Peers Labeling Peers: A Theoretical Analysis of Youth with Mental Illness and the Campaigns to End the Stigma

Beth BeemanSeattle University

ABSTRACT

A perceived barrier to adolescent avoiding help-seeking behavior for mental illness is

stigma from their peer group. Utilizing Modified Labeling Theory, this paper examines the

processes in which labels and stigma negatively impact youth with mental illness as well as

evaluate certain components of anti-stigma campaigns aimed at middle and high school

students. The analysis finds that conceptions of and prejudices against people with mental

illness vary according to the type of disorder and term used to describe the condition. Self-

labeling is a predicator negative outcomes, but there is also a counter-discourse of self that

refuses clinical labels which may be able to deviate from the model. Race is also a salient

factor when it comes to labeling, possibly due to people of color already being part of a

stigmatized group and African Americans’ history with the psychiatric profession. Finally

the theory is used to evaluate the effectiveness of contact-method, youth-lead initiatives,

and continuing anti-stigma groups, such as clubs within the modified labeling approach.

Peers Labeling Peers: A Theoretical Analysis of Youth with Mental Illness and the Campaigns to End the Stigma

INTRODUCTION

Approximately 22 percent of youths suffer from a mental disorder that has the

potential to affect their functioning in adulthood. Adolescents of ethnic minorities can be at

an increased risk for mental illness (Bulanda, Bruhm, Byro-Johnson, and Zentmyer 2014).

However, most youth who show evidence of mental health problems, especially minorities,

do not receive any form of mental health care (Moses 2009). One possible factor for why

youth might avoid seeking help is fear of being stigmatized by their peers.

The first section of this paper evaluates research into labels and stigma regarding

mental illness among adolescents, those with and without mental health diagnoses. It will

also contain themes and methods of contemporary efforts in anti-stigma programs. The

next section goes over the groundwork for Modified Labeling Theory (Link, Cullen,

Struening, Shrout, and Dohrwend 1989), including its predecessor conceived by Thomas J.

Scheff (1966, 1984, 1999) and the five-step model linking stigmatization to harmful

consequences for mental patients. Finally the theory is applied to the literature to locate key

concepts from each article within the model and to examine the effectiveness of certain

aspects of anti-stigma campaigns.

LITERATURE REVIEW

There is little in the way of literature when it comes to the stigmatizations of

adolescents with mental illness, most of which has been done by a limited pool of

researchers. Therefore, this review uses literature from multiple disciplines including

sociology, social work, psychology, and psychiatry.

Labels and Stigma from Self and Peers:

Labeling theory is the theory of how individuals’ behaviors and self-identity are

determined or influenced by terms or “labels” used to classify them. It is often used to

describe patterns of stigma of deviant populations, such as those with mental illness. This

will be explained further in the next section.

While there are several types of stigma (Wright, Jorm, and Mackinnon 2011), the

literature focuses primarily on self-stigma which is stigmatizing views one holds of oneself,

perceived stigma (also known as public stigma) beliefs regarding stigmatizing attitudes of

others, and personal (social) stigma the stigmatizing views one has regarding others.

Another variable measured is social distance, or the degree to which a person is willing to

associate with someone culturally different from them (in this case, someone with a mental

illness).

Moses (2009) and Munson, Floersch, and Townsend (2009) examined attitudes

toward mental health services among adolescents with mental disorders in the Midwest.

Moses’s study showed that about one in five adolescents with mental illness self-label their

disorders. These teens are more inclined to depression and self-stigma than teens who

refuse labels (37%) or demonstrate uncertainty about the nature of their problem (42%).

Adolescents of lower socio-economic status and ethnic minorities are less likely to self-label

than their peers. Munson et al. find the majority of the their participants show fairly positive

attitudes in regards to seeking help and feeling indifferent to stigma, with white youth more

indifferent to stigma than youth of color. A small group of participants reported higher

emotional responses associated with their mood disorder, such as fear or anger, and these

youth experienced more stigma than their peers.

In a study examining perceived stigmatization on the part of adolescents being

treated for mental illness, about two thirds of participants experienced at least some stigma

from peers and one in five reported being socially isolated from their peers. Peer

stigmatization commonly occurred through losing friends who were intolerant, judgmental,

or uninterested in them after disclosure or symptom became apparent. Some respondents

who reported no peer stigma explained they concealed their treatment from peers while

others reported socializing with peers also receive treatment for various health problems,

substance abuse, or delinquency (Moses 2010).

