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People with mental disorders are strongly stigmatized. Among mental-health professionals, stigmatizing attitudes often manifest as desire for social distance from people with mental disorders. Currently ascendant biomedical conceptualizations of psychopathology could exacerbate this problem by engendering dehumanization, which is linked to prejudice. Given the clinical implications of such an occurrence, the present research tested a possible mitigation strategy. In an online study of 216 U.S. mental-health clinicians, two strategies for mitigating dehumanization in healthcare were tested—personification, highlighting personal traits of people with mental disorders rather than presenting them as malfunctioning brains, and agency reorientation, underscoring people’s ability to make choices and decisions. This approach yielded significantly less desire for social distance, among clinicians, from a person with depression whose symptoms were explained biologically. These findings may suggest an avenue for decreasing stigma in clinical practice.
People with mental disorders are highly stigmatized (Hinshaw & Stier, 2008), and stigma is an important reason why many affected individuals do not receive adequate treatment (Corrigan, 2004; Rusch, Angermeyer, & Corrigan, 2005; Thornicroft, 2008). Surprisingly, such negative attitudes are about as strong among mental-health professionals as they are in the general public (Lauber, Nordt, Braunschweig, & Rössler, 2006). For example, one large study found that clinicians endorsed numerous negative stereotypes regarding people with mental disorders, including that such individuals are more “weird,” “threatening,” and “delinquent” than the general population (Lauber et al., 2006). Clinicians have also been shown to express considerable desire for social distance from people with mental disorders, including reluctance about having such individuals live near them, marry into their families, or work alongside them (Wahl & Aroesty-Cohen, 2010). Given their regular interactions with psychiatric patients, the social and clinical harms of clinicians’ stigmatizing attitudes are likely to be especially severe (Hinshaw & Stier, 2008). Changing clinicians’ attitudes has been identified as an important step toward reducing the stigmatization of people with mental disorders (Sartorius, 2002).
Biological explanations for mental disorders are often thought to reduce stigmatizing attitudes, by creating the impression that patients are not in control of their symptoms and thus cannot be blamed for them. Yet, empirical evidence has actually shown that biological explanations are associated with increased stigmatizing attitudes (Kvaale, Gottdiener, & Haslam, 2013). Thus, the recent ascendancy of biomedical conceptualizations of mental disorders (Pescosolido et al., 2010; Schomerus et al., 2012) may engender even more negative attitudes among clinicians.
One possible reason is that biological construals of psychopathology can dehumanize patients by casting their symptoms as mechanical malfunctions rather than subjective mental states experienced by a human being (Haslam, 2006). Because dehumanization and stigmatization are closely linked (Haslam, 2006; Haslam & Loughnan, 2014), the present study sought to test whether an intervention designed to counteract dehumanization could blunt mental-health clinicians’ negative attitudes toward patients in the context of a biological explanation for their symptoms.
Several strategies have been suggested for mitigating dehumanization in healthcare (Haque & Waytz, 2012). Among these are “personification,” which consists of emphasizing people’s personal traits (so as to distinguish them from objects or machines) and can be accomplished by increasing clinicians’ mindfulness of personal details about a patient—such as their occupations and hobbies—or increasing the visibility of patients’ faces. Another approach, “agency reorientation,” refers to the process of increasing clinicians’ awareness of patients’ personal agency by drawing attention to patients’ ability to make choices and decisions for themselves (Haque & Waytz, 2012).
The present study constitutes a preliminary test of the effects of agency reorientation and personification on mental-health clinicians’ desire for social distance—i.e., unwillingness to interact with people with mental disorders—which is a principal means in the literature of gauging stigmatizing attitudes regarding psychopathology (Haslam, 2011; Link, Yang, Phelan, & Collins, 2004). Because dehumanization in healthcare is also linked to decreases in clinician empathy (Haque & Waytz, 2012; Lebowitz & Ahn, 2014), the present study also examined whether the intervention would affect empathy. However, social distance appears to be a type of stigmatization that is particularly prevalent among mental-health professionals, even when they do not display other types of negative views (Wahl & Aroesty-Cohen, 2010). Thus, measures of social distance may be more sensitive among clinicians and were considered the primary dependent variable in the present study. Given the novelty of the intervention approach tested in the present study, the main research aim was to take a “first step” toward examining its effects on clinicians’ reactions to patients with psychiatric symptoms by measuring its impact among a heterogeneous sample of mental-health clinicians.
