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Public Conceptions of Mental Illness in 1950 and 1996: What Is Mental Illness and Is It to be Feared? Author(s): Jo C.

Phelan, Bruce G. Link, Ann Stueve and Bernice A. Pescosolido Source: Journal of Health and Social Behavior, Vol. 41, No. 2 (Jun., 2000), pp. 188-207 Published by: American Sociological Association Stable URL: http://www.jstor.org/stable/2676305 . Accessed: 25/02/2014 15:13
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Public Conceptions ofMental Illnessin 1950 and 1996: What is MentalIllnessand Is It to be Feared?*
JOC. PHELAN
Columbia University

BRUCE G. LINK
ColumbiaUniversity and NewYork StatePsychiatric Institute

ANN STUEVE
Columbia University

BERNICE A. PESCOSOLIDO
Indiana University Journal ofHealthand Social Behavior Vol 41 (June)188-207

In the 1950s, thepublic definedmentalillness in muchnarrower and more termsthandid psychiatry, extreme and fearfuland rejecting attitudes toward people with mental illnesses were common.Several indicatorssuggest that definitions of mentalillnessmayhave broadenedand thatrejection and negativestereotypes mayhave decreasedsince thattime. lack ofcomparaHowever, ble data overtime usfrom prevents drawing firmconclusions on thesequestions. To addressthis theMentalHealthModule of the1996 GeneralSocial problem, the meaningof mentalillness thatwas Surveyrepeateda questionregarding firstasked ofa nationally representative sample in 1950.A comparison of 1950 and 1996 results showsthatconceptions illnesshave broadened someofmental whatoverthistime disperiod to includea greater proportion ofnon-psychotic thatmentally ill people are violentor frightening orders,but that perceptions substantially increased,ratherthan decreased. This increase was limitedto who viewed mental illness in termsof psychosis.Among such respondents the whodescribed illpersonas beingviolent respondents, proportion a mentally increasedby nearly2 1/2timesbetween1950 and 1996. Wediscuss thepossithatthere has been a real movetoward bility acceptanceofmany formsofmental illnessas something thatcan happento one of "us,"butthat people with psy" whoare more chosisremain a "them werehalfa century fearedthanthey ago. In the 1950s, social scientists began to address questions concerning howthelaypubmentalillness and how they lic understood reacted to peoplewho suffered from suchilllearned was notheartening. nesses.Whatthey that, notonlywas thepubEarlystudies found uninillnesslargely lic's orientation to mental thinking of psychiatric formed by thecurrent

*We wish to acknowledge the contribution of Dr. MentalHealthModule of the 1996 GeneralSocial Shirley Star, whosethoughtful, painstaking andorig- Survey was funded Foundation. by the MacArthur inal analysis of publicconceptions of mental illness Partial bya Senior support for Dr.Linkwas provided the NationalAlliancefor inspired thepresent paper. We thank Patrick Bova of Investigator Awardfrom theNational Opinion and Major Depression. Research Center, whofacilitat-Research on Schizophrenia Division of to:JoC. Phelan, correspondence ed ouraccessto Star's original data, coding materials, Address L. MailmanSchool and unpublished and we thankthe Sociomedical Sciences,Joseph manuscripts, reviewers of twoversions of thismanu- ofPublicHealth, Columbia University, 600 W 168th anonymous NY 10032. who providedmany helpfulinsights. The Street, NewYork, script,

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theday,butpublicconceptions weresuffused psychiatrist theyoughtto be put in a nut withnegative stereotypes, fear, and rejection. house"(Star1957:3). Thesefindings werediscouraging to mental Regarding publicconceptualizations ofmental professionals and researchers forseverillness, Star(1952, 1955),based on interviews health Theyimplied that publiceducation with over 3,000 Americans, concludedthat al reasons. regarding mental illnesshad produced therewas a strong for people to efforts tendency effect. Theyimplied that persons identiequate mentalillnesswithpsychosisand to little ill fied as mentally might suffer extreme rejeckindsof emotional, or view other behavioral, Andthey implied that personality problemsin non-mental health tionand stigmatization. peoplewouldfailto seek mental health terms as, "an emotional or character differ- many that might benefit them. ence ofa non-problematic sort"(Star1952:7). treatment As we enter the new millennium, however, it was because According to some authors, there are reasons to believe that orientations mental illness was defined in suchnarrow and mental illness mayhavechanged-perthat thepublicfeared, extreme terms rejected, toward and devalued people with mentalillnesses haps dramaticallysince these earlystudies The clearestchangeis that (Star 1952; Crocetti, Spiro,and Siassi 1974; were conducted. many more people now seek mentalhealth ofthesourceof these Gove 1982). Regardless in terms treatment. Whether measured ofpoptheir was welldocnegative attitudes, presence of ulation surveys self-reported help-seeking umented. found Nunnally (1961), for example, KulkaandDouvan 1981; Regier et al. that to applya broad (Veroff, peopleweremorelikely of rangeof negative adjectives suchas "danger- 1993; Kesslerand Zhao 1999) or in terms of service facility-based records utilization ous," "dirty,""cold," "worthless,""bad," and Henderson 1998),thedata and "ignorant" to a personlabeledas (Manderscheid "weak," of of profesthat the rate utilization suggest "insane"or "neurotic" thanto an "average" has at leastdousionalmental health services person(p. 46). Similarly, Star (1952, 1955) between the1950sand bled,andmaybe tripled, inusingtheir found that many Americans, own that the today. These trends indirectly suggest wordsto describe their of the understanding about public has come to thinkdifferently term "mental illness," included characteristics mental illness that they nowdefine a broader such as dangerousness and unpredictability. in mental health terms and of problems array andCumming two Cumming (1957), studying that there is less stigma attached to these probthat most lemsandtheir communities in Saskatchewan, found treatment. It is difficult to imagpeoplepreferred to avoid close personal con- inesuchdramatic inutilization inthe increases ill absenceof suchchanges. tactwithsomeonewho had been mentally and thatthe researchers' efforts to change There is also more direct evidence for thoseattitudes weremetwith andhos- changes in public beliefs and attitudes. anxiety Not surprisingly, tility. Yarrow, Clausen,and Regarding of mentalillness, lay definitions that was a severalstudies Robbins fear ofstigma (1955) found the"Starvignettes" employing serious concern for wives of psychiatric (Star1955) in which a respondent is presented patients. witha description ofa person criteria meeting The public's negativeorientations toward for a particular and is disorder psychiatric to theprofession- asked how likelyit is thatthe personhas a mental illnessalso extended that "mental als whotreated it.Nunnally (1961) found haveshown a fairly cleartrend illness" the public evaluated who treat toward professionals increased identification ofthevignettes mental disorders morenegatively as instances significantly and of mental illness(Cumming thanthosewho treat Star Cumming1957; Dohrenwend, physicaldisorders. and Bernard, thattheidea of consulting (1957) found psy- Kolb 1962; Crocetti andLemkau1963; Meyer chiatrists enjoyedlittlepublic endorsement, 1964; Dohrenwend and Chin-Shong1967; whohadcon- Bentz, Edgerton, and Kherlopian 1969; with few peopleknowing anyone a psychiatrist orwhothey sulted thought might Brockman andD'arcy 1978; Linket al. 1999). As one respondent Veroff be helped bya psychiatrist. an increase between et al. (1981) found I'd haveto go to 1957 and 1976 not onlyin reports bluntly putit: "I don'tthink of actual holdmyhand help-seeking to tellme I was crazy, anybody but also in hypothetical "readiandtalktome for dollars an hour... If ness for self-referral," twenty suggesting that utilization at least in part, didn't haveanymoresensethan to go to a increased reflects, they

