dimensions of mental illness stigma: what about

Journal of Social and Clinical Psychology, Vol. 26, No. 2, 2007, pp. 137–154 FELDMAN AND DIMENSIONS OFCRANDALL MENTAL ILLNESS STIGMA

DIMENSIONS OF MENTAL ILLNESS STIGMA: WHAT ABOUT MENTAL ILLNESS CAUSES SOCIAL REJECTION? DAVID B. FELDMAN Santa Clara University CHRISTIAN S. CRANDALL University of Kansas

The stigma of mental illness can be as harmful as the symptoms, leading to family discord, job discrimination, and social rejection. The existence of mental illness stigma has been well established, but stigma theory must go beyond demonstrations and mere descriptions. This article addresses which characteristics across mental disorders lead to stigmatization and social rejection. Participants (N = 270) read case histories depicting individuals with 40 mental disorders, rated those individuals on 17 dimensions (e.g., dangerousness to others, treatability, social disruptiveness), and indicated how willing they were to reject these individuals on a social distance scale. This yielded a ranking of mental disorders by degree of stigmatization; most importantly it reveals the structure of mental illness stigmatization. Only three dimensions were essential in accounting for rejection: personal responsibility for the illness, dangerousness, and rarity of the illness. These dimensions provide an efficient and effective account of the causes of social rejection in mental illness (Multiple–R of .78, p < .0001).

In 1972, presidential candidate George McGovern named U.S. Senator Thomas Eagleton as his running mate. Only two weeks later, however, McGovern asked Eagleton to withdraw his nomination, a request that the vice presidential candidate reluctantly honored. The reason for this sudden withdrawal was simple—Eagleton had admitted to being hospitalized and receiving electroconvulsive—“shock”— therapy for depression.

Address correspondence to David B. Feldman, Department of Counseling Psychology, Bannan Hall, Santa Clara University, 500 El Camino Real, Santa Clara, CA 95053; E-mail: [email protected].

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Mental illness causes two kinds of harm. The first is from the direct effects of the disorders—cognitive, affective, and behavioral difficulties that limit one’s ability to function effectively. It is the second kind of harm that is the focus of this article—the social rejection, interpersonal disruption, and fractured identity that comes from the stigma of mental illness. Goffman (1963) defines stigma as “an attribute which is deeply discrediting” (p. 3); the stigmatized person is “the bearer of a ‘mark’ that defines him or her as deviant, flawed, limited, spoiled, or generally undesirable” (Jones et al., 1984, p. 6). Mental illness stigma can lead to strained familial relationships (Lefley, 1989), employment discrimination (Farina, Felner, & Boudreau, 1973), and general social rejection (Corrigan, Edwards, Green, Diwan, & Penn, 2001). The more individuals with mental illness feel stigmatized, the lower their self–esteem (Link, Struening, Neese–Todd, Asmussen, & Phelan, 2001), life satisfaction (Rosenfield, 1997), and social adjustment (Perlick et al., 2001). Moreover, stigma may prevent some from seeking professional help (Robertson & Donnermeyer, 1997) and render others less likely to adhere to treatment (Sirey et al., 2001), ultimately compromising the therapy process (Davison, 1976). Given that it is clear that people with mental illness experience social rejection, we ask: why does mental illness cause rejection? Rejection of mentally ill persons is certainly based in part on their deviant (i.e., non–normative) behavior. Deviance can lead to social rejection, but surely not all deviancies are equal. Crandall and Moriarty (1995) provide some examples: “Shortness can cause social disruption, but left–handedness rarely does; skin color can strongly affect social relationships, but hair color may have a more modest impact (p. 67).” What determines when such differences lead to social rejection? In this study, we compare a wide variety of mental illnesses that represent a large range of symptoms, severity, and prognoses. We set out to reduce this daunting array of characteristics to a small number of dimensions that can be used to predict the social rejection of individuals with mental illness.

