250 labels used to stigmatise people with mental illness

  • Diana Rose1,

    Affiliated with

    • Graham Thornicroft2Email author,

      Affiliated with

      • Vanessa Pinfold3 and

        Affiliated with

        • Aliya Kassam2

          Affiliated with

          BMC Health Services Research20077:97

          DOI: 10.1186/1472-6963-7-97

          Received: 16 January 2007

          Accepted: 28 June 2007

          Published: 28 June 2007

          Abstract

          Background

          The stigma against people with mental illness is a major barrier to help-seeking in young people for mental health problems. The objective of this study was to investigate the extent of stigma in relation to treatment avoidance in 14 year-old school students in England in relation to how they refer to people with mental illness.

          Methods

          This is a qualitative, cross-sectional study. The data were gathered as part of the baseline assessment for an intervention study intended to reduce stigma among 14 year old school students. The participating schools were two grammar (selective) schools and three comprehensive (non-selective) schools. At the start of the lesson, the students were asked 'What sorts of words or phrases might you use to describe someone who experiences mental health problems?' Words and terms used to refer to mental illness were enumerated. Using the grounded theory approach, words and terms were grouped in terms of their denotative and connotative meanings. Labels were then derived to capture the key themes attached by the students to the concepts of mental illness. The frequencies of occurrence for each word were also tabulated.

          Results

          400 of the 472 participating students (85%) provided 250 words and terms to describe a person with mental illness. Five themes were identified from the data. The first theme called 'popular derogatory terms' (116 items) accounted for nearly half of the words examined. The second theme occurred less often and was described as 'negative emotional state' (61 items). The third theme demonstrated the confusion of young people between physical disabilities, learning difficulties and mental health problems (38 items). The use of psychiatric diagnoses (15 items) and terms related to violence (9 items) were unexpectedly uncommon.

          Conclusion

          Our findings suggest the hypothesis that help-seeking by mentally ill young people may be improved by interventions that address both their lack of factual information about mental illness, and those which reduce their strong negative emotional reactions towards people with mental illness.

          Background

          Most young people who are mentally ill do not seek help [15]. Yet mental illnesses among children and adolescents are common, affecting about 10% of young people [6, 7]. The rates for some mental disorders, including suicide, are increasing [8, 9]. Up to half of those who fail to complete secondary school have mental illness [10]. Those who do, more often turn to friends and family for help than to health professionals [11, 12]. Teenagers seek help less often than adults [13]. As few as 4% of young people with a mental illness seek help from a family doctor [14], and consultation rates are especially low among young men [15]. This paper argues that the stigma against mental illness is a powerful (and potentially reversible) contributory factor towards the reluctance of many young people to seek help for mental illness.

          Research on help-seeking has paid particular attention to the confidentiality of healthcare, young people's knowledge about services, and how accessible they are [16]. But such factors do not fully explain the very low rates of consultation among young people who are mentally ill [17, 18]. Recent work has focussed attention on whether young people know enough to allow them to correctly identify mental illness in themselves or in their peers (so called 'mental health literacy') [19], and upon their emotional/attitudinal responses (and associated stigma) to people with mental illness, as potential explanatory factors for help-seeking or help-avoidance [20].

          Stigma is a term which has evaded clear, operational definition [2124]. It can be considered as an amalgamation of three related problems: a lack of knowledge (ignorance), negative attitudes (prejudice), and excluding or avoiding behaviours (discrimination) [2527]. In relation to knowledge about mental illness it is clear that there are striking knowledge gaps. [2830]. For example, in Scotland most children do not know what to do if they have a mental health problem, or what to recommend to a friend with mental health difficulties. Only 1% mentioned school counselling, 1% nominated helplines, 4% recommended talking with friends, 10% said that they would turn to a doctor, but over a third (35%) were unsure where to find help [31].

          There is also fairly strong evidence that negative emotions and attitudes act as barriers to care. Compared with adults, young people have less favourable attitudes towards people with mental illness [32]. Conversely, young people with mental illness may be exposed to higher levels of stigma than adults [33]. Commonly young people feel that mental illness is embarrassing [34], should be handled privately, and people with these views tend to seek help less often [3537]. Attributions for the cause of the condition are also important. Young people who believe that mental illnesses are the responsibility of the person affected are more likely to react to people who are mentally ill with anger, pitilessness or avoidance [38]. There are therefore grounds to consider that stigma may be one important factor in reducing help-seeking for mental illnesses, for example by avoiding the embarrassment of diagnosis [37, 39, 40].

