(p. 599) Stigma
(p. 600) The Oxford English Dictionary (2016) defines stigma as a “mark of disgrace or infamy; a sign of severe censure or condemnation … impressed on a person or thing.” Stigma occurs when a person or group, such as those with mental illness, is stereotyped in a pejorative way that sets those individuals apart from the majority and treats them as socially unacceptable. Dissatisfied with the notion that stigma is merely an attribute that an individual possesses, and aware that social processes are at work in labeling, Link and Phelan (2001) apply the term “stigma” when “elements of labeling, stereotyping, separation, status loss, and discrimination co-occur in a power situation that allows them to unfold.” For some, stigma becomes internalized (also known as self-stigma), with further harmful consequences to health and well-being (Corrigan, 2004). The Surgeon General’s Report on Mental Illness from 1999 highlighted the importance of reducing the stigma of mental illness in order to increase the rate of diagnoses and improve the treatment and well-being of those with mental disorders in the United States (USDHS, 1999).
Stigma has serious consequences. For example, those with severe mental illness are less likely to have apartments leased to them (Page, 1995), be given job opportunities (Farina & Felner, 1973; Link & Phelan, 2001), or be provided with adequate healthcare (Lawrie, 1999) relative to individuals without such illness. Furthermore, for the mentally ill, stigmatization is associated with a lowered quality of life (Mechanic, McAlpine, Rosenfield, & Davis, 1994), reduced self-esteem (Link, Struening, Neese-Todd, Asmussen, & Phelan, 2001; Wright, Gronfein, & Owens, 2000), and increased symptoms and stress (Markowitz, 1998). To manage stigma, those with mental illness may use strategies that lead to social isolation (Perlick et al., 2001), such as avoiding others or engaging in secrecy (Link, Mirotznik, & Cullen, 1991), which in turn could lower their social support and increase their likelihood of relapsing. Therefore, stigma poses a significant threat to the recovery of persons with severe mental illness.
The stigma attached to mental illness can affect the likelihood that those with symptoms of mental health disorders will seek treatment. Fear of disclosing one’s mental or substance use disorder is the most commonly reported reason for not seeking help, especially in youth (Gulliver et al., 2010). In adults, both treatment-related and internalized stigma were frequently associated with failure to seek help (Clement et al., 2015). Label avoidance can also be harmful when it results in nondisclosure to an employer and hence a lack of access to the protections afforded by the Americans with Disabilities Act (Cummings et al., 2013). A national survey found that about 10% of adult respondents reported not having sought or having avoided mental health treatment because of fear of negative social or work consequences (SAMHSA, 2013).
Reluctance to seek treatment is especially critical for adolescents, because numerous disorders, such as major depression, bipolar disorder, anxiety disorders, anorexia and bulimia, and schizophrenia, emerge in adolescence or early adulthood. Because those with a greater number of affective episodes prior to receiving pharmacotherapy have a less favorable prognosis than those with fewer episodes (Post, Leverich, Xing, & Weiss, 2001), such delays in seeking treatment have important implications for youth. In schizophrenia, the duration of untreated psychotic episodes may also be linked with poorer long-term prognosis (Lieberman et al., 2001; Norman & Malla, 2001).
A study from the Annenberg Public Policy Center at the University of Pennsylvania that was described in the first edition of this volume concluded that young people attach less stigma to help seeking when the source of help is seen as more effective, as it is in the case of seeing a doctor/nurse or taking medication (Penn et al., 2005, p. 535). On the other hand, for sources of help perceived to be less effective, stigma tended to be negatively related to help seeking, particularly for the least effective sources, the Internet and telephone help lines. For the subsample of youth who reported symptoms of depression, poorer perceptions of treatment effectiveness were present for all but one of the sources of help. The findings are consistent with results from (p. 601) a large (N = 1,387) U.K. national adult survey, which concluded that the most common reason individuals with “neurotic disorders” (22%) did not seek treatment was that they didn’t think any action or individual could help them (Meltzer et al., 2003).
