Expectations of Mental Illness Disclosure Outcomes in the Work Context: A Cross-Sectional Study Among Dutch Workers.

Purpose The decision whether to disclose mental illness at work can have important positive and negative consequences for sustainable employment and well-being. The aim of the study is (1) to examine workers' expectations of outcomes of mental illness disclosure in the workplace and to evaluate their expectations regarding which factors are of influence on these outcomes, (2) to identify distinct subgroups of workers, and (3) to characterize these subgroups in terms of personal, sociodemographic, and work-related characteristics. Methods In this cross-sectional survey study, a sample of 1224 Dutch workers was used. Latent Class Analysis (LCA) was used to identify classes of workers based on expected workplace mental illness outcomes. A three-step approach LCA was chosen to investigate whether the classes differed in characteristics. Results The majority of workers expected predominantly positive outcomes of workplace mental illness disclosure (e.g., being able to be one's authentic self; 82.4%), even though they simultaneously expected disclosure to lead to advancement-related discrimination (e.g., lower chances of contract renewal; or getting a promotion; 68.4% and 57%, respectively). Six distinct subgroups of workers were identified based on expected workplace mental illness disclosure outcomes: two positive classes (50.1%), two negative classes (33.3%), and two classes who indicated not to know what the outcomes would be (16.7%). Significant differences between the classes were found on personal experience, work-related association with mental illness, gender, educational level, and workplace atmosphere. Conclusion The disclosure process is complex, as most workers were optimistic (i.e., expected generally positive outcomes) whilst simultaneously expecting workplace discrimination. Subgroup differences in expectations regarding workplace mental illness disclosure outcomes were found.

Stigma-related stress, shame and avoidant coping reactions among members of the general population with elevated symptom levels.

BACKGROUND: It is unclear whether mental illness stigma affects individuals with subthreshold syndromes outside clinical settings. We therefore investigated the role of different stigma variables, including stigma-related stress and shame reactions, for avoidant stigma coping among members of the general population with elevated symptom levels. METHODS: Based on a representative population survey, general stress resilience, stigma variables, shame about having a mental illness as well as avoidant stigma coping (secrecy and social withdrawal) were assessed by self-report among 676 participants with elevated symptom levels. Stigma variables and resilience were examined as predictors of avoidant stigma coping in a path model. RESULTS: Increased stigma stress was predicted by lower general stress resilience as well as by higher levels of perceived stigma, group identification and perceived legitimacy of discrimination. More shame was associated with higher perceived legitimacy. Lower resilience as well as more perceived stigma, group identification and perceived legitimacy predicted avoidant coping. Stigma stress partly mediated effects of resilience, perceived stigma and group identification on avoidant coping; shame partly mediated effects of perceived legitimacy on coping. Stigma stress and shame were also directly and positively related to avoidant stigma coping. Analyses were adjusted for symptoms, neuroticism and sociodemographic variables. CONCLUSIONS: Stigma may affect a larger proportion of the population than previously thought because stigma variables predicted secrecy and withdrawal among members of the general population with elevated, but overall mild symptom levels. Avoidant stigma coping likely has harmful effects, potentially exacerbating pre-existing psychological distress and undermining social networks. This highlights the need to reduce public stigma as well as to support individuals with subthreshold syndromes in their coping with stigma stress and shame reactions.

Evolution of public attitudes about mental illness: a systematic review and meta-analysis.

OBJECTIVE: To explore whether the increase in knowledge about the biological correlates of mental disorders over the last decades has translated into improved public understanding of mental illness, increased readiness to seek mental health care and more tolerant attitudes towards mentally ill persons. METHOD: A systematic review of all studies on mental illness-related beliefs and attitudes in the general population published before 31 March 2011, examining the time trends of attitudes with a follow-up interval of at least 2 years and using national representative population samples. A subsample of methodologically homogeneous studies was further included in a meta-regression analysis of time trends. RESULTS: Thirty-three reports on 16 studies on national time trends met our inclusion criteria, six of which were eligible for a meta-regression analysis. Two major trends emerged: there was a coherent trend to greater mental health literacy, in particular towards a biological model of mental illness, and greater acceptance of professional help for mental health problems. In contrast, however, no changes or even changes to the worse were observed regarding the attitudes towards people with mental illness. CONCLUSION: Increasing public understanding of the biological correlates of mental illness seems not to result in better social acceptance of persons with mental illness.

