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Corrigan 2005 Applied and Preventive Psychology
Corrigan 2005 Applied and Preventive Psychology
The stigma of mental illness: Explanatory models and methods for change
Patrick W. Corrigan a, , Amy Kerr b , Lissa Knudsen c
a
Center for Psychiatric Rehabilitation, Evanston Northwestern Healthcare, 1033 University Place,
Suite 440-450, Evanston, IL 60201, USA
b Loyola University of Chicago, USA
c California State University, Northridge, USA
Abstract
For people with mental illness, diminished quality of life and loss of personal goals does not result solely from the symptoms, distress,
and disabilities caused by their psychiatric disorder. Quality of life and personal goals are also hindered by people who embrace the stigma
that accompanies mental illness and mental health care. This paper reviews evidence of the impact of mental illness stigma and strategies for
seeking to ease its impact. To achieve these goals, we (a) describe the ways in which stigma harm people with mental illness, (b) summarize
models that explain the development and maintenance of these stigmatizing effects, and (c) review strategies that have been shown to decrease
the impact of stigma. Concerns about stigma are on the political agendas of many mental health advocacy groups. It has recently also become
the focus of extensive research. Our goal in this paper is to balance the practical concerns raised by mental health advocates against data that
support or contradicts specific assertions.
2005 Elsevier Ltd. All rights reserved.
Keywords: Mental illness; Stigma; Quality of life
Corresponding author. Tel.: +1 224 364 7200; fax: +1 224 364 7201.
E-mail address: Corrigan@iit.edu (P.W. Corrigan).
0962-1849/$ see front matter 2005 Elsevier Ltd. All rights reserved.
doi:10.1016/j.appsy.2005.07.001
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181
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Fig. 1. Cognitive levels that explain the distinction between public stigma and self-stigma.
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and its effect. For example, the Court has refused to declare
school segregation unlawful unless direct evidence of
discriminatory intent on the part of the school district could
be found, regardless of segregations effect on minority
children (Graglia, 1980; Hill, 1988).
According to a structural view, group-neutral goals are
frequently not accomplished because they seem to clash
with dominant ideologies that unintentionally maintain the
unequal status quo (Hill, 1988; Jackman & Muha, 1984).
Two dominant viewpoints are a democratic belief in meritocracy and a capitalist value in cost-effectiveness (Pincus,
1999). Note that although they are not malicious in intent,
both ideologies yield unintended negative consequences.
Meritocracy, for example, is the value that drives standardized test scores; i.e., decisions about college admissions,
and the opportunities that those decisions entail, should be
based on the candidates intellectual merit (e.g., abilities and
achievements). Societal concerns about cost-effectiveness,
and decisions representing good business, also seem to yield
structural discrimination and may be especially relevant to
mental illness. Link and Phelan (2001) expound upon the
business value in listing examples of structural discrimination related to mental illness. Less money is allocated
to research and treatment on psychiatric illness than other
health disorders because illnesses like cancer and heart
disease have dominated the American public health agenda.
Many psychiatrists and other mental health professionals
opt out of the treatment system serving people with the most
serious psychiatric and substance abuse disorders. Salaries
and benefits are better in the private health sector that is more
likely to treat relatively benign illnesses like adjustment
disorders, relational problems, and phase of life problems
so providers opt for those kinds of jobs. Hence, the quality
of services for people with more serious mental disorders is
inferior to many other less serious conditions.
Problems with mental health insurance parity (i.e.,
insurance benefits for mental health problems equaling those
provided for general health) are an especially prominent
example of structural stigma related to mental illness. Strong
opposition to mental health parity legislation was heard from
the business community, citing the kind of cost concerns
frequently used to justify other forms of structural discriminations. Lobbyists for the business sector argued that parity
requirements could bankrupt small businesses by raising
health care costs (Levinson & Druss, 2000). The history and
subsequent impact of parity reveals key elements of structural
discrimination. First, the resulting act leads to fewer financial
resources for psychiatric disorders, compared to medical
illness, thereby yielding diminished opportunity for people
with mental illness. Second, this disparity does not seem to
reflect conscious prejudice on the part of Congress or the
public. Most members of both houses, regardless of political
affiliation, support equal care for mental health disorders, as
does the American public (Hanson, 1998). Lack of support
for many of the provisions of parity stems from financial
concerns that are frequently at the root of other structural
184
discriminations: parity makes for bad business. The seemingly contradictory tension between wanting to support
treatment equity but not wanting to make a bad business move
is evident in public attitude. One review found that participants of national surveys on parity supported equal resources
for mental health and medical diagnoses, on the one hand,
but, on the other hand, did not support paying higher premiums or redistributing funds from medical/surgical services
to mental health services to accomplish this goal (Hanson,
1998).
3. Changing stigma
Given that processes giving rise to and producing differential effects of stigma vary by level of analysis, it seems
reasonable to suggest that stigma change methods vary by
conceptual level. Hence, we summarize the stigma-change
literature in terms of its impact on public stigma, self-stigma,
or institutions and structures that maintain stigma.
3.1. Erasing public stigma
In recent years, advocacy groups have made reducing
stigma a priority, implementing campaigns aimed at the
public and the media. These efforts have targeted various
components of mental stigma with a variety of strategies,
few of which have been formally evaluated. However, social
psychological research on ethnic minority and other group
stereotypes provides important insight on the effectiveness of
these strategies for reducing mental illness stigma (Corrigan
& Penn, 1999). Based on this literature, we have grouped
the various approaches to changing public stigma into three
processes: protest, education, and contact (Corrigan & Penn,
1999).
