Stigmatizing attributions about mental illness

STIGMATIZING ATTRIBUTIONSABOUT MENTAL ILLNESS

Patrick W. Corrigan, L. Philip River, Robert K. Lundin, Kyle Uphoff Wasowski, John Campion, James Mathisen, Hillel Goldstein, Maria Bergman, and Christine GagnonUniversity of Chicago Center for Psychiatric Rehabilitation

Mary Anne KubiakPrairie State College

■

Work and housing opportunities of persons with psychosis, substance abusedisorder, and other mental illnesses are significantly hampered by societalstigma. Earlier research by Weiner and colleagues (1988) examinedstigmatizing attitudes associated with general health disabilities in terms of attributions about the controllability and stability of these disabilities. The relevance of this model for describing attributions about four psychiatricdisorders is examined in this study. One hundred and fifty two adults ratedfour psychiatric groups (cocaine addiction, depression, psychosis, and mentalretardation) and two physical health groups (cancer and AIDS) on six itemscorresponding with controllability and stability attributions. Findings from afactor analysis supported the distinction between controllability and stabilityfactors. Results also suggested that mental health disabilities were rated morenegatively on these factors than physical disabilities. Participants clearlydiscriminated among mental health disabilities, with cocaine addiction ratedmost negative in terms of controllability and mental retardation rated mostnegative in terms of stability. Attribution analyses provide usefulinformation for changing the community’s reactions to persons with mentalillness. © 2000 John Wiley & Sons, Inc.

The social dysfunctions and loss of opportunities experienced by persons with severemental illness are greatly exacerbated by societal stigma (Farina, 1998; Link, Cullen,

A R T I C L E

JOURNAL OF COMMUNITY PSYCHOLOGY, Vol. 28, No. 1, 91–102 (2000)© 2000 John Wiley & Sons, Inc. CCC 0090-4392/00/010091-12

Correspondence to: Patrick Corrigan, University of Chicago Center for Psychiatric Rehabilitation, 7230 ArborDrive, Tinley Park, IL 60477. E-mail [email protected]

Struening, & Shrout, 1989; Penn, Guynan, Daily, & Spaulding, 1994). Research suggests,for example, that employers are less likely to hire persons who are labeled mentally ill(Bordieri & Drehmer, 1987; Farina & Felner, 1973; Link, 1987), less likely to lease themapartments (Alisky & Iczkowski, 1990; Page, 1977, 1983), and more likely to knowinglypress charges against them for violent crimes (Sosowsky, 1980; Steadman, 1981). Hence,advocacy groups like the National Alliance for the Mentally Ill and the National MentalHealth Association have identified anti-stigma efforts as a necessary adjunct to clinicalservices for enhancing the quality of life of people with mental illness. Anti-stigma strate-gies include education (challenging the myths of mental illness with factual informa-tion), protest (making moral appeals to stop stigmatizing persons with mental illness),and contact (facilitating equal interactions between the public and persons with mentalillness.

Research conducted by social psychologists suggests these strategies may have limit-ed effects on stereotypes and discrimination (Corrigan & Penn, in press). Changingmyths through education may not generalize to broader, less stigmatizing, attitudesabout mental illness (Keane, 1990, 1991). Protest seems to yield rebound effects due tosocial reactance; individuals may develop more negative attitudes to mental illness as aresult (Macrae, Bodenhausen, Milne, & Jetten, 1994). Improvements due to positive con-tact with persons with mental illness may lead to compartmentalization and the conclu-sion that this experience is not indicative of most people with severe mental illness(Kolodziej & Johnson, 1996).

Theoretically-based description of mental illness stigma may generate models thatbetter inform the anti-stigma efforts of these groups (Corrigan, in press). Researchershave identified three paradigms that explain stigmatizing attitudes about any outgroup:socio-cultural perspectives (i.e., stigmatizing attitudes develop to justify existing com-munity injustices); motivational biases (stigmatizing attitudes develop to meet basic psy-chological needs); and social cognitive theories (stigmatizing attitudes are understood asknowledge structures that develop from community experience) (Corrigan, 1998; Crock-er & Lutsky, 1986). Social cognitive models are especially promising because they pro-vide a rich theoretical base, research methodology, and intervention approach for un-derstanding and changing stigmatizing attitudes at the societal level (Augoustinos,Ahrens, & Innes, 1994; Essess, Haddock, & Zanna, 1994; Hilton & von-Hippel, 1996; Judd& Park, 1993; Krueger, 1996; Mullen, Rozell, & Johnson, 1996). Moreover, research inthis area has shown that prejudicial attitudes about outgroups like mental illness relateto behavioral reactions in the community (Fiske, 1998). For example, persons who en-dorse stigmatizing attitudes are less likely to hire persons with severe mental illness orlease them property.

