Tammy Oladapo

IR 1 10 CC Pd.2

April 23, 2020

Reducing the Public Stigma Associated with Schizophrenia and Psychotic Disorders

Psychosis is a symptom of schizophrenia, characterized by delusions, hallucinations, and

behavior that may not be appropriate for the situation (DSM-5). Psychosis is often associated

with crazy, uncontrollable, unacceptable, strange and dangerous behavior. These stereotypes are

false, yet they are still widely believed. This negative stigma is a major impairment in the

treatment and the quality of life for schizophrenics (Morrison et al., 2016). Schizophrenics are

8% more likely to report stigmatization than people with other mood disorders (Patten et al.,

2016). Along with the stigma that the public associates with psychosis, schizophrenics also

experience internal stigma, where they begin to associate negative qualities with themselves

(Wood, 2017). This is called self-stigma or internalized stigma. Both public and internal stigma

can lead to delayed treatment, reduced social interactions, and feelings of depression and

hopelessness. There is a strong negative relationship between internalized stigma and hope,

self-esteem, empowerment, and adherence to treatment. (Birchwood, 2007). Both public stigma

and self-stigma are further perpetuated through negative media, such as reports of mass

shootings conducted by people with serious mental illness. Negative media along with a lack of

education on schizophrenia lead to the belief that schizophrenics are dangerous and/or incapable

of caring for themselves. These, along with similar beliefs are the basis of negative stereotypes
associated with psychosis. Despite the negative impact of miseducation and perceived

dangerousness, the overall stigma associated with psychosis can be greatly decreased

through increasing public information, integrating schizophrenics into society, and

reducing internalized stigma within schizophrenics.

The belief that schizophrenics are dangerous and cannot care for themselves increases

social distance and perpetuates the general stigma associated with psychotic disorders. However,

Educating the public through increasing social contact with schizophrenics, dispelling

perceived dangerousness, and raising exposure to information about psychosis will

significantly reduce public stigma in psychosis.​ People who have an authoritarian attitude

toward mental illness (believing that a paternalistic mental health system is responsible for

making decisions for persons with psychiatric disability because they are unable to care for

themselves) are more likely to socially distance themselves from schizophrenics than others.

(Corrigan, 2001). Authoritarian beliefs perpetuate negative stereotypes such as schizophrenics

being less able to complete jobs and incapable of being trusted with their own wellbeing,

worsening public stigma and reducing the quality of life for schizophrenics. Increasing social

distance has a possibility of increasing stigma, as less people are exposed to the reality of the

disease and continue to believe negative stereotypes. Additionally, in a study assessing beliefs

about the dangerousness of people with mental illnesses, respondents heard the vignette of

‘John’, a person who had either depression or schizophrenia. For the schizophrenia vignette,

“28.3% agreed or strongly agreed that John is dangerous while 56.3% agreed that other people

would perceive John as dangerous.” Although many didn’t personally believe that John was

dangerous, the majority of participants believed that the general public would perceive him as
dangerous. This displays the prevalence of stigma, as participants generally believed that society

saw schizophrenics as dangerous. In the same study, “Those with a higher level of education

were less likely to agree with the statement that others would view ‘John’ as dangerous”

(Reavley, 2016). Given that participants who were better educated and had experience/social

contact with mentally ill people were less likely to perceive the schizophrenic vignette as

dangerous, having previous educational or physical contact with mental illness can reduce levels

of stigma. Eliminating perceived dangerousness and authoritarian attitudes through social contact

and public education will significantly reduce public stigma related to schizophrenia.

Despite perceived dangerousness worsening stigma, educating the public through

increasing social contact can reduce negative attitudes towards psychosis. In the Compeer

program, volunteers were paired with a schizophrenic friend in order to promote social contact

between the public and schizophrenics. A study within the program found that “a higher [Match

Bond Scale] score was associated with less stigma . This suggests that those who were in more

satisfying relationships were likely to have fewer stigmatizing attitudes” (Sacca & Ryan, 2011).

