Stigma Surrounding Mental Illness and Its Reduction: What ...
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Undergraduate Honors Theses Student Research
5-2018
Stigma Surrounding Mental Illness and ItsReduction: What Sort of Information Is MostEffective?Natalie S. Tanner
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Recommended CitationTanner, Natalie S., "Stigma Surrounding Mental Illness and Its Reduction: What Sort of Information Is Most Effective?" (2018).Undergraduate Honors Theses . 7.https://digscholarship.unco.edu/honors/7
UniversityofNorthernColorado
Greeley,Colorado
StigmaSurroundingMentalIllnessandItsReduction:WhatSortofInformationisMost
Effective?
AThesisSubmittedinPartialFulfillmentfor
GraduationwithHonorsDistinctionandtheDegreeofBachelorofArts
NatalieS.Tanner
SchoolofPsychology
May2018
SignaturePage
StigmaSurroundingMentalIllnessandItsReduction:WhatSortofInformationisMost
Effective?
Preparedby:________________________________________ NatalieTanner
Approvedby:________________________________________ Dr.JamesKole
HonorsLiaison:______________________________________ Dr.MelissaLea
HonorsDirector:______________________________________ LoreeCrow
RECEIVEDBYTHEUNIVERSITYTHESIS/CAPSTONEPROJECTCOMMITTEEON:
May5,2018
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Acknowledgements
IwouldliketoacknowledgetheUniversityofNorthernColorado’sHonors
Departmentforassistingmethroughouttheresearchprocess.Iwouldliketothank
LoreeCrow,theheadoftheHonorsDepartment,aswellas,Dr.KevinPugh,my
departmentalliaison.Mostimportantly,Iwouldliketomythesisadvisor,Dr.JamesKole.
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TableofContents
TableofContents
Abstract......................................................................................................................5
StigmaandReduction..................................................................................................6
ReviewoftheLiterature..............................................................................................7HistoryofMentalIllnessandStigma....................................................................................9MentalIllnessandStigmainthePresent............................................................................11HowDoesStigmaAffectIndividualswithaMentalIllness?................................................12HopefortheFutureandReductionofStigmas...................................................................14
Method.....................................................................................................................19Participants........................................................................................................................19Materials...........................................................................................................................19Procedure..........................................................................................................................20Design................................................................................................................................20
Results......................................................................................................................21
GeneralDiscussion....................................................................................................23
References................................................................................................................25
AppendixA................................................................................................................29ConsentForm....................................................................................................................29
AppendixB................................................................................................................31DebriefingStatement.........................................................................................................31
AppendixC................................................................................................................32Articleusedintheeducationalgroupofthequantitativestudy.........................................32
AppendixD................................................................................................................35Articleusedinthecontrolgroupofthequantitativestudy................................................35
AppendixE................................................................................................................37Mentalhealthstigmatizationsurveyusedforthequantitativestudy.................................37
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Abstract
Thepurposeofthismixed-methodsstudywastoexaminewhetherornotan
educationalinterventioncanreducementalhealthstigmatization.Thequantitative
pieceofthisprojectisarandomizedexperiment;participantswereassignedtooneof
threeconditions:1.anexperimentalgroupthatreadanarticleaboutmentalhealth
stigmatization,2.anactivecontrolgroupthatreadanarticleonanxiety,and3.an
inactivecontrolthatdidnotreadanymaterial.Mentalhealthstigmatizationwas
measuredviasurveybothpreandpostintervention.Althoughtheresultswerenot
significant,theeducationalinterventiongroupshowedlessbiasimmediatelyafterwards
thantheactiveandinactivecontrolgroups,andtheeducationalinterventiongroupand
activecontrolgroupshowedlessincreaseinbiasoverthe1-weekdelaythanthe
inactivecontrolgroup.Thisprojectmaypotentiallyinformfutureresearchand
programmingtoreducementalillnessstigma.
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StigmaSurroundingMentalIllnessandItsReduction:WhatSortofInformationisMost
Effective?
StigmaandReduction
Thestigmasurroundingmentalillnessandmentalhealthtreatmentare
importantissuesbecausetheyserveasbarrierstotreatmentseeking.Accordingtothe
NationalAllianceonMentalIllness,nearly1in5adultsintheUnitedStates(18.5%or
43.8millionpeople)experiencementalillnessinagivenyear(NAMI,2015).While
effectivetreatmentsexistformanymentaldisorders,nearlyhalfofthosewithasevere
mentalillnessdonotseektreatment(SoRelle,2000).InarecentstudybytheAmerican
PsychologicalAssociation,whichusedarandomsampleof1,000Americans,itwas
foundthat30%ofrespondentshadconcernsaboutothersfindingoutthattheyhad
soughtmentalhealthtreatment,and20%saidthatstigmaisanimportantreasonto
avoidseekinghelpfrommentalhealthprofessionals(Chamberlin,2004).Thefailureto
seektreatmentformentaldisordersnotonlyhasdetrimentaleffectsontheindividual,
butonsocietyaswell.IthasbeenestimatedthatmentalillnesscoststheUnitedStates
$193.2billioninlostearningsannually(NAMI,2015).Inadditiontofinancialcosts,itis
estimatedthatofthosehomelessadultsresidinginshelters,26%livewithserious
mentalillness,and46%ofthoseareclassifiedasseverementalillness(NAMI,2015).
Stigmareductionprogramscan(andhavebeen)becreatedtoreducethestigma
surroundingmentalillnessandtreatment,withtheintentthatreducingthis
stigmatizationwouldincreasetreatmentseeking.Itisthusimportantfortheprograms
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tobeeffective;however,itisunclearwhattypeofprogramismostimportantto
reducingstigma.Thepresentstudyfocusesonmetacognitivefactorsinstigmareduction
andinvestigateswhetherornotanawarenessofsuchstigmatizationreducesit.Inthe
literaturereviewsectionofthisthesis,Iwillreviewstudiesonmentalhealthstigma.Of
specialfocusishowstigmahasbeenmeasured,andtheefficacyofvarioustypesof
interventionemployedtoreducestigmatization.
ReviewoftheLiterature
AccordingtoThePsychologyofPrejudicebyToddD.Nelson,stigmaisthe
possessionofacharacteristicorattributethatconveysanegativesocialidentity.Stigma
canalsobedefinedas“amarkofdisgracethatsetsapersonapart.Whenapersonis
labelledbytheirillnesstheyareseenasapartofastereotypedgroup.Negative
attitudescreateprejudicewhichleadstonegativeactionsanddiscrimination”
(AustralianGovernment).ParkerandAggletonarguethatstigmamustberegardedasa
socialprocessinwhichpeopleoutoffearofthediseasewanttomaintainsocialcontrol
bycontrastingthosewhoarenormalwiththosewhoaredifferent(Neema,2012).
AccordingtoPsychologyToday,therearetwomaintypesofmentalhealthstigma.
Thesedistincttypesaresocialstigmaandperceivedstigma/self-stigma.Socialstigmais
categorizedbydiscriminatorybehaviorandprejudicialattitudestowardspeoplewith
mentalillness/mentalhealthproblemsduetothepsychiatriclabelassociatedwiththem.