THE STRUCTURE OF MENTAL ILLNESS STIGMA One sensible strategy to illuminate the underlying structure of mental illness stigma is to delineate the dimensions that cause others to socially reject affected individuals—does having a biological basis increase or decrease social rejection? Are persons with rare mental illnesses more or less likely to be rejected than those with common ones? Although several studies have dealt with the dimensions of social stigma (e.g., Mac-

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Donald & Hall, 1969; Shears & Jensema, 1969; Tringo, 1970), this research has been small in scope, with little specifically on the structure of mental illness stigma. Jones and colleagues (1984) have identified six dimensions to help explain which conditions or characteristics are stigmatizing: concealability (can it be kept secret?), course (is it stable?), disruptiveness (does it strain relationships?), origin (what caused it?), aesthetics (it is displeasing to the sense?), and peril (is it dangerous?). Their list of dimensions is not exhaustive; for any specific condition or characteristic, additional dimensions might be relevant. Moreover, these dimensions may overlap. A highly disruptive characteristic, for instance, also might be aesthetically unpleasant and low on concealability. Finally, these dimensions were conceptually created, without a specific empirical test of their independence or predictive value. It is not clear how well this conceptualization applies to mental illness stigma.

WHAT ABOUT STIGMAS CAUSES REJECTION? Jones et al.’s (1984) dimensions have conceptual value regarding stigma in general, but we ask a more specific question—which particular dimensions predict what is stigmatizing about mental illness? To some extent, people reject or accept stigmas on a piecemeal basis. Experience with a particular stigmatized group, for instance, can increase acceptance of that group (Wright, 1983). Nonetheless, we suggest that there is an underlying regularity to the stigmatization of mental illness that transcends individual experience. In support of this assertion, researchers have found a reliable ordering of rejection across a variety of stigmas and social groups in the absence of experience (Bishop, 1991; Gruman & Sloan, 1983; Richardson, Hastorf, Goodman, & Dornbusch, 1961). This pattern of rejection should reflect cultural norms. Implicit in the cultural norms of acceptance are “the rules of status, organization, conventions of conformity and deviance, and the implicit and explicit systems of justice, value, morality, and prestige that form social relations” (Crandall & Reser, 2005, p. 4). These norms are likely used in the evaluation of individuals with symptoms of mental illness. Such symptoms, of course, are extremely diverse. The current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM–IV–TR; American Psychiatric Association, 2000) contains about 200 diagnosable adult mental disorders. It should not be surprising, then, that mental illness varies across all of the dimensions identified by Jones et al. (1984). A dimension of particular interest in the literature discussing mental illness stigma is peril. The more people believe that mental illness is associated with dangerous or aggressive behavior, the more willing they are

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to discriminate (Angermeyer & Matschinger, 1996; Corrigan, Green, Lundin, Kubiak, & Penn, 2001; Crandall & Reser, 2005). Unfortunately, from 1950 to 1996, Americans increasingly perceived mentally ill persons as violent (Phelan & Link, 1998). Another important dimension in the mental illness stigma literature is origin. A common belief among mental health professionals is that if biological causes of mental illness are emphasized above psychosocial ones, mental illness stigma could be reduced (see Weiner, 1995). Research indicating that biological attributions are associated with increased stigma (Read & Harre, 2001), however, has led some to question this assumption, suggesting more complex relationships between causal attributions and stigma (Phelan, 2002). Personal responsibility (or onset controllability) is a key dimension of physical illness stigma (Crandall & Moriarty, 1995; Meyerowitz, Williams, & Gessner, 1987), and the perception that a disease is onset–controllable leads to social rejection (Crandall, 1994; Turk, Rudy, & Salovey, 1986). For instance, Weiner, Perry, & Magnusson (1988) found that when various stigmas (e.g., blindness, homelessness) were perceived as onset-controllable, they led to greater social rejection than when perceived as onset–uncontrollable. This also should be the case for mental illness stigma. In the present study, we use a paradigm developed to study physical illness stigma (Crandall & Moriarty, 1995) to investigate how the different dimensions proposed by Jones et al. (1984) relate to the social rejection of those with mental illness. Participants read vignettes containing bogus but typical “case histories” describing individuals with one of 40 mental illnesses. These particular 40 mental disorders were selected in order to adequately represent those routinely seen in mental health clinics (in addition to a few rarer disorders) and to present a broad array of symptoms varying across as many of the aforementioned dimensions as possible.

METHOD PARTICIPANTS Participants were 281 undergraduate students in an introductory psychology course. Students were mostly in their first year of college and about 85% were White. The questionnaires were a regular part of classroom demonstrations, but participation was voluntary. Because 11 participants did not follow instructions, they were eliminated from the sample. Responses from the remaining 270 participants were used in data analysis.


