Psychological Correlates of Perceived Stigma in a Non-Clinical Sample

1. Psychological Correlates of Perceived Stigma in a Non-Clinical Sample Maeve Proctor* Roger Woodward University of Ulster *presenting author: eveamp@gmail.com

2. Abstract Research over the past number of decades indicates that individuals with mental health difficulties are likely to encounter discrimination and stigma in their lives. Modified labelling theory suggests that expectations of rejection may work to generate negative outcomes for these individuals. It has been noted that in this way stigma can act as a barrier to recovery and rehabilitation. Through the use of a postal questionnaire this study aimed to explore the psychological consequences for individuals who experience stigma. Ninety-four volunteers from the general public completed a battery of questionnaires. Results indicate that perceived experiences of stigma and discrimination were related to higher levels of shame, lower levels of positive mood and poor self-esteem. Expectations of rejection were found to mediate the relationship between stigma and psychological outcomes in some cases. The clinical implications for those working with individuals experiencing stigma and directions for future research are also discussed.

3. What is Stigma? Stigma is: ‘A social construction that defines people in terms of a distinguishing characteristic or mark and devalues them as a consequence’. Dinos et al. (2004) p176

4. Stigma and Mental Health In a study by Crisp et al. (2000) participants agreed that individuals with mental health difficulties were dangerous, unpredictable, hard to talk to, have only themselves to blame, and could pull themselves together if they wanted to.

5. Community Integration Kelly and McKenna (1997) argue that there is a ‘real danger’ that seclusion within institutions will be eliminated only to be replaced with a different form of seclusion within the community. Prince and Prince (2002) point out that even when individuals do manage to participate sufficiently to experience physical and social integration, they often have difficulties in achieving psychological integration due to their perceptions of victimisation and stigmatisation.

6. Expectations of Rejection Modified labelling theory (Link 1989) proposes that negative outcomes for those with mental health problems are the result of a process consisting of several steps. Firstly, the individual concerned develops an internalised model of societal beliefs of what it means to be mentally unwell. This involves beliefs about the devaluation of and discrimination against the mentally ill. If the individual then receives a label of mental illness themselves, these internalised beliefs become personally relevant. It now matters if the individual believed that society would devalue or reject persons with mental health problems. The individual will then respond to the experience of being labelled. This may involve a range of reactions such as withdrawal, secrecy and educating others. Outcomes arise as a result of beliefs as well as reactions. These outcomes may include social isolation or poor self-esteem.

7. Outcomes of Stigma Self-Esteem: Studies show conflicting results- self-estem may be damaged (Nese-Todd et al. 2001) or relatively protected (Crocker et al. 1993) by the experience of stigma Anxiety: Stigma has been related to higher levels of anxiety (Gilman et al. 2001). The anxiety of disclosure appears to be particularly pertinent for those with mental health problems (?sbring and Närvänen 2002)

8. Outcomes of Stigma continued.. Mood: Low mood has often been associated with the experience of stigma e.g. Lee et al. (2005) have found that over half of respondents reported feelings of worthlessness due to the stigma of their psychotic illness and almost 44% had considered suicide. Shame: Dinos et al. (2004) found that individuals with mental illnesses were likely to feel guilt and embarrassment as a result of stigmatising experiences.

9. Method This study was carried out by means of a postal questionnaire. Notices were placed in a variety of community settings asking for participants. These settings including third-level colleges and universities in the Dublin region, a variety of support groups, community health centres, gyms, libraries and online community websites.

10. Participants One hundred and thirty one questionnaires were sent to volunteers who expressed a desire to participate in the study. Ninety-four participants (72%) completed and returned questionnaires between October 2006 and January 2007.

11. Outcome Measures Used Harvey’s Stigma Scale The Schedule of Racist Events Devaluation-Discrimination Scale Penn State Worry Questionnaire Positive and Negative Affect Schedule The Experience of Shame Scale Rosenberg Self-Esteem Scale Brief COPE Personal Details Form

12. Results and Discussion Participants who experienced Discrimination: 52.7% Participants who had experienced discrimination who felt stigmatised as a result: 46.9% Most common reason for feeling stigmatised: A combination of two or more reasons! Reasons cited for experiencing stigma: sexuality, academic ability, job status, financial status, unemployment, religious beliefs, smoking, age, political beliefs, gender, race, family background, mental health, physical health, and disability.

