Ashruth Marla
Common discourse around mental health includes the mention of social-stigma and biases associated with having a mental health diagnosis. However, this can become a lot more alarming when clinicians themselves tend to engage in, or endorse such stigma—especially given their diagnostic, and at times, psychotherapeutic roles. Thus, it becomes important to understand how clinician biases, especially in terms of demonised diagnoses, can play a huge role in determining mental health outcomes. In order to gain a better understanding of this, this blogpost aims to specifically examine how stigma perpetuated by mental health professionals during clinical assessment can affect help-seeking behaviours and disorder presentations, in patients with personality disorders.
In clinical assessment, labelling is a form of classification of a patient according to a certain diagnostic category. While this is useful for the purposes of categorization, it can become difficult if the label is incomplete, misleading or if it does not accurately represent the standard diagnostic category properly (APA, 2022). Labelling Theory or Societal-Reaction Theory is when a patient is labelled to have a certain disorder, even if it is inaccurate, it might affect their behaviour as a form of self-fulfilling prophecy (APA, 2022).
Additionally, diagnostic labels can be very influential on a person to the extent where their impact might be felt even after a person makes a full recovery (Hooley et al., 2021). When a person is labelled to have a certain disorder, this can invite certain assumptions and biases which might be inaccurate, forming the basis for stigmatisation. Hooley et al. (2021) also note how labelling, if followed by such stigmatisation, can often also cause individuals to believe that their disorder is their identity, such that they can feel pressured to play out the “expectations” of that role, significantly affecting mental health outcomes. Thus, given the larger implications of labelling and the very real question of stigmatisation, it becomes even more imperative to examine in clinical settings.
Clinicians themselves are often not exempt from creating stigmatised spaces, especially when they can exert considerable power not just over the client they are diagnosing, but also the wider community. Take, for example, a Therapist-turned-YouTuber called Kati Morton, who appeared in the YouTube series, “The Mind of Jake Paul”, which aimed to analyse the behaviour of another internet influencer, Jake Paul. In this series which amassed over 176 million views, Morton as a licensed therapist explains the symptoms and manifestations of Antisocial Personality Disorder(ASPD) while referring to the DSM-5. While validating Shane Dawson, the host’s apprehension over the disorder, she opines how ASPD is “creepy”, “icky” and makes her “want to take a shower after having this conversation” due to their lack of emotions and empathy (Dawson, 2018). She even goes so far as to mention that intervention would be unsuccessful for individuals with ASPD as the results would only be dependent on the patient’s motivation owing to their highly manipulative nature (Dawson, 2018). This elucidates quite starkly how pervasive stigma, especially around certain types of personality disorders, is rampant in clinical settings.
What is more alarming, yet not unsurprising, is that Morton is not alone as a clinician in her perpetuation of stigma especially towards cluster-B personality disorders. Latalova et al. (2020) starkly illustrate how psychiatric staff often operate on stereotypic assumptions towards individuals with Borderline Personality Disorder, with mental health practitioners “stigmatising individuals with borderline personality disorder even more than the general population”. They further go into detail about how clinicians often perceive the disorder to be “incurable”, even though that is not the case. Given that it can already be difficult to diagnose individuals with BPD, inherent biases about the nature of the disorder can make it even more difficult for individuals to seek the help that they require, while also damaging the rapport between clinician and client (Dingfelder, 2004; Hooley et al., 2021).
In specifically examining personality disorder diagnoses, Flannagan and Blashfield (2003) also illustrate that when social stereotypes are consistent with associations of gender, they influenced how personality disorder case vignettes were rated by novices. Additionally, Mikton and Grounds’ (2007) study indicates a similar result when examining clinical judgements based on case vignettes in forensic psychiatrists in the UK—diagnoses depended on the ethnicity of the client. Both of these studies shed light on how diagnoses are extremely malleable to prevailing stereotypes and when combined with the biases associated with certain disorders, can often breed mistrust in communities, especially when approaching clinical settings (Suite et al., 2007). In this sense, the pre-existing biases against personality disorders get intertwined with other prejudices, such as those of race and gender, presenting barriers to diagnosis and treatment.
Examining the role of these biases towards personality disorders is exceptionally important considering that they are not restricted to assessment, but can also carry over to other parts of clinical practice. It has been shown that therapists’ emotional countertransference varies based on different personality disorders such as Narcissistic Personality Disorder(NPD) and ASPD (Colli et al. 2014). Additionally, Colli et al. (2014) also note how negative feelings in therapists were more strongly correlated with working with low-functioning patients. Biases can therefore seep into the psychotherapeutic process. They can also influence the prescribed medication, therapeutic approaches and in severe cases, institutionalisation (Bulhan, 1987; Hooley et al., 2021).
Henceforth, it is imperative to make sure that clinical spaces are free from such stigmatisation due to diagnostic biases surrounding specific personality disorders. One way in which this can be achieved is through consistent reflexivity on the part of mental health professionals to ensure that proper care and sensitivity is afforded to all patients regardless of their assumed prognosis. Therefore, this can help increase trust while decreasing stigma between diagnoser and diagnosed.
References
American Psychological Association, (2022). Apa Dictionary of Psychology. American Psychological Association. Retrieved October 10, 2022, from https://dictionary.apa.org/labeling
Bulhan, H. A. (1985). Black Americans and psychopathology: An overview of research and theory.Psychotherapy: Theory, Research, Practice, Training, 22(2S), 370–378. https://doi.org/10.1037/h0085517
Colli, A., Tanzili, A., Dimaggio, G. & Lingiardi, V. (2014). Patient Personality and Therapist Response: An Empirical Investigation. The American Journal of Psychiatry 171(1), 102-108. doi: https://doi.org/10.1176/appi.ajp.2013.13020224
Dingfelder, S. (2004). Personality disorders--treatment for the 'untreatable'. Treatment for the 'untreatable'. Retrieved October 10, 2022, from https://www.apa.org/monitor/mar04/treatment
Flanagan, E. H., & Blashfield, R. K. (2003). Gender bias in the diagnosis of personality disorders: The roles of base rates and social stereotypes. Journal of Personality Disorders, 17(5), 431-46. https://www.proquest.com/scholarly-journals/gender-bias-diagnosis-personality-disorders-roles/docview/195237256/se-2
Hooley, J.M., Nock, M.K. & Butcher, J.N. (2021). Abnormal Psychology (18th ed.). Latalova, K., Ociskova, M., Prasko, J., Sedlackova, Z., & Kamaradova, D. (2020, April 15). If you label me, go with your therapy somewhere! borderline personality disorder and stigma: European Psychiatry. Cambridge Core. Retrieved October 10, 2022, from https://www.cambridge.org/core/journals/european-psychiatry/article/if-you-label-me-go-with-your-therapy-somewhere-borderline-personality-disorder-and-stigma/058DF61415FF7C2964CE8DE84A75B90A
Mikton, C., & Grounds, A. (2007). Cross-cultural clinical judgment bias in personality disorder diagnosis by forensic psychiatrists in the UK: A case-vignette study. Journal of personality disorders, 21(4), 400.
Shane. (2018). The Dark Side of Jake. YouTube. Retrieved October 10, 2022, from https://www.youtube.com/watch?v=vTLkSpY_aYg&list=PLDs0tNoNYTz1P3dO8m5Wdv0WE2lPTQSJm&index=3.
Suite, D. H., La Bril, R., Primm, A., & Harrison-Ross, P. (2007). Beyond misdiagnosis, misunderstanding and mistrust: relevance of the historical perspective in the medical and mental health treatment of people of color. Journal of the National Medical Association, 99(8), 879–885.
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