Soc Psychiatry Psychiatr Epidemiol (2007) 42:295–300 DOI 10.

1007/s00127-007-0160-9

ORIGINAL PAPER

Bertil Lundberg Æ Lars Hansson Æ Elisabeth Wentz Æ Tommy Björkman

Sociodemographic and clinical factors related to

devaluation/discrimination and rejection experiences
among users of mental health services

Accepted: 8 January 2007 / Published online: 13 February 2007

j Abstract Background A major goal in mental

health research and policy is to identify ways to re-
Introduction
duce stigma among persons with mental illness.
Negative attitudes towards individuals with mental
Aims The aims of the present study were to (1)
illness is widespread, they constitute a major barrier
investigate the prevalence of rejection and devalua-
to treatment and have been found to be one of the
tion/discrimination in a cross-sectional sample of 200
most important obstacles for integration of people
individuals with experiences of mental illness and (2)
with mental illness in the society. Frequently, studies
investigate the relationship between sociodemo-
investigating attitudes among the general public have
graphic and clinical, client characteristics and per-
shown that people with mental illness are perceived as
ceived devaluation/discrimination and experiences of
strange, frightening, unpredictable, aggressive and
rejection. Methods A total of 200 subjects in current
lack self-control [13, 18, 22]. Particularly a diagnosis
contact with mental health services or with earlier
of schizophrenia has been found to be stigmatizing
experiences of this were interviewed regarding beliefs
and associated with negative stereotypes such as
about devaluation/discrimination and rejection
violence and dangerousness [3, 4].
experiences. Results The results showed that subjects
In contrast to studies of attitudes in the general
with a higher degree of global functioning perceived
population, there are relatively few studies investi-
less devaluation/discrimination. With regard to
gating the way people with mental illnesses them-
rejections experiences associations were found be-
selves experience adverse reactions by others, and in
tween rejection experiences and global functioning,
most cases negative attitudes in the general popula-
number of admissions to inpatient psychiatric care
tion seem to have been internalized among people
and current contact with social services. Conclu-
with the mental illness. They expect negative reactions
sion Further research should investigate the causal
from the public [27]. Most of them have experienced
relationship between stigma experiences and psy-
stigmatizing comments, been treated as less compe-
chosocial functioning. To understand what conse-
tent, and people have tried to avoid them. Moreover,
quences perceived devaluation/discrimination has for
findings indicate that stigma plays a role in social
the afflicted, a psychological and social approach in
isolation, income loss [15], opportunities for
the research must be taken into consideration.
employment and housing [6], quality of life [23], and
access to medical care [2, 25].
j Key words stigma – mental illness – devaluation –
One of the major goals in mental health research
discrimination
and policy is to identify ways to reduce stigma. To
accomplish this it is necessary to understand the
background factors of stigma.
One of these background factors is the use of
psychiatric labels and societal misinformation about
mental illness, misinformation, which is often medi-
B. Lundberg, RN, RNT, (&) Æ L. Hansson, PhD Æ E. Wentz, MD ated by the media [9, 10].
T. Björkman, PhD In order to reduce stigma it is necessary to change
Dept. of Health Sciences, Division of Nursing
labels associated to persons with a mental illness.
SPPE 160

