Ungar, Knaak and Szeto propose that the most effective way to reduce stigmas felt by the mentally ill in healthcare is to take a multidimensional and multilevel approach “that address stigma holistically, from programming to structural change” (Ungar et al). The authors call for the employment of a “human centered design approach” to be used in healthcare, where the focus is on the individual as a human rather than a burdensome sick person. The approach encourages using pre-existing methods of stigma reduction in addition to taking into account various group and individual factors.
In Gove’s article, The Career of the Mentally Ill: An Integration of Psychiatric, Labeling/Social Construction, and Lay Perspectives, Gove explores the experience of being labeled “mentally ill.” He provides a definition of mental illness using the framework utilized by Aneshensel in 1999 and Karp in 1996: “According to this framework many persons spend a lifetime being normal, even though they may occasionally experience periods when they are very distressed and/or act in problematic ways… A career of mental illness starts when the prospective patient and/or those close to the prospective patient strongly sense that something is wrong, and that sense shapes one’s actions and the actions of those around the person”(Gove).
In this framework, first, he compares and contrasts a nervous breakdown from a mental illness. He gives the example of how “a nervous breakdown as an episode seen by the lay public as a transitory disorder that almost anyone might experience if they were subjected to an inordinate level of stress”(Gove). This stands in contrast with someone who is labeled with a mental disorder–“the lay public tends to believe that persons who are ‘mentally ill’ are dirty, bizarre, unpredictable, and dangerous (Gove). These undesirable associations with the diagnoses of a mental disorder, often cause labeled people to feel stigmatized and stereotyped for their mental disorders. The stigmatization can give labeled people a sense of anomie and fear of social rejection.
According to “modified labeling theory,” the cultural and societal stereotypes that surround mental illness, are perceived as threatening to “labeled people,” or those who have been diagnosed with a mental disorder. They fear “devaluation or rejection by the ‘normals’’ in our society (Thoits). To manage these newly perceived threats, labeled people often employ various coping mechanisms. Some of these mechanisms are believed to have negative impacts on the labeled person, such as secrecy, withdrawal, and avoidance from society. Other strategies can improve the labeled people’s’ quality of life. According to Thoits, the most commonly discussed coping mechanism that has beneficial effects on the labeled person, is challenging or confronting the stigmas that surround the labeled person’s diagnosis. Thoits states, “challenging [the labelization] promotes self-esteem, lower depressive symptoms, better quality of life, and a sense of empowerment, all of which are considered key outcomes in the recovery literature “ (Thoits). While acknowledging that all of these coping mechanisms exist, Thoits argues that the coping strategy of deflection that is the least researched or analyzed.
Identity deflection, also referred to as just “deflecting”, is a coping strategy employed by labeled people to discredit negative stereotypes that are associated with their diagnoses. By refusing to define themselves as “mentally ill,” these labeled people are able to negate their fears of being stigmatized by society. The act of deflection by those labeled mentally ill has been researched, but Thoits argues that identity deflection has only truly been studied in patients with “psychoses” or severe mental disorders.
Thoits’s article “I’m Not Mentally Ill,” aims to expand this research by drawing analysis from a National Comorbidity Survey Replication (NCS-R), which drew from a sample of 9,282 English-speaking adults ages 18 and older who were living in the United States. The survey took place between 2001 and 2003 and each respondent was interviewed in person. The first part of the study aimed to evaluate the prevalence of the most common and severe mental disorders using the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders. The second part of the study had a sample size of 5,692 respondents, consisting of all of the respondents from part one of the survey who fit the DSM-IV criteria to be diagnosed with a life long mental disorder, as well as a random sample of respondents from part one of the survey who did not fit the criteria for a lifelong diagnoses (Thoits). Thoits’s article only analyzes “respondents who met DSM-IV criteria for one or more mental disorders in the past year ” (Thoits). Reducing the sample to only respondents who have had recent mental disorder(s) distinguishes them from the respondents who believed they were mentally ill but in fact did not meet the DSM-IV criteria for mental disorder. Thoits refers to the latter subset as the “worried well,” from those who were deemed DSM-IV mentally ill by the survey.
