Effects of the mental illness label in 1993: acceptance and rejection in the community

A quantitative analysis of human rights-related attitude changes towards people with mental health conditions and psychosocial, intellectual, or cognitive disabilities following completion of the WHO QualityRights e-training in Ghana

BACKGROUND

Despite growing recognition of essential human rights, people with mental health conditions and psychosocial, intellectual, or cognitive disabilities' rights are known to be frequently violated in mental healthcare worldwide, with common use of coercive practices and limited recognition of people's right to exercise their legal capacity and make decisions for themselves on treatment and other issues affecting them. To tackle this issue, Ghana adopted the WHO QualityRights Initiative in 2019. This aims to introduce a right-based, person-centred recovery approach within the mental health care system, protecting and promoting the rights of people with mental health conditions, psychosocial, cognitive, and intellectual disabilities in the healthcare context and community.

METHODS

E-training (capacity-building) was provided in Ghana across a broad array of stakeholder groups including healthcare professionals, carers, and people with lived experience. The training covered legal capacity, coercion, community inclusion, recovery approach, service environment, and the negative attitudes commonly held by stakeholder groups; it was completed by 17,000 people in Ghana as of December 2021. We assessed the impact of the e-training on attitudes through comparing trainees' pre- and post-questionnaire responses on 17 items, each measured on a 5-point Likert scale (strongly disagree to strongly agree), such that higher scores indicated negative attitudes towards persons with mental health conditions and psychosocial disabilities as rights holders. Analyses were conducted on two main groups: matched pairs (417 pairs of baseline and follow-up questionnaire responses matched to a high degree of certainty), and the unmatched group (4299 individual completed questionnaire responses).

RESULTS

We assessed the impact of the WHO QualityRights e-training on attitudes: training resulted in highly significant attitude changes towards alignment with human rights, with scores changing by approximately 40% between baseline and follow-up. In particular, attitude changes were seen in items representing treatment choice, legal capacity, and coercion. This change was not affected by age, gender, or background experience.

CONCLUSIONS

The QualityRights e-training programme is effective in changing people's (especially healthcare professionals') attitudes towards people with mental health conditions and psychosocial, intellectual, or cognitive disabilities: this is a step towards mental healthcare being more with human rights-based worldwide.

Negative Transgender-Related Media Messages Are Associated with Adverse Mental Health Outcomes in a Multistate Study of Transgender Adults

Purpose: The purpose of this study was to examine the extent to which transgender people have observed negative transgender-related messages in the media and the relationship between negative media message exposure and the mental health of transgender people. Methods: In 2019, 545 transgender adults completed an online survey assessing demographics, negative transgender-related media messages, violence, and mental health. Separate multivariable logistic regression models examined the association of frequency of negative media exposure and clinically significant symptoms of depression, anxiety, post-traumatic stress disorder (PTSD), and global psychological distress. Results: Mean age of the sample was 31.2 years (standard deviation [SD] = 11.2). Nearly half identified as nonbinary (42.2%), 82.0% were White, non-Hispanic, 56.9% had a college degree, and 67.0% were financially insecure. The majority reported experiencing childhood abuse (60.6%) and abuse in adulthood (58.0%). The mean frequency of exposure to negative transgender-related media was 6.41 (SD = 2.9) with 97.6% of the sample reporting exposure to negative media depictions of transgender people across a range of mediums. In separate multivariable models adjusted for age, gender identity, race, education, income, and childhood/adult abuse, more frequent exposure to negative depictions of transgender people in the media was significantly associated with clinically significant symptoms of depression (adjusted odds ratio [aOR] = 1.18; 95% confidence interval [CI] = 1.08-1.29; p = 0.0003); anxiety (aOR = 1.26; 95% CI = 1.14-1.40; p < 0.0001); PTSD (aOR = 1.25; 95% CI = 1.16-1.34; p < 0.0001); and global psychological distress (aOR = 1.28; 95% CI = 1.15-1.42; p < 0.0001). Conclusion: Exposure to negative media messages from multiple sources necessitates multilevel interventions to improve the mental health of transgender people and curb stigma at its source.

