Psychiatry Should Do Away with Diagnostic Categories and Labels

Recent research into the prevalence of mental health disorders in the UK has found that 1 in 4 people suffer from a current mental health disorder (Parkin & Powell, 2018), with 1 in 6 people experiencing a common disorder, such as anxiety or depression, in the past week alone (Baker, 2018). This extremely high prevalence of mental health disorders requires a reliable process for diagnosing, treating and preventing these disorders. Psychiatry therefore uses consistent diagnostic categories and labels for people with mental, emotional and behavioral disorders.

The official system of diagnosis for mental health disorders was devised and revised by the American Psychiatric Association (APA). The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) is used most frequently in psychology in America and worldwide and was developed to produce a standardized set of descriptions, definitions, and symptoms to diagnose mental health disorders. It is believed that the purpose of the DSM was to provide a common language for psychiatrists to communicate about their patients’ disorders and produce consistent and reliable diagnoses. Using the DSM to categorize and label psychiatric patients enables health care professionals to identify a patient’s disorder and provide a systematic pathway for treatment amongst those who display similar psychiatric symptoms. By using a standardized measure of diagnosis, it allows us to ensure diagnoses are made consistently worldwide.

Whilst using diagnostic categories and labeling can produce positive results, such as effective treatment pathways, there is contradictory research which suggests that the effects of psychiatric labeling may be detrimental and outweigh the positives of classifying a patient. These include labeling someone as being mentally ill rather than having a mental illness (Pasman, 2011) and can also produce negative consequences such as stigma (Rosenfield, 1997).

Scheff (1974) developed labeling theory (or social reactant theory) explaining how a person’s behavior is influenced by the terms used to classify them and applied it to patients who had been diagnosed with a mental health disorder. Scheff suggested that negative stereotypes of people with poor mental health are represented in the media as crazy, dangerous and associated with criminal behavior, behaviors that are not typically considered the norm in society. These stereotypes are reinforced by the general public through social interaction, resulting in mentally ill people being considered as a social deviance in society. Once psychiatry labels a person, they then experience a uniform negative response from society and the public possess negative evaluations, making it hard to shake the label.

These responses from the public encourage the patients to take on the role of someone who is deemed to be mentally ill, and they start to internalize their own beliefs about themselves. This is known as the self-fulfilling prophecy (Merton, 1948), where people live up to falsely assigned labels by changing their behavior so that the original label becomes true. Therefore, it is crucial that psychiatric labels are applied accurately otherwise people who are not mentally ill, will start behaving as if they were (Pasman, 2011). Additionally, people who are given psychiatric labels tend to conform to behavior that is stereotypically associated with someone who is deemed mentally ill, even if they did not originally display this behavior before diagnosis. Thus, once labeled psychiatric patients self-fulfil behaviors that they generally expect psychiatric patients to display, making them worse off and increasing the negative effects of their disorder.

Labeling theory has been further developed and expanded regarding mental health to suggest that even if labeling a person does not directly produce a mental disorder, it can lead to negative consequences such as feelings of devaluation and discrimination (Link, Cullen, Struening, Shrout & Dohrenwend, 1989). Society’s reaction, behavior and beliefs towards a person with a mental health disorder induce these feelings, and in turn leads patients to fear this potential devaluation and discrimination. This effects their levels of social interaction and results in negative outcomes in terms of employment, self-esteem and social networks. Hence this culminates in psychiatric patients endorsing strategies of withdrawal and secrecy to cope with the perceived threat from society.

Most people suffering from mental health disorders are doubly challenged. On the one hand they endure pain from the primary impact of the disorder, such as physical symptoms and mental disabilities, and on the other hand they are confronted with public misconceptions leading to stigma. Stigma is composed of two constructs: behavioral and cognitive (Corrigan & Shapiro, 2010). The cognitive aspect compromises of prejudice (feelings and attitudes directed towards a specific group, for example mental health patients), and stereotypes (societies beliefs about a specific group). The behavioral aspect is what influences discriminatory behavior. This subjection of stigma can lead to feelings of rejection, experiencing discrimination, lowered self-esteem and loss of socio-economic status.

