An exploration into the stigma surroundin university students with depression in the UK final
1. Nottingham Trent University
School of Social Sciences
An exploration into the stigma surrounding university students
with depression in the United Kingdom (UK).
Student name: Samantha Varty
Student number: N0503749
Course title: BA (Hons) Health and Social Care
Module title: Integrative Research/ Practice Dissertation
Option: Critical Literature Review
Supervisor: Linda Kemp
Word Count: 10,500
2. 1
Acknowledgements:
First and foremost, I would like to thank my supervisor, Linda Kemp. Thank you very
much for your patience, understanding, guidance and advice.
To my friends who helped me throughout the entire duration of my degree, I am
extremely grateful. Special thanks go to my course mate, best friend and sister from
another Mister, Nina Merritt. Thank you for helping me overcome my setbacks,
motivating me to keep going and just being your optimistic self. For the moments of
madness and the library sessions. I could not have done it without you.
To my partner, Stanley. Though the road of third year has been bumpy, there is no
one else I’d wish to have by my side throughout the journey. Your humour, love and
support has kept me going.
And last but by no means least, my mum and dad. The education you have given me
over the years goes beyond the world of academia, and for this, I am extremely
grateful. Thank you for all your love, encouragement and constant support.
4. 3
Abstract
The focus of this dissertation is to enlighten readers on the topic of mental health
stigma amongst depressed university students in the UK. The review will explore a
variety of different literature surrounding the topic. Beginning with the
conceptualisation of stigma by Link and Phelan followed by its application as to
whether stigma acts as a barrier for students seeking help for their depression, it
then delves into the topic of overcoming stigma. The review will consider theories
surrounding effective approaches to tackling self-stigma and public stigma, such as
Corrigan and Penn’s stigma reduction theory, in order to evaluate existing
campaigns, drawing conclusions upon the best method to tackle stigma at university.
The key findings from this literature review suggest that new approaches may be
required in order to successfully tackle stigma of mental health in universities in the
future.
5. 4
Introduction:
‘Mental illness is nothing to be ashamed of, but stigma and bias shame us all.’
– Bill Clinton (1999)
After losing a friend to suicide, former US president Bill Clinton expressed his anger
toward stigma surrounding mental health. This profound statement by Clinton (1999)
epitomises the focus of this dissertation and therefore this quote seems apt. In
recent years, stigma surrounding mental illness has become an emerging issue for
researchers attention. Hattenstone (2013) reports that student Toby Thorn, unaware
of his crippling depression, never sought help for his state of mind -- instead, he
committed suicide at university. This is not a lone case, in fact, according to the
Office for National Statistics (2012), the number of students who took their own life in
England and Wales rose by 50% between 2007 and 2011. Hattenstone (2013)
emphasises the need for openness surrounding the subject, yet suggests that stigma
stands in the way of this happening. Given the seriousness surrounding this topic,
there is need to consider the stigma of mental illness at university. It is the aim of this
dissertation to specifically look at the stigma of depression amongst students. Mental
health stigma prevents 32% of young people with a mental health issue from
applying for further education (Time to Change, 2016a). This dissertation seeks to
delve into the topic of how stigma works, how it is applied to students with
depression and consequently ways in which stigma can be tackled.
Before approaching this dissertation, it is important to understand what is meant by
the key terms in the title. For the purpose of this review, students will be defined as
undergraduates between the ages of eighteen and twenty-five. The World Health
Organisation (2015) define depression as ‘a common mental disorder, characterized
by sadness, loss of interest or pleasure, feelings of guilt or low self-worth, disturbed
sleep or appetite, feelings of tiredness, and poor concentration.’ The Equality Act
(2010:4) adds to this definition stating that a mental health condition can become a
disability if it has a long-term effect on a person’s ability to carry out day-to-day
activities. Therefore, individuals with depression are entitled, under the law, to
challenge discrimination. This literature review will specifically focus on the stigma
6. 5
surrounding depression. England’s biggest anti-stigma campaign, Time to Change
(2016d), have defined stigma as ‘the perception that a certain attribute makes a
person unacceptably different from others, leading to prejudice and discrimination
against them’. Mental illness is surrounded by prejudice, ignorance and fear and it is
due to these stigmatic attitudes that difficulties arise or intensify for those with a
mental illness. There are two types of stigma which will be focussed on in this
review: self-stigma and public stigma. The concept of stigma will be looked at further
in chapter one.
This dissertation will be divided into three distinct chapters, each of which deals with
emergent categories that are found in literature surrounding stigma amongst
university student populations. The first chapter will specifically focus on the
conceptualisation of stigma, as outlined by Link and Phelan (2001). This
conceptualisation acts as a framework into further themes such as such as labelling,
stereotypes and discrimination. Delving into the conceptualisation by researching its
components will help elucidate whether stigma has an impact on mentally ill people.
Chapter two will consider the prevalence and risk factors surrounding the issue of
depression amongst students and research help-seeking attitudes in order to
determine whether stigma acts as a barrier to students with depression. It will
consider help-seeking attitudes by reviewing relevant studies. The third chapter will
consider theories surrounding reducing both self-stigma and public stigma. By
reviewing an anti-stigma campaign aimed at a British University, strengths and
limitations can be drawn from the literature, allowing conclusions to be made upon its
efficacy and using theory to suggest improvements for future campaigns.
Walliman and Appleton (2009) suggest that a critical literature review should follow a
systemic process. Firstly, there needs to be a clear area of research. Next, research
and appraisal of relevant literature should be carried out. Then, synthesising the
material to develop new insights into the specific topic. A critical literature review
provides the opportunity for new insights to be developed through re-analysing past
studies allowing a possible gap within research to be exposed (Aveyard, 2010). A
critical exploration of literature will be carried out in order to critically analyse the
aims and objectives of this review, which are outlined below. It is hoped that
reviewing differing viewpoints within literature can provide different opinions and
insight into the topic allowing literature to elucidate whether there is a stigma
7. 6
surrounding this focus group and provide suggestions on what can be done to
overcome stigma.
Methodology, Aims and objectives.
Methodology:
In order to carry out this literature review successfully, the use of specialist
literature will be implemented, with focus to journal articles and books in order to
obtain existing literature surrounding the topic of stigma. Other literature, such as
charity documents, will be heavily implemented. Documents and studies
completed by Time to Change will be used in order to help understand many
different issues surrounding stigma.
Literature, such as books and journals, will be obtained by using the University’s
library, along with their online tool; Library OneSearch which will aid access to e-
books and journal articles. Google Books and Google Scholar will also aid me in
research and I will use advanced searches on all databases in order to gain
precise information that is required for such a specific topic. One heavily cited
author throughout this dissertation is Patrick Corrigan, a well-known scholar
surrounding the field of mental health and stigma. ResearchGate was used in
order to browse through his publications.
Aim:
- To devise a critical literature review exploring current research surrounding
the topic of stigma amongst university students in the United Kingdom, to
highlight any gaps in the literature.
Objectives:
- To look into the process of stigmatisation in order to gain knowledge and
understanding of how the process works and what components are involved.
- To look into help-seeking attitudes surrounding university students with
mental illness in order to elucidate whether stigma acts as a barrier to help-
seeking, concluding with the effects of not seeking help.
- To consider possible approaches to overcome stigma among university
students.
8. 7
Chapter One: The stigma surrounding
mental illness.
Introduction:
The aim of this chapter is to determine whether there is a stigma surrounding mental
illness. To do so, the components of stigma, as outlined by Bruce Link and Jo
Phelan (2001) as labelling, stereotyping, separation and status loss, will be
examined. This is to draw conclusions on the concept of stigma and what effect it
has on those suffering with a mental illness.
Typesof stigma:
This review will specifically focus on self-stigma and public stigma. Corrigan and
Watson (2002:16) state that ‘public stigma is the reaction that the general population
has to people with mental illness’. This refers to the attitudes and beliefs held by the
general public surrounding mental illness. These negative attitudes and beliefs held
by society lead to stereotyping, prejudice and discrimination against people with a
mental illness (Corrigan, 2004). Therefore, the public stigma associated with
someone seeking mental health services is that they are undesirable or socially
unacceptable (Vogel et al, 2006). Self-stigma, however, is defined by Corrigan and
Watson (2002) as the prejudice which people with a mental health problem turn
against themselves. Self-stigma also includes stereotyping, prejudice and
discrimination. In order to experience self-stigma, the individual must be aware of the
stereotypes that are held against a stigmatized group (Corrigan et al, 2009). A
mentally ill individual may start to believe the negative thoughts displayed by others
and consequently think that they are unable to recover, not deserving of treatment,
responsible for their illness or potentially dangerous (Corrigan et al, 2012a).
The components ofstigma:
According to Link and Phelan (2001), stigma is made up of four components;
labelling, stereotyping, separation and status loss. In 2004, Link and Colleagues
worked together to update the conceptualisation by adding the ‘emotional reaction’
stage.
9. 8
Labelling:
The first component highlighted by Link and Phelan is labelling. The labelling theory
was first applied to mental illness in 1966 when sociologist Thomas Scheff published
‘Being Mentally Ill.’ Scheff (1966) proposed that the act of being labelled as mentally
ill would in fact cause mental illness. Scheff (1966) argued that society was so
influential that once a person had been labelled, the person changed their behaviour
to adapt to the expectations of society, thus becoming mentally ill.
