The stigma of mental illness: Explanatory models and methods for change

Applied and Preventive Psychology 11 (2005) 179–190

The stigma of mental illness: Explanatory models and methods for change

Patrick W. Corrigana,∗, Amy Kerrb, Lissa Knudsenc

a Center for Psychiatric Rehabilitation, Evanston Northwestern Healthcare, 1033 University Place,Suite 440-450, Evanston, IL 60201, USA

b Loyola University of Chicago, USAc California State University, Northridge, USA

Abstract

For people with mental illness, diminished quality of life and loss of personal goals does not result solely from the symptoms, distress,and disabilities caused by their psychiatric disorder. Quality of life and personal goals are also hindered by people who embrace the stigmathat accompanies mental illness and mental health care. This paper reviews evidence of the impact of mental illness stigma and strategies forseeking to ease its impact. To achieve these goals, we (a) describe the ways in which stigma harm people with mental illness, (b) summarizemodels that explain the development and maintenance of these stigmatizing effects, and (c) review strategies that have been shown to decreasethe impact of stigma. Concerns about stigma are on the political agendas of many mental health advocacy groups. It has recently also becomet inst data thats©

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he focus of extensive research. Our goal in this paper is to balance the practical concerns raised by mental health advocates agaupport or contradicts specific assertions.2005 Elsevier Ltd. All rights reserved.

eywords: Mental illness; Stigma; Quality of life

. The impact of mental illness stigma

Goffman (1963)adopted the term stigma from the Greeksho used it to represent bodily signs indicating somethingad about the moral character of the person marked with thetigma. This mark can be obvious (such as skin color) orubtle (as in gays or people with mental illness). This kindf moral imputation has egregious affects on at least two

evels, what we have calledpublic stigma and self-stigmaCorrigan & Watson, 2002). Public stigma is the phenomenonf large social groups endorsing stereotypes about and actinggainst a stigmatized group: in this case, people with mental

llness. Self-stigma is the loss of self-esteem and self-efficacyhat occurs when people internalize the public stigma. Theistinction between public and self-stigma is important fornderstanding, explaining, and building strategies to changetigma.

∗ Corresponding author. Tel.: +1 224 364 7200; fax: +1 224 364 7201.

1.1. Public stigma

Public stigma impacts many people beyond those dirstigmatized. Although our review is limited to the impof stigma onpeople with mental illness, research suggespublic stigma impacts other groups as well.Family membersand friends suffer the impact of public stigma (Lefley,1987; Phelan, Bromet, & Link, 1998; Thompson & Doll1982). Mental health provider groups involved in mentahealth services have reported being harmed by pstigma (Dichter, 1992; Dickstein & Hinz, 1992; Fink, 1986;Gabbard & Gabbard, 1992; Persaud, 2000).

The stigma of mental illness can rob people labeled “mtally ill” of important life opportunities that are essentialachieving life goals. Two goals, in particular, are centrathe concerns of most people, including those with sermental illness (Corrigan, in press): (a) obtaining competitivemployment and (b) living independently in a safe and cfortable home. Clearly, housing and work problems can odirectly because of the disabilities that result from meillness (Corrigan, 2001). People with some mental illness

E-mail address: [email protected] (P.W. Corrigan). frequently lack the social and coping skills needed to meet the

962-1849/$ – see front matter © 2005 Elsevier Ltd. All rights reserved.oi:10.1016/j.appsy.2005.07.001

180 P.W. Corrigan et al. / Applied and Preventive Psychology 11 (2005) 179–190

demands of a competitive work force and independent living.Nevertheless, the problems of many people with psychiatricdisability are further hampered by stigma. Several studieshave documented the public’s widespread endorsementof stigmatizing attitudes. In a survey administered to twotowns, one served by community psychiatry and the otherserved by a traditional mental hospital,Brockington, Hall,and Levings (1993)found that three primary factors arose inattitudes toward people with mental illnesses: benevolence,authoritarianism, and fear. Between the two towns, peoplefrom the one served by the traditional mental hospital wereslightly more tolerant than people from the town served bycommunity psychiatry (1993). Other research has foundsimilar stigmatizing results (Bhugra, 1989; Hamre, Dahl, &Malt, 1994; Link, 1987; Madianos, Madianou, Vlachoniko-lis, & Stefanis, 1987; Rabkin, 1974; Roman & Floyd, 1981).These attitudes have a deleterious impact on obtainingand keeping good jobs (Bordieri & Drehmer, 1986; Farina& Felner, 1973; Farina, Felner, & Boudreau, 1973; Link,1982; Link, 1987; Olshansky, Grob, & Ekdahl, 1960; Wahl,1999; Webber & Orcutt, 1984) and leasing safe housing(Aviram & Segal, 1973; Farina, Thaw, Lovern, & Mangone,1974; Hogan, 1985a, 1985b; Page, 1977, 1983, 1995; Segal,Baumohl, & Moyles, 1980; Wahl, 1999). Classic researchby Farina (Farina & Felner, 1973) provides an example ofthe employment problem. A male confederate, posing asa . Thes iewse bouta lysesf rtiveo atrich

rka nessw za-t essa f them ealths utedt jail( hmP e,1i oplew s ing treat-mCp riousm d byt on ist pendm ness( e

with mental illness like criminals has implications not onlyfor their life, liberty, and well being, but also for the largercommunity such as loss of potential contributions by viablecitizens.

