Abstract
Objective
Important components of stigma include imagining what others might think of a stigmatized status, anticipating what might transpire in an interaction with others, and rehearsing what one might do if something untoward occurs. These imagined relations are here called “symbolic interaction stigma” and can be impactful even if the internalization of negative stereotypes fails to occur. Concepts and measures that capture symbolic interaction stigma are introduced and a preliminary assessment of their impact provided.
Methods
Four self-report measures of symbolic interaction stigma (perceived devaluation discrimination, anticipation of rejection, stigma consciousness and concern with staying in) were developed or adapted and administered to a sample of individuals who have experienced mental illness (N=65). Regression analyses examined whether forms of symbolic interaction stigma were associated with withdrawal, self-esteem and isolation from relatives independent of measures of internalization of stigma and rejection experiences.
Results
As evidenced by scores on four distinct measures symbolic interaction stigma was relatively common in the sample, somewhat more common than the internalization of stigma. Additionally, measures of symbolic interaction stigma were significantly associated with withdrawal, self-esteem and isolation from relatives even when a measure of the internalization of stigma was statistically controlled.
Conclusions and Implications for Practice
The study suggests the potential importance of considering symbolic interaction forms of stigma in understanding and addressing stigma and its consequences. Being aware of symbolic interaction stigma could be useful in enhancing rehabilitation goals if an approach to counteracting the negative effects of these aspects of stigma can be developed.
A very useful distinction between “public stigma” and “self stigma” was introduced by Corrigan and Watson (2002). Following on that distinction, there has been a growth of interest in understanding self-stigma (Corrigan and Watson, 2002; Drapalski et al 2013), measuring it (Ritsher et al., 2003; Corrigan et al., 2012; Barney et al., 2010), evaluating its consequences (Livingston & Boyd 2010), and intervening to mitigate those consequences (Mittal et al., 2012; Yanos et al., 2012; Lucksted et al., 2011). Broadly conceived, self-stigma might be conceptualized to include anything that is perceived, anticipated, interpreted or embodied by the stigmatized person –anything that is in any way psychologically processed by the individual. But as introduced by Corrigan and colleagues (Corrigan and Watson 2002; Corrigan et al., 2005; Corrigan et al. 2010) self-stigma is a more focused concept that refers to the process of internalizing negative stereotypes. As Corrigan and Watson (2002, p. 35) put it, self-stigma accompanies public stigma as a “second misfortune” that results when “persons with mental illness, living in a culture steeped in stigmatizing images, may accept these notions and suffer diminished self-esteem and self-efficacy as a result.” Corrigan and Watson (2002) use social cognitive theory to conceptualize how the process of internalization unfolds at four levels. At the first level, stereotype awareness, people are aware of societal stereotypes about people with mental illnesses but may not necessarily agree with those stereotypes. The second level, stereotype agreement, occurs when people believe the stereotypes are true – people with mental illnesses are dangerous, incompetent and weak willed – but they may not believe the stereotypes to be true about themselves. The third level concerns whether a person with mental illness believes that he or she is personally dangerous, incompetent or weak willed. Finally in a fourth level, a person experiences what Corrigan and colleagues call “self-esteem decrement” by losing respect for one’s self because one fits the stereotypes. Thus for “self-stigma” to be fully manifested, the societal stereotypes and prejudices must be internalized. Then to the extent that stereotypes (dangerousness, incompetency) are internalized, “diminished self–esteem and self–efficacy” is the consequence (Corrigan et al., 2006, p. 875).
Stigma in the Domain of Symbolic Interaction
Substantial evidence shows that the internalization of negative stereotypes is indeed a critically important “second misfortune” experienced by people with mental illnesses (Livingston and Boyd 2010). But the internalization of stereotypes is not the only way harm can be produced. We focus attention on processes involving the anticipation of reactions of others that are potentially harmful even if internalization of stereotypes does not occur. Because these processes are distinct from internalization, we give them a new name drawing on sociological concepts to call them “symbolic interaction stigma.” Although similar ideas could be drawn from multiple strands of social science theory, we use the symbolic interaction approach (Mead 1934; Stryker 1980) within sociology for the observation that people commonly anticipate and rehearse expected interactions. People seek to foretell what others might think, conjure notions about what could transpire, and imagine useful strategies to achieve desired ends -- all before an interaction takes place. This sort of “symbolic interaction” can be consequential for self-evaluations and for guiding future behavior. It can be evident in the anticipation of what “most people” think (e.g. Link et al 1989) or in what particularly important “significant others” (parents, partners, employers) think (Markowitz et al. 2011). We chose the symbolic interaction formulation for this project because it focuses on a class of concepts (see below) that are linked together by the fact that they are all one form or another of anticipated interaction. At this point we do not conceptualize them as constituting a process with one aspect leading to another but rather focus on the possibility that while they are distinct from the internalization of negative stereotypes they may, nevertheless, induce substantial difficulty in the lives of people with mental illnesses.
