Perceptions of Mental Illness Stigma: Comparisons of Athletes to Nonathlete Peers

Jan Arminio & Robert D. Reason, associate editors Perceptions of Mental Illness Stigma: Comparisons of Athletes to Nonathlete Peers Emily Kaier Lisa DeMarni Cromer Mitchell D. Johnson Kathleen Strunk Joanne L. Davis Stigma related to mental health and its treatment can thwart help-seeking. The current study assessed college athletes personal and perceived public mental illness stigma and compared this to nonathlete students. Athletes (N = 304) were National Collegiate Athletic Association (NCAA) Division I athletes representing 16 teams. Results indicated that athletes reported greater perceived public stigma than personal stigma. Athletes reported significantly higher levels of stigma compared to nonathlete peers (n = 103). Accordingly, athletes may benefit from education that can reduce the stigma of mental illness and reduce prejudices toward those who are seeking treatment. Additional implications for improving access to care are discussed. One in four Americans has a diagnosable mental disorder, most of which onset by age 24 (Kessler et al., 2005). College athletes are a vulnerable group because of cumulative stresses related to competitive sport (e.g., Papanikolaou, Nikolaidis, Patsiaouras & Alexopoulos, 2003). In addition to extensive sport-related time demands, sport-related travel translates into being academically disadvantaged due to lost classroom and laboratory instructional time. Furthermore, sport-related injuries often increase time demands because of the added commitment of physical therapy and rehabilitation. Few studies have compared rates of psychopathology between college athletes and nonathletes. Storch, Storch, Killiany, and Roberti (2005) found that female athletes reported lower levels of social support and greater levels of depressive and social anxiety symptoms than did female nonathletes; however, there were no differences between athletes and nonathletes in rates of clinical mental health problems. Approximately 10 15% of college athletes experience issues Emily Kaier is a student member of The University of Tulsa Institute of Trauma, Adversity and Injustice, and a doctoral candidate of Psychology at The University of Tulsa. Lisa DeMarni Cromer is Codirector at The University of Tulsa Institute of Trauma, Adversity and Injustice and Associate Professor of Psychology at The University of Tulsa. Mitchell D. Johnson graduated with his Bachelor s of Science in Psychology at The University of Tulsa. Kathleen Strunk is Cofounder and Codirector at The University of Tulsa Institute of Trauma, Adversity and Injustice and a Clinical Associate Professor in the School of Nursing at The University of Tulsa. Joanne L. Davis is Cofounder and Codirector at The University of Tulsa Institute of Trauma, Adversity and Injustice and Associate Professor of Psychology at The University of Tulsa. The authors wish to acknowledge the Athletics Department at The University of Tulsa for their cooperation and assistance with this research as well as the athletes who took time out of already busy schedules to complete measures. October 2015 vol 56 no 7 735

significant enough to warrant psychological services (Ferrante, Etzel, & Lantz, 1996; Parham, 1993; Watson, 2006). Despite potential elevated risk, college athletes underutilize psychological services (Watson, 2006). This may be a corollary of athletics culture that emphasizes self-reliance (Etzel, Ferrante, & Pinkney, 1991) and prioritizing the team over self. Additionally, athletes are often well known on campus and, hence, may not have privacy if seen walking into campus counseling (Etzel et al., 1991). Individuals seen at a mental health clinic may be labeled as mentally ill and stigmatized (Corrigan, 2004). According to the National Institute of Mental Health, stigma is the primary impediment to seeking treatment for a mental illness (U.S. Department of Health and Human Services, 1999). Mental illness stigma could contribute to athletes underutilization of services and less positive attitudes toward help-seeking (Watson, 2006). Stigma can be public or personal. Public stigma is a belief about others perceptions, and personal stigma is one s own beliefs (Corrigan, Watson, & Barr, 2006). Corrigan (2004) suggested that stigmas develop sequentially, first by recognizing public or peer group stigma, then by forming one s own personal stigma. Perceived public stigma (PPS) may prevent an individual from seeking psychological help for fear of peers negative judgments, and personal stigma may harm self-esteem when one sees oneself as part of a stigmatized group (Corrigan, 2004). The idea that PPS might prevent an individual from seeking psychological services is consistent with empirical data. A survey of undergraduates found that students who reported higher mental illness stigma were less likely to seek psychological help (Cooper, Corrigan, & Watson, 2003). In a college sample, Eisenberg, Downs, Golberstein, and Zivin (2009) found that PPS was considerably higher than personal stigma and that higher levels of personal stigma were associated with less help-seeking. The current study examined PPS and personal stigma about mental health helpseeking in a sample of college athletes and a comparison sample of nonathletes. We hypothesized that: (a) personal stigma and PPS about mental illness would be positively correlated, (b) PPS would be significantly higher than personal stigma, and finally, (c) athletes would experience higher personal and PPS than would a group of nonathletes. The ultimate goal of exploring these questions was to provide feedback to athletic administration at the present university. MEthoD Participants There were 304 athlete participants (129 women and 175 men) from 16 NCAA Division I teams with an average age of 20 (SD = 1.36). Ethnicity was: Caucasian (68%), African American (20%), American Indian (1%), Hispanic, Latino or Spanish (4%), and other (7%). Nonathletes (n = 103) consisted of 72 women and 31 men, with average age of 21 (SD = 4.33) years. Nonathletes ethnicity was: Caucasian (62.7%), African American (6.9%), Hispanic, Latino or Spanish (6.9%), American Indian (4.9%), other (17.6%), and one who declined to say (1%). Procedure Athlete data collection was conducted in conjunction with practices and team meetings. Participation was voluntary. A comparison sample of nonathletes was recruited through an online human subjects pool (HSP). Because the HSP was small at this university, the comparison sample was smaller than the athlete sample. Any participants enrolled in Psychology classes were given research credit; the rest volunteered without compensation. 736 Journal of College Student Development