Finally, research seems to indicate that people withmental illness are less likely to benefit from the Americanhealth care system than people without these illnesses.Research by Druss and colleagues suggests that peoplewith mental illness receive fewer medical services thanthose not labeled in this manner (Desai, Rosenheck, Druss,& Perlin, 2002; Druss & Rosenheck, 1997). Moreover,studies suggest people with mental illness are less likelyto receive the same range of insurance benefits as peoplewithout mental illness (Druss, Allen, & Bruce, 1998; Druss& Rosenheck, 1998). Previous research has used rates ofprocedures for cardiovascular disorders as an index of biasby race (Ayanian, Udvarhelyi, Gatsonis, Pashos, & Epstein,1993; Wenneker & Epstein, 1989) and gender (Ayanian &Epstein, 1991; Krumholz, Douglas, Lauer, & Pasternak,1992). Druss, Bradford, Rosenheck, Radford, and Krumholz(2000)examined the likelihood of a range of medical pro-cedures after myocardial infarction in a sample of 113,653.Compared to the remainder of the sample, Druss et al. foundthat people with comorbid psychiatric disorder were sig-nificantly less likely to undergo percutaneous transluminalcoronary angioplasty (PTCA), also known as coronary arteryb atica n,2

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area ness.U son’ss con-s ichl hese“ ents( tali t andb f theird e nete& -g es ofs veryL d per-c s att Afterc oms,d owedt 90thp thant per-c field

n unemployed worker, sought jobs at 32 businessesame work history was reported at each of the job intervxcept 50% of confederates also included information a

past psychiatric hospitalization. Subsequent anaound interviewers were less friendly and less suppof hiring the confederate when he added his psychiospitalization.

Apart from its role in the universal concerns of wond housing, stigma also impacts people with mental illho interact with the criminal justice system. Criminali

ion of mental illness occurs when people with mental illnre dealt with by the police, courts and jails, instead oental health system. Inadequate funding for mental h

ervices and “get tough” on crime policies have contribo the increasing proportion of serious mental illness inWatson, Corrigan, & Ottati, 2004). Public fear of people witental illness has increased over the past 40 years (Martin,escosolido, & Tuch, 2000; Phelan, Link, Moore, & Stuev997; Phelan, Link, Stueve, & Pescosolido, 2000), resulting

n a higher degree of preferred social distance from peith mental illness. The growing intolerance of offendereneral has led to harsher laws and hampered effectiveent planning for mentally ill offenders (Jemelka, Trupin, &hiles, 1989; Lamb & Weinberger, 1998). As Teplin (1984)oints out, people exhibiting symptoms and signs of seental illness are more likely than others to be arreste

he police. The selective process continues if the persaken to jail. Someone with a mental illness tends to sore time incarcerated than people without mental ill

Steadman, McCarty, & Morrissey, 1989). Treating peopl

alloon dilation. PTCA is a less expensive, less traumlternative to bypass surgery (American Heart Associatio004).

.2. Impact of stigma on the self

Prior to the onset of mental illness, most peopleware of culturally endorsed stereotypes about mental illpon diagnosis, awareness of stigma may affect a perense of self in at least two ways. First, people maytrict their social networks in anticipation of rejection, wheads to isolation, unemployment and lowered income. Tfailures” result in self-esteem and self-efficacy decremLink, 1987; Markowitz, 1998). Second, people with menllness may consider such stigmatizing ideas self-relevanelieve that they themselves are less valuable because oisorder in the same way they are described by others. Thffect of these processes we define as self-stigma (CorriganWatson, 2002; Crocker & Major, 1989). Research sug

ests that both perceived- and self-stigma result in losself-esteem and self-efficacy and limit prospects for recoink and colleagues (1980) assessed self-esteem aneived stigma in 70 people with serious mental illneshree time points: baseline and 6 and 24 months (2001).ontrolling for baseline self-esteem, depressive symptiagnosis, and demographic characteristics, results sh

hat those with high perceptions of perceived stigma (ercentile) were more likely to have low self-esteem

hose with low perceptions of perceived stigma (10thentile). These findings along with other research in the

P.W. Corrigan et al. / Applied and Preventive Psychology 11 (2005) 179–190 181

suggest that stigma perceived by people with mental illnessharms their self-esteem (Corrigan, 1998; Holmes & River,1998; Link, 1987; Link, Cullen, Struening, & Shrout, 1989;Link, Mirotznik, & Cullen, 1991; Markowitz, 1998; Perlicket al., 2001; Rosenfield, 1997; Sirey et al., 2001).

Of course not everyone with a mental illness suffers aloss of self-esteem due to stigma (Crocker & Major, 1989).Research has found that people with mental illness whilebeing aware of the negative stereotypes endorsed by thepublic do not experience a sharp decline in self-esteem(Hayward & Bright, 1997). Elsewhere, we detail a modelof personal reactions to stigma in which people may: (1)self-stigmatize and suffer a loss of self-esteem, (2) remainrelatively indifferent to stigma, or (3) become empowered bystigma and advocate on behalf of themselves and others withmental illness (Corrigan & Watson, 2002). Among variousfactors, research suggests people who strongly identify witha stigmatized group – i.e., opt to strongly relate with con-sumer and survivor groups – are less likely to fall victim toself-stigma.

