Abstract
Background:
People diagnosed with mental illness develop a variety of explanatory models of their conditions in the face of uncertainty. Explanatory models matter because they are associated with internalized stigma and illness behaviors such as treatment preferences.
Aims:
This paper explores how working professionals in the United States draw on biological and/or environmental factors to explain the cause(s) of their diagnoses of bipolar or depression.
Method:
Findings are derived from an analysis of transcripts of in-depth interviews with 52 individuals from across the United States who were invited to participate in a study of working professionals diagnosed with mental illness. About 25 self-identified as having bipolar disorder and 27 as having major depression. Transcript data were analyzed following the principles of flexible coding with the goal of establishing a typology of explanatory models of self-identified bipolar versus depression.
Results:
Six types of explanatory models emerged from the analysis. One was exclusively biological, a second was exclusively environmental, and the remaining four combined biological and environmental factors in different ways. Quotations from the interviews are provided to illustrate each type, and comparisons between types are made based on primary diagnosis (bipolar vs. depression), and self-reports of trauma and stressful experiences.
Conclusion:
Implications for the future research on explanatory models and how they may impact people who are diagnosed with a mental illness across multiple dimensions of their lives are presented.
Introduction
Being diagnosed with a mental illness likely raises many questions in people’s minds, including whether the diagnosis is correct and if so, what caused it. Formulating a causal explanation may help individuals who identify with a psychiatric diagnosis to increase their sense of control (Whittle, 1996), deflect blame from the self (Sayre, 2000), and find meaning in their experience (McCormack & Thomson, 2017). Mental health experts are divided regarding the cause(s) of psychiatric disorders on ideological and scientific grounds (Kendler, 2005), and reliant on patient self-reports of symptoms to form diagnoses given the absence of biomarkers (Paris, 2015). Some argue mental illness is predominantly biological (e.g. Blows, 2021), whereas others view it as a human response to trauma (e.g. Dillon et al., 2014). A middle view is that exposure to stressors cause biological vulnerabilities to manifest as mental illness, that is, the diathesis-stress model (Colodro-Conde et al., 2018). Given this state of uncertainty, people diagnosed with psychiatric disorders seek information from multiple sources beyond their treatment providers, including the internet, the media, and their internal psychological experiences (Schroder et al., 2020).
Understanding how people explain the cause(s) of their diagnosed psychiatric condition matters because casual beliefs are related to internalizing negative stereotypes (i.e. self-stigma) and to decision-making regarding treatment (Larkings et al., 2019). Self-stigma predicts lower self-esteem (Corrigan et al., 2006), self-reliance versus seeking treatment (Jennings et al., 2015), and discontinuation of treatment (Hajda et al., 2016). While there is no definitive population-based study of how people diagnosed with mental illness explain the causes of their condition, interview studies of mental health consumers living in the community, in the hospital, or in partial hospital programs indicate they tend to endorse environmental causes more often than biomedical ones (Elliott et al., 2012; Larkings et al., 2017; Schroder et al., 2020).
Most research on attributions for mental illness focus on the public and the relation between their causal beliefs and expressed stigma (Kvaale et al., 2013). According to attribution theory, if the cause of mental illness is viewed as uncontrollable, the public is less likely to blame people with mental illness for their condition and think poorly of them, an argument used to support the promulgation of the biomedical model of mental illness (Lebowitz & Appelbaum, 2019). While subscribing to the biomedical model is associated with a lower likelihood of blaming others for having a mental illness, it tends to be positively associated with desire for social distance, perceived dangerousness, and prognostic pessimism (Haslam & Kvaale, 2015).
Research on how people with mental illness explain their own condition indicates that attributions to biomedical factors also have mixed effects, reducing self-blame while diminishing hope for recovery and interest in psychotherapeutic treatments (Lebowitz, 2014). Disinterest in therapy is especially problematic when people are misdiagnosed, such as when people who meet criteria for borderline personality disorder are misdiagnosed as having bipolar (Ruggero et al., 2010). Biomedical attributions also predict concealing one’s mental illness, whereas psychosocial attributions predict the opposite (Wigand et al., 2019).
