Nottingham Trent University

School of Social Sciences

An exploration into the stigma surrounding university students with depression in the United Kingdom (UK).

Student name: Samantha Varty

Student number: N0503749

Course title: BA (Hons) Health and Social Care

Module title: Integrative Research/ Practice Dissertation

Option: Critical Literature Review

Supervisor: Linda Kemp

Word Count: 10,500

Acknowledgements:First and foremost, I would like to thank my supervisor, Linda Kemp. Thank you very

much for your patience, understanding, guidance and advice.

To my friends who helped me throughout the entire duration of my degree, I am

extremely grateful. Special thanks go to my course mate, best friend and sister from

another Mister, Nina Merritt. Thank you for helping me overcome my setbacks,

motivating me to keep going and just being your optimistic self. For the moments of

madness and the library sessions. I could not have done it without you.

To my partner, Stanley. Though the road of third year has been bumpy, there is no

one else I’d wish to have by my side throughout the journey. Your humour, love and

support has kept me going.

And last but by no means least, my mum and dad. The education you have given me

over the years goes beyond the world of academia, and for this, I am extremely

grateful. Thank you for all your love, encouragement and constant support.

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ContentsAcknowledgements:....................................................................................................1

Abstract.......................................................................................................................3

Introduction:................................................................................................................4

Methodology, Aims and objectives...........................................................................6

Chapter One: The stigma surrounding mental illness.................................................7

Chapter Two: To what extent does stigma act as a barrier to help-seeking amongst

students with depression?.........................................................................................14

Chapter Three: Tackling mental health stigma at university.....................................21

Conclusion:...............................................................................................................31

References:...............................................................................................................34

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AbstractThe focus of this dissertation is to enlighten readers on the topic of mental health

stigma amongst depressed university students in the UK. The review will explore a

variety of different literature surrounding the topic. Beginning with the

conceptualisation of stigma by Link and Phelan followed by its application as to

whether stigma acts as a barrier for students seeking help for their depression, it

then delves into the topic of overcoming stigma. The review will consider theories

surrounding effective approaches to tackling self-stigma and public stigma, such as

Corrigan and Penn’s stigma reduction theory, in order to evaluate existing

campaigns, drawing conclusions upon the best method to tackle stigma at university.

The key findings from this literature review suggest that new approaches may be

required in order to successfully tackle stigma of mental health in universities in the

future.

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Introduction: ‘Mental illness is nothing to be ashamed of, but stigma and bias shame us all.’

– Bill Clinton (1999)

After losing a friend to suicide, former US president Bill Clinton expressed his anger

toward stigma surrounding mental health. This profound statement by Clinton (1999)

epitomises the focus of this dissertation and therefore this quote seems apt. In

recent years, stigma surrounding mental illness has become an emerging issue for

researchers attention. Hattenstone (2013) reports that student Toby Thorn, unaware

of his crippling depression, never sought help for his state of mind -- instead, he

committed suicide at university. This is not a lone case, in fact, according to the

Office for National Statistics (2012), the number of students who took their own life in

England and Wales rose by 50% between 2007 and 2011. Hattenstone (2013)

emphasises the need for openness surrounding the subject, yet suggests that stigma

stands in the way of this happening. Given the seriousness surrounding this topic,

there is need to consider the stigma of mental illness at university. It is the aim of this

dissertation to specifically look at the stigma of depression amongst students. Mental

health stigma prevents 32% of young people with a mental health issue from

applying for further education (Time to Change, 2016a). This dissertation seeks to

delve into the topic of how stigma works, how it is applied to students with

depression and consequently ways in which stigma can be tackled.

Before approaching this dissertation, it is important to understand what is meant by

the key terms in the title. For the purpose of this review, students will be defined as

undergraduates between the ages of eighteen and twenty-five. The World Health

Organisation (2015) define depression as ‘a common mental disorder, characterized

by sadness, loss of interest or pleasure, feelings of guilt or low self-worth, disturbed

sleep or appetite, feelings of tiredness, and poor concentration.’ The Equality Act

(2010:4) adds to this definition stating that a mental health condition can become a

disability if it has a long-term effect on a person’s ability to carry out day-to-day

activities. Therefore, individuals with depression are entitled, under the law, to

challenge discrimination. This literature review will specifically focus on the stigma

surrounding depression. England’s biggest anti-stigma campaign, Time to Change

(2016d), have defined stigma as ‘the perception that a certain attribute makes a

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person unacceptably different from others, leading to prejudice and discrimination

against them’. Mental illness is surrounded by prejudice, ignorance and fear and it is

due to these stigmatic attitudes that difficulties arise or intensify for those with a

mental illness. There are two types of stigma which will be focussed on in this

review: self-stigma and public stigma. The concept of stigma will be looked at further

in chapter one.

This dissertation will be divided into three distinct chapters, each of which deals with

emergent categories that are found in literature surrounding stigma amongst

university student populations. The first chapter will specifically focus on the

conceptualisation of stigma, as outlined by Link and Phelan (2001). This

conceptualisation acts as a framework into further themes such as such as labelling,

stereotypes and discrimination. Delving into the conceptualisation by researching its

components will help elucidate whether stigma has an impact on mentally ill people.

Chapter two will consider the prevalence and risk factors surrounding the issue of

depression amongst students and research help-seeking attitudes in order to

determine whether stigma acts as a barrier to students with depression. It will

consider help-seeking attitudes by reviewing relevant studies. The third chapter will

consider theories surrounding reducing both self-stigma and public stigma. By

reviewing an anti-stigma campaign aimed at a British University, strengths and

limitations can be drawn from the literature, allowing conclusions to be made upon its

efficacy and using theory to suggest improvements for future campaigns.

Walliman and Appleton (2009) suggest that a critical literature review should follow a

systemic process. Firstly, there needs to be a clear area of research. Next, research

and appraisal of relevant literature should be carried out. Then, synthesising the

material to develop new insights into the specific topic. A critical literature review

provides the opportunity for new insights to be developed through re-analysing past

studies allowing a possible gap within research to be exposed (Aveyard, 2010). A

critical exploration of literature will be carried out in order to critically analyse the

aims and objectives of this review, which are outlined below. It is hoped that

reviewing differing viewpoints within literature can provide different opinions and

insight into the topic allowing literature to elucidate whether there is a stigma

surrounding this focus group and provide suggestions on what can be done to

overcome stigma.

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Methodology, Aims and objectives.Methodology:

In order to carry out this literature review successfully, the use of specialist

literature will be implemented, with focus to journal articles and books in order to

obtain existing literature surrounding the topic of stigma. Other literature, such as

charity documents, will be heavily implemented. Documents and studies

completed by Time to Change will be used in order to help understand many

different issues surrounding stigma.