Lund University, PO Box 157

22100 Lund, Sweden Efforts to reduce stigma by replacing myths regarding
E-Mail: bertil.lundberg@med.lu.se mental illness with more accurate, empirically based
296
information on mental illness have however not come
up to expectations. Studies investigating this con-
cludes that negative attitudes are easier to affect in
education programs directed to smaller and chosen
groups [7, 26] and if the content in the program are
focussing on specific negative stereotypes i.e. schizo-
phrenia and dangerous [19, 20, 26].
Societal misinformation and psychiatric labels
describing mental illnesses are not the only factors
accounting for stigma. A further factor is related to
the stigmatized person himself; Studies indicate that
persons with severe symptoms and poorer social skills
will be more likely to experience mental illness stigma
[14]. Severe symptoms such as disorganized behav-
iour and flat affect may scare others and reinforce the
fear of mental illness [12].
Most stigma studies investigating the role of
behaviour and symptoms have relied on vignettes [8].
Among the few studies investigating factors associ-
ated to stigma regarding schizophrenia the results are
divergent. Dickerson et al. [11] reported no relation-
ship between symptoms or social functioning and
stigma. In contrast, Penn et al. [21] found a robust
association between negative symptoms and more
social distance and the authors conclude that social
skills, negative symptoms and perceived strangeness,
may contribute to stigma.
In order to identify ways to reduce stigma on an
individual level, the knowledge about sociodemo-
graphic and clinical factors relationship to stigma is
of great importance.
In the present study we examine sociodemographic
and clinical factors influence on perceived discrimi-
nation/devaluation and rejection experiences in a
sample representing different psychiatric diagnosis
and experiences of mental health care.
Aims
The aims of the study were (1) to investigate the
prevalence of rejection and devaluation/discrimina-
tion experiences in a cross-sectional sample of indi-
viduals with an ongoing contact with mental health
services or earlier experiences of this (2) to investigate
the relationship between perceived devaluation/dis-
crimination, rejection experiences and sociodemo-
graphic and clinical patient characteristics.
Methods and subjects
j Design
The study was designed as a cross—sectional study using a con-
venience sampling procedure among consumers in current contact
with mental health services or with earlier experiences of this. In
order to reach subjects with different experiences of mental illness
the recruitment were made at inpatient psychiatric wards, outpa-
tient clinics, rehabilitation units and among members of user
organizations. Oral and written information about the aim of the
study was given to prospective subjects at all units. At the time of
the interview further information about the study was given by the
interviewer. Of the 200 subjects who take part in the study, all
fulfiled the interview.
The prevalence of rejection and discrimination/devaluation
experiences in the sample was obtained by interviews using self-
report questionnaires. Information on diagnosis was colleted from
case record after consent from the subject.
Global functioning was rated according to the Global Assess-
ment of Functioning Scale (GAF), Axis V in the DSM-III-R (APA
[1]). In addition, information on sociodemographic characteristics,
history of psychiatric care and duration of illness was obtained
from the subjects during the interview. The interviews were per-
formed by one of the authors (BL) and took place at inpatient or
outpatient services or in the subjects’ home. Participation was
based on informed consent from the subjects. Ethical approval was
received from the Regional Ethical Review Board in Southern
Sweden.
j Measures
Stigma experiences were assessed by two self-report questionnaires
measuring perceived rejection and beliefs about devaluation/dis-
crimination. Rejection experiences were assessed using a Swedish
version of the Rejection experience scale [5]. The self-report ques-
tionnaire contains 11 questions and is partly based on the Consumer
Experiences of Stigma Questionnaire (CESQ) [27] and the Rejection
experience scale developed by Link [15]. Each of the 11 questions in
the Swedish version of the questionnaire have a 5-point response
scale; never = 1, seldom = 2, sometimes = 3, often = 4, very of-
ten = 5. In one item the scoring of the item is reversed in creating a
sum score.
Beliefs of devaluation and discrimination were investigated by a
questionnaire developed by Link [15]. The questionnaire include 12
items were the individual items are responded to in a 4-point scale;
strongly agree = 4, agree = 3, disagree = 2, strongly disagree = 1. In
six of the items the scoring of item is reversed in creating a sum score.
The Devaluation and Discrimination scale is one of four scales in
the Perceived Stigma Questionnaire [15] and measures attitudes
towards people with mental illness. The self-report questionnaire
includes 12 items and each item consists of a 4-point response scale;
strongly agree = 4, agree = 3, disagree = 2, strongly disagree = 1.
In six of the items the scoring of the item is reversed in creating
a sum score. The Swedish versions of the two stigma scales have
been tested for reliability and validity in a separate study with
satisfactory results [5].
j Statistics
The statistical software used was SPSS for windows, release 11.5.
Student’s t-test was used to analyze differences between subgroups
of participants and the Pearson product-moment correlation test
was used to investigate associations between Perceived devaluation/
discrimination, rejection experiences and sociodemographic and
clinical variables. In order to investigate the relationship between
rejection experiences and sociodemographic and clinical charac-
teristics a stepwise multiple regression analyses was performed. In
these analyses, sum score of the Rejection experiences scale was
used as the dependent variable and global functioning, diagnosis,
years from first admission, type of psychiatric care, current contact
with social services and admissions into psychiatric care as inde-
pendent variables.
Results
Sociodemographic and clinical background charac-
teristics are presented in Table 1. Most subjects
 297

