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Mental Health Systems and Policy: Introduction to Part III
Bruce G. Link, Distinquished Professor of Sociology and Public Policy, University of California at Riverside,
Jo C. Phelan, Professor, Sociomedical Sciences, Mailman School of Public Health, Columbia University
This chapter provides a frame for examining extant issues and evidence concerning labeling and stigma as it pertains to mental illnesses. The issues addressed are: (1) the conceptualization of labeling and stigma, (2) evidence about trends in stigma-relevant public attitudes and beliefs, and (3) how labeling and stigma affect individuals who develop mental illnesses. Both modified labeling theory and the conceptualization of stigma developed by Link and Phelan point to the importance of attitudes and beliefs, leading to questions about how such attitudes and beliefs are faring in trends over time. The research reviewed in this chapter shows that the public recognizes mental illnesses as illnesses with genetic and biological bases; however, the core stereotypes of dangerousness and incompetence have either changed little or actually become stronger. No change in social distancing responses has accompanied the increasingly medical conception of mental illnesses. Discrimination against people with mental illnesses occurs through multiple mechanisms, including direct person-to-person discrimination, discrimination operating through the stigmatized person, discrimination that emerges silently but perniciously through social interaction, and structural stigma. What are the policy implications of this chapter?
When we ask who is labeled mentally ill and what the consequences of such labeling are, we ask questions that are central to the sociological understanding of mental disorder. Such questions are relevant to those who are concerned that so many people with serious mental illnesses go unlabeled and untreated (Regier et al., 1993; Wang et al., 2005). Such questions are also relevant to people attempting to recover from mental illnesses who often feel that they suffer as much from being labeled mentally ill as they do from mental illness itself (Deegan, 1993).
As a society, we have created specific professions (including psychiatry, clinical psychology, psychiatric social work, and psychiatric nursing) upon whose members we confer the authority to define, label, and treat mental illnesses. Social processes determine who encounters these professionals and many of the important consequences that might follow from such an encounter. The treatment they receive may ameliorate their symptoms, improve their well-being, and enhance their social and occupational functioning. At the same time, along with treatment comes the possibility of pejorative labeling and stigma. Social science research on labeling and stigma can help us understand the processes involved, and, by bringing those processes to light, open the possibility of addressing some of their negative consequences.
This chapter aims to further our understanding of how genetic research and genetic explanations of alcoholism and other addictions may affect the stigma that is attached to addictions. Because we found practically no empirical research directly addressing the connections among genetic causal attributions, stigma, and addictions, we approach the chapter in the following way. First, we review key conceptual models of stigma, which address three basic questions: (1) What is stigma? How can stigma be defined? (2) What are the dimensions of stigma? How does stigma vary depending on the characteristic that is stigmatized and the circumstances in which it is encountered? (3) Why do we stigmatize? How does stigmatization benefit the dominant nonstigmatized group? Second, we review existing conceptual and empirical work concerning the stigmatization of addictions, focusing primarily on alcohol and substance dependence, and we discuss addictions in relation to each of the general conceptual models of stigma.
Next, we focus on the implications of genetic explanations and understandings of addictions (or the “geneticization” of addictions) for stigma. Here we focus first on theories that have implications for the connection between genetic causal attributions and stigma, and then on empirical research that has addressed the connection between genetic attributions and stigma for characteristics such as mental illness, obesity, sexual orientation, anorexia, stuttering, and cancer. Finally, we use the theoretical models and empirical findings to construct predictions concerning the likely impact of genetic attributions for stigma related to addictions.
The mental health consumer/survivor movement is the human rights movement devoted to securing the rights and just treatment of persons identified as mentally ill. This chapter reviews trends in the struggles of activists to achieve the rights. After describing early conditions and moments in the movement, it examines the modern mental health consumer/survivor movement, focusing on the expatients and other advocates who fueled the modern movement, the reformist turn from antipsychiatry to consumerism, forces that bolstered or challenged the movement, subsequent challenges and more recent developments. In a political climate in which National Alliance on Mental Illness (NAMI) had acquired considerable influence, Community Support Program (CSP) was losing power and had become less favorably positioned to promote the consumer/ survivor cause. National and state organizations advance their consumer/ survivor agendas, and every state has a mandated consumer office through which consumers and survivors directly engage with policy makers.
Detailed interviews were conducted with 1523 married professional and managerial employees of a major US corporation to test associations of acute and chronic occupational and domestic stress with DSM-III-R major depression and current depressive symptoms. After controlling for demographic and clinical risk factors, both sources of stress were significantly associated with the two measures of depression. On the other hand, neither the demographic and clinical risk factors, nor several psychosocial characteristics (social support, sense of mastery and organizational commitment) moderated the relationship between stress and depression.
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