How Stigma Interferes With Mental Healthcare

Medscape Psychiatry & Mental Health 9(2), 2004. C 2004 Medscape

Editor's Note:

The stigmatization of people with mental illness is widespread in our
society. What is stigma? How does it negatively affect patient outcomes and
how can it be reduced? Randall F. White, MD, contributing writer at
Medscape, interviewed Patrick W. Corrigan, PsyD, about these issues. Dr.
Corrigan is a Professor of Psychiatry and Psychology at Northwestern
University and Executive Director of the Center for Psychiatric
Rehabilitation at Evanston Northwestern Healthcare, both in Evanston,
Illinois. He and his collaborators work at the forefront of understanding
the stigmatization of people with mental illness in our society.

Medscape: What is stigma in mental illness and how does it operate in
individuals and in the social context?

Dr. Corrigan: I've tended to look at stigma in a social-cognitive way;
namely, as a series of attitudes we have about groups. Stereotypes are the
attitudes about a group of people: "all Irishmen are drunks; all people
with mental illness are dangerous." Prejudice is agreeing with the
stereotypes. Discrimination is the behavior that results: "I don't want
Irishmen around me, therefore I discriminate against them."

Public stigma is when the public knows the stereotypes. Most people know
the stereotype that the mentally ill are dangerous. Agreeing with the
stereotype is where prejudice comes in and results in discrimination.

Self-stigma is when people do it to themselves; that is, they grew up in
society with the same stereotypes as everyone else, then find themselves in
the stigmatized group and beat themselves up about it.

Self-prejudice is agreeing with the stereotype and turning it against
yourself: "Yes, people with mental illness are incompetent, I'm mentally
ill, therefore I must be incompetent." Self-discrimination is what I call
the "why-try" effect: "Why should I even try getting a job? I'm mentally
ill and not capable of doing it."

Stigma leads to label avoidance, which is what my latest paper[1] was
about; namely, that people with mental illness know that if they come out
of the closet, if they're seen with a doctor, the public will discriminate
against them. One of the best ways not to be seen with other mental
patients is not to go where they are receiving care.

Medscape: Another term you have used in your writing is "structural
stigma." Can you discuss that, and is it another way to say
"discrimination"?

Dr. Corrigan: It leads to discrimination. Structural stigma is a way
sociologists look at the problem. Because of economic and political
reasons, certain institutions have been created in our society that either
promote stigma or result in discrimination. An obvious structural stigma
for mental illness is the laws in some of the 50 states that undermine a
person's ability to have a family, to vote, and things like that.

Parity is a big item in the mental health agenda, which would make the
quality of insurance the same for mental health as for other health
conditions. I would argue that the actions to block parity are a form of
structural stigma. So you'll find legislators who are against parity
because they argue it tends to undermine the good quality of healthcare we
already have. Economists will tell you that parity would not have that kind
of effect, and that legislators are acting in a naive way.

Medscape: You mentioned in your article that people with mental illness are
less likely to get certain cardiac procedures.

Dr. Corrigan: Druss' work shows that people with mental illness were
significantly less likely to get cardiac care compared with another group
that was not labeled that way.[2] I would argue that the general healthcare
system is one of those bodies that tends to treat people with mental
illness differently.

Medscape: Let's go back to something you said a moment ago. You used the
words "label" and, of course, "stigma." Do those reside in the individual
with mental illness?

Dr. Corrigan: You just hit a big issue. The advocacy world is not in favor
of the term "stigma" because it suggests that the social wrong is in the
person. I would not throw away the word "stigma." I would argue with
caution that people who are stigmatized have some social cues that signal
to the rest of the world. Sometimes they are fairly obvious social cues,
such as skin color or other body characteristics. Other people don't have
an obvious mark but are labeled once they come out, and they tend to have
all the problems with stigma. An example is gay people. We can't tell if
someone is gay by looking at them, only if someone points the person out.
Religious background, level of education, and history of being in prison
are all things you can't tell unless the person comes out.

People can come out by association. This is the biggest way that people
with mental illness come out. If you see someone leaving a community mental
health clinic, you might assume they're mentally ill and tag them with the
stigma of it. So I would argue that stigmata are signals that can lead to
prejudice and discrimination.

Medscape: Let's go on from there. How does stigmatization interfere with
treatment of mental illness?

Dr. Corrigan: As I discuss in the paper, there are many people who decide
never to get treatment even though they would benefit from it. So people
who want to avoid labels, avoid treatment so their neighbors don't see them
coming out. Or for that matter, they don't want to admit it to themselves,
so they don't go see a psychiatrist.

The next issue is people adhering to treatment. Some people already in
treatment have identified themselves as having mental illness but might
have that "why-try" effect: "why should I try to get better, I'm not
capable of doing it." Therefore, they might not adhere to services as well
as they should. These 2 effects might lead to worse care and worse
outcomes.

Medscape: What are effective ways to combat stigma?

Dr. Corrigan: Looking at public stigma, we've broken down change mechanisms
into 3 -- education, contact, and protest. Protest is usually a
"shame-on-you" kind of statement and an appeal to stop thinking that way.
As an attitude changer, protest tends to give you a rebound effect.
Research shows that attitudes get worse. Behavior, on the other hand, might
see some benefit.

