Stigma and Health
Summary and Keywords
Stigma is a complex process that results from the interaction of stereotypes, prejudice, and discrimination. When applied to health conditions (e.g., mental illness, HIV/AIDS, diabetes, obesity), stigma can contribute to a lack of recovery and resources as well as devaluation of the self. People with stigmatized health conditions may be too embarrassed to seek treatment and others may not provide them with equal opportunities. This often results in discrimination in employment, housing, and health care settings. Strategies have been proposed to prompt stigma change with strategic contact between those with the health condition and everyone else likely to have the best effects.
Stigma is a complex construct that manifests itself in multiple forms. Most widely discussed is stigma in the form of racism that leads to discrimination that often forces ethnic minorities into the lower tiers of society. This chapter focuses on the interaction of stigma and health. The American Psychological Association recently launched a new journal entitled Stigma and Health (www.apa.org/pubs/journals/sah/) designed to encompass this growing area of research. Types and structures of stigma are reviewed as they relate to health and conclude with a discussion of ways to address stigma and promote change.
Social Psychological Structures
Erving Goffman (1963) identified three categories of stigma: (1) tribal identities, (2) abominations of the body (physical abnormalities), and (3) blemishes of individual character (e.g., illness, addiction). Tribal identities refer broadly to social groups into which individuals are born such as racial, ethnic, and religious groups (Goffman, 1963). Stigma manifests itself in the form of negative beliefs and behaviors against individuals who belong to such groups. A social-cognitive model has since been utilized to explain the development and enforcement of stigma across Goffman’s three categories. It is especially useful when describing the impact of stigma processes on health. According to this model (see Table 1), stigma is formed by the interactions of stereotypes, prejudice, and discrimination. Stereotypes refer to the public’s attitudes of a particular group (e.g., “Most people think individuals with diabetes are unhealthy eaters.”), prejudice refers to the emotional reaction that results from agreeing with the stereotype (“Yes, individuals with diabetes are irresponsible when it comes to their diets, and it is their fault that they developed the disease.”), and discrimination is the behavior that follows the stereotypes and prejudices (e.g,. employers do not accommodate time for illness self-management in the workplace).
For a stereotype to occur, the health condition must be discernible to the public so they can view the stigmatized group as different from themselves (Link & Phelan, 2001). Wheelchair users and individuals who have lost their hair due to chemotherapy treatments are health conditions that present overt signs that can be readily stigmatized. Individuals with mental illness or dementia may only ignite the social-cognitive model when signs of psychotic symptoms or memory loss provide a cue for their membership in the stigmatized group. It may not be obvious that individuals are diabetic unless they are seen administering insulin. Health-related stigma occurs when stereotypes associated with the mark are negative and cause the person to be singled out and labeled, thus resulting in a loss of status and opportunity (“He has diabetes so we shouldn’t hire him because he can’t even take care of himself”) (Link & Phelan, 2001).
Table 1: A Matrix for Understanding Stigma.
People with diabetes are unhealthy eaters.
People with diabetes are irresponsible.
People with diabetes are to blame for their illness.
Nobody wants to hire Bob for the job. He’ll go into a diabetic coma.
I think “why try” and stop looking for a job because no one will hire me.
I don’t want to be disrespected so I don’t talk to my doctor about possible symptoms of diabetes.
