The stigma of mental illness harms people in many ways, including prejudice (i.e., endorsing stereotypical beliefs about a group) and discrimination (behaviorally acting against this group based on prejudice), that robs people of rightful opportunities (Rusch et al., 2005). Hence, reducing stigma has been identified as a significant public health issue in the United States (National Academy of Sciences, 2016). Antistigma campaigns have been launched in many countries around the world, often wedded to potent messages seeking to erase stigma's harmful effects (Sartorius and Schulze, 2005). These programs have benefitted from preexisting research and development in the fields of public health mass communication (Randolph and Viswanath, 2004) and social marketing (Lee et al., 2002). One framework identifies key elements of messaging including rational, emotional, moral, and nonverbal (Kotler and Roberto, 1989). Research has also been completed, attempting to identify messages germane to antistigma campaigns in mental health (Ashton et al., 2018; Vaughan and Hansen, 2004). Clement et al. (2010) identified important messages via a consensus discussion of 32 international experts; they included notions of the high prevalence of mental disorders, social inclusion, recovery, and “seeing the person.”
This study examines the merits of two messages reflecting Kotler and Roberto's framework: emotional (designed to elicit either negative feelings such as shame or positive emotions such as worth) and moral (directed toward the target's sense of right and proper) elements of effective messages—normalcy and solidarity (Corrigan, 2016). Their impact might be understood by how messages address a fundamental characteristic of stigma change identified in the consensus discussion by Clement et al. (2010)—undesired differentness—that results from a mark distinguishing and discrediting minority from majority groups (Goffman, 1963). From a normalcy perspective, stigma arises because people with mental illness are viewed as different from the norm and, hence, somehow broken. Messages that accentuate similarities between people with mental illness and the rest of the population will decrease stigma by promoting normalcy: “People with mental illness, they're just like me.” Normalcy messages are often used in social marketing campaigns that frame mental illnesses like any kind of illness. There may, however, be unintended effects. For example, insights from other stigmatized groups suggest celebrating differentness, rather than hiding it, may decrease stigma better (Corrigan, 2016). Proponents of LGBT rights, for example, believe people should not be compelled to “pass” as heterosexual but instead proudly embrace their LGBT identity (Holt and Griffin, 2003). Normalcy messages might suggest that people with mental illness should keep aspects of their identity secret to accentuate their normalcy. Suppressing aspects of any part of one's identity, however, harms a person's mental and physical health, relationships, and well-being (Smart and Wegner, 2000). Studies suggest that people who come out as part of the LGBT community experience a better sense of well-being and relationship (Beals et al., 2009). In similar fashion, research has showed that people who are out with their mental illness report less self-stigma and better mental health (Corrigan et al., 2016).
What then becomes the goal of stigma change programs in this light? The public needs to acknowledge positive aspects of some people's identity with mental illness and do this by standing in solidarity with them. Solidarity has two meanings here (Corrigan et al., 2013). First, people with lived experience of mental illness gain strength through association with peers. More broadly, however, is the experience where the majority stands with the group who is publicly out with their stigmatized identity, where they are in solidarity with people in recovery. Solidarity represents a more empowered view of people with mental illness.
In this article, we report findings from a preliminary investigation to identify relative merits of solidarity and normalcy messaging using identified merits of effective public health communications (Randolph and Viswanath, 2004): how understandable, compelling, and effective are each? We expected to show solidarity to be viewed as relatively more meritorious because it represents a more empowered view of people with mental illness. In addition, experience and identity with mental illness will interact with solidarity-normalcy judgments. Research has shown that some people who identify with mental illness report better self-esteem and personal empowerment, which might be expected to impact perceptions of solidarity (Lysaker et al., 2007). Hence, we expect to show people with lived experience of mental illness to view solidarity more positively than normalcy.
Adults were solicited to participate in this study using Amazon's Mechanical Turk (MTurk), a crowd-sourcing Internet marketplace network that, among other things, is used to solicit participants for social science research. Data show that more than 100,000 survey participants from the United States are registered with MTurk (Pontin, 2007). Research is mixed regarding the degree to which demographics of MTurk survey participants match the US population (Buhrmester et al., 2011; Paolacci et al., 2010; Ross et al., 2010), although this is less of a problem for studies like the current one, which are more concerned about internal validity to test hypotheses. Data quality has been shown to be significantly greater for MTurk compared with other crowd-sourcing platforms (Kraiger et al., 2016). A solicitation was posted in MTurk requesting survey participants to partake a 15-minute survey “about knowledge and thoughts about mental health issues.” Findings reported here are from a larger data set on describing the characteristics of effective antistigma campaigns. Consistent with our commitment to pay MTurk participants minimum wage, those completing this 15-minute task were reimbursed $2.55.
