Many people who would benefit from mental health services opt not to pursue them or fail to fully participate once they have begun. One of the reasons for this disconnect is stigma; namely, to avoid the label of mental illness and the harm it brings, people decide not to seek or fully participate in care. Stigma yields 2 kinds of harm that may impede treatment participation: It diminishes self-esteem and robs people of social opportunities. Given the existing literature in this area, recommendations are reviewed for ongoing research that will more comprehensively expand understanding of the stigma-care seeking link. Implications for the development of antistigma programs that might promote care seeking and participation are also reviewed.

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How stigma interferes with mental health care.

Understanding the impact of stigma on people with mental illness.

In this study, we build on previous work by developing and estimating a model of the relationships between causal attributions (e.g., controllability, responsibility), familiarity with mental illness, dangerousness, emotional responses (e.g., pity, anger, fear), and helping and rejecting responses. Using survey data containing responses to hypothetical vignettes, we examine these relationships in a sample of 518 community college students. Consistent with attribution theory, causal attributions affect beliefs about persons' responsibility for causing their condition, beliefs which in turn lead to affective reactions, resulting in rejecting responses such as avoidance, coercion, segregation, and withholding help. However, consistent with a danger appraisal hypothesis, the effects of perceptions of dangerousness on helping and rejecting responses are unmediated by responsibility beliefs. Much of the dangerousness effects operate by increasing fear, a particularly strong predictor of support for coercive treatment. The results from this study also suggest that familiarity with mental illness reduces discriminatory responses.

An attribution model of public discrimination towards persons with mental illness

All Our Kin: Strategies for Survival in a Black Community. C. B. Stack. New York: Harper & Row. 1974. Carol Stack wrote one of the most powerful books of the last half century about African American families. The book's power derived from its focus on the stories and the lives of persons who were struggling to manage with limited resources and who had evolved seamless methods of survival and coping strategies. Stack was not content to view the problems of impoverished African American families from an outside perspective, as had been done in the past, but chose instead to present her work from the view of the participants. She presented a sensitive view of families that has not been duplicated to this day. Stack put specific emphasis on being accepted by the families before she began interviewing them. She and her son took a long time to be accepted by the families as they gradually became participants in the day-to-day lives of the "Flats." She was sensitive to the patterns of interactions among the networks of family and friends that would have been overlooked by almost any other researcher or method of observation. The book showed how a person from another racial and economic group was able, with skill, to become an intimate part of the experience and the lives of very poor families. Her anthropological approach stands in sharp contrast to the countless attempts of others to quickly go in and pull out slices of families' lives with a preexisting conceptual framework. The African American families of the Flats were presented as they were, not from a White academic theoretical perspective that was not based on reality. Stack made many observations that allowed one to see the intricate workings of the families that "outsiders" had not been documented before. Participants were allowed to make observations about their own families' patterns of interaction and to uncover truths of family functioning based on the reality of their lives. Important data on these second-generation urban dwellers are presented in such a calm manner that one could overlook their significance to the field. The impact of the economic pressures on the men and women in the African American community show how persons can have mainstream values but are prevented from achieving them because of the lack of employment and economic security within the community. In response to the reality, Stack found that African Americans have cooperated to produce an adaptive strategy of exchanging goods and trading resources, as well as offering child care or temporary fosterage. Kinship boundaries were more elastic than they were in more affluent families because these individuals immersed themselves in a domestic network of kinfolk and fictive kin, or those who became as kin. The participants in Stack's study moved around and had loyalties to more than one household grouping at a time, making their family networks unlike the "household" structures of most American families. These networks were diffused over several kin-based households that changed frequently. The usual method of arbitrarily specifying widely accepted definitions of the family as nuclear or matrilocal may block one from seeing the world as it exists in very poor communities. Stack's observations refuted the "culture of poverty" position that had seen African Americans as having no culture or totally negative qualities of family disorganization, personal disorganization, and fatalism. Unfortunately, too many current writings on African Americans still take these same positions. The views may be the result of ignorance, naivete, or complex levels of racism that insidiously make their way into present family literature. Stack continued to reflect on the poverty of the participants' situations. By doing so, she avoided another position that is all too common-assumption that all African American families are the same, regardless of their levels of poverty or affluence. …

