On Stigma and Its Consequences

On Stigma and Its Consequences: Evidence from a Longitudinal Study of Men with Dual
Diagnoses of Mental Illness and Substance Abuse
Author(s): Bruce G. Link, Elmer L. Struening, Michael Rahav, Jo C. Phelan and Larry
Nuttbrock
Source: Journal of Health and Social Behavior, Vol. 38, No. 2 (Jun., 1997), pp. 177-190
Published by: American Sociological Association
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On Stigmaand Its Consequences:Evidencefroma Longitudinal
StudyofMen withDual DiagnosesofMental Illnessand
SubstanceAbuse*
BRUCE G. LINK
ELMER L. STRUENING
ColumbiaUniversity
and New YorkStatePsychiatric
Institute
MICHAEL RAHAV
ArgusCommunity
JOC. PHELAN
University
ofCaliforniaat Los Angeles
LARRY NUTTBROCK
ArgusCommunity
Journal
ofHealthand Social Behavior1997,Vol. 38 (June):177-190
Numerous
studieshavedemonstrated
a strongconnection
betweentheexperience
of
Butin thearea ofmentalillnessthere
stigmaand thewell-being
ofthestigmatized.
has beencontroversy
themagnitude
anddurationoftheeffects
surrounding
oflabelthathas been used to downplaytheimporingand stigma.One of thearguments
tanceof thesefactorsis thesubstantialbodyof evidencesuggesting
thatlabeling
leads topositiveeffects
mentalhealthtreatment.
through
However,as Rosenfield
inducebothpositiveconsequences
(1997) pointsout,labelingcan simultaneously
treatment
and negativeconsequencesthrough
through
stigma.In thisstudywe test
on well-being
whether
84 menwithdual
stigmahas enduring
effects
byinterviewing
diagnosesof mentaldisorderand substanceabuse at twopointsin time-at entry
intotreatment,
whentheywereaddictedto drugsand had manypsychiatric
symptomsand thenagain aftera yearoftreatment,
whentheywerefar less symptomatic
and largelydrug-and alcohol-free.
Wefounda relatively
strongand enduring
effect
Thisfindingindicatesthatstigmacontinuesto complicate
ofstigmaon well-being.
thelivesof thestigmatized
evenas treatment
andfuncimprovestheirsymptoms
wanttomaximize
thewell-being
tioning.
Itfollowsthatifhealthprofessionals
ofthe
inits
people theytreat,theymustaddressstigmaas a separateand importantfactor
ownright.
Recentresearchhas demonstrated
a strong (Harris et al. 1992; Sibickyand Dovidio),
connection
betweentheexperienceof stigma social networks
(Lennonet al. 1989; Link et
ofthestigmatized.
Numer- al. 1989),employment
andthewell-being
(Farinaet
opportunities
ous naturalistic
and experimental
studieshave al. 1971; Link 1982, 1987), self-esteem,
shownthatstigmaaffectssocial interactions depression(Link 1987),and qualityof lifein
Stigmahas
forthcoming).
general(Rosenfield,
with
lives
of
people
to
affect
the
been
shown
* This research was supportedby award
al.
1989);
people
illnesses
(Link
et
mental
DA-06968-93fromtheNationalInstitute
of Drug
Abuse.We thankAnnStueveandthreeanonymous experiencing
pain (Lennonet al.
unexplained
reviewersforhelpfulcomments.Addresscorres- 1989; Marbachet al. 1990); gay men(Meyer
pondence to: Bruce G. Link, Epidemiologyof 1995); people withpsoriasis(Ginzburgand
MentalDisorders,100 Haven Avenue,Apartment
31D, New York,NY 10032; e-mail:bgl1 colum- Link1993);andpeoplewhoareobese(Dejong
studieshavemanipulated
1980).Experimental
bia.edu.
177
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178
JOURNALOF HEALTH AND SOCIAL BEHAVIOR
the applicationof labels like homosexuality ative StudyGroup 1991), and majordepresandmentalillnesstoproduceeffects
on social sion(Prienet al. 1984).
interaction
even forpeople who have never
Considering
theweightoftheevidencejust
been taggedwiththesedesignationsoutside reported,
itis easyto assumethatanycounterthe experimental
context(Farina,Allen,and vailingnegativeeffects
of stigmamustbe relSaul 1968; SibickyandDovidio 1986).
atively trivial in comparison.Surely, any
by theposiNevertheless,
some influential
researchers effectsof stigmaare outweighed
believe the effectsof stigmaare small and tive benefitsof treatment,which are so
transitory.
For example,Gove claimsthatfor impressiveand extensive.Also, given the
the "vast majorityof mentalpatientsstigma emphasisin Scheffs (1966) theoryon the
consequencesofcontactwithtreatappearsto be transitory
anddoes notappearto deleterious
pose a severeproblem"(1982:290).One ofthe mentsystems("agentsof control")theaccutreatment
effecused to supportthisclaim and to mulatingevidenceregarding
arguments
of labelingand stig- tivenessseemsto provehimwrongand some
downplaytheimportance
ma is the substantial
body of evidencecon- mayconclude"all wrong."However,a study
questionssuch
cerningthe effectiveness
of mentalhealth by Rosenfield(forthcoming)
theimportance
by demonstrating
treatments
(Gove 1980). In Scheffs (1966) assumptions
originalstatement
aboutthelabelingperspec- of stigmaevenwithinthecontextof an effecprogram.In a cross-sectional
tive,he arguedthattheconsequencesoftreat- tive treatment
thatbothservices(access to
she
shows
study,
mentwereprimarily
negative,due to stigma
and stigma (Link's
specific
interventions)
andto thedehumanizing
ofpsychiatric
effects
1987
measure
of
perceived
devaluationand
hospitals(Goffman1961). However, since
are
related-in
discrimination)
oppositedirecs
Scheff writings,
a substantialand growing
of the"quality
bodyof evidencehas emergeddemonstratingtions-to multipledimensions
of
life"
of
a
(Lehman
1983)
people
attending
the positivebenefitsof mentalhealthtreatmodel
clubhouse
program.
Services
have
posments.Bothpsychosocialand pharmacologiin curbingthe itiveeffectson dimensionsof qualityof life
cal interventions
are effective
suchas livingarrangements,
familyrelations,
symptoms
of,andpreventing
relapsein,many
financialsituation,safety,and health,while
typesof mentaldisorder.For example,metastigmahas equallystrongnegativeeffectson
analysesof psychotherapy
outcomeresearch
suchdimensions.
have demonstrated
positive effectsacross
of suchdual and opposite
The significance
types of therapiesand types of outcomes
processesof stigmaand treatment
benefitsis
(Smith,Glass,and Miller1980). Morerecent heightenedby an importantqualification
meta-analyses
focusingon specificconditions regardingthe impactof mentalhealthinterlike depression (Robinson, Berman, and ventions.While it is an incontrovertible
fact
Neimeyer 1990) and obsessive-compulsivethatinterventions
canproducepositiveeffects,
et al. 1987) have also it is also truethattheeffectstendto be reladisorder(Christensen
in reporting
beenconsistent
of tivelyshort-lived-that
positiveeffects
with time treatment
psychotherapy.