Attribution theory is one example of a social cognitive model that has been usefulfor understanding stigma and discriminatory behavior. Attribution theory examines per-ceived causes of the activities of others. For example, what are the causal factors and fu-ture expectancies related to mental illness? In one attribution study (Weiner et al., 1988),59 students were asked to rate disability groups on items representing two important con-structs in attribution theory: controllability (how much is the person versus outsideforces, such as the environment or biological disease agents, responsible for a specificdisability?) and stability (how much is a specific disability expected to change and im-prove over time?). Controllability attributions reflect frequently voiced concerns aboutpsychoses, substance abuse disorders, and other mental illnesses; namely, persons withmental illness are to blame for their disorder, should not be pitied, and should be avoid-

92 • Journal of Community Psychology, January 2000

ed because they are dangerous (Brockington, Hall, Levings, & Murphy, 1993; Farina,1998; Taylor & Dear, 1980). Stability attributions reflect concerns about responsivenessto treatments and the likelihood of recovery (Corrigan & Penn, 1997).

Weiner and colleagues (1988) examined differences in controllability and stabilityattributions across two groups of disabilities: “mental-behavioral” (specific groups in-clude Acquired Immune Deficiency Syndrome(AIDS), child abuse, drug abuse, obesity,and Vietnam War syndrome) and “physical genesis” (Alzheimer’s disease, blindness, can-cer, heart disease, and paraplegia). Research participants perceived the mental-behav-ioral group as more in control of their disorders, less worthy of pity, and worse prog-nostically than the physical genesis group. Hence, the mental-behavioral group seemedto be the greater victim of stigmatizing attributions. Results of the study by Weiner andcolleagues answered an important question about disability stigma: namely, the generalpublic seems to discriminate among disability groups—viewing persons with mental illnessmore harshly.

Although Weiner and colleagues found the mental-behavioral group to be the ob-ject of more negative attributions than the physical genesis group, their selection of psy-chiatric disabilities seemed to be a heterogeneous mix of mental illnesses (e.g., VietnamWar syndrome, drug abuse) as well as problems that might not be sorted under the typ-ical stereotype of psychiatric disability (child abuse and AIDS). For example, neitherchild abuse nor AIDS are included in the DSM-IV (American Psychiatric Association,1994). Hence, it is not clear whether more negative attributions about mental illness re-flect attitudes about psychiatric disorders or the effect of the community’s reaction tochild abusers and AIDS. One purpose of our study is to examine attributions about se-lected groups of adult psychiatric disorders that are frequently the victims of mental ill-ness stigma: psychotic disorders, depression, substance abuse, and mental retardation(Corrigan, 1998). We were also extending the question about disability stigma to deter-mine whether the public differentiates among psychiatric disorders; i.e., do they stig-matize psychotic disorders differently than depression? Given the harsh reactions to psy-chotic disorders and substance abuse (Chappel, 1992; Farina, 1998; Geller et al., 1989;Hamre, Dahl, & Malt, 1994), we believe the public differentially stigmatizes disabilitieswithin the psychiatric spectrum, with attributions about psychosis and substance abuseviewed most negatively.

We suspect, however, that differences across disability groups will vary with specificattributions. For example, persons with psychotic disorders will be viewed as more in con-trol of their disorder than other psychiatric disability groups in the study. Persons withmental retardation will be viewed as having a more stable and worse prognosis than theother groups. Unfortunately, items selected to represent controllability and stability fac-tors were not validated by factor analysis in the study by Weiner et al. (1988). Hence, asecond goal of this study will be to determine the structure of attribution factors. We willthen use these factors to determine how differences across psychiatric disabilities vary byattribution.

METHOD

Research Participants

Adults enrolled at a community college in metropolitan Chicago were recruited for thisstudy; they were students in a variety of liberal arts classes. Community college students

Stigmatizing Attitudes • 93

were recruited for the study because they tend to be more demographically representa-tive of the population than 4-year university students. The sample in this study had anaverage age of 25.7 years (SD 5 9.7) ranging from 17 to 53. The sample was 67.8% fe-male. It was 35.5% African American, 50.0% European American, 7.9% Latino, and 6.6%other (including Asian and Native American). In terms of marital status, 76.3% of thesample were single, 11.8% were married, and 11.9% were separated, divorced, or wid-owed. In terms of income, 28.3% reported a household income less than $19,999, 27.0%ranged from $20,000 to $39,999, 21.1% ranged from $40,000 to $59,999, and 23.6% hada household income greater than $60,000. All of the 152 adults solicited for the studyagreed to participate and completed the measures.