Self-stigmaorperceivedstigmaiscausedbytheinternalizationofboththepsychiatric
labelanindividualwithamentalhealthconcernhasandtheperceptionsof
discrimination(Davey,2013).Stigmacanmakepeoplefeelandexperiencethingssuch
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asshame,blame,hopelessness,distress,andmisrepresentationinthemedia,
reluctancetoseekand/oracceptnecessaryhelp(Owenetal.,2012).
Stigmatakesonmanyforms.Someoftheseformsincludeprejudice,discrimination,fear,
distrust,andstereotyping.Stigmatizingactionsalsotakeplace.Thesestigmatizingactions
includeignoring,avoiding,andbeingunwillingtoworkwiththosewhofallintothestigmatized
out-group.Thetablebelow,createdbyresearcherNicholasRusch(2012),showsthevarious
componentsofpublicorsocialstigmaandself-stigma.Public/socialstigmaasdescribed
previouslyisdiscriminatorybehaviorsandprejudicialattitudestowardsindividualswithmental
illnesscausingthatindividualtofeelstigmaandothernegativeemotions.Self-stigmaisthe
mentalhealthsufferer’sperceptionoftheirillnessandhowotherstreatthem.
Table1.
ComponentsofPublicandSelf-Stigma
PublicStigma:
Negativebeliefaboutagroupsuchas
Incompetence
Characterweakness
Dangerousness
Prejudice:
Agreementwithbeliefand/or
Negativeemotionalreactionsuchas
AngerorFear
Discrimination:
Behaviorresponsetoprejudicesuchas:
Avoidanceofworkandhousingopportunities
Withholdinghelp
Self-Stigma:
Stereotype:
Negativebeliefabouttheself-suchas
Incompetence
Characterweakness
Dangerousness
Prejudice:
Agreementwithbelief
Negativeemotionalreactionsuchas
Lowself-esteemor
Lowself-efficacy
Discrimination:
Behaviorresponsetoprejudicesuchas:
FailstopursueworkandhousingopportunitiesandDoesnotseekhelp
Stigmasarealearnedbehavior.Thismeansthatindividualsaretaughtthebehavior
throughouttheirlivesthroughmodeling.Discrimination,stigma,andprejudicearemodeledby
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parents,teachers,friends,andevenstrangers.
HistoryofMentalIllnessandStigma
Stereotypesandstigmasaboutthosewithamentalillnessbeganasxenophobia.Most
peoplewhohadamentalillnessorknewsomeonewithamentalillnesswereshamedbecause
therewasnoscienceorreasoningbehindtheillnessatfirst.Inancientcivilizations,mental
healthproblemswereconsideredtobeofareligiousnature.Somethoughtapersonwitha
mentaldisordermaybepossessedbydemons,thusprescribingexorcismasaformof
treatment.Duringthe5thcenturyBC,GreekphysicianHippocrates,however,believedthat
mentalillnesswasphysiologicallyaffiliated.Asaresult,hismethodsinvolvedachangein
environment,livingconditions,oroccupations(DualDiagnosis,2014).AccordingtotheU.S.
NationalLibraryofMedicine,mentalillnessintheUnitedStatesstartedinthefollowingway:
FamilymembersinearlyAmericancommunitiescaredforthementallyillwithintheirfamilies.
Withveryintenseorseverecasesofmentalillnessfamilieswouldbringtheirmentallyillfamily
membereithertoanalmshouse,orthefamilymembermayendupinjail.Duringthistime
peoplegenerallybelievethatmentalillnesseswerecausedbyaspiritualormoralfailingsothe
mentallyillwereoftenshamedandpunishedbysociety.Oftentimestheshamewouldspread
tothefamilyofthementallyillaswell.Ascommunitiesgrewandbecamemoresettledmental
illnessbecameamuchlargersocialissue.Inordertosolvethisissue,communityinstitutions
werecreatedtohelphandletheneedstomentallyillindividualsasawhole.
Thecommunityinstitutionsthatwerecreatedwereoftenreferredtoasinsaneasylums.
EuropeanideasaboutthecareandtreatmentofthementallyillwerebroughttotheUnited
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StatesofAmericaasasylumsbegintoopen(D’Antonio,2016).TheseEuropeanideaswere
referredtoasthe“moraltreatment,”andtheypromisedacureformentalillnessestothose
whosoughttreatment.Asylumsfollowedthemoraltreatment,whichassumedthatindividuals
sufferingfrommentalillnesswouldbeabletofindtheirownwaytorecoveryandacureto
theirillnessiftheyweretreatedkindly.Themoraltreatmentalsosaidthatbytreating
individualswithmentalillnesskindly,onewasappealingtothepartsofthemindthatwerestill
rational.Forpatientswhodidnotgetbetter,themoraltreatmentassumedthattheywerenot
tryinghardenoughtoheal,solongperiodsofisolationsandharshrestraintswereusedinorder
todiscouragethedestructivebehaviorsofpatientswithmentalillness.(D’Anontio,2016).
ThefirstofficialasylumtobecreatedwascalledthePennsylvaniaHospitalforthe
Insane.Itopeneditsdoorsin1856.Thishospitalremainedopenuntil1998,andchangednames
multipletimes.Thishospital,beingthefirst,setthebeginningstandardsforhowthoseaffected
bymentalillnessesshouldbehandledandtreated.AccordingtotheU.S.NationalLibraryof
Medicine,thestandardsinwhichthePennsylvaniaHospitalsetincludedprovidingbasement
roomscompletewithshacklesattachedtothewallstobethehomeforasmallnumberof
patientsaffectedbymentalillnesses.
Althoughsocietynowhasverydifferentviewsonhowpeopleaffectedbymentalillness
shouldbetreatedandhandled,thenegativityandstigmastillsurroundstheaffected.Astudy
wasdonein1993byHuxley,whichshowedthatshameoverrideseventhemostextreme
symptomsofmentalillness.TwoidenticalUKpublicopinionsurveysweredonebyHuxley
(2009).Thesurveysshowedthatlittlechangewasrecordedover10years,withover80%
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endorsingthestatementthat“mostpeopleareembarrassedbymentallyillpeople”,andabout
30%agreeing“Iamembarrassedbymentallyillpersons”(Sharma,2016).Theseviewsremain
almostthesameintoday’ssociety.IntensestigmatizationofmentalillnessinAmerica
throughouthistoryhasleadtocontinuedbeliefsandperceptionsaboutmentallyillindividuals
andhavethereforecontinuedthecycleofstigmatization.
MentalIllnessandStigmainthePresent
Attitudesoffearandshamecontinuetocreatestigmaforthoseaffectedbymental
illnesstoday.Onmanyoccasionsfamilymembersandfriendssometimesendureastigmaby
association,referredtoas“courtesystigma”(Goffman,1963).Thissecrecyandfearcontinueto
perpetuatestigmatizationofthosewithmentalillnesses.InastudydonebyPhelanetal.in
1998,156parentsandspousesoffirst-admissionpatients,halfreportedmakingeffortsto
concealtheillnessfromothers.Intoday’ssocietysecrecycreatesasanobstaclesurrounding
mentalhealth.Todaybecauseoffearandshame,individualsaffectedbymentalillness
generally,tryandconcealwhatishappeningtothemandmoreoftenthannot,areafraidto
seektreatmentduetostigma.
