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

Section 22
The Dangers of Stigma Regarding Schizophrenic Clients

Question 22 | Test | Table of Contents | Schizophrenia CEU Courses
Social Worker CEU, Psychologist CE, Counselor CEU, & MFT CEU

Stigma harms people with mental illness in three ways: label avoidance, blocked life goals, and self-stigma.

Label Avoidance
Epidemiological research has consistently shown that the majority of people who might benefit from mental health care either opt not to pursue it or do not fully adhere to treatment regimens once begun. As an example, consider people with schizophrenia, the group that might be construed as being most in need of services. Results from the Epidemiologic Catchment Area Study showed that only 60 percent of people with schizophrenia participated in treatment (Regier, Narrow, Rae, & Manderscheid, 1993). Taking into account symptom severity, Narrow and colleagues (2000) found that people with serious mental illness were no more likely to participate in treatment than those with relatively minor disorders. The National Comorbidity Survey showed similar results (Kessler et al., 2001); fewer than 40 percent of respondents with a serious mental illness such as schizophrenia had received medical treatment in the past year. Research has suggested that many people choose not to pursue mental health services because they do not want to be labeled a "mental patient" or suffer the prejudice and discrimination that the label entails. Results from the Yale arm of the Epidemiological Catchment Area data showed negative attitudes about mental health inhibit service use in those at risk of a psychiatric disorder (Leaf, Bruce, Tischler, & Holzer, 1987). Findings from the National Comorbidity Survey identified stigmatizing beliefs that might sway people from treatment (Kessler et al., 2001). These included concerns about what others might think and the desire to solve one's own problems. Sirey and colleagues (2001) found a direct relationship between stigmatizing attitudes and treatment adherence. Endorsing stigma was associated with whether 134 adults were compliant with their antidepressant medication regimen three months later. Hence, people may opt not to pursue treatment where labels are conferred to avoid the egregious effects of stigma.

Blocked Opportunities
A primary goal of mental health and rehabilitative services is to assist people in accomplishing their work, independent living, and relationship goals. In part, difficulties achieving goals occur because of the disabilities that result from serious mental illness (Corrigan, 2001). Some people with serious mental illness lack the social and coping skills to meet the demands of the competitive workforce and independent housing. Nevertheless, the problems of many people with psychiatric disability are further hampered by labels and stigma. People with mental illness are frequently unable to obtain good jobs or find suitable housing because of the prejudice of employers and landlords. Several studies have documented a consensus about the public's widespread endorsement of stigmatizing attitudes (Bhugra, 1989; Brockington, Hall, Levings, & Murphy, 1993; Hamre, Dahl, & Malt, 1994; Link, 1987). These attitudes have a deleterious impact on people's ability to obtain and keep good jobs (Farina & Felner, 1973; Farina, Felner, & Boudreau, 1973; Link, 1982,1987; Wahl, 1999) and lease safe housing (Farina, Thaw, Lovern, & Mangone, 1974; Hogan, 1985a, 1985b; Page, 1977, 1983, 1995; Wahl). Similar research has shown that stigma may undermine the general medical care received by people with mental illness (Druss, Bradford, Rosenheck, Radford, & Krumholz, 2000).

People with mental illness who live in a society that widely endorses stigmatizing ideas may internalize these ideas and believe that they are less valued because of their psychiatric disorder (Link, 1987; Link & Phelan, 2001; Ritsher, Otilingam, & Grajales, 2003). Like public stigma, self-stigma includes "buying into" a set of stereotypes: "That's right; I am weak and unable to care for myself!" Self-stigma leads to automatic thoughts and negative emotional reactions; prominent among these are shame, low self-esteem, and diminished self-efficacy. Self-stigma may also have a behavioral effect. Low self-efficacy and demoralization have been shown to be associated with people's failing to pursue work or independent living opportunities at which they might otherwise succeed (Link, 1982, 1987). Fueled by shame, their consequent behavior is to escape and avoid future similar situations.

A Social Cognitive Definition Of Stigma
Researchers working at the interface of social work and psychology have framed the stigma process in terms of four cognitive structures: cues, stereotypes, prejudice, and discrimination. This model (Figure 1) parallels a cognitive behavior model of action by specifying signal, cognitive mediator, and behavioral result (Corrigan, 2000). The process begins with stigmas, which are the cues that signal subsequent prejudice and discrimination.

Goffman (1963) adopted the term stigma from the Greeks who defined it as a mark meant to publicly and prominently represent immoral status. Stigmas are typically the marks that, when observed by a majority group member, may lead to prejudice. Goffman noted that some stigmas are readily apparent and based on a physical sign such as skin color (a cue for ethnicity) or body size (a cue for obesity). Other stigmas are relatively hidden; for example, the public cannot generally tell who among a group of people falls into such stigmatized groups as gay men, Catholics, undereducated people, and people with mental illness. Instead of an unequivocal physical cue, hidden stigma is signaled by label or association (Link, Cullen, Frank, & Wozniak, 1987; Penn & Martin, 1998). Labels may be self-promoted ("I am a gay male") or given by others ("That person is mentally ill"). Hidden stigma can also be ascertained based on association; for example, observation of someone leaving a psychiatric clinic might lead to the assumption that the person is mentally ill. Theorists in this area of study view stereotypes as knowledge structures that are learned by most members of a cued social group (Augoustinos, Ahrens, & Innes, 1994; Judd & Park, 1993; Krueger, 1996). Stereotypes are especially efficient means of categorizing information about social groups. Just because most people have knowledge of a set of stereotypes does not imply that they agree with them (Devine, 1989; Jussim, Nelson, Manis, & Soffin, 1995). For example, many people can recall stereotypes about different racial groups but do not agree that the stereotypes are valid. People who are prejudiced, on the other hand, endorse these negative stereotypes ("That's right; all people with mental illness are violent") and generate negative emotional reactions as a result ("They all scare me") (Devine, 1995; Krueger). In contrast to stereotypes, which are beliefs, prejudicial attitudes involve an evaluative (generally negative) component (Eagly & Chaiken, 1993).

Prejudice, which is fundamentally a cognitive and affective response, leads to discrimination, the behavioral reaction (Crocker, Major, & Steele, 1998). Discriminatory behavior manifests itself as negative action against the out-group. Out-group discrimination includes outright violence (for example, lynching experienced by African Americans and assaults directed at gay men) and coercion (for example, laws that restrict the full rights of people in an ethnic or religious minority group, such as the Jim Crow laws of the late 1800s through the early 1960s). Out-group discrimination may also appear as avoidance, not associating with people from the out-group. This can be especially troublesome when employers decide not to hire and landlords decide not to rent to people from an ethnic or religious minority group to avoid them.
- Corrigan, Patrick W; How Clinical Diagnosis Might Exacerbate the Stigma of Mental Illness; Social Work; Jan2007; Vol. 52 Issue 1

Personal Reflection Exercise #8
The preceding section contained information about the dangers of stigma regarding schizophrenic clients. Write three case study examples regarding how you might use the content of this section in your practice.

What are three ways in which stigma harms people with a mental illness? Record the letter of the correct answer the Test.

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