stig1 western ontario 2006

Understanding Stigma and Its Consequences for People with Mental Illnesses: 

Understanding Stigma and Its Consequences for People with Mental Illnesses Bruce G. Link University of Western Ontario April 4, 2006

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Surgeon General’s Report Stigma erodes confidence that mental disorders are valid, treatable conditions. It leads people to avoid socializing, employing or working with, or renting to or living near persons who have a mental disorder, especially a severe disorder like schizophrenia. Stigma deters the public from wanting to pay for care and, thus, reduces consumers’ access to resources and opportunities for treatment and social services. A consequent inability or failure to obtain treatment reinforces destructive patterns of low self-esteem, isolation and hopelessness. Stigma tragically deprives people of their dignity and interferes with their full participation in society. It must be overcome.

Stigma Talk Outline : 

Stigma Talk Outline Historical overview The definition of stigma Evidence from a study of the general public Evidence concerning the consequences of stigma for people with mental illnesses Thoughts about changing stigma

Early Studies: 

Early Studies Shirley Star 1950 Nationwide Study Nunnally’s description of the stereotype of mental illness Cumming and Cumming failed effort to change attitudes

A Shift in Professional Views in 1970’s and Early 1980’s: 

A Shift in Professional Views in 1970’s and Early 1980’s Gove, 1982 “the evidence of the 1950s would indicate that . . . the public was ignorant about mental illness, had a very negative image of persons identified as mentally ill, and excluded them. Since then there has been a massive education effort focused on mental illness: furthermore, the generally transitory nature of mental illness and effectiveness of treatment has become fairly visible”

The Down Playing of Stigma in the Late 1970’s and Early 1980’s: 

The Down Playing of Stigma in the Late 1970’s and Early 1980’s Sociologist Walter Gove (1982) -- “stigma appears to be transitory and does not appear to pose a severe problem” Crocetti et al. (1974) Former patients “enjoy nearly total acceptance in all but the most intimate relationships”

Recent Indicators of Interest in the Stigma of Mental Illnesses: 

Recent Indicators of Interest in the Stigma of Mental Illnesses The Surgeon General’s Report National Campaign to Address Stigma NIH organized the first international conference to address the global consequences of stigma Great Britain’s Royal College of Psychiatrists -- “Changing Minds” initiative World Health Organization

Number of Articles Mentioning “Stigma” in Title or Abstract: 

Number of Articles Mentioning “Stigma” in Title or Abstract

Implicit Definitions of Stigma: 

Implicit Definitions of Stigma When stigma is not defined explicitly it usually refers to one of the following: The attribute/characteristic/mark/label. The linking of the label to undesirable characteristics, “stereotyping.” The experience of rejection, disapproval, exclusion or discrimination

Some Definitions of “Stigma”: 

Some Definitions of “Stigma” Dictionary Definition -- a mark of disgrace or infamy. Goffman (1963) -- “an attribute that is deeply discrediting” and reduces the bearer “from a whole and usual person to a tainted, discounted one.” Jones et al. (1984) -- “a mark that sets a person apart and links the marked person to undesirable characteristics”

The Stigma Concept: 

The Stigma Concept Stigma exists when the following interrelated components converge: 1. people distinguish and label human differences 2. labeled persons are linked to undesirable characteristics -- to negative stereotypes 3. labeled persons are viewed as an outgroup as “them” and not “us” 4. people experience emotional reactions to labeled people – fear, repulsion, disgust and labeled persons may feel shame, embarrassment, humiliation 5. labeled persons experience status loss and discrimination as a consequence 6. stigma is dependent on power

Some Recent Evidence Regarding Public Attitudes : 

Some Recent Evidence Regarding Public Attitudes

The 1996 General Social Survey: 

The 1996 General Social Survey A nationally representative sample of 1444 persons living in households In person interviews conducted by National Opinion Research Corporation (NORC) Response rate 76% Collaboration between Indiana University and Columbia University 5 vignettes (4 mental disorders, 1 “troubled person”) one of the five randomly assigned to each respondent

Vignette Depicting Drug Dependence: 

Vignette Depicting Drug Dependence John is a [Ethnicity] man with an [Educational Level] education. A year ago John sniffed cocaine for the first time with friends at a party. During the last few months he has been snorting it in binges that last several days at a time. He has lost weight and often experiences chills when bingeing. John has spent his savings to buy cocaine. When John’s friends try to talk about changes they see, he becomes angry and storms out. Friends and family have also noticed missing possessions and suspect that John has stolen them. He has tried to stop snorting cocaine, but he can’t. Each time he tries to stop he feels very tired and depressed and is unable to sleep. He lost his job a month ago after not showing up for work.

