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Exploring the Public Stigma of Addiction through Stakeholder Focus Groups

Katherine N., Tyas T.H., Anastasia T., Rachel D., Lorenzo W, Patrick W. Corrigan.

 

Problem or Purpose: The National Academy of Science reported that research on the stigma of addiction is scarce in comparison to that on the stigma of mental illness (National Academy of Science, Engineering & Medicine, 2016).  The stigma of addiction differs from the stigma of mental illness in three main ways: (1) discrimination against people with addictions is legally sanctioned, (2) stigma is used as a tactic in public health campaigns to promote drug use prevention, and (3) some addiction interventions facilitate self-stigma through their focus on wrongdoing by the addict (Corrigan et al., in press). The purpose of the current study was to gather all possible forms of public stigma against addiction to inform the literature and pave the way for quantitative studies on the harmful impacts of the stigma of addiction as well as strategies to reduce the stigma against addicts.  Illinois Institute of Technology

Procedure: Twelve focus groups were conducted with a population of current addicts, former addicts, family members of addicts, and substance use treatment providers.  Focus groups lasted 90 minutes with questions focusing on stereotypes, prejudice, and discrimination perpetrated by the public against addicts.  The conceptualization of these three items is based on a social-cognitive model of stigma where stereotypes are negative beliefs, prejudices are negative emotional reactions, and discrimination is the resulting negative behavior against the stigmatized group (Link & Phelan, 2001).  Additional questions measured what is shameful and embarrassing about addiction to gather more forms of stigma that may have been missed by the conceptualization of the social cognitive model.

Results: A total of 99 individuals participated in the focus groups with 16.2% identifying as current addicts, 54.5% identifying as former addicts, 22.2% identifying as family members, and 23.2% identifying as treatment providers.  Qualitative coding identified stigma candidates in five main categories: stereotypes, prejudice, discrimination, shame, and embarrassment.  Sub-categories under each main category further describe the stigma experienced by addicts.

Conclusions/Implications:  These results can help inform more supportive services for individuals with addiction and will pave the way for quantitative research on the effects of addiction stigma.

 

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Behind Closed Doors: The Stigma of Suicide Bereavement

Lindsay S., Hoi Ting, W., Patrick W. Corrigan.

 

Problem or Purpose: Around 40,000 Americans die by suicide each year, leaving many thousands of families in bereavement (Xu et al., 2016). The stigma experienced by family survivors threatens to further burden families and impede the grieving process (Pitman et al., 2014; Seagal, 2009). However, past research has not systematically identified the subcomponents of stigma experienced by the suicide bereaved.  This study used a community-based participatory research (CBPR) process to explore the family stigma of suicide from a social-cognitive perspective.

Procedure: A CBPR team, consisting of suicide attempt survivors, family survivors, social service providers and advocates, worked together to design and conduct the study.  Sixty-two participants (52% male and 48% female) were recruited from the Chicago area to take part in focus groups.  Focus group participants (n=62) had themselves survived a suicide attempt, experienced the loss of a family member to suicide, or provided suicide bereavement services.

Results:Thematic analysis of focus group data resulted in themes describing stereotypes, prejudice and discrimination.  Results suggest that surviving families are viewed as contributing to their loved ones death through abuse, neglect, denial or failure to provide adequate help. Family survivors may be viewed as emotionally strong, victims of the suicide or as “contaminated” by their association with the deceased family member.  Families encounter pressure to keep the suicide a secret (shushing) and may experience withdrawal of support systems following the suicide (shunning).  

Conclusions/Implications: This research can provide the foundation for services that better meet the needs of families bereaved by suicide and suggests the necessity for clinicians to address internalized stigma in families grieving a loss. These data can be used in developing measures that capture stigma directed at the suicide bereaved.

 

 

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Public Perceptions of Mothers of Children with Fetal Alcohol Spectrum Disorder (FASD)

Binoy S., Lara JL., Patrick W. Corrigan.

 

Problem or Purpose: Chronic alcohol consumption during pregnancy can result in a myriad of impairments in the child. This syndrome is now defined as Fetal Alcohol Spectrum Disorder (FASD). The public stigma of behavioral health is a significant barrier to health service engagement (NAS, 2016).  Past research has conceptually reviewed the stigma of FASD, indicating that the public sympathizes with FASD children, but disdains the mother (Eguiagaray, Scholz & Giorgi, 2016). However, the literature lacks systematic investigations on this phenomenon.  The present study analyzes the public stigma towards mothers’ of children with FASD. 

