The Stigma Effect

The Stigma Effect: Unintended Consequences of Mental Health Campaigns is written by Patrick Corrigan, whose research on stigma I first encountered when I was working on my Master's thesis.  The author is a psychologist and researcher, and also has lived experience of mental illness, which he shares in the book.  Much of the book is written from an objective stance, but interspersed throughout are boxes of text that include the author's own personal experiences.

The stigma effect that the book is based on refers to unintended negative consequences of anti-stigma efforts.  While public campaigns to reduce stigma are well-intentioned, in some cases they may actually end up having the opposite effect.  The author approaches this from a stance of curiosity, and a desire to find the most effective ways to tackle stigma.  There is no sense that he is criticizing specific approaches; instead he focuses on what research has to tell us about what works.

Corrigan explains that stigma is socially constructed rather than being naturally inherent in that which is stigmatized.  That doesn't mean that stigma isn't real, but rather that it is based on beliefs about mental illness rather than the inherent nature of mental illness.  Stigma shows up in two different ways: stereotyped beliefs that are framed as facts, and behavioural discrimination that often limits the opportunities of those that are stigmatized.  Stigma may be public or applied to oneself (i.e. self-stigma), and it may cause some people to avoid taking on the stigmatized label. Cues that signal the application of stereotypes include psychiatric symptoms, social skills deficits, poor physical appearance, and illness labels.

According to the book, some of the most problematic beliefs are those related to people with mental illness being dangerous and unpredictable, as well as irresponsible and incompetent.  In a 2006 study, around 40% of Americans thought people with mental illness were dangerous.  This was about the same as the figure in 1996, and double that from 1956.  That means that despite all of the anti-stigma efforts and attempts at education, we're actually worse off than we were back in the 1950s.

The book outlines three broad types of anti-stigma approaches: protest, education, and contact.  These may be informed by different agendas:

services agenda: the idea that decreasing stigma will lead to decreased service avoidance; often this agenda is espoused by professional groups
rights agenda: so that people can enjoy rightful life opportunities
self-worth agenda: replace shame with dignity
There is a discussion of the types of activities that aren't effective, and some of the conclusions will likely be surprising.  Others, like politicians blaming gun violence on mental illness, unsurprisingly strengthen negative stereotypes.

The book talks about "slacktivism", which involves easy endorsements (eg on social media) that don't tend to lead to any sort of meaningful action.  There are a number of high-profile online campaigns that capitalize on the easy buy-ins across a broad swath of the population, but from what Corrigan has to say these may not be very effective.

The book addresses issues around attempt at language change, and has perhaps a novel take on the matter.  Telling people what to say and what not to say can have some unintended consequences. Much like with the thought experiment to try not to think of a white bear, if you tell people not to think about stigmatized ideas they will in fact think of them.  Additionally, telling people what not to do naturally triggers psychological resistance to change.  Corrigan points out that language does not actually lead to stigma; rather stigma leads to shame as the result of association with a label.  He concludes that "the call for different language is an easy but ineffective way to meaningfully challenge stigma."  This is a very interesting finding, as such efforts to address language are fairly common.

On another interesting note, he uses the term patient to refer to a role that people play.  I choose the same term in the same context, although I recognize some may see it as archaic.  Surveys of people with lived experience show no particularly label that's preferred; however, consumer has been found to be the least preferred.  That rather surprised me.  Personally I can't stand the term consumer, but thought I was somewhat alone in this; apparently not.

When it comes to attempts to educate the public about mental illness, Corrigan doesn't mince words: "Education, at least for adults, is an overrated, mostly feckless approach to erasing stigma."  He explains that this approach that's often used by the services agenda, and may take the form of myths versus facts (too bad, I love a good myths vs. facts!).  Educational approaches may  be hampered by education overload.  Also, people who are prejudiced often believe they're not, and so tend to think that public service ads (PSAs) aren't relevant to them.  There may be a boomerang psychological resistance effect, as has been observed with campaigns to educate parents about vaccines.

The book mentions one study of people watching Cymbalta ads that found that viewers were actually less likely to support notions of recovery and self-determination unless they themselves had a history of depression.  PSAs regarding mental illness being biological tend to make non-mentally ill people think that recovery is unlikely.  Messages that mental illness is just like any other illness also increase perceptions of dangerousness and unpredictability.

Based on available evidence, Corrigan concludes that contact with people with mental illness is the most effective strategy to combat stigma.  Contact works best when it is with people who don't highly conform to stereotypes, yet are convincing as someone who has experienced serious mental illness.  Contact with average people is more effective than celebrities coming out in a public way, and it works best when people come from similar sociocultural groups.

Contact is effective because not only does it decrease negative beliefs, it helps to replace them with positive ones.  It is 2-3 times more effective than education at changing stigmatized attitudes.

Corrigan describes what makes an effective story, something that's very relevant for those of us in the mental illness community wanting to engage in activism.  Effective messages include an "on-the-way-down" story about being sick.  While this is emotionally compelling, it's also essential to have an "on-the-way-up" story about recovery and overcoming.  Finally, the story should end with a moral message about having experienced stigma despite what has been overcome with the illness, and a call to action to address this social injustice.

The book looked at different approaches to disclosure, ranging from secrecy to broadcasting experiences in an effort to bring about change.  Since contact is the best way to reduce stigma, creating significant change will require people with mental illness to come out about their illness.  That means us.  We need to speak up.

This book is an important read for anyone who's interested in engaging in anti-stigma activism.  It cuts through the hype of various popular approaches and gets down to what really works.  And in the end, it comes down to those of us in the mental illness community talking openly about our experiences and owning our mental illness identities.  We truly can be the change we wish to see in the world.