Literature, such as books and journals, will be obtained by using the University’s

library, along with their online tool; Library OneSearch which will aid access to e-

books and journal articles. Google Books and Google Scholar will also aid me in

research and I will use advanced searches on all databases in order to gain

precise information that is required for such a specific topic. One heavily cited

author throughout this dissertation is Patrick Corrigan, a well-known scholar

surrounding the field of mental health and stigma. ResearchGate was used in

order to browse through his publications.

Aim:

- To devise a critical literature review exploring current research surrounding

the topic of stigma amongst university students in the United Kingdom, to

highlight any gaps in the literature.

Objectives:

- To look into the process of stigmatisation in order to gain knowledge and

understanding of how the process works and what components are involved.

- To look into help-seeking attitudes surrounding university students with

mental illness in order to elucidate whether stigma acts as a barrier to help-

seeking, concluding with the effects of not seeking help.

- To consider possible approaches to overcome stigma among university

students.

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Chapter One: The stigma surrounding mental illness.

Introduction:

The aim of this chapter is to determine whether there is a stigma surrounding mental

illness. To do so, the components of stigma, as outlined by Bruce Link and Jo

Phelan (2001) as labelling, stereotyping, separation and status loss, will be

examined. This is to draw conclusions on the concept of stigma and what effect it

has on those suffering with a mental illness.

Types of stigma: This review will specifically focus on self-stigma and public stigma. Corrigan and

Watson (2002:16) state that ‘public stigma is the reaction that the general population

has to people with mental illness’. This refers to the attitudes and beliefs held by the

general public surrounding mental illness. These negative attitudes and beliefs held

by society lead to stereotyping, prejudice and discrimination against people with a

mental illness (Corrigan, 2004). Therefore, the public stigma associated with

someone seeking mental health services is that they are undesirable or socially

unacceptable (Vogel et al, 2006). Self-stigma, however, is defined by Corrigan and

Watson (2002) as the prejudice which people with a mental health problem turn

against themselves. Self-stigma also includes stereotyping, prejudice and

discrimination. In order to experience self-stigma, the individual must be aware of the

stereotypes that are held against a stigmatized group (Corrigan et al, 2009). A

mentally ill individual may start to believe the negative thoughts displayed by others

and consequently think that they are unable to recover, not deserving of treatment,

responsible for their illness or potentially dangerous (Corrigan et al, 2012a).

The components of stigma: According to Link and Phelan (2001), stigma is made up of four components;

labelling, stereotyping, separation and status loss. In 2004, Link and Colleagues

worked together to update the conceptualisation by adding the ‘emotional reaction’

stage.

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Labelling:The first component highlighted by Link and Phelan is labelling. The labelling theory

was first applied to mental illness in 1966 when sociologist Thomas Scheff published

‘Being Mentally Ill.’ Scheff (1966) proposed that the act of being labelled as mentally

ill would in fact cause mental illness. Scheff (1966) argued that society was so

influential that once a person had been labelled, the person changed their behaviour

to adapt to the expectations of society, thus becoming mentally ill.

Two decades later, a modified version of the labelling theory was published by Link

and colleagues (1989). The modified labelling theory obtains aspects from the

original theory but disagrees with the notion that labelling is causal of mental illness.

The modified version dismisses the causal relationship, focusing more on the

consequences of labelling (Amzat and Razum, 2014). Leff and Warner (2009) reject

the idea that labels create mental illnesses directly and instead suggest that labelling

can lead to a poor outcome for the individual. Link and colleagues (1989) state that

people with a mental illness hold an expectation to be labelled and it is this

expectation which often causes service users to withdraw from society. They add

that mentally ill people being labelled are constantly rejected from society in

seemingly minor ways, however when considered holistically, all of these small

snubs can severely adjust their self-concept. Pasman (2011:124) concurs this by

stating that ‘diagnosis has a negative influence self-concept, through stigma and

stigma expectations.’

With their self-concept damaged, mentally ill people are at risk of internalising

negative labels and falling victim to self-stigma. Corrigan and Colleagues’ (2009)

‘why try’ effect functions on a three-step process: awareness of the stereotype,

agreement with the stereotype and applying it to oneself. This model exceeds the

modified labelling theory as it introduces the idea of self-efficacy. Self-efficacy refers

to believing in your ability to succeed in specific situations to accomplish a task

(Bandura, 1997). Self-efficacy can play a major role in how someone will approach

goals, tasks and challenges. Whilst the modified labelling theory acknowledges

people may avoid situations which make them feel publically disrespected as a result

of self-stigma, the ‘why try’ model exceeds these notions. The ‘why try’ model

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expands by suggesting that people who agree with negative stereotypes and apply it

to themselves will find it difficult to maintain a positive self-concept and may feel

unable to tackle specific life goals. It is named the “why try” effect as this is the effect

felt by the stigmatised person. Due to the internalised stigma, they feel incapable of

tackling life goals such as attending university. ‘Why should I go to university?

Someone like me is not worthy of such a goal.’ However, the depth of self-stigma is

dependent upon whether the individual has been through the process. Alternatively,

reactions to stigma may evoke personal empowerment (Corrigan et al, 2009:77). As

a result of the mentally ill individual experiencing hostility towards themselves in the

form of stereotypes, they generate the negativity and react in a manner where they

are energized by the stereotype and become empowered in reaction to them

(Corrigan et al, 1999). From reviewing the ‘why try’ model, it is evident that there are

two opposite sides of the spectrum to how people will react to the process of being

stigmatized. Where some mentally ill people will consider themselves to be the

negative stereotype that they associate with their own mental illness, leading to self-

stigmatisation, others will purposely distance themselves from the stereotype to

empower themselves.

Stereotyping:Link and Phelan (2001) believe that the labels link the person to a set of undesirable

characteristics, forming a stereotype. Green et al (2005:197) describe stereotyping

as ‘the assignment of negative attributes to socially salient differences.’ Perhaps the

most common stereotype is that all mentally ill people are violent (Joseph, 2016).

This stereotype could increase the social exclusion of many people with a mental

illness as the public believe them to be dangerous. The Mental Health Foundation

(2015b) point out that realistically, there is a greater risk of the mentally ill person

being attacked or harming themselves rather than harming others. Media can

influence stereotypes surrounding mental illness. In a study carried out by anti-

stigma campaign, Time to Change (2009), almost half (49%) of the people surveyed

stated that they had witnessed a portrayal of a mentally ill character acting violently

in films. The survey also highlighted that 44% believe that people with a mental

illness will act violently. From these statistics, it can be inferred that people still

believe the misconception that all mentally ill people are violent and dangerous. This

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misconception is not helped by sensationalism and exaggeration by the media.

Joseph (2016:8) states that violent incidents conducted by a minority of mentally ill

people are exaggerated by mass media and can dominate the news-cycle. Huang

and Priebe (2003) conducted a study which aimed to assess the content and tone of

British print media articles surrounding mental illness by comparing them with

Australian and American versions. The study found that 76.3% of UK articles had a

negative tone towards both mental illness and mental health care. This study is

limited as it only considers two newspapers per country. The study would be more

reliable should more newspaper brands has been used- perhaps even then the

findings would have been different.

