ESSENTIALISM AND PERCEIVED TREATMENT EFFICACY 1 1 2 3 4 5 6 7 Reframing mental illness: 8 The role of essentialism on stigmatization and perceived treatment efficacy 9 10 Danielle E. Peters 11 David Menendez 12 University of Wisconsin - Madison 13 14 Karl S. Rosengren 15 University of Rochester 16 17 18 Corresponding author: [email protected] 19 20 This is the peer reviewed version of the following article: Peters, D., Menendez, D., & 21 Rosengren, K. (2020). Reframing mental illness: The role of essentialism on perceived treatment 22 efficacy and stigmatization. Memory & Cognition, 48(8), 1317-1333, which has been published 23 in final form at 10.3758/s13421-020-01061-1. ESSENTIALISM AND PERCEIVED TREATMENT EFFICACY 2 24 25 Acknowledgements: The research reported here was supported in part by the Institute of 26 Education Sciences, U.S. Department of Education, through Award #R305B150003 to the 27 University of Wisconsin-Madison. The opinions expressed are those of the authors and do not 28 represent views of the U.S. Department of Education. 29 30 ESSENTIALISM AND PERCEIVED TREATMENT EFFICACY 3 31 Abstract 32 People believe that treatments for illnesses are effective when they target the cause of the illness. 33 Prior work suggests that biological essentialist explanations of mental illness lead people to prefer 34 medications or other pharmacological treatments. However, prior work has not distinguished 35 between biological and essentialist explanations. In three studies (total n = 517), we presented 36 adults with vignettes about an individual with an artificial mental illness and manipulated the 37 descriptions to emphasize or de-emphasize essentialist characteristics. Critically, none of the 38 vignettes made reference to a biological basis for the disorder. Participants rated their willingness 39 to interact with the person described in the vignettes and how effective they believed drug 40 treatment and talk therapy would be on the mental illness. Across the three studies, describing 41 mental illness with an essentialist framing led participants to think drug treatments would be more 42 effective, but there was no effect for stigma or perceived effectiveness of talk therapy. This effect 43 appears to be mediated by how much participants essentialized individuals with the disorder. The 44 first framing that participants encountered seemed to shape their reasoning for the remainder of 45 the study, even if they saw conflicting framing later on. The framing manipulation had similar 46 effects for individuals with and without a mental illness. Results suggest that it is important to 47 consider how mental illness is framed to the general public as it might impact people’s treatment 48 preferences. 49 50 Keywords: Cognitive Processes, Essentialism, Social Cognition, Perceived treat Effectiveness 51 Stigma 52 ESSENTIALISM AND PERCEIVED TREATMENT EFFICACY 4 53 Reframing mental illness: 54 The role of essentialism on perceived treatment efficacy and stigmatization 55 One in five Americans suffer from a mental illness (NIMH, 2017), but less than half of 56 the people who had experienced a mental illness in the past year received treatment (NIMH, 57 2017). Patient preferences play a significant role in treatment. Past research has shown that 58 patients with depression who receive treatment that aligns with their own preference for 59 medication or psychotherapy are more likely to initiate and adhere to treatment (Raue, 60 Schulberg, Heo, Klimstra, & Bruce, 2009) and have higher remission rates and lower levels of 61 depression (Kocsis et al., 2009). Given this association between preference and adherence to 62 treatment, it is critical to understand why people might prefer certain treatments or believe them 63 to be more effective. One possible factor that could influence beliefs and attitudes about 64 treatments might be essentialist beliefs. 65 Essentialism and Mental Illness 66 Psychological essentialism refers to the notion that people believe that categories have an 67 underlying property (an essence) that determines category membership (Medin & Ortony, 1989). 68 People tend to hold essentialist beliefs about simple categories such as “dogs” or “vegetables,” 69 but also about complex social categories such as race, gender, and sexual orientation (Dar- 70 Nimrod & Heine, 2011). Essentialist beliefs encompass a variety of sub-components. People 71 who hold essentialist beliefs about a category are likely to believe that knowing that someone is a 72 member of a certain category is greatly informative (informativeness), that the category has 73 existed across history with very few changes (historical invariance), that the category has all-or- 74 none boundaries (discreteness), and that members of the category are highly similar to one 75 another (uniformity; Gelman, 2003, 2004; Haslam & Ernst, 2002). They are also likely to believe ESSENTIALISM AND PERCEIVED TREATMENT EFFICACY 5 76 that it is difficult or impossible for a category member to lose membership (immutability), that 77 there are certain characteristics necessary to be a category member (necessary features), that 78 category membership is due to an inherent underlying reality (inherence), and that the category is 79 naturally occurring rather than socially constructed (naturalness; Gelman, 2003; Haslam & Ernst, 80 2002). 81 Many people hold essentialist beliefs about mental illness, believing that the disorder is 82 caused by something inside the person that is core to their identity (Ahn, Flanagan, Marsh, & 83 Sanislow, 2006). This might be problematic as essentialist beliefs of mental illness affect both 84 stigmatization and views on treatment (Dar-Nimrod & Heine, 2011). One reason why people 85 might hold essentialist beliefs about mental illness is that explanations of mental illness 86 frequently attribute internal biological factors as the causes. This is not unique to mental illness 87 as in other domains people often appeal to an underlying biological cause such as the heart, other 88 organs, DNA, or blood to explain category membership (Balkcom, Alogna, Curtin, Halberstadt, 89 & Bering, 2019; Roberts & Gelman, 2015; Waxman, Medin, & Ross, 2007). Biological framing 90 of mental illness may also serve to activate essentialistist reasoning and lead to negative 91 outcomes such as stigma (Loughman & Haslam, 2018). 