Stigmatizing attitudes toward mental illness, individuals suffering from mental illness, and psychological service utilization are widespread. They result in social isolation, reduced opportunities, and outright discrimination against affected individuals (Gaebel, Zäske, Baumann, Klosterkötter, Maier, & Decker et al., 2008). The negative effects of stigma also extend to the families of individuals with mental illness, their close relationships, and even the professionals who work with them (Goffman, 1963; Sadow & Ryder, 2008). This stigma is associated with treatment underutilization, treatment delay, and premature termination (Masuda et al., 2007; Gaebel et al., 2008; Gould, Greenberg, & Hetherton, 2007; Corrigan, 2004).
Definitions & Understandings of Stigma
In his classic text on stigma as “spoiled identity,” Goffman (1963) describes stigma as a visible or invisible ‘mark’ that disqualifies its bearer from full social acceptance. Mental illness marks affected individuals as having “blemishes of individual character,” the acquisition of which “spoils” their identities and removes them from their place within the social hierarchy. While some argue that stigma should be clearly distinguished from discrimination, others define stigma as a multilevel interaction between affective, cognitive, behavioral, and contextual aspects. Campbell & Deacon (2006) elaborate:
The failure of individual-level approaches to effect widespread stigma reduction has led to an alternative focus on the links between stigma and wider macro-social inequalities (e.g. gender, ethnicity). Such analyses suggest that stigma is not something that individuals impose on others, but a complex social process linked to competition for power, tied into existing mechanisms of dominance and exclusion (Parker and Aggleton, 2003). Macro-social analyses imply that interventions such as anti-discrimination legislation or poverty-reduction will assist in stigma reduction. But taking this view can mean that researchers pay little attention to the individual psychological dimensions of stigma (2006, p. 412).
Those individual psychological dimensions, it is argued, have their basis in a universal human need to project fears of uncertainty and danger onto stigmatized ‘out-groups.’ The universality of this need can be seen in the separation and stigmatization of out-groups across cultures—the targets of stigma vary widely based on local power differentials, but the process of stigmatization can be seen anywhere (Joffe, 1999). For example, the stigmatization of HIV/AIDS sufferers in late-twentieth century United States culture helped to reinforce “middle American” morality through its association with marginalized out-groups who failed to meet prevalent social expectations: intravenous drug users, homosexual men, and prostitutes (Crawford, 1994). While applications of this principle to the stigma currently associated with mental illness can certainly be surmised, no research on the moral bases of mental health stigma could be found.
Why Mental Health Stigma is a Problem
Regardless of its causes, mental illness stigma has been found to pose a major barrier to some of the most basic tasks of life, such as establishing and maintaining friendships, employment, and housing. Stigma has also been found to significantly interfere with access to and outcomes for both psychological treatment and general medical treatment (Sadow & Ryder, 2008). Through shame, humiliation, and damage to the affected individual’s sense of self, stigma negatively impacts the likelihood of service utilization and treatment compliance. Consequently, patients who score higher of measures of stigmatizing attitudes are at higher risk for negative outcomes (Gould, Greenberg, & Hetherton, 2007; Corrigan, 2004). Stigmatizing attitudes have also been observed among students and professionals from many segments of medical and psychological service. As a result, people diagnosed with mental illness receive fewer medical services and a reduced range of insurance benefits; (Sadow & Ryder, 2008).
Review of Interventions for Mental Health Stigma
Corrigan & O’Shaughnessy (2007) list three main avenues for addressing the stigma associated with mental illness: protest, education, and contact. While each of these avenues has some degree of validity on its face, the efficacy of interventions based on any of these principles leaves much to be desired. Of the three, only direct contact has shown any effectiveness in reducing stigmatizing attitudes toward mental illness over an extended period of time.
Protest Interventions
Protest tactics involve directly challenging negative or stigmatizing representations of mental illness in the popular media in order to undermine the cultural maintenance of those representations. The primary means of protesting stigmatization in popular media is by way of economic boycott. Organized boycotts and threats of boycott from advocacy groups targeting the producers, distributors, and advertisers responsible for entertainment commodities have been successful in removing stigmatizing materials from public view in at least two instances.
An ABC television series called Wonderland depicted a person with mental illness behaving in a violent and sadistic manner. After intense targeting from mental health advocacy groups directed both at the network and the show’s advertisers, the show was discontinued after just a few episodes. Another instance cited by Corrigan & O’Shaughnessy (2007) is the advertising campaign leading up to the release of the comedy film Crazy People. Advocacy groups threatening Paramount Pictures with potential economic consequences convinced the company to remove movie posters depicting a large cracked egg with arms and a caption reading “Warning: Crazy people are coming.”
