pessimistic about their chances for recovery. My guess is that they are also unlikely to participate wholeheartedly in psychotherapy. That is a big problem because intervention at the level of the mind through psychotherapy is so much more beneficial and less risky that intervening at the level of the brain with drugs and electroshock, it is amazing that as many people choose to intervene at the level of the brain as do. That would be my retort to the people who say Oh well yes, there may be some psychosocial factors and life factors involved in "mental illness" but "mental illness" obviously must involve the brain so that is a more fundamental place to intervene. Well it may be more fundamental but it is also associated with extremely harmful risks and the benefits of such intervention are minimal at best. After all, taking a pill is not very likely to help you learn to use your mind in healthy ways. That is what psychotherapy is all about.

  • Before I can comment on stigma, and imaginary "mental illnesses" myself, here's ANOTHER "mental illness" popping up! YO!, "Joan West", what's "Caucasian"? Are you aware that "caucasian" *itself* is racist? Why do you still believe in the old myth of "races"? There's only ONE RACE, the human race. We come in lots of different sizes, shapes, and COLORS. So please stop stigmatizing "races". If I'm not a black guy, or Asian, or Indian, or whatever, does that mean I'm a "person of NO color"? I think the REAL problem is in YOUR mind.... All so-called "mental illnesses" are exactly as real as presents from Santa Claus,(who's an old White Guy), and any belief system which sqays otherwise only creates and perpetuates stigmas.... (c)2016, Tom Clancy, Jr., *NON-fiction

  • why is it that all the faces that have been displayed on your webside are Caucasian? With all the people, a large number of whom are people of color one would have thought your organization would be representative of that fact. Don't bother to respond as the email listed is not mine. Myself and others are discouraged by your organizations lack of INCLUSION

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