All Our Kin: Strategies for Survival in a Black Community

https://link.springer.com/content/pdf/10.2307/3343529.pdf

Making Ends Meet: How Single Mothers Survive Welfare and Low-Wage Work

Neighborhood Types and Community Reaction to the Mentally Ill: A Paradox of Intensity STEVEN P. SEGAL JIM BAUMOHL EDWIN W. MOYLES University of California. Berkeley Journal of Health and Social Behavior 1980, Vol. 21 (December):345-359 Employing data from a statewide study of sheltered-care residents and facilities in California. combined with archival data describing the census tracts in which these facilities are located. the authors analyze the impact of community reaction on sheltered-care residents in diﬁerent types of neighborhoods. Findings suggest that conservative middle-class communities are most likely to exhibit extreme negative reactions that can have a deleterious impact on the social integration of residents in community care. Liberal. nontraditional neighborhoods conform most closely to the ideal accepting community. In liberal. nontraditional neighborhoods and conservative working-class neighborhoods a moderate level of community reaction actually facilitates the social integration of sheltered-care residents. Community reaction to the mentally ill has been an oft discussed and researched phenom- enon during the past ten years. and it has been well established that such reaction affects both the ability of the mentally ill to participate in community life and the willingness of local government to provide or permit the provision of services (Segal and Aviram. I978). In this paper we are concerned with the immediate environment of the community-based sheltered-care facility. a residential setting that is intended to provide supervised living for a handicapped group, in this case. the mentally ill. The oldest fonn of sheltered-care facility is the family-care home. which has traditionally aimed to maintain the chronically mentally ill in local areas (Morrissey. I967). Later. halfway houses with more rehabilitative goals devel- This paper was prepared for the conference New Directions for Research on Stigma Toward the Mentally Ill. sponsored by the National Institute of Mental Health, Bethesda. Md., January 24 and 25. I980. Thanks to Mark Kaplan for his comments and assistance. This research is supported in part by the National Institute of Mental Health. Center for Epidemiologic Studies. Grant SROI MH254l7-06 ESR. Address communications to: Dr. Steven P. Segal, School of Social Welfare. University of California. Berkeley, CA 94720. __345 oped as an element of sheltered-care (Apte. I968). &#39;l1Iese have been joined by board-and- care facilities that have assumed all three functions of community-based sheltered-care: long-term care. transitional care. and place- ment of first resort (Segal and Avir-am. I978). in California there ate approximately l,l55 sheltered-care facilities serving nonretarded individuals between I8 and 65 years old who have had some experience in a psychiatric in- patient ‘setting. Family-care homes constitute 26% of these facilities and serve l4% of all sheltered-care residents. Halfway houses, which have received the greatest attention of the mental health professions, account for only 2% of all facilities and serve only 3% of the state&#39;s sheltered-care population. Board-and- care homes. which have developed in an un- planned, ad hoc manner, make up 72% of the state&#39;s facilities and serve 82% of Califomia‘s sheltered-care residents (Segal and Aviram, 1978). The community sunounding the sheltered- care facility may be a place in which ex-mental patients ﬁnd a comfortable home or an oppres- sive one; a place in which their safety is threatened or in which they can feel free to be about; a place in which they can establish re- lationships or in which others are unavailable to them; a place in which their public depen-

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Neighborhood types and community reaction to the mentally ill: a paradox of intensity.

Conceptual and methodological problems plague efforts to prevent homelessness. Attempts to identify individuals at risk are inefficient, targeting many people who will not become homeless for each person who will. Such interventions may do useful things for needy people, but evidence that they prevent homelessness is scant. Subsidized housing, with or without supportive services, has ended homelessness for families and played a key role in ending it for people with serious mental illnesses. Other risk factors may be less important once housing is secured. But programs that allocate scarce housing may simply reallocate homelessness, determining who goes to the head of the line for housing, not shortening the line itself. We recommend reorienting homelessness prevention from work with identified at-risk persons to efforts to increase the supply of affordable housing and sustainable sources of livelihood nationwide or in targeted communities.

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The Prevention of Homelessness Revisited

Twenty-two percent of a young vagrant population reported on in this study, and believed to be representative of similar groups in many American cities, have been hospitalized for psychological disorder. These young mentally disordered vagrants are the most marginal members of the vagrant subculture, lacking social margin (i.e. resources, relationships, and a credible identity) with their families, community services and their peers. Their critical lack of social margin is due to an incongruence of expectations between disordered vagrants and potential benefactors. This incongruence generates a situation in which apparently eligible clients fall or slip through cracks in the service system. Ultimately, these individuals will become the core of a new chronically disordered and dependent population housed, at best, in community-based sheltered living arrangements as they grow older.