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1961; Link et al. 1999; to view emotional or Lemkauand Crocetti tendency botha greater as something that a men- MacLean 1969; Meyer 1964; Olmstedand behavioral problems might be able to help Durham 1976; Phillips 1964; Purdue tal health professional and Lafare 1965; 1959; Rootman willingness to seek such University withand a greater also found andinterpret-Star1952,1955). help.Theseauthors The Mental Health Module of the 1996 ed as evidence for reduced stigma an the betweenrespondents' GeneralSocial Survey(GSS) presented increasing congruence to addressthislimitation by colfor opportunity endorsement of mentalhealthtreatment of mental illness data on conceptions crisis lecting someoneelse facingan unmanageable to those comparable to seek suchhelpthem- thatwould be directly and their willingness health gatheredin earlier research.By repeating disclosures of mental selves.Voluntary problems by public figures(e.g., journalist questionsfroman earlierstudythatused a it and sampling frame, in similarmethodology WilliamStyron) Mike Wallaceand author comparisons fear of wouldbe possibleto makedirect a diminishing recent years also suggest andattitudes overtime. Star's (1952, have con- ofbeliefs some researchers stigma.Finally, in 1955) open-endedquestion asking responreviewsof studiesconducted cludedfrom illness the 1950sand 1960s that bothsocial distance dentsto definetheconceptof mental for thispurandnegative stereotypes regarding peoplewith was chosenas theone bestsuited use face-to-face didStar's study mental illnessesabatedoverthattimeperiod pose.Notonly representative with a nationally etal. 1974).Gove(1982) interviews (Gove 1982;Crocetti liketheGSS, butitwas also conductsample, forexample: states, theevidence indicate ed by the same organization: of the1950swould the National menthat wasignorant about ... the public Center (NORC). A random Opinion Research tal illness,had a verynegative image of interview schedules is sampleofStar's original persons identifiedas mentallyill, and archivedat NORC, allowingthe 1950 and them. Sincethen there has beena excluded 1996 responses to be coded in a consistent effort focused on mental massive education manner.Diagnostic categoriesand criteria thegenerally transitoillness:furthermore, since the 1950s ofmental illness andeffectiveness have changedsignificantly rynature Association 1952; (American Psychiatric hasbecomefairly visible[with oftreatment of compa1994). This wouldcause problems inthevastmajority theresult ofcases that] of mental illrability overtimeifconceptions thestigma bymental patients] [experienced a set of ness were assessed by presenting tobe transitory anddoesnotappear appears to pose a severe problem. (P 290). or behaviorsthat match current symptoms are indications thatsubstantial diagnosticgroupingsand elicitingresponThus,there illness dents'reactions, inpublicorientations tomental changes as is thecase withthemore place sincethe1950s.Butthe widely used "Star vignettes." mayhavetaken Because our is notfirm. in ser- open-endedquestion elicits definitions evidence Whiletheincrease of to mental vice utilization is unquestionable, theextent therespondent than illnessfrom rather which changesin conceptions and attitudes presenting tohimorher, inpsythem changes account for thisincrease is notclear.The con- chiatric nomenclature werenotproblematic.1 moredirect from clusionsthatcan be drawn Stigma has typicallybeen measured in are termsof social distance(Owen, Eisnerand evidence andattitudes on beliefs empirical con- McFaul 1981) or of negativeimages and limited of thestudies by incomparability timepoints. These studies stereotypes(Star 1952; Nunnally 1961; ducted at different in thepopulations havesam- Olmstedand Durham 1976). Our question havevaried they forthe issue of stig- asksaboutrespondents' ofmental pled and-particularly conceptions ma-in thequestions haveaskedofstudy illnessand is notwell suitedto assess social they subjects (Belson 1957; Bentz et al. 1969; distance. However, negative images and and Miller 1969; Blizzard stereotypes are an integral Bentz, Edgerton, partof individuals' and D'arcy 1978; Crocetti definitions ofmental andwe use these 1970; Brockman illness, of stigma. and Lemkau 1963; Crocetti et al. 1974; negativeimages as an indicator we look at mentions of violence and Cumming 1957; Dohrenwend Specifically, Cumming characteris1966; Dohrenwend and Chin-Shong1967; and other potentially frightening and unpredictability. and Bentz tics such as instability Dohrenwend et al. 1962; Edgerton is notmeasured 1969; Elinson, Padilla, and Perkins 1967; Whilesocialdistance directly,

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ofdangerousness perceptions havebeenshown METHODS to be an important factor underlying thedesire for socialdistance from ill- Sampleand Procedure peoplewith mental ness (Linketal. 1987;Linketal. 1999). In thispaper,we assess whether Starused a modified apparent TheStarsurvey. areasampleof U.S. residents. We have changesin publicorientations toward mental probability documentation of the illness are reflected in people's self-stated located littlewritten ofmental method. However, JacobFeldman, a descriptions illness.Specifically, we sampling assess whether definitions have broadened at NORC at the time, to samplingstatistician includea greater proportion of less serious recalls thatthe sample entailedmulti-stage selection downthrough theblocklevel (i.e., non-psychotic) disorders2 and whether random there has been a lessening of fearful of respondents within the imagery and quotasampling interselected blocks.3 Face-to-face surrounding mental illness. We also assess the randomly 1 1/2 association between thesetwovariables, test- viewsof approximately hours wereconingthenotion (Star1952;Crocetti with3,529 adults(age 21 or older)by et al. 1974; ducted Gove 1982) that fear andnegative are NORC in May and June of 1950. Most of the attitudes tied to psychosisand thatattitudes toward originalinterview scheduleswere eventually ill peopleimprove mentally whenpublicdefi- discarded, buta randomly selected one-tenth of at NORC, resulting in a nitions of mental illnessbroaden to includea them remain archived morediverse setofproblems. thecurrent By this thinking, sampleof352 for study. Excluding if definitionsbroaden over time, fearful non-responsesand non-codable responses shouldalso decline.If thisprovesto resulted ina sampleof337 for imagery analysis ofsynbe thecase, a further can be asked: drome/problem question anda sampleof335 categories Are positivechangesin attitudes limitedto foranalysisof symptoms/manifestations (see withnon-psychotic or does below). persons disorders, tolerance greater fora broader overall concept The GSS. The 1996 GeneralSocial Survey, of mental illnessfeedback to soften negative conducted byNORC (Davis and Smith1996), attitudes toward as well? used a full probability peoplewith psychosis sample of EnglishThatis, does theinclusion of less seriousdis- speaking livpersons18 yearsof age or over4 orders thewholegestalt ill- ing in non-institutional of"mental change within arrangements ness,"rendering it moreacceptableand less theUnitedStates. The response ratewas 76.1 ordoes this create frightening, broadening two percent.Interviews 1 1/2 of approximately that elicitdistinct reactions? subgroups hours were conductedface-to-face between ifthere has been movement toward MarchandMayof 1996.The question Finally, we anamore broadlyinclusiveand less stereotyped lyzewas askedofa random of710 sub-sample of mentalillness,one possible respondents. conceptions and Excluding non-responses is thesociodemographic transfor-non-codable explanation in a sampleof results responses mation oftheU.S. population overthelasthalf 653 foranalysisof syndromes/problem cateofthetwentieth Socioeconomic century. status, goriesand a sample of 622 foranalysisof urbanresidence, and race/ethnicity have all symptoms/ manifestations (see below).5 been shown to be associated withconceptions ofmental attitudes toward illness, peoplewith mental illness and general tolerance Dependent Variables and Carter1986; Phelanet al. (Abrahamson from measuresare derived 1995; Kiecolt 1988; Cumming and Cumming The dependent to thefollowing and Chin-Shong1967; answers 1957; Dohrenwend open-ended question, Freeman1961; Parra1985; Star 1952, 1955; askedin 1950and 1996: "Of course, everyone illnessand Westbrook, Lege, and Pennay1993), and the hearsa good deal aboutphysical distribution of each of these variableshas disease,butnow,whatabouttheones we call since 1950. We therefore mental or nervous illness . . . When you hear changedmarkedly test thehypothesis that in conceptions someonesay thata personis 'mentally-ill,' changes of and attitudes toward mentalillnessare in whatdoes that meanto you?"If respondents' mediated socioeconomic sta- answers wereunclearor incomplete, the folpart byincreased tus particularly education andbyincreased lowingprompts were used: (1) "How would a person whois mentally-ill?" urbanicity. youdescribe (2)