Perceptions of Societal-Level Devaluation and Discrimination is a concept put forward by Link and colleagues (1987; 1989) in the development of “modified labeling theory.” Consistent with symbolic interaction, devaluation-discrimination concerns what people think “most other” people think about someone identified as having a mental illness. Will they look down on, lose respect for, and distrust someone with mental illness, and will they avoid marrying, hiring or socially interacting with such a person? This imagining of others’ reactions can induce internalization but it can also be harmful in other ways. Even if a person is convinced of his/her competence, certain that he/she is trustworthy and confident that he/she is harmless, such a person may still worry about the reactions of others. He/she may avoid anticipated negative reactions and stay away as a consequence, thereby losing opportunities that might bring desired ends such a job, a date, a place to live or just some enjoyable interaction. Additionally even if one stays engaged, anticipating negative reactions can impair performance as some of the classic social psychological studies of stigma clearly demonstrated (Farina et al., 1971). Thus while societal level perceptions of devaluation and discrimination may induce internalization of negative stereotypes, they may also be problematic in ways that do not involve internalization.
Stigma Consciousness is a concept developed by Pinel (1999) regarding race, gender, and sexual minority bias. Stigma consciousness is an anticipation of being stereotyped and having the stereotyped status be a central feature guiding how others evaluate and relate to you. For example, gender stigma consciousness for a woman may be evident in agreement with the statement, “When interacting with men, I feel like they interpret all of my behaviors in terms of the fact that I am a woman.” Because it involves anticipation about what others might be thinking, it coheres with the theme of symbolic interaction regarding stigma. Although Pinel did not address it, people with mental illnesses could be concerned that their history of mental illness is a central feature guiding how others relate to them. Again, even in the absence of internalization, stigma consciousness can be harmful because it keeps the stigmatized status salient, thus demanding focused attention that might otherwise have been directed elsewhere.
Rejection Sensitivity is a concept developed by Downey and Feldman (1996) that refers to the anxious expectation of rejection from others. Originally applied to the anticipation of rejection from significant others, in an extension, African-American participants are asked for example, to imagine “that you are in a pharmacy, trying to pick out a few items. While you're looking at the different brands, you notice one of the store clerks glancing your way.” The respondent is then asked, “How concerned/anxious would you be that the clerk might be looking at you because of your race/ethnicity?” (Mendoza-Denton et al., 2002). Thus the rejection sensitivity concept is about what you think others might be thinking about you. Link and Phelan (2014) applied this approach to the area of mental illness stigma and relabeled the scale “Concern with Staying In,” based on the observation that people with mental illness frequently fear that others will view them as symptomatic and unable to stay within normative bounds of feelings, beliefs or behaviors. Again, in accord with the notion of symbolic interaction, the concept refers to anticipated scenarios, and again, one can be sensitive to rejection or concerned with staying in whether or not one has internalized negative stereotypes.
Anticipation of Rejection is a concept closely related to rejection sensitivity, but instead of focusing on what a person concludes about someone else’s action (e.g. the store keeper above), anticipation of rejection focuses on the person’s own forecasting of whether rejection will occur. How much does the person worry that others will look down on him, devalue her opinions, or not want to date him or hire her? The concept is a new extension of modified labeling theory that focused, as described above, on what people thought most other people believed about a person who developed mental illness. Implicit in the theory was the idea that a person’s perception that most people devalue and discriminate against people with mental illnesses would translate into a personal worry about rejection. As have others (e.g. Quinn et al, 2009) we measure this anticipation of rejection in the current research, providing an extension of modified labeling theory. Again, this concept is about symbolic interactions – an anticipation of a negative reaction – and can also be experienced even if one does not internalize stereotypes and apply them to the self.
The Importance of Symbolic Interaction Stigma
While symbolic interactions as described above involve imagined interactions, what is imagined could have a very strong reality base. To understand this point, imagine telling people with mental illnesses, “No – it is just your perception – people are totally accepting of people with a history of mental illness (societal level devaluation-discrimination); you are wrong to think that people’s interactions with you are framed by your having had a mental illness (stigma consciousness); people are not watching you to see if your symptoms are re-emerging in ways that could make you behave outside of normative bounds (concern with staying in); and you have no reason to worry that people might reject you if they know you have been hospitalized for mental illness (anticipation of rejection).” These arguments are probably not realistic and highlight the point that people with mental illnesses have a real predicament to confront and when they conjure, imagine and rehearse, it is about situations and perceptions that are potentially very real and possibly threatening.
