Culture and stigma: Adding moral experience to stigma theory

Definitions and theoretical models of the stigma construct have gradually progressed from an individualistic focus towards an emphasis on stigma's social aspects. Building on other theorists' notions of stigma as a social, interpretive, or cultural process, this paper introduces the notion of stigma as an essentially moral issue in which stigmatized conditions threaten what is at stake for sufferers. The concept of moral experience, or what is most at stake for actors in a local social world, provides a new interpretive lens by which to understand the behaviors of both the stigmatized and stigmatizers, for it allows an examination of both as living with regard to what really matters and what is threatened. We hypothesize that stigma exerts its core effects by threatening the loss or diminution of what is most at stake, or by actually diminishing or destroying that lived value. We utilize two case examples of stigma--mental illness in China and first-onset schizophrenia patients in the United States--to illustrate this concept. We further utilize the Chinese example of 'face' to illustrate stigma as having dimensions that are moral-somatic (where values are linked to physical experiences) and moral-emotional (values are linked to emotional states). After reviewing literature on how existing stigma theory has led to a predominance of research assessing the individual, we conclude by outlining how the concept of moral experience may inform future stigma measurement. We propose that by identifying how stigma is a moral experience, new targets can be created for anti-stigma intervention programs and their evaluation. Further, we recommend the use of transactional methodologies and multiple perspectives and methods to more fully capture the interpersonal core of stigma as framed by theories of moral experience.

Racial differences in stigmatizing attitudes toward people with mental illness

OBJECTIVE

Stigma is a significant impediment to the successful treatment of individuals with mental illness, especially among racial minority groups. Although limited, the literature suggests that African Americans are more likely than Caucasians to believe that people with mental illnesses are dangerous. The authors reexamined this issue and assessed whether racial differences also extend to beliefs about how people with mental illness should be treated if violent.

METHODS

A nationally representative probability sample of 1,241 respondents participated in a telephone survey. The analysis focused on the 81 African-American and 590 Caucasian respondents who participated in a vignette experiment about a person with schizophrenia or major depressive disorder. The authors analyzed respondents' perceptions that the person would be violent, as well as their attitudes about blame and punishment.

RESULTS

African Americans were more likely than Caucasians to believe that individuals with schizophrenia or major depression would do something violent to other people. At the same time they were less likely to believe these individuals should be blamed and punished for violent behavior. These racial differences were not attributable to sociodemographic factors.

CONCLUSIONS

The study found racial differences in stigmatizing attitudes toward individuals with mental illness; however, African Americans' negative perception did not necessarily result in endorsement of harsher treatment of mentally ill persons. This study highlights the complexity of the stigma process and emphasizes the need to consider racial differences in developing interventions targeted to improve public attitudes.

Trends in the association of poverty with overweight among US adolescents, 1971-2004

CONTEXT

Prevalence of adolescent overweight in the United States has increased substantially during the past 3 decades. Whether socioeconomic disparities in adolescent overweight increased, decreased, or remained constant during this period is not known.

OBJECTIVE

To examine trends in adolescent overweight from 1971 to 2004 by family poverty status, as well as trends in potentially relevant eating and physical activity behaviors.

DESIGN, SETTING, AND PARTICIPANTS

Four cross-sectional, nationally representative surveys (US National Health and Nutrition Examination Surveys [NHANES] of 1971-1974, 1976-1980, 1988-1994, and 1999-2004) were examined for trends in the prevalence of overweight among adolescents aged 12 to 17 years by family poverty status.

MAIN OUTCOME MEASURES

Prevalence of adolescent overweight, defined as body mass index at or above the 95th percentile for age and sex in the 2000 Centers for Disease Control and Prevention growth charts. Intermediate outcomes were physical inactivity in the past 30 days, proportion of caloric intake from sweetened beverages (24-hour recall), and whether respondent skipped breakfast (24-hour recall).

