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Coverage of Psychological Disorder Stigma in Introductory Psychology.

The public's perception of mental illness is formed through various channels. Arguably, one of the most prevalent information sources shaping social perceptions is the media. Unfortunately, media frequently misinform and use psychiatric terms inaccurately and offensively (Wahl, 2003). In entertainment media, film and television productions often reduce individuals with psychological disorders to caricatures ranging from hopeless (e.g., Kiersten Dunst in Melancholia) to horrifying (e.g., Christian Bale in American Psycho). While these depictions predominantly portray fictionalized characters, the news media also tend to defame everyday people living with psychological disorders (Edney, 2004). McGinty, Kennedy-Hendricks, Choksy, and Barry (2016) found that over 50% of all news coverage of mental illness between 1995 and 2014 were embedded within reports associated with violence.

Whether originating from Hollywood or legitimate news agencies, erroneous and offensive depictions of mental illness often lead to stigmatizing attitudes (Arboleda-Florez & Stuart, 2012) that foster complex social, psychological, and economic consequences (Corrigan, 2004). Even the use of psychiatric labels can degrade individuals with psychological disorders and influence stigmatizing attitudes (Angermeyer & Matschinger, 2005). For example, stigma against people with psychological disorders can result in job discrimination (Stuart, 2006) despite the fact that the Americans with Disabilities Act (ADA) of 1990 established the unlawfulness of workplace discrimination against an individual with a psychological disorder.

Stigma is also consequential when it comes to treatment for psychological disorders. Higher self-stigma, an identification with the stigmatized group and an application of corresponding negative stereotypes and prejudices to the self, is associated with lower help seeking among both adults (Cooper, Corrigan, & Watson, 2003) and adolescents (Penn et al., 2005).Help-seeking behavior is further influenced by cultural variation in the experience of stigma. For example, members of many racial and ethnic minority groups are less likely to seek mental health services than Caucasians, perhaps because of the lingering stigma surrounding psychotherapy in these minority groups (Sue & Lam, 2002).

In a concerted effort to combat the stigma surrounding mental illness, the psychological community has recently launched a variety of international stigma-reduction campaigns. The American Psychological Association (APA), Mental Health America (MHA), and the National Alliance on Mental Illness (NAMI) figure prominently in these awareness campaigns. Social media sites have also become involved through developing campaigns such as #HereForYou (www.Instagram.com), which encourages users to share personal challenges of living with mental illness.

An additional opportunity to raise stigma awareness among large audiences, and to engage the public in active conversation, presents itself in the college classroom. Introductory psychology is the second most popular college course (Landrum & Gurung, 2013), and, for most undergraduates, the only psychology course in which they will ever enroll. The majority of introductory courses already include a unit on psychological disorders (Griggs & Bates, 2014). However, in order to assess the contribution of the introductory psychology course in regards to combating stigma, it is important to identify the manner in which the information is being presented. Historically, in academic settings, courses addressing psychological disorders are typically dominated by lectures on symptoms and diagnoses (Halonen, 2005). While this approach can be effective in communicating diagnostic categories, a lack of addressing the accompanying stigma could in effect perpetuate stigmatizing attitudes towards those living with psychological disorders. Accordingly, Wahl, Jones, and Reiss (2014) urged that lessons on psychological disorders would benefit from explicitly acknowledging the accompanying role of stigma. While it is difficult to definitively determine the specific degree to which instructors are addressing certain topics within the classroom, Griggs (2014) concluded that the content coverage within introductory textbooks greatly impacts the structure of the introductory psychology course. Thus, there is likely a strong relationship between introductory psychology textbook coverage of psychological disorders and actual course content coverage.

Currently, aside from Maranzan's (2016) review of the literature concerning pedagogical techniques, there is very little research exploring coverage of psychological disorder stigma in psychology courses. A noteworthy exception is the empirical work of Wahl et al. (2014), who focused their analysis on abnormal psychology textbooks. To date, this analysis has not been extended to introductory psychology courses. Accordingly, the purpose of the present study is to assess the coverage of psychological disorder stigma within introductory psychology courses. This will be done via a textbook analysis of the breadth and depth of coverage of psychological disorder stigma. The results can offer insight into the ways in which psychology instructors already do or potentially could contribute to the reduction of psychological disorder stigma.