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"Whatdo you think a mentally-ill and acutenervestorms or tensions. personis neurosis, like?"(3) "What doesa person likethis do that This category was codedifa respondent mentellsyouhe is mentally-ill?" (4) "How does a tionedanxiety or depressive symptoms (e.g., personlike thisact?" Because we were con- "appear worriedor anxious all the time," that affect notonly "depressed"), extreme or labileemotions (e.g., cerned socialchange might social ups and downs," "angry"), public responsesbut the coding process as "emotional comfrom the Star withdrawal (e.g., "stayto themselves"), well, all open-ended questions inability to function or take andGSS surveys werecodedbythesameindi- pulsivebehavior, code- care of oneself(e.g., "can't cope withreality viduals thesameprocedures. Star's using malaiseorcollapse, or physical book is archived at NORC, and we used her andfunction"), to code ifrespondents referred to an "emotional probcoding categoriesand definitions responsesto both surveys.To address our lem." illquestions regarding conceptions Social deviancewas coded when responof mental references to abnornessandstigma, twovariables werecoded:(1) dentsmade non-specific behavior(e.g., "not normal ofmen- mal or strange andmanifestations specific symptoms in withsociety," and (2) behavior," talillness as described byrespondents, "difficulty fitting into "strange"). Also includedare more specific broader or problem syndromes categories in thesymptoms ofdeviant which andmanifestations canbe mentions behavior (e.g.,"urinates grouped. public"), mentions of abnormalappearance These are specif- (e.g., "look derelict-clothes in rags"), subSymptoms/manifestations. ic forms ofbehavior or experience therespon- stance problems, sexualdeviations, and crimident as beingindicative ill- nal or delinquent mentions ofmental behavior. ness. In all, there are 97 symptom/manifesta-Mental deficiency/cognitive impairment tions codes.Up to three symptoms werecoded refers with toproblems thinking andreasoning for In thepresent eachrespondent. we (e.g., "slow in thinking," "cannot reason," analysis, on thefollowing report "can'thandlemoney"), as well as cognitively symptoms/manifestations: extreme/excessive, withcopingand functioning unstable, unpre- based difficulties and violent. (e.g.,"couldnotmakegooddecisions for himdictable, uncontrolled, irrational, Violence includedmentions of violent sex self," "one who is notable to do forhimself," homicidal or impulses, crimes, tendencies sui- "does not have the capacity to function norcidal tendencies, violence againstproperty,mally in everyday life"). ofviolence. andunspecified forms Othernon-psychotic problemsincludesa and syndromes that Syndromes/problem categories.These are wide rangeof problems moregeneral ofsyndromes ortypes included categories no references to psychosis butwere of problems thatrespondents associatewith not clear enough to classifyfurther (e.g., mental illness. If a respondentdescribed "unbalanced in his thinking-one decisionfor behavior withmorethanone cate- himis aboutas important as another," consistent "chemiwerecoded. The cal imbalance,""borderline gory, up to three categories nervousbreakand codingcriteria areas follows. down," "lifeis getting "reaccategories awayfrom them," was coded whentherespondent tions "mental orbrain disorPsychosis disproportionate," mentioned symptoms indicating breakswith der," "psychological problem"). inreality," Two of these categories(psychosisand notcompletely reality (e.g.,"person "livesinhisownworld," "imaginary friends"). mood/anxiety problems) correspondquite Mentions of bizarre behavior (e.g., "wanders closelyto broadpsychiatric diagnostic groupofffordays,comes back partially dressed") ings, as defined by the Diagnostic and characteristic ofpsychosis anduse ofcolloqui- Statistical Manual of Mental Disorders al terms suchas "nuts," or (American Psychiatric Association 1994).The "deranged," "crazy," "out of his mind"were also coded as psy- other three less directly categories correspond chosis.In addition, was subtyped as withDSM-definedmentaldisorders. Mental psychosis iftherespondent violent also mentioned includes both oneor deficiency/cognitive impairment more of the violentbehaviors or tendencies clear-cut indications ofmental retardation and indicated underviolentsymptoms/manifestaothermanifestations (e.g., difficulty making tions. mental retardecisions)that maynotindicate Anxiety/mood problems combines Star's dation.Social deviance includesmanifestacodes of neurasthenic other tions of antisocialpersonality disorder original and neurosis,

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substance-related but is a broader bothsurveys, disorders we usedthemidpoints ofthecatcategorythat also includes descriptions of egories. The lowest and highestcategories "abnormal" or "strange" thatdo not werecoded,respectively, behavior $3,750 and $13,330 to anypsychiatric obviously correspond cate- (Star) and $750 and $100,000 (GSS). For involving bothtimepoints, we creatgory.Similarly, othernon-psychotic is a het- analyses that erogeneous does notcorrespond ed a variable in which Star values were category clearly withanyparticular psychiatric diagno- unchanged but GSS values were dividedby 6.53 to correct for inflation (U.S. Bureauofthe SiS. Codingofdependent variables. Each verba- Census1997). timresponse Community size, in the Star survey, was was codedindependently bytwo of three measured in persons self-report, trained to code all theopen- based on respondent of fivecategories: (5) metropolitan disended material from the Mental Health terms over 1,000,000;(4) metropolitan district Module.The codershad clinicaltraining and trict (3) citiesof2,500to 50,000; master's in psychology. Coders'ques- under1,000,000; degrees tions were discussedwith the firstauthor. (2) townsunder2,500; and (1) farm.In the size was based on Census Reliability was assessedusingCohen's(1960) GSS, community and place of residence kappa,a measure of agreement corrected for data forrespondents' in terms of tencategories. Six chanceexpected agreement. Kappa valuesare was measured 0 whenraters agree no morethanwould be categoriesare for places within Standard Statistical Areas (SMSAs): (10) expected is Metropolitan by chanceand 1 whenagreement In thisstudy, citiesover250,000; (9) their suburbs; perfect. kappaswerecomputed central foragreement between thetworaters as to the (8) their cities unincorporated areas;(7) central or absenceof the fourratings most between 50,000and249,999;(6) their suburbs; presence relevant to our central unincorporated areas.The other questions: Kappa was and (5) their are forplaces outside SMSAs: .93 for violent .95 four categories .96 for psychosis, psychosis, (4) cities between 10,000 and 49,999; (3) for dangerousness, and .89 for frightening 2,500 and 9,999; symptoms excluding violence (i.e., townsand villagesbetween areas between1,000 and extreme/excessive, unstable,unpredictable, (2) unincorporated within larger civil excellent 2,499; and (1) opencountry uncontrolled, irrational), indicating divisions.For analysesinvolving both time reliability. an additional we created variable:(3) points, large metropolitan district (comprising Star variables categories4 and 5 and GSS categories5 Independent through 10); (2) smallcity/town (Starcategory The primary variable is yearof 3 and GSS categories independent 3 and 4); and (1) rural 1 and 2 and GSS cateinterview (1950 or 1996). We also measure area (Star categories variablesthat we gories1 and2). several sociodemographic mediatechangesin conhypothesized The Starsurvey raceas white or might categorized andattitudes ceptions overtime. andwe usedthesecategories for the non-white, intheStarsurvey, was measured GSS as well. Education, in terms of sevencategories, from ranging no Table 1 reports charactersociodemographic formal to completion of college.In isticsfor bothsamples as wellas the1950and schooling theGSS, itwas measured in terms of fivecat- 1990 Censuses.First, the Starand comparing from less thanhighschoolto GSS samples,severaldifferences shouldbe egories, ranging We used thesecategories noted.Mean age was slightly graduate education. lowerin 1996 a smallnumforanalysesrestricted to one timepoint.For (partly becausetheGSS included bothtimepoints, we creat- berof 18 to 20 yearoldswhomStarexcluded), analyses involving ed a third variable: education was a somewhat of (1) less than high andthere higher proportion school;(2) highschool;(3) somecollege;and women in 1996. Larger differencesare observed for race, educationalattainment, (4) collegedegree. intheStarsurvey, was mea- family and community size. The perFamily income, income, interms sured ofninecategories, from centageof non-white rose from respondents ranging is under In theGSS, it 10.7 in 1950 to 18.1 in 1996. Most striking $500 to $10,000andover. in terms of 21 categories, in levelsof formal education in was measured rang- theincrease hada high ingfrom under For 1950,only37 percent ofthesample $1,000to $75,000or over.