Forming bonds with schizophrenics allowed for a more accepting point of view for the

volunteers, reducing the levels of stigma they showed towards schizophrenics. This proves that

increased social contact with schizophrenics reduces levels of stigma towards psychotic

disorders within Compeer volunteers. Outside of the program,“A number of studies have found

that participants who report having previous contact with persons with mental illness are less

likely to endorse negative attitudes, such as being unwilling to hire people with [Serious Mental

Illness] for babysitting, being unwilling to date them, and being unwilling to rent them a

room”(Couture & Penn, 2003). Increasing social contact with schizophrenics will overall
improve their quality of life, decreasing stigma as more people trust them with their own

wellbeing. Also, increased social contact associated with reduced perceived dangerousness, with

people feeling safer dating, hiring, and renting to schizophrenics. With more contact between the

public and schizophrenics, the public becomes more comfortable around them, seeing them as a

person rather than an illness.

Lastly, providing the public with information on schizophrenia has shown to disprove

and reduce public stigma. Providing the public with facts regarding the ‘dangerousness’ of

schizophrenics dispels perceived dangerousness, leading to decreased public stigma. “First,

information comparing the prevalence rates of violent behavior across different disorders

resulted in lower ratings of perceived dangerousness relative to all other conditions... Second,

specific information about violence and mental illness significantly affected the perceptions only

of persons with a severe mental illness in general, rather than a specific target individual” (Penn,

1999). Once people understood that violent behaviour isn’t as common in schizophrenia in

comparison to other disorders, they were less likely to perceive schizophrenics as dangerous.

Specific information altered perceptions of severe mental illnesses in general rather than an

individual person, meaning that information on one person can reduce negative stereotyping and

generalization for the disease itself. Plus, in a separate study “participants endorsed significantly

less stigma across some domains for the psychosis risk designation when an informational insert

was added. The informational insert was associated with less belief in violence toward self and

also with reduced desire for casual social distance.” (Yang, 2013). This shows that simply

providing information on the disease allows the public to feel safer, reducing beliefs of violence

and social distance. By becoming more knowledgeable on schizophrenia, college students

destigmatized schizophrenia and felt safer and more comfortable with schizophrenic patients.

Although much stigma in psychosis is caused by misconceptions regarding the dangerousness of

schizophrenics, educating the public through social contact and accurate information has the

power to greatly reduce public stigma in psychosis.

Asides from public stigma, cognitive therapy approaches can also decrease internalized

stigma. Normalizing and reducing negative appraisals of psychotic experiences can reduce

self-stigma in patients. By normalizing, decatastrophizing, and deshaming understanding of

psychotic experiences, harmful appraisals/judgments of these experiences are reduced. A study

utilized cognitive therapy techniques that were focused towards stigma, such as guided

discovery, skills development, normalizing and belief change strategies. Patients were also given

self-help guides aimed toward normalization and self-esteem. This study resulted in Cognitive

Therapy reducing levels of internalized shame, depression, hopelessness, and self-rated recovery

(Morrison et al., 2016). By normalizing psychotic experiences, patients can feel less ashamed of

their disease. Shame is a major factor in internalized stigma, as they do not want to associate

themselves with the stigma of the disease for fear of losing social status (Birchwood et al., 2007).

By reducing shame, internalized stigma is reduced as they no longer fear themselves. Cognitive

therapy also reduces many effects of internalized stigma, such as depression and hopelessness.

Through normalizing psychotic experiences, cognitive therapy builds confidence and reduces

internalized shame, which helps to reduce internalized stigma.