RESULTS

Trends in the association of adolescent overweight with family poverty differed by age stratum (P = .01). In 12- to 14-year-old adolescents, prevalence did not significantly differ by family poverty status in any of the surveys; however, among non-Hispanic black adolescents, overweight prevalence increased faster in nonpoor vs poor families. In contrast, a widening disparity that disfavored adolescents from poor families was present in the 15- to 17-year-old adolescents. This trend was similar among male, female, non-Hispanic white, and non-Hispanic black adolescents, resulting in an overall prevalence of overweight in 1999-2004 more than 50% higher among adolescents in poor vs nonpoor families (23.3% vs 14.4%, respectively; P<.001). Additional analyses suggest that physical inactivity, sweetened beverage consumption, and skipping breakfast may contribute to these disparities.

CONCLUSIONS

Trends of increasing overweight showed a greater impact in families living below the poverty line vs not living below the poverty line among older (15-17 years) but not younger (12-14 years) adolescents. Furthermore, physical inactivity, high consumption of sweetened beverages, and breakfast skipping may be candidate targets for prevention programs aimed at reducing this recently emerged disparity.

Effects of attributing serious mental illnesses to genetic causes on orientations to treatment

OBJECTIVE

Professional services for persons with serious mental illnesses are underutilized. The genetics revolution has the potential to increase professional help seeking by increasing biomedical interpretations of mental illness among the public. The objective of this study was to assess whether genetic attributions for serious mental illnesses are associated with more positive orientations to professional treatment among members of the general public.

METHODS

Data from two nationally representative surveys were analyzed. First, associations between perceptions of genetic causes of both schizophrenia and depression and treatment recommendations and perceived treatment effectiveness were assessed in a vignette study that was part of the 1996 General Social Survey (GSS). Second, the effect of various descriptions of the role of genetic factors in schizophrenia and depression on perceived treatment effectiveness was assessed in a vignette experiment conducted in 2002-2003.

RESULTS

Perception of genetic causes was associated with more recommendations for mental hospitalization and prescription medication but not with more recommendations to see a psychiatrist, a therapist, or a general medical practitioner. Perception of genetic causes was not related to perceived treatment effectiveness in the GSS, and genetic causes as described in the vignette were associated with lower perceived effectiveness of treatment.

CONCLUSIONS

Increasing emphasis on genetic causes of mental illnesses may have multifaceted effects on orientations to professional treatment. Genetic attributions appear to direct people's help seeking toward the most extreme or biological forms of intervention, possibly because people view genetically influenced disorders as more serious and chronic. At the same time, such attributions lead to pessimism that intervention will be effective.

Controlling disease and creating disparities: a fundamental cause perspective

The United States and other developed countries experienced enormous improvements in population health during the 20th century. In the context of this dramatic positive change, health disparities by race and socioeconomic status emerged for several potent killers. Any explanation for current health disparities must take these changing patterns into account. Any explanation that ignores large improvements in population health and fails to account for the emergence of disparities for specific diseases is an inadequate explanation of current disparities. We argue that genetic explanations and some prominent social causation explanations are incompatible with these facts. We propose that the theory of "fundamental causes" can account for both vast improvements in population health and the creation of large socioeconomic and racial disparities in mortality for specific causes of death over time. Specifically, we argue that it is our enormously expanded capacity to control disease and death in combination with existing social and economic inequalities that create health disparities by race and socioeconomic status: When we develop the ability to control disease and death, the benefits of this new-found ability are distributed according to resources of knowledge, money, power, prestige, and beneficial social connections. We present data on changing mortality patterns by race and socioeconomic status for two types of diseases: those for which our capacity to prevent death has increased significantly and those for which we remain largely unable to prevent death. Time trends in mortality patterns are consistent with the fundamental cause explanation.

Geneticization of deviant behavior and consequences for stigma: the case of mental illness

One likely consequence of the genetics revolution is an increased tendency to understand human behavior in genetic terms. How might this "geneticization" affect stigma? Attribution theory predicts a reduction in stigma via reduced blame, anger, and punishment and increased sympathy and help. According to "genetic essentialist" thinking, genes are the basis of human identity and strongly deterministic of behavior. If such ideas are commonly accepted, geneticization should exacerbate stigma by increasing perceptions of differentness, persistence, seriousness, and transmissibility, which in turn should increase social distance and reproductive restrictiveness. I test these predictions using the case of mental illness and a vignette experiment embedded in a nationally representative survey. There was little support for attribution theory predictions. Consistent with genetic essentialism, genetic attributions increased the perceived seriousness and persistence of the mental illness and the belief that siblings and children would develop the same problem. Genetic attribution did not affect reproductive restrictiveness or social distance from the ill person but did increase social distance from the person's sibling, particularly regarding intimate forms of contact involving dating, marriage, and having children.