Stereotypes specific to mental illness have been especially well studied and provided as an example. One of the most common and damaging stereotypes is that people with mental illness are dangerous and unpredictable (“That guy with Bipolar disorder can switch and go crazy on us at any moment!”) (Broussard, Goulding, Talley, & Compton, 2012; Hayward & Bright, 1997; Link, Phelan, Bresnahan, Stueve, & Pescosolido, 1999). The Treatment Advocacy Center (TAC) estimates that 1,000 homicides per year are committed by persons with mental illness (TAC, 2002). This data suggests that people with mental illness are more violent, but it fails to take into account specific factors or symptoms of mental illness that may cause violence (Corrigan, 2016). Data from criminal records is also not generalizable to the overall sample of persons with mental illness in the public (Corrigan, 2016). Endorsement of this dangerous and violent stereotype affects whether people accept individuals with mental illness as friends, neighbors, and colleagues (Angermeyer & Matschinger, 2005). Exaggerated portrayals in the media may contribute to the image that individuals with mental illness are violent (Haller, Dorries, & Rahn, 2006; Michalak, Livingston, Hole, Suto, Hale, & Haddock, 2011; Stout, Villegas, & Jennings, 2004; Vahabzadeh, Wittenauer, & Erika, 2011), especially when news outlets choose to focus on the person’s diagnosis rather than the crime itself (Angermeyer & Schulze, 2001). Individuals with mental illness are also stereotyped as being incompetent, or unable to make their own decisions (“She has depression, so she is incapable of managing her own life.”) (Pescosolido, Medina, Martin, & Long, 2013). A history of coercive practices such as involuntary hospitalizations, forced medications, and restraint, while addressed by legislative practices in recent decades, have contributed to the public’s perception of people with mental illness as unable to make their own decisions and manage their own lives (Strauss et al., 2013). The stereotype of incompetence also results in workplace ridicule and criticism against abilities to perform cognitive tasks (Jenkins & Carpenter-Song, 2009).
Types of Stigma
Thus far, this chapter has focused on specific examples of stereotypes against individuals with health conditions. Moving forward, types of stigma that affect the quality of life and mindsets of these individuals will be examined. This includes public stigma, self-stigma, and label avoidance (see Table 1).
Public stigma occurs when the general population endorses stereotypes and decides to discriminate against people labeled with a health condition. Research has shown landlords are less likely to rent to and employers are less likely to hire people with mental illness (Corrigan & Kosyluk, 2014). People who are obese are also discriminated against in the hiring process despite having the same credentials as other applicants (Rooth, 2009). Particularly sobering forms of discrimination have been identified in the health care sector. Health care professionals view obesity as a lack of self-control (Maroney & Golub, 1992) and blame individuals for their noncompliance toward weight loss (Hoppe & Ogden, 1997). People labeled with mental illness receive fewer primary care and specialty health services (Desai, Rosenheck, Druss, & Perlin, 2002; Druss & Rosenheck, 1997) as well as fewer insurance benefits (Berk, Schur, & Cantor, 1995; Mark & Mueller, 1996) than those not labeled with such a health condition. It is important to note that there are also other reasons that people with mental illness may not receive adequate treatment services such as low perceived need (Mojtabai et al., 2011), choosing not to seek treatment, or dropping out of treatment altogether (Corrigan, Druss, & Perlick, 2014). These effects may contribute to public stigma on a systemic level.
Public stigma also leads to a greater call for coercive treatments for people with mental illness (Swanson, Swartz, Elbogen, Wagner, & Burns, 2003). One of the most historical examples of coercion is involuntary hospitalizations or sedative practices involved in mental health care. Even though reforms have been made to protect individuals with mental illness from these forceful behaviors, there are still issues involved in medication administration, seclusion, restraint, and even interactions with law enforcement (Strauss et al., 2013). Another debilitating form of public stigma is segregation. Even though mental asylums are largely a thing of the past, employment and housing discrimination may prevent individuals from obtaining independent housing or other community-based options (Corrigan, Larson, Watson, Boyle, & Barr, 2006; Newman & Goldman, 2009). People with epilepsy experience similar barriers to work and housing goals (Chesaniuk, Choi, Wicks, & Stadler, 2014).