13. Stigma and Outcome Variables Stigma was found to have significant relationships with poor self-esteem, low levels of positive mood, and high levels of shame. Crocker and Major (2003) suggested that individuals who felt personally responsible for the stigma they experienced were more likely to experience low self-esteem. Although individuals in this study were readily able to identify the factors behind the discrimination they had experienced e.g. appearance, it is possible that they felt a sense of personal responsibility for these issues. This would be likely to lead the individual to feel less worthy of positive outcomes, thus impacting negatively on their self-esteem.

14. Stigma and Outcome Variables Continued.. Negative mood was not shown to be related to stigma. Therefore, the results of this study cannot be said to support the previous literature in the area, which shows a link between low mood and stigma. The significant findings in relation to positive mood, but not with regard to negative mood, in this study may indicate a lessened capacity for positive emotion for those who are stigmatised. This may occur even in the absence of mood difficulties. The findings of the study are still of concern as positive mood has been shown to play a role in mental health, particularly in terms of recovery (MacLeod and Moore 2000). Folkman and Moskowitz (2000) suggest that positive emotions may play a functional role during stress and may aid coping. Thus, the fact that stigma appears to be related to lower levels of positive mood is of note.

15. Stigma and Outcome Variables Continued.. It would appear that those individuals who feel they do not live up to societal expectations are likely to experience shame (Miller and Mason 2005). This would appear to tie-in with suggestions posed in relation to self-esteem, i.e. attributions of personal deservingness bringing about higher levels of shame

16. Stigma and Outcome Variables Continued.. Much of the literature looking at anxiety in this area has focused on issues that may be specific to particular types of stigma e.g. disclosure about one’s stigmatising condition. It is possible that the more anxiety-provoking aspects of stigma were not prominent in this study.

17. Other findings The results in terms of discrimination follow a similar pattern to those obtained in relation to stigma Rejection was found to mediate the relationship between stigma and the outcome variables of anxiety, shame and positive mood.

18. Possible Clinical Implications In this study stigma and discrimination were found to be linked to poor self-esteem, lower positive mood and higher levels of shame. These difficulties are likely to impact on an individual’s lifestyle and social functioning. The difficulties outlined here may be even more pronounced within a mental health population.

19. Possible Clinical Implications Continued.. We can see that issues such as self-esteem, shame and mood should therefore be addressed within populations who experience stigma when offering them health services. Poor self-esteem, high levels of shame and lowered positive mood may also serve to compound already existing psychological difficulties. This may need to be teased out and addressed separately if necessary. Given that shame and embarrassment can persist despite effective treatment of the illness that causes them (Miller and Mason 2005) it is of particular importance that this issue be addressed separately.

20. Possible Clinical Implications Continued.. Given that discrimination was associated with similar outcomes to those obtained in relation to stigma we need to be mindful of similar issues when working with individuals who have experienced discrimination. Individuals who find discriminatory experiences more stressful and those who perceive that their lives would be more different if it were not for the discrimination are more likely to experience shame and to have higher levels of stigmatisation and higher expectations of rejection. These factors can therefore be used clinically as a potential marker of greater difficulties in these areas.

21. Possible Clinical Implications Continued.. Some of the difficulties outlined here have been seen to be barriers to treatment. Shame, poor self-esteem and the preception of stigma itself have been highlighted as significant obstacles to initiating and maintaining treatment (Ehrim 2001, Wahl 1999, Sirey et al. 2001 ). Given that this is the case it is important for services to address these issues with their clients and patients from the outset of their involvement. It would also appear that there is a need for less traditional forms of service that may serve to cater for individuals who find it difficult to engage with more conventional services. Assertive outreach is an example of the types of service option that has been found to cater for patients who find it difficult to engage (Meaden, Nithsdale, Rose, Smith, and Jones 2004).

22. PossibleClinical Implications Continued.. This study has highlighted the role that expectations of rejection may play in perpetuating the difficulties caused by experiences of stigma and discrimination. This is an issue that needs to be addressed within the wider community. Previous programmes attempting this task have shown benefits within target groups (Gaebel and Baumann 2003) but further work is needed to generalise these gains to the wider community. For the individual who has already experienced these difficulties and developed these expectations, we need to offer them strategies to manage these challenges and assistance in dealing with the problems they bring about.

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