Stigma Stress Research Articles

Minority Stress in the Context of Rural Economic Hardship: One Lesbian Mother's Story

ABSTRACTIn this article, we use case study methodology to provide a detailed description of the life of Lucy, a single, lesbian mother living in a rural community on a low income. Using the lens of stigma and minority stress theory (Meyer, 2003), we highlight the ways in which sexual-minority stress interacts with other life stressors, and analyze how they affect health and well-being. Four main themes emerged to describe Lucy's understanding of these stress processes: the intersection of her identities as a local, lesbian mother; the portability or mobility of these identities; conflicting messages of support and hostility; and the permanent or transitory nature of her stress. We contribute to the literature by examining the tenets of Meyer's original minority stress model and extending its theoretical applications.

Understanding stigma from a sociocultural context: mothers’ experience of stigma directed towards children with special educational needs

ABSTRACTAlthough the need for a better understanding and deconstruction of the barriers that underpin and impede the realisation of inclusive education in many developing countries is acknowledged, few studies focus specifically on exploring how stigma affects the choices that parents in developing countries make on behalf of their children. This paper contributes to the understanding of the stigma experience of mothers of children with special educational needs (SEN) in a Nigerian context. The aim of the study was to explore how parents’ interpretation of stigma directed towards their children with SEN affects the educational decision they make on behalf of these children. The study consisted of eight interviews with mothers of children with SEN in Lagos, Nigeria. Specifically, stigmatisation of children with SEN was found to be underpinned by a ‘non-materialistic’ culture and worldviews that construct disability as ‘non-normal’. Findings also uncover a range of coping mechanisms adopted by mothers to deal with courtesy stigma and stigma stress. Theoretical and practical contributions to the literature on stigma and inclusive education are subsequently discussed. Theoretically, we introduce and discuss the import of ‘stigma transference’ (the different modes that stigma can be transferred from one individual to the other) and practically, we discuss implications of findings for anti-stigma intervention.

Pathways between stigma and suicidal ideation among people at risk of psychosis

Mental illness stigma may contribute to suicidality and is associated with social isolation and low self-esteem among young people at risk of psychosis. However, it is unclear whether mental illness stigma contributes to suicidality in this population. We therefore examined the associations of self-labeling and stigma stress with suicidality among young people at risk. Self-labeling as “mentally ill”, stigma stress, social isolation, self-esteem, symptoms and suicidal ideation were assessed in 172 individuals at risk of psychosis. Self-labeling and stigma stress were examined as predictors of suicidality by path analysis. Increased self-labeling as “mentally ill” was associated with suicidality, directly as well as indirectly mediated by social isolation. More stigma stress was related to social isolation which in turn was associated with low self-esteem, depression and suicidal ideation. Social isolation fully mediated the link between stigma stress and suicidal ideation. Interventions to reduce the public stigma associated with risk of psychosis as well as programs to facilitate non-stigmatizing awareness of at-risk mental state and to reduce stigma stress among young people at risk of psychosis might strengthen suicide prevention in this population.

Weight Loss Is Not the Answer: A Well‐being Solution to the “Obesity Problem”

AbstractAmericans have been gaining weight in recent decades, prompting widespread concern about the health implications of this change. Governments, health practitioners, and the general public all want to know: What is the best way to reduce the health risks associated with higher body weight? The dominant weight‐loss solution to this “obesity problem” encourages individuals to lose weight through behavior change. This solution rests on the assumptions that higher body weight causes health problems, that permanent weight loss is attainable, and that weight loss improves health. But comprehensive reviews of the scientific evidence find mixed, weak, and sometimes contradictory evidence for these premises. We suggest that a different solution to the “obesity problem” is needed – a solution that acknowledges both the multifaceted nature of health and the complex interaction between person and situation that characterizes the connection between weight and health. Thus, we use the lens of social psychological science to propose an alternative, well‐being solution to the “obesity problem”. This solution has the potential to improve health by encouraging eating and exercising for optimal health rather than weight loss, by developing interventions to reduce weight stigma and discrimination, and by helping higher body‐weight people cope with the stress of stigma and discrimination.

Diminishing the self-stigma of mental illness by coming out proud

This randomized controlled trial examined the impact of the Coming Out Proud (COP) program on self-stigma, stigma stress, and depression. Research participants who experienced mental health challenges were randomly assigned to a three session COP program (n=51) or a waitlist control (n=75). Outcome measures that assessed the progressively harmful stages of self-stigma, stigma stress appraisals, and depression were administered at pre-test, post-test, and one-month follow-up. People completing COP showed significant improvement at post-test and follow-up in the more harmful aspects of self-stigma compared to the control group. COP participants also showed improvements in stigma stress appraisals. Women participating in COP showed significant post-test and follow-up reductions in depression after COP compared to the control group. Men did not show this effect. Future research should determine whether these benefits also enhance attitudes related to recovery, empowerment, and self-determination.