Ingroup perception and responses to stigma among persons with mental illness.

OBJECTIVE: Mental illness stigma is common, but it is unclear why it affects some individuals more than others. We tested the hypothesis that the way persons with mental illness perceive their ingroup (people with mental illness) in terms of group value, group identification and entitativity (perception of the ingroup as a coherent unit) shapes their reaction to stigma. METHOD: Ingroup perceptions, perceived legitimacy of discrimination and reactions to stigma (educating or helping others, social performance, secrecy, social distance, hopelessness) were assessed among 85 people with mental illness using questionnaires and a standardized role-play test. RESULTS: Controlling for depression and perceived discrimination, high group value and low perceived legitimacy of discrimination predicted positive reactions to stigma. High group identification and entitativity predicted positive reactions only in the context of high group value or low perceived legitimacy of discrimination. CONCLUSION: Group value and perceived legitimacy of discrimination may be useful targets to help people with mental illness to better cope with stigma.

Stigma, grief and depressive symptoms in help-seeking people bereaved through suicide.

BACKGROUND: The painful experience of mourning after suicide can be further complicated by the stigma surrounding suicide survival. We investigated how grief and depression influence the perception of stigma towards survivors in a sample of help-seeking persons bereaved through suicide. METHODS: Cross-sectional design. Information on sociodemographic variables and responses to the Stigma of Suicide Survivor Scale, Beck Depression Inventory (BDI) and Inventory of Complicated Grief (ICG) was collected from 240 people bereaved through suicide who consecutively accessed an online support initiative. RESULTS: Despite the strong correlation between ICG and BDI scores, the intensity of depressive but not of grief symptoms was related to perceived stigma towards survivors. Time since loss was also positively related to levels of perceived stigma against survivors. The links between depression and perceived stigma persisted after taking into account relationship with the deceased and other sociodemographic factors. LIMITATIONS: The main study limitations are the cross-sectional design, reliance on self-report measures, and the self-selection of the sample of people bereaved through suicide, seeking help through a website. Social support was not measured and the sample included a large proportion of women. CONCLUSIONS: Specific interventions designed for persons bereaved by suicide should consider that psychological distress and mourning are qualitatively different reactions to a suicide loss. The relationship among perceived stigma, depressive suffering and time elapsed since the suicide loss suggests the usefulness of closely investigating the experience of stigma in all people bereaved through suicide with depressive symptoms, even long after the event.

Schizophrenic patients' sensitivity to social cues: the role of abstraction.

OBJECTIVE: Since individuals with schizophrenia often have difficulty with abstract tasks, they should have more problems recognizing abstract social cues (e.g., inferences regarding actors' affect and goals) than concrete cues (e.g., observations of actors' behavior and dialogue). Moreover, recognition of abstract and concrete cues should interact with the level of emotional arousal engendered by the situation; previous research has shown that schizophrenic patients perform better on cue recognition tasks when the situation produces moderate rather than low levels of arousal. METHOD: These hypotheses were tested in 24 patients with schizophrenia diagnosed according to the DSM-III-R criteria and 15 normal comparison subjects. All subjects viewed eight short vignettes of interpersonal situations that produce low and moderate levels of arousal. They then answered questions representing perception of abstract and concrete cues that had been matched for difficulty and consistency. RESULTS: The schizophrenic patients were significantly less sensitive to interpersonal cues than the normal subjects. The patients were also less sensitive to abstract than to concrete social cues, and for them there was a significant interaction between cue abstraction level and situational arousal. Specifically, the schizophrenic subjects performed worse on the abstract cue recognition task for the low-arousal situations. CONCLUSIONS: Findings regarding the social cue recognition patterns of schizophrenic patients could play an important role in the development of valid measures of social cognition for this population.

Social cognition in schizophrenia.