Takinga different
approach,a benefitsevaporate.Thus,forexample,Smith
large-scalemultisiteclinical trialevaluating and colleagues(1980) in a forcefully
positive
the effectsof two highlystandardized
psy- assessmentof the benefitsof psychotherapy
treatment
chotherapy
protocolsshowed evi- acknowledgethat"thebenefits
ofpsychotherdenceofpositiveeffectsformajordepression apy are notpermanent,
butthenlittleis" (p.
(Elkinet al. 1989). Even fora severedisorder 183). In otherarenas,researchers
the
identify
research
has shownthat need for "booster"sessions and "maintensuchas schizophrenia,
have ance" doses to extendthe benefitsof psymultipleand singlefamilyinterventions
effects(McFarlaneet al. chotherapeutic
positivetreatment
and pharmacological
interven1995). Concerningpharmacologicaltreat- tions,respectively
(Kupfer,Frank,and Perel
from 1989; Kupfer,Frank,and Perel 1989). Such
setof findings
ments,an ever-expanding
double-blindcontrolledtrials have demon- efforts
speakmoreto theelusivenessof longforsuchcondi- termbenefits
strated
treatment
effectiveness
meansofensurthanto effective
tionsas schizophrenia
(Kane 1989), bipolar ing thattheyare achieved.This set of facts
disorder
(Prienetal. 1984),obsessive-compul-leaves open thepossibilitythatother,as yet
sive disorder(The ClomipramineCollabor- unidentified
processesoperatesimultaneously
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ON STIGMA AND ITS CONSEQUENCES
179
to offsetand ultimately
erodetreatment
bene- behavioralsequelaeofsuchcognitive
processfits.Stigmatization
is an obviouspossibility es in whichstigmatizers
rejectthestigmatized
along these lines because, as Rosenfield or the stigmatizedengage in "secondary
(forthcoming)
pointsout,officiallabelingcan deviance,"suchas secrecyorwithdrawal,
as a
simultaneouslylead to positive treatment means of "defense,attack,or adaptation"
effects
andnegativestigmaeffects.
(Lemert1967).
Pursuingthis possibility,and in keeping
Usingthisdefinition
of thecorefeatures
of
with Rosenfield's integrationand partial stigma,we nextdrawupon and expandthe
accommodationof the so-called psychiatric ideas of Linkand colleagues(1989) aboutthe
andlabelingperspectives,
thispaperexamines processby whichstigmacomes to influence
whetheraspects of stigma have enduring peoplemarkedwithundesirable
labels.In this
inthecontextofa longitudinal
thereare essentially
threecompoeffects
studyof framework,
menenrolledin one of twoprograms
process:(1) culturthatare nentsofthestigmatization
designedto treatpeopleduallydiagnosedwith ally induced expectationsof rejection,(2)
mentaldisorder
andsubstanceabuse.Research experiences
ofrejection,
and(3) efforts
atcopontheeffectiveness
oftreatment
wouldleadus ingwithstigma.
to believe that these men will experience Accordingto Link and colleagues(1989),
improvements
in theirpsychiatric
inducedexpectations
symptoms culturally
emergein the
andsubstanceabuseat leastovertheshortrun. followingmanner.In thecourseof socializaBelow, we outlineour conceptualization
of tion,people developa conceptionof whatit
ill person
as a mentally
the stigmaprocess and considerhow this meansto be identified
process mightproduce negative outcomes ora personaddictedto drugs.Theyhaveideas
even withinthe contextof improvements
in about whethermostpeople will rejectsuch
individuals
as employees,
and intineighbors,
symptomatology.
mates,or whethertheywill devalue them,
trustbelievingthemto be less intelligent,
CONCEPTUALIZATION OF THE STIGMA worthy,
and competent.
These beliefsare of
PROCESS
littlerelevanceto theway in whichmostpeople conducttheiraffairs.For example,such
Ourconceptualization
ofthestigmaprocess beliefsdo not affectthe searchfora job or
startswithJonesand co-workers'
with a new acquain(1984) two- influenceinteractions
of stigmaas a "mark"that(1) tance. However, when someone becomes
partdefinition
sets a personapartfromothersand (2) links labeled as havinga mentalillness or being
themarkedpersonto undesirablecharacteris- addictedto drugs,beliefsabout how others
tics.Whenthepersonis linkedto undesirable will treatsuch a persontake on heightened
a thirdaspectof stigmacomes importance-theybecome personallyrelecharacteristics,
intoplay-rejectionand isolationof thestig- vant.If one believesthatotherswill devalue
matizedperson.Stigmais therefore
of and rejectmentalpatients,
a matter
one mustnow fear
degree,as themarkor label can varyin the that this rejectionapplies personally.The
extentto which it sets a personapart;the newly labeled person may wonder,"Will
markedperson can be stronglyor weakly othersthinklessofme,rejectme,becausenow
linkedto a varietyof undesirable
characteris- I am a personidentified
as havinga mentalilltics;andtherejecting
responsecan be moreor ness (or being addictedto drugs)?"In this
less strenuous.
Withrespectto mentalillness, way, labelingtriggers
powerfulexpectations
a clearexampleofstigmawouldexistifa per- ofrejectionthatin turnerodeconfidence,
disson were hospitalizedfor mentalillness (a ruptsocial interaction,
and impairsocial and
markor label) andthenassumedto be so dan- occupationalfunctioning.
that
and untrustworthy
Whena personbecomesnegatively
gerous,incompetent,
labeled,
of rejectionbecome
avoidanceandsocialisolationensue.Thus,the notonlydo expectations
conceptofstigmaas we defineitincludesboth activated,but actualexperiencesof rejection
cognitive and behavioral components.It occur as well (Link and Cullen 1983, 1990;
includescognitiveprocessesin whichpeople Linket al. 1987). These experiences
of rejecofourconceptual-stigmatizersor thestigmatized-uselabels tion,thesecondcomponent
to inferthata markedpersonpossessesunde- ization,rangefrommajorexclusionsto "putsirable characteristics.
It also includes the downs"and slights.Forexample,Page (1977)
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180
JOURNALOF HEALTH AND SOCIAL BEHAVIOR
which
theprocessthrough
demonstratedan enormous helpsus understand
experimentally
withregardtotherenting stigmamayhave harmful
effect
effectson people's
discrimination
may
Landlordsweremuchless like- lives and thewaysin whichsucheffects
ofapartments.
was available endureevenwhentheperson'sdeviantbehavly to indicatethatan apartment
as a former iorsubsides.Thisconceptualschemehasguid(27%) if a callerwas identified
mentalhospitalpatientthanif he or she was ed previousresearchdemonstrating
thedeleteand rious consequencesof stigmaand strategies
(83%). Painfulput-downs
notso identified
slights were documented in Rosenhan's forcopingwithit(Link1987;Linketal. 1989,
psychi- 1991). The purposeof thepresentpaperis to
(1973) studyin whichpeoplewithout
atricdisordersposed as patientsand entered determinewhetherthereare any enduring
psychiatric
hospitals.The studydocumented effectsof stigmaeven whentreatment
effeclegiti- tivelyreducessubstanceabuse and symptoms
manyways in whichpseudo-patients'
materequestsweredismissedandtheirnormal ofmentalillness.Ifwe findevidenceforsuch
as evidenceof psycho- enduring
behaviorinterpreted
in
we will seekto determine
effects,
pathology.
identifuture
studieswhichofthemechanisms
of fied above appearto be most important
Bothexpectations
andactualexperiences
for
rejectionare likelyto lead peoplewithmental whichoutcomes.
illnessor drugor alcohol problemsto seek
ofrejection.
