Reducing Mental Illness Stigma in the Classroom

Abstract

Psychology courses present unique opportunities to reduce mental illness stigma. The literature highlights contact with people diagnosed with disorders as the best stigma reduction technique. Simple stigma education, however, is also promising and can be accomplished as part of course content coverage. Abnormal psychology students participated in one of five conditions to gauge the impact of different stigma reduction techniques. Results for overall stigma reduction indicate robust effect sizes (Cohen’s d; range = 0.77–1.52) for all interventions conditions, but no effect for the control condition. The current study supports the use of stigma reduction techniques but highlights the usefulness of stigma education as a simple but powerful tool for stigma reduction within standard course curricula.

Keywords

stigma mental illness contact education abnormal psychology teaching college and university

Changing Beliefs About Mental Illness Through Exposure

Despite decades of research focus, stigma of individuals diagnosed with a mental illness remains a considerable problem (Pescosolido, 2013; Schomerus et al., 2012). Jones and Corrigan (2014) report that individuals diagnosed with psychological disorders are subjected to a range of negative thoughts, feelings, and behaviors by others, and Corrigan and Kleinlein (2005) noted that stigma also impacts a variety of other groups. Families of individuals diagnosed with mental illness, for example, report being subjected to social distancing and engaging in related attempts to hide a loved one’s mental illness from others; treatment professionals may experience stigma by association from working with people who have a mental illness; and the general public both maintains its fear of mental illness and loses out on the contributions to society that people who have a mental illness could make because of stigma. Of the groups outlined by Corrigan and Kleinlein, the general public often endorses the most stigmatizing attitudes toward mental illness (Grausgruber, Meise, Katschnig, Shöny, & Fleischhacker, 2007; Peris, Teachman, & Nosek, 2008). Furthermore, despite gains in general knowledge about mental illness, such as its causes, stigmatizing attitudes about mental illness have not decreased (Angermeyer, Holzinger, & Matschinger, 2009).

In addition to research on the scope of stigma, there is a robust literature on stigma reduction. Corrigan and Penn (1999) identified protest, education, and contact as potential techniques to reduce stigma. Protest highlights stigma and works, often through social activism, to change how mental illness is depicted, education specifically targets stereotypes and myths about mental illness in order to reduce or eliminate such misconceptions, and contact brings people with and without mental illness diagnoses together to highlight commonalities and diminish stereotypes. Corrigan and Penn noted that while these techniques often do not operate in isolation, the effects of the primary or most salient technique used are often highlighted. In examining which technique best reduces stigma, Corrigan, Morris, Michaels, Rafacz, and Rüsch (2012) found that contact has the highest likelihood of reducing stigma followed by education about stigma and that protest is rarely tested. Much of the research design in this area (e.g., Reinke, Corrigan, Leonhard, Lundin, & Kubiak, 2004) tends to utilize brief (e.g., 15 min) instances of education or contact. However, providing enough information to counter, in many cases, long-standing and firmly held attitudes may be difficult in such brief encounters (Corrigan & Penn, 1999). Although this makes conceptual sense within the larger contact hypothesis literature (Islam & Hewstone, 1993), Kolodziej and Johnson’s (1996) meta-analysis of contact and decreased mental illness stigma indicates that longer periods of contact do not lead to greater change in attitudes. In explaining these results, Kolodziej and Johnson noted specific characteristics of the study designs (such as participants spending more time in places that arguably do not promote positive attitudes in order to experience prolonged contact) as potentially informing this effect. Thus, at the current time, understanding how the amount of contact impacts stigma reduction is still unclear.

