I was inspired to write this post after reading the book The Stigma Effect: Unintended Consequences of Mental Health Campaigns.  It’s written by psychologist Patrick Corrigan, whose research on stigma I first encountered when I was working on my Master’s thesis, and in it he challenges a lot of commonly held ideas about how we should fight stigma.

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 turns out that in some cases they may actually end up having the opposite effect.  That’s why I think it’s really important that we pay attention to what Corrigan has to say in order to make sure that we’re being as effective as possible in the fight against stigma.

What is stigma?

Corrigan starts the book with a primer on what stigma is.  Stigma is not actually inherent in mental illness itself.  Instead, things like psychiatric symptoms, social skills deficits, poor hygiene, and illness labels act as cues for people to apply stereotyped beliefs and discriminatory behaviours.  Stereotyped beliefs are framed as facts, but in reality are based in inaccurate assumptions.

We’ve all been exposed to the stigmatized belief that people with mental illness are dangerous and unpredictable.  Corrigan explains that 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.  Yet it would seem that there is much more education now about the reality of mental illness and public exposure to anti-stigma campaigns, so something isn’t adding up here.

How do we fight it?

The book outlines three broad types of anti-stigma approaches: protest, education, and contact.  These may be informed by different agendas depending on who’s leading the campaign.  Professional groups tend to promote the idea that decreasing stigma will lead to more people accessing mental health services.  Families and other supporters may have a similar agenda, whereas people with mental illness may be more focused on promoting dignity and self-worth.

Slacktivism

Corrigan uses the term “slacktivism” in which people are able to easily endorse or support something, e.g. on social media.  This takes little effort and generally doesn’t translate into any sort of meaningful action.  There are multiple large campaigns that allow for slacktivist engagement, like Time To Change’s Time To Talk Day or Bell Let’s Talk Day.  There is a ton of promotion and these efforts 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.

Language usage

Chances are many of us have seen (or been) people arguing about language change, such as using “completed suicide” rather than “committed suicide”, or “person with schizophrenia” rather than “schizophrenia”.  Except you know what?  It can actually have a negative effect, according to Corrigan.  There are a couple of elements to this.  If you tell someone not to think about a white bear, what are they guaranteed to think about?  A white bear.  Also, we haven’t necessarily come that far from our inner 6-year-old; telling people what not to do naturally triggers psychological resistance resistance to change.  Corrigan also points out that language is the result of stigma, not the cause of it, so targeting language ends up trying to address the issue backwards.

I found it interesting that Corrigan 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.  Apparently 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.  The term consumer is fairly popular, though, which makes me wonder if its use is because organizations are trying to be politically correct.

Education as an anti-stigma strategy

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 gives the example of myths versus facts as a common type of educational approach.  This seems rather unfortunate; I certainly love me a good myths vs facts!  The messages are likely to go right over the head of the average person who is already prejudiced; plus, they can trigger a psychological resistance effect that can actually increase stigma.  Corrigan gave the example that something similar been observed with campaigns to educate parents about vaccines, which have actually increased resistance to vaccination.

Another surprise?  Apparently public service messages that mental illness is biologically based are actually unhelpful, because people seeing these messages tend to conclude that recovery is unlikely.  Even cheerful antidepressants about suddenly un-depressed people singing and dancing and enjoying life can also lean people towards conclusions that recovery is unlikely.  One of the messages that I tend to be quite attached to is that mental illness is just like any other else, but guess what?  Such messages can actually increase perceptions of dangerousness and unpredictability.

Contact as an anti-stigma strategy

Ok, so what does work?  For “normal” people to have contact with people living with mental illness.  It’s most effective when the contact is with average people rather than seeing celebrities open up about their experiences with mental illness.  Contact works best with people who are believable as having a mental illness, but don’t conform closely with stereotypes.  Contact with someone who is acutely unwell and acting like a “crazy person” is more likely to reinforce stereotypes.  Contact also works better when it’s with people from similar sociocultural groups.

Corrigan explains that contact is effective because not only does it decrease negative beliefs, it helps to replace them with positive ones.  It’s 2-3x more effective than education at changing stigmatized attitudes.

What advice does he have for us to share our stories effectively?  We should share stories of our illness experiences, but also about our recovery journeys.  We should talk about how we have been affected by stigma in spite of what we’ve managed to overcome, and conclude with a call to action to address this injustice.

The thing with contact, though, is that it requires us within the mental illness community to speak up.  To have the greatest effect, we need to not openly speak up anonymously online, but also “come out” as mentally ill in our regular environments.  We need to make it personal.  We need to demonstrate that there are many faces of mental illness, not just the stereotyped homeless person on the street.  That’s not to say that coming out is easy, but to really make a dent in stigma a critical mass of us needs to do so. We truly can be the change we wish to see in the world.

Were you surprised by anything this book had to say about what does and doesn’t work? Do you have any ideas about the best way for us to tackle stigma?

 

I received a reviewer copy of The Stigma Effect from the publisher via www.netgalley.com.

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