Clinical Psychologists’ Perceptions of Persons with Mental Illness




Room doortag in session

Many people have fabulous relationships with their psychologists. They feel supported, understood, well-liked. But there are also those who feel a little uneasy. Research by Lynn Servais and Stephen Saunders of Marquette University in Milwaukee, Wisconsin may have unearthed one of the reasons why.

Some psychologists have a hard time connecting with people with mental illness, especially when they have diagnoses of borderline personality disorder or schizophrenia.

Most psychologists start off by evaluating people — that’s what a diagnosis is. Diagnoses, by their very nature, look at what’s not working. Most would agree that’s a good thing — if you don’t know where the problem is, it’s hard to fix it.

On the other hand, psychologists are people. Like you and me, they have personal likes and dislikes; perhaps they are even not so different from the employer who, research has shown, often decides who to hire within the first few minutes of meeting a prospective employee.

What Servais and Saunders looked at specifically was the concept of “disidentification” which

involves the process of characterizing persons with mental illness as easily recognizable and different from “normal” individuals while characterizing oneself as normal and not susceptible to mental illness (Cumming & Cumming, 1957; Mahatane & Johnston, 1989).

This is similar to the concept of othering you may have heard of and which often comes up when people talk about ethnocentrism (e.g. “I don’t know that I want to live in Surrey; there are so many East Indians there. They are just… different.”)

Disidentification can help boost a person’s self esteem; from my research in chronic pain, I have also formed the hypothesis that it goes even further — there may be a very primitive sense that by distancing oneself from someone who is “afflicted”, one could avoid “catching” an illness. (Of course this goes on at an unconscious level; very few psychologists would consciously hold such an irrational thought.)

The researchers analyzed surveys returned by 306 psychologists. It’s interesting to note that 95% of them were Caucasian; 83% saw mostly mildly or moderately “disturbed” clients.

Psychologists tended to see themselves as quite dissimilar to persons with borderline features and persons with schizophrenia. Borderlines tended to be experienced as quite dangerous and as least desirable of the five classes of people psychologists were asked to rate (themselves, a member of the public, a person with moderate depression, a person with borderline features, and a person with schizophrenia.

What is the effect of such disidentification? The researchers speculate (and find some basis for it in already existing research) that such perceptions detract from the therapist-patient relationship; could dissuade people in need of psychological services from seeking help; make it difficult for the therapist to feel and express empathy and genuine concern; could decrease the therapist’s belief in their clients’ recovery; and may model inappropriate behaviour.

Where does all of this come from? The need to keep up one’s self esteem and a fear of “infection” were already mentioned. Other sources are professional training, especially when it overemphasizes the psychologist as an expert. Personally, I also think that a focus on diagnosis which, as I mentioned earlier on, focuses on what’s wrong, is unhelpful. Additionally, I wonder whether the fact that 95% of those surveyed were Caucasian had something to do with it; conceivably, non-Caucasians may be more sensitive to the detrimental effects of disidentification.

Lastly, and most importantly, how can psychologists be helped to see clients with mental illness as more like themselves, less “other”?

  • Psychologists could take a more holistic view of their patients and focus not only on their problems but also on their strengths. Solution focused approaches such as advocated by Scott Miller de-emphasize diagnosis and concentrate on concrete, future-oriented solutions, with great success.
  • Universities and other training bodies need to a) specifically address stigmatization and stereotyping; and b) help psychologists form the belief that individuals who have a mental illness can indeed recover.
  • Persons with mental illness could be used as trainers for psychologists.

Reference

Servais, L., & Saunders, S. (2007). Clinical psychologists’ perceptions of persons with mental illness. Professional Psychology: Research and Practice, 38 (2), 214-219 DOI: 10.1037/0735-7028.38.2.214

  • http://ClinicallyClueless.blogspot.com ClinicallyClueless

    This is a difficult issue as I have experienced many in the mental health field and automatically “knowing” what a person is like based on their diagnoses. This automaticaly creates a negative and positive bias which effects treatment and the therapeutic relationship. It is hard to remember and express that each patient is an individual even if they have the same diagnosis how that is experienced, expressed and how it interferes with thier life is very individual. As a social worker, I had the luxury of purposefully not looking a diagnoses before meeting the client, so I was able to understand who they were as indivuals first. Then, read about their diagnoses. I was able to relate to them as a person first.