Although stigma research focus is mainly on adults (Roe, Lysaker, & Yanos, 2014), there is some literature on stigma and its reduction efforts in adolescence. Bailey (1999) confirmed that the existence of mental illness stigma in adolescents was at comparable levels to adult samples. In relation to stigma reduction in this age-group, however, the best method of stigma reduction differs from that of the adult population. While Corrigan et al.’s (2012) meta-analysis found that contact was the best method for reducing stigma in adults, stigma education, not contact, had greater overall effect sizes in reducing mental illness stigma in adolescents. Corrigan et al. hypothesized that beliefs about mental illness may still be developing in adolescents and therefore may also be more malleable through stigma education. These contrasting findings by age-group raise an interesting question as to which method of stigma reduction may be best for college and university-age students. Arnett (2007) asserts that the period ranging from the late teenage years through the mid-20s is a distinct period between adolescence and adulthood and has termed it “emerging adulthood.” He also views the college environment as the epitome of where emerging adulthood can be seen (Arnett, 2016). The concept of emerging adulthood, then, signals a need to understand where college students may fall in relation to stigma and stigma reduction efforts. Kendra, Cattaneo, and Mohr (2012) confirm that college/university students have mental illness stigma at comparable levels to adults, and Yamaguchi et al. (2013) found that as with adults, contact was the best technique to reduce stigma in college students participating in stand-alone research aimed at stigma reduction. The definition of education used in the Yamaguchi et al.’s (2013) study, however, appears to be more general education that “presents the features of mental illness” (p. 490) rather than stigma-specific education as defined by Corrigan and Penn (1999) and reaffirmed by Corrigan et al., which calls into question the usefulness of these findings in relation to stigma education methods specifically.

The potential impact that straightforward stigma education efforts might have in college/university students is a promising area of focus for stigma reduction because it can be accomplished as part of course content coverage, as opposed to a stand-alone research study. Due to the content coverage of mental illness in both introductory and abnormal psychology courses and the frequency with which they are offered within psychology curricula (Stoloff et al., 2010), engaging in stigma reduction within these courses presents unique, natural opportunities to reduce mental illness stigma. Mann and Himelein (2008) noted the practicality of attempting to reduce stigma while teaching and reiterating Corrigan and Penn’s (1999) assertion that the education must be stigma-specific, cautioned that general education about mental illness (e.g., symptoms, causes, treatments) that does not specifically focus on disconfirming stereotypes typically has no impact on stigma attitudes. Notwithstanding the potential benefits to conducting stigma reduction as part of an existing course, there is relatively little formal research on the topic. Maranzan’s (2016) recent review of the literature specifically addressing mental illness stigma in the classroom identified only seven articles that attempted to address stigma in both general/introductory (n = 4) and abnormal (n = 3) psychology courses using various techniques; contact was the most common technique (n = 4) used to combat stigma in the classroom, followed by education (n = 2) and popular and educational videos (n = 1). Across these studies, stigma reduction was typical (e.g., Faigin & Stein, 2008; Mann & Himelein, 2008; Matteo & You, 2012; Poorman, 2002; Rusch, Kanter, Angelone, & Ridley, 2008), but not always accomplished (e.g., Kendra, Cattaneo, & Mohr, 2012; Owen, 2007), with the contact-based techniques showing the strongest stigma reduction (three vs. two studies supporting the effectiveness of education techniques). Effect sizes for the interventions were not provided, however, so it is unclear whether contact was actually more effective in reducing stigma or simply more frequently studied as a stigma reduction technique. Given this, further study into stigma reduction techniques in the college classroom is warranted.

To summarize, the current state of the literature favors contact as the best stigma reduction technique for adults but stigma education as the best stigma reduction technique for adolescents. The concept of emerging adulthood (2007) as a distinct period between adolescence and adulthood raises the question of which stigma reduction technique would have the most impact on college-age students. Attempting to effect stigma reduction within the bounds of a naturally occurring college/university course has clear appeal, but the state of the current literature provides no definitive answers on which technique(s) best reduce stigma. Therefore, continued investigation of stigma reduction techniques in the college/university population is warranted to better understand which techniques should be employed for stigma reduction.

The purpose of the current research was to examine stigma reduction techniques that are infused within the college/university course curricula in order to provide guidance to teaching professionals as they consider whether and how to implement stigma reduction programs in the college/university classroom. Maranzan's (2016) review contained only seven studies that targeted stigma reduction as part of the normal course curricula, and while the results were positive for both contact and education techniques, overall, there were mixed results for the impact of stigma reduction, with 29% (two of seven) of the studies producing no change in stigma. The change in undergraduate students’ beliefs about mental illness in a pre-/postdesign for a variety of experimental conditions exposed to one or more stigma reduction techniques versus an instruction-as-usual group was measured. It was hypothesized that exposure to mental illness stigma reduction techniques would result in greater mental illness stigma reduction than an instruction-as-usual control group.