METHOD

Selection of Textbooks

The initial attempt to obtain a list of the most commonly adopted introductory psychology textbooks through local sales representatives for well-known publishers was futile. Publishing company sales representatives advised that it is nearly impossible in today's textbook market to precisely determine adoption rates. Accordingly, we ultimately employed a searchable online textbook database and selected a random sample of 36 full-length introductory psychology textbooks. We used 'introduction to psychology' and 'psychology' as an initial filter to identify candidate texts. The selection was further constrained to newest editions and publication dates between 2011 and 2018. The sample consisted of works from the following publishers: Wadsworth, Worth, Pearson, Wiley, McGraw-Hill, Oxford University Press, and Cengage. Appendix 1 presents the textbooks reviewed.

Compiling of Stigma Statements

To minimize issues surrounding reliability and validity, each text was assessed via three independent judges. Because the primary focus of the analysis was on the substantive presentation of psychological disorder stigma, the analysis was limited to chapter content and did not extend to the contents, preface, appendix, glossary, and subject index sections of the books. Judges were instructed to only track mentions of stigma directly relevant to psychological disorders. An electronic term search was conducted for each textbook seeking the term "stigma" and its derivatives (e.g. stigmatizing, stigmatization, etc.). This allowed us to identify sections of the text that directly discussed stigma in regards to psychological disorders and to begin the analysis of the breadth and depth of coverage over psychological disorder stigma. The search was narrowed to these terms in particular, because, although relevant psychological concepts such as stereotypes may seem appropriate to include in the search, our goal was to focus on negative social perceptions. The concept of stigma is seen as a distinct negative quality ascribed to a target, whereas stereotypes are preconceived notions that can be positive or negative. Thus, a search for the term "stereotypes" and its derivatives (e.g., stereotyping, stereotypical) would not necessarily return results relevant to our purpose. Moreover, a preliminary search for the term "prejudice" confirmed our suspicion that this term would primarily not return results relevant to psychological disorder stigma. The preliminary search overwhelmingly directed us into the cognitive and social psychology chapters of the textbooks. Any mention of "prejudice" detected in relation to psychological disorders was embedded within the compiled stigma statements.

Given that stigma is a prominent topic within the psychology literature (e.g., Corrigan, 2004; Torrey, 2011), we wanted to determine the breadth and depth of how certain issues surrounding the topic of psychological disorder stigma are reflected within the textbooks beyond a simple word frequency count. Rather than doing a straightforward tally for the number of times "stigma" and its derivatives appeared in the text, judges compiled and recorded the number of distinct statements made on the topic of stigma. A stigma statement was operationally defined as a distinct sentence that references psychological disorder stigma and its pertinent issues. For example, the search might have returned only a single instance of the word "stigma" but the text surrounding that term might contain additional sentences referencing pertinent issues. Even if those sentences did not explicitly contain the word "stigma" they were still in reference to issues pertaining to psychological disorder stigma. Therefore, each pertinent sentence was counted as a stigma statement. By counting the number of sentences that directly correspond to psychological disorder stigma and its applicable issues, this allowed for a more accurate representation of the depth of coverage.

Coding of Stigma Themes

To conduct a content assessment for how psychological disorder stigma is presented within the textbooks, all statements were compiled across texts. From this compilation, the statements tended to organically categorize into distinct themes. The emergent themes from this compilation included: labeling effects, impact on help-seeking, discrimination, misconceptions, and cultural variations. For example, stigma statements regarding therapy or professional treatment were to be coded into the help-seeking theme. As another example, stigma statements regarding minority groups and other countries were to be coded into the cultural variations theme. Examples of statements reflecting each theme are presented in Table 1. Depicted are stigma themes the statements were coded into along with corresponding examples. It is worth noting that labeling effects, discrimination, and misconceptions align with the themes that were identified through Wahl et al.'s (2014) analysis of psychological disorder stigma in abnormal psychology textbooks.