Participants were 216 U.S. mental-health clinicians (see Table 1 for demographics; see Appendix for analyses of demographic factors as potential moderators of the effects of the intervention). We sent recruitment postcards to 1,970 clinicians in a variety of U.S. states who either advertised their services on PsychologyToday.com or were included in a membership directory of the American Psychiatric Association. Thus, the overall response rate was approximately 11%, which is comparable to response rates observed in other published studies of mental-health clinicians (Lebowitz & Ahn, 2014). The postcards invited recipients to participate in “an online study of clinicians’ thinking about psychopathology” seeking to “better understand the role of clinicians’ beliefs in the treatment of patients.” Clinicians were offered a $25 Amazon.com gift certificate in exchange for their participation.
All procedures were approved by the institutional review board and were administered using Qualtrics.com online survey software. There was only one independent variable of interest, which was the presence (versus absence) of an intervention based on personification and agency reorientation. This variable was manipulated on a within-subjects basis, in order to minimize error stemming from individual differences among participants. As a result, two vignettes were developed so that each participant could view one vignette with the intervention and the other vignette without the intervention. Each vignette described a young woman (either Terry or Alex) with symptoms of depression. Although the two vignettes described two different potential patients, we attempted to equate the descriptions as much as possible in terms of symptom severity (see the Appendix for the full vignettes). Nonetheless, which vignette was paired with the intervention was counterbalanced across participants so that the effects of the intervention would not be confounded with those of the contents of the vignette with which it was paired.
Each vignette was paired with a paragraph containing biological explanations for the patient’s depression (i.e., neurobiological and genetic information). Again, since a within-subject design was used, two different biological explanations were developed so that the same participant would not see the same biological explanation twice (see the Appendix for the full stimuli). Which biological explanation was paired with the intervention was also counterbalanced across participants so that the effects of the intervention would not be confounded with those of the contents of the biological explanation with which it was paired.
We also counterbalanced the order in which our stimuli were presented to participants, so that some participants viewed the intervention (and its accompanying vignette-explanation pair) before viewing the other vignette-explanation pair, while other participants viewed the stimuli in the opposite order.
The intervention was always presented as a cohesive whole, including both the “personification” components and the “agency reorientation” components. The “personification” components of the intervention consisted of a facial photograph purportedly depicting the woman from the vignette, as well as three sentences of personal information about her, which read:
Terry/Alex grew up in a medium-sized town, where she lived with her parents and brother until she moved away to attend college. She drives a 4-year-old Honda Civic and works at a dentist’s office as a receptionist. Before she developed her symptoms, she used to enjoy cooking, outdoor photography, and reading historical biographies.
These personal details were selected to include no information that could be seen as explaining the source of the individual’s symptoms, as such explanatory information could have “competed” with the biological information provided.
The “agency reorientation” component consisted of one sentence: “Terry/Alex states that in her efforts to receive treatment for her current symptoms, she is attempting to decide among several local clinicians.” This was intended to highlight the patient’s ability to make plans and decisions for herself.
The vignette not paired with the intervention did not contain the personifying details or the agency reorientation statement. In place of the facial photograph, it included a structural fMRI image, captioned, “An anatomical image of Terry/Alex’s brain from a recent neuroimaging scan.”