2. Models of mental illness stigma

Most current models that explain the phenomenon ofmental illness stigma have emerged from basic behav-i intot ermso nalm icalm andd h oft

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nowt resa scribeh aineda e upt e,aa berso 4E1J anso ypesa tivelya are“ ionsa ypedg nf ounto ,

1993). Common stereotypes about mental illness includedangerousness, incompetence, and character weakness.

Just because most people have knowledge of a set ofstereotypes does not require that they agree with them(Jussim, Nelson, Manis, & Soffin, 1995). People who areprejudiced endorse these negative stereotypes (“that’s right;all people with mental illness are violent!”) and generatenegative emotional reactions as a result (“they all scare me!”)(Devine, 1988, 1989, 1995; Hilton & von Hippel, 1996;Krueger, 1996). In contrast to stereotypes, prejudicial atti-tudes involve agreement with an evaluative (generally neg-ative) component (Allport, 1954; Eagly & Chaiken, 1993).

Prejudice, which is fundamentally a cognitive andaffective response, may or may not lead todiscrimination,the behavioral reaction (Crocker, Major, & Steele, 1998).Prejudice that yields anger can lead to hostile discrimina-tory behavior (e.g., physically harming a minority group)(Weiner, 1995). Angry prejudice may lead to withholdingmental health care or replacing mental health care withservices provided by the criminal justice system (Corrigan,2000). Fear may also lead to discriminatory avoidance, e.g.,employers do not want people with mental illness nearbyso they do not hire them. As outlined inFig. 1, stereotype,prejudice, and discrimination manifest differently dependingon whether the public is considering stigma or the self.

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ofa rgest ion-a aten

oral science. Explanatory models can be dividedhree general groups: those that explain stigma in tf naturally occurring cognitive structures; motivatioodels that explain why people stigmatize; sociologodels that ground some of the experiences of stigmaiscrimination in social institutions and structures. Eac

hese is described more fully in turn.

.1. Individual cognitive models

Psychologists argue that the way humans come to khe world is bound by the limits of their cognitive structund processes. For example, social cognitive models deow stigma-related processes are formed and maintt the psychological level. Three components that mak

his model are outlined inFig. 1: stereotypes, prejudicnd discrimination. Social psychologists viewstereotypess knowledge structures that are learned by most memf a social group (Augoustinos, Ahrens, & Innes, 199;sses, Haddock, & Zanna, 1994; Hilton & von Hippel,996; Judd & Park, 1993; Krueger, 1996; Mullen, Rozell, &ohnson, 1996). Stereotypes are especially efficient mef categorizing information about social groups. Stereotre considered “social” because they represent collecgreed upon notions about groups of people. Theyefficient” because people can quickly generate impressnd expectations of people who belong to a stereotroup (Hamilton & Sherman, 1994). The categorizatio

unctions as a method for people to organize the vast amf stimulus encountered in everyday life (Eagly & Chaiken

.1.1. Motivational modelsMotivational theories seek to explain why people stig

ize, or the function that stigma serves for the stigmathree such motivations have emerged in the literature:

ustification, group-justification, and system-justificatJost & Banaji, 1994). Psychoanalysts were amongrst to write about ego-justification, suggesting thatelf is protected when internal conflicts are projected otigmatized groups (Bettelheim & Janowitz, 1964; Freud946). In this way, stigma serves to shield self-este

rom the effects of personal failings. Social psychologxpanded the ego-justification idea beyond personal deechanisms to include any function that protects id

mages, or behaviors that reflect the self by projecting tegative conceptualizations and actions on others (KatzBraly, 1935). Little empirical evidence has been fou

o support ego-justification as an explanation of stigesearch has, however, provided support for stigmatereotypes serving a self-protective function that doeave psychodynamic origins. This research suggests

he function of stigma may be to avoid potential thro one’s body or psychological self possibly throughotivation to avoid danger of a socially perceived thr by rationalizing negative group-based attitudes andrimination (Biernat & Dovidio, 2000; Stangor & Crandal000).

Group-justification models purport that stigmatizationn out-group, such as those with mental illness, eme

o support the goals of the in-group. From an evolutry perspective, stigmatizing out-groups who may thre


Fig. 1. Cognitive levels that explain the distinction between public stigma and self-stigma.

the effective functioning of the in-group is highly adaptivefor group survival and gene transmission (Neuberg, Smith,& Asher, 2000). Stigmatizing out-groups enhances groupcohesion, protects against contamination, and helps mem-bers avoid poor social exchange partners (Kurzban & Leary,2001). Using group-justification as an explanation for men-tal illness stigma is a bit problematic, however. What exactlyis the in-group against which people with mental illness arecontrasted? The “normal” in-group is a default category thatonly gains definition in the absence of mental illness. Hence,there is no readily apparent source of in-group motivation todrive group-justification.