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TABLE 1. Sociodemographic Characteristicsof the Star and GSS Samples and United States Censusesfor1950 and 1990
Star(N = 352) (1950) Census (1950) GSS (N = 658) (1996) Census (1990)

N N % % % % Gender Female 170 49.0 50.3 370 56.2 51.0 Male 177 51.0 288 43.8 Race/ethnicity White 310 89.3 89.5 539 81.9 79.9 Non-white 37 10.7 119 18.1 Education Less than highschool 218 63.0 64.0 97 14.7 24.8 64 18.5 342 Highschool 52.0 34 Some college 9.8 45 6.8 30 8.7 174 College 26.4 Family income 44 Less than$1,000 12.9 5 0.8 $1,000-2,999 135 39.8 5 0.8 12 35.1 $3,000-4,999 119 2.0 34 $5,000-9,999 10.0 46 7.8 2.1 $10,000or over 7 $10,000-29,999 171 28.9 156 26.5 $30,000-49,999 120 20.3 $50,000-74,999 $75,000or over 76 12.9 MedianIncome $2,500 $3,073 $37,502 $36,095a to (Adjusted $5,743 1950dollars) size Community Largemetropolitan district 185 515 53.3b 78.3 52 Smallcity ortown 15.0 83 12.6 Ruralarea 110 31.7 60 9.1 Age 25 to 54C 227 73.7 430 68.2 71.0 72.9 40 61 55 to 64 13.0 15.1 10.3 13.6 41 65+ 13.3 13.9 99 16.8 18.2 MeanAge 44.9 44.3 to 1996dollars PriceIndex. aAdjusted usingtheConsumer theStarsurvey, size is basedon self-reported theGSS, itis basedon censusclassifibFor size ofplace; for community No censuscomparisons aregiven. cations. 25 years ofage or older. cAgedistributions amongpersons

in respondents withdatafrom thecorresponding schooldiploma, as compared to 85.3percent 1996. Similarly, thepercentage ofrespondents Census,itcan be seenthat bothsurveys reprewhohad graduated from collegerosefrom 8.7 sented theU.S. population atthetime ofsurvey in 1950 to 26.4 in 1996. Medianincomerose reasonably well.The correspondence is particfrom $2,500to $37,502.Even after adjusting ularly impressive fortheStarsurvey, withthe forinflation, medianreal incomemorethan NORC sample and Census including nearly percentages of women,whites, and doubled to $5,743-between1950and 1996. identical in whichrespon- persons with less than a highschooleducation. The size of thecommunities dentslived also increased with The largest is forfamily discrepancy income, substantially, the proportion of respondents livingin large witha medianvalue of $2,500 forStar and metropolitan districts increasing from justover $3,073 forthe Census. Giventhe scarcity of in surviving half in 1950 to more thanthree-quarters of theStarsampling documentation 1996,andthepercentage ofrespondents living procedures and the fact that the sampling in rural included a combination ofprobability areasdecreasing from over30 percent method to less than tenpercent. and quota sampling, the overall corresponthecharacteristics to Censusdatais parComparing ofthesurvey denceoftheStarsurvey

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who included behavior ticularly reassuring and providesclear evi- respondents indicative dence of the high quality of the sample. ofpsychosis in their description of a mentally Whereas theStarsurvey in the ill person did decrease-from 40.7 in 1950 to was conducted same yearas theCensus,the 1996 GSS was 34.9 in 1996.Thisdecrease is notquitesignifconducted six yearsafter thenearest Census, icantat the .05 level.Analyzing theseresults differently (notshown in Table2), we so thatthecorrespondence between thelatter slightly that thepercentage of respondents whose two cannot be expected to be as close. find are limitedexclusively to psyNevertheless, the GSS samplecharacteristicsdescriptions are reasonably from 25.5 in 1950 to 19.6 in consistent withthose of the chosis dropped thepercentage ofall the Census.The largest are forgen- 1996(p < .05) andthat discrepancies mentioned (allowingformultiple der and educational Womenare syndromes attainment. that referred topsychosis decreased overrepresented (56.2% intheGSS vs. 51% in mentions) theCensus),andthosewith less education are from 37.8 in 1950 to 30.4 in 1996 (p < .01).6 ofrespondents whosedescripunderrepresented (14.7% intheGSS vs. 24.8% The percentage intheCensushaveless than to anxiety/mood proba highschooledu- tionsincludereference cation). While these discrepancies mightin lems also decreased-from48.7 percentin in 1996 (p < .001). By thesix-year the 1950 to 34.3 percent reflect difference between part descriptions thatincludedbehavior administration of the Census and the GSS, contrast, ofsocial deviance, mental deficienwomen andpeoplewith socioeconomic indicative higher impairment, and othernon-psystatus are often in contempo- cy/cognitive overrepresented Both surveys rarysocial surveys. somewhat choticsyndromes all increasedsubstantially. the age of 25 The percentage of respondents to referring overrepresent people between and 54, relative from to to olderpeople. social devianceincreased 7.1 percent All of our coreresults will be adjustedfor 15.5 percent (p < .001). References to mental and interac- deficiency/cognitive increased impairment sociodemographic characteristics, tions andeach char- from to 13.8 percent between 6.5 percent (p < .001), yearofinterview acteristic to othernon-psychotic willbe assessed. and references problems increased from 7.1 percent to 20.1 percent(p < .001). in thepotenRESULTS Because ofthelargeincreases of mental tially heterogeneous categories deficiency/cognitive impairment, social deviance, ChangesinDefinitions ofMentalIllness it is of and othernon-psychotic syndromes, is whether and to knowwhatspecificsymptoms Ourfirst question publicconcep- interest tions of mental illness have broadenedto manifestations forthose may be accounting We cannot answer thisquestion preincludea greater proportion of non-psychoticincreases. there are Table 2 reports the cisely and problems. because,for many respondents, syndromes each syndrome frequency with which was rep- multiplesymptom codes and multiplesynresented in descriptions of mentalillness in drome codes,andwe cannot saywith certainty led thecoders to enter 1950and 1996.Because up to three which categories which symptoms in a syndrome if a particular were coded per respondent, codes. For example, percentages response was codedwithsyndromes ofmental given yearsumto morethan100 percent. and other Table 2 indicatesthat the percentage of deficiency/cognitive impairment
TABLE 2. Diagnostic Categories with Which Respondents' Descriptions of Mental Illness Corresponded
Star 1950 (N = 337) 40.7% 48.7% 7.1% 6.5% 7.1% GSS 1996 (N = 653) 34.9%+ 34.3%*** 15.5%*** 13.8%*** 20.1%***

Psychosis Anxiety/depression Social deviance Mentaldeficiency/cognitive impairment Other non-psychotic + p <. 10; ***p < .001 (two-tailed tests)