Bithell (2010) conducted research targeting medias attitude towards mental illness in

the United Kingdom. It was found that media coverage surrounding mental illness is

often negative in tone, portraying mentally ill people as violent, which emphasises

the negative stereotype and connotations surrounding mental illness. The research

completed by Bithell (2010) also compared attitudes towards mental health in the UK

to attitudes held by the US and Australia, finding that British attitudes are far more

negative in tone out of the three. The use of primary data alongside research around

the area somewhat strengthens the reliability of the findings as it shows the research

encompasses many different methods of research. These findings offer a more up to

date source in comparison to Huang and Priebe (2003). Furthermore, both studies

prove the same point: that media has a negative influence on mental illness in the

United Kingdom. This document is still being worked on, reducing its reliability as it

has not yet been peer reviewed. The media portrayal of mental illness has a degree

of sensationalism involved. Corrigan et al (2011) support this notion by stating that

newspapers and magazines often include sensational headlines that portray

mentally ill people as violent, suggesting that news stories present mentally ill people

as violent and dangerous. This is an example of how media promotes stigma

surrounding mental illness. Noakes (2004:55) emphasizes that the press must

accept responsibility in the stigmatization of mental illness, by indulging in

sensationalism. As discussed in this section, stereotyping an individual with a mental

illness contributes to the stigma process and stereotypes can add to the

discriminatory ways in which people with mental illnesses are treated.

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Emotional Reactions: Link and Phelan’s conceptualisation was modified in 2004. Link et al (2004) sought

the importance to introduce ‘emotional reactions’ to the model. Link et al (2004:513)

state that those who are separated as “them” – in this case the mentally ill individual,

are more likely to feel ‘anger, irritation, anxiety, pity and fear’. Link et al (2004)

emphasise that the way the general public react in response to their emotional

reactions results in discrimination and status loss for people with mental illness. For

example, a person with a mental illness may be spoken to in a pitiful way, with a soft

calm tone. This only reiterates the sense that the mentally ill person is perceived as

different by society, and they need to be spoken to differently. (Link et al, 2004). This

further emphasises the ‘us and them’ component- the mentally ill people are seen as

different and separate, with a need to be treated differently from other ‘normal’

people, despite that ‘they’ display emotions like everyone else.

Separation:Green et al (2005:198) states that ‘separation occurs when the reactions of others to

these differences lead to a distinct sense of “otherness.”’ This is the stage in which

the individual with a mental illness internalises the stigma as a result of the labelling,

stereotyping and being treated as different. Watkins (2008:18) elaborates on this

notion, stating that an ‘us and them’ attitude is apparent in society towards those

labelled “mad”. This part of stigmatisation involves a separation of ‘us’ from ‘them’,

implying that those that fall under the category of “them”, in this case people with a

mental illness, are not really human and deserve to be treated differently, potentially

worse (Link et al, 2014: 52). An example of this component, given by Link and

Phelan (2014: 79), states that ‘a person has heart disease, cancer or an infection but

a person who develops schizophrenia ‘is’ a ‘schizophrenic’ - a different sort of person

than the rest of ‘us.’ By marking out someone as different, it makes it easier to

isolate them from the rest of society.

Discrimination and status-loss:The next component of stigmatization is status loss and discrimination.

Discrimination refers to treating some groups less well than others, in this case it

refers to stigmatizing attitudes against the mentally ill (Moonie et al, 2000). ‘Status

loss and discrimination occur when stigma interferes with an individual’s ability to

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contribute fully to the social and economic life of their community.’ (Green et al,

2005:198). Stigmatized people are labelled, isolated from the rest of society, and

linked to adverse characteristics, leading them to experience status loss and

discrimination. Stigmatized groups are disadvantaged when it comes to a general

profile of life opportunities, according to Corrigan et al (2009). Link and Phelan

(2001:373) state that ‘a lower position on the status hierarchy can have a cascade of

negative effects on all manner of opportunities’. For example, lower status may make

the individual less likely to be socialised with, thus socially withdrawing from the

community.

Power:Power must be exercised for stigmatisation to occur (Link and Phelan, 2001).

Stigmatization is entirely dependent on access to social, economic and political

power that permits the identification of otherness, the construction of stereotypes,

the emotional response period when mentally ill discover their ‘otherness’ - the

separation process which categorises individuals, and the full execution of status

loss and discrimination.

Bruce Link and Jo Phelan’s (2001) components of stigma provide discussion into the

key issues surrounding stigma. The components analysed above (labelling,

stereotyping, emotional reactions, separation and status loss) are combined in order

to make a hierarchical theory which is structured by power. Sayce (2016) states that

it is not enough to just label and belittle a group for stigmatisation to occur. This is

due to the accuser’s lack of power in imbuing their accusations with serious

discriminatory processes. The conceptualisation defines stigma in relation to its

interrelated components and encourages further investigation into each one of the

four components.

Upon delving into the conceptualisation of stigma, each component encouraged

further investigation into the process of stigmatisation which have been outlined

above. Jo Phelan and Bruce Link each have numerous peer reviewed articles

surrounding the topic of stigma. Whilst the original conceptualisation was published

in 2001, they expanded on it in 2004, showing development on the subject. The

conceptualisation built on past criticisms surrounding stigma by making it more

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focussed on the effects of stigma, by considering emotional responses of labelling

and stereotypes.

Conclusion:In conclusion, it can be elucidated from the literature reviewed that there is a stigma

surrounding mental health, resulting in a negative impact on the individual with a

mental illness. The conceptualisation of stigma (Link & Phelan, 2001. Link et al,

2004) offers clarity of the different components providing knowledge of a step by

step explanation of how stigma is processed. Public stigma is apparent as there are

many stereotypes surrounding those who are mentally ill, including the notion that all

mentally ill people are violent. This is often not helped by the sensationalism within

the media. The labelling aspect of stigma encouraged extensive research

surrounding the matter, of which an alternative model was found: the ‘why try’ effect.

The ‘why try’ effect proved to be a significant milestone in this research area as it

provides both a positive and a negative response to the labelling process.

Furthermore, the ‘why try’ effect delved into its own theory suggesting that for people

to self-stigmatise, they need to be aware first of the connotations and stereotypes

surrounding their illness. Using Link and Phelan’s conceptualisation proved helpful to

aid further research as it encouraged further reading. It can be inferred by reviewing

the above literature that there is a stigma surrounding mental illness and whilst in

some cases it works as a “reverse effect” and empowers individuals, in many cases

it results in separation, emotional reactions, status loss and discrimination which can

result in negative effects on individuals. Stigma has been explored by looking at

various theoretical concepts. The next chapter focuses on stigma in a practical

setting, specifically of mentally ill students in a university setting, and how stigmatic

processes form a barrier to help seeking.