After reading each vignette, participants rated the extent to which each of 12 adjectives characterized their feelings toward the patient described, on a scale from 1 (not at all) to 7 (very much). Six of these (compassionate, moved, soft-hearted, sympathetic, tender, warm) measured the participants’ empathy (i.e., other-oriented feelings of concern) for the patient (Batson et al., 1997), which could potentially be increased by the anti-dehumanization intervention as discussed in the introduction. The other six adjectives (alarmed, distressed, disturbed, troubled, upset, worried) measured the participants’ personal distress (i.e., self-focused feelings of unease). Because ratings of these adjective measure one’s own distress caused by witnessing another’s misfortune, rather than the extent to which one experiences sympathy for the other (Batson, 2011), we did not expect personal distress to be affected by our anti-dehumanization intervention. We included personal distress ratings so that if our intervention showed significant effects on empathy, the absence of such effects on personal distress would allow us to rule out the possibility that any effects on empathy were merely evidence of a general positive mood induction.
Ratings of the six empathy adjectives were averaged to compute an empathy score for each participant’s response to each vignette, and ratings of the six personal distress adjectives were likewise averaged to compute personal distress scores. In each case, the items averaged to compute these scores showed high reliability (all Cronbach αs ≥.88), indicating that they were internally consistent.
Next, participants rated their desire for social distance from the target individual, by indicating—from 1 (very much) to 7 (not at all)—how much they would like to have each of five types of social interaction (working together, being neighbors, socializing for an evening, becoming friends, or becoming relatives by marriage) with her (Pescosolido et al., 2010). Ratings of these five ratings were averaged to compute a social distance score for each participant’s response to each vignette (αs =.95). Participants were not asked to imagine the target individuals as their own patients, so that social interactions would not appear professionally inappropriate.
At the end of the study procedures, participants were asked optional demographic questions and fully debriefed.
Paired-samples t-tests1 revealed that desire for social distance was significantly lower when the intervention was present (M=5.11, SD=1.41) than when the intervention was absent (M=5.27, SD=1.34), t(215)=4.50, p<.001. This effect did not significantly interact with any demographic variables.
Personal distress scores did not differ significantly between the vignette that included the intervention (M=2.32, SD=1.43) and the vignette that did not (M=2.33, SD=1.42), t(215)=.04, p=.97. Because personal distress is a self-focused measure of unease, this null effect does not undermine the effectiveness of the intervention.
Yet, empathy scores did not differ significantly between the vignette that included the intervention (M=4.17, SD=1.32) and the vignette that did not (M=4.18, SD=1.31), t(215)=.06, p=.95. While the intervention did not significantly affect empathy, it is interesting to note that differences in social distance between responses to vignettes in which the intervention was present versus when it was absent were correlated with differences in empathy. For both empathy and social distance, we calculated the difference between participants’ scores when the intervention was versus was not present, and examined the relationship between the two difference scores. This revealed that the more a participant’s social distance score was lower when the intervention was present (versus absent), the more likely that participant’s empathy score was to be higher when the intervention was present (versus absent), r(215)=−.29, p<.001. Thus, although on average there was no significant effect of the intervention on empathy, those participants who did show greater empathy in response to the intervention were the ones most likely to also show less social distance in response to the intervention.
We found that providing mental-health clinicians with personal details about people with depression, coupled with orienting their attention toward such individuals’ ability to make plans and decisions for themselves, can lead them to express less desire for social distance—an indicator of stigmatizing attitudes toward people with mental disorders. These attitude-improving measures are examples, respectively, of “personification” and “agency reorientation” (Haque & Waytz, 2012). Because biological conceptualizations of psychopathology can be particularly dehumanizing (Haslam, 2006), the intervention tested in the present study was presented in the context of a biological explanation for a patient’s psychiatric symptoms, and found to be effective.
The magnitude of the reduction in social distance yielded by our intervention was relatively small; this may be because the experimental manipulations involved in our intervention were quite minor. Clinicians in the present study were merely presented with one image of the target individual and a few sentences regarding personal traits and agency. This may explain the relatively small effect on social distance that we observed; the statistical significance of this effect may be attributable, at least in part, to our relatively large sample. It remains to be seen whether a relatively small effect like the one we observed would translate into meaningful behavior in real-world clinical settings. Still, it is notable that despite the subtlety of the intervention, it had a statistically significant impact on social distance. The intervention consisted of strategies suggested as approaches for decreasing dehumanization in healthcare. Thus, even if one instance of incorporating personification and agency reorientation into descriptions of patients had only a small effect, it may be that larger cumulative improvements in clinician attitudes would be possible given larger overarching changes in which clinical settings come to be saturated with higher levels of personification and agency reorientation.