    • Anna

      Its funny they refer to themselves as experts in certain specialties and yet they are are equally broken & lost as the client.They cause just as much harm towards clients with their assumptions. The therapist also participate in stigma because of their own fears & inability to connect& pick up vital cues.

      If the client doesn’t fit the kinds of diagnosis that they are used to, the therapist panics & make incompetent knee-jerk decisions & reactions. Therapist are at a loss outside their protective system of rules & regulation.Its understandable when clients take retribution on therapist to even up the humiliation & violation the therapist has cast.

      Some therapists should be struck off and de-registered for the pain the have caused from their lack of skills.Too many go into the profession to remedy their own unhealed unhinged chaos.

      • http://www.moritherapy.org/ isabella mori

        As a therapist myself, I find it extremely important to always remember that I, too, have issues, some of them dealt with and others still raw. There is also no point in hiding that from clients.

        • jazz

          A client of mine recently got ejected from a DBT program run by the government health ‘system’. This seems to be one place where stigma & excessive panic- judgment decisions are rife. Consent gets taken away, privacy & trust is constantly invaded by peer review or from corporate minded powers from above.

          Sadly for the client, because the system deemed the client’s expressive vocal behaviour dangerous or something to be feared they moved the client on into the ‘too hard’ basked. Thus setting them up for failure & unplugging the client from the very program help that this client needed.

          What was even more telling about stigma & discrimination was each time any range of descriptive words using terminology like rage or murderous thoughts or violent fantasy or retribution scenarios-discipline & panic by the system would ensue for the client-All help would be suspended & staff protected but client segregated.

          The disciplinary board was controlling, patronizing & almost army like. They were derogatory and focused only on lectures on the hospital’s zero tolerance poster advertising. There was no accountability of the trigger actions of any of the incompetent treating therapist or DBT team.

          Sadly at the end of it all the client was dumped & back outside with no network by themselves once again. This from a program who’s skills training is supposedly founded in the ethos of distress tolerance, mindfulness, taking a non-judgmental stance,separating fact from feeling.

          Yet when it came down to it the mental health professionals themselves participated in the counter transference of non-crisis management skills.

          It seems more evident that in the face of tricky aggressive feature symptoms,the clients have more insight & compassion inspite of it all. Even if the professionals have the labels of Masters or PhDs.

  • http://chipur.com Bill White

    Nice piece. You know it’s interesting – given my personal emotional and mental health history, I often see things in clients that remind me of, well, me – either in the past or the present. I find that kind of cool, actually. It helps me come to understand my own pathology, as well as peaking my empathy for my client. And I gotta’ tell you, I’ve been involved with client presentations that I know could easily have been mine had I not sought and responded well to assorted interventions. Oh, and let’s not forget – my personal familiarity with a client’s pathology only makes me a more effective counselor. And it’s always amazed me that there just seems to be an almost telepathic bit of communication going on that tells the client I’ve been there. And it really makes him or her very much more at ease.

    • http://ClinicallyClueless.blogspot.com ClinicallyClueless

      Bill,

      As a patient, self-disclosure from my therapist has increased my trust as I know from an experiencial stand point that he understands.

      • http://chipur.com Bill White

        I was assessing a 40 year old man yesterday who was absolutely at wits end. He has a long hx of assorted diagnoses, medications, and inpatient admissions. You name it – bipolar I, schizoaffective – Lamictal, Risperdal, Depakote, Seroquel, Zyprexa, Klonopin, Ativan, Xanax, Valium – they were all a part of his life. Pritiq, Valium, and Trazodone still are. He was horribly anxious and shared his years long bout with agoraphobia and social phobia. Now, mind you, he had no insurance and no money – unfortunately, that speaks volumes re the kind of tx he’d likely received over the years. As in distress as the man was, I didn’t really feel a pervasive mood disorder, other than his obvious depression over the way he’s lived his life and his immediate anguish. I focused more upon the anxiety piece. And it was then I related a portion of my personal anxiety hx, which goes back to childhood. The man lit up like a Christmas tree, his affect improving markedly. I followed with the very same statement made to me by a psychiatrist some 20 years ago, “You simply don’t have to live like that anymore.” The impact was amazing. No doubt, he faces many challenges in the coming months – and it truly is up to him whether or not he gets out of the woods – however, he left our time together with something he didn’t have when he came it – hope. And without self-disclosure that couldn’t have occurred.