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judgment of to 8.1%), followedby impaired problemsand a symptom non-psychotic from0 to 3.4%) and functional we cannotbe certain (increasing impairment, functional from 0 to 2.9%). thefunctional impairment contributedimpairment (increasing whether deficiency code, theothernonthe findings relating to our to themental To summarize illWhatwe wereable to first ofmental question: Publicdefinitions psychotic code,or both. that nesshaveindeedbroadened beyond psychosis do is examinethe types of symptoms among respondents to some degree.It is notclearto whatextent increasedin frequency these this indicatesan increasedcorrespondence whoseanswers werecodedas indicating deficiency/cognithree Formental of syndromes. between conceptions publicandpsychiatric of psychiatric increase illnessor the influence was fora mental tiveimpairment, thelargest of definitions indicative code that seemsclearly a symptom on publicones.On theone hand, Among 1950 responses good deal ofthechange mentalretardation: is toward descriptions a syndrome of that psythatwerecoded as indicating do notcorrespond directly to specific impairment, chiatricdiagnosticcategories(e.g., social mental deficiency/cognitive of devianceor impaired retardation/lack of intellectual symptoms On theother judgment). peo- hand, by eight werementioned breadth perse ofthepublic's comprehension thegreater ple (2.4% of the totalsample);this number current illnessis moreconsisimageofmental roseto 51 people(8.3% ofthetotalsample)in tent deftraditionally broader psychiatric with 1996. Also showingsizable increaseswere initions and is also consistent with thegeneral and functional thrust of incompetence symptoms of changesto theDSM overtheyears, witha syn- whichhas seen a proliferation Amongrespondents impairment. of increasingly drome code of mental deficiency/cognitive disorders. diverse eachofthesesymptoms was menimpairment, tioned (less than1% ofthetotal byoneperson ofDangerousness sample)in 1950and23 people(3.7%) in 1996. ChangesinPerceptions Characteristics in social devianceand other and Other Frightening The increases seem to be largely syndromes non-psychotic is whether Our secondquestion perceptions accounted for by symptoms/manifestations and relatedcharacteristics withpsychiatric diag- of dangerousness whose correspondence have and instability nostic categories is ambiguous. Among like unpredictability three Table 3 reports typesof data codes of social decreased. with syndrome respondents to thisquestion: symptom/manifestathat relevant deviance, the symptom/manifestation behav- tion codes indicatingviolent behavior or was sociallydeviant increased themost codes ior (increasing from 2.1% of thetotalsample tendencies; symptom/manifestation frightening characother potentially in 1950 to 8.8% in 1996), followed by disor- indicating unor excessive, unstable, (extreme from teristics (increasing abnormal, unspecified dered, or irrational); and uncontrolled, (increasing predictable, 2.7% to 6%), and incompetent codes indicating category lessthan1% to2.8%). Forother non-psy- syndrome/behavior from eachof The tableshowsthat violent psychosis. the symptoms/manifestachotic syndromes, of perceiveddangerousness the mostwere irrational these indicators tionsthatincreased 0 to 5.2%) and disordered, shows increase nota decrease buta significant from (increasing The percentage of under from 2.7% overtheperiod study. unspecified (increasing abnormal,
Characteristics ofViolenceand otherFrightening TABLE 3. Perceptions
Star 1950 7.2% (N = 335) .23 (N = 335) 6.8% (N = 337) GSS 1996 %* 12.1 (N = 622) .31* (N = 622) 12.4%** (N = 653)

symptoms/manifestations mentioning violent Percent ofrespondents characteristics ofother frightening ofmentions Mean number irrational) unpredictable, uncontrolled, unstable, (extreme/excessive, as "violent wereclassified whosedescriptions ofrespondents Percent psychosis" tests) *p < .05; ** p < .01 (two-tailed

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respondents mentioning violentbehavioror important findings. First, forbothtimeperitendencies increased from 7.2 percent in 1950 ods,those interms whodescribe mental illness are morelikelyto includevioin 1996 (p < .05),7 whilethe of psychosis to 12.1 percent lenceintheir descriptions. Second, thisassocimeannumber ofmentions ofother frightening behaviors increased from .23 in 1950to .31 in ationbetweendescriptions of psychosisand of dangerousness increased substan1996 (p < .05). The percentage of responses mentions indicating violent psychosis increased from 6.8 tially over the period under study.Among whodidnotmention psychosis in in 1950 to 12.4 percent in 1996 (p < respondents percent their ill person, description of a mentally the .01).8 percentage whomentioned violencedecreased in 1950 to 2 percent in 1996. from 3 percent Relation Between Definitions ofMental However, amongthosewhosedescriptions are Illnessand Perceptions ofDangerousness classified as indicating thepercentpsychosis, age mentioning violencemorethandoubled, Our third questionis whether people who increasing from 12.7percent in 1950to 31 perdefine mental illness more broadly (i.e., centin 1996.In a logistic regression predicting includenon-psychotic conditions) have fewer mentions of violencefrom mentions of psyillnessthando chosis, negative stereotypes of mental yearof interview, andtheir interaction, itmore those whodefine narrowly andwhether the interaction termwas statistically signifihas changedoverthe period cant(p < .05).Thus, thatassociation theunexpected increase in The fact that definitions have perceptions understudy. of violenceis confined to those at the same timenegative broadened stereo- who think illnessin terms of mental of psyhaveincreased that theassocia- chosis.9 types suggests thetwomust havechanged. tionbetween This Given these itis clearthat broadened results, in Figure1, whichcontains is confirmed two definitions of mental illnessovertimecannot
Whose Descriptionof Mental Illness Includes Perceptions of FIGURE 1. Percentof Respondents Violence
35-

30-

25-

20-

15-

10-

5-

0does notinclude Descniption psychosis 1950 includes Description psychosis 1996

ofpsychosis byyearofinterview) was in theFigure(descriptions presented Note:The interaction at the .05 level(two-tailed test). and was foundto be significant regression testedin a logistic

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mediatea reduction in negative stereotypes,tistically significant, thepattern of findings is becausethere was no reduction. Thiswas con- consistent withprevious results and supports firmed bylogistic regressions predicting men- theidea that sociodemographic characteristics tionof violencefrom yearof survey, conceptions andattibefore playsomeroleinshaping for ofpsychosis. tudes. Because the U.S. population has andafter controlling mention in 1996 would changedsubstantially The odds thata respondent since 1950 withregard mention violencein describing a mentally ill to income, racialcomeducational attainment, and urbanicity, and because women personwere 1.8 timesthe odds thata 1950 position, inthe1996sammore prevalent respondent would mentionviolence. When aresomewhat mentions of psychosis were entered mayhave intothe ple, one or moreof thesevariables in contheadjusted equation, odds ratioincreased to playeda rolein thechangesobserved and attitudes. 2.3. Thus,without the broadening To evaluatethisquesof defini- ceptions a seriesof logistic we performed regrestionsof mental illnessthatoccurred between tion, 1950 and 1996,it appearsthat perceptions of sions. Mentionsof psychosisand violence on yearof interview regressed only. wouldhaveincreased evenmorethan werefirst violence We thenadded race and gender, did. educational they attainment andfamily andcommunity income, size to the equations in three successive Sociodemographic Characteristics, blocks.Nextwe entered terms forinteractions Definitions ofMentalIllness, andPerceptions betweenyear of interview and each of the ofDangerousness sociodemographic variables. Recall thatthese variables for famianalyses employ education, Finally, we assess thepossiblecontributionlyincome, andcommunity size that synthesize ofdemographic tothechanges theStarand GSS codingschemes. transformations in mental-illness we havereport- Finally,to further conceptions evaluatethe increased ed. We first examined the bivariate associa- association between of pyschosis perceptions tions,separately forthetwosurveys, of men- and of violence(first in Figure1) presented tionsof psychosisand violencewitheduca- whilecontrolling for factors sociodemographic size andchanges, tion, familyincome, age, community we addtwoadditional steps tothe (using t-tests), race, and gender(using chi- series of regressions predicting mentions of squaretests). violence. Afterthe sociodemographic variIn theStarsurvey, noneof thesociodemo- ables,we addedmentions ofviolence andthen was significantly graphicfactors relatedto a term fortheinteraction of mentions of psymentions of psychosis or violenceat the .05 chosisandyearofinterview. level.Less educated (p = .064) and non-white As Table4 shows, there was a marginal (p < mentioned (p = .076) respondents psychosis .10) decrease in mentions of psychosis moreoften. Lowerfamily income between 1950and 1996.Themagnitude ofthis marginally tomentions was marginally related ofviolence association was increased slightly bytheinclusion of race and genderand thenmorethan (p = .056). In theGSS, education (p < .05) andrace(p < halvedandreduced to non-significance bythe related to mentions of inclusion ofeducation andfamily income. The .01) weresignificantly Mean education was 1.42 for those addition ofcommunity had psychosis. size totheequation who mentioned and 1.61 forthose little onthecoefficient for ofinterimpact year psychosis 2 = some view. Race was the only sociodemographic whodidnot(1 = highschooldegree; with 45.3 variable that was significantly associated college).Amongnon-white respondents, in theseequations, with ofpsychosis percentmentioned psychosis,comparedto mentions 32.6 percentamong whites.Familyincome non-white respondents mentioning psychosis was also marginally related morefrequently than whites (p < (p = .102) to men- significantly tionsofpsychosis, withlower incomes among .05 in the finalmodel).Wheneach sociodethosewho mentioned None of the mographic variablewas enteredalone with psychosis. inTable4), highvariables was significantlyyearofinterview sociodemographic (notshown racewere related ofviolence atthe.05 level, er educational and white tomentions attainment mentions were somewhatmore significantly associatedwithfewer althoughnon-whites ofpsychosis income was marto mention violence(p = .078). (p < .01),family likely fewofthese associations weresta- ginallyassociatedwithfewer mentions (p < Although