We
waysofcopingwiththethreat
considertwo such responses.In the first- RESEARCH STRATEGY
secrecy-clientsmaychoose to concealtheir
or
fromemployers,
relatives,
treatment
history
To testthe idea thatstigmahas enduring
potentiallovers to avoid rejection (Link, consequencesevenwhentreatment
effectively
and Cullen1991). In thesecond- reduces substanceabuse and symptomsof
Mirotznik,
limitinteraction
to avoid mentalillness,we examinedmen withdual
withdrawal-clients
the possibilityof rejection(Link,Mirotznik, diagnosesof severementalillnessand drug/
and Cullen 1991). When clientsadopt this alcoholabusewhowereenrolledinmodelprofromtherejection gramsdesignedto treattheseconditions.
response,theyareprotected
We
thatmightensueif theyventured
out to seek interviewed
thesemenat entryintotreatment,
friends,
jobs, and thelike in thewidersocial whentheywereaddictedto drugsand highly
environment.
and thenagain aftera yearof
symptomatic,
it treatment,
conceptualization,
Based on theforegoing
when theywere far less symptois possible to identifyseveral mechanisms maticand largelydrug-andalcohol-free.
throughwhich stigma may have enduring Our studyincludesmeasuresthatoperaeffectson people's lives even if theirsymp- tionalizeour major independent
variableof
tomsor otherformsof deviantbehaviorsub- stigmaas well as severalimportant
control
side.First,oncelabeled,itis possiblethatothvariablesthatmeasuresubstanceabuse,social
ers maycontinueto rejectthelabeledperson
ofpsychiandseveraldimensions
functioning,
even when symptomsimprove.Second, the
Whilethereare several
atricsymptomatology.
traumaofpastrejection
maycontinuetohaunt
of
livesthatmightbe usedto
the stigmatized
personand therebyproduce aspects people's
of
the
effects
assess
stigma,we have chosen
life.
negativeoutcomesin his or her current
as measuredby the
symptoms,
depressive
Third,stigmamay have harmfuleffectsnot
StudiesDepresCenter
for
Epidemiological
directrejection
byothersbutalso
onlythrough
variable.
of rejection sionscale (CES-D), as ourdependent
via the internalized
expectations
variable
because
both
We
chose
this
outcome
on thepartoflabeledpersons,whichmayconits
and
research
suggest
plauempirical
theory
tinueto operateevenifrejection
byothersdis(Link
or expecta- sibilityas a responseto stigmatization
sipates.Fourth,eitherexperiences
tionsof rejectionmay cause people to adopt 1987). Moreover,in thisstudydesign,where
fora fullyear,other
such as withdrawalor menremainin treatment
coping orientations
or socialsupport
like
earned
income
outcomes
secrecythatmay lead to isolationand other
are not as releharmfulconsequences.Thus it is networks(outsidetreatment)
potentially
tochangewhile
theoretically
possibleforstigmatohaveharm- vantbecausetheyareunlikely
context.
fulandenduring
effects
severalmech- themenare in thetreatment
through
above, our
anisms.
Using the measuresidentified
We have outlineda conceptualschemethat longitudinaldesign allows us to determine
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181
ON STIGMA AND ITS CONSEQUENCES
whetherstigmahas enduringeffectsover a characteristics
of thesemen are describedin
one-year
period.The longitudinal
aspectofthe greaterdetailin a previouspaper(Rahav and
designhelpsus go beyondwhatcan be deter- Link 1995).
minedfromcross-sectional
designsby allowAlthoughour hypothesis
is statedwithout
ingus to testwhether
theeffects
ofstigmacan regardto specifictreatment
contexts,
itis posbe accountedforby eitherbaselinemeasures sible that the type of treatment
influences
of psychiatric
symptoms
and social function- whetherthe effectsof stigmaendureor not.
ing,or by changesin such factorsover the For thisreason,we examinedthepossibility
one-year
period.In thisway,ourdesignallows that our findingsmightvary accordingto
us to assess whetherstigma continuesto whether
clientswereenrolledin a therapeutic
impingeon thelives of themenwe studyor community
ora community
residence.Results
whetherthe effectsof stigmaare small and of theseanalysesare reported
in thetextor in
in theirlives.
transitory
footnotesfollowing analyses of the full
sample.
METHODS
Sample
Measures
StigmaVariables.Our conceptualization
of
In 1990,a majorinitiative
was launchedto thestigmaprocessincludesthreecomponents:
provideand evaluatetreatment
of mentally
ill culturallyinducedbeliefsabout devaluation
chemicalabusers(MICAs) in New YorkCity and discrimination,
experiencesof rejection,
(Rahavetal. 1995).Clientswitha majormen- and ways of coping with stigmatization.
tal disorderand a historyof substanceabuse Devaluation/discrimination
is operationalized
wererecruited
fromhospitals,clinics,shelters in thisstudyusinga modification
of Link's
forthehomeless,thecriminal
justicesystem, (1987) measure.Respondentswere asked to
and otheragenciesin contactwithMICAs in indicatethe extentto whichtheyagreewith
the New York City area. Inclusioncriteria statements
like"Mostpeoplebelievethatforweremalegender,21 yearsof age or older,a mer mentalpatientscannotbe trusted"and
majorDSM-III-R Axis I disorder,
at leasttwo "Most employerswill nothirea personwho
psychiatric
and a confirmed has been hospitalizedfor mental illness."
hospitalizations,
of abusingalcoholand/orotherdrugs. Response categoriesare "stronglyagree,"
history
Referralsmeetingthese criteriawere eval- "agree,""disagree,"and"stronglydisagree."
uatedon a battery
of psychiatric
instruments,Becausethissampleincludespeoplewithdual
assignedto a residential
treatment
facility
par- diagnoses of mental illness and substance
ticipatingin the study(eithera therapeutic abuse, the modifiedversionincludesitems
or a community
community
residence),'and referring
to drugabuse as well. The 15-item
reassessedafterone yearwithregardto psy- versionwe use in this study(alpha = .78)
chiatricstatusand substanceuse.
includessevenitemsthatfocuson drugabuse
Thepresentanalysisis basedon the84 men andeightfocusedon mentalpatientstatus(see
who completedone yearof treatment
in their Appendixforitemwording).
assignedprogram(48 in thetherapeutic
comWe operationalizedrejectionexperiences
munityand 36 in thecommunity
residence). usinga 12-itemscale (alpha = .80) thatonce
Sixty-three
percentof themenin thesample againincludesquestionsregarding
drugaddicare AfricanAmerican,23 percentare His- tion(six items)and mentalpatientstatus(six
panic,withtheremaining
14 percentWhiteor items).Itemcontent
focuseson beingavoided,
other.The meanage was 34, and theaverage being treateddifferently,
havingpeople feel
educationalattainment
was slightlyless than uncomfortable
aroundtherespondent,
ordrop11 years.Mostofthemen(58%) had a DSM- pingtherespondent
as a friend.
