Abstract
Research shows that stigma toward mental illness prevents a large percentage of college students from seeking help. Finding pedagogies that can be utilized in the classroom to reduce stigma is important. The present study replicated previous research that utilized celebrity case material in the teaching of abnormal psychology for the purpose of reducing public stigma toward mental illness and help seeking. The present study also examined whether stigma reductions would persist beyond the initial post-testing. Data were collected using a pre-post design from 48 (experimental group) and 23 (control group) college undergraduates enrolled in an abnormal psychology course. Compared to the control group, the use of celebrities as narratives to teach about mental illness resulted in reduced public stigma toward mental illness and reduced stigma toward seeking help which persisted over a 6-month time period.
In 2001, the World Health Organization reported that one in four people worldwide had a mental or behavioral disorder and identified stigma and discrimination toward the mentally ill as the “single most important barrier to overcome in the community.” College students represent a significant proportion of those afflicted with mental illness. Two national surveys, the National College Health Assessment (NCHA) and the Healthy Minds Study (as cited in Duffy et al., 2019), found that rates of anxiety and mood disorders, as well as suicide, increased significantly from 2011–2012 to 2017–2018 among college students; the largest increases were found with depression (Duffy et al., 2019). According to the NCHA study (as cited in Duffy et al., 2019), 42% (compared to 31% in 2011–2012) of those surveyed reported that they felt “so depressed” in the past year that they “found it difficult to function;” this represented an increase of 34% (Duffy et al., 2019). Similarly, Healthy Minds research (as cited in Duffy et al., 2019) showed a 77% increase from 2007 with 41% of students reporting moderate to severe depression in 2017–2018 (Duffy et al., 2019). While the overall percentage of college students utilizing mental health services increased from 19% in 2007 to 34% in 2017 (Lipson et al., 2019), approximately two-thirds still did not, and stigma has been posited to be the culprit (Downs & Eisenberg, 2012; Eisenberg et al., 2009). The present study examined whether pedagogical methods previously found to reduce stigma in college students continued to do so and whether changes in stigma persisted over time.
Stigma can exist in many forms, including public stigma toward having a mental illness as well as the stigma of seeking professional services for a mental illness. Public stigma has been defined as prejudice and discrimination directed toward the mentally ill by the public (Corrigan & Watson, 2002) and research shows that public stigma includes perceiving those with mental illness as dangerous, dysfunctional, lazy, unintelligent, and noncontributing members of society (Arboleda-Florez, 1998; Crisp et al., 2000). The public’s perception toward seeking help for a mental illness are also fraught with stigma (Bathje & Pryor, 2011; Downs & Eisenberg, 2012; Einsenberg et al., 2009). Lannin et al. (2016) found that higher levels of stigma were associated with reduced likelihood of seeking online mental health counseling.
Corrigan and Penn (1999) recommend contact with those with mental illness as a powerful tool for reducing stigma. Instructors in higher education have sought and tested contact techniques to reduce stigma toward mental illness and increase help seeking in their college classrooms and many have been met with success (Ferrari, 2016; Kendra et al., 2012; Mann & Himelein, 2008; Matteo & You, 2012; Reinke et al., 2004). Vogel and Wade (2009), known for their work in the creation of instruments to measure various forms of stigma, advise that mental illness can be normalized by famous people admitting to having sought counseling. Using their advice, Ferrari (2016) taught her abnormal psychology class through the lens of celebrities who disclosed their diagnoses and help-seeking behaviors. Analyses of her class at the course’s completion revealed that students taught using the celebrity method were significantly more likely to seek help for a mental illness and had significantly less stigma toward others with mental illness than the control group who were taught in traditional methods (Ferrari, 2016). However, it was unknown whether the experimental group’s attitude change would persist over time.
Researchers have analyzed the staying power of the public’s health changes subsequent to celebrity endorsement or disclosure. After Katie Couric famously televised her colonoscopy, the Clinical Outcomes Research Initiative found a significant increase in performed colonoscopy procedures among a sample of 400 endoscopists. While 15 colonoscopies per month were performed prior to Couric’s televised procedure, 18.1 were performed after it. This increase was sustained for a period of 9 months (Cram et al., 2003). When Charlie Sheen publicly disclosed that he was HIV positive, sales of an HIV home testing kit rose by 95% and remained significantly elevated for the next 4 weeks (Allem et al., 2017). After Angelina Jolie disclosed that she underwent a prophylactic mastectomy after learning that she tested positive for the BRCA gene, testing for BRCA gene increased by 64% in the following 2 weeks (Igoe, 2016; Liede et al., 2018). Behaviors surrounding mental illness have been found to be similarly affected by celebrity disclosures. Coinciding with interviews revealing his own struggles with anxiety (Phull, 2017), rapper Logic’s release of his hit single 1-800-273-8255, the number for the National Suicide Prevention Lifeline (NSPL), resulted in calls to the NSPL rising by 27% in the following 3 weeks and an increase of 100,000 visits to the website which was sustained for 2 months (Armstrong, 2017).