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Falling Through the Cracks: Mental Disorder and Social Margin in a Young Vagrant Population

Reprinted from SOCIAL WORK. Vol. 25. No. S. September 1980 ngaging the disengaged: proposals on madness and Vagrancy Steven P. Segal and Jim Baumohl Urban areas have become host to young chronic ex-mental patients who often live on the street or in single-room occupancy hotels. The authors analyze obstacles to humane community care and sug- gest future policies and programs. Steven P. Segal. Ph.D.. is Associate Professor and Director. and Jim Baumohl. MS W. is Field Research Specialist. Mental Health and Social Welfare Research Group, Scltool of Social Welfare. University of Califor- nia. Berkeley. The research on which this paper is based was supported in part by Grant No. SROI MI! 254 I 7-05 from the Center for Epidemiologic Studies. National In- stitute ofMental Health, ttnda Faculty Research Grant from the Committee on Research. University of C altfornia. Ber/reley. This paper is a revised ver- sion of one prepared for the President&#39;s Commission on Mental Health. Winter I977. The authors express appreciation to Howard Levy, Kathryn Komatsu. Satinder Cheema. Lynn Everett-Dille. and Elsie ./ohnsonfor their comments. 358 YOUNG ADULT males will be the most difficult mental patients of the 19805. Although the rate of residence in men- tal hospitals for the overall population has declined markedly since I955. the‘ rate for young adult males has changed little in this time. Moreover. the size of this population has grown enormously and is projected to grow further during the 19805.‘ As elderly patients are removed to nursing homes and similar institutions, state and county hospitals will contend with a growing population of young patients. many of whom will become familiar, periodic guests. In this era of commu- nity care. most will receive only “re- volving-doorq treatment: they will be brieﬂy hospitalized. treated with major tranquilizers. and discharged. After discharge, some of these young people will “return to parents or spouses; others will find congenial halfway houses or board-and-care set- tings. Some will gravitate to cults or other communities of believers and. in retrospect. may view their madness as a necessary religious awakening.’ A signiﬁcant number. who have lost or exhausted their kin or who place au- tonomy before the refuge of home. will pursue independent lives. Perhaps they will never again need treatment. Unfortunately. many of these young. primarily male ex-patients will simply disappear into the tenderloins. youth ghettos. and -skid rows of America. Between hospitalizations. they will live on the street and. in time, become qcareerq mental patients and middle- aged urban nomads. Most probably. they will drift through rundown welfare hotels and be repeatedly involved with the police and mental health agencies as a result of public complaints.’ This article is concerned with the di- lemmas of this group of ex-mental patients—the so—cal|ed space cases. The authors discuss six major obstacles to their humane care in the community and describe approaches to social sup- port that might prevent the worst con- sequences of madness and disatTiIia- tion. in this article the authors use the terms qex-mental patient“ (or “ex- puticntq). qstreet person.q and qspace case“ to describe the subjects of their inquiry. These terms are not synony- mous. and the authors will be remiss in their obligation to those who partici- pated in the research if the distinctions are not clear. The term qstreet peopleq is a gross. imprecise term that is applied to a het- erogeneous population with only a few characteristics in common. Street people hang out on the street, using the sidewalks and parks of the city as the living rooms that most cannot afford: they participate in the various social and economic activities associated with street life the world over. However. there is no widely accepted “code of the streetsq in this country. If there is an encompassing tradition among street people in predominantly white. univer- sity-dominated Berkeley. California. rather than sets of expectations adher- ing to speciﬁc roles (such as that of the drug dealer). it is a vague legacy of the “psychedelic leftq that is. today. more veheer than substance.‘ The term “space case.q however. is specific and grounded in the authors‘ field research on social boundaries among street people. Space cases are those judged by other street people to be delusionary. unpredictable. and unreliable—in the lexicon of the street “burned out.q qfried.q or qspaced.“ Space cases have invariably been hos- pitalized. but not all street people who have been hospitalized are space cases.’ The term “ex-mental patientq refers to all individuals of such status. space cases included. Since the space case is a particular son of street person. he or she is also a special kind of ex-mental patient. PRESENTING PROBLEM In addition to psychiatric status. two dimensions of the ex-mental patient‘s life are of primary importance to caretakers: social functioning and propensity to violence. Kears. although referring to the whole population of young male ex-patients -in his area. provides a description that fairly repre- sents the mental health professional‘: view of space cases. He finds that space cases are “chronically dysfunc- tionalq or “violent and destructive.q‘ 0037-8046/803505-0358 $0.50 © I980. National Association of Social Workers. lnc.

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Jim Baumohl

Papers

Neighborhood types and community reaction to the mentally ill: a paradox of intensity.

The Prevention of Homelessness Revisited

Falling Through the Cracks: Mental Disorder and Social Margin in a Young Vagrant Population

Engaging the disengaged: proposals on madness and vagrancy

Held in Abeyance: Rethinking Homelessness and Advocacy