Method

Participants

One hundred and ninety-five students (43 males, 149 females, 3 did not report gender) registered in seven sections of abnormal psychology across five semesters at a midsize, primarily undergraduate institution participated in the study. The abnormal psychology course fulfilled requirements for a psychology minor and general education curricula and required general psychology as a prerequisite. In terms of class standing, 4.6% were first years, 40% were sophomores, 30.3% were juniors, 23.1% were seniors, and 2.1% did not report class year. The ethnicity of the participants included 4.1% African Americans, 89.2% Caucasians, 3.6% Latino/Latina, 1% Asian, and 1% Other.

Materials

Baseline and outcome measures

The Beliefs Toward Mental Illness (BMI) Scale (Hirai & Clum, 2000) is a reliable and valid 21-item self-report questionnaire designed to measure beliefs about mental illness on a Likert-type scale from 0 (completely disagree) to 5 (completely agree). Cumulative scoring of the BMI results in a total scale score and three subscales. The Dangerousness subscale consists of 5 items designed to measure perceived dangerousness of individuals in relation to mental illness. The Poor Interpersonal and Social Skills subscale consists of 10 items designed to measure perceived poor interpersonal and social skills of individuals in relation to mental illness. The Incurability subscale consists of 6 items designed to measure the perceived incurability of mental illness itself. In all cases, higher scores indicate more negative beliefs about mental illness. Cronbach’s α on the total scale score for the current sample was .88 and .91 for the pre- and posttest administrations, respectively.

Research Design and Procedure

Table 1 contains descriptions of all conditions. Three instructors (one man, two women) teaching seven sections of abnormal psychology were the instructors for this study. The author of the study taught the experimental sections (n = 5, 109 students). The remaining two sections (n = 38 students) were taught by adjunct faculty and served as the control group.

Table 1.

Experimental and Control Conditions.

Condition	Number of Sections and Students	Description
Education	One section, n = 26	Students received explicit classroom instruction about stigma, including lecture material addressing various stereotypes of mental illness and a 30-min video addressing misconceptions about mental illness (Films for the Humanities [Producer], 1999) in the beginning of the semester. Ongoing reminders about the presence of stigma in relation to coverage of specific disorders (e.g., how treatment outcomes for Schizophrenia may be impacted by the incurability myth) were discussed throughout the semester
Education + protest	One section, n = 22	Students received explicit classroom instruction on stigma as outlined above and engaged in stigma-related advocacy by creating a 60-s public service announcement dispelling common myths about mental illness for partial course credit. Details on the assignment mandated that students identify the problem of stigma and provide the viewing audience with a message of how to think about or treat people with mental illness differently
Education + contact	Two sections, n = 36	Students received explicit classroom instruction on stigma as outlined above and participated in six contact hours in the community for partial course credit. Each activity was arranged by the professor with cooperation with from local organizations. Opportunities ranged from interacting with individuals who attend social rehabilitation groups at a local agency to interacting with the presenters of the National Alliance on Mental Illness’s (2017) In Our Own Voice presentation
Education + protest + contact	One section, n = 25	Students received explicit classroom instruction on stigma as well as the protest and contact protocols as outlined above
Control group	Two sections, n = 38	Students received course instruction explaining causes, symptoms, and treatments for mental illness. No specific instruction on stigma was provided

At the outset of the research, the primary researcher spoke with both adjuncts who taught abnormal psychology to confirm that their course did not include any mental illness exposure components (i.e., course instruction centered on symptoms, causes, and treatments of disorders without a focus on stigma per se) and, therefore, could serve as the control group. Upon confirmation that they did not engage in any stigma reduction techniques as outlined by Corrigan and Penn (1999) in their teaching, the next section taught by each adjunct faculty member was included in the data collection.