Stigma towards mental health disorders is a current problem in society, with nearly 9 out of 10 of those diagnosed facing negative discrimination through stigma, attitudes and behavior directed towards them (Mental Health Foundation, 2018). Two types of stigma have been identified and both create negative beliefs towards mental health issues (Corrigan & Watson, 2002). Firstly, social stigma is the most common type, with negative beliefs including ineptitude, incompetence and precariousness towards mental health patients. This public form of stigma leads to avoidance behaviors and withdrawing the same opportunities as a ‘healthy’ individual. For example, unemployment and declining housing applications. The second type of stigma comes from the self, where individuals internalize the behavioral and cognitive aspects of stigma, similar to a self-fulfilling prophecy. Negative beliefs about the self, lead to character doubt and weaknesses in personality, often resulting in low self-esteem, lack of socialization and failing to pursue opportunities and goals.

To understand the effects of labeling on stigma, research has aimed to measure an individual’s beliefs about how others respond to mental health patients, like themselves (Link, 1987). They hypothesized that patients develop misconceptions of what the general population think of patients long before they have even been diagnosed. As a result of this, when people are officially labeled it leads to feelings of self-devaluation and fear of social rejection, resulting in a negative impact on social functioning. A scale was administered to calculate the extent to which patients thought they would be devalued and demoralized by the general public. A series of groups completed the scale, ranging from being labeled ‘severe psychiatric disorders’ to people with ‘no symptoms of psychiatric disorders’. In the labeled groups, scores on the scale were associated with effects related to self-devaluation such as unemployment, lack of a serious relationship and minimal social contact in labeled groups, but not in unlabeled groups. This study concludes that labeling a patient may produce negative outcomes as they assume the public will have conceptions leading to devaluing and discrimination, so their behavior represents this. For example, not attending job interviews as they feel they will be discriminated against because of their psychiatric disorder, and therefore experiencing income loss as a result of not getting the job.

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Labeling theory suggests that once a person has been given a psychiatric label, then their reactions from others mean they will not be able to function in normal societal rules and will turn to a life of deviance. However, labeling mental health patients does not always result in rejection from the general population. Gove and Fain (1973) analyzed the experience of former mental health patients and found that their relationships with others had improved and their social activities had increased post-treatment. Amongst the former and present sufferers, only a small minority experienced stigma against their psychiatric treatment and there were inconsistencies amongst patients in reporting instances of rejection and discrimination. This study suggests that labeling someone with a psychiatric illness may not have long term effects, as people’s attitudes towards those who have been diagnosed change post-treatment. Therefore, the effect of stigma may not cause rejection and withdrawal amongst patients, instead this could be a result of the mental patients’ actions that form people’s attitudes such as self-fulfilling the psychiatric label they were assigned, concluding that the notion that stigma has long-term effects can be dismissed.

If psychiatry relies on categorizing and labeling patients, then there are potential strategies which can be implemented to reduce psychiatric stigma. These strategies include protest, education and promoting contact between society and those diagnosed with mental health problems.

Protest strategies aim to diminish negative attitudes of mental disorders by highlighting and protesting inaccurate representations in the media and society. It attempts to encourage the media to stop portraying inaccurate representations of people with mental disorders and for society to stop believing these negative views that are presented in the media. Evidence suggests that effective protest campaigns have reduced the number of stigmatizing images of mental health in the media and patients are encountering less stereotyping and discrimination due to these efforts (Wahl, 1997). However, protesting stereotypes can often lead to the minority group, such as mental health patients, experiencing higher levels of stigma. This is due to a paradoxical theory known as the rebound effect (Wegner, Schneider, Carter & White, 1987). In essence, if you are asked to think of this group in a non-stereotypical way and suppress your existing negative thoughts about them, then you are essentially priming and confirming these stereotypes. Macrae, Bodenhausen, Milne, and Jetten (1994) found that participants who were required to not think about a specific minority group in a stereotypical way, were more likely to describe the group in a negatively stereotypical way, identified stigmatizing adjectives quicker, and naturally distanced themselves from the group. These findings demonstrate that by attempting to suppress existing negative beliefs may actually be priming these stereotypes of people who are labeled with a psychiatric disorder.