Four hundred MTurk respondents replied to the solicitation and were assessed for eligibility. One concern about online surveys is research participants who demonstrate insufficient effort responding (Huang et al., 2015) by failing to fully attend to tasks. As in similar research, our MTurk survey included validity questions meant to exclude people in this group who were not attending well; for example, “Please choose the number ‘4’ for your answer below.” We also excluded participants whose time on task was below minimal cutoff (3 minutes after viewing vignette) to complete the survey competently. As a result, 373 MTurk survey participants provided useable data. Before beginning the survey, prospective research participants were informed of the goals and methods of the study and asked for an electronic signature as an indicator of their consent. The study was fully reviewed and approved by the institutional review board at the Illinois Institute of Technology. Participants were exposed to consent form, measures, and conditions through Qualtrics, an online self-administered survey platform.
After consenting to participate, survey respondents answered items about demographics. Overall, the sample was 32.1 years of age on average (SD = 9.7) and 39.7% female. Most respondents self-reported as white (78.3%); others self-reported as African/African American (8.0%) and Asian/Asian American (10.7%). Approximately 10% of the sample reported being Latino/Latina. The overall sample was 89.8% heterosexual and 10.0% LGBT. Participants were mostly single (46.9%) or married/partnered (45.9%), whereas 7.0% reported being divorced or widowed. Educational achievement varied, with more than 80.7% reporting some college or higher. In terms of employment, 60.9% were working full time and 18.0% part time. Incomes varied with 89.2% of participants reporting annual income less than $50,000.
Based on a measure used elsewhere (Corrigan and Al-Khouja, 2018), lived experience was assessed when research participants completed five yes-no questions (1,0) representing varied services for mental illness: 1) “Have you ever received counseling or psychotherapy?,” 2) “Have you ever been diagnosed?,” 3) “Have you ever taken medications?,” 4) “Have you ever seen a psychiatrist?,” or 5) “Have you ever been hospitalized?”
Next, research participants were oriented to the challenges of stigma in a brief paragraph that outlined definitions of stigma, its prevalence, and its egregious effects on employment, housing, and access to quality health care. They were then presented, in random order, “two messages to stop stigma: solidarity and normalcy.” Briefly, normalcy was described as a message that includes, “the public does not view individuals as their mental illness, but rather they view them as a valuable member of society. Normalcy gives the message ‘You are just like me!’” Solidarity was defined as, “Expressing solidarity for people with mental illness means standing with them in the fight against stigma…. Solidarity gives the message ‘I stand with you!’” Consistent with communication scholar recommendations (Lee et al., 2002; Randolph and Viswanath, 2004), messages were crafted by a panel of antistigma experts with lived experience; they are provided verbatim in the Appendix.
Immediately upon completing each message, participants were given three questions to answer with a 10-point agreement scale (10 = agree not at all). How understandable, effective, or compelling was each message? Items were summed into a total merit score for normalcy and solidarity with higher scores representing lower merit. Research participants also completed measures of public and self-stigma to validate normalcy and solidarity merit ratings with the assumption that higher stigma would yield more negative ratings of messages. Public stigma was assessed using the short version of the Attribution Questionnaire (AQ; Corrigan et al., 2014). In the AQ, respondents are presented a brief vignette about Harry, “a 30-year-old, single man with schizophrenia.” The short version includes single items measuring nine factors—responsibility, pity, danger, help, dangerousness, fear, avoidance, coercion, and institutionalization—on a seven-point agreement scale (7 = very much). Items were summed to create a single public stigma scale with higher scores representing more stigma.
Self-stigma was assessed using the short form of the Self-Stigma of Mental Illness Scale (SSMIS; Corrigan et al., 2012). Only one, 5-item subscale from the SSMIS was used representing harm to self-esteem that results from internalizing stigma (“I currently respect myself less because I am dangerous.”). Items were summed to yield total scores with higher values representing greater self-stigma. Both AQ and SSMIS have strong reliability (internal consistencies greater than 0.7) and construct validity (correlations with separate indices related to public stigma [r = 0.41, p < 0.001] and self-stigma [r = 0.48, p < 0.001]) as used in this study (Corrigan et al., 2006; Watson et al., 2007).
First, Cronbach alphas were completed to determine internal consistency of normalcy and validity scales. This was followed by Pearson product moment correlations to determine construct validity of solidarity and normalcy total ratings: correlations between merit ratings and public and self-stigma were examined. Differences in merit score between normalcy and solidarity for the overall sample was determined with a repeated measures one-way analysis of variance (ANOVA).
The sample was then divided into groups of participants who did or did not report themselves with any of the specific experiences of mental illness services. We did this by creating a total experience score, adding up responses to the five experience items. Respondents were then divided into two groups: those with no experience (sum = 0) or those with at least one of the five experiences (sum ranges from 1 to 5). A difference score between solidarity and normalcy was also determined (solidarity minus normalcy); negative difference scores represented greater endorsement of solidarity's merit compared with normalcy. A Pearson product moment correlation examined the relationship between those with or without self-reported mental health experience and the solidarity-normalcy difference score. Finally, preliminary correlations between report of each individual experience and the solidarity-normalcy difference score were completed to determine how form of experience (e.g., previous hospitalization or diagnosis) impacted relative perception of solidarity versus normalcy merit.