Stigma as a stressor and transition to schizophrenia after one year among young people at risk of psychosis

According to stress-vulnerability models, social stressors contribute to the onset of schizophrenia. Stigma and discrimination associated with mental illness may be a stressor for young people at risk of psychosis even prior to illness onset, but quantitative longitudinal data on this issue are lacking. We examined the cognitive appraisal of stigma-related stress as predictor of transition to schizophrenia among young people at risk of psychosis. In Zürich, Switzerland, 172 participants between 13 and 35years old and with either high or ultra-high risk of psychosis or risk of bipolar disorder were included. With 71 dropouts, transition was assessed during 12months among 101 participants of whom 13 converted to schizophrenia. At baseline, the cognitive appraisal of stigma as a stressor was measured by self-report, based on the primary appraisal of stigma as harmful and the secondary appraisal of resources to cope with stigma. Positive and negative symptoms were examined using the Positive and Negative Syndrome Scale. Compared with participants who did not convert to schizophrenia, converters had significantly more positive (p<.001) and negative (p<.001) symptoms and reported higher levels of stigma-related harm (p=.003) and stress (p=.009) at baseline. More perceived harm due to stigma at baseline predicted transition to schizophrenia (odds ratio 2.34, 95%-CI 1.19–4.60) after adjusting for age, gender, symptoms and functioning. Stigma stress may increase the risk of transition to schizophrenia. Research is needed on interventions that reduce public negative attitudes towards young people at risk and that support individuals at risk to cope with stigma-related stress.

Stigma and Mental Health Challenges in Medical Students

Historically, a stigma was a scar on the skin of ancient Greek criminals. It was a sign to all that these people were unsafe, unclean and unwanted. Stigma still persists today in the attitudes towards those who have mental health challenges. Nowhere is this more apparent than in the medical profession. Indeed, the 2008 Stigma Shout Survey of almost 4000 people using mental health services and carers revealed that healthcare professionals were a common source of stigma reported by people with mental illness. A recent study identified stigma to be a barrier to the use of mental health services by 30 % of medical students experiencing depression. There is a growing perception that science alone provides overall insufficient foundation for the holistic understanding of the interaction between health, illness and disease. The health humanities has emerged as a distinct entity in attempts to ameliorate the limitations in the provision of healthcare services and can broadly be described as the application of literature and art to medicine. Autobiographical narrative is gaining popularity among medical students with mental health challenges both as a means to campaign against stigma and as an effective form of adjunctive therapy. Indeed, a recent randomized controlled trial on the efficacy of Coming Out Proud with mental health challenges revealed immediate positive effects on stigma stress related variables. We herein provide a candid and courageous narrative from a British medical student who has first-hand experience of a psychotic episode in the context of a severe depressive illness.

Mental health-related discrimination as a predictor of low engagement with mental health services.

This study aimed to test the hypothesis that mental health-related discrimination experienced by adults receiving care from community mental health teams is associated with low engagement with services and to explore the pathways between these two variables. In this cross-sectional study, 202 adults registered with inner-city community mental health teams in the United Kingdom completed interviews assessing their engagement with mental health services (service user-rated version of the Service Engagement Scale), discrimination that they experienced because of mental illness, and other variables. Structural equation modeling was conducted to examine the relationship of experienced discrimination and service engagement with potential mediating and moderating variables, such as anticipated discrimination (Questionnaire on Anticipated Discrimination), internalized stigma (Internalized Stigma of Mental Illness Scale), stigma stress appraisal (Stigma Stress Appraisal), mistrust in services, the therapeutic relationship (Scale to Assess Therapeutic Relationships), difficulty disclosing information about one's mental health, and social support. Analyses controlled for age, race-ethnicity, and symptomatology. No evidence was found for a direct effect between experienced discrimination and service engagement. The total indirect effect of experienced discrimination on service engagement was statistically significant (coefficient=1.055, 95% confidence interval [CI]=.312-2.074, p=.019), mainly via mistrust in mental health services and therapeutic relationships (coefficient=.804, CI=.295-1.558, p=.019). A 1-unit increase in experienced discrimination via this pathway resulted in .804-unit of deterioration in service engagement. Findings indicate the importance of building and maintaining service users' trust in mental health services and in therapeutic relationships with professionals and countering the discrimination that may erode trust.