Measures The Perceived Discrimination Devaluation (PDD) Scale measures mental illness stigma (Link, 1987). The PDD has 12 items that assess agreement with statements about how most people view psychiatric patients. The PDD queries personal stigma and public stigma. An example of a personal stigma item is: I would willingly accept someone who has received mental health treatment as a close friend. Public stigma refers to peer groups (Eisenberg et al., 2009). For example, for athletes a public stigma item is: Most of my fellow student athletes would willingly accept someone... ; whereas for nonathletes the item would query: Most of my fellow students would willingly accept someone.... Responses were given on a 6-point Likerttype scale from 0 (strongly agree) to 5 (strongly disagree), and scores were averaged. Higher values reflected more stigma. In the current sample, the full scale Cronbach s alpha was.78. RESuLtS Consistent with previous research (Eisenberg et al., 2009), among athletes we found a significant positive correlation between personal and perceived stigma (r =.29, p <.0001), and it was a medium effect size (Cohen, 1988). This finding supports the notion that more PPS is associated with higher personal stigma about mental illness. A pairedsamples t-test revealed that PPS (M = 2.38) was significantly higher than personal stigma (M = 2.19), t(278) = 4.52, p <.001. To explore if athletes experienced higher personal and PPS than a comparison group of students, a multivariate analysis of variance (MANOVA) with student status (athlete or nonathlete) as the independent variable and personal and PPS scores as the dependent variables was conducted. The omnibus MANOVA was significant, F(2, 372) = 174.53, p <.001, Wilks s lambda =.52, partial η 2 =.48. The univariate analyses between group differences for both personal and PPS resulted in the following, F(1, 373) = 23.11, p <.001, partial η 2 =.06 and F(1,373) = 349.77, p <.001, partial η 2 =.48, respectively. Athletes had higher levels of personal stigma (M = 2.18, SD = 0.70) than did nonathletes (M = 0.65, SD = 0.66) and higher PPS (M = 2.38, SD = 0.47) than did nonathletes (M = 2.05, SD = 0.80). Post hoc mean levels of personal stigma and PPS from this study were compared to that of Eisenberg et al. s (2009) sample of college students (N = 5,555). We examined whether the group of athletes in the present study differed from a larger population of students. A one-sample t-test revealed that, compared to Eisenberg and colleagues study, athletes in the current sample reported more personal stigma, t(284) = 28.12, p <.001; however, the athletes level of PPS was not different from that in Eisenberg and colleagues study, t(277) = 1.94, p =.05. DiSCuSSion Relative to peers, college athletes underutilize mental health services (Watson, 2006). Previous research has demonstrated that negative attitudes toward mental health can be an encumbrance to help seeking. The current study examined stigmatized attitudes toward mental illness that could deter athletes from help seeking (U.S. Department of Health and Human Services, 1999). Based on previous research, we postulated that stigma could be heightened because of athletes celebrity status on campus (Etzel et al., 1991). Because athletes are in the public eye, they could experience less privacy, which could then make them more vulnerable to fears of mental ill stigma (Corrigan, 2004). Predictions were partially supported. October 2015 vol 56 no 7 737