All itemswere
III-R chartdiagnosisof nonaffective
psychot- askedina yes/no
format
andsummedtocreate
ic disorder(mainlyschizophrenia).
An addi- the scale of rejection experiences (see
tional14 percenthad a diagnosisof a major Appendixfor item wording).Some of the
mood disorder(mainlybipolardisorderand itemsin thisscale ask whether
therespondent
major depression)while the remainderhad "ever" experiencedthe formof rejection.
otherdiagnoses.The social and psychiatric Wordedin thisway we would not expecta
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182
JOURNALOF HEALTH AND SOCIAL BEHAVIOR
to as "positive
declinein meanlevelsof rejectionovertime. it manytraitsoftenreferred
effectiveness,
social
as
such
health,"
Whatis at issuewithregardto thismeasureis mental
71 to 80
from
Scores
integrity.
and
warmth,
symptoms
depressive
on
whetherits effects
or
withno symptomatology
declineover timeas one mightexpectif the areforindividuals
Scores from31 to 70
of past rejectionfadedwithtime onlyminorsymptoms.
importance
be appliedto subjectsin need
wouldgenerally
improvement.
and symptom
services. Scores
psychiatric
outpatient
coping
of
two formsof
We operationalized
care
who
need
inpatient
those
for
are
30
below
assessed
The
first-secrecy-is
withstigma.
withan 8-itemscale (alpha= .72). The content and supervision.
RatingScale (BPRS)
The BriefPsychiatric
of the itemsfocuses on hidingor keeping
of drugaddictionor treatment(Overall and Gorham1962) is a semi-strucsecreta history
assessmentof psychiatric
formentalillness.The secondformof coping turedinterviewer
both client reportsand
on
based
4-item
status
a
using
assessed
-withdrawal-is
scale (alpha = .78). These itemsmeasurethe observeddemeanorduringthe interview.In
by a
tendencyto refrainfromapplyingfora job thisstudy,the BPRS was administered
who was also
duetoaddic- clinicallytrainedpsychologist
becauseitmightinducerejection
trainedin theuse oftheBPRS. Responsesare
tionor mentalillness.2
sympDepressive Symptoms.Depressive symp- elicitedwithregardto ninepsychiatric
toms are operationalizedusing the CES-D tomssuchas anxiety("Duringthepastweek
and halluciscale (Radloff1977). This is a highlyreliable have you felttenseor uptight?")
20-item measure of depressive symptoms nations("Duringthepastweek,did you hear
duringthepastweek(alphainthis thingsthatotherpeople couldn'thearor see,
experienced
sample = .87). Typical itemsreferto self- suchas noisesor voicesofpeoplewhispering
reportedmood (e.g., "Did you feel de- or talking?").Nine aspectsof demeanorare
(defiwithdrawal
pressed?"),energylevel (e.g., "Did you feel evaluated,suchas emotional
motor
and ciencyin relatingto the interviewer),
you did was an effort?"),
thateverything
and
(obviouslyslow movements),
(e.g., "Did you feel thatyou retardation
self-evaluation
to person,
(lack of orientation
werejustas goodas otherpeople?").Response disorientation
categoriesrangefrom"rarelyor none of the place, or time).All itemsof the BPRS are
time"(coded 0) to "mostor all of thetime" coded from1 (notobserved)to 7 (extremely
ofill(coded3) duringthepriorweek.Withall items severe).A finalitem,theoverallseverity
the
(among
to
7
1
(normal)
from
ranges
depression,
ness,
reflect
scores
codedso thathigher
range mostseverelyill). Scoreson the 19 itemsare
the summedscoreshave a theoretical
rating.
summedto forman overallpsychiatric
from0 to 60.
Other Aspects of PsychiatricCondition.
Psychoticideationis a 10-itemscale (alphain
hal- RESULTS
experienced
thissample= .92) ofrecently
lucinationsand delusionsthatwas adapted
and DrugAbuse
inPsychiatric
froma 13-itemscale developedby Dohren- Improvement
wendand colleagues(1980). It was designed Status
peoplelikelyto
scale to identify
as a screening
indicatesthatstigBecause ourhypothesis
bipolardisbe diagnosedwithschizophrenia,
thatcoexistwith
effects
psychotic mawillhaveenduring
involving
disorders
order,and~other
success,we beginour
evidenceof treatment
symptoms.
thatthemenin these
The Global Assessmentof Functioning inquiryby documenting
in
factimprovesubdo
programs
treatment
ratingofoverall
(GAF) scale is an interviewer
shows
means, standard
1
Table
stantially.
widely
has
been
which
disturbance
psychiatric
research(Endicottet al. deviations,and paired t-testsfor several
used in psychiatric
As thetable
thescale rangesfrom1, dimensionsof psychopathology.
1976). Theoretically,
fora year
in
treatment
remain
sickestpossibleindividual, shows,menwho
thehypothetically
in
psychiimprovements
dramatic
experience
The
scale
healthiest.
to 100,thehypothetically
low of
a
from
range
Changes
atric
symptoms.
beginning
intervals,
10
equal
into
divided
is
of a standarddeviationuniton the
with 1-10 and endingwith91-100. Scores two-thirds
whoarenotonly baselineCES-D scale to morethantwo stanabove 80 areforrespondents
butexhib- darddeviationunitson theGAF scale. Recent
symptomatology,
freeofsignificant
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183
ON STIGMA AND ITS CONSEQUENCES
substanceabuse (alcoholor drugabuse in the nothire(72%), and mostyoungwomenwill
past six months)is veryrareat follow-upin not marry(62%) someonewho has abused
thesepreviously
addictedmenwhether
abuse drugs.Withrespecttohospitalization
formenis assessedvia self-report
(10.7%) or byurine tal illness,a similarpercentagreethatpeople
tests(11%). Although
recentabuseis higherin are rejecting(look downon, 69%; employers
the community
residenceprogram(19.4%) refuseto hire,50%; refuseto marry,56%).
thanin thetherapeutic
community
(4.2%) itis The mean (2.72) forthe perceiveddevaluaclearlydramatically
reducedin bothcontexts, tion/discrimination
measureis significantly
(p
sinceat baselineall themenhadbeenabusing <.001) higherthanthescale's midpoint
of2.5,
eitheralcohol or drugs.Whenwe examined indicating
thatrespondents
generallyendorse
changesin psychiatric
symptoms
by typeof the belief thatdually diagnosedclientsare
treatment
we foundsignificant
improvementdevaluedand discriminated
against.