Table 1 Sociodemographic and clinical characteristics (N = 200) thought that most employers will pass over the
application of a former mental patient in favour of
N %
another applicant, and that they are not seen as being
Sex as trustworthy as the average citizen (67%) or as
Male 88 44.0 intelligent (56%) as other people. Except for a few
Female 112 56.0 areas, more than half of the participants believed that
Age (mean range) 42 (18–84)
Education
psychiatric patients might face severe devaluation and
Primary school 56 28.0 discrimination.
College 75 37.5
University 69 34.5 j Rejection experiences
Living situation
Alone 120 60.0
Partner 64 32.0 Table 3 illustrates the data of Rejection experiences.
Parents 16 8.0 The highest reported frequencies of perceived rejec-
Children tion were found in the areas; that they were treated
No 97 48.5 differently after they had been a patient in a mental
Yes 103 51.5
Accommodation hospital and; that they felt that people were uncom-
Own or rented apartment/house 169 84.5 fortable around them after being hospitalized for
Second hand/lodger/parents 19 9.5 mental illness.
Sheltered housing 7 3.5 The lowest reported frequencies of perceived neg-
Homeless 5 2.5
Employment status/support the last 6 months
ative rejection experiences were found in the area of
Open labour market 36 18.0 being refused an apartment or a room because they
Sheltered/supported employment 16 8.0 had been a patient in a mental hospital and in the area
Unemployed 9 4.5 of being denied a passport, driver’s licence, or other
Student 14 7.0 kinds of permits when it was revealed that the
Reporting sick 26 13.0
Disability pension (N = 89) 99 49.5 applicant had a mental illness.
retirement pension (N = 10)
Diagnosis ICD-10 (N = 196) j Factors associated with Devaluation/discrimination
Psychosis F 20–29 70 35.0
Affective disorders F 30–39 68 34.0 and Rejection experiences
Other diagnosis 58 29.0
GAF md, (range) 55 (40–90) No significant relationships were found between
Treatment history psychiatric care perceived Devaluation/discrimination and sociode-
Years from first admission m, sd 14 ± 12 mographic or clinical characteristics e.g. sex, age,
Number of previous psychiatric 2 (0–80)
admissions md, (range) education, employment status, diagnosis, number of
Current contact with mental health services (N = 187) admissions to a mental hospital, current contact with
Inpatient 62 31.0 psychiatric care, primary health care or social ser-
Outpatient 125 62.5 vices. However, a negative correlation was found be-
tween perceived devaluation/discrimination and
global functioning (GAF) r = )0.20 (p = .004) and a
were women, living alone in own apartments, not
positive correlation was found between perceived
working and mainly on disability pension. Of the
Devaluation/discrimination and Rejection experi-
196 subjects with a psychiatric diagnosis 46 re-
ences r = 0.45 (p = 0.001).
ported the diagnosis themselves. Among the sub-
Perception of Rejection experiences showed no
jects with a diagnosis of psychosis 63% had a
relationship with sociodemographic characteristics
diagnosis of schizophrenia. About 42% had a self
e.g. sex, age, education, somatic illness or current
reported somatic illness.
contact with primary health. Subjects with no or one
The most common diseases according to ICD-10
children reported more rejection experiences than
[28] were musculoskeletal (M00-M99) endocrine,
subjects with two or more children (2.0 ± 0.7 vs.
nutritional and metabolic diseases (E00-E90), dis-
1.8 ± 0.6 p = 0.01). With regard to employment
eases in the respiratory system (J00-J99) and in the
status, students and subjects with paid or self-
circulatory system (I00-I99). About 94% had a
employment reported less rejection experiences than
current contact with psychiatric care. About 28% of
subjects who were unemployed, had sheltered/sup-
the subjects reported a contact with primary health
ported employment or pension (1.75 ± 0.5 vs.
care and 23% a contact with social services. About
2.0 ± 0.7 p = 0.001). With regard to clinical vari-
48% of the subjects had no children.
ables, a positive correlation was found between
Rejection experiences and number of previous
j Perceived devaluation/discrimination psychiatric admissions r = 0.28 (p = 0.001).
A negative correlation was found between Rejec-
In Table 2, reported perceived devaluation/discrimi- tion experiences and global functioning r = )36
nation is given. A majority of the subjects (73%) (p = 0.001). Subjects with a diagnosis of psychosis
298

Table 2 Perceived devaluation/discrimination (N = 199)

Strongly agree Agree Disagree Strongly disagree

N (%) N (%) N (%) N (%)