All sections of abnormal psychology taught by the primary researcher were designated as experimental sections and were randomly assigned to an experimental condition until all four experimental conditions had been taught. At the end of the initial data collection, one additional section of abnormal psychology received the education + contact experimental group instruction due to the low number of participants for that condition in the original data collection semester.

At the beginning of each semester, students were informed that the goal of the study was to understand current beliefs about mental illness and the individuals who are diagnosed with psychological disorders and that these beliefs would be measured both at the beginning and later in the semester. They consented to participate and provided an identifying four-digit number to match up their pre- and posttests. The BMI was administered within the first three class meetings at the beginning of the semester and again within the last three class meetings at the end of the semester. For all sections, the questionnaire was administered at the start of the class period. Administration date of pre- and posttests was matched for semesters (n = 2) where more than one section of abnormal psychology was taught.

Results

Demographic and baseline data from the BMI were compared across students who did (n = 147) and did not (n = 48) complete both the pre- and postmeasures to determine whether there were preexisting group differences that might influence the analyses; no differences were found on age, F(1, 192) = .284, p = .60; sex, χ²(2) = 1.00, p = .61; year, χ²(3) = 3.10, p = .38; ethnicity, χ²(4) = 6.55, p = .16; or BMI pretest total score, F(1, 184) = 2.06, p = .15. All further analyses were conducted using data (n = 147) from students who completed both pre- and postmeasures. A one-way analysis of variance (ANOVA) comparing BMI pretest data across all sections was not significant, F(6, 140) = .815, p = .56, indicating that the conditions had the same attitudes at the beginning of the study.

To determine the change in undergraduate students’ beliefs about mental illness based on exposure to stigma reduction techniques, a mixed-design 2 (Pre–Post) × 5 (All Conditions) ANOVA for BMI was conducted and revealed a main effect for time, F(1,142) = 122.93, p < .001, partial η² = .46,¹ and a significant interaction between time and type of technique, F(4,142) = 13.92, p < .001, partial η² =.28. No main effect for technique was found, F(4,142) = 0.67, p = .61. t tests with Bonferroni correction examining the effect of the stigma reduction technique over time indicated that the control condition did not change, but significant changes resulting in large (n = 3) or medium (n = 1) effect sizes were found for all four experimental conditions on overall BMI scores (see Table 2). The hypothesis that exposure to mental illness stigma reduction techniques would result in greater mental illness stigma reduction than an instruction-as-usual control group was supported.

Table 2.

Comparison of Stigma Reduction Techniques on Total Scale Scores.

Stigma Reduction Technique	Total Scale Pretest Means		Total Scale Posttest Means		t Test	Cohen’s d
Stigma Reduction Technique	M	SD	M	SD	t Test	Cohen’s d
Control	39.49	11.93	40.22	12.64	t(37) = −.47, p = .64	−0.08
Education	45.42	13.10	30.50	12.42	t(25) = 7.38, p = .000	1.45***
Education + protest	44.05	9.41	27.68	11.37	t(21) = 7.02, p = .000	1.52***
Education + contact	41.47	11.89	34.25	11.98	t(35) = 4.64, p = .000	0.77**
Education + protest + contact	41.12	10.83	31.24	11.95	t(24) = 4.34, p = .000	0.87***

Note. ***d = .80 large effect, **d = .50 medium effect, and *d = .20 small effect (Cohen, 1992).

