A recent study published in Psychology and Psychotherapy: Theory, Research, and Practice examines the effects of psychoeducation on perceptions toward depression. The study tests how biological and person-environment interaction explanations differ in effects on treatment preference, prognostic pessimism, and stigma. The authors approach the issue from the lens of attribution theory, which explores how the framing of ‘mental illness’ can contribute to beliefs and actions around the phenomenon.
“For example, the biomedical model assumes that depression is a brain-based dysfunction and that brain function is largely the result of a predetermined genetic makeup or chemical imbalance. In this way, attributing depression to a biomedical etiology entails a causality that is internal, stable, and uncontrollable. In contrast, by emphasizing learned cognitive patterns, environmental contingencies, and the interactions between these factors, cognitive and behavioral model of depression can be characterized as more external, variable, and controllable. The examination of this process is essential in determining how depression etiology should be framed in a way that supports effective treatment-seeking and relevant attitudes,” write Martha Zimmerman and Dr. Anthony Papa of the University of Nevada.
Researchers have for some time been interested in the iatrogenic, or unintended, effects of different explanatory models of mental illness. Some evidence suggests that biological explanations of depression can result in greater self-blaming, pessimism, and stigma. Philosopher and historian of science Ian Hacking suggested that it’s common to interpret ourselves through available cultural “tools” such as psychiatric diagnoses, leading to a kind of feedback loop in which we construct ourselves in response to these notions.
“Attribution theory” is another relevant proposal which argues that the effects of different explanations can be measured along the lines of locus of control (external versus internal), stability, and controllable or uncontrollable. In other words, an account could convince us that a phenomenon (like mental illness) is outside of our control, stable and not open to change, and uncontrollable, in a worst-case scenario.
“Patterns of attribution have important consequences for subsequent affective responses and behavior. Believing a negative event or trait to be internal, for example, may result in more self-blame,” explain the authors.
The current study expands on existing attribution theory research as it relates to explanations of depression. The authors asked research participants to read three different prompts: a biological account of depression, a person-environment interaction explanation of depression, and a description of depression that attempted to avoid explanation. Participants were recruited from the anonymous crowd-sourcing platform, Amazon’s Mechanical Turk.
Only participants not currently receiving treatment and without a history of pharmacological treatment for depression were included, to avoid pre-existing biases toward specific therapies. The presence of depression was measured in participants via the Beck Depression Inventory. After reading the prompts, participants filled out questionnaires measuring locus of control, stability, controllability, treatment preferences, and attitudes such as stigma and prognostic pessimism.
The results of the study indicated that the biomedical explanation was associated with a much firmer belief in medication credibility compared to the psychosocial and control groups. Regarding confidence in psychotherapy, none of the groups differed significantly.
Participants exposed to the biomedical explanation were also more likely to believe that depression is a life-long disorder, that depression is akin to “feeling sorry for oneself,” and that being diagnosed with depression is likely to cause others to view them as dangerous. Prognostic pessimism and stigma were significantly affected by the biomedical explanation.
The dimensions of attribution theory did not turn out to be significantly affected by the explanations. The authors offer several speculative points here, including the possibility that this could be the result of studying currently depressed individuals, many of whom are resistant to “self-relevant treatment information” and are more likely to misinterpret information about treatment.
Additionally, participants in the control group preferred antidepressant treatment. The authors speculate that this may be related to pharmaceutical company media campaigns, exposing many to the biomedical explanation before the study.
“Pre-existing beliefs about the cause of depression may have prevented the psychosocial condition from proving effective in increasing psychotherapy preference. Thus, future research should examine pre-existing beliefs that may impact the effectiveness of psychoeducation.”
Relatedly, they state that despite participants finding the explanations equally believable, compelling, convincing, and similar to existing beliefs, biomedical explanations were associated with a greater perception of belief change. This may be related to what the authors term “genetic essentialism,” or the socially accepted and intuitive belief in the truth of genetic explanations, over and above more complicated and contextual explanations.
The study did have some limitations. Most participants were white and reported higher levels of education than the general population. Also, the choice not to include participants currently receiving treatment, and with a history of pharmacological treatment, may affect the study’s generalizability.
