January 8, 2010
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).
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.
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).
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 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).
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).