Of note, our intervention did not affect clinicians’ self-reported empathy. This may have occurred because the techniques included in our intervention were not powerful enough to yield an overall difference in the amount of empathy clinicians experienced for two patients with the same disorder. Future research could test whether interventions more directly influencing the extent to which clinicians feel concern about (or value) patients’ welfare—such as instructions to imagine how they feel, which have been utilized extensively in research to induce empathy (Batson, 2011)—might be beneficially used with clinicians. However, methodological explanations for the absence of significant effects on empathy are also possible. For example, our study did not include a manipulation check to ensure that agency reorientation and personification were successfully manipulated by our stimuli. Thus, one cannot rule out the possibility that empathy was not significantly affected because our intervention did not successfully manipulate personification or agency reorientation, or both. While it is not clear through what other mechanism our experimental manipulations could have led to the differences in social distance, it represents an important limitation of the present study. In general, our study represents a preliminary attempt to assess the effectiveness of agency reorientation and personification on clinicians’ social reactions toward people with mental disorders. Future research beyond this “first step”—perhaps incorporating manipulation checks to ensure that agency reorientation and personification are being successfully manipulated—could examine whether the small magnitude of the statistically significant effect we observed on social distance, as well as the absence of significant effects on empathy, reflect general limits of the two strategies we employed, or alternatively, specific characteristics of our methodology.
A limitation of the present research is that our intervention combined multiple components: informing clinicians about personifying details of the patient’s life and highlighting the patient’s agency, as well as displaying a photograph of the patient’s face instead of an fMRI image to emphasize her personhood rather than the biological correlates of her symptoms. Due to the multifaceted nature of the intervention, it is not possible to discern from the present data whether all of its constituent elements were necessary in order to bring about the effects observed in the present study, or whether instead only one or two sub-components served as the “active ingredient.” Furthermore, while most of the contents of the intervention (that is, the personal details about the patient and the agency-reorientation sentence) had no counterpart in the vignette presented without the intervention, the facial photograph did have such a counterpart (the brain-scan image). Thus, it is not possible to discern from our data whether omitting the brain-scan image from vignettes presented without the intervention would have altered our pattern of results.
Another limitation of the present study is that our response rate of approximately 11%, while comparable to existing research using similar recruitment methods, was nonetheless low. This could potentially bias results in unpredictable ways. Future studies could attempt to address this issue using strategies specifically aimed at obtaining a higher response rate, perhaps by offering higher rates of compensation to participants. Our sample also consisted mostly of non-Hispanic White clinicians. Although this may be largely attributable to the fact that mental-health clinicians in the U.S. are predominantly non-Hispanic Whites (National Association of Social Workers, 2006; Zarin, Pincus, Peterson, West, & et al., 1998), it would nonetheless have been desirable to obtain a more diverse sample. Stigmatizing attitudes and other social reactions of clinicians to people with mental disorders, as well as the effectiveness interventions like ours, may vary among clinicians of different racial and ethnic backgrounds. Unfortunately, the relative homogeneity of our sample restricts our ability to examine such potential demographic moderators of the effects observed in our study.
Personification and agency orientation have been suggested as strategies for counteracting dehumanization in healthcare (Haque & Waytz, 2012), and our finding that they have beneficial effects on social distance is consistent with this account, given that dehumanization and stigmatization are closely linked. However, the methods of the present study did not allow us to specifically test whether reducing dehumanization was the mechanism by which our intervention affected social distance. Future research could accomplish this by including measures gauging dehumanization more directly. Additionally, counter-dehumanization processes like personification and agency reorientation may play a role in existing strategies for reducing prejudice. One widely studied example is that having interpersonal contact with members of stigmatized groups tends to reduce negative social attitudes, including toward people with mental disorders (Couture & Penn, 2003). Perhaps one mechanism of this effect may be that getting to know a person with a mental disorder can help to counter dehumanizing conceptions of such individuals as lacking the defining characteristics of personhood and the basic agency that allows human beings to be in control of their choices and decisions. Future research could directly study personification and agency reorientation as mediators of the effects of personal contact on prejudice reduction.