Two decades later, a modified version of the labelling theory was published by Link
and colleagues (1989). The modified labelling theory obtains aspects from the
original theory but disagrees with the notion that labelling is causal of mental illness.
The modified version dismisses the causal relationship, focusing more on the
consequences of labelling (Amzat and Razum, 2014). Leff and Warner (2009) reject
the idea that labels create mental illnesses directly and instead suggest that labelling
can lead to a poor outcome for the individual. Link and colleagues (1989) state that
people with a mental illness hold an expectation to be labelled and it is this
expectation which often causes service users to withdraw from society. They add
that mentally ill people being labelled are constantly rejected from society in
seemingly minor ways, however when considered holistically, all of these small
snubs can severely adjust their self-concept. Pasman (2011:124) concurs this by
stating that ‘diagnosis has a negative influence self-concept, through stigma and
stigma expectations.’
With their self-concept damaged, mentally ill people are at risk of internalising
negative labels and falling victim to self-stigma. Corrigan and Colleagues’ (2009)
‘why try’ effect functions on a three-step process: awareness of the stereotype,
agreement with the stereotype and applying it to oneself. This model exceeds the
modified labelling theory as it introduces the idea of self-efficacy. Self-efficacy refers
to believing in your ability to succeed in specific situations to accomplish a task
(Bandura, 1997). Self-efficacy can play a major role in how someone will approach
goals, tasks and challenges. Whilst the modified labelling theory acknowledges
people may avoid situations which make them feel publically disrespected as a result
of self-stigma, the ‘why try’ model exceeds these notions. The ‘why try’ model
10. 9
expands by suggesting that people who agree with negative stereotypes and apply it
to themselves will find it difficult to maintain a positive self-concept and may feel
unable to tackle specific life goals. It is named the “why try” effect as this is the effect
felt by the stigmatised person. Due to the internalised stigma, they feel incapable of
tackling life goals such as attending university. ‘Why should I go to university?
Someone like me is not worthy of such a goal.’ However, the depth of self-stigma is
dependent upon whether the individual has been through the process. Alternatively,
reactions to stigma may evoke personal empowerment (Corrigan et al, 2009:77). As
a result of the mentally ill individual experiencing hostility towards themselves in the
form of stereotypes, they generate the negativity and react in a manner where they
are energized by the stereotype and become empowered in reaction to them
(Corrigan et al, 1999). From reviewing the ‘why try’ model, it is evident that there are
two opposite sides of the spectrum to how people will react to the process of being
stigmatized. Where some mentally ill people will consider themselves to be the
negative stereotype that they associate with their own mental illness, leading to self-
stigmatisation, others will purposely distance themselves from the stereotype to
empower themselves.
Stereotyping:
Link and Phelan (2001) believe that the labels link the person to a set of undesirable
characteristics, forming a stereotype. Green et al (2005:197) describe stereotyping
as ‘the assignment of negative attributes to socially salient differences.’ Perhaps the
most common stereotype is that all mentally ill people are violent (Joseph, 2016).
This stereotype could increase the social exclusion of many people with a mental
illness as the public believe them to be dangerous. The Mental Health Foundation
(2015b) point out that realistically, there is a greater risk of the mentally ill person
being attacked or harming themselves rather than harming others. Media can
influence stereotypes surrounding mental illness. In a study carried out by anti-
stigma campaign, Time to Change (2009), almost half (49%) of the people surveyed
stated that they had witnessed a portrayal of a mentally ill character acting violently
in films. The survey also highlighted that 44% believe that people with a mental
illness will act violently. From these statistics, it can be inferred that people still
believe the misconception that all mentally ill people are violent and dangerous. This
11. 10
misconception is not helped by sensationalism and exaggeration by the media.
Joseph (2016:8) states that violent incidents conducted by a minority of mentally ill
people are exaggerated by mass media and can dominate the news-cycle. Huang
and Priebe (2003) conducted a study which aimed to assess the content and tone of
British print media articles surrounding mental illness by comparing them with
Australian and American versions. The study found that 76.3% of UK articles had a
negative tone towards both mental illness and mental health care. This study is
limited as it only considers two newspapers per country. The study would be more
reliable should more newspaper brands has been used- perhaps even then the
findings would have been different.
Bithell (2010) conducted research targeting medias attitude towards mental illness in
the United Kingdom. It was found that media coverage surrounding mental illness is
often negative in tone, portraying mentally ill people as violent, which emphasises
the negative stereotype and connotations surrounding mental illness. The research
completed by Bithell (2010) also compared attitudes towards mental health in the UK
to attitudes held by the US and Australia, finding that British attitudes are far more
negative in tone out of the three. The use of primary data alongside research around
the area somewhat strengthens the reliability of the findings as it shows the research
encompasses many different methods of research. These findings offer a more up to
date source in comparison to Huang and Priebe (2003). Furthermore, both studies
prove the same point: that media has a negative influence on mental illness in the
United Kingdom. This document is still being worked on, reducing its reliability as it
has not yet been peer reviewed. The media portrayal of mental illness has a degree
of sensationalism involved. Corrigan et al (2011) support this notion by stating that
newspapers and magazines often include sensational headlines that portray
mentally ill people as violent, suggesting that news stories present mentally ill people
as violent and dangerous. This is an example of how media promotes stigma
surrounding mental illness. Noakes (2004:55) emphasizes that the press must
accept responsibility in the stigmatization of mental illness, by indulging in
sensationalism. As discussed in this section, stereotyping an individual with a mental
illness contributes to the stigma process and stereotypes can add to the
discriminatory ways in which people with mental illnesses are treated.
12. 11
EmotionalReactions:
Link and Phelan’s conceptualisation was modified in 2004. Link et al (2004) sought
the importance to introduce ‘emotional reactions’ to the model. Link et al (2004:513)
state that those who are separated as “them” – in this case the mentally ill individual,
are more likely to feel ‘anger, irritation, anxiety, pity and fear’. Link et al (2004)
emphasise that the way the general public react in response to their emotional
reactions results in discrimination and status loss for people with mental illness. For
example, a person with a mental illness may be spoken to in a pitiful way, with a soft
calm tone. This only reiterates the sense that the mentally ill person is perceived as
different by society, and they need to be spoken to differently. (Link et al, 2004). This
further emphasises the ‘us and them’ component- the mentally ill people are seen as
different and separate, with a need to be treated differently from other ‘normal’
people, despite that ‘they’ display emotions like everyone else.
Separation:
Green et al (2005:198) states that ‘separation occurs when the reactions of others to
these differences lead to a distinct sense of “otherness.”’ This is the stage in which
the individual with a mental illness internalises the stigma as a result of the labelling,
stereotyping and being treated as different. Watkins (2008:18) elaborates on this
notion, stating that an ‘us and them’ attitude is apparent in society towards those
labelled “mad”. This part of stigmatisation involves a separation of ‘us’ from ‘them’,
implying that those that fall under the category of “them”, in this case people with a
mental illness, are not really human and deserve to be treated differently, potentially
worse (Link et al, 2014: 52). An example of this component, given by Link and
Phelan (2014: 79), states that ‘a person has heart disease, cancer or an infection but
a person who develops schizophrenia ‘is’ a ‘schizophrenic’ - a different sort of person
than the rest of ‘us.’ By marking out someone as different, it makes it easier to
isolate them from the rest of society.
Discrimination and status-loss:
The next component of stigmatization is status loss and discrimination.
Discrimination refers to treating some groups less well than others, in this case it
refers to stigmatizing attitudes against the mentally ill (Moonie et al, 2000). ‘Status
loss and discrimination occur when stigma interferes with an individual’s ability to
13. 12
contribute fully to the social and economic life of their community.’ (Green et al,
2005:198). Stigmatized people are labelled, isolated from the rest of society, and
linked to adverse characteristics, leading them to experience status loss and
discrimination. Stigmatized groups are disadvantaged when it comes to a general
profile of life opportunities, according to Corrigan et al (2009). Link and Phelan
(2001:373) state that ‘a lower position on the status hierarchy can have a cascade of
negative effects on all manner of opportunities’. For example, lower status may make
the individual less likely to be socialised with, thus socially withdrawing from the
community.
Power:
Power must be exercised for stigmatisation to occur (Link and Phelan, 2001).
Stigmatization is entirely dependent on access to social, economic and political
power that permits the identification of otherness, the construction of stereotypes,
the emotional response period when mentally ill discover their ‘otherness’ - the
separation process which categorises individuals, and the full execution of status
loss and discrimination.
Bruce Link and Jo Phelan’s (2001) components of stigma provide discussion into the
key issues surrounding stigma. The components analysed above (labelling,
stereotyping, emotional reactions, separation and status loss) are combined in order
to make a hierarchical theory which is structured by power. Sayce (2016) states that
it is not enough to just label and belittle a group for stigmatisation to occur. This is
due to the accuser’s lack of power in imbuing their accusations with serious
discriminatory processes. The conceptualisation defines stigma in relation to its
interrelated components and encourages further investigation into each one of the
four components.