When individuals with a health condition are aware of the public’s stigmatizing attitudes toward them, they often internalize these attitudes, which results in self-stigma (Muñoz, Sanz, Perez-Santos, & de los Angeles Quiroga, 2011). There are three steps involved in the formation of self-stigma: awareness, agreement, and application. First, the person must be aware of the stereotype (“People who are obese are disgusting.”). Second, he/she must agree with that stereotype (“Yes, obesity is a disgusting trait.”). Third, he/she must apply that stigma or stereotype into his/her own identity (“My obese appearance means I look disgusting.”) (Corrigan & Calabrese, 2005; Corrigan, Watson, & Barr, 2006). The internalization of such stigma hurts the person’s self-esteem (“I’m a disgusting human being.”) (Drapalski et al., 2013). A blow to one’s self-esteem consequently leads to a “why try” effect (Corrigan, Larson, & Rüsch, 2009): “Why should I go to that job interview? I’m not attractive enough to get the job,” or “Why should I ask that girl out? She won’t want a disgusting boyfriend like me.” As demonstrated, people with higher levels of self-stigma feel less empowered to make important life choices (Drapalski et al., 2013; Rüsch, Muller et al., 2014). Additionally, self-stigma appears stable over time (Lysaker et al., 2012) and has been connected to a lower quality of life (Rüsch, Muller et al., 2014).
Awareness of public stigma and stereotypes may also result in conscious avoidance of the label. Modified labeling theory posits that labels prompt certain stereotypes and beliefs about a health condition, which then place the individual into a particular category (e.g., mentally ill) and ignite the person’s expectations toward public rejection and mistreatment (Kroska & Harkness, 2006; Link, 1987). When this occurs, individuals with health conditions may refuse or drop out of treatment, stop taking medications, or avoid asking for job accommodations. Most people with schizophrenia, for instance, express some desire to hide or conceal their diagnosis from the public (Harangozo et al., 2014). In order to avoid these labels, they may refrain from seeking services for their condition, or drop out of treatment completely (Ben-Zeev, Corrigan, Britt, & Langford, 2012; Clement et al., 2015; Corrigan et al., 2014; Parcesepe & Cabassa, 2013). Those labeled as consumers of psychiatric medications may discontinue use of medications (Jenkins & Carpenter-Song, 2009). Despite efforts to hide the condition, it may be difficult to get rid of a label once an individual has already been placed in that stigmatized group. Research shows that, even after weight loss, individuals who were overweight or obese still experienced stigma because of their past appearance (Latner, Ebneter, & O’Brien, 2012).
Labeling is still largely due to the visibility of the stigmatizing condition. People who have more overt symptoms or characteristics will be quickly labeled as a member of that group, thus having more supports available in regard to health care and even their social relationships (e.g., family, friends). Nevertheless, individuals that are more readily labeled are also more vulnerable to the rejection and discrimination that results from public stigma. This is known as the labeling paradox (Perry, 2011). A person with HIV who has experienced rapid weight loss or developed mouth sores may have an easier time enrolling in treatment than someone who experiences chronic pain from a more hidden medical condition. However, the person with HIV is also more likely to experience negative reactions and labels from others because of greater visibility.
The Americans with Disabilities Act (ADA) provides certain protections for individuals with both physical and psychiatric illness by ensuring reasonable accommodations and other job supports. Engaging in label avoidance for fear of stigma, however, does not allow individuals to benefit from these protections (Cummings, Lucas, & Druss, 2013). Similar consequences arise when individuals decide not to disclose their health condition to others in order to avoid labels, thus causing them to reject support that they may have gotten from family, friends, or others in the community. There are informal processes in which individuals can participate in order to decide whether or not to disclose (Michalak et al., 2011) as well as more formal peer-support programs (e.g., Corrigan, Kosyluk, & Rüsch, 2013).