Despite these apparent successes, no empirical research has demonstrated that such efforts have a positive impact on the general public’s prejudices toward individuals with mental illness. In fact, the opposite may be true; some research suggests that protest strategies may produce an “attitude rebound.” The negativistic nature of protest interventions, which fail to provide positive alternatives to the attitudes they seek to undermine, seems to inspire an overall worsening of the public’s stigmatizing attitudes (Corrigan et al., 2001).
Educational Interventions
The educational approach, on the other hand, seeks to cultivate accepting attitudes toward mental illness by disseminating accurate information and dispelling myths about mental illness, such as the popular beliefs that persons suffering from mental illness are more likely to commit violence, or that mentally ill individuals are unable to be productive in the work force (Corrigan & O’Shaughnessy, 2007; Corrigan et al. 2001). The basis for this approach rests on a number of studies that have found individuals who are more knowledgeable about mental illness to hold fewer stigmatizing attitudes. Additionally, educational strategies for reducing stigma tend to be attractive to both researchers and policy-makers because they are affordable and easily reproducible. Some educational instruments that have been used in this way in the past include public service announcements, flyers, books, and informative videos.
Educational approaches are also the most-studied form of intervention for reducing mental health stigma. Unfortunately, the research seldom supports their effectiveness. Many studies have found significant reductions on stigmatizing attitudes through exposure to college courses or informational sessions, but the magnitude and duration of the effects tends to be very limited. Furthermore, the effects of educational interventions correlate to participants’ knowledge of mental illness prior to participation in the educational programs, indicating that the effects of education-based interventions may primarily reflect the attitudes of participants who had already agreed with the programs’ messages (Corrigan & O’Shaughnessy, 2007).
One notable implementation of the educational approach to stigma reduction has been the UK Royal Navy’s trauma risk management (TRiM) program, which seeks to improve recognition of and response to PTSD by reducing the stigma associated with the diagnosis. The TRiM program trains nonmedical personal in basic assessment of trauma risk and the administration of psychological first aid. The training encompasses only traumatic stressors and seeks only to facilitate early referral to appropriate counseling services. According to Gould, Greenberg, & Hetherton (2007), “the aims for participants are to understand PTSD and stress reactions, so that negative representations of mental illness are modified, and the problems associated with other posttraumatic management strategies (e.g., PD) are addressed” (p.507).
While the TRiM program does encourage individuals to share their experiences of stress and stress-related problems in order to reduce stigma, the program’s primary intervention is to provide education about the effects of traumatic stress and ways of assessing for risk and symptoms of PTSD. A brief longitudinal study of personnel who volunteered to receive this training found both significantly improved attitudes toward stress-related ailments and increased help-seeking. However, in light of evidence that attitudinal effects are unlikely to be maintained over the long-term, the study was severely limited by lack of follow-up. Additionally, the authors note that highly stigmatizing individuals tend to be those least likely to volunteer to attend educational packages, further weakening the evidence for this intervention’s effectiveness. In spite of these shortcomings, the study’s authors argue that the tightly integrated structure of the military organization makes it more susceptible to real-world improvements as a result of this type of intervention than the population at large (Gould et al., 2007).
Direct Contact Interventions
Among the general population, the most effective methods of reducing stigma appear to be those which facilitate direct contact between individuals with mental illness and members of the general population. Researchers have consistently found that greater levels of personal familiarity with mentally ill individuals tend to equate with fewer prejudicial attitudes toward mental illness. Additionally, while some reduction of stigmatizing attitudes can result from the disclosure of popular figures such as celebrities who disclose their experiences with mental illness, greater effects result from the disclosures of individuals perceived to be more similar to the recipient of the message, people “just like me” (Corrigan & O’Shaughnessy, 2007).
One program that has sought to reduce stigma using this direct-contact approach is the National Alliance for Mental Illness (NAMI) In Our Own Voice program, in which mentally ill individuals share their history and experiences with treatment in a workshop format. Audience members are encouraged to asked questions and interact with the presenters. Preliminary research has shown good initial responses from program participants along with promising reductions in stigmatizing attitudes several weeks after their participation in the program (Corrigan & O’Shaughnessy, 2007).