Judges examined each individual stigma statement with respect to content and coded according to the identified themes. Judges also worked to establish consensus through discussion of any discrepancies within the compiled statements and the coded themes.

RESULTS

The analysis on the extent to which introductory psychology textbooks cover the topic of psychological disorder stigma is broken into two parts. First, we present the percentage of texts that cover psychological disorder stigma. For those texts that do cover the topic, we then identify the breadth and depth of coverage through an analysis of stigma statements and themes.

Textbook Coverage

Of the 36 texts sampled in the study, ~17% (n = 6) had no clear coverage of psychological disorder stigma. All subsequent primary analyses reflect the 30 texts that specifically address psychological disorder stigma.

Stigma Statements and Themes

Breadth and depth of coverage of psychological disorder stigma, as represented through the number of stigma statements expressed within each textbook and across each theme, is depicted in Appendix 2. Across the 30 texts that mentioned psychological disorder stigma, we further explored each individual textbook to determine the breadth with which it addressed various issues surrounding the topic of psychological disorder stigma. We found, on average, textbooks discussed a median of 3 out of the 5 identified stigma themes.

A Chi-Square analysis revealed a significant difference in depth of coverage for each theme, [X.sup.2](4, N = 230) = 3.16, p<.05. Textbook discussions were focused predominantly on the effects of diagnostic labeling. Specifically, diagnostic labels were linked to stigmatizing attitudes in 50.5% (n = 116) of the statements. It is worth noting that ~53% (n = 19) of the textbooks made specific reference to the famous Rosenhan (1973) study on the stigmatizing effects of labels.

Textbook discussions regarding issues surrounding the topic of psychological disorder stigma were focused less on psychological disorder stigma as a barrier to professional help-seeking, discrimination resulting from psychological disorder stigma, misconceptions of psychological disorders, and cultural variations in the experience of psychological disorder stigma. Results revealed that 20.5% of the statements (n = 47) indicated that psychological disorder stigma can prevent individuals from seeking treatment and from reaching out to loved ones. Only 12% (n = 28) of the statements addressed the detrimental discrimination that individuals with psychological disorders face in many aspects of daily living and only 11% (n = 25) of the statements drew attention to misconceptions of psychological disorders. In addition, the analysis revealed a shortage of psychological disorder stigma discussion in reference to cultural variations in the experience of a psychological disorder (6% of statements, n = 14).

DISCUSSION

The psychological community has placed ample importance on combating widespread stigmatization of people with psychological disorders. Introductory psychology courses offer an opportunity to assist in this effort and to reach a broad audience. As such, the current study involved an analysis to investigate the extent to which the stigma surrounding psychological disorders is covered in introductory psychology courses. Specifically, we examined the breadth and depth with which introductory psychology textbooks address issues surrounding the topic of psychological disorder stigma.

Our analysis determined that there was one theme around which most introductory psychology textbooks currently address the issue of psychological disorder stigma. This theme was the impact of diagnostic labels (Granello & Gibbs, 2016; Martinez, Piff, Mendoza-Denton, & Hinshaw, 2011). Notably, a large portion of textbooks made specific reference to the famous Rosenhan (1973) study on the stigmatizing effects of psychiatric labels. As contextualized within the texts, this seminal piece of research illustrates the complicated challenges surrounding the battle against stigma, even within the psychiatric community. In the classroom, this study can be used to promote discussion as to whether it is possible to classify psychological disorders in a way that allows us to help people without stigmatizing them. However, limiting the discussion to that singular question does not fully address the public's stigmatizing attitudes. Positioning the text coverage squarely over the arguments for and against labels shrinks the scope of the stigma discussion along a singular dimension. This circumvents the overarching discussion that can be had on the reason labels are stigmatizing in the first place and on how society's predominantly negative view of psychological disorders can be alleviated through proper education grounded in the scholarly literature.