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Chapter Two: To what extent does stigma act as a barrier to help-seeking amongst students

with depression?Introduction:The notion that stigma is a hindrance on those suffering with a mental illness will be

further explored throughout this chapter by critically reviewing the literature

surrounding the topic of depression among students. Mental health issues amongst

students and academics have become a growing issue (The Guardian, 2016).

Depression in particular is a wide-spread illness with one in five people experiencing

depression in their lifetime. This chapter will firstly consider why depression is an

important focus point, discussing factors that may develop or exacerbate depression.

Coughlan (2015), emphasizes that mental health problems within universities have

‘increased dramatically’, indicating that there are a rising number of students

struggling to cope with life on campus and a sharp rise in the demand for

counselling. As highlighted in the introduction, student’s mental illness is worsening

and becoming a significant focus of research attention. Whilst mental illness is

becoming more common, there is also a concern with help-seeking attitudes and the

issue of under-reporting. Due to the fact mental illness is an increasing concern

within universities and contemporary society, there is need to research this further.

This chapter will research the help-seeking attitudes of depressed students by

considering studies and literature surrounding the topic, in order to elucidate whether

stigma acts as a barrier to help-seeking amongst students with depression.

Pressures students face concerning mental health: Beckett and Taylor (2010:94) highlight that ‘any change in human life involves a

psychological readjustment, a coming to terms with an ending and coming to terms

with things being different.’ The University of York (2016) acknowledge that whilst

transitioning to university is an exciting time, the change is not always easy for all

students to cope with. This is supported by Warwick et al (2006) who found that the

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transition into university can contribute to poor mental health. The National Union of

Students (2014) highlight that the university environment is often considered to be

associated with high pressure and stress for students, academically and socially.

Another consideration is the pressure of making friends. Mackaskill (2012:427)

states that companionship could be a difficulty as ‘students are now taught in larger

groups, which can make it more difficult to make friends and develop a sense of

belonging.’ Wilcox et al (2005) found that those struggling to make friends were more

likely to withdraw themselves from university, and consequently drop out. In a report

by the Telegraph (2014) entitled ‘Dealing with Depression at University’, the head of

well-being at the University of Surrey stated that students are under financial

pressure, the pressure to do well in their degree in addition to the pressure of

competing in a job market to secure employment after graduation. From the literature

reviewed above, it can be suggested that although the transition to university life is

often described as an exciting time, this is not always the case, and there are

different pressures faced by different students.

Possible outcomes of pressures at university: Morris (2011) states that for some students, university can be a stressful experience

and even detrimental to mental health. Students Against Depression (2016), is a

student-run website designed to help students by offering advice, information,

guidance and resources surrounding low mood, depression and suicidal thoughts.

Students Against Depression (2016) suggest that the transition from social familiarity

to a new social environment with different people can trigger episodes of anxiety and

depression to those who are already battling depression or are vulnerable to it.

Andrews and Wilding (2004) inspected questionnaires completed by university

students one month before university entry and at the mid-course. The study found

that 9% of previously depression symptom-free students had become depressed by

mid-course and 20% became anxious at a clinically significant level. This was the

first British study to confirm that factors introduced to students at university, such as

managing their own finance, can increase levels of anxiety and depression and that

financial difficulties can affect academic performance. However, it is important to

highlight that findings were not completely negative. In fact, Andrews and Wilding

(2004:517) state that ‘both positive and negative changes were apparent in anxiety

and depressive conditions from before university entry to mid-course’. Whilst 29% of

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symptom-free students developed anxiety or depression by mid-course, 36% of

those with prior conditions had ‘recovered’. This study suggests that university is not

necessarily a negative experience and in this case, the transition into higher

education offers positive opportunities. Roberts et al (1999) sampled students from

two universities in London with questionnaires. Data found from the study linked

mental illness to financial difficulties, stating that students’ financial problems were

linked to poor academic performance, poor psychological functioning and

depression. The findings of this study are indicative that there is a link between

financial issues and mental health problems among students. Whilst the study

presents a plausible link between financial pressure and mental health, the study

was carried out in 1999, which may regard the results as outdated when applied to

today.

Help-seeking attitudes amongst university students: First it is important to determine what is meant by help-seeking. Help seeking can be

spit up into two sections- formal or informal help seeking (Rickwood et al, 2012:10).

Formal help-seeking involves ‘assistance from professionals who have a legitimate

and recognised professional role in providing relevant advice, support and/or

treatment.’ Phippen (2010) outlines the various different methods of formal help-

seeking which are available specifically for students. These include medical support,

support from university tutor and counselling. Jackson (2006:223) states that

informal help-seeking involves seeking help from ‘family, friends or indigenous

persons and systems.’ The literature reviewed outlines many options for students

with depression.

The number of students seeking help for depression has more than doubled at some

of the country’s top institutions. This leads us to question why mental health

problems have increased. Research completed by The Higher Education Funding

Council for England (2015) suggests that societal attitudes are changing which

consequently means that students are feeling more able to open up about their

mental health issues. This is a factor which may have contributed to the rise in

demand for mental health support amongst students.

However, it is important to consider both sides of the story. One in four people

experience some kind of mental health problem in the course of a year, according to

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the Mental Health Foundation (2015a). Not only are mental health problems

increasing amongst university students, it can be suspected that there is also a case

of under-reporting. The report released by the Equality Challenge Unit (2012) found

that only 1 in 150 (0.7%) disclosed a mental illness to their universities. Given that

one in four people experience some kind of mental health issue in the course of a

year, this disclosure rate suggests a case of under-reporting. If there is under-

reporting, like these statistics imply, and there are students who are not being

treated for their depression, then it can result in intensified negative effects. This

raises the question of why students suffering from depression do not seek help

available to them. One likely reason is due to the stigma surrounding mental illness

(Patel, 2007).

The effect of stigma on help-seeking attitudes:In this section, studies will be reviewed in order to elucidate the link between stigma

and help-seeing. Time to Change (2016b) are an anti-stigma campaign run by the

leading mental health charities Mind and Rethink Mental Illness. Time to Change

(2014b), conducted a survey in order to gather experiences of education amongst

those who have experienced a mental illness. Results from the survey found that just

over three quarters of young people (77%) with a mental health problem have

missed out on education. The survey also found that one in four students did not

attend school due to the fear of what other pupils would say. Nearly one third (31%)

were on the receiving end of derogatory language with respondents citing the terms

“crazy”, “mental”, and “attention seeking.” To conclude, it is perhaps unsurprising

that nearly half of those questioned (48%) chose not to tell anyone at their academic

institution about their mental illness. The survey indicates that students had concerns

of what people thought of them, which is consistent with the stigmatisation process.