The present study’s purposes were two-fold. Firstly, the study sought to replicate previous research (Ferrari, 2016) surrounding use of celebrity models as case material in abnormal psychology courses and its relationship to students’ public stigma and stigma toward help-seeking. Secondly, the present research examined whether changes in attitudes of public stigma and help-seeking would persist over time. It was hypothesized that: (a) students receiving the celebrity method (experimental group) would experience reductions in stigma levels and increases in their help-seeking behavior compared to the control group from Time 1 (pretest) to Time 2 (first posttest); and, (b) all students, both the control group and those receiving the celebrity method, would maintain the levels of public stigma and stigma toward help seeking reported in Time 2 over a six-month time period to Time 3 (second posttest).
Method
Participants
Participants consisted of 71 racially and ethnically diverse college students at a small liberal arts college in the northeast who had been enrolled in an abnormal psychology course. The majority were female while 21% were male and the mean age was 21.3 (1.2) at Time 1. The majority were upperclassman and by Time 3, a small number had graduated. Their self-reported ethnic and racial breakdown was 48% Hispanic, 34% Black, and the remainder either White or mixed. There were 48 students in the experimental group, derived from two different sections of the course, who received instruction in abnormal psychology using the celebrity method. There were 23 students in the control group who received instruction in a traditional manner, without the use of celebrity examples. The experimental and control groups were similar in gender (79% female, 21% male; 78% female, 22% male, respectively), race (46% Hispanic, 35% Black, and 19% White/mixed; 53% Hispanic, 32% Black, and 15% White/mixed, respectively), and age (M = 21.2 [1.2]; M = 21.3 [1.1], respectively) composition. In addition, the experimental and control groups scored similarly on pretest scales, as can be seen in Table 1.
Means and Standard Deviations for Social Distance Scale and Self-Stigma of Seeking Help Scale.
Materials
Participants completed three instruments consisting of a demographic questionnaire, an adaptation of Mann and Himelein’s (2008) Social Distance Scale; and the Vogel et al. (2006) Self-Stigma of Seeking Help Scale. These instruments were administered over three time periods: pre (Time 1), post (Time 2), and, second posttest follow-up (Time 3).
Student stigma toward others with mental illness was assessed through the Social Distance Scale using a vignette like that of Mann and Himelein (2008). Mann and Himelein provided students with a vignette about “Bill” and “John” who have schizophrenia and bipolar illness. Instead of schizophrenia and bipolar disorder, the present study utilized the more frequent diagnosis of major depression due to the findings presented by the Healthy Minds Study, namely, that rates of severe depression among college students more than doubled over the past decade (Duffy et al., 2019). The vignette read:
Person A has been diagnosed with major depression for which he or she is receiving treatment. How willing would you be to: Date him or her (assuming he or she was in all ways suitable for you). Be a roommate with him or her. Be friends with him or her. Marry him or her (assuming he or she was in all ways suitable for you).
After reading the vignette, participants were asked to rate each statement on a 3-point Likert-type scale ranging from 0 (definitely willing) to 3 (definitely unwilling). Scores ranged from 0 to 12 with lower scores indicating less stigma toward those with mental illness. Internal consistency as measured by Cronbach alpha on Time 1, 2, and 3 was found to be .86, .82, and .84, respectively. These values were consistent with those reported by Mann and Himelein (2008).
The Self-Stigma of Seeking Help Scale is a 10-item scale designed by Vogel et al. (2006) that is used to assess the self-stigma associated with seeking psychological help. Participants rate the items on a 4-point Likert-type scale ranging from 1 (strongly disagree) to 5 (strongly agree). A sample item is “My self-confidence would not be threatened if I sought professional help.” Five of the 10 items are reverse scored to prevent acquiescence response bias. Scores ranged from 10 to 50, with higher scores indicating less perceived stigma toward getting help for a mental illness. Internal consistency as measured by Cronbach α was found to be .82 at Time 1, .84 at Time 2 and .83 at Time 3. Vogel et al. (2006) reported an internal consistency of .84.
Procedure
The present study utilized two groups (n = 48) and (n = 23), one which received the experimental condition and one which served as the control group. Due to small class size and abnormal psychology only being taught in the spring, data for the experimental group who received the celebrity method of instruction were collected in two waves in spring 2016 (n = 25) and 2017 (n = 23) and aggregated. Data for the control group, who received traditional instruction, were collected in spring 2018 (n = 23). Course sections were assigned to experimental and control group conditions by flipping a coin. After heads (for experimental group) was obtained on the first two flips for the first two course sections (spring 2016 and 2017), the control group was assigned to the remaining class section (spring 2018). All sections were taught by the same instructor.