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TABLE 4. Logistic Regressions Predicting Definitions of Mental Illness (i.e., Log-odds that and Sociodemographic Factors, Description Refersto Psychosis)from Year of Interview
N = 904 1 Year (0 = 1950; 1 = 1996) Race/ethnicity 1 = white) (0 = non-white; Gender (0 = male;(1 = female) Family income Education size Community 2.69+ Chi-square 1 df tests). +p < .10; *p < .05; **p < .01 (two-tailed in parentheses arestandard Note:Numbers errors. 10.32* 3 -.237+ (.144) 2 -.265+ (.146) -.498** (.188) -.136 (.140) 3 -.107 (.164) -.433* (.192) -.156 (.142) -.017 (.021) -.119 (.076) 15.18** 5 4 -.101 (.168) -.435* (.193) -.156 (.142) -.017 (.021) -.118 (.076) -.017 (.097) 15.21* 6

size nor gender shownin Table 5), onlyrace was marginally .10), and neither community associated withmentions of associated was significantly (p < .10) with mentions ofviolence, between whites psychosis. None of the interactions mentioning violence less often. Noneof and sociodemographic fac- the interactions yearof interview betweensociodemographics in and year of interview significant (notshown torswas statistically was significant (not itappears that broadened shownin Table 5 and not included tables).In summary, in subseto quentstepsshown illnessweremediated definitions of mental in columns 5 and 6). Thus, some degreeby increasesin socioeconomic unlikethe situation of mental fordefinitions might have broad- illness, status and thatdefinitions changing demographic profiles didnot ened evenmorein the absenceof increasing appearto playa noteworthy role in increased that perceptions racial diversity. There is no indication of violence between 1950 and urbanization or a greater proportion 1996. increased of womenin theGSS sampleplayeda rolein rolein increasWhatdoesplayan important ofdefinitions ofmental ing perceptions themodest broadening of violence is the changing illness any relationship between 1950and 1996,noris there of psychosis betweenmentions thatthe sociodemographic corre- andviolence. indication 5 and6 confirm as Columns that, ofmental illnesschanged indicated latesof conceptions 4 (without inFigure congraphically overthistime period. mentions trolsforsociodemographic factors), of violence of psychosis As shownin Table 5, mentions are significantly associatedwith between 1950and 1996 mentions increased significantly of violence(p < .001) and thatthe (p < .05). The additionof race and gender twoaremorestrongly in 1996 than associated foryearof in 1950 (p < .05). reduced thesize of thecoefficient the subsequent addition interview somewhat, it of education and family incomeincreased of DISCUSSION value,and theaddition beyondits original itagainslightly. size reduced None community in the 1950s painteda bleak Researchers thestatisofthese however, changed additions, illofpublicorientations toward mental of the association between picture tical significance mental illnessin narrow of violence. ness peopledefined and mentions year of interview werefearful terms, and attitudes in the final model, none of the and extreme Moreover, factorswas significantlyand rejecting. Several factors, including sociodemographic utilization ofmental health services, of violence.When increased associatedwithmentions of mentalhealthproblems disclosure variableswas greater each of the sociodemographic enteredalone with year of interview (not by public figures,and empiricalfindings

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TABLE 5. LogisticRegressions Predicting Perceptions ofViolence(i.e., Log-odds that Description ReferstoViolence)from Year ofInterview and Sociodemographic Factors, N = 866
1 Year .616* (0 = 1950; 1 = 1996) (.262) Race/ethnicity 1 = white) (0 = non-white; Gender (0 = male; 1 = female) Family income Education size Community Mentions psychosis x year Mentions psychosis 6.01* 10.33+ Chi-square 9.54* 3 1 5 df +P < .10; * P < .05; ** P <.01; *** P < .001 (two-tailed tests) in parentheses Note:Numbers arestandard errors. 10.35 6 2 .580* (.264) -.534+ (.278) -.094 (.230) 3 .671* (.288) -.483+ (.284) -.122 (.233) -.027 (.033) -.006 (.123) 4 .660* (.296) -.479+ (.285) -.121 (.233) -.027 (.033) -.008 (.123) .028 (.169) 5 .785* (.310) -.280 (.304) -.045 (.246) -.017 (.035) -.037 (.132) .047 (.179) 2.480*** (.305) 102.99*** 7 6 -.392 (.567) -.285 (.308) -.039 (.248) -.015 (.036) .027 (.133) .055 (.179) 1.430** (.499) 1.490* (.634) 108.19*** 8

and attitudes, However, regarding public conceptions the significant increasein mensuggest thatthissituation mayhave changed tions of dangerousness in respondents' com- descriptions significantly, but no study has directly of mentalillness nearlydouover this time blingbetween1950 and 1996 is difficult pared public beliefs andattitudes to period. We wereable to makesucha compari- fitintoa picture ofnormalization or increased son by analyzingresponsesto an identical acceptability of mentalillness.A potentially in of nation- important clue to thisincongruity is found question askedin thesamemanner of dangerousness only ally representative samplesin 1950 (Shirley the factthatmentions in theField of increasedamong respondents who include Star'sstudy, "Popular Thinking in theirdescriptions of mentalillMentalHealth")and 1996 (theGeneral Social psychosis ness.Americans arenowless likely to describe Mental HealthModule). Survey's that concep- psychosis Ourresults suggest thepublic's when askedaboutmental illness, but do they aremuch to include tualization of mentalillness has broadened ifthey morelikely This as part oftheir description. somewhat suchthat dominated peo- dangerousness psychosis ple's descriptions of mental illnessto a lesser changewas notattributable to changesin the in 1996 thanin 1950. It is notclearto sociodemographic of the U.S. extent composition limreflects a closer population, whatextent thisbroadening norwerementions ofviolence withpsychiatric The itedto,or evensignificantly morefrequent in, conceptions: alignment of respondents mentioning anxiety anyparticular percentage sociodemographic groups. theimplications of these or mood problems (very commondisorders Beforediscussing data; Kessleret results,we would like to consider some according to epidemiological al. 1994) decreased, and therewas a large strengths and limitations of our analysis. in the data give us confiin thepercentage who Several strengths increase ofrespondents the andto dencein thevalidity referred to non-specific socialdeviance ofthefindings. First, and analysis ofthetwosurveys orproblems that do notfit anyofthe administration behaviors both surveys used a ("other were verycomparable: diagnostic-related syndrome groupings thetradi- nationalprobability that non-psychotic"). Yetwe didfind sample and face-to-face a smaller interviews of aboutthesamelength; thesame ofpsychosis played tionalstereotype ill- questionwas repeated at bothtime ofmental verbatim partin respondents' descriptions ness in 1996 thanit did in 1950.The findings points;thesame codingschemewas used by ill- the same coders.The use of an open-ended thussupport theidea that, mental overall, has bothadvantages and ness is now conceivedof as something less question potentially alienandless extreme thanitwas in 1950. Because itaskspeopleto speak disadvantages.