Testing the Utility of Symbolic Interaction Stigma
Having drawn attention to concepts that could have effects irrespective of the internalization of stigma, the critical question lying before us is whether such concepts capture processes important in determining outcomes like experiencing social exclusion or evaluating one’s self negatively. We use a small sample of people with psychosis (N=65) who answered multiple questions pertaining to societal-level perceived devaluation-discrimination, stigma consciousness, concern with staying in, and the anticipation of rejection, to gauge whether these constructs influenced outcomes independently of measures of internalized stigma and experienced rejection. Additionally, since we also expect internalized stigma to be important, we assess whether these same constructs are predictive of the internalization of stigma. If we find no independent association between the four domains of symbolic interaction stigma and internalized stigma, and the outcomes of withdrawal, self-esteem or isolation from relatives, then these symbolic domains can be ignored in efforts to reduce the negative impact of stigma. On the other hand, if we find independent associations between these domains and self-esteem and exclusion, then approaches to addressing stigma in people with mental illnesses may need to give additional consideration to these phenomena. Additionally, to the extent that domains of symbolic interaction stigma are associated with internalized stigma, we might worry that if left unaddressed by interventions, these symbolic domains might cause levels of internalized stigma to recalibrate to original levels during a post-intervention period – even if an intervention temporarily improves internalized stigma.
METHODS
Participants (N=65) were inpatients recruited from three psychiatric hospitals in New York City and one psychiatric hospital in New Jersey between 2007 and 2009. We recruited patients if they had a primary diagnosis of schizophrenia (N=26), schizophreniform (N=1), schizoaffective (N=11), delusional (N=1), or psychotic disorder not otherwise specified (N=26). Patients were eligible if they were able to complete study instruments in English and had experienced fewer than seven previous hospitalizations in their lifetime. The latter requirement was implemented to facilitate the assessment of stigma amongst people whose experience was not overly affected by a chronic course of illness. Hospital medical records of newly admitted patients and staff recommendations were used to identify possibly eligible participants. Very few eligible patients declined to participate when approached by study staff. The median age of participants was 25 (range 18–54), 72% were male, and 44% had completed at least some college. Thirty-seven percent (N=24) were experiencing their first hospitalization, 32% (N=21) their second, with the remaining 31% (N=20) having experience between 3 and 6 hospitalizations. Interviews were conducted only after the participant’s symptoms had improved enough to be deemed competent to give informed consent usually after at least two weeks (only 5 were interviewed within two weeks). Based on self-identification, 49% of participants were African American, 22% Hispanic, 18% white and 11% other (mainly Asian). As a measure of severity of impairment, we extracted from participants’ hospital charts assessments of global assessment of function that can vary from 1 (severely compromised) to 100 (superior) and that showed a mean of 40 and a range of 10 to 65 in our sample..
Measures
We operationalized stigma constructs using self-report multiple-item scales, some of which we developed or adapted for the first time for this study. We provide alpha coefficients and example items in the text. The exact wording of each question, frequencies and summary scale statistics are in online tables S1–S5. All scales are scored by summing items (with appropriate reversals) and dividing by the number of items in the scale. Because participants experiencing a first hospitalization (N=24) may have had relatively short periods of time to have experienced stigma-related anticipations and experiences, we examined alpha coefficients within that group and found them generally similar to those in the overall sample. In rare instances of missing item data, the missing value was replaced by the sample mean for that item.
Experience of Rejection -- Daily Indignities
Participants were asked whether, as a result of a psychiatric hospitalization, he/she had experienced others avoiding or treating them unfairly very often (4), fairly often (3), sometimes (2), almost never (1) or never (0) during the past three months (eight items, Cronbach’s alpha = .85). Example items ask how often in the past three months did people “treat you unfairly because you have been a patient in a mental hospital?” and “avoid you because they knew you had been hospitalized in a psychiatric hospital?”
Symbolic Interaction Stigma
Perceived Societal-Level Devaluation-Discrimination is a 12-item version of Link’s (1987) (alpha = .80) measure that asks whether respondents strongly agree (3), agree (2), disagree (1) or strongly disagree (0) with statements indicating that most people devalue or discriminate against people who have been in mental health treatment. Example items of this widely used scale are: “Most people believe that entering a psychiatric hospital is a sign of personal failure” and “Most employers will not hire a person who has been hospitalized for mental illness.”
Stigma Consciousness is a five-item measure (alpha = .64) that assesses whether participants are acutely aware of their stigmatized status and monitor situations to determine whether people are treating them in accordance with that status. Participants are asked whether they “strongly disagree” (3), “disagree” (2), “agree” (1) or “strongly agree” (0) with statements such as: “My having a mental illness does not influence how people act with me,” and “I almost never think about the fact that I have a mental illness when I’m around others.”
