Journal of Mental Health

ISSN: 0963-8237 (Print) 1360-0567 (Online) Journal homepage: http://www.tandfonline.com/loi/ijmh20

Changing public stigma with continuum beliefs

Patrick W. Corrigan, Annie Schmidt, Andrea B. Bink, Katherine Nieweglowski,

Maya A. Al-Khouja, Sang Qin & Steve Discont

To cite this article: Patrick W. Corrigan, Annie Schmidt, Andrea B. Bink, Katherine Nieweglowski,
Maya A. Al-Khouja, Sang Qin & Steve Discont (2016): Changing public stigma with continuum
beliefs, Journal of Mental Health, DOI: 10.1080/09638237.2016.1207224

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ISSN: 0963-8237 (print), 1360-0567 (electronic)

J Ment Health, Early Online: 18

! 2016 Informa UK Limited, trading as Taylor & Francis Group. DOI: 10.1080/09638237.2016.1207224

ORIGINAL ARTICLE

Changing public stigma with continuum beliefs

Patrick W. Corrigan, Annie Schmidt, Andrea B. Bink, Katherine Nieweglowski, Maya A. Al-Khouja, Sang Qin, and
Steve Discont

Illinois Institute of Technology, Chicago, IL, USA

Abstract Keywords
Background: Given the egregious effect of public stigma on the lives of people with mental Stigma, change messages and processes
illness, researchers have sought to unpack and identify effective components of anti-stigma
programs. History
Aim: We expect to show that continuum messages have more positive effect on stigma and
affirming attitudes (beliefs that people with mental illness recover and should be personally Received 13 August 2015
empowered) than categorical perspectives. The effect of continuum beliefs will interact with Revised 31 March 2016
contact strategies. Accepted 10 May 2016
Method: A total of 598 research participants were randomly assigned to online presentations Published online 26 July 2016
representing one of the six conditions: three messages (continuum, categorical, or neutral
control) by two processes (education or contact). Participants completed measures of
continuum beliefs (as a manipulation check), stigma and affirming attitudes after viewing
the condition.
Results: Continuum messages had significantly better effect on views that people with mental
illness are different, a finding that interacted with contact. Continuum messages also had
better effects on recovery beliefs, once again an effect that interacted significantly with contact.
Conclusions: Implications of these findings for improving anti-stigma programs are discussed.