withineach treatment
modalityforpsychotic Clients also reportedhavingexperienced
theBPRS, andtheGAF scale. The rejectionassociated with drug abuse and
symptoms,
resultsalso showedthattheCES-D declined mentalillness.Withrespectto drugabuse,6
less in thecommunity
residenceprogram
than percentreported
havingbeen deniedmedical
in thetherapeutic
community
program,
a fact treatment,
16 percentreportedhavingbeen
thatled us to includea dummyvariableto deniedan apartment,
and 24 percentreported
reflect treatmentmodality in subsequent beingpaidlowerwagesbecauseofa history
of
analyses.
drugabuse. Withrespectto havingbeen in a
While it is impossibleto determinehow mentalhospital,6 percentreported
havinglost
much of this improvementin psychiatric a job and 10 percentreported
beingdeniedan
and substanceabuseis due to treat- apartment
symptoms
or a roomto live in. More clients
mentand how much is due to spontaneous endorseditemsreflecting
less severeformsof
remission, it is neverthelessclear that rejection,
suchas beingavoided(37%) orhavimprovement
has occurred.It is therefore ing a historyof psychiatrichospitalization
possibleto ask whetherstigmahas enduring used to hurtone's feelings(45%). Veryfew
effectsin thecontextof dramaticchangesin clientsreported
no incidents
ofrejectionat all
and substanceabuse sta- (6%), and over 70 percentreportedfouror
condition
psychiatric
tus.
moretypesofrejection.
Finally,clientsalso endorsedstigmacoping
strategiesof secrecy and withdrawal.For
Do ClientsPerceiveand Reportthe
example,withrespectto a historyof drug
ExperienceofStigmaat theBeginning
of
abuse, clientsare about evenly split as to
Treatment?
it is a good idea to keepa historyof
whether
druguse a secret(52% yes vs. 48% no). A
Althoughclientsvaryin theirresponses,a largemajority
(76%) thinkthatitwouldnotbe
majority
believethat"mostpeople"willreject a good idea to tella potentialemployer
about
peoplewhoabusedrugsandhavebeenhospi- a history
of drugproblems.Withrespectto a
talizedformentalillness.Withrespectto drug historyof mentalhospitalization,
57 percent
abuse,clientstendto agreethatmostpeople believeitis a good idea tokeepita secret,and
willlookdownon (65%), mostemployers
will 75 percent would not tell a prospective
TABLE 1. Means, Standard Deviations,and Paired t-testsforPsychiatricSymptomsand Drug
Use at Baseline and One-Year Follow-Up (N = 84)
Baseline
Means
(s.d.)
Variable
CES-D
RatingScale (total)
BriefPsychiatric
(GAF)
ofFunctioning
GlobalAssessment
Scale
Symptoms
Psychiatric
23.2
(12.0)
31.1
(7.8)
42.5
(6.5)
8.2
(8.5)
Follow-Up
Means
(s.d.)
14.7
(11.2)
25.1
(6.4)
54.9
(6.3)
2.7
(4.3)
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Significance
ofPaired
(p)
t-tests
.001
.001
.001
.001
184
JOURNALOF HEALTH AND SOCIAL BEHAVIOR
employer.Many clientsalso endorsewithdrawalas a way of copingwithstigma.Most
clientswouldnotapplyfora job iftheyknew
theemployer
didnotwantto hireformer
drug
addicts(57%) or peoplewho had beenhospitalizedformentalillness(60%).
Thesedescriptive
datasuggestthatmostof
theclientsbelievetheywill be rejected,have
experienced
at leastsomeformofrejectionby
others,and have takensteps to avoid such
rejection.
Atthesametime,clientsalso varyin
theirperceptions,
copingefforts,
and reported
experiences,suggestingthe possibilitythat
thesestigma-related
variablesmaybe associated withimportant
aspectsof clients'wellbeingsuchas depressivesymptoms.
of stigmaover
levels of thesefourindicators
theone-yearperiod.None of thepairedt-tests
at the
significance
even approachesstatistical
.05 level.3Thisindicatesthat,unlikesymptom
reports,
thereareno declinesin theperception
or in
of stigma,in stigmacopingorientations,
the recall of rejectionexperiencesover the
one-yeartimeperiodwhile themen were in
whenwe examinedthese
treatment.
Moreover,
resultsseparatelyforthe two typesof treatment,we foundno evidenceof a decreasein
eithertreatment
setting.Thus thereis no evidence to suggestthatthe effectsof stigma
mighthave declinedbecause mean levels on
thestigmameasuresdeclined.
Does theAssociationBetweenStigma
Variablesand DepressiveSymptoms
DissipateAfterOne YearofTreatment?
Do ReportsofStigmaDeclineoverthe
CourseofOne YearofTreatment?
At baseline,perceiveddevaluation/discrimThereare twowaysin whichtheeffectsof
of inationand rejectionexperiencesare signifistigmamightdissipate.First,theperception
stigmamightdeclineovertimein responseto cantlyassociatedwithdepressivesymptoms
improving
symptoms
or otheraspectsof the (r = .318,p < .01 andr = .307,p < .01,respecof
treatment
experience.Second,theassociation tively),whilethestigmacopingorientations
betweenstigmaanddepressivesymptoms
(the secrecy(r = .171, n.s.) and withdrawal
(r =
slope) may decrease over time. Our main .033, n.s.) are not.4Whenenteredas a block,
interest
is in testingthesecondofthesepossi- thefourstigmavariablesexplain15 percentof
bilities.However,it is theoretically
possible thevariancein baselinedepressivesymptoms.
betweenstigmavariablesand
fortheslopeofstigmaon depression
toremain The correlation
bothmeasuredoneyear
over time,thereby depressivesymptoms,
constantand significant
withdevaluaindicating
an enduring
effectof stigma,while later,shows a similarpattern,
(r = .244, p < .05) and
at thesametimemeanlevelsofreported
stig- tion/discrimination
ma declinein sucha wayas to reducedepres- rejectionexperiences
(r = .436,p < .001)5sigand
sive symptoms.
Thus it is important
to evalu- nificantly
relatedto depressivesymptoms,
(r =
ate bothpossibilitiesto obtaina fullunder- secrecy(r = .143, n.s.) and withdrawal
thefourstigma
oftheeffects
of stigmaovertime.
standing
.034, n.s.) not.At follow-up,
Table 2 showsmeans,standarddeviations, variablesexplain20 percentofthevariancein
no declinein
andpairedt-tests
forthefourstigmameasures depressivesymptoms,
indicating
variables
at baselineand one year later.As the table the importanceof stigma-related
shows,thereis verylittlechangein themean with time. The fact thatthe stigma-related
forStigmaScales at Baselineand
TABLE 2. Means,StandardDeviations,and Pairedt-tests
One-YearFollow-Up(N = 84)
Variable
PerceivedDevaluation/Discrimination
RejectionExperiences
Secrecy
Withdrawal
Baseline
Means
(s.d.)
Follow-Up
Means
(s.d.)
2.72
(.40)
.46
(.27)
.57
(.28)
.43
(.37)
2.76
(.41)
.42
(.26)
.57
(.31)
.44
(.37)
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Significance
ofPaired
t-tests
(p)
n.s.
n.s.
n.s.
n.s.