92 Biology, Essentialism, and Perceived Treatment Efficacy 93 Biological explanations of mental illness influence people’s beliefs about the efficacy of 94 treatment in general. Lebowitz, Rosenthal, and Ahn (2012) found that, when reading vignettes 95 about children with ADHD, reading a biological explanation of the disorder decreased stigma but 96 increased doubt about treatment efficacy. Additionally, Marsh and Romano (2016) found that 97 people often think that drug treatment would be more effective for symptoms perceived as 98 medically-based and that talk therapy would be more effective for symptoms perceived as ESSENTIALISM AND PERCEIVED TREATMENT EFFICACY 6 99 psychological in nature. Beliefs about the etiology of mental illness influence beliefs about what 100 kind of treatment is appropriate. That is, if the person believes that symptoms are due to an 101 internal, biological cause, they might perceive treatments that modify something inside the 102 person to be more effective. Yopchick and Kim (2009) found that when making judgements 103 about treatment efficacy, people consider the root cause of the mental illness to be most 104 important. If the root cause of the illness was described as biological, people believed that drug 105 therapy would be more effective, and if the root cause was described as psychological, they 106 believed psychotherapy would be more effective at treating the illness. Similarly, Lebowitz and 107 Appelbaum (2017) found that reading genetic explanations of addiction increased confidence in 108 pharmacotherapy and decreased confidence in psychotherapy. In addition, Phelan, Yang, and 109 Cruz-Rojas (2006) found that belief in a biological cause of mental illness was related to greater 110 endorsement of hospitalization and medication, but lower expectations that a mental health 111 professional could help treat the illness. 112 Although biological explanations of mental illness frequently attribute internal factors as 113 the cause of the illness, this need not be the case as individuals can hold essentialist beliefs about 114 non-biological categories (e.g., art; Gelman & Bloom, 2000). Therefore, it could be that 115 appealing to internal causes, without mentioning a biological cause, might promote an 116 essentialist view of mental illness. Appealing to an internal cause might also influence treatment 117 decisions (Kim & LoSavio, 2009). For example, Schroeder, Dawood, Yalch, Donnellan, and 118 Moser (2015) found that people who had an essentialist view were more likely to prefer 119 medication alone over psychotherapy or a combined treatment. If this is true, then describing 120 mental illnesses in essentialist terms might lead people to prefer treatments (such as medication) 121 that have effects internally, even if a biological cause is not mentioned in the explanation. ESSENTIALISM AND PERCEIVED TREATMENT EFFICACY 7 122 Biology, Essentialism and Stigma 123 In addition to influencing beliefs about treatment, essentialist beliefs about mental illness 124 might also play a role in stigmatization (Dar-Nimrod & Heine, 2011). Stigmatization is the act of 125 distinguishing and labeling differences between humans, normally with a negative connotation, 126 and separating “us” and “them” based on those social differences (Link & Phelan, 2001). The 127 consequences of stigmatization are wide-ranging, including loss of self-esteem, job 128 discrimination, and avoidance of treatment (Rüsch, Angermeyer, & Corrigan, 2005). 129 Essentialist views about social categories such as race, gender, and sexual orientation 130 have been shown to be related to prejudice and stereotyping (Dar-Nimrod & Heine, 2011). 131 People who hold essentialist beliefs are more likely to support legislation that enhances 132 boundaries between social groups, and these beliefs can be manipulated by providing 133 information that either confirms or disconfirms the essentialist belief (Roberts, Ho, Rhodes, & 134 Gelman, 2017). Researchers have also found that people who hold essentialist beliefs about 135 mental illness have more stigmatizing attitudes about people with a mental illness (Howell, 136 Weikum, & Dyck, 2011). However, some studies have failed to find an association between 137 different sub-components of essentialism and stigmatization of individuals with mental illness 138 (Marsh & Shanks, 2014). 139 Biological explanations of mental illness and essentialist beliefs may interact in complex 140 ways to influence stigmatization. Biological explanations of mental illness may reduce stigma by 141 shifting the blame from the individual to biological factors outside of the individual's control. 