Jost and Banaji (1994), Jost, Kruglanski, and Simon(1999)andStangor and Jost (1997)have identified an evenbroader (beyond the self or group) target for justification,arguing that stereotypes and prejudice develop to “confirmthe system.” Once a set of events produces specific socialrelationships, whether by historical accident, biologicalderivation, public policy, or individual intention, the result-ing arrangements are explained and justified simply becausethey exist. For example, the stereotype that people withmental illness are violent and need to be controlled mayhave arisen from, and to justify, the establishment andmaintenance of institutions that suggest people labeledwith mental illness need to be controlled via state hospitalsand prisons. Although system justification helps people tom ups,i thes

2.2. Institutional and structural models

Focusing on the individual psychological level ofexplanation in terms of cognition and motivation gives anincomplete picture of the problem of stigma. Stigma anddiscrimination may also be understood at societal levels interms of the historical, political, and economic forces thatinfluence institutions and social groups. For example, in bet-ter understanding racism in America, civil rights activists(Carmichael & Hamilton, 1967; US Commission on CivilRights, 1981) and sociologists (Friedman, 1975; Hill, 1988;Merton, 1948; Pincus, 1999, 1996; Wilson, 1990) realizedthat discrimination impacts people of color in ways notexplained by the direct effects of other people’s bigotedbehavior. Activists and sociologists made the distinctionbetween these individual-levels of impact and bothinstitu-tional andstructural causes of prejudice and discrimination.Institutional discrimination manifests itself as rules, policies,and procedures of private and public entities in positionsof power that intentionally restrict the rights and opportu-nities of people with color. Jim Crow Laws were exam-ples of public institutional discrimination. Mississippi, forexample, passed legislation that required separate schoolsfor whites and “colored people.” Extending from the endof the nineteenth to the middle of the twentieth century,these laws largely enacted by Southern States explicitlyu itala oda-t

ake cognitive sense of current differences among grot does not offer any explanation of the origins ofystem.

ndermined the rights of African Americans in such vreas as employment, education, and public accomm

ion.


The effects of institutional discrimination are by definitionintentional, perhaps not by the line-level person carrying outthe policy, but by a small group of powerful people at thetop of an institution who explicitly sought to diminish theopportunities of racial or ethnic groups by passing laws or reg-ulations (Hill, 1988; Mayhew, 1968; Pincus, 1999). Hence,one might conclude that institutional discrimination is thedirect result of the stigmatizing behaviors and attitudes of afew powerful people. There is a separate set of public and pri-vate sector policies – what is called structural discrimination– whoseunintended consequences restrict the opportunitiesof members of minority groups (Feagin, 1978; Hill, 1988).For example, many universities and colleges use the SAT orACT to restrict admission offers to students who have earnedthe highest scores (Pincus, 1999). Given that African Amer-ican and Hispanic students typically score lower on thesetests, universities that rely on test scores for admissions arelikely to prevent an unequal number of Black and Hispanicstudents from being educated at these institutions. Note thatin this example, people at the top of the organization did notintend to restrict the prospects available to people of color.College presidents are typically people who seek to bettertheir community by advancing principles related to socialjustice. Nevertheless, the results of these kinds of policieslimit the possibilities for people because of their ethnicgroup and the economic and historical forces that havef

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and its effect. For example, the Court has refused to declareschool segregation unlawful unless direct evidence ofdiscriminatory intent on the part of the school district couldbe found, regardless of segregation’s effect on minoritychildren (Graglia, 1980; Hill, 1988).

According to a structural view, group-neutral goals arefrequently not accomplished because they seem to clashwith dominant ideologies that unintentionally maintain theunequal status quo (Hill, 1988; Jackman & Muha, 1984).Two dominant viewpoints are a democratic belief inmeri-tocracy and a capitalist value incost-effectiveness (Pincus,1999). Note that although they are not malicious in intent,both ideologies yield unintended negative consequences.Meritocracy, for example, is the value that drives standard-ized test scores; i.e., decisions about college admissions,and the opportunities that those decisions entail, should bebased on the candidate’s intellectual merit (e.g., abilities andachievements). Societal concerns about cost-effectiveness,and decisions representing good business, also seem to yieldstructural discrimination and may be especially relevant tomental illness.Link and Phelan (2001)expound upon thebusiness value in listing examples of structural discrimi-nation related to mental illness. Less money is allocatedto research and treatment on psychiatric illness than otherhealth disorders because illnesses like cancer and heartdisease have dominated the American public health agenda.M nalso mosts alariesa morel entd lemss alityo rs isi

i.e.,i thosep nente rongo romt ernsf im-i arityr isingh ds turald cialr dicali plew m tor r thep iticala s, asd tf ialc tural

orged that group’s place in society (Merton, 1948, 1957).

.2.1. Institutional discrimination and mental illnessAccording toLink and Phelan (2001), there is evidenc

f institutional discrimination against people labeled wental illness in both public and private sectors. A g

xample from the public sector is legislative activity testricts the rights and opportunities of people with mellness. Results of two comprehensive reviews of lawstate showed that approximately one-third restrict the rf an individual with mental illness to hold elective offiarticipate in juries, and vote (Burton, 1990; Hemmensiller, Burton, & Milner, 2002). Even greater limitationere evident in the family domain. More than 40% of st

imit the rights of people with mental illness to remarried. Depending on the year of the survey, from 40% of states limited the child custody rights of parentsental illness (Hemmens et al., 2002).