Work-related discrimination and change in self-stigma among people with mental illness during supported employment.

The relationship of work-related discrimination to the change in self-stigma and stigma stress was assessed among supported employment participants in Switzerland. Self-stigma and the cognitive appraisal of mental illness stigma as a stressor were measured at baseline among supported employment participants (N=116). These variables and work-related discrimination in the past year were assessed one year later (N=96). Compared with participants who did not find employment (N=30), those who worked without experiencing discrimination (N=25) had lower levels of self-stigma and stigma stress at one year. Among those who worked and reported work-related discrimination (N=38), these measures did not decrease significantly. Experiencing discrimination at work may determine whether employment has positive effects in terms of self-stigma and stigma stress among individuals with mental illness. Interventions to reduce discrimination in work settings and to improve coping resources of these individuals could augment the positive effects of supported employment.

Longitudinal course of self-labeling, stigma stress and well-being among young people at risk of psychosis

Stigma may undermine the well-being of young people at risk of psychosis. We therefore measured self-labeling, stigma variables and well-being at baseline and again one year later among 77 at-risk participants. An increase in self-labeling during this period predicted heightened stigma stress after one year and a decrease in stigma stress predicted better well-being at follow-up, controlling for symptoms, psychiatric comorbidity and sociodemographic variables. Besides early intervention programmes, strategies are needed to reduce the public stigma associated with at-risk status and to support young people at risk to better cope with self-labeling and stigma stress.

Efficacy of Coming Out Proud to reduce stigma's impact among people with mental illness: pilot randomised controlled trial

Facing frequent stigma and discrimination, many people with mental illness have to choose between secrecy and disclosure in different settings. Coming Out Proud (COP), a 3-week peer-led group intervention, offers support in this domain in order to reduce stigma's negative impact. To examine COP's efficacy to reduce negative stigma-related outcomes and to promote adaptive coping styles (Current Controlled Trials number: ISRCTN43516734). In a pilot randomised controlled trial, 100 participants with mental illness were assigned to COP or a treatment-as-usual control condition. Outcomes included self-stigma, empowerment, stigma stress, secrecy and perceived benefits of disclosure. Intention-to-treat analyses found no effect of COP on self-stigma or empowerment, but positive effects on stigma stress, disclosure-related distress, secrecy and perceived benefits of disclosure. Some effects diminished during the 3-week follow-up period. Coming Out Proud has immediate positive effects on disclosure- and stigma stress-related variables and may thus alleviate stigma's negative impact.

Stigma and disclosing one’s mental illness to family and friends

People with mental illness face the dilemma whether or not to disclose their condition. We examined stigma variables and their relationship with comfort disclosing. Comfort with disclosure, well-being, symptoms and aspects of experiencing and reacting to stigma were assessed among 202 individuals with mental illness. Controlling for symptoms, greater comfort disclosing one's mental illness was associated with lower anticipated discrimination and lower stigma stress; more comfort disclosing was related to greater well-being. Anticipated discrimination as an external threat and stigma-related stress as an internal process may reduce comfort with disclosure and could be targeted in interventions.

Well-Being Among Persons at Risk of Psychosis: The Role of Self-Labeling, Shame, and Stigma Stress

When young people at risk of psychosis experience early signs of the disorder or early intervention, they may label themselves as "mentally ill." However, empirical data related to the potentially harmful effects of self-labeling and stigma among young people at risk of psychosis are lacking. This study used a stress-coping model to examine mechanisms by which stigma may exert an impact on young people at risk of psychosis. The authors assessed self-reports of perceived public stigma, shame about having a mental illness, self-labeling, and the cognitive appraisal of stigma as a stressor (stigma stress) as predictors of well-being among 172 residents of Zürich, Switzerland, who were between 13 and 35 years old. All participants were at high risk or ultra-high risk of psychosis or at risk of bipolar disorder. Psychiatric symptoms were assessed by the Positive and Negative Syndrome Scale, and well-being was measured by instruments that assessed quality of life, self-esteem, and self-efficacy. Perceived public stigma, shame, and self-labeling were independently associated with increased stigma stress. More stigma stress, in turn, predicted reduced well-being, independent of age, gender, symptoms, and psychiatric comorbidity. Stigma stress partly mediated the effects of perceived public stigma, shame, and self-labeling on well-being. Perceived public stigma, shame, and self-labeling appear to be associated with stigma stress and reduced well-being among young people at risk of psychosis. With early intervention programs gaining traction worldwide, effective strategies to address the shame and stigma associated with at-risk states and early psychosis are needed.

