Lecture 3: Stigma of Personality Disorders - Sheehan 2016 PDF

Lecture 3: Stigma The Stigma of Personality Disorders Sheehan 2016 Introduction Personality disorders are psychiatric conditions experienced by between 5 and 15% of the population affected. Overall, public knowledge of personality disorders is low, and people with personality disorders may be perc...

Lecture 3: Stigma The Stigma of Personality Disorders Sheehan 2016 Introduction Personality disorders are psychiatric conditions experienced by between 5 and 15% of the population affected. Overall, public knowledge of personality disorders is low, and people with personality disorders may be perceived as purposefully misbehaving rather than experiencing an illness. Characteristics and prevalence of personality disorder - PDs with the highest prevalence: Antisocial PD: 3.8% BPD: 2.7% OCPD: 1.9% Paranoid PD: 1.9% Avoidant PD: 1.2% - 3 clusters 1) Cluster A: eccentricity cluster - Schizotypal - Paranoid - Schizoid 2) Cluster B: “dramatic” cluster, very emotionally unstable - Antisocial PD - BPD - Paranoid PD - Narcissistic personality disorder Cluster B PDs are the most common 3) Cluster C: anxious cluster - OCPD - Avoidant personality disorder - Dependent personality disorder - People who experience a personality disorder are more likely to self-harm, abuse substances, and have co-occurring psychiatric problems such as mood disorders and post-traumatic stress disorder (PTSD); 67% of PD patients meet the criteria for at least one more psychiatric disorder Defining stigma  - What is stigma? Social rejection, resulting in negatively perceived characteristics. - Goffman’s conceptualization of 4 qualities of stigma: a) Individual differences are recognized b) these differences are perceived by society as negative c) the stigmatized group is seen as an outgroup d) the end result is loss of opportunity, power or status - Social-cognitive perspective: Stigma can be cognitive, affective, and behavioral, or also called stereotype, prejudice and discrimination - Public stigma manifests in social exclusion and discrimination. Public stigma can potentially lead to self-stigma if the person believes that negative societal attitudes imposed upon them are true. Structural stigma refers to discriminatory policies and practices, which legislation such as the Americans with Disabilities Act aims to address by safeguarding the rights of individuals with disabilities. Stigma of mental illness - 3 important stereotypes for people with mental health problems: incompetence, dangerousness and responsibility - Example of schizophrenia stereotype: A person diagnosed with schizophrenia may be labeled as incompetent; employers doubt their ability to perform on the job (prejudice) and avoid hiring them (discrimination). - Media often exaggerates the link between mental illness and violence, perpetuating the dangerous stereotype - With the stereotype of responsibility, people with mental illness are viewed as to blame for the illness. That is, the public believes these individuals have made choices that led to their symptoms or have not made sufficient recovery efforts; they are responsible for developing the disorder they have - Individuals with mental illness who have internalized the public stigma may feel shame or have low self-esteem.  - “why try” effect: recovery efforts stall when the person has fully incorporated the stigmatized mentality of incompetence - People with personality disorder are likely subject to both the general stigma of mental illness and the stigma attached to the particular personality disorder Public stigma of personality disorder - PDs may be more stigmatised than the other psychiatric disorders. In fact, the public reacts less sympathetically to individuals described as having a personality disorder and is less likely to think these individuals need professional help than those with other psychiatric disorders - People generally do not recognize personality disorders as well as depression or schizophrenia for example Bordeline personality disorder - one of the most stigmatized - People with BPD are often seen as annoying and undeserving, which results in inadequate treatment and help - Frequent interactions between individuals with borderline personality disorder (BPD) and law enforcement, often stemming from issues like anger and suicidality, can lead to police feelings of frustration and powerlessness, which may be exacerbated by stigma and stereotypes that portray people with BPD as deliberately troublesome. BPD may experience harsher treatment by the police since they are not well-designed to serve their unique needs. Antisocial Personality disorder - Individuals with antisocial personality disorder (ASPD) often display symptoms like lack of remorse, empathy, aggressiveness, and recklessness from childhood. - Children with ASPD are frequently labeled as delinquents by parents, teachers, and peers, contributing to a self-fulfilling prophecy of believing they are "bad" and leading to criminal behavior. - A significant number of adults with ASPD become involved in the criminal justice system. - Stigmas associated with ASPD, including perceptions of dangerousness, can hinder access to treatment and recovery, particularly within the justice system. - Individuals with ASPD are often referred to as psychopaths or sociopaths and stigmatized as evil. - A survey found that jury duty participants viewed those with ASPD as more violent but generally sane and responsible for their actions. - Many court officials do not classify ASPD as a mental illness, affecting legal outcomes and rehabilitation opportunities. - The stigma can lead to harsher sentencing and challenges in rehabilitation for individuals with ASPD in prison.  - Recent neurological research indicates specific brain abnormalities in individuals with ASPD, potentially prompting a reevaluation of legal processes and treatment in the future. OCPD - Perfectionism and overemphasizing order and control - well understood by the general public due to its similarity to OCD - Attitudes and behaviors towards people with OCPD would be more favorable than other personality disorders Narcissicstic PD - not familiar to the general public - people with NPD are seen as being fragile, lacking self-esteem, and experiencing problematic social relationships - NPD was seen as an advantage in the business area Provider stigma - health care providers also hold negative attitudes towards people with personality disorders. especially BPD - psychiatric nurses: the most stigmatizing attitudes - In a study, psychiatrists had the lowest empathy towards people with BPD in comparison to other providers, including nurses, social workers, and psychologists - Stigma with health providers: can reduce service availability and quality of service and discourage people from seeking treatment - Diagnosis of BPD: can even cause exclusion from treatment - suicide attempts for PDs are seen as attention seeking - People with BPD were discharged more quickly from emergency room as well as waited longer for help after self-harm (4 hours or more) Self-Stigma - People accept public stereotypes about themselves - established problem for people with BPD - BPD people have more “existential shame” compared to those with other diagnosis Structural stigma - Structural stigma can impact availability of services, quality of services, insurance coverage, and research on personality disorders - Less funding, research and services available for people with PDs - Diagnostic and screening tools are absent or not sufficient enough to accurately assess this population, presumably because of lack of funding for research or lack of interest (especially BPD) - BPD petions are frequently misdiagnosed  - Psychiatrists may avoid diagnosing people with PD to protect them from stigma or avoid telling them the diagnosis Antistigma Interventions for PDs - Education: changing stigma by correcting misperceptions about stigma - A second commonly used strategy to combat stigma involves members of the stigmatized group engaging in personal contact with others, such as through an interactive presentation about their story of recovery from mental illness. - Both interventions that educate and provide meaningful interpersonal contact with people with the mental illness are most effective, but contact interventions have a distinct advantage - After BPD anti-stigma training, clinicians had more positive attitudes towards clients with BPD - Current brain imaging studies provide evidence that personality disorders have visible neurobiological differences and challenge widespread ideas that personality disorders are merely a character flaw or the intentional actions of the person. - brief training that stressed the neurology of PD showed change in knowledge and attitudes but not empathy of healthcare staff Gaps in the literature - develop more sensitive measures of stigma unique to PDs - How does' Debate: Stigma implications for diagnosing personality disorders in adolescents Sheehan et. al (2022) There are various forms of stigma that may harm youth and their families, including public stigma, selfstigma, and associative stigma. Public stigma - Public stigma is comprised of stereotypes, prejudice, and discrimination that are directed at people who are living with PDs - Common stereotypes for PDs: attention-seeking, manipulative, violent, deviant, selfish - People who hold those stereotypes may experience fear or frustration of people diagnosed with PDs - Discriminatory behavior directed at young people with PDs could include being called crazy or other insults, and denial of supportive educational services or lower expectations from teachers/parents.  - Label avoidance: young people will not want to engage in services or take advantage of accommodations to avoid being “labeled” as different from their peers. Self-stigma - youth with PD internalise public stigma, believing it is true - associated with lower self-esteem, depression, suicide ideation, social isolation, secrecy, and avoidance of help - leads to “why try” effect: a sense of behavioral futility in which youth feel neither worthy nor able to pursue personal goals Associative stigma - Families feel blamed or tainted by the young person’s illness and may be judged or ostracized by their communities: “It’s your fault that your son is getting in trouble at school because of his mental illness.” - Families also suffer seeing how their children are stigmatised by others - To avoid associative and vicarious stigma, families might prefer that their child not receive a diagnostic label by the mental health system Moderators of stigma - Believing that people are to blame for their conditions tends to increase stigma - In contrast, viewing mental health disorders as occurring on a continuum (“we all have mental health challenges sometimes”) tends to result in reduced stigma - dichotomous ("all-or-nothing"), rather continuous diagnoses, potentially lead to greater stigma; moreover, diagnosing Pd early may increase the stigma - Biogenetic explanations may be used to reduce stigma, but at the same time, those threaten to undermine beliefs about recovery if individuals or families become resigned to the diagnosis as a physical illness that can only be “fixed” via medical interventions - In both youth and adults BDP: higher stigma than other personality disorders - For ASPD, labeling it as a “condition” may lead to more of a rehabilitative focus during interactions with the justice system; however, people with ASPD tend to be labeled as psychopaths and sociopaths, and this could result in decreased rehabilitative efforts, coercive treatments, and restricted resources Developmental aspects of stigma - Adolescence have limited knowledge and experiences with mental illness and may not have not incorporated the illness into their personality; this may lead to less stigma, however, increased knowledge about the long-term prognosis of a PD or continued exposure to public stigma will likely increase harm over time  - Adolescents experience different social context than adults; often they experience mental health care through schools, where they can be more vulnerable to public stigma from peers while receiving services - Adolescents have less experience and opportunity for autonomous decision-making, specifically around care-seeking and managing disclosure of diagnosis Health care and public stigma implications - health providers are particularly stigmatising individuals with PDs, presumably due to perceived chronicity, lack of effective treatments, and treatment resistance in PD - Example: When an adolescent is diagnosed with borderline PD, health practitioners generate a medical record that follows them into adulthood. When healthcare practitioners reinforce PD stereotypes, they may misunderstand help-seeking as attention-seeking, leading to frustration. - However, a diagnosis might enhance general understanding about these disorders; recognition through formal diagnosis could result in youths with PD being viewed as recovering from a treatable illness rather than being judged as inherently “bad” or “different.” - studies show that adolescence tends to be stigmatized based on the severity of the symptoms rather than diagnostic label per se Borderline personality disorder and stigma: Lived experience perspectives on helpful and hurtful language Van Schie et al (2024) Introduction - Stigma towards people with BPD: remains a challenge - people with BPD can face significantly more stigma than others with other diagnoses - Stigma can lead to reduced access to health services - Language is an important reinforcer of stigma - the wellbeing of individuals with PD and their careers have been negatively impacted by unhelpful and stigmatizing communication from clinicians - We need to understand how words and phrases can be reframed in a recovery-oriented and compassionate way that fosters relationships, support and hope - The Core Conflictual Relationship Theme Framework that can capture interpersonal difficulties from language use measures relationship patterns from interpersonal narratives by distinguishing the wishes of a person, the response of others towards  a person and the response of a self towards another Responses of others: how others behave towards you Responses of self: how you react to the response of others Wishes: How would you like others to behave? - The unhelpful language used regarding BPD can be experienced as reinforcing prejudice, marginalization and disempowerment The Current Study - Investigates both helpful and unhelpful language in different environments such as health services, outside health services, and the immediate environment of family and friends - Participants: BPD patients (n = 33) and BPD carers (n = 30) - Devided by 3 groups: BPD patients only, BPD caregivers only, mixed group - 3 activities 1. Participants were given 2 index cards each to write down 3 harmful and 3 helpful phrases that they encountered 2. Participants were provided with 3 separate sheets of paper per group labeled “diagnosis”, "treatment," and "recovery.” Participants offered through a discussion written recommendations for language use around those 3 topics 3. Participants were provided with individual cards with statements where they needed to fill the blanks “Dear ____, I wish you would stop saying _____, because it makes me feel ____ and instead say ______” - The Core Conflictual Relational Theme methodology was used to distinguish responses