Stigmainpresenttimesismuchlessovertthenithasbeeninthepast.Inmodern
society,individualswithmentalhealthwillnotbesenttoinsaneasylumsortreatedasifthey
arealunatic.Individualswithmentalillnessinpresenttimeswillbesubjectedtolingering
stigmasfromthepast,andwillbediscriminatedagainst.Inonestudy,researchersfoundthat
threedimensionsarestillimportantinaccountingforrejectionbaseduponandsurrounding
mentalillness.Thesedimensionsaretherarityoftheillness,personalresponsibilityforthe
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illness,andoveralldangerousnessoftheindividualandtheillness(Feldman&Crandall,2007).
Rarityofillnessmeansthatfrequencyofoccurrenceinthegeneralpopulation.Personal
responsibilityfortheillnessiswhetherornotcontrolcanbeexertedoversymptoms,and
dangerousnessisiftheindividualispronetoviolentacts.
HowDoesStigmaAffectIndividualswithaMentalIllness?
Duetothesecrecyandstigmatizationofmentalillnesstherearemanycomplications
thatarisenotonlyintreatmentbutinotheraspectsofapatient’slife.Complicationsbeginwith
publicattitudestowardsindividualswithamentalillness.Thesepublicattitudesincludevarious
aspectsoflifeincludingsocial,physical,andeconomic-standing.Theattitudesofthegeneral
publicarepervasiveandseepintoeverythingthathappenswithinacommunity.Thismeans
thatasagroup,thementallyillbecomeanout-groupinacommunity.Theindividualswith
mentalillnessareavoidedinworking,living,andgeneralsocialenvironments.Theyare
discriminatedagainstinclassroomsandonoccasionbyhealthcarephysicians,suchasdoctors
andtherapists(Schulze,2007).
Alargereasonwhythesestigmatizingattitudesareaproblemisbecausetheycanlead
todiscriminationinareasofemployment,andjustasofteninhousingopportunities.Beyond
that,thebiggestproblemcreatedbystigmaisthatitallowsforthedevaluationofindividuals,
whichisharmfultoboththein-groupandout-group.Thedevaluationofthestigmatizedgroup
isalsohowstereotypesaboutthesegroupsarecreated.Stereotypesthatareoftenheldabout
individualswithamentalillnessarethattheyareuselessintheworkforce,unreliable,
dangerous,andincompetentinotheraspectsoflife,suchasrelationships.GordonAllportonce
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statedthatstereotypesholdakerneloftruth,butalwaysareextremelyincorrectinalmostall
ways(Nelson,2006).Anexampleofthesestereotypesisstatedthroughoutastudydoneby
Wahl(1999).Wahlexaminedtheextenttowhichpeoplewithmentalhealthproblems
encounterstigmaintheirdailylives.Wahldevelopedaquestionnairebasedonstigmatization
experiencescommonlyreportedinpersonalaccountsofmentalillnessandquestioned1,301
mentalhealthconsumersfromacrosstheU.S.andCanada.Respondentsreportedhaving
witnessedstigmatizingcommentsordepictionsofmentalillness,havingbeentreatedasless
competentbyothersoncetheirillnesswasdisclosed,beingshunnedoravoided,andbeing
advisedtolowertheirexpectationsinlife.
Corrigan,Druss,andPerlick(2014)veryclearlysumuptheaffectsindividualswith
mentalfeelduetostigma.Theysaidthat,“fromapublicstandpoint,stereotypesdepicting
peoplewithmentalillnessasbeingdangerous,unpredictable,responsiblefortheirillness,or
generallyincompetentcanleadtoactivediscrimination,suchasexcludingpeoplewiththese
conditionsfromemploymentandsocialoreducationalopportunities.”Corrigan,Druss,and
Perlickalsosawtheseaffectsinmedicalsettingsandnoticedthat,“negativestereotypescan
makeproviderslesslikelytofocusonthepatientratherthanthedisease,endorserecoveryas
anoutcomeofcare,orreferpatientstoneededconsultationsandfollow-upservices.”
Discriminationcanleadindividualswithmentalillnesstointernalizenegativethoughts
andfeelingsandbeganself-stigmatization(Corrigan,Druss,&Perlick,2014).Self-stigmacan
makeindividualsfeelliketheymaybeunabletorecover,undeservingofcare,dangerous,or
responsiblefortheirillnesses.“Self-stigmacanalsoleadtothedevelopmentofthe‘whytry’
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effect,wherebypeoplebelievethattheyareunabletorecoverandlivenormallyso‘whytry?’”
(Corrigan,Druss,&Perlick,2014).
HopefortheFutureandReductionofStigmas
Mostindividualswhohaveamentalillnesswillgoontobesuccessfulafterreceiving
treatment.Theseindividualshavebrightfuturesincludinghavingagoodjob,goingtoschool,
owningahome,havingchildren,andbeingsuccessfulinrelationships.Thegoalofreductionof
stereotypestohelpallofsociety.Thetwomainwaysreductionofstigmascanhelpisby
positivelyaffectingindividualswithmentalillnessandbypositivelyaffectingthosewhodonot
haveamentalillness.
Stereotypesareembarrassingandhumiliating,andevenmoresotheyarepainful,and
leadtodiscrimination.Perhapsworstofall,stigmakeepspeoplefromseekinghelp(Carter,
2010).AnotherstudydoneatCambridgeUniversityfoundthatmorethan70%ofadultsand
youngpeoplegloballydonotreceivetreatmentdueto“expectationsofdiscriminationagainst
peoplewhohaveadiagnosisofmentalillness”(Thornicroft,2008).Thisiswhyreductionto
stereotypesisvastlyimportant.Individualswithmentalillnessmustdealwithsecrecy,shame,
andridiculejusttoreceivethetreatmentthattheyneedinordertonolongerbestigmatized.
Stigmaisahindrancetoeveryone.Itallowsforsocietaldivisionandifitisreducedeveryone
willbebetteroff.
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TableII.
Stigma-reductionstrategies.LevelStrategies
IntrapersonallevelTreatment
Counselling
Cognitive–behavioraltherapy
Empowerment
Groupcounseling
Self-help,advocacyandsupportgroups
InterpersonallevelCareandsupport
Homecareteams
Community-basedrehabilitation
Organizational/institutionallevel
Trainingprograms
(New)policies,likepatient-centeredand
integratedapproaches
Communitylevel
Education
Contact
Advocacy
Protest
Governmental/structurallevel
Legalandpolicyinterventions
Rights-basedapproaches
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AsnotedaboveinthechartbyHeijndersandVanDerMeij(2007),thereareamultitude
ofwaysinwhichresearchershavelookedatreducingstigmas.Themethodsabovehavebeen
experimentedandtested,allowingfutureresearcherstolookthroughthemandseewhichis
themostattainableandthemosteffective.AliteraturereviewdonebyDalky(2011)evaluated
variousmethodsofstigmareductionandtheireffectivenessinrelationtomentalillness.The
literaturethatwasreviewedwaseverythinginvolvingstigmareductionmethodsbetween1998
and2008andusedPubMed,CINALH,Scopus,Medline,andPsychINFOdatbases.Thereview
resultsshowedthatcontact-basedandeducationalstigmareductionprogramscreatedthe
strongestadvancesinknowledge.Educationalandcontact-basedmethodsalsocreatedthe
mostpositivechangesinbehaviorandattitudewhichinturndecreasedstigmaassociatedwith
mentalillness(Dalky,2011).
