Forensic psychiatric patients face three stigmas—mental illness, race, and criminal history—and there is a dearth of research focusing on these areas. This is the bottom line of a recently published article in International Journal of Forensic Mental Health. Below is a summary of the research and findings as well as a translation of this research into practice.
Featured Article | International Journal of Forensic Mental Health| 2014, Vol. 13, No. 1, 75-90
Triple Stigma of Forensic Psychiatric Patients: Mental Illness, Race, and Criminal History
Michelle L. West, John Jay College of Criminal Justice
Philip T. Yanos, John Jay College of Criminal Justice
Abby L. Mulay, Long Island University
Stigma involves negative beliefs and devaluations of people in socially identified groups, which some people internalize. Research has increasingly explored mental illness self-stigma, when people with mental illness believe society’s negative beliefs are true of them (e.g., they are hopeless due to mental illness). Self-stigma predicts poorer functional and treatment outcomes. Forensic psychiatric patients experience multiple stigmas, yet no research has explored how stigmas due to mental illness, race, and criminal history influence each other. This review discusses relevant stigma research, which suggests that self-stigma in forensic psychiatric populations likely interferes with rehabilitation and avoiding re-arrest. Forensic psychiatric stigma is particularly relevant given increasing social attention on violence, incarceration, mental illness, and race. Conclusions discuss targets for future research.
forensic psychiatric patients, mental illness, offenders, race, self-stigma, stigma
Summary of the Research
Individuals with a mental illness and a criminal history, labeled forensic psychiatric patients, endure stigmatization. Research has skimmed over stigmatizations and their influence on the wellbeing of these individuals; however, “expanding self-stigma research to a forensic psychiatric population could provide an opportunity to examine how different stigmas influence each other and the relative impact of these stigmas on self-concept and outcomes” (p .75).
The goal of this review was to “overview theory and research on stigma, self-concept, and how stigma impacts self-concept, as well as research on three stigmas that are particularly relevant in
forensic psychiatric populations” (p. 75). The three stigmas discussed are mental illness, racial stigma, and criminality stigma. Reactions to each stigma and self-stigma are discussed.
People with mental illness are often seen as being inferior, violent, vulnerable, and unable to have romantic experiences or to contribute to society. Although Western cultures have attempted to minimize the stigma by attributing mental illness to biological factors, surveys have found that adults (in the United States and Australia) still view mental illnesses as dangerous and some have stated that they would prefer to minimize interactions with people who have a mental illness. However, research “indicates that the great majority of people (90% or more) with severe mental illness do not engage in any violent behavior and the remaining violence risk attributable to mental illness is small in contrast with more common characteristics such as age and gender” (p. 78).
People with mental illness face many challenges like finding adequate shelter and treatment. Stigmatization may also cause difficulties in developing a good mental health professional-patient relationship. Research has provided “evidence that mental health and medical professionals commonly exhibit negative attitudes towards people with mental illness. Stigmatization is likely particularly harmful coming from such caregivers” (p. 79).
Reactions to Mental Illness Stigma People who have mental illness are aware of the stigma. “Research indicates that about 90 percent of people with mental illness are aware of stigmatizing
views about mental illness, but stereotype consciousness by itself is generally unrelated to self-esteem and depression” (p .79). This may cause some individuals to be in denial of the diagnosis since it would mean “integrating the diagnosis into their self-concepts” (p. 79). Some individuals accept the illness as part of their identity in a positive manner, while others adopt the “illness identity.” The way that a person copes with the mental illness can play a strong influence in motivation, behavioral changes, and creating goals in therapy.
Self-stigma of Mental Illness-“One consequence of stigma is that people with mental illness may internalize stigmatizing beliefs” (p. 79). The stigma endorsement scale evaluates agreement with common negative attitudes towards mental illness, and the discrimination experience scale focuses on experiences with discrimination due to mental illness” (p. 80). Scales such as this and past research suggests there is self-stigma in individuals with mental illness. Self-esteem, self-efficacy, quality of life, individuals’ likelihood of becoming depressed and their ability to cope with mental illness are all factors that can be affected by their self-stigma.