There are several difficulties in implementing contact-based interventions, not least of which is that they require disclosure from individuals living with mental illness. This type of disclosure puts the mentally ill participants at risk to experience the exact stigma which the interventions would hope to circumvent. While much greater reductions result from programs which put mentally ill individuals in contact with members of the general population, the effect may be insufficient to warrant this added risk. Furthermore, there is some evidence that the segments of the population who hold the most stigmatizing attitudes are also the least likely to become involved in this type of program (Corrigan & O’Shaughnessy, 2007).
One area in which this risk may be both minimized and justified is in the training of future health professionals. Sadow & Ryder (2008) have performed a number of studies aimed at decreasing stigmatizing attitudes towards mental illness among this group, typically with poor results. Various educational efforts that did not include personal contact with mentally ill individuals, including training programs which utilized videos of presentations by such individuals were not effective in reducing stigma among nursing students. However, when personal presentations by individuals with mental illness were presented in the classroom and followed by an opportunity to process the experience with a psychologist, stigmatizing attitudes were significantly decreased among this group. This is an important finding given our previous discussion of the dangers of mental health stigma among healthcare providers.
In their review of contact-based interventions to reduce stigma among schoolchildren, Pettigrew & Tropp (2000) identify five factors which they see as necessary for optimal stigma-reducing contact: equal status between majority and minority groups; a shared goal between members of both groups; a cooperative, rather than competitive, framework for accomplishing the common goal; institutional support for the interactions between members of each group; and minority members who moderately disconfirm the prejudicial stereotypes about their group. However, the efficacy of these school-based programs has been disappointing, with most studies showing mixed results or no differences in stigmatizing attitudes among the exposed children. On top of this, the risk of amplifying stigmatization is increased when working with children, as Corrigan & O’Shaughnessy (2007) argue:
The threat of “coming out of the closet” once again becomes a key factor in realising this kind of contact. Decisions need to be made as to whether children with mental illness will disclose their group status in order to facilitate contact effects. This means that some parents of children with mental illness, who are rightfully concerned about their child’s socialisation and education, must risk their child being stigmatised to attempt this kind of friendship building. Moreover, the mother and father must risk experiencing family stigma that suggests, for example, that bad parenting produced their child’s mental illness (p. 94).
Another notable shortcoming of contact-based approaches to reducing stigma is that they may be limited in the scope of attitudinal change they can realistically effect. While contact with mentally ill individuals helps to undermine beliefs that such individuals pose an immediate physical danger, it is less likely to affect other types of stigmatizing thoughts and feelings, such as overall anxiety and thoughts about “us versus them” (Masuda et al., 2007).
A Large-Scale Combined Interventive Approach
The World Psychiatric Association (WPA) has been working to implement a combined program including all three of the discussed strategies for stigma reduction through their “Global Program Against Stigma and Discrimination Because of Schizophrenia — Open The Doors.” In cooperation with the German Research Network on Schizophrenia, this program has been implemented as a large-scale controlled trial throughout Germany since 2001. Anti-stigma intervention programs, schizophrenia awareness intervention programs, and a no-intervention control condition were each assigned to two German cities. Cities were relatively homogenous in terms of population, with each city being home to a university-affiliated department of psychiatry and offering free psychiatric services to the community (Gaebel et al., 2008).
Several strategies were employed in the anti-stigma intervention cities. Educational programs were targeted at influential groups such as health professionals and educators, and direct-contact programs were initiated. These consisted of “lectures at adult education centers, art exhibitions, cinema events, readings, theatre events, and charity concerts. Most events included panel discussions with mental health professionals as well as people who were affected by mental illness as participants. Prior to the events, press conferences were held and/or press mailings were distributed. Furthermore, press workshops about schizophrenia and its misconceptions in the public were conducted to improve the reporting in the mass media about schizophrenia and mental illness in general” (Gaebel et al., 2008, p.185) Protest actions were also orchestrated to discourage structural discrimination and stigmatizing messages.
The researchers hypothesized a reduction in total mental health stigma in anti-stigma intervention cities, with no comparable reduction in the cities receiving awareness programs or no intervention. Stigmatizing attitudes were measured using pre- and post-testing of representative samples of each cities population via telephone survey. The results showed small but significant reductions in stigmatizing attitudes in the anti-stigma intervention cities, with most of the change relating to measures of perceived social distance in transient situations. The average citizen in these cities reported significantly more comfort having incidental day-to-day interactions with persons with schizophrenia in 2004 than in 2001, but was no more likely to be involved in repeated social or professional contact with these individuals (Gaebel et al., 2008).