Students are afraid of the labels surrounding by stigma, which are set in stone due to

the stereotypes held of mental illnesses. Students feel as though they are being

treated differently, and separated from the rest of the ‘normal’ students. This

separation leads to discrimination for being different and in this case, they are

missing out on education. This is a representation of how the stigma

conceptualisation works in practice. This is also consistent with the ‘why try’ effect

as students feared the labelling process to the extent they missed out on education,

thus not tackling life goals and affecting life opportunities.

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The Time to Change survey was completed online, which, considering the topic of

the survey is stigma, is more efficient than through a more personal medium. In a

medium such as a focus group, the individual may not contribute honestly due to the

fear of being stigmatised- this weakness is erased when the computer screen acts

as a protective screen of anonymity. However, the questions revolved around the

student’s whole educational career- primary and secondary school, further and

higher education- which limited the accuracy of the survey in regards to specificity to

stigma surrounding university students.

Student Minds (2016) is a mental health charity specifically focussing on student

mental health in the UK. They carry out research in order to gain knowledge and

understanding surrounding mental illness amongst the student population, identifying

this as an under researched area. Grand Challenges (2014) is a research project

which aims to find out what university students and staff find most difficult about

living with a mental illness at university. As a result of this research, there were

several key challenges identified by students relating to peer relationships and the

impact of stigma such as the fear of being judged which was rated the biggest

challenge in student mental health. Another grand challenge was the fact that mental

health problems are seen as a ‘weakness.’ This also shows students fear being

stigmatised which prevents them from seeking help. This is again due to the label

and stereotype surrounding mental illness as “weak” the separation of the weak and

the strong and the discrimination against the weak. Those with mental illness then

will feel stigmatised and unable to adapt an open approach about their mental

illness. This research provides us with the knowledge that there are significant

feelings of stigma in the university environment in the UK surrounding the topic of

mental health. The Grand Challenges research project focusses specifically on

undergraduate student mental health and draws attention to certain challenges

surrounding mental health.

A survey by the National Union of Students (2013) was conducted which found only

one in ten students affected by mental illness use their university counselling service

despite the availability of seeking help. Drum et al (2009) suggest that student’s

associate seeking psychological help or counselling with the fear of being labelled

and stigmatized, consequently avoiding seeking help. Few teenagers receive

treatment for their mental health problem due to the fact they worry about what other

18

people think, according to Meredith et al (2009) – this presents a crucial barrier to

help seeking. These findings are consistent with the conceptualisation theory and the

aforementioned studies. The Chief Executive of Mind, Paul Farmer, suggests that

students chose not to seek help due to the stigma surrounding mental illness

(Raconteur, 2015). It can be inferred that stigma is present which is acting as a

barrier to seek help. Students therefore face a quandary; if they do seek the help

they require, they run the risk of being stigmatized, yet if they do not seek help it is

likely that they will continue to suffer in silence.

The studies above offer insight into the issue of stigma surrounding mental illness

amongst students. However, when searching specifically for data surrounding help

seeking attitudes amongst students with depression, there were few British studies

to be found, and so this could be an avenue of future research. Despite the lack of

available studies, depression is still a common and growing mental illness and there

is a suspicion of under-reporting, which suggests that depression among students is

higher than anticipated and stigma is a potential barrier to help-seeking.

The consequences of stigma:Stigma can decrease the likelihood that an individual will access and utilise mental

health services, despite the potential consequence of not seeking help is intensified

suffering (McDaid, 2008). The British Association for Counselling and Psychotherapy

(2014) state that when psychological distress and mental illness are left untreated it

can lead to students dropping out of university or failing to reach their full potential.

The consequences of not seeking help are long term, with issues such as low self-

esteem, poor future life-chances and on-going mental health issues throughout their

adulthood.

The Social Exclusion Unit (2004) highlight that people with a mental illness are at

greater risk of physical health problems such as obesity, cardiovascular disease,

respiratory disease and diabetes. Parle (2012) state that stigma can result in a

detrimental effect on physical health because sufferers do not access help seeking

services.

Stigma can also affect students with future employment. Parle (2012) states that

many people with a mental illness have experienced discrimination, a facet of the

stigmatic process, when applying for jobs. This includes having to try and explain

19

gaps in their CV for episodes of mental illness. The consequences of not confronting

nor overcoming stigma, as has been shown, can result in long term dangers in

health, employment and self-concept for the student, in addition to potentially

dropping out.

Conclusion: It can be concluded that depression is a common mental illness amongst the specific

focus group of students. Students are considered more likely to suffer with

depression due to the pressures they are faced with at university. The process of

stigmatisation is apparent in the aforementioned studies. It is clear to see, when

reflecting upon the studies, that students fear the process of stigmatisation. Students

were scared of being called ‘crazy’ or ‘mental’ which consequently meant they chose

not to disclose their mental illness. For this reason, there is suspicion surrounding

how accurate the statistics surrounding mental illness are due to the number of

people who are silenced due to stigma. All of the studies above made reference to

stigma acting as a barrier in some way. The majority of literature reviewed shows

that there are still students who feel they are faced with a choice between facing

stigma and suffering in silence. In order to prevent the latter, there is an importance

to explore methods to overcome stigma.

-

20

Chapter Three: Tackling mental health stigma at university

Introduction: The issue of help seeking attitudes amongst university students with depression has

previously been explored in chapter two. It was identified that stigma plays a key role

in why students do not seek help- either formally or informally- for their depression.

Stigmatisation is a central reason for not seeking help and potentially also under-

reporting, regardless of the negative consequences for not seeking help. It is the aim

of this chapter to consider methods of tackling mental health stigma in order to

elucidate whether these approaches are effective amongst a student population. The

first part of the chapter will focus on theories surrounding stigma reduction: literature

will be reviewed in order to understand what the best approach is for tackling both

self-stigma and public stigma. This chapter will then review an anti-stigma campaign

conducted by the University of Sussex in order to review the approaches they

applied in their campaign, to elucidate how effective the theory is in practice.

Following this analysis, conclusions will be made regarding suggestions to improve

the approaches and consequently improve people’s attitudes towards mental illness,

hence removing the stigma surrounding mental illness.

Tackling self-stigma:Self-stigma can be tackled in a number of different ways. A Briefing Paper conducted

by the Royal College of Psychiatrists outlined methods of tackling self-stigma

including: empowerment, improving self-esteem and using cognitive-behavioural

techniques which challenge the individual’s negative stereotypes and thought (The

Royal College of Psychiatrists in Scotland, 2015).