Measuring mental illness stigma

The effectiveness of efforts designed to address mental illness stigma will rest on our ability to understand stigma processes, the factors that produce and sustain such processes, and the mechanisms that lead from stigmatization to harmful consequences. Critical to such an understanding is our capacity to observe and measure the essential components of stigma processes. This article is designed to assist researchers in selecting or creating measures that can address critical research questions regarding stigma. Our conceptualization of stigma processes leads us to consider components of labeling, stereotyping, cognitive separating, emotional reactions, status loss, and discrimination. We review 123 empirical articles published between January 1995 and June 2003 that have sought to assess mental illness stigma and use these articles to provide a profile of current measurement in this area. From the articles we identify commonly used and promising measures and describe those measures in more detail so that readers can decide whether the described measures might be appropriate for their studies. We end by identifying gaps in stigma measurement in terms of concepts covered and populations assessed.

Internalized stigma predicts erosion of morale among psychiatric outpatients

Stigma in society causes harm to people with severe mental illness (SMI) and internalized stigma represents its psychological point of impact. We evaluated the extent of internalized stigma in a sample of outpatients with SMI, using the Internalized Stigma of Mental Illness (ISMI) Scale, developed with consumer input. About a third of the sample reported high levels of internalized stigma. We tested whether internalized stigma predicted increased depressive symptoms and reduced self-esteem at 4-month follow-up, controlling for baseline levels. Depression was predicted by Alienation, Stereotype Endorsement, Social Withdrawal Scales and total ISMI score. Reduced self-esteem was predicted by Alienation. ISMI results were stronger than those for the widely used Devaluation-Discrimination Scale. The finding that alienation further reduces morale speaks to the difficulty of pulling oneself out of this type of vicious cycle without assistance.

"Fundamental causes" of social inequalities in mortality: a test of the theory

Medicine and epidemiology currently dominate the study of the strong association between socioeconomic status and mortality. Socioeconomic status typically is viewed as a causally irrelevant "confounding variable" or as a less critical variable marking only the beginning of a causal chain in which intervening risk factors are given prominence. Yet the association between socioeconomic status and mortality has persisted despite radical changes in the diseases and risk factors that are presumed to explain it. This suggests that the effect of socioeconomic status on mortality essentially cannot be understood by reductive explanations that focus on current mechanisms. Accordingly, Link and Phelan (1995) proposed that socioeconomic status is a "fundamental cause" of mortality disparities-that socioeconomic disparities endure despite changing mechanisms because socioeconomic status embodies an array of resources, such as money, knowledge, prestige, power, and beneficial social connections, that protect health no matter what mechanisms are relevant at any given time. We identified a situation in which resources should be less helpful in prolonging life, and derived the following prediction from the theory: For less preventable causes of death (for which we know little about prevention or treatment), socioeconomic status will be less strongly associated with mortality than for more preventable causes. We tested this hypothesis with the National Longitudinal Mortality Study, which followed Current Population Survey respondents (N = 370,930) for mortality for nine years. Our hypothesis was supported, lending support to the theory of fundamental causes and more generally to the importance of a sociological approach to the study of socioeconomic disparities in mortality.

Fear of people with mental illnesses: the role of personal and impersonal contact and exposure to threat or harm

Vignette and laboratory experiments suggest that negative reactions to people with mental illness are a direct consequence of their symptomatic behavior, but because of their poor external validity, these studies cannot tell us whether widespread negative public reactions to people with mental illness actually result from observation of symptomatic behavior. Focusing on perceived danger, we use a large national survey to test the "behavior hypothesis" in the general population. We reason that, if this hypothesis is correct, contact with people with mental illnesses should be associated with more perceived danger, and exposure to threat or harm should mediate this association. On the contrary, respondents with more personal and impersonal contact perceive people with mental illness to be less dangerous. Exposure to threat is more common among people with more contact, but this exposure explains very little of the variance in perceived danger. These findings do not support the conclusion that public fear of people with mental illness is due to the observation of violent behavior.

Genetic bases of mental illness -- a cure for stigma?