Once in treatment, perceived stigma may be a barrier to medication compliance and treatment continuation (Buck, Baker, Chadwick, & Jacoby, 1997; Pugatch, Bennett, & Patterson, 2002; Sirey et al., 2001a, 2001b). A 2010 meta-analysis identified strong relationships between internalized stigma and psychiatric symptom severity and treatment nonadherence (Livingston & Boyd, 2010). These findings indicate that stigma may affect the course of the illness by interfering with treatment compliance.
Community Attitudes Toward Persons With Mental Illness
Stigmatizing attitudes toward persons with severe mental illness have a number of recurring themes: they are viewed as dangerous, unpredictable, irresponsible, and childlike (Brockington, Hall, Levings, & Murphy, 1993; Levey & Howells, 1995) and unable to manage their own treatment needs (Pescosolido, Monahan, Link, Stueve, & Kikuzawa, 1999). For example, a significant percentage of adult Australian respondents reported that those with mental disorders such as depression or schizophrenia were unpredictable and dangerous and were less likely to be hired for employment (Reavley and Jorm, 2011). A survey of U.S. adults found that 81% considered children with depression to be dangerous to others (Pescosolido et al., 2007).
Unfavorable attitudes toward persons with mental illness are not only held by those in the community but also may be present among mental health professionals and trainees. Specifically, there is evidence that some mental health professionals, including psychiatrists (Chaplin, 2000; Miller, Shepard, & Magen, 2001), social workers (Dudley, 2000; Minkoff, 1987), general mental health providers (Ryan, Robinson, & Hausmann, 2001; Sartorius, 2002), and medical and mental health graduate students (Hasui, Sakamoto, Sugiura, & Kitamua, 2000; Mukherjee, Fialho, Wijetunge, Checinski, & Surgenor, 2002; Werrbach & DePoy, 1993), may hold stigmatizing beliefs about those with mental disorders. These findings suggest that efforts to destigmatize mental illness should not be limited to community members but also should include mental health/medical training professionals.
The tendency to stigmatize individuals with mental illness often has its roots in childhood. In a review of the literature, Wahl (2002) concluded that negative attitudes toward persons with mental illness are evident as early as third grade. In general, those with mental illness are viewed more negatively and with more fear than are individuals with physical disabilities (Wahl, 2002). Wahl reported evidence that these negative attitudes increase over time, suggesting a longitudinal process in which negative stereotypes become increasingly ingrained, culminating in potentially discriminatory behaviors in adulthood.
The presence of stigmatizing beliefs in young people was documented in a 2002 Annenberg Public Policy Center survey of U.S. adolescents ages 14 to 22 that was reported in this volume’s first edition (Penn et al., 2005, p. 533). It found that large proportions of young people believed that peers with major depression, bipolar disorder, schizophrenia, and eating disorders are different from other people. For example, over half of respondents reported that persons with major depression are more likely to be violent; over 90% reported that they are more prone to suicide, and about three quarters said they are less likely to be good in school than other people. In that survey, violence was most associated with schizophrenia and depression was most associated with doing poorly in school, while eating disorders were less associated with violence than the other disorders (Penn et al., 2005, p. 533).
Factors That Contribute To Stigma
The role of stigma in reducing help-seeking behavior in youth increases the importance of understanding the factors that contribute to stigma. In this section, we summarize (p. 602) the research on this topic for both the general population and among youth. In general, factors contributing to stigma include (a) pejorative labels for the symptoms and/or anomalous behaviors associated with mental illness; (b) causal attributions about mental illness; (c) misinformation about mental illness and negative images promulgated by the mass media; and (d) lack of contact with persons who have been successfully treated for mental illness.