Cognitive therapy also lessens negative appraisals of psychotic experiences,

which can have a great effect on internalized stigma. Another study tested the effect of cognitive

therapy on negative appraisals and social acceptability in psychosis. The cognitive therapy
allowed for an individualized, goal-oriented approach to focus on normalizing and reducing

negative appraisals. There was a significant decrease in negative appraisals, however, there was

no statistically significant decrease in social acceptability (Morrison et al., 2013). This study

showed that cognitive therapy successfully reduces negative beliefs about psychosis. However, it

is more difficult to change social acceptability through therapy due to deep cultural stigma. A

reduction of negative appraisals of unusual experiences, in turn, reduces internalized stigma by

reframing negative beliefs about the disease that patients may associate with themselves.

In a different study, through framing self-stigma as irrational self-statements, patients

learn to identify negative appraisals and strategically challenge judgements by collecting

feedback from others. These challenges help to develop short and meaningful counters to those

appraisals to use any time that they are self-stigmatizing (Corrigan et al., 2013). By challenging

these beliefs and identifying them as something negative, patients can gradually stray away from

believing and identifying themselves with the negative stigma. Enabling the patients to combat

internalized stigma both in and out of therapy allows them to more effectively reduce negative

appraisals of psychosis, which is the starting point for reducing self-stigma. Once patients

disprove their negative beliefs about the disease, they are more likely to be proud to identify

themselves with psychosis.

Shame about the stigma in psychosis can often contaminate social interactions. This leads

to less effective communication between people with psychosis and the people they interact with.

One of the most prominent stereotypes in psychosis is that schizophrenics are dangerous or tend

to show aggression. This can sometimes be true, as patients may become angry or avoidant if

they feel as if someone is thinking of them to be in a lower social rank. However, this aggression
may only perpetuate the stigma, creating a sense of fear in the general public. Although shame

about stigma can harm social interactions and lead to creating and/or maintaining social phobia,

Cognitive Therapy and Social Cognitive Therapy techniques combat this by reducing aggression,

improving social relationships, and improving overall social skills.

Social Cognitive Interaction Training (SCIT) aims to improve social relationships by

improving social cognition. It addresses social cognitive domains such as Theory of Mind,

emotion attribution, and attributional style. Along with improving social cognition, SCIT can

also reduce aggression and improve social relationships in patients with schizophrenia. “SCIT

participants showed improvement in cognitive flexibility, need for closure, and self-reported

social relationships and a significant reduction in the number of aggressive behaviors” (Combs et

al., 2007). With social cognitive training, patients showed significantly less aggressive behaviors

in general and interacted more with the public. This helps reduce stigma by normalizing the

disease and reducing social exclusion. Moreover, reducing aggression disproves the negative

stereotype of psychotic people being dangerous, strange, and/or unapproachable. By reducing

aggression and encouraging social interaction, Social Cognitive Therapy shows promise in

reducing public stigma in psychosis.

Aside from reducing aggression, Social Cognitive Therapy also increases social

interaction and improves the quality of such interactions. “Participants also reported

improvements in their ability to interact with others and the size and quality of their social

network on the treatment ward” (Combs et al., 2007). Social Cognitive Training helped increase

and improve social interactions among schizophrenics; increasing overall social integration.

With more social integration, cultural stigma is gradually reduced through the normalization and
deshaming of psychotic experiences. This also improves their overall quality of life, reducing

feelings of loneliness, depression, and hopelessness. Larger and higher quality social networks

allow for more effective communications both with the people close to the schizophrenics and

the public, making it easier for them to make friends and form relationships. Through improving

and increasing social interactions, Social Cognitive Therapy is able to reduce public stigma and

increase social integration.

By improving social interactions, Social Cognitive Therapy reduces social distance,

helping to combat public stigma in psychosis. “Social distance was best statistically predicted by

perceived strangeness, which in turn was best statistically predicted by ratings of overall social

skills” (Baumann, 2007). Improving overall social skills can decrease social isolation, increasing

social integration. Social Cognitive Therapy improves social skills by reducing aggression and

helping patients perceive, interpret and respond to the emotions of others. By improving social

skills, Social Cognitive Therapy can decrease perceived strangeness and decrease social distance.