Changing public stigma with continuum beliefs mental illness) (Phelan, 2002; Read et al., 2006), it also makes
other manifestations of stigma worse. For example, research
This study addresses four hypotheses about the impact of
participants exposed to biogenetic messages are more likely to
continuum versus categorical messages, interaction of mes-
believe people with mental illness are dangerous and
sages with contact versus education strategies, impact on
unpredictable (Kvaale et al., 2013; Walker & Read, 2002),
measures of stigma including the differences and impact on
leading to more discrimination (Mehta & Farina, 1997).
affirming attitudes of recovery and empowerment. Public
Biogenetic models may also worsen stigma because they
stigma has egregious effects on the life opportunities of
unintentionally accentuate group differences; i.e. that mental
people labeled with mental illness, having been shown to
illness is biologically hard wired into the person, making
undermine work, independent living, health and relationship
them different beings from everyone else.
goals (Callard et al., 2013; Sartorius & Schulze, 2005). As a
Researchers and advocates have proposed continuum
result, impacting stigma has become a major public health
beliefs as an alternative to the categorical messages of
priority. Goffman (1963) characterized stigma as undesired
biogenetic explanations (Angermeyer et al., 2014; Schomerus
differentness that results from a mark distinguishing and
et al., 2013; Wiesjahn et al., 2014). In continuum beliefs,
discrediting a social outgroup from the majority. This sense of
symptoms and disabilities of mental illness are framed as
differentness may occur because of categorical conceptualiza-
differences on an interval scale of behavior rather than
tions of mental illness; that people labeled with psychiatric
qualitatively unique phenomena. Visual hallucinations, for
disorders are somehow in a class that is qualitatively distinct
example, vary along a continuum from the most pathogno-
from the norm. One way often used to diminish the idea of
monic (clearly seeing people), to vague images (glowing
difference is to frame psychiatric illnesses as a biogenetic
auras), to corner of the eye experiences (Was that my
disorder; that they are biological in origin, just like other
dead Aunt Gertrude I just saw?), to normal vision.
medical illnesses (Kvaale et al., 2013; Lincoln et al., 2008).
Understanding psychiatric phenomena such as psychosis as a
Although this kind of message often decreases public
continuum has been supported by research in experimental
blame for mental illness (i.e. that the person chose to have a
psychopathology (van Os et al., 2009). Framing symptoms
such as visual hallucinations on a continuum may reduce
stigma by decreasing categorical beliefs about those with
Correspondence: Patrick W. Corrigan, 3424 S. State Street, Chicago, IL
60616, USA. Tel: (312)567-6751. Fax: (312)567-6753. E-mail: serious mental illness and everyone else. In fact, research has
corrigan@iit.edu shown that people who endorse continuum beliefs are less
2 P. W. Corrigan et al.
likely to endorse social distance (Angermeyer et al., 2014;
Schomerus et al., 2013; Wiesjahn et al., 2014).
Continuum messages have been incorporated into anti-
stigma programs to reduce public prejudice towards people
with mental illness. One randomized controlled trial (RCT)
showed research participants exposed to a continuum message
were less likely to endorse ideas of incompetence and
unpredictability compared to those who received a categorical
message (Wiesjahn et al., 2016). The study presented in this
paper seeks to replicate the beneficial effects of continuum
messages compared to categorical or neutral, control
messages.
A separate, larger body of research has examined how two
broad sets of processes affect stigma change: education
(contrasting the myths of mental illness versus the facts)
versus contact (interacting with people in recovery). Results
of meta-analyses of 13 RCTs showed contact, compared to
education, had significantly better effects on attitudes and
behavioral intentions at pre versus post-test (Corrigan et al.,
2012) and at follow-up (Corrigan et al., 2015c). In this RCT,
messages are crossed with process. We hypothesize that
contact will yield better effects than education and that
beneficial effects of contact will interact with continuum
messages.
Measures of stigma are often affected by social desirability
effects; namely, people are hesitant to endorse stereotypes
about a stigmatized group to avoid being perceived as
prejudiced (Hawke et al., 2013). Hence, studies on the
impact of anti-stigma interventions often include measures
less susceptible to social desirability; one such measure
assesses differentness. Differentness is known as the workers completing this 10-min task were reimbursed $1.20.
content-less prejudice where there is no substantive attribu-
tion for separateness, only the relatively benign assertion that