Concern with Staying In/Rejection Sensitivity is a six-item scale (alpha = .76) that is derived from the concept of “rejection sensitivity” (Downey and Feldman 1996). Participants were presented with brief scenarios describing situations in which they might be perceived to be losing control or identified as having a mental illness and asked whether they would be very unconcerned (1), somewhat unconcerned (2), somewhat concerned (3), or very concerned (4) about other people’s reactions in the described situation. An example scenario is, “Imagine that you are having dinner with some good friends who know about your psychiatric hospitalization. It’s late, and you are really tired, and you say some things that don’t completely make sense. How concerned or worried would you be that your friends will think you are starting to show symptoms of mental illness?”
Anticipation of Rejection is a seven-item measure (alpha = .85) that asks whether during the past three months particpants had anticipated rejection because of their hospitalization for mental illness, with the responses being very often (4), fairly often (3), sometimes (2), almost never (1), or never (0). Example items include, “How often did you worry that employers might not hire you if they knew you had been hospitalized for mental illness?” and “feel that people would look down on you because of your hospitalization for mental illness?”
Although the sample is small, to gain some purchase on the potential overlap of constructs, we conducted an exploratory factor analysis to assess whether the four symbolic interaction measures formed separate factors.. Using principal axis factor analysis we found that items consistently clustered with items from the same construct, thereby providing some evidence that the constructs are distinct (Results are available in Table S6 in online supplement. Table S7 reports bivariate correlations between all study variables).
Internalized Stigma
We assessed Internalized Stigma using an eight-item scale (alpha = .89) with items assessing current or recent (past three months) beliefs and feelings indicative of internalization. Items capture the extent to which developing mental illness and entering a psychiatric hospital induced embarrassment, shame, sadness, feeling very different from other people, or feeling like a failure. Example items are: “How often in the past three months – very often (4), fairly often (3), sometimes (2), almost never (1) or never (0) – did you feel ashamed that you were hospitalized for mental illness?” or “feel embarrassed because you were hospitalized for psychiatric problems?”
Hypothesized Outcome Variables
Withdrawal is measured using a five-item scale (alpha = .69) that assesses whether respondents prefer being with people who also have a mental illness and whether they tend to avoid others who may reject them based on their hospitalization. Example items ask: “How often in the past three months – very often (4), fairly often (3), sometimes (2), almost never (1) or never (0) – did you: avoid social situations involving people who have never been hospitalized for mental illness?” and “think it was easier for you to be friendly with people who have been hospitalized for mental illness than with other people?”
Self-Esteem is an eight-item version of Rosenberg’s self-esteem scale (alpha = .81) that asks respondents whether they strongly disagree (0), disagree (1), agree (2) or strongly agree (3) with questions about whether respondents feel they can do things as well as most people or have respect for themselves. Example items are: “I feel I have much to be proud of” and ”I am able to do things as well as most other people.” An example of a reverse-score item is, “At times I think I am no good at all.”
Isolation from Relatives is assessed by a single item that asks whether after being hospitalized for mental illness respondents saw their relatives “less often,” “about the same amount” or “more often.” Because our focus is on isolation, we scored respondents who experienced less contact (1) whereas respondents with the same or more contact were scored (0).
RESULTS
How Common are Internalized Stigma and Symbolic Interaction Stigma?
Supplementary online Tables provide detailed evidence about how frequently and at what levels participants endorse each item in each domain of stigma. In order to summarize the results more succinctly we present, in this section, the proportion of participants responding above the midpoint of each of the scales (in all subsequent analyses scales are analyzed as continuous variables). The midpoint of the internalized stigma scale, which registers feeling embarrassed, ashamed, alienated, sad and different from others is three, corresponding to a report of “sometimes” to each of the eight items in the scale. Slightly more than one quarter of participants (26.2%) scored above the midpoint on this scale, suggesting that high levels of internalized stigma are present only in a minority of participants. The four domains of symbolic interaction stigma were slightly to substantially more common than internalized stigma when assessed as the percent above the midpoint: anticipation of rejection 29.2%; stigma consciousness 37.5%; perceived devaluation discrimination 49.2%; and concern with staying in 79.7%. As would be expected based on these results, a substantial percentage of the participants who report little internalized stigma nevertheless report symbolic interaction forms of stigma at moderate to high levels. In fact, of the 73.5% of participants who were below the midpoint on internalized stigma, more than four out of five (83.0%) were above the midpoint on one of the other four scales and 53.2% were above the midpoint on two or more. This evidence indicates that symbolic interaction stigma occurs with some frequency and among people who have not internalized stigma.
Are forms of Symbolic Interaction Stigma Independently Associated With Stigma-Related Outcomes?
