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(p. 232) Concluding Issues 

(p. 232) Concluding Issues
Chapter:
(p. 232) Concluding Issues
Author(s):

Stephen P. Hinshaw

DOI:
10.1093/med:psych/9780199730926.003.0012
Page of

date: 24 April 2019

To close this book I present several issues and controversies that may be of interest to the next generation of individuals and groups interested in stigma. These include the conceptual models used to understand mental illness, the role of mental health screening in preventive efforts, basic versus applied research priorities, problems inherent in mounting stigma reduction, and the movement advocating neurodiversity. My final comments include a hopeful yet realistic appraisal of the chances for success in reducing stigma in the years ahead.

Conceptions of Mental Disorder

Widening Boundaries

An expanding number of conditions are now counted as forms of mental illness. This trend, exemplifying the increasing tendency to adopt biomedical models (see Chapter 4), produces several consequences. For one thing, negative connotations of the terms “mental illness” and “mental disorder,” previously reserved for conditions such as schizophrenia, bipolar disorder, and autism, may now be invoked for a wide range of behavior patterns. Secondary labeling theory posits that stigmatization will be directed to behavioral displays formerly viewed as part of the general human condition but now believed to represent a feared and threatening category.

As an example, alcohol and substance use disorders now fall under the umbrella of mental illness, leading to a clash between the moral terms often used to understand such conditions and the biological connotations of medical-model perspectives. Are alcohol abuse, heroin use, or crack or methamphetamine (p. 233) usage truly disease states, or is this branding just one more attempt by secular scientists to take away personal blame and responsibility for most forms of human deviance? Furthermore, will there be a paradoxical weakening of personal resolve to fight such problems when they are construed as forms of mental illness—that is, uncontrollable outcomes of a disease? Modern social critics and antipsychiatrists have lambasted the tendency to place ever-widening forms of behavioral deviance under the rubric of mental illness, whereas those defending this model point to genetic predispositions, clear psychobiological risk factors, and sophisticated brain-imaging studies of neural correlates.1

This entire issue is complicated by the increasing realization that most mental disorders appear to differ quantitatively, but not qualitatively, from normal-range behavior.2 In other words, most conditions appear to be “spectrum” in nature. Parallel to medical entities such as hypertension, when diagnoses are applied to continuous distributions of underlying processes, the question of where to draw the line between normality and pathology is not clear cut. Even though scientific efforts can help in this regard, when the underlying process is dimensional there is no indisputable criterion above which a disorder is present or below which it is clearly absent.

A major issue for future generations of both scientists and clinicians will be where to place these thresholds of deviance and dysfunction. Wider boundaries could, once again, stigmatize greater amounts of behavior. On the other hand, they could allow for the realization that normal and abnormal behavior are separated only by degree, with the potential for greater identification and empathy on the part of society and with the hope that help can become available to larger numbers of people. The underlying value judgments placed on conformity and deviance will serve as crucial determinants of ultimate acceptance.

Future Views of Mental Illness

Indeed, what will views on mental illness come to be a century from now and beyond? It is imaginable that advances in genetics, developmental psychopathology, and cultural psychology will be of such magnitude that current conceptions of what is disordered and what is normal will seem as primitive as the views of a century ago appear to us today. For example, considerably more focus may be placed on the potentially adaptive value of many forms of behavior today termed deviant or pathological. The benefits to human societies of having partial risk for mental disorder may be fully appreciated in terms of the diversity that can accrue to our societies and our species. Even now, for example, we know that biological relatives of individuals with bipolar disorder are particularly likely to achieve artistic, scientific, or financial success.3 In addition, as the study of resilience continues to mature, it may become possible to identify those who are at risk for mental illness and provide them with the kinds of protective experiences that could significantly turn around the potential for negative outcomes without necessarily altering their underlying natures or their potential for unique contributions.

(p. 234) Yet this is undoubtedly an optimistic view. A more likely occurrence is that the increasing power of molecular genetic techniques will allow future neonatologists and clinicians to specify, within bands of probability, the extent of risk that a fetus or infant may carry for developing various forms of mental illness. Such designation may well promote tendencies to stereotype and pathologize, given the pervasive assumption that mental disorder should be avoided at all costs. There may be a rush to early intervention of the kind that involves abortion of the fetus or involuntary medication treatment for the child. Considerable blame may attend to those who could be accused of knowing about their (or their child’s) genetic risk for mental illness but did not take steps to prevent it.