Our analysis also determined that the remainder of the themes we identified received very little coverage in introductory psychology textbooks. The shortage of this coverage could represent a missed opportunity to foster valuable conversation in service of combating psychological disorder stigma. One of these themes was the impact of psychological disorder stigma on help-seeking efforts. Such coverage is of particular value among college student populations. Despite having mental health services available free of charge on most college campuses, many students do not seek professional treatment (Martin, 2010). Among college students, untreated mental health issues often interfere with attendance and reduce the likelihood of degree completion (King, Meehan, Trim, & Chassin, 2006). Therefore, the inclusion of this material might ultimately assist in students seeking mental health resources when necessary. In addition, we found a scarcity of coverage over discrimination. Yet, if the public understood, for example, that people with psychological disorders are unfairly judged as being more responsible for their condition than those with certain physical ailments (Corrigan et al., 2000) perhaps the institutional discrimination against people with psychological disorders that limits access to mental health care (Thornicroft, 2008) could be reduced.

Our sample of textbooks also revealed no clear evidence of intentional efforts to correct misconceptions surrounding psychological disorders. This represents a missed opportunity, as research has shown that efforts made to refute common misconceptions by presenting evidence supporting the correct information can result in both short and long-term knowledge revisions (Lassonde, Kendeou, & O'Brien, 2016). The final theme we found to receive minimal coverage was the cultural variations in the stigma accompanying a psychological disorder. There is relatively more stigma present in certain cultures when it comes to disclosing symptoms of psychological disorders (Gureje et al., 2006). This coverage oversight conflicts with efforts within the psychological community to address issues of cultural and social diversity. Greater coverage could help build a society more responsive to multicultural and global concerns.

Given that our sample consisted of textbooks that we obtained from a database that allowed for the upload of texts to a private account, it may be limited. While sensible search terms were used to guide the search, with the wide variety of options for introductory psychology textbooks, it is unlikely that the search was exhaustive. However, previous published analyses of introductory psychology textbooks (e.g., Goldstein, Siegel, & Seaman, 2010; Haselhuhn & Clopton, 2008) include a similar or even smaller sample of textbooks. In addition, we caution the reader, just as Wahl et al. (2014) did with their textbook analysis, that without the proper means to establish more extensive rater reliability these data are not definitive.

We also acknowledge that regardless of the relative perceived importance of a topic, psychology instructors have a limited amount of time to address all topics. Nonetheless, the psychological community has already shown stigma to be a priority issue, as evidenced in the community's international anti-stigma campaigns (Borschmann, Greenberg, Jones, & Henderson, 2014). Logistically, considering that psychological disorders are already one of the core topics discussed in introductory psychology, more consensual coverage of the accompanying stigma would only require minimal additional time. One could simply contextualize the information within the framework of combating stigma to both provide adequate descriptions of the disorders as well as address this pressing social issue.

Stigma against individuals with psychological disorders perpetuates and deepens the adversity already faced by these individuals. While efforts to change this narrative are being made through international anti-stigma campaigns, psychology instructors can also play an active role. Absent a consensually derived set of topics recognized to be important to be covered in an introductory course, it is encouraging to find that the majority of textbooks analyzed did contain at least some discussion of psychological disorder stigma. If instructors do, as research would indicate, 'teach from the text' (Griggs & Bates, 2014), it is likely that most students will obtain some understanding of psychological disorder stigma. Current textbook coverage, however, appears to render the multifaceted account of psychological disorder stigma incomplete.

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Edney, D. (2004). Mass media and mental illness: A literature review. Canadian Mental Health Association, 1-27.

Goldstein, S. B., Siegel, D., & Seaman, J. (2010). Limited access: The status of disability in introductory psychology textbooks. Teaching of Psychology, 37, 21-27.

Granello, D.H., Gibbs, T.A. (2016). The power of language and labels: "The mentally ill" versus "people with mental illnesses". Journal of Counseling and Development, 94, 31-40.

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Landrum, R. E., & Gurung, R.A. (2013). The memorability of introductory psychology revisited. Teaching of Psychology, 40, 222-227.

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APPENDIX 1

Introductory Psychology Textbooks Examined for Psychological Disorder Stigma Content

1. Bernstein, D. A. (2016). Psychology: foundations and frontiers (1st ed.). Boston, MA: Cengage Learning.

2. Blair-Broeker, C., & Ernst, R. M. (2013). Thinking about psychology: the science of mind and behavior (3rd ed.). New York, NY: Worth.