Most people would accept a former mental patient 28 (14.0) 94 (47.0) 70 (35.0) 7 (4.0)
as a close friend.
Most people believe that a person who has been 18 (9.0) 70 (35.0) 98 (49.0) 13 (7.0)
in a mental hospital is just as intelligent
as the average person.
Most people believe that a former mental patient 11 (5.0) 55 (28.0) 108 (54.0) 25 (13.0)
is just as trustworthy as the average citizen.
Most people would accept a fully recovered former 16 (8.0) 87 (44.0) 84 (42.0) 12 (6.0)
mental patient as a teacher of young children
in a public school.
Most people believe that entering a mental hospital 21 (10.0) 105 (53.0) 57 (29.0) 16 (8.0)
is a sign of personal failure.
Most people would not hire a former mental patient 43 (22.0) 104 (52.0) 40 (20.0) 11 (6.0)
to take care of their children, even if he or she
had been well for some time. N = 198
Most people think less of a person who has been 30 (15.0) 89 (45.0) 73 (37.0) 7 (3.0)
in a mental hospital.
Most employers will hire a former mental patient 11 (6.0) 83 (42.0) 92 (46.0) 12 (6.0)
if he or she is qualified for the job. N = 198
Most employers will pass over the application of a 34 (17.0) 112 (56.0) 48 (24.0) 5 (3.0)
former mental patient in favour of another applicant.
Most people in my community would treat a former 27 (14.0) 88 (44.0) 76 (38.0) 8 (4.0)
mental patient just as they would treat anyone.
Most young women would be reluctant to date a man 35 (17.0) 105 (53.0) 53 (27.0) 6 (3.0)
who has been hospitalized for serious mental disorder.
Once they know a person was in a mental hospital, 21 (11.0) 95 (48.0) 76 (38.0) 7 (3.0)
most people will take his or her opinions less seriously.

Table 3 Rejection experiences (N = 200)

Never Seldom Sometimes Often Very often

N (%) N (%) N (%) N (%) N (%)

Did some of your friends treat you differently 54 (27.0) 49 (24.5) 63 (31.5) 18 (9.0) 16 (8.0)
after you have been a patient in a mental hospital?
Have you ever been avoided by people because 76 (38.0) 54 (27.0) 51 (26.0) 13 (6.5) 5 (2.5)
they knew you were hospitalized in a mental
hospital? N = 199
Have people used the fact that you were in a mental 105 (52.5) 37 (18.5) 41 (21.0) 8 (4.0) 8 (4.0)
hospital to hurt your feelings? N = 199
Have you ever been refused an apartment or a room 186 (93.0) 4 (2.0) 5 (2.5) 4 (2.0) 1 (0.5)
because you had been a patient in a mental hospital?
Do you sometimes avoid people because you think they 82 (41.0) 28 (14.0) 57 (29.0) 20 (10.0) 12 (6.0)
might look down on people who were in a mental
hospital? N = 199
After being hospitalized for mental illness were people 57 (28.5) 51 (25.5) 73 (37.0) 13 (6.5) 5 (2.5)
uncomfortable around you? N = 199
I have been turned down for a job for which I was qualified 80 (40.0) 41 (21.0) 46 (23.0) 23 (11.5) 9 (4.5)
when it was revealed that I am a consumer. N = 199
I have been advised to lower my expectations in life 88 (44.0) 38 (19.0) 45 (22.5) 19 (9.5) 10 (5.0)
because I am a consumer.
I have been treated fairly by others \ know I am a 8 (4.0) 18 (9.0) 38 (19.0) 86 (43.0) 49 (25.0)
consumer. N = 199
I have been treated as less competent by others when 165 (84.0) 12 (6.0) 8 (4.0) 6 (3.0) 5 (3.0)
they learned I am a consumer. N = 196
I have been denied a passport, driver’s license, or other kinds of 179 (90.5) 5 (2.5) 10 (5.0) 2 (1.0) 2 (1.0)
permits when I revealed that I am consumer. N = 198

reported more Rejection experiences compared to
subjects with other diagnosis (2.2 ± 0.7 vs. 1.9 ± 0.6,
p = 0.002) and subjects in inpatient psychiatric care
reported more Rejection experiences compared to
subjects in outpatient psychiatric care (2.1 ± 0.7 vs.
1.8 ± 0.6, p = 0.01) and subjects with a current con-
tact with social services reported more Rejection
experiences compared to subjects with no contact
with the social services (2.2 ± 0.8 vs. 1.8 ± 0.6
p = 0.001).
In a stepwise forward multiple regression analysis
using the sum score of the Rejection experiences scale