Stigma, trauma and sexuality: the experiences of women hospitalised with serious mental illness

Women with serious mental illness (SMI) occupy a social position in which their experiences are simultaneously influenced by stigmatisation, institutionalisation and gendered dimensions of trauma and power. Women with SMI are stigmatised in society, pushed to the margins and left vulnerable to victimisation and rejection, particularly if hospitalised in psychiatric institutions. Using modified labelling theory, I investigate how women hospitalised with SMI, especially those who have histories of sexual abuse and trauma, experience sexuality and perceive men and masculinity. I extend modified labelling theory by empirically analysing the role of social status and power in the labelling process. Specifically, I focus on gender, and analyse interviews with 55 women in US psychiatric hospitals, focusing on gendered experiences of trauma, stigma and attitudes about sexuality. I show how trauma increases the salience of stigma and potential for retraumatisation, both of which are amplified by the institutional setting. I find meaningful differences in the narratives of women who have experienced trauma and those who have not. Modified labelling theory helps explain how labelling can perpetuate self-stigma, which threatens women's self-esteem, safety and trust in others. The intersection of these experiences extends modified labelling theory and may have profound implications for recovery.

Stigma and social support in substance abuse: Implications for mental health and well-being

Individuals with substance abuse may suffer from severe public and internalized stigma. Little is known about how social support can reduce stigma and improve mental health and well-being for them. This research examined how perceived stigma influences individuals in treatment for substance abuse, and whether internalized stigma and shame are mechanisms which link social support with better mental health and well-being. Sixty-four participants in treatment for substance abuse (alcohol, drugs), aged between 18 and 64, completed an online survey measuring perceived stigma, internalized stigma, shame, perceived social support, and mental health and well-being (self-esteem, depression and anxiety, sleep). We found that perceived stigma was associated with lower self-esteem, higher depression and anxiety, and poorer sleep. Furthermore, perceived social support followed the opposite pattern, and was associated with higher self-esteem, lower depression and anxiety, and better sleep. The effects of perceived stigma and of perceived social support on our outcome measures were mediated by internalized stigma and by internalized shame. Helping individuals with substance abuse to utilize their social support may be fruitful for combatting the negative impact of internalized stigma and shame on mental health and well-being.

Clinical profiles of stigma experiences, self-esteem and social relationships among people with schizophrenia, depressive, and bipolar disorders

Some mental illnesses and certain mental health care environments can be severely stigmatizing, which seems to be related to decreased self-esteem and a deterioration of the quality of social relationships for people with mental illness. This study aims to identify clinical profiles characterized by clinical diagnoses more strongly associated with the treatment settings and related to internalized stigma, self-esteem and satisfaction with social relationships. It also aimed to analyze associations between clinical profiles and socio-demographic indicators. Multiple correspondence analysis and cluster analysis were performed on a sample of 261 individuals with schizophrenia and mood disorders, from hospital-based and community-based facilities. MCA showed four distinct clinical profiles allowing a differentiation among levels of: internalized stigma, social relationship satisfaction and self-esteem. Overall, results revealed that internalized stigma remains a pervasive problem for some people with schizophrenia and mood disorders. Particularly, internalized stigma and social relationships dissatisfaction and associated socio-demographic indicators appear to be a risk factor for social isolation for individuals with schizophrenia, which may worsen the course of the disorder. Our findings highlight the importance to develop structured interventions aimed to reduce internalized stigma, and exclusion of those who suffer the loss of their social roles and networks.

How does direct to consumer advertising affect the stigma of mental illness?