One example is a show on ABC called Wonderland. In the first episode, which
aired on March 30, 2000, a person with mental illness shot 5 people and
stabbed a pregnant woman in the abdomen. Lots of advocacy groups came out
and said, "We're not going to put up with this grossly stigmatizing image."
ABC thought this was great because it got them a lot of press, but then the
advocacy groups went to the sponsors and ABC eventually pulled the show off
the air.

Medscape: In your paper, you focus on contact.

Dr. Corrigan: Let's talk about education first, which is transposing the
myths of mental illness with facts. Education is popular because it's
exportable -- you can package it up and send it around, such as public
service announcements on TV. Unfortunately, the effects of education are
small and tend to wash out altogether in a week or two.

Contact is introducing people with mental illness to the rest of the
population, and usually that leads to a decrease in stigma. We've done a
couple of studies on it. In 2 studies, we compared contact with education,
and contact led to significant changes in attitudes and behavior that were
maintained until a month later.

We did a study in which we randomly assigned college students to 1 of 3
groups in which they had contact with either a live or videotaped person
with mental illness.[3] One we called high contact, which would be meeting
a person who would greatly challenge the stereotypes of people with mental
illness. An example would be a famous person coming out of the closet, such
as Mike Wallace or Patty Duke. A second type would be low contact. This
would be people who greatly mirror the stereotype of mental illness, such
as a person who's homeless. The third group is in the middle, someone
struggling with mental illness who, despite that, is living on their own
with a full-time job.

We measured attitudes precontact, postcontact, and at follow-up, and found
that low contact does not work very well -- meeting a homeless person on
the street does not challenge a stereotype; if anything, it reinforces it.
High contact -- knowing about famous people -- did not tend to have a big
effect.

What tends to work most is the middle group, when you find out a coworker
or person in your church or a neighbor is struggling with a mental illness.
That tends to greatly challenge the stereotypes.

Medscape: In your paper, you wrote that combating structural stigma is a
matter of social justice. What are the implications of this?

Dr. Corrigan: As I was finishing the paper, I was at a conference where
people were saying that stigma is like any medical condition that can be
just treated away. I appreciated their intent, but we need to remember that
some problems in the health field are not best looked at as a health
disorder. I think that it's an injustice to call this a problem of the
person with mental illness, because in doing that, we suggest that it's up
to that person to get over the problem. Instead, it's society's problem,
and we need to look at changes in society that will help give people an
equal chance.

One of the ways to do this is through advertising and social-marketing
campaigns. A second way is through something like affirmative action. The
best example is the idea of reasonable accommodation in the Americans With
Disabilities Act (ADA). If you're a person with mental illness working in a
job and you need an extra leg up, I'd be compelled to give it to you.

Reasonable accommodation for mental illness is a support structure to allow
someone to stay on their job. So, for example, in our supportive services
program here, this includes job coaches to help people get to work and make
sure they get what they need to stay there. It's conceivable that the ADA
would give legal protection for a coach to come on the job every day.

Medscape: Can you discuss the role of self-disclosure in combating stigma
and the risks and benefits for the individual?

Dr. Corrigan: Another public movement that will have great effect on the
stigma of mental illness is "coming out." I think that people with mental
illness can learn a lot from the gay community. In some ways, there are
similarities between the groups. Both have a condition that the parents did
not have, so they don't have the parents' wisdom to deal with it. Both are
forced into it in adolescence and young adulthood, and both frequently rely
on members of their group to be successful.

There's some thinking that the gay community, over the past 10 to 15 years
in the United States, has benefited from coming out. Similarly, I think
there are benefits to coming out if you're mentally ill. One of the
benefits includes using the ADA. Second, a person with mental illness has
the same experience as a gay person about being in the closet. There tends
to be anger and some sort of doubt about themselves or their illness (I
don't mean to say that gays are ill). Most people who come out tend to feel
more satisfied after doing it. The third is that if you come out, you're
more likely to find other people who are like you so you can draw near to
each other.

Is there a risk? For sure -- I think that one of the risks is just in
perception. People are constantly going to wonder whether or not peers are
doing things to them because they're mentally ill. And the other one is
that when you come out, it's hard to go back, so people have to understand
that and be appropriately cautious about it.

Medscape: What draws you to this work?

Dr. Corrigan: I think 2 reasons. One, I am a rehabilitation-services
provider, and I have had clients ready to go back to work or to live on
their own, and once they met a landlord or an employer who found out they
had a mental health history, all sorts of barriers were thrown up that kept
them from progressing. To fix disability, we need not just to look at the
person with the problem, but we need to look at the community and the
environment the person lives in.

The other reason is that I call myself a 60s voyeur. I wasn't old enough to
participate, but I was old enough to watch. That striving toward community
justice applies in this case. There's a part of me that likes to rectify
injustices.

References

   Corrigan P. How stigma interferes with mental health care. Am Psychol.
      2004;59:614-625.

   Druss BG, Bradford DW, Rosenheck RA, Radford MJ, Krumholz HM. Mental
      disorders and use of cardiovascular procedures after myocardial
      infarction. JAMA. 2000;283:506-511. Abstract

      Reinke RR, Corrigan PW, Leonhard C, Lundin RK, Kubiak MA. Examining
      two aspects of contact on the stigma of mental illness. J Soc Clin
      Psychol. 2004;23:377-389.