Although administering the study procedures online strengthened the present research by allowing us to recruit a larger and more geographically diverse sample than would otherwise have been possible, it also prevented us from collecting data regarding real-world behavior. Future studies could investigate whether an intervention like the one used in the present study would produce observable changes in clinicians’ behavior toward potential clients—such as in nonverbal communication of desire for social distance—in addition to self-reported attitudes.
The benefits of our intervention suggest that strategies aimed at agency reorientation and personification could be incorporated into the training of mental-health professionals as part of efforts to reduce their stigmatizing attitudes toward people with mental disorders, particularly if additional research beyond the current preliminary study continues to support their effectiveness. For example, explicitly training mental-health treatment providers in how to actively involve patients in treatment planning and clinical decision making could be a useful strategy not only for encouraging treatment adherence, consumer satisfaction, and positive clinical outcomes among people with mental disorders (Joosten et al., 2008), but also for facilitating positive social attitudes among clinicians. Similarly, stigmatizing attitudes among clinicians could be decreased by ensuring that even when the primary treatment offered is a biologically based intervention (e.g., medication), clinicians maintain awareness of personal details about their patients. This approach is likely to be ever more important as biomedical approaches increasingly transform the field of mental health service provision.
This work was supported by the National Institutes of Health [grant number R01-HG007653, to W.A.] and by a grant from the American Psychological Foundation (to M.S.L.).
To examine whether clinicians’ training backgrounds moderated the effects of our intervention, we coded each clinician into one of four categories: social workers, psychiatrists, psychologists (Ph.D., Psy.D., or Ed.D.), and other clinicians. We then conducted a 2 × 4 ANOVA, with one within-subjects factor (representing the presence, versus absence, of the intervention) and one between-subjects factor (training category). Personal distress, empathy, and social distance scores were all included as dependent variables. This revealed no significant interactions (all Fs<1.7, all ps≥.18), suggesting that the effects of the intervention were relatively constant across training backgrounds.
We were not able to analyze whether racial and ethnic differences among clinicians moderated the effects of the intervention, because the subsample of participants who reported being Hispanic/Latino or selected a race other than White totaled only 18 (8.2% of the sample). We were also unable to analyze whether clinicians using different treatment methods responded differently to the intervention, because more than three quarters (76.4%) of the clinicians selected at least three of the seven treatment-method options, making it difficult to form discrete sub-groups.
We conducted ancillary analyses to examine whether or not differences between the two vignettes (that is, the vignette describing “Terry” and the vignette describing “Alex”) or between the two biological explanations (explanation “A” and explanation “B”) might have moderated the effects of our intervention (the full vignettes and explanatory paragraphs are reproduced at the end of this Appendix). To accomplish this, we conducted a 2 × 2 × 2 ANOVA, with one within-subjects factor, representing the presence, versus absence, of the intervention, and two between-subjects factors, representing which vignette was paired with the intervention (i.e., whether “Terry” was paired with the intervention and “Alex” was paired with the absence of the intervention, or vice versa) and which biological explanation was paired with the intervention (i.e., whether Explanation A was paired with the intervention and Explanation B was paired with the absence of the intervention, or vice versa). Personal distress, empathy, and social distance scores were all included as dependent variables.