Measure

Participants completed the Psychiatric Disability Attribution Questionnaire (PDAQ) incohorts of twenty to forty. The PDAQ was constructed by us based on Weiner et al.’s(1988) earlier attributional analysis. Weiner and colleagues were concerned about lim-ited reliability and validity of their measure because of the excessive number of items tobe judged. For example, a measure that included 5 items each addressing controllabili-ty and stability for 10 disability groups would be 1,000 items long, excessively long forunpaid research volunteers. Hence, we asked participants to rate only six disabilitygroups on six attribution items. Four of the six disability groups represented commonlystigmatized psychiatric diagnoses found in the DSM-IV (American Psychiatric Associa-tion, 1994): mental retardation, cocaine addiction, psychosis, and depression. Psychosiswas chosen as the stimulus term, rather than schizophrenia or severe mental illness, be-cause a pilot study (n 5 20) showed participants were more familiar with the psychosislabel. We completed a second pilot study with 29 participants; it showed that participantsreliably discriminated these four psychiatric diagnoses. We also selected two other dis-abilities from the list prepared by Weiner and colleagues: cancer, because it was the phys-ical disability rated most sympathetically by their group, and AIDS because it was ratedhighly negatively.

Participants in this study rated each disability group in terms of six attributions us-ing a 7-point Likert scale (7 5 strongly disagree). Attribution items were selected fromthe study by Weiner et al. to sample cognitions related to controllability attributions(blame for problems and deserving pity) and stability attributions (persons benefit fromcounseling and from medicine). Two additional items were selected from previous re-search on mental illness; one for controllability (persons with mental illness should beavoided (Brockington et al., 1993)) and one for stability (persons with mental illness re-cover (Fisher, 1994; Miller, Gold, & Smith, 1997)). Research participants completed thePDAQ twice, with one day intervening, to determine test-retest reliability.

RESULTS

Factor Analysis of PDAQ Items

We examined the factor structure of PDAQ items for each of the disability groups to de-termine which factors replicated across disability groups. The results of these six princi-pal component factor analyses with varimax rotations are summarized in Table 1. Twoor three factor solutions resulted per group; these empirically derived factors are labeled


Tabl

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7.6

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82

.28

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ontr

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void

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42

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me

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a, b, and c in the table. Each factor’s eigenvalue exceeded 1.00. We then used a vote-counting method (where trends are discerned through frequency counts of resulting cat-egories (Light & Smith, 1971)) to discern two common factors across disability groups.

The Stability Factor discussed by Weiner and colleagues was found consistently acrossgroups. Factor analyses for four of the six disability groups yielded a factor with the samethree items; benefit from counseling, benefit from medication, and will recover. Two ofthe remaining three items (persons are to blame and they should be avoided) groupedto form a Controllability Factor. These factor structures were used to generate Stabilityand Controllability Factor Scores for the PDAQ. Scoring was reversed on the Controlla-bility Factor to facilitate consistent interpretation of the two factors. Hence, a high scoreon controllability represents a negative attribution about the disability group; they are toblame for their disability. A high score on the stability factor also represents a negativeattribution; persons will not change over time nor benefit from treatment.

Reliability of the PDAQ Factors

Reliability of the PDAQ Factors is summarized in Table 2. Test-retest reliabilities (withone day intervening) was determined for the two factors across the six disability groups.Results showed individual coefficients were fair to good, ranging from 0.57 to 0.83.

PDAQ Differences Across Disability Groups

Mean and standard deviations of the PDAQ factor scores for each of the disability groupsare summarized in Table 3. Results of within group analysis of variance (ANOVAs)


Table 2. Reliability of the Psychiatric DisabilityAttribution Questionnaire (PDAQ)

PDAQ Groups Test-Retest Reliability

Cocaine addictionStability .65Controllability .82

PsychosisStability .60Controllability .63

AIDSStability .79Controllability .83

DepressionStability .57Controllability .72

Mentally retardedStability .64Controllability .75

CancerStability .71Controllability .56

Note. *p , .05; **p , .01; ***p , .001.

showed significant differences (p ,.0001) across the six disability groups for each factor;the F-tests are summarized at the bottom of Table 3. Post hoc Tukey’s Tests were thencompleted to examine the group rankings for each factor. Multiple analyses using fac-tors comprised of one to three items may lead to Type I error; hence, we used a con-servative alpha for judging results (p ,.001). Note that even with this conservative crite-rion, research participants differentiated the six disabilities into five significantly distinctgroups for each factor. The superscripts designating post hoc contrast groups are listedin ascending order of stigma; i.e., groups with higher superscripts represent greater en-dorsement of stigmatizing attributions.