Vignette Depicting Alcohol Dependence: 

Vignette Depicting Alcohol Dependence John is a [Ethnicity] man with an [Educational Level] education. During the last month John has started to drink more than his usual amount of alcohol. In fact, he has noticed that he needs to drink twice as much as he used to to get the same effect. Several times he has tried to cut down, or stop drinking, but he can’t. Each time he tried to cut down he became very agitated, sweaty and he couldn’t sleep, so he took another drink. His family has complained that he is often hungover, and has become unreliable -- making plans one day and canceling them the next.

Vignette Depicting Schizophrenia: 

Vignette Depicting Schizophrenia John is a [Ethnicity] man with an [Educational Level] education. Up until a year ago, life was pretty okay for John. But then, things started to change. He thought that people were making disapproving comments and talking behind his back. John was convinced that people were spying on him and that they could hear what he was thinking. John lost his drive to participate in his usual work and family activities and retreated to his home, eventually spending most of his day in his room. John was hearing voices even though no one else was around. These voices told him what to do and what to think. He has been living this way for six months.

Vignette Depicting Major Depressive: 

Vignette Depicting Major Depressive John is a [Ethnicity] man with an [Educational Level] education. For the past two weeks John has been feeling really down. He wakes up in the morning with a flat heavy feeling that sticks with him all day long. He isn’t enjoying things the way he normally would. In fact nothing gives him pleasure. Even when good things happen, they don’t seem to make John happy. He pushes on through his days, but it is really hard. The smallest tasks are difficult to accomplish. He finds it hard to concentrate on anything. He feels out of energy and out of steam. And even though John feels tired, when night comes he can’t go to sleep. John feels pretty worthless and very discouraged. John’s family has noticed that he hasn’t been himself for about the last month and that he has pulled away from them. John just doesn’t feel like talking.

Vignette Depicting a Troubled Person: 

Vignette Depicting a Troubled Person John is a [Ethnicity] man with an [Educational Level] education. Up until a year ago, life was pretty okay for John. While nothing much was going wrong in John’s life he sometimes feels worried, a little sad, or has trouble sleeping at night. John feels that at times things bother him more than they bother other people and that when things go wrong, he sometimes gets nervous or annoyed. Otherwise John is getting along pretty well. He enjoys being with other people and although John sometimes argues with his family, John has been getting along pretty well with his family.

Do Members of the Public Recognize/Label the Vignettes as Mental Illnesses?: 

Do Members of the Public Recognize/Label the Vignettes as Mental Illnesses?

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In your opinion, how likely is it that ______ is experiencing a mental illness -- Very likely, somewhat likely, not very likely, not at all likely.

Percent Indicating that Vignette Person is Very or Somewhat Likely to be Experiencing a Mental Illness: 

Percent Indicating that Vignette Person is Very or Somewhat Likely to be Experiencing a Mental Illness Link et al. Am.J. of Public Health 1999 44% 49% 88% 22% 69%

Percent Labeling the Vignette as the Specific Condition it was Written to Describe : 

Percent Labeling the Vignette as the Specific Condition it was Written to Describe Link et al. Am.J. of Public Health 1999 97% 98% 85% 95%

Question About Causes of Vignette Conditions: 

Question About Causes of Vignette Conditions In your opinion how likely is it that ______’s situation might be caused by: (Very Likely, Somewhat Likely, Somewhat Unlikely, Very Unlikely) His/her own bad character A chemical imbalance in the brain The way (he/she) was raised Stressful circumstances in his/her life A genetic or inherited problem God’s will

Percent Believing “Stressful Circumstances in the Person’s Life” is Very Likely or Somewhat Likely to be a Cause: 

