Chapter 2 Literature Review Literature Review
4.2. Contact Theory
4.2.2. Intergroup contact and mental illness
The contact hypothesis has also been extended to mental health studies, and there is evidence of the importance of appropriate intergroup contact for reducing negative attitudes or stigma towards people with mental illness. Using contact theory, authors such as Angermeyer, Matschinger and Corrigan (2004), as well as Corrigan, Green, Lundin, Kubiak and Penn (2001), hypothesised that attitudes and stigma about mental illness in general are influenced by an individual’s degree of familiarity or contact with mental illness. Familiarity or contact could range from seeing a television portrayal of mental illness, to having a friend or co-worker who has a mental illness, to having a family member who has a mental illness, to having a mental illness oneself (Corrigan, Green et al., 2001). In brief, according to the contact hypothesis, members of the public who have contact with people with mental illness would have more positive attitudes toward that group, including less desire for social distance (Phelan & Link, 2004).
Empirical support for contact theory is evident from a series of studies that have been conducted in which vignettes or real patients have been used to measure the public’s stigmatising attitudes and social distance in relation to mental illness. Unfortunately, stigma is not a rare phenomenon and stigmas about mental illness are widely endorsed by the general public (Corrigan, Edwards, Green, Diwan & Penn, 2001). Stigma is a negative evaluation of a person who has been tainted or discredited on the basis of attributes such as race, ethnicity, illness, religion or culture (Adhikari, 2007). In their review of literature, Angermeyer and Matschinger (2003) provide the following three components of stigma as summarised from the work of Corrigan and Watson (2002), namely stereotype, prejudice and discrimination. They write that: a) stereotypes represent notions of groups or a person (the mentally ill), b) people who are prejudiced endorse these
negative stereotypes and, as a result, generate emotional responses; and c) prejudice then leads to social discrimination. Consequently, people with mental illness are robbed of the opportunities that define a decent quality of life such as good jobs, safe housing, satisfactory healthcare and affiliation with a diverse group of people (Corrigan & Watson, 2002). Negative views such as those implying that people with mental illness are irresponsible and therefore incapable of making their own decisions, or are dangerous and are to be feared, are widespread (Gureje et al., 2005).
While using derogatory terminology and making jokes about marginal groups has become socially unacceptable, it is still commonplace to draw on stereotypical images and stigma of mental illness in media and everyday language (Schulze, Richter-Werling, Matschinger & Angermeyer, 2003). The media perpetuate stigma, giving the public narrowly-focused stories about people with mental illness based around stereotypes. In cinema and television, according to Byrne (2000), mental disorders are substrate for comedy, and are also conferred with highly charged negative connotations of self-infliction, an excuse for laziness and criminality. Such depictions elicit fear and apprehension from the public and lead to stigmatisation of and distancing from mentally ill patients. To show support for this, in a study investigating the relationship between people’s television watching and the desire for social distance from people with schizophrenia, Angermeyer, Dietrich, Pott and Matschinger (2005) found that the desire for social distance increases almost continuously with the amount of television watched.
It is also important to note that, not only do people with mental illness suffer from the public’s stigmatising attitudes, they also suffer from self-stigma. Self-stigma has been shown to yield deleterious effects on the lives of people with mental illness (Corrigan, Watson & Barr, 2006). Numerous studies conducted on patients with mental illness indicate that self-stigma is a serious problem that leads to diminished self-esteem (Estroff, 1989; Link, Struening, Nesse-Todd, Asmussen & Phelan, 2001;
Ritsher, Otilingam & Grajales, 2003). According to Corrigan and Watson (2002), when living in a society that widely endorses stigmatising ideas, people with mental illness are likely to internalise these ideas and believe that they are less valued because of their illness. Corrigan et al. (2006) argue that the effects of such self- stigma on self-esteem, psychological well-being, and self-efficacy may impact on behavioural goals. They claim that self-stigma could consequently interfere with
the pursuit of rehabilitation goals in terms of living independently and obtaining competitive work.
Corrigan, Edwards et al. (2001) suggest that individuals who perpetuate stigma are likely to distance themselves socially from persons with mental illness.
Stereotypes about mentally ill people make it easier to dismiss these ill people, and in so doing, the stigmatiser maintains social distance (Byrne, 2000). Social distance is likely to manifest itself in such discriminatory practices as being less likely to hire persons who are labelled mentally ill, being unwilling to lease apartments to them, or being reluctant to freely interact with them (Corrigan, Green et al., 2001). The negative views or stigmatising attitudes held tend to be indicative of the degree of tolerance individuals might have about people with mental illness (Gureje et al., 2005). Link et al. (1999) reported in their study that 90% and 47% of their participants were unwilling to interact with people who were considered ‘troubled’ or
‘depressed’, respectively. Their participants desired the most social distance from the person described through vignettes as having cocaine dependence followed, in order, by those with alcohol dependence, schizophrenia and major depression.