Reactions to Racial Stigma– Racial stigmatization occurs through “its impact on the emotions, beliefs, and behaviors of racial minorities” (p. 81). Some individuals have come to expect racial discrimination, even from the government. Alas, it also results in emotional consequences such as individuals’ experiencing anger and the feeling of being disrespected. “Discrimination can have an emotional impact…and has been linked to negative consequences including mental and physical health problems, which in turn can negatively impact functioning” (p. 82). Stigmatization can also influence how a group perceives discrimination. Research has found that it could lead to drug use, fights, stereotype activation, and impaired performance on assessments of abilities.
Racial self-stigma– “Mental illness self-stigma may be more common than racial self-stigma, although no research directly compares them” (p. 82). Contrary to the strong evidence found in mental illness self-stigma, racial self-stigma has a low prevalence. “Possible reasons for lower
prevalence of this explicit racial self-stigma include the current rejection, at least overtly, of the legitimacy of racial discrimination, the relatively more positive racial minority role models, the relatively younger age at which race becomes integrated into self-concept, and the increased likelihood that children will learn coping skills for racial discrimination from family members. However, racial minorities may also internalize stigmatizing attitudes towards their racial group, perhaps especially the more implicit type of self-stigma” (p. 82).
There is a dearth of research on stigmatization in criminality, “despite evidence of stigma against this group” (p. 83). Although it could be argued that hiding one’s criminal history is easier than hiding one’s race, criminal stigmatization can exist. For example, in the workforce past offenders are required to inform an employer of their criminal history. In a competitive job market, the chances of being hired with a criminal history are unlikely. More research on criminal stigmatization is needed, especially with adults. However, “there is evidence that stigma against offenders can limit social networks and supports. For instance, a longitudinal study of adolescents concluded that being labeled a criminal and the resulting stigma impacts peer networks, which in turn impacts future criminal involvement (p. 83).
Responses to Stigma of Criminality– “A large study of inmates near release found a general consensus of anticipated rejection by others in multiple social contexts, and participants in a qualitative study of stigma experiences of ex-offenders in higher education described fears about social and employment discrimination, and exhibited secrecy through attempts to hide their offense history and selectively choosing who to tell” (p. 83). Stigma against criminals may also affect their health, in terms of stress, coping, and social support. These factors “likely contribute to elevated suicide rates among recently released prisoners” (p. 83).
Self-stigma of Criminality-“Although the impact of stigma on offenders has been explored somewhat, research has largely not addressed the role of self-stigma in these outcomes” (p. 83). Research has studied the Labeling Theory as a means to explore the self-concept of criminality; however, this theory has remained unsupported in its claims about criminals changing identity due to being labeled offenders.
Translating Research into Practice
“Despite the multidimensionality of self-concept, less research has investigated the experiences of individuals with multiple stigmatized identities, including how they may affect each other, become internalized, and affect outcomes” (p. 83). Preliminary research has found that individuals with multiple stigmatized identities experience a unique set of difficulties in the real world. Forensic psychiatric patients are especially vulnerable to multiple stigmatized identities. Aside from being stigmatized for having a mental illness, they have to struggle with an “offender” label.
The present review found that research is beginning to focus on these three stigmas; however, it also underscored that “there is no research on self-stigma related to criminal offense history, nor is there an existing measure of this construct” (p. 84). There is also growing concern for mental health care providers and whether they hold these same stigmas for the patients they treat as this could be detrimental to the successful treatment of these patients, resulting in weak provider-patient relationships. Stigmatizations can damage an individual’s self-esteem and emotional balance. Providing empirical data to inform the mental care field and the general population about stigmas and of their negative influence could help forensic psychiatric patients navigate the outside world with more ease.
This review remains optimistic by concluding that “there is a growing body of research separately investigating stigmatizing attitudes towards relevant groups: people with mental illness, racial/ethnic minorities, and criminal offenders, including labeled individuals’ reactions to stigma ranging from empowerment to self-stigma. There is growing research on the impact of stigma on self-concept, particularly for mental illness stigma” (p. 84).
Other Interesting Tidbits for Researchers and Clinicians
Future research could focus on investigating self-stigma on mental illness, race, and criminality in the forensic population. Special attention should be paid to factors that could be affected by stigmatization such as depression, coping skills, social functioning, treatment-adherence, etc. In addition, research on addressing stigmatization and how to minimize its effects could prove to be beneficial for forensic psychiatric patients.
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