Seton Hall University
The Phenomenon of Social Isolation in the Severely Mentally Ill
Sheila Linz
College of Nursing
Seton Hall University
Introduction
This paper seeks to explore the phenomenon of social isolation in the severely mentally ill. The concept of social isolation as it affects the general population has been defined through concept analysis (Warren, 1993). Although social isolation has been described as a powerful force in the everyday lives of mentally ill individuals (Mostafanejad, 2006; Wright, Gronfein, & Owens, 2000), and in fact, social isolation and severe psychiatric disabilities appear to be intertwined (Davidson, Haglund, et al, 2001), there has been no direct exploration of the phenomenon of social isolation as it uniquely applies to the mentally ill.
The search terms, “social isolation” and “social isolation and the mentally ill” were submitted to CINAHL, Science Direct, Proquest and PsycInfo. The range was limited to ten years, from 2000-2010. Follow up articles were selected from the reference lists of articles read. The articles selected discussed social isolation and related terms, such as perceived isolation, loneliness, alienation, exclusion and stigma. Excluded were articles pertaining to children.
The 1960’s heralded in the era of deinstitutionalization (Sadock & Sadock, 2003). State hospitals released their mentally ill patients into the communities to receive community based care. The policy was premised on the basis that individuals with psychiatric illness would integrate into their communities (Granerud & Severinsson, 2006; Ware, Hopper, Tugenberg, Dickey, & Fisher, 2007). This anticipated integration has not proven to be the case. Severely mentally ill individuals physically reside in the community but rarely establish social ties (Ware, et al., 2007; Wong, Sands, & Solomon, 2010). The most frequent complaint by individuals residing in the community is that they feel socially isolated and lonely (Davidson, et al., 2004).
Social neuroscience theory posits that man has evolved as a social being (Cacioppo & Patrick, 2008). Numerous studies have shown that when social isolation is not by choice, it is deleterious to mental and physical health (Berkman & Syme, 1979; Cacioppo, Hughes, Waite, Hawkley & Thisted, 2006; Cornwell & Waite, 2009). Studies have affirmed the negative effects of social isolation on physical health on the general population; however, research in this area has not yet been conducted in regards to the severely mentally ill. In the United States 2.6 % of our population is diagnosed with a severe mental illness in any given year (National Institute of Mental Health [NIMH], 1999). Thus, social isolation and its effects on the mentally ill is a serious mental and physical health problem facing our society. Research has shown that the life span of individuals with schizophrenia is markedly reduced, with an increased risk of metabolic syndrome and cardiovascular disease (McEvoy, et al., 2005; Newcomer & Hennekens, 2007). Nursing is integral to the provision of physical and mental healthcare services in our communities, and as such, is naturally concerned with the problem of social isolation and the severely mentally ill.
This paper will present a comprehensive perspective of the theoretical definitions related to the phenomenon of social isolation, offer the historical views of mental illness as they have progressed over time, and present methodological approaches used to investigate the phenomenon. This paper will use Warren’s (1993) constructs of stigma, alienation, and loneliness as the key influences impacting on the phenomenon of social isolation in the severely mentally ill.
Definition of Severe Mental Illness
The definition of severe mental illness used in this paper will be consistent with the definition of severe and persistent mental illness as put forth by the Surgeon General. Severe and persistent mental illness includes schizophrenia, bipolar disorder, and other severe forms of depression (National Institute of Mental Health [NIMH], 1999). Studies referring specifically to schizophrenia will be noted as such.
Theoretical Perspectives
Definitions-Social Isolation as it Applies to All
Carpenito, (2006) defines social isolation as a “state in which a person or group experience a need or desire for increased involvement with others but is unable to make that contact” (p.634). Nicholson (2009) defines social isolation as “a state in which the individual lacks a sense of belonging socially, lacks engagement with others, has a minimal number of social contacts and they are deficient in fulfilling quality relationships” (p. 1346). Hawthorne (2006) refers to the term social isolation as “living without companionship, social support, or social connectedness” (p.523).
Social isolation has been linked in definition to loneliness. Loneliness has been described as the experiential state of the phenomenon of social isolation. Cacioppo & Patrick (2008) define loneliness as the subjective sense of social isolation. Peplau (1955) describes this subjective state as feelings of intense desperation and dread, at times unbearable. A dictionary definition for loneliness is “standing apart from others of its kind: isolated” (Webster’s New World Dictionary, 1988). Peplau and Perlman (1979) write “loneliness exists to the extent that a person’s network of social relationships is smaller or less satisfying than the person desires” (p.101).