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TABLE 1. Mean Social Distance Ratings of 40 Mental Illnesses Disorder Antisocial Personality Pedophilia Factitious Disorder Exhibitionism Voyeurism Cocaine Dependence Frotteurism Kleptomania Narcissistic Personality Alcohol Dependence Paranoid Personality Substance–Induced Dementia Pathological Gambling Int. Explosive Disorder Borderline Personality Dissociative Identity Hypochondriasis Dysthymic Disorder Somatization Disorder Paranoid Schizophrenia

M 5.93 5.91 5.71 5.52 5.47 5.39 5.27 5.25 5.18 5.13 5.05 5.07 4.91 4.89 4.83 4.82 4.81 4.79 4.69 4.57

SD .99 1.11 .75 1.08 .66 .73 .90 1.01 1.06 .86 .82 .87 .93 1.44 1.04 .93 .71 .62 .82 1.29

Disorder Obsessive–Comp. Disorder Major Depression Disorganized Schizophrenia Adjustment Disorder Brief Psychosis Primary Insomnia Panic Disorder Transvestic Fetishism Specific Phobia (spider) Anorexia Nervosa Bipolar Disorder Attention-Deficit Disorder Bulimia Nervosa Male Erectile Disorder Mild Retardation Autism Social Phobia Posttraumatic Stress Female Sexual Arousal Narcolepsy

M 4.55 4.50 4.47 4.33 4.30 4.25 4.20 4.12 4.05 3.92 3.91 3.87 3.87 3.86 3.85 3.81 3.81 3.80 3.50 3.49

SD 1.01 .83 1.02 .78 1.03 .90 .83 .74 .83 .99 .68 .62 .69 .74 .82 .81 .99 .86 .83 1.14

VIGNETTES A total of 40 mental disorders were chosen from the DSM–IV–TR (American Psychiatric Association, 2000) for use in this study (see Table 1). For each disorder, a vignette was created depicting a target individual with the most “typical” or average presentation. A variety of sources were used to determine the modal gender and symptom profile, average age range of onset, most common treatment, and usual prognosis (Andrews, Crino, Hunt, Lampe, & Page, 1994; American Psychiatric Association, 2000; Barlow & Cerny, 1988; Follette, Ruzek, & Abueg, 1998; Beckham & Leber, 1995; Nathan & Gorman, 1998). In our vignettes, each individual had only one diagnosis; that is, comorbidity was purposely omitted from this study. Each vignette consisted of two paragraphs. The first paragraph contained a brief description of the afflicted individual, including gender, current age, age of disorder onset, and symptom presentation. The second paragraph contained a diagnostic label, a brief definition of the disorder, the probable cause(s) of the symptoms (or, if the causes are un-

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known, a statement to this effect), a general description of the treatment in which the individual participated, the immediate outcome of therapy, and the long–term prognosis. In cases where prognosis typically depends upon a particular treatment, the vignette indicated the individual’s prognosis after having received treatment, as well as a prognosis if the person had not received treatment. A typical vignette (for Major Depression) follows: Janet is a 25 year–old female. Janet has a history of episodes of depressed mood. Her first one occurred when she was 17, another occurred when she was 21, and the most recent occurred 6 months ago. During these episodes, she reports that the following symptoms occur all day, almost every day: intense depressed mood, little interest in anything (including fun activities), oversleeping and not getting out of bed in the morning, not eating, feelings of complete worthlessness, fatigue, difficulty concentrating, and thoughts of suicide. These episodes last for a month or two each. Janet has been diagnosed with Major Depressive Disorder, a mental disorder typically characterized by negative mood that occurs almost all the time, nearly every day. People with this disorder also experience a number of other symptoms (like those listed in the paragraph above). This disorder appears to be caused by a genetic predisposition combined with stress. During the past 4 months, Janet has attended one–on–one therapy sessions once a week. The treatment has been designed to teach her to think more positively and lift her negative mood. She also has been taking the antidepressant medication Zoloft. Currently, she reports that she no longer feels depressed and that her other symptoms have largely lifted as well. It is moderately likely that she will experience another episode of depression in the future. However, if she continues the Zoloft, this episode may not occur for a long time (or never). Without treatment, however, it is likely that another depressive episode would occur.