Research regarding stigmatizing attitudes from adolescents in general has garnered

mixed results. In one study of middle school students across the country, researchers found

that while there were significant gaps in students’ knowledge about mental illnesses,

attitudes toward people with mental illnesses were generally positive; though there was a

substantial number of respondents with negative attitudes (Wahl, Susin, Lax, Kaplan, and

Zatina 2012). Corrigan, Lurie, Goldman, Slopen, Medasani, and Phelan (2005) presented

high school students with four vignettes describing peers with different conditions: alcohol

abuse, mental illness, mental illness from a brain tumor, and leukemia. They found that the

adolescents stigmatized peers who abuse alcohol most severely and treated peers with

leukemia most benignly. Having a brain tumor mediated the stigmatizing effect of mental

illness. Wright et al. (2011) also used vignettes with 2802 Australian youths aged 12-25,

this time asking respondents to label the people described in the vignettes based on

description of symptoms. Findings show no significant associations between labels and

most of their measured stigma components. In two of the three studies, social distance

scores implied that respondents showed considerable reluctance to engage in close

interactions with a person with a mental illness (Wahl et al. 2012; Corrigan et al 2005).

Anti-Stigma Strategies:

Anti-Stigma strategies can be enacted at the individual level, managing self-stigma,

and at the institutional level, addressing public stigma.

Prior (2011) addresses strategies utilized by Scottish high school students who had

completed a course of counseling in the previous year. He found that the teenagers had

framed their experiences using a “problem solver” position and resisting positioning

themselves in within a mental illness discourse. Rather, they utilized discourses of

individualism, agency, and self-care. In the process they normalized their difficulties as

ordinary teenage problems and experiences and redefined self-reliance to include help-

seeking.

There are three main categorical approaches to changing public stigma. Protest is

used to examine the stigmatizing ways people with mental illness are portrayed in the

public eye and remove them. Education-based programs provide factual information about

mental illness in aims of increasing knowledge and disproving false assumptions and

stereotypes. Contact involves face-to-face interactions with people with mental illness as a

means to change general public attitudes.

Research has shown protest strategies do not change stigmatizing attitudes

and may actually have a “rebound” effect and worsen them. Education and contact have

been shown to make positive gains in attitudes about mental illness, however studies to

determine which approach is better vary in results depending on how researchers measure

outcomes (Corrigan, Rafacz, Hautamaki, Walton, Rüsch, Rao, Doyle, O’Brien, Pryor, and

Reeder 2010; Murman, Buckingham, Fontilea, Vilanueva, Leventhal, and Hinshaw 2014).

Youth-led approaches, in which adolescents organize and facilitate programs to

reduce stigma, are another method that has shown to be effective in ameliorating stigma.

Participants in such programs have shown statistically significant improvement in attitudes

and knowledge. (Bulanda et al. 2014; Murman et al. 2014; Pinfold, Toulmin, Thornicroft,

Huxley, Farmer, and Graham 2003).

Pinfold, et al. (2003) observed that six months after a mental health workshop for

students in the UK, all gains had substantially declined. They hypothesized this may be due

to the duration of the program (two one hour long sessions), being too few sessions to

challenge students’ longstanding prejudices. Murman et al. (2014)’s study of Let’s Erase the

Stigma (LETS), a high-school club program in Los Angeles, addresses this by giving

questionnaires to two groups: one that has not yet started the program and one that has

completed one semester with LETS. They found that LETS participants showed statistically

significant differences from non-participants in regards to attitudes, social distance, anti-

stigma actions, and knowledge.

MODIFIED LABELING THEORY

Thomas J. Scheff is the foremost scholar in labeling theory as it applies to mental

illness. His theory, however, by his own admission “highly specialized, yet insufficiently

detailed” (1999). As such, many scholars currently using labeling theory in their research

use a modified approach as articulated by Link, et al (1989). In this section, Scheff’s theory

is summarized for foundation, followed by the modified labeling model.

Scheff’s Original Theory and Criticisms

Thomas J. Scheff introduced the application of labeling theory to mental illness in his

book, Being Mentally Ill (1966, 1984, 1999). According to Scheff the process of becoming

mentally ill is a product of societal influence. He classifies what are commonly known as

symptoms of mental illness as instances of rule breaking and deviance. When someone

breaks a social norm regarding “involvements” (being present in mind while in public),

society has two courses of action. Most often, the behavior is ignored or rationalized; a

pattern known as “normalization.” In a small proportion of cases, society reacts strongly

and labels the deviance as mental illness. Once labeled, the individual is subjected to certain

societal expectations and forced to adopt the role of a “mentally ill person.” When the

individual internalizes the role and adopts the identity of a “mentally ill person,” the process

is finalized and the result is a stable mental illness.

This theory has been controversial since its introduction and as such has been

subject to a considerable amount of criticism. The most notable critique comes from Walter

Gove who insists that society has no influence on mental illness and that the “vast majority

of mental patients stigma appears to be transitory and does not appear to pose a severe

problem.” A number of other studies conclude that any rejection felt by mental health

patients is more likely caused by their deviant behavior than the label of “mental health

patient” (Link et al., 1989).

