A conceptual model of mental illness stigma constructs

Abstract

Mental illness (MI) stigma negatively impacts a range of psychosocial and functional outcomes, and has yielded a significant volume of empirical literature. In a recent meta-analysis of 256 studies of mental health providers’ stigma towards their own patients, over 90 named stigma instruments were identified and 85 publications created their own instrument to be used in a single study. The exceptional number of stigma instruments in the literature raises questions about the conceptualization of stigma and limits the conclusions that can be drawn across studies. Current literature broadly conceptualizes stigma towards MI as consisting of stereotypes (beliefs), prejudice (emotions), and discrimination (actions). The current analysis expands this framework by categorizing each instrument into primary, secondary, and tertiary stigma categories to produce a model displaying the variety of constructs being assessed (briefly outlined below). Understanding the diversity of these constructs may allow for a nuanced interpretation of existing literature, and may spark discussion as to the centrality of certain constructs within MI stigma. Understanding the current stigma measurement landscape may allow for a reduction in the number of instruments currently in use, enhancing consistency and interpretability of empirical results. Stereotype instruments assess beliefs about the abilities or fundamental qualities of individuals with MI. Four secondary categories emerged. Negative Attributes measures undesirable personal characteristics of individuals with MI and contains four tertiary categories: dangerousness, personal control (i.e., MI symptoms are volitional), moral failing (i.e., symptoms are due to a weakness in character), and resistance to treatment. Prognosis measures beliefs about outcomes and future functioning of individuals with MI within two tertiary categories: optimism for treatment outcome and stability. Present Functioning requires respondents to estimate patients’ likely social integration and quality of life. Competence assesses beliefs about general intelligence, talents, and abilities of individuals with MI. Prejudice instruments assess emotion-based reactions to those with MI. The two secondary categories that emerged were Emotional Reactions and Beliefs about Managing Mental Illness. Emotional Reactions includes the tertiary categories of empathy, negative emotions (i.e., fear, disgust, anger), and professional burnout. Beliefs about Managing Mental Illness measures emotional- and value-based approaches to societal management of individuals with MI and contained four tertiary categories. Authoritarianism emphasizes individuals with MI are inferior and should be handled in a restrictive or coercive manner. Benevolence encompasses paternalistic pity and the belief that individuals with MI must be cared for like children. The prosocial view espouses a Community Mental Health Ideology, in that individuals with MI are just like anyone else and treatment should be integrated into the community and society. Finally, some instruments assess whether it is worthwhile to treat MI. Discrimination instruments assess intent or desire to treat individuals with MI differently from others. The three secondary categories that emerged were Social Distance, Willingness to Treat, and Civil Rights. Social Distance describes the desire to limit social contact with individuals with MI, while Willingness to Treat assesses whether mental health professionals are willing to care for individuals with MI. Civil Rights instruments assess restriction of patients’ human rights within four tertiary categories, including whether individuals with MI should be allowed to: engage in common social roles (e.g. parent, spouse, citizen, employee); participate in their own care; and refuse treatment. These instruments also assess whether patients should be forcibly restrained or secluded. Instruments with items that fell into at least two primary stigma categories and assessed a range of emotions, intended behavior, and beliefs about MI were categorized as General stigma.