Upon delving into the conceptualisation of stigma, each component encouraged
further investigation into the process of stigmatisation which have been outlined
above. Jo Phelan and Bruce Link each have numerous peer reviewed articles
surrounding the topic of stigma. Whilst the original conceptualisation was published
in 2001, they expanded on it in 2004, showing development on the subject. The
conceptualisation built on past criticisms surrounding stigma by making it more
14. 13
focussed on the effects of stigma, by considering emotional responses of labelling
and stereotypes.
Conclusion:
In conclusion, it can be elucidated from the literature reviewed that there is a stigma
surrounding mental health, resulting in a negative impact on the individual with a
mental illness. The conceptualisation of stigma (Link & Phelan, 2001. Link et al,
2004) offers clarity of the different components providing knowledge of a step by
step explanation of how stigma is processed. Public stigma is apparent as there are
many stereotypes surrounding those who are mentally ill, including the notion that all
mentally ill people are violent. This is often not helped by the sensationalism within
the media. The labelling aspect of stigma encouraged extensive research
surrounding the matter, of which an alternative model was found: the ‘why try’ effect.
The ‘why try’ effect proved to be a significant milestone in this research area as it
provides both a positive and a negative response to the labelling process.
Furthermore, the ‘why try’ effect delved into its own theory suggesting that for people
to self-stigmatise, they need to be aware first of the connotations and stereotypes
surrounding their illness. Using Link and Phelan’s conceptualisation proved helpful to
aid further research as it encouraged further reading. It can be inferred by reviewing
the above literature that there is a stigma surrounding mental illness and whilst in
some cases it works as a “reverse effect” and empowers individuals, in many cases
it results in separation, emotional reactions, status loss and discrimination which can
result in negative effects on individuals. Stigma has been explored by looking at
various theoretical concepts. The next chapter focuses on stigma in a practical
setting, specifically of mentally ill students in a university setting, and how stigmatic
processes form a barrier to help seeking.
15. 14
Chapter Two: To what extent does
stigma act as a barrier to help-seeking
amongst students with depression?
Introduction:
The notion that stigma is a hindrance on those suffering with a mental illness will be
further explored throughout this chapter by critically reviewing the literature
surrounding the topic of depression among students. Mental health issues amongst
students and academics have become a growing issue (The Guardian, 2016).
Depression in particular is a wide-spread illness with one in five people experiencing
depression in their lifetime. This chapter will firstly consider why depression is an
important focus point, discussing factors that may develop or exacerbate depression.
Coughlan (2015), emphasizes that mental health problems within universities have
‘increased dramatically’, indicating that there are a rising number of students
struggling to cope with life on campus and a sharp rise in the demand for
counselling. As highlighted in the introduction, student’s mental illness is worsening
and becoming a significant focus of research attention. Whilst mental illness is
becoming more common, there is also a concern with help-seeking attitudes and the
issue of under-reporting. Due to the fact mental illness is an increasing concern
within universities and contemporary society, there is need to research this further.
This chapter will research the help-seeking attitudes of depressed students by
considering studies and literature surrounding the topic, in order to elucidate whether
stigma acts as a barrier to help-seeking amongst students with depression.
Pressures students faceconcerning mentalhealth:
Beckett and Taylor (2010:94) highlight that ‘any change in human life involves a
psychological readjustment, a coming to terms with an ending and coming to terms
with things being different.’ The University of York (2016) acknowledge that whilst
transitioning to university is an exciting time, the change is not always easy for all
students to cope with. This is supported by Warwick et al (2006) who found that the
transition into university can contribute to poor mental health. The National Union of
16. 15
Students (2014) highlight that the university environment is often considered to be
associated with high pressure and stress for students, academically and socially.
Another consideration is the pressure of making friends. Mackaskill (2012:427)
states that companionship could be a difficulty as ‘students are now taught in larger
groups, which can make it more difficult to make friends and develop a sense of
belonging.’ Wilcox et al (2005) found that those struggling to make friends were more
likely to withdraw themselves from university, and consequently drop out. In a report
by the Telegraph (2014) entitled ‘Dealing with Depression at University’, the head of
well-being at the University of Surrey stated that students are under financial
pressure, the pressure to do well in their degree in addition to the pressure of
competing in a job market to secure employment after graduation. From the literature
reviewed above, it can be suggested that although the transition to university life is
often described as an exciting time, this is not always the case, and there are
different pressures faced by different students.
Possible outcomesof pressures atuniversity:
Morris (2011) states that for some students, university can be a stressful experience
and even detrimental to mental health. Students Against Depression (2016), is a
student-run website designed to help students by offering advice, information,
guidance and resources surrounding low mood, depression and suicidal thoughts.
Students Against Depression (2016) suggest that the transition from social familiarity
to a new social environment with different people can trigger episodes of anxiety and
depression to those who are already battling depression or are vulnerable to it.
Andrews and Wilding (2004) inspected questionnaires completed by university
students one month before university entry and at the mid-course. The study found
that 9% of previously depression symptom-free students had become depressed by
mid-course and 20% became anxious at a clinically significant level. This was the
first British study to confirm that factors introduced to students at university, such as
managing their own finance, can increase levels of anxiety and depression and that
financial difficulties can affect academic performance. However, it is important to
highlight that findings were not completely negative. In fact, Andrews and Wilding
(2004:517) state that ‘both positive and negative changes were apparent in anxiety
and depressive conditions from before university entry to mid-course’. Whilst 29% of
symptom-free students developed anxiety or depression by mid-course, 36% of
17. 16
those with prior conditions had ‘recovered’. This study suggests that university is not
necessarily a negative experience and in this case, the transition into higher
education offers positive opportunities. Roberts et al (1999) sampled students from
two universities in London with questionnaires. Data found from the study linked
mental illness to financial difficulties, stating that students’ financial problems were
linked to poor academic performance, poor psychological functioning and
depression. The findings of this study are indicative that there is a link between
financial issues and mental health problems among students. Whilst the study
presents a plausible link between financial pressure and mental health, the study
was carried out in 1999, which may regard the results as outdated when applied to
today.
Help-seekingattitudes amongstuniversity students:
First it is important to determine what is meant by help-seeking. Help seeking can be
spit up into two sections- formal or informal help seeking (Rickwood et al, 2012:10).
Formal help-seeking involves ‘assistance from professionals who have a legitimate
and recognised professional role in providing relevant advice, support and/or
treatment.’ Phippen (2010) outlines the various different methods of formal help-
seeking which are available specifically for students. These include medical support,
support from university tutor and counselling. Jackson (2006:223) states that
informal help-seeking involves seeking help from ‘family, friends or indigenous
persons and systems.’ The literature reviewed outlines many options for students
with depression.
The number of students seeking help for depression has more than doubled at some
of the country’s top institutions. This leads us to question why mental health
problems have increased. Research completed by The Higher Education Funding
Council for England (2015) suggests that societal attitudes are changing which
consequently means that students are feeling more able to open up about their
mental health issues. This is a factor which may have contributed to the rise in
demand for mental health support amongst students.
However, it is important to consider both sides of the story. One in four people
experience some kind of mental health problem in the course of a year, according to
the Mental Health Foundation (2015a). Not only are mental health problems
18. 17
increasing amongst university students, it can be suspected that there is also a case
of under-reporting. The report released by the Equality Challenge Unit (2012) found
that only 1 in 150 (0.7%) disclosed a mental illness to their universities. Given that
one in four people experience some kind of mental health issue in the course of a
year, this disclosure rate suggests a case of under-reporting. If there is under-
reporting, like these statistics imply, and there are students who are not being
treated for their depression, then it can result in intensified negative effects. This
raises the question of why students suffering from depression do not seek help
available to them. One likely reason is due to the stigma surrounding mental illness
(Patel, 2007).
The effectof stigma on help-seeking attitudes:
In this section, studies will be reviewed in order to elucidate the link between stigma
and help-seeing. Time to Change (2016b) are an anti-stigma campaign run by the
leading mental health charities Mind and Rethink Mental Illness. Time to Change
(2014b), conducted a survey in order to gather experiences of education amongst
those who have experienced a mental illness. Results from the survey found that just
over three quarters of young people (77%) with a mental health problem have
missed out on education. The survey also found that one in four students did not
attend school due to the fear of what other pupils would say. Nearly one third (31%)
were on the receiving end of derogatory language with respondents citing the terms
“crazy”, “mental”, and “attention seeking.” To conclude, it is perhaps unsurprising
that nearly half of those questioned (48%) chose not to tell anyone at their academic
institution about their mental illness. The survey indicates that students had concerns
of what people thought of them, which is consistent with the stigmatisation process.
Students are afraid of the labels surrounding by stigma, which are set in stone due to
the stereotypes held of mental illnesses. Students feel as though they are being
treated differently, and separated from the rest of the ‘normal’ students. This
separation leads to discrimination for being different and in this case, they are
missing out on education. This is a representation of how the stigma
conceptualisation works in practice. This is also consistent with the ‘why try’ effect
as students feared the labelling process to the extent they missed out on education,
thus not tackling life goals and affecting life opportunities.
19. 18
The Time to Change survey was completed online, which, considering the topic of
the survey is stigma, is more efficient than through a more personal medium. In a
medium such as a focus group, the individual may not contribute honestly due to the
fear of being stigmatised- this weakness is erased when the computer screen acts
as a protective screen of anonymity. However, the questions revolved around the
student’s whole educational career- primary and secondary school, further and
higher education- which limited the accuracy of the survey in regards to specificity to
stigma surrounding university students.