A New Model

Responding to the criticism, Link et al. (1989) presented a modified approach to

Scheff’s theory, to prove the salience of labeling in regard to mental health patients. The

aptly named “Modified Labeling Theory Approach” does not claim labeling to directly create

mental illnesses, but that it can have negative consequences. The approach is comprised of

five steps. They are 1) beliefs about devaluation and discrimination, 2) official labeling

through treatment contact, 3) patient’s responses to their stigmatizing status, 4)

Consequences of the stigma process on patients’ lives, and 5) vulnerability to future

disorder.

Modified Labeling Theory differs from Scheff’s model in three key ways. First, this

approach emphasizes the variability of people’s attitudes toward mental illness. Some

people will feel people with mental illness are vilified while others believe society’s opinion

to be more moderate. Second while both observe that labeled individuals have internalized

the same cultural views of the general public, Scheff’s theory puts an emphasis on the

responses of others, while Link et al. highlight the labeled person’s response on the basis of

her or his beliefs about how others will react. Lastly, as mentioned before, unlike Scheff’s

model, Link’s approach doesn’t give labeling the power to directly produce mental illness.

Instead, the authors view labeling and stigma as possible causes for “negative outcomes that

may place mental patients at risk for the recurrence or prolongation of disorders that

resulted from other causes.”

ANALYSIS

The first two subheadings of this section relate the literature to the five steps of

Modified Labeling Theory, with some insights on deviance within the process. The final

subheading applies the theory to devices used in anti-stigma programs.

Step One: Beliefs About Devaluation and Discrimination

As state before, there is mixed evidence about the attitudes of adolescents toward

mental illness. One possible factor to account for this could be the use of language in each

study. Corrigan et al. (2005) provided a general label for the mental illness and received

responses in which peers with mental illness are stigmatized severely. Wright et al. (2011),

on the other hand facilitated unprompted responses to vignettes describing a set of

symptoms and found that labeling mental disorders using psychiatric or lay mental health

terms was rarely associated with stigma. The one exception was the psychosis vignette,

where the accurate label, “psychosis/schizophrenia,” and to a lesser degree, lay mental

health labels such as “mental illness” and “psychological/mental problem,” are associated

with belief the person would be unpredictable and dangerous. Therefore, the term used to

describe the condition being measured could be a salient factor.

Another interesting disparity is social distance scores between the studies.

Social distance scores for Corrigan et al. (2005) and Wright et al. (2011) positively correlate

with other attitude scores, as might be expected. The responses in Wahl et al. (2012),

however, have an inverse correlation between attitudes and social distance. A possible

explanation for this might be that, as middle school students, the participants in the Wahl et

al. study may have at their stage of social development internalized some social conceptions

involving people with mental illness, but not others.

Steps Two Through Five: Stigma Status and Identity

Outcomes of Steps 3 through 5 in many ways depend on how adolescents label

themselves in Step 2. Moses (2009) noted that the participants in her study who self-labeled

reported higher ratings of self-stigma and depression in comparison to the rest of the

sample who either were unsure about the nature of their problems or conceptualized their

problems in a non-pathological way. This might suggest that for adolescents, addressing the

accurate psychological term for one’s problems reinforces the labeling process, thus

creating a heightened awareness of stigma in those individuals. Using alternate

conceptualizations of their problems may help adolescent mental health service users

better navigate or avoid stigma and its effects.

Prior (2011)’s research corroborates this conjecture. The alternate discourses of

self-reliance and strength provided by the respondents serve to counter any self-stigma

they might have as well as challenge interpersonal-stigma from peers and educate them.

Race is also a salient factor in regard to labeling and stigma. Munson et al. (2009)

notes that while on the whole, youth with mood disorders had positive attitudes in regard

to seeking mental health services, youth of color in her study were more concerned about

stigma than white youth. Black youth reported higher levels of stigma in regard to seeking

psychological help than their white peers. There was also a non-significant trend in Moses’s

(2009) study on self-labeling that indicated ethnic and racial minority youth were less likely

to self-label compared to their white counterparts. A possible explanation for these trends is

that youth of color are already a stigmatized group with a history of being treated

unethically by the medical and psychiatric communities. Avoiding self-labeling may be a

way to avoid further stigmatization.