PROCEDURE Participants were given a packet at the beginning of class, with an explanatory cover sheet, followed by two mental illness vignettes. Assignment of vignettes was random, as was the order within the packet. Participants were given 10 minutes to respond. MENTAL ILLNESS RATINGS Below each vignette, participants rated the target individual’s illness on 17 dimensions using 7–point semantic differential scales. The dimen-


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TABLE 2. Correlations between Dimensions of Mental Illness and Social Distance

r with Dimensions Anchor Text Social Distance Not at all dangerous to others/Very dangerous to others .60** Symptoms are the person’s fault/Symptoms are not the person’s fault .53** Disorder is avoidable/Disorder is unavoidable –.48** Person is completely in touch with reality/Person is completely out of ... .45** Quite common/Very rare .44** Not at all disruptive in social situations/Very disruptive ... .40** Not treatable with medication/Treatable with ... –.33* Causes problems at work/Does not cause problems at work Not embarrassing to have/Embarrassing to have .28† Symptoms are not sexual in nature/Symptoms are very sexual ... – .25 Acute (short–lived) without treatment/Chronic (long–lasting) without treatment .22 Person is in complete control of him/herself/Person is completely unable to ... .21 Mild/Severe Not treatable with psychotherapy/Treatable with ... .13 One sex gets it/Both sexes get it –.10 Potentially concealable/Publicly visible –.09 Not hereditary or genetic/Hereditary or genetic –.03 Note. † p < .10, *p < .05, **p < .01. Correlations are in descending absolute value. The text of the dimensions is as it appeared in the questionnaire, excepting when marked with “…”, which indicates that the text of the right–hand side of the dimension continued in the same fashion as the complete text on the left–hand side.

sions were selected based on two criteria. First, we selected only dimensions that were relevant to mental illness. Second, we selected dimensions found to be critical in other areas of research, including attribution theory (Weiner, 1995), physical disability (Richardson, Ronald, & Kleck, 1974), class and status (Gallagher, 1987), and illness representation (Crandall & Moriarty, 1995; Ditto, Jemmott, & Darley, 1988; Leventhal, Meyer, & Nerenz, 1980). Because mental illness is treated using two distinct methods, we added “treatable with psychotherapy” and “treatable with medication.” The items tapping all 17 dimensions are presented in Table 2. SOCIAL DISTANCE Social rejection was measured with a social distance scale adapted from Bogardus (1923, 1925) and used in previous research (e.g., Crandall,

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1991, see Biernat & Crandall, 1999). It consists of seven items rated on a 1 (Strongly Disagree) to 7 (Strongly Agree) scale, including “I would like this person to be a close personal friend,” and “This is the kind of person that I tend to avoid.” To create an index of social distance (α ?= .86), the items were appropriately reversed and then averaged; higher numbers indicate greater rejection. ANALYTIC STRATEGY A total of 540 mental illness vignette ratings were obtained from the 270 completed packets. The number of participants rating each disorder ranged from nine to 17, with an average of 13.5 (SD = 2.01) participants per disorder. Because each participant responded to more than one mental disorder, there is a modest degree of dependence among observations. If we proceeded as if there were 540 separate participants, the essential parameter estimates (e.g., means and correlations) would not be affected by this dependence, but the degrees of freedom would be overestimated and thus the reported p values would be liberal. To control for this, we calculated mean ratings across participants and treated each disorder as if it were an individual case. The mean rating on each dimension was computed across participants for each disorder; these averages were used as the raw data for analysis. This resulted in a sample size of 40 observations (one per disorder), each rated on the 17 dimensions of mental illness and seven social distance items. Because each mental disorder represents an average of 13.5 (SD = 2.01) independent responses, using the mean rating provides a conservative (but highly stable) estimate of statistical significance. The design of this study is a true experiment—with each mental disorder vignette representing one level of a 40–cell study and participants randomly assigned to condition. Because comparisons among 40 cells are unwieldy at best (offering 780 cell–wise comparisons for each of the 17 dimensions, or 13,260 separate t–tests), we simplify matters by describing patterns among the means using correlations and regression. Unfortunately, this approach may give the incorrect impression that the design of this experiment is correlational. The reader is thus reminded that the validity of any causal conclusions we draw turns not on whether or not the design allows for causality (as we have manipulated the independent variables), but on which essential underlying variables our vignettes actually manipulate and on the extent to which our dimensions faithfully capture people’s responses to the various mental disorders.