Table 1 reports standardized regression coefficients for stigma measures predicting the stigma-related outcomes of withdrawal and self-esteem while controlling sociodemographic variables, psychiatric diagnosis and global assessment of functioning. For each outcome variable, two equations are shown. Equation 1 presents the effect of daily indignities (a measure of self-reported rejection) and internalized stigma; Equation 2 adds the four variables we have termed symbolic interaction stigma: perceived devaluation discrimination, stigma consciousness, concern with staying in, and anticipation of rejection. Our interest is in whether the variables gauging symbolic interaction stigma are independently associated with each outcome when internalized stigma and daily indignities are controlled. Concerning a tendency to withdraw, Table 1 Equation 1 shows that exposure to daily indignities (but not internalized stigma) is a significant predictor of withdrawal. Equation 2 adds the four symbolic interaction stigma measures, which increase the explained variance by 19%, principally because of the strong association between anticipation of rejection and the tendency to withdraw. Next, turning to self-esteem as an outcome variable, the first equation shows internalized stigma to be a strong predictor such that together with daily indignities it explains an additional 15% of the variance over and above the control variables. Equation 2 for self-esteem adds the symbolic interaction stigma variables, leading to an additional 16% increment in explained variance, mostly because stigma consciousness is strongly related to self-esteem.
Table 1.
Regression analysis showing effects of stigma variables on withdrawal and self-esteem (standardized coefficients)a
| Withdrawal |
Self Esteem |
|||
|---|---|---|---|---|
| Eq.1b | Eq. 2b | Eq. 1b | Eq. 2b | |
| Daily indignities | .35** | .30* | −.02 | .11 |
| Internalized stigma | .20 | −.23 | −.42** | −.36* |
| Perceived devaluation discrimination | — | .15 | — | −.02 |
| Stigma consciousness | — | −.20 | — | −.43** |
| Concern with staying in | — | .11 | — | −.12 |
| Anticipation of rejection | — | .56** | — | .01 |
| R-square | .30 | .48 | .32 | .48 |
| R-square Increment | .18** | .19** | .15** | .16** |
P < .10;
P < .05;
P< .01.
Standardized coefficients adjusted for age, gender, education, race/ethnicity psychiatric diagnosis and global assessment of functioning.
”Eq.” is an abbreviation for “Equation.”
Table 2 reports the results of a logistic regression analysis investigating whether participants were “less likely” (1) opposed to “as” or “more” likely” (0) to interact with relatives after being hospitalized for mental illness. To facilitate interpretation of the results, each of the predictor variables in Table 2 was standardized so that reported odds ratios represent the effect of a one standard deviation change in the predictor variable. As Equation 1 shows, the measure for daily indignities (but not internalized stigma) is significantly associated with isolation from relatives such that a one standard deviation unit change is associated with more than a doubling of the odds of isolation from relatives. Equation 2 shows the results with the four symbolic interaction stigma domains added to the equation. Notably the variable assessing a concern with staying in is significant with a one standard deviation unit change in that variable being associated with more than four times the odds of isolation.
Table 2.
Logistic regression analysis showing effects of stigma variables on isolation from relatives (odds ratios and 95% confidence intervals)a
| Isolation from Relatives |
||
|---|---|---|
| Eq. 1b | Eq. 2b | |
| Daily indignities | 2.43* (1.14, 5.16) | 2.88* (1.08, 7.64) |
| Internalized stigma | .95 (.41, 2.18) | .70 (.18, 2.67) |
| Perceived devaluation discrimination | — | 1.46 (.54, 3.95) |
| Stigma consciousness | — | .61 (.22, 1.74) |
| Concern with staying in | — | 4.33 (1.31, 14.35)* |
| Anticipation of rejection | — | .85 (.20, 3.51) |
P < .10;
P < .05;
P< .01.
Odds ratios associated with a one standard deviation unit change in an independent variable. Both equations adjusted for age, gender, education, race/ethnicity, psychiatric diagnosis and global assessment of functioning.
”Eq.” is an abbreviation for “Equation.”
Is Symbolic Interaction Stigma Associated with Internalized Stigma?
Table 3 Equation 1 shows the effects of daily indignities and perceived devaluation discrimination on internalized stigma with sociodemographic variables, diagnosis and global assessment of functioning controlled. Perceived devaluation discrimination is entered in this first step because modified labeling theory indicates that perceptions of what most other people think is a starting point for the internalization of stigma. As Table 3 shows, perceived devaluation discrimination and daily indignities are each marginally associated with internalized stigma, together accounting for an additional 10% of explained variance. Equation 2 adds the three other symbolic interaction stigma measures and shows that anticipation of rejection is strongly associated with internalized stigma and accounts for the marginal effects of perceived devaluation discrimination and daily indignities. As the table shows, a substantial proportion of the variance in internalized stigma is explained by symbolic interaction stigma (an increment of 35% from Equation 1 to Equation 2).