Labels are so powerful that those with mental illness “are faced with recovering not just from mental illness, but also from the effects of being labeled mentally ill” (Deegan, 1993). Many labels commonly capsulizing mental illness contribute to stigma, including such pejorative terms as “schizo,” “psycho,” and “wacko,” all of which connote violent or erratic behavior. The meanings attached to such labels are shaped and reinforced in media accounts as well as personal encounters (Link & Phelan, 1999; Phelan & Link, 1999).
Labels do not exist in a vacuum but derive meaning from their relationship with characteristics of the disorder, both real (e.g., hearing voices) and portrayed in the media culture (e.g., being homicidal). Thus, the behaviors associated with mental illness may be stigmatizing in their own right. Evidence in support of this hypothesis comes from studies showing that the social behaviors of individuals with depression can elicit negative reactions from others (Segrin, 2000) and that the social skill deficits present in patients with schizophrenia (Mueser & Bellack, 1998) may increase stigma even beyond the contribution of symptoms (Penn, Kohlmaier, & Corrigan, 2000).
Modified labeling theory explains how stigma can shape people’s lives through their acceptance of being labeled as mentally ill or disordered and the resulting experiences of social rejection and loss of social support (Link et al., 1989). Such effects lead to the acceptance of the label and the resulting sense of self-stigma. Thoits (2006) proposed a version of modified labeling theory suggesting that some individuals with mental illness “do exercise their personal agency by resisting the devaluation tied to stigmatization.”
Attributions are thought to play a role in the creation of stigma because our explanations for mental and physical illness (i.e., in terms of controllability and responsibility) affect our attitudes toward these disorders (Weiner, 1993; Weiner, Perry, & Magnusson, 1988). Tests of this model applied to severe mental illnesses, such as schizophrenia, indicate that when such conditions are seen as under the person’s control and something for which she or he is responsible, the tendency to blame and stigmatize that individual increases (Corrigan, 2000).
One approach to counteracting these attributional biases has been to educate the public about the role of brain processes in the etiology of mental disorders (Pescosolido et al., 2010). The President’s New Freedom Commission on Mental Health (2003) advocated this educational strategy in predicting that attributing mental illness to brain dysfunction would reduce stigma. While the strategy appears to have increased public support for services to treat mental disorders, it has not resulted in reductions in stigma toward persons with these disorders (Pescosolido et al., 2010). Also, while attributing causality to biological factors, such as genetics, can decrease attributions of responsibility, it may also increase beliefs that the problem cannot be changed or that relatives of the person may have similar problems (i.e., a courtesy stigma; Phelan, Cruz-Rojas, & Reiff, 2002).
The fact that the mass media are the most frequent source of information about mental illness for people in the United States (Wahl, 1995) may account in part for widespread misinformation about mental illness, especially in regard to the supposed violent (p. 603) characteristics of persons with severe mental disorders. Although there has been little research that directly links stigma with media images of mental illness, there is evidence that greater exposure to television viewing is associated with heightened intolerance toward persons with mental illness (Granello & Pauley, 2000). In addition, persons with mental illness are disproportionately portrayed in films, television, and newspapers as violent, erratic, and dangerous (Angermeyer & Schulze, 2001; Diefenbach, 1997; Granello, Pauley, & Carmichael, 1999; Hyler, Gabbard, & Schneider, 1991, Monahan, 1992; Nairn, Coverdale, & Claasen, 2001; Wahl 1995; Wahl & Roth, 1982; Williams & Taylor, 1995). As noted by Wahl (2002), entertainment media depictions of violence committed by persons with a mental disorder are more graphic and disturbing than depictions of violence in persons without a mental disorder. Nevertheless, despite the stereotypes promulgated by the media, mental health status contributes only slightly to violent behavior (Appelbaum, 2013; Monahan, 1992).