In order to determine the change in specific beliefs about mental illness based on exposure to stigma reduction techniques, separate 2 (Pre/Post) × 4 (Experimental Conditions) ANOVAs were conducted on each subscale of the BMI. The Dangerousness subscale of the BMI revealed a main effect for time, F(1, 142) = 182.28, p < .001, partial η² = .56, and a significant interaction between time and type of technique, F(4, 142) = 15.17, p < .001, partial η² = .30, respectively. No main effect for technique on the Dangerousness subscale was found, F(4, 142) = 1.86, p = .12. The Poor Interpersonal and Social Skills subscale analysis of the BMI revealed a main effect for time, F(1, 142) = 67.85, p < .001, partial η² = .32, and a significant interaction between time and type of technique, F(4, 142) = 9.95, p < .001, partial η² =.22, respectively. No main effect for technique on the poor interpersonal and social skills subscale was found, F(4, 142) = .63, p = .64. The Incurability subscale analysis also revealed a main effect for time, F(1, 142) = 38.51, p < .001, partial η² =.21, and a significant interaction between time and type of technique, F(4, 142) = 5.52, p < .001, partial η² =.14, respectively. No main effect for technique on the Incurability subscale was found, F(4, 142) = 0.20, p = .94. t tests with Bonferroni correction found significant change over time resulting in small (n = 1), medium (n = 5), and large (n = 6) effect sizes for all four experimental conditions across all three of the BMI subscales (see Table 3). Thus, in addition to overall stigma reduction, exposure to mental illness stigma reduction techniques reduced stereotypical beliefs about danger, poor interpersonal and social skills, and the incurability of stigma.

Table 3.

Comparison of Stigma Reduction Techniques on Subscale Scores.

Stigma Reduction Technique	Dangerousness Pretest Means		Dangerousness Posttest Means
Stigma Reduction Technique	M	SD	M	SD	t Test	Cohen’s d
Education	9.96	3.55	4.46	2.97	t(25) = 8.90, p = .000	1.77***
Education + protest	9.59	4.77	4.14	2.59	t(21) = 6.80, p = .000	1.70***
Education + contact	9.17	2.98	5.72	2.82	t(35) = 7.78, p = .000	1.30***
Education + protest + contact	8.80	2.99	5.08	3.16	t(24) = 5.89, p = .000	1.18***
	Poor Interpersonal and Social Skills Pretest Means		Poor Interpersonal and Social Skills Posttest Means
Education	19.31	5.90	12.27	6.40	t(25) = 7.04, p = .000	1.39***
Education + protest	17.18	4.29	11.09	5.30	t(21) = 6.15, p = .000	1.33***
Education + contact	16.69	6.41	14.72	6.40	t(35) = 2.26, p = .030	0.38*
Education + protest + contact	16.00	6.10	12.44	6.63	t(24) = 3.12, p = .005	0.63**
	Incurability Pretest Means		Incurability Posttest Means
Education	15.00	4.56	13.00	4.36	t(25) = 2.73, p = .011	0.54**
Education + protest	16.36	3.57	12.00	4.45	t(21) = 3.69, p = .001	0.79**
Education + contact	14.72	3.98	12.97	3.87	t(35) = 3.04, p = .004	0.51**
Education + protest + contact	15.44	3.91	13.08	3.67	t(24) = 2.83, p = .009	0.57**

Note. ***d = .80 large effect, **d = .50 medium effect, and *d = .20 small effect (Cohen, 1992).

Discussion

The purpose of this research was to assess change in college and university students’ beliefs about mental illness following infusion of stigma reduction techniques into the course curriculum. It was hypothesized that the application of any of Corrigan and Penn's (1999) techniques designed to reduce stigma would result in greater mental illness stigma reduction than standard abnormal psychology course coverage that did not specifically include stigma reduction techniques. A pre-/postdesign for a variety of stigma reduction experimental groups versus an instruction-as-usual (no stigma reduction efforts) control group was conducted. All experimental conditions demonstrated significant change in stigma beliefs, while the control condition revealed no change; significant change was also found for all the BMI subscales. This supports the literature (Faigin & Stein, 2008; Mann & Himelein, 2008; Maranzan, 2016; Matteo & You, 2012; Poorman, 2002; Rusch et al., 2008) on the utility of stigma reduction techniques in a college/university classroom setting.