Stigma interferes with life goals of people with mental illness. Direct-to-consumer advertising (DTCA) may impact stigmatizing attitudes. The purpose of this study is to examine the effects of psychiatric medication DTCA on the stigmatizing and affirming attitudes of the general population versus individuals self-identified with mental illness. Participants (n = 272) were randomly assigned to watch a DTCA about Cymbalta, an antidepressant, embedded in two other advertisements for non-pharmaceutical products. Participants completed measures of stigmatizing and affirming attitudes before and after viewing this DTCA. Results indicate that the Cymbalta DTCA worsened the attitudes of the general public. These participants were less likely to offer help, endorse recovery, and agree with self-determination attitudes towards people with mental illness following viewing the DTCA. The self-identified group reported less blame, less dangerousness, less social avoidance, more pity, and greater willingness to help after viewing the DTCA. Moreover, there was significant improvement in their endorsement of recovery. Results suggest that DTCAs about psychiatric medication may increase the public's stigma towards people with mental illness but reduce stigma among individuals who identify as having a mental illness. Findings are somewhat limited by selection biases and self-report. Implications for further development of DTCAs are considered.

Genetic attributions and mental illness diagnosis: effects on perceptions of danger, social distance, and real helping decisions

Genetic essentialism suggests that beliefs in genetic causes of mental illness will inflate a desire for social distance from affected individuals, regardless of specific disorder. However, genetic contingency theory predicts that genetic attributions will lead to an increased desire for social distance only from persons with disorders who are perceived as dangerous.

PURPOSE

To assess the interactive effect of diagnosis and attribution on social distance and actual helping decisions across disorders.

METHODS

Undergraduate students (n = 149) were randomly assigned to read one of the six vignettes depicting a person affected by one of the three disorders (i.e., schizophrenia, bipolar disorder, or major depression) with either a genetic or environmental causal attribution for disorder. Participants completed measures of perceived dangerousness, social distance, empathic concern, familiarity with mental illness, and actual helping decisions.

RESULTS

When provided with genetic attributions, participants' desire for social distance was greater for targets with schizophrenia relative to targets with depression or bipolar disorder. This effect was mediated by perceived dangerousness. The indirect effect of diagnosis on helping decisions, through social distance, was significant within the genetic attribution condition.

CONCLUSION

Consistent with genetic contingency theory, genetic attributions for schizophrenia, but not affective disorders, lead to greater desire for social distance via greater perceived dangerousness. Further, results suggest that genetic attributions decrease the likelihood of helping people with schizophrenia, but have no effect on the likelihood of helping people with affective disorders. These effects are partially accounted for by desired social distance from people with schizophrenia.

The effect of parental intellectual disability status on child protection service worker decision making

BACKGROUND

There is evidence to suggest that parents with an intellectual disability (ID) constitute a higher proportion of child-protective services (CPS) cases than would be expected based on the prevalence of ID in the general population. Researchers have suggested that the stereotypic assumptions and expectations that CPS workers have about parents with an ID might influence decisions and responses made to such parents. This study examined whether parental ID (having an ID vs. not) had an effect on CPS workers' emotional reactions, attributions and decisions about risk to the child, whether to remove the child and workers' general willingness to help the parent.

METHOD

Two hundred and twelve CPS workers read vignettes describing parents who were labelled as either having or not having an ID. Workers responded to the vignettes by making ratings of their emotional reactions, attributions and decisions regarding risk, removal and helping.

RESULTS

CPS workers made significantly higher ratings of pity, willingness to help and risk for parents with an ID than for parents without an ID. Lower ratings of anger and disgust were found for parents with an ID than for parents without an ID. Parents' intellectual status did not have a direct effect on workers' attributions or removal decisions.

CONCLUSIONS

The results show evidence for the influence of stereotypes regarding parental ID due to its differential effect on CPS workers' emotional reactions and decisions about child risk and their willingness to help.

The 'side effects' of medicalization: a meta-analytic review of how biogenetic explanations affect stigma

Reducing stigma is crucial for facilitating recovery from psychological problems. Viewing these problems biomedically may reduce the tendency to blame affected persons, but critics have cautioned that it could also increase other facets of stigma. We report on the first meta-analytic review of the effects of biogenetic explanations on stigma. A comprehensive search yielded 28 eligible experimental studies. Four separate meta-analyses (Ns=1207-3469) assessed the effects of biogenetic explanations on blame, perceived dangerousness, social distance, and prognostic pessimism. We found that biogenetic explanations reduce blame (Hedges g=-0.324) but induce pessimism (Hedges g=0.263). We also found that biogenetic explanations increase endorsement of the stereotype that people with psychological problems are dangerous (Hedges g=0.198), although this result could reflect publication bias. Finally, we found that biogenetic explanations do not typically affect social distance. Promoting biogenetic explanations to alleviate blame may induce pessimism and set the stage for self-fulfilling prophecies that could hamper recovery from psychological problems.