Decreasing social distance helps to further integrate schizophrenics into society, making it easier

for them to handle social situations and survive in public. Schizophrenics can best learn social

skills by interacting with the public, and with a decreased social distance, they become more

comfortable in social situations. Also, a decreased social distance reduces stigma, as the public

becomes more comfortable/ less fearful of people with psychosis. Improving social skills and

reducing social distance will greatly assist in decreasing the overall stigma around psychosis.

By reducing aggression, improving social skills, and decreasing social distance, Social

Cognitive Therapy can decrease stigma in psychosis. Reducing aggression helps to limit

stereotypes while improving social skills and social distance help to integrate schizophrenics into
society. Utilizing social cognitive approaches allows for public stigma to be reduced, destroying

stereotypes through public integration and reducing perceived danger.

With psychosis being one of the most stigmatized symptoms, the negative stigma

associated with it can have a great negative effect on the lives of schizophrenics, causing feelings

of hopelessness, depression, isolation, and low quality of life. However, social cognitive

treatment techniques can be utilized to reduce these feelings and improve the quality of life for

many schizophrenics. By targeting and improving Theory of Mind, schizophrenics can more

deeply empathize and understand social situations which were likely to be awkward or

stigmatizing. Decreasing internalized stigma allows for an improved sense of self-worth, leading

to increased social contact and mental freedom. Through increasing social contact, public stigma

can be gradually yet greatly reduced. More exposure to people with schizophrenia diminishes

automatic stereotyping. Although psychotic diseases are often associated with the words ‘crazy’

and ‘dangerous’, exposure to psychotic patients who are not violent reduces the sense of

‘strangeness’ (Arioli et al., 2018) and increases social contact between schizophrenics and the

general public. More research is necessary to identify and evaluate the exact effects of social

cognition on stigma in psychosis. Social cognitive and cognitive interventions show great

promise in reducing stigma in psychosis, which can overall increase employment and

educational opportunities, improve social relationships, and reduce feelings of depression and

hopelessness. Utilizing Social Cognitive treatments, both internal and external stigma can be

reduced, improving the quality of life for 1 in 100 people worldwide who experience psychosis.
 Works Cited