OrganizationssuchastheNationalAllianceonMentalIllnesshaveevencreated
campaignstoendmentalhealthstigmaanddiscrimination.ThecampaigncreatedbyNAMI
challengesparticipantstakethefirststeponlearningaboutmentalhealthissuesandeducating
others.Thesecondstepintheircampaignistohaveparticipants,“seethepersonandnotthe
illness.”Thefinalstepsincludetakingactiononmentalhealthissuesandtakingapledgetobe
stigmafree.NAMIisnottheonlyorganizationouttheretryingtoendmentalhealthstigmas.
NAMIhasalsobeen“particularlysuccessful…intheUS.”NAMIuses“agroupoffamily
membersandpersonswithmentalillness,[to]educatethepublicinordertodiminish
stigmatizingconditions;e.g.bypressingforbetterlegalprotectionforpersonswithmental
illnessintheareasofhousingandwork”(Rusch,2005).
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AnotherorganizationtryingtomakeadifferenceisActiveMinds.ActiveMindsisa
groupwhosemissionistochangetheconversationaboutmentalhealth.Theircurrent
campaignistheNationalDayWithoutStigma.Thesloganforthisdayis,“Stigmaisshame.
Shamecausessilence.Silencehurtsusall.“SimilartoNAMI,theyaskparticipantstojoinintoa
threestepprogram.Thestepsincludechangingyourlanguage,chalkingyoursupport,and
reachingothers.IncludedintheNationalDayWithoutStigmacampaign,thereisachapter
actionkit,acommunityactionkit,andaplacewhereindividualscantakeapledgetobestigma
free.
Whilecampaignsliketheseareextremelyimportant,largerandmoreuniversalstigma
reductionstepshavebeentakingplace.Accordingtothe2001,WorldHealthOrganization
Reporttherearemanystepsthatcanbetakeninordertoreducethestigmasurrounding
mentalhealthandmentalillness.Thefirststepthatislistedistoprovidetreatmentinprimary
care.Otherstepsincludemakingpsychotropicdrugsavailable,givingcareinthecommunity,
andeducatingthepublic.Thelistalsoincludesinvolvingcommunities,families,andconsumers,
aswellas,establishingnationalpolicies,programs,andlegislation,anddevelopinghuman
resources.ThefinalstepsinstigmareductionascreatedbytheWHOarelinkingwithother
sectors,monitoringcommunityhealth,andsupportingmoreresearch.TheWorldHealth
OrganizationhostedaWorldHealthDayin2001whichwasthemed,“Stopexclusion-Dareto
care.”“Itsthemewasthatthereisnojustificationforexcludingpeoplewithamentalillnessor
braindisorderfromourcommunities–thereisroomforeveryone.”
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Thestigmareductionmethodthatwillbeusedinthisstudywillbesimilartoother
educationalreductionmethods.Forthestudy,participantswillberandomlyassignedtooneof
threeconditions:education-basedinterventiongroup,activecontrol,orinactivecontrol.
Participantsintheeducation-basedinterventiongroupwillfirstreadthearticledescribing
mentalhealthstigmatization,andafterwardswillimmediatelycompleteasurveymeasuring
mentalhealthstigmatization.Participantswillreturn1weeklaterandwillcompletethesame
surveyasecondtime.Theprocedurefortheactivecontrolgroupwillbethesameasforthe
education-basedinterventiongroup,however,insteadofreadingthearticleonmentalhealth
stigmatization,theywillinsteadreadthecontrolarticleonanxiety.Theinactivegroupwillnot
readanymaterial;theywillcompletethesurveyduringthefirstsession,andagainduringthe
secondsessionheldoneweeklater. Itwillbedifferentfromothereducationalstigma
reductionmethodsbecauseinsteadofjustlookingateffectivenessinthemoment,itwilllook
ateffectivenessoveraperiodoftime.
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Method
Participants
Participantsincluded14volunteersfromtheintroductorypsychologypool(PSY120)at
theUniversityofNorthernColorado.Participantsreceivedcoursecreditfortheirparticipation.
Thetasksweredescribedaspresentedintheconsentform(seeAppendixA);participantswere
assuredoftheirconfidentiality.Nospecialpopulationswereinvestigated,andallparticipants
werethoroughlydebriefed.TheattacheddebriefingstatementisAppendixB.Allparticipants
weretreatedinaccordancewithethicalguidelinesfromtheUniversityofNorthernColoradoas
wellastheAmericanPsychologicalAssociation(2002).
Materials
ThefirstpieceofmaterialusedforthisexperimentwasanarticlefromPsychology
Today,entitled,“Mentalhealth&stigma:Mentalhealthsymptomsarestillviewedas
threateninganduncomfortable”.Thisarticleis1215wordsinlength,anddiscussesthestigma
thatsurroundsmentalillness,aswellasfactorsunderlyingthestigmatizationofmentalillness.
Thearticlealsoaddressestwodimensionsofstigmatization,personalresponsibilityand
dangerousness(seeAppendixC).
ThecontrolarticlebeingusedforthisexperimentisalsofromPsychologyTodayandis
entitled,“Whatisanxiety?”.Thisarticlewaswrittenbythesameauthorwhowrotethe
previouslydescribedarticleonstigmatizationandis1146wordsinlength.Thearticlewas
selectedbecausethetwoarticlesareapproximatelythesamelength,havecommonauthorship,
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andbothdealwithmentalillness.Thecontrolarticlediscussesanxietyandthepitfallsthatare
associatedwithit(seeAppendixD).
AsurveycreatedbyMindforBetterMentalHealthandRethinkMentalIllnesswillbe
usedtoassessmentalhealthstigmatization.Thesurveyincludes52itemsandhasbeenusedin
previousstudies(seeAppendixE).
Procedure
Forthestudy,participantswererandomlyassignedtooneofthreeconditions:
education-basedinterventiongroup,activecontrol,orinactivecontrol.Participantsinthe
education-basedinterventiongroupfirstreadthearticledescribingmentalhealth
stigmatization,andafterwardsimmediatelycompletedasurveymeasuringmentalhealth
stigmatization.Participantsreturned1weeklaterandcompletedthesamesurveyasecond
time.Theprocedurefortheactivegroupwasthesameasfortheeducation-basedintervention
group;however,insteadofreadingthearticleonmentalhealthstigmatization,theyinstead
readthecontrolarticleonanxiety.Theinactivecontrolgroupdidnotreadanymaterial;they
completedthesurveyduringthefirstsession,andagainduringthesecondsessionheldone
weeklater.
Design
Thequantitativestudyutilizesamixed-factorialdesign,withtheinterventioncondition
(education-based,activecontrol,inactivecontrol)abetween-subjectsfactorandtest
(immediate,one-weekdelay)awithin-subjectsfactor.Thedependentvariableistotalscoreon
thementalhealthstigmatizationsurvey.
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Results
Ananalysiswasconductedtotesttheinternalconsistencyreliabilityofthemental
healthstigmatizationsurvey.Thisanalysisfoundthatreliabilitywaslessthanthedesiredrange
ofgreaterthan.7(α =.646).Thereliabilityanalysisalsoshowedthreequestionthatservedas
adragonreliability.Thus,asecondreliabilityanalysiswasconductedexcludingthosethree
items,whichboostedCronbach’salphato.791.Totalscoresforparticipantswerecalculated
excludingthesethreeitems.
Fortheseitems,theaveragescorewas3.31(s=.433).Thisvalueindicatesthaton
averagesubjectswereneutralonthestatements,neitherstigmatizingnorrejectingstigmatizing
statementsaboutmentalillness.