.2.2. Structural discrimination and mental illnessInstitutional discrimination is marked by an expli

nd conscious attempt to distinguish between groupsithhold from the stigmatized subset some rightsrivileges. Structural discrimination is based more on e

han intent, and hence it is much more difficult to dePincus, 1996, 1999). Examples from the US Supreme Coighlight the distinctions between structural and institutioiscrimination. In determining whether state or federal lere unconstitutional because they promoted segregustices frequently distinguished betweenthe law’s intent

any psychiatrists and other mental health professiopt out of the treatment system serving people with theerious psychiatric and substance abuse disorders. Snd benefits are better in the private health sector that is

ikely to treat relatively benign illnesses like adjustmisorders, relational problems, and phase of life probo providers opt for those kinds of jobs. Hence, the quf services for people with more serious mental disorde

nferior to many other less serious conditions.Problems with mental health insurance parity (

nsurance benefits for mental health problems equalingrovided for general health) are an especially promixample of structural stigma related to mental illness. Stpposition to mental health parity legislation was heard f

he business community, citing the kind of cost concrequently used to justify other forms of structural discrnations. Lobbyists for the business sector argued that pequirements could bankrupt small businesses by raealth care costs (Levinson & Druss, 2000). The history anubsequent impact of parity reveals key elements of struciscrimination. First, the resulting act leads to fewer finanesources for psychiatric disorders, compared to mellness, thereby yielding diminished opportunity for peoith mental illness. Second, this disparity does not see

eflect conscious prejudice on the part of Congress oublic. Most members of both houses, regardless of polffiliation, support equal care for mental health disorderoes the American public (Hanson, 1998). Lack of suppor

or many of the provisions of parity stems from financoncerns that are frequently at the root of other struc


discriminations: parity makes for bad business. The seem-ingly contradictory tension between wanting to supporttreatment equity but not wanting to make a bad business moveis evident in public attitude. One review found that partici-pants of national surveys on parity supported equal resourcesfor mental health and medical diagnoses, on the one hand,but, on the other hand, did not support paying higher premi-ums or redistributing funds from medical/surgical servicesto mental health services to accomplish this goal (Hanson,1998).

3. Changing stigma

Given that processes giving rise to and producing differ-ential effects of stigma vary by level of analysis, it seemsreasonable to suggest that stigma change methods vary byconceptual level. Hence, we summarize the stigma-changeliterature in terms of its impact on public stigma, self-stigma,or institutions and structures that maintain stigma.

3.1. Erasing public stigma

In recent years, advocacy groups have made reducingstigma a priority, implementing campaigns aimed at thepublic and the media. These efforts have targeted variousc ies,f cialp roups ss oft& pedt threep ,1

rmso andb t cance entr d,”w s andu thes BC,t sorsi om-p e as ap reas-i hep evantf byt ingA ingc tigmaa withm yers

who hire and provide reasonable accommodations to peoplewith psychiatric disabilities.

Although organized protest can be a useful tool forconvincing television networks to stop running stigmatizingprograms, protest may produce an unintended “rebound”effect in which prejudices about a group remain unchangedor actually become worse. Protest programs asking peopleto suppress their prejudice about a group can promotepsychological reactance (do not tell me what to think)and worsen attitudes as a result (Corrigan et al., 2001;Macrae, Bodenhausen, Milne, & Jetten, 1994; Penn &Corrigan, 2002). Hence, while protest may be a useful toolfor changing thebehavior, it may have little or negativeimpact on public attitudes about people with mental illness.

Educational approaches to stigma change attempt tochallenge inaccurate stereotypes about mental illness andreplace these stereotypes with factual information. Evidenceabout educational strategies targeting race and other minor-ity group stereotypes is mixed and suggests that effects ofeducational interventions may be limited (Devine, 1995;Pruegger & Rogers, 1994). Educational strategies aimedat reducing mental illness stigma have used public serviceannouncements, books, flyers, movies, videos, and otheraudio visual aids to dispel myths about mental illness andreplace them with facts (Bookbinder, 1978; National MentalHealth Campaign, 2002; Pate, 1988; Smith, 1990). Someb andb ughe udes( ,1 ,K ,Cp se ons Sub-j ge ofm aire.R pre-e ess.T roma se.

con-t longb roupp ls ntali ta essp , edu-c ntacta s andp altha na witha ypes(

omponents of mental stigma with a variety of strategew of which have been formally evaluated. However, sosychological research on ethnic minority and other gtereotypes provides important insight on the effectivenehese strategies for reducing mental illness stigma (Corrigan

Penn, 1999). Based on this literature, we have grouhe various approaches to changing public stigma intorocesses: protest, education, and contact (Corrigan & Penn999).