people with mental illness are different from me (Link about online surveys is research participants who fail to fully
et al., 2004). A measure of difference per se has been shown
to be more sensitive to personal beliefs about stigma
compared to standard measures that represent the degree to
which the public endorses beliefs about dangerousness,
unpredictability, or incompetence (Corrigan et al., 2015a).
We hypothesize that both a standard stigma measure and one
that assesses difference will be significantly improved in
conditions that include continuum messages and interpersonal
contact. We also expect an interaction between process and
message, such that scores on stigma measures will be lowest
among participants in the continuum-contact condition.
Changing stigma is not enough; programs also need to
promote affirming attitudes related to mental illness. Two
affirming attitudes that have been used in stigma research are
recovery and personal empowerment (Corrigan et al., 2013b).
Recovery is a complex and evolving construct that replaces
pessimistic notions of poor prognosis with empirically-based
constructs that show people with even the most serious of
mental illnesses such as schizophrenia are capable of
achieving personally meaningful life goals and hence should
be hopeful (Davidson et al., 2008). Recovery demands
empowerment; namely, the people with serious mental illness
should have full control over all life choices and the mental
health interventions that help achieve them (Brohan et al.,
2010). We hypothesize that continuum messages and contact
will improve affirming attitudes related to recovery and
J Ment Health, Early Online: 18
empowerment better than the other conditions. We also
expect an interaction between process and message, such that
scores on affirming attitude measures will be highest among
participants in the continuum-contact condition.
Methods
Research participants for this study were randomized to one
of the six online conditions, defined by message (continuum,
categorical, or neutral control) crossed with process (educa-
tion or contact). Upon completing conditions, they were
administered measures of continuum beliefs (as a manipula-
tion check), stigma and affirming attitudes. The manipulation
check allows us to test whether the continuum message
validly portrayed the idea of continuum beliefs. Adults were
solicited to participate in this study using Mechanical Turk
(MTurk). MTurk, operated by Amazon, is a crowdsourcing
internet marketplace network that, among other things, is used
to solicit participants for social science research. Data show
more than 100 000 workers from the United States are
registered with MTurk (Pontin, 2007). Research is mixed
regarding the degree to which demographics of MTurk
workers match the US population (Buhrmester et al., 2011;
Paolacci et al., 2010; Ross et al., 2010), though this is less of a
problem for studies like the current one, which is more
concerned about internal validity to test hypotheses. A
solicitation was posted in MTurk requesting workers to
participate in a 10-min survey about knowledge and
thoughts about mental health issues. Consistent with our
commitment to pay MTurk participants minimum wage,
Six hundred and eighty-three MTurk workers responded to
the solicitation and were assessed for eligibility. One concern
attend to task. Our MTurk survey included validity questions
meant to exclude people in this group; e.g. Please choose the
number 8 for your answer below. Participants who failed
to enter 8 suggest they were not attending carefully to task.
Data from these participants were omitted from analyses. In
addition, audio and video checks of participants equipment
were performed through use of a test video to assure that
intervention videos could be adequately viewed by partici-
pants. To maintain consistent display of the Likert scales used
as outcome measures, participants who attempted to take the
survey from a smart phone were not allowed to go forward
because survey layout was not compatible with smaller
devices. We also excluded data from analyses for people
whose time on task was below minimal cutoff (3 min after
viewing vignette) to complete the survey competently. As a
result, 598 MTurk workers provided useable data. Prior to
beginning the survey, prospective research participants were
informed of the goals and methods of the study via an online
consent form and had to agree to participate before
proceeding. The study was fully reviewed and approved by
the IRB at the Illinois Institute of Technology.
After consenting to participate, survey respondents
answered items about demographics. Table 1 summarizes
demographics by message condition. Overall, the sample was
35.6 years of age on average and 51.7% female. The sample
self-reported largely as white (85.8%) though it did include
DOI: 10.1080/09638237.2016.1207224 Continuum beliefs 3
Table 1. Demographics by message condition.