Totesttheefficacyoftheeducationalintervention,amixed-factorialANOVAwas
conductedincludingthebetweensubjectsfactorofcondition(educationalintervention,active
control,inactivecontrol)andtime(immediatetest,delayedtest).Onaverage,therewasa
slightincreaseinstigmatizationscoresfromtheendofthefirstsession(M=3.085)tothe
secondsession(M=3.538);however,thisincreasewasnotsignificant,F(1,11)=1.73,p>.05.
Further,althoughthemaineffectofconditionwasnotsignificant,thepatternofmeanswas
somewhataspredictedwiththeeducationalinterventiongroupshowingthelowestlevelof
mentalhealthstigmatizationacrossbothsessions(M=2.958),followedbytheactivecontrol
(M=3.390)andtheinactivecontrol(M=3.446),F(2,11)=2.64,p>.05.Finally,theinteraction
betweenconditionandtimewasnotsignificant,butthepatternwassuchthattheaverage
increaseinstigmatizationscorewassmallerfortheeducationalinterventioncondition(M
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GeneralDiscussion
Resultswerenotsignificantduetothenumberofparticipantsinthestudy.Theresults
leanedtowardstheeducationalmethodbeingeffectiveoveraweek-longperiodwhichmeans
thatwithmoreparticipantsitispossiblethatusingeducationalreadingmaterialoveraweek-
longperiodcouldbeusefulinthereductionofmentalhealthstigmatization.Intheexperiment,
participantswererandomlyassignedtooneofthreeconditions:education-basedintervention
group,activecontrol,orinactivecontrol.Participantsintheeducation-basedintervention
groupfirstreadthearticledescribingmentalhealthstigmatization,andafterwardsimmediately
completedasurveymeasuringmentalhealthstigmatization.Participantsreturned1weeklater
andcompletedthesamesurveyasecondtime.Theprocedurefortheactivegroupwasthe
sameasfortheeducation-basedinterventiongroup;however,insteadofreadingthearticleon
mentalhealthstigmatization,theyinsteadreadthecontrolarticleonanxiety.Theinactive
controlgroupdidnotreadanymaterial;theycompletedthesurveyduringthefirstsession,and
againduringthesecondsessionheldoneweeklater.
Theresultsalsoindicatedthatthementalhealthstigmatizationsurveywasareliable
instrumenttomeasurethisconstruct,excludingthreeitems.Theresults,aspreviously
mentionedwerenotsignificantduetothenumberofparticipantsinthestudy.However,in
generaltheresultsarepromisinggiventhelargeliteratureinotherdomains,suchasproblem
solvingandreasoning,demonstratingthatde-biasingindividualsisdifficulttoachieve.Itwas
believedthatitwouldbeeasiertoobtainmoreparticipants.Duetothetimelinefortheproject,
Iwasunabletotakemoretimetogetmoreparticipantsinordertotryandhavesignificant
results.IfIwereabletocontinueworkingonthestudy,Iwouldcontinuetoobtainandtest
24
participants.Oneimprovementtotheexperimentaldesignwouldbetohaveanexactplanto
keeptrackofallparticipantsandtheirloginIDforthesurvey.
Continuedresearchinthisareacouldhelpreducethestigmatizationofmentalhealth
andmentalillness.Thisresearchstudycanbeusedasasteppingstonetocreatefurther
researchonstigma,mentalhealth,andstigmatizationsurroundingmentalwell-beingand
illness.
25
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29
AppendixA
ConsentForm
CollegeofEducationandBehavioralSciencesSchoolofPsychologicalSciencesInformedConsentforParticipationinResearchUniversityofNorthernColoradoProjectTitle:StigmatizationofMentalIllnessResearcher: NatalieS.Tanner SchoolofPsychologicalSciencesPhone: 970-689-4254email:[email protected]:JamesKolePhone:970-351-2422email:James.Kole@unco.eduThepurposeofthisstudyistoexaminetheperceptionsthatsurroundmentalhealthandmentalillness.Thisstudyinvolvesrespondingtosurveyquestionsandpotentiallyreadinganarticle.Thisstudyincludestwosessions,spacedoneweekapart.Participationisexpectedtotakeapproximately60minutesforbothsessions(40minutesduringthefirstsession,20minutesduringthesecondsession).Allofyourresponseswillbeanonymousandstrictlyconfidential.Toensureanonymity,pleasedonotwriteyournameoranyidentifyinginformationonanyportionofthepacket.Allresponseswillbecompletelyanonymous;yournamewillnotberecorded,anditwillnotbepossibletomatchthedatatoyouinanyway.Resultsofthestudywillbepresentedingroupformonly(e.g.,averages)andalloriginalpaperworkwillbekeptinlockedofficesoncampus.Yourdecisiontoparticipateinthisstudyiscompletelyvoluntary.ParticipationinthisstudyisonlyonewaytosatisfytheresearchexperiencerequirementforyourPSY120classortogainextracreditinanotherclass,andyoumay,ifyouchoose,selectanalternativeassignmentinsteadofbeingaresearchparticipant.Yourparticipationinthisstudyisunlikelytoresultinanydirectbenefitstoyouasanindividual;however,yourparticipationwillcontributetotheknowledgeofmentalhealthstigmatization.Inthisproject,therearenoknowneconomic,legal,physical,psychological,orsocialriskstoparticipantsineitherimmediateorlong-rangeoutcomes.Iunderstandthatitisnotpossibletoidentifyallpotentialrisksinanexperimentalprocedure,butIbelievethatreasonablesafeguardshavebeentakentominimizeboththeknownandthepotential,butunknownrisks.Youmaywithdrawyourconsentanddiscontinueyourparticipationatanytimewithoutpenalty.Page1of2_______pleaseinitial
30
AppendixA,cont.Participationisvoluntary.Youmaydecidenottoparticipateinthisstudy,andifyoubeginparticipationyoumaystilldecidetostopandwithdrawatanytime.Yourdecisionwillberespectedandwillnotresultinlossofbenefitstowhichyouareotherwiseentitled.Yourcompletionandreturnofthisquestionnaireindicatesconsenttoparticipateinthestudy.Thisformwillbegiventoyoutoretainforfuturereference.Ifyouhaveanyconcernsaboutyourselectionortreatmentasaresearchparticipant,pleasecontactSherryMay,IRBAdministrator,intheOfficeofSponsoredPrograms,KepnerHall,UniversityofNorthernColoradoGreeley,CO80639:970.351.1910.
___________________________________________________Subject’sSignature Date___________________________________________________Researcher’sSignature DatePage2of2
31
AppendixB
DebriefingStatement
Thestudyinwhichyouhaveparticipatediscalled“StigmatizationofMentalIllness”.Inthisstudy,weexaminebeliefsandperceptionssurroundingmentalhealthandillness,andwhetherornotprovidinginformationregardingmentalhealthstigmatizationreducesitbothshort-andlong-term.Thankyouforyourparticipation!Yourcontributionisgreatlyappreciated.Ifyouhaveanyquestionsorconcerns,pleasecontactmeatanytime.NatalieS.TannerSchoolofPsychologicalSciencesUniversityofNorthernColoradoGreeley,CO80639Phone:(970)-689-4254Email:[email protected]
32
AppendixC
Articleusedintheeducationalgroupofthequantitativestudy.