Examination of newspaper reports suggests that mental illness is more frequently associated with criminality in U.S. media than in other Western countries. An analysis of two decades of research concluded that “descriptions of mental illness and the mentally ill are distorted due to inaccuracies, exaggerations, or misinformation” and that those with mental illness are often presented as peculiar, different, and dangerous (Klin & Lemish, 2008; Ma, 2017). U.S. newspaper stories exaggerate the incidence of violence in persons with mental illness. Violence was associated with bipolar disorder 29.1% of the time and with depression, 15.2% (Silver, 2001). Conrad and Schneider (1992) found that in the United States, newspaper coverage associated mental illness with criminality 34% of the time, while in Germany and Iceland the rate was only 20%. These negative depictions are not limited to adult media but also are present in children’s programming (Wahl, 2002, 2003; Wahl, Wood, Zaveri, Drapalski, & Mann, 2003; Wilson, Nairn, Coverdale, & Panapa, 2000).
Reducing the Stigma of Mental Illness
Approaches to reducing the stigmatization of mental disorders have included education and promotion of personal contact. Consistent with earlier research, a 2012 meta-analysis of data from 72 outcome studies in 14 countries (Corrigan et al., 2012) concluded that education about mental illness and contact with people who have mental illness are both effective, with contact more effective at reducing stigma among adults (Couture & Penn, 2003) and education more so among adolescents (Corrigan et al., 2014). Thornicroft et al.’s (2016) more recent review of antistigma and antidiscrimination interventions found that the most effective programs for adults without mental illness involved contact with those diagnosed with mental illness. In addition, indirect evidence demonstrates the effectiveness of information about psychiatric/psychological treatments, either through direct instruction (Esters et al., 1998) or via role modeling (Schulze et al., 2003).
Interventions to reduce self-stigma have also been undertaken with varying degrees of success (Mittal et al., 2012). These have involved small-group sessions involving educational and cognitive-behavioral approaches. However, the sustainability of effects has not been evaluated, which suggests the need for further research. While the long-term effects of these programs remain unstudied, assessments of the Opening Minds program in Canada (described below) indicate that school-based programs can be successful. However, there is less evidence of intervention efficacy for programs delivered in primary and secondary schools, with evidence on important outcomes often lacking (Mellor, 2014).
Healthcare providers are another important audience for stigma-reduction efforts. A recent review of programs implemented in Canada revealed that such interventions have greater success when they involve multiple forms of direct contact with presenters who have recovered from mental disorders and when those contacts focus on disproving stereotypes and myths about these conditions ( (p. 604) Knaak et al., 2014). Providing training in best practices for interacting with patients was also found to be helpful, but more long-term outcome evaluations are needed.
Promoting personal contact between a stigmatized group and community members is based on the “contact hypothesis,” which has an extensive history in the study of racism (Jackson, 1993; Kolodziej & Johnson, 1996). Pettigrew and Tropp (2006) suggested that contact could disconfirm negative stereotypes about mental illness and reduce discrimination. According to this hypothesis, contact effects will be strongest when the individuals meet as equals and have a chance to work cooperatively rather than competitively on a task, and when the target person mildly disconfirms the stereotype. The last criterion refers to the finding that encountering someone who greatly disconfirms a stereotype may result in categorizing that target as an “exception” to the rule; therefore, positive experiences with the target individual may not generalize to the broader group (Johnstone & Hewstone, 1992). Nevertheless, Sadow and Ryder (2008) found that a personal presentation from a person who is recovering that includes elements of personal relevance and inspiration can reduce stigmatizing attitudes held by future health professionals. In addition, other research suggests that if multiple examples of disconfirming evidence about a stereotype are received, the stereotyped group may no longer be seen as homogeneous, thereby opening the potential for greater acceptance of the group (Brewer, 1981).
