Motivation and emotion/Book/2018/Mental illness identity motivation

Mental illness identity motivation:
What motivates some people to adopt a mental-illness-based identity?

Multimedia presentation (3 min)

Overview

Figure 1. A Netflix television series that addresses themes of bullying, suicide and mental-illness-based identities.

The Netflix television show, 13 Reasons Why (2017), was a catalyst for interest and controversy regarding prevalent issues such as mental disorders, suicide and bullying. While some people appreciated the fact that the show encouraged speaking about mental illness, others were outraged and concerned. The idea that the show not only accepted self-harm as an avenue of self-medication, but also glamorised suicide and mental illness has sparked concerns. The risk that individuals could potentially see the identity of being "mentally ill" as enticing, forms the basis of the key questions explored in this chapter.

This chapter begins with an overview of the key concepts of motivation and mental illness. The second section explores the motivation of both the adoption and maintenance of mental-illness-based identities from psychological theories and research, including learned helplessness, the identity-psychopathology link, labelling theory, and the sick role. The chapter ends with future direction for research, including the ways in which the adoption of a mental-illness-based identity could be prevented.

Focus questions What is motivation? What is mental illness? What motivates some people to adopt a mental-illness-based identity?

What is motivation?

Figure 2. Can mental illness be motivated like someone rock climbing for pleasure - an intrinsically motivated activity?

Figure 3. Generalised anxiety disorder is the most common mental disorder in Australia (ABS, 2016).

Motivation is a key component in human performance (Ryan & Deci, 2000). Motivational forces can be either extrinsic or intrinsic and guide the direction of behaviours (Cerasoli, Ford & Nicklin, 2014). Extrinsically motivated behaviours are motivated by a gain or loss (known as an incentive). Intrinsically motivated behaviours, on the other hand, are an enjoyable and purposive behaviour that the individual takes delight or pleasure in doing (Ryan & Deci, 2000; Cerasoli, Ford & Nicklin, 2014).

What is mental illness?

Mental illness refers to poor mental health and includes all of the diagnosable mental disorders (Goldman & Grob, 2006). A mental disorder is a health condition associated with impaired functioning and is characterised by changes in cognitions, behaviour or both (Goldman & Grob, 2006). Psychopathology is the study of mental disorders. Mental disorders are diagnosed by both psychologists and psychiatrists with assistance from a psychological manual, namely the Diagnostic Statistical Manual of Mental Disorders, fifth edition (DSM-5, 2018).

Statistics: Recognising the prevalence of mental illnesses. 45% of Australians aged between 16 and 85 years have experienced a mental disorder at some point in their lives. Generalised anxiety disorder (GAD) is the most common mental disorder, with 14% of all people experiencing mental disorders affected by GAD (ABS, 2018). Fifty-four percent of people with mental illness in Australia do not access any form of treatment (Black Dog Institute, 2018). One in seven Australians will experience depression in their lifetime and every day, at least six Australians die from suicide and a further 30 Australians per day attempt to take their own life (Black Dog Institute, 2018).

What motivates some people to adopt and maintain a mental-illness-based identity?

Case study: 13 Reasons Why Schools in Florida, U. S. have reported an increase in both self-harming and suicidal behaviour in their students. The National Association of School Psychologists advised youth with any form of suicidal ideation to not watch the Netflix television show, 13 Reasons Why (Marra, 2017). On the final episode of season one, the series shows a graphic depiction of a suicide method. Headspace, an Australian youth mental health organisation has explained that research has shown suicide exposure can lead to a risk coined 'suicide contagion' (2018). Before each episode, warnings for viewers are issued, and a website is given at the conclusion of each episode which has been created by the producers and offers help with finding crisis resources (13reasonswhy.info, 2018). Jia Tolentino, a staff writer for The New Yorker, raised the issue that the program does not address mental illness but rather presents the protagonists' suicide as an act that gives the protagonist the respect and adoration that she did not receive when she was alive.

What happens when you combine motivation with mental illness? 13 Reasons Why has been a controversial and popular television show. It is important to understand that, although this show encourages those who are suffering to speak out, there is a risk that it paints mental-illness in a light that could be enticing for young, impressionable adolescents. Could the series motivate some people to adopt a mental-illness-based identity? Research concerning the intricate concept of adopting and maintaining a mental-illness-based identity is of interest to psychologists, individuals, educational institutions and other funding bodies. However, there is a dearth of research regarding the motivational component of mental illness within the current body of literature. This section of the chapter examines research and psychological perspectives and theories to help assist in explaining the intricate concepts of (1) mental-illness-based identity adoption and (2) mental-illness-based identity maintenance.

