The Subtle Side of Stigma: Understanding and Reducing Mental Illness Stigma from a Contemporary Prejudice Perspective

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Journal Article

Ableism, as it relates to mental illness, is a serious social issue that exists across nations and cultures. Implicit stigma caused by ableism can be especially problematic given that it is typically expressed subtly and automatically causing it to remain unnoticed and thus unchanged. This research illustrated across two studies that individuals have automatic ableist attitudes toward mental illness, yet the expression of stigma depends on the combination of their implicit and explicit attitudes. Furthermore, Study 2 was the first to demonstrate an effective intervention designed to specifically target implicit stigmatizing attitudes toward mental illness. The findings have implications for implementing social policies that serve to raise awareness of and reduce implicit stigma to ultimately improve the lives for those affected by mental illness.

Journal of Social Issues
Type of Article
Journal Article
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The following is an excerpt of the intervention methodology. For more information, please see the full text of the article on the publisher's website or through your institution's library.

Study 1

Participants Participants were 65 (54 women, 11 men; Mage = 21, SD = 4.31) introductory psychology students from York University in Toronto, Canada [...]. Approximately 33% of participants identified their ethnicity as South Asian, 26% East Asian, 19% White, 14% Black, and 3% Latin American. Approximately 75% were single, 20% in a committed relationship, 3% common law, and 1% married.


Explicit attitudes. Explicit stigmatizing attitudes toward mental illness were measured with the Mental Illness Stigma Scale. The MISS is a 28-item questionnaire that assesses seven factors related to mental illness stigma, including anxiety, relationship disruption, hygiene, visibility, treatability, professional efficacy, and recovery. [...] All items are measured on a Likert scale from 1 (“strongly disagree”) to 7 (“strongly agree”). [...]

Implicit attitudes. Implicit stigmatizing attitudes toward mental illness were measured with the Go/No-Go Association Task. The GNAT assesses implicit attitudes or beliefs based on the strength of association between a target category (e.g., mental illness) and two poles of an attribute dimension (e.g., dangerous–harmless). The GNAT is based on signal detection theory whereby the strength of association is measured by the degree to which items belonging to the target category (e.g., mental illness) and attribute (e.g., dangerous) can be discriminated from distracter items that do not belong to those concepts. [...] To assess automatic attitudes toward mental illness, participants were instructed to associate mental illness with the attributes (1) negative versus positive, (2) dangerous versus harmless, and (3) helpless versus competent. [...] During the critical blocks, participants were presented with two categories on the computer screen at the same time (e.g., mental illness and negative), followed by a single stimulus presented in the middle of the screen. In this study, the stimuli presented in the middle of the screen were words belonging to either of the two categories as well as distracters. [...] Participants were asked to determine whether or not the stimulus in the middle of the screen belonged to one of the two categories whose labels appeared at the top of the screen. If the stimulus belonged to either of these categories (e.g., mental illness and negative), participants were told to press the space bar (the “go” response). If the stimulus was a distracter item and did not belong to either of the two categories (e.g., positive), they were told not to press anything (the “no-go” response). [...] The same procedure was applied to assess participants’ automatic associations between mental illness and dangerous/harmless and mental illness and helpless/competent. Each attribute pairing consisted of 60 trials (20 practice trials and 40 critical trials) for a total of 180 trials. [...]

Social distance. A modified version of the Social Distance Scale was used as a proxy measure for behavioral manifestations of mental illness stigma (i.e., avoidance). In the current study, participants responded to seven items based on their willingness to interact with an individual with a mental illness [...]. Responses were rated on a scale of 1 (“definitely not willing”) to 7 (“definitely willing”). [...]

Helping behavior. We also examined participants’ actual willingness to help individuals with mental illness by allowing them to choose whether to donate to a mental illness versus a physical illness charity. Participants were told that the researchers would be donating $50 to support either the Canadian Mental Health Association or the Canadian Diabetes Association depending on the total number of votes that participants allocated to each organization. Specifically, participants were given a total of 10 votes that they could distribute to each organization however they wished [...] and that the organization that received the most votes at the end of the study would receive the $50 donation [...].

Covariates. Participants also completed two scales that assess constructs known to be associated with reduced self-reported mental illness stigma, including familiarity with mental illness and social desirability bias.

Familiarity with mental illness. To assess familiarity with mental illness, participants completed a version of the Level of Contact Report, which is a self-report measure that provides respondents with a list of situations in which they may have encountered individuals with mental illness. [...] Scores range from 0 (least familiar, e.g., “I have never observed a person with mental illness”) to 11 (most familiar, e.g., “I have a mental illness, or have had one at some point in my life”).