A strong form of genetic determinism and elitism could come to dominate societal views, with harsh discrimination against those of lower “castes” who carry what are deemed to be genetic taints. The “elite” without mental illness may view themselves as defenders of an increasingly restricted concept of normality, needing to use eugenic means to prevent despoiling the gene pool. After all, if unfavored genes can be selected out, great blame may accrue to families who opt not to enact such procedures. A new eugenics may emerge in the attempt to purify and improve the human species, with intensified stigma emerging with respect to “failures” in this effort.4

The ultimate question is likely to be how future scientists, clinicians, policy makers, and citizens will come to view the human potential of persons with mental illness. Will the perspective be one of enacting all means possible to prevent such conditions from ever emerging? Or will it instead be one of early identification, toward the end of enacting preventive care—but with the assumption that there may still be valuable contributions from those with mental disturbances and that unduly narrowing the gene pool may weaken diversity across our species? It is hard to imagine a more important set of ethical, clinical, and scientific questions.

Reactions Against Mental Disorder Designations

As ever-increasing domains of behavior continue to be annexed under the domain of mental illness, there are bound to be counterresponses. An example involves the pro-anorexia (“pro-ana”) movement. Relevant websites glorify the extreme restrictions of caloric intake characteristic of anorexia nervosa, portraying them as lifestyle choices rather than symptoms. These views strongly deny that any biomedical causal factors could account for such behavior patterns; promoted instead is the perspective that the restriction of eating constitutes an individual, even politically motivated, lifestyle choice.5 A clear message is that eating-related problems should not be stigmatized, as they are not a form of mental illness at all.

When eating problems are portrayed in this way, the young women receiving such messages would be expected to have little or no motivation to alter their eating patterns—which are in fact lionized by the pro-ana perspective.6 In other words, the reductions in stigma that apply to an entirely volitional (p. 235) account like pro-ana may greatly reinforce and intensify eating pathology. As a wide variety of lifestyles proliferates in pluralistic societies, clashes between those who view certain forms of deviance as symptoms of an underlying illness and others who emphasize the voluntary, chosen, and rational bases of such behaviors are likely. There is potential for a paradoxical intensification of disturbed behavior patterns when stigma reduction is attempted by circumventing the biomedical perspective altogether.

Mental Health Screening

I advocated earlier for the inclusion of mental health and behavioral indicators into general health care screenings, certainly for children but also for adults. When screening recommendations were made by the President’s New Freedom Commission in 2003, however, considerable backlash emerged.7 I pause to analyze some of the issues involved and what they may tell us about the stigmatization of mental illness.

Clearly, there are very real scientific and clinical issues that surround the early prediction of mental disorders.8 Detecting any relatively rare event in the general population is bound to be accompanied by a number of “false positive” appraisals (overpredictions), in which the assessment is made that the individual in question will contract the condition of interest when that person is not truly at risk. In fact, if the attempt is made to predict extremely rare events (for example, schizophrenia, with an overall prevalence of less than 1% of the population), overall accuracy would be maximized by predicting that such an outcome would never occur. In this instance, the prediction will be correct more than 99% of the time—at the expense, of course, of missing all of the actual cases. The real question pertains to the relative costs of overprediction of relatively rare events versus the failure to accurately detect true cases.

For nearly all physical illnesses, “false negatives” (underpredictions) are the crucial error to be avoided. A false negative appraisal could potentially be fatal, whereas a false positive may alarm the screened individual but, at worst, motivate further diagnostic tests. However, the strong stigma that attends to labels of mental illness (or to designations of high risk status for mental disorders) means that false positive errors are highly undesirable in this domain. Furthermore, until relatively recently, the virtual absence of effective treatments has meant that there was no particular advantage for the early screening and prediction of mental illness. This situation is clearly changing, however, given the increasing promise related to prevention and intervention strategies.

The relevant question remains as follows: in order to avoid underprediction with respect to mental disorder, how many false positive cases are we willing tolerate? The answer will hinge largely on the continuing presence of stigmatization with respect to mental illness, as well as the continued funding for prevention and treatment studies that can provide meaningful data on the personal and societal benefits from early intervention.