Control (N 193) Categorical (N 205) Continuum (N 200)

M (SD) or frequency (N) M (SD) or frequency (N) M (SD) or frequency (N) Group differences
Age 36.69 (11.24) 34.56 (11.20) 35.68 (12.48) F(2, 597) 1.66, p0.19
Gender 20.93, p 0.63
Female 52.8% (102) 53.2% (109) 49.0% (98)
Male 47.2% (91) 46.3% (95) 51.0% (102)
Sexual orientation 25.16, p 0.076
Heterosexual 95.3% (184) 90.2% (185) 89.5% (179)
Gay 4.7% (9) 9.8% (20) 10.5% (21)
Marital status 29.81, p 0.044
Single/never married 40.9% (79) 47.8% (98) 43.0% (86)
Married 36.3% (70) 41.0% (84) 37.5% (75)
Other 22.8% (44) 11.2% (23) 19.5% (79)
Race *
White 86.5% (165) 85.4% (169) 85.5% (159)
Nonwhite 14.5% (28) 18.0% (36) 21.5% (41)
Ethnicity 20.14, p 0.93
Latino/Latina 7.8% (15) 6.8% (14) 7.5% (15)
Not Latino/Latina 92.2% (178) 93.2% (191) 92.5% (185)
Highest education 214.63, p 0.26
Some high school 0.0% (0) 0.5% (1) 2.0% (4)
High school diploma 13.0% (25) 10.2% (21) 12.5% (25)
Some college 25.9% (28) 21.0% (31) 31.0% (22)
Associates degree 14.5% (50) 15.1% (43) 11.0% (62)
Bachelors degree 34.2% (66) 36.1% (73) 29.5% (59)
Some graduate school 2.6% (19) 2.4% (30) 2.5% (23)
Graduate degree 9.8% (5) 14.6% (5) 11.5% (5)
Employment *
Full time 56.0% (108) 61.0% (36) 57.5% (63)
Part time 18.7% (125) 18.5% (38) 18.5% (57)
Other 32.6% (115) 27.8% (37) 35.5% (71)
Annual income 221.38, p 0.38
510 000 16.6% (32) 11.7% (24) 19.0% (38)
10 00019 999 14.5% (28) 11.7% (24) 17.5% (35)
20 00029 999 15.0% (29) 16.1% (33) 13.5% (27)
30 00039 999 11.4% (22) 17.1% (35) 16.0% (32)
40 00049 999 13.0% (25) 10.7% (22) 9.0% (18)
50 00059 999 7.3% (14) 9.8% (20) 7.0% (14)
60 00069 999 7.3% (14) 10.2% (21) 4.5% (9)
70 00079 999 6.2% (12) 4.9% (10) 4.5% (9)
80 00089 999 3.6% (7) 2.4% (5) 2.5% (5)
90 00099 999 1.0% (2) 3.4% (7) 2.5% (5)
4100 000 4.1% (8) 2.0% (4) 4.0% (8)

Note. * Group differences could not be determined because cells were not independent of each other. Specifically, individual participants could endorse
multiple ethnicities or employment categories.