Most interpersonal contact studies have been conducted either with college-age students or with adults in the community. In addition, there have been numerous grassroots and community efforts to reduce stigma, some focused on children and adolescents (Estroff, Penn, & Toporek, 2004; WPA, 2005). For interventions to reduce the stigma of mental illness, contact has occurred through volunteer activities, classroom experiences, job training, and simulated laboratory encounters (Couture & Penn, 2003; Kolodziej & Johnson, 1996). Consistent with results from studies of interethnic contact (Pettigrew, 2016), the findings suggest that interpersonal contact effects are robust (Corrigan, 2002; Couture & Penn, 2003); an early meta-analysis of the literature reported that the average effect size of contact on attitudes was .34 (Kolodziej & Johnson, 1996). These effects were greater when the contact was provided for students, rather than professionals, especially if the contact was not a required part of the classroom or training experience (Kolodziej & Johnson, 1996).
The message that mental disorders can be successfully treated is another strategy that appears to hold success in reducing stigma. An experiment conducted with youth ages 14 to 22 found that evidence about treatment efficacy (namely that a depressed peer had fully recovered thanks to treatment) reduced harmful stereotypes about the peer (Romer & Bock, 2008). This effect extended to those who reported recent symptoms of depression, suggesting that “treatment efficacy” is a powerful message even for those most affected by stigma. A second more recent study with adults replicated more favorable responses to vignettes of mentally ill persons if they were described as having received successful treatment for their condition (McGinty et al., 2015). In this study, effects were evident for persons described as diagnosed with schizophrenia, depression, and drug addiction. These studies suggest that interventions to reduce stigma should focus on the potential for successful treatment, such that mental disorders are seen as more similar to other health conditions from which recovery is possible.
Media exposure may influence negative and/or positive beliefs about mental illness in adolescents. A qualitative study with 12- to 14-year-olds found that television was their primary source of information about mental illness (Secker, Armstrong, & Hill, 1999). Adolescents are heavy consumers of mass media (total media use for 8- to 18-year-olds per day was reported as 7 hours and 38 minutes by Rideout, Foehr, & Roberts, 2010), and their attitudes and behaviors are influenced by such exposure. Reviews of the literature indicate a relationship between media exposure and the formation of gender stereotypes (Signorielli, 2001); aggression (p. 605) and desensitization to violence (Bushman & Anderson, 2001), particularly among children and young adolescents (Roberts & Foehr, 2004); and body image in adolescent women (Groesz, Levine, & Murnen, 2002). Furthermore, the media serve as a source of information for youth; over half of teenage women report learning about sex and birth control from TV, movies, and magazines (Brown & Witherspoon, 2001).
The Entertainment Industries Council supports efforts by film and television producers to portray mental illness and substance use in educationally helpful ways and to reduce harmful stereotypes associated with these conditions. However, little is known about the effectiveness of these efforts on the general public. The belief of adolescents that they cannot get effective treatment for mental illness was greater in depressed as well as suicidal adolescents the more they reported having watched films that portrayed mentally ill characters (Jamieson, Romer, & Jamieson, 2006). As noted earlier, such beliefs may be linked with mental illness stigma. This raises the question of whether stigma reduction could be achieved with films that emphasize the recovery of persons with mental illness. For example, the film A Beautiful Mind (2002) did well at the box office (IMDB, 2016), won four Oscars, and was given the year’s “Most Outstanding Contribution to Public Understanding of Mental Illness” award from the National Alliance for the Mentally Ill (NAMI, 2002). The film was based on the life of Princeton mathematician John Nash (1928–2015) (played by Russell Crowe), whose academic work in an era before helpful treatments for mental illness were available later earned him a Nobel Prize.
Examples of Successful Stigma-Reduction Programs
Beginning in 2007, Great Britain’s anti-stigma “Time to Change” (TTC) program included a national marketing effort, community outreach, and endorsements by celebrities. In addition to its antistigma marketing campaign, TTC sponsored exercise events, such as “Time to Get Moving,” in order to increase contact with people who had experienced long-term mental health problems. A phone survey conducted in 2009 reported significantly less discrimination among friends and family and the inability to find and keep employment (Henderson et al., 2012). A 2009–2012 evaluation also found positive effects, concluding that in England “important gains were made in reducing public stigma and discrimination” (Evans-Lacko, 2014).