This analysis revealed only one significant effect indicating moderation of the effects of the intervention: a two-way interaction of the presence (versus absence) of the intervention by which biological explanation was presented with the intervention, F(1,212)=4.19, p=.04, for social distance. Decomposing this interaction revealed that while the intervention led to lower social distance regardless of whether it was paired with Explanation “A” or “B,” the effect was greater in the presence of Explanation B (M = 5.43 without intervention, M=5.21 with intervention, t(109)=4.65, p<.001) than in the presence of Explanation A (M = 5.10 without intervention, M=5.01 with intervention, t(105)=1.73, p=.09). While it is unclear what accounts for the enhanced strength of the intervention in the context of Explanation B as opposed to Explanation A, the difference may relate to the fact that without the intervention mean social distance was higher given Explanation B (versus Explanation A), suggesting that perhaps there was some sense in which Explanation B may have been more dehumanizing than Explanation A. (It is unclear why this baseline difference might have occurred, but one potential explanation might be that the neurochemical imbalance explanation appearing only in Explanation B was more plausible to participants, or that because Explanation B began by describing the hereditary basis of the patient’s symptoms as stretching back multiple generations, the subsequent biological explanations may have appeared even more mechanistic and dehumanizing.) Given that Explanation B induced higher baseline social distance, the intervention could have created a sharper contrast when paired with Explanation B, resulting in the intervention’s effects being greater (see Lebowitz & Ahn, 2012, for a related phenomenon and discussion). To summarize, this analysis suggests that while the intervention effect was in the same direction regardless of the specific biological explanations selected for the study, the effect was greater in the context of the biological explanation that resulted in greater baseline social distance.
There were no other significant main or interaction effects involving the effectiveness of the intervention (all Fs<3.01, all ps>.08).
Terry is a 28-year-old woman who is seeking treatment because she has felt deeply sad for the past 4 weeks. She reports that she has lost interest in activities that normally bring her pleasure. She states that ever since the current period of sadness began, she has had difficulty with her memory and concentration. She has canceled plans with friends several times because she felt too tired to go out. She reports that her outlook on life has become quite pessimistic; she describes feeling hopeless about the future and perceiving herself to be totally worthless. She has reportedly experienced similar symptoms (a low mood that lasted several weeks) on 3 previous occasions in her life.
Alex is a 29-year-old woman who is seeking treatment because she has reportedly “lost the ability to take pleasure in anything.” She states that she began “feeling blue” approximately a month ago, and has spent most of her free time since then in her apartment because she is uninterested in any of her usual social or recreational activities. She says that her negative mood has left her “in a fog,” unable to focus. As such, she has been falling behind in schoolwork for the graduate program in which she is enrolled. She feels overwhelmed by guilt and describes herself as “a complete failure.” She recalls two previous periods in her life, each lasting several weeks, when she suffered from similar symptoms.
Terry/Alex recently underwent genetic testing, which revealed the presence of a variant of the serotonin transporter gene that is especially common among people with symptoms like hers. Additionally, using a device called a “Wireless Instantaneous Neurotransmitter Concentration System,” Terry/Alex’s doctors concluded that she has abnormally low levels of the neurotransmitter serotonin in certain parts of her brain. A recent brain scan using functional magnetic resonance imaging (fMRI) revealed that compared to most healthy people, emotion-related parts of Terry/Alex’s brain were overactive when reading sad words, suggesting a hard-wired hypersensitivity to negative stimuli. Structures in a part of Terry/Alex’s brain called the “limbic system,” which is known to play an important role in proper emotional functioning, were found to be abnormally small compared to most people her age.
Terry/Alex reports that before she was born, her father struggled with problems similar to the symptoms she has been experiencing lately, and that she believes her grandparents did as well. Terry/Alex’s doctor once told her that she had a chemical imbalance in her brain, involving norepinephrine and possibly other neurotransmitters. A recent brain scan using positron emission topography (PET) showed that parts of the prefrontal cortex involved in regulating emotions were underactive in Terry/Alex’s brain. Additionally, a part of Terry/Alex’s brain called the subgenual anterior cingulate cortex—which is known to be highly involved in emotion—has been found to be overactive compared to most healthy people.
1The counterbalancing of the vignettes and explanations was used to balance out the idiosyncrasies of the vignettes and explanations so that they would not confound the effects of the intervention. Therefore, we used within-subjects comparisons testing for main effects of the intervention as our principal analyses. See Appendix for analyses of differences between the two vignettes and the two biological explanations as potential moderators of the intervention’s effects.