On the first day of class, prior to any instruction, the participants were administered the consent form, the demographic form, the adaptation of Mann and Himelein’s (2008) Social Distance Scale, and Vogel et al. (2006) Self-Stigma of Seeking Help Scale. Students were provided with the informed consent form to sign and return as well as one to retain. They were made aware that their participation was voluntary. This testing period represented Time 1. Upon completion of the class, all participants again received the same instruments at the end of the semester. This testing time represented Time2. Finally, follow-up data (Time 3) consisting of the same instruments were collected in November 2016, 2017, and 2018, 6 months after Time 2 for each group. Time 3 data were collected online through Survey Monkey. The study received Institutional Review Board approval.
All classes were taught by the same instructor, used the same textbook (Abnormal Psychology: An Integrative Approach, 7th Edition, by Durand, V. M. & Barlow, D. H. 2014, Cengage Learning), and completed the same assignments. However, the experimental group received instruction using examples of celebrities with mental illness and the control group received traditional instruction.
Instruction for experimental group
For each category of psychopathology being taught, at least one celebrity with a mental illness from that category was presented as a case study. When discussing dissociative identity disorder (DID), we watched an interview (Harris, 2010) with Hershel Walker, the professional football player and winner of the Heisman Trophy, who discusses his experiences with DID as well as his treatment. The interview can be found on youtube.com (https://www.youtube.com/watch?v=YXuG2zI39yA&feature=youtu.be). From this example, the symptoms of DID were presented along with possible origins and treatments. Other celebrities used as case studies included Eminem (factitious disorder by proxy), Kid Cudi and Kendrick Lamar (major depression), Adam Duritz (depersonalization disorder), Mariah Carey (bipolar disorder), Olivia Munn (trichotillomania), David Beckham (obsessive compulsive disorder), Brian Wilson (schizophrenia), Megan Fox (borderline personality disorder), Michael Phelps (attention deficit disorder with hyperactivity), Kesha (bulimia nervosa), Winona Ryder (kleptomania), Demi Lovato (substance abuse disorder), Jack Antinoff (illness anxiety disorder), Billie Joe Armstrong (panic disorder), and Uma Thurman (body dysmorphic disorder). All the celebrities had self-disclosed their mental health problems through online or print interviews.
Instruction for control group
The control group learned about mental illness through the reading of the criteria from the Diagnostic and Statistical Manual of Mental Disorders and learning the symptoms, origins, and prognosis for each illness. No examples from videos or any well-known individuals were provided.
Data Analysis
Two separate mixed model analyses of variance (ANOVAs) were conducted for each dependent variable: public stigma and help seeking. A 3 (time) by 2 (group) ANOVA was performed to ascertain whether the variables of time (Time 1, Time 2, and Time 3) and group (experimental or control) impacted the dependent variable of public stigma as measured by the Social Distance Scale. A separate 3 × 2 ANOVA was performed to determine if there was an effect on the dependent variable of willingness to seek help as measured by the Self-Stigma of Seeking Help Scale due to the variables of time (Time 1, Time 2, and Time3) and group (experimental or control).
Results
Means and standard deviations for the experimental and control groups were calculated for Time 1, Time 2, and Time 3 on both the dependent variables of the Social Distance Scale and the Self-Stigma Help Seeking Scale. Table 1 shows the scores.
For Dependent Variable of Stigma Toward Mental Illness
A two-way mixed factor ANOVA showed a significant main effect for time, F (2, 213) =16.4, p < .01, η2 = .14. Time 1 mean scores were significantly greater than mean scores for Time 2 and Time 3. Mean scores for Time 2 and Time 3 were not significantly different. A significant main effect was found for group, F (1, 213) = 25.2, p < .01, η2 = .11. Mean scores for the experimental group were significantly lower than mean scores for the control group. However, a significant interaction between time and group was found, F (2, 213) = 19.9, p < .01, η2 = .16. At both Time 2 and Time 3, the experimental group’s mean score was significantly lower than the control group’s mean score, indicating less stigma for the experimental group at the end of the course (Time 2) as well as 6 months (Time 3) later (See Figure 1). Post hoc comparisons using the Tukey HSD test showed that for the experimental group, mean scores at Time 3 did not differ significantly from Time 2, indicating persistence in reduced stigma levels. Post hoc comparisons using the Tukey HSD test showed that for the control group, mean scores for Time1, Time 2, and Time 3 did not differ significantly from each other, indicating no change in stigma for participants not receiving the celebrity method.
Means on social distance scale depicting public stigma for experimental and control groups on Time 1, Time 2 and Time 3 measures.