Adopting the identity

The correlation between identity and psychopathology

When considering the adoption of a mental-illness-based identity, one should consider the link between identity strength and psychopathology. Erikson (1950) described developing an identity as a central developmental task in adolescence and regarded identity as an important part of life. A lack of identity, referred to as "identity confusion" is linked to psychopathology (Erikson, 1950). Meta-analyses have found that forming an identity is correlated with internalising and externalising problems (Lillevoll, Kroger & Martinussen, 2013; Schwartz et al., 2011). The DSM-5 classifies identity disturbances as being the main factor of personality functioning (Klimstra & Denissen, 2017). Marcia (2006) questioned whether Borderline Personality Disorder was anything more than just a severe case of identity confusion and McAdams and Olsen (2010) developed a theoretical model to explain the identity-psychopathology correlation, coined the model of personality development.

Research has consistently shown empirical evidence for a correlation between identity and psychopathology (Klimstra & Denissen, 2017; Lillevoll, Kroger & Martinussen, 2013; McAdams & Olsen, 2010; Schwartz et al., 2011). This idea that a lack of identity may be a catalyst for developing a mental disorder should be an area for further exploration. If an individual's identity can be strengthened, perhaps the maintenance of a mental-illness-based identity will weaken.

Social identity theory

Figure 5. Social identity theory states that a part of an individual's self-concept comes from their membership in social groups.

When exploring mental-illness-based identity adoption and behaviour, it is important to consider psychosocial factors such as social influence, group norms, and group behaviour. Social identity theory states that part of one's self-concept comes from their membership in social groups and categories (Terry, Hogg, & White, 1999). Theoretically, individuals will be much more likely to form attitudes about mental illness when others around them hold the same kind of attitudes about mental illness. This is where "13 Reasons Why" becomes so controversial. It is one thing to sweep mental illness out from under the rug, but it is another thing to normalise and glamorise the mental-illness-based identity. Following the release of the show, school teachers and counsellors have reported a rise in both suicidal and self-harming behaviour (Marra, 2017).

Maintaining the identity

Learned helplessness

Figure 6. Learned helplessness can be seen in many mental illnesses, including depression.

What about people who have been diagnosed with a mental illness that really have suffered but are on the road to recovery after receiving psychological treatment? What makes these individuals stick to their diagnosis and let the label define them and become part of their identity? Is it because they are given more attention? Is it because of the benefits such as flexed work hours, inclusion, and welfare, like extensions on assessment? Perhaps, but to assume that someone is feigning a mental illness for rewards or attention is not only unethical but potentially very damaging.

When exploring the maintenance of a mental-illness-based identity, the theory of learned helplessness is useful. The theory of learned helplessness, coined by Seligman and Maier (1967) can help explain the phenomena of sticking to a mentally-ill label. Learned helplessness is a psychological trait whereby one has learnt to withdraw in a particular situation because they do not believe that particular situation can be changed, even when there is the ability and power to do so (Seligman & Maier, 1967). It is a psychological state in which an individual beliefs that life's outcomes are uncontrollable. In Seligman and Maier's original study (1967), they established that when exposed to uncontrollable events and environments, it can impair learning and exploration in the future. Their original study was with dogs, in which they had no control over shocks (inescapable shock condition) so as a result they stopped exploring the environment. When the shocks were taken away (escapable shock experimental condition), the dogs still did not attempt to explore the environment - even when control was given back to the dogs.

Hiroto and Seligman (1975) replicated the study with humans by manipulating learned helplessness in problem solving and more recently, Taylor et al. (2014) manipulated learned helplessness in healthy adults. Learned helplessness can lead to a reduction in a range of responses to demands and has three main effects: motivational deficits such as decreased willingness to try, cognitive deficits such as a negative mindset that interferes with ability to learn, and emotional deficits such as energy depleting emotions like depression and listlessness (Bargai, Ben-Shakhar & Shalev, 2007). The feeling of helplessness and incapability has been shown to lead to low self-esteem and depression (Bargai, Ben-Shakhar, & Shalev, 2007). Learned helplessness theory is about behaviour and motivation and can help explain - or help us understand - why people choose to stay sick or mentally ill even when they are better or have the power to get better. Learned helplessness can be understood in terms of many behavioural problems (Teodorescul & Erev, 2014; Clark & Beck, 1999). It has also been linked to many mental disorders such as posttraumatic stress disorder (Bargai, Ben-Shakhar & Shalev, 2007), test anxiety (Akca, 2011) and depression (Alloy & Abramson, 1982; Klein, Fencil-Morse & Seligman, 1976; Maier, 2001).