Percent Believing “Stressful Circumstances in the Person’s Life” is Very Likely or Somewhat Likely to be a Cause Link et al. Am.J. of Public Health 1999 72% 92% 91% 95% 94%

Public Perceptions of Causes of Major Depressive disorder : 

Public Perceptions of Causes of Major Depressive disorder Link et al. Am.J. of Public Health 1999 73% 48% 95% 53% 15% 38%

Public Perceptions of Causes of Schizophrenia : 

Public Perceptions of Causes of Schizophrenia Link et al. Am.J. of Public Health 1999 85% 45% 91% 67% 17% 33%

Question About Chances for Improvement of Vignette Conditions: 

Question About Chances for Improvement of Vignette Conditions In your opinion how likely is it that ______’s situation will improve on its own: In your opinion how likely is it that ______’s situation will improve with treatment:

Percent Believing Vignette Person’s Condition is Likely to Improve on its Own or with Treatment: 

Percent Believing Vignette Person’s Condition is Likely to Improve on its Own or with Treatment

Percent Believing Vignette Person is Likely to be Violent Toward Others: 

Percent Believing Vignette Person is Likely to be Violent Toward Others 87% 71% 61% 33% 17% Question: How likely is it ____ would do something violent toward other people

Percent Desiring Social Distance from Vignette Person: 

Percent Desiring Social Distance from Vignette Person Willingness to have as an acquaintance, friend, neighbor, co-worker, in-law 86% 66% 57% 38% 18%

Percent of US Public Desiring Social Distance by Perceptions of Likelihood of Violence: 

Percent of US Public Desiring Social Distance by Perceptions of Likelihood of Violence

The question: 

The question Of course, everyone hears a good deal about physical illness and disease, but now, what about the ones we call mental or nervous illness . . . When you hear someone say that a person is “mentally-ill,” what does that mean to you?

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Percent of Respondents Spontaneously Mentioning Violence in Response to a Question About the Nature of Mental Illness Nationwide in 1950 and 1996 3% 2% 12.7% 31.0% Phelan et al. Journal of Health and Social Behavior 2000

Public Views Concerning Whether Mental Illness is an Illness Like Any Other: 

Public Views Concerning Whether Mental Illness is an Illness Like Any Other Nationally Representative Random Digit Dial Telephone Survey N = 670 Conducted 2002 -2003 Response Rate 62%

Physical Illness Descriptions: 

Physical Illness Descriptions Brief description of a persons background, age, gender, education… then Heart Disease ____ has and illness the doctors diagnosed as “heart disease” and on several occasions he has had to go to the local hospital for treatment. Because of the condition ___ sometimes has shortness of breath, chest pains, dizziness and fainting spells that are signs of restricted blood flow to the heart. ___ has had one heart attack. Diabetes ___ has an illness the doctors diagnosed as “diabetes” and on several occasions has had to go to the local hospital for treatment. Because of his condition, ___ has high blood sugar levels that can result in complications such as frequent infections, heart disease or kidney failure.

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Arthritis ____ has a condition the doctors diagnosed as “arthritis” and on several occasion she has had to go to the local hospital for treatment. Because of his condition, ___ has stiffness and a lot of pain in his hip and lower back that has been getting worse and worse. Sometimes it gets bad enough that he just can’t do most of the things he used to do. Melanoma ____ has an illness the doctors diagnosed as “melanoma” and on several occasions he has had to go to the local hospital for treatment. Because of his condition, ___ has a large spot on his arm that recently changed color and looked different than it used to. It turns out that ____ has a serious form of skin cancer and will have to have treatment to keep it from spreading.

Question Wording: 

Question Wording Thinking about what I have just told you about ___ How SERIOUS would you consider his problem to be? Very Serious, Somewhat Serious, Not Very Serious, Not Serious At All. ___ is to BLAME for his condition. Strongly Agree, Somewhat Agree, Somewhat Disagree, Strongly Disagree ___ should be give GOVERNMENT ASSISTANCE for health care for his problem if he needs it. Strongly Agree, Somewhat Agree, Somewhat Disagree, Strongly Disagree In your opinion how likely is that ___ would do something VIOLENT toward other people Very likely, somewhat likely, somewhat unlikely, not likely at all.