For Dependent Variable of Stigma Toward Help Seeking
A two-way mixed factor ANOVA for the dependent variable of stigma toward help seeking showed a significant main effect for time, F (2, 213) = 3.8, p < .05, η2 = .04. Mean scores at Time 1 were significantly lower than mean scores for both Time 2 and Time 3. A significant main effect was found for the variable of group, F (1, 213) = 22.4, p < .01, η2 = .10. Experimental group mean scores were significantly greater than control group mean scores. However, a significant interaction of time and group was found, F (2, 213) = 6.7, p < .01, η2 = .06. The experimental group’s mean scores were significantly greater than the control group’s mean scores at both Time 2 and Time 3, indicating less reported stigma toward seeking help (See Figure 2). Post hoc comparisons using the Tukey HSD test showed that for the experimental group, mean scores at Time 3 did not differ significantly from Time 2, indicating persistence over time in reporting less stigma toward seeking help. Post hoc comparisons using the Tukey HSD test showed that for the control group, mean scores for Time 1, Time 2 and Time 3 did not differ significantly from each other, demonstrating no change in stigma toward help-seeking from students not receiving the celebrity method.
Means on self stigma of seeking help scale for experimental and control groups on Time 1, Time 2, and Time 3 measures.
Discussion
The present study’s hypotheses were supported. Firstly, the use of celebrity case material to teach abnormal psychology resulted in reduced public stigma toward mental illness and increased help-seeking behaviors in the experimental group at Time 2 compared to the control group who were taught with traditional methods. In contrast, the control group showed no attitude changes in levels of stigma toward mental illness and help seeking from Time 1 to Time 2. This finding replicated previous research by Ferrari (2016). Secondly, changes in stigma were maintained over time. The experimental group showed no significant differences in their stigma toward mental illness and help-seeking at Time 3 than they did at Time 2. Therefore, their reduction in stigma was sustained over the 6-month period. Similarly, the control group showed no significant differences in their levels of stigma and help-seeking at Time 3 than they did at Time 2, indicating their stigma levels remained unchanged.
Celebrities’ behavior has great potential to impact human life and their disclosures surrounding mental illness influence young people especially (Carpentier & Parrot, 2016; Francis, 2018; Hoffner & Cohen, 2017; Vogel & Wade, 2009). Research analyzing the behavioral aftermath of Robin Williams’s suicide found that young people were more likely to seek out information about depression and suicide (Carpentier & Parrot, 2016) and showed greater willingness to seek treatment or reach out to others afflicted with these disorders (Hoffner & Cohen, 2017). Similarly, Francis (2018) found that young black men’s information seeking on the topics of depression and their own risk factors increased after rapper Scott Mescudi’s disclosure of his depression diagnosis and treatment plan. Within the current climate of increased celebrity disclosures (Gay, 2019), psychology instructors would be served well by harnessing this trend in their classrooms.
The current study had limitations. Given the small classroom size and infrequency by which courses were offered, data were collected over three separate semesters with the experimental group data being aggregated over two of them. This caused the control group sample size to be comparably smaller. In addition, although the college had become coeducational in the fall of 2016, the student body remained overwhelmingly female as reflected in the current study’s participants. Therefore, cohort effects may have influenced the results.
In order to provide the control group with the opportunity to possibly reduce their stigma toward mental illness and help seeking, all participants in the control group were sent a Power-Point presentation created by the author that featured photographs of celebrities with excerpts from interviews where they disclosed their diagnosis. This PowerPoint was considered an enhancement to their regular class instruction and was sent to them after their final Time 3 participation.
Although it was heartening to see that the experimental group maintained their reduced levels of stigma over a 6-month time period, it is unknown whether the reduction would continue beyond this point. Recent frequent disclosures by celebrities through the media (Gay, 2019) may prove helpful in serving to maintain attitude change. Rap, America’s most popular musical genre, has experienced an increase in the number of songs featuring a discussion of mental illness, according to a computerized study analyzing lyrics (Iqbal, 2019). Capitalizing on this increase, a group of Cambridge University psychiatrists have formed a group, “Hip Hop Psych” (2014), as a mechanism of providing new tools to promote mental health in the United Kingdom. Hip Hop Psych uses implicit and explicit references to mental health often found in rap music to raise awareness, implement early diagnosis and treatment, and remove stigma. Their program focuses not only on the general public, but also on bringing teaching innovations to professionals in medical and psychological fields who might serve as an interface, linking hip hop with mental health (Hip Hop Psych, 2014). The racial, ethnic, and cultural diversity of rappers also bodes well for maximum benefits of “contact” with a mentally ill person (Corrigan & Penn, 1999), as it allows diverse individuals, such as the participants in this study, to see their reflection in the disclosing celebrity. Similar endeavors might be considered in the United States to prolong beneficial behavioral and attitudinal changes that result from celebrity disclosures.
Footnotes
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.