What makes mental illness stigma so hard to change (and also to study)?

by Ava T. Casados about her recently published article in Clinical Psychology: Science and Practice

Society holds negative attitudes about mental illness, and these attitudes form a stigma that impacts many individuals on both interpersonal levels (e.g., blaming, name-calling) and institutional levels (e.g., employment discrimination). The stigma experienced because of one’s mental illness can in turn exacerbate psychological symptoms and deter treatment-use and recovery, thus further compromising an individual’s mental health (e.g., Corrigan, Druss, & Perlick, 2014; Link, Phelan, & Sullivan 2017). With the prevalence of mental illness increasing worldwide, mental illness stigma has become a major public health concern. Governments and advocacy groups have introduced initiatives to combat mental illness stigma, and researchers have worked to identify ways to measure and improve attitudes about mental illness. The stigma of mental illness appears only to be worsening, however (e.g., Pescosolido, 2013). This recent Clinical Psychology: Science and Practice article outlines a number of key challenges and limitations in mental illness stigma reduction research, a few of which are summarized here.

Currently, contact with persons with mental illness is the most well-supported way to reduce mental illness stigma. Social psychological research has demonstrated that contact can increase knowledge about and empathy toward stigmatized individuals, as well as reduce the inter-group anxiety that leads to avoidance of members of stigmatized groups (see Pettigrew & Tropp, 2011). On the one hand, a contact approach for reducing mental illness stigma holds great promise: Nearly half of Americans have a mental illness at some point in their lives, so we are all statistically likely to interact with a person with mental illness nearly every day, and many of us have at least one friend or family member living with mental illness (Kessler et al., 2005). On the other hand, although contact is more effective at reducing stigma than other approaches (e.g., educational campaigns, protests), it is unclear how well contact reduces mental illness stigma in everyday life.

As already noted, stigmatizing attitudes appear to be worsening, even as rates of mental illness are increasing in the general population, and thus opportunities for contact are become more abundant. One primary problem is that we may only realize we are in contact with persons with mental illness it if they willingly disclose their diagnosis, or if the symptoms are especially severe and thus apparent. The mild and moderate cases of mental illness, which might be most effective at negating misconceptions about mental illness, are also the least likely to be visible in public. There are therefore innumerable missed opportunities for contact to improve attitudes in our daily lives because the nature of the contact is concealed.

Moreover, this problem cannot easily be solved by people simply opening up about their experiences with mental illness. Talking about one’s mental illness can be arduous, and unless handled very carefully, this contact can be ineffective or even backfire. There is significant burden placed on the person with mental illness to reveal their status at the appropriate time, in the appropriate way such that they will appear friendly, competent, healthy, and stereotype-disconfirming (e.g., Corrigan, 2011, Rüsch et al., 2005). In addition to the shattering stereotypes on which mental illness stigma is built, the individual must also be just typical enough that they are seen as a fair representation of people with mental illness more broadly, rather than as an outlier (see Brown & Hewstone, 2005). Without these criteria being met, the contact experience might not generalize favorably to others with mental illness.

Herein lies another major challenge: mental illness is incredibly heterogeneous, encompassing both mild and severe symptoms, and including everything from social anxiety to schizophrenia. Would increasing empathy toward people with depression also increase empathy toward people with anxiety? Does contact with a person with bipolar disorder improve attitudes about people with “mental illness” more broadly? Many of these boundaries are unclear, and too little research has considered the relationship between these various labels and severity levels. The majority of research has focused on only severe mental illness (Dalky, 2012). More mild and moderate mental illness can actually be associated with greater stigma and more personal blaming, however, and it is among the milder cases that stigma is mostly likely to thwart treatment-use (e.g., Andrade et al., 2014; Crisp, Gelder, Rix, Meltzer, & Rowlands, 2000). Greater attention to mild and moderate mental illness is therefore needed.

Both of these issues noted above point to a larger problem in overall research approach: the inadequate consideration of persons with mental illness themselves. These considerations are complex. For example, focusing on contact as the main way to reduce mental illness stigma can be overly demanding of the person with mental illness. Focusing solely on severe mental illness likewise under-serves persons with mental illness, as this focus may exclude the majority of those who are stigmatized.