California's historic effort to reduce the stigma of mental illness: the Mental Health Services Act

In a historic effort to reduce the stigma of mental illness, California voters approved the Mental Health Services Act in 2004. The law funds a comprehensive statewide prevention initiative that places stigma and discrimination reduction at its center, with 25 projects providing interventions at the institutional, societal, and individual levels. Stakeholders selected specific strategies from the research-based California Strategic Plan on Reducing Stigma and Discrimination. Strategies range from social marketing to increase public knowledge to capacity building at the local level, including training that emphasizes participation by consumers of mental health services and cultural competence. Collectively, these strategies aim to foster permanent change in the public perception of mental illness and in the individual experience of stigma. We examined the context, planning, programming, and evaluation of this effort.

Stigma as a fundamental cause of population health inequalities

Bodies of research pertaining to specific stigmatized statuses have typically developed in separate domains and have focused on single outcomes at 1 level of analysis, thereby obscuring the full significance of stigma as a fundamental driver of population health. Here we provide illustrative evidence on the health consequences of stigma and present a conceptual framework describing the psychological and structural pathways through which stigma influences health. Because of its pervasiveness, its disruption of multiple life domains (e.g., resources, social relationships, and coping behaviors), and its corrosive impact on the health of populations, stigma should be considered alongside the other major organizing concepts for research on social determinants of population health.

Volunteering in the care of people with severe mental illness: a systematic review

BACKGROUND

Much of the literature to date concerning public attitudes towards people with severe mental illness (SMI) has focused on negative stereotypes and discriminatory behaviour. However, there also exists a tradition of volunteering with these people, implying a more positive attitude. Groups with positive attitudes and behaviours towards people with SMI have received relatively little attention in research. They merit further attention, as evidence on characteristics and experiences of volunteers may help to promote volunteering. The present paper aims to systematically review the literature reporting characteristics, motivations, experiences, and benefits of volunteers in the care of people with SMI.

METHODS

In November 2010, a systematic electronic search was carried out in BNI, CINAHL, Embase, Medline, PsycINFO, Cochrane Registers and Web of Science databases, using a combination of 'volunteer', 'mental health' and 'outcome' search terms. A secondary hand search was performed in relevant psychiatric journals, grey literature and references.

RESULTS

14 papers met the inclusion criteria for the review, with data on a total of 540 volunteers. The results suggest that volunteers are a mostly female, but otherwise heterogeneous group. Motivations for volunteering are a combination of what they can 'give' to others and what they can 'get' for themselves. Overall volunteers report positive experiences. The main benefit to persons with a psychiatric illness is the gaining of a companion, who is non-stigmatizing and proactive in increasing their social-community involvement.

CONCLUSIONS

The evidence base for volunteers in care of people with SMI is small and inconsistent. However there are potential implications for both current and future volunteering programmes from the data. As the data suggests that there is no 'typical' volunteer, volunteering programmes should recruit individuals from a variety of backgrounds. The act of volunteering can not only benefit people with SMI, but also the volunteers. Further research may specify methods of recruiting, training, supervising and using volunteers to maximise the benefit for all involved.

Differences in attributions of mental illness and social distance for portrayals of four mental disorders

For individuals with mental illness, others' perceptions of mental illness often limit integration into communities. Perceptions of mental illness manifest as social stigma in the form of social distance and may depend on individuals' attributions of the origins of mental illness. 180 university students completed a survey on attribution of mental illness and social distance across several disorders (psychiatric and physical). Participants indicated greater social distance for severe mental illness (i.e., schizophrenia) than less severe mental illness and physical illness. More desire for social distance may be related to unfamiliarity with severe mental illness rather than less severe mental and physical illnesses. Greater understanding of how individuals perceive mental illness can inform efforts to educate the public.