When isolation is sought out as a form of “aloneness” in order to facilitate reflection, or to increase concentration, isolation does not result in loneliness (Peplau, 1955). It is only when social isolation or the lack of social relationships causes distress and is not by choice, that loneliness results. In other words, it is the perception of social isolation that causes loneliness. Cacioppo and Hawkley (2009) write that it is perceived social isolation that is known more colloquially as loneliness. Perceived social isolation has also been defined as loneliness and a lack of perceived social support (Cornwell & Waite, 2009). Social isolation and its relation to loneliness is measured on the UCLA loneliness scale (Russell, Peplau, & Cutrona, 1980). For the purposes of this paper, social isolation will be defined as a perceived form of isolation that is not by choice, causing distress and resulting in loneliness.
Social isolation is considered an aberrant condition. The ability to connect with others has long been held as an important and natural component of human existence. Sullivan (1953) writes, “ man requires interpersonal relationships, …being cut off is perhaps not as fatal as for an animal to be cut off from all sources of oxygen; but the lethal aspect of it is nonetheless well within the realm of correct referential speech ” (p. 32). The philosopher Buber writes “The individual is a fact of existence insofar as he steps into a living relation with other individuals….The fundamental fact of human existence is man with man” (Glatzer, 1966, p.113).
Societal Views of Mental Illness over Time
Foucault (2006) begins his history of European society’s treatment of the mentally ill with the image of the “ship of fools”. By the 14th century the mentally ill were regularly expelled from their walled cities and entrusted to the care of river boat men who would ferry them far downstream before they were put ashore and left to wander and beg. Inspired by the hospitals for the mentally ill in North Africa, the 15th century saw several hospitals constructed in Europe for the care of the mentally ill (Livianos, Miguel, & Moreno, 2010). Later in the 17th and 18th centuries, for the most part, the mentally ill, criminals, and other undesirables were confined together in workhouses and institutions that had originally been built to hold the leprous population. It was not until the end of the 18th century that mental illness came to be generally viewed as an object of medical perception and many institutions entirely devoted to the care of the mentally ill were established (Foucault, 2006).
The very nature of severe mental illness is inextricably linked to social isolation. In fact, The DSM IV includes disruption of interpersonal relations as part of the criteria for diagnoses of schizophrenia (American Psychiatric Association [APA], 2000). Theories were not developed in order to define the social isolation seen in the mentally ill; they were developed to understand the social isolation experienced within the illness, and the causes of the illness that included social isolation as a major symptom.
In the early to middle of the 20th century, prior to the neurobiological theory of mental illness, the prominent theories of mental illness were based in the psychoanalytical models (Luhrmann, 2007). Jaco (1954) described the person with schizophrenia as living in a world of their own creation, cut off from real contact and communication with others. Fromm-Reichmann (1948/1959) describes the person with schizophrenia as withdrawing into his own private world, with its unique thoughts and losing partial contact with the outside world, in effect, the person with schizophrenia isolates himself.
It was during this period that Fromm-Reichmann (1948/1959) introduced the concept of the “schizophrenogenic” mother. Mark (1953) studied the attitudes of mothers of male schizophrenics toward child behavior and compared these with the attitudes of mothers of non-schizophrenics. He found that the attitudes of the mothers of schizophrenics were different than the other mothers in that they were more restrictive, controlling and exhibited both excessive devotion and cool detachment. In the battle of nature over nurture, which was already raging (Mark, 1953), the mother was vilified. The idea of the “schizophrenogenic” mother was perhaps more extreme, but not inconsistent with the maternal deprivation hypothesis as suggested by Bowlby’s (1951/1973) report for the World Health Organization. The report suggested that children deficient in maternal (or primary care giver) stability and warmth would have significant and long-lasting negative effects on their ability to develop healthy social connection.
The social isolation hypothesis.
The early middle of the 20th century also produced “social psychiatry”, a blending of psychiatry and sociology to look at severe mental illness (Dunham, 1948). In contrast to the theory that severe mental illness or impairment in social functioning was caused by the mother, or early childhood experiences, these theorists postulated that social isolation in society might also contribute to the cause of severe mental illness (Dunham, 1948; Hollingshead & Redlich, 1954; Jaco, 1954; Kohn & Clausen, 1955).