MentalhealthsymptomsarestillviewedasthreateninganduncomfortableGrahamC.L.Davey,PhDTherearestillattitudeswithinmostsocietiesthatviewsymptomsofpsychopathologyasthreateninganduncomfortable,andtheseattitudesfrequentlyfosterstigmaanddiscriminationtowardspeoplewithmentalhealthproblems.Suchreactionsarecommonwhenpeoplearebraveenoughtoadmittheyhaveamentalhealthproblem,andtheycanoftenleadontovariousformsofexclusionordiscrimination–eitherwithinsocialcirclesorwithintheworkplace.Whoholdsstigmatizingbeliefsaboutmentalhealthproblems?Perhapssurprisingly,stigmatizingbeliefsaboutindividualswithmentalhealthproblemsareheldbyabroadrangeofindividualswithinsociety,regardlessofwhethertheyknowsomeonewithamentalhealthproblem,haveafamilymemberwithamentalhealthproblem,orhaveagoodknowledgeandexperienceofmentalhealthproblems(Crispetal.,2000;Moses,2010;Wallace,2010).Forexample,Moses(2010)foundthatstigmadirectedatadolescentswithmentalhealthproblemscamefromfamilymembers,peers,andteachers.46%oftheseadolescentsdescribedexperiencingstigmatizationbyfamilymembersintheformofunwarrantedassumptions(e.g.,thesuffererwasbeingmanipulative),distrust,avoidance,pityandgossip,62%experiencedstigmafrompeerswhichoftenledtofriendshiplossesandsocialrejection(Connolly,Geller,Marton&Kutcher,1992),and35%reportedstigmaperpetratedbyteachersandschoolstaff,whoexpressedfear,dislike,avoidance,andunder-estimationofabilities.Mentalhealthstigmaisevenwidespreadinthemedicalprofession,atleastinpartbecauseitisgivenalowpriorityduringthetrainingofphysiciansandGPs(Wallace,2010).Whatfactorscausestigma?Thesocialstigmaassociatedwithmentalhealthproblemsalmostcertainlyhasmultiplecauses.Throughouthistorypeoplewithmentalhealthproblemshavebeentreateddifferently,excludedandevenbrutalized.Thistreatmentmaycomefromthemisguidedviewsthatpeoplewithmentalhealthproblemsmaybemoreviolentorunpredictablethanpeoplewithoutsuchproblems,orsomehowjust“different”,butnoneofthesebeliefshasanybasisinfact(e.g.,Swanson,Holzer,Ganju&Jono,1990).Similarly,earlybeliefsaboutthecausesofmentalhealthproblems,suchasdemonicorspiritpossession,were‘explanations’thatwouldalmostcertainlygiverisetoreactionsofcaution,fearanddiscrimination.Eventhemedicalmodelofmentalhealthproblemsisitselfanunwittingsourceofstigmatizingbeliefs.First,themedicalmodelimpliesthatmentalhealthproblemsareonaparwithphysicalillnessesandmayresultfrommedicalorphysicaldysfunctioninsomeway(whenmanymaynotbesimplyreducibletobiologicalormedicalcauses).Thisitselfimpliesthatpeoplewithmentalhealthproblemsareinsomeway‘different’from‘normally’functioningindividuals.Secondly,themedicalmodelimpliesdiagnosis,anddiagnosisimpliesalabelthatisappliedtoa‘patient’.Thatlabelmaywellbeassociatedwithundesirableattributes(e.g.,‘mad’peoplecannotfunctionproperlyinsociety,orcansometimesbeviolent),andthis
33
AppendixC,cont.
againwillperpetuatetheviewthatpeoplewithmentalhealthproblemsaredifferentandshouldbetreatedwithcaution.Iwilldiscusswaysinwhichstigmacanbeaddressedbelow,butitmustalsobeacknowledgedherethatthemediaregularlyplayaroleinperpetuatingstigmatizingstereotypesofpeoplewithmentalhealthproblems.Thepopularpressisabranchofthemediathatisfrequentlycriticizedforperpetuatingthesestereotypes.Blamecanalsobelevelledattheentertainmentmedia.Forexample,cinematicdepictionsofschizophreniaareoftenstereotypicandcharacterizedbymisinformationaboutsymptoms,causesandtreatment.InananalysisofEnglish-languagemoviesreleasedbetween1990-2010thatdepictedatleastonecharacterwithschizophrenia,Owen(2012)foundthatmostschizophreniccharactersdisplayedviolentbehaviour,one-thirdoftheseviolentcharactersengagedinhomicidalbehaviour,andaquartercommittedsuicide.Thissuggeststhatnegativeportrayalsofschizophreniaincontemporarymoviesarecommonandaresuretoreinforcebiasedbeliefsandstigmatizingattitudestowardspeoplewithmentalhealthproblems.Whilethemediamaybegettingbetteratincreasingtheirportrayalofanti-stigmatisingmaterialoverrecentyears,studiessuggestthattherehasbeennoproportionaldecreaseinthenewsmedia’spublicationofstigmatisingarticles,suggestingthatthemediaisstillasignificantsourceofstigma-relevantmisinformation(Thornicroft,Goulden,Shefer,Rhydderchetal.,2013.Whydoesstigmamatter?Stigmaembracesbothprejudicialattitudesanddiscriminatingbehaviourtowardsindividualswithmentalhealthproblems,andthesocialeffectsofthisincludeexclusion,poorsocialsupport,poorersubjectivequalityoflife,andlowself-esteem(Livingston&Boyd,2010).Aswellasit’saffectonthequalityofdailyliving,stigmaalsohasadetrimentalaffectontreatmentoutcomes,andsohindersefficientandeffectiverecoveryfrommentalhealthproblems(Perlick,Rosenheck,Clarkin,Sireyetal.,2001).Inparticular,self-stigmaiscorrelatedwithpoorervocationaloutcomes(employmentsuccess)andincreasedsocialisolation(Yanos,Roe&Lysaker,2010).Thesefactorsalonerepresentsignificantreasonsforattemptingtoeradicatementalhealthstigmaandensurethatsocialinclusionisfacilitatedandrecoverycanbeefficientlyachieved.Howcanweeliminatestigma?:Wenowhaveagoodknowledgeofwhatmentalhealthstigmaisandhowitaffectssufferers,bothintermsoftheirroleinsocietyandtheirroutetorecovery.Itisnotsurprising,then,thatattentionhasmostrecentlyturnedtodevelopingwaysinwhichstigmaanddiscriminationcanbereduced.Aswehavealreadydescribed,peopletendtoholdthesenegativebeliefsaboutmentalhealthproblemsregardlessoftheirage,regardlessofwhatknowledgetheyhaveofmentalhealthproblems,andregardlessofwhethertheyknowsomeonewhohasamentalhealthproblem.Thefactthatsuchnegativeattitudesappeartobesoentrenchedsuggeststhatcampaignstochangethesebeliefswillhavetobemultifaceted,willhavetodomorethanjustimpartknowledgeaboutmentalhealthproblems,andwillneedtochallengeexistingnegativestereotypesespeciallyastheyareportrayedinthegeneralmedia
34
AppendixC,cont.