Empowerment:Empowerment refers to enabling individuals to take responsibility for their own lives

by making informed decisions (Davenport, 2010). In the context of this review, it

refers to an individual with a mental illness being able to exercise choice and being

powerful enough in certain situations to take part in decision making (Adams,

21

2007b). Corrigan and Rao (2012) suggest that empowerment is integral to tackling

self-stigma as it is associated with high self-esteem and better quality of life. An

individual who is self-stigmatising suffers with a damaged self-confidence, self-

efficacy and self-esteem and so empowerment, as a method that increases these

same attributes, is considered an effective concept to tackle self-stigma. (Corrigan et

al, 2011)

Cognitive-behavioural techniques:The term cognition is referred to as our consciousness and feelings, thoughts,

intentions and decisions, whereas the term behaviour is defined as what we actually

do. (Adams, 2007a) In reference to mental illness and tackling stigma, cognitive

behavioural techniques are used to reduce self-stigma by altering the negative

behaviour of the individual with mental illness. Vogel and Wade (2009) state that

cognitive behavioural techniques focus on replacing inaccurate beliefs with accurate

information, making the distinction that mental illness is not abnormal and attempt to

nurture self-acceptance. Corrigan and Calabrese (2005) note that these methods

could have a positive impact on self-stigmatisation.

Lucksted and colleagues (2011) provide positive development on tackling self-

stigma. Their approach, ‘Ending Self-Stigma Intervention’, aims to tackle self-stigma

by combining both cognitive behavioural techniques and empowerment in a group

setting. Their intervention utilises methods such as: lectures, discussions, group

support and problem-solving to replace the individual’s internalised irrational beliefs

with positive beliefs. The use of this cognitive behavioural technique empowers the

individual. Furthermore, according to Corrigan and Roe (2012), this technique alters

the sufferer’s perception of themselves. They reiterate that depression is not their

defining feature, which prevents self-stigmatisation. Nine sessions were carried out

for this intervention, and it was concluded that self-stigma significantly decreased,

suggesting that this empowerment and cognitive behavioural technique approach

could be a potential method in tackling self-stigma in the future. (Gela and Corrigan,

2015) Despite the Lucksted approach offering a promising method to tackling self-

stigma, it requires further evidence, such as testing on more people, to verify its

results.

22

Despite this gap in literature, there are studies, such as the one conducted by Lawlor

and Kirakowski (2014), which state that there is a positive correlation between

participation in mental health support groups and self-confidence, self-esteem, self-

efficacy, empowerment, decreased blame upon oneself and resistance to label

oneself as ‘mentally ill’. These effects of mental health support groups are factors

which counter-act self-stigma, so support groups may be useful in tackling self-

stigma. This study, however, only considers online support groups, which have been

criticised by Corrigan and colleagues (2009) as being a form of ‘social avoidance.’ if

this were the case, online support groups would make the individual more withdrawn

from society, arguably worsening self-stigma and definitely not combatting it. The

Global Anti-Stigma Alliance, cited in Time to Change (2016c) suggest that interactive

social contact is an effective way of empowering people with a mental illness. In the

Ending Self-Stigma intervention, social contact was used and this was proven to be

a significant method in tackling self-stigma. There is lack of clarity surrounding the

best approach of contact when tackling self-stigma; some argue that online contact

is effective at improving factors of an individual’s life, such as self-confidence, that

consequently tackle self-stigma whilst others argue that using online support groups

is a form of social avoidance, worsening self-stigma. From the literature reviewed,

the Ending Self Stigma approach incorporates both empowerment and cognitive

behavioural techniques that were proven to be successful in its pilot. Consistent with

this, groups were found by Lawlor and Kirakowski to be a successful device to tackle

the effects of self-stigma, thus consequently improving it. This seems like a

promising recommendation in the somewhat limited area of research.

One of the most integral issues associated with self-stigma is the individual’s feeling

of shame (Lewis, 1995). Due to their shame, they are likely to avoid certain

situations specifically regarding help-seeking. In order to tackle their self-stigma, it is

vital for them to disclose their mental illness. However, whilst some people are

empowered by stigma, others have the opposite effect, withdrawing from society and

more likely to believe they are to blame for their illness rather than seek help. This

ambiguity makes it difficult to predict in which way the individual will react. Whilst

studies have been conducted surrounding tackling self-stigma with medical students

and international students, there has been no evidence found to suggest that self-

23

stigma reduction approaches are successful in regards to tackling stigma among

general British undergraduates. In this area of research, there is a gap in literature.

Tackling public stigma: Patrick Corrigan and David Penn (1999) grouped strategies for tackling public stigma

surrounding mental illness into three approaches: protest, education and contact.

Protest:The protest approach aims to suppress stigmatising attitudes towards mental illness.

Corrigan and Watson (2002:17) state that ‘groups protest inaccurate and hostile

representations of mental illness as a way to challenge the stigmas they represent’.

The protests are aimed at two recipients: the media and the public. They aim to

change the misrepresentations of mental illness as portrayed by the media and stop

the public believing negative views surrounding mental illness. However, there is a

gap in the literature so it remains uncertain whether this method of tackling stigma is

effective. Penn and Couture (2002) add to its limitations by stating that the protest

approach could potentially cause stigmatising attitudes to increase rather than

decrease. This opinion is shared by Monteith and Colleagues (1998:73) who found

that demanding people to supress their negativity towards a stigmatised group can

result in a ‘rebound effect’. If this is the case, it can be suggested that protest

approaches do not improve people’s attitudes towards mental illness and in some

cases, worsen them. Another concern with the protest approach is that it aims to

diminish negative attitudes yet does not promote positive attitudes.

Education:The education approach to reducing stigma is similar to the protest approach in how

it aims to diminish negative stereotypes surrounding mental illness. However, the

difference is that the education approach replaces inaccurate stereotypes with

factual information (Watson et al, 2004). There are many methods, such as videos,

flyers, podcasts, films and other audio visual tools, which are utilised to educate

people on mental illness (Finkelstein et al 2008). According to Gela and Corrigan

(2015), this approach has the potential to be effective as it is cheap, accessible and

produce can be easily distributed. Despite this, when Corrigan and Penn (1999)

24

originally conducted the theory they suggested that there may be difficulties in

educating people towards different attitudes as many stereotypes are hard to

change. Watson and Colleagues (2004) argue that educating people so that they

understand mental illness means that they are less likely to have discriminatory and

stigmatising attitudes. The idea that better education surrounding mental illness will

decrease stigma is persuasive. However, Corrigan and O’Shaughnessy (2007)

highlight that the strength of the attitude change may be limited considering the

duration of the education approach was short-lived. Research conducted by Corrigan

and colleagues (2002) suggests that education can result in short term

improvements in tackling stigma. However, once the education is over, a short time

will pass and attitudes could potentially return back to normal.

