The impact of stigma on severe mental illness

COGNITIVE AND BEHAVIORAL PRACTICE 5, 201-222, 1 9 9 8

The Impact of Stigma on Severe Mental Illness

Patrick W. Corngan University of Chicago Center for Psychiatric Rehabilitation

Movies, newspapers, magazines, television shows, books, radao programs, and advertisements have all been vehicles for communicating the experience of severe mental illness This has, however, tended to be a misrepresentation of the experience. Persons wtth psychiatric dlsablhty suffer societal scorn and discrimination because of the stigma that evolves out of these misrepresentations. This kind of re- buff frequently leads to dlmlmshed self-esteem, fear of pursuing one's goals, and loss of socml opportunmes (e.g., landlords are hesitant to rent apartments to persons with severe mental illness) Social psychologists have developed a model of stereotype that frames stagma as a cognitive structure. Thew social cognltwe paradigm seems especially useful for a model of cognmve behaworal therapy for sugma. This model identifies three targets' (a) persons who hide their mental health experience from the public and suffer a private shame; (b) persons who have been pubhcly labeled as mentally 111 and suffer socmtal scorn, and (c) society ~tself, which suffers fears and misinformation based on stigma and myth. Each of these three targets suggests specific behavtoral interventions that may alleviate the impact of sugma

Cl in ic ians f r equen t ly u n d e r s t a n d the i m p a c t o f severe m e n t a l i l lness in t e rms

of s y m p t o m s like psychosis, the def ic i t synd rome , depress ion , a n d mania . Al-

t h o u g h these symptoms are pa infu l a n d disrupt ive , severe m e n t a l i l lnesses l ike

s c h i z o p h r e n i a are d i s t ingu i shed by b r o a d social disabili t ies that have a g r ea t e r

i m p a c t on the i m m e d i a t e o u t c o m e a n d long - t e rm course o f the pe r son ' s life.

Many pe r sons with d i sorders like s c h i z o p h r e n i a suffer i n t e rpe r sona l , self-care,

a n d cogni t ive deficits that p r e v e n t t h e m f r o m ach iev ing the i r l ife goals. T h e s e

pe r sons are o f ten u n a b l e to live i ndependen t ly , ge t compe t i t i ve jobs , m a k e a sat-

201 1077-7229/98/201-22251 00/0 Copyright 1998 by Association for Advancement of Behavior Therapy

All rights of reproducuon m any form reserved

202 CORRIGAN

isfactory income, and develop long-term inumacles. Persons with severe psychiatric disabilities 1 typically rate their quality of life as poor.

Research suggests that inabihty to mee t the chal lenges of life and attain age-appropr ia te roles and goals develops as a result of d isabhng illnesses. How- ever, the negative impac t o f severe menta l illness is no t ent irely due to the ram- ifications of a biological disorder. Society's react ion to the disease seems to have an equally harmful impac t on the person 's abilities to successfully achieve life goals. The publ ic at large holds a variety of negative stereotypes abou t severe menta l illness. "Mental pat ients are dangerous." "They can ' t lwe on thei r own." "There is no cure for menta l illness." These stereotypes l ead to expectat ions that persons with sch izophren ia will fail when trying to live independent ly , get a job , or bmld a long-term relat ionship. Stigma and pessimistic expecta t ions lead to discr iminat ion. Landlords are less likely to ren t apar tments to persons wtth psychiatric disabihties. Employers do no t want to hire persons with a long history of psychiatric hospital izat ion. Neighbors are afraid to visit with acquaintances who may be "dangerous ex-patients."

S t igma and Behavior Therapy

Behavior therapy needs to b roaden its agenda to cover bo th disease and dis- c r iminat ion factors that affect the impact of severe menta l illness. Practi t ioners must cont inue skills t r a inmg and incentive therapies that assist persons in lea rn ing to cope with the i r biological illness; persons use these skills to get their in te rpersona l needs me t as well as to deal with r ecu r r en t life stressors (Liber- man, 1992). Researchers and pract i t ioners also need to identify a m e n u of behavioral in tervent ions that he lp persons with severe psychiatric disability deal with stigma. These strategies include decisions abou t disclosing one 's history of menta l illness or ways that empower the person dur ing his or he r t rea tment . So- cietal change may be an equally impor t an t focus of behavior change. Behavior therapists should identify and imp lemen t strategies that improve publ ic attitudes about menta l illness and that stop discr iminat ion of peop le with psychiatric disability.

This p a p e r provides a m o d e l for a behavior therapy of stigma. The pape r be- gins with a d i s t incuon be tween disease and discr iminat ion models of severe menta l illness. The full impac t of st igma and discr iminat ion is then discussed; unde r s t and ing the b r ead th of st igma is impor t an t for identifying targets of a

1 In this paper, I adhere to National Insutute of Disability and Rehabilitauon Research grade- lines and refere to person~ with severe mental illness rather than mentally 111 patients (Blaska, 1993). Terms such as the latter promote stigmatizing views by reducing people to their roles as patients in the mental health system rather than indlxaduals m the world who happen to suffer a psychiatric disability This kind of person-first language reminds the reader that mental illness is only a small part of what is experienced by the people we serve

T H E I M P A C T O F S T I G M A 203

cor re spond ing behavior therapy. Social psychological research on the knowledge structures re la ted to s tereotype and discr iminat ion provide impor t an t concepts for a cognitive behavior therapy of menta l illness stigma. This research is reviewed in the paper. The p a p e r ends with a m o d e l of behavior therapy that in- tegrates in format ion about the full impac t of st igma with social cognitive concepts abou t prejudice.

What Happened to Mr. Goodman?

Somet imes stigma and discr iminat ion are overt acts of a naive public. O t h e r times, unfa i r t r ea tment is posed in the guise of the panent ' s best interest . A br ie f case history illustrates stigma's obvious and insidious character.

Frankl in G o o d m a n had been recent ly re leased f rom an Illinois state hospi tal after a r ecen t exacerbat ion of psychotic symptoms. At the t ime of admission, Mr. G o o d m a n was highly agitated, yell ing that the pol ice were going to ha rm h im because he 's the Boston Strangler 's brother . Mr. G o o d m a n totd the on-call psy- chiatr ist in the emergency room that he was hear ing voices of the devil p r each ing about his murde rous relatives. This was the pat ient 's th i rd hospitalization since schizophrenia was first d iagnosed 12 years ear l ier at age 22. Mr. G o o d m a n had made an excel lent recovery from previous hospital stays: He had been working as a salesman at a hardware store for the past 6 years and lived nearby in a small, bu t comfortable , apar tment . He visited a psychiatrist for med- icat ion abou t once a m o n t h at the communi ty menta l heal th cen te r where he also me t with a counselor to discuss strategies to cope with his menta l illness. Mr. G o o d m a n had several fr iends in the area and was fond of playing softball with them in park district leagues. He had been da t ing a woman in the group for about a year and r epo r t ed he was "get t ing serious." Frankl in was also active in the local Baptist church, where he was co-leading Bible classes with the pastor. Clearly, the r eappea rance of his symptoms had dera i led his job , apar tment , and social life.

Recupera t ing f rom this episode was no t a funct ion of r e me d ia nng symptoms alone. The reacnons of friends, family members , and professionals also affected what h a p p e n e d to him. The hardware store owner, Mr. Simpson, was f r igh tened by Frankl in ' s "mental hospital izat ion." H e had h e a r d that mental ly ill peop le become violent and worr ied that the stress of the j o b might lead to a dangerous outburs t in the shop. Franklin 's m o t h e r had o the r concerns. She worr ied that the demands of living a lone were excessive: "He's push ing himself much too ha rd trying to keep that apa r tmen t c lean and do all his own cooking." She feared Frankl in might abandon his a p a r t m e n t and move to the streets jus t like o ther menta l ly ill people .