As per Cicchetti (1994), internal consistencies of total solidarity and normalcy ratings were good (0.89) and excellent (0.93), respectively. Pearson product moment correlations seemed to support construct validity of normalcy and solidarity ratings. As expected, participants from the entire sample who reported higher public stigma were likely to view solidarity and normalcy antistigma messages more negatively (0.18 and 0.19, respectively, p < 0.01). Similarly, participants with at least one of the previous experiences with mental illness who reported greater self-stigma viewed solidarity and normalcy messages more negatively (0.34 and 0.38, respectively, p < 0.01). Results of a one-way ANOVA showed the overall sample rated merit of the solidarity message (M = 9.74, SD = 7.22) as more positive than the normalcy message (M = 10.62, SD = 7.03) (F(1,372) = 12.38, p < 0.001).
A Pearson product moment correlation also examined the association between research participants who reported any of the five experiences (n = 128) or those with no experiences (n = 245). Results were inverse and significant (r = −0.12, p < 0.05); this is consistent with a small effect size according to Cohen (1977) effect size criteria. Participants with lived experience versus those with no self-reported experience viewed solidarity as more meritorious compared with normalcy. Table 1 summarizes Pearson product moment correlations for the difference score and the five specific self-reports of service for mental illness. Results found two of the indices more significant; people who have experienced services with a psychiatrist or hospitalization were more likely to rank merit of solidarity greater than normalcy.
A central element of antistigma efforts is its messages. Here we looked at two: normalcy, “you're just like me,” and solidarity, “I stand with you.” We sought to describe relative merits of each message in preparation for subsequent work on impact of existing antistigma campaigns. Merit was defined as ratings of whether messages were understandable, effective, and compelling. Results showed the overall group of research participants viewed solidarity messages with greater merit than normalcy. Participants with self-reported mental illness seemed to view solidarity, compared with normalcy, even better than participants without mental illness.
Subsequent analyses suggested only certain experiences were significantly related to the solidarity-normalcy difference. Those who self-reported previous services with a psychiatrist or previous hospitalization were likely to view solidarity messages better. What might account for varied significance of correlations in Table 1? Perhaps difference between groups in Table 1 increased as participants admitted to more stigmatizing experiences related to mental illness services; for example, being hospitalized as opposed to participating in psychotherapy or counseling. Research has shown that public stigma is worse for people who participate in services needed for more harmful mental illness (Angermeyer et al., 2004; Corrigan et al., 2005). People who have been hospitalized are viewed more negatively than the other four experiences (Corrigan and Al-Khouja, 2018) and therefore may experience stigmatization more than those without this experience. The greater stigma leads to a preference for solidarity. However, these findings need to be interpreted with caution, because, for example, defined groups of yes-no for diagnosis or medication or hospitalization were not independent of each other. A research participant could report having been diagnosed with a mental illness and receiving medication for it. Future research needs to control for this confound.
There are additional limitations to this study. Despite efforts to equate content, specific wording in each message may have accounted for these results. For example, the solidarity message referred to people with mental illness as different, whereas normalcy called them devalued. Proxies for the two types of messages were limited to brief written paragraphs instead of a better nuanced program. The study's design also posed solidarity and normalcy as mutually exclusive messages, which they are not. The antistigma impact is likely to become richer when embedded in more complete antistigma campaigns like those already in use around the world (Sartorius and Schulze, 2005). Still, the goal of this preliminary study was to examine the merit of solidarity and normalcy messages in a well-controlled design. The challenge going forward is to mesh these discrete messages with broader campaigns.
Differences in perceived merit does not equate with differences in impact. Future research needs to use randomized design to test message outcomes related to stigmatizing attitudes and behaviors. Impact should also show improvements in affirming attitudes, such as recovery and self-determination, as well as affirming behaviors. Finally, this study was completed in the somewhat sterile world of MTurk. Future research needs to determine how antistigma messages are viewed in real-world targets.
The authors declare no conflict of interest.
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Verbatim transcript of paragraphs representing normalcy and solidarity.
Normalcy is when people view those in devalued groups as the same as everyone else. Normalcy for people with mental illness is expressed by treating the person as an individual that is separate from his or her illness. Through normalcy, the public does not view individuals as their mental illness, but rather they view them as a valuable member of society. Normalcy gives the message “You are just like me!”
Solidarity is when people from different groups join together to work toward a common goal. Expressing solidarity for people with mental illness means standing with them in the fight against stigma. With solidarity, stigma can be challenged by speaking up when false beliefs and stereotypes about mental illness are shared by friends, family, colleagues, or in the media. Solidarity gives the message “I stand with you!”