The Gender Identity Reflection and Rumination Scale: Development and Psychometric Evaluation

The authors describe the development of the Gender Identity Reflection and Rumination Scale (GRRS), which measures rumination in the context of gender identity among transgender persons. GRRS items were formulated taking into account previous research on rumination, stigma stress, and identity processing. Two national U.S. samples were collected to investigate the psychometric properties of the GRRS, resulting in 3 factors of gender identity rumination: Reflection, Rumination, and Preoccupation With Others’ Perceptions.

The Stress of Stigma

To determine the physiological impact of exposure to weight stigma by examining alterations in salivary cortisol among lean and overweight women. Participants were 123 lean and overweight adult women (mean body mass index = 26.99 [7.91] kg/m(2)). Participants' salivary cortisol was assessed both before and after either a weight stigmatizing or a neutral video. Participants completed self-report measures of mood and reactions to the video. Height and weight were obtained at the conclusion of the study. Participants in the stigmatizing condition exhibited significantly greater cortisol reactivity when compared with those in the neutral condition, irrespective of weight status (Pillai trace = 0.077; F(1,85) = 7.22, p = .009). Lean and overweight women in the stigmatizing condition were equally likely to find the video upsetting and were equally likely to report that they would rather not see obese individuals depicted in a stigmatizing manner in the media. Exposure to weight-stigmatizing stimuli was associated with greater cortisol reactivity among lean and overweight women. These findings highlight the potentially harmful physiological consequences of exposure to weight stigma.

Comorbidity, stigma and emotional perception in psychiatric disorders

Schizophrenia is associated with significant comorbidity and mortality—patients seemingly suffer more often from type-2 diabetes mellitus, diabetogenic complications plus environmentally influenced conditions than non-schizophrenic patients. Schoepf et al. [1] in a 12-year follow-up study with 1,418 adult schizophrenic patients and 14,180 ageand gender-matched hospital controls compared whether comorbidities with somatic diseases in fact lead to higher mortality. They discovered many of them to be more prevalent plus associated with a worse outcome in the schizophrenia population, whereas these patients suffered less from hypertension, hyperlipidemia, angina and cataract than controls. In the end, except parkinsonism the hospital mortality due to comorbid physical diseases did not significantly differ from the control population. Parkinsonism, again, was significantly prevalent in deceased schizophrenic patients compared to those surviving the study period. Anyhow, the authors recommend to thoroughly monitor and manage the most prevalent comorbidities in schizophrenia. Since there is an overlap between affective and schizophrenia symptoms in a large group of patients, Wilson et al. [2] critically question the reliability and clinical utility of the diagnosis of schizoaffective disorder after finding statistically significant deviances between clinical and research diagnoses in 134 psychiatric inpatients: While the treating clinicians had diagnosed 48 of these patients with schizophrenia, 50 with schizoaffective disorder and 36 with psychotic bipolar disorder, trained research personal again using the Structured Clinical Interview of the DSM-IV-TR inclusive an explicit time threshold for criterion C diagnosed 64 patients with schizophrenia, 38 with schizoaffective disorder and 32 with psychotic bipolar disorder. The authors assume a tendency for less severe diagnoses on clinician side and advocate a more stringent criterion C for the diagnosis schizoaffective disorder to address an implicit bias in clinical practice, which in the end might affect the prevalence of the psychotic disorder diagnoses. Only few studies so far have broached the issue of disempowerment and stigma-related stress in patients with mental illness due to involuntary hospitalization. Rusch et al. [3] assessed shame and self-contempt, self-stigma, empowerment, quality of life and self-esteem in 186 seriously mentally ill persons. Self-stigma was significantly associated with higher stigma stress levels independent of psychiatric symptoms, diagnosis, age, gender or the number of involuntary hospitalizations during lifetime inducing a negative effect on quality of life and empowerment. Thus, emotional reactions and stigma as a stressor should be considered in interventions to reduce the negative effects of compulsory measures. In an fMRI study with 18 female patients with a diagnosis of borderline personality disorder and 18 healthy female controls, Scherpiet et al. [4] investigated whether not only the perception of emotional stimuli but also the mere anticipation of upcoming emotional pictures leads to emotional dysregulation associated with the disorder. Compared to controls, the patient sample showed deficient recruitment of various brain areas related to cognitiveemotional interaction already in the anticipation phase of both negative and ambiguously announced stimuli possibly adding to the emotional dysregulation and contributing to hypersensitivity toward emotional cues. Emotional perception is also subject of Schonenberg and Jusytes [5] A. Schmitt (&) P. Falkai Department of Psychiatry and Psychotherapy, LudwigMaximilians-University Munich, Nusbaumstr. 7, 80336 Munich, Germany e-mail: Andrea.Schmitt@med.uni-muenchen.de