Support to overcome or erase stigma of the health condition itself is not enough. Instead, prejudice and discrimination should be replaced with affirming, or positive, attitudes and behaviors. Two examples of affirming attitudes have been examined specifically for people with mental illness (Corrigan & Sokol, 2013), but may also be applied to other health conditions: recovery and self-determination. (1) People with mental illness can and do recover in significant numbers (Harding, Brooks, Ashikaga, Strauss, & Breier, 1987). A longitudinal study of 269 individuals with serious mental illnesses supports this affirmation. At the 25-year follow up with 262 of these participants, it was revealed that one-half to two-thirds of the group had considerably improved or achieved recovery (Harding et al., 1987). (2) Self-determination of life goals is closely related to recovery. People with mental illness are capable of working toward and accomplishing life goals including education, employment, independent living, interpersonal relationships, recreation, and spirituality (Corrigan et al., 2012). Self-determination is important to establish because the public tends to see people with mental illness as incapable and incompetent in most areas of life.
The behaviors that result from affirming attitudes about stigmatized groups are called affirmative actions. When institutional policies restrict the opportunities of people with health conditions, either intentionally or unintentionally, this leads to structural discrimination (Corrigan, Markowitz, & Watson, 2004). Affirmative actions are a collection of government-approved activities that are designed to eliminate inequality and disparities that are the consequences of historical and structural discrimination.
The ADA serves as a prime example of affirmative action in its provision to provide reasonable accommodations (e.g. quiet work place, job coach) for people with various illnesses and disabilities (e.g., physical, psychiatric, sensory, and cognitive, etc.) (Corrigan et al., 2004). ADA clauses that prohibit discrimination against these individuals in the workplace are effective for barring individual and institutional levels of stigma. The Fair Housing Act requires that landlords provide reasonable accommodations in order for people with disabilities to be able to live independently (e.g., on-site support, housing coach). Affirmative actions such as these are necessary in tackling the injustices that have continued because of attitudes and barriers resulting from structural discrimination (Corrigan et al., 2005).
Stigma of Addiction
The same affirmative actions to eliminate the structural discrimination of substance use disorders (SUD) may not be applicable to other health conditions. The most notable reason for this is that the stigma of drug addiction is socially sanctioned. People with SUDs and addictions experience roadblocks to recovery and self-determination because (1) discrimination against people with SUDs is legally permissible, (2) stigma is utilized as a tactic in public health campaigns to promote substance use prevention, and (3) the focus of hopelessness and past mistakes may cause self-stigma in addiction interventions. We will briefly discuss each of these three roadblocks.
Unlike other illnesses, the stigma of addiction is reinforced with legal sanctions. Any use or possession of controlled substances can result in monetary fines and extended prison terms. The war on drugs, launched by the Nixon administration in the 1970s, began the incarceration of many individuals; in 2005, 1 in every 136 adults was reportedly in prison for drug possession (Peterson, 2005; Walmsley, Scott, & Campbell, 2006). Although people with mental illness and other health conditions may experience injustice in the criminal justice system, their rights are ultimately protected by the law. The same cannot be said for many people with SUDs and addiction.
The stigma of addiction is used in public health campaigns to promote prevention (Phelan, Link, & Dovidio, 2008). This is done by linking substance use to criminal activity (Room, 2005) and poor health (Guttman & Salmon, 2004; Sachs, 1996). The 2002 Super Bowl in the United States, for example, once compared drug use to terrorism by connecting the purchase of drugs to extremists that operate the drug market. More recently, the 2014 World AIDS campaign targeted 15- to 24-year-olds by identifying drug use as a way to contract HIV. These linkages of substance use to portrayals of violence and chronicity greatly build upon the stigma that is associated with addiction.
Self-stigma can also result from certain SUD intervention programs. This is, in part, due to the disease model that suggests that people with SUDs are biologically predisposed to develop addictions (Acker, 1993). For example, 12-step programs may encourage members to see that certain character deficits have resulted in their addictions. Members are advised to apologize to those they have wronged due to their powerlessness. While people with mental illness are encouraged to build self-determination and independence in recovery programs, people with addictions are warned that they have already developed a pattern of failure that should serve as a concern for their ability to accomplish future goals (Stevens et al., 2014). These intervention strategies may cause individuals to internalize feelings of failure and worthlessness related to their history of substance use.