The study of social cognition in schizophrenia may augment the understanding of clinical and behavioral manifestations of the disorder. In this article, the authors describe social cognition and differentiate it from nonsocial cognition. They garner evidence to support the role of social cognition in schizophrenia: Nonsocial information-processing models are limited to explain social dysfunction in schizophrenia, measures of social cognition may contribute greater variance to social functioning than measures of nonsocial cognition, task performance on nonsocial-cognitive measures may not parallel performance on social-cognitive tasks, and symptomatology may be best understood within a social-cognitive framework. They describe the potential implications of a social-cognitive model of schizophrenia for the etiology and development of the disorder.

Rehabilitation research methods for schizophrenia.

Given the ever increasing complexity of rehabilitative models of schizophrenia, research methods testing these models must be rigorous and include a wide range of investigative strategies. This paper reviews four elements of rehabilitation research: definition of independent variables, selection of dependent variables, setting up the research design, and the development of conservative inferences from the data analysis. Methodological decisions must be made carefully prior to implementing a research protocol to assure the most valid conclusions when the study is complete.

Social cue perception and intelligence in schizophrenia.

Previous research has shown that both acutely ill and remitted schizophrenic patients are more sensitive to the concrete, than the abstract, cues of a social situation. The purpose of this study is to determine whether this difference is attributable to a generalized performance deficit by determining whether difference in concrete and abstract cue recognition correlates with verbal intelligence. A second goal of this study is to determine whether differences in the cue perception of schizophrenic and normal control samples is also attributable to differences in verbal intelligence. Samples of inpatients (n = 23) and outpatients (n = 20) with DSM-III-R diagnosis of schizophrenia or schizoaffective disorder completed the Social Cue Recognition Test, the Vocabulary Subtest of the WAIS-R, and the Brief Psychiatric Rating Scale. Standardized residual scores representing differences in sensitivity across abstract and concrete cue recognition were not found to correlate significantly with verbal IQ in either sample. However, overall sensitivity was significantly associated with intelligence in both samples and standardized residual scores were significantly associated with thinking disturbance in the inpatients. Differences in cue perception across schizophrenic and normal control samples remained significant after adjusting cue perception scores by scores on the Vocabulary Subtest. These findings suggest that the differential deficit in cue recognition may not be attributable to generalized performance deficit.

The effects of cognitive complexity on a social sequencing task in schizophrenia.

Information processing research has suggested that the schizophrenia patient's performance on cognitive tasks is significantly diminished by the complexity of that task. The effects of cognitive complexity on a social cognitive task-sequencing actions that describe a social situation-were examined in this study. A task comprising short and long temporal sequences was administered to 26 subjects with DSM III-R diagnosis of schizophrenia. Differences in discriminating power across the short and long sequences in this task were diminished using standardization and cross-validation samples of normal control subjects. Results showed that schizophrenia patients earned significantly lower scores on the longer sequences. Additional analyses showed that the differential deficit was significantly associated with negative symptoms of social withdrawal and retardation but not with thinking disturbances associated with positive symptoms. Understanding deficits in processing situational schemata may lead to better models of the cognitive underpinnings of social functioning in schizophrenia.

Memory and vigilance training to improve social perception in schizophrenia.

Previous research has suggested that social cue recognition in schizophrenia may be significantly associated with visual vigilance and verbal memory. Therefore, we predicted that subjects who participated in a cognitive rehabilitation program that incorporated vigilance and memory training strategies would show significantly better social cue recognition than subjects participating in vigilance training alone. Forty subjects with a DSM-III-R diagnosis of schizophrenia or schizoaffective disorder were randomly assigned to either a vigilance-alone or a vigilance-plus-memory training condition. Results showed that subjects in the vigilance-plus-memory condition were able to identify social cues in the videotaped training materials significantly better than subjects in the vigilance-alone condition. This difference was evident in an independent measure of social cue recognition and was present at a 48 h follow-up. Implications for future development of cognitive rehabilitation for schizophrenia were discussed.

Deficits in social schemata in schizophrenia.