(Pinfold,Toulmin,Thornicroft,Huxleyetal.,2003).IntheUK,the“TimetoChange”campaignisoneofthebiggestprogrammesattemptingtoaddressmentalhealthstigmaandissupportedbybothcharitiesandmentalhealthserviceproviders(http://www.time-to-change.org.uk.Thisprogrammeprovidesblogs,videos,TVadvertisements,andpromotionaleventstohelpraiseawarenessofmentalhealthstigmaandthedetrimentalaffectthishasonmentalhealthsufferers.However,raisingawarenessofmentalhealthproblemssimplybyprovidinginformationabouttheseproblemsmaynotbeasimplesolution–especiallysinceindividualswhoaremostknowledgeableaboutmentalhealthproblems(e.g.psychiatrists,mentalhealthnurses)regularlyholdstrongstigmatizingbeliefsaboutmentalhealththemselves!(Schlosberg,1993;Caldwell&Jorm,2001).Asaconsequence,attentionhasturnedtowardssomemethodsidentifiedinthesocialpsychologyliteratureforimprovinginter-grouprelationsandreducingprejudice(Brown,2010).Thesemethodsaimtopromoteeventsencouragingmassparticipationsocialcontactbetweenindividualswithandwithoutmentalhealthproblemsandtofacilitatepositiveintergroupcontactanddisclosureofmentalhealthproblems(oneexampleisthe“TimetoChange”Roadshow,whichsetsupeventsinprominenttowncentrelocationswithhighfootfall).Analysisofthesekindsofinter-groupeventssuggeststhatthey(1)improveattitudestowardspeoplewithmentalhealthproblems,(2)increasefuturewillingnesstodisclosementalhealthproblems,and(3)promotebehavioursassociatedwithanti-stigmaengagement(Evans-Lacko,London,Japhet,Ruschetal.,2012;Thornicroft,Brohan,Kassam&Lewis-Holmes,2008).
35
AppendixD
Articleusedinthecontrolgroupofthequantitativestudy.
Whatisanxiety?GrahamC.L.Davey,PhDAnxiety-basedproblemsareverycommon,andaround30-40%ofindividualsinWesternsocietieswilldevelopaproblemthatisanxietyrelatedatsomepointintheirlives.Soprevalentareanxietyproblemsinmodernsocietythatin2014‘Whatisanxiety?’wasoneofthetop10mostGoogledsearchphrasesintheUK.Sowhatexactlyisanxiety,andwhydosomepeoplefindthatanxietybecomessomethingthatblightstheirlife?Formanypeople,anxietyisadistressingexperiencethatpreventsthemundertakingmanyordinaryday-to-dayactivitiessuchasgoingtowork,educatingthemselves,lookingaftertheirfamilies,andsocializing.First,let'sbeginbybeingclearthatanxietyisnotanabnormalexperience.Weallexperiencefeelingsofanxietyquitenaturallyinmanysituations–suchasjustbeforeanimportantexam,whilemakingapresentationatworkorcollege,ataninterview,oronafirstdate.It’sanemotionthatcanhavebeneficialeffectsbymakingyoualertandfocusedwhenfacedwithpotentialchallengesinyourlife-ifanxietydidn’thavethisadaptivefunction,thenit’sunlikelythatitwouldhaveevolvedanditcertainlywouldn’tbeasbigapartofouremotionalrepertoireasitistoday.Weexperienceanxietyinanumberofwaysbothphysicallyandmentally.Thephysicalreactionsincludetensemusclesandadrymouth,sweatingandtremblinganddifficultyswallowing.Yourheartbeatsfasterandyoufeelcontinuallyalertandvigilant.Butlet’sbeclear,anxietyisn’tthesamethingasfear.Fearisaverybasicemotion,andmanyofyourfearreactionsarereflexiveresponsestoimmediatethreatsthathavebeenbiologicallypre-wiredovermanythousandsofyearsofselectiveevolution.Thesereactionsincludestartleandphysiologicalarousalasaresultofsuddenloudnoises,loomingshadows,rapidmovementstowardsyou,andevenstaringeyes!Didyouspotthecommonlinkbetweenallthosereactions?Yes,they'reallcharacteristicswe'dbelikelytospotifwewerebeingpouncedonbyapredatoryanimal–andwithsurvivalagainstpredatorsbeinganurgentbusiness-pre-wiredreflexiveresponsesthatmakeyoualerttoandavoidthesephysicalthreatshaveevolved.However,anxietyisalittledifferent.Themodernworldismadeupofmanymorepotentialthreatsandchallengesthanthethreatposedbypredatoryanimalssowehavedevelopedamoreflexiblesystemformanagingpotentialthreats,andthisiswhatanxietyis.Anxietyisnotaresponsetoimmediatethreats(likebeingattackedbyapredatoryanimal),butaresponsetoanticipatedthreats(likeasurgicaloperationyou’reduetohaveinthenextfewmonths).Itisabitlikefear,butwithanadded'thinking'elementdesignedtoidentifyfuturethreatsandchallengesandhelpyouprepareforthem.Manypeoplecanuseanxietyadaptivelyinthisway.Ithelpsthemtoidentifypotentialfuturethreatsandchallenges,andgivesthemtimetothinkabouthowtomanageorcopewiththoseevents.Butthereareatleastthreepotentialpitfallswiththisprocessthatcanleadyoutodevelopformsofanxietythatcanbepervasiveanddistressing.
36
1.Becauseanxietyisanemotionevolvedtodealwithfutureanticipatedthreatsandchallengesthathavenotyethappened,wemighteasilythinkthatsomeeventsaregoingtobethreateningorchallengingwheninfacttheyturnoutnottobeso.Forexample,wemayworryaboutstartinganewjobbecausethepeoplewewillhavetoworkwithmaynotlikeus,butoncewedostart,everythingisfine.Thecatchwithanxietyisthatonceitbecomesaregularlyexperiencedemotion,itmakesyousearchforreasonswhythingsmightbebadorproblematic.Breakingthatviciouscycleisdifficult,butonceyou’veidentifiedthisprocessinyourself,itcanbemanagedusingavarietyoftherapeutictechniquesincludingCBTforanxiety.2.Pervasiveanxietycanalsoexaggeratethreatsandchallengesthatareinrealityonlymildonesthatshouldnotconcernustoomuch.Forexample,oncewe’vefeltanxiousforaperiodoftime,wecometoexpectbadthingstohappen–youthinklifewillhandyoumorelemonsmoreoftenthaninfactitdoes!Arelatedeffectofanxietyisthatitcausesustomakemountainsoutofmolehills–whenwethinkwe’veidentifiedafuturethreat,ourworryingcausesustocatastrophisewhatmighthappen.Soapersistentlyanxiousindividualwillbelivingdaytodaywithproblemsthesizeof‘mountains’thatmanyothernon-anxiousindividualswouldseeonlyas‘molehills’.3.Thirdly,becauseanxietyisdesignedtohelpyouthinkaboutandmanagefuturethreatsandchallenges,howsuccessfulyouareatthiswilldependonwhatcopingresourcesyouhaveavailabletoyou,andhowgoodyouareatgeneratingpractical,successfulsolutions.Differentpeoplewillhavedifferentapproachestocopingwithafuturethreatorchallenge.Somepeoplewillbeproblem-orientedandtrytofindasolutionthatwilleffectivelydealwiththethreat(e.g.,bydevisingarevisionstrategyforadifficultforthcomingexam).Butothersmaybelessresourceful,andtrytomanagefuturenegativeeventsbysimplyavoidingthem(e.g.,decidingnottogotoadinnerpartywheretheythinktherearelikelytobesomeconversationstheywillfinddifficultorembarrassing).Butthereisaveryimportantconsequenceofusingavoidanceasawayofcopingwithfuturethreats.Thisis,ifyoucontinuetoavoid,youwillneverfindoutifthethreatisarealone,orsimplyanimaginedorexaggeratedone,andasaresultitwillbesomethingthatwillcontinuetobeapersistentsourceofanxiety(forexample,thinkaboutwhatmighthappenifyoucombinepoint1above,withtheprocessesofavoidancewe’veoutlinedhereinpoint3).Pervasiveavoidanceofthingswefindanxietyprovokingcanhavesignificantlong-termconsequences,becausetheindividualwilloftendevelopquiteingrainedbeliefsthatsomethingisthreateningwheninrealityitisn’t.Thesebeliefsthenacttogenerateandprolongfurtheranxiety,whichiswhy‘facingyourfears’anddisconfirmingthesebeliefsisanimportantprocessinrelievingdistressinganxiety.Thesethreepitfallsassociatedwithanxietythatturnitfromanadaptiveemotionintoadistressingonearenotdirectlytodowiththephysiologicalcharacteristicsofanxiety,butwiththe‘thinking’componentthatanxietybringstoourattemptstomanagefutureanticipatedthreats.That’sthebadnews.Thegoodnewsisthatmodernpsychologicalinterventionsforanxiety(suchasCBT)canbehighlysuccessfulbyhelpingyoutoidentifythekindsof‘thinking’thatcreatesdistressinganxiety(describedinthethreepointsabove),andwillhelpyoutochangeormanagethesewaysofthinkingtorelievedistressinganxiety.
