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Conceptualizing Stigma and Barriers to Care 55
stigma, occurs when people internalize the negative beliefs and responses of others.
Another type is courtesy stigma. Ron Kessler discussed how much money goes into
mental health research. Institutional stigma is enacted in organizations, including
treatment sites. We have conducted studies of both long-term care facilities and
acute psychiatric hospitals and find dramatically different attitudes toward people
with mental illness in those two sectors of the mental health system. Finally, there is
provider-based stigma. Here we are talking about whether or not people who come
in for care are given a sense of hope or a sense of discouragement.
Here are some of the findings from the national stigma studies we conducted.
The first important finding is that the public has become more sophisticated over
time. When we asked individuals, “What is mental illness” they were able to give
us a much broader spectrum of problems that might be considered mental health
problems than they could in 1950. The second finding is that there have been
changes in formal and informal treatment responses to the onset of mental health
problems. There were no dramatic changes in the use of the formal treatment sector;
the people who were using avoidance as a strategy continue to use avoidance. In
contrast, there has been a dramatic change in how proactive people are in response
to mental health problems, and further, the American public has opened up to talk
about mental health problems with their informal supports.
Psychiatrists do not use the term nervous breakdown, but the question was
whether or not the American public did. We set up a two-stage question. To have
comparability with the earlier studies, the first part asked about the term ‘nervous
breakdown.’ The second part asked about mental health problems, and we found
that most people did respond to nervous breakdown. I would argue that if you
watch one episode of Judge Judy you will see that it is still in the common parlance.
The third finding from the national stigma studies shows that stigma is alive
and well, that there are clear gradients, and that both the behavior and the label
matter. What does this mean Approximately 50% of the American population
indicates some form of prejudice towards people with a variety of mental health
problems. I should mention that we did not ask, “Do you want to sit on the bus
next to somebody with a mental illness” We did not even ask the second generation
question, “Would you like to sit next to someone on the bus who has depression”
We provided a vignette which is exactly what people confront in the community.
We wanted to know one of the most important questions that other approaches did
not provide: Do people recognize problems that would meet DSM (Diagnostic and
Statistical Manual of Mental Disorders) criteria for mental health That turned out
to be very important in understanding whether or not people want to respond to
mental health problems.
There are two clear gradients. First, the type of mental health problem matters.
It turns out that schizophrenia is not at the end of the negative spectrum; drug
dependence is, followed by alcohol abuse, schizophrenia, and then depression. The
second gradient is the venue in which we are asking people to have contact matters.
The more intimate the contact, the greater the levels of rejection. In America, and
this turns out to be a particularly American phenomenon, the highest levels are in
work and marriage. We see the marriage phenomenon everywhere, but the work
phenomenon appears to be specific to the United States.
In the 1970s there was a debate in the social science literature about whether
it was the behaviors that people were rejecting or the label of mental illness. This
debate went on for a number of years, and what we find in our studies is that both
The first important
finding is that the
public has become
more sophisticated
over time.