          A recent study investigated whether accurate recognition and labelling of mental disorders by young people (aged 12 to 25 years) is associated with better help-seeking preferences [41]. After being shown a vignette of either a young person with depression or psychosis, each participant was asked what they thought was wrong with the person in the vignette, how long the person should wait to get help and what form of help they should seek. The results showed that the young people who correctly labelled the disorder were also those who most identified appropriate help-seeking and treatment options. Although the Wright et al. study explored help-seeking directly, the stigmatising attitudes and beliefs held by young people towards mental illness and people with mental illness which may deter them from seeking help were not explored. The purpose of our study was to determine what young people actually think about mental illness/people with mental illness and explore the type of language they use to label it.

          Methods

          Much stigma-related research has used vignettes or social distance scales which may constrain what respondents can express about stigma. Our method was intended to allow young people to express what they thought about mental illness in a way that was not pre structured by attitude scales or vignettes. To explore the role of stigma in relation to treatment avoidance further, we describe here the terms used by 14 year-old school students in England to refer to people with mental illness. These data were gathered as a part of the baseline assessment in an intervention study intended to reduce stigma among school students. Full details of the method are given elsewhere [42]. Briefly, members of Mid-Kent Mental Health Awareness group, including service users, delivered two educational sessions in 5 local secondary schools. Two educational lessons, each one hour long, were given within the Personal Social Health and Education curriculum students aged 14. The participating centres were two grammar (single-sex selective state) school, and three comprehensive (co-educational, non-selective state) schools, typical of those in the local area. At the start of the lesson the young people filled out baseline questionnaires where they were asked 'What sorts of words or phrases might you use to describe someone who experiences mental health problems?' The project was approved by the local research ethics committee.

          The data analysis was deliberately straightforward. First we enumerated the words and terms used to refer to mental illness. Although some of the young people elaborated a little upon the words they chose, most of the data consisted of single words. The first part of the analysis was to tabulate them in order of frequency where the words or terms were offered by at least 3 different students. This was done to map the meanings that students gave to mental illness in terms of their relative importance. Secondly, using the approach of grounded theory [43], the words were grouped in terms of both their denotative and connotative meanings, and labels were derived which captured the key themes attached by the young people to these concepts of mental illness. Denotative meanings are what a term refers to, what it 'names', and connotative meanings are the associations, values, and judgements that surround this. A preliminary examination of our material suggested that connotative meanings would be very significant. We went on to calculate the frequencies of occurrence for each category, and finally over-arching concepts were derived.

          Results

          Of the 634 14-year old students identified in the four schools, 472 (74%) students received both of the two mental health awareness workshops and completed baseline and follow-up assessments. Of these 400 (85%) pupils provided 250 words and terms, and 20 longer phrases, to describe a person with a mental health problem in their baseline assessment. The sample was predominantly female (73%). Fifty two per-cent of the sample attended co-education state schools whilst 48% attended single sex grammar schools. Two hundred and eight students (52%) reported that they personally knew someone with mental illness.

          Table 1 show the 44 most frequently occurring words and terms, namely those that were stated by 3 or more students. Three quarters (n = 33) of these terms are strongly negative in referring to people with mental health problems. Seven terms (16%) of those shown were broadly neutral, including the use of medical diagnostic terms, and only 4 (9%) could be described as at all empathic or eliciting compassion, 'sad' or 'isolated'.
          Table 1

          Most frequently occurring words and terms

          Term

          Frequency

          Term

          Frequency

          Disturbed

          11

          Scary

          5

          Nuts

          11

          Div

          4

          Confused

          10

          Dumb

          4

          Psycho

          10

          Ill

          4

          Spastic

          10

          Loneliness

          4

          Crazy

          9

          Loony bin

          4

          Depression

          7

          Psychiatric

          4

          Disabled

          7

          Screw loose

          4

          Mad

          7

          Stress

          4

          Unpredictable

          7

          Violence

          4

          Insane

          6

          Brain dead

          3

          Loony

          6

          Demanding

          3

          Mental

          6

          Demented

          3

          Schizophrenia

          6

          Dinlo

          3

          Thicko

          6

          Distressed

          3

          Weird

          6

          Embarrassed

          3

          Depressed

          5

          Flid

          3

          Different

          5

          Frustrated

          3

          Freak

          5

          Isolated

          3

          Odd

          5

          Sad

          3

          Problem

          5

          Strait jacket

          3

          Retard

          5

          Wheel chairs

          3

          We identified five themes which emerged from these data (Table 2). The labels used for these themes reflect the overwhelmingly negative connotations used by young people to describe people with mental health problems. The first theme accounts for nearly half the words (116 items) we examined. We have termed this 'popular derogatory terms', and they are in effect 'slang'. In terms of the distinction between denotative and connotative meaning, these terms appear to have no referent but are a set of negative associations and judgements in and of themselves. The second theme occurred about half as often as the first, and is described as 'negative emotional state' (61 items). Not one positive emotional state was mentioned. The most frequently mentioned words were 'disturbed' and 'confused'. These are powerful terms and appear to reflect anxiety on the part of respondents when thinking about mental health problems and the people affected by them.
          Table 2