Finally, Amazon’s Mechanical Turk crowd-sourcing platform may have been inadequate at ensuring that participants were giving the explanations their full attention or feeling fully engaged in the task. There may also be self-selection bias among people who sign up for the Mechanical Turk service, presenting further problems with the sample’s generalizability.
The authors conclude:
“Taken together, the findings indicate that the way aetiology is framed in psychoeducation has important effects on treatment-seeking attitudes. Psychoeducation emphasizing a biological aetiology of depression in particular increased the credibility of antidepressant medication for depressed individuals, had no effect on psychotherapy credibility, and does not appear to reduce stigma. These findings are generally consistent with past work.”
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Zimmermann, M. & Papa, A. (2019). Causal explanations of depression and treatment credibility in adults with untreated depression: Examining attribution theory. Psychology and Psychotherapy: Theory, Research, and Practice. (Link)
So the bio-medical model increases self blame and stigma. Ironic, since according to NAMI and all those other groups it’s supposed to do the reverse.
I found rejecting the bio-medical explanation empowering. As soon as I read William Glasser’s book Warning: Psychiatry can be Hazardous… I felt a sense of hope and joy I never had before. And I quit hating myself. I could change my life after all! 🙂
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Speaking from my own experience of treatment for “bipolar disorder”, the psychiatric practitioners themselves are extremely inconsistent in their own approach, taking neither a strictly biomedical nor a psychosocial approach to patients behaviors and affect. In this way, it is possible to both blame the patient for their behavior and keep the patient believing they have an illness outside their control that requires pharmaceutical treatment.
It’s also easy to see why the “just like insulin for diabetes” metaphor is so useful to them in keeping patients compliant with pharmaceutical treatment. With diabetes, especially with type 2 diabetes, there is a measure of patient control over diet and exercise that will mitigate the illness, but some patients will still need insulin therapy or blood sugar regulating medications – especially when there is a hybrid type disease. Not all patients can fully control their diabetes (an actual progressive disease) with lifestyle factors, in other words.
In using this metaphor with the “severe mental illnesses”, it is possible for the practitioners to push both the recovery and biomedical models at the same time. My experience was that my reactions to external circumstances beyond my control (social and family situations) were often met with medication changes at the same time as I was being “educated” about recovery methods such as good diet, exercise, reducing stress and conscious behavior alterations. Unfortunately, the medication changes have their own strong effects on the behavior of the drug consumer in terms of inducing hypomania with the antidepressants and stimulants, or conversely inducing stupor-like states with the neuroleptics.
I have come to see this hybrid response as a type of psychiatric/medical gaslighting. In contrast to using insulin judiciously to lower blood sugar – something that can be instantly measured and that an educated and experienced patient can and should themselves learn to adjust the amount of insulin they inject – there are no direct measurements or patient control over the psychoactive effects of psychiatric drugs. And in fact, it would be dangerous to allow the patient in an altered state induced by the drugs to make such decisions.
The problem therefore with these notions that there is either a biomedical or a recovery focus – either psychiatric or psychosocial – and notions of external vs internal loci of control, is that you cannot separate the effects of the drugs from the psychosocial conditions the patient is living in and any amount of personal growth or maturity the patient might be capable of gaining. Psychiatry, in my experience, is very adept at claiming the patient is ill while blaming them for behaviors directly induced by the psychiatric drugs. It becomes a hamster wheel of trying to learn new ways of being while also chasing drug effects.
I have a binder of handouts leftover from my days as a patient that perfectly illustrates both the “you are sick and need drugs/interventions” and the “you can recognize the warning signs and/or alter your behavior”. Again, this is gaslighting. There is no either/or once the patient is medicated and targeted as being “mentally ill”, which the statistic show usually happens in that order, with most patients being given antidepressants by general practitioners without psychiatric diagnoses, and only then progressing on to psychiatric care after they’ve been exposed to the psychoactive effects of the drugs.
The question then becomes, how do we stop the introduction of psychoactive drugs by general practitioners to those in mild distress or to those who are indeed ill with physical illnesses inducing altered mental states? How do we change the approach to those in distress to be both more humane and to include sound social and medical understandings of the effects of physical illness and psychodynamics?