Physical proximity in anticipation of meeting someone with schizophrenia: the role of explicit evaluations, implicit evaluations and cortisol levels

It has been suggested that the study of the stigma of mental illness should include more behavioral measures and further investigation of the possible importance of implicit evaluations in predicting responses to those with such illness. In the current paper, we report a study testing the relationship of implicit and explicit evaluations to physical proximity and cortisol levels in anticipation of meeting someone with schizophrenia. The results showed that both explicit evaluations and cortisol levels independently predicted physical proximity. Implicit evaluations were not related to either physical proximity or cortisol levels. The findings suggest that there are aspects of emotional response to those with mental illness that are not reflected in explicit measures of evaluation and that these, as well as explicit responses, can contribute to the prediction of behavior.

Mental illness stigma and willingness to seek mental health care in the European Union

OBJECTIVE

It is often assumed that individual stigmatizing attitudes toward the mentally ill are linked to stigmatizing attitudes in the social milieu and that both, individual and social stigmatizing attitudes are major barriers to mental health treatment seeking. This study aims to examine these assumptions.

METHOD

Data from the 2005-2006 Eurobarometer general population survey (N = 29,248) are used to examine the association of social stigmatizing attitudes assessed in a random half of the sample with individual stigmatizing attitudes assessed in the other half of the sample, and to examine the association of both individual and social stigmatizing attitudes with willingness to seek professional help.

RESULTS

Social stigmatizing attitudes are specifically and strongly associated with individual stigmatizing attitudes. Both social and individual stigmatizing attitudes are associated with willingness to seek professional help. Believing the mentally ill to be dangerous or not likely to recover, or living in a community with such beliefs, are associated with increased willingness to seek help; whereas, believing the mentally ill to be unpredictable or blameworthy for their illness, or living in a community with strong beliefs in blameworthiness of the mentally ill, are associated with decreased willingness to seek professional help.

CONCLUSION

The view that all stigmatizing attitudes toward mental illness are associated with reluctance to seek professional help may be naive as some stigmatizing attitudes may be associated with increased willingness to seek help. The complex association of different stigmatizing attitudes with professional help seeking should be carefully considered in planning anti-stigma campaigns.

The relationship of multiple aspects of stigma and personal contact with someone hospitalized for mental illness, in a nationally representative sample

The stigma of mental illness has been shown to be affected by personal contact with mental illness and by a belief in the genetic heritability of mental illness. We use data from a nationally representative survey to test whether the relationship of stigma with contact remains after taking into account the effects of genetic beliefs and other background characteristics. Contact was defined as a history of psychiatric hospitalization among respondents themselves, their family members, or their friends. Respondents answered questions about a vignette character with a mental illness. We found that respondents with contact felt less anger and blame toward the character, thought that the character had a more serious problem, and would want less social distance from the character, including both casual and intimate aspects of social distance. Respondents with contact were not significantly different from the general population in the degree to which they expressed sympathy, thought the problem would last a lifetime, or wanted to restrict reproduction. Thus, contact is associated with having a less ostracizing, critical attitude toward a stranger with mental illness. The results underscore the importance of this experienced group as a resource in fighting stigma in society. Since many people who have had a psychiatric hospitalization have not told their friends or family members about it, this lower-stigma group could be enlarged.

Stereotype threat contributes to social difficulties in people with schizophrenia

OBJECTIVE

The experience of stereotype threat (where the prospect of conforming to a stereotype, or of being treated in terms of it, becomes self-threatening) affects members of social groups about whom devaluing stereotypes exist. Although a widely endorsed stereotype of schizophrenia concerns social skill impairment, it is unclear whether the experience of stereotype threat impacts social functioning in this group. The purpose of the present study was to test whether people with schizophrenia would perform more poorly in a social setting in which they felt stereotyped as mentally ill.