  • Anonymous

    Scott Miller is no longer advocating Solution Focused.

    I am also not so sure it is good to see ourselves as more similar as objectivity and boundaries may be compromised.

    You seem to think that objectivity obviates empathy. I would respectfully disagree.

    • http://www.moritherapy.org Isabella Mori

      I know Scott Miller now focuses on excellence (his thought on Supershrinks is something I’d like to write about soon) but I have not seen any evidence that he is disavowing solution focused approaches. There is also a difference between being solution focused as a therapeutic philosophy and Solution Focused Brief Therapy as a therapeutic technique or modality. But I will follow up on this; in fact, I’ve just signed up with his Centre For Clinical Excellence.

      Aaah! Objectivity! An interesting topic. How would you define objectivity?

  • Matt Bishop

    The basic idea behind this study sounds like something that philosophers and religious teachers have been talking about for a long time: that you can’t really understand and connect with another, unless: to speak religiously, your perception of them is that “There, but for the grace of God, go I”; and philosophically, that not only are they a unique other perspective on the world, but that they share fundamentally with me a common humanity (with all that last word means in its richest sense).

    I guess a solution-focussed version of this study might focus on the fact that counselling *is so helpful* precisely because this is the basic ethical orientation out of which many counsellors *do in fact* relate to their clients.

    And then of course, as Anonymous stated, we have to consider how we can most helpfully enact that ethic with regard to our clients and our selves.

  • http://www.moritherapy.org Isabella Mori

    Matt and Anonymous – I’m not sure that in order to stop disidentifying one needs to move over into the opposite corner. For example, I have worked in the correctional field even though I’ve never robbed a bank or shot another person and still done a good job connecting with my clients (I hope). At the some time, there are fears and desires that I share with my clients. I think the point that this study makes (and if you have access to something like PubMed you can verify it yourself) is that it is the explicit disidentification as embodied in statements like, “I am very different from people with schizophrenia” that is problematic. Thanks for pushing me to clarify that.

  • http://wellbeingandhealth.net/ Evan

    Hi Isabella,

    ‘Those who regard their white skin as a cancer are diagnosed as schizophrenic, those who regard others as being inferior because of their black skin aren’t.” (RD Laing from memory).

    Of the ‘psychologically disturbed’ (you know the one’s with diagnoses) I’ve known and spoken with; of the ones I’ve got to know; I’ve always been surprised with how well they are doing in light of what they have been through and what they currently deal with. This means they are saner and healthier than me (and perhaps even a shrink or two) I think.

    I think a diagnosis can help the person with a difficulty to feel less alone. I think diagnosis can be helpful in this way. But analysis and classification are different to design and creativity. I doubt that diagnosis helps with healing.

    As to objectivity: why would it be desirable to regard another as an object?

    • http://www.moritherapy.org/ isabella mori

      Evan, thanks for your comment.

      I hope this article isn’t taken as saying that diagnoses are a problem per se. As you say, Evan, they can be very helpful. It’s useful to know what one is dealing with. At the same time, it’s also important not to get hung up on the diagnosis.

    • I’m just saying

      Thank you Evan, for what you’ve said here.

      I worked with therapists for many years: social workers, GPs, psychiatrists, psychologists, etc… Some of them gave me short term relief, but none of them provided me any assistance that worked for the long term. In fact, most of the guidance they gave me was detrimental in the long term. None of them ever identified the real problem, even though I’m sure many, if not most, could have identified it.