Attitudes towards help-seeking and stigma among young people at risk for psychosis

The role of self-labeling as ‘mentally ill’ and of stigma-related stress for help-seeking among young people at risk for psychosis is unknown. Stronger self-labeling and less stigma stress predicted better attitudes towards psychiatric medication and psychotherapy, controlling for clinical and sociodemographic variables. Interventions could target stigma-related stress to increase help-seeking.

Emotional reactions to involuntary psychiatric hospitalization and stigma-related stress among people with mental illness

Compulsory admission to psychiatric inpatient treatment can be experienced as disempowering and stigmatizing by people with serious mental illness. However, quantitative studies of stigma-related emotional and cognitive reactions to involuntary hospitalization and their impact on people with mental illness are scarce. Among 186 individuals with serious mental illness and a history of recent involuntary hospitalization, shame and self-contempt as emotional reactions to involuntary hospitalization, the cognitive appraisal of stigma as a stressor, self-stigma, empowerment as well as quality of life and self-esteem were assessed by self-report. Psychiatric symptoms were rated by the Brief Psychiatric Rating Scale. In multiple linear regressions, more self-stigma was predicted independently by higher levels of shame, self-contempt and stigma stress. A greater sense of empowerment was related to lower levels of stigma stress and self-contempt. These findings remained significant after controlling for psychiatric symptoms, diagnosis, age, gender and the number of lifetime involuntary hospitalizations. Increased self-stigma and reduced empowerment in turn predicted poorer quality of life and reduced self-esteem. The negative effect of emotional reactions and stigma stress on quality of life and self-esteem was largely mediated by increased self-stigma and reduced empowerment. Shame and self-contempt as reactions to involuntary hospitalization as well as stigma stress may lead to self-stigma, reduced empowerment and poor quality of life. Emotional and cognitive reactions to coercion may determine its impact more than the quantity of coercive experiences. Interventions to reduce the negative effects of compulsory admissions should address emotional reactions and stigma as a stressor.

Sexual minority status and trauma symptom severity in men living with HIV/AIDS.

Traumatic experiences are common among populations living with HIV; furthermore, the minority stress model indicates that sexual minority group members, such as men who have sex with men (MSM), are more likely to experience negative psychological outcomes after exposure to trauma, given the stress of minority stigma. The current study examined the prevalence of traumatic events and the impact of these events on trauma symptoms in a sample of 113 MSM and 51 men who have sex with women (MSW) who are living with HIV/AIDS. Rates of experiencing trauma were similar for both MSM and MSW. However, MSM, as sexual minority group members, were more likely to report symptoms of trauma and dissociation than MSW. The current study indicates that MSM may experience additional negative psychological outcomes after exposure to trauma. Findings are discussed in the context of implications for HIV prevention with sexual minority group members.

P03-183 - A stress-coping model of mental illness stigma: cognitive stress appraisal, emotional reactions, coping and outcomes

BackgroundStigma is a major stressor for many individuals with mental illness. Recent stigma models highlight the role of cognitive stress appraisal, emotional and cognitive coping responses, and their impact on outcomes such as self-esteem and social interactions. We tested this model, applying it to mental illness stigma.MethodsIn 85 people with mental illness, stigma stress appraisal and stress predictors (level of perceived stigma, rejection sensitivity, ingroup perception) as well as emotional reactions (anxiety, shame) and cognitive coping responses to stigma-related stress were assessed. In addition to selfdirected outcome (self-esteem, hopelessness), social performance in contact with outgroup members (i.e. members of the general public) was assessed by role-play and seating distance measures.ResultsHigher levels of perceived stigma, rejection sensitivity and holding one's ingroup in low regard predicted high stigma stress which in turn was associated with anxiety and shame, but not with cognitive coping responses. Anxiety and shame predicted lower self-esteem and more hopelessness; the coping mechanism of ingroup comparisons predicted poorer social performance.DiscussionOur findings support the stress-coping model of stigma when applied to people with mental illness. Emotional reactions to stigma stress as well as coping responses predicted largely negative outcomes. Trade-offs between different stress reactions may render them helpful for some, but harmful for other outcome domains. Predictors of stress appraisal and poor outcomes could be useful targets for interventions that aim to reduce the impact of stigma on people with mental illness.