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"off thecuff," we believethistypeof question to respondents whodescribed mental illnessin has the potentialto circumvent, to some terms ofpsychosis argues against sucha bias. degree,the social desirability bias thathas if it were couldbe a problem Confounding been shownto influence expressed attitudes something about the type of person who towardmentally ill people when measured describes mental illnessin terms of psychosis with fixed-response surveyitems(Link and thatleads to mentions of violencerather than Cullen 1983). On theother hand, theanalysis the psychosis conceptitself. Arguing against of thistypeof question relieson raters' however, is the factthatperjudg- thispossibility, ments, which raisesquestions ofreliability and ceptionsof dangerousness were not signifitheinter-rater of cantly to anyof thesociodemographic validity. However, reliability related the rating categories we examined was high. variablesat eithertime point.Also, in the is vignette evidenceforconstruct experiment component of the 1996 Moreover, validity offered that ofviolence survey, in whichdescriptions bythefact perceptions of different psyweremorecommon thosewhodefined chiatric wererandomly among disorders assignedto mental illnessinterms ofpsychosis andbythe respondents (eliminating the possibilityof of(modest) associations ofsociodemo- confounding), the person described with pattern graphic characteristics with definitions of symptoms of schizophrenia was perceived as mental illnessandperceptions ofviolence. nearly twiceas likely (61% vs. 33%) tobe vioOne methodological between the lentas theperson with majordepressive disordifference twosurveys is a potential sourceof bias. The der. One notable limitation is that questionanalyzedhere was precededin the we haveonly GSS study by a Star-type vignette describing one typeof measureof negative perceptions either schizophrenia, majordepression, alco- and stigma, mentioned namely spontaneously hol dependence, cocainedependence, ora per- perceptions ofdangerousness and other frightson withnon-clinical problems and worries. eningcharacteristics. theseare core Although The vignette ofthestigma was followed bya seriesofques- features ofmental illness(Jones tionsincluding thelikelihood theproblem et al. 1984), and although that perceived dangerdescribed is a mental illness andthelikelihood ousnessis strongly related to social distance that theperson described might be dangerous. from illness(Link et al. personswithmental In the Starsurvey, desirour question was notpre- 1987;Linketal. 1999),itwouldbe very ill- able to testthegeneralizability of thesefindcededby anyother aboutmental questions thatthe ingstoother ofstigma, measures suchas social ness. Thus, thereis the possibility influenced the type of syndromes distance or direct vignette queries(as opposedto spondescribed and/or their mentions) concerning dangerousness. byrespondents tendency taneous to mention there for thevalidity violence. are severwe believeevidence However, Overall, al indications that thepreceding were of the present is reasonably findings vignettes strong, the and we believe thattheyrepresent notan important sourceofbias. Regarding the best the diagnosis availabledatapertaining to historical typesof syndromes mentioned, changes was notsignificantlyinpublic definitions andconceptions ofmental assignedin thevignette associatedwiththe syndromes and stigma. described stereotypes by illnessand in negative in the open-ended toa discussion oftheimplications respondents question,as Wenowturn assessedwitha chi-square test.Notably, even oftheresults. ofincreased ofdanthoughroughly40 percentof respondents Ourfinding perceptions received a vignettedescribing substance gerousnesswas unexpected and appears at of decreased sixoftheentire men- odds withother indications dependence, only sample stigOne tioned alcohol or drug problemsin their ma. How can thesefactsbe reconciled? of mental is that of mental illness.Nor did thepar- possibility illness acceptance description ofmenticularvignette receivedsignifi- hasnotincreased. Increased utilization respondents vio- talhealth influence their tomention services maybe due to other cantly tendency factors, lence.A farther is that definitions illness concern whether suchas broadened ofmental asking could or greater or affordability of treatthevignette be dangerous subject might availability thetendency to mention violencein ment.Disclosureof mentalillnessby public increase all the figures an effort to destigmatize to theopen-ended for response question may reflect thanan indication that 1996 respondents. the factthatthe mentalillnessrather However, Rather inmentions ofviolence was restricted that than reflectincrease goalhasbeenrealized.

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ingtrue attitude change, apparent trends inthe thathas leftbehindthe most seriously illfindings ofempirical studies mayreflect either those withpsychosis-who are viewedwith methodological differences between studies or greater fear than they werehalfa century ago. theexpression of changing sociallyappropri- If it is truethatsome mental illnesses, but not those involving ateattitudes psychosis, have gained (Rabkin1974). A second possibility is thatotherdimen- acceptance in oursociety, thisis notin itself a sionsof stigma haveabatedeventhough per- bad thing.Overall, it represents progress, ofdangerousness haveincreased. This because it improves ceptions the lives of people with disorders. thestrong asso- less serious The danger is in obscurseems unlikely, however, given in perceptions differences between of thetwo ciation and ingstark perceived dangerousness tiersof mental illness, socialdistance attitudes whichappear (Linketal. 1987,1999). A third possibility is that gainshaveindeed to havehadvery different livesandtrajectories andpub- overthepasthalfcentury. beenmadein terms ofnormalization Thus,ifwe look at lic acceptance of less severementalillnesses changing orientations toward less severe mentopeople tal illnesses, attibutthat these we mayfalsely conclude that gainsdo notgeneralize Sucha possibility ill peoplehave with is consistent tudestoward severely psychosis. mentally withthe dramatic in our results, also improved. Results ofresearch on attitudes distinction, and non- toward illness" betweendescriptions of psychotic a generalconceptof "mental over mayalso obscure thisdistinction. psychotic syndromes andtheir divergence more than Whileitremains time.Mentionsof dangerousness unclear whether thesocial doubledbetween1950 and 1996 in descrip- climate forpeoplewithnon-psychotic mental tionsinvolving whereasmentions illnesses has improved, psychosis, whatourresults show fornon-psychoticclearly of dangerousness decreased is that theclimate has notimproved for thatsuch Perceptions syndromes. Perhapsit is the case thatless people withpsychosis. severeproblems depression, anxiety, prob- peoplearedangerous increased twoand nearly lems coping, problems functioning-are a halftimes since1950toa point in 1996, that, seen as something thatis partof nearly of respondents one-third increasingly spontaneously lifethatcan happento anyone, as something volunteered the idea thatpsychotic persons The stereotype of theviolent thatone can be somewhat open about,while maybe violent. in our psychosisremainsalien, stigmatized, some- psychotic personhas becomestronger inoneself society than it was in the time when tobe concealed thing whenitoccurs first or one's family(Link et al. 1989; Phelan, researchers pointed outand lamented the of suchnegative This is Bromet and Link 1998),and something to be existence stereotypes. fearedin others.Perhapspeople with less a seriousset-back forpeople withpsychosis. forms ofmental of thisresult can be severe disorder do increasing- The practical importance lybelongto "us,"whilepeoplewith psychosis underscored by notingLink et alia's (1987, thatperceptions of dangerousremain "them." 1999) finding in determining Ifwye re-examine theindicators ofdecreased nessarea keyfactor thedegree in lightof thisdis- ofsocialdistance referred to earlier thepublicdesires from a perstigma tinction between a mental illness. and non-psychoticsonwith psychotic Thus,increased perof dangerousness are likely to havea we see thatthoseindicators reflect ceptions disorders, the less severe, non-psychoticillnesses. veryreal impacton thepersonal, social, and Increased of mental health services economic ofpeoplewhohaveor utilization opportunities is primarilyfor non-psychotic problems. who have previously experienced psychosis Notable instances of public disclosurehave (Linketal. 1989). beenfor moodrather than schizophrenia-spec- An obviousquestionis whythisnegative trum Research results a stereotype has not decreased or remained disorders. suggesting buthas actually decrease in social distancehave generally steady, increased. significantly ill" people, Two particularly salientpossibilities are the askedrespondents about"mentally ofthemediaand ofde-institutionalizaa label thatis apparently increasingly applied effects illnesses that to thosewith documented non-psychotic (Crocetti tion.Ithas beenclearly negaarecon- tivestereotypes of etal. 1974;Rabkin1974).Thesefacts (including dangerousness) in which there has been people withmentalillnessesabound in the sistent with a scenario a realmovetoward andless media(Wahl1995; Signorelli 1989; Steadman greater acceptance in theGSS (the views of mentalillness,buta move and Cocozza 1978). However, negative