      A serious illness left me off work with time on my hands to do my own research. Researching corruption in my field of work (financial services industry) led me to the book “Snakes in Suits”, which introduced me to the term “psychopath” (which I, like most people, had always associated with “serial killer”). My world started to shift, and what for years had been inexplicable re: my family of origin suddenly started making sense. Predictable behaviour and situational patterns emerged and everything started to line up and become clear. From there I eventually found my way to the term “sadism” (which, again I had only associated with de Sade and sexuality). And there, finally illuminated, was my mother – in all her “glory”. Luckily for me, my father, paternal grandparents, and maternal grandmother were loving, kind and caring, which provided a good deal of ‘immunization’ against my mother’s influence (but not, unfortunately, from her harm). I have classic PTSD type problems, but I am an honest, loving, hard-working person. No thanks to the many many therapists I saw who always made any mention of my mother’s problems verboten, and made my therapy “all about you and your behaviour choices”. What’s really turned things around for me in the ‘home stretch’ of my self-therapy is an understanding of victim selection, and how growing up with a sadist/psychopath sets you up to be the world’s perennial prey unless you get the right kind of help. And in this regard is where all of my past therapy was the most dangerous: it trained me to convince myself I was exaggerating fear instead of clearly and accurately learning WHAT to be genuinely fearful of, or that as a former victim, most particularly as the former victim of a sadist, my vulnerability is heightened.

      What I’ve finally learned to conclude is that most mental “health” professionals, like most of society, have neither the skills, training, inclination, nor courage to understand what is involved in the most severe interpersonal violations. Most of society is truly afraid and prefers to deny its existence, which then leads to patronizing its victims. You, sir, are an extremely rare exception. Kudos to you!

      For most of those victims, the only ‘diagnosis’ that is required is naming the situation – not the individual! And from THAT diagnosis, giving them sympathy, compassion, and then appropriate skills to recognize and deal with it (which requires putting yourself in their shoes and seeing them as equals) is really all that’s needed. If, after THAT, the individual remains disordered, THEN you might look at diagnosis of the individual.

      For the uninitiated I would highly recommend:
      1) read about the Greyson/Stein study;
      2) find the documentary “I, Psychopath” available for free download on the net and review the work of Professor Angela Book (starts at 34 minutes into the doc);
      3) teach your clients how to recognize interpersonal violation and victim selection, and what to do about it
      e.g. http://www.protectivestrategies.com/victim-selection.html

      Sorry about the rant… What you said touched a nerve – in a good way! And thank you most especially for the following comment:

      As to objectivity: why would it be desirable to regard another as an object?

      • http://www.livingauthentically.org Evan

        You’re welcome ISJ. Glad it helped. Thanks for the Greyson/Stein reference. I’d heard about this study – but never knew it’s name.

      • Sam

        @ I’m Just Saying

        Yours is probably the most insightful, most lucid, most intelligent, most helpful summation I’ve ever read anywhere in regards to how human beings treat each other and, in particular, how the psychology industry treats patients as scapegoats.

        Your post should be #1 required reading for every doctor, psychologist, psychotherapist and client everywhere.

        (Speaking as someone who has under and post graduate quals in psychology, I left the industry a long while ago for the reasons you outline and the sheer them/us prejudices that the industry heaps on patients which it scapegoats for all society’s ills. I am also impressed by the work of psychiatrist Dr Hew Len, who healed a whole ward full of ‘criminally insane’ patients by meditating to himself ‘I am sorry, I love you’ over and over. http://hooponoponoworks.blogspot.com/2008/01/interview-with-dr-hew-len.html

      • I’m just saying

        @Evan and Sam,
        Thank you for your kind words.

        Re: Victim Selection study from documentary “I, Psychopath”
        To view the “Victim Selection” portion of the documentary “I, Psychopath” (in my opinion the most worthwhile part of this documentary) you can use the following Youtube link:
        “I,Psychopath – Sam Vaknin – Documentary – [part 5]”

        For those interested in viewing the entire documentary you can use the following link:
        http://topdocumentaryfilms.com/i-psychopath/

      • I’m just saying

        FYI – this is a more complete version of the Victim Selection segment of I, Psychopath

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  • Say

    Really interesting study! And I appreciated your commentary quite a bit. Do you have any idea how many of the psychologists in the survey were women? It’s not that I think that women are naturally more empathic than men, but I wonder about the “othering” factor. I wonder if, like people of color, women psychologists might be less likely to other their clients because they are coming from a socially marginalized position as well.

    I’m writing from the U.S., and the problem here is that no diagnosis means no insurance coverage. I’ve worked with many clinicians (both as a client and a colleague) who are very resistant to diagnosis, but must diagnose in order to get coverage for their clients.