Protest strategies highlight the injustices of various fof stigma chastising the offenders for their attitudesehaviors. Anecdotal evidence suggests that proteshange somebehaviors significantly (Wahl, 1995). Forxample, in 2000 NAMI StigmaBusters played a prominole in getting ABC to cancel the program “Wonderlanhich portrayed people with mental illness as dangerounpredictable. StigmaBusters’ efforts not only targetedhow’s producers and several management levels of Ahey encouraged communication with commercial sponncluding the CEOs of Mitsubishi, Sears, and the Scott Cany. Hence, research might show protest to be effectivunishing consequence to discriminatory behavior dec

ng the likelihood that people will repeat this behavior. Tunishing consequences of protest are especially rel

or examining the effects of legal penalties prescribedhe Americans with Disabilities Act and the Fair Housct. In like manner, research might identify reinforconsequences to affirmative actions that undermine snd encourage more public opportunities for peopleental illness, e.g., government tax credits for emplo

enefits of educational interventions include lower costroad reach. It is important to note, however, that thoducation produces short-term improvements in attitCorrigan et al., 2001, 2002; Keane, 1991; Morrison & Teta980; Penn, Guynan, Daily, & Spaulding, 1994; Pennommana, Mansfield, & Link, 1999); In a study byHolmesorrigan, Williams, Canar, and Kubiak (1999), for exam-le, participants either took either a semester-long courerious mental illness or a general psychology course.ects were administered a pre- and post-test on knowled

ental illness and opinions of mental illness questionnesults showed that the education group interacted withducation depending on the attitude about mental illnhose with greater prejudice were less likely to benefit fn education group like the semester long, stigma cour

The third strategy for reducing stigma is interpersonalact with members of the stigmatized group. Contact haseen considered an effective means for reducing intergrejudice (Allport, 1954; Pettigrew & Tropp, 2000). Severatudies specifically focusing on contact’s effect on mellness stigma have produced promising findings.Corrigan el. (2001)found that contact with a person with mental illnroduced greater improvements in attitudes than protestation, and control conditions. In a subsequent study, cogain produced the greatest improvements in attitudearticipant willingness to donate money to a mental hedvocacy group (Corrigan et al., 2002). Improvements ittitudes seem to be most pronounced when contact isperson who moderately disconfirms prevailing stereot

Reinke, Corrigan, Leonhard, Lundin, & Kubiak, 2004).


Table 1Understanding targets of anti-stigma programs

Targets Discriminatory behavior Corresponding attitudes Social context Change strategies

Landlords Fail to leaseNo reasonable accommodation

Employers Fail to hire Dangerousness Economy ADANo reasonable accommodation Incompetence Hiring pool Erasing the stigma

Health care providers Withhold some servicesUnnecessarily coercive treatment

Criminal justice professionals Unnecessarily coerciveFail to use mental health services

Policy makers Insufficient resource allocationUnfriendly interpretation of regulations

The media Perpetuation and dissemination of stigmatizing images

3.1.1. Targeted stigma changeAnti-stigma programs are more successful when they

target specific groups of people instead of the general public.“Target” has a double meaning here. It is first defined interms of specific social groups who are powerful vis-a-vispeople with mental illness. Examples of these groupsare listed in the first column ofTable 1. Power is basedon functional relationships (Fiske, 1993); the groups inTable 1are frequently in positions of control and authorityrelative to people with mental illness. In particular, they canexercise discriminatory behavioral options that curtail thelife opportunities of people with mental illness. These arethe second set of targets for anti-stigma programs, which arehighlighted inTable 1as specific discriminatory behaviors.Table 1is meant to be an example of the elements in targetedstigma change. As an example,Table 1illustrates parts ofthe table: targets, discriminatory behavior, correspondingattitudes, social context, and change strategies. The tableis not to be a comprehensive treatment of targeted stigma.Let us more fully consider how certain power groups mayspecifically harm people with mental illness.

By virtue of their social position, landlords and employersare in the position to influence two important life goalsfor people with mental illness: living independently andobtaining good jobs (Corrigan et al., 2002). Landlords andemployers who believe stereotypes about mental illness mayr fraido ertyt ;S ep tentw ,1 ,1 tog diciaa werg itieso es?D rted“ r).

This kind of convergence between discriminatory behav-ior and attitude change strategies echoes what is generallyknown about attitude change in basic behavioral research,namely, behaviors are more likely to change when strategiestarget attitudes that correspond with the behavior (Ajzen &Fishbein, 1977; Cacioppo, Petty, Feinstein, Jarvis, & Blair,1996). Correspondence is a function of several elementsincluding participating actors and the context in whicha specific event is likely to occur. Hence, changing theprejudice and discrimination of mental illness is likely to bemore successful when specific power groups are targeted inthe settings in which they might discriminate.

Consider some of the other important targets for stigmachange listed inTable 1. Health care providers and admin-istrators may endorse stigma about mental illness. Asa result, general medical providers may fail to providenecessary treatments that would otherwise be prescribed topeople (Felker, Yazel, & Short, 1996). As discussed earlier,research has shown that people with mental illness are lesslikely to receive appropriate cardiovascular procedures aftermyocardial infarct compared to a demographically matchedgroup that is not labeled mentally ill (Druss et al., 2000;Druss, Bradford, Rosenheck, Radford, & Krumholz, 2001).Alternatively, mental health providers may endorse coerciveor other mandatory treatments (e.g., being committed toa psychiatric hospital) when the person’s current profileo arew maya &L ce,m tallyi ssr erst