7.4% African/African American and 6.7% Asian/Asian
American. About 7% of the sample reported being Latino/
Latina. The overall sample was 91.6% heterosexual and 5.0%
bisexual. Participants were mostly either single (44.0%) or
married (38.3%). Educational achievement varied, with more
than 70% reporting some college or more. In terms of
employment, 58.2% were working full time and 18.6% were
part time. Common responses in the other category
included homemaker and self-employed. Incomes varied
greatly, with two-thirds of participants reporting annual
income less than $50 000. The far right column of Table 1
provides inferential statistics testing for demographic differ-
ences by message; note that these analyses were not done for
race or employment because individual participants could
positively endorse multiple categories. Only one was found
significant; marital status varied by message condition
(2 9.81, p 0.04), with the categorical sample showing
more participants widowed or divorced compared to the other
groups. There was only a single missing item in response
to demographic questions. One person randomized to the
categorical condition did not report gender. No significant
differences in demographics were found across process group
(education versus contact).
Interventions
Research participants were randomly assigned to one of the
six conditions determined by fully crossing three messages
(continuum beliefs, categorical beliefs, or neutral control
condition) with two processes (contact or education).
Participants were exposed to the conditions through
Qualtrics, an online self-administered platform; interventions
varied from 35 to 60 s. (See Appendix for full scripts of the
six conditions. e-Copies of the interventions can be obtained
from the first author.) Those in the contact condition saw a
videotape of Jason, a 32-year old college graduate and
paralegal who lives in a one bedroom condo. Jason discusses
symptoms he has experienced due to schizophrenia (hears
voices and believes CIA is investigating him), and previous
experiences with hospitalization and medication histories.
4 P. W. Corrigan et al.
The education condition, in a PowerPoint format, presented a
generic review of schizophrenia that paralleled many of the
experiences of Jason, including symptoms (hallucinations
and delusions), treatments (hospitalizations and medication)
and feasible life accomplishments consistent with recovery
(college, paralegal career and homeownership).
Messages varied in three ways. The neutral, control
condition summarized just the facts outlined above. These
facts were moderated in the categorical condition in three
ways: (1) by representing mental illness in terms of a clear
boundary between those with schizophrenia and most other
people; (2) by stipulating that hallucinations and delusions do
not happen to others; and (3) by reporting very few people are
ever hospitalized for psychiatric reasons. In attempting to
equate continuum with categorical message, three similar
moderators were provided for the continuum condition: (1)
there is no clear boundary between those with schizophrenia
and most other people; (2) hallucinations and delusions can
happen to anyone when they are distressed; and (3) anyone
can be hospitalized for many different reasons.
Measures
After completing the online intervention, participants imme-
diately completed five outcome measures on the Qualtrics
platform. In this survey, participants could only proceed to a
test item if they provided an answer to the previous question.
This led to very few missing data. Research participants
completed the Continuum Beliefs Questionnaire (CBQ:
Wiesjahn et al., 2014) as a manipulation check. The CBQ
comprises sixteen items e.g. hallucinations or thought Data analyses
disorder can happen to anyone if they are very stressed to
which respondents answer using a six-point Likert agreement
scale (6 completely agree). A CBQ index was determined
from the mean of scores across the 16 items with higher
scores representing greater endorsement of continuum beliefs.
Internal consistency of scores for participants in this study
was 0.78. Stigma and affirming attitudes were assessed using
the California Assessment of Stigma Change (CASC:
Corrigan et al., 2015b). Composite measures of the CASC