37
AppendixE
Mentalhealthstigmatizationsurveyusedforthequantitativestudy.
Pleasetellhowmuchyouagreeordisagreewitheachone...01:Agreestrongly02:Agreeslightly03:Neitheragreenordisagree04:Disagreeslightly05:Disagreestrongly1.Oneofthemaincausesofmentalillnessisalackofself-disciplineandwill-power.2.Thereissomethingaboutpeoplewithmentalillnessthatmakesiteasytotellthemfrom
normalpeople.3.Assoonasapersonshowssignsofmentaldisturbance,theyshouldbehospitalized.4.Mentalillnessisanillnesslikeanyother.5.Lessemphasisshouldbeplacedonprotectingthepublicfrompeoplewithmentalillness.6.Mentalhospitalsareanoutdatedmeansoftreatingpeoplewithmentalillness.7.Virtuallyanyonecanbecomementallyill.8.Weneedtoadoptafarmoretolerantattitudetowardpeoplewithmentalillnessinour
society.9.Wehavearesponsibilitytoprovidethebestpossiblecareforpeoplewithmentalillness.10.Peoplewithmentalillnessdon'tdeserveoursympathy.11.Peoplewithmentalillnessareaburdenonsociety.12.Increasedspendingonmentalhealthservicesisawasteofmoney.13.Therearesufficientexistingservicesforpeoplewithmentalillness.14.Peoplewithmentalillnessshouldnotbegivenanyresponsibility.15.Iwouldnotwanttolivenextdoortosomeonewhohasbeenmentallyill.16.Anyonewithahistoryofmentalproblemsshouldbeexcludedfromtakingpublicoffice.17.Noonehastherighttoexcludepeoplewithmentalillnessfromtheirneighborhood.18.Peoplewithmentalillnessarefarlessofadangerthanmostpeoplesuppose.19.Thebesttherapyformanypeoplewithmentalillnessistobepartofanormalcommunity.20.Asfaraspossible,mentalhealthservicesshouldbeprovidedthroughcommunitybased
facilities.Whichofthesedoyoufeelusuallydescribesapersonwhoismentallyill?01:Agreestrongly02:Agreeslightly03:Neitheragreenordisagree04:Disagreeslightly05:DisagreestronglySomeonewhohasseriousboutsofdepressionSomeonewhoisincapableofmakingsimpledecisionsabouthisorherownlifeSomeonewhohasasplitpersonality
38
AppendixE,cont.SomeonewhoisbornwithsomeabnormalityaffectingthewaythebrainworksSomeonewhocannotbeheldresponsibleforhisorherownactionsSomeonepronetoviolenceSomeonewhoissufferingfromschizophreniaSomeonewhohastobekeptinapsychiatricormentalhospitalThefollowingquestionsaskaboutyourexperiencesandviewsinrelationtopeoplewhohave
mentalhealthproblems.BythisImeanpeoplewhohavebeenseenbyhealthcarestaffforamentalhealthproblem.
01:Yes02:NoAreyoucurrentlylivingwith,orhaveyoueverlivedwith,someonewithamentalhealth
problem?Areyoucurrentlyworking,orhaveyoueverworked,withsomeonewithamentalhealth
problem?Doyoucurrently,orhaveyouever,hadaneighborwithamentalhealthproblem?Doyoucurrentlyhave,orhaveyoueverhad,aclosefriendwithamentalhealthproblem?Pleasesaytowhatextentyouagreeordisagreethateachofthefollowingconditionsisatype
ofmentalillness...01:Agreestrongly02:Agreeslightly03:Neitheragreenordisagree04:Disagreeslightly05:DisagreestronglyDepressionStressSchizophreniaBipolardisorderDrugaddictionGriefInthelistbelowpleasecirclethetypesofpeoplewhoyoupersonallyknow,whohaveamental
illness.01:Immediatefamily(spouse\child\sister\brother\parentetc.)02:Partner(livingwithyou)03:Partner(notlivingwithyou)AppendixE,cont.
39
04:Otherfamily(uncle\aunt\cousin\grandparentetc.)05:Friend06:Acquaintance07:Workcolleague08:Self09:NooneknownIfyoufeltthatyouhadamentalhealthproblem,howlikelywouldyoubetogotoyourGeneral
Physicianforhelp?01:Verylikely02:Quitelikely03:Neitherlikelynorunlikely04:Quiteunlikely05:VeryunlikelyIngeneral,howcomfortablewouldyoufeeltalkingtoafriendorfamilymemberaboutyour
mentalhealth,forexampletellingthemyouhaveamentalhealthdiagnosisandhowitaffectsyou?
01:Veryuncomfortable02:Moderatelyuncomfortable03:Slightlyuncomfortable04:Neithercomfortablenoruncomfortable05:Fairlycomfortable06:Moderatelycomfortable07:VerycomfortableIngeneral,howcomfortablewouldyoufeeltalkingtoacurrentorprospectiveemployerabout
yourmentalhealth,forexampletellingthemyouhaveamentalhealthdiagnosisandhowitaffectsyou?
01:Veryuncomfortable02:Moderatelyuncomfortable03:Slightlyuncomfortable04:Neithercomfortablenoruncomfortable05:Fairlycomfortable06:Moderatelycomfortable07:Verycomfortable(Notapplicable)Doyouthinkthatpeoplewithmentalillnessexperiencestigmaanddiscriminationnowadays,
becauseoftheirmentalhealthproblems?01:Yes-alotofstigmaanddiscrimination02:Yes-alittlestigmaanddiscrimination03:NoDoyouthinkmentalhealth-relatedstigmaanddiscriminationhaschangedinthepastyear?01:Yes-increasedAppendixE,cont.