An increased emphasis on biological causes of mental illness has been viewed as having the potential to significantly reduce stigma. From this perspective, the current genetics revolution can be seen as a source of hope. However, some have argued that biological attributions could increase stigma, for example by making the ill person seem 'defective' or 'physically distinct' -- 'almost a different species'. In this paper, I use a multicomponent conceptualization of stigma as a guide in forming hypotheses about the likely impact of genetic attributions on the stigma of mental illness.

McKeown and the idea that social conditions are fundamental causes of disease

In an accompanying commentary, Colgrove indicates that McKeown's thesis-that dramatic reductions in mortality over the past 2 centuries were due to improved socioeconomic conditions rather than to medical or public health interventions-has been "overturned" and his theory "discredited." McKeown sought to explain a very prominent trend in population health and did so with a strong emphasis on the importance of basic social and economic conditions. If Colgrove is right about the McKeown thesis, social epidemiology is left with a gaping hole in its explanatory repertoire and a challenge to a cherished principle about the importance of social factors in health. We return to the trend McKeown focused upon-post-McKeown and post-Colgrove-to indicate how and why social conditions must continue to be seen as fundamental causes of disease.

Stigma as a barrier to recovery: The consequences of stigma for the self-esteem of people with mental illnesses

OBJECTIVE

The objective of this study was to determine whether stigma affects the self-esteem of persons who have serious mental illnesses or whether stigma has few, if any, effects on self-esteem.

METHODS

Self-esteem and two aspects of stigma, namely, perceptions of devaluation-discrimination and social withdrawal because of perceived rejection, were assessed among 70 members of a clubhouse program for people with mental illness at baseline and at follow-up six and 24 months later.

RESULTS

The two measures of perceptions of stigma strongly predicted self-esteem at follow-up when baseline self-esteem, depressive symptoms, demographic characteristics, and diagnosis were controlled for. Participants whose scores on the measures of stigma were at the 90th percentile were seven to nine times as likely as those with scores at the 10th percentile to have low self-esteem at follow-up.

CONCLUSIONS

The stigma associated with mental illness harms the self-esteem of many people who have serious mental illnesses. An important consequence of reducing stigma would be to improve the self-esteem of people who have mental illnesses.

Who are "the homeless"? Reconsidering the stability and composition of the homeless population

OBJECTIVES

This study assessed the extent to which the use of point-prevalence samples biases conclusions drawn about homeless people.

METHODS

Three data sets and published research were used to examine the degree to which conditions leading to point-prevalence bias (turnover in the homeless population, variability in the persistence of homelessness, and associations between personal characteristics and persistence) characterize the homeless population. Results were compared from point-prevalence studies concerning persistence of homelessness and characteristics of homeless people with those from a study of formerly homeless people.

RESULTS

Conditions leading to point-prevalence bias strongly characterize the homeless population. Moreover, profiles of homeless people differed dramatically between point-prevalence studies and the study of formerly homeless people. In the former, average duration of homelessness was longer, and samples included higher proportions of men, minorities, non-high school graduates, and people with histories of psychiatric hospitalization, incarceration, and detoxification.

CONCLUSIONS

Reliance on point-prevalence samples, when such samples are generalized beyond the currently homeless population, leads to overestimations of the persistence of homelessness, the demographic distinctiveness of the homeless population, and the prevalence of personal disabilities and deviant lifestyles among homeless people.

Public conceptions of mental illness: labels, causes, dangerousness, and social distance

OBJECTIVES

The authors used nationwide survey data to characterize current public conceptions related to recognition of mental illness and perceived causes, dangerousness, and desired social distance.

METHODS

Data were derived from a vignette experiment included in the 1996 General Social Survey. Respondents (n = 1444) were randomly assigned to 1 of 5 vignette conditions. Four vignettes described psychiatric disorders meeting diagnostic criteria, and the fifth depicted a "troubled person" with subclinical problems and worries.

RESULTS

Results indicate that the majority of the public identifies schizophrenia (88%) and major depression (69%) as mental illnesses and that most report multicausal explanations combining stressful circumstances with biologic and genetic factors. Results also show, however, that smaller proportions associate alcohol (49%) or drug (44%) abuse with mental illness and that symptoms of mental illness remain strongly connected with public fears about potential violence and with a desire for limited social interaction.