Contact:The contact approach to tackling stigma is said to be the most effective in improving

public attitudes towards mental illness (Gela and Corrigan, 2015). This approach

consists of interpersonal contact between members of the public and an individual

with a mental illness. The theory is based on the notion that those with experience of

interacting with a mentally ill person are less likely to discriminate in comparison to

those without this contact. In a study conducted by Clement and colleagues (2012),

both film based contact and live social contact were tested in order to see which was

the most effective method at talking stigma. The study found that both methods

produced a significantly better response on attitudes towards mental illness

compared to education strategies. Corrigan and colleagues (2001), compared a total

of 208 student responses to two anti-stigma approaches; education and personal

contact. The study found that personal contact had a greater positive impact. They

also suggested that contact increases people’s familiarity of mental illness which

consequently decreases stigma. This approach to tackling stigma is dependent on

specific conditions. Young Minds (2010) state that in order for the contact method to

work, the mentally ill person mustn’t be seen as conforming to the standard

stereotype and the audience must be of equal status.

From theory to practice: implementing stigma reduction theories to university settings.

25

Up to this point in the chapter, theories and methods surrounding tackling self and

public stigma have been examined. In the second half of the chapter, these theories

will be assessed to find out if they are effective in practice, when the theories are

applied practically as campaigns.

In 2013, the University of Sussex signed the Time to Change pledge and launched

an anti-stigma campaign (Time to Change, 2013). The pledge was made with the

aim of improving both staff and students knowledge, attitudes and behaviour towards

mental health and illness. In the previous chapter, it was highlighted just how much

of an obstacle stigma is for depressed students and the severity in consequences of

not seeking help. Thus, it cannot be emphasised enough how important it is to

overcome stigma amongst students.

As part of the campaign, the University worked alongside UniTV who produced a

mini-documentary. Within the UniTV (2013) documentary, many interviews were

carried out as well as coverage of a flash mob conducted and completed by just shy

of 50 students at Sussex. By deconstructing the campaign, we can see how it has

utilised the stigma reduction theory. Aspects of the protest approach have been

utilised as one of the aims for the campaign was to supress negative attitudes

surrounding mental illness (University of Sussex Students’ Unions, 2016). In order to

achieve this objective, they challenge media misrepresentations by producing their

own form of media, a flash mob, which provides a positive stance on mental health.

Instead of media promoting negative attitudes, this form of media aims to show the

positivity of mental health, by promoting awareness. In addition, the mini -

documentary alongside it challenges public beliefs, incorporating an education

approach. The education approach has been utilised through the mini-documentary

which teaches the importance of openness about mental illness. This also adopts the

contact approach of tackling stigma as it features individuals who have personally

experienced mental illness themselves and importantly do not fall subject to the

stereotypes. Many interviews highlight people’s experiences of mental illness, from

staff members to students. This video emphasises the importance of a culture of

openness. Mental Health charity, Mind (2016), highlights the importance of

normalising conversations about mental illness in order to eliminate stigma. The

video produced by UniTV reiterates this idea. The individuals being interviewed all

utilise an empowerment approach as the speakers are now able to acknowledge that

26

although they have experienced mental illness, it does not define who they are. With

a campaign adapting every theoretical approach within self-stigma and public stigma

reduction, it can be suggested that this should be successful in changing public

attitudes surrounding mental illness.

Prior to the anti-stigma campaign, the University of Sussex conducted a student

mental health and well-being survey in order to determine the views and experiences

of mental health among students (Students’ Union University of Sussex, 2013). This

survey was conducted again two years later, after efforts had been taken to improve

mental health through anti-stigma campaigns. From reviewing the findings from the

Student Mental Health and Well-Being Survey (2016), the attitudes surrounding

mental illness at the University of Sussex, despite the efforts of the anti-stigma

campaign, had worsened.

Improving anti-stigma campaigns in universities:

Using the University of Sussex as a case study, it can be suggested that this

seemingly theoretically sound anti-stigma campaign has not worked to its expected

standard. In this section, suggestions on how to improve the campaign will be

highlighted by drawing observations from the surveys and by proposing alternative

approaches which could strengthen the campaign.

Findings from the Student Mental Health and Well-being Survey (2015) suggest that

although students and staff at the University of Sussex thought the campaign to be

positive, there is a need for continuing campaign activities for a longer duration,

specifically those education based. Although the education approach worked for

tackling stigma immediately after the campaign, these attitudes were not maintained.

One suggestion drawn from this literature is to develop education approaches so that

they are spread over a longer period, and so lessons learnt against stigmatic

stereotypes may not be so short term. This is consistent with findings highlighted in

the theory section (Corrigan & Watson: 2002, Corrigan & O’Shaughnessy: 2007).

This is a barrier that needs to be overcome in order for education to improve and

maintain people’s positive attitudes about mental health and illness.

The UniTV (2013) documentary aims to supress public stigma by including people

discussing methods to overcome stigma in university. This method combines protest

and contact. However, the contact is done through a video format which could have

27

contributed to why the campaign did not improve attitudes. Pinfold et al (2005)

support this view by suggesting that face to face contact with a person, who is able

to dynamically converse about their experience, is a key factor in mental health

awareness. Corrigan and colleagues (2012b) conducted an investigation into

articles, dissertations and population studies surrounding stigma, mental illness and

change programmes in order to analyse the best way of tackling stigma. This study

found that ‘face-to-face contact with the person, and not a story mediated by

videotape, had the greatest effect’. The University of Sussex could learn from this

method in future campaigns and. However, whilst face-to-face is better, it is not

always feasible. Video approaches are easier and cheaply distributed to a larger

audience which could be potentially more suitable for a university due to the difficult

of attracting every student to attend the contact activity. This could be tackled by the

use of social media, another method which could be introduced into the University of

Sussex Time to Change campaign and throughout other university campaigns too.

Whilst researching the anti-stigma campaign at the University of Sussex, it is difficult

to find any evidence that social media has been utilised to its best capacity.

According to Fertman et al (2014), social media can serve as a tool to combat

mental health stigma. Young adults are increasingly turning to social networking

sites such as Facebook and Twitter to seek health information (Giota and Kleftaras,

2015). It can be seen how this can act as an education forum. Lee (2010) explains

that hashtags (#) can be used in order to categorise keywords in Twitter. For

example, if you were to type “#depression” into the Twitter search bar, you would be

able to delve into posts about that specific subject. Due to young adults increasingly

using this platform and how easy it is to post information online, this seems like a

significant method for universities to utilise in order to spread normalisation of mental

illness and to spread awareness. Student Minds epitomise this method. Student

Minds are a British mental health charity, specifically focussing on students. Student

Minds have recently produced a new campaign, Ripple (2016). The Ripple campaign

specifically focuses on tackling stigma surrounding depression amongst university

students. To do so, Ripple aims to increase students’ knowledge surrounding

depression, to increase students’ confidence to talk about their experience of

depression, to encourage them to acquire support, and to help students understand

what their friends with depression are going through and how they can support them.

28

This is an example of a campaign which focuses particularly on social media.

