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Implications of
Educating the Public on Mental Illness, Violence, and Stigma
Patrick W.
Corrigan, Psy.D., Amy C. Watson, Ph.D., Amy C. Warpinski, B.A.
and Gabriela Gracia, B.S., B.A.
www.psychservices.psychiatryonline.org/cgi/content/full/55/5/577
Abstract
This study examined how two types of public education programs
influenced how the public perceived persons with mental
illness, their potential for violence, and the stigma
of mental illness. A total of 161 participants were
randomly assigned to one of three programs: one that
aimed to combat stigma, one that highlighted the
association between violence and psychiatric disorders,
and a control group. Participants who completed the
education-about-violence program were significantly
more likely to report attitudes related to fear and
dangerousness, to endorse services that coerced
persons into treatment and treated them in segregated areas,
to avoid persons with mental illness in social situations,
and to be reluctant to help persons with mental
illness.
Introduction
Results of a nationwide probability survey showed that 75
percent of the public view persons with mental
illness as dangerous (1).
Why do so many members of the general public think that
mental illness is strongly linked to a potential for
violence? Two answers are common: that this view
represents the impact of the stigma of mental illness
and that this view is an accurate representation of
the level of dangerousness among persons with mental
illness. The purpose of this study was not to determine
which of the two responses is more accurate but rather to
explain the impact of educating the public on the two
perspectives.
Some advocates
believe that highlighting the relationship between
violence and mental illness may be a significant wake-up call
for the public (2).
D. J. Jaffe of the Treatment Advocacy Center
suggests, "Laws change for a single reason, in reaction to
highly publicized incidences of violence. People care
about public safety. I am not saying it is right. I
am saying this is the reality.... So if you're
changing your laws in your state, you have to
understand that" (3).
Other advocates point to studies that show that
stereotypes about the dangerousness of persons with
mental illness are a key source of prejudice and discrimination
against persons with mental illness by the public (4,5).
These two positions lead to contradictory public
education goals. In this study we examined the impact
of two public education programs—one that aimed to
combat the stigma of mental illness and one that
highlighted the association between violence and
psychiatric disorders—on participants' attitudes toward
persons with mental illness and their resource allocation
preferences for different types of mental health
programs.
Methods
A total of 161 persons from a local community college were
informed of our study and were asked to participate;
all agreed and completed all measures. By means of a
random number table, participants were randomly
assigned to one of three conditions: an education-about-violence
program, an education-about-stigma program, and a control
program, in which issues related to mental illness or
physical disability were not discussed. Each program
was scripted and read verbatim, accompanied by eight
to 12 slides. Four presenters were rotated through
the conditions so as to diminish any unintended effects
that may have resulted from different presentation styles.
Two of the research conditions in this study—the
education-about-stigma program and the control
program—have been studied previously (6,7).
The
education-about-violence program juxtaposed facts about
mental illness and violence—for example, "Fact: Annually
approximately 1,000 homicides are committed by individuals
with untreated mental illness"—with poignant examples
of persons with mental illness who did not receive
effective treatment—for example, "July 24, 1998:
Russell Weston killed two U.S. Capitol guards" (8).
The education-about-stigma program reviewed seven
myths that were drawn from the literature (7)
and presented facts that challenged these myths. This
program also showed several poignant examples of
persons with mental illness with differing illness
courses and outcomes.
Research
participants completed three sets of measures to assess
the impact domains that are of interest to public
education: attitudes, behavioral decisions, and
resource allocation. So that participants' attitudes
and behavioral decisions could be assessed, research
participants completed the Attribution Questionnaire
(7).
The questionnaire presented a very short, neutral
statement about a man named Harry who has been hospitalized
for schizophrenia, followed by 27 items that measured
participants' responses to Harry on a 9-point Likert
Scale; (1, not at all, through 9, very much) (7).
On the basis of our earlier work, the following six
factor scores were obtained from the Attribution
Questionnaire to answer the questions of this study:
dangerousness, for example, "I would feel unsafe
around Harry"; fear, for example, "Harry would
terrify me"; avoidance (reverse scored), for example,
"If I were an employer, I would interview Harry for a job";
coercion, for example, "If I were in charge of Harry's
treatment, I would require him to take his
medication"; segregation, for example, "I think it
would be best for Harry's community if he were put
away in a psychiatric hospital"; and help, for example,
"How likely is it that you would help Harry?" Research
participants were administered the Attribution
Questionnaire immediately before the program
(pretest), immediately after the program (posttest),
and one week after the program (follow-up test).
Participants
were told to rank the importance of allocating state
monies to one of four mental health services on a 9-point
Likert scale (1, not at all important, to 9, extremely
important); the measure was based on a research
method of Skitka and Tetlock (9).
The four mental health services were selected to represent
treatment options that represented either coercion,
punishment, empowerment, or independence. The
treatment options had been previously shown to
represent these features in a pilot study in which 17
students and staff members used Likert scales to rate
how they perceived eight mental health services. Items
from the resource allocation measure were combined to
yield two subscale scores: the importance of funding
rehabilitation services (vocational rehabilitation
and psychosocial rehabilitation services), which
represented empowerment and independence, and the
importance of funding mandated treatments (involuntary
hospitalization and outpatient commitment), which
represented coercion and punishment. We administered
the resource allocation measure at posttest and at
the one-week follow-up.
