Bruce G. Link
Stigma and Mental Illness Conference
May 22, 2011

• 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

• 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”

• 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

• 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

• 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

• 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?

– 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

• 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

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.

• 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

• 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

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.

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.

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.

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.

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.

Percent Labeling the Vignette as the Specific
Condition it was Written to Describe
98%
97%
95%
100
90
80
40
30
20
10
70
60
50
0
85%
Drug Dependence
Alcohol Dependence
Schizophrenia
Major Depression
% Identifying as Specific Condition
Link et al. Am.J. of Public Health 1999

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

100
90
80
70
60
50
40
30
20
10
0
Percent Believing “Stressful Circumstances in the
Person’s Life” is Very Likely or Somewhat Likely to be a Cause
92% 91%
95%
94%
72%
Drug Dependence
Alcohol Dependence
Schizophrenia
Major Depression
Troubled Person
Link et al. Am.J. of Public Health 1999

50
40
30
20
10
0
100
90
80
70
60
Public Perceptions of Causes of Major
Depressive disorder
95%
38%
73%
48%
53%
15%
Bad Character
Chemical Imbalance
Way raised
Stressful
Circumstances
Genetic or Inherited
God's Will
Link et al. Am.J. of Public Health 1999

50
40
30
20
10
0
100
90
80
70
60
Public Perceptions of Causes of
Schizophrenia
91%
33%
85%
45%
Link et al. Am.J. of Public Health 1999
67%
17%
Bad Character
Chemical Imbalance
Way raised
Stressful
Circumstances
Genetic or Inherited
God's Will

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
100
90
80
70
60
50
40
30
20
10
0
On its own
With treatment

Percent Believing Vignette Person is Likely to be Violent Toward Others
90
80
70
60
50
40
30
20
10
87%
71%
61%
33%
17%
Drug Dependence
Alcohol Dependence
Schizophrenia
Major Depression
Troubled Person
0
Likely to be Violent
Question: How likely is it ____ would do something violent toward other people

Percent Desiring Social Distance from
Vignette Person
90
80
70
60
50
40
30
20
10
0
86%
66%
57%
38%
18%
Drug Dependence
Alcohol Dependence
Schizophrenia
Major Depression
Troubled Person
Willingness to have as an acquaintance, friend, neighbor, co-worker, in-law

• 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?

Percent of Respondents Spontaneously Mentioning Violence in
Response to a Question About the Nature of Mental Illness
Nationwide in 1950 and 1996
35
30
25
20
15
10
5
0
3%
2%
12.7%
31.0%
Non Psychotic Psychotic
Phelan et al. Journal of Health and Social Behavior 2000
Star 1950
GSS 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

• 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.

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

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

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

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

100
90
80
70
60
50
40
30
20
10
0
Percent Indicating that Described Person’s Situation is Very or Somewhat Likely to Improve on its Own or Improve with Treatment 1996 -2006
96 97.4
8.4
14.4
94.1
96.4
36.5
34.4
94.1
97.9
13.4
10.5
86.6
67.3
96 Improve Own
96 Imprv Trt
06 Imprv own
06 Imprv Trt
Alcohol Maj Dep SZ Troubled

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

• 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

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.

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

Percent Indicating that Described Person’s
Situation is Very or Somewhat Likely to be
Violent Towards Other People 1996 -2006

Percent Above Median on Social Distance
Scale 1996 -2006 (All Items)
Willingness to have as an acquaintance, befriend, neighbor, co-worker, in-law

• Compared to the 1950’s and continuing in the period between 1996 and 2006
– People now identify disorders in a manner consistent with medical conceptions
– People have made dramatic changes in beliefs about biological and genetic causes that are consistent with a medical model approach.
– People are much more likely to suggest medical and psychiatric contact and have increased medical help seeking for such disorders over time.
– These changes are not limited to descriptions of alcohol abuse, major depressive disorder and schizophrenia but extend as well to the “troubled person” vignette – suggesting a blunt diffuse effect rather than a targeted on.
• All of this indicates that efforts to change public beliefs along these dimensions has been enormously successful .

• Some might have thought that a massive change from a social deviance to a medical view of mental disorders would have broadly reduced stigma.
• It has not.
• The best evidence indicates that the dangerousness stereotype has remained stable in the midst of these other major changes.
• Similarly inferences of incompetence have either not improved dramatically (e.g. major depression) or have actually become stronger (schizophrenia).
• Social distance has not appreciably changed for any of the disorders.
• The news about these elements of public beliefs is not good for people with mental illnesses

• We have been enormously successful in changing public knowledge and beliefs about mental illnesses but only in some domains.
• Core stereotypes of dangerousness and incompetence remain as strong and perhaps even stronger than they were decades ago.
• We cannot address these problems through the message we have already delivered… that mental illnesses are illnesses with biological and genetic causes that can be treated… such messages do not solve the problems of stereotyping and discrimination.

• Direct discriminatory behavior by other people
• Structural discrimination
• Discrimination that operates through the stigmatized person

• 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

… heard others say unfavorable or offensive things about consumers or their illnesses
… seen or read things in the mass media about consumers … that I found offensive or hurtful
I have had the fact that I am a consumer used against me in legal proceedings
I have been denied educational opportunities when it was revealed that I am a consumer
Wahl, Schizophrenia Bulletin 1999
Sometimes,
Often, or
Very Often
78%
77%
20%
17%

• 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

• Schizophrenia and other severe mental illnesses are not fully covered by health insurance in the
United States
• 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

The Perceived Devaluation/Discrimination
Measure
• People were asked do you Strongly Agree (6), Agree (5),
Slightly Agree (4), Slightly Disagree (3), Disagree (2) or
Strongly Disagree (1):
• 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 a person who has been hospitalized for mental illness cannot be trusted

• 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, Link et al.
2008)

• Core beliefs about the nature and causes of mental illnesses have been changed in ways that will facilitate helpseeking.
• Core stereotypes about people with mental illnesses have not been changed.
• The resilience of these stereotypes insures enduring problems for people with mental illnesses through interpersonal discrimination, structural discrimination, and discrimination that operates through the individual.
• A strong and effective response to the stigma and discrimination associated with mental illnesses lies before us.