Mr. Goodman ' s doc to r was conce rned that this hospital izat ion s ignaled an overall lack of stability. His doc to r bel ieved that schizophrenia was a progres- sively degenerat ive disease, a classic view of the d i sorder first p r o m o t e d by Krae-

204 CORRIGAN

pel in (1913). Psychiatric hospital izations r ep resen ted milestones that the disease was worsening. The doc tor conc luded that Franklin 's ability to live i ndependen t ly would soon wane, it was be t te r to p r e pa re for this loss now ra ther than wait for the inevitable forfei ture of i n d e p e n d e n t funcnonlng. So, the doctor, with the he lp of Frankl in 's mo the r and boss, ta lked him into leaving his job , giving up his apar tment , and moving back home. Frankl in 's m o t h e r lived across town, so he s topped a t tending the Bapust church. Mr. G o o d m a n was also

unable to mee t with his fr iends and d r o p p e d out of league sports soon after. He s topped seeing his girf fnend. In 1 month ' s time, he lost his job , apar tment , and friends.

The t ragedy of these decisions is especially evident when contras t ing Mr. Goodman ' s exper ience to that of Har r ie t Ogglesby. Like Frankhn Goodman , Ms. Ogglesby had been d iagnosed with a significant and chromc disease: diabetes. Ms. Ogglesby was a 34-year-old clerk-typist for a small insurance b roker m Omaha . She had to carefully mon i to r he r sugar intake and self-administer in- sulin each day. She watched he r lifestyle closely for si tuations that might exacer- bate he r condi t ion. Ms. Ogglesby also met regularly with a physician and dmu-

cian to discuss b lood sugar, diet, and exercise. Despite these cautions, Harr ie t had an active social life. She be longed to a folk danc ing club that she a t t ended at a nearby high school. She was engaged to be mar r i ed to an accoun tan t at the insurance company.

Despite carefully watching her illness, Ms. Ogglesby suffered a few setbacks, the last occurr ing abou t a m o n t h ago when she requ i red a 3-day hospi ta l izauon to adjust her med i caaon . The doc tor r e c o m m e n d e d a 2-week b reak f rom work after discharge and re fe r red her to the diet ician to discuss appropr i a t e changes

in lifestyle. Even though diabetes is a l i fe- threatening dasease (in he r most recent episode, Har r ie t Ogglesby was near coma when whee led into the hospital) , no one suggested she cons ider some kind of inst i tut ional care where professionals could mon i to r he r b lood sugar and intervene appropr ia te ly when needed . No one r e c o m m e n d e d Harr ie t give up her j o b to avoid work-related stressors that might throw off her b lood sugar.

What is the difference? How could Frankl in lose his job , apar tment , and fr iends while Harr ie t ' s s i tuat ion r ema ined relatively unchanged? It was not the illnesses; both persons had been living successfully with their afflictions for several years. Nor their seventy. Both are biological in origin, chronic , and perva- sive across several hfe domains . The difference seems to lie with the reactions of hea l th professionals, fr iends, and family to each illness. Harr ie t ' s suppor t system real ized that recovery r equ i r ed a hohstic unde r s t and ing of the disease; work and social actlwties were vKal. Franklin 's family and doctors missed the impor- tance of friends, work, i ndependence , and recreat ion, ins tead basing their decisions on misconcept ions abou t schizophrema. Misconcept ions like these are the fundamenta l unde rp inn ings of st igma and discr iminat ion.

THE IMPACT OF STIGMA 205

Disease and Stigma Models of Severe Mental Illness

A better unders tanding of concepts related to dxsease and stigma is needed to identify misconceptions that underlie negative public attitudes. Once, prom- inent voices in mental health believed that viewing mental illness as a disease actually led to sngma. Thomas Szasz (1961) and R. D. Laing (1964) argued that psychiatry and mental illness were created by a conservative society tryang to put down eccentric or bohemian lifestyles by calling them sick. Psychiatric &sease

was a mirage produced by a cultural tyrant. Szasz and Laing viewed the only so- lution to correcting stigma required rejecting mental illness as a disease entity.

More current conceptualizations of disease and stigma seem not to be at odds (Corrigan & Penn, 1997). As can be seen f rom Figure 1, models that explain the impact of disease and discrimination parallel one another (Corrigan, 1997). These simple linear models show how disease and discrimination processes cause the loss of opportunities commonly experienced by persons with severe mental illness. According to a disease model, biological events including genetic heritage (Asherson, Mant, & McGuffin, 1995) and in-utero insult

The Impact of Disease

Biological Vulnerability )

Psychiatric Symptoms )

Diminished Social Functioning ¢

Failure to Achieve Social Roles ¢

Loss of Social Opportunities )

Poor Quality of Life

The Impact of Stigma and Discrimination

Biological Vulnerability ¢

Psychiatri~ Symptoms

Misconceptions )

Stigma )

Discrimination

) Loss of Social Opportunities

) Poor Quality of Life

FIGURE 1 Simple hnear models of disease and discr iminat ion paradigms that outhne their

impact on severe mental illness

206 CORRIGAN

(Susser & Lin, 1992; Torrey, Bowler, & Rawlings, t992; Wyatt, 1996) create a psy- chobiological vulnerability in some persons. These vulnerabilities combine with the stress of life events to produce psychotic symptoms, mood disorders, or social apathy in late adolescence or young adul thood (Bebbington et al., 1993; Nuechterlein et al., 1992). Moreover, subtle cognitive and interpersonal deficits that occur in chi ldhood and late adolescence prevent many persons with severe mental illness f rom learning social and instrumental skills that help them ward off life stressors as well as assist them with the needs of independen t living (Green, 1998; Liberman, Spaulding, & Corrigan, 1995).

Persons who are plagued by psychiatric symptoms and who lack social skills soon find they are missing a supporuve social network. Few people are willing to befriend them or help them with their problems (Meeks & Murrell, 1994). As a result, many persons with severe mental illness do not attain age-appropriate social roles: They do not finish school, enter a vocation, or get married. This chain of events leads to a loss of social opportunity. Persons with severe mental illness are less likely to be employed competitively, to live in dignified housing, or to have sufficient monies to meet dally needs. Persons report a poor quality of life because of the losses.

A stigma and discnminat ion model of severe mental illness yields a different picture of the relationship between biological cause and failure to avail social opportuni ty (see the right panel in Figure 1). Proponents of a stigma and discrimination model acknowledge that biological agents cause psychiatric symptoms; the combinat ion of symptoms and vulnerabilities, in turn, leads to diminished social skills and support networks. However, proponents of the stigma and discrimination model suggest stigmatizing attitudes about these symptoms have an equally damaging effect on social funct ioning (Corrigan & Penn, 1998; Fisher, 1994; Link, Cullen, Struening, Shrout, & Dohrenwend, 1989; Penn et al., 1994). Members of the general public who endorse these stigma are likely to dis- criminate against persons with severe mental illness. Because the public does not unders tand the impact of severe mental illness and frequently fears persons with these disorders, members of society withhold opportunit ies related to housing, work, and income (Monahan, 1992; Nagler, 1994; Riger, 1994; Stephens & Belisle, 1993). Thus, the loss of social opportuni ty that accompanies severe mental illness is due as much to the injustices of societal stigma as to the effects of biology.

