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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

22

=.104)andtheactivecontrol(M=.039)thanfortheinactivecontrol(M=.467),F(2,11)=1.27,

p<.05.

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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:tann1498@bears.unco.eduAdvisor: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:tann1498@bears.unco.edu

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.

40

02:Yes–decreased03:NoDemographicInformation:Pleaselistyourgender.Pleaselistyourethnicity.Pleaselistyourage.