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RESULTS DESCRIPTIVE ANALYSES Mean social distance scores for the mental disorder vignettes are displayed in Table 1. Higher social distance scores signify that participants indicated less willingness to interact socially with and greater willingness to reject individuals with those disorders. Participants’ social distance ratings were highest for Antisocial Personality Disorder (M = 5.93, SD = .99), Pedophilia (M = 5.91, SD = 1.11), and Factitious Disorder (M = 5.71, SD = .75), and were lowest for Narcolepsy (M = 3.49, SD = 1.14), Female Sexual Arousal Disorder (M = 3.50, SD = .83), and Posttraumatic Stress Disorder (M = 3.80, SD = .86). In order to determine the degree to which specific characteristics of mental illness relate to social distance, we computed correlations between social distance scores and ratings on the mental illness dimensions. Ratings on seven dimensions were statistically significant: dangerousness, personal responsibility, unavoidability, “out of touch with reality,” rarity, social disruptiveness, and “treatable with medication” (see Table 2). It is equally interesting to note which dimensions proved of little value in predicting stigmatization. Because our method provides highly reliable estimates of parameters with few degrees of freedom, we define “little value” as r < .20. Such a list includes whether or not the genders are affected differentially, whether or not the cause is hereditary, the overall severity of the mental illness, whether or not psychotherapy is effective, and whether or not the mental illness is obvious to others. REGRESSION ANALYSES To simplify the results, we sought to present a parsimonious list of the causes of social rejection—the “essential” characteristics that determine stigmatization. We conducted a forward stepwise multiple regression analysis with social distance as the criterion variable and the 17 mental illness dimensions as predictors. This yielded a 3–predictor result, displayed in Table 3, that is a remarkably efficient account of social distance, Multiple–R = .78, adjusted Multiple–R = .76, F(3, 36) = 18.34, p < .0001. The largest predictor was Personal Responsibility, β = .43, p < .0001, followed by Dangerousness, β = .38, p < .005 and Rarity, β = .33, p < .01. No other potential beta exceeded .22, all ps > .18. Thus, the most stigmatizing mental illnesses appear to be those that people perceive to be dangerous, uncommon, and the sufferer’s own fault, and the combination of these

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FELDMAN AND CRANDALL TABLE 3. Predictors of Social Distance Of Mental Illness

Predictor Dimension Personally Responsible Dangerous Rare

.43 .38 .33

t 3.95 3.35 3.01

p < .005 < .005 ≤ .01

Note. Multiple–R = .78[comma here] Adjusted Multiple–R = .76[comma here] F(3[comma here] 36) = 18.34[comma here] p < .0001.

three characteristics accounts for a very large proportion of variance. No interaction terms using these predictors added any significant predictive value.

DISCUSSION This experiment offers three empirical findings of value in understanding mental illness stigma. First, we empirically assessed the relative amount of social rejection associated with 40 mental illnesses. Second, we identified which dimensions of mental illness are associated with social rejection. Third, we developed a simple but powerful list of three dimensions that are essential in accounting for social rejection; these three dimensions provide a squared multiple correlation approaching two-thirds of all available variance to explain. LEVEL OF STIGMA ASSOCIATED WITH THE MENTAL DISORDERS Because we assessed the social distance associated with a large number of mental disorders, we can offer an empirically informed answer to the question, “Which disorders are the most stigmatized or socially rejected?” In as much as the vignettes depicted the most typical personal characteristics, symptoms, treatments, and prognoses for each disorder, the social distance ratings indicate the rejection of modal individuals with the 40 diagnoses. These ratings can be used to create a rank–ordered list of mental disorders, ranging from most to least rejected (see Table 1). Of note, there was a noteworthy rejection of most mental illnesses described in the vignettes, with almost three-quarters of these disorders leading to overall rejecting attitudes (i.e., mean social distance ratings above the mid–point of the scale). These ratings, of course, are relative to the population being studied. Undergraduates have a pattern of concerns that differ from the popula-