reflect more than 10 years of independent research (Corrigan
et al., 2013a; Corrigan et al., 2015b; Corrigan et al., 2004;
Corrigan et al., 2006; Rogers et al., 2010). Psychometrics for
the CASC was gleaned from four separate studies and
supports its reliability and validity (Corrigan et al., 2015b).
CASC subtests measure stigma, recovery, and empowerment.
Stigma is assessed in the CASC using the eight-item
version of the Attribution Questionnaire (Corrigan et al.,
2003). Single items assess each of eight constructs that
emerged from path analyses of responsibility and dangerous-
ness: blame, anger, help, danger, fear, avoidance, coercion and
institutionalization. Items are posed in response to a brief
vignette about Jim, a 30-year old, single man with
schizophrenia. Research participants respond to individual
items (e.g. How dangerous would you feel Jim is?) on a
nine-point Likert scale (9 very much). Mean AQ-8 scores
are reported here and range from one to nine, with higher
scores representing more stigmatizing views toward people
with mental illness. Alpha for AQ-8 scores was 0.82.
Stigma findings were further assessed in the CASC using
J Ment Health, Early Online: 18
the three-item Difference Measure (Corrigan et al., 2015a).
In response to the same, Jim vignette, participants were asked
to rate how much Jim is similar, unlike and compar-
able to me on a nine-point semantic differential. Items were
reversed where appropriate, with a mean total score ranging
from one to nine; higher scores mean greater endorsement
of difference (lower scores, more similar). The Alpha for
Difference scores was 0.95.
Recovery was assessed on the CASC using items from the
Recovery Scale (RS: Corrigan et al., 2004). Items that load
best into three factors were selected for the short form:
personal confidence and hope; goal and success orientation;
and no domination by symptoms. A sample item is, People
with mental illness are able to do things as well as most other
people. Research participants responded to individual items
using a nine-point agreement scale (9 strongly agree).
Means scores range from 1 to 9 on this scale, with higher
scores representing better views of recovery. The alpha for
Recovery scores was 0.54, of concern and addressed in the
limitations section of the Discussion. Empowerment is
assessed in the CASC using three items from the
Empowerment Scale (ES: Rogers et al., 2010) reflecting
self-efficacy/self-esteem; e.g. I see people with mental
illness as capable people. Research participants responded
to the scale using a nine-point scale of agreement (9
strongly agree). Mean scores range from 1 to 9 on this scale,
with higher scores representing better views of empowerment
regarding people with mental illness. The Alpha for
Empowerment scores was 0.95.
Analyses were conducted using IBM SPSS Statistics Version
22. Five 3  2 ANOVAs (message: continuum, categorical,
control BY process: contact, education) were completed to
examine effects of the two conditions by outcome variable.
Post hoc tests were conducted when main or interaction
effects suggested they were appropriate. In addition, effects
due to marital status were examined in additional 3  23
ANOVAs.
Results
Means of dependent measures are summarized in five graphs
in Figure 1; the graphs represent post-test scores by message
and by process. There were no missing data in response to
these dependent measures. As expected for the manipulation
check, the 3  2 ANOVA for continuum beliefs yielded a
significant effect for message (F(2,592) 32.46, p50.001)
but not process (F(1,592) 0.96, n.s.) nor the interaction
(F(1,592) 0.35, n.s.). Post hoc one-way ANOVAS showed
significant results for contact (F(2,296) 15.03, p50.001)
and for education (F(2,296) 17.71, p50.001). In all cases,
CBQ was significantly higher for continuum beliefs compared
to the other message interventions (p50.001).
We hypothesized that continuum message would
interact with contact to impact stigma. Two graphs represent
effects on stigmatizing beliefs and difference in Figure 1.
The 3  2 ANOVA for stigmatizing beliefs using the AQ-8
yielded nonsignificant effects for message (F(2,592) 0.72,
n.s.), process (F(1,592) 1.70, n.s.) and interaction
DOI: 10.1080/09638237.2016.1207224 Continuum beliefs 5