185
ON STIGMA AND ITS CONSEQUENCES
variablescontinueto have a strongeffecton chopathologyand shows thatthe effectof
depressivesymptomsat follow-upindicates rejectionexperiencesremainssignificant
and
thatthe effectsof stigmaendureeven when quitestrongevenwiththesecontrols.In fact,
indexesof severepsychiatric
symptoms
(psy- whenwe add thetwo follow-upindicators
of
choticsymptom
scale and BPRS) and social stigma(perceiveddevaluation/discrimination
functioning
(GAF) show dramaticimprove- andrejectionexperiences)
to an equationconment.
tainingtreatment
settingand thefourbaseline
Thispattern
ofresultsmakesitseemhighly measuresofpsychopathology
(notshown),we
unlikelythatstigma-related
perceptionsand findthatthestigmaindicators
accountforan
experiencesare merelyalternatemanifesta- additional10.9 percentof thevariancein the
tionsof symptoms.
If themeasureswerecon- follow-upCES-D. This suggeststhatstigma
foundedin thisway,themean scoreson the has a relativelystrongeffecton follow-up
stigmameasuresshouldhave declinedfrom depressivesymptoms
and is as important,
for
baselineto follow-up.Nevertheless,
thereare example, as baseline depressivesymptoms
otherways in which psychiatricand drug (whichaccountforabout9% ofthevariancein
abuse conditions
mightaccountforthecorre- follow-updepressivesymptoms).
The pattern
lationsbetweenstigmaand depressedmood. ofresultsinTable 3 is robustto changesinthe
In particular,
it is possiblethatinitialpsychi- specification
ofvariablesincludedintheequaatriccondition
mightaccountforlevelsofboth tion.Thusifwe add to each equationcontrols
stigmaand depressedmoodone yearlater.To forthebaselinevalueofthestigmameasure(s)
considerthispossibility,
Table 3 showsfour in question,we continueto findthatthefolregressionequationsrelatingfollow-upper- low-upmeasuresofstigmahavethesamepatand ternof significant
ceptions of devaluation/discrimination
effects
as shownin Table 3.
rejectionexperiencesto follow-updepressive In addition,ifwe entercontrolsforfollow-up
while holdingbaselinesymptoms scoreson the BPRS, the GAF, and thepsysymptoms
constant.
By holdingconstantbaselinesymp- choticsymptoms
scale to equation4, followtoms,we partialout of the stigmavariables up rejectionexperiences
remainsa significant
any influencethesesymptoms
mayhave had predictorof depressivesymptoms.We also
on them.Equation 1 shows thatfollow-up conductedanalysesentering
age, educational
devaluation/discrimination
is significantly level, and ethnicity
(AfricanAmerican,Hisassociatedwith follow-updepressivesymp- panic, and other)as controlvariables,but
toms net of baseline depressivesymptoms. becausethesevariableswereunrelated
to folEquation2 showsthesamepatternof results low-upCES-D withbaselineCES-D heldconforrejectionexperiences.Equation3 shows stant,andbecausetheydidnotaltertheeffects
that when both rejectionexperiencesand of eitherindicatorof stigma,we did not
perceiveddevaluation/discrimination
are in- include them in the equationsreportedin
has a uniqueeffecton Table 3. Finally,we testedfortwo formsof
cluded,onlytheformer
follow-updepressivesymptoms.6
thatmighthave led us to qualify
Equation4 interaction
adds severalothermeasuresof baselinepsy- our results.Firstwe testedwhethertypeof
TABLE 3. RegressionAnalysesShowingthe Effectsof Stigma Variables on Follow-Up
DepressiveSymptoms
Controlling
forBaselineSymptoms
(N = 84)
Standardized
RegressionCoefficients
BaselineCES-D
Treatment
Setting(TC = 1; CR-0)
PerceivedDevaluation/Discrimination
RejectionExperiences
BaselineBriefPsychiatric
RatingScale
BaselineGlobalAssessment
ofFunctioning
BaselinePsychoticSymptoms
R'2.184
Equation
1
Equation
2
Equation
3
.354**
-.219*
.256**
-.240*
.257*
-.235*
.115
-.219*
.094
.065
.211*
.386**
.351**
.273
.281
**p <.Ol; *p <.05.
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Equation
4
.325**
.104
-.181
.031
.323
186
JOURNALOF HEALTH AND SOCIAL BEHAVIOR
vs. commu- measuresof psychiatricsymptoms.In this
community
(therapeutic
treatment
with stigmamea- view, theperceptionof stigmais shapedby
nityresidence)interacted
Depressedpeopleare sensibut symptomatology:
symptoms
depressive
in
sures predicting
parainteraction.tiveto slightsand see themeverywhere,
foundno evidenceof significant
con- noidpeoplethinkothersaredoingthingstoget
This suggeststhatstigmahas relatively
settings. them,and so on. The associationbetween
acrossthetwotreatment
stanteffects
andbetweenstigmaand
betweenstig- stigmaandsymptoms
Secondwe testedforinteraction
be attributmameasuresandoutcomelevelsontheBPRS, otheroutcomeswould ultimately
on stigmameaofsymptoms
theGAF, andsubstanceabusebutagainfound able tothiseffect
Thismeansthereis sures.Butthepresentstudycastsdoubton this
no evidenceofinteraction.
associano strongevidenceto suggestthattheeffects explanation.If the symptom-stigma
effect,
an
such
by
dominated
indeed
were
tion
forpeople who are
of stigmaare different
inthe
decline
a
sharp
have
expected
would
one
symptoms,
to
BPRS
regard
with
well
doing
social functioning,and substance use as perceptionof stigmawhen symptomsimButthisdidnotoccur
opposedto thosewho are doingless well on provedso dramatically.
-the mean of the stigmameasureshardly
thesedimensions.
changedat all frombaseline,whensymptoms
whenthey
werehigh,to one-yearfollow-up,
weremuchlower.7The failureof thishypothDISCUSSION
becauseitpoints
esishasbroaderimplications,
explanaas an alternative
At theoutsetof thispaper,we drewatten- to itsineffectiveness
intheliterature
reported
the tionforotherfindings
tion to extensiveevidencedocumenting
positiveeffectsof mentalhealth on stigmaand itsconsequences.
short-term
withGove's
One mayalso argue,consistent
on symptomsand relapse. Given
treatment
such strongevidence concerningpositive (1982) claims, that the effectsof stigma
small("do notpose
herearerelatively
effectsof mentalillnesslabelingand subse- reported
one mightwonderwhether a severe problem") and have only been
quenttreatment,
to lastforone year("are transinegativeeffectsthrough demonstrated
any countervailing
above) indicates
(reported
stigmacan be of muchconsequenceby com- tory").Ourfinding
and rejection
parison.But the evidence also shows that thatdevaluation/discrimination
over
10 percent
explain
uniquely
time
that,
and
experiences
dissipatewith
benefits
treatment
at folas a result,otherprocessesare likelyto oper- ofthevariancein depressivesymptoms
thatis largerthantheeffect
to offsetthe benefitsof low-up-an effect
ate simultaneously
It is also as
treatment.This coupled with theoryand of baselinedepressivesymptoms.