Student Minds (2016) is a mental health charity specifically focussing on student
mental health in the UK. They carry out research in order to gain knowledge and
understanding surrounding mental illness amongst the student population, identifying
this as an under researched area. Grand Challenges (2014) is a research project
which aims to find out what university students and staff find most difficult about
living with a mental illness at university. As a result of this research, there were
several key challenges identified by students relating to peer relationships and the
impact of stigma such as the fear of being judged which was rated the biggest
challenge in student mental health. Another grand challenge was the fact that mental
health problems are seen as a ‘weakness.’ This also shows students fear being
stigmatised which prevents them from seeking help. This is again due to the label
and stereotype surrounding mental illness as “weak” the separation of the weak and
the strong and the discrimination against the weak. Those with mental illness then
will feel stigmatised and unable to adapt an open approach about their mental
illness. This research provides us with the knowledge that there are significant
feelings of stigma in the university environment in the UK surrounding the topic of
mental health. The Grand Challenges research project focusses specifically on
undergraduate student mental health and draws attention to certain challenges
surrounding mental health.
A survey by the National Union of Students (2013) was conducted which found only
one in ten students affected by mental illness use their university counselling service
despite the availability of seeking help. Drum et al (2009) suggest that student’s
associate seeking psychological help or counselling with the fear of being labelled
and stigmatized, consequently avoiding seeking help. Few teenagers receive
treatment for their mental health problem due to the fact they worry about what other
20. 19
people think, according to Meredith et al (2009) – this presents a crucial barrier to
help seeking. These findings are consistent with the conceptualisation theory and the
aforementioned studies. The Chief Executive of Mind, Paul Farmer, suggests that
students chose not to seek help due to the stigma surrounding mental illness
(Raconteur, 2015). It can be inferred that stigma is present which is acting as a
barrier to seek help. Students therefore face a quandary; if they do seek the help
they require, they run the risk of being stigmatized, yet if they do not seek help it is
likely that they will continue to suffer in silence.
The studies above offer insight into the issue of stigma surrounding mental illness
amongst students. However, when searching specifically for data surrounding help
seeking attitudes amongst students with depression, there were few British studies
to be found, and so this could be an avenue of future research. Despite the lack of
available studies, depression is still a common and growing mental illness and there
is a suspicion of under-reporting, which suggests that depression among students is
higher than anticipated and stigma is a potential barrier to help-seeking.
The consequencesof stigma:
Stigma can decrease the likelihood that an individual will access and utilise mental
health services, despite the potential consequence of not seeking help is intensified
suffering (McDaid, 2008). The British Association for Counselling and Psychotherapy
(2014) state that when psychological distress and mental illness are left untreated it
can lead to students dropping out of university or failing to reach their full potential.
The consequences of not seeking help are long term, with issues such as low self-
esteem, poor future life-chances and on-going mental health issues throughout their
adulthood.
The Social Exclusion Unit (2004) highlight that people with a mental illness are at
greater risk of physical health problems such as obesity, cardiovascular disease,
respiratory disease and diabetes. Parle (2012) state that stigma can result in a
detrimental effect on physical health because sufferers do not access help seeking
services.
Stigma can also affect students with future employment. Parle (2012) states that
many people with a mental illness have experienced discrimination, a facet of the
stigmatic process, when applying for jobs. This includes having to try and explain
21. 20
gaps in their CV for episodes of mental illness. The consequences of not confronting
nor overcoming stigma, as has been shown, can result in long term dangers in
health, employment and self-concept for the student, in addition to potentially
dropping out.
Conclusion:
It can be concluded that depression is a common mental illness amongst the specific
focus group of students. Students are considered more likely to suffer with
depression due to the pressures they are faced with at university. The process of
stigmatisation is apparent in the aforementioned studies. It is clear to see, when
reflecting upon the studies, that students fear the process of stigmatisation. Students
were scared of being called ‘crazy’ or ‘mental’ which consequently meant they chose
not to disclose their mental illness. For this reason, there is suspicion surrounding
how accurate the statistics surrounding mental illness are due to the number of
people who are silenced due to stigma. All of the studies above made reference to
stigma acting as a barrier in some way. The majority of literature reviewed shows
that there are still students who feel they are faced with a choice between facing
stigma and suffering in silence. In order to prevent the latter, there is an importance
to explore methods to overcome stigma.
-
22. 21
Chapter Three: Tackling mental health
stigma at university
Introduction:
The issue of help seeking attitudes amongst university students with depression has
previously been explored in chapter two. It was identified that stigma plays a key role
in why students do not seek help- either formally or informally- for their depression.
Stigmatisation is a central reason for not seeking help and potentially also under-
reporting, regardless of the negative consequences for not seeking help. It is the aim
of this chapter to consider methods of tackling mental health stigma in order to
elucidate whether these approaches are effective amongst a student population. The
first part of the chapter will focus on theories surrounding stigma reduction: literature
will be reviewed in order to understand what the best approach is for tackling both
self-stigma and public stigma. This chapter will then review an anti-stigma campaign
conducted by the University of Sussex in order to review the approaches they
applied in their campaign, to elucidate how effective the theory is in practice.
Following this analysis, conclusions will be made regarding suggestions to improve
the approaches and consequently improve people’s attitudes towards mental illness,
hence removing the stigma surrounding mental illness.
Tackling self-stigma:
Self-stigma can be tackled in a number of different ways. A Briefing Paper conducted
by the Royal College of Psychiatrists outlined methods of tackling self-stigma
including: empowerment, improving self-esteem and using cognitive-behavioural
techniques which challenge the individual’s negative stereotypes and thought (The
Royal College of Psychiatrists in Scotland, 2015).
Empowerment:
Empowerment refers to enabling individuals to take responsibility for their own lives
by making informed decisions (Davenport, 2010). In the context of this review, it refers
to an individual with a mental illness being able to exercise choice and being powerful
enough in certain situations to take part in decision making (Adams, 2007b). Corrigan
23. 22
and Rao (2012) suggest that empowerment is integral to tackling self-stigma as it is
associated with high self-esteem and better quality of life. An individual who is self-
stigmatising suffers with a damaged self-confidence, self-efficacy and self-esteem and
so empowerment, as a method that increases these same attributes, is considered an
effective concept to tackle self-stigma. (Corrigan et al, 2011)
Cognitive-behaviouraltechniques:
The term cognition is referred to as our consciousness and feelings, thoughts,
intentions and decisions, whereas the term behaviour is defined as what we actually
do. (Adams, 2007a) In reference to mental illness and tackling stigma, cognitive
behavioural techniques are used to reduce self-stigma by altering the negative
behaviour of the individual with mental illness. Vogel and Wade (2009) state that
cognitive behavioural techniques focus on replacing inaccurate beliefs with accurate
information, making the distinction that mental illness is not abnormal and attempt to
nurture self-acceptance. Corrigan and Calabrese (2005) note that these methods
could have a positive impact on self-stigmatisation.
Lucksted and colleagues (2011) provide positive development on tackling self-
stigma. Their approach, ‘Ending Self-Stigma Intervention’, aims to tackle self-stigma
by combining both cognitive behavioural techniques and empowerment in a group
setting. Their intervention utilises methods such as: lectures, discussions, group
support and problem-solving to replace the individual’s internalised irrational beliefs
with positive beliefs. The use of this cognitive behavioural technique empowers the
individual. Furthermore, according to Corrigan and Roe (2012), this technique alters
the sufferer’s perception of themselves. They reiterate that depression is not their
defining feature, which prevents self-stigmatisation. Nine sessions were carried out
for this intervention, and it was concluded that self-stigma significantly decreased,
suggesting that this empowerment and cognitive behavioural technique approach
could be a potential method in tackling self-stigma in the future. (Gela and Corrigan,
2015) Despite the Lucksted approach offering a promising method to tackling self-
stigma, it requires further evidence, such as testing on more people, to verify its
results.
Despite this gap in literature, there are studies, such as the one conducted by Lawlor
and Kirakowski (2014), which state that there is a positive correlation between
24. 23
participation in mental health support groups and self-confidence, self-esteem, self-
efficacy, empowerment, decreased blame upon oneself and resistance to label
oneself as ‘mentally ill’. These effects of mental health support groups are factors
which counter-act self-stigma, so support groups may be useful in tackling self-
stigma. This study, however, only considers online support groups, which have been
criticised by Corrigan and colleagues (2009) as being a form of ‘social avoidance.’ if
this were the case, online support groups would make the individual more withdrawn
from society, arguably worsening self-stigma and definitely not combatting it. The
Global Anti-Stigma Alliance, cited in Time to Change (2016c) suggest that interactive
social contact is an effective way of empowering people with a mental illness. In the
Ending Self-Stigma intervention, social contact was used and this was proven to be
a significant method in tackling self-stigma. There is lack of clarity surrounding the
best approach of contact when tackling self-stigma; some argue that online contact
is effective at improving factors of an individual’s life, such as self-confidence, that
consequently tackle self-stigma whilst others argue that using online support groups
is a form of social avoidance, worsening self-stigma. From the literature reviewed,
the Ending Self Stigma approach incorporates both empowerment and cognitive
behavioural techniques that were proven to be successful in its pilot. Consistent with
this, groups were found by Lawlor and Kirakowski to be a successful device to tackle
the effects of self-stigma, thus consequently improving it. This seems like a
promising recommendation in the somewhat limited area of research.