Under the auspices of California’s Mental Health Services Act of 2004, the state undertook an ambitious program of stigma and discrimination reduction in 2011. The program involved 10 projects focused on various groups, including segments of the general public and healthcare providers (Clark et al., 2013). A major component was a social marketing campaign involving the dissemination of an hour-long film entitled A New State of Mind: Ending the Stigma of Mental Illness, as well as media programming directed to adolescents and young adults. A website, EachMindMatters.org, provided a central location for dissemination of program materials and discussion forums.
The RAND Corporation evaluated the program in 2014 using a statewide survey of over 1,000 adults who had indicated in an earlier survey that they experienced moderate to severe symptoms of psychological distress. Approximately 35% of this sample reported exposure to either the film or other aspects of the campaign. Compared to a matched subsample who did not see the campaign, those with some campaign exposure were more likely to have sought professional help for a mental or behavioral health condition in the past 12 months (49.7% vs. 34.3%). RAND attributed half of this difference to the campaign and estimated that as a result over 120,000 adults received treatment for their condition. A cost–benefit analysis that took into account the cost of the campaign, state expenses for treatment, and time away from work, the program delivered $35 in benefit to the state budget for every dollar spent on the campaign. Thus, on a cost–benefit basis, the campaign was considered a success (Ashwood et al., 2016).
(p. 606) A program of stigma-reduction projects has been ongoing in Canada since 2007. The Opening Minds program targets adolescents, healthcare providers, the workforce, and the news media in various educational programs (Mental Health Commission of Canada, 2015). The communication strategy has focused on in-person interventions featuring contact between audiences and persons with mental illness. Preliminary results indicate that the school-based programs for adolescents increase knowledge about mental illness; however, the effectiveness of the programs in increasing social acceptance of persons with mental illness has varied. The programs that increased knowledge the most were also more successful in reducing stigma. However, long-term follow-up has not yet been assessed. Nevertheless, going forward, the project aims to focus on those programs for youth that have exhibited the strongest outcomes.
This chapter reviewed evidence that addressing the stigma of mental illness in adolescence is an important endeavor. It is likely that adolescents who are informed about mental illness, both in terms of facts and the dispelling of myths, will be less likely to stigmatize others and more likely to seek and stay in treatment for their own mental health symptoms. In particular, there is evidence that increasing awareness of the efficacy of treatment can reduce harmful stereotypes and discrimination against those who experience mental illness.
This chapter has also highlighted the potential role of the mass media in destigmatizing mental illness, a role that will be more effective in partnerships with mental health professionals. Destigmatization also depends on mental health educators. Promoting positive contact by inviting persons with mental illness to classrooms as guest speakers and/or providing opportunities for adolescents to volunteer with persons with mental illness has been shown to be beneficial (Couture & Penn, 2003).
A recent report from the National Academy of Science (2016) on strategies to reduce stigma laid out an ambitious national agenda for the reduction of mental illness stigma. Indeed, that report and the review of successful programs in this chapter suggest that, if they are consistently pursued over the long term, such efforts can succeed. Part of the challenge involved in facilitating early intervention for mental illness is promoting and developing liaisons between mental health professionals and gatekeepers, such as general practitioners and school teachers and counselors, who are often the first to identify adolescent mental health problems. Such contact facilitates mental health referrals and reduces the time from symptom onset to treatment. In addition, to address the stigma or shame of seeking treatment for physical disorders (e.g., AIDS; Gewirtz & Gossart-Walker, 2000) or psychiatric disorders (prodromal symptoms; McGorry, Yung, & Phillips, 2001), there have been efforts to provide treatment at home or in settings that are not identified as psychiatric facilities. These approaches, coupled with increased education and contact opportunities with those diagnosed with mental disorders and efforts to provide accurate and helpful views of mental illness in media, are important steps in minimizing harm from stigma and ensuring that adolescents get early treatment for their developing or active mental disorders.