(p. 236) Strongly political arguments are being raised about the value and meaning of early detection. In particular, claims abound that mandatory screening of mental health–related problems will usher in an era of unprecedented use of psychotropic medications for at-risk children.9 In such views, early screening efforts would not only incur potential stigmatization but also trigger the inappropriate and unethical prescription of medications. Increases in the use of psychoactive medications for children and adolescents in recent years make it clearer why such fears would develop.10

The goal of screening, however, is not to promote automatic prescription of medication at the first sign of future risk for mental illness via mandatory procedures. Rather, a preventive approach to mental health issues should be embedded in the kinds of medical checkups now in place—so long as there is full realization that better access to medical care is a key priority—in order that trained health professionals can help to gauge potential high-risk situations for mental disorder. If positive screenings occur, the first step would be to perform additional evaluation not only of the child but also of caregivers, as well as school or neighborhood settings. In many cases, the information could suggest the provision of psychosocial interventions or accommodations. As medication treatments become validated for certain conditions in young children, these may be recommended in such cases, but only with better data as to their safety and efficacy and not as the primary option.11

In all, a “positive” screening should not automatically place the source of the problem in the children themselves and should not mandate forced treatment. The objective is to find problems in their incipient stages and in their full contexts rather than to wait until they have become fully entrenched. It is just as stigmatizing to deny the potential value of early screening and detection— under the misguided assumption that mental illnesses are imaginary constructs invented by pernicious agents of social control—as it is to promote universal and mandatory screening without parental consent and with an inevitable push toward involuntary treatment.

Research Priorities

In recent years there has been an explicit policy shift at the National Institute of Mental Health (NIMH) toward prioritization of the types of research that can fundamentally ease the burden of mental illness in society. In other words, an increased emphasis has been placed on research efforts that directly target understanding the causal factors for mental illness, their epidemiology (i.e., distribution throughout society), the optimal assessment and treatment strategies for such conditions, and the viability of current service delivery systems intended to guarantee their care. De-emphasized are investigations of basic processes related to cognition, attention, emotion, social processes, development, and neurobiology, unless these studies have direct application to mental disorder. The belief is that NIMH should be geared toward clinical application.12 (p. 237) This shift has been prompted by analyses, conducted by both scientists and advocates, which highlight the acute lack of funding for serious mental illnesses (e.g., schizophrenia, bipolar disorder, severe forms of depression, autism, panic disorder, and obsessive compulsive disorder) in relation to the societal costs of such debilitating conditions.13

There is no doubt that funding for research on and treatment of serious mental illnesses must become a priority. Indeed, these are the most stigmatized variants of mental disorder, and they have received a disproportionately low level of funding in relation to their long-term human and economic costs. It is worth considering, however, the costs incurred in the other direction—namely, those related to an intentional neglect of basic psychological, biological, and social research.

This stance is reminiscent of the attempt 35 years ago by the Nixon administration to lead a “war on cancer” by earmarking federal funds for research and clinical efforts with direct relevance to combating this vicious disease (or, rather, set of diseases).14 Given the state of the art of molecular biology, virology, and other basic sciences at that time, the rush to end cancer without funding basic research efforts was fundamentally misguided. In other words, in the absence of considerably more knowledge about how and why cells proliferate as they do, a budgetary focus devoted exclusively to application was premature.

Parallel arguments apply to the current situation in mental health. Despite clear advances, the entire field is still in a period of ignorance about a great many fundamental processes related to both normal and atypical functioning. Genetic propensities, neural pruning in early brain development, prenatal environments, temperament, emotion and emotion regulation processes, developmental changes linked to puberty, attention, memory, family socialization, wider environmental influences (e.g., schools and peer groups), and cultural factors are just a few examples of such processes. Without better understanding of these and other systems, how can we be sure that intervention efforts are being directed toward the right targets?

Furthermore, it is not even known whether the current means of classifying mental illness is correct. There may well be underlying dimensions of dysfunction at neurobiological, psychological, and social levels that cut across existing psychiatric classifications. Basic knowledge of genes, brains, and environments (and their nearly infinitely complex interchanges) is surely required before mental health and mental illness can be understood with sufficient clarity to devote complete resources to applied endeavors.

