A recent study, published in the Journal of College Student Psychotherapy, explores how receiving a psychiatric diagnosis and being prescribed psychotropic medication can lead to social stigma for college students. The study draws on earlier research suggesting that biological characterizations of mental illness, especially when tied to pharmaceutical intervention, can produce social stigma by attributing responsibility for experienced distress mainly to the individuals who experience it.
According to the authors of the study, led by Benjamin Johnson, a Ph.D. student in clinical psychology at Marquette University:
“Stigma toward mental illness has been studied extensively, and numerous themes of research have emerged. For example, researchers have examined determinants of stigmatizing attitudes as a function of both the personal characteristics of people holding those attitudes and also of the clinical characteristics of the person or people that are the subject of the stigma”
Going further, they add that:
“[A]n important and frequent attribution about mental illness concerns control and responsibility. Studies have found that people tend to attribute more controllability to mental illness than to medical illness . . . Attributions of responsibility, which is sometimes attributed as personal weakness . . . have been found to be associated with negative emotional reactions (such as fear and anger) and discriminatory behavioral reactions (such as avoidance or unwillingness to hire someone).”
This is part of a long history of psychiatrists using brain research to explain individual behaviors that appear to deviate from established social norms. This tendency toward a biomedical model of mental health became more pronounced following the publication of the DSM-III, the third edition of the Diagnostic and Statistical Manual for Mental Disorders, in 1980. Since then, there has been an overarching goal to develop operational criteria for mental disorders that can be linked more successfully to pharmaceutical intervention.
And yet, the biomedical model of mental illness has increasingly become a target of criticism by clinical researchers, mental health professionals, and psychiatric survivors/service users. Beyond charges that neurobiological approaches to psychology are based on a set of faulty assumptions, it has been suggested that biomedical approaches to mental health care marginalize the voices and experiences of those receiving services. This phenomenon has been described in terms of contributory injustice, whereby those experiencing distress are not allowed to contribute to discussions about what may or may not be wrong with them.
Johnson et al., the authors of the study, further describe how recent “public education campaigns seeking to reduce stigma have asserted biological causes of mental illness,” and yet “the effect of these campaigns has been mixed and potentially even counterproductive.” As such, while the promotion of biomedical explanations might have lead to a general shift in public perception about individuals’ abilities to “control” their symptoms, such campaigns “do not appear to be successful at reducing other stigmatizing reactions and may actually be enhancing them in some ways.”
The research carried out by these authors looked specifically at how such stigmatizing reactions could play a role in the lives of college students. Focusing on this population is especially important given the ways that mental health services are generally more accessible, with ADHD medications being more available, for them than they are for other groups.
The authors developed the following three hypotheses to test how college students might react cognitively, emotionally, and behaviorally to a peer’s distress when it is characterized in psychiatric terms:
- “First, based on the expectation that schizophrenia would be more likely to be perceived as being caused by biological factors than would major depressive disorder, it was predicted that participants would attribute more responsibility to the Target Student described as being depressed.
- Second, based on attribution research, it was predicted that participants would endorse more negative emotional reactions and more stigmatizing behavioral dispositions toward the Target Student with depression.
- Finally, it was predicted that participants would attribute more responsibility, endorse more negative emotional reactions, and endorse more stigmatizing behavioral dispositions when the vignette included a statement that the Target Student had taken a medication for the illness but then stopped.”
To carry out this research, the authors created four separate vignettes of male college students, half which described “an episode of severe depression” and the other half “an episode of schizophrenia.” Each college-aged participant was given one vignette to read before completing a questionnaire about how such a person might be perceived if encountered.
The survey spanned six different scales of stigma, categorized in terms of responsibility, lack of sympathy, anger, unwilling to help, coercion into treatment, and social distance. Possible attributions participants could select ranged from sentiments like “I would think that his present condition is his own fault” and “society should force him to seek treatment” to “I would feel sorry for him.”
The group of researchers ran several ANOVA statistical analyses to find correlations between these variables. As they explain, the results seem to indicate that when ‘Target Students’ were considered responsible for their actions, there was a higher likelihood for negative emotions or otherwise stigmatizing beliefs expressed towards them. Additionally, stigma increased if a ‘Target Student’ had been prescribed psychotropic medications at some point but had, for whatever reason, stopped taking them.
The participants also responded very differently to cases described as ‘severe depression’ than they did to those described as ‘schizophrenia.’ In general, ‘Target Students’ diagnosed with depression were considered more responsible for their distress, which in turn garnered less sympathy from participants. ‘Target Students’ diagnosed with schizophrenia, by contrast, were considered “less responsible [but] more sympathetic presumably because of a belief in the biological cause of the disorder.”
And yet, participants were also much more likely to consider ‘Target Students’ diagnosed with ‘schizophrenia’ to be more dangerous (to both self and others) than those diagnosed with ‘severe depression.’ This was likewise associated with the assumption that coercion into medical treatment in cases involving schizophrenia can be not only useful but often necessary when psychotropic medications are not used as prescribed.
Taken at face value, the study seems to suggest that college students who receive mental health services are likely to encounter social stigma from peers in a variety of forms. It also supports earlier research indicating this stigma can be enhanced by popularly held assumptions that a) there are biological causes for mental distress, and b) pharmaceutical treatments are an effective form of psychiatric intervention for distress. Finally, the authors note that stigmatizing beliefs were less likely for participants who had some prior experience with mental health services, either for themselves or with friends/family.
While the above insights are important, there are noteworthy limitations to keep in mind regarding this research. The vignettes given to participants were, self-admittedly, overly simplistic representations of situations involving mental distress, while focusing exclusively on male individuals. They were also written in ways that intentionally included common stereotypes related to ‘mental illness.’ In fact, given how often the term ‘mental illness’ was referenced throughout the study, it is not clear from the article what an alternative set of assumptions might look like, or how the researchers would propose studying this.
The authors also noted that participants had disproportionately low rates of exposure to mental health services when compared to the general population. Given that the participants were all undergraduate students, and the biomedical model is regarded as the standard approach to mental health care, it could have been worth exploring whether such stigmatizing beliefs and assumptions were reinforced in college courses the participants took themselves.
Nonetheless, the Johnson and colleagues express optimism that their research can, at the very least, serve as a pilot study for further exploration into the ways that stigma related to mental health services affects the lives of college students. Specifically, they hope such research will spur college educators and administrators to reflect more thoughtfully on the ways in which students with a history of receiving mental health services:
“may face a special burden of expectation—and associated stigma—if they do not take medications, which have been promoted as helpful for several decades. This is especially relevant given that medications do not help all people with depression and, indeed, have been shown to be less effective than psychotherapy in the treatment of depression in adults.”
Benjamin T. Johnson, Peter P. Grau & Stephen M. Saunders (2019): Psychiatric Medications and Stigmatizing Attitudes in College Students, Journal of College Student Psychotherapy, DOI: 10.1080/87568225.2019.1600092 (Link)