Figure 1. Means of impact indicators by message (continuum, categorical, or control) and process (contact or education). Note. CBQ: Continuum
Belief Questionnaire; AQ8: eight item Attribution Questionnaire; DM: Difference Measure; ES: Empowerment Scale; RS: Recovery Scale.

(F(2,592) 1.28, n.s.). However, a post hoc one-way ANOVA
yielded nonsignificant trends suggesting AQ-8 scores were
lower for those in the contact compared to education
condition (F(1,198) 3.12, p50.10). Difference Scale
scores showed some positive effects. Significant main effects
were found for message (F(2,592) 7.18, p50.001), but
not process (F(1,592) 0.34, n.s.) or the interaction
(F(2,592) 0.71, n.s.). Post hoc tests showed significant
improvement for continuum message for those in the contact
(F(2,296) 5.96, p50.005) but not the education condition
(F(2,296) 1.85, n.s.). Post hoc Tukeys tests showed the
continuum message yielded significantly lower (p50.05)
difference scores than those in the categorical or neutral
conditions.
We also hypothesized that continuum message would
interact with contact to improve affirming attitudes. Two sets
6 P. W. Corrigan et al.
of 3  2 ANOVAs examined effects on affirming attitudes.
No significant effects for empowerment were found for
message (F(2,592) 0.94, n.s.), process (F(1,592) 1.84,
n.s.), or interaction (F(2,592) 0.26, n.s.). However, the
3  2 ANOVA for recovery was significant for message
(F(2,592) 3.41, p50.05), process (F(1,592) 6.78,
p50.01) and interaction (F(2,592) 3.42, p50.05). The
most notable post hoc test demonstrating the interaction was
the significant difference between contact and education for
continuum message (F (1,198 11.95, p50.001).
Groups differed significantly by marital status. Hence,
3  23 (message by process by marital status) ANOVAs
were conducted to determine whether marital status sig-
nificantly interacted with the other two independent variables.
Results failed to show significant marital interactions with
message, process, or three way interaction for any of the
outcome variables.
Discussion
Findings from this study provided limited support for the
benefit of continuum belief messages compared to categorical
or neutral message. Continuum beliefs seem to have some
effects on stigma and affirming attitudes, though these
findings were mixed. Although type of message did not
seem to impact measures of the kind of explicit prejudice and
discrimination assessed by the AQ-8, continuum beliefs were
significantly more positive on difference scores compared to
both the categorical and control conditions. Namely, people
with mental illness were seen as more similar to respondents
when those respondents were exposed to continuum beliefs.
The difference in AQ-8 and difference score effects may
represent the impact of social desirability; that the beneficial
effects of stigma change only occur using subtle indicators of
prejudice, those that are less susceptible to the disapproval of
peers.
Process effects were surprisingly less apparent on stigma.
Education and contact showed no impact on difference scores.
Although the process effect for stigmatizing beliefs assessed
on the AQ-8 was nonsignificant, post hoc one-way ANOVAs
yielded nonsignificant trends suggesting contact led to less
stigma on the AQ-8 compared to education. This finding is
consistent with previous meta-analyses (Corrigan et al., 2012;
Griffiths et al., 2014) examining education versus contact
effects in two ways. First, contact yields better effects than
education on measures of stigmatizing attitudes. Second,
contact effects are relatively muted when conducted through a
medium (like an online platform) rather than face-to-face.
Findings were also mixed in terms of message and process
effects on affirming attitudes. No differences were found on
empowerment. However, significant differences occurred for
recovery as it interacted with contact. In particular, people
randomized to Jasons continuum message showed signifi-
cantly greater improvements in recovery compared with the
other five conditions. This finding needs to be considered
conservatively given the low index of internal consistency
found on the recovery score. Still, this is an especially
important finding given the role recovery has assumed in the
vision of mental health systems. President George W. Bushs
New Freedom Commission called for a mental health system
J Ment Health, Early Online: 18
anchored in recovery, one that promotes hope and the pursuit
of personal goals (Hogan, 2003). Results from this study
suggest continuum messages, when combined with the
personal story of contact, best foster public opinions that
reflect recovery. Future research needs to unpack recovery
definitions to determine how continuum beliefs impact
notions of hope versus goal achievement (Davidson et al.,
2008.
Limitations
There are some limitations in this study that need to be
examined in future research. There might have been
unintended effects from all groups completing the
Continuum Beliefs Questionnaire. Namely, people in condi-
tions that did not manipulate continuum beliefs might still be
influenced by the idea when completing the CBQ. Future
research should consider whether to include the CBQ across
conditions. Still, findings here ae not really diminished by this
concern because differences were found despite all conditions
being administered the measure.
Effect sizes of significant differences are muted which
moderates confidence in these findings. At a minimum, future
research first needs to replicate these findings and then seek
to extend them by identifying variables that moderate or
mediate effects. Research suggests stigma and affirming
attitudes are influenced by culture and ethnicity (Abdullah &
Brown, 2011). Future research should study how messages
and processes interact with ethnicity and other diversity
constructs (gender and sexual orientation) of program
participants. This study did not determine whether benefits
maintained over time; future investigations should include
follow-up assessment. Outcomes in this study were largely
attitudinal. Subsequent studies should include proxies of
behavior or behavior intention, both in terms of social
distance representing the impact of prejudice as well as
affirming behaviors such as reasonable accommodations and
social supports.
These findings have implications for improving anti-
stigma programs. Given the importance of contact-based
approaches to stigma change, mixed methods research has
identified key ingredients in contact strategies (Corrigan
et al., 2015c; Corrigan et al., 2013b). This mixed methods
research has shown that recovery based stories are essential to
effective contact. Findings from this study reported here
suggest the experience of recovery is enhanced when framed
as continuous progression rather than quantum leap. The
public seems to be more responsive to messages that suggest
the persons journey to recovery is on the same continuum as
every other attempt at achieving personal life goals. Hence,
advocacy programs moving forward need to have people with
lived experience incorporate messages about how their
experiences fall on the same continuum of behaviors that
everyone experiences.
Declaration of interest
Authors and investigators received no financial support nor
have no financial relationships that pose a conflict of
interest.
DOI: 10.1080/09638237.2016.1207224
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Appendix