Table 3.
Regression analysis showing effects of perceived devaluation, daily indignities, stigma consciousness, concern with staying in, and anticipation of rejection on internalized stigma (standardized coefficients)a
| Internalized Stigma |
||
|---|---|---|
| 1 | 2 | |
| Perceived devaluation discrimination | 20+ | .06 |
| Daily indignities | .21+ | .07 |
| Stigma consciousness | — | −.09 |
| Concern with staying in | — | .10 |
| Anticipation of rejection | — | .62** |
| R-square | .26 | .58 |
| R-square Increment | .10* | .32** |
P < .10;
P < .05;
P< .01.
Standardized coefficients adjusted for age, gender, education, race/ethnicity, psychiatric diagnosis and global assessment of functioning
DISCUSSION
We began our paper by noting that a prominent and potentially difficult aspect of stigma involves forecasting how others will react to a stigmatizing label, wondering what to expect in specific social situations and perhaps fearing the worst in an anticipation of rejection. We set out to determine how these “symbolic interaction” forms of stigma related to “self-stigma” and in particular the internalization of stigma.
Using the rough metric of the percent of participants scoring above the scale’s midpoint, we found forms of symbolic interaction stigma to be slightly or substantially more common than internalized stigma. Only a very small minority of participants (12.5%) was below the midpoint on all four symbolic interaction stigma scales and a majority of participants were above the midpoint on at least two of them. With respect to their power to predict stigma-related outcomes of withdrawal, self-esteem and isolation from relatives, we found considerable evidence that they did so. Specifically, when controlling for sociodemographic variables, psychiatric diagnosis, global assessment of functioning and internalized stigma, we found that anticipation of rejection predicted withdrawal, stigma consciousness predicted self-esteem, and concern with staying in predicted isolation from relatives. Finally, we also found that symbolic interaction forms of stigma predicted the internalization of stigma with anticipation of rejection playing the largest role. Together, these results point to the importance of symbolic interaction forms of stigma in predicting stigma-related outcomes either directly or through their influence on internalized stigma.
Limitations
Clearly, results from this relatively small cross-sectional study need to be further investigated using other samples and other designs. Although the measures we adapted or developed are an asset for this presentation of symbolic interaction, some are used for the first time and should therefore be further tested for evidence of reliability and validity. Additionally, future research should attend more directly to whom the symbolic interaction involves – most people in general (Link et al 1989) and/or significant others (Markowitz et al. 2011). The results are from one specific group (people with psychosis), who were relatively early in their illness experience and currently hospitalized in inpatient units when they were recruited, thereby limiting generalization of study results to other groups or to the same group at different times. Additionally, because this is a cross-sectional design it is possible that instead of stigma affecting withdrawal, isolation, and self-esteem, it is those variables that affect levels of stigma. Finally our results have shown that some aspects of symbolic interaction stigma predict one outcome whereas others aspects predict other outcomes. While this could be due to the small sample size and the relatively wide confidence bands around estimates, future research would do well to construct and test any anticipated specificity of effects like the ones we found. Notwithstanding these limitations, our research represents a contribution by signaling the potential importance of symbolic interaction stigma and by providing measures that might be used in future studies to assess it. Our study could have found symbolic interaction stigma to be rare and/or unrelated to outcomes of stigma, a set of findings that would have diminished interest in these processes had they been observed. They were not. Thus while our results cannot confirm the utility of symbolic interaction stigma concepts, they nevertheless provide supportive evidence of their plausibility and thereby their potential usefulness in future work.
Conclusions and Implications for Practice
Our concepts, measures and empirical results point to an important space between “public” and “self” stigma that we have chosen to call “symbolic interaction stigma.” The predicament that stigma confers is not fully captured by the attitudes, beliefs and behaviors of the non-stigmatized, nor by the internalization of stereotypes and an attendant devaluing of the self by those who are stigmatized. Our lens focuses on a space that lies between these poles in which people who are stigmatized conjure, imagine, assess and strategize, seeking to evaluate the circumstance they confront and manage it the best way they can. The fact that we found symbolic interaction stigma to be both relatively common and potentially very impactful indicates that these aspects of stigma are important to consider in any full accounting of stigma.