Admittedly, there are hard choices to make, given the enormity of the problem and the relatively limited resources available (in comparison, for example, with the vast sums of money used to promote current defense and war efforts). Although important work on prevention, treatment development, clinical trials, evaluation of long-term outcome, and dissemination must be promoted, careful thought needs to be given to the appropriate weighting of research on basic processes versus more applied endeavors. Scientists, policy makers, and the general public need to be engaged in continuing self-education and debate about these (p. 238) priorities before we realize, some years down the road, that funds were squandered on attempts to cure mental illness that were implemented too quickly and without full knowledge of the underlying causes and mechanisms.

The call for clinical relevance applies to research on stigma as well. Investigations of basic psychological, evolutionary, and social processes that may be of major pertinence to stigmatization are now viewed as less crucial than work with direct implications for reducing stigma. Again, it is wonderful that NIMH has finally recognized the clear importance of stigma for all aspects of mental health and mental illness, but the balance of basic versus applied investigations needs serious thought.15 At this time, do we really know all of the most promising targets for viable antistigma efforts? How do basic social psychological and evolutionary psychological mechanisms link with structural factors in relation to stigmatization? Which targeted areas are likely to have the best chance producing change? Debate about these vital issues is required.

Stigma Reduction: Trends and Challenges

Following the coverage of strategies to overcome stigma in Chapters 9, 10, and 11, I note several issues of direct relevance to future efforts.

First, in any educational campaigns regarding mental disorder, two important talking points should be strongly considered: Mental disorder is more common than often thought, and stigma harms all of society. In other words, the message needs to be circulated widely that it is your parent, your offspring, your uncle or aunt, your boss, your employee, your student, or your teacher who may be dealing with a mental disorder, often in silence. Another component of the message is that without giving these members of our families and our social networks a chance to receive treatment and be part of the mainstream of society, we all lose.

Even considering the most serious mental disorders, a prevalence of 6% means that, on average, at least one child in every classroom, one close or extended relative, or one workmate is contending with mental illness. When moderately severe forms are included, the presence of an additional 20% or more of the population makes mental illness far from a rare occurrence. Rather, it is a part of everyday life for each citizen and every family.

Mental illness has been so often hidden from public view and so frequently relegated to the back burner of public concern that many individuals are surprised at just how frequently it can and does occur, even in its most serious forms. The wasted potential within families, communities, businesses, and the nation as a whole is both tragic and unnecessary. Finding ways to deliver such messages should be an essential part of future campaigns, along with portrayals that emphasize the underlying humanity of persons and families who contend with mental illness.

Second, recall the provocative point from Chapter 6 that some individuals and groups interested in eradicating stigma may be overly serious and overly (p. 239) sensitive. Is this in fact true? Should those engaging in antistigma efforts lighten up in crucial respects? Is political correctness receiving greater priority than meaningful change? For example, attempting to erase our language of all offhanded references to mental illness or other stigmatized conditions makes little sense. Should we actually attempt to ban the use of phrases such as “what a crazy idea”? These kinds of provisions would be impossible to implement and serve no real purpose. As a parallel, for instance, should we stop using the phrase “left-handed compliment” to reduce the stigma of non-right-handed individuals?

There is a major caveat here, however: A great deal of the stigmatization of mental illness, parallel to a large amount of racial and ethnic bias and prejudice, is not performed at the level of mild teasing or poking fun but instead consists of grossly mean-spirited and degrading language and images that dehumanize those with mental disorders. This is a difficult legacy to overcome, and individuals and family members who have contended with mental illness stigma are justifiably sensitive to slurs and ridicule.

Some gay and lesbian individuals now use the word “queer” to refer to themselves, and some African American persons may playfully refer to one another as “niggah.” Yet it is still extremely derogatory for persons outside of these minorities to utilize such language. Because of the history of massive stereotyping, prejudice, discrimination, and stigma of sexual minorities, racial groups, and those with mental illness, those in the majority should be sensitive to the roots of the hurt and shame felt by those who have been stigmatized. They should also be aware of the one-sidedness of the legacy of stigmatization. Still, we are all human, and to the extent that the climate changes, some lightness of tone and message may be welcome and may signal interpersonal closeness between people with mental disorder and the rest of the population.