3. Cacioppo, J. T., & Freberg, L. (2016). Discovering psychology: the science of mind (2nd ed.). Boston, MA: Cengage Learning.

4. Cervone, D., & Caldwell, T. L. (2015). Psychology: the science of person, mind, and brain (1st ed.). New York, NY: Worth.

5. Ciccarelli, S. K., & White, J. N. (2017). Psychology (5th ed.). Boston, MA: Pearson Learning Solutions.

6. Comer, R., & Gould, E. (2013). Psychology Around Us (2nd ed.). Hoboken, NJ: John Wiley & Sons.

7. Coon, D., & Mitterer, J. O. (2016). Introduction to psychology: gateways to mind and behavior, (14th ed.). Belmont, CA: Wadsworth Cengage Learning.

8. Davis, S. F., Palladino, J. J., & Christopherson, K. M. (2013). Psychology (7th ed.). Boston: Pearson Learning Solutions.

9. Feist, G. J., & Rosenburg, E. (2015). Psychology: perspectives and connections (3rd ed.). York, NY: McGraw Hill Education.

10. Feldman, R. S. (2013). Psychology and your life (2nd ed.). New York, NY: McGraw-Hill Education.

11. Gerrig, R. J. (2013). Psychology and life (20th ed.). Boston, MA: Pearson Learning Solutions.

12. Gray, P., & Bjorklund, D. F. (2014). Psychology (7th ed.). New York, NY: Worth.

13. Griggs, R. A. (2014). Psychology: A concise introduction (4th ed.). New York, NY: Worth.

14. Hockenbury, S. E., Nolan, S. A., & Hockenbury, D. H. (2015). Psychology (7th ed.). New York, NY: Worth.

15. Kalat, J. W. (2017). Introduction to psychology (11th ed.). Boston, MA: Cengage Learning.

16. King, L. A. (2017). The science of psychology: An appreciative view (4th ed.). New York, NY: McGraw-Hill Education.

17. Kowalski, R., & Westen, D. (2011). Psychology (6th ed.). Hoboken, NJ: John Wiley & Sons.

18. Krause, M. A., & Corts, D. P. (2016). Psychological science: Modeling scientific literacy (2nd ed.). Boston, MA: Pearson Learning Solutions.

19. Krull, D. (2014). Introduction to Psychology. Charlotte, NC: Kona Publishing and Media Group.

20. Lahey, B. (2102). Psychology: An introduction. New York, NY: McGraw-Hill.

21. Licht, D. M., Hull, M. G. & Ballantyne, C. (2014). Scientific American: Psychology. New, NY: Worth Publishers.

22. Lilienfeld, S. O., Lynn, S. J., Namy, L. L. & Woolf, N. J. (2014). Psychology: From inquiry to understanding. Upper Saddle River, NJ: Pearson Education.

23. Morris, C. G. & Maisto, A. A. (2016). Understanding Psychology. Upper Saddle River, NJ: Pearson Education.

24. Myers, D. G. & DeWall, C. N. (2017). Psychology in everyday life. New York, NY: Worth Publishers.

25. Myers, D. G. & DeWall, C. N. (2015). Psychology. New York, NY: Worth Publishers.

26. Nairne, J. S. (2013). Psychology. Belmont, CA: Wadsworth, Cengage Learning.

27. Nevid, J. S. (2018). Essentials of psychology: Concepts and applications. Boston, MA: Cengage Learning.

28. Okami, P. (2014). Psychology: Contemporary perspectives. New York, NY: Oxford University Press.

29. Passer, M. W. & Smith, R. E. (2011). Psychology: The science of mind and behavior. New York, NY: McGraw-Hill.

30. Pastorino, E. & Doyle-Portillo, S. (2016). What is psychology? Foundations, applications, and integration.. Boston, MA: Cengage Learning.