METHODS

Thirty individuals with schizophrenia engaged in conversations with two confederates, one of whom they were told knew nothing about them (control conversation), and the other of whom they were told had been informed of their diagnosis (stereotype threat conversation). In reality, neither confederate had been informed of participants' mental health status.

RESULTS

Although participants with schizophrenia did not perceive any differences in their own social behaviour across the two conditions, their social skill was rated by the confederates as poorer in the stereotype threat conversation on three out of the six measures used.

CONCLUSIONS

These results suggest that social skill difficulties in people with schizophrenia may be exacerbated by their awareness that others know of their diagnosis. These findings have implications for disclosure of mental health status.

`They Don't Like Our Kind': Consequences of Being Ostracized While Possessing a Group Membership

Individuals are ostracized nearly on a daily basis, which thwarts the satisfaction of fundamental needs and is painful (Williams, 2007). While facing prejudice or discrimination, possessing a group membership can be self-protective (Crocker & Major, 1989) or harmful, depending on group identification (Schmitt & Branscombe, 2002a). How will individuals react to ostracism when a group membership attribution is available? Participants were ostracized or included during Cyberball, a virtual online ball-tossing game, while possessing a temporary, permanent, or no group membership. Participants reported need satisfaction and mood during the game and after a short delay to assess recovery. Initially, ostracized participants felt equally distressed. Possessing a permanent group membership resulted in slower recovery compared to possessing a temporary group membership.

Reducing the stigma of mental illness among adolescents and young adults: the effects of treatment information

The stigma of mental illness is pervasive in adolescents and interferes with treatment and overall life quality for those with disorders. A strategy for reducing stigma is to create awareness of counterstereotypes that can undermine the perceived homogeneity of the stigmatized group and promote help seeking for those with the illness. This study tested the strategy by presenting counterstereotypical information about the effectiveness of treatment for major depression in a national survey of youth ages 14 to 22 (N = 1,258), some of whom had experienced symptoms of depression (N = 284). The information was presented either before or after evaluating an untreated person with major depression. Despite the stigma of the mental illness stereotype, respondents reported lower levels of unfavorable stereotype expectations and reduced stigma for an individual with major depression who had been successfully treated compared with one who was not treated. The effect was robust across differences in beliefs about treatment efficacy and experiences with symptoms of depression; it was even stronger when the counterstereotypical information was presented after respondents evaluated an untreated person. The results indicate that messages focusing on persons who have been successfully treated are part of a promising strategy for reducing the stigma of mental illness in young people.

The role of perceived norms in the stigmatization of mental illness

BACKGROUND

Past research on stigmatization of the mentally ill has emphasized the importance of beliefs about mental illness in determining preferred social distance to those with such illnesses. In the current paper we examine the importance of perceived social norms in improving the prediction of social distance preferences.

METHODS

Two hundred university students completed scales measuring their beliefs about either depression or schizophrenia; their perception of relevant social norms and their preferred level of social distance to someone with schizophrenia or depression. Measures of social desirability bias were also completed.

RESULTS

The proportion of variance in preferred social distance was approximately doubled when perceived norms were added to beliefs about illness in a regression equation. Perceived norms were the most important predictor of social distance to an individual with either illness. A general preference for social distance towards a control, non-ill person was also an independent predictor of behavioral intentions toward someone with either schizophrenia or depression.

CONCLUSIONS

Perceived social norms are an important contributor to an individual's social distance to those with mental illness. Messages designed to influence perceived social norms may help reduce stigmatization of the mentally ill.

Construing stigmatized identities: a golden section study

OBJECTIVES

In order to examine whether persons belonging to stigmatized groups are evaluated more negatively than others, this study employed the golden section hypothesis, which predicts that people organize their evaluations in a ratio of roughly 62% positive to 38% negative.

METHOD

Surveys were administered to 154 participants, with 143 surveys analysed. Participants rated nine different identities (business person, politician, lawyer, police officer, college professor, criminal, mental patient, homeless person, and self) along 12 different bipolar dimensions (generous-stingy, pleasant-unpleasant, true-false, fair-unfair, active-passive, energetic-lethargic, sharp-dull, excitable-calm, strong-weak, bold-timid, hard-soft, and rugged-delicate). These dimensions had well-established positive and negative poles.