Stigma and Change
Research on the stigma of health should be judged by the depth of information provided to advocates so that they can develop and evaluate effective strategies for undermining the stigma of health conditions. Although research on anti-stigma programs has fallen behind more descriptive and explanatory models of stigma, investigations have still increased over the past decade. There has been emerging literature on the stigma of HIV/AIDS, but most of this research has focused on the stigma of mental illness. Our goal is to use these examples. We start by describing the three specific agendas guiding anti-stigma intervention in the mental health literature and then identifying the different stakeholders involved in each agenda.
To avoid the label of their illness individuals may fail to seek or fully engage in treatment or evidence-based services. One way to address this is by promoting mental health literacy through health communication campaigns. Mental health literacy refers to education that helps individuals with recognition, management, and prevention of mental illness (Jorm, 2012). Individuals who are better able to recognize their illness and identify appropriate treatment options are more likely to benefit from and utilize those options. Stakeholders that drive this agenda include professionally trained providers, family members, and people with lived experience who have benefited from specific treatments.
An Australian program called beyondblue targets public stigma and label avoidance to promote care seeking. Beyondblue is a social marketing campaign that includes public service announcements (PSAs) that frame depression as a “treatable illness.” More than 60% of the Australian population recognizes this campaign (Yap, Reavley, & Jorm, 2012a), and this awareness is associated with better understanding of the benefits of treatment for mental illness (Yap, Reavley, & Jorm, 2012b). Mental health first aid (MHFA) is another Australian program that seeks to decrease stigma by promoting mental health literacy (Kitchener & Jorm, 2008). MHFA is a two-day course that reviews basics of mental illness and interpersonal strategies that anyone can use to help a person in need. A meta-analysis of 15 studies on MHFA demonstrated increased knowledge, which was inversely related to negative attitudes (Hadlaczky, Hokby, Mkrtchian, Carli, & Wasserman, 2014). Research has shown that improved health literacy is also inversely related to the stigma of conditions such as epilepsy (Bautista, Shapovalov, & Shoraka, 2015) and HIV/AIDS (Mackert, Donovan, Mabry, Guadagno, & Stout, 2014). One study also showed that literacy program effects increased knowledge of substance use disorders (Dermota et al., 2013).
Services agendas are successful when they promote higher rates of treatment seeking. Successful services campaigns should also promote engagement. People who are participating in services should participate for long periods of time and report greater satisfaction with treatment and the therapeutic relationship. They should also report that the services have helped them to attain their personal goals. Ultimately, benefits of treatment seeking are expected to decrease the symptoms of illness and replace them with well-being.
The rights agenda is endorsed by stakeholders who have been personally victimized by stigma and are demanding to replace this discrimination with opportunity in settings such as work, housing, and health care. The UN Convention for the Rights of Persons with Disabilities asserts that people with disabilities have the right to life opportunities as citizens and workers, as well as the right to reasonable accommodations to help them enjoy those opportunities. The rights agenda has also been extended to people with mental illness in the report of President George W. Bush’s New Freedom Commission (Hogan, 2003).
Programs directed toward decreasing public stigma to promote rights are grouped into education (contrasting the myths and facts of a disorder) with contact (promoting interactions among the public and people in recovery). England’s Time to Change program combined education and contact to change people’s attitudes toward mental illness. A comprehensive analysis measured the impact of both education (in the form of PSAs) and contact (Evans-Lacko, Henderson, & Thornicroft, 2013; Evans-Lacko, Malcolm et al., 2013). Results showed that both people who were aware of the program and people who had contact with the participants engaged less frequently in negative, stigmatizing activities. The rights agenda is only successful if societal barriers have diminished and these barriers have been replaced with opportunity for people with mental illness to fulfill their personal goals.