Mental Illnesses Compared to other Illnesses: 

Mental Illnesses Compared to other Illnesses

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Evidence concerning the consequences of stigma for people with mental illnesses

Three Ways in Which Stigma Affects People’s Life Chances: 

Three Ways in Which Stigma Affects People’s Life Chances Direct discriminatory behavior by other people Structural discrimination Discrimination that operates through the stigmatized person

Discriminatory Behavior by Others: 

Discriminatory Behavior by Others Experiments -- e.g. Page study of apartment availability Non-experimental studies -- Druss et al. study of cardiovascular procedures after myocardial infarction Self Reports of Consumers -- Wahl study of 1,301 consumers through NAMI

Self Reports of Discriminatory Experiences: 

Self Reports of Discriminatory Experiences Wahl, Schizophrenia Bulletin 1999

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Structural Discrimination

Examples of Structural Discrimination for Schizophrenia: I: 

Examples of Structural Discrimination for Schizophrenia: I Suppose that because schizophrenia is a stigmatized illness: there is less funding for research than for other illnesses --so we know less about how to prevent it or treat it than we would have known if it weren’t a stigmatized illness less money to provide care and treatment given the knowledge we currently have

Examples of Structural Discrimination for Schizophrenia: II: 

Examples of Structural Discrimination for Schizophrenia: II Schizophrenia is not fully covered by health insurance treatment facilities are either isolated or confined to areas that don’t have the clout to exclude this stigmatized group -- rates of crime, violence, pollution, noise and infectious disease are all higher in these areas

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Discrimination Operating through the Individual

The Perceived Devaluation/Discrimination Measure: 

The Perceived Devaluation/Discrimination Measure Example items: Most women would not marry a man who has been a patient in a mental hospital Most people think less of a person who has been hospitalized for mental illness Most employers will not hire a person who has been hospitalized for mental illness Most people believe that former mental patients cannot be trusted

Washington Heights Study: Mean Devaluation Discrimination Scale Scores: 

Washington Heights Study: Mean Devaluation Discrimination Scale Scores None of the differences between groups are significant

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Lo Hi Functioning: Jobs, Social Networks, Self Esteem Good Poor After Being Linked to Stereotypes Before Being Linked to Stereotypes Perceived Devaluation-Discrimination Predictions Based On Stigma Theory Pre - Labeling Post - Labeling

Consequences of Stigma for Persons with Mental Illnesses: 

Consequences of Stigma for Persons with Mental Illnesses 1) Unemployment and income loss (Link 1982; 1987; Link et al. 1991) 2) Constricted social support networks (Link et al. 1989; Perlick et al. 2001) 3) Quality of life (Rosenfield 1997; Markowitz 1998) 4) Depressive symptoms, demoralization (Link 1987; Link et al. 1997) 5) Delayed help seeking (Sirey 2001) 6) Self-esteem (Wright 2000, Link et al. 2001)

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What Can We Do About Stigma?

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Many things not just one Need a multifaceted – multi-level approach to address Direct discrimination Structural Discrimination Discrimination operating through individual

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Suggestions that derive from ideas put forward in the presentation 1. Intervene in socialization/attitude formation with curricula -- contact 2. Humanize people with mental illness -- shift from a “them” to an “us” Teach people what to do to help a person with mental illness-- have approaches and options available to reduce discomfort and helplessness.

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4. Develop the capacity to respond to stigmatizing material in the media or in every day life. 5. Encourage consumer groups efforts designed to enhance “empowerment.” 6. Develop an evidence-based stigma-reducing plan to educate people who develop mental illnesses about their condition. 7. Policy to change structural discrimination.

Papers Available via E-mail: 

Papers Available via E-mail BGL1@Columbia.edu Conceptualizing Stigma: Annual Review of Sociology, 2001 Measuring Mental Illness Stigma: Schizophrenia Bulletin 2004. On Describing and Seeking to Change the Experience of Stigma: Rehabilitation Skills – contains measures of stigma and stigma coping that we have developed