Marlowe-crowne social desirability scale – short form.  To account for the potential effect of a socially desirable response style on explicit self-reported attitudes toward mental illness, a short version of the Marlowe-Crowne Social Desirability Scale was included [...] The scale consists of 11 items that assess participants’ tendency to respond in a socially desirable manner [...].

Procedure Participants were provided a URL that allowed them to complete the entire study online. [...] After first providing informed consent, participants were instructed to complete the GNAT, which was described as a reaction time task, followed by the questionnaire. After completing both parts of the study, they were directed to a debriefing screen explaining the full details about the nature and purpose of the study.

Study 2

[...] The aim of Study 2 was to design and implement a novel intervention to reduce implicit stigmatizing attitudes toward mental illness. [...] Although Devine’s intervention utilized a number of different bias-reducing strategies, we incorporated the three that have been shown to be particularly effective in the bias-reducing process and applied them to mental illness specifically, including (1) education, (2) bias feedback, and (3) contact.

Intervention to Reduce Implicit Mental Illness Stigma Education. The education component of the intervention involved educating participants about the existence and nature of negative automatic bias toward mental illness and how it can influence discrimination. Education about explicit mental illness stigma and its negative impact on individuals with mental illness has shown to be effective in reducing explicit negative attitudes toward mental illness. [...]

Bias feedback. The bias feedback component consisted of providing feedback to participants about their own implicit bias toward mental illness (which they were told was based on their GNAT score from part 1 of the study) of which they were likely unaware. [...]

Contact. The contact component involved providing virtual interpersonal contact with an individual with mental illness (through watching a video). [...] Four conditions were created to examine the effectiveness of the different intervention components in reducing negative automatic attitudes toward mental illness. Condition 1 included the education and bias feedback components. [...] Condition 2 included the education, bias feedback, and contact components because it was of interest to examine whether contact would augment the effects of education and bias feedback. Condition 3 included contact only to determine whether contact with mental illness would independently reduce negative implicit attitudes as has been shown with explicit attitudes. Condition 4 consisted of a control condition to determine whether the intervention components were at least more effective than no intervention at all. [...] Finally, the contact-only condition (Condition 3) was predicted to be more effective than the control condition (Condition 4).

Participants Participants were 195 (143 women, 50 men, two unreported; Mage = 20, SD = 4.79) introductory psychology students from York University in Toronto, Canada [...]. Approximately 20% of participants identified their ethnicity as South Asian, 20% East Asian, 25% White, 15% Middle Eastern, 8% Black, and 2% Latin American. Approximately 65% were single, 30% in a committed relationship, 3% married, and 1% common law.

Measures All of the measures used to assess the variables in Study 1 were also used in Study 2. [...]

Procedure Part 1. Participants completed the study in the laboratory on a computer with an experimenter present. [...] After providing informed consent, participants completed the implicit attitudes measure (GNAT), followed by an online questionnaire that contained the explicit attitudes measure and measures of discrimination (i.e., social distance and helping behavior). Participants were then reminded to return to complete the second part of the study at a later date (approximately 1 week later for all participants to maintain consistency).

Part 2. Part 2 of the study was also completed in the laboratory on a computer with an experimenter present. Participants were randomly assigned to one of the four conditions. In Condition 1 (education and bias feedback), participants read information on how automatic negative attitudes are developed, contribute to subtle forms of discrimination toward mental illness, and how to begin to reduce negative automatic bias. After the education component, participants were told that they would receive feedback on their GNAT score from part 1 of the study to indicate the extent to which they have a negative automatic bias toward mental illness. However, all participants were given the same feedback regardless of how they scored. The feedback message included: [Text Stimulus A]. The purpose of informing participants that they had a negative automatic bias toward mental illness was to produce feelings of dissonance in those who genuinely did not want to be biased, thus providing motivation to reduce the bias. In Condition 2 (education, bias feedback, and contact), participants received the same information in Condition 1 followed by the contact portion. The contact condition involved watching a TED Talk video online of a young male university student describing his experience with depression as well as the stigma he faced as a result. The intention of the video was to disprove negative stereotypes of mental illness and elicit concern about the effects of discrimination, both of which are factors believed to be involved in reducing stigma toward mental illness through contact. This particular video was also chosen because it was believed to be a good fit with the target audience in terms of promoting their level of engagement and connection with the individual with mental illness. Research on the effectiveness of varying types of interpersonal contact in reducing mental illness stigma has shown that forms of virtual contact can be just as effective as in person. In Condition 3 (contact only), participants only watched the video of the person with mental illness. In Condition 4 (control), participants read an article about emotions and psychology. After receiving the intervention or control conditions, participants completed the GNAT (to assess implicit attitudes) followed by the questionnaire assessing explicit attitudes. [...]

Type of Prejudice/Bias