One of the most integral issues associated with self-stigma is the individual’s feeling
of shame (Lewis, 1995). Due to their shame, they are likely to avoid certain
situations specifically regarding help-seeking. In order to tackle their self-stigma, it is
vital for them to disclose their mental illness. However, whilst some people are
empowered by stigma, others have the opposite effect, withdrawing from society and
more likely to believe they are to blame for their illness rather than seek help. This
ambiguity makes it difficult to predict in which way the individual will react. Whilst
studies have been conducted surrounding tackling self-stigma with medical students
and international students, there has been no evidence found to suggest that self-
stigma reduction approaches are successful in regards to tackling stigma among
general British undergraduates. In this area of research, there is a gap in literature.
25. 24
Tackling public stigma:
Patrick Corrigan and David Penn (1999) grouped strategies for tackling public stigma
surrounding mental illness into three approaches: protest, education and contact.
Protest:
The protest approach aims to suppress stigmatising attitudes towards mental illness.
Corrigan and Watson (2002:17) state that ‘groups protest inaccurate and hostile
representations of mental illness as a way to challenge the stigmas they represent’.
The protests are aimed at two recipients: the media and the public. They aim to
change the misrepresentations of mental illness as portrayed by the media and stop
the public believing negative views surrounding mental illness. However, there is a
gap in the literature so it remains uncertain whether this method of tackling stigma is
effective. Penn and Couture (2002) add to its limitations by stating that the protest
approach could potentially cause stigmatising attitudes to increase rather than
decrease. This opinion is shared by Monteith and Colleagues (1998:73) who found
that demanding people to supress their negativity towards a stigmatised group can
result in a ‘rebound effect’. If this is the case, it can be suggested that protest
approaches do not improve people’s attitudes towards mental illness and in some
cases, worsen them. Another concern with the protest approach is that it aims to
diminish negative attitudes yet does not promote positive attitudes.
Education:
The education approach to reducing stigma is similar to the protest approach in how
it aims to diminish negative stereotypes surrounding mental illness. However, the
difference is that the education approach replaces inaccurate stereotypes with
factual information (Watson et al, 2004). There are many methods, such as videos,
flyers, podcasts, films and other audio visual tools, which are utilised to educate
people on mental illness (Finkelstein et al 2008). According to Gela and Corrigan
(2015), this approach has the potential to be effective as it is cheap, accessible and
produce can be easily distributed. Despite this, when Corrigan and Penn (1999)
originally conducted the theory they suggested that there may be difficulties in
educating people towards different attitudes as many stereotypes are hard to
change. Watson and Colleagues (2004) argue that educating people so that they
understand mental illness means that they are less likely to have discriminatory and
26. 25
stigmatising attitudes. The idea that better education surrounding mental illness will
decrease stigma is persuasive. However, Corrigan and O’Shaughnessy (2007)
highlight that the strength of the attitude change may be limited considering the
duration of the education approach was short-lived. Research conducted by Corrigan
and colleagues (2002) suggests that education can result in short term
improvements in tackling stigma. However, once the education is over, a short time
will pass and attitudes could potentially return back to normal.
Contact:
The contact approach to tackling stigma is said to be the most effective in improving
public attitudes towards mental illness (Gela and Corrigan, 2015). This approach
consists of interpersonal contact between members of the public and an individual
with a mental illness. The theory is based on the notion that those with experience of
interacting with a mentally ill person are less likely to discriminate in comparison to
those without this contact. In a study conducted by Clement and colleagues (2012),
both film based contact and live social contact were tested in order to see which was
the most effective method at talking stigma. The study found that both methods
produced a significantly better response on attitudes towards mental illness
compared to education strategies. Corrigan and colleagues (2001), compared a total
of 208 student responses to two anti-stigma approaches; education and personal
contact. The study found that personal contact had a greater positive impact. They
also suggested that contact increases people’s familiarity of mental illness which
consequently decreases stigma. This approach to tackling stigma is dependent on
specific conditions. Young Minds (2010) state that in order for the contact method to
work, the mentally ill person mustn’t be seen as conforming to the standard
stereotype and the audience must be of equal status.
From theory to practice:implementing stigma reductiontheoriesto
university settings.
Up to this point in the chapter, theories and methods surrounding tackling self and
public stigma have been examined. In the second half of the chapter, these theories
will be assessed to find out if they are effective in practice, when the theories are
applied practically as campaigns.
27. 26
In 2013, the University of Sussex signed the Time to Change pledge and launched
an anti-stigma campaign (Time to Change, 2013). The pledge was made with the
aim of improving both staff and students knowledge, attitudes and behaviour towards
mental health and illness. In the previous chapter, it was highlighted just how much
of an obstacle stigma is for depressed students and the severity in consequences of
not seeking help. Thus, it cannot be emphasised enough how important it is to
overcome stigma amongst students.
As part of the campaign, the University worked alongside UniTV who produced a
mini-documentary. Within the UniTV (2013) documentary, many interviews were
carried out as well as coverage of a flash mob conducted and completed by just shy
of 50 students at Sussex. By deconstructing the campaign, we can see how it has
utilised the stigma reduction theory. Aspects of the protest approach have been
utilised as one of the aims for the campaign was to supress negative attitudes
surrounding mental illness (University of Sussex Students’ Unions, 2016). In order to
achieve this objective, they challenge media misrepresentations by producing their
own form of media, a flash mob, which provides a positive stance on mental health.
Instead of media promoting negative attitudes, this form of media aims to show the
positivity of mental health, by promoting awareness. In addition, the mini -
documentary alongside it challenges public beliefs, incorporating an education
approach. The education approach has been utilised through the mini-documentary
which teaches the importance of openness about mental illness. This also adopts the
contact approach of tackling stigma as it features individuals who have personally
experienced mental illness themselves and importantly do not fall subject to the
stereotypes. Many interviews highlight people’s experiences of mental illness, from
staff members to students. This video emphasises the importance of a culture of
openness. Mental Health charity, Mind (2016), highlights the importance of
normalising conversations about mental illness in order to eliminate stigma. The
video produced by UniTV reiterates this idea. The individuals being interviewed all
utilise an empowerment approach as the speakers are now able to acknowledge that
although they have experienced mental illness, it does not define who they are. With
a campaign adapting every theoretical approach within self-stigma and public stigma
reduction, it can be suggested that this should be successful in changing public
attitudes surrounding mental illness.
28. 27
Prior to the anti-stigma campaign, the University of Sussex conducted a student
mental health and well-being survey in order to determine the views and experiences
of mental health among students (Students’ Union University of Sussex, 2013). This
survey was conducted again two years later, after efforts had been taken to improve
mental health through anti-stigma campaigns. From reviewing the findings from the
Student Mental Health and Well-Being Survey (2016), the attitudes surrounding
mental illness at the University of Sussex, despite the efforts of the anti-stigma
campaign, had worsened.
Improving anti-stigmacampaigns in universities:
Using the University of Sussex as a case study, it can be suggested that this
seemingly theoretically sound anti-stigma campaign has not worked to its expected
standard. In this section, suggestions on how to improve the campaign will be
highlighted by drawing observations from the surveys and by proposing alternative
approaches which could strengthen the campaign.
Findings from the Student Mental Health and Well-being Survey (2015) suggest that
although students and staff at the University of Sussex thought the campaign to be
positive, there is a need for continuing campaign activities for a longer duration,
specifically those education based. Although the education approach worked for
tackling stigma immediately after the campaign, these attitudes were not maintained.
One suggestion drawn from this literature is to develop education approaches so that
they are spread over a longer period, and so lessons learnt against stigmatic
stereotypes may not be so short term. This is consistent with findings highlighted in
the theory section (Corrigan & Watson: 2002, Corrigan & O’Shaughnessy: 2007).
This is a barrier that needs to be overcome in order for education to improve and
maintain people’s positive attitudes about mental health and illness.
The UniTV (2013) documentary aims to supress public stigma by including people
discussing methods to overcome stigma in university. This method combines protest
and contact. However, the contact is done through a video format which could have
contributed to why the campaign did not improve attitudes. Pinfold et al (2005)
support this view by suggesting that face to face contact with a person, who is able
to dynamically converse about their experience, is a key factor in mental health
awareness. Corrigan and colleagues (2012b) conducted an investigation into
29. 28
articles, dissertations and population studies surrounding stigma, mental illness and
change programmes in order to analyse the best way of tackling stigma. This study
found that ‘face-to-face contact with the person, and not a story mediated by
videotape, had the greatest effect’. The University of Sussex could learn from this
method in future campaigns and. However, whilst face-to-face is better, it is not
always feasible. Video approaches are easier and cheaply distributed to a larger
audience which could be potentially more suitable for a university due to the difficult
of attracting every student to attend the contact activity. This could be tackled by the
use of social media, another method which could be introduced into the University of
Sussex Time to Change campaign and throughout other university campaigns too.
Whilst researching the anti-stigma campaign at the University of Sussex, it is difficult
to find any evidence that social media has been utilised to its best capacity.