 

Procedure: Data was collected on Amazon’s MTurk. Our sample comprised of 389 participants (mean age=35.2, SD=10.9), of which 45% were female 82% self-identified as white. Participants were asked how they viewed mothers based on randomly assigned conditions.  Public stigma was measured via self-reported levels of difference, disdain, and blame across the four conditions (SMI: serious mental illness, SUD: substance use disorder, jail, FASD). Stigma towards mothers of children with FASD (main condition) was contrasted with stigma towards women with SMI, SUD and jail experience (comparison conditions). Prior experience with each of the four conditions was tested as a moderator. Thereafter, a budget allocation task was administered as a behavioral proxy of discrimination (Skitka & Tetlock, 1992). 

 

Results:The public viewed mothers of children with FASD as more different, disdained, and blamed than women with SMI, SUD and jail experience (p<.001). Familiarity with the three comparison conditions moderated most of the stigma ratings, but this effect was not seen in the FASD condition. Budget allocation towards FASD service programs was significantly lower than all other human service programs (p<.001).

 

Conclusions/Implications: The results showed that mothers of children with FASD are highly stigmatized for their past behavior. The data also suggests that the public might discriminate against this population. Since familiarity was shown to moderate some of the negative effects of stigma, anti-stigma interventions should focus on contact-based strategies. Future research should adopt big data strategies, and focus on other types of stigma (for example, self-stigma).

 

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The Specificity of Suicide Stigma

Rachael D., Lindsay S., Patrick W. Corrigan.

 

Problem or Purpose: Each year, approximately 1.3 million Americans survive a suicide attempt.  While stigma has been widely reported by suicide attempt survivors, and stigma may prevent individuals from seeking out or engaging in mental health services or by receiving social support from friends, family members and acquaintances by avoiding discussions with them about their attempt (Calear, Batterham, & Christensen, 2014; Chan, Batter, & Christensen, 2014; Corrigan, Druss, & Perlick, 2014; Yakunina, Rogers, Waehler, & Werth, 2010). However, limited research has examined how suicide stigma may differ from the stigma of mental illness.  Distinguishing between the stigma of mental illness and that of suicide may reveal that suicide attempt survivors face both suicide and mental health related stigmas (Sheehan et al., 2016).  

Procedure: U.S. adults (n=440) completed an online survey in which they were randomly assigned to one of four vignettes.  Vignettes depicted a target individual with either past depression, past suicide attempt, death by suicide, or no information on suicide or mental illness (control).  Participants completed a general measure of stigma, a suicide-specific stigma measure, and were surveyed on the recovery potential of individuals with mental illness and suicide attempt.  Participants were roughly equal on gender (female; 47%); the average age was 36 years old; ethnicity was 83% white, 7.3% African-American/Black, 8% Asian, 5.9% other; 90% identified as heterosexual; 64% were employed full-time; and a majority of participants had household incomes between $25,000-75,000.  A series of one-way ANOVAs were conducted to determine whether significant differences existed between outcome responses for the four vignette conditions.  Additionally, Tukey post-hoc tests were performed when F-tests were significant at p < .004.  

Results: Significant differences on the suicide stigma scale (SSAS-44) emerged between participants assigned to the depression and suicide conditions, and for the stereotype and prejudice subscales. Across conditions, participants believed that recovery was more realistic for someone described as having a mental illness than it was for someone described as having attempted suicide

Conclusions/Implications: These findings suggest that individuals who have attempted suicide are subject to different stereotypes and prejudices than people with mental illness alone, however discriminatory behavior directed at the two groups is very similar.  Anti-stigma programs that recognize and address both the similarities and differences between the suicide stigma and mental illness stigma may better meet the needs of individuals who have experiences with both.  

 

 

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Reactions to Normalcy versus Solidarity Messages for Anti-Stigma Campaigns

Maya. A., Patrick W. Corrigan.

 

Problem or Purpose: The stigma of mental illness harms people in many ways, including and discrimination that robs people of rightful opportunities (Rusch, Angermeyer, & Corrigan, 2005).  Hence, reducing stigma has been identified as a significant public health issue in the United States (National Academy of Sciences, 2016).  This study examined the merits of two messages that might be incorporated into anti-stigma campaigns: normalcy and solidarity.  Normalcy messages are often used in social marketing campaigns that frame mental illnesses like any kind of illness: “People with mental illness.  They’re just like me.”  But, insights from other stigmatized groups suggest celebrating differentness, rather than hiding it, may decrease stigma better, more reflective of the solidarity message (Corrigan, 2016).  