Our identification of symbolic interaction stigma naturally leads to questions about how the constructs we include in that domain might be related to one another and to other stigma-related concepts and measures. While full development of a causal model for symbolic interaction stigma needs to be taken up in future research, we provide some initial thoughts that may be helpful in such future research. In our conception the process starts with the societal context of mental illness that includes, for example, how the media portrays and reports about mental illnesses, how ordinary people use mental illness related words like “crazy,”“insane” and “lunatic” to describe people they do not like, fear or want to diminish in status and what their use of such words coveys about what people with mental illnesses are like. The societal context also involves structural arrangements including how facilities that treat people with mental illnesses compare to places where physical illnesses are treated and whether people with mental illnesses are denied rights like voting or visitation with children. These aspects of the societal context are critical for a first stage of symbolic interaction stigma – conceptualizing what most people think about people with mental illnesses (perceptions of societal-level devaluation discrimination). For the person who develops a mental illness, this initial conjuring about how most people will view and treat someone with mental illness poses some level of threat that can then lead to an anticipation of rejection, a concern that people are centrally focused on the attribute of mental illness in any interactions that transpire (stigma consciousness), and/or concerned that other people will watch their behavior closely for signs that symptoms may be worsening or returning (concern with staying in). We advance no claim about a causal ordering between the latter three constructs but rather see them as different ways in which symbolic interaction stigma can be problematic and lead people to withdraw from interaction, conceal their illness when they can, or feel badly in such a way as to deepen internalized stigma in a manner consistent with self-stigma theory. In sum, while the current study findings are broadly consistent with the causal sequencing suggested above, it will take further research to provide a more rigorous test.
One very important implication of symbolic interaction stigma is its strong connection to reality– the conjuring, imagining, assessing and strategizing that takes place is about things that can and do happen. Certainly, the voluminous literature on public stigma has documented that problematic attitudes, beliefs and behaviors regarding mental illnesses exist and persist at relatively high levels (Pescosolido et al. 2010). Thus while perceptual errors can be made in judging the attitudes, beliefs or likely behaviors of others, the core problem is not one of misperception. There is a reality that needs to be assessed, evaluated and addressed. To the extent that this is so, self-stigma interventions designed to reframe perceptions to allow more benign interpretations of others’ attitudes, intentions and behaviors might have only short-lived benefits. Specifically, if the social context delivers messages that diverge from benign interpretations, reframed messages will be re-reframed to take account of the experienced reality. More generally, to the extent that symbolic interaction stigma exists at levels and with impacts consistent with our preliminary estimates, both understandings of stigma and interventions designed to reduce its effects need to address symbolic interaction stigma. Effectively changing public stigma would alter the reality that people contemplate, assess and respond to in symbolic interaction stigma. At the same time, efforts focused on people with mental illnesses can expand to creatively address symbolic interaction stigma by identifying it as an issue and developing skills to address it. Stigma interventions that counter experienced discrimination might be adapted to also explicitly counter symbolic interaction stigma. That is, consumers might be prepared in advance to select the most adaptive cognitive, emotional, and behavioral responses to symbolic interaction stigma as it arises in their consciousness and holds the possibility of affecting their behavior. A failure to counteract this aspect of stigma could stall progress in efforts to address this very important issue for people with mental illnesses and their families.
Supplementary Material
Acknowledgments
This research was supported by grant MH074996 from the National Institute of Mental Health
Contributor Information
Bruce G. Link, Columbia University
Jennifer Wells, Columbia University.
Jo C. Phelan, Columbia University
Lawrence Yang, Columbia University.
References
- Barney LJ, Griffiths KM, Christensen H, Jorm AF. The Self-Stigma of Depression Scale (SSDS): development and psychometric evaluation of a new instrument. International Journal of Methods in Psychiatric Research. 2010;19(4):243–254. doi: 10.1002/mpr.325. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Corrigan PW, Watson AC. The Paradox of Self-Stigma and Mental Illness. Clinical Psychology: Science and Practice. 2002;9(1):35–53. [Google Scholar]