of others, responses of self and wishes - 2 authors coded the data, following the same coding process - Word clouds were used to present frequently used phrases Results Current language use - Phrases that stood out as unhelpful Attention seeker manipulative crazy  - Phrases that stood as helpful Validating someone’s feeling Understand Doing their best Consumer and carer perspective on language use  The following responses of others, responses of self, wishes and reframing language were identified in this study Responses of others: Responses of self: 4 Wishes Reframing 6 subtypes identified responses identified langugae 1. Being blamed 1. despair 1. acknowledgeme 1. acceptance 2. Being given up 2. frustration nt of and insight 2. connection on 3. guilt and shame into the disorder 3. empowerme 3. Not being 4. inadequacy as 2. acknowledgeme nt accepted as a a person. nt of distress 4. gratitude person 3. hope 5. hope 4. Having needs 4. support from 6. validation misunderstood others 5. Not being 5. being seen as a accepted as a person person 6. feeling 6. Having understood and experiences validated trivialised Perspencive from consumer (BPD patients) participants on stigmatizing language Unhelpful communication patterns - Most often Responses of others pictures their experiences of BPD patients aas trivializing; they are misunderstood and ignored, and not being accepted as a person - Phrases such as trvivalized experiences: over-reacting; just get over it; Stop getting so emotional - Misunderstood needs: It is always about you or Stop getting so emotional - Sometimes maladaptive thoughts like “there is no hope for me and it is too late are not response to others but internal conversation - Response of shame and guilt: patients withdraw themselves from others, feel like a burden; they also repost feeling frustrated - Most frequently unhelpful communication pattern for consumer participant: not being accepted as a person and feelings of inadequacy in response Understanding wishes and helpful ways of responding to wishes - Most often reported wishes wanting to be seen as a person feel understood and validated receive support from others - If participant felt inadequate: wish to be seen as a person of wish to feel understood and validated - Reframing:  BPD patients want to be seen as worthy of life Acceptance language for themselves, like “learning to be with myself”; “takes as long as it takes” (in terms of recovery) - In their wish to be supported, consumers indicated that they would like to have someone being and connecting with them - language that provides hope and empowerment was suggested Perspective from carer participants on stigmatizing language Unhelpful communication patterns: - Carers often feel ignored or misunderstood, especially by clinicians. - Responses such as "they'll grow out of it" or blaming parents for poor parenting were reported. - Carers expressed frustration, guilt, shame, and despair, feeling disrespected despite their efforts. - Most common communication issues: having their needs ignored, trivialized, or blamed. Understanding wishes and helpful ways of responding: - Carers wish for support and for their loved ones to be treated as individuals. - Helpful responses include curiosity, validation, and empowerment. - Caregivers value gratitude and acknowledgment of distress. - Education about the diagnosis and empowering language foster recovery. Discussion Hurtful language and stigma: - Both people with BPD and carers have encountered stigmatizing language, such as being labeled "manipulative" or "attention-seeking." - Stigma extends beyond clinical settings, affecting public and media views. - Self-stigma is common among those with BPD, causing shame and withdrawal. Unhelpful Communication Patterns - Unhelpful communication from both professional and personal relationships includes trivialization of concerns, blame, and dismissiveness, which exacerbate feelings of inadequacy and frustration in people with BPD - Clinicians often struggle with countertransference, leading to negative emotional responses such as frustration, uncertainty, and hopelessness. This can manifest in a lack of empathy and reflective practice, further distancing them from the individual’s challenges. Helpful Communication: - People with BPD and carers value compassionate, hopeful language that provides validation, empowerment, and connection.  - Clinician training and reflective practices can reduce stigma and improve therapy outcomes. Challenges and recommendations: - Delayed diagnosis and lack of education exacerbate stigma. - Future research should integrate perspectives from family, friends, and clinicians. Recommendations: - Reframing negative language to promote connection, validation, hope, and empowerment can help foster better therapeutic outcomes. Clinicians need to adopt reflective practices and engage in continuous education about BPD to mitigate the stigma in their language. - Carers and individuals with BPD recommend using empowering, accepting, and strength-based language to support recovery. Suggestions include expressing gratitude for efforts and providing realistic hope for change and improvement.