Table 4 Factors associated to Rejection experiences
Beta coefficient
Global functioning )0.32
Admissions psychiatric care 0.23
Current contact with social services 0.16
Total explained variance
Stepwise forward multiple regression analysis. Dependent variable: Rejection experiences
as the dependent variable and sociodemographic and
clinical characteristics as independent variables, glo-
bal functioning, number of admissions into psychi-
atric care and current contact with the social services
explained 17.3% of the variance, Table 4.
Discussion
In order to reduce stigma among people with mental
illness it is important to identify factors, which con-
tribute to stigma. In the present article we have
examined the prevalence of devaluation/discrimina-
tion and rejection experiences and the relationship
between these experiences and clinical and sociode-
mographic characteristics.
The findings of the present study suggest that
rejection experiences are associated to sociodemo-
graphic and clinical characteristics where level of
psychosocial function seems to be the dominating
factor. In accordance with similar studies [16, 23, 24,
27] investigating rejection experiences among men-
tally ill persons the present study also found a higher
degree of rejection experiences among participants
with psychosis diagnosis.
Persons with psychosis diagnose might as a con-
sequence of the disease be vulnerable and distrustful
and perceived more stigmatization because they ex-
pect more negative attitudes from others. It may also
be possible that symptoms of the disease may cause
behavioural change and attention, which may be
frightening for others and cause reactions from the
social environment. In order to reach additional
knowledge about this, studies that include actual re-
ports of the afflicted surroundings are needed. This
would help us to understand the relationship between
clinical characteristics and stigmatization experiences
more clearly. The rather strong relationship between
actual rejection experiences and beliefs of devalua-
tion/discrimination may not be entirely surprizing. It
seems plausible that actual rejections experiences
reinforce expectations of stigma and vice versa.
With regard to beliefs about devaluation and dis-
crimination the findings confirm earlier studies
showing that individuals with experiences of mental
illness believe that they may face severe devaluation
and discrimination by the public [16]. Except for a
few areas, a majority of the subjects believed that the
public might devaluate and discriminate people be-
299
R Square change F-change Sig. F change
0.099 21.6 0.001
0.051 17.2 0.001
0.023 13.6 0.001
0.173
cause of mental illness. Further analysis investigating
relationships between beliefs about devaluation and
discrimination and specific sociodemographic or
clinical characteristics did only detect one relation-
ship. A worse global functioning was found correlated
to a higher degree of beliefs about devaluation and
discrimination. This finding may suggest that the
functional level may play a central role in under-
standing the relationship between stigma and mental
illness.
The interpretation of the weak relationships be-
tween beliefs about devaluation/discrimination and
sociodemographic or clinical characteristics, may be
that beliefs about devaluation and discrimination
correlate more to internal psychological aspects and
self-stigmatization.
Studies investigating this issue suggest that nega-
tive attitudes in the general population often are
internalized among people with a mental illness and
that expected devaluation and discrimination may
have a negative influence on mental illness. According
to the ‘‘Label Theory’’ [17] persons internalize nega-
tive attitudes towards mental illness from the society.
When someone become labelled as having a mental
illness the beliefs of stigma and mental illness will
become personally relevant. In this way, labelling
triggers expectations of rejection that maybe disrupt
social interaction and impair social and psychological
functioning.
In order to increase our understanding of the
implication of a psychiatric illness more attention
should be put on the experiences of the person af-
flicted. Further research should investigate the causal
relationship between stigma and psychosocial func-
tion. To understand what consequences perceived
devaluation/discrimination has for the afflicted, a
psychological and social approach in the research
must be taken into consideration.
Finally some limitations of the study should be
mentioned. Due to the cross-sectional design the
direction of causality cannot be determined. More-
over, due to the convenience sampling procedure and
with no data available about persons not participating
in the study, generalization of the findings must be
taken by cautiousness. However, in spite of the fairly
large sample included in the study and the recruit-
ment of participants from different mental health
services and user organizations may somewhat over-
come these shortcomings.
300
j Acknowledgement The study was supported by grants from the
Vardal Institute, Sweden.
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