- Corrigan PW, Kerr A, Knudsen L. The stigma of mental illness: Explanatory models and methods for change. Applied and Preventive Psychology. 2005;11(3):179–190. [Google Scholar]
- Corrigan PW, Michaels PJ, Vega E, Gause M, Watson AC, Rüsch N. Self-stigma of mental illness scale--short form: reliability and validity. Psychiatry Research. 2012;199(1):65–69. doi: 10.1016/j.psychres.2012.04.009. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Corrigan PW, Larson JE, Kuwabara SA. Social psychology of the stigma of mental illness:Public and self-stigma models. In: Maddux JF, Tangney J, editors. Social psychological foundations of clinical psychology. New York City: Guilford Press; 2010. [Google Scholar]
- Corrigan PW, Watson AC, Barr L. The Self-Stigma of Mental Illness: Implications for Self-Esteem and Self-Efficacy. Journal of Social and Clinical Psychology. 2006;25(8):875–884. [Google Scholar]
- Downey G, Feldman SI. Implications of rejection sensitivity for intimate relationships. Journal of Personality and Social Psychology. 1996;70(6):1327–1343. doi: 10.1037//0022-3514.70.6.1327. [DOI] [PubMed] [Google Scholar]
- Drapalski AL, Lucksted A, Perrin PB, Aakre JM, Brown CH, DeForge BR, Boyd JE. A Model of Internalized Stigma and Its Effects on People With Mental Illness. Psychiatric Services. 2013;64(3):264–9. doi: 10.1176/appi.ps.001322012. [DOI] [PubMed] [Google Scholar]
- Farina A, et al. Mental illness and the impact of believing others know about it. Journal of Abnormal Psychology. 1971;77(1):1–5. doi: 10.1037/h0030496. [DOI] [PubMed] [Google Scholar]
- Link BG, Phelan J. Stigma power. Social Science & Medicine. 2014;103:24–32. doi: 10.1016/j.socscimed.2013.07.035. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Link BG. Understanding labeling effects in the area of mental disorders: An assessment of the effects of expectations of rejection. American Sociological Review. 1987:96–112. [Google Scholar]
- Link BG, Cullen FT, Struening E, Shrout PE, Dohrenwend BP. A Modified Labeling Theory Approach to Mental Disorders: An Empirical Assessment. American Sociological Review. 1989;54(3):400–423. [Google Scholar]
- Livingston JD, Boyd JE. Correlates and consequences of internalized stigma for people living with mental illness: a systematic review and meta-analysis. Social Science & Medicine (1982) 2010;71(12):2150–2161. doi: 10.1016/j.socscimed.2010.09.030. [DOI] [PubMed] [Google Scholar]
- Lucksted A, Drapalski A, Calmes C, Forbes C, DeForge B, Boyd J. Ending self-stigma: pilot evaluation of a new intervention to reduce internalized stigma among people with mental illnesses. Psychiatric Rehabilitation Journal. 2011;35(1):51–54. doi: 10.2975/35.1.2011.51.54. [DOI] [PubMed] [Google Scholar]
- Markowitz FE, Angell B, Greenberg JS. Stigma, reflected appraisals, and recovery outcomes in mental illness. Social Psychology Quarterly. 2011;74(2):144–165. [Google Scholar]
- Mead GH. Mind, Self and Society. Chicago: University of Chicago Press; 1934. [Google Scholar]
- Mendoza-Denton R, Downey G, Purdie VJ, Davis A, Pietrzak J. Sensitivity to status-based rejection: Implications for African American students’ college experience. Journal of Personality and Social Psychology. 2002;83(4):896–918. doi: 10.1037//0022-3514.83.4.896. [DOI] [PubMed] [Google Scholar]
- Mittal D, Sullivan G, Chekuri L, Allee E, Corrigan PW. Empirical studies of self-stigma reduction strategies: a critical review of the literature. Psychiatric Services. 2012;63(10):974–981. doi: 10.1176/appi.ps.201100459. [DOI] [PubMed] [Google Scholar]
- Muñoz M, Sanz M, Pérez-Santos E, Quiroga M de los Á. Proposal of a socio–cognitive–behavioral structural equation model of internalized stigma in people with severe and persistent mental illness. Psychiatry Research. 2011;186(2–3):402–408. doi: 10.1016/j.psychres.2010.06.019. [DOI] [PubMed] [Google Scholar]
- Pescosolido BA, Martin JK, Long JS, Medina TR, Phelan JC, Link BG. “A disease like any other”? A decade of change in public reactions to schizophrenia, depression, and alcohol dependence. American Journal of Psychiatry. 2010;167(11):1321–1330. doi: 10.1176/appi.ajp.2010.09121743. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Pinel EC. Stigma consciousness: The psychological legacy of social stereotypes. Journal of Personality and Social Psychology. 1999;76(1):114–128. doi: 10.1037//0022-3514.76.1.114. [DOI] [PubMed] [Google Scholar]
- Ritsher JB, Otilingam PG, Grajales M. Internalized stigma of mental illness: psychometric properties of a new measure. Psychiatry Research. 2003;121(1):31–49. doi: 10.1016/j.psychres.2003.08.008. [DOI] [PubMed] [Google Scholar]
- Quinn DM, Chaudoir SR. Living with a concealable stigmatized identity: the impact of anticipated stigma, centrality, salience, and cultural stigma on psychological distress and health. Journal of personality and social psychology. 2009;97(4):634. doi: 10.1037/a0015815. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Stryker Sheldon. Symbolic Interactionism: A Social Structural Version. Menlo Park, CA: Benjamin/Cummings; 1980. [Google Scholar]
- Yanos PT, Roe D, West ML, Smith SM, Lysaker PH. Group-based treatment for internalized stigma among persons with severe mental illness: findings from a randomized controlled trial. Psychological Services. 2012;9(3):248–258. doi: 10.1037/a0028048. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.