In addition to examining post hoc contrasts, we made sense of scores in Table 3 bycomparing group means to a criterion rating representing endorsement of a specific at-tribution. This comparison would help to determine whether research participantsviewed controllabilty or stability attribution negatively. Given the 7-point agreement scaleused to rate PDAQ items (7 5 strongly disagree), research participants who rated itemscomprising the controllability factor greater than four (4 5 neither agree nor disagree)viewed the corresponding attribution negatively; i.e., persons are responsible for theirdisability. There are two items in this factor; therefore, total controllability factor scoresgreater than eight identify a research participant who endorses a negative view of con-trollability. Moreover, items comprising the stability factor receiving a score greater thanfour were viewing this attribution negatively; i.e., persons will not improve. There arethree items in this factor; hence, total stability scores greater than twelve identify a re-search participant who endorses a negative view of stability.

Post hoc analyses for the Controllability Factor showed cocaine addiction was en-dorsed as the worst of the six disability groups. Moreover, cocaine addiction was the onlygroup to meet the endorsement criterion for this factor; its mean was greater than eight.Cancer was rated least controllable in these groups. Psychosis was rated second to co-caine addiction in terms of controllability. AIDS was ranked equal to psychosis followedby depression and mental retardation.


Table 3. Mean and Standard Deviations of PDAQFactor Scores for Each of the Diagnostic Groups

Controllability Stability

Endorse PDAQ factor? $8.0 $12.0M SD M SD

Cocaine addiction 9.25 3.5 10.54 3.6Psychosis 5.34 2.5 9.63 3.4AIDS 5.24 3.0 10.64 3.9Depression 4.13 2.5 6.91 3.2Mentally retarded 3.32 1.9 13.45 4.0Cancer 2.81 1.5 7.92 3.5Results of within group F 5 183.47 F 5 87.59

ANOVA (df 5 5, 755) p , .0001 p , .0001

Note. Results of post hoc contrasts suggest mean in each column withdifferent superscripts differ significantly (p , .001).Superscripts are listed in order of ascending stigma; i.e., higher super-scripts represent scores which are more stigmatizing.

A different priority was found in terms of the Stability Factor of the PDAQ. Mentalretardation was viewed as the most stable and hence, least likely to recover and benefitfrom counseling and medications. Mental retardation also met the endorsement criteri-on for the Stability Factor; its mean was greater than twelve. AIDS and psychosis wereranked next stable, followed by psychosis and cancer. Depression was viewed as the mostlikely to benefit from medications and therapy as well as to recover.

DISCUSSION

Results from this study addressed two questions. 1. What attributions are relevant to mentalillness stigma? We examined whether individual PDAQ items grouped together to formthe attribution factors described by Weiner and colleagues (1988). Results from six analy-ses suggested items from the PDAQ represented two factors corresponding with the ear-lier study. Stability reflected expectations about the changeability of a disorder and be-liefs about responsiveness to therapy. Controllability represented expectations aboutwhether the individual (versus the external or biological environment) caused the dis-ability and attitudes about blaming and avoiding the person as a result. The finding thatavoidability and blame comprise controllability agrees with other attribution research(Weiner, 1995). Namely, viewing a person as in control of a situation (like their mentalillness) may lead to blame and efforts to avoid that individual.

The number of items in the factor analysis was relatively small. Hence, the contentand meaning of factors need to be investigated in further studies like this. These issueswere examined in part by evaluating the reliability of factors. The factors were shown tohave fair to good test-retest reliability.

2. How does the public view different mental health disabilities? Results clearly suggestedthat, rather than stigmatizing persons with disability equally, students discriminateamong disabilities, with psychiatric diagnoses such as cocaine addiction and psychosesviewed more negatively than physical diagnoses like cancer. Of particular interest in thisstudy was the finding that the public seems to also discriminate within the mental healthspectrum. Moreover, this discrimination depended on type of attribution. In terms ofcontrollability, cocaine addiction was rated the worst, followed by psychotic disorders andAIDS. Depression was viewed relatively benignly along with cancer. A different patternwas found for stability attributions with mental retardation viewed most negatively. Onceagain, cancer and depression were viewed more benignly.