RESULTS

Non-stigmatized identities were evaluated slightly more positively than the golden section hypothesis predicts, while stigmatized identities were rated in a 'reverse' golden section pattern. A criminal identity was rated more negatively than the golden section hypothesis predicts and the self more positively. Follow-up analyses suggested that the percentages of positive adjectives assigned to the self and non-stigmatized others were consistent with a model that expands upon the golden section hypothesis.

CONCLUSION

Stigmatized identities are rated using a reverse golden section ratio. This has implications for understanding how people construe stigmatized people. While the golden section hypothesis did not hold for non-stigmatized identities, this may be because the data are better explained by a more refined model that is slightly different from the golden section.

Stigma as related to mental disorders

Individuals with mental illness receive harsh stigmatization, resulting in decreased life opportunities and a loss of independent functioning over and above the impairments related to mental disorders themselves. We begin our review with a multidisciplinary discussion of mechanisms underlying the strong propensity to devalue individuals displaying both deviant behavior and the label of mental illness. Featured is the high potential for internalization of negative perceptions on the part of those with mental disorders-i.e., self-stigmatization. We next focus on several issues of conceptual and practical relevance: (a) stigma against less severe forms of mental disorder; (b) the role of perceptions of dangerousness related to mental illness; (c) reconciliation of behavioral research with investigations of explicit and implicit attitudes; (d) evolutionary models and their testability; (e) attributional accounts of the causes of mental illness, especially to personal control versus biogenetic factors; and (f) developmental trends regarding stigma processes. We conclude with a brief review of multilevel efforts to overcome mental illness stigma, spanning policy and legislation, alterations in media depictions, changed attitudes and practices among mental health professionals, contact and empathy enhancement, and family and individual treatment.

Reducing stigma by meeting and learning from people with mental illness

OBJECTIVE

This study examines the effects of a public education program, developed in large part by consumers of mental health services, on the attitudes of high school students toward people with mental illnesses.

METHODS

Four hundred and twenty-six students were provided an informational session delivered by consumers and a faculty member from the University of Medicine and Dentistry of New Jersey (UMDNJ). The content of these sessions included facts about mental illness, characteristic symptoms, recovery strategies, and personal stories told by the consumer presenters. The students' attitudes were assessed pre- and post-session using the Attribution Questionnaire-Short Form for Children. Independent samples t-tests were used to assess changes in attitudes from pre- to post-assessment.

RESULTS

After viewing these presentations, students reported less stigmatizing views toward people with mental illness on seven of the nine factors and the total scale score.

CONCLUSIONS

A 1-hour informational session developed and facilitated by consumers of mental health services can significantly affect the attitudes of adolescents toward people with major mental illnesses. Future studies will evaluate the sustainability of attitude changes as the result of these presentations, as well as the effects of demographic and socioeconomic differences on attitude change.

Measuring self-stigma of mental illness in China and its implications for recovery

This study translated and validated the Chinese Version of the Self-stigma of Mental Illness Scale (CSSMIS), which may be used to measure self-stigma of mental health consumers in China. We also examined its correlation with self-esteem, self-efficacy and psychosocial treatment compliance. A cross-sectional observational study was implemented. Some 51 males and 57 females who suffered from severe mental illness were recruited from psychiatric settings in Hong Kong. They were required to complete the Chinese Version of the Self-stigma of Mental Illness Scale, the Rosenberg Self-esteem Scale and the Self-efficacy Scale. Their level of compliance during psychosocial treatment and their demographic information were recorded by their case managers. Exploratory factor analysis revealed two homologous factors for the four subscales of the CSSMIS. Factor 1 was related to the negative beliefs and consequences of having mental disorders, whereas Factor 2 was related to positive beliefs. The perceived stigma subscale and the three self-stigma subscales were strongly inter-correlated. Significant correlations were also found between almost all subscales of the CSSMIS and the remaining scales. The psychometric properties of the CSSMIS are statistically acceptable. The results also suggest that stigma played a detrimental role in undermining self-esteem, self-efficacy and psychosocial treatment compliance. Implications for recovery of mental health consumers are discussed.