researchdocumentingpervasive effectsof largeas orlargerthantheassociationtypically
ofthestress
thatstigmamay foundbetweenmanycomponents
stigmaled us to hypothesize
life
stressful
mastery,
on depressivesymptoms process(social support,
effects
haveenduring
mentalhealth events, chronic stressors)and depressive
evenin thecontextof effective
We tested symptoms
(e.g.,Pearlinetal. 1981;Turnerand
and substanceabuse interventions.
studyof men Marino 1994). At the very least, then,the
in a longitudinal
thishypothesis
improve- effectis not small relativeto the kinds of
whoshowedtheexpectedshort-term
and substanceabuse effectsthatsocial scientistshave takenserimentin theirpsychiatric
to one- ously in other contexts. Moreover, with
conditionsfromentryintotreatment
natureof
ortransitory
yearfollow-up.In supportof ourhypothesis, respecttotheshort-term
we foundthattwo aspectsof stigmathatwe theeffectsof stigma,our studyputsdefinite
the
limitson whatcan be claimedregarding
devaluation/discriminaidentified-perceived
reportsof discriminationmeaningof suchterms.We have showna reltionand respondent
to affectthe men in ativelystrongassociationbetweenstigmaand
experiences-continued
one yearaftertreatment
fashioneventhoughthemengen- depressivesymptoms
anuntoward
inresponsetothe began. While it is possiblethatsuch effects
presumably
erallyimproved,
mightdissipateovera longertime,theirmagoftreatment.
positiveeffects
explanationthatmightbe nitudeat one yearsuggeststheywouldlikely
An alternative
to accountfortheassociationbetween endureat leastfora whileaftertheone-year
offered
is mark.Ratherthanbeingdismissedas transitostigmameasuresand depressivesymptoms
with ry,effectsthatlast as long as thisshouldbe
thatthestigmameasuresareconfounded
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ON STIGMA AND ITS CONSEQUENCES
187
aspectof the NOTES
takenseriouslyas an important
formental
livesofpeoplewho seektreatment
1. One of thegoals of thestudyas a wholewas to
healthand substanceabuseproblems.
of thesetwo formsof
evaluatetheeffectiveness
we
In the contextof theseconsiderations,
is based
community
therapeutic
The
intervention.
evidenceof the
believewe haveaddedfurther
in
on a modelthatinvolvesintenseintervention
of stigmaas an influ- whichmembersare confronted
importance
fundamental
by one another
ence on people withmentalillnessand subchanges
and givensupportto makefundamental
stanceabusers.Of course,futureworkwill
residencemodel
in theirlives. The community
need to assess the externalvalidityof the
providessupervisedlivingand access to treatthefindingin different mentbutinvolvesless oftheintensegroupexperesultsby replicating
These
community.
typesof stigmatizing riencethanthe therapeutic
withdifferent
contexts,
imporcentral
of
are
not
in
approach
differences
stigconsequencesof
and different
conditions
tanceto thispaperbutwe do takeaccountofany
ma. To theextentthatsuchfutureworkconmayhaveas describedbelow.
firmsour results,practicaland theoretical effectsthey
2. The fourmeasures-devaluation/discrimination,
follow.
implications
secrecy,andwithdrawalrejectionexperiences,
Froma practicalpointof view,thefinding formedseparatefactorsin a factoranalysis.The
in thisstudy,coupledwiththegrowreported
analysiswas basedon a largernumber(N = 267)
ing evidencefrommanyotherstudies,raises
of subjects.Thesesubjectscompletedthestigma
in
measuresbut did not necessarilyparticipate
an importantchallenge for health care
studythatformsthebasisofthis
thelongitudinal
The messageis simple:Stigmahas
providers.
sample.
effects,effectsthat remaineven
important
section,our
we indicatedin themeasurement
3.
As
in
participating
while
improve
whenpeople
scale includesitemsthat
experiences
rejection
are
Healthcareproviders
programs.
treatment
"ever" experireferto whetherthe respondent
facedwiththechallengeof how to
therefore
preformof rejectionthereby
enceda particular
addressstigmain itsownrightiftheywantto
cludinga validdecreasein meanlevelsof rejecmaximizethequalityoflifeforthosetheytreat tion experiencesover time. Still the recall of
beyond
oftreatment
thebenefits
andmaintain
rejectionexperiencesmighthave declined,particularlyif reportsof rejectionexperiencesare
theshortterm.
so as toproduce
bysymptoms
pointof view,thisstudy heavilyinfluenced
Froma theoretical
For thisreasonit is
adds evidenceto a modifiedlabelingperspec- confoundedmeasurement.
to knowthatreportsof rejectiondid
instructive
causal role to
tive thatassignsan important
notdecline.
or
outcomes
untoward
in
stigma producing
similarto the
4. Measuresof copingorientations
"secondarydeviance."It does so by demon- ones used in thisstudyhave been significantly
stratingthat stigma has a substantialand
associatedwithnegativeoutcomesin otherstudthat
enduringeffecton depressivesymptoms
ies (Link et al. 1989, 1991). Thereare several
Like
operateswhilepeople are in treatment.
possiblereasonsthatwe failedto findsuch an
we find that the
associationin thisstudy.First,thesampleis relRosenfield(forthcoming),
ativelysmall.Second,thesecopingorientations
and stigmacoexistand
effectsof treatment
on outcomesotherthandepresmayhaveeffects
yielda kindof"packagedeal" ofgoodandbad
likelyforthe
This
is particularly
sive
symptoms.
effectsthatresultfromofficiallabeling.The
used in thisstudywhich
withdrawal
of
measure
ofan effectof stigmaraises
finding
consistent
Finally,
onjob procurement.
is focusedexplicitly
new theoreticalquestionsabout the mechathesecopingmechanismsmay have been relanisms throughwhich stigmahas enduring tivelyunimportant
timebutmay
at thisparticular
effects.Does theeffectendurebecauserejecforgood or ill at otherpointsin the
have effects
tionby otherscontinuesunabated?Is it diffi- stigmatized
person'slife.
to notethatthe"ever"wordingof
cult forthe labeled personto shake offthe 5. It is important
from
itemsdoes notdetract
the
of
rejection
some
to
it?
attached
meanings
the
markand personal
thiscorrelation
(or subseOr is it thetraumaand pain of past rejection ourabilityto interpret
as indicatingan
quentregressioncoefficients)
person?Most
thatstayswiththe stigmatized
tellsus
ofstigma.The correlation
effect
enduring
betweenthese
likelysome dynamicinterplay
thatregardlessof whenthe reportedrejections
mechanismsaccountsfortheenduringeffect mayhaveoccurredtheassociationremains.
researchwould 6. Thisresultsuggeststhepossibility
of stigma.In anyevent,future
thatrejection
do well to conceptualizeand testthesepossioverperceiveddevalupredominate
experiences
in explainingdepressive
bilitiesin orderto achievea morecomplete ation/discrimination
to adoptthisinterWe are reluctant
symptoms.
of stigma'seffects.