College athletes personal stigma was corre lated with higher PPS, and athletes reported greater PPS than personal stigma. These findings suggest that athletes may be internalizing prejudices (personal stigma) about mental illness. The current study extended findings by Eisenberg et al. (2009), who found high levels of PPS among college students. However, we caution that we used a modified (albeit recommended) version of the measure. In the current study we modified public to reference participants peer group, i.e., fellow athletes. This modification was based on Eisenberg et al. s recommendations for future study. They noted that the term most people was ambiguous and recommended that future research specify the reference group. Thus, when we compared the data and found that the athletes mean level of PPS was significantly less than the Eisenberg et al. sample, this could be an artifact of how the reference group was operationalized. It is important to note that the current sample had significantly higher personal stigma than did the Eisenberg et al. sample. Limitations of the study include the selfreport nature of the measures and potential social desirability bias. We also note that differences between athlete and nonathlete means may be an artifact of the data collection method. Almost all of the athletes completed the measures in a paper and pencil format and in a room with other participants. In contrast, nonathletes completed measures online. Additionally, the study adapted the modified terminology used by Eisenberg and colleagues (2009) in describing mental illness patients. The wording of the PDD measure former mental patient was changed to a person who has received mental health treatment. The less stigmatized language could have influenced participants responses. As pointed out by an anonymous reviewer, another potential limitation is that we directed athletes to reference their own peer group (i.e., fellow student athletes), not the entire student body. The athlete population is a small subgroup of the student body and, as such, athletes may naturally see themselves as more similar to one another in contrast to nonathletes who compared themselves a larger group (i.e., entire student body). Consequently, the differences in PDD wording may have been a factor in the differences between the personal and PPS for athletes as opposed to the nonathlete group. As such, future research could explore whether these findings replicate when athletes are asked to reference the entire student body. The current study findings were disseminated on the campus where we collected the data and have had a positive impact. We presented findings in an annual report to the athletic director and head coaches, and they expressed a desire to address the problem. We developed a collaborative relationship between athletics and the campus counseling center and arranged a position in which a clinical psychologist is holding walk-in consulting and referral service hours in the athletics building. We also developed psychoeducation workshops for athletes, tailored to their interests and needs. These workshops helped improve athletes attitudes toward psychology as evidenced by enthusiastic evaluations following the workshops (Kaier, Cromer, Strunk, & Davis, 2013). The current study is important for understanding the nature and extent of mental illness stigma among NCAA athletes. Future research should investigate what levels of mental illness stigma are great enough to influence an individual s decision not to seek treatment. It also would be helpful to understand what aspects of athletic culture may be prohibitive for individuals seeking treatment. Implications of the current study suggest that athletes and 738 Journal of College Student Development

college students in general could benefit from education that reduces both the stigma of mental illness and prejudices towards those who are seeking treatment. Correspondence concerning this article should be addressed to Lisa DeMarni Cromer, Psychology Department, The University of Tulsa, 800 S. Tucker Drive, Tulsa, OK 74104 9700; lisa-cromer@utulsa.edu REfEREnCES Cohen, J. (1988). Statistical power analysis for the behavioral sciencies. Hillsdale, NJ: Lawerence Erlbaum Associates. Corrigan, P. (2004). How stigma interferes with mental health care. American Psychologist, 59, 614-625. doi:10.1037/0003-066x.59.7.614458. doi: 10.1007/s10597-007-9084-9 Cooper, A. E., Corrigan, P. W., & Watson, A. C. (2003). Mental illness stigma and care seeking. Journal of Nervous and Mental Disease, 191, 339-341. Corrigan, P. W., Watson, A. C., & Barr, L. (2006). The selfstigma of mental illness: Implications for self-esteem and self-efficacy. Journal of Social and Clinical Psychology, 25, 875-884. doi:10.1521/jscp.2006.25.8.875 Eisenberg, D., Downs, M. F., Golberstein, E., & Zivin, K. (2009). Stigma and help seeking for mental health among college students. Medical Care Research and Review, 66, 522-541. Etzel, E. F., Ferrante, A. P., & Pinkney, J. (1991). Counseling college student-athletes: Issues and interventions. Morgantown, WV: Fitness Information Technology. Ferrante, A. P., Etzel, E., & Lantz, C. (1996). Counseling college athletes: The problem, the need. In E. Etzel, A. P. Ferrante, & J. W. Pinkney (Eds.), Counseling college athletes: Issues and inter ventions (pp. 3-26). Morgantown, WV: Fitness Information Technology. Kaier, E., Cromer, L. D., Strunk, K. & Davis, J. L. (2013). Student health, athletic performance, and education study: 2nd annual report. Unpublished manuscript, Department of Psychology, The University of Tulsa, Tulsa, OK. Retrieved from http://orgs.utulsa.edu/shape/wp-content/ uploads/2015/09/year 2-SHAPE-White-Paper.pdf Kessler, R. C., Berglund, P., Demler, O., Jin, R., Merikangas, K. R., & Walters, E. E. (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the national comorbidity survey replication. Archives of General Psychiatry, 62, 593-602. Link, B. G. (1987). Understanding labeling effects in the area of mental disorders: An assessment of the effects of expectations of rejection. American Sociological Review, 52, 96-112. doi:10.2307/2095395 Papanikolaou, Z., Nikolaidis, D., Patsiaouras, A., & Alexopoulos, P. (2003). Commentary: The freshman experience: High stress low grades. Athletic Insight: The Online Journal of Sport Psychology, 5. Retrieved from http://www.athleticinsight.com /Vol5Iss4/Commentary.htm Parham, W. D. (1993). The intercollegiate athlete: A 1990s profile. Counseling Psychologist, 21, 411-429. Storch, E. A., Storch, J. B., Killiany, E. M., & Roberti, J. W. (2005). Self-reported psychopathology in athletes: A comparison of intercollegiate student-athletes and nonathletes. Journal of Sport Behavior, 28, 86-98. U. S. Department of Health and Human Services. (1999). Mental health: A report of the surgeon general. Rockville, MD: National Institute of Mental Health. Watson, J. C. (2006). Student-athletes and counseling: Factors influencing the decision to seek counseling services. College Student Journal, 40, 35-42. October 2015 vol 56 no 7 739