Through analyzing the surveys of these 1,368 respondents, Thoits shows that identity deflection is extremely common among people with mental disorders. He states, “83% of respondents with any 12-month disorder did not see themselves as mentally ill. Even among those who had a severe disorder or a serious functional impairment, deflection was common- 72% and 60%, respectively” (Thoits). She also concludes that certain factors increase a labeled person’s likelihood of employing identity deflection. Having a less severe or impairing mental disorder was one factor. Labeled people, who are newly diagnosed or new to treatment, were also found to be more likely to utilize deflection. Holding multiple established social role identities (such as father, teacher, hockey player etc.), also increased deflection, as these people did not want their new illness identity to overtake their previously established social identities. Thoits finds that “people who believed they were not mentally ill indeed had significantly lower psychological distress and higher positive affect, even net of the severity of their disorder, the impairment caused by their condition, and their past and recent experiences of mental health service use” (Thoits).
Unfortunately, this survey was done in the early 2000s, before the 2013 release of the fifth edition of the the Diagnostic and Statistical Manual. The new edition of the DSM is thought to be a better diagnostic tool than the DSM-IV, so it would be interesting to see if the survey, and subsequently Thoits’ analysis of the responses, would have been affected by the changes made to the DSM.
A medical ethics case study published in the American Medical Association’s Journal of Ethics writes of a case in which a patient felt stigmatized by their potential, checks-many-of-the-boxes on the DSM diagnosis, and thus rejected the potential label. The case study, titled, Psychiatric Diagnostic Uncertainty: Challenges to Patient-Centered Care, tells the story of Tina, a college freshman who has recently become overwhelmed with feelings of depression. Tina had a friend who also had suffered from depression and had responded very well to sertraline, a selective serotonin reuptake inhibitor (SSRI). Tina also visited a psychiatrist hoping that she too could be helped by sertraline. However, the psychiatrist was concerned by some inconsistencies in Tina’s symptoms, and was not entirely comfortable prescribing her a drug that could work well for depression for some, but could make potential underlying disorders even more pronounced and unmanageable for others. The doctor was further concerned by her family history of Bipolar disorder, and believed that Tina may fit the criteria to be diagnosed with Bipolar II disorder Aultman).
When asked about her family history, Tina responded, “‘I’m not like them at all! They’re crazy and irresponsible when they’re sick. I’ve never had anything like that”’ (Aultman). Tina knew the way people treated her family members who had been diagnosed as bipolar. She was a college student, who had never experienced any depressed episodes before. She will not allow herself to be “like them,” or “crazy” in the eyes of society.
Reluctantly, Tina’s doctor agreed not to diagnose her with Bipolar II disorder, so long as she agrees to take Lurisadone, an atypical antipsychotic medication rather than the SSRI she had requested. This case shows the significance of resistance to being labeled with a mental disorder.
Tina knew she needed help, and so she did the responsible thing and went to the psychiatrist seeking medication. But she could not accept the possibility that she, like other members in her family, might fit the diagnostic manual for Bipolar disorder. She was fortunate to have an understanding doctor. Her doctor was extremely hesitant to prescribe Tina Lurisadone without giving her a clear diagnosis. However, she was understanding that Tina did not want to be labeled as bipolar, and not entirely certain Tina fit all the criteria for the diagnosis anyways. By prescribing her Lurisadone, Tina’s doctor took a risk. She was unsure if Tina’s insurance would cover the price of the medication without a bipolar diagnosis. She also feared that prescribing Lurisadone to a patient who does not have bipolar disorder would raise suspicion and finally that someday she would have to betray Tina’s wishes and diagnose her with bipolar disorder if it truly was found to be the best fit for her symptoms (Aultman).
In conclusion, the end of state-run mental institutions ushered in an era not of freedom and humane treatment, but rather, just a new form of shackles were placed upon the released in the form of imprisonment, homelessness, and stigmatization. To avoid the stigmatization the labelled persons received, the labelled persons would engage in identity deflection. In the future, scholars and medical practitioners have a duty to study the effects of what labelling a human with a mental disorder does to that person, as well as to study the benefits of identity deflection.
Originally published 15.10.2019