          Super-ordinate categories emerging from the terms used

          Theme

          1 Popular derogatory terms

          2 Negative Emotional State

          3 Physical Illness or Learning Disability

          4 Psychiatric categories

          5 Violence

          6 Loneliness

          Number of instances

          114

          61

          38

          15

          9

          10

          Examples

          Nuts

          Disturbed

          Disabled

          Schizophrenia

          Scary

          Isolated

           

          Psycho

          Confused

          Spastic

          Depression

          Violence

          Loneliness

           

          Crazy

          Depression

          Dumb

          Psychiatric

            
           

          Loony

          Ill

          Demented

             
           

          Weird

          Stress

          Wheelchairs

             
           

          Freak

          Distressed

              
           

          Screw Loose

          Embarrassed

              

          The third theme demonstrates confusion by the young people between physical disabilities, learning difficulties and mental health problems (38 items). It is notable that the young people hardly used formal psychiatric diagnoses (the fourth theme) at all, preferring the use of emotionally-charged negative terms which represent people with mental illness as someone having a physical disability (15 items).

          Against our expectations, the fifth theme of violence was relatively rare (9 items). This is surprising given that psychiatric patients are so often portrayed by the UK media as perpetrators of violence. We have no explanation for why the theme of violence was used in such a limited way, except to say that many of the derogatory terms have a covert connotation, referring to something to be feared. Only two terms made up the final theme of sadness and isolation, but they do have a slightly more positive connotation than the rest of the material. Isolation and loneliness suggest pity rather than fear.

          More striking was the sheer range and emotional power of the words used (n = 250) showing both a remarkable virtuosity (encroaching upon the vulgar) and a lack of precision in how students expressed themselves when speaking about people with mental illness (see Table 3).
          Table 3

          Terms used by 14 year old school students to refer to mental illness

          Abnormal

          Frustration

          Not fair

          Sometimes lacking brain power

          Abusive

          Fucked

          Not happy

          Spakka

          Alone

          Funny

          Not obvious

          Spanner

          Alzheimers

          Gay

          Not quite there

          Spastic

          Angry

          Get lost

          Not the sharpest knife in the drawer

          Spaz

          Anti-social

          Gone in the head

          Numscull

          Split personality

          Asylums

          Goon

          Nutcase

          Spoone

          Attention seekers

          Green room

          Nutter

          Stiggy nutter

          Autism

          Halfwit

          Nuts

          Stigma

          Bewildered

          Hallucinating

          Nutty as a fruitcake

          Strait jackets

          Bimbo

          Hallucinations

          OCD

          Strange

          Bonkers

          Hand fed

          Odd

          Stress

          Brain damage

          Handicapped

          Oddball

          Stressed

          Brain dead

          Happy club

          Off their rocker

          Therapist

          Breakdown

          Hard

          Out of it

          Therapy

          Childish

          Hard work

          Outcast

          Thick

          Cola sweat

          Head banging

          Padded cells

          Thicko

          Confused

          Head case

          Paedophile

          Thicky

          Crackers

          Helpless

          Panicked

          Tiring

          Crazy

          Hurting yourself

          Paranoid

          Too much pressure

          Cushioned walks

          Idiot

          Patch Adams

          Touchy to talk to

          Dangerous

          Ill

          People who are obsessed

          Troubled

          Deformed

          Indecisive

          Perfectly normal

          Twisted

          Demanding

          Infixed in bad habits

          Perverted

          Twister

          Demented

          Insane

          Physical problems

          Ugly

          Depressed

          Insecure

          Physically ill

          Unable to make decisions

          Depression

          Intellectually challenged

          Pills

          Unappreciated

          Deranged

          Intimidating

          Pinflump

          Unapproachable

          Difficulty learning

          Irrational

          Pive

          Uncomfortable

          Dildo

          Isolated

          Plank

          Under pressure

          Dinlo

          Joe from Eastenders

          Ponce

          Understandable

          Disabled

          Jumpy

          Pressure

          Unfair

          Disarmed

          Learning difficulties

          Pressurising families

          Unfortunate

          Disorientated

          Lonely

          Problems

          Unhappy

          Distorted

          Loony

          Psychiatric

          Unpredictable

          Distressed

          Loony bin

          Psychiatric health

          Unstable

          Distressing

          Loser

          Psychiatrist

          Upsetting

          Disturbed

          Lost

          Psycho

          Veg

          Disturbing

          Lunatic

          Psychopath

          Vegetable

          Disturbing images

          Mad

          Reject

          Victim

          Div

          Made fun of

          Retard

          Victimised

          Dizzy

          Madness

          Sad

          Violence

          Doctors

          Manic depression

          Sandwich/pepperoni short of a picnic

          Violent

          Dofuss

          Mass murderers

          Scared

          Voices

          Dopy

          M.E.