The Stigma and Discrimination of Mental Illness

Movies, newspapers, radio programs, and television shows are obvious pur- veyors of misinformation and stigma about severe mental illness. Media analyses of film and print representations of mental illness have identified three c o m m o n misconceptions: people with mental illness are homicidal maniacs who need to be feared; they have childlike perceptions of the world that should


be marveled; or they are rebellious, free spirits who should be cultivated (Hyler, Gabbard, & Schneider, 1991; Mayer & Barry, 1992; Wahl, 1995). Several examples from the popular media collected from Otto Wahl's book Medza Madness

depict sensational and misleading newspaper headlines (i.e., NUTTY PSYCHI- ATRIC PATIENTS and FREED MENTAL P A T I E N T KILLS MOM) and cartoons that falsely represent menta l illness as a zany, childlike lifestyle. Despite flagrant ex-

amples like these, much of society is still insensitive to menta l health stigma. Table 1 provides an exercise that sensitizes persons to what might seem to be relatively innocuous statements about menta l illness.

Results of two factor analyses on more than 2,000 individuals from England and the U.S. revealed three common themes to Western attitudes about menta l illness (Brockington, Hall, Levings, & Murphy, 1993; Taylor & Dear, 1980): (1)

Fear and exclusion: persons with severe menta l illness should be feared and, therefore, be kept out of most communit ies . (2) Authoritarianism: persons with severe menta l illness are irresponsible; life decisions should be made by others;

(3) Benevolence: persons with severe menta l illness are childlike and need to be cared for.

Stigmatizing attitudes are no t l imited to menta l illness. Persons with physical illness and disabilities are also the objects of disparaging opinion. However, the

general public seems to disapprove of persons with severe menta l illness significantly more than persons with physical disabilities like Alzheimer's disease,

blindness, or paraplegia (Piner & Kahle, 1984; Weiner, Perry, & Magnuson, 1988). Severe mental illness has been viewed as more similar to drug addiction,

prosti tution, and criminality than physical disability (Albrecht, Walker, & Levy, 1982; Skinner, Berry, Griffith, & Byers, 1995). Unlike physical disabilities, persons with menta l illness are perceived to be in control of their illness and re-

TABLE 1 AN EXERCISE THAT SENSITIZES PERSONS TO MENTAL ILLNESS STIGMA

Make a list of overgeneralizatxons and mlsattnbutxons about mental illness on A M radio and network telev~saon

"That person acts that way because he's crazy" "All psychos are violent." "Crazy people can't take care of themselves."

Replace terms like "crazy" and "psycho" with the name of an ethmc minority group "That person acts that way because he's Black." "All Latinos are violent." "Irish people can't take care of themselves."

Most cmzens, who might have thought these were innocuous statements about mental illness, qmckly become homfied at the samxlanty between disrespecting persons wath mental illness and persons of color. In fact, some advocates for dxsablhty have equated the experience of mental health sugma with the lnjusUce of disrespecting racaal mmormes (Ross, 1992; Stephens & Behsle, 1993).

208 CORRIGAN

sponsible for causing it (Weiner et al., 1988). Furthermore, research respondents are less likely to pity persons with mental illness, instead reacting to psychiatric dxsability wath anger and believing that help xs not deserved (Weiner et al.).

The Impact of Stigma and Discrimination Stigmatizing attitudes like these have a significant impact on mental illness.

First-person accounts in Schzzoph~enza Bulletin, a NIMH-sponsored journal, re- peatedly describe the pain of stigma and discrimination. More carefully sam- pled survey research supports these accounts; one study found that 75% of family members participating in a survey said that relatives with mental illness had been affected adversely by sugma (Wahl & Harman, 1989). Family members in this sample believed that stigma decreased self-esteem, hindered ability to make friends, and undermined success in obtaining employment. Persons with severe mental illness living in New York City viewed stigma with similar concern (Link et al., 1989). They believed the public would exclude them from close frmndships or competitive jobs because of their mental illness.

The impact of stigma is not limited to the individual diagnosed with mental illness. One in five respondents in a family survey reported lowered self-esteem and strained relationships with other family members because of stigma (Wahl & Harman, 1989).

The impact of stigma is not limited to negative public attitudes (Corrigan & Penn, 1997). Several studies have documented the behavioral impact (or discrimination) that results from stigmatizing attitudes. Citizens are less likely to hire persons who are labeled mentally ill (Bordleri & Drehmer, 1986; Farina & Felner, 1973; Link, 1987), less likely to lease them apartments (Alisky & Icz- kowski, 1990; Page, 1977, 1983), and more likely to falsely press charges for wo- lent crimes (Sosowsky, 1980; Steadman, 1981). The detrimental impact of stigma is not limited to discrimination by others. Some persons with severe mental illness also endorse stigmatizing attitudes about psychiatric disability and, in essence, about themselves. These persons may experience diminished self-esteem, which correlates with a lower quality of life (Mechanic, McAlpme, Rosenfield, & Davis, 1994). Moreover, persons who self-stigmatize are less likely to be successful in work, housing, and relataonshlps (Link et al., 1989). These individuals seem to convince themselves that socially endorsed stigmas are correct and that they are incapable of independent living.

Social Cognition, Stigma, and Discrimination

Researchers have identified three paradigms that explain stigma: SOClO- cultural perspectives, motivational biases, and social cognitive theories (Crocker & Lutsky, 1986). The first two models are described in Table 2. The third model--social cognitive paradigm--is especially relevant for cognitive behav-

THE IMPACT OF STIGMA

TABLE 2 SOCIO-CULTURAL AND MOTIVATIONAL PARADIGMS THAT EXPLAIN STIGMA

209

Definition Examples

Soclo-cultural Sugma develops tojusufy The behef that African Americans prevalent social injustices, are inferior justifies slavery

The belief that Mexican Americans are not iutelhgeutjustlfies economic disadvantage.

Motivational Basic psychological needs that affect attitudes and prejudice

Just-world hypothesis

Self-enhancement theory

It is fundamentally a fair world. Poor people are often the victims of crime. Therefore, they must be inferior or aggressive

I feel better about myself when I compare myself against a bad group.

Adapted from Crocker & Lutsky, 1986

ioral approaches to changing stigma and is thus more fully discussed here. Ac- cording to this view, stigmas are cognitive structures that individuals construct to make sense of their social world (Crocker & Lutsky). In this light, stigmas are examples o f the natural propensity to categorize information in an effort to make sense of the relative infinity of data with which people are bombarded (Baddeley, 1982). For example, individuals make sense of a word l ist--dog, top, wrench, skates, hammer, horse, pig, cow, saw, puzzle, drill, ba l l - -by organizing the words into three categories: animals, tools, and toys. They may organize expe- riences with police officers, co-workers, guards, friends, neighbors, ticket takers, bosses, and family members into two groups: authorities and personal associates.

Stereotypes are especially efficient means of categorizing information about social groups (Esses, Haddock, & Zanna, 1994; J u d d & Park, 1993; Krueger, 1996; Mullen, Rozell, &Johnson, 1996). Stereotypes are considered "social" because they represent collectively agreed upon notions of groups of persons. They are efficient because people can quickly generate impressions and expectations of individuals who belong to a stereotyped group (Hamilton & Sherman, 1994; Nosofsky, Palmeri, & McKinley, 1994). For example, that man in the urn- form is a police officer; he will likely be an authoritative person I can seek out when I need help. Stereotypes do not necessarily represent a group pejoratively; the police example above is evidence of this. Stigmas are stereotypes that reflect a group negatively (Devine, 1989; Krueger, 1996); for example, "persons with mental illness are dangerous or incapable of making their own decisions."

Social psychologists distinguish knowledge of stigmas from endorsement o f

210 CORRIGAN

them (Devine, 1988, 1989; Jussim, Nelson, Mares, & Soffin, 1995; Krueger, 1996). Many people are familiar with the Irish American drinking stigma. How- ever, they do no t endorse it as a true reflection of Americans with Irish back- grounds. To endorse such negative attitudes would be preju&cial. The harmful effects of stigma come f rom its prejudicial endorsement . Hence, it is the endorsement of stigma, and no t knowledge, that is the target of stigma-busting ac- tivities. This, o f course, is a more reasonable goal. Knowledge of a cognitive structure can never be erased. However, the contingencies that affect agree- ment with these attitudes can be changed such that people are less willing to endorse the stigma, or at least act on the endorsement.

