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Stereotypes are one way in which a naive public identifies and describes a stigmatized group, in this case people with mental illness. Mental health professionals use diagnosis and nosology to describe this group. As outlined in systems such as the Diagnostic and Statistical Manual of Mental Disorders (4th ed., or DSM-IV) (American Psychiatric Association [APA], 1994) and the International Statistical Classification of Diseases and Related Health Problems (10th ed.) (World Health Organization, 1992), diagnosis is fundamentally a classification enterprise. (Classification is not the only approach to diagnosis; continuous dimensions, which are discussed more fully later in this article, provide an alternative paradigm that is less prone to the stigma associated with categorization.) Thus, diagnosis assumes that all members of a group are homogeneous and that all groups are distinguished by definable boundaries (APA, 2000). Diagnostic classification serves several goals. It neatly corresponds with a dominant cognitive efficiency used by humans to understand a large amount of information (First, Frances, & Pincus, 1997; Rosch & Mueller, 1978). It provides clinicians with an efficient means for describing their patients that includes not only presentation of symptoms, but also expected course and prognosis. Diagnostic categorization may also suggest the causes of a syndrome as well as specific interventions that may ameliorate the disorder.
Despite these benefits, mental health professionals also recognize pitfalls to diagnosis and categorization (APA, 2000); one of these pitfalls is their impact on stigma. First, the label provided by a diagnosis may act as a cue that signals stereotypes. Second, the criteria that define a diagnosis may augment the stereotypes that describe mental illness. Three processes--groupness, homogeneity, and stability--that influence the cognitive structures of stigma (that is, cues, stereotypes, prejudice, and discrimination) illustrate how diagnosis may exacerbate stigma. They are used here to further illustrate how diagnosis may exacerbate stigma.
Groupness and stereotypes have a bidirectional causal relationship (Crawford, Sherman, & Hamilton, 2002; Yzerbyt, Leyens, & Schadron, 1997; Yzerbyt, Rocher, & Schadron, 1997; Yzerbyt, Schadron, & Leyens, 1997). Stereotypes only make sense in terms of a meaningful group of people; the public fails to regularly recall stereotypes for amorphous classes. Hence, diagnoses that increase the sense of groupness will strengthen the stereotypes associated with mental illness. Conversely, stereotypes are the negative attributes that provide description to the group (Link & Phelan, 2001). Perceptions of groupness do not endure when not associated with attributes that describe them.
Is It the Label or the Bizarre Behavior? Does diagnosis make the stereotypes worse or does it merely highlight meaningful differences from the population that in fact occur because of abnormal psychiatric symptoms? Put another way, is aberrant behavior and not labels per se the source of stigma from the public (Gove, 1982; Clausen & Huffine, 1979)? According to Gove (1975), the label does not elicit negative stigmatizing reactions; rather, negative reactions result from the bizarre behaviors displayed by people with mental illness.
In an effort to resolve differences between labeling theory and actual symptoms, Link (1987) conducted a study in which label and aberrant behavior were independently manipulated in a series of vignettes. Results indicated that members of the general public were likely to stigmatize a person labeled mentally ill even in the absence of any aberrant behavior. Subsequent studies have replicated this finding (Link et al., 1987; Link, Phelan, Bresnahan, Stueve, & Pescosolido, 1999). Link and colleagues (1987,1999) posed a modified labeling theory to make sense of the diverse literature, concluding that psychiatric labels are associated with negative societal reactions that exacerbate the course of the person's disorder. Although the debate over the mechanics of labeling remains unresolved, it seems clear that stigmatization has a negative impact on the lives of people with mental illness (Link & Cullen, 1983; Mechanic, McAlpine, Rosenfield, & Davis, 1994).
Homogeneity of Group Membership
Despite this concern, clinical writings are replete with examples in which people with specific disorders are reduced to caricatures based on their diagnoses. In his classic text on neurotic styles, Shapiro (1965) described diagnoses thusly: Hysterical people, we know, are inclined to a Prince-Charming-will-come-and-everything-will-turn-out-all-right view of life. (p. 118)
In the paranoid person, even more sharply and severely than in the case of the obsessive-compulsive, every aspect and component of normal autonomous functioning appears in rigid, distorted, and in general hypertrophied form. (p. 80)
Narcissists feel justified in their claim for special status, and they have little conception that their behaviors may be objectionable, even irrational. (p. 167)
Most borderlines exhibit a single, dominant outlook or frame of mind, such as a self-ingratiating depressive tone, which gives way periodically, however, to anxious agitation or impulsive outbursts of inappropriate temper or anger. (p. 349)
People in the "dramatic" cluster are rarely capable of empathy. They are often self-centered and prone to temper tantrums. They tend to be irresponsible, impulsive, and remarkably free of remorse. Deceit, superficiality, and arrogance cloud all of their relationships. (from chapter 5, p. 175)
Perhaps most troubling about these kinds of messages are the poor prognoses and limited implications for treatment that often accompany them. In writing further about people with diagnoses in the "dramatic" cluster, Fischler and Booth (1999) said, "They have great power to create confusion, disruption, and violence in the workplace; their presence there is a stick of dynamite waiting for a match" (p. 222). This clearly undermines any attempt to place an individual with this diagnostic label in a work setting. Tying diagnosis to vocational rehabilitation plan in this fashion is especially disconcerting given that research has largely suggested that diagnosis is not predictive of a person's success in working with rehabilitation providers in obtaining employment (Bond et al., 2001).
Stability of Group Descriptors
Research has suggested that stability attributions can be especially troublesome for people with psychiatric diagnoses. Studies have shown that people with psychiatric disorders are viewed by the public as less likely to overcome their disorders than those with physical illnesses (Corrigan et al., 2000; Weiner et al., 1988). This coincides with an especially egregious myth about people with mental illness, especially those with serious psychiatric disorders; namely, that people with mental illness do not recover (Harding & Zahniser, 1994). This kind of myth leads to a general pessimism that can undermine people's sense of self-esteem and self-efficacy, which, in turn, prevents many people with psychiatric disorders from pursuing their life goals (Corrigan, in press).
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