Studies specific to beliefs about depression find patients in a partial hospitalization program who thought depression was caused by ongoing stressors were more likely to believe in cognitive- and behavior-based therapy, whereas those who thought it was caused by a chemical imbalance were less likely to believe therapy would alleviate symptoms (Schroder et al., 2020). Experimental studies that manipulate causal models to depressed subjects demonstrate similar effects of attributions. For example, university students with depression who were told depression is caused by environmental factors (and who agreed) reported less severe symptoms, less stigma, and more optimism about their recovery than subjects exposed to the idea that depression is a chronic brain condition (Zimmermann et al., 2020). Similarly, university students who were manipulated to believe a chemical imbalance caused their depression were less likely to believe they would recover, or that therapy could help them (Kemp et al., 2014).
Relatively few studies examine causal attributions among people diagnosed with bipolar disorder, although limited evidence suggests they tend to make a variety of attributions including biomedical ones. Meiser et al. (2007) surveyed 95 people who endorsed multiple causes of their bipolar including abuse, their family environment, life stress, and genetics, whereas Peay et al. (2009) interviewed 25 people and found that most believed their bipolar condition was genetic but provoked by environmental stressors.
This study delves into the multifaceted causal explanations made by people diagnosed with bipolar or depression who are thriving in professional careers – a group that has defied stereotypes associated with their self-identified disorders. The results reveal a variety of explanatory models that appear to bear some relation to their diagnosis and history of trauma.
Materials and methods
Recruitment
Participants were recruited via a flyer announcing an opportunity for working professionals diagnosed with mental illnesses to be interviewed to express the experiences of the many individuals in the US who play a vital role in society while simultaneously dealing with the symptoms and stigma of mental illness. The flyer was posted in mental health clinics, on the author’s social media, and on listservs for mental health professionals and professionals diagnosed with mental illness. Potential participants emailed the author, received an information sheet and answers to their questions, and in all cases moved forward to schedule the interview. After each interview, participants were asked to share the flyer with eligible people they knew who might want to be interviewed.
Interviews
The semi-structured in-depth interviews were conducted by the author in person, over the phone, or via videoconference from 2015 to 2018. Each interview was audio-recorded and transcribed, and participants consented to being recorded and included in the research. The University of Nevada, Reno Institutional Review Board deemed Protocol #684370-2 exempt owing to posing minimal risks. The author presented as a mental health scholar, not a clinician, and only disclosed her lived experience when asked, which happened twice at the interviews’ end. As such, the participants seemed at ease being treated as experts on their experience and spoke freely. The interviews averaged 1.5 hours long and covered many topics including their mental health history and how it intersected with their educational and career trajectories, and their beliefs about their diagnosis, including a question about what they believed were the primary cause(s) of it.
Analysis
Transcripts were uploaded to Dedoose software (Dedoose, 2018) and analyzed in four stages following the method of flexible coding (Deterding & Waters, 2021) with the goal of creating a typology of causal explanations of one’s self-identified mental illness. The first stage involved categorizing participants by demographic characteristics and diagnosis, and the second stage entailed highlighting all text in each interview related to causal attributions. Highlighted text constituted the ‘parent’ code of causal beliefs that was subdivided into ‘child codes’ that differentiated between references to biology (e.g. genetics, brain chemistry), life experiences (e.g. traumatic life events, chronic stressors), and how multiple causes combined to cause their mental illness. A team of student researchers assisted in stages one and two, whereas the author conducted stages three (analytic coding) and four (cross-case theoretical validity testing).
The three types of child codes were analyzed in stage three to identify similarities, differences, and themes common to people’s causal beliefs, resulting in a person-level typology of causal explanations. During this stage, diagnosis was ignored to avoid confirmation bias. In the final stage, the text from which causal types were derived was cross-checked against the assigned causal explanation type, and the full interview was revisited to ensure quotations were not taken out of context. Comparisons were then made between people diagnosed with bipolar versus depression, and explanatory models were compared with reports of traumatic events and stressful life circumstances.
Results
Participants
All but 4 of the 56 people interviewed identified as having bipolar disorder (n = 25) or major depression (n = 27). Participants age ranged from 31 to 68, and 34 (65%) were female. The bipolar subsample was more evenly split by gender (56% female) than the depression subsample (74% female). Forty-eight of the 52 had completed college, and of them, 32 had advanced degrees (e.g. JD, MBA, MD, or PhD). Eighty-five percent identified as White, while the remaining eight included four who identified as Asian-American, two as African American, one as Latina, and one as Middle Eastern. The sample included a variety of professionals such as doctors, lawyers, engineers, professors, and business consultants. Detailed information linking each participant’s characteristics to their diagnosis and explanatory model are omitted to protect their anonymity, and all are referred to with pseudonyms.