A second way to diminish stigma towards people with poor mental health is to use educational strategies. These work by providing accurate information about people with mental health disorders and challenging stereotypes by providing evidence that contradicts them. Keane (1990) reported that people who participate in a short educational course on mental health treatment have improved attitude towards mental health patients. This suggests that negative attitudes can be challenged, and stigma reduced by educating people about how mental illness can be treated and readdressing false stereotypes. However, the evidence for educational strategies to reduce stigma has not been assessed in the long term. Most of the evidence comes from short educational programs, but these studies cannot explain how educational programs facilitate behavior and attitude change in the long-term. Although the immediate impact of educational strategies seems to reduce stigma towards people with mental health disorders, it does not suggest if these strategies will work to change long-term attitudes.

A third way of reducing psychiatric stigma is to encourage interpersonal contact between individuals with diagnosed disorders and the general public. By encouraging and facilitating contact, this allows people to disconfirm stereotypes when the stigmatized group displays non-stereotypical features, for example, having a job or numerous friends. Research has shown that those that have more contact with mental health patients endorse reduced levels of psychiatric stigma (Desforges et al., 1991). In this study, participants who had more contact with a former mental health patient had more positive attitudes towards this person and increased liking and acceptance. Thus, suggesting that contact reduces stigma and reduces negative attitudes towards people with mental health disorders.

Further research into anti-stigma campaigns have attempted to assess whether the effects of labeling can be overcome by adopting a few simple approaches. Link, Mirotznik and Cullen’s (1991) research attempted to identify whether mentally ill patients can ameliorate labeling effects through certain coping strategies: educating others about mental illness, keeping their disorder a secret and avoiding social situations where rejection may occur. The results depicted that the coping strategies were not effective in diminishing the negative effects of labeling and increased withdrawal and voidance behaviors, suggesting the strategies produced more harm than good. Link, Mirotznik and Cullen (1991) concluded that labeling effects are hard to overcome, and coping strategies have minimal impact on diminishing stigma. Based on these results, it can be concluded that stigma is a powerful social effect as a result of categorizing or labeling a person as mentally ill.

However, the question remains, are strategies towards reducing psychiatric stigma working? Effective anti-stigma campaigns have shown that social contact strategies decrease stigma the most, by improving knowledge and creating positive attitude changes (Thornicroft et al., 2016). Though it must be considered that this research has only found short-term attitude changes and it is unclear if a reduction in stigma would occur long term. Therefore, more research into strategies to reduce stigma is needed with larger sample sizes and conducted over a longer time period.

A strategy that may be effective but has little evidence to support it, is the process of using positive labeling rather than degrading labels. Although labels can be motivating and encourage people to act, people often adopt the negative psychiatric labels that are applied to them. Through the self-fulfilling prophecy patients then exhibit stereotypical behaviors of people diagnosed with mental health disorders, for example becoming reclusive. Therefore, a proposed intervention could be using Merton’s self-fulfilling prophecy to label people positively rather than defining them by their mental illness. This in term may reduce their psychiatric symptoms as they do not automatically fulfil the stereotypical behaviors of this label, and instead fulfil the positive behaviors associated with their positive label.

In conclusion, it appears that using diagnostic categories and labels in psychiatry provides a reliable method for psychiatrists to consistently diagnose disorders and treatments for those with poor mental health. However, the implications of labeling a person with a psychiatric illness can lead to irreversible prejudice and stigmatization. Most of the research in this essay suggests that whilst protest, education and contact strategies have been applied to try and reduce stigma against psychiatric patients, these strategies may not be effective long-term. Therefore, more research needs to be conducted to enhance these strategies rather than abandon them.

References

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