Several recent studies have examined the manner in which social information is processed in an attempt to better understand the interpersonal functioning deficits of schizophrenia. In this study, the manner in which schizophrenic subjects represent social information, and the relationships between these social representations and measures of information processing, are examined. Specifically, 30 DSM-IIIR patients with schizophrenia and 15 normal controls were assessed on measures of social schema processing, information processing, and symptomatology. Results showed that schizophrenic patients earned significantly lower schema processing scores than the normal comparison group. Schema deficits of the schizophrenic group were significantly associated with recall memory and vigilance. These findings suggest that deficits in the representation of social information provides a unique perspective for understanding the interpersonal dysfunctions of schizophrenia.

Interpersonal factors contributing to the stigma of schizophrenia: social skills, perceived attractiveness, and symptoms.

This study investigated the interpersonal factors (i.e., social skills, symptoms, perceived physical attractiveness) which are related to the stigma of schizophrenia. Social skills performance was assessed for 39 individuals with schizophrenia who participated in two role-plays with a confederate. Social skills ratings comprised 'overall social skill', 'meshing', 'clarity', and 'fluency' of speech, 'gaze', 'pleasantness' of conversation, 'involvement' in conversation, 'number of questions asked' during conversation, and 'perceived strangeness'. Symptomatology was assessed with the Brief Psychiatric Rating Scale. Ratings of perceived physical attractiveness were obtained by pausing the videotaped role-plays after the first 2s of the interaction. Ratings of 'social distance', based on an independent sample who observed the role-plays, were used as a proxy measure of stigma. The results showed that social distance was best statistically predicted by perceived strangeness, which in turn, was best statistically predicted by ratings of overall social skill. Negative symptoms appeared to have a more robust association with desired social distance than positive symptoms. Interpersonal factors, such as overall social skill, negative symptoms, and perceived strangeness, may contribute to stigma.

The construct validity of empowerment among consumers of mental health services.

Subscales of the Empowerment Scale (Rogers, E. S., Chamberlin, J., Ellison, M. L., Crean, T., 1997. A consumer-constructed scale to measure empowerment among users of mental health services. Psychiatr. Serv. 48, 1042-1047) were examined to see whether they fit a model of consumer empowerment that distinguishes self- and community orientations. In addition, the relationship of these two superordinate factors to several psychosocial factors was examined. Thirty-five participants in a partial hospitalization program were administered the Empowerment Scale and measures of quality of life, social support, self-esteem, psychiatric symptoms, needs and resources, global functioning, and verbal intelligence. Analysis of the subscales of the Empowerment Scale yielded two factors consistent with self- and community orientations to empowerment. Correlational analyses revealed that the two superordinate factors were associated with different sets of psychosocial variables. A self-orientation to empowerment was significantly associated with quality of life, social support, self-esteem, and psychiatric symptoms. Community orientation was correlated with self-esteem, resources, verbal intelligence, and ethnicity. The implications of these findings for a model of consumer empowerment are discussed.

Are there patients with late-onset schizophrenia in state hospitals?

Diagnoses of all individuals admitted between 1989 and 1991 to a State of Illinois Hospital were examined to determine the prevalence of patients meeting DSM-III-R criteria for late-onset schizophrenia. Four prevalence rates were determined for each year based on the frequency of late-onset patients in (1) total psychiatric admissions, (2) total admissions over age 45, (3) admissions with diagnoses of schizophrenia, and (4) admissions over age 45 and diagnosed schizophrenia. Results showed that the mean (across the three years) of the four prevalence rates of late-onset schizophrenia ranged from 0.24% to 4.1%. This range is far below prevalence rates on hospitalized patients previously reported in the literature (6 to 34%). Reasons for discrepancy are discussed.

Interpersonal problem solving and information processing in schizophrenia.

Cognitive models of interpersonal problem solving have been proposed for, but infrequently tested on, samples of schizophrenia subjects. This study undertook to examine the relationships between the receiving, processing, and sending skills that comprise one model of interpersonal problem solving with information processing and social cue perception. Twenty-six patients with a DSM-III-R diagnosis of schizophrenia or schizoaffective disorder completed measures of interpersonal problem solving, social cue perception, visual vigilance, verbal memory, conceptual flexibility, and psychiatric symptoms. Significant and robust relationships were found between sensitivity to social cues and receiving, processing, and sending skills. Only recognition and recall memory, of the various other information-processing measures, were found to be related to any of the three problem-solving skills. Associations between problem solving and cognitive deficits did not seem to be attributable to psychiatric symptoms. Implications of these findings for understanding and remediating the problem-solving deficits of schizophrenia patients are discussed.