 

Procedure: Adults were solicited to participate in this study using Amazon’s Mechanical Turk (MTurk) requesting workers to participate in a 15-minute survey “about knowledge and thoughts about mental health issues.”  Overall, the sample (n= 373) was 32.1 years of age on average, 39.7% female, and largely white (78.3%).  Research participants completed five yes-no questions to assess whether they self-report mental illness: “have you ever…?” (1) received counseling, (2) been diagnosed, (3) taken medications, (4) seen a psychiatrist, or (5) been hospitalized.” Participants were presented in random order a solidarity and a normalcy message and asked immediately after each one to assess how understandable, effective, and compelling the message was. They were also assess on public and self-stigma.

 

Results: Participants from the sample who reported higher public stigma were likely to view normalcy and solidarity anti-stigma messages more negatively (.19 and .18 respectively, p<.01).  Similarly, participants with previous experiences with mental illness who reported greater self-stigma viewed normalcy and solidarity messages as worse (0.38 and 0.34 respectively, p<.01).  Significant main effects were found for message, with solidarity being viewed more positively across the five analyses.

 

Conclusion/Implication: Results showed the overall group of research participants viewed solidarity messages with greater merit than normalcy.  Participants with self-reported mental illness seemed to view solidarity, compared to normalcy, even better than participants without mental illness.  Difference between groups increased as participants admitted to more stigmatizing experiences related to mental illness.  These findings suggest that people with more stigmatizing experiences with mental illness are more opposed to the traditional idea of reducing stigma through integration.  

 

 

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Mental Health Journalism Fellowship Evaluation

Patrick W. Corrigan and Karina J. Powell

The purpose of this research study was to evaluate the effects of representative media pieces created by a Mental Health Journalism Fellowship.  The mission of the journalism fellowship is to develop materials for consumption by the general public that do not use stigmatizing images of people with mental illness. The primary research objective was to assess the impact that these media pieces have on the public stigma of mental illness through quantitative assessment in an intervention and a control group.  Two hundred study participants were randomly assigned to one of four conditions, two written journalism pieces from the MHJF (one chosen to represent a highly stigmatizing article and the other chosen to represent a low stigmatizing article), one outside journalism article (selected for its journalistic sensitivity), and a no-intervention control condition.  Stigmatizing and affirming attitudes were assessed pre-intervention, post-intervention, and at one week follow-up.  Results indicated a statistically significant difference on a measure of coercion between the highly stigmatizing fellowship article and the outside journalism article, with the group exposed to the former scoring worse.  With regard to goal orientation, recovery, and empowerment, the outside journalism article condition showed significantly better attitudes than the MHJF highly stigmatizing condition.

 

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WRAP, Self-Determination and Adherence

Patrick W. Corrigan, Nev Jones, Janice Parker and Drexler James

Background: Wellness Action Recovery Plan (WRAP) initiatives have been established in many states and significant impacts on symptoms, hope, and recovery have been documented through both quasi-experimental evaluations and a rigorous randomized control trial. No existing studies, however, have examined the impact of WRAP on treatment engagement or investigated WRAP’s impact using qualitative methods.

Methods: Five focus groups were held around the state of Illinois with a diverse group of WRAP facilitators and program participants. Focus group participants were asked a series of open-ended questions regarding their past and present treatment experiences, understanding of the terms self-determination and adherence, and the ways in which they thought WRAP had affected their lives in general as well as their relationships with providers and attitudes toward mental health services.

Results: Analysis of the focus group transcripts revealed a number of consistent themes. With regard to past experiences of treatment engagement and disengagement, participants emphasized two themes: first, the importance of self-determined motivation, and second the importance of caring and egalitarian relationships with providers. With respect to the terms self-determination and adherence, provocative differences emerged, with some participants arguing that adherence and self-determination were conceptually opposed terms, and others arguing that they could be complementary. Finally, with respect to the impact of WRAP, participants focused on the ways in which WRAP increased both honesty and self-advocacy with providers and awareness of their symptoms and the role of medications and other supports. These gains seemed to be mediated by increases in hope, self-confidence, and self-determination, as well as positive interactions with peers and peer facilitators.

Conclusions: Self-determination, including perceived control over treatment choices, and autonomous motivation, appear to be crucial not only to recovery but to sustained and meaningful treatment engagement. Peer-run interventions like WRAP that promote self-determination are thus not only building blocks of subjective recovery but also for meaningful engagement with traditional mental health services, including medications. Future quantitative research investigating these themes with a larger sample is suggested.

 

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Humor Study

Patrick W. Corrigan, Karina J. Powell, J. Konado Fokuo and Kristin A. Kosyluk

 

Background: Public stigma is frequently a barrier to many personal goals for people with mentalillness including job opportunities, housing, and quality health care. A number of anti-sigma programs have been developed with the intention of reducing stigma’s harmful effects. Humor, though often associated with the promulgation of negative stereotypes, may have the potential to decrease stigmatizing attitudes in the context of disclosure. Research suggests the effects of humor are impacted by personal differences in humor style.