An Alternative Approach: Cognitive Restructuring
A fourth method for reducing mental health stigma is the use of cognitive restructuring. For example, Sadow & Ryder (2008) describe a method of “turning the tables” on stigma within healthcare training programs by using the technique of “inspirational recruitment,” in which poorly paid and unpleasant work is elevated to the status of a noble cause. They cite a previous study in which this technique increased the rate at which psychiatry students were able to be recruited into otherwise undesirable positions working with severe mental illnesses in public health clinics.
Few other studies have utilized this more psychologically informed approach to stigma reduction, and we are aware of no studies which attempt to reduce stigma among the general population using similar techniques. However, modern understandings of perception and belief certainly make cognitive restructuring an attractive option, particularly in light of the previously cited evidence for its potential. This is a direction that stigma researchers should definitely be turning toward in the coming years, in both community psychology settings and clinical training programs.
Acceptance and Commitment Therapy As a Stigma Intervention
A similarly oriented approach is the use of Acceptance and Commitment Therapy (ACT) to reduce stigma. This approach addresses stigma only indirectly; ACT “uses acceptance, mindfulness, and value-directed behavioral change strategies in order to increase psychological flexibility” (Masuda et al., 2007, p. 2765). According to Masuda et al., research has supported the idea that increased self-acceptance produces increased empathy. While contact-based education only undermines beliefs about danger, ACT addresses the overarching avoidance of discomfort by increasing acceptance.
For example, in a study on substance abuse counselors, multicultural training reduced stigmatizing attitudes toward racial and cultural groups immediately after the intervention, but not at three-month follow-up. On the other hand, an ACT intervention which encouraged counselors to reflect on the automatic nature of judgmental processes and the “paradoxical effect of deliberate attempts to eliminate both self-stigma and stigmatizing attitudes” (Masuda et al., 2007, p. 2766) showed much better results. The ACT intervention reduced both stigmatizing attitudes among the counselors as well as measures of workplace burnout at follow-up.
Refocusing on more general factors like mental flexibility as contributors to stigma can also help to clarify the mixed results typically seen when other tactics are used. One study subjected college students to a single 2 1/2 hour ACT workshop focused on stigmatizing attitudes toward mental illness. Prior to the intervention, it was found that students with a lower level of general mental flexibility were more stigmatizing than their more flexible counterparts. The ACT intervention reduced stigma in both flexible and inflexible individuals, and in fact showed a particularly high comparative effectiveness for psychologically inflexible study participants. The authors speculate:
This pattern of results suggests that some forms of stigma may reflect uninformed attitudes about legal, cultural, and institutional practices related to mental illness. In more experientially avoidant individuals, however, stigmatizing views may become entangled in psychologically avoidant processes linked to the perceived threats of the stigmatized condition (Goffman, 1963) and to the inability to deal with the thoughts and feelings that arise as a result. These differences might help explain the somewhat inconsistent results for education in the stigma literature (Masuda et al., 2007, p.2769).
Conclusions
There has been much research on the effects of mental health stigma, but quite a good deal less research has examined potential interventions for reducing its presence or impact. This area of study is also significantly less ideologically sophisticated at present. None of the primary avenues for reducing stigma have proven satisfactory, although direct-contact programs have shown some promise and education programs have been effective within controlled social contexts such as military organizations.
A greater level of psychological savvy is needed in developing interventions for this purpose. Along these lines, some preliminary research on cognitive restructuring efforts and ACT-based interventions have shown a great deal of promise. It is unlikely that these early efforts cannot be bested by additional consideration for individual, social, and community psychological understandings.
While stigmatizing attitudes among the general public have been fairly well-studied, self-stigma and mental health service users’ reactions to stigma are more poorly understood. Bagley & King (2005) argue that the success or failure of expensive public campaigns to reduce the stigmatization of mental illness should be measured by the resulting feelings and experiences of the individuals affected by the stigma. To this end, they argue that primary interventions for newly-diagnosed cases of mental illness should include counseling aimed at mediating the effects of and improving responses to stigmatizing interactions.
Alternatively, an argument could be made for a more general measurement of the efficacy of anti-stigma efforts. The success or failure of these programs should hinge on the increased utilization of services and increased effectiveness of services utilized. This latter goal is likely to be too heavily confounded to be adequately measured as an effect of anti-stigma interventions. Therefore, future anti-stigma research should use the likelihood of the general public to utilize services, along with actual service utilization, as measures of outcome for anti-stigma interventions.
References
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