In Madness and Civilization, French philosopher and activist Michel Foucault wrote that, “from the fifteenth century on, the face of madness has haunted the imagination of Western man.” Foucault argues that the concept of ‘madness’, at least in the 1800s, was characterized as a loss of ‘reason’ – the essential mental faculty which made human beings distinct from other animals. Those who lacked reason (which all rational beings possessed) were perceived as a threat to humanity. Eventually barriers were raised – both literally and figuratively – which separated these ‘irrational’ individuals from the rest of humanity.
Such stigmatizing and social-distancing attitudes towards those living with mental illness are still deeply enmeshed in the social and cultural norms of many industrialized nations. In the 1960s, sociologist Erving Goffman spoke of stigma as a “spoiled identity;” more closer to us Bruce Link and Jo Phelan conceptualize stigma as occurring when “elements of labeling, stereotyping, separation, status loss, and discrimination occur in a power situation that allows them.” A related concept, social distance, is defined as the degree of proximity an individual is comfortable with in relation to an individual who is living with mental illness, particularly as it relates to the perceived dangerousness or unpredictability of that individual. Prevailing views amongst the public see the behaviour of individuals living with mental illness as volitional; at times these individuals might be considered ‘lazy’ (in the case of major depression and the ethical values tied to participation in the workforce), and so, intuitions about mental illness are believed to be justified blaming these individuals, or perhaps even punishing them.
The study of stigma and social distance in mental illness has been a fruitful, yet terribly underfunded, research program. Time and time again, the evidence points to a similar conclusion: stigmatizing those living with mental illness is incredibly damaging: it creates barriers to treatment service, treatment adherence, housing, employment, and relationships. Self-stigma leads to internalized feelings of devaluation. Taking this evidence as a matter of social justice, many clinicians, policy makers, scientists, activists, and others began to promote a medicalized view of mental illness as a somatic disease: “a disease like any other”. Therefore, since the “disease” of mental illness occurred beyond the individual’s control perhaps as a genetically inherited condition (these were culturally-bound concepts that were accessible to much of the Western populace when such views began to gather steam), the logic is clear: these individuals are not responsible for acquiring the disease. If the individual is not responsible, a more compassionate view towards the mentally ill should replace previous stigmatizing intuitions, and the barriers and challenges to treatment, housing, employment, and other psychosocial necessities should be reduced, if not entirely eliminated. A beneficent and laudable objective.
Not so fast.
In the mid-1990s, several studies started to emerge which suggested that, to paraphrase Jason Schnittker, the rise of a biological model of mental illness has not increased tolerance amongst the lay public. In fact, biological attributions may have complex effects for the stigma process, such that biological (specifically genetic in some cases) attributions were actually found to increase stigma and certain aspects of social distance, and emphasize mental illness as permanent and untreatable. Jo Phelan argued that these findings are consistent with “genetic essentialism,” the view that genes are both essential to identity and deterministic of behaviour. While the results of international studies are mixed, by and large it seems that the medicalized anti-stigma campaign may be having the exact opposite effect of what was intended.
In a recent paper published online in advance for the American Journal of Psychiatry, Pescosolido and colleagues examined a similar hypothesis to the genetic-and-stigma idea: embracing mental illness as a neurobiological disease should, in the public’s view, help reduce barriers to service use, treatment adherence, and reduce stigma. This view represents a similar underlying assumption to the genetic model of mental illness where it is believed that adopting neuroscientific beliefs about mental illness would correspond with a reduction in stigma. The authors examined responses to vignettes put forward in both the 1996 and 2006 General Social Survey in the United States which described individuals meeting DSM-IV criteria for schizophrenia, major depression, and alcohol dependence. The authors aimed to study the impact of a neurobiological causal explanation of these mental health conditions with a 10-year comparison of public endorsement of treatment and prejudice. What they found was that having a neurobiological conception of schizophrenia, depression and alcohol dependence was associated with an increased likelihood of support for health-seeking behaviour, but not a decrease in stigma. Thus the assumption is incorrect that a widespread change in neuroscientific beliefs would translate into widespread reductions in public stigma.
Interestingly enough, they found that more of the public in 2006 (67%) embraces a neurobiological understanding of mental illness than that of ten years prior (54%). Although beyond briefly referring to the proclamations made concerning the ‘Decade of the Brain’ and other policy efforts with optimistic statements about neurobiology, the authors did not really discuss what may account for this increase in the acceptance of neurobiological explanations. Why was it assumed that a neurobiological account would denote a “real” illness and not behaviours driven by the individual’s volition? Is there something peculiar about neurobiology? Perhaps this increase in the neurobiological embrace may be an effect of the modern neuroculture, but at this time it is difficult to say. Either way, we are still left with the challenge of constructing effective anti-stigma efforts, and the duty to eliminate the stigma and discrimination directed towards those living with mental illness, particularly as it continues to prevent access to health and social services, employment, and housing, and to increase alienation, marginalization, and suffering.