Faris (1934) proposed that it was painful social experience and social rejection that caused a person to withdraw inward. He wrote “Any form of isolation which cuts the person off from intimate social relations for an extended period of time may possibly lead to this type of disorder” (p.157). Hollingshead and Redlich (1954) studied the relationship of social stratification to schizophrenia. Their study determined that the accepted downward drift hypothesis (schizophrenics become poor and relocate to slum areas) did not hold. They found a significant relationship between originating from a lower class position, urbanized location, and schizophrenia, thus linking the larger adverse societal influences to the illness.
Jaco (1954) identified communities with high rates of schizophrenia, and studied the conditions that might lead to an increase in that illness. He found that typical of highly urban areas, they shared the characteristics of anonymity, less social participation, renting rather than owning, and greater unemployment. These findings continue to be duplicated today, with the highest rates of psychoses found in the most urbanized areas, even after controlling for other factors (Allardyce & Boydell, 2006; Kelly et al, 2010; Sundquist, Frank, & Sundquist, 2004). Kohn and Clausen (1955) elucidate the concept of “alienation” within the social isolation hypothesis “ they do not really belong to their peer groups, that is, they become alienated from their peers…alienation may lead to withdrawal from social interaction, that [will lead] to isolation” (p. 273).
Medical model/ Neurobiological model.
The medical model assumes that severe mental illness is a disease of the brain, that brain pathology causes symptoms, and that to some extent it can be treated (Wong & Van Tol, 2003). The medical model also accepts that based on twin studies and animal models, severe mental illness is in part, an inherited disease (Mc Gue, 2010; Pearlson & Folley, 2008). In the discussion of nature vs. nurture, the illness, and thus the symptoms of social withdrawal are caused by brain pathology. The cause includes a variety of influences, and is not solely influenced by parenting or by social environment. Thorazine appeared on the scene in 1952 and psychiatry heralded the age of treatment for severe mental illness through pharmacology. Although many other psychotropic medications have been formulated since the discovery of Thorazine, medication remains the primary treatment of severe mental illness (Ban, 2007). The symptoms targeted by medication include symptoms causing alienating behaviors such as hallucinations (positive symptoms), and symptoms such as apathy and social withdrawal (negative symptoms). However, it was soon discovered that negative symptoms were resistant to medication (Letemendia & Harris, 1967). Severe negative symptoms were observed to be endemic to this population. Andreason (1979) recommended that affective flattening be used as one of the criteria for diagnosis of schizophrenia. Crow (1985) wrote that negative symptoms foretold of poorer prognosis, were resistant to treatment, and rarely remitted.
The late eighties produced Clozaril and other atypical antipsychotics considered more effective at treating both the positive and negative symptoms of schizophrenia (Kane, Honigfeld, Singer & Meltzer, 1988). These brought hope for a healthier and less isolated life. Schizophrenia was considered a disease amenable to treatment, although hope of recovery was not offered.
Recovery.
Severe mental illness was viewed throughout most of the twentieth century as having an inevitable downhill course (Wexler, Davidson, Styron, & Strauss, 2007). Deegan (2007), a leader in the recovery movement describes her diagnosis of schizophrenia; she was told that she had a disease for which she would need to take medication for the rest of her life in order to cope; a disease that offered no hope of recovery. The Vermont Longitudinal Research Project (Harding, Brooks, Ashikaga, Strauss & Breier, 1987) brought hope for recovery. Severely mentally ill individuals institutionalized for many years were enrolled in an innovative rehabilitation program, released to the community with appropriate supports and followed for 32 years. At their ten year follow up 70% remained out of the hospital, although they were socially isolated and required occasional hospitalization. However, after 25 years, one-half to two-thirds of the study subjects had made a substantial improvement in their psychiatric status (Harding et al., 1987). Another longitudinal study following individuals with schizophrenia for an average of 22.4 years found that 22% of the patients had had a complete psychiatric remission, with no psychotic symptoms (Huber, Gross, Schutter, & Linz, 1980). In the past several decades continued research has shown that a substantial percentage of individuals with schizophrenia do not have the dire outcomes that were expected (DeSisto, Harding, McCormick, Ashikaga, & Brooks, 1995; Harrison et al., 2001; Silverstein & Bellack, 2008).
The consumer driven recovery model focuses on empowerment, social justice, participation in healthcare decisions, taking the locus of control, and learning how to live with symptoms while accomplishing ones goals (Deegan, 1992). The severely mentally ill individual is a “consumer” of mental health care, not a perennial patient. Recovery is not outcome based; it is focused on overcoming the effects of the psychiatric condition, poverty, stigma and social isolation (Silverstein & Bellack, 2008). Social isolation is no longer seen as inevitable.