Baumann, A. E. (2007). Stigmatization, social distance and exclusion because of mental illness:
The individual with mental illness as a ‘stranger.’ ​International Review of Psychiatry​, ​19​(2),
131–135. https://doi.org/10.1080/09540260701278739
Birchwood, M., Trower, P., Brunet, K., Gilbert, P., Iqbal, Z., & Jackson, C. (2007). Social
anxiety and the shame of psychosis: A study in first episode psychosis. ​Behaviour
Research and Therapy​, ​45​(5), 1025–1037. https://doi.org/10.1016/j.brat.2006.07.011
Corrigan, P. W., Edwards, A. B., Green, A., Diwan, S. L., & Penn, D. L. (2001). Prejudice,
Social Distance, and Familiarity with Mental Illness. ​Schizophrenia Bulletin​, ​27​(2),
219–225. https://doi.org/10.1093/oxfordjournals.schbul.a006868
Corrigan, Patrick W., Kosyluk, K. A., & Rüsch, N. (2013). Reducing Self-Stigma by Coming
Out Proud. ​American Journal of Public Health​, ​103​(5), 794–800.
https://doi.org/10.2105/AJPH.2012.301037
Couture, S. (2020, January 9). The Impact of Social Cognition on the Negative Stigma
Associated with Psychosis.
Couture, S. M., & Penn, D. L. (2003). Interpersonal contact and the stigma of mental
illness: A review of the literature. Journal of Mental Health, 12(3), 291–305.
https://doi.org/10.1080/09638231000118276
DSM-5 » What is Psychosis? (n.d.). Retrieved February 12, 2020, from
https://www.nimh.nih.gov/health/topics/schizophrenia/raise/what-is-psychosis.shtml
Link, B. G., & Phelan, J. C. (2001). Conceptualizing Stigma. ​Annual Review of Sociology​, ​27​(1),
363–385. https://doi.org/10.1146/annurev.soc.27.1.363
Morrison, A. P., Birchwood, M., Pyle, M., Flach, C., Stewart, S. L. K., Byrne, R., … French, P.
(2013). Impact of cognitive therapy on internalised stigma in people with at-risk mental
states. ​British Journal of Psychiatry​, ​203​(2), 140–145.
https://doi.org/10.1192/bjp.bp.112.123703
Morrison, A. P., Burke, E., Murphy, E., Pyle, M., Bowe, S., Varese, F., … Wood, L. J. (2016).
Cognitive therapy for internalised stigma in people experiencing psychosis: A pilot
randomised controlled trial. ​Psychiatry Research,​ ​240,​ 96–102.
https://doi.org/10.1016/j.psychres.2016.04.024
Patten, S. B., Williams, J. V. A., Lavorato, D. H., Bulloch, A. G. M., Charbonneau, M., Gautam,
M., … Stuart, H. (2016). Perceived Stigma among Recipients of Mental Health Care in the
General Canadian Population. ​The Canadian Journal of Psychiatry​, ​61​(8), 480–488.
https://doi.org/10.1177/0706743716639928
Penn, D. L., Kommana, S., Mansfield, M., & Link, B. G. (1999). Dispelling the stigma of
schizophrenia: II. The impact of information on dangerousness. ​Schizophrenia Bulletin,​
25​(3), 437–446. https://doi.org/10.1093/oxfordjournals.schbul.a033391
Reavley, N. J., Jorm, A. F., & Morgan, A. J. (2016). Beliefs about dangerousness of people
with mental health problems: the role of media reports and personal exposure to
threat or harm. ​Social Psychiatry and Psychiatric Epidemiology,​ ​51(​ 9), 1257–1264.
https://doi.org/10.1007/s00127-016-1215-6
Roberts, D. (2019, December 2). Social Cognition and Cognitive Behavioral Therapy in the
Treatment of Psychosis.
Sacca, R., & Ryan, C. (2011). Relationships between Interpersonal Contact as a Volunteer
Companion and Stigma - Rose Sacca, Christopher Ryan, 2011. ​Australian Psychiatry:,​
19​(5). https://doi.org/10.3109/10398562.2011.603325.
Wood, L., Byrne, R., Burke, E., Enache, G., & Morrison, A. P. (2017). The impact of stigma on
emotional distress and recovery from psychosis: The mediatory role of internalised shame
and self-esteem. ​Psychiatry Research,​ ​255,​ 94–100.
https://doi.org/10.1016/j.psychres.2017.05.016
Wood, L., Byrne, R., & Morrison, A. (2017). An Integrative Cognitive Model of Internalized
Stigma in Psychosis | Behavioural and Cognitive Psychotherapy | Cambridge Core, ​45(​ 6),
545–560. https://doi.org/10.1017/S1352465817000224
Wood, L., Byrne, R., Varese, F., & Morrison, A. P. (2016). Psychosocial interventions for
internalised stigma in people with a schizophrenia-spectrum diagnosis: A systematic
narrative synthesis and meta-analysis. ​Schizophrenia Research,​ ​176(​ 2–3), 291–303.
https://doi.org/10.1016/j.schres.2016.05.001
Yang, L. H., Anglin, D. M., Wonpat-Borja, A. J., Opler, M. G., Greenspoon, M., &
Corcoran, C. M. (2013). Public Stigma Associated With Psychosis Risk Syndrome in a
College Population: Implications for Peer Intervention. ​Psychiatric Services,​ ​64(​ 3),
284–288. https://doi.org/10.1176/appi.ps.003782011