Protest strategies highlight the injustices of various forms
of stigma chastising the offenders for their attitudes and
behaviors. Anecdotal evidence suggests that protest can
change some behaviors significantly (Wahl, 1995). For
example, in 2000 NAMI StigmaBusters played a prominent
role in getting ABC to cancel the program Wonderland,
which portrayed people with mental illness as dangerous and
unpredictable. StigmaBusters efforts not only targeted the
shows producers and several management levels of ABC,
they encouraged communication with commercial sponsors
including the CEOs of Mitsubishi, Sears, and the Scott Company. Hence, research might show protest to be effective as a
punishing consequence to discriminatory behavior decreasing the likelihood that people will repeat this behavior. The
punishing consequences of protest are especially relevant
for examining the effects of legal penalties prescribed by
the Americans with Disabilities Act and the Fair Housing
Act. In like manner, research might identify reinforcing
consequences to affirmative actions that undermine stigma
and encourage more public opportunities for people with
mental illness, e.g., government tax credits for employers
185
Table 1
Understanding targets of anti-stigma programs
Targets
Discriminatory behavior
Landlords
Fail to lease
No reasonable accommodation
Employers
Fail to hire
No reasonable accommodation
Unnecessarily coercive
Fail to use mental health services
Policy makers
The media
Corresponding attitudes
Social context
Change strategies
Dangerousness
Incompetence
Economy
Hiring pool
ADA
Erasing the stigma
This kind of convergence between discriminatory behavior and attitude change strategies echoes what is generally
known about attitude change in basic behavioral research,
namely, behaviors are more likely to change when strategies
target attitudes that correspond with the behavior (Ajzen &
Fishbein, 1977; Cacioppo, Petty, Feinstein, Jarvis, & Blair,
1996). Correspondence is a function of several elements
including participating actors and the context in which
a specific event is likely to occur. Hence, changing the
prejudice and discrimination of mental illness is likely to be
more successful when specific power groups are targeted in
the settings in which they might discriminate.
Consider some of the other important targets for stigma
change listed in Table 1. Health care providers and administrators may endorse stigma about mental illness. As
a result, general medical providers may fail to provide
necessary treatments that would otherwise be prescribed to
people (Felker, Yazel, & Short, 1996). As discussed earlier,
research has shown that people with mental illness are less
likely to receive appropriate cardiovascular procedures after
myocardial infarct compared to a demographically matched
group that is not labeled mentally ill (Druss et al., 2000;
Druss, Bradford, Rosenheck, Radford, & Krumholz, 2001).
Alternatively, mental health providers may endorse coercive
or other mandatory treatments (e.g., being committed to
a psychiatric hospital) when the persons current profile
of needs fails to show these kinds of interventions are
warranted. Several levels of the criminal justice system may
also be impacted by stigma (Watson, Hanrahan, Luchins, &
Lurigio, 2001). Police, overestimating the risk of violence,
may respond with undue force to people labeled mentally
ill. The judiciary, holding people with mental illness
responsible for their symptoms, may fail to divert offenders
to appropriate services in the mental health system.
Two sets of discriminatory behaviors seem to be relevant
to legislators and policy makers. First, members of this group
seem to be unwilling to allocate sufficient resources to mental
health services. This is evidenced by 1990s levels of funding
having dropped more than 8% from the preceding decade
even though service needs did not change (Willis, Willis,
186
institutional discrimination. For example, one way to diminish legislative actions that unjustly restrict the opportunities
of people with mental illness is to educate House and
Senate members about how their actions are impinging
on an important part of their constituency. More difficult,
however, is altering the course of structural discrimination.
Because its impact is unintentional, educational and other
individual-level strategies should have no effect on structural
factors. Instead, various social change strategies that fall
under the rubric of affirmative action may be relevant for
stopping the harm caused by structural discrimination.
Affirmative actions are a collection of governmentapproved activities, which are meant to redress the disparities
that have arisen from historical trends in prejudice and discrimination. According to affirmative models, membership in
a stigmatized group is added to considerations of an individuals skills and achievements for access to specific limited
opportunities. The American with Disabilities Act seems
to be a Federal Policy that mirrors affirmative goals. ADA
clauses that prohibit discrimination by employers because
of a persons psychiatric disability are effective for barring
individual and institutional levels of discrimination. It is the
ADA clause on reasonable accommodation, however, that is
an affirmative action, which decreases structural discrimination. Reasonable accommodations are changes to the work
environment that assist the person in working. Reasonable
accommodation gives people with psychiatric disabilities an
edge towards keeping their job. The 1988 amendments to the
Fair Housing Act provide similar guarantees to reasonable
accommodations for people with psychiatric disabilities in
the housing sector. Affirmative actions like these are needed
to offset the injustices that continue because of structural discrimination against people with mental illness.
4. Final thoughts
Psychiatric disability is defined as an inability to achieve
significant life goals e.g., a vocation that yields a reasonable income and living in a home with ones family that
results from serious mental illness. Our thesis in this paper
was that achievement of life opportunities like these is also
hampered by public and personal reaction to mental illness:
stigma. We summarized cognitive, motivational, and institutional/structural models that explain from whence comes
mental illness stigma. We used these models to describe ways
to diminish stigma at the public and self-levels. With this kind
of information, researchers can join advocates in understanding and diminishing this major barrier to a quality life.
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