In my own case, recovery has included eliminating contact with my traumatic family of origin; antibiotic and herbal treatment for Lyme Disease and coinfections (TBD); CPAP treatment for sleep apnea; dating/marrying my way out of poverty so that I had access to the things that financial security provides in this culture such as a healthy diet (gut *and* brain health), a safe neighborhood to live in, alternative supports like massage/yoga/etc; and completely eliminating psychiatric drugs so that (now two years and ten months later) my intellect and emotions are stable enough such that I can invest in others to a degree that I am developing that elusive support system I was always told I needed but could not obtain while my behaviors and affect were so unstable. The only remaining effects of my time in psychiatric care are my electronic health records and the scars on my arms from my psychiatric-drug-induced suicide attempt (17 years ago) which remain a visible and readily identifiable way to target me despite all the progress I have made.
In a culture that systematically refuses to actually address the underlying issues that lead to extreme mental states, and that continues to demand more “mental health care” – which, for most of us translates into pharmaceutical management – I do not foresee the majority of (extraordinarily oppressed) people being able to access the kinds of lifestyle and environmental changes that will lead them out of their distress, regardless of whether they personally believe they have an internal vs external locus of control. And surely not for those who do not possess the amount of privilege I have as a white, decently educated, and relatively non-targeted woman passing as straight and aligned with a high-earning white male spouse. I did not personally earn most of the privilege I enjoy, and my method of “recovery” is not widely available. I will never have to worry about being stopped and frisked, driving while black, having my immigration status questioned, or even having my socioeconomic status questioned as long as I continue to play the social games this totally upside-down rich white dominating society requires.
External vs internal locus of control? Biomedical vs recovery orientation? It is SOOOO much more complicated than that and reducing people’s personal difficulties or extreme states to such trivial factors for tidy research papers is a way to continue to ignore how complicated and interwoven both psychosocial *and* biomedical factors are in creating (and perpetuating) emotional distress and extreme mental states. This is essentially the real crux of living in a capitalist bootstrap culture – the continued elusive search for easy answers.
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Yes. Psychiatry is great at making you question your own sanity.
Feeding you drugs to cause bizarre sensations and claiming “they never have that effect.” Either you’re lying or crazy.
Telling your family you obviously are lying about taking your “meds” since if you were “compliant” all your problems would magically vanish. All the time you take them religiously though they make you feel horrible.
And the shrink blames your cognitive problems, sleeping too much, mood swings, annoying habits you’re too stupified to control on you. Either you’re 1. Lying about your “meds.” 2. Faking the seizures, dizziness, etc. since the “meds NEVER do that.” 3. It’s just your inherint defectiveness showing through. Requiring more pun–uh–treatments in the form of doubling the drugs making you sick and imprisonment.
Came to a point I started lying all the time–since I couldn’t tell what was real anymore. And no one believed me anyhow. Psychiatry=insanity. It exists to gain life long guinea pigs to exploit. To gas light and drive people insane.
Shrink: You know if you weren’t totally insane you wouldn’t be coming to me for help.
Me: Took the words out of my mouth Doc.
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This is an example of what happens when you consider “depression” to be an entity unto itself instead of a symptom of some pathological process that can be identified and readily (for the most part) treated, frequently without the use of psych meds, once its origin can be pinpointed. It should be no surprise that the pseudo-biological explanation for depression given by the average shrink will tend to make patients more depressed.
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Real biology explains depression as the natural expression of depressing experiences; psychiatry increases prognosis pessimism by pathologizing natural emotional suffering.
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This is confusing. “Real biology” wouldn’t involve itself with emotion or behavior at all, but maybe that’s not what you mean.
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Normal people explain depression as the natural expression of depressing experiences.
Or they did before shrinks and Big Pharma poisoned our thinking with ads everywhere saying the slightest uncomfortable emotion is a disease required massive amounts of emotional pain killers.
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Well said Rachel 777. It seems therapeutic to understand that depression is a natural reaction to depressing experiences so that depressing experiences can be addressed and countered. Consistently, if depression is understood as the natural reaction to depressing experiences, assistance would take the form of empathy and support rather than drugs and coercion.
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Removed for moderation.
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“Explaining Depression Biologically Increases Prognostic Pessimism”
We have to stand up for ourselves. We should not ever allow anyone to talk about us as being “depressed” in any manner.
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