Results
Participants had a mean±SD age of 25.8±9.7 years, and
67 percent were women. In terms of marital status, 73 percent
of the participants were single, 19 percent were married,
2 percent were separated, 6 percent were divorced,
and 1 percent were widowed. A total of 60 percent of
the participants were European American, 42 percent
were African American, 4 percent were Latino, and 4
percent were from another racial or ethnic group.
Some participants indicated more than one racial or ethnic
group. In terms of education, 8 percent of the
participants completed high school, 85 percent
completed some college, and 7 percent had a college
degree.
Table 1
summarizes the mean±SD subscale scores of participants.
To test how the two types of programs affected
participants' attitudes and behavioral decisions
toward persons with mental illness, two sets of
three-by-two analyses of variance (ANOVAs) (condition
by trial) and post hoc tests were completed for each
of the six subscale scores of the Attribution Questionnaire:
pretest versus posttest scores and pretest versus
follow-up.
Persons in the education-about-violence group consistently
demonstrated more negative attitudes and behavioral
decisions toward persons with mental illness. In
terms of participants' attitudes about the
dangerousness of persons with mental illness, the scores
of the education-about-violence group increased
significantly from the pretest to the posttest and
from the pretest to the follow-up test; however, the
scores of the education-about-stigma group and the
control group decreased from the pretest to the
posttest and from the pretest to the follow-up test. Closely
corresponding to concerns about dangerousness, a
significant interaction was found for the differences
between the pretest and posttest scores across the
three groups for fear and avoidance; only fear showed
a significant interaction for the pretest to
follow-up analysis. Results from post hoc tests showed that
persons in the education-about-violence group showed
significantly higher rates of fear and were
significantly more likely than participants in the
other two groups to avoid persons with mental illness
in social places. Persons in the education-about-stigma
group were significantly less likely to endorse social
avoidance than those in the control group.
Differences
were also found for endorsement of coercion and
segregation. A significant interaction was found for both
measures representing the difference from pretest to
posttest across conditions; a significant interaction
was also found for segregation for the pretest to
follow-up difference. Post hoc tests showed that
persons in the education-about-violence group were significantly
more likely than those in the other two groups to endorse
coercing persons with mental illness into treatment
and setting up treatment in segregated areas. The
last subscale score represented a research
participant's willingness to help a person with mental illness.
Posttest scores showed that participants in the
education-about-stigma group were more willing to
help persons with mental illness than were
participants in either of the two other groups; however,
a significant interaction was found only for the
difference between pretest scores and posttest
scores.
Findings from
the resource allocation measure tested whether the
education conditions affected participants' preferences
for funding mental health programs. One-way ANOVAs did not
find a significant effect between the three groups in
the pretest or posttest scores for the importance of
funding mandated treatments or rehabilitation
services. Two-by-two post hoc ANOVAs were completed
to determine whether any significant change from the
posttest to follow-up scores was evident in pairwise
comparisons. No significant results were found.
However, we did find a nonsignificant trend that
indicated that the education-about-stigma group was
more likely than the education-about-violence group to support
funding for rehabilitation services at the time of
follow-up. This finding runs counter to the argument
on some fronts that educating the public about the
potential for violence among persons with mental
illness will lead to more funds for mental health
programs.
Discussion and conclusions
Our findings consistently question the strategy of highlighting
the association between untreated mental illness and
violence, which has been touted by some community
groups. Research participants who completed programs
that educate the public on this association reported
that persons with mental illness are more dangerous
and should be feared. This finding seemed fairly obvious because
of the nature of the education-about-violence program.
Persons who completed the education-about-violence
program also tended to endorse treatment programs
that segregate persons with mental illness from the
community and that promote coercive or mandated
treatments. Perhaps most stigmatizing were the findings that
participants who completed education-about-violence
programs were more likely to withhold help from
people with mental illness and avoid them socially.
Proponents of
public education programs that focus on the association
between violence and mental illness might respond to these
findings by arguing that increasing negative
attitudes about mental illness is a necessary evil
when trying to get the public in general, and
legislators in particular, to increase resources for mental
health services. If this assertion is correct, we would
have expected participants' assessments to indicate
that more resources should be provided for mental
health services after they participated in the
education-about-violence program. However, findings from
our study did not support this kind of conclusion.
Posttest and follow-up measures did not find a
significant endorsement of more resources for
mandated treatments or rehabilitation services across
any of the three groups. Interestingly, a nonsignificant
trend seemed to yield findings that contradicted the
education-about-violence perspective.
Of course,
researchers should always be skeptical about conclusions
that are based largely on null findings. Findings from our
study did not clearly challenge the assertions that
education-about-violence programs lead to a greater
support for allocating funds for mental health
programs. However, our evidence also did not support
these assertions. Hence, community groups should not use
information about the link between mental illness and
violence in an attempt to improve resources for
mental health programs. Finally, findings from our
study were somewhat limited in terms of generalizability
because college students, who tend to be more educated
than the general population, were recruited for our
study. Additional research should include a more
diverse sample.
Footnotes
The authors are affiliated with the department of psychiatry
at the University of Chicago, 7230 Arbor Drive, Tinley
Park, Illinois 60477 (e-mail,
p-corrigan@uchi cago.edu).
References
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