Learning Stigma Stereotypes and stigma are learned m two ways (Crocker, 1983; Crocker &

Lutsky, 1986). Cognztzvely constructed stereotypes are acquired th rough regular contact with members o f a particular group. The public learns stereotypes about mental illness by directly interacting wath persons who have a psychiatric disability. Soaally gwen stereotypes represent cultural lore about a group handed down by communi ty elders and other authorities. Socially given stereotypes often include attributes that are not easily observed, like motivations, morality, and intentions. As a result, socially given stereotypes are frequently more diffi- cult to change because they do not rest on prior experience and, therefore, are not affected by subsequent, contrary evidence (Kunda & Oleson, 1995; Roth- bart & Lewis, 1988).

Goffman (1963) made a distinction between &scre&ted and &scre&tablegroups that has implications for acquiring and challenging cognitively constructed and socially given stereotypes. Members of discredited groups have patently manifest stigma. They show a physical characteristic that signals group membership (e.g., skin color distinguishes African Americans and yarmulkes identify Jews). Mental illness is an example of discreditable stigma, which is relatively hidden from pubhc wew. Clnzens do not realize an individual has a history of mental illness and psychlatnc hospitalization unless that person reports it. Much of the mental health experience is private and the corresponding stigma discreditable.

Persons with obvious or discredited stigma are typically the objects o f cognitively constructed stereotypes. The public can discern stereotypical characteristics of a group when these qualities are manifest. Physical characteristics that define race, culture, or physical disability are f requent sources of cognitively constructed stereotypes. Typically, stigma about mental illness is socially given. The public learns that persons with mental illness are dangerous or incompetent based on messages provided by authonties in the culture. Hence, mental health stigma tends to be more resilient to evidence that contradicts the stigma (Corrigan & Penn, 1998). For example, education campaigns aimed at dis- count ing negative atutudes about mental illness have had limited impact (Holmes, Corrigan, Williams, Canar, & Kubiak, 1997).


Although much of the mental health experience is private, one aspect is public and discredited: the mentally ill label. Persons who are called "mentally ill" (e.g., through a diagnosis such as schizophrenia or hospitalization for psychiatric illness) frequently are the butt of societal stigma and discrimination (Link, 1987; Link et al., 1989). People with public labels are the source of cognitively constructed stereotypes. The public learns by observing the "crazy guy" at the end of the train platform that persons with mental illness are disheveled, drunk, and larcenous. However, cognitively constructed stigma based on labels may lead to even greater misinformation than typical stereotypes. Individuals who are not true members of a minority group (e.g., people who are not chal- lenged by a psychiatric disability) are misidentified as members of that group because they have been mislabeled. For example, many homeless people are labeled mentally ill, leading to inaccurate beliefs about persons with mental illness choosing to be poor and live on the streets (Koegel, 1992; Koegel, Burnham, & Farr, 1988).

Stigma and Discrimination Discrimination is the behavioral consequence of prejud:ce and stigma (Cor-

rigan & Penn, 1998). People who act on stigma by withholding opportunities from minority group members, or by behaving aggressively against these minority members, are discriminatory. Perhaps the worst part of stereotypes and prejudice is this behavioral consequence. Although being viewed negatively by the majority may generate anguish, anger, or self-reproach, it is loss of jobs, un- fair housing, diminished income, physical violence, and verbal abuse that cause the greater misery. Hence, understanding the relationship between the cognitive phenomenon of stigma and the behavioral phenomenon of discrlmmation is essential to discounting their harmful effects on persons with severe mental illness.

The relationship between attitudes and behaviors has been an important co- nundrum for psychologists. Fazio (1990) distinguished two models--automatic and deliberative--that explain the effect of stigma on discrimination. Ac- cording to the automatic model, many social behaviors are elicited by the perception of social cues (Langer, 1978). For example, a passenger changes seats after seeing an unkempt person talking to himself on the train. These are well-learned responses that require little awareness and seem to occur in specif- ically defined situations. Automatic responses are fairly adaptive because they do not require much cognitive effort to accomplish; people are able to respond almost reflexively to the social situation as a result.

How does a cognitive structure like attitude or stigma affect automatic responses? Stereotypes govern automatic responses by affecting the perceptions of social cues that elicit these stereotypes (Crocker & Lutsky, 1986; Fazlo, 1986). Stereotypes serve as the encoding template that gives meaning to the sensation and lead to a behavioral response. A disheveled person encountered on the

212 CORRIGAN

train may alternatively be pe rcewed as a "dangerous menta l pat ient" (based on a psychiatric s tereotype) or "a person down on his luck" (based, perhaps, on an a tu tude of Christ ian charity). The first pe rcep t ion may lead the passenger to move to a different seat. The second may cause the passenger to ask whether the person needs help. Strategies that change the underlying stereotype will alter automatic responses by changing the cues that signal these responses. For example, changing the percept ions of homeless people from "dangerous pauents" to "persons down on their luck" may lead to less distancing and more concern.

All behavioral responses to social situations do no t occur automatically; the second mode l that descr ibes the re la t ionship between stereotypes and behavior is deliberat ive in na ture (Ajzen, 1987; Ajzen & Fishbein, 1980; Fazio, 1990). In novel situations, individuals must construct responses f rom a variety o f behavioral possibilities. For example , Mary Smith, trying to carry a large load of groceries f rom her car to the house, encounters a person act ing menta l ly ill who asks to he lp her. This is a novel si tuation to which Mary must choose a response f rom a range of options: She could accept the person 's help, send h im away, or ignore him. Accord ing to the deliberative model , the individual is a rat ional be ing who weighs the costs and benefits o fvarmus opt:ons.

Costs and benefits are affected, in part , by stereotypes about the minori ty g roup m e m b e r (e.g., "persons with menta l illness are dangerous , so one cost of let t ing h im help me with my groceries is he may attack me"). Costs and benefits are also inf luenced by externa l motivators. These might be immedia t e moUva- tions (e.g., "one benef i t of le t t ing him help is I would get my grocer ies in the house easier"). Motivat ion may also occur at the inst i tut ional level. Inst i tut ions like schools, businesses, and governments may apply penal t ies for pe r fo rming a st igmatizing behavior. For example , the Federa l government passed the Amer- ican with Disabilities Act of 1990 and the Fair Hous ing Act of 1988, which dis- courage employers and landlords f rom discr iminat ing against persons with disabilities such as menta l illness.

Sugges t ions fo r a Behavior Therapy of St igma

The b read th of p rob lems caused by menta l illness st igma suggests targets for behavior therapy; social cognitive research on stigma and discr iminat ion suggest h u m a n processes that mit igate a behavioral app roach to these targets. Figure 2 summarizes a m o d e l o f behavior therapy that combines the b read th of targets with social cognitive processes. As o u d i n e d in Figure 2, st igma comes f rom a variety of sources. The media, inc luding newspapers, movies, and television, disperses various sugmatiz ing images and slogans abou t severe menta l illness t h roughou t our community. Messages f rom parents and o the r authori t ies teach chi ldren that persons with menta l illness are dangerous or canno t care for themselves. Observat ions of labe led "patients," hke the homeless, lead to biased at t r ibut ions about menta l illness. These various sources of st :gma :mpac t severe


(2) Empowerment

Sources of Stigma

Medm Informal Commumcatmn

Observations of the labeled

!