Adolescents’ experiences with stigma in reference to peers strongly correlates with

Steps 3 and 4 in the modified labeling model. A number of the adolescents who described

experiencing no or some stigma from peers utilized either secrecy or withdrawal, two out of

the three possible responses to labeling. Secrecy was utilized by some in the no peer stigma

group. In these cases they were either “careful not to disclose” their treatment to peers or

treatment simply never came up in conversation. Participants said that secrecy was used to

avoid “intrusions” or giving others reasons to devalue them. Other participants who

experienced no peer stigma utilized withdrawal; their social groups were made up of people

“in the same boat.” This was also the case with some participants in the some peer stigma

group, after having been rejected by other friends or peers. Affiliating with peers in similar

situations can be an effective coping strategy for social stigma, but it also may lead to more

constricted social networks and limit life chances later on (Moses 2010).

Modified Labeling Theory and Anti-Stigma Campaigns

The modified labeling approach is primarily used to examine the relationship

between social processes and mental illness, however ideas expressed in each step of the

model can be used to evaluate the effectiveness of an anti-stigma campaign.

Step 1 is concerned with beliefs about devaluation and discrimination of people

with mental illness. The components of this step can be used to evaluate contact anti-stigma

strategies as articulated in Corrigan et al. (2010) and Murman et al. (2014). Both NAMI’s In

Our Own Voice (IOOV) and LETS use contact for some if not all of if its curriculum. Not only

is contact an effective way to combat stigma for the public, as it gives a face and a story to

the label, but it is also beneficial to the facilitators and other guests with mental illnesses

involved. In giving them a position to speak and share their experiences, it gives a devalued

individual back some value. This is not to say that education programs aren’t important –

they are – but including contact in anti-stigma campaigns helps break down the

stigmatization process in a personalized way.

Youth-led approaches, such as S.P.E.A.K. (Bulanda et al. 2014) and LETS

(Murman et al. 2014), can also be desirable. Most significant others for an adolescent are

their peer groups. Therefore, they are more likely to pay attention to the attitudes,

behaviors, and knowledge of other adolescents. Both S.P.E.A.K. and LETS have shown

effectiveness in changing attitudes and knowledge in its participants, if only for a short

while.

Frequency should also be a consideration. Society already has a firm conception of

what it means to be labeled mentally ill. This conception is reinforced by a variety of

mechanisms such as jokes, cartoons, and media reports of mental patients (Link et al. 1989;

Scheff 1966). As Pinfold et al. have found out, one or two sessions are not enough to

challenge longstanding prejudices. LETS tries to address this issue with its year-long after-

school club format, but as of this writing, no studies of longitudinal effects have been

published.

CONCLUSION

This paper explores literature about attitudes and stigma regarding adolescents

with mental illness, as well as efforts by some anti-stigma programs to educate and change

attitudes toward mental illness. Evidence regarding social stigma among adolescents is

mixed. In regards to anti-stigma campaigns, research shows that use of the contact method

and youth-led initiatives are at least at surface level effective in improving knowledge and

attitudes among youth.

An overview of Thomas J. Scheff (1966,1984, 1999)’s Labeling Theory is given,

accompanied by critiques. It is followed by a summary of Modified Labeling Theory (Link et

al. 1989) listing the five steps of how labeling and stigma can produce negative outcomes

that can exacerbate conditions of people with mental illness.

The analysis positions the literature within Modified Labeling Theory and finds that

conceptions of and prejudices against people with mental illness vary according to the type

of disorder and term used to describe the condition. Self-labeling is a predicator for Steps 3

through 5, but there is also a counter-conception of self that refuses clinical labels. Race is

also a salient factor when it comes to labeling, possibly due to people of color already being

part of a stigmatized group and African Americans’ history with the psychiatric profession.

Finally the theory is used to evaluate the effectiveness of certain aspects of anti-stigma

campaigns.

There are a number of limitations in the literature. Most of the studies reviewed in

this paper used self-selected surveys and/or small samples in restricted locales. This limits

the generalizability of their findings. Language and terminology is inconsistent in the

studies observing stigma, so there is no clear baseline to interpret the results. Additionally,

both Murman et al. (2014) and Wright et al.’s results may be affected by social desirability

bias; participants may have been inclined to answer more positively to conform to the social

norms of the researcher. This is because Murman et al. (2014)’s survey was self-reporting

and Wright et al. (2011) ‘s was conducted over the phone. Wright et al included youth up to

25 in their sample. That may influence analysis in which participants from other literature

were generally aged 12-18. Finally, the LETS study (Murman et al. 2014) is of a quasi-

experimental design, which prohibited the opportunity to control for confounding variables.

This may have contributed to the observed differences in answers between the two groups.

Much of the current research regarding adolescents and their experiences with

mental health stigma are still at the fundamental level and are being conducted by a small

group of researchers. The next step that needs to be taken is to expand upon these

preliminary studies and include more researchers and represented regions to the body of

work. Without a deeper understanding of the processes involved in forming of stigmatic

attitudes among youth and how to address them, the same patterns will continue and many

adolescents with mental illness will still not get the treatment they need.

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