The severity of attributions was examined by comparing disability group ratingsagainst the criterion for agreeing with a negative attribution. This criterion was arith-metically determined by summing the minimal agreement rating (4 5 neither agree nordisagree) for all items comprising a factor. Results suggest that attributions were, for themost part, not severe. Only ratings about the cocaine addicted group met severity crite-rion for controllability attributions. Ratings for the mental retardation group met crite-rion for stability attributions.

Using this Information to Change Stigma

Information from studies like these are useful for changing the community’s reactionsto mental illness through anti-stigma campaigns. In an earlier article, we grouped changestrategies for mental illness stigma into three approaches: protest, education, and con-tact (Corrigan & Penn, in press). We now consider how information from our study may


enhance two of these three strategies. There is significant evidence that protest may havelittle impact on attitudes and attributions (Macrae et al., 1994). Hence, this discussionfocuses on ways to enhance the impact of education and contact on stigma.

Protest is a reactive strategy; it diminishes negative attitudes about mental illness, butfails to promote more positive attitudes that are supported by facts. Education providesinformation so that the public can make more informed decisions about mental illness.This approach to changing stigma has been thoroughly examined by investigators. Re-search, for example, has suggested that persons who evince a better understanding ofmental illness are less likely to endorse stigma and discrimination (Brockington et al.,1993; Link & Cullen, 1986; Link et al., 1987; Roman & Floyd, 1981). Hence, the strate-gic provision of information about mental illness seems to lessen negative stereotypes.Several studies have shown that participation in education programs on mental illnessand corresponding treatment led to improved attitudes about persons with mental ill-ness (Holmes, Corrigan, Williams, Canar, & Kubiak, in press; Keane, 1990, 1991; Morri-son, 1976, 1977, 1980; Morrison, Becker, & Bourgeois, 1979; Morrison, Cocozza, & Van-derwyst, 1980; Morrison & Teta, 1977, 1978, 1979, 1980; Penn et al., 1994, Penn,Kommana, Mansfield, & Link, in press; Thornton & Wahl, 1996). However, the impactof these programs seem to have limited generalization to broader attitudes about psy-chiatric disability.

There is a small body of research that suggests targeting controllability and stabili-ty attributions may significantly diminish stigma (Corrigan, in press; Foersterling, 1985;Weiner, 1985). This research replaced incorrect attributions—e.g., “persons with men-tal illness are not responsible for their symptoms and cannot care for themselves”—withcorrect ones; “most persons with mental illness have some control over their behaviorsand can live independently with sufficient supports.” Alternatively, changing attribu-tions may involve the provision of information that challenges a specific knowledgestructure (Weiner, 1985). Education efforts that facilitate uncontrollability attributionsshould lead to more public sympathy and greater assistance. Crandall (1994) examinedthis hypothesis in terms of public attitudes about obesity. He educated a group of re-search participants on genetics and metabolism related to obesity believing this infor-mation would prove to the participants that obesity is uncontrollable. Anti-fat attitudesdiminished after learning this information. This approach parallels efforts of the Na-tional Alliance for the Mentally Ill to reframe mental illness as a brain disorder (Corri-gan & Penn, in press).

Research from our study also suggests anti-stigma efforts must be specific to the di-agnostic group. Education programs challenging stigma related to specific disabilitiesmust include myths and facts that directly challenge misconceptions about those groups(Penn & Martin, 1998). For example, research suggests that persons with psychotic ill-nesses are no more dangerous than the rest of the population except when they areacutely ill; i.e., when their psychotic symptoms and agitation have suddently changedfrom baseline (Steadman et al., 1998). This fact does not apply to persons who abuse sub-stances; they tend to be much more dangerous than the rest of the population regard-less of mental state (Steadman et al., 1998). Education on this distinction may improveattitudes about persons with psychosis but not change attitudes about persons who abusealcohol and other drugs.

Stigma is further diminished when members of the general public have contact withpersons with psychiatric disabilities who are able to hold down jobs or live as good neigh-bors in the community. Research has shown an inverse relationship between having con-


tact with a person with mental illness and endorsing psychiatric stigma (Holmes et al.,in press; Link & Cullen, 1986; Penn et al., 1994; in press). Hence, opportunities for thepublic to meet persons with severe mental illness may discount stigma. Research fromour study suggests that the positive effects of contact with a member of one group (e.g.,persons with mental retardation) would not generalize to a second group (e.g., personswith psychosis). Therefore, anti-stigma programs incorporating contact should includerepresentatives from a diverse set of disabilities to strengthen the breadth of impact.

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Stigmatizing attributions about mental illness