IMPACT

(3) Pubhc Actton

Society

• IVhsmformatlon • M~spereept~ons • Incorrect expectations

Labeled - Poor self expectation - Poor self esteem - Butt of socmtal disapproval - Loss of opportunity

Indaviduals with

Mental Illness

Dlscre&table

• Hostility • W~thheld Opportunmes

(1) Attttude change and dzsclosure dectstons

- Poor self expectation - Poor self esteem

FIGURE 2 This model points to the three targets of a behavior therapy for psychlamc sugma' individuals experiencing dlscre&table sugma, mdwaduals labeled with mental illness, and society that endorses stigmatizing attitudes. These targets suggest three mtervenuons numbered m the figure (1) cognitive therapies that help persons challenge irrational attitudes about self-worth due to stigma and that help people strategize about disclosing their psychiatric history; (2) strategies that foster empowerment and help persons challenge the social disgrace that occurs with psychlamc labels; and (3) pubhc action that changes societal attitudes about mental illness or suppresses discriminatory behavior

m e n t a l i l lness t h r o u g h pa ths , n u m b e r e d 1 t h r o u g h 3 in F igure 2, t ha t are con-

s i d e r e d sequent ia l ly h e r e .

1. C h a l l e n g i n g the Private S h a m e o f D i sc red i t ab l e S t igma T h r o u g h

A t t i t ude C h a n g e

S o m e p e o p l e e x p e r i e n c e s t igma a n d p r e j u d i c e as a d i sc red i t ab l e p h e n o m -

e n o n , a pr iva te s h a m e tha t d i m i n i s h e s t he p e r s o n ' s se l f -es teem. This k ind o f

214 CORRIGAN

shame leads to self-doubt about whether the person is able to live indepen- dently, holddobs, earn a livelihood, or find life mates (Link et al., 1989). Even though they may have mastered their symptoms and disabilities, persons with mental illness must overcome stigmatizing reminders that they fail to recover or do not become useful members of society.

Struggling with going m and out of the hospital and the depression and craziness was bad enough. And all the disapproval sure hur t too. My parents thinking I was lazy, especially because my brother was a doctor. My uncles no longer asking me to go fishing with them because I needed my rest

But what really hurt was when my parents gave up. I think it was after my hospitalization in 1990 when I tried to kill myself. They stopped believang I would beat it. They stopped pushing me to get a job. They talked about me living in a home. They thought I was a mental patient and not their son. Morn and Dad had bought into all the societal stuff about mentally ill pauents.

The loss o f faith was much harder than my time in the hospital. I began to beheve it too. I 'm not going to be able to work. I'll never find someone to marry. I'll always live in homes.

- - a d u l t with severe mental illness

Behavaor therapists might help persons with mental illness cope with the loss of self-esteem that results f rom stigma by using cognitive therapies. Persons who are depressed learn to reframe dysphoric thoughts about themselves ("I'll never be successful") and the world ("Everybody else is able to cope. Why can' t I?") in a more positive light (Haaga & Davison, 1991). A variety of cognmve strategies help people challenge depressogemc thoughts and develop beliefs that counter the sadness. In a similar manner, persons can learn to challenge stigmatizing views of themselves and negative expectations about their future using cognitive therapies. For example, persons struggling with mental health stigma ("I 'm mentally 211; I can ' t make it on my own") might learn to collect evidence that dis- putes the stigma ("Many people with worse dlsabiliues have made it") and construct counters for subsequent times when bothered by the public ("If others can do it, so can I!"). Holmes and River (1998; m this series) write more fully about the role of cognitive therapies in deahng with the personal shame of stigma.

Some people may choose to deal with stigma by selectively disclosing their history with mental illness. They may decide to avoid pubhc disapproval by not sharing their difficulties with others. Instead, they seek out a small number of persons who are likely to empathize with their challenges and support efforts in pursuit of their goals.

THE IMPACT OF STIGMA 2 1 5

I felt like I was going to exp lode at work when I cou ldn ' t tell someone. Co-workers would be talking about their col- lege years, or their stretch in the Army, or that t ime they got thei r first j o b . . , years when I was in and ou t of the hospital . They 'd turn to me and ask what I was up to and I ' d have to excuse myself or make someth ing up. I felt ashamed that I cou ldn ' t be honest . But, I also felt angry that no one would unders tand. It 's no t my fault I have this gap.

Then I met Beverly. I t took several months , bu t eventu- ally I f igured she would be someone who could handle my disclosure. Beverly never seemed to get nervous when I

fai led to discuss my past. Instead, she had a cha rming way of teasing me about my l i fe , just like a good friend. A n d she always r e sponded with an open m i n d when I tested her views about menta l illness. We saw this movie once where they presen ted a depressed person as a moral degenera te . Over coffee afterwards, Beverly actually got mad about it.

Beverly has known abou t my menta l illness for abou t a year now. I thought she migh t pull away, you know, be scared of the crazy. But now, I can go to he r desk and bi tch about work and I feel she knows.

- - a d u l t with severe menta l illness

Behavior therapists can help persons cons ider the costs and benefits of disclosure. Persons with disabilities need to weigh the benefits, for example , o f let- ring the i r employer know ("She'll be more pa t ien t with me") versus the cost of disclosing ("The boss might no t th ink I can hand le my job") . Therapis ts can also he lp persons consider characterist ics that signal a safe person to whom to disclose. Is a person likely to r e spond and be support ive like Beverly?

Behavior therapists need to be aware o f the pa r a dox in trying to he lp peop le dec ide whe ther to disclose. An u n i n t e n d e d message could be given, namely, that menta l illness is i ndeed someth ing that should be hidden. This k ind of message could re inforce at t i tudes of shame.

2. Chal lenging the Pain o f Public Labels Th rough Empowermen t People who have been labe led as mental ly ill exper ience addi t ional ha rm

from stigma. Labels frequently come f rom publ ic knowledge that the person was hospital ized.

I know my family t r ied to keep it to themselves. But these things jus t get out. I went away for two weeks and it seemed that everyone knew I had been In a psych hospital . Whe the r it was genu ine conce rn or the object of gossip,

216 CORRIGAN

people at church, at the store, at the local park all seemed to know and look at me differently.

- - a d u l t with severe mental illness

The label of mental illness may also come f rom misinformation. Many homeless or d:sheveled people are called mentally 111. Persons who are labeled mentally ill are unable to hide from public disapproval. As a result, they are more likely to experience societal hostility and discrimination, resulting in disenfranchisement.

Empowerment has been conceptualized as the opposite of the disenfranchisement experienced by persons who are stigmatized (Corrigan, Faber, Rash:d, Leary, & Okeke, 1998; McLean, 1995; Rogers, Chamberhn, Ellison, & Crean, 1997). The impact of empowerment is significant; despite societal stigma, empowered consumers endorse positive attitudes about themselves. They have positive self-esteem, believe themselves to be self-efficacious, and are optimistic about the future. The impact of empowerment on the community is manifested by the person's desire to affect his or her stigmatizing community. Persons believe they have some power within society, are interested in affecting change, and wish to p romote community action.

Faith Dickerson (1998) writes about cognitive behavioral strategies that foster empowerment . Central to this effort is a behavioral definition of the construct. Empowerment includes any strategy that provides the person control over his or her treatment. For example, behavior therapists have developed training programs by surveying mental health consumers about skills they need to meet life goals (Corrigan & Holmes, 1994; Goldsmith & McFall, 1975). Prac- tmoners have also turned the entire t reatment enterprise over to consumers in the spirit of empowerment . For example, George Fairweather (1969) developed a residenual p rogram run by program participants. He believed that the symptoms and deficits of institutionalized persons would greatly diminish if these individuals were empowered to care for themselves in a lodge setting. In such a setting, persons benefit from the consensus-building process needed to design and maintain effective residential and vocational programs. Moreover, their sense of self-efficacy and -esteem is enhanced by living and working with peers. Results o f a 36-month follow-up of the Fairweather Lodge were prom- lsing; participants m this program showed a s:gmficantly lower rate of hospitalization and significantly greater rates of employment than participants in a control program.

