Dr. David L Vogel is a Professor of Psychology at Iowa State University. Dr. Vogel received his doctorate in Counseling Psychology from the University of Florida. His research interests focus on stereotyping and stigma in the counseling process, counselor training, and the decision to seek professional help. Among his body of work is over 100 papers (published and under review) and over 60 conference presentations. His recent paper, titled “Is stigma internalized? The longitudinal impact of public stigma on self-stigma” was published in the journal Journal of Counseling Psychology.
Background of the study
I came about the study based on the findings that, despite psychological treatments being effective for a broad range of mental health concerns (Lambert & Ogles, 2004), most (approximately three fourths of Americans) who experience a mental health concern never seek treatment, delay in seeking treatment for months or even years, and/or drop out of treatment early and thus experience unnecessary pain (NIMH, 2005).
One of the most cited reasons for treatment avoidance is stigma surrounding mental health concerns and therapy. In particular, based on the work of Corrigan (2004), my colleagues and I have been studying the impact of two types of stigma: public and self-stigma. Public stigma refers to the stigmatizing perception, endorsed by the general population, that a person who seeks mental health services is undesirable or socially unacceptable. Self-stigma is defined as the reduction in a person’s self-esteem or sense of self-worth due to the perception held by the individual that he or she is socially unacceptable.
We have found in several previous studies that self-stigma may be particularly pernicious and a stronger cause of avoidance of seeking therapy than public stigma. Self- stigma is also thought to occur when people self-label as someone who is socially unacceptable and in doing so internalize stereotypes and apply negative public attitudes to themselves. Thus, self-stigma is believed to be the internalization of external public stigma. However, this internalization process had not been examined.
This study examined the relationship between public stigma and self-stigma over a 3-month time span. Consistent with the hypothesis that public stigma is internalized as self-stigma over time, higher initial public stigma predicted higher subsequent self-stigma, but this was not the case for the reverse. This finding supports previous assertions regarding the role of public stigma on the development (i.e., internalization) of self-stigma. Specifically, results support the theory that people internalize negative perceptions about mental illness (Link & Phelan, 2001; Vogel et al., 2007).
Past studies have highlighted that negative societal perceptions about mental illness and seeking help can have negative consequences, especially for individuals suffering from mental illness. One such example is that individuals with mental illnesses may avoid seeking treatment for fear of receiving a negative label. Furthermore, the results of this study support the notion that public stigma may serve as a direct barrier to not only seeking treatment but also to people’s ability to form positive and healthy attitudes about themselves and their capabilities (i.e., increased self-stigma). This insidious effect of public stigma can be particularly problematic, as it may not only reduce the likelihood of seeking services but also increase the occurrence of symptoms, relapse, and feelings of distress and hopelessness (Corrigan, 2004).
The results add important information to the way in which public stigma might operate on attitudes and intentions concerning seeking help: through the development of self-stigma.
Whereas public stigma is based on societal factors that can be difficult to change, this study highlights an alternate avenue for reducing the negative effects of stigma: the individual. Changing society’s attitudes toward mental illness and psychological help seeking remains an important step and may be the ultimate goal.
Researchers and clinicians could assist those in need by helping them to interrupt the internalization of public stigma. This could be done by developing interventions that can be applied in clinical settings or by the individuals themselves (e.g., online self-help materials)—interventions that focus on strategies and techniques to combat the influence of public stigma and reduce extant self-stigma. For example, borrowing from the social psychological literature, mechanisms known to impact the ways that stigma affects the individual (i.e., expectancy confirmation, stereotype activation, identity threat processes; Major & O’Brien, 2005) could be used to reduce self-stigma.
Given the association between stigma and treatment adherence, reducing self-stigma may lead to better treatment adherence and decreased premature termination (Sirey, Bruce, Alexopoulos, Perlick, Friedman, & Meyers, 2001).
Ultimately, further research is needed to examine additional variables (e.g., conformity to masculine norms, level of exposure to education about mental illness and its treatment) that may impact the internalization of self-stigma over time. The focus on internal factors as opposed to external factors may provide a more direct way to examine the role of stigma and the magnitude of its impact on help-seeking behaviors of individuals with mental illness. Additional research is also needed to provide information regarding the efficacy of specific interventions.