Third, should antistigma campaigns be directed at the populace at large or instead targeted to specific groups? Marketing strategists often deploy targeted initiatives under the assumptions that certain segments of the population will be more responsive than others to input and persuasion regarding specific programs. But who are the relevant groups or subgroups for receipt of antistigma messages? As we come to know more about children’s development of attitudes toward mental illness, targeted programs in grade schools or middle schools may be productively developed. Furthermore, adolescence is an extremely important age of risk for the development of mental illness, as well as for peer relations and the consolidation of prejudicial attitudes. Media campaigns have already been developed for adolescents and young adults who are viewers of MTV and other youth-oriented outlets. Regarding adults, it is difficult to conceptualize particular subgroups who might be particularly amenable to anti-stigma efforts or who may be considered the most likely purveyors of stigma. This remains an important research direction.16

Fourth, related to the essential area of changing media portrayals of persons with mental illness, presentations of truly human stories of mental disorder could go far in changing public opinion. In addition, the intentional use of newer (p. 240) (and in some cases more controversial) marketing tactics should be actively considered by those interested in fighting the stigma of mental illness. Although buzz marketing and stealth marketing are controversial, it is worth considering all of the alternatives to spread messages about mental illness that can overcome stigma. Indeed, powerful political and commercial interests commonly use a wide range of intentional media strategies related to a host of products, services, and topics. Furthermore, there is nothing unethical about intentionally framing important messages about mental illness—for example, that it is not inevitably chronic and tragic, that resilience is a possibility, and that human potential is wasted if we let people with mental disorders languish. It may take novel means of communicating such messages to the public at large; media watch groups, advocacy organizations, and clinical entities interested in overcoming stigma should weigh them carefully.

Fifth, the mental health professions need to confront their own views toward mental illness and promote change, where indicated, with respect to their attitudes and practices (see Chapter 10). Even if displayed by only a small minority of professionals and staff members, the stigma revealed by those working in the mental health fields is unacceptable. Raising the status of mental health professions, countering the stress that attends to mental health work, and removing the shame that attends the admission of any sign of personal weakness are potential components. Additional solutions include increased scrutiny in the selection of students, trainees, and personnel for the professions of interest; self-examination of stigmatizing attitudes and practices, including probing of their roots in outmoded conceptual models; admission of mental health workers’ need for support and access to therapy without shame; and a revamping of training models and methods to include a less authoritarian view, replaced by one incorporating respect, flexibility, and rigor regarding best practices.

Finally, more careful attention should be paid to other cultures’ means of dealing with and caring for persons with mental illness, with special focus on non-Western societies. Industrialized nations do not necessarily provide the best outcomes for individuals with serious mental disorders.17 Effective care requires more than the provision of optimal individual and family treatments; it must also include the availability of social and vocational roles for individuals whose experiences of mental disorder have temporarily prompted removal from the mainstream. Although some forms of mental illness may never become completely nonthreatening to social observers, systems that can promote societal and familial reentry following episodes are crucial for positive prognosis.

Neurodiversity and the Acceptance of Difference

Even if treatments do a better and better job of alleviating core symptoms and fostering adaptive functioning for persons with mental disorders, no intervention will be able to remove a history of mental illness or the difficult life experiences (p. 241) and self-perceptions often left in its wake. Particularly for severe forms of mental illness, the most effective intervention strategies cannot, as of yet, promote complete normalization of functioning. Residual symptoms, recurrences, lingering impairments, and permanent alterations of self-image are often likely to survive effective treatment. It is mistaken to think that, if treatment were universally available, all of the problems related to mental illness, including its rampant stigmatization, would suddenly disappear.

The concept of neurodiversity has become a potent topic in recent years.18 Its premises are that (a) many important and gifted individuals throughout history have had various forms of mental or neurological disorders and that (b) appreciating the contributions from people with this kind of diversity is essential. Given the pervasively negative images promulgated about mental illness through general language and the media, it is indeed crucial that narratives of strength as well as weakness, normality as well as deviance, and diversity as well as conformity filter to the public’s consciousness if inroads are to be made against stigma.

The potential danger here is that overemphasis on neurodiversity could end up romanticizing or glorifying mental illness, which is clearly not a worthy goal. The impairments accruing from many forms of mental disorder are real and often devastating. Still, to the extent that normality and pathology exist on a continuum—and to the extent that it is difficult to say with certainty which traits and propensities will have the greatest chances of being adaptive as societies and cultures continue to evolve—the neurodiversity construct is provocative.