Modified labelling theory and sick role

Drawing on learned helplessness theory, the diagnosis of mental illness can have harmful effects for individuals and can generate feelings of helplessness, powerlessness and vulnerability (Moses, 2009). Modified Labelling Theory (MLT) provides understanding as to how stigma and labels can affect health and well-being, with a strong focus on psychiatric symptoms and mental health (Hunter et al, 2017). Modified labelling theory describes how labelling and being diagnosed with a mental illness affects individuals (Hunter et al, 2017). Labelling can lead to social withdrawal and rejection due to the stigma attached to mental illness diagnoses (Perry, 2011). In a longitudinal study by Shifrer (2013), MLT was investigated in 11,740 adolescents who had been labelled with learning disabilities. It was found that teachers and parents were more likely to perceive a labelled adolescent as being disabled as well as holding lower expectations them as opposed to adolescents who behaved and achieved similarly but were not labelled as having a disability. Elkington, Hackler, and McKinnon (2011) explored the mental illness stigma amongst youth in psychiatric outpatient treatment by using Link and Phelan's 2001 model of stigmatisation to investigate the psychosocial role of stigma and labelling. They found that stigma and labels greatly affected and influenced patient's self-concept, with majority of patients letting these labels become the most important and prominent aspect of their self-concept. Negative effects of stigma should be targeted to reduce this stigma and therefore help patient's self-concept which in turn will weaken their mental-illness-based identity.

Extending on the labelling theory, the "sick role", coined by Parsons (1951), argues that illnesses are associated with rights and obligations and individuals' are expected to be cared for and granted exemption in many different situations in their life. Perry (2011) conducted a longitudinal study which investigated those who had been diagnosed with a mental illness such as depression, bipolar disorder, and schizophrenia, and the assumption of the sick role. The results were consistent with the sick role theory, concluding that labelling an individual with a mental illness means that there is a social safety net when these individuals can assume the sick role.

Pop quiz: Test your knowledge on this topic

1 What percentage of Australians aged between 16 and 85 years had at some point in their life experienced a mental disorder?

	5%
	15%
	25%
	35%
	45%

2 The strength of an individuals' ______ is strongly correlated with and linked to their psychopathology

	Self-esteem
	Identity
	Self-efficacy
	Positive affect
	Relationship with others

What motivates some people to fabricate a mental illness?

Studies have been conducted regarding the validity of mental illness inventories such as the Depression Anxiety and Stress Scale-21 (DASS-21) and the Minnesota Multiphasic Personality Inventory-2 (MMPI-2). Research has consistently found that the construct validity and convergent validity for both the MMPI-2 and the DASS-21 are strong (Franz, Marrop & McCord, 2016; Le, Tran, Holton, Nguyen, Wolfe & Fisher, 2017). While there is a plethora of research regarding the validity and fabrication of mental illness inventories, there is a dearth of research regarding the fabrication of actual mental illnesses. One may question why research has not be done in this field. Essentially, accusing someone of feigning a mental illness and exploring the reasons as to why people are motivated to fabricate mental illness is unethical.

While not being able to study participants directly, Yoxall, Bahr, and O'Neill (2017) hypothesised some reasons as to why people would be motivated to feign a mental illness within the workplace. They explored rates of elevation in the Personality Assessment Inventory (PAI) among an Australian workers compensation sample. They questioned whether elevation of negative distortion scales on the PAI was an indication of feigning the inventory. Although they could not establish feigning, they state that elevation on these inventories could mean increased accuracy in detecting feigning and extreme amplification of symptoms is the approach taken by people purposely distorting their mental health.

In a study by Stanford psychologist Rosenhan (1973), the validity of mental illness labels was explored. Eight pseudopatients (of which did not have any mental illnesses or psychiatric diagnoses) faked hallucinations in order to be admitted into psychiatric hospitals. Once they had been admitted, the pseudopatients were to act completely normal and mentally sane. The psychiatrists in the hospitals evaluated the patients as "severely ill". The questionable validity of psychiatric labels comes into play: the patients were normal, but the psychiatrists deemed them as "severely ill", perhaps because they had been labeled that way. The label profoundly influenced other's perceptions of that individual, even the clinically trained psychiatrists. While unable to draw conclusions about the motivation of mental illness, this study supports the notion that mental illness can be fabricated.