While the question of whether stigma reduction techniques can be successfully implemented into existing course curriculum can be answered in the affirmative, the question of which stigma reduction techniques should be used is more difficult to answer. Because this research was conducted within the real-world class setting, the pedagogical value of the stigma reduction techniques and their ability to make sense within the overall course was accorded the greatest precedence. Due to the well-recognized (Corrigan & Penn, 1999) difficulty of assigning an advocacy or contact component in a course without providing the necessary education about stigma to make the advocacy or contact component pedagogically relevant, all experimental conditions contained a component of stigma education. This study, therefore, cannot directly address the relative superiority of one form of stigma reduction over another since significant change in stigma beliefs was found for all repeated-measures analyses regardless of stigma reduction technique. However, examination of effect sizes can give some indication of the potential scope of impact. The stigma education technique and the education + protest technique had the most robust effect sizes, while education + contact had the smallest (although still moderately robust) effect size on total BMI scores. These effect sizes suggest potential differences in overall impact based on type of technique but await further research that can extricate the need for stigma education as a basis for contact or protest techniques. Based on the current findings, however, stigma education, as the simplest form of stigma reduction, is clearly warranted. The power of stigma education in the college classroom to reduce stigma more closely resembles research recommendations for adolescents than for adults (Corrigan, Morris, Michaels, Rafacz, & Rüsch, 2012). Although this does not specifically differentiate college students as emerging adults as Arnett (2007) asserts, it does call into question recommendations (Maranzan, 2016) to utilize contact to the exclusion of stigma education in college students.

These findings provide guidance to instructors of introductory and abnormal psychology for which stigma reduction techniques to include in a course. Instructors should be cautioned, however, against uniformly choosing to engage only in stigma education because it is the easiest of the conditions to implement. Contact as a technique is clearly a robust way to impact stigma (Corrigan et al., 2012). Rejecting it out of hand given its demonstrated utility ignores its clear stigma reduction impact. Additionally, choosing to include aspects of protest or contact as stigma reduction techniques may serve other pedagogical purposes. Both techniques, for example, fulfill specific aspects of the American Psychological Association’s (2013) Guidelines for the Undergraduate Psychology Major (e.g., Indicators 3.3A, where students interact respectfully with people who face discrimination, and 3.3C, where students advocate in ways that benefit the larger community). Thus, teaching professionals should carefully consider the specific goals of any technique used in a course to best decide what should be included in constructing a course.

This study should be considered in light of several limitations. First, this study was quasi-experimental because of nonrandom assignment of students to each condition. To address this issue, a comparison of the different classes at pretest confirmed similarity at the start of the research, and as detailed in the Method section, assignment of when a specific experimental condition would be taught was randomly determined at the outset of the research. Second, there was no control over instructor material or efficacy in teaching the material. Both instructors of the control condition confirmed that they did not provide any instruction on the stigma of mental illness. Further, textbook coverage of stigma constituted less than one page in the text (Barlow & Durand, 2009, 2012) used by all instructors in the course. The same instructor taught all experimental conditions in order to minimize potential effects in teaching style within the experimental condition. Although analysis confirmed that student’s stigma beliefs were consistent regardless of condition at the beginning of the semester, having different instructors teaching the control and experimental conditions may have differentially impacted the change in stigma beliefs of students. Finally, a number of different community activities were offered in the contact condition in order to meet students’ scheduling needs and no effort was made to track which contact options a student attended. Interestingly, the only small effect size of the data set was found for the education + contact condition in relation to the BMI Poor Interpersonal and Social Skills subscale, and the education + contact condition was the only condition to have a medium-level (instead of large) effect size on BMI total scores. The pattern of these effect sizes is interesting given the superiority of contact in the overall literature. Although not tested within this data set, the available contact activities were often with a population that exhibited more severe and persistent forms of mental illness. Lower relative effect sizes may lend credence to Kolodziej and Johnson’s (1996) assertion that specific types of contact potentially lessen the impact that the technique might have. Further exploration of the impact of different types of contact and different levels of mental illness involved would help to clarify how these factors impact outcome.

The results of this study strengthen the existing literature support for the use of a variety of stigma reduction techniques in a college/university setting and specifically provide clear evidence for the use of stigma education as a powerful technique for instructors to target in order to effect stigma reduction.

Footnotes

Acknowledgment

The author would like to thank Joshua D. Landau for providing feedback on drafts of this article.

Declaration of Conflicting Interests

The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author received no financial support for the research, authorship, and/or publication of this article.

Note

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