vantt roups ntalh dingh cadee

espond in a discriminatory manner. Landlords may be af people with mental illness and decide not to rent prop

o them (Farina et al., 1974; Hogan, 1985; Page, 1995egal et al., 1980; Wahl, 1999). Employers might believeople with mental illness are incapable of compeork, and therefore, not hire them (Bordieri & Drehmer986; Farina & Felner, 1973; Farina et al., 1973; Link982, 1987; Wahl, 1999). Hence, stigma programs needenerate change strategies that target the specific prejuttitudes and discriminatory behaviors of these two poroups to advance the empowerment and life opportunf people with mental illness. (“behaviors” or attitudiscrimination cannot be an attititude can it? I inse

prejudicial attitudes and” before discriminatory behavio

l

f needs fails to show these kinds of interventionsarranted. Several levels of the criminal justice systemlso be impacted by stigma (Watson, Hanrahan, Luchins,urigio, 2001). Police, overestimating the risk of violenay respond with undue force to people labeled “men

ll.” The judiciary, holding people with mental illneesponsible for their symptoms, may fail to divert offendo appropriate services in the mental health system.

Two sets of discriminatory behaviors seem to be releo legislators and policy makers. First, members of this geem to be unwilling to allocate sufficient resources to meealth services. This is evidenced by 1990s levels of funaving dropped more than 8% from the preceding deven though service needs did not change (Willis, Willis,


& Male, 1998). Also, legislators have been unwilling topass a parity bill that equalizes insurance benefits for mentaland physical health (Gitterman, Strum, Pacula, & Sceffler,2001). Second, policy makers and legislators seem unwillingto interpret existing legislation in a manner that is friendly tomental health. Note that it took more than 5 years for the EqualEmployment Opportunity Commission to issue an interpre-tation of the Americans with Disabilities Act (ADA) that issensitive to the needs of people with psychiatric disabilities.

Two additional elements inTable 1influence the relation-ship between discriminatory behavior and change strategies:corresponding attitudes and social context. As an example,consider the relevance of these factors to the possible set ofdiscriminatory behaviors of employers. According to a socialcognitive perspective, stigmatizing attitudes precede discrim-inatory behaviors (Corrigan, 2000). Path analytic research hasshown that believing people with mental illness are danger-ous leads to socially avoidant behavior, such as unwillingnessto work alongside of people labeled mentally ill (Corrigan etal., 2002). Perceived incompetence may be an additional atti-tude that will influence discriminatory behaviors. This is thebelief that people with mental illness are not able to workeffectively so employers may refuse to hire them or to pro-vide reasonable accommodations when they do.

The context in which targets behave may also influencethe form of discriminatory behaviors (Liska, 1990; Newman,2 iche oplew oingt fromp ablep ed”n fe endo thej f thec ess”o allyd ot beu ces,a gma.

3

ssp ty,c erala tiver one’ss nts int mayb entso ly asa ownt thec and

the consequences of self-stigma (Chadwick & Lowe, 1990;Drury, Birchwood, Cochrane, & MacMillan, 1996; Kuiperset al., 1997; Tarrier, Beckett, Harwood, & Baker, 1993).Kingdon and Turkington (1991)specifically used a cognitivebehavioral approach to help people reframe stigma as a nor-mal event. While this study was not a randomized-controlledtrial, the interventions were well received by consumers andseemed to lead to greater illness acceptance. Subsequentstudies have more carefully examined the impact of similarcognitive therapies on psychotic symptoms, self-statements,and service utilization (Beck & Rector, 2000; Gould, Mueser,Bolton, Mays, & Goff, 2001; Turkington & Kingdon, 2000).

Another approach to changing self-stigma is facilitatingpersonal empowerment, which has been argued as the oppo-site of self-stigma. Being empowered means having controlover one’s treatment and one’s life (Rappaport, 1987).People who have a strong sense of personal empowermentcan be expected to have high self-efficacy and self-esteem.Communities and health service providers can fosterpersonal empowerment among mental health consumers bygiving consumers greater control over their own treatmentand reintegration into the community. Empowering servicesinvolve the consumer as a partner in treatment planningand promote the self-determination of consumers in relationto employment opportunities, housing, and other areasof social life. Research findings indicate that programst ofi onala &LR

andb ams( edc rvices utuala NewY enttd is orh lopings ctiv-i ent,h reaset anys

3

d toi ual-l cientf gelycE itedi d by

001). In particular, the social-economic context in whmployers operate may affect the likelihood of hiring peith mental illness beyond the stereotypes of those d

he hiring. Some studies suggest that people dischargedsychiatric hospitals often find employment in less desirarts of cities, sometimes called “socially disorganizeighborhoods (Silver, 1999, 2000). The likelihood omployers hiring people with mental illness may depn the economic context of the neighborhood in which

ob site is located. Employers in more desirable parts oity may conform to norms regarding the “appropriatenf employees. However, employers in more economicisadvantaged and less desirable parts of the city may nnder community pressure to restrict their hiring practind therefore, less likely to be as greatly influenced by sti