Conclusion

Accusing an individual of feigning a mental illness and exploring the reasons as to why people are motivated to fabricate mental illnesses are unethical means of research. While one cannot suggest that an individual is faking a mental illness, it is worthwhile to put in effort to make sure that adopting a mental-illness-based identity is not an enticing avenue. Overall, future research should aim to explore this relevant, current and important topic. The idea that a lack of identity may be a catalyst for developing a mental disorder should be an area for further exploration. Social psychologists should explore what helps individual's strengthen their identity as strong identities means a smaller risk of developing a mental illness. If an individual's identity can be strengthened, perhaps the maintenance of a mental-illness-based identity will weaken. The main concern is that the glamorised trend of being mental ill does not become a norm, as social identity theory states that individuals will do things things to fit in with their peers around them and the social norms.

The take-home message: mental illness is a serious condition, but there is a fine line between encouraging people to seek help and making mental illness seem like a trendy, glamorous norm.

See also

• 13 Reasons Why (Wikipedia)
• Labeling theory (Wikipedia)
• Learned helplessness (Wikipedia)
• Suicidality in the elderly (Book chapter, 2018)
• Suicidality across the lifespan (Book chapter, 2018)

References

Alloy, L.B., & Abramson, L.Y. (1982). Learned helplessness, depression and the illusion of control. Journal of Personality and Social Psychology, 42(6), 1114-1126. Retrieved from: http://web.a.ebscohost.com/ehost/pdfviewer/pdfviewer?vid=1&sid=6840ca07-0e0f-4f4e-b364-d0330e020699%40sdc-v-sessmgr03

Australian Bureau of Statistics. (2009). National Survey of Mental Health and Wellbeing: Summary of Results, 4326.0, 2007. ABS: Canberra.

Australian Bureau of Statistic. (2012). Australian Health Survey: First Results. ABS, Canberra.

Bargai, N., Ben-Shakhar, G., & Shalev, A.Y. (2007). Posttraumatic stress disorder and depression in battered women: the mediating role of learned helplessness. Journal of Family Violence, 22, 267-275. https://doi:10.1007/s10896-007-9078-y

Cerasoli, C.P., Ford, M.T., & Nicklin, J.M. (2014). Intrinsic motivation and extrinsic incentives jointly predict performance: a 40-year meta-analysis. Psychological Bulletin, 140, 980-1008. https://doi:10.1037/a0035661

Clark, D. A., & Beck, A. T. (1999). Scientific foundations of cognitive theory and therapy of depression. New York, NY: Wiley.

Elkington, K.S., Hackler, D., & McKinnon, K. (2011). Percieved mental illness stigma among youth in psychiatric outpatient treatment. Journal of Adolescent Research, 27, 290-317. https://doi.org/10.1177/0743558411409931

Erikson, E. H. (1968). Identity: Youth and crisis. New York, NY: Norton.

Franz, A.O., Harrop, T.M & McCord, D.M. (2017) Examining the Construct Validity of the MMPI–2–RF Interpersonal Functioning Scales Using the Computerized Adaptive Test of Personality Disorder as a Comparative Framework. Journal of Personality Assessment, 99, 416-423, http://dx.doi.org/10.1080/00223891.2016.1222394

Goldman, H.H., & Grob, G.N. (2006). Defining ‘mental illness’ in mental health policy. Health Affairs, 25, 737-749. https://doi:10.1377/hlthaff.25.3.737

Hunter, B.A., Mohatt, N.V., Prince, D.M., Thompson, A.B., Matlin, S.L., & Tebes, J.K. (2017). Socio-psychological mediators of the relationship between behavioural health stigma and psychiatric symptoms. Social Science & Medicine, 181, 177-183. https://doi:10.1016/j.socscimed.2017.03.049

Klein, D.C., Fencil-Morse, E., & Seligman, E.P. (1976). Learned helplessness, depression and the attribution of failure. Journal of Personality and Social Psychology, 33(5), 508-516. Retrieved from: http://web.a.ebscohost.com/ehost/pdfviewer/pdfviewer?vid=1&sid=c0ae4362-a616-41fa-83bc-58a2234b03d4%40sdc-v-sessmgr03

Klimstra, T.A., & Denissen, J.J. (2017). A theoretical framework for the associations between identity and psychopathology. Developmental Psychology, 53, 2052-2060. https://doi:10.1037/dev0000356