An investigation of stigma in individuals receiving treatment for substance abuse

This study examined the impact of stigma on patients in substance abuse treatment. Patients (N=197) from fifteen residential and outpatient substance abuse treatment facilities completed a survey focused on their experiences with stigma as well as other measures of drug use and functioning. Participants reported experiencing fairly high levels of enacted, perceived, and self-stigma. Data supported the idea that the current treatment system may actually stigmatize people in recovery in that people with more prior episodes of treatment reported a greater frequency of stigma-related rejection, even after controlling for current functioning and demographic variables. Intravenous drug users, compared to non-IV users, reported more perceived stigma as well as more often using secrecy as a method of coping. Those who were involved with the legal system reported less stigma than those without legal troubles. Higher levels of secrecy coping were associated with a number of indicators of poor functioning as well as recent employment problems. Finally, the patterns of findings supported the idea that perceived stigma, enacted stigma, and self-stigma are conceptually distinct dimensions.

Will filmed presentations of education and contact diminish mental illness stigma?

This study examines the impact of two versions of anti-stigma programs-education and contact-presented on videotape. A total of 244 people were randomly assigned to education or contact conditions and completed pre-test, post-test, and follow-up measures of stereotypes. Results suggest that the education videotape had limited effects, mostly showing improvement in responsibility (people with mental illness are not to blame for their symptoms and disabilities). Watching the contact videotaped showed significant improvement in pity, empowerment, coercion, and segregation. Contact effects were evident at post-test and 1 week follow-up. Implications of these findings for future research are discussed.

Psychophysiological evaluation of stigma towards schizophrenia

Stigma is a potentially destructive phenomenon that may result in negative consequences for individuals diagnosed or labeled as having a mental illness. Several recent studies suggest that contact with various stigmatized out-group members result in psychophysiological reactions indicative of negative affect. It is unclear whether such reactions extend to encounters with individuals with mental illness. Participants imagined interacting with individuals labeled or unlabeled as having schizophrenia, while corrugator supercilii (brow) EMG, palmer skin conductance, and heart rate activity were monitored. Participants were 15 males and 20 females mainly African American students between the ages of 18 and 28 who attended a historically black university in the Southeastern region of the United States. Participants reported higher SUDS ratings and exhibited higher brow muscle tension during imagery with labeled than non-labeled individuals. Psychophysiological reactivity predicted global self-reported attitudes of stigma towards labeled individuals. The findings suggest that one reason why individuals avoid individuals with mental illness is physiological arousal, which is likely experienced as negative.

How stigma interferes with mental health care

Many people who would benefit from mental health services opt not to pursue them or fail to fully participate once they have begun. One of the reasons for this disconnect is stigma; namely, to avoid the label of mental illness and the harm it brings, people decide not to seek or fully participate in care. Stigma yields 2 kinds of harm that may impede treatment participation: It diminishes self-esteem and robs people of social opportunities. Given the existing literature in this area, recommendations are reviewed for ongoing research that will more comprehensively expand understanding of the stigma-care seeking link. Implications for the development of antistigma programs that might promote care seeking and participation are also reviewed.

Target-specific stigma change: a strategy for impacting mental illness stigma

In the past decade, mental health advocates and researchers have sought to better understand stigma so that the harm it causes can be erased. In this paper, we propose a target-specific stigma change model to organize the diversity of information into a cogent framework. "Target" here has a double meaning: the power groups that have some authority over the life goals of people with mental illness and specific discriminatory behaviors which power groups might produce that interfere with these goals. Key power groups in the model include landlords, employers, health care providers, criminal justice professionals, policy makers, and the media. Examples are provided of stigmatizing attitudes that influence the discriminatory behavior and social context in which the power group interacts with people with mental illness. Stigma change is most effective when it includes all the components that describe how a specific power group impacts people with mental illness.