understanding
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188
JOURNALOF HEALTH AND SOCIAL BEHAVIOR
betweenthe
because the correlation
pretation,
high(r = .44) and the
twomeasuresis relatively
to
small,makingitdifficult
samplesize relatively
obtainstableestimatesof theuniqueeffectsof
is that
thesevariables.Whatis moreimportant
these differentoperationalizationsof stigma
amountsof variance
explainsignificant
together
inpsychiatric
evenwhendramatic
improvements
haveoccurred.
anddrugabuseconditions
7. As we notedabove,someofthestigmaitemsask
As a
reports
ofrejectionexperiences.
forlifetime
result,totheextentthatthemeasuresareperfectof
ly valid,one would not expecta diminution
Butthe
stigmascoresfrombaselineto follow-up.
we
explanation
corerationaleforthealternative
is thatthemeasuresarenotvalid
areconsidering
at
bya person'ssymptoms
confounded
butrather
Thus, accordingto this
the time of reporting.
thestigmascoresshould
explanation
alternative
negativeviews of
declineas symptom-induced
diminish
lifein generaland stigmain particular
The factthatthemean
withdecliningsymptoms.
scores on the stigmavariablesremainconstant
overtimeis whatleadsus to doubtthevalidityof
explanation.
thisalternative
APPENDIX
ItemWording
PerceivedDevaluation/Discrimination
mentalpatientscannotbe trusted.
1. Mostpeoplebelievethatformer
a manwhohas beena patientin a mentalhospital.
2. Mostwomenwouldnotmarry
formentalillnessis dangerous.
3. Mostpeoplebelievethata manwhohas beenhospitalized
formentalillness.
4. Mostpeoplethinkless ofa personafterhe has beenhospitalized
formentalillness.
5. Mostpeoplelookdownon peoplewhohavebeenhospitalized
as theaverageperson.
6. Mostpeoplethinkthatmentalpatientsarejustas intelligent
formentalillness.
willnothirea personwhohas beenhospitalized
7. Mostemployers
8. Do youbelievethatmanypeopleareafraidofthosepeoplewhohavebeenpatientsin mentalhospitals?
9. Mostpeoplebelievethatdrugaddictscannotbe trusted.
a manwhohas beenaddictedto drugs.
10. Mostwomenwouldnotmarry
11. Mostpeoplebelievethata manwhohas beenaddictedto drugsis dangerous.
fordrugproblems.
12. Mostpeoplethinkless of a personafterhe has beenhospitalized
fordrugproblems.
13. Mostpeoplelookdownon peoplewhohavebeenhospitalized
as theaverageperson.
14. Mostpeoplethinkthatdrugaddictsarejustas intelligent
willnothirea personwhohas beenaddictedto drugs.
15. Mostemployers
RejectionExperiences
afteryouhad beena patientin a mentalhospital?
treatyoudifferently
1. Did someofyourfriends
in a mentalhospital?
2. Have youeverbeenavoidedbypeoplebecausetheyknewyouwerehospitalized
3. Have peopleusedthefactthatyouwerein a mentalhospitalto hurtyourfeelings?
or a roombecauseyouhadbeena patientin a mentalhospital?
4. Have youeverbeenrefusedan apartment
avoidpeoplebecauseyouthinktheymightlookdownon peoplewhowerein a mental
5. Do yousometimes
hospital?
aroundyou?
formentalillnesswerepeopleuncomfortable
6. Afterbeinghospitalized
7. Did someofyourfriends
rejectyouaftertheyfoundoutyouwereusingdrugs?
8. Did someofyourfamilygiveup on youwhentheyfoundoutyouwereusingdrugs?
9. Weresomepeopleafraidofyouwhentheyfoundoutyouuseddrugs?
becausetheyknewyouwerea drugaddict?
10. Have peopletreatedyouunfairly
11. Do yousometimes
avoidpeoplebecauseyouthinktheymightlookdownon peoplewhohavehad a drug
problem?
paid youlowerwagesbecausetheyknewyouhada drughistory?
12. Have someemployers
Secrecy
hidethefactthatyouwerea patientin a mentalhospital?
1. Do yousometimes
a secret?
ofmentalhospitalization
2. Do youthinkitis a good idea to keepyourhistory
3. Wouldyouadvisea close relativewhohadbeentreatedformentalillnessnotto tellanyoneaboutit?
4. Do youwaituntilyouknowa personwellbeforeyoutellthemyouhavebeena patientin a mentalhospital?
5. Do yousometimes
hidethefactthatyouwereonce addictedto drugs?
ofdruguse a secret?
6. Do youthinkitis a good idea to keepyourhistory
7. Wouldyouadvisea close relativewhohad a seriousdrugproblemnotto tellanyoneaboutit?
8. Do youwaituntilyouknowa personwellbeforeyoutellthemaboutyourproblemwithdrugs?
Withdrawal-Employment
of mental
was goingto ask aboutyourhistory
1. Wouldyouapplyfora job ifyouknewtheemployer
hospitalizations?
mentalpatients?
didn'tliketo hireformer
2. Wouldyouapplyfora job ifyouknewtheemployer
ofdruguse?
wouldask aboutyourhistory
3. Wouldyouapplyfora job ifyouknewtheemployer
didn'tliketo hireformer
drugaddicts?
4. Wouldyouapplyfora job ifyouknewtheemployer
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ON STIGMA AND ITS CONSEQUENCES
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Measurement
Bruce G. Link is associateprofessor
ofpublichealthat ColumbiaUniversity
and a ResearchScientistat
New YorkStatePsychiatric
Institute.
His researchinterests
includetheimpactof labelingand stigmaon
peoplewithmentalillness,theassociationbetweenmentalillnessandviolence,andthesocial epidemiologyofmentalandphysicalillnesses.
New York
ElmerL. Strueningis DirectoroftheEpidemiology
ofMentalDisordersResearchDepartment,
researchis focused
StatePsychiatric
Institute,
and AssociateProfessor,
ColumbiaUniversity.
His current
on thesocialandpsychological
experience
ofpeoplewhoarecaregivers
forpeoplewithmentalillness,on
ofhometheevaluationoftreatment
programs
forpeoplewithmentalillness,andon thesocialexperience
lessness.He also has a stronginterest
in theinfluence
ofattitudes
towardmentalillnesson thewelfareand
behaviorofpeoplewithmentaldisorders.
Inc. and the Principal
Michael Rahav is Directorof Researchand Evaluationat ArgusCommunity
ofDrugAbusegrantto studyhomeless,mentally
ill,chemically
abusInvestigator
on a NationalInstitute
illassociatedwiththehomelessness-mental
ingmen.His researchfocuseson familyandsocialconditions
ness-chemicalabuse syndrome.
of SouthernCalifornia.Her research
of sociologyat theUniversity
Jo C. Phelan is assistantprofessor
and actionsrelatedto inequality
and itslegitiinterests
includehomelessness,
social stigmaand attitudes,
mation.
ResearchInstitute
(NDRI) inNew York
LarryNuttbrockis ProjectDirectorattheNationalDevelopment
focuson thesocial
City,evaluatingthedeliveryof servicesto homelesspeople. His researchinterests
menandwomen.
experienceofhomeless,substance-abusing
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