An interesting paradox arises out of the empowerment movement. Rather than choosing to hide one 's mental illness, many persons fight stigma by coming out of the closet and grabbing public control of their lives. This is evi- denced by the n u m b e r of consumer advocacy and self-help groups that have been founded for persons with mental illness. These groups provide support for the person to fight the shame and discrimination that accompanies stigma.

T H E I M P A C T O F S T I G M A 217

3. Challenging Societal Ignorance Through Pubhc Action Society also suffers f rom stigma about severe mental illness. Citizens are

mis informed about members of their communi ty with psychiatric dlsabihties. This misinformation leads to unnecessary fears and worries. It also leads to mlsperceptions about the actions of fellow citizens. Fear and misinformation result in hostility and anger. Members act on this fear by robbing persons with mental illness of rightful opportunities. Employers fail to hire and landlords do no t lease to persons with severe mental illness. Entire communit ies express outrage at the thought that a mental health residence might move into their ne ighborhood.

Social psychologists have developed a variety of strategies for trying to change attitudes about racial minorities. In this issue, David Penn (Mayville & Penn, 1998) discusses the relevance of these strategies for changing public attitudes about mental illness. These strategies include protest, education, and contact (Corrigan & Penn, 1998). Groups protest inaccurate and hostile representations of mental illness as a way to challenge the stigmas they represent These efforts send two messages. To the media: Stop report ing inaccurate representations of mental illness. To the public: Stop believing negative views about mental illness. Protest is a reactive strategy; it diminishes negative attitudes about mental illness, but fails to p romote more positive beliefs that are supported by facts. Education provides information so that citizens make more informed decisions about mental illness. Education also corrects the myths and misconceptions that underlie mental illness stigma. Education strategies are augmented by face-to-face contact. Stigma is diminished when members of the general public meet persons with severe mental illness who are able to hold down jobs or live as good neighbors in the community.

Unfortunately, research that has examined efforts to change racial prejudice has shown these stereotypes to be fairly resilient. It is likely that these limited effects define boundaries to busting mental illness stigma as well. For example, research suggests that attitude change that results f rom contact with persons f rom ethnic minority groups rarely generalizes to the group as a whole (Hewstone & Brown, 1986; Kunda & Oleson, 1995; Rothbart & Lewis, 1988). The discon- firming effects of the atypical group member have been shown to have no impact on the broader group stereotype. For example, members of the general public who view an individual with mental illness as friendly and capable will probably show no overall change in stigma about mental illness. They will con- clude that this person is an outlier; most persons with mental illness are still seen as dangerous and incompetent .

Research suggests there are potent moderators of stigma-busting efforts (Corrigan & Penn, 1998). Cognmve behavior therapists, among others, have much work to complete before effective strategies are identified and packaged in ways that lead to substantive social change.

218 CORRIGAN

Conclusions

Behavior therapy is fundamental ly a climcal enterprise that seeks to arm persons with ways o f coping with problems caused by environmental , biological, or imagined agents. In this hght, teaching persons who are plagued by psychiatric stigma how to cope with stigma makes sense. Attitude change to offset the loss of self-esteem c o m m o n to the stigmauzed is a famihar target to cognitive behavioral therapists. Helping people consider the costs and benefits of specific decisions provides another way to cope. Setting up therapy programs that empowers participants is also consistent with a behavioral approach. Perhaps the odd bed- fellow in this a rmamentar ium is trying to change public attitudes about mental illness. What business does behavior therapy have seeking societal change?

Actually, behaviorists have a long and distinguished history writing about the role of behavioral theory in affecting societal-level metamorphoses. B. E Skinner (1953) wrote m Sczence and Human Behavzor,

Why should the design of a culture be left so largely to acci- dent? Is it no t possible to change the social envi ronment dehberately so that the human produc t will meet accept- able specif icat ions?. . . Once a given feature of an environment has been shown to have an effect u p o n h u m a n behavior which is reinforcing, either m itself or as an escape from a more aversive condition, constructing such an environment is as easily explained as building a fire or closing a window when a room grows cold . . . (pp. 426- 427).

In his popular book Walden Two, Skinner (1948) presented an even grander image of behavioral theory as societal change agent. He describes the social agenda of an entire communi ty based on principles of operant psychology.

Others have written more prosaically about the role o f behavior therapy for social change. Cyril Franks (1984) believed that behavior therapists should not limit their work to climcal practice. We need to be advocates, renovators, activ- ists, and planners to have a broad effect on persons' problems. Behavior therapy is built on a model that represents the fit of person and envi ronment factors in the cause of behavior and behavioral problems. Clinicians are exquisitely sensi- tive to individual factors that cause behaviors. They are able to change the environment to influence individual factors. A natural extension of this model is to affect the environment in its broadest s ense - - chang ing societal attitudes and behavioral responses to a specific group.

O 'Donnel l and Tharp (1982, 1990) have discussed this agenda in terms of communi ty psychology. They have reviewed societal programs that have sought to change a variety of communi ty concerns, including litter control, energy con- servation, reducing the use of te lephone assistance, lowering noise levels, using

T H E I M P A C T OF S T I G M A 219

d e n t i s t s m o r e , a n d i m p r o v i n g t h e p a c k a g i n g o f g a r b a g e . Recent ly , J a s o n , Bil-

lows, S c h n o p p - W y a t t , a n d King (1996) h a v e s h o w n t h e p o w e r o f b e h a v i o r a l

s t r a teg ies f o r c h a n g i n g soc ie ta l a t t i t u d e s a n d b e h a v i o r s r e l a t e d to s m o k i n g .

Clearly, t h e s e m e t h o d s a re r e l e v a n t to c h a n g i n g soc ie ta l a t t i t u d e s a n d b e h a v i o r s

t o w a r d p e r s o n s wi th severe m e n t a l i l lness. T h e c o m b i n a t i o n o f cogn i t ive b e h a v -

io ra l s t r a t eg ies t h a t t a r g e t t he p e r s o n ' s e x p e r i e n c e a n d t h e c o m m u n i t y ' s en-

d o r s e m e n t o f s t i g m a o f fe r t h e b r o a d e s t a r m a m e n t a r i u m fo r r e d u c i n g its impac t .

References

Ajzen, I (1987). Attitudes, traits, and acUons. DlsposaUonal predlcUon of behavior in personality and social psychology In L. Berkowitz (Ed.), Advance~ *n expenmental soc~alpsycholog 3 (Vol. 20, pp. 1-63) NewYork. Academic Press

Ajzen, I., & Flshbem, M (1980). Understand*ng attitudes and pred~etzng social behavwr Englewood Cbffs, NJ' Prentice-Hall

Albrecht, G. L., Walker, V. G., &Levy, J A. (1982) Social distance from the stigmauzed. A test of two theories Social Saence and Medzczne, 16, 1319-1327.

AlIsky, J. M., & Iczkowska, K. A. (1990). Barriers to housing for demsUtutlonallzed psychiatric patients Hospztal and Communzty Psychzatry, 41, 93-95.