Along these lines, Corrigan emphasizes that, in the final analysis, stigma is an issue of social injustice. In other words, civil and human rights cannot be denied on the sole basis of a mental disorder label, and antistigma campaigns centering solely on access to treatment may ignore systemic and structural roots of bias.19 Although mental illness is indeed dysfunctional and requires excellent treatment, reduction of stigma requires joint emphasis on individual and family treatment, encouragement of a better fit between individuals and social institutions, enforcement of basic rights, and appreciation of human diversity. These objectives are not mutually exclusive but instead complementary.

Overall Perspective

If I had to state in one phrase my view of the likelihood of successfully combating stigma in the years to come, I would term it “extremely cautious optimism.” In other words, I am well aware of the historical, cross-cultural, and in all probability hard-wired nature of human tendencies to be exquisitely sensitive to interpersonal dysfunction and to stigmatize outgroups. It is also clear that mental disturbance poses both real and symbolic threats to social perceivers. The battle before us is indeed uphill, particularly given our increasingly education-dominated, technologically sophisticated, and conformity-conscious world.

(p. 242) At the same time, I am swayed by those eras in history when bravery trumped ignorance and compassionate views of mental illness emerged. I am cognizant, too, of the great progress in science and clinical practice of recent decades and the potential for humans to overcome their proclivities to categorize and stereotype, by empathizing and providing justice. Still, wide-eyed visions related to quick attainment of destigmatization are not productive. Despite clear progress toward eliminating racial bias over the last 50 years, the United States is facing harsh evidence of the pervasive, lingering effects of its own racism, as evidenced by the hugely inadequate efforts to rescue the largely poor, minority, displaced victims of Hurricane Katrina in New Orleans in 2005. Implicit bias, as well as explicit policies of racism, institutionalized poverty, and bureaucratic inertia, remain in place.

Indeed, it will take a long, dedicated, and patient fight to grant fundamental rights, change media images, ensure adequate treatment, and foster real compassion with respect to mental illness. The length of the struggle is important to keep in mind, as overzealous promises of quick reform invariably lead to resentment and subsequent retrenchment.20

Several concluding points are in order. First, the most severe forms of mental illness receive major stigma, yet those experiencing and dealing with other types also confront rejection. For instance, caregivers of children with ADHD, high-functioning autism, and learning disorders are constantly reminded of the shortcomings of their offspring—and, tacitly, of their own parenting— at school, in social groups, and in public venues, often receiving considerable blame. In societies concerned with achievement and, to a large extent, conformity, many forms of mental illness may be prone to receive stigmatization because of the widespread belief that exerting volitional control and providing stricter child rearing are all that is required to eliminate the problems. In nearly all instances mental disorder exists on a continuum, so that stigma does not pertain solely to the most virulent forms of disturbance.

Second, it will take creative efforts to emphasize the fundamental humanity of people who contend with mental illness, particularly those with the most severe forms. Exposure to personal and family narratives that document everyday realities is critical, as I have repeatedly emphasized. Mental disorder retains an aura of mystery, confusion, and threat; we simply cannot afford the repeated promotion of stereotypes of violence, constant and utter irrationality, and hopelessness that surround mental illness. Narratives of strength, courage, and resilience matter, and showcasing them is essential. Stories on treatment-related successes do not make for sensational headlines, yet they should receive far more media attention than tales of horror, crime, or despair.

Third, mental illness touches far more individuals and families than many people would ever suspect. Exposing to public consciousness the facts and realities that nearly all families know at a private level, but rarely voice in public, would go far in eliminating the denial that still constitutes a major barrier to effective change. We cannot afford to bury the realities of mental illness any longer.

(p. 243) Fourth, realistic strategies for change must be emphasized. By this I mean that promises of eliminating mental illness through modern psychopharma-cology or universal means of primary prevention—or comparable promises of eradicating stigma solely through public education—are simply not attainable in the foreseeable future, if ever. To the extent that such quixotic objectives are promoted, there is bound to be discouragement and demoralization in the aftermath. A likely consequence is that the problems related to mental illness will be perceived as all the more intractable, with subsequent increases in the blaming of persons with mental disorders or their families. In implementing meaningful, multilevel approaches to combat stigma, it will be important not to overpromise. At the same time, momentum toward change must be sustained.

