Stigma: Concepts and Public Conceptions

1. Stigma: Concepts and Public Conceptions Bruce G. Link Stigma and Mental Illness Conference May 22, 2011

2. Stigma Talk Outline • Conceptual Distinctions Regarding Stigma • Evidence from a studies of the general public in the United States… six decades of changes • Changes from 1950 to 1996 • Changes from 1996 to 2006 • Evidence concerning the consequences of stigma for people with mental illnesses

3. 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”

4. What is Stigma?Link and Phelan Conceptualization Stigma exists when the following interrelated components converge: 1. people distinguish and label human differences 2. labeled persons are linked to undesirable characteristics -- to unwarranted 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

5. How Do Stigmatizing Circumstances Differ from Each other • Jones et al. • Concealability – How obvious or detectable is the circumstance? • Course – is it reversible? • Disruptiveness – how strained are interactions? • Aesthetics – is there a negative affective reaction that is almost instinctual? • Origin – is the circumstance under the person’s control? • Peril – Is fear or threat induced? Jones et al. Stigma: The Psychology of Marked Relationships. 1986

6. Why Do People Stigmatize? • Keeping People Down • Exploitation and Domination • Keeping People In • Enforcement of Social Norms • Keeping People Away • Avoidance of Disease Phelan, Link and Dividio Stigma and Prejudice: One Animal or Two? Social Science and Medicine 2008

7. Studies of Public Attitudes and Beliefs 1950 -2006 in the United States

8. Questions to be Answered We will ask the following Questions: Does the general public Think of mental illnesses as illnesses? attribute causes that relieve the person of blame? express optimism about the outcome of treatment? recommend policies indicating that mental illnesses are illnesses like other illnesses? reject stereotypes of dangerousness and incompetence? show a willingness to interact with people with mental illnesses?

9. Mammoth Contextual Changes 1950 to 2006 • Educational Attainment • Media – TV, Film, Internet • Institutionalization to Deinstitutionalization • Treatment advances – Psychopharmacology, psychotherapy • Enormous efforts to educate public that mental illness is an illness like any other • Direct to consumer advertising of drug treatments

10. Studies in the 1950’s Cohen and Struening’s Opinions About Mental Illness (OMI) documented the prevalence of authoritarian and socially restrictive attitudes Nunnally’s description of the stereotype of mental illness Cumming and Cumming failed effort to change attitudes Shirley Star 1950 Nationwide Study

11. Star 1955: Mental illness is a very threatening, and fearful thing and not an idea to be entertained lightly about anyone. Emotionally, it represents to people a loss of what they consider to be the distinctively human qualities of rationality and free will, and there is a kind of horror in dehumanization. As both our data and other studies make clear, mental illness is something that people want to keep as far from themselves as possible.

12. 1950’s Does the general public see mental illnesses as illnesses? No attribute causes that relieve the person of blame? Probably not express optimism about the outcome of treatment? Probably not recommend policies indicating that mental illnesses are illnesses like other illnesses? No reject stereotypes of dangerousness and incompetence? No show a willingness to interact with people with mental illnesses? no

13. Public Attitudes and Beliefs 1996

14. 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

15. 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.

16. 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.

17. 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.

18. 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.

19. 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.

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

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

22. 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

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

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

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

26. 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:

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

28. 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

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

30. Follow Up of Star

31. 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?

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

33. 1996 Does the general public recognize mental illnesses as illnesses? yes attribute causes that relieve the person of blame? Generally yes express optimism about the outcome of treatment? Definitely yes reject stereotypes of dangerousness? No show a willingness to interact with people with mental illnesses? Limited by fear of violence

34. 2006 General Social Survey • A nationwide survey identical to the survey conducted in 1996 that was conducted by the same survey organization -- NORC. • Another collaboration between Indiana University and Columbia University to Create the Mental Health Module. This time funded by NIMH • 1,434 Face to face interviews of national probability sample. Response rate 70%. • This time 4 vignettes (3 mental disorders, 1 “troubled person”) one of four randomly assigned to each respondent. Cocaine dependence left out this time.

35. Identification of Disorders in a Manner Consistent with Psychiatric Definitions?

36. Percent Indicating that Described Person is Very or Somewhat Likely to be Experiencing Specific Disorder 1996 and 2006

37. Perceived Causes

38. Percent Indicating that Described Person’s Situation is Very or Somewhat Likely to be Caused by Stressful Circumstances 1996 -2006

39. Percent Indicating that Described Person’s Situation is Very or Somewhat Likely to be Caused by A Chemical Imbalance in the Brain 1996 -2006

40. Percent Indicating that Described Person’s Situation is Very or Somewhat Likely to be Caused by a Genetic or Inherited Problem 1996 -2006

41. Necessity of and Hopefulness About Treatment

42. Percent Indicating that Described Person’s Situation is Very or Somewhat Likely to Improve on its Own or Improve with Treatment 1996 -2006

43. Medical/Psychiatric Treatment Seeking

44. Percent Indicating that Described Person Should Seek Help from a Medical Doctor

45. Percent Indicating that Described Person Should Seek Help from Psychiatrist

46. Percent Indicating that Described Person Should take Prescription Medication

47. Generality of Change The changes from 1996 to 2006 concerning causes of disorders and recommendations of medical and psychiatric treatment where very similar across gender, educational levels and age. Results are suggestive of a broad sweeping change in public attitudes in the United States

48. Percent of People with 12 Month Disorders Who Sought Treatment for Mental Health Problems in those 12 Months (all sectors) – ECA, NCS, NCS-R • Wang, Phillip et al. 2005. Archives of General Psychiatry • 62:629-640.

49. Stereotypes – Incompetence and Dangerousness

50. Percent Indicating that Described Person is Very or Somewhat Able to Decide about Managing their Own Money