Understand Diagnosis as a Continuum
An alternate way to understand diagnosis is dimensionally rather than categorically (Widiger, 2001). Rather than assign someone to a class of people with similar symptoms, course, and disabilities, dimensional diagnosis seeks to describe a person's profile of symptoms on a continuum. This changes the question of diagnosis from "yes or no, the person is mental illness 'X'" to "the person is having the following sets of problems compared with a standard." This also changes the notion of treatment from moving the person out of the diagnostic class to decreasing his or her problems as indexed by the symptom and disability continua.
Experimental psychopathologists have convincingly argued that diagnoses may be better described in terms of dimensions, which vary continuously on symptom and other deficit indicators, rather than as independent classes or taxa, which are described by discrete syndromes (Widiger & Clark, 2000). In part, support of a dimensional view is based on the inability to support taxometric models with empirical research (Widiger, 2001). Support of dimensional models also rests on the descriptive and prognostic benefits sowed by multidimensional, continuous models of disorder (Widiger, 1983). In terms of diagnosis as an instrument of stigma, a dimensional model diminishes the groupness of psychiatric disorders. Instead of people with mental illness being qualitatively distinct from the "normal" population, mental illness falls on a continuum that includes normalcy. Interestingly, although the DSM-IV already recognizes the utility of a dimensional approach, it has not yet adapted this view because dimensions are less familiar to clinicians and less descriptive than categorical labels (APA, 2000). Perhaps future iterations of the DSM will move toward a dimensional approach that will decrease the stigmatizing effects of diagnosis.
Have Contact with the Individual
One problem with diagnosis as classification is replacing idiographic perceptions of the individual with normative statements about the group. One way to overcome this problem is to stress the individual over the group. Research on stigma change shows that contact between the public and people with mental illness leads to significant change in stereotypes about mental illness (Corrigan, 2001; Corrigan et al., 2002). Contact counters the stigma by highlighting people as individuals with complex lives that exceed the narrow descriptions of diagnosis.
There are nevertheless significant limitations to contact. Mental health providers, for example, have frequent contact with people labeled mentally ill but unfortunately tend to endorse the stigma (Chaplin, 2000; Lyons & Ziviani, 1995; Mirabi, Weinman, Magnetti, & Keppler, 1985). In part, this may reflect their focus on diagnosis and psychopathology, largely seeing people in terms of diagnostic groups rather than as individuals. This may also be a consequence of the type of contact that professionals have with people with mental illness; namely, professionals tend to interact with people when they are most in need of services, when they are acutely ill. Professionals are much less likely to interact with their clientele when they have recovered and when they are living a life that challenges the stigma. Stigma might be better challenged if professionals round out their picture of individuals with mental illness by purposefully interacting with those who have recovered (Corrigan & Lundin, 2001). Student training, for example, may include encounters with people in recovery so trainees can learn early that psychopathology is only one side of the illness coin; recovery is the other.
Replace Assumptions of Poor Prognosis with Models of Recovery
The stability of stereotypes has led to the notion that many people with mental illness fail to respond to treatment and recover. This phenomenon is reflected in classic writings about the prognoses of people with serious mental illness. Kraepelin (1913), for example, said that people with schizophrenia and other serious mental illnesses will inevitably experience a progressive downhill course, ending up demented and incompetent. The impact this has had on treatment is insidious; why try valiant interventions if the person is going to eventually end up on a back ward of a psychiatric hospital? Longitudinal research, however, has failed to support Kraepelin's assertion. For example, researchers in Vermont and Switzerland followed several hundred adults with severe mental illness for 30 years or more to find out how mental illness affected the long-term course of the disorder (Harding, 1988). If Kraepelin was right, the majority of these people should have ended up on the back wards of state hospitals. Instead, researchers discovered that between half to almost two-thirds of the sample no longer required hospitalization, were able to work in some capacity, and lived comfortably with family or friends; they recovered. Although Kraepelin's work is almost 100 years old, it is still reflected in modern psychopathology tests and even in the third revised edition of the DSM (APA, 1987). Professionals need to broaden their perspectives to include notions of recovery.
Sociologists have developed models of stigma that are helpful for understanding the impact of diagnosis. They defined structural stigma as institutional efforts that unintentionally lead to discrimination of a group (Hill, 1988; Wilson, 1990). For example, many universities and colleges use the SAT or ACT to limit admission to students who have earned high scores, believing this to be an unbiased way to select students. However, given that African American and Hispanic students typically score lower than white students on these tests, universities that rely on the SAT and ACT are likely to prevent a disproportionate number of black and Hispanic students from receiving an education with them (Pincus, 1999). In this case, structural stigma unintentionally leads to race discrimination. Diagnosis is an example of structural stigma as applied to mental illness. Although diagnostic systems are developed by social work and other mental health professionals to better understand mental illness, they unintentionally exacerbate the stigma of mental illness. Diagnostic classifications augment public perceptions of the groupness and differentness of people with mental illness. These classifications are perceived as homogeneous, and composite traits are seen as stable. As a result, individual members of a diagnostic class tend to be seen in terms of their diagnosis instead of the idiosyncratic nature of their problems. One way to change this kind of stigma is to challenge the very foundation on which it rests. Changing to a dimensional perspective of diagnosis undermines the sense of difference perpetuated by diagnosis and replaces psychiatric classification with a continuum that includes normal life. Stressing the evidence that supports recovery will diminish the stigma related to diagnosis. Facilitating interactions between professionals and people in recovery will also challenge the stigma.
The diagnostic enterprise has much value for clinical care. I do not mean to suggest that it be discarded. Instead, my effort here is to alert the reader to the insidious effects of diagnosis on stigma. Following the recommendations in this article may ensure that diagnosis does not add to the prejudice and discrimination experienced by many people with mental illness.
- Corrigan, Patrick W; How Clinical Diagnosis Might Exacerbate the Stigma of Mental Illness; Social Work; Jan2007; Vol. 52 Issue 1
Reflection Exercise #10
The preceding section contained information
about steps to help alleviate the stigma of schizophrenia. Write three
case study examples regarding how you might use the content of this section in
What are three ways in which the stigma that results from diagnosis may be reduced? Record the letter of the correct answer the .