People who feel shame as a result of self-stigma are the ones that drive the efforts of the self-worth agenda. These efforts are largely carried out in the form of peer-support services. Peers refer to people who have a past history of significant illness that caused significant disability. Emotional and instrumental support is combined by peers to bring about social and personal change in the lives of people with mental illness (Copeland & Mead, 2004; Davidson, 2015; Davidson, Chinman, Sells, & Rowe, 2006). Peer support is mutually beneficial because the process of giving and receiving support is based on respect and shared responsibility (Mead, Hilton, & Curtis, 2001). It is through this system of sharing and confiding where self-stigma of the individual is targeted and changed (Stroul, 1993).
Self-worth agendas are often assessed using self-report measures that aim to illustrate a decrease in stigma (Livingston & Boyd, 2010) and an increase in recovery and empowerment (Rogers, Ralph, & Salzer, 2010; Salzer & Brusilovskiy, 2014). One of the ways to identify this change is by looking for decrease in the “why try” effect (Corrigan et al., 2009). People who have an increase in self-worth are more likely to pursue their personal life goals rather than feeling hopeless to try (Corrigan, Bink, Schmidt, Jones, & Rüsch, 2015a). The goal for self-worth agendas research is to identify a feasible way for behavioral outcomes to be measured.
Strategies to Change Public Stigma
The first two agendas—services and rights—are typically pursued as ways to decrease public stigma. The most common way to do this is through educational approaches and contact approaches. Educational approaches contrast myths with facts about an illness by using PSAs, books, flyers, movies, videos, and other visual aids (National Mental Health Campaign, 2002; Pate, 1988 Smith, 1990). Although research suggests that better understanding of mental illness leads to better attitudes, such as the notion that people with mental illness benefit from and have the potential to recover with treatment (Corrigan, River et al., 2001; Holmes, Corrigan, Williams, Canar, & Kubiak, 1999), there is evidence that increased knowledge does not always seem to result in decreased stigma. This may be, in part, due to the information that is provided. For example, results of a meta-analysis of studies between 1990 and 2006 showed that the public had an increased understanding that mental illness is genetically caused (Schomerus et al., 2012). Instead of decreasing stigma, this knowledge actually demonstrated significant decreases in the social acceptance of almost 20% for people with schizophrenia (Schomerus et al., 2012).
Contact, however, has been shown to decrease stigma more effectively. The four elements for optimal contact interventions include (1) equal social status between groups; (2) working toward a common goal; (3) working together, or not competing against one another; and (4) some form of authoritative sanction for contact (e.g., sponsored by a community board) (Cook, 1985; Gaertner, Dovidio, & Bachman, 1996; Pettigrew & Tropp, 2000). An example of this might be people in the community working alongside people with mental illness who are part of the same social group to design a community park at a town hall meeting. A meta-analysis of 79 studies, 13 of which were randomized controlled trials, suggested that adults participating in contact interventions had significantly better changes in stigmatizing attitudes and behavior intentions than those participating in educational interventions (Corrigan, Morris, Michaels, Rafacz, & Rüsch, 2012). This suggests that interacting with individuals whose empowerment and self-determination actively combats stigma is more valuable than education alone.