142 Indeed, Goldstein and Rosselli (2003) found that people who believe that depression is caused by 143 biological factors were less likely to blame people with depression for their illness. However, 144 biological explanations may increase the stigma towards people with a mental illness (Phelan, ESSENTIALISM AND PERCEIVED TREATMENT EFFICACY 8 145 2002). For example, Walker and Read (2002) found that people who heard a biological 146 explanation of schizophrenia believed that people with schizophrenia were more dangerous and 147 unpredictable than those who heard a psychosocial (non-essentialist) explanation. Even in the 148 same studies there have been conflicting findings. For example, Breheny (2007) found that 149 providing a genetic explanation for schizophrenia decreased stigmatization, but that providing a 150 genetic explanation for depression increased stigmatization. These results suggest that the 151 relation between stigma and biological or essentialist explanations is complex, as biological 152 essentialist explanations could decrease some components of stigma (such as blame), but 153 increase others (such as social distancing; Haslam & Kvaale, 2015). Currently it is difficult to 154 predict when one of the outcomes will occur. One issue with the prior research is that many of 155 these studies combine essentialist and biological information. This combination makes it difficult 156 to pin point whether different types of information have either beneficial or negative effects. In 157 our study we hope to shed light on this relation by examining the effects of essentialist 158 information on its own. 159 Essentialism Among People with a Mental Illness 160 Most of the literature on essentialism and mental illness has focused on the beliefs of the 161 general public, but less attention has been given to how individuals with a mental illness respond 162 to essentialist explanations. People who have received psychiatric services have more accepting 163 attitudes towards others with a mental illness (Segal, Kotler, & Holschuh, 1991; Walker & Read 164 2002), and so might interpret essentialist information differently. It has been found that people 165 who belong to a stigmatized group often respond differently to essentialist information. For 166 example, although essentialist views of sexual orientation (such as “born this way”) relate to 167 lower stigma among heterosexual individuals (Haslam & Levy, 2006; Haslam, Rothschild, & ESSENTIALISM AND PERCEIVED TREATMENT EFFICACY 9 168 Ernst, 2002), essentialist views of sexual orientation have mixed effects among homosexual and 169 bisexual individuals (Morandini, Blaszczynski, Costa, Godwin, & Dar-Nimrod, 2017; 170 Morandini, Blaszczynski, Ross, Costa, & Dar-Nimrod, 2015; Morton & Postmes, 2009). 171 One important context in which people with a mental illness may encounter essentialist 172 information is the context of treatment. Biological explanations of psychological symptoms, 173 when viewed through an essentialist lens, may influence people’s beliefs about the course and 174 treatment of their illness. In one study that examined the effects of biological explanations 175 among people with mental illness, Kemp, Lickel, and Deacon (2014) randomly assigned 176 individuals who have had a depressive episode to either being told that the episode was due to a 177 neurochemical imbalance (i.e., a biological explanation) or not. Participants who were told that 178 their depression was caused by a neurochemical imbalance displayed increased perceived stigma, 179 greater pessimism about their diagnosis and treatment, and lower perceived ability to regulate 180 their own negative mood states. These results suggest that biological explanations for mental 181 illness may negatively affect those who suffer from mental illnesses. 182 Similarly, past research has also demonstrated that people with depression who endorse 183 biological explanations for their symptoms display greater prognostic pessimism, the belief that 184 mental illnesses are likely to be stable over time and difficult or impossible to treat (Lebowitz, 185 Ahn, & Nolen-Hoeksema, 2013). This effect is not limited to depressive disorders; people with 186 generalized anxiety disorder who read a biological description of the etiology of the disorder felt 187 decreased personal responsibility for their symptoms but also displayed increased prognostic 188 pessimism (Lebowitz, Pyun, & Ahn, 2014). In the present studies, we examined whether people 189 with a mental illness responded differently to essentialist explanations, even when an underlying 190 biological cause was not mentioned. It is possible that people with a mental illness have greater ESSENTIALISM AND PERCEIVED TREATMENT EFFICACY 10 191 knowledge about mental illness and experience with treatment than the general population, so 192 they may interpret essentialist information differently. Having greater knowledge about 193 treatment may make someone more resistant to the negative effects of essentialist framings of 194 mental illness. 195 Present Studies 196 In this article we present three studies examining whether essentialism is causally related 197 to the perceived effectiveness of different treatments and to people’s stigmatization towards 198 individuals with mental illness. In the present studies, we presented adults with different 199 vignettes about an individual with an artificial mental illness to examine how essentialist beliefs 200 influence their views on treatment effectiveness and stigmatization. We used artificial mental 201 illnesses in order to more easily manipulate participants’ perception of the illness (either 202 essentialist or not). We manipulated the vignettes by emphasizing essentialist-consistent, 203 essentialist-inconsistent, or neutral aspects of the mental illnesses. Critically, none of the 204 vignettes made explicit reference to biology or internal causes in order to isolate the effect of 205 essentialist framing on people’s beliefs about treatment efficacy and stigmatization. 206 Rather than asking participants whether they have been diagnosed with a specific 207 disorder (e.g., depression), we simply asked participants whether they have even been diagnosed 208 with a disorder. As participants were judging novel disorders, we did not believe that any 209 specific diagnosis would be more informative than another. We hypothesized that when 210 participants read essentialist-consistent vignettes they would perceive drug treatment to be more 211 effective and talk therapy to be less effective than when reading essentialist-inconsistent 212 descriptions. We also predicted that people with a mental illness would believe that both drug 213 treatment and talk therapy would be more effective than people without a mental illness. In