    • http://www.moritherapy.org/ isabella mori

      Hello – am finally catching up with a few comments here. There was no mention, if I recall correctly, whether women psychologists were more empathic. This would a very interesting question. My suspicion is that it is at least partly the education of a psychologist that encourages the “othering”; it would be interesting to know whether women are more resistant to that.

  • http://www.microphonesstyle.com microphonesstyle

    You seem to think that objectivity obviates empathy. I would respectfully disagree.
    But,really interesting study!

    • http://www.moritherapy.org/ isabella mori

      Objectivity (whatever that is – it’s actually quite a complicated process) does not obviate empathy but it sure can pave the way for less empathy.

  • rasheed

    well,one of my friend having the mental illness,she is at the age of about 40 years.the main problem is she never tell truth i mean always laing and fighting with her husband always.

    can you tell me where and which type psychiatric doctors can cure her/

    • http://www.moritherapy.org/ isabella mori

      Unfortunately, Brainblogger cannot give this sort of advice.

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  • Lodi

    It was indeed an interesting study on many levels. I have said it before that being to see may doctors, of which each had a different diagnoses, and each gave me different cocktails of meds, I’ve come to the conclusion that not only it doesn’t really help in the long run, but being diagnosed actually can make things worse at times. I feel that some practitioners are more likely to just give a diagnose than to actually really listen to what his/her patient is telling them verbally or otherwise. I have met clinicians which were so over the top with the idea that they were different and I was just another case so lets move on, that it has shrunk the belief of them in me. I understand one must keep an objective view of who he/she is seeing at the time, but on the other hand, a little eye contact can go a long way, and knowing that my doctor is just as human as I am, would make the whole situation so much easier to handle. I agree with Evan when he says that’s amazing what people with BPD go through and still make it out of bed everyday and go to work, as well as participate in social life, interacting even though with very big difficulties. I was and still am one of those people that for those very few times when I did meet a human being (doctor) made him feel like we should switch chairs. As I am fully aware of my condition and have read and studied more about it, making me a little bit of a doc in the field of my disease. Not having an ego trip, just stating my experience that’s all.
    Always remember, we are not a case study, a folder, the next appointment; we’re human beings, with a very strong need for help, and even stronger desire to achieve our goal and live better lives.

    • A Human Being

      Thank you for that reminder, “we are not a case study, a folder, the next appointment; we’re human beings, with a very strong need for help, and even stronger desire to achieve our goal and live better lives.”

      I am a college student, who is with a mental illness. I have been reading and studying my diagnosis. I also have told many different diagnosis. I was even “black balled” by a mental center because I stood for the first in my life. I was told that I graduated from any community mental health center. It is sad to hear that we are considered more of a case study than a human being. I may have to study a lot hard than an “average” person, but I am going to make it in my recovery of my diagnosis. I am in a community college, and in one of my classes I am doing graduate research. What does that you tell about a human being?

  • http://www.petreicarari.blogspot.com ank

    looking at people and finding what’s wrong is not my concept of diagnosis. the presenting problem (the conscious motivation of the person to seek therapy) is just part of a larger image and rarely does it have to do with what the person wants or needs. It’s rather a manifestation of cry in the form of words and gestures. When we look at the person and expect to find “what is wrong with that person” that’s what we’ll find, and the attitude of “there is something wrong with you is, i think, a factor that influences the quality of the interpersonal exchange.
    As I see it, diagnosis is a description, a complex description of how a person works in relation to his/her environment. It’s almost like looking at the behavior of any living organism in several contexts and see the patterns that emerge. Now that person, is a complex human machine that works by a logic of the living, not by the logic of mere mechanics. And you can see, if you look, that not only there’s nothing wrong with the person, the person actually creatively adapts… perhaps not efficiently, but that’s not because it’s in contradiction with what most people would do in such situations (based on culturally prescribed solutions), but because the person adapting says at some point: I feel hurt. Or tired. Or… pointless. I feel something that I dislike, continuously. I’d like a break from it and I don’t know how to take it.

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Isabella Mori

Isabella Mori is a psychotherapist in private practice in Vancouver. She has been working in the field of mental health, counseling, psychotherapy and movement therapy for 18 years.
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