Strategies to Change Self-Stigma
Strategies to changing self-stigma can also be divided into education and contact approaches (Corrigan & Rao, 2012; Mittal, Sullivan, Chekuri, Allee, & Corrigan, 2012; Yanos, Lucksted Drapalski, Roe, & Lysaker, 2015). Educational approaches are combined with efforts of cognitive restructuring. Cognitive restructuring helps clients to explore distressing cognitions and attempt to reframe them as beliefs rather than facts; this is done through reviewing evidence and seeking out less distressing interpretations of their symptoms and behavior (e.g., “I am not crazy; sometimes stress at work just affects my mood”) (Chadwick, Birchwood, & Trower, 1996; Garety, Fowler, & Kuipers, 2000). Programs utilizing this technique include Healthy Self-Concept (McCay et al., 2006, 2007), Self-Stigma Reduction Program (Fung, Tsang, & Cheung, 2011), and Ending Self-Stigma (Lucksted et al., 2011). Randomized controlled trials on the first two programs have demonstrated a decrease in self-stigma and an increase in hopefulness (Fung et al., 2011; McCay et al., 2007). An additional approach to self-stigma change called Narrative Enhancement and Cognitive Therapy (NECT) combines cognitive restructuring and psychoeducation with narrative strategies meant to promote self-reflection and redefinition of one’s mental health experiences (Yanos, Roe, & Lysaker, 2011). Although an RCT failed to yield significant results (Yanos, Roe, West, Smith, & Lysaker, 2012), a quasi-experiment with more than 100 participants conducted in Israel showed reduced self-stigma and improved self-esteem, hope, and quality of life (Roe et al., 2014).
Contact strategies for changing self-stigma, such as peer interactions and mutual support, require the person to “identify” with the illness, the treatment, or the social reactions toward the illness. In mental health, this seems contrary to avoiding the negative consequences of illness identity. Studies have found that assuming the “sick patient” role, or deciding to identify with the illness, resulted in a worse prognosis and greater pessimistic attitudes (Lally, 1989; Thompson, 1988; Yanos, Roe, & Lysaker, 2010). However, this all depends on whether or not the individual perceives the stigma associated with the illness as legitimate. One study showed that those who identified with their illness and embraced stigma reported less hope and diminished self-esteem; on the other hand, those who identified with the illness and rejected stigma reported more hope and better self-esteem (Lysaker, Davis, Warman, Strasburger, & Beattie, 2007). This demonstrates that identifying with the illness does not automatically lead to more stress; rather it is the perceived legitimacy of the stigma that harms emotional health (Rüsch et al., 2009; Rüsch, Lieb, Bohus, & Corrigan, 2006). If identity with the illness has a potentially positive impact, then disclosure may yield beneficial changes to health and self-stigma. Honest Open Proud is a standardized program that is meant to help people challenge the self-stigma of mental illness by deciding whether or not to disclose (Corrigan, Sokol, & Rüsch, 2013). Two randomized controlled trials conducted for this program demonstrated immediate positive effects on disclosure and measures of self-stigma (Corrigan et al., 2015b; Rüsch, Abbruzzese et al., 2014).
The process of stigma formation is complex. First, an individual is identified as a member of a stigmatized group and associated with stereotypes of that group. Next, there must be an emotional reaction, or prejudice, placed on that individual in response to agreement with the stereotype. Finally, discrimination will result that prevents the individual from adequately participating in society. Although stigma greatly varies across health conditions, people with both mental health (e.g., schizophrenia, depression) and physical health conditions (e.g., diabetes, HIV/AIDS, obesity) are often devalued and seen as undesirable, or even dangerous. If an individual begins to agree with and internalize these public attitudes, then it can result in self-stigma and label avoidance. Affirming attitudes related to recovery and self-determination may be one way to help individuals overcome the stigma of health and treatment seeking. However, such efforts are overturned for people with addictions because public stigma is ingrained into legal sanctions and even treatment programs.
Three agendas exist for stigma change: (1) the services agenda, which seeks to increase knowledge and awareness of stigmatized health conditions and treatment; (2) the rights agenda, which seeks to eliminate structural discrimination that limits the opportunities of individuals with stigmatized health conditions; and (3) the self-worth agenda, which seeks to provide support for individuals dealing with internalized stigma. Education and contact approaches characterize both strategies to change public stigma and strategies to change self-stigma. Contact has been shown to produce better long-term effects on public stigma compared to education. Since the research literature has largely focused on the stigma of mental illness, future research should continue to examine the impact of stigma change interventions on other health conditions as well.
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