PSY-380 Introduction to Probability and Statistics Benchmark - Project 2 The Stigma Scale: A Canadian Perspectives. Social

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The Stigma Scale: A Canadian Perspective Amanda Meier, Rick Csiernik, Laura Warner, and Cheryl Forchuk

Stigma is a devastating psychosocial issue for many individuals with mental illness. This study examined the mental illness stigma experiences of 380 individuals with a self-reported psy- chiatric diagnosis in London, Ontario, Canada, using the Stigma Scale, a tool recently de- veloped in the United Kingdom (UK). Data for the Canadian sample were examined and compared with those from the UK pilot group. Results indicated that both samples experi- enced mental illness stigma, with Canadian participants reporting fewer stigma experiences on close to half of the scale items. In general, the results suggested that antistigma efforts have achieved some successes, particularly for targeted recipient groups; however, the need remains for continued and varied methods of stigma reduction to eliminate stigma within society.

KEY WORDS: mental health; mental illness; psychiatric survivors; stigma; Stigma Scale

It is estimated that 20% of Canadians live with mental illness, with close to 500,000 missing work each week for psychiatric reasons ( Mental Health Commission of Canada, 2014b). Moreover, the Men- tal Health Commission of Canada (2014b) reported that 60% of people with mental health issues do not seek help for fear of being labeled. Stigma toward those who are perceived as different has existed for centuries, with mental illness stigma being a par- ticularly prominent and detrimental issue in society today ( Arboleda-Florez & Stuart, 2012). Expanded understanding of stigma and its associated conse- quences for individuals with mental illness is neces- sary to counteract its oppressing impact within society.

MENTAL ILLNESS STIGMA Stigma has been defined as “a feeling of being nega- tively differentiated owing to a particular condition, group membership or state in life” ( Arboleda-Florez & Stuart, 2012, p. 458). There are two main forms of mental illness stigma discussed in literature. Public stigma, also referred to as societal stigma, denotes prejudicial attitudes held by the public toward people with mental illness ( Arboleda-Florez & Stuart, 2012; Corrigan, Markowitz, Watson, Rowan