In a similar study, Stuart and Arboleda-Florez (2001) reported that one in five of their participants stated that they would be unable to share a room with, and three- quarters of participants would be unable to marry, someone with schizophrenia.
This clearly supports an assertion made by Gureje et al. (2005) that attitudes to mental illness are characterised by intolerance of even basic social contact with people known to have such illness.
Phelan and Link (2004) raise a concern that where perception of danger is present, it may increase rejection and avoidance of people with mental illness. This means that people with mental illness are, therefore, likely to be feared if perceived as dangerous. It is of concern to note that the ‘dangerousness’
stereotype has endured and has probably increased over the past 50 years, even though there have been large-scale public education efforts focused on the nature, causes and treatment of mental illness in the United States (Link et al., 1999).
Fear generally yields avoidant behaviours, or a strong preference for social distance from the feared person or object (Angermeyer et al., 2004). Link et al.
(1999) found, from their study, a correlation of 0.432 (P<.001) between perceptions of violence and social distance towards people with mental illness. They, therefore, concluded that there was a significant association between the belief that a
mentally ill person is likely to be violent and the desire to maintain social distance from that person. In Africa, a Nigerian study conducted by Gureje et al. (2005) recorded findings that support this conclusion. Their results showed that most respondents would be afraid to have a conversation with and would be disturbed to work with a person with mental illness. Arvaniti et al. (2009) argue, however, that familiarity with patients with mental health problems should imply less fear of dangerousness and more positive attitudes, in general, towards them.
Consistent with this familiarity argument, in their study of familiarity with mental illness and social distance from people with schizophrenia and depression, Angermeyer et al. (2004) found that respondents in Germany who were familiar with mental illness were less likely to believe that people with mental disorders are dangerous. They also reported that weaker perceptions of dangerousness corresponded closely with less fear of such people, which in turn was associated with less social distance. There is also evidence from other literature (Angermeyer
& Matschinger, 1997; Corrigan & Watson, 2002; Stuart & Arboleda-Florez, 2001) supporting the postulation that there is a strong relation between social distance and knowledge of mental illness. Most of these studies contend that people with the highest and most accurate knowledge of mental illness are the least socially distancing. Stated another way, Stuart and Arboleda-Florez (2001) concluded from their study that people with the greatest knowledge of mental illness were ten times more likely to express highly tolerant attitudes, compared with those with the least amount of knowledge. Angermeyer and Matschinger (1997) went beyond investigating only the knowledge of mental illness and concluded that increased educational level, referring to formal schooling education, increased the desire for social distance to people with mental illness. Education provides information so that the public can make more informed decisions about mental illness (Corrigan
& Watson, 2002). Stuart and Arboleda-Florez’s (2001) study also revealed that older respondents were significantly less knowledgeable about mental illness and were thus more distancing than their younger counterparts. Similar findings have also been recorded in studies conducted by Angermeyer and Matschinger (1997), as well as Wolff, Pathare, Craig and Leff (1996).
In general, the current review of the existing literature generally supports the basic premise of the contact hypothesis, that is, that contact with the mentally ill can help to reduce stigma and social distance, and increase their acceptance.
When summarising 3651 articles reviewing population-based attitude research studies in psychiatry covering a period of over 15 years, Angermeyer and Dietrich (2006) concluded that, if indeed any relationship exists, there is a positive association between familiarity with mental illness and acceptance of people with mental disorders. They add that it becomes evident from these numerous studies that facilitation of contact with people with mental disorders may prove effective in reducing negative attitudes.
Phelan and Link (2004) offer an interesting critique to consider when applying the contact hypothesis to studies of mental illness. Taking into account the fact that positive effects of intergroup contact occur under optimal conditions (equal status, sharing common goals, etc.), as stated earlier in this chapter, they argue that the kind of contact the general public often has with mentally ill patients is often quite impersonal, for example, the general public may only see a television portrayal of a person with mental illness, or may experience having a person with mental illness in the neighbourhood. According to Phelan and Link (2004), since this kind of contact is so impersonal and does not meet the optimal criteria, it is possible that this contact could be associated with more negative attitudes, even though personal contact is generally associated with more positive ones. It would be significant to test this critique in the present study.
The contact hypothesis could also be extended to the public’s familiarity with services that provide treatment of mental health illnesses. For this current research, it is hypothesised that people who may have had contact with mental illness, as described above, will show high levels of mental health literacy.
Numerous studies such as those conducted by Anderson (1995), Phelan and Link (2004), as well as Callaghan et al. (1997), have recorded findings that support this hypothesis.
Based on the contact theory hypothesis as presented here, it would be expected in the current study that members of the public who have contact with people suffering from mental illness, and/or contact with mental health treatment facilities would have higher levels of mental health literacy. Conversely, those individuals with a greater social distance are likely to have more stigmatising attitudes and less mental health literacy. Other hypotheses originating from contact theory to be tested in this study include the effect of age and level of education in terms of social distance towards the mentally ill.