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tion at large, often being more concerned with issues of identity and self–presentation (Sears, 1986). Although we do not think that undergraduates are particularly skewed in perceiving mental illnesses or in being more or less rejecting of affected individuals, the local social norms of any group may play a role in determining a pattern of rejection (Crandall, Eshleman, & O’Brien, 2002). Nonetheless, to the best of our knowledge, this is the most comprehensive list of its kind. PREDICTIVE ABILITY OF THE MENTAL ILLNESS DIMENSIONS Table 2 provides an assessment of the degree to which 17 important characteristics of mental illness lead to greater social distance. People with mental illness tend to be stigmatized based on their exemplification of seven dimensions: dangerousness, disruptiveness, being out of touch with reality, personal responsibility, rarity, not being treatable with medication, and degree of avoidability. Although useful separately, many of these dimensions may be redundant when combined. Which dimensions of mental illness are essential in determining social rejection? A regression analysis narrowed the list of 17 mental illness characteristics—seven of which were significant—to a simple 3–dimensional account of what leads to social rejection: personal responsibility, dangerousness, and rarity. This model makes redundant other variables that intuitively might seem to lead to stigmatization, but do not. Information about the responsibility, danger, and rarity of a mental illness renders information about disruptiveness, embarrassingness, and treatability superfluous. A SIMPLE MODEL OF MENTAL ILLNESS STIGMA What is special about the three traits of responsibility, dangerousness, and rarity that lead them to capture the lion’s share of variance in explaining mental illness stigma? In what follows, we consider what each of these dimensions means for stigma. Responsibility. Responsibility represents the degree that people perceive that an individual is at fault for the mental illness. Personal responsibility plays a key role in other areas of stigma research (Crandall & Moriarty, 1995; Crandall, 1994; Turk et al., 1986; Weiner et al., 1988), and it is hardly surprising that it appears here. Our data are quite consistent with Weiner’s (1995) attribution–affect–action model, in which perceptions of responsibility for a negative outcome lead to anger and other negative emotions, which in turn lead to low levels of sympathy and helping, and high levels of avoidance and punishment. Danger. Dangerousness is the extent to which people believe that a person with mental illness poses a threat to them. Consistent with previ-

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ous work (Angermeyer & Matschinger, 1996; Levey & Howells, 1995; Corrigan et al., 2001), the more dangerous a mentally ill individual is perceived to be, the more people are willing to reject that individual. This finding, too, dovetails well with recent research in the expression of prejudice (Crandall & Eshleman, 2003; Stangor & Crandall, 2000; Horstman & Crandall, 2003). Rarity. Rarity is the degree to which people believe that a mental disorder is uncommon. Why is rarity an important and independent predictor of social distance? Research and theory in this area are not well developed, but one line of research suggests that the participants may have perceived rarer conditions to be more severe. Ditto and Jemmott have shown that physical illnesses are seen as more severe when they are perceived to be less prevalent (Ditto & Jemmott, 1989; Jemmott, Ditto, & Croyle, 1986). However, whereas rarity was related to social distance in our study, severity was not. At this point, we resist concluding that perceived severity mediates the relationship between rarity and rejection. Still, the independent importance of rarity in this dataset suggests that there is an opportunity for further investigation, as research and theory to date do not supply obvious justifications for this effect. What Did Not Matter. Equally interesting to note is one dimension that did not lead to greater social distance. Whereas the “treatable with medication” dimension did individually (but not uniquely) predict less social distance, the “treatable with psychotherapy” dimension did not. Thus, people apparently are willing to be socially closer to a mentally ill individual the more they perceive medications to be the prescribed treatment for his or her disorder. This finding is consistent with the somewhat fading notion that biological causes of mental illness are less stigmatizing than psychological ones (see Weiner, 1995). Although our data do not allow for a direct test of this conclusion, it is clear that, at least for our participants, these two modes of treatment carry different implications. STIGMA, SOCIAL DISTANCE, AND VIGNETTE METHODOLOGIES Mental illnesses that lead to greater social distance usually are perceived to be high in personal responsibility, dangerousness, rarity, or some combination of the three. In fact, these three characteristics account for so much variability in social distance scores that it may not be entirely overzealous to call them the “big three” dimensions of mental illness stigma. This statement depends upon two caveats that must be considered when interpreting the results. To begin, we must consider the vignette methodology utilized in the present study. Participants’ willingness to