The experiences of persons living with mental illness are theoretically but not practically central to much current research on mental illness stigma. That is, many interventions that are designed to reduce public stigma of mental illness do not evaluate the effect that those interventions have on persons with mental illness, so it unclear the extent to which these programs benefit those who are actually stigmatized. Although there is an important and increasingly substantial body of work looking at “self-stigma” (i.e., negative attitudes persons with mental illness might have about their own status/condition), empirical attention is rarely given to the stigma that these individuals face from others (e.g., Watson, Corrigan, Larson, & Sells, 2007). Research demonstrating that a particular intervention is effective in reducing self-reported mental illness stigma tells us little about the impact that intervention might have on the quality of life of persons with mental illness.

Expanding or refocusing research questions may be necessary in order to address some of the primary challenges in mental illness stigma reduction. Having a better understanding of the limits of contact, the nuance of labels, and the lived experiences of persons with mental illness are just a few of the ways in which the current research can be strengthened. As the recent article discusses, there may be simple ways in which to enhance established practices in order to better examine some currently neglected but essential populations and outcomes.

Reference Article

Casados, A. T. (in press) Reducing the stigma of mental illness: Current approaches and future directions. Clinical Psychology: Science and Practice.

Discussion Questions

  1. What can be done to reduce the burden placed on persons with mental illness in contact scenarios, while still maintaining the efficacy of the interaction?
  2. How can the experiences of persons with mental illness be considered when designing studies or interventions?
  3. In what ways might contact with a person with mental illness be different from contact with a person with a visible physical stigma, and how would this difference impact the contact dynamic?

Author Biography

Ava T. Casados is a Ph.D candidate in clinical psychology at Yale University, where she works with Dr. Alan Kazdin and Dr. John Dovidio. Her research focuses on barriers to mental health treatment. She is specifically concerned with cognitive or attitudinal barriers to care, including mental illness stigma, lay conceptualizations of mental illness, and cultural factors.

References cited

Andrade, L. H., Alonso, J., Mneimneh, Z., Wells, J. E., Al-Hamzawi, A., Borges, G., . . . Kessler, R. C. (2014). Barriers to mental health treatment: results from the WHO World Mental Health surveys. Psychological Medicine, 44, 1303-1317. doi:10.1017/s0033291713001943

Brown, R., & Hewstone, M. (2005). An integrative theory of intergroup contact. Advances in Experimental Social Psychology, 37, 255-343. doi:10.1016/s0065-2601(05)37005-5

Corrigan, P. W. (2011). Best practices: Strategic Stigma Change (SSC): Five principles for social marketing campaigns to reduce stigma. Psychiatric Services, 62, 824-826. doi:10.1176/appi.ps.62.8.824

Corrigan, P. W., Druss, B. G., & Perlick, D. A. (2014). The impact of mental illness stigma on seeking and participating in mental health care. Psychological Science in the Public Interest, 15, 37-70. doi:10.1177/1529100614531398

Crisp, A. H., Gelder, M. G., Rix, S., Meltzer, H. I., & Rowlands, O. J. (2000). Stigmatisation of people with mental illnesses. The British Journal of Psychiatry, 177, 4-7. doi:10.1192/bjp.177.1.4

Dalky, H. F. (2012). Mental illness stigma reduction interventions: Review of intervention trials. Western Journal of Nursing Research, 34, 520-547. doi: 10.1177/0193945911400638

Kessler, R. C., Berglund, P., Demler, O., Jin, R., Merikangas, K. R., & Walters, E. E. (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62, 593-602. doi:10.1001/archpsyc.62.6.593

Link, B. G., Phelan, J. C., & Sullivan, G. (2017). Mental and physical health consequences of the stigma associated with mental illnesses. In B. Major, J. F. Dovidio, & B. G. Link (Eds.), The Oxford handbook of stigma and health.  New York, NY: Oxford University Press.

Pescosolido, B. A. (2013). The public stigma of mental illness: What do we think; What do we know; What can we prove? Journal of Health and Social Behavior, 54, 1–21. doi:10.1177/0022146512471197

Pettigrew, T. F., & Tropp, L. R. (2011). When groups meet: The dynamics of intergroup contact. Philadelphia, PA: Psychology Press.

Rüsch, N., Angermeyer, M. C., & Corrigan, P. W. (2005). Mental illness stigma: Concepts, consequences, and initiatives to reduce stigma. European Psychiatry, 20, 529-539. doi:10.1016/j.eurpsy.2005.04.004

Watson, A. C., Corrigan, P., Larson, J. E., & Sells, M. (2007). Self-stigma in people with mental illness. Schizophrenia Bulletin, 33, 1312-1318. doi:10.1093/schbul/sbl076

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