Finally, the ultimate question regarding stigma may well be whether we as a society and a species are content to keep in place attitudes and policies that allow such a shocking waste of human talent and potential. The ultimate irony of stigmatization and discrimination is that all of society and all of humanity lose when these practices are perpetuated. I have the hope that too many concerned people are now dealing with mental illness on a daily basis—suffering from the degrading and wasteful consequences of stigma—to allow mental illness to stay hidden and to allow practices of neglect, punishment, and banishment to remain in place. Change must emanate from altered policies and laws, but the motivation for reform must emerge from a multitude of impassioned, informed pleas from individuals and families and from a continued insistence on promoting and funding effective treatments. The challenge is real, but we all stand to gain from joining the fight. (p. 244)

Notes:

1. For example, see Kutchins and Kirk (1997) versus Hyman (2002). Once again, the developmental psychopathology perspective, which integrates psychobiological predispositions with psychosocial risks in terms of transactional processes, could serve as a more balanced antidote.

2. Beauchaine (2003). Still, the possibility exists that some variants of mental disorder may reflect qualitative differences, though these have been difficult to detect.

3. See S. Johnson (2005) regarding bipolar disorder in this regard.

4. Consider a parallel issue related to future societies’ views of intelligence in children. Given the increasingly technological basis of Western cultures, it is easy to imagine that a child’s academic potential, as measured by intelligence tests, will receive ever-greater scrutiny in future generations. The underlying model in this scenario is that intelligence is a single entity, with an individual’s score on an IQ test predicting important life outcomes and determining much in the way of access to resources. An alternative perspective is that multiple forms of intelligent behavior exist, with differential predictive validity to key outcomes—and that motivation and drive may be more important for ultimate outcomes than a single IQ score (see, for example, Gardner, 1985). Could it be that a parallel conception of mentally healthy behavior will emerge to the extent that there is no single standard of conformity?

(p. 283) 5. Such websites were quite prevalent several years ago but have tapered recently (in fact, some have been taken over by those who view eating disorders as forms of mental illness that require treatment). See, for example, http://www.Anorexic_Life.com and related links. Viewing the adoration of emaciated human figures on such sites is extremely disconcerting. I thank Andrea Stier for thoughtfully raising this important issue.

6. Such a stance clashes directly with evidence for the strong biological, psychological, and familial roots of serious eating pathology—see Wilson, Becker, and Heffernan (2003).

9. See, for example, “An out of control profession,” the posting of April 3, 2006 at the Alliance for Human Research Protection website, http://www .ahrp.org.

11. Far more aggressive medication treatment exists today for childhood asthma than was imagined only two decades ago; yet, because asthma is a disease of the lungs and not of the brain and mind, stigma is less of an issue in this regard. The analogy is intriguing, given that asthma—a biologically based and genetically linked condition—is highly exacerbated by living in smog-ridden, decrepit urban environments. Intervention for asthma therefore needs to be delivered at broad levels of policy and housing, as well as through individual pharmacology. Nonetheless, stigma regarding asthma exists, including its associations with frailty, weakness, and sickliness. See Beamer (2005).

13. See, for example the report titled “A Federal Failure in Psychiatric Research: Continuing NIMH Negligence in Funding Sufficient Research on Serious Mental Illnesses” at http://www.psychlaws.org/nimhreport/federalfailure.htm. This report outlines the huge imbalance in spending between mental and physical disorders and also decries the lack of mandated funding for the serious forms of mental illness noted in the text. It recognizes the need for basic research but notes that other agencies, such as the National Science Foundation, might be more appropriate as funding sources toward these ends.

14. The goal of this initiative, announced in 1971, was to eliminate cancer in the United States within a 7-year period. With hindsight, the naive optimism of this objective is apparent.

15. In fact, it is too narrow to conceptualize only three means of effecting change in stigma—that is, the three empirically supported procedures of protest, education, and contact cited by Corrigan and Penn (1999). There may well be additional means of changing minds and behavior (see Chapter 9).

20. I raised a similar point in Chapter 4, citing the work of Grob (1994), who believes that overzealous promises and excessively high expectations were partly to blame for the failure of the deinstitutionalization movement of the 1960s and beyond. (p. 284)