According to Fertman et al (2014), social media can serve as a tool to combat
mental health stigma. Young adults are increasingly turning to social networking
sites such as Facebook and Twitter to seek health information (Giota and Kleftaras,
2015). It can be seen how this can act as an education forum. Lee (2010) explains
that hashtags (#) can be used in order to categorise keywords in Twitter. For
example, if you were to type “#depression” into the Twitter search bar, you would be
able to delve into posts about that specific subject. Due to young adults increasingly
using this platform and how easy it is to post information online, this seems like a
significant method for universities to utilise in order to spread normalisation of mental
illness and to spread awareness. Student Minds epitomise this method. Student
Minds are a British mental health charity, specifically focussing on students. Student
Minds have recently produced a new campaign, Ripple (2016). The Ripple campaign
specifically focuses on tackling stigma surrounding depression amongst university
students. To do so, Ripple aims to increase students’ knowledge surrounding
depression, to increase students’ confidence to talk about their experience of
depression, to encourage them to acquire support, and to help students understand
what their friends with depression are going through and how they can support them.
This is an example of a campaign which focuses particularly on social media.
‘#RippleTips’ are shared over the internet in order to educate and communicate with
other people who may or may not suffer with depression. The use of social media
attains the attention of students and young people. It is difficult to estimate whether
30. 29
this is an effective campaign as it is extremely new however, the campaign has
applied the public stigma reduction theory as outlined in the first part of the chapter
in addition to focussing particularly on social media, a platform which many students
partake in.
Within the Sussex case study, it was found from the 2015 survey that people chose
not to disclose their mental illness upon applying for university, due to their shame
and fear. This suggests that self-stigma is an issue for students. This indicates that
there needs to be more of an emphasis on empowerment at university and people
should be able to feel like they can disclose an illness and feel supported in this
decision.
The University of Sussex signed the Time to Change pledge to tackle stigma at their
university. Thus far, there is little evidence from the literature reviewed that their
efforts, which are encompassing all of the approaches outlined by the stigma
reduction theory, are working. This is inconsistent with the findings from the national
campaign. Evans-Lacko et al (2014) used data from 2003 (six years before Time to
Change) and from 2007 -2013 National Attitudes to Mental Health Survey in order to
investigate the effectiveness of the anti-stigma campaign. The national campaign
differs from the University of Sussex findings, showing that the positive effects of the
Time to Change campaign are significant and moderate. However, Smith (2013)
states that ‘whilst some positive attitudes are shown, the overall picture is still mixed
and falls short of the wholescale shift in attitudes that is needed’. From a poster
produced by Time to Change (2014a) public attitudes towards people with a mental
illness have improved significantly with 6.4% improvement in attitudes since Time to
Change started in 2007. However, the poster highlights the need to continue with the
campaign and the fight to diminish the negative attitudes surrounding mental illness.
It is important to note that student bodies are included in the national attitudes and
therefore represent a small percentage. However student specific research
surrounding this particular field is limited and is often full of literature/theories and not
so much evidence.
Conclusion:
To conclude, there are many approaches to tackling stigma which have been
discussed above. However, it has been elucidated that some are more effective than
31. 30
others in improving attitudes surrounding help seeking. When applying theory to
practice by looking at the University of Sussex’ anti-stigma campaign, although many
of the approaches were taken in tackling stigma, survey results indicated that
attitudes did not improve and this is a cause for concern. Literature was then
considered surrounding ways the campaign could have been improved and
suggestions were made for further campaigns. Social media was a significant
approach despite the University of Sussex not using it to its full potential. Statistics
from the Time to Change campaign on a National basis were considered,
highlighting that attitudes towards people with mental illness in England are
improving slightly each year. It can be suggested, by reflecting on the literature
discussed in this chapter that further research needs to be carried out toward the
development of approaches to tackle stigma in a university population. Further
research needs to move towards an approach which includes all theories, is mindful
of past lessons and learns from mistakes, garnering significant exposure. This would
help launch a campaign that improves attitudes towards depression, and mental
illness in general, and amongst university students.
32. 31
Conclusion:
The purpose of this critical literature review has been to examine and appraise
literature and studies surrounding mental health stigma amongst British universities-
in order to understand the extent to which stigma acts as a barrier to seeking help
and can be detrimental to student’s lives. An extensive body of literature, along with
an array of relevant sources, have been reviewed to develop arguments and
contribute towards a greater understanding of the concept of stigma, help-seeking
attitudes amongst university students, the consequences of stigma and approaches
to tackling stigma.
Yet, as was discovered in the first chapter, defining stigma is not a simple task. The
conceptualisation of stigma, as outlined by Link and Phelan (2001, 2004), was
analysed closely in order to understand the stigma process. It was learned that the
process of stigma is complex, with components underpinning whether it works or not.
This conceptualisation was useful as it allowed further research into significant
issues such as labelling. Here, the modified labelling theory was considered, which
helped to understand why labelling contributes to the process of stigmatisation. The
‘why try’ effect was considered and revealed to be a milestone in this research; it
does not only consider the negative effect labelling has, but also its positive effects,
such as empowerment. By looking into further components, such as stereotyping, it
was clear to see the media’s influence on negative stereotypes surrounding mental
illness. These labels and negative stereotypes in some instances lead to emotional
reactions of which the mentally ill person feels separated and the separation stage.
This conceptualisation was structured by power, meaning that if an individual did not
hold social, economic and political influence, then they were unable to stigmatise.
This chapter helped determine the two types of stigma this dissertation aimed to
focus on: public stigma and self-stigma, and discussed the different factors which are
involved in the stigmatisation process.
Chapter two then sought to understand how stigma can be applied to students with
depression. Possible pressures and their outcome, such as life transitions, were
looked at to determine why the student population may be vulnerable to depression
and why they are important to consider in terms of mental illness. The chapter then
delved into help-seeking attitudes of students with depression by looking at a
33. 32
number of studies surrounding the topic. Whilst research was found surrounding the
issue of general mental illness and help-seeking, there was a lack of literature found
that particularly focussed on students with depression and those which did were
ruled out of consideration due to their origin, as this dissertation particularly focussed
on UK studies. Despite the lack of depression focussed studies, it can still be
suggested that stigma affects a high percentage of students as depression is
extremely common among the general UK population, and that statistics support the
likelihood that under-reporting is present. The studies concerning help-seeking
attitudes all highlighted either public stigma or self-stigma as a barrier to help-
seeking, which poses a serious concern. It was easy to adapt the conceptualisation
theory, as discussed in chapter one, to life as students were fearful of the process of
stigma, thus avoiding help-seeking. Avoiding help can lead to detrimental effects on
the student. This chapter therefore highlighted the importance of eliminating stigma
in order for students to be able to come forward to seek help.
In the first half of chapter three, literature surrounding methods of improving self-
stigma and public stigma was considered. The possible methods of overcoming self-
stigma such as empowerment and cognitive-behavioural techniques were
considered in order to determine how effective they were. However, little literature
was found regarding its efficacy amongst UK university students and a definitive
conclusion was not reached. Corrigan and Penn (1999) offered a stigma-reduction
theory which featured three methods: protest, education and contact. These
methods were examined to determine how successful they are at overcoming public
stigma surrounding mental illness. Overall, the literature reviewed points towards the
contact and education method being most successful at tackling stigma, however
only one study was specifically targeted at university students which emphasised the
importance of further research surrounding this target group. The second part of the
chapter analysed a specific anti-stigma university campaign in order to apply theory
to practice. The University of Sussex failed in their campaign to improve attitudes
and overcome stigma, despite applying the approaches outlined in the theory
section. There were a number of improvements which were identified from the
campaign, including a better use of social media in order to approach stigma. It was
concluded that more research is needed to specifically focus upon tackling stigma in
the university population.
34. 33
Overall, this dissertation has established the need for further research specifically
focussing on general undergraduate students as much of the literature focusses
specifically on either medical students or non-UK universities. The development and
maintenance of research surrounding this subject is paramount to ending the stigma
surrounding mental illness in general and making students able to come forward with
their illness, thus needs to be focussed on.
35. 34
References:
Adams, R. (2007a) Cognitive- behavioural Work. In: Adams, R. ed. Foundations
of Health and Social Care. Basingstoke: Palgrave Macmillan, 2007, pp. 387-396
Adams, R. (2007b) Empowerment and Advocacy. In: Adams, R. ed. Foundations
of Health and Social Care. Basingstoke: Palgrave Macmillan, 2007, pp. 371-377
Amzat, J., and Razum, O. (2014) Medical Sociology in Africa. New York: Springer
Andrews, B., and Wilding, J.M. (2004). The relation of depression and anxiety to
life-stress and achievement in students. The British Psychological Society, 95,
pp. 509-521
Aveyard, H. (2010) Doing a Literature Review in Health and Social Care. 2nd ed.
Berkshire: Open University Press, McGraw-Hill Education
Bandura, A. (1997). Self-Efficacy: The Exercise of Control. Duffield: Worth
Publishers
Beckett, C., and Taylor, H. (2010). Human Growth and Development. London:
SAGE
Bithell, C. (2010) Mental health research in the media: recommendations for a
new function at the Science Media Centre. Science Media Centre.