Le M.T., Tran T.D., Holton, S., Nguyen, H.T., Wolfe, R., & Fisher J. (2017) Reliability, convergent validity and factor structure of the DASS-21 in a sample of Vietnamese adolescents. PLoS ONE, 12, 1-14. https://doi.org/10.1371/journal.pone.0180557

Lillevoll, K.R., Kroger, J., & Martinussen, M. (2013). Identity Status and Anxiety: A Meta Analysis. Identity, 13(3), 214-227. https://doi.org/10.1080/15283488.2013.799432

Marcia, J. E. (2006). Ego identity and personality disorders. Journal of Personality Disorders, 20, 577–596. http://dx.doi.org/10.1521/pedi .2006.20.6.577

Maier, S.F. (2001). Exposure to the stressor environment prevents the temporal dissipation of behavioral depression/learned helplessness. Society of Biological Psychiatry, 49, 763-773. https://doi.org/10.1016/S0006-3223(00)01095-7

McAdams, D. P., & Olson, B. D. (2010). Personality development: Continuity and change over the life course. Annual Review of Psychology, 61, 517–542. http://dx.doi.org/10.1146/annurev.psych.093008.100507

Moses, T. (2009). Self-labeling and its effects among adolescents diagnosed with mental disorders. Social Science & Medicine, 68, 570-578. https://doi:10.1016/j.socscimed.2008.11.003

Perry, B. (2011). The labeling paradox: stigma, the sick role and social networks in mental illness. Journal of Health and Social Behaviour, 52, 460-477. http://doi:10.1177/0022146511408913

Rosenhan, D. L. (1973). On being sane in insane places. Science, 179(1), 250-258. Retrieved from: https://www.ncbi.nlm.nih.gov/pubmed/4683124

Ryan, R.M., & Deci, E.L. (2000). Intrinsic and extrinsic motivations: classic definitions and new directions. Contemporary Educational Psychology, 25, 54 - 67. https://doi:10.1006/ceps.1999.1020

Tatz, S. (2017). 13 Reasons Why - suicide the last taboo. Australian Medicine, 29(10), 1. 11. Retrieved from: <https://search-informit-com-au.ezproxy.canberra.edu.au/documentSummary;dn=853761186810659;res=IELAPA> ISSN: 2202-1701

Terry, D. J., Hogg, M. A., & White, K. M. (1999). The theory of planned behaviour: self identity, social identity and group norms. British Journal of Social Psychology, 38, 225-244. doi:10.1348/014466699164149

Taylor, J.J., Neitzke, D.J., Khouri, G., Borckardt, J.J., Acierno, R., Tuerk, P.W., Schmidt, M., & George, M.S. (2014). A pilot study to investigate the induction and manipulation of learned helplessness in healthy adults. Psychiatry Research, 219, 631-637. http://doi:10.1016/j.psychres.2014.05.045

Teodorescul, K., & Erev, I. (2014). Learned helplessness and learned prevalence: exploring the casual relations among perceived controllability, reward prevalence and exploration. Psychological Science, 25, 1861-1869. https://doi:10.1177/0956797614543022

Seligman, M. E., & Maier, S. F. (1967). Failure to escape traumatic shock. Journal of Experimental Psychology, 74, 1–9. https://doi:10.1037/h0024514

Shifrer, D. (2013). Stigma of a label: educational expectations for high school students labeled with learning disabilities. Journal of Health and Social Behaviour, 54, 462-480. https://doi:10.1177/0022146513503346

Schwartz, S. J., Klimstra, T. A., Luyckx, K., Hale, W. W., & Meeus, W. H. (2012). Characterizing the self-system over time in adolescence: Internal structure and associations with internalizing symptoms. Journal of Youth and Adolescence, 41, 1208 –1225. http://dx.doi.org/10 .1007/s10964-012-9751-1

Yoxall, J., Bahr, M., & O'Neill, T. (2017) Faking Bad in Workers Compensation Psychological Assessments: Elevation Rates of Negative Distortion Scales on the Personality Assessment Inventory in an Australian Sample. Psychiatry, Psychology and Law, 24, 682-693. https://doi.org/10.1080/13218719.2017.1291295

External links

• 13 Reasons Why crisis help website
• The psychology of self motivation (Tedx Talk, Scott Geller, YouTube, 15:53 mins)
• Imagine there was no stigma to mental illness (Tedx Talk, Dr. Jeffrey Lieberman, YouTube, 22:07 mins)
• eHeadspace (eHeadspace Australia, 2018)
• Lifeline Crisis Support (Lifeline Australia, 2018)