‘#RippleTips’ are shared over the internet in order to educate and communicate with

other people who may or may not suffer with depression. The use of social media

attains the attention of students and young people. It is difficult to estimate whether

this is an effective campaign as it is extremely new however, the campaign has

applied the public stigma reduction theory as outlined in the first part of the chapter

in addition to focussing particularly on social media, a platform which many students

partake in.

Within the Sussex case study, it was found from the 2015 survey that people chose

not to disclose their mental illness upon applying for university, due to their shame

and fear. This suggests that self-stigma is an issue for students. This indicates that

there needs to be more of an emphasis on empowerment at university and people

should be able to feel like they can disclose an illness and feel supported in this

decision.

The University of Sussex signed the Time to Change pledge to tackle stigma at their

university. Thus far, there is little evidence from the literature reviewed that their

efforts, which are encompassing all of the approaches outlined by the stigma

reduction theory, are working. This is inconsistent with the findings from the national

campaign. Evans-Lacko et al (2014) used data from 2003 (six years before Time to

Change) and from 2007 -2013 National Attitudes to Mental Health Survey in order to

investigate the effectiveness of the anti-stigma campaign. The national campaign

differs from the University of Sussex findings, showing that the positive effects of the

Time to Change campaign are significant and moderate. However, Smith (2013)

states that ‘whilst some positive attitudes are shown, the overall picture is still mixed

and falls short of the wholescale shift in attitudes that is needed’. From a poster

produced by Time to Change (2014a) public attitudes towards people with a mental

illness have improved significantly with 6.4% improvement in attitudes since Time to

Change started in 2007. However, the poster highlights the need to continue with the

campaign and the fight to diminish the negative attitudes surrounding mental illness.

It is important to note that student bodies are included in the national attitudes and

therefore represent a small percentage. However student specific research

surrounding this particular field is limited and is often full of literature/theories and not

so much evidence.

29

Conclusion: To conclude, there are many approaches to tackling stigma which have been

discussed above. However, it has been elucidated that some are more effective than

others in improving attitudes surrounding help seeking. When applying theory to

practice by looking at the University of Sussex’ anti-stigma campaign, although many

of the approaches were taken in tackling stigma, survey results indicated that

attitudes did not improve and this is a cause for concern. Literature was then

considered surrounding ways the campaign could have been improved and

suggestions were made for further campaigns. Social media was a significant

approach despite the University of Sussex not using it to its full potential. Statistics

from the Time to Change campaign on a National basis were considered,

highlighting that attitudes towards people with mental illness in England are

improving slightly each year. It can be suggested, by reflecting on the literature

discussed in this chapter that further research needs to be carried out toward the

development of approaches to tackle stigma in a university population. Further

research needs to move towards an approach which includes all theories, is mindful

of past lessons and learns from mistakes, garnering significant exposure. This would

help launch a campaign that improves attitudes towards depression, and mental

illness in general, and amongst university students.

30

Conclusion:The purpose of this critical literature review has been to examine and appraise

literature and studies surrounding mental health stigma amongst British universities-

in order to understand the extent to which stigma acts as a barrier to seeking help

and can be detrimental to student’s lives. An extensive body of literature, along with

an array of relevant sources, have been reviewed to develop arguments and

contribute towards a greater understanding of the concept of stigma, help-seeking

attitudes amongst university students, the consequences of stigma and approaches

to tackling stigma.

Yet, as was discovered in the first chapter, defining stigma is not a simple task. The

conceptualisation of stigma, as outlined by Link and Phelan (2001, 2004), was

analysed closely in order to understand the stigma process. It was learned that the

process of stigma is complex, with components underpinning whether it works or not.

This conceptualisation was useful as it allowed further research into significant

issues such as labelling. Here, the modified labelling theory was considered, which

helped to understand why labelling contributes to the process of stigmatisation. The

‘why try’ effect was considered and revealed to be a milestone in this research; it

does not only consider the negative effect labelling has, but also its positive effects,

such as empowerment. By looking into further components, such as stereotyping, it

was clear to see the media’s influence on negative stereotypes surrounding mental

illness. These labels and negative stereotypes in some instances lead to emotional

reactions of which the mentally ill person feels separated and the separation stage.

This conceptualisation was structured by power, meaning that if an individual did not

hold social, economic and political influence, then they were unable to stigmatise.

This chapter helped determine the two types of stigma this dissertation aimed to

focus on: public stigma and self-stigma, and discussed the different factors which are

involved in the stigmatisation process.

Chapter two then sought to understand how stigma can be applied to students with

depression. Possible pressures and their outcome, such as life transitions, were

looked at to determine why the student population may be vulnerable to depression

and why they are important to consider in terms of mental illness. The chapter then

delved into help-seeking attitudes of students with depression by looking at a

31

number of studies surrounding the topic. Whilst research was found surrounding the

issue of general mental illness and help-seeking, there was a lack of literature found

that particularly focussed on students with depression and those which did were

ruled out of consideration due to their origin, as this dissertation particularly focussed

on UK studies. Despite the lack of depression focussed studies, it can still be

suggested that stigma affects a high percentage of students as depression is

extremely common among the general UK population, and that statistics support the

likelihood that under-reporting is present. The studies concerning help-seeking

attitudes all highlighted either public stigma or self-stigma as a barrier to help-

seeking, which poses a serious concern. It was easy to adapt the conceptualisation

theory, as discussed in chapter one, to life as students were fearful of the process of

stigma, thus avoiding help-seeking. Avoiding help can lead to detrimental effects on

the student. This chapter therefore highlighted the importance of eliminating stigma

in order for students to be able to come forward to seek help.

In the first half of chapter three, literature surrounding methods of improving self-

stigma and public stigma was considered. The possible methods of overcoming self-

stigma such as empowerment and cognitive-behavioural techniques were

considered in order to determine how effective they were. However, little literature

was found regarding its efficacy amongst UK university students and a definitive

conclusion was not reached. Corrigan and Penn (1999) offered a stigma-reduction

theory which featured three methods: protest, education and contact. These

methods were examined to determine how successful they are at overcoming public

stigma surrounding mental illness. Overall, the literature reviewed points towards the

contact and education method being most successful at tackling stigma, however

only one study was specifically targeted at university students which emphasised the

importance of further research surrounding this target group. The second part of the

chapter analysed a specific anti-stigma university campaign in order to apply theory

to practice. The University of Sussex failed in their campaign to improve attitudes

and overcome stigma, despite applying the approaches outlined in the theory

section. There were a number of improvements which were identified from the

campaign, including a better use of social media in order to approach stigma. It was

concluded that more research is needed to specifically focus upon tackling stigma in

the university population.

32

Overall, this dissertation has established the need for further research specifically

focussing on general undergraduate students as much of the literature focusses

specifically on either medical students or non-UK universities. The development and

maintenance of research surrounding this subject is paramount to ending the stigma

surrounding mental illness in general and making students able to come forward with

their illness, thus needs to be focussed on.

33

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