          Scared to talk to if they were a murderer or rapist

          Voices in your head

          Downy

          Mental

          Scary

          Vulnerable

          Dribbling

          Mental hospital

          Schizo

          Wacky

          Drugged-up

          Mental illness

          Schizophrenia

          Wally

          Dulally

          Mental institution

          Schizophrenic

          War

          Dumb

          Mentally challenged

          School can cause it

          Wheelchair jockey

          Embarrassed

          Mentally handicapped

          School pressure

          Weird

          Embarrassing

          Mentally ill

          Screw loose

          Weirdo

          Empty

          Misunderstood

          Screwed

          Wheel chairs

          Escaped from an asylum

          Mong

          Sees things in a different way

          White coats

          Excluded

          More common than you think

          Segregation

          Wild

          Feel sorry

          Muppets

          Self-harm

          Wild funny noises

          Few sandwiches short of a picnic basket

          Needing help

          Shock syndrome

          Window licker

          Flid

          Nervous

          Shouts

          Withdrawn

          Flip in the head

          Nightmares

          Sick in the head

          World of their own

          Freak

          Non-caring

          Simple

          Worried

          Fruit cake

          None caring

          Simpleton

          You belong in a home

          Frustrated

          No-one upstairs

          Some people born mentally ill

           

          Frustrating

          Not all there

          Sometimes includes drugs

           

          Discussion

          How do young people learn such wide-ranging, emotionally-charged and negative terms about mental illness? The primary sources appear to be from the media, and from family and peers [4446]. Derogatory references about people with mental illness appear commonly in the print, broadcast and cinematographic media [47, 48]. For television and newspaper items about mental illness, for example, between one third and two thirds refer primarily to violence [25]. The highest rate of such negative coverage occurs in children's animations, where up to two-thirds of all references are to violence [49, 50]. Interestingly, almost a half (46%) of all the episodes contained some reference to mental illness, especially in cartoons, where the vocabulary analysed in one New Zealand study was 'predominantly negative fundamentally disrespectful. The characters were typically losing control, constantly engaged in illogical and irrational actions', and were 'stereotypically and blatantly negative, and served as objects of amusement, derision or fear.' [50] Children's programmes in the USA have produced almost identical results, where the images were 'typically used to disparage and ridicule' [44, 51]. More specifically, a Canadian study examined Disney animated films for children and found that 85% contained verbal references to mental illness and they were mainly used to 'set apart and denigrate' the characters [52].

          Our results, alongside previous research, suggest the following conclusions. First, the level of factual knowledge among 14 year old school children about mental illness is remarkably low, and this may partially explain why their rates of recognition of mental illness are poor. The magnitude of this information gap has previously been underestimated [53]. Second, the strongly negative emotions described in this paper offer a route for future investigation on whether this helps to explain why young people, even more than adults [5456], are so reluctant to seek help when experiencing mental illness, and often tend to feel that they should cope alone [57].

          Our methodological approach has three important limitations. First, our method of data collection may be described as over-simplistic. However, our method has given a clear account of the full range of language used by young people when referring to mental illness which would be difficult otherwise to ascertain and so this study can be used as a benchmark for future research. Second, as the study was predominantly female, the sample size did not allow us to explore important possible gender differences, for example whether the words and terms used suggested a greater degree of mental health literacy for female students [58]. Third, the nature of the results, very largely showing the use of negative terminology, did not allow us to establish whether those students with personal contact with people with mental illness used systematically more favourable terms.

          Conclusion

          An appreciation of both factual ignorance and the degree of emotionally-charged prejudice by school students against people with mental illness is necessary when planning interventions intended to improve help-seeking [25, 59, 60]. The strongest evidence-based intervention known to reduce stigmatising attitudes (but not yet shown to change discriminatory behaviour) is direct social contact with a person who has mental illness [21, 26, 42, 61, 62]. Our findings, if replicated, suggest that help-seeking by mentally ill young people may be improved by interventions that address both their lack of factual information about mental illness, and those which reduce their strong negative emotional reactions towards people with mental illness [63].

          Declarations

          Acknowledgements

          This work was funded by an education grant by Lundbeck UK. The authors are independent of the funder. We would like to acknowledge the very helpful comments of Dr. Ann Law on earlier drafts of this paper.

          Authors’ Affiliations

          (1)
          Service User Research Enterprise, Health Service and Population Research Department, Institute of Psychiatry, King's College London
          (2)
          Section of Community Mental Health Health Service and Population Research Department Institute of Psychiatry, King's College London
          (3)
          Rethink severe mental illness

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          64. Pre-publication history

            1. The pre-publication history for this paper can be accessed here:http://​www.​biomedcentral.​com/​1472-6963/​7/​97/​prepub

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          © Rose et al. 2007

          This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://​creativecommons.​org/​licenses/​by/​2.​0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.