Contact process

Message
Control Hi, I am Jason and I have a serious mental illness called schizophrenia. I am 32 years old, a college graduate, and currently work as a
paralegal at a downtown law firm. I live on my own in a one bedroom condo on Lake Street. I dont always have symptoms, but
when I do, I hear voices and sometimes believe the CIA is investigating me. Aside from symptoms of schizophrenia, I also get
uncontrollably anxious which can cause me to miss days of work. I have been hospitalized three times and currently take
medication for my illness.
Continuum Hi, I am Jason and I have a serious mental illness called schizophrenia. People with schizophrenia, like me, are not very different from
others who are considered mentally healthy. I am 32 years old, a college graduate, and currently work as a paralegal at a downtown
law firm. I live on my own in a one bedroom condo on Lake Street. I dont always have symptoms, but when I do, I hear voices and
sometimes believe the CIA is investigating me. Aside from symptoms of schizophrenia, I also get uncontrollably anxious which
can cause me to miss days of work. There is no clear boundary between my experience and beliefs and the experiences of most
people. For example, hallucinations and delusions can happen to anyone when they are stressed and most people get nervous at
some time in their life. I have been hospitalized three times and currently take medication for my illness. Like me, anyone may be
hospitalized for many different reasons.
Categorical Hi, I am Jason and I have a serious mental illness called schizophrenia. People with schizophrenia, like me, are very different from
others who are considered mentally healthy. I am 32 years old, a college graduate, and currently work as a paralegal at a downtown
law firm. I live on my own in a one bedroom condo on Lake Street. I dont always have symptoms, but when I do, I hear voices and
sometimes believe the CIA is investigating me. Aside from symptoms of schizophrenia, I also get uncontrollably anxious which
can cause me to miss days of work. There is clearly a boundary between my experiences and beliefs and the experiences of most
people. For example, hallucinations and delusions dont happen to others when they are stressed and most people do not get
nervous in their daily lives. I have been hospitalized three times and currently take medication for my illness. Unlike me, very few
people are ever hospitalized.

Education process

Message
Control Some adults can have a serious mental illness called schizophrenia. They may graduate college, work in a job like a paralegal, and live
in their own condo. They dont always have symptoms, but when they do, they may hear voices and sometimes believe the CIA is
investigating them. Aside from symptoms of schizophrenia, they may also get uncontrollably anxious which can cause them to
miss days of work. People with schizophrenia are often hospitalized and take medication for their illness.
Continuum Some adults can have a serious mental illness called schizophrenia. People with schizophrenia have a psychological disorder like any
other. They may graduate college, work in a job like a paralegal, and live in their own condo. They dont always have symptoms,
but when they do, they may hear voices and sometimes believe the CIA is investigating them. Hallucinations and delusions like
these can happen to anyone when they are stressed out. Aside from symptoms of schizophrenia, they may also get uncontrollably
anxious which can cause them to miss days of work. Most people get nervous in their daily lives. People with schizophrenia are
often hospitalized and take medication for their illness. People get hospitalized for many different reasons.
Categorical Some adults can have a serious mental illness called schizophrenia. People with schizophrenia are very different from those with other
illnesses. They may graduate college, work in a job like a paralegal and live in their own condo. They dont always have symptoms,
but when they do, they may hear voices and sometimes believe the CIA is investigating them. Aside from symptoms of
schizophrenia, they may also get uncontrollably anxious which can cause them to miss days of work. There is clearly a boundary
between their experiences and beliefs and the experiences of most people. For example, hallucinations and delusions dont happen
to others when they are stressed and most people do not get nervous in their daily lives. People with schizophrenia are often
hospitalized and take medication for their illness. Very few people ever get hospitalized.