Explanatory models
Participants invoked various explanations of the causes of their mental illness, most of which were multifactorial. The vast majority (n = 45 or 87%) referenced biological factors, and almost as many (n = 42 or 75%) cited environmental influences. A total of 7 (13%) believed the cause was exclusively biological and 5 (10%) believed it was strictly environmental (i.e. life experiences). The remainder (77% of the sample) presented four types of explanations that involved combinations of causes described below.
Strictly biological
Of the seven people who subscribed to a strictly biological explanation, three had bipolar, and four had depression. Referencing terms like biology, brain chemicals, genetics, and nature, each of the participants in this category presented a straightforward explanation that attributed their mental illness, in full, to biological factors. Certainly, all of them wondered if life experiences played a role, but none could identify anything in their lives that could account for their condition. As Aidan, a teacher with a history of depression and psychosis explained, ‘I don’t have any bad childhood memories. I had a very happy childhood. And so, my thought, I think, my idea was the most significant cause of my condition was just nature, you know. I was born with it kind of thing’.
In the absence of obvious environmental causes, knowledge of family history was sufficient causal evidence for four of them, like Ned, a professor with bipolar disorder: ‘I think it’s largely genetic and the reason I say that is because it runs in my father’s side of the family. My grandmother was severely bipolar. She had to be hospitalized multiple times throughout her life’.
Having a family history filled a gap in understanding that was reassuring, especially for Violet, a writer with bipolar: ‘One of the things that’s hard for me when I see a psychiatrist or a therapist is they try to find things in my childhood. There was nothing. I have really loving parents, and I had a really stable childhood and no trauma’. She hoped the same was true of the home environment she provided her own children, who were in therapy: ‘I get asked the same things in these appointments for her [daughter]. . .and I’m like “I don’t think so. I think it’s just genetic”’.
Although none of these individuals believed that life experiences were causally related to their mental illness, half of the seven described traumatic events they had experienced in life such as emotional abuse or death of a loved one. Moreover, three of them (all with bipolar) said that those experiences were the outcome, rather than the cause of their condition. For example, Amanda, an IT specialist, cited plenty of problematic experiences she said were caused by her bipolar disorder: ‘Things have happened in my life like bad relationships and like bad interactions and poor choices. And I mean stuff like not getting along with my parents and not getting along with my siblings or not getting along with friends of mine. . . . I think it’s an effect of the bipolar and not the cause of the bipolar’.
Strictly environmental
All five individuals who cited environmental causes had depression, and four of the five referenced extreme child abuse, with two stating that their parents wanted to kill them. The fifth individual described an ongoing campaign of on-the-job harassment directed against her. In each case, life experiences were perceived as sufficiently severe to cause their condition without invoking a biological explanation. For example, Suzanne, a researcher, described abuse at the hands of her parent as chronic and senseless: ‘It did not matter how I behaved or what I did, I got minimally beaten with a belt every day if not more than once a day’. Years later, after extensive therapy, she came to understand that ‘it didn’t have anything to do with me’, yet she understand why she blamed herself at the time.
Biological and environmental
Four types of explanatory models emerged that included elements of biological and environmental factors: (1) condition is biological, but stressors trigger symptoms (n = 6 or 10%), (2) trauma induced neurochemical changes in the brain lead to mental illness (n = 4 or 6%), (3) a genetic predisposition that was activated by stressful life experiences (diathesis-stress; n = 14 or 27%), and (4) biological and environmental influences acted independently (n = 14 or 27%).
Biological, but triggered by stress
The six individuals in this category all had bipolar. They believed their condition was biological in nature although their symptoms were triggered by stressors ranging from life events like moving and starting a new job to extreme trauma, such as sexual assault. For them, what happened in their lives mattered, but only in so far as causing a flare-up of their pre-existing condition.
Hattie said she ‘wasn’t an abused child. I didn’t have any really horrible childhood experience’, but she did think her parents’ divorce contributed to the onset of her mood disorder: ‘They were very adversarial at that point in my life, so I do feel like I had probably an unusual amount of stress for a teenager, but I think I have a biological mental illness’. In Nora’s case, there was abuse, but she was clear that ‘something is chemically wrong with me’. The fact that her mother was ‘emotionally abusive’ was not the cause of her bipolar disorder, although it ‘exacerbated it’.