Asherson, P, Mant, R., & McGuffin, E (t995) Genetics and schlzophrema In S R Hlrsch & D R Weanberger (Eds), Sch~zophrenza (pp 253-274). Cambridge, MA Blackwell Science

Baddeley, A. D. (1982) Domains of recollection. Psycholog~calRevzew, 89, 708-729 Bebbxngton, E, Wllkms, S,Jones, P B., Foerster, A., Murray, R, Toone, B, & Lewis, S. (1993) Life

events and psychosis. Imtial results from the Camberwell Collaborative Psychosis study Bntzsh Journal of Psychiatry, 162, 72-79

Blaska,J (1993). The power oglanguage. Speak and write using "person first." In M Nagler (Ed.), Perspectzves on disabdzty (2nd ed, pp. 25-32). Palo Alto, CA. Health Markets Research

Bordlerl, J , & Drehmer, D (1986) Hiring decisions for disabled workers' Looking at the cause Journal of Apphed Soc~al Psychology, 16, 197-208.

Brockington, I., Hall, P, Levmgs,J., & Murphy, C. (1993) The commumty's tolerance of the mentally 111 BntzshJournal of Psychiatry, 162, 93-99.

Corrigan, E W. (1997) Behavior therapy empowers people with severe mental illness Behawor Mod~fieatzon, 21, 45-61.

Corrigan, E W, Faber, D., Rashid, E, Leary, M, & Okeke, I. (1998) The construct vahd~ty ofempow- ~ t among consumers of mental health se~wces. Manuscript submitted for pubhcatlon

Corrigan, P W, & Holmes, E P (1994). Patient IdentlficaUon of"Street Skills" for a psychosoclal training module. Hospztal and Communzty Psychzatry, 45, 273-276

Corrigan, E W., & Penn, D L. (1997) Disease and discrimination. Two paradigms that descrthe severe mental illness Journal of Mental Health, 6, 355-366

Corngan, E W, & Penn, D L (1998) Stzgma-bustzng and stereotype Lessons from soczalpsychology on dzscredzt~ngpsychzatnc stzgma. Manuscript submitted for publication

Crocker, J (1983) Changmg stereotypes about stzgmatzzed groups Paper presented at the annual meet- mg of the American Psychological Assocmtion, Anaheim, CA.

Crocker, J , & Lntsky, N. (1986). Stigma and the dynamics of socml cognmon In S. C Alnlay, G. Becker, & L. M. Coleman (Eds), The ddemma of d~fference. A multzd~sctphnary vzew of stzgma (pp 95-122). NewYork" Plenum Press

Dewne, P G (1988) Stereotype assessment: Theoretzcal and methodological zssues. Unpublished manuscript, University of Wisconsin-Madison

Devine, P G (1989) Stereotypes and prejudice. Their automatic and controlled components Journal of Personahty and Soczal Psychology, 56, 5-18

Dickerson, E (1998) Strategies that foster empowerment CogmtweandBehavzoralPractzce, 5, 255- 275

220 CORRXGAN

Esses, V M, Haddock, G , & Zanna, M P (1994) The role o5 mood in the expression of rater- group stereotypes. In M P Zanna &J M Olson (Eds.), The psychology ofpreludzce The Ontario experience (Vol 7, pp 77-101) Hlllsdale, NJ Erlbaum

Falrweather, G W (1969). Communzty l~fe Jm the mentally zll An altematzve to znstztutzonal cam Chi- cago Aldme

Farina, A , & Felner, R D (1973) Employment mtervaewer xeacUons to former mental paUents Journal of Abnormal Psychology, 82, 268-272

Fazlo, R H (1986) How do attatudes guide behavaor~ In R M Sorrentmo & E T Hlggans (Eds.), The handbook of motwatzon and cognzt~on Foundat~ons of soczal behawor(pp. 204-243) NewYork: Gmlford Press

Fazlo, R H (1990) Muluple processes by wtuch atutudes grade behavior The mode model as an integrative framework. In M. E Zanna (Ed) , Advances zn expenmentalsoc~alpsychology (Vol. 23, pp 75-109) NewYork Academic Press

Flshel, D B (1994) Health care reform based on an empowerment model of recovery by people vath psychxatllc dlsablhtles Hospital and Community Psychzatry, 45, 913-915

Franks, C (1984) Behawor therapy An overview In C. M Franks, G T Wilson, P C, Kendall, & K K Brownell, Annual revzew ofbehavzor therapy Theory &practzce (Vol. 10, pp 1-46) New York Gmlford Press

Goffman, E (1963) Stzgma, Notes of the management of spoded ~dentzty Englewood Chffs, NJ Prentice-Hall

Goldsmith, J B , & McFall, R M (1975) Development and evaluation of an interpersonal skill training program for psychiatric mpaUents Journal of Abnormal P6ychology, 84, 51-58

Green, M F (1998) Schlzoph*enza from a neurocognztwe perspectzve" Probzng the zmpenetrable darkness Boston Allyn and Bacon

Haaga, D A., & Davison, G C (1991) CogmUve change methods In F H Kanfer & A P Gold- stein (Eds), Helpzngpeople change A textbook of methods (4th ed , pp 248-304). NewYork Per- gamon Press

Hamilton, D L , & Sherman,J W (1994). Stereotypes In R S Wyer & T K. Srull (Eds,), Handbook oJsoczal cogmtzon (2nd e d , Vol 2, pp 1-68) Hlllsdale, NJ. Erlbaum

Hewstone, M, & Brown, R J (1986) Contact is not enough An intergroup perspecUve on the "contact hypothesis." In M Hewstone & R Brown (Eds), Contact and conflzct zn *ntergroup encounters (pp 1-44) Oxford, England. Blackwell

Holmes, E E, Corngan, P W,, Wllhams, P, Canar, J , & Kublak, M. (1997, November) The relatzon of knowledge and attztudes about persons w~th a severe mental zllrmss Poster session presented at the 31st annual convenUon of the AssociaUon for the Advancement of Behavior Therapy

Holmes, E. P, & Raver, L. P (1998) Indlvxdual strategies for coping with the stigma of severe mental illness Cognztzve and Behavzo*al P*actzce, 5, 231-239

Hyler, S E., Gabbard, G O , & Schneider, I (1991) Hormcldal maniacs and narcissistic parasites StlgmatlzaUon of mentally dl persons m the mowes Hospital and Communzty Psychzatry, 42, 1044-1048

Jason, L , Billows, W, Schnopp-Wyatt, D , & King, C (1996) Reducing the illegal sales of cigarettes to minors Analysxs of alternaUve enforcement schedules Journal ofApphed Behavror Analysts, 29, 333-344

Judd, C.M. ,&Park , B (1993) Def imtaonandassessmentofaccuracyinsoc la ls te reo types Psycho- logzcal Revzew, 100, 109-128

Jusslm, L., Nelson, T E , Mares, M., & Soffin, S (1995) Prejudice, stereotypes, and labeling effects Sources of bias m person perception Journal of Personaltty and Soczal Psychology, 68, 228-246

Koegel, P (1992). Unders tanding homelessness ' An ethnographic approach In R I Jahlel (Ed) , Homelessness A prevention-oriented approach (pp 127-138) Baltimore Johns Hopkins Umver- slty Press

Koegel, P., Burnam, M A , & Farr, R K (1988). The prevalence of specific psychiatric disorders among homeless indlwduals m the inner city of Los Angeles Amhzves of GeneralPsychzatry, 45, 1085-1092

Kraepelln, E (1913) Lectum~ on d,nzcalpsychzatry (3rd ed ) NewYork. Wflham Wood Krueger, J. (1996) Personal behefs and cultural stereotypes about racial characterxstics Journal of

Personalzty and Soczal Psychology, 71, 536-548


Kunda, Z , & Oleson, K. C (1995) M amt mnmg stereotypes m the face of dlsconfirmatlon' Con- strucUng grounds for subtyplng dewants Journal of Per~onal, ty and Social Psychology, 68, 565- 579

Lamg, R D (1964) Is schlzophrema a thsease? International Journal of Soc~alPsychology, 10, 184- 193

Langer, E (1978) Re-thinking the role of thought in social mteracUon InJ. H Harvey, W. Ickes, & R. E Kldd (Eds), New d~rectzons zn attnbutzon research. Hlllsdale, NJ. Erlbaum

L b e r m a n , R P (Ed) (1992) Handbook oJpsyeh,atrzc rehab,htat~on Elmsford, NY. Pergamon Liberman, R P, Spauldmg, W., & Corrxgan, P W (1995). Cognmve-behavaoral therapies m psy-

chiatric rehablhtatlon In S R Hlrsch & D. Wemberger (Eds), Schzzophrenza (pp 605-625). Oxford. Blackwell SclenUfic PublicaUons

Link, B. G. (1987). Unders tanding labehng effects m the area of mental disorders An assessment of the effects of expectaUons of rejecUon American Soaolog, calRevzew. 52, 96-112.