Methods: Research participants completed pre-tests of stigmatizing attitudes and humor style and were then randomized to one of three conditions (a comedy sketch where the comic discloses his mental illness, the same sketch where all allusion to the comic’s mental illness is omitted, and a control comedy sketch). Research participants then repeated the measure of stigmatizing attitudes and provided perceptions of the comic.

Results: Humor styles and perceptions of the comic significantly interacted with sketch type to diminish stigma. Perceptions of the comic when he self-disclosed as having a mental illness, were associated with reduced stigma from pre to post when the comic was viewed as humorous, having a mental illness, “like me,” and sincere. The self-disclosed comic who was viewed as less aggressive also showed significantly better change in stigma on the AQ. People with affiliative humor style significantly decreased stigma after participating in either mental health comedy sketch compared to the control.

Conclusions: People who seem to enjoy humor and making people laugh were shown to have significantly larger changes in the disclosed comic condition compared to the nondisclosed and control condition. An affiliative style was also found to interact with the nondisclosed comic condition which suggests comedy about mental health in general might reduce stigma in a person who enjoys laughing. An aggressive humor style was not found to interact with either comic condition, a notable finding that suggests offense at a comic’s statement about mental illness does not seem to impede attitude change. These findings suggest people exposed to comedy about mental health are not empty vessels. Person-level variables need to be considered in crafting these approaches. We began with humor styles here as natural mediators of the way comedy routines are experienced.

 

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The California Contact-Based Anti-Stigma Program

Patrick W. Corrigan and Patrick J. Michaels

 

Research shows contact-based anti-stigma programs are among the most effective.  Such findings call for clarity to define the components of consumer-directed anti-stigma programs.  Using Community Based Participatory Research (CBPR) was a first step of a mixed methods design to describe the active ingredients comprising these kinds of programs.  CBPR investigators developed an interview guide and subsequently facilitated four focus groups to identify key components.  Included participants were anti-stigma experts with lived experience.

 

Using grounded theory, two independent raters identified discrete themes.  Two additional coders then sorted themes into constructs representing key ingredients of contact-based programs.  Coders agreed upon constructs then grouped them into a hierarchical model of key ingredients in consumer-directed stigma change.  Two major model categories emerging from the focus groups were problem and solution to stigma; diversity and family were also compelling categories.  The problem was described by: forms, impacts, qualities, and protective factors.  Solutions were described by: principles, targets, messages, unintended consequences, empowerment, program support, evaluation, and needs assessment/organizational engagement.

 

Overall, five criteria represent indicators of successful consumer-directed programs: program design, targeting, staffing, messaging, and follow-up and evaluation.  Obtained data from Solutions were used to populate a fidelity measure for consumer-directed anti-stigma programs.  This new instrument is entitled the California Quality Improvement, Fidelity, Assessment, and Implementation Ratings for Stigma and Discrimination Reduction Programs (CQI-FAIR).  The second step in this mixed method design is a cross-validation study. The purpose is to collect data from an independent sample of mental health advocates familiar with consumer-based anti-stigma programming to rate the importance of items comprising the CQI-FAIR as it pertains to public stigma, self-stigma, and label avoidance.

 

Methodology

One hundred people who are mental health advocates with lived experience will be recruited for this online Qualtrics-based survey.  Eligible participants will be advocates or consumers familiar with contact-based anti-stigma programming conducted in California. For this study, participants will complete also questionnaires assessing stigma and affirming attitudes as well as review the CQI-FAIR.  Analyses will be conducted to evaluate which items within the 5 criterions are most important to elimination of public stigma, self-stigma, and label avoidance.

 

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Honest, Open, Proud (Formerly: Coming Out Proud program)

Patrick W. Corrigan and Blythe Buchholz

 

Buchholz et al., Qualitative Results Table

Click Here to view table

 

Self-stigma is one of the egregious impacts of mental illness stigma, a diminished sense of self-esteem and self-efficacy leading to a “why try” effect in many people: “why try get a regular job, someone like me doesn’t deserve it.” Recently, innovative programs have emerged to challenge self-stigma, programs based in part on psychoeducation and cognitive reframing skills meant to challenge stigmatizing self-statements. An interesting result has emerged out of research by our group that informs an alternative program for dealing with self-stigma: the Coming Out Proud program (COPp). Research shows those who have disclosed aspects of their mental illness frequently report a sense of personal empowerment that enhances self-esteem and promotes confidence to seek and achieve individual goals. In this light, a group of people with lived experience and stigma researchers developed the Coming Out Proud program, now being used in beta research in the United States, Europe, Australia, and China. COPp is a three-session group program run usually by pairs of trained leaders with lived experiences. COPp has a comprehensive, user-friendly manual; step-by-step workbook and corresponding worksheets; fidelity measure; and leader training program which can be obtained from NCSE1.ORG. The three lessons include:

1. Considering the Pros and Cons of Disclosing:

1. My identity and mental illness.
2. Secrets are part of life.
3. Weighing the costs and benefits of disclosing.

2. Different ways to Disclose:

1. Five ways to come out.
2. Testing a person for disclosure.
3. How might others respond to my disclosure?

3. Telling your Story:

1. How to tell a personally meaningful story.
2. Who are peers that might help me with coming out?
3. Review how telling my story felt.
4. Putting it all together to move forward.

The program is designed to aid in the facilitation of disclosure of certain aspects of lived experience with the objective of reducing the self-stigma associated with mental illness.

Click here to download the COPp Manual.

Click here to download the COPp Workbook.

Click here to download the COPp Workbook Fidelity Measure.

 

Testing the Efficacy of the Coming Out Proud Program: a Randomized Controlled Trial
Approximately 100 individuals with the lived experience of mental illness will be recruited to participate in the trial. After a brief phone screening, potential participants will be fully informed of the study and if interested, informed consent will be obtained. Participants will then be randomized to either the COPp (intervention group) or be wait-listed for the program (control group). For those in the COPp group, the program will be provided at a time and place convenient to participants, usually three days or nights within a single week. The program will be facilitated by two trained leaders with lived experience, in groups of approximately 6-10 participants. During this time, facilitators will thoroughly cover each lesson of the COPp program workbook (one lesson per each session). Participants in both the control and intervention groups will be administered measures at baseline (one week window before starting COPp or the control), post-test (one week window after COPp or the control) and follow-up (one month after COPp or control). Measures will include standardized instruments that assess self-stigma, disclosure, personal empowerment, self-esteem, self-efficacy, and recovery. The protocol aims to determine if the COPp reduces secrecy- and disclosure-related distress, self-stigma, shame, secrecy, social withdrawal, stigma-related stress and stigma as a barrier to seek help as compared to the control group. Additionally, it aims to determine if the intervention increases empowerment, self-esteem, disclosure-related self-efficacy and quality of life as compared to the control group.

 

For more information, please contact Dr. Jon Larson at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

 

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The Impact of Active Minds Speakers Bureau: A Contact-Based Anti-Stigma Program

Patrick W. Corrigan and Patrick J. Michaels

 

Three main stigma reduction strategies have been used with members of the general public: protest, education, and contact.  Yet interactions with people with mental health challenges have been shown to have a stronger and longer lasting impact.  One high profile intervention among college students is Active Minds Speakers Bureau. Presentations use personal experiences to counteract stigma’s consequences, and promote mental health awareness and treatment.  A qualitative study of Active Minds Speakers Bureau was conducted as a data-driven basis for a subsequent quantitative study.  Community Based Participatory Research (CBPR) was a first step of a mixed methods design to decipher the active ingredients of Active Minds Speakers Bureau presentations. CBPR investigators collaboratively developed an interview guide and subsequently facilitated three focus groups.  Focus groups included participants who recently viewed a presentation including college students, community members, and Active Minds National Organization staff.

 

Two independent raters separately analyzed qualitative data.  Distinct themes were then categorized into 15 conceptual frameworks including Active Minds intentions, attitudinal and cognitive reactions, awareness of consequences, awareness of public stigma, awareness of self-stigma, community advocacy, community intentions, general awareness, interpersonal advocacy, mental health knowledge, mental health maintenance, recovery, self-advocacy, societal acceptance, and treatment availability.  The next intermediate step in this mixed method design is a cross-validation study. The purpose is to collect data from an independent sample of people who are leaders in Active Minds communities to determine the importance of these 15 different conceptual frameworks. Study results will guide measurement tool selection and design of a quantitative study of Active Minds Speakers Bureau.

 

Methodology

One hundred people who are leaders in Active Minds communities will be recruited for this online Qualtrics-based cross-validation study.  Eligible participants will be Active Minds staff and board members as well as student leaders.  For this study, participants will rate the importance of each of the 15 frameworks considering Active Minds’ mission and mental health agenda.  Analyses will be conducted to evaluate which of the 15 frameworks are most important to the leadership of Active Minds.

Exploring the Public Stigma of Addiction through Stakeholder Focus Groups