Deborah was clear that her bipolar was biological. ‘I was born with it’, she said. ‘I am who I am because I have bipolar disorder. That’s just how my brain is wired’. Regarding the effects of stress, she described a physically abusive and emotionally coercive marriage as relevant because having bipolar made her more sensitive to it: ‘Trauma is absolutely one of my triggers’, she said. ‘I do worry a lot about what will happen the next time there’s an unexpected trauma in my life’.
Neurochemical impact of trauma
Three of the four people in this category had depression, and all four described the phenomenon in conjunction with narratives of extreme trauma. Beatrice, a scientist with depression and social anxiety who was sexually molested in adolescence, understood that ‘trauma triggers the release of chemicals in the brain’. Tamara, a specialist in workplace mental health with depression who was sexually abused as a child, put it like this: ‘I have a child’s brain that learned how to survive on hardwiring itself a certain way so I could literally survive my life’.
Diathesis-stress
The 14 individuals in this category were evenly split between 7 with bipolar and 7 with depression. In contrast with the participants in the previous two categories for whom biology was presented as the overriding cause, these participants believed biology was necessary, but required stressful life experiences to make it manifest. By biology, they referred to their genetic predisposition, whereas by life experiences, they meant all sorts of things.
About 6 of the 14 worked in the mental health field, and it was evident that their professional expertise influenced how they thought about their own condition. Dirk, a psychiatrist with bipolar, said ‘I believe in the stress-diathesis model of mood disorders’. Dana, a clinical psychologist with depression and borderline personality disorder, subscribed to ‘Marsha Linehan’s biosocial theory’. Anthony stated that ‘The confluence of emotional vulnerability with an invalidating environment’ caused his depression with borderline features, noting a combination of alcoholism running in his family and being bullied as a child. Whereas Richard, an attorney, used a non-clinical expression: ‘genetics loads the gun and external stressors fire it’.
Unlike most of the participants who attributed their condition primarily to biology, those who subscribed to the diathesis-stress model tended to describe their childhood and early adulthood as unhappy. For example, Dana was emotionally abused while living in foster care, ran away, and did sex-work before eventually earning a PhD. Others focused more on young adulthood stressors that coincided with the onset of their illness. For example, Abigail had a psychotic break and was diagnosed with bipolar disorder at a time when she was ‘trying to make it in New York on no income’ and who thought that ‘. . .if I hadn’t been in such a pressure cooker. . .I could have easily continued on for who knows how long, maybe forever, still going through these cycles, but never getting so bad that I actually had to address it’.
Biomedical and environmental factors are independent
The other equally most common explanation was also evenly split between people with bipolar versus depression. In contrast with the diathesis-stress-like model, this explanation did not specify how biomedical and environmental factors combined yet referenced both. Annie attributed her bipolar to a chemical imbalance and to being bullied, but she was not sure how the two interacted, describing it as ‘a chicken and the egg kind of thing’. Faith, a writer with depression, cited numerous factors converging: ‘There can be trauma that brings it on, there can be grieving that brings it on, there can be a genetic component, there can be an environmental component. I think I had the perfect storm’.
Jack, who has bipolar, couldn’t think of anything that happened to him, yet he still believed that life experiences played some role in addition to genetics: ‘Family, friends, and sure, the global climate change – all of these things have probably had some effect on me. I just can’t attribute it back to when I was 10, something horrible happened and that clearly I am living the repercussions of that experience. . .It’s just odd that I spent a good portion of my childhood wanting to kill myself despite the fact that I was happy’.
I have no idea
Only two people (one with bipolar and one with depression) did not provide an explanatory model of their mental illness. Carrie, a health coach with bipolar, was adopted and knew nothing of her family health history, nor could she cite life experiences related to her sudden onset of paranoia that led to temporary total disability. Cameron, a writer with depression and suicidal ideation, thought deeply and extensively about the causes of his condition, and ultimately deemed it a mystery. Unable to cite any life experiences commensurate with his pain (‘I had a very good childhood’), he acknowledged ‘there are some logical grounds perhaps for rooting my problems in biology, but who really knows?’ Both fascinated and frustrated by the ‘unwillingness to really recognize a level of mystery and enigma that we are really in’ on all sides of the debate over what causes mental illness, he found a silver lining to his uncertainties, noting that ‘my mulling the paradoxes and contradictions of my history has been a source of creativity for me’.