31. Plotnik, R. & Kouyoumdjian, H. (2013). Introduction to psychology. Belmont, CA: Wadsworth, Cengage Learning.

32. Schacter, D. L., Gilbert, D. T., Wegner, D. M. & Nock, M. K. (2014). Psychology. New York, NY: Worth Publishers.

33. Wade, C. & Tavris, C. (2017). Psychology. Upper Saddle River, NJ: Pearson Education.

34. Weiten, W., Dunn, D. & Hammer, E. Y. (2018). Psychology applied to modern life: Adjustment in the 21st Century. Boston, MA: Cengage Learning.

35. Wood, S. E., Wood, E. G. & Boyd, D. (2014). Mastering the world of psychology. Upper Saddle River, NJ: Pearson Education.

36. Zimbardo, P., Johnson, R. & McCann, V. (2017). Psychology: Core concepts. Upper Saddle River, NJ: Pearson Education.

APPENDIX 2

Distribution of Stigma Statements Relevant to Themes across Textbooks

This provides a breakdown of the depth of coverage introductory psychology textbooks give to psychological disorder stigma. Depicted are the number of stigma statements each textbook devotes to each theme that emerged in our analysis. Textbook numbers reference Appendix 1. Column 2 gives a total summation across themes of the number of stigma statements made in reference to psychological disorders within its respective textbook.
Distribution of Stigma Statements Relevant to Themes across Textbooks

Text-   # of     Labeling   Help-     Discrim-   Miscon-    Cultural
book    Stigma   Effects    Seeking   ination    ceptions   Variation
        State-
        ments

1       0        0          0         0          0          0
2       12       11         0         1          0          0
3       2        0          2         0          0          0
4       2        0          0         0          2          0
5       0        0          0         0          0          0
6       2        0          2         0          0          0
7       7        3          1         3          0          0
8       16       10         4         2          0          0
9       2        0          2         0          0          0
10      0        0          0         0          0          0
11      7        0          1         4          2          0
12      7        5          1         0          0          1
13      0        0          0         0          0          0
14      20       8          4         0          7          1
15      5        3          1         0          1          0
16      12       3          3         5          1          0
17      16       12         0         4          0          0
18      16       7          6         2          1          0
19      0        0          0         0          0          0
20      6        0          4         1          1          0
21      10       3          2         1          4          0
22      11       8          1         0          1          1
23      1        0          0         1          0          0
24      0        0          0         0          0          0
25      9        7          0         1          1          0
26      10       10         0         0          0          0
27      7        2          1         1          0          3
28      2        1          0         1          0          0
29      14       10         2         0          0          2
30      2        0          1         0          1          0
31      5        0          3         0          0          2
32      11       7          2         0          2          0
33      4        0          1         0          0          3
34      6        2          3         0          1          0
35      0        0          0         0          0          0
36      6        4          0         1          0          1
Total   230      116        47        28         25         14


Victoria L. DeSensi

Wilmington College

Bethany S. Jurs

Transylvania University

Author info: Correspondence should be sent to: Victoria DeSensi, Ph.D., Department of Psychology, Wilmington College, Wilmington, OH 45177
TABLE 1 Breakdown of the Breadth of Coverage Introductory
Psychology Textbooks Give to Psychological Disorder Stigma

Theme              Example Stigma Statement

Labeling Effects   Labeling a psychological problem as an illness or a
                   disorder tends to attach a stigma that can be
                   difficult to overcome.' (Nairne, 2013, p. 448).
Impact on Help-    Some people may be reluctant to seek treatment
seeking            because of the stigma that is still associated with
                   psychological problems.' (Hockenbury, Nolan, and
                   Hockenbury, 2015, p. 641).
Discrimination     Among the most feared aspects of stigma is
                   discrimination.' (King, 2017, p. 527).
Misconceptions     Rates of suicide are probably grossly
                   underestimated due to the attached stigma.'
                   (Pastorino & Doyle-Portillo, 2016, p. 568).
Cultural           "The low rates of mental illness in countries such
Variations         as Nigeria are likely to be biased because of a
                   cultural stigma in disclosing symptoms of
                   psychological disorders." (Hockenbury, Nolan, &
                   Hockenbury, 2015, p. 571)


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