British Association for Counselling and Psychotherapy. (2014). Looking after our
students’ mental health. Lutterworth: BACP House
Clement, S., van Nieuwenhuizen, A., Kassam, A., Flach, C., Lazarus, A., de
Castro, M., McCrone, P., Norman, I., and Thornicroft, G. (2012) Filmed v. live
social contact interventions to reduce stigma: randomised controlled trial. The
British Journal of Psychiatry, 201(1), pp. 57-64
Clinton, W.J. (1999) The President’s Radio Address. (Online). Available at:
http://www.presidency.ucsb.edu/ws/?pid=57689 [Accessed 12 March 2016]
Corrigan, P.W, and Penn, D. (1999) Lessons from social psychology on
discrediting psychiatric stigma. American Psychologist, 54, pp. 765-776
Corrigan, P.W. (2004). How stigma interferes with mental health care. American
Psychologist, 59, pp. 614-625
Corrigan, P.W., and Calabrese, J.D. (2005) Strategies for assessing and
diminishing self-stigma In: Corrigan, P.W. ed. On the stigma of mental illness:
Practical strategies for research and social change. American Psychological
Association: Washington, DC, pp. 239-256
Corrigan, P.W., and O’Shaughnessy, J.R. (2007) Changing mental illness stigma
as it exists in the real world. Australian Psychologist, 42(2), pp. 90-97
36. 35
Corrigan, P.W., and Rao, D. (2012). On the self-stigma of mental illness: stages,
disclosure, and strategies for change. Canadian Journal of Psychiatry, 57(8), pp.
464-469
Corrigan, P.W., and Watson, A.C. (2002). Understanding the impact of stigma on
people with mental illness. World Psychiatry, 1(1), pp. 16-20
Corrigan, P.W., Druss, B.G, and Perlick, D.A. (2012a). The Impact of Mental
Illness Stigma on Seeking and Participating in Mental Health Care. Psychological
Science in the Public Interest, 15(2), pp. 37-70
Corrigan, P.W., Faber, D., Rashid, F.M and Leary, M. (1999). The construct
validity of empowerment among consumers of mental health services.
Schizophrenia Research, 38, pp. 77-84
Corrigan, P.W., Green, A., Lundin, R., Kubiak, M.A., Penn, D.L. (2001).
Familiarity With and Social Distance from People Who Have Serious Mental
Illness. Psychiatric Services, 52, pp. 953-958
Corrigan, P.W., Lason, J.E, and Rüsch, N. (2009). Self-stigma and the “why try”
effect: impact on life goals and evidence-based practices. World Psychiatry, 8(2),
pp. 75-81
Corrigan, P.W., Morris, S.B., Michaels, P.J., Rafacz, J.D., & Rüsch, N. (2012b)
Challenging the public stigma of mental illness: a meta-analysis of outcome
studies. Psychiatric Services, 63(10), pp. 963-973
Corrigan, P.W., Roe, D., and Tsang, H.W.H. (2011) Challenging the Stigma of
Mental Illness: Lessons for Therapists and Advocates. Chichester: Wiley-
Blackwell
Corrigan, P.W., Rowan, D., Green, A., Lundin, R., River, P., Uphoff-Wasowski,
K., White, K., and Kubiak, M.A. (2002). Challenging Two Mental Illness Stigmas:
Personal Responsibility and Dangerousness. Schizophrenia Bulletin, 28(2), pp.
293-309
Coughlan, S. (2015). Rising numbers of stressed students seek help. (Online).
Available at: http://www.bbc.co.uk/news/education-34354405 [Accessed 12
February 2016]
Davenport, P. (2010) Values and planning in social care. In: Stretch, B., and
Whitehouse, M. eds. BTEC Level 3 National Health and Social Care: Student
Book 2. Essex. Pearson Education
Drum, D.J., Brownson, C., Denmark, A.B., and Smith, S.E. (2009). New data on
the nature of suicidal crises in college students: Shifting the paradigm.
Professional Psychology: Research and Practice, 40(3), pp. 213-222
Equality Act 2010, c. 15. London: Stationery Office.
37. 36
Equality Challenge Unit. (2012) Equality in higher education: statistical report
2012. (Online) Available at: http://www.ecu.ac.uk/publications/equality-in-he-
stats-2012/ [Accessed 26 November 2015]
Evans-Lacko, S., Corker, E., Williams, P., Henderson, C., and Thornicroft, G.
(2014) Effect of the Time to Change anti-stigma campaign on trends in mental-
illness-related public stigma among the English population in 2003-13: an
analysis of survey data. The Lancet, 1(2), pp. 121-128
Fertman, C.I., Delgado, M.M, and Tarasevich, S.L. (2014). Promoting Child and
Adolescent Mental Health. Burlington: Jones & Barlett Learning
Finkelstein, J., Lapshin, O., and Wasserman, E. (2008). Randomised study of
different anti-stigma media. Patient Education and Counselling, 71, pp. 204-214
Gela, N.R., and Corrigan, P.W. (2015). The Stigma of Families with Mental
Illness. In: Arditti, J.A. ed. Family Problems: Stress, Risk and Resilience.
Chichester: Wiley-Blackwell
Giota, K.G., and Kleftaras, G. (2015). Cyberpsychology and Social Media In:
Kommers, P.A.M., Isaias, P., and Issa, T. eds. Perspectives on Social Media: A
Yearbook. Abingdon: Routledge
Green, S., David, C.S., Karshmer, E., Marsh, P, and Straight, B. (2005) Living
Stigma: The Impact of Labelling, Stereotyping, Separation and Discrimination in
the Lives of Individuals with Disabilities and Families. Sociological Inquiry, 75(2),
pp. 187-215
Hattenstone, S. (2013) Students and depression: the struggle to survive. (Online)
Available at: http://www.theguardian.com/education/2013/mar/23/student-suicide-
depression-debt-recession [Accessed 15 January 2016]
Higher Education Funding Council for England. (2015). Understanding provision
for students with mental health problems and intensive support needs. Brighton:
Institute for Employment Studies
Huang, B., and Priebe, S. (2003) Media coverage of mental health care in the
UK, USA and Australia. Psychiatric Bulletin, 27, pp. 331-333
Jackson, J. (2006) Encyclopaedia of Multicultural Psychology. London: SAGE
Joseph, M.A. (2016) Discrimination against the Mentally Ill. California:
Greenwood
Lawlor, A., and Kirakowski, J. (2014) Online support groups for mental health: A
space for challenging self-stigma or a means of social avoidance? Computers in
Human Behaviour, 32, pp. 152-161
Lee, T.M. (2010) Healthcare Hashtags – a Social Project. (Online) Available at:
http://www.symplur.com/blog/healthcare-hashtags-social-project/ [Accessed 12
April 2016]
38. 37
Leff, J., and Warner, R. (2009) Social Inclusion of People with Mental Illness.
Cambridge: Cambridge University Press
Lewis, M. (1995) Shame: The Exposed Self. London: The Free Press
Link, B.G, and Phelan. J.C. (2014). Mental Illness Stigma and the Sociology of
Mental Health. In: Johnson, R.J., Turner, R.J., & Link, B.G. eds. Sociology of
Mental Health: Selected Topics from Forty Years 1970’s-2010’s. London:
Springer
Link, B.G, Cullen, F.T, Struening, E., and Dohrenwend, B.P. (1989) A Modified
Labelling Theory Approach to Mental Disorders: An Empirical Assessment.
American Sociological Review. 54(3), pp. 400-423
Link, B.G, Phelan, J.C., and Hatzenbuehler, M.L. (2014) Stigma and Social
Inequality. In: McLeod, J.D., Lawler, E.J., and Schwalbe, M. eds. Handbook of
the Social Psychology of Inequality. London: Springer
Link, B.G., and Phelan, J.C. (2001). Conceptualising Stigma. Annual Review of
Sociology, 27(3), pp. 363-385
Link, B.G., Yang, L.H., Phelan, J.C., and Collins, P.Y. (2004). Measuring mental
illness stigma. Schizophrenia Bulletin, 30(3), pp. 511-541
Lucksted, A., Drapalski, A., Calmes, C., Forbes, C., DeForge, B., and Boyd, J.
(2011) Ending self-stigma: plot evaluation of a new intervention to reduce
internalised stigma among people with mental illnesses. Psychiatric
Rehabilitation Journal, 35(1), pp. 51-54
Macaskill, A. (2012). The mental health of university students in the United
Kingdom. British Journal of Guidance and Counselling. 41(4), pp. 426-441
McDaid, D. (2008). Countering the stigmatisation and discrimination of people
with mental health problems in Europe. Luxembourg: European Commission.
Mental Health Foundation, (2015a). Mental health statistics. (Online). Available
at: http://www.mentalhealth.org.uk/help-information/mental-health-statistics/
[Accessed 7 November 2015]
Mental Health Foundation. (2015b) Stigma and discrimination. (Online). Available
at: https://www.mentalhealth.org.uk/a-to-z/s/stigma-and-discrimination [Accessed
22 March 2016]
Meredith, L.S., Stein, B.D., Paddock, S.M., Jaycox, L.H., Quinn, V.P., Chandra,
A., and Burnam, A. (2009). Perceived Barriers to Treatment for Adolescent
Depression. Medical Care, 47(6), pp. 677-685
Mind. (2016). Resource 3: How to promote wellbeing and tackle the causes of
work-related mental health problems. (Online). Available at:
https://www.mind.org.uk/media/428496/Resource3_HowToPromoteWellBeingFIN
AL.pdf [Accessed 12 April 2016]
39. 38
Monteith, M.J., Sherman, J.W., and Devine, P.G. (1998). Suppression as a
stereotype control strategy. Personality and Social Psychology Review, 2(1), pp.