Discussion
Working professionals who identified as having bipolar disorder or major depression were interviewed to learn how they understood and managed their diagnosed mental illness in the context of their careers. This paper focused on their explanatory models of why they believed they had bipolar or depression. Six types of models emerged, one based exclusively on biomedical factors, one based on environmental factors, and four that combined biomedical and environmental influences.
Only seven people invoked biomedical factors only (three with bipolar and four with depression), and none could identify problematic life experiences prior to the onset of symptoms, although some said their illness caused bad experiences. Just five people (all with depression) invoked environmental factors only, and in contrast to the first group, they all reported significant lifetime traumatic events, such as child abuse.
Most people in this socioeconomically advantaged sample drew on biomedical and environmental factors in explaining why they thought they had bipolar or depression. Exactly 6 (all with bipolar), believed their illness was biologically based, but triggered by stressors, in contrast with 14 (split evenly between those with bipolar or depression), who believed that their biologically based illness would never have expressed itself if not for environmental triggers. Four others (one with bipolar) invoked the physiological effects of life experiences by describing how exposure to trauma since birth impacted their neurochemistry, leading to mental illness. Another 14 (7 with bipolar and 7 with depression) believed their biological constitution and life experiences contributed to their condition but did not articulate how the two combined.
Two trends are notable when comparing participants diagnosed with bipolar versus depression. First, everyone with bipolar cited biological causes, whereas four people with depression attributed it exclusively to trauma. This finding may reflect the mainstream medical conclusion that bipolar disorder is a genetically based chronic brain condition (McIntyre et al., 2020). In contrast, depression is more common than bipolar (Kessler et al., 2012), and is used colloquially in everyday conversation to describe how bad experiences make one feel. Moreover, the criteria for major depressive disorder are so broad that people having typical emotional reactions to loss may receive the same diagnosis as people who are so ill that they require hospitalization (Horwitz, 2021). The second trend was that only people with bipolar described their condition as primarily biological but triggered by stressors, a finding that is also likely attributable to the biomedical viewpoint that bipolar is biological. In contrast, the only people with depression who attributed it exclusively to biology were four individuals who could not cite any life experiences upsetting enough to account for the severity of pain that characterized their condition.
These findings depart from other qualitative interview studies of small samples where people were more likely to attribute their illness to life experiences than to biomedical factors (Elliott et al., 2012; Larkings et al., 2017; Schroder et al., 2020). The heterogeneity and relative complexity of the explanatory models found here could reflect the above average levels of education of the participants, which may have trained them to systematically study the causes of their conditions, leading to explanatory models similar if not identical to those presented by mainstream psychiatry (e.g. diathesis-stress). Their socioeconomic advantages also granted them access to a variety of treatments and therapies that brought opportunities to discuss the nature of their diagnosis with mental health professionals.
Given the sample is small and non-probability based, it is not possible statistically to link individuals’ explanatory models to outcomes they might affect, such as internalized stigma, prognostic pessimism, self-esteem, or social withdrawal. Nonetheless, the richness of the qualitative data informs measurement development for larger-scale quantitative studies. Existing studies suggest the framing mental illness as a biomedical phenomenon reduces self-blame yet deters individuals from utilizing psychotherapy (Lebowitz, 2014). This study suggests that most people (at least among working professionals) draw on biomedical and environmental factors in accounting for their illness, but the consequences for them of these explanatory models are unknown.
Given the ongoing enigmatic nature of mental illness, serious consideration should be given to how people diagnosed with it make sense of their experience. Future research should explore how different types of causal explanations relate to people’s illness experiences over time, such as which treatments they try, and to what effect, and whether their diagnosis impacts their investment and success in their education, family, vocation, and other social endeavors.
Conclusion
While the influence of mainstream psychiatry on working professionals’ explanatory models of their mental illness is evident, individuals contribute original and insightful analyses of their lived experience that transcend psychiatric classifications. Just as mental health researchers and practitioners differ in their beliefs about the causes of psychiatric disorders, so too do those who are diagnosed with them. Considering how people who identify as having a mental illness make sense of their experience should be integrated into ongoing efforts to explicate the etiology of poor mental health and how to alleviate it.
Footnotes
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was supported by a generous grant from the University of Nevada, Reno College of Liberal Arts Scholarly and Creative Activities Grants Program.
