A Disease Just Like Any Other

The Hedgehog Review: Vol. 17 No. 2 (Summer 2015)

A Disease Just Like Any Other

Joseph E. Davis

 

 

The suicide last summer of the actor and comedian Robin Williams sparked the latest round in our ongoing public discussion of mental illness. Predictably, once speculation about details of his life subsided, the concern shifted to “stigma” (prejudice and discrimination) and how mental illness is misunderstood and misrepresented. Unlike the reality of physical illness, the now-familiar argument runs, the reality of mental illness is denied, shrouded instead in benighted moral judgments. “It is NOT cowardly to suffer or seek help,” tweeted Williams’s daughter on World Mental Health Day in October, giving fresh voice to this widely shared position.

As early as 1961, the Joint Commission on Mental Illness and Health—“the last word of the mental health establishment”—in its final report, Action for Mental Health, lamented how the public had turned “deaf ears” to the psychiatric “cardinal tenet” that the “mentally ill…are sick in the same sense as the physically sick,” and therefore should be understood and treated just as nonjudgmentally as those with somatic afflictions. This tenet, the commission made clear, was not only a scientific truth, but also critical to overcoming negative attitudes and fostering “humane, healing care.”

That rationale has since informed countless public campaigns by government commissions, professional associations, and advocacy organizations to promote mental health “literacy” and improved treatment. Adding a new twist in recent decades, such campaigns now place a central emphasis on neuroscience, both to promote the view that mental health problems arise from neurobiological aberrations and to undermine resistance to the use of neurobiological (i.e., psychopharmaceutical) solutions. Pharmaceutical companies, which actually fund many of these campaigns, advance the same viewpoint.

The strategy of promoting disease theories to the public arose long before the “decade of the brain” (1990–2000), and does not now reflect any actual breakthrough in our understanding of brain abnormalities. While there is constant talk of “revolutionized thinking” and “dramatic improvements in understanding the biology of mental illness,” the reality is far more pedestrian.

Indeed, if anything, new findings in genetics and neuroscience are doing more to undermine current ideas and diagnostic categories than to provide new models or biological markers, and have so far yielded no treatment discoveries. The effective medications remain those that were discovered serendipitously long ago, the last jackpot being the class of antidepressants referred to as selective serotonin reuptake inhibitors (Prozac, for example), introduced in the 1980s. Even now, we don’t understand the relationship between the action of psychiatric medications (e.g., increasing serotonin levels) and the causes of disorder. This is not to downplay the scientific research or its potential. It is simply to observe that clinical payoffs remain aspirational.

The brain-disease promotion strategy rests not on scientific advances but on an assumption—one might even say a wager—about personal responsibility. The logic behind this wager has three steps.

First, the root cause of the stigma that attaches to mental health problems lies in misguided attributions of responsibility by sufferers and non-sufferers alike. Both mistakenly believe that problems are caused by moral failings or weak willpower. The effort to combat stigma must begin by undercutting this blame.

Second, treating a mental health problem as a somatic disorder or disease presupposes the presence of some underlying and dysfunctional mechanism in the individual that reduces volitional control. (Talk of disease thus always implies a removal of personal responsibility. The addition of overstated claims from neuroscience, which suggest that underlying somatic mechanisms have in fact been identified, fortifies and justifies the disease model.)

Third, once the burden of responsibility is lifted, sufferers will be open to seeking help and accepting and staying in treatment. This, in turn, will have the consequence of improving how other people react to them.

This logic has an intuitive and, paradoxically, moral appeal. Promotion of the “disease just like any other” view is widely regarded, in the words of one study, to be a measure of a “liberal, knowledgeable, benevolent, supportive orientation toward the mentally ill.” No wonder anti-stigma promoters have so doggedly conducted campaigns in its terms.

But there is a catch. Studies of the relationship between belief in brain disorders and stigmatizing attitudes do not find greater tolerance, either among psychiatric patients or the general public. If anything, they show just the opposite.

Over the past two decades, both the general public and patients themselves—historically quite resistant to disease models of emotional and psychological problems—have become relatively more biologically minded. This change correlates with an increased endorsement of seeking professional help and using prescription medicine, as well as some reduction in attributions of blame: three of the central goals of the public anti-stigma campaigns (and pharmaceutical advertising). The change, however, also correlates with more intensely negative attitudes toward those with mental health problems, attitudes that are shared even by sufferers themselves.

Promoting the brain disease model has had the intended consequence of contributing to the medicalization of distress and boosting the sale of psychopharmaceuticals. If that wasn’t troubling enough, the campaign has also had the unintended consequence of promoting the very stigma and discrediting attributes it sought to reduce.

What went wrong? Is this just more evidence of ignorant laypeople drawing the wrong conclusions after finally catching on to the brain disease idea? Or does the problem lie with the wager on responsibility itself?

My interviews with people over the years suggest that trading personal agency for a kind of medical absolution exacts a high price. After all, what level of brain abnormality is implied by the claim that diagnosed persons are not responsible for their actions? Surely, it must be a high level—one at which behavior is effectively determined by forces, disease processes, beyond a person’s intentional control. And this would be a level we normally associated with only the most severe psychoses.

At stake in the mental domain, but far less in the strictly physical one, is our very notion of personhood. Should it be a surprise that accepting a disease model that effectively strips people of their agency and freedom leads to prognostic pessimism for sufferers and avoidance of sufferers by others? The model, as my interviews suggest, implies a categorical difference, a situating of sufferers outside the community of viable selves in which persons are responsible for their actions. Contrary to the theory, removing responsibility results in a less favorable and more patronizing view of sufferers—and as a result, more stigma, and more isolation.

Reprinted from The Hedgehog Review 17.2 (Summer 2015). This essay may not be resold, reprinted, or redistributed for compensation of any kind without prior written permission. Please contact The Hedgehog Review for further details.