Link, B. G., Cullen, E T., Struenmg, E. L., Shrout, P E , & Dohrenwend, B. P (1989) A modified labehng theory approach to mental disorders An empmca l assessment American Soczolog~cal Revzew, 54, 400-423

Mayer, A , & Barry, D D (1992) Working with the medm to desugmatlze mental illness Hospztal and Community Psychzatry, 43, 77-78.

Maywlle, E., & Penn, D. L (1998) Changing societal attitudes toward persons with severe mental dlness Cogmtwe and Behavzeral Practzce, 5, 241-253

McLean, A (1995) Em powermen t andpsychmt r l cconsumer / ex -paUen tmovemen tmtheUnx ted States Contradlcuons, crisis and change Social Science and Medicine, 40, 1053-1071

Mechamc, D , McAlplne, D , Rosenfield, S , & Daws, D. (1994) Effects of illness a t tnbut :on and depression on the quahty of life among persons wxth serious mental illness. Soczal Sczence and Medzcme, 39, 155-164

Meeks, S, & Murrell, S A (1994) Service provaders xn the social networks of chents vath severe mental illness Schzzophren~a Bullet,n, 20, 399-406

Monahan,J . (1992). Mental disorder and vmlent behavaor American Psychologist, 47, 511-521 Mullen, B., Rozell, D., &Johnson, C (1996) The phenomenology of being in a group Complex-

lty approaches to operaUonahzmg cognmve representation In J L Nye & A. M. Brower (Eds.), What's soaal about soaal cognztwn~ (pp 205-229) Thousand Oaks, CA' Sage

Nagler, M (Ed) (1994) Pe~spectwes on d~sab~hty (2nd ed ). Palo Alto, CA Health Markets Research Nosofsky, R M, Palmen, T. J., & McKinley, S C (1994) Rule-plus-exception model of classifica-

tion learning Psycholog~calRevzew, 101, 53-79. Nuechterlem, tC H., Dawson, M. E , Glthn, M , Ventura, J , Goldstem, M J , Snyder, K S, Yee,

C M, & Mmtz,J (1992). Developmental processes in schizophrenic disorders: Longitudinal stuthes ofvulnerablhty and stress Sch~zoph,enza Bullet,n, 18, 387-425

O'Donnell , C. R , & Tharp, R G. (1982) C ommumt y anterventaon and the use of multld~sc:- plinary knowledge. In A. S. Bellack, M Hersen, & A E Kazdm (Eds), International handbook ofbehawor modzficat, on and therapy (pp 291-318) NewYork Plenum Press.

O'Donnell , C. R , & Tharp, R. G. (1990). Commumty mtervenUon graded by theoretical develop- men t In A S Bellack, M Hersen, & A E Kazdm (Eds) , International handbook ofbehavzor mod- zfieatzon and therapy (2nd ed., pp. 251-266) NewYork" Plenum Press

Page, S (1977) Effects of the mental illness label m attempts to obtain accommodatxon. Canadian Journal of Behawoural Saence, 9, 85-90.

Page, S (1983) Psychmtrlc sUgma' Two studies of behawor when the chips are down Canadian Journal of Communzty Mental Health, 2, 13-19.

Penn, D L , Guynan, tC, Daffy, T, Spanldlng, W. D., Garbm, C P, & Sulhvan, M. (1994). Dlspelhng the stigma of schizophrenia: What sort of mformatmn is best? Schzzophren*a Bullet~n, 20, 567- 577

Pmer, K , & Kahle, L (1984). Adapung to the stagmaUzmg label of mental illness' Forgone but not forgotten Journal of Personahty and Social Psychology, 47, 805-811

Pager, A L (1994, December). Beyond ADA APA's respons~bxhty to d~sabfl~ty rights APA Monitor, p. 34

Rogers, D , C h a m b e r h n , J , Elhson, M. L., & Crean, T (1997) A consumer-constructed scale to measure empowerment among users of mental health servaces P~ych*atnc Services, 48, 1042- 1047.

222 CORRIGAN

Ross, E C (1992) Success and failure of advocacy groups. A legislative perspective Admmzstratzon and Pohcy zn Mental Health, 20, 57-66

Rothbart, M, & Lewis, S (1988) Inferring category attributes from exemplar attributes Geomet- ric shapes and social categories.Journal of Personahty and Soaal Psychology, 55, 861-872.

Skinner, B F (1948) Walden two NewYork. Macmillan. Skinner, B. F (1953) Saence and human behavzor NewYork: Macmillan Skinner, L J , Berry, K K, Graffith, S E., & Byers, B. (1995). Generahzablhty and specificity of the

stigma associated with the mental illness label A reconsideration twenty-five years later Jour- nal of Commumty Psychology, 23, 3-17

Sosowsky, L (1980). Explaining the increased arrest rate among mental paUents. A cautionary note. Amencan Journal of Psychzatry, 137, 1602-1604.

Steadman, H J (1981 ) Cntlcally reassessing the accuracy of public percepuons of the dangerous- ness of the mentally ill.Journal of Health and Soaal Behavzor, 22, 310-316

Stephens, C L, & Behsle, K C (1993) The "consumer as prowder" movement Journal of Mental Health Admmzstratzon, 20, 178-182

Susser, E S., & Lin, S P (1992) Schizophrenia after prenatal exposure to the Dutch hunger win- ter of 1944-1945. Archwes of General Psychzatry, 49, 983-988

Szasz, T (1961) The myth of mental ~llness NewYork Harper & Row Taylor, S M., & Dear, M.J. (1980) Scaling community attitudes toward the mentally ill Schzzophre-

nza Bullet~n, 7, 225-240 Torrey, E F, Bowler, A E., & Rawhngs, R (1992) Schlzophrema and the 1957 Influenza epidemic.

Schzzophrema Research, 9, 141 Wahl, O. F (1995) Medza madness Pubhc ~mages of mental *llness New Brunswick, NJ Rutgers Uni-

versity Press Wahl, O, & Harman, C (1989) Family wews of stigma. Schzzophrema Bullet*n, 15, 131-139 Wemer, B, Perry, R E, & Magnuson, J (1988) An attributional analysis of reacuons to sugmas

Journal of Personahty and Soaal Psychology, 55, 738-748 Wyatt, R J (1996) Neurodevelopmentalabnormahuesandschizophrenia.AfamllyaffalrArchwes

of General Psychzatry, 53, 11-31

Address correspondence to Patrick Corngan, University of Chicago Center for Psychiatric Re- habilitation, 7230 Arbor Drive, Tmley Park, IL 60477; 708-614-4770; fax" 708-614-4780, e-mall [email protected] uchlcago edu

RECEIVED May 23, 1998 ACCEPTED: J~tly 15, 1998

Documents

The impact of stigma on severe mental illness