Conceptual Basis of Social Isolation
Warren (1993) looked at social isolation as it applied to the general population, and conceptualized social isolation with five constructs as sub-headings that describe the full range of the meaning of social isolation. The five constructs are stigma, alienation, loneliness, aloneness, and powerlessness. In review of the literature in relation to social isolation and the mentally ill, the only three constructs that re-emerge as consistent components of the topic are the constructs of stigma, alienation and loneliness. Since no one theory of social isolation and the mentally ill that specifically focuses on and adequately defines the topic was found in an extensive literature review, several constructs differentiated by the sub headings of stigma, alienation, and loneliness will be described theoretically as they relate to the phenomenon of social isolation as it uniquely applies to the severely mentally ill.
Stigma
In the late 1950’s and the 1960’s, the mental health field felt sociology’s influence on the understanding of social isolation and the mentally ill through the investigation of “stigma” and its impact on social isolation in the labeling theory. In Asylum, Goffman (1961) presented his ethnographic study of psychiatric patients in a mental hospital. He observed a process by which individuals with psychiatric difficulties enter a mental hospital and discover that not only have they lost contact with reality and lost control of their behavior, they have also lost their identity as a “normal” person. They are viewed and view themselves differently than before as the results of stigma and internalized stigma. In trying to regain access to society they accept their role and act as a “mental patient”. However, once stigmatized, true access to community is never fully regained (Goffman, 1963).
In describing labeling theory as it applied to the severely mentally ill, Scheff (1963) said in effect, that the mentally ill, once diagnosed and stigmatized, perhaps unconsciously “act” the role of the insane. These radical assertions, widely held in the 60’s, brought about a firm rebuttal in the 1970’s. Cove (1970) in particular, rejected the labeling theory. He firmly believed that the mentally ill person’s behavior caused others to view them in a negative light and it was continued bad behavior that kept them in a stigmatized position, and not the other way around.
Link (1987), in response to Cove (1970) and other critics in the 1970’s and the 1980’s, developed the modified labeling theory to explain stigma and it’s isolating effects on individuals with mental illness. The modified labeling theory posits that stigma is a serious force in the lives of the severely mentally ill, significantly affecting their acceptance in society and in the perceptions of themselves. This differed from the labeling theory in that individuals with severe mental illness did not “act” in order to fulfill a societal expectation. However, the experience of external stigma and the internalization of stigma would affect the self esteem in individuals with severe mental illness and cause these individuals to disengage from social situations, thus increasing their social isolation (Link, 1987; Link, Cullen, Struening, Shrout, & Dohrenwend, 1989; Link, Phelan, Bresnahan, Stueve, & Pescolido, 1999).
Based on the modified labeling theory, research has continued on the effects of stigma and internalized stigma as a major cause of social isolation in the severely mentally ill. Aviram and Segal (1973) noted that from the beginning of deinstitutionalization, the severely mentally ill had been excluded from integration in communities due to the public’s attitude toward them. Rosenfeld (1997) found that only interventions that provided needed services to the mentally ill and reduced stigma within communities could effectively change the quality of life for individuals with severe mental illness.
Wright et al. (2000) elaborated on the role of social rejection and its relationship to internalized stigma. They write “stigma is a powerful and persistent force in the lives of long-term mental patients….experiences of rejection increase and crystallize patients’ self-deprecating feelings” (p. 80). Schulze and Angermeyer (2003) conducted focus groups with the severely mentally ill in order to ascertain their experience of stigma. They found that 49% percent of their study participants with schizophrenia believed that their experience of social isolation was caused by the stigma related toward their diagnosis. Even when asymptomatic, they experienced stigma. Wright, Wright, Perry and Foote-Ardah (2007) looked at the sexual isolation of people with severe mental illness through the lens of stigma and modified labeling. Their results indicated that the study participants were “fundamentally isolated from their own sexuality, both psychologically and socially” (p. 93).
Because much is known about stigma and its effects on individuals with severe mental illness, research has begun to focus on methods to combat it. Mueller et al. (2006) found that social support decreased the amount of perceived stigma in individuals with a recent onset of psychiatric illness. With support, the level of social isolation remained the same as before their first hospitalization. Their findings contrasted with the modified labeling theory which holds the effects of stigma as stable, and resulting in social withdrawal. This study’s finding lends some support to the recovery model’s position that holds a more flexible and hopeful attitude towards the diminishment of internalized stigma in the mentally ill (Anthony, 1993).
