A Resilience Model for Anti-Stigma Campaigns

The frequency of athletes disclosing behavioral health problems seems to be growing. Each painful story is quietly added to the narrative promoted by our field that they have a “disease like any other.” Swimmer Michael Phelps spoke of his drug use and depression. Gymnast Simone Biles described the “twisties,” perhaps a more acceptable reason for withdrawing from Olympics events than her psychological state.

Our anti-stigma strategy rests on the premise that public attitudes will change as people understand the medical nature of these problems. Attitudes are not changing, and we need a new message. Athletes can help. Current campaigns hinge less on whether behavioral conditions are diseases and more on whether believing so decreases stigma. Changing cultural beliefs, not promoting science, is the goal.

A robust research study on this issue found that acceptance of the medical viewpoint increases the likelihood of supporting treatment, but it does not impact stigma. Researchers found stigma to be “surprisingly fixed” and found little encouragement for continuing with this anti-stigma approach. They suggested it may be better to focus on people’s abilities and competencies.

This suggestion has been ignored. The medical model is still the preferred solution. One might object to medicalization for many reasons. The parade of athletes disclosing their struggles sadly seems to reduce each one to a diagnosis. It also seems like offering them refuge or absolution with an authoritative medical system. One might ask, is stigma OK when the rejected behavior is not disease based?

These objections to medicalization are largely philosophical. What we need is a better strategy. The researchers may have had the right idea, but a flawed marketing spin. Their idea might best be described as replacing the medical model with a resilience model. We should admire the way so many top athletes have overcome both physical and mental pain. They can be our guides to resilience.

Resilience is a common goal and not the prerogative of top athletes. Resilience may be aided by medication, therapy, friends, and family. Some stories will be idiosyncratic and reinforce the idea that there are many pathways to a better life. The emphasis is on hope and recovery, not on the problem, and yet it is not overly cheerful. Pain is shared as part of the process of healing.

This is a biopsychosocial approach, and athletes can embrace each dimension. They have long embraced biology. They refine eating and exercise routines to excel. The mental focus tends to be dominated by sports psychology (i.e., using your mind for athletic success), and yet it should encompass both clinical and positive psychologies. Athletes can benefit from nurturing the mind beyond a performance focus.

Resilience expands in another critical direction based on a social perspective. In some cases, resilience means overcoming social barriers or blatant injustice. Athletes have long participated in protest. This has ranged from fights against being treated as a commodity (e.g., free agency) to the way women and racial minorities have addressed professional limitations that mirror social discrimination.

These social obstacles intersect with stigma, and resilience is needed in the face of all such difficulties. Jackie Robinson broke the color barrier in baseball in 1947, and his resilience still inspires. This year a discrimination lawsuit was filed against the NFL, where 70% of players and 3% of coaches are Black. It is only natural for athletes to step up to shatter behavioral health stigmas as well.

The medical model seems to be a weak solution to stigma. Why? It corrects moralistic and discriminatory thinking with a different idea, disease, vaguely hoping new thoughts launch new behaviors. Too much faith is also being placed in medical authority. The authorities similarly declared segregation in baseball to be over in 1947. Racism did not dissolve by saying baseball is now integrated.

Research finds the public may favor treatment for those afflicted with brain diseases, but most people prefer to keep a social distance from “them” nonetheless. By contrast, resilient people like Michael Phelps or Simone Biles draw you in for conversation, and dialogue must reach a personal level to end stigma. People are attracted to stories of resilience. We relate to Michael and Simone at some level.

The most essential narrative for our field right now is improving access to care. Figuring out how to end stigma is a big part of that. We need a model that starts conversations that attract people to care. The resilience model is one of attraction, not a professional model demanding agreement.

Our current strategy is to eliminate stigma by fiat based on medical authority. We will get further by attracting people to conversations about real people recovering and adapting to challenges. We need to reduce the fear and intimidation of stigma. Let us find common feelings as we all seek resilience.

Ed Jones, PhD is currently with ERJ Consulting, LLC and previously served as President at ValueOptions and Chief Clinical Officer at PacifiCare Behavioral Health.

The views expressed in Perspectives are solely those of the author and do not necessarily reflect the views of Behavioral Healthcare Executive, the Psychiatry & Behavioral Health Learning Network, or other Network authors. Perspectives entries are not medical advice.