.2. Coping with self-stigma

While the responsibility for eliminating mental illneublic stigma rightfully falls on the shoulders of sociehange will be slow. In the meantime, there are sevpproaches to diminish self-stigma including cognieframe of stigmatizing self-statements and enhancingense of personal empowerment. Recent developmehe area of cognitive therapy suggest that self-stigmae understood as resulting from maladaptive self-statemr cognitive schemata of mental illness developed largeresult of socialization. Cognitive therapy has been sh

o be an effective strategy for helping people changeognitive schemata that lead to anxiety, depression,

hat include the person with disabilities in all facetsntervention are conducive to the attainment of vocatind independent living goals (Corrigan, Faber, Rashid,eary, 1999; Corrigan & Garman, 1997; Rappaport, 1990;ogers, Chamberlin, Ellison, & Crean, 1997).Many consumers have empowered themselves

ecome staff members of traditional treatment progrMowbray et al., 1997), while others have developonsumer-operated alternatives to the traditional seystem, such as lodges, clubhouses, and self-help/mssistance groups. The Fountain House clubhouse inork is a paradigmatic example of consumer empowerm

hrough mutual help (Corrigan & Calabrese, in press). Itestigmatized the recovering person by focusing on her strengths rather than weaknesses, and by deveocial competence through involvement in the very aties that constitute community integration (employmousing, education, etc.). Services like these greatly inc

he consumer’s sense of power, thereby challengingelf-stigma with which they might be struggling.

.3. Changing structures and institutions

Social scientists who have developed ideas relatenstitutional and structural factors conclude that individevel strategies for stigma change are probably not suffior remediating prejudice and discrimination that are laraused by collective variables (Hill, 1988; Pincus, 1999).ducation of key power groups might have some lim

mpact on the kinds of intentional biases represente


institutional discrimination. For example, one way to dimin-ish legislative actions that unjustly restrict the opportunitiesof people with mental illness is to educate House andSenate members about how their actions are impingingon an important part of their constituency. More difficult,however, is altering the course of structural discrimination.Because its impact is unintentional, educational and otherindividual-level strategies should have no effect on structuralfactors. Instead, various social change strategies that fallunder the rubric of affirmative action may be relevant forstopping the harm caused by structural discrimination.

Affirmative actions are a collection of government-approved activities, which are meant to redress the disparitiesthat have arisen from historical trends in prejudice and dis-crimination. According to affirmative models, membership ina stigmatized group is added to considerations of an individ-ual’s skills and achievements for access to specific limitedopportunities. The American with Disabilities Act seemsto be a Federal Policy that mirrors affirmative goals. ADAclauses that prohibit discrimination by employers becauseof a person’s psychiatric disability are effective for barringindividual and institutional levels of discrimination. It is theADA clause on reasonable accommodation, however, that isan affirmative action, which decreases structural discrimina-tion. Reasonable accommodations are changes to the workenvironment that assist the person in working. Reasonablea s ane to theF ablea s int ededt l dis-c

4

eves son-a hatr aperw alsoh ess:s sti-t mesm wayst indo tand-i

R

A eti-

Allport, G. (1954).The nature of prejudice. Oxford, England: Addison-Wesley.

American Heart Association (2004). Angioplasty, percutaneous trans-luminal coronary (PTCA). Retreived October 12, 2004 fromhttp://www.americanheart.org/presenter.jhtml?identifier=4454.

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Aviram, U., & Segal, S. P. (1973). Exclusion of the mentally ill: Reflectionon an old problem in a new context.Archives of General Psychiatry,29, 126–131.

Ayanian, J. Z., & Epstein, A. M. (1991). Differences in the useof procedures between women and men hospitalized for coro-nary heart disease.New England Journal of Medicine, 325, 221–225.

Ayanian, J. Z., Udvarhelyi, I. S., Gatsonis, C. A., Pashos, C. L., & Epstein,A. M. (1993). Racial differences in the use of revascularization pro-cedures after coronary angiography.Journal of the American MedicalAssociation, 269, 2642–2646.

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Biernat, M., & Dovidio, J. F. (2000). Stigma and stereotypes. In T. F.Heatherton, R. Kleck, M. Hebl, & J. Hull (Eds.),The social psychol-ogy of stigma (pp. 88–125). New York: Guilford Press.

Bookbinder, S. R. (1978).Mainstreaming—what every child needs toknow about disabilities. Providence, RI: Rhode Island Easter Seal

B led

B tol-

B notected

C , G.and

C

C n of

C ness.

C pli-

C digm

C cting

C inski,

C nitive

ccommodation gives people with psychiatric disabilitiedge towards keeping their job. The 1988 amendmentsair Housing Act provide similar guarantees to reasonccommodations for people with psychiatric disabilitie

he housing sector. Affirmative actions like these are neo offset the injustices that continue because of structurarimination against people with mental illness.

. Final thoughts

Psychiatric disability is defined as an inability to achiignificant life goals – e.g., a vocation that yields a reable income and living in a home with one’s family – tesults from serious mental illness. Our thesis in this pas that achievement of life opportunities like these isampered by public and personal reaction to mental illntigma. We summarized cognitive, motivational, and inutional/structural models that explain from whence coental illness stigma. We used these models to describe

o diminish stigma at the public and self-levels. With this kf information, researchers can join advocates in unders

ng and diminishing this major barrier to a quality life.

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The stigma of mental illness: Explanatory models and methods for change