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reject actual persons with mental illness may be more or less than their willingness to reject persons depicted in vignettes. We chose the vignette methodology for two reasons. First, it ensures presentation of a standardized target. As mentioned previously, the vignettes were designed to depict the modal gender and symptom profile, average age range of onset, most common treatment, and usual prognosis for each target individual. Second, vignette methodologies are widely employed in the stigma literature (e.g., Ben Porath, 2002; Corrigan et al., 2005; McBride, 1998; Schumacher, Corrigan, & Dejong, 2003; Schwartz, Weiss, & Lennon, 2000; Walkup, Cramer, & Yeras, 2004), rendering the results of the present study readily comparable to past research. Another important consideration is whether social distance validly taps the stigma construct. In the present study, we chose to operationalize stigma with a measure of social distance—that is, people’s willingness to avoid individuals with mental illness. There are good reasons for this operationalization. Social distance is an important aspect of social stigma because avoidance is damaging, distressing, and disruptive to people’s lives (Crandall & Coleman, 1992). Thus, social distance is most relevant to the assertion with which we began this article—that it is crucial to study mental illness stigma because of its potenti a l h a r m. M o r e o ver , s o c i a l d i s ta n c e i s a wi d e l y s tu d i e d operationalization of stigma, and social distance measures are the most frequently employed measures of stigma in the research literature (e.g., Biernat & Crandall, 1999; Corrigan et al., 2001). The fact that we have measured social distance with a self–report scale begs the question of whether participants actually would reject mentally ill persons. Notably, however, past research demonstrates significant associations between such social distance scales and behavioral social avoidance (see Crandall & Warner, 2005). SUBJECTIVITY AND THE REDUCTION OF STIGMA The critical issue in determining whether individuals will accept or reject people with a particular mental disorder is not whether that disorder is objectively high or low on any of the mental illness dimensions, but the extent to which it is subjectively perceived to be. Our participants judged people with Primary Insomnia to be moderately highly personally responsible for causing their disorder; but this perception is at variance with scientific thinking about the disorder (Parrino et al., 2004; Reynolds, Kupfer, Buysse, Coble, & Yeager, 1991; Roth & Roehrs, 2003). Given that public perceptions of mental illness are often greatly different from reality (Holden, 1986), efforts to alter such perceptions can play a significant role in reducing stigma.

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Intervention strategies addressing the three dimensions identified in this study are likely to be the most effective in reducing stigma. With this in mind, we suggest a 3–pronged approach to reducing stigmatization of individuals with mental illness, focusing on: (1) therapist behavior, (2) self–concept of the target, and (3) mass education of society. The Therapist. Most mental health providers receive little or no training regarding mental illness stigma. In fact, when we performed a literature search on working with mental illness stigma in psychotherapy, we found virtually nothing directly addressing this topic; this state of affairs is less than ideal. In this article, we have empirically isolated three factors underlying mental illness stigma—perceptions that mental illness is rare, mentally ill individuals are dangerous, and mentally ill individuals are responsible for their symptoms. Although mental health providers are unlikely to harbor these perceptions or directly communicate them to clients, they may do little to dispel them. Failing to address stigma in therapy may lead to missed opportunities to provide clients with more functional strategies, skills, and views of self (Gingerich, 1998). Of note, research and theory on cognitive therapy links distorted views of self with both mood and anxiety disorders (Beck, 1976; Clark, Beck, & Alford, 1999). The Target. Stigma may detrimentally affect mentally ill individuals’ self–concepts. The roots of such internalized stigma may be the same three components that were identified in the present study as leading to social distance (see Table 3). Internalized stigma has been demonstrated in lesbian and gay persons (Williamson, 2000), people with HIV/AIDS (Lee, Kochman, & Sikkema, 2002), and families of fat people (Crandall, 1995), among many others. Research on this problem is still relatively undeveloped, with case reports (Deegan, 2001) and measures of internalized mental illness stigma (Ritsher, Otilingam, & Grajales, 2003) only recently reaching the literature. It seems likely that internalized stigma is an important therapeutic problem, however. Considering that no extant research concerns the efficacy of addressing stigma in therapy, researchers may wish to begin by investigating the effects of addressing these three dimensions with clients. Society. Finally, mental health providers can and often do function as political advocates, playing roles in dispelling false perceptions of mental illness at a societal level (Matorin, 2002). Although general information delivered through media outlets, classroom education, and other forms of public advocacy are useful, empirical findings may be helpful in most effectively targeting messages (Kommana, Mansfield, & Penn, 1997). The current results suggest that messages might profitably address the public’s perceptions of the dangerousness, personal responsibility, and rareness involved in mental illness.


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CONCLUSION Whether or not people’s perceptions of specific mental illnesses are accurate, people are more willing to socially reject individuals with disorders that they perceive to be high on personal responsibility, dangerousness, and rarity. If we wish to reduce the impact of mental illness stigma in our society, we can begin by addressing these particular dimensions in clinical training, psychotherapeutic treatment, and public education. An understanding of these dimensions and the pathways through which they lead to rejection may aid in this task.

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