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Schizophrenia: Practical Strategies for Relapses & Reducing Symptoms
10 CEUs Schizophrenia: Practical Strategies for Relapses & Reducing Symptoms

Section 23
Cognitive Behavioral Therapy for Schizophrenia

Question 23 | Answer Booklet | Table of Contents | Schizophrenia CEU Courses
Social Worker CEU, Psychologist CE, Counselor CEU, & MFT CEU

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. AsTherapy Schizophrenia Practical Strategies psychology continuing education 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.

Perceived Groupness
Groupness, or entitativity, is the degree to which a collection of people is perceived as a unified or meaningful entity (Campbell, 1958; Hamilton & Sherman, 1996). Groups have a sense of differentness from the population, based on a salient and socially important characteristic. Eye color and foot size are generally not qualities that lead to meaningful groups, whereas skin color and bizarre behavior are. Diagnosis adds to the salience of groupness for the collection of people with mental illness (Link & Phelan, 2001). It distinguishes people who are somehow different in terms of their psychiatric status from the general population. Note that the collection of people with mental illness still has a sense of groupness even without diagnostic systems. Research has shown a nonspecific prejudice against people who are mentally ill compared with people with other health conditions (Corrigan et al., 2000; Weiner, Perry, & Magnusson, 1988). However, diagnostic labels such as schizophrenia and psychosis seem to worsen the level of prejudice (Phelan, Link, Stueve, & Pescosolido, 2000).

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
Members of stereotyped out-groups are seen as more homogeneous than in-groups (Ashton & Esses, 1999; Rothbart, Davis-Stitt, & Hill, 1997; Tajfel, 1978). This leads to an overgeneralization error; namely, that all members of a group are expected to manifest the characteristics attributed to that group. All people diagnosed with schizophrenia are expected to hallucinate and all people with depression are assumed to be suicidal. Diagnosticians have noted this concern when advising clinicians in the text revision of the DSM-IV (APA, 2000) to use clinical judgment and flexibility to ensure that the description of individual cases is not solely voiced in terms of the diagnostic criteria: "There is no assumption that all individuals described as having the same mental disorders are alike in all important ways" (p. xxxi).

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)
More recently, Millon (1981) described people with personality disorders in terms of the group with which they are classified:

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)

These examples are more than 20 years old, and there is evidence that diagnosticians are writing in a less stigmatizing tone now. The Institute of Medicine (2001) provided a comprehensive summary on the international state of neurological, psychiatric, and developmental disorders. This text is remarkable in the ways in which people with specific disorders were portrayed: not in terms of specific characteristics that automatically represent them because of diagnosis but instead as a range of dimensional probabilities. The Institute of Medicine text did a marvelous job of describing diagnoses while respecting the heterogeneity of individuals with that diagnosis. Nevertheless, there continue to be contemporary examples of professional texts that equate diagnosis with person. For example, a book by Fischler and Booth (1999) attempted to explain vocational disabilities in terms of psychiatric diagnoses.

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
Stereotypic descriptions about stigmatized groups often include a component of stability; namely, the traits that describe a group are believed to remain relatively static and unchanging (Anderson, 1991; Kashima, 2000). This quality of stereotypes can be especially problematic for health conditions because it suggests that people with specific disorders do not recover from those disorders. This can lead to unnecessarily pessimistic attitudes about prognosis and the treatment efficacy.

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).
- Corrigan, Patrick W; How Clinical Diagnosis Might Exacerbate the Stigma of Mental Illness; Social Work; Jan2007; Vol. 52 Issue 1

Personal Reflection Exercise #9
The preceding section contained information about whether diagnosis can be a form of stereotyping for schizophrenics. Write three case study examples regarding how you might use the content of this section in your practice.

According to Corrigan, why is the “stability” quality of stereotypes especially problematic for health conditions? Record the letter of the correct answer the Answer Booklet.

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