Sibitz, Unger, Woppmann, Zidek, and Amering (2009) proposed the teaching of stigma resistance (the experience of resisting or being unaffected by stigmatizing attitudes) to the severely mentally ill. This theoretical basis was borrowed from the battle against stigma by the HIV community (Poindexter & Shippy, 2010). Sibitz et al. (2009) found stigma resistance helpful in enabling the severely mentally ill to be less susceptible to internalized stigma. Estroff, Penn, and Toporek (2004) looked at the effectiveness of various programs designed to reduce stigma such as engagement in broader coalitions and advocacy in housing and employment. They suggested a change in vocabulary, from stigma to discrimination in order to remove the burden from the mentally ill individual, and place the onus on the discriminator (Estroff et al., 2004). Here, following the tenets of the recovery model, the label of “mental patient” has been discarded and replaced by “consumer”. The premise of the inevitability of internalized stigma of the labeling theories is abandoned, and the severely mentally ill individual emerges from isolation into a proactive societal role.
Stigma or the process of “labeling” relates to Buber’s (1937/1970) philosophical treatise describing the “I and Thou” relationship. Buber (1937/1970) asserts that to truly be in relation to another, the relationship must be as “I /Thou”. One person in their entirety views another in their entirety. However, when a person has been stigmatized, they are no longer seen as a full human being, they become objectified, the object becomes an “it” and the relationship becomes “I /it”. The stigmatized person is not seen as a whole person apart from their “label”. When this occurs, no true relationship between two beings is possible.
Alienation
Marx (1844/1963) used the term alienation to describe the process by which the worker becomes secondary to his production, and in doing so feels removed from his own body, his creative thoughts, the natural world, and his own particular human nature. The concept of alienation has also been applied to the field of mental health in order to explain the phenomena of social isolation. Erdner, Magnusson, Nystrom, and Lutzen (2005) define alienation as “an estranged relationship between individuals and their social environment” (p.374). In their ethnographic study of individuals with severe mental illness, they found that these individuals perceived themselves as “odd”, felt like “outsiders”, unable to fit in, and filled with a terror of social rejection. DeNiro (1995) described alienation as a sense of “non belonging”, a feeling that drives a person to withdraw from a society that they cannot comfortably participate in with any measure of solidarity. Erdner et al. (2005) found that the fear of social failure often led their severely mentally ill study participants to lose hope, and to give up on attempts at communicating with others. Echoing the concept of “giving up”, Luhrmann (2007) theorizes that the life of the individual with schizophrenia is lived in “social defeat”, after repeated social failure; they simply stop trying.
Alienation differs from the experience of stigma in that the severely mentally ill individual can be affected by stigma, but is foremost affected by their psychiatric symptoms. They are estranged by virtue of their own illness. It is not the internalization of a stereotype that affects their behavior as much as a true change in their ability to connect with the social world. Erdner et al. (2005) quote one of their study participants “Maybe I’m not interested in socializing. I feel empty, everything I do is difficult! Don’t fit in, it doesn’t matter what I do” (p.378). In a study by Estroff, Lachicotte, Illingworth, and Johnston (1991) an individual with severe mental illness reported that he had cut himself off from others because he realized how sick he was and could not put forth the amount of effort needed to maintain a conversation without being embarrassed. Another person with severe mental illness described herself as “broken” (Erdner, Andersonn, Magnusson & Lutzen, 2009).
Davidson and Staynor (1997) offer the term “empty shell” as a term that has been used clinically to describe the person with schizophrenia; lacking in social skills, socially isolated, taken care of by others but lacking the ability for reciprocal relationships. Although they might reside in the community, community life does not bring connection; often the person with severe mental illness views their neighbors with as much suspicion as they themselves are viewed (Agget & Goldberg, 2005). Here, alienation relates to Buber’s (1937/1970) description of the “I and Thou” relationship. It is the alienated, severely mentally ill person who, in effect, also objectifies and withdraws from the larger society that they have lost all relation to; the relationship becomes “it /it”.
Loneliness
Brown (1996) compared living situations and their relationship to loneliness for individuals with severe mental illness. The study found that this population experienced high levels of loneliness whether they lived with others or alone, suggesting that loneliness is an ongoing and pervasive experience for this population.