CONCLUSIONS

While there is reason for optimism in the public's recognition of mental illness and causal attributions, a strong stereotype of dangerousness and desire for social distance persist. These latter conceptions are likely to negatively affect people with mental illness.

The growing belief that people with mental illnesses are violent: the role of the dangerousness criterion for civil commitment

In response to a controversy concerning whether the stigma of mental illness has declined significantly in the United States in the past several decades, we assessed changes in public perceptions that mentally ill people are violent. Specifically, we compared answers to an open-ended question regarding respondents' understanding of the term "mental illness" from two nationally representative surveys, one conducted in 1950 and one in 1996. In an earlier paper, we reported the finding that perceptions of violence not only failed to decrease but actually increased significantly between 1950 and 1996. In this paper, we explore the possibility that the dangerousness criterion for involuntary commitment, widely adopted in the United States beginning in the 1960s, has contributed to the unexpected increase in perceptions that mentally ill people are dangerous. We find that, among respondents who mention violence in their description of a mentally ill person, the percentage who use "dangerous to self or others" phrasing to indicate this belief increased substantially, from 4.2% in 1950 to 44.0% in 1996. Moreover, eliminating these respondents from consideration, there was a slight decrease in perceptions of violence between 1950 and 1996. We discuss the possibility that the adoption of the dangerousness criterion, which was intended to protect the civil liberties of mentally ill persons, may also have had the unintended consequence of increasing the stigma of mental illness in the United States.

Social epidemiology and the fundamental cause concept: on the structuring of effective cancer screens by socioeconomic status

Since the early 1800s, studies have consistently demonstrated that people higher in the socioeconomic hierarchy live longer than people of lower rank. One hypothesis for the persistence of this association is that people who are relatively better off are more able to avoid risks by adopting currently available protective strategies. In a partial test of this idea, the social distributions of two cancer screening tests--Pap smears and mammography--were examined. A review of the literature and an analysis of Behavioral Risk Factor Surveillance System (BRFSS) data showed a consistent association between indicators of socioeconomic status and recent screening. These findings support the theory that societies create and shape patterns of disease. Innovations beneficial to health are carried out within the context of inequalities that shape the distribution of the health benefit, thereby affecting patterns of morality.

Psychiatric illness and family stigma

Considerable research has documented the stigmatization of people with mental illnesses and its negative consequences. Recently it has been shown that stigma may also seriously affect families of psychiatric patients, but little empirical research has addressed this problem. We examine perceptions of and reactions to stigma among 156 parents and spouses of a population-based sample of first-admission psychiatric patients. While most family members did not perceive themselves as being avoided by others because of their relative's hospitalization, half reported concealing the hospitalization at least to some degree. Both the characteristics of the mental illness (the stigmatizing mark) and the social characteristics of the family were significantly related to levels of family stigma. Family members were more likely to conceal the mental illness if they did not live with their ill relative, if the relative was female, and if the relative had less severe positive symptoms. Family members with more education and whose relative had experienced an episode of illness within the past 6 months reported greater avoidance by others.

On stigma and its consequences: evidence from a longitudinal study of men with dual diagnoses of mental illness and substance abuse

Numerous studies have demonstrated a strong connection between the experience of stigma and the well-being of the stigmatized. But in the area of mental illness there has been controversy surrounding the magnitude and duration of the effects of labeling and stigma. One of the arguments that has been used to downplay the importance of these factors is the substantial body of evidence suggesting that labeling leads to positive effects through mental health treatment. However, as Rosenfield (1997) points out, labeling can simultaneously induce both positive consequences through treatment and negative consequences through stigma. In this study we test whether stigma has enduring effects on well-being by interviewing 84 men with dual diagnoses of mental disorder and substance abuse at two points in time--at entry into treatment, when they were addicted to drugs and had many psychiatric symptoms and then again after a year of treatment, when they were far less symptomatic and largely drug- and alcohol-free. We found a relatively strong and enduring effect of stigma on well-being. This finding indicates that stigma continues to complicate the lives of the stigmatized even as treatment improves their symptoms and functioning. It follows that if health professionals want to maximize the well-being of the people they treat, they must address stigma as a separate and important factor in its own right.