Changing attitudes about schizophrenia.

Research on the effectiveness of short-term education programs in changing societal attitudes about mental illness has been mixed. Education efforts seem to be mediated by characteristics of the program participants. This study determines whether the effects of a specially prepared, semester-long course on severe mental illness are mediated by pre-education knowledge about and contact with severe mental illness. Eighty-three participants who were enrolled in either a course on severe mental illness or general psychology completed the Opinions about Mental Illness Questionnaire before beginning the course and at completion. Research participants also completed a pre-and posttest of knowledge about mental illness and a pretest on their contact with people who have severe mental illness. The education program had positive effects on some attitudes about mental illness. Interestingly, the effects of education group interacted with pre-education knowledge and contact and varied depending on attitude. Participants with more pre-education knowledge and contact were less likely to endorse benevolence attitudes after completing the education program. Participants with more intimate contact showed less improvement in attitudes about social restrictiveness. Implications of these augmentation and ceiling effects are discussed.

Situational familiarity and feature recognition in schizophrenia.

Research has shown that schizophrenia patients are less able to identify a situation's abstract features (goals) than its concrete features (actions). However, it has been unclear whether this differential deficit represents a cognitive dysfunction or a lack of familiarity with many situations because of impoverished social experiences. Twenty-nine inpatients with DSM-III-R diagnosis of schizophrenia completed the Situational Feature Recognition Test, Version 2 (SFRT-2). The SFRT-2 included familiar and unfamiliar situations of which subjects were asked to identify characteristic goals and actions. A 2 x 2 x 2 analysis of variance (group by feature abstraction by situational familiarity) found a significant three-way interaction. Post-hoc analyses suggested that patients were better able to recognize concrete features in familiar situations. Differences in discriminating power of the four conditions of the SFRT-2 had been diminished on standardization and cross-validation groups. Therefore, the differential deficits shown by the patient sample probably do not represent psychometric confound. Implications for remediation of social cognitive deficits are discussed.

Prejudice, social distance, and familiarity with mental illness.

In this study, the paths between two prejudicial attitudes (authoritarianism and benevolence) and a proxy measure of behavioral discrimination (social distance) were examined in a sample drawn from the general public. Moreover, the effects of two person variables (familiarity with mental illness and ethnicity) on prejudice were examined in the path analysis. One hundred fifty-one research participants completed measures of prejudice toward, social distance from, and familiarity with mental illness. Goodness-of-fit indexes from path analyses supported our hypotheses. Social distance is influenced by both kinds of prejudice: authoritarianism (the belief that persons with mental illness cannot care for themselves, so a paternalistic health system must do so) and benevolence (the belief that persons with mental illness are innocent and childlike). These forms of prejudice, in turn, are influenced by the believers' familiarity with mental illness and their ethnicity. We also discuss how these findings might contribute to a fuller understanding of mental illness stigma.

Three strategies for changing attributions about severe mental illness.

The effects of three strategies for changing stigmatizing attitudes--education (which replaces myths about mental illness with accurate conceptions), contact (which challenges public attitudes about mental illness through direct interactions with persons who have these disorders), and protest (which seeks to suppress stigmatizing attitudes about mental illness)--were examined on attributions about schizophrenia and other severe mental illnesses. One hundred and fifty-two students at a community college were randomly assigned to one of the three strategies or a control condition. They completed a questionnaire about attributions toward six groups--depression, psychosis, cocaine addiction, mental retardation, cancer, and AIDS--prior to and after completing the assigned condition. As expected, results showed that education had no effect on attributions about physical disabilities but led to improved attributions in all four psychiatric groups. Contact produced positive changes that exceeded education effects in attributions about targeted psychiatric disabilities: depression and psychosis. Protest yielded no significant changes in attributions about any group. This study also examined the effects of these strategies on processing information about mental illness.