In a study exploring the experiences of loneliness in individuals with severe mental illness who lived alone in the community, Nilsson, Naden, & Lindstrom (2008) found that loneliness had a strong relation to the experience of suffering. The loneliness described by the study participants is an existential loneliness, ever present, coloring the experience and meaning of their lives. They were grateful to have their own apartments, but never really felt at home. The loneliness expressed was so profound that it reached an ontological level. One respondent described his feelings “My God, why have you left me….it’s a sore in the soul to be left, there’s a depth to loneliness…a pain” (p.165).
Granerud & Severinsson (2006) also found loneliness to be a main theme in individuals with severe mental illness struggling to integrate socially into a community. Individuals felt alone, even when with people (Erdner, Nystrom, Severinsson, & Lutzen, 2002). Again, loneliness is described as an existential experience. A study participant responded “I am alone wherever I am. It is dreadful to be lonely and forgotten and isolated. I have nobody” (p. 290). Another main theme found was “shame”. The study participants felt different than others. The shame they described about that difference is akin to the experience of internalized stigma.
All was not bleak, in reporting experiences of loneliness, respondents also reported that their creative endeavors, visual arts, music and writing, brought relief from loneliness (Nilsson et al., 2008), as did their relationships with their pets (Erdner et al.,2009). Although several studies found that relationship with God was conflicted and ambivalent (Erdner et al., 2009; Nilsson et al., 2008), other studies have shown spirituality to be a healing force in the lives of individuals with severe mental illness (Bussema & Bussema, 2007; Davidson, Staynor, et al., 2001).
Chernomas, Clarke, and Marchinko (2008) studied the relationships of women with severe mental illness and their support systems. The women studied expressed a belief that it was “reciprocity” in relationships that was most satisfying. When they could be seen and valued as a person, satisfying interaction would result. In a study of supported socialization, Davidson, Haglund et al. (2001) found that individuals with severe mental illness were not “empty shells” and could engage with others as long as they felt that the relationships were reciprocal, and that they had something to offer. In this way they can feel cared about as a unique individual and not as a recipient of charity. This finding supports the recovery models suggestion that when stigma is reduced, alienation, loneliness and internalized stigma can also be reduced. True reciprocity in relationship is the “I and Thou” described by Buber (1937/1970).
In order to fully appreciate the extent of social isolation experienced by the severely mentally ill, the constructs of stigma, alienation and loneliness when taken together provide a multidimensional understanding of the depth of this phenomenon.
Methods
The majority of research on social isolation in the mentally ill has focused on stigma. Since much is known about stigma, researchers primarily used quantitative measures to test theories. Methods have included the use of surveys, correlation, and regression analysis (Jorm & Griffiths, 2008; Rosenfeld, 1997) and a three way-longitudinal design with a time –lagged regression analysis (Wright, Gronfein, & Owens, 2000). A strength of quantitative methods is that comparisons between differences in groups and changes over time can be readily examined.
Several studies researching social isolation in the severely mentally ill will be presented. These studies have been chosen to represent both quantitative and qualitative methodologies that have been used to explore this phenomenon. In addition, the selected studies have investigated particular theories that are important to the understanding of social isolation in the severely mentally ill such as stigma, internalized stigma, alienation and existential loneliness.
In a seminal cross-sectional study testing the labeling theory, stigma and its effects on family and social network, Link et al. (1989) investigated the effects of labeling on several groups with and without psychiatric illness. The study sample included community residents (n=429) and identified psychiatric patients with major depression or schizophrenia (n= 164). Tools used were the devaluation-discrimination tool with an adequate internal consistency (a =.76). Patients with a psychiatric history were assessed by a tool developed to measure secrecy, withdrawal and education (patient educating others), and coping skills related to stigma. Internal consistency reliability was a Cronbach’s alpha of .71(low, but acceptable) for secrecy, .67 for withdrawal (this is low, they later strengthened this factor in a confirmatory factor analysis), and .71(low, but acceptable) for education. Social network measures were elicited with Fisher’s questions (a list of questions assessing social network was attached as an appendix to the study, no reliability measures were included). The subjects were divided into five groups: first treatment contact patients (n=67), repeat treatment contact patients (n=117), former patients (n=96), untreated psychiatric cases, (n=142), (diagnosed by research staff using the modified DIS to generate DSM-III diagnoses and discriminate function analysis), and untreated well respondents (n=171). The results indicated that the individuals with a history of psychiatric treatment (labeling) showed significant effects of stigma (p ................
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