63-82
Moonie, N., Pensley, K.C., Stretch, B., and Price, C. (2000). Intermediate Health
and Social Care. Oxford: Heinemann
Morris, C. (2011). Open Minds: towards a ‘mentally well’ university. In: Marshall,
L., and Morris, C. eds. Taking wellbeing forward in higher education: reflections
on theory and practice. Brighton: University of Brighton Press
National Union of Students. (2013) Mental Distress Survey: Overview. (Online)
Available at:
http://www.nus.org.uk/Global/Campaigns/20130517%20Mental%20Distress%20
Survey%20%20Overview.pdf [Accessed 12 February 2016]
National Union of Students. (2014). Isolation and Vulnerability Report:
Researching the experiences of students of faith and belief in higher education.
London: NUS
Noakes, S. (2004). Living with depression: The Reality. In: Crisp, A.H. ed. Every
Family in the Land: Understanding prejudice and discrimination against people
with mental illness. London: Royal Society of Medicine Press
Office for National Statistics. (2012). Deaths by suicide for students aged 18 and
above, 2007-2011. (Online) Available at:
http://webarchive.nationalarchives.gov.uk/20160105160709/http:/www.ons.gov.u
k/ons/about-ons/what-we-do/publication-scheme/published-ad-hoc-data/health-
and-social-care/november-2012/index.html [Accessed 13 January 2016]
Parle, S. (2012). How does stigma affect people with mental illness? Nursing
Times, 108(28), pp. 12-14
Pasman, J. (2011). The Consequences of Labelling Mental Illnesses on the Self-
concept: A Review of the Literature and Future Directions. Social Cosmos.2, pp.
122-127
Patel, V. (2007). Mental health in low-and middle-income countries. British
Medical Bulletin, 81-82(1): 81-96
Penn, D. L., and Couture, S.M. (2002) Strategies for reducing stigma toward
persons with mental illness. World Psychiatry, 1(1), pp. 20-21
Phippen, M. (2010) ‘International Perspectives: College Mental Health in the
United Kingdom. In: Kay, J., and Schwartz, V. eds. Mental health care in the
college community. Chichester. Wiley-Blackwell
Pinfold, V., Thornicroft, G., Huxley, P., and Farmer, P. (2005) Active ingredients
in anti-sigma programmes in mental health. International Review of Psychiatry,
17(2), pp. 123-131
40. 39
Raconteur (2015). The tide is turning for mental health. (Online) Available at:
http://raconteur.net/healthcare/the-tide-is-turning-for-mental-health [Accessed 19
March 2016]
Rickwood, D., Thomas, K., and Bradford, S. (2012) Help-seeking measures in
mental health: a rapid review. (Online) Available at:
https://www.saxinstitute.org.au/wp-content/uploads/02_Help-seeking-measures-
in-mental-health.pdf [Accessed 12 March 2016]
Roberts, R., Golding, J., Towell, T., and Weinreb, I. (1999). The Effects of
Economic Circumstances on British Students’ Mental and Physical Health.
Journal of American College Health, 48(3), pp. 103-109
Sayce, L. (2016) From Psychiatric Patient to Citizen Revisited. London: Palgrave
Scheff, T.J. (1966). Being mentally ill: A sociological theory. Chicago: Aldine
Smith, M. (2013). Anti-stigma campaigns: time to change. The British Journal of
Psychiatry, 202(55), pp. 49-51
Social Exclusion Unit. (2004). Mental Health and Social Exclusion: Social
Exclusion Unit Report Summary. London: The Office of the Deputy Prime
Minister
Student Minds. (2014). Grand Challenges in Student Mental Health. (Online).
Available at:
http://www.studentminds.org.uk/uploads/3/7/8/4/3784584/grand_challenges_in_st
udent_mental_health.pdf [Accessed 17 March 2016]
Student Minds. (2016). About Us. (Online). Available at:
http://www.studentminds.org.uk/about.html [Accessed 17 March 2016]
Student Minds. (2016). Ripple. (Online) Available at:
http://www.studentminds.org.uk/ripple-tips.html [Accessed 12 April 2016]
Students Against Depression. (2016). Student stress & depression. (Online).
Available at: http://studentsagainstdepression.org/student-issues/stress-
depression/ [Accessed 14 March 2016]
Students’ Union University of Sussex. (2013) Student Mental Health and Well-
being Report. Welfare Officer: Falmer House
Telegraph, (2014). Student Life: dealing with depression at university. (Online).
Available at: http://www.telegraph.co.uk/education/universityeducation/student-
life/11003952/Student-Life-dealing-with-depression-at-university.html [Accessed
16 February 2016]
The Guardian, (2016). Mental health: a university crisis. (Online) Available at:
http://www.theguardian.com/education/series/mental-health-a-university-crisis
[Accessed 12 February 2016]
41. 40
The Royal College of Psychiatrists. (2015). Stigma – a harm and safety issue.
(Online) Available at:
http://www.rcpsych.ac.uk/pdf/briefing%20paper2_stigma%202015_for%20websit
e.pdf [Accessed 6 April 2016]
Time to Change. (2009). Mental health stereotypes in the movies crueller than
ever, new report claims. (Online). Available at: http://www.time-to-
change.org.uk/news/mental-health-stereotypes-movies-crueler-ever-new-report-
claims [Accessed 23 March 2016]
Time to Change. (2013).University of Sussex Students’ Union. (Online) Available
at: http://www.time-to-change.org.uk/node/71565 [Accessed 7 April 2016]
Time to Change. (2014a) Public attitudes to mental illness 2013-2014. (Online)
Available at: http://www.time-to-
change.org.uk/sites/default/files/Attitudes_Infographic_FIN%20WEB.pdf
[Accessed 12 April 2016]
Time to Change. (2014b). Students missing out on education because of mental
illness. (Online). Available at: http://www.time-to-change.org.uk/news/students-
missing-out-education-because-mental-illness [Accessed 17 March 2016]
Time to Change. (2016a). Mental health at school, college and university.
(Online) Available at: http://www.time-to-change.org.uk/category/blog/school-
college-and-university [Accessed 12 January 2016]
Time to Change. (2016b). Who we are. (Online). Available at: http://www.time-to-
change.org.uk/about-us/what-is-time-to-change [Accessed 18 March 2016]
Time to Change. (2016c). Global Anti-Stigma Alliance. (Online) Available at:
https://www.time-to-change.org.uk/sites/default/files/gasa%20leaflet.pdf
[Accessed 3 April 2016]
Time to Change. (2016d). What is Stigma? (Online) Available at: http://www.time-
to-change.org.uk/what-is-stigma [Accessed 21 April 2016]
Uni TV. (2013). Let’s Talk About Mental Health! (Online) Available at:
https://www.youtube.com/watch?v=ayFF_13KKag [Accessed 7 April 2016]
University of Sussex Students’ Union. (2016). Findings from the Student Mental
Health and Well-being Survey 2015. (Online) Available at:
http://www.sussexstudent.com/asset/News/6412/Summary-
studentmentalhealthandwell-beingsurvey2015.pdf [Accessed 8 April 2016]
University of York. (2016). Adjusting to university life. (Online). Available at:
https://www.york.ac.uk/students/support/health/problems/adjusting/ [Accessed 11
March 2016]
Vogel, D.L., and Wade, N.G. (2009) Stigma and help-seeking. The British
Psychological Society, 22, pp. 20-23
42. 41
Vogel, D.L., Wade, N.G, and Haake, S. (2006). Measuring the self-stigma
associated with seeking psychological help. Journal of Counselling Psychology,
53(3), pp.325-337
Walliman, N. and Appletpon, J.V. (2009) Your Undergraduate Dissertation in
Health and Social Care: The Essential Guide for Success. London: SAGE
Warwick, I., Maxwell., C., Simon., A., Statham, J., and Aggleton, P. (2006).
Mental health and emotional well-being of students in further education – a
scoping study. London: University of London
Watkins, P.N. (2008) Mental Health Practice: A Guide to Compassionate Care.
Edinburgh: Elsevier
Watson, A.C., Otey, E., Westbrook, A.L., Gardner, A.L., Lamb, T.A., Corrigan,
P.W., and Fenton, W.S. (2004). Changing Middle Schoolers’ Attitudes about
Mental Illness Through Education. Schizophrenia Bulletin, 30(30), pp. 563-572
Wilcox, P., Winn, S., and Fyvie-Gauld, M. (2005). ‘It was nothing to do with the
university, it was just the people’: the role of social support in the first-year
experience of higher education. Studies in Higher Education, 30(6), pp. 707-722
World Health Organisation (2015) Depression. (Online) Available at:
http://www.who.int/topics/depression/en/ [Accessed 14 January 2016]
Young Minds (2010) Stigma – A Review of the Evidence. London: Young Minds.