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ill people are dangerous. forwhichthesedata wereavail- tionsthatmentally onlysurvey thereis some evidencethat the werenotsig- Ironically, able),mentions ofdangerousness of reading "dangerousto self or others"criterion for nificantly related to thefrequency may have playeda commitment television. Two involuntary thenewspaper or of watching here:First, each media rolein strengthening thestereotype ofthedancaveatsare important (Phelanand Link 1998). We variable was measured witha single gerouspsychotic exposure of the measures emphasize that theseanalyses question, and the reliability again,however, itremains a chalandthat and theparticulars of themediaexposure are arefar from decisive to assess the lenge forfuture unknown; second,to attempt research to explainwhythe has psychotic person effects of changes in exposureto negative stereotype ofa dangerous at varia- becomestronger mediamessages overtime bylooking itwas in 1950.For than today time now,it is important tions in media exposure at the present that we recognize that the III error"-get- stereotype of a "type has becomestronger. maybe an instance of tingthe right answerto the wrongquestion increased acceptance Despitethepossible and Carpenter whichmay 1999). In particular, the less seriousmentalillnesses, (Schwartz in 1950, indeed increasingly be viewed as "illnesses television was notpartof ourculture is ubiquitous. Current like anyother," thatfear and now its influence our findings suggest in television at themostserious mental viewingmay not be and stigma variations directed respects, illnesses are,in someveryimportant that massive cultural change. able to mimic De-institutionalization is a secondpotential stronger thantheywere46 yearsago. While that mentally theterm reasonforincreased perceptions illness"is now less likely to "mental ill people,particularly thosewithpsychosis, bring ofAmericans thepicture of to theminds are dangerous. One consequence ofde-institu- a person with psychosis, somethinghas is thatexposureto mentally ill occurred tionalization in ourculture overthepasthalfcenpsychosisand tury people who oftenexperience that has increased theconnection between and behavein bizarre psychosisand violence in the public mind. often appeardisheveled and incomprehensible thatsomething ways has become a Whatever is, it has had this A positive salient life. associa- effect aspectofurban ourbestefforts to achieveexactdespite tion betweencommunity size and perceived ly theopposite is required to Research result. in the 1996 sam- identify ofthese unfortunate theprecise source dangerousnessparticularly evidenceforthe stereotypes, ple-would provide indirect and advocacy is required to of dangerous- changethem.In theabsenceof such efforts, idea thatincreased perceptions from to mentally thelivesofpeoplewith ness result exposure mengreater themostserious as frightening. ill people who are perceived by willcontinue tobe complicated talillnesses thatcommunity theinjurious Our data indicate, andrejection. however, effects of stigma of dangersize was unrelated to perceptions at bothtime ousness Usingmoredirect points. of dangerous- NOTES dataon contact and perceptions ness from a nationwidesurvey of 1,507 describe hypothetical conducted Americans byLinketal. (1994),we 1. The "Starvignettes" criteria for various psyindividuals meeting thatmembers of the examined thepossibility as defined bythepsychichiatric disorders, moreimpersonal contact or publicwhoreport and ask respondents quesill people(meaatric profession, contact with mentally negative the including tions about the individual, sured with two single items) would regard has a "mental likelihood that theindividual themas more dangerous(measuredwith a of thesevignettes, adaptillness." Versions tothis seven-item scale; alpha= .77). Contrary psychiatric definitions, current whoreported frequent- ed to reflect reasoning, respondents in the1996GSS Mental werealso included ly seeingpeople in publicwho seemedto be HealthModule (see Link et al. 1999 and ill or seeinghomeless peoplemaking mentally to themselves Pescosolidoet al. 1999 foranalysesusing or talking weresignifigestures thevignettes). However, they werenotwell ill perless likely to perceive mentally cantly changesin cultural concepsuited to track sons as dangerous(p < .001 and p < .05, were tionsovertimebecause thevignettes dataavaillimited respectively). Thus,thevery no support for theinfluence notrepeated verbatim. abletous provided as disorders to non-psychotic on increased of de-institutionalization percep- 2. By referring

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less severe or serious, we do notmeanthat to describe"mentalillness" (and consethey are notseriousor that they are necesin our analyses)is sysquently inclusion characterto theill person tematically related to respondent sarily less distressing than is psychosis. Rather, we refer to whatwe istics. here,we believe are public perceptions that psy- 6. In subsequent analysespresented chosis is a more extreme deviation from assess conceptionsof mental illness in describes normal psychological functioning. terms of whether therespondent 3. Thismeant that there wereno callbacks for they describe psychosis rather than whether were potential respondents whowerenotathome onlypsychosis. However, all analyses on thefirst runwith bothmeasures, andthetwosetsof orhadrefused call at a dwelling results do not differin any important unit.However, refusalrates in the early yearsof survey research weresubstantially respects. from the are omitted lower thanthey are now; consequently, the 7. If suicidaltendencies ofthesample from 5.7 analysis, thepercentage increases ultimate is probably as quality in 1950to 9.3 in 1996 (p < .05). thanmanysamplesused by good or better for therep- 8. As notedpreviously, diagnostic up to three socialscientists Evidence today. oftheStarsample is providresentativeness andup to three symptoms/manicategories ed inTable 1. festations couldbe coded foreach respon4. The GSS included those18 to 20 years old, dent.In the GSS, somewhat fewer sympper whereasStaronlysampledpersons21 or toms/manifestations were mentioned respondent (mean= 2.09) thanin the Star In oursample, there older. were22 (3.3%) GSS respondents more betweenthe ages of 18 survey(mean = 2.54), and slightly and 20, whom we have includedin the diagnostic categories were coded per results reported here.However, all analyses respondent (mean= 1.48 forGSS vs. 1.37 were re-runexcludingthose 22 responforStar).Thus,ifwe compute thepercentin any do notdiffer menandthoseresults age of all symptoms/manifestations dents, notable thosewe report. violent respects from tionedin a givenyearthatindicate 5. Mostofthemissing ornon-usable or frightening rather thanthe responssymptoms, es in theGSS werenotrefusals to answer, of respondents who mention percentage inmentions reflect theincrease of butrather therespondent's suchsymptoms, inability to answer the question (e.g., "I don't violent and frightening between symptoms likethat") than reported 1950and 1996is evengreater know-I don'tknowanyone ora in Table 3. Fordescriptions of violent psyresponse(e.g., "hopefully they're getting thissamekindofadjustment results help") that was not codable for choses, 1950 in a slightly smaller between increase syndrome/problem category,for sympForsynintheperor foreither. and 1996.However, thisincrease toms/manifestations, of the 51 percent centageof diagnosescoded thatindicate drome/problem category, is stillsignificant at the non-usable wereofthisnon-codviolent psychoses responses level. able, type, and for symptoms/manifesta- .05 probability of vio69 percent wereofthistype. Because 9. We wereconcerned thatmentions tions, ofthesubstantial lence might be more frequentamong ofmissing data proportion illnessin for these corevariables who describe mental (7.8% for syndrome respondents and 12.1% forsymptoms), we attempted to terms ofdeviant behavior which (a category determine whether some kindsof responalso includesantisocial behavior and subtoprovide dents wereless likely usabledata stance respondents might abuse),that many foreach variable mention andsocially deviant both psychosis thanothers. Specifically, theserelationships we logistically andthat might regresseda dichotomous behavior, theassociation at leastpartially account for variable(usable vs. missing data) on genof psychosis between mentions and mender,age, race, education, family income, of andcommunity tions of violence. However, mentions size.In both cases,all associations characteristics violencewerenotelevated amongresponbetween respondent and usable responses werenon-significant dentswhosedescriptions werecategorized and extremely weak.Thus,at leastin terms as indicatingsocially deviant behavior. forthe of sociodemographic therewas no tendency we characteristics, Moreover, or ability findno evidence that willingness categories of psychosis and antisocial/

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Jo C. Phelan is Assistant Professor ofPublicHealthat Columbia University. Herresearch interests include social stigma, ofmental conceptions illness, theimpact ofthe"genetics revolution" on thestigma ofmental illness, attitudes and beliefs relating to social inequality and itslegitimation, and social inequalities in health andmortality. of PublicHealthat ColumbiaUniversity and a Research Bruce G. Link is Professor Scientist at theNew YorkStatePsychiatric Institute. His research interests include theimpact of labeling and stigma on people withmental theroleof social factors causesof disease,publicconandphysical illnesses, as fundamental ofmental andtherelationship between mental ceptions illness, illnessandviolence. Ann Stueveis Associate Professor ofClinicalPublicHealthat Columbia Herresearch focuses University. on therelationship mental illness andviolence, thedevelopment ofproblem behaviors between childduring andtheprevention in hoodandadolescence, methodological issuesinevaluation ofHIV infection research, high-risk populations. BerniceA. Pescosolidois Chancellor's Professor of Sociologyat IndianaUniversity and Director of the IndianaConsortium MentalHealthServicesResearch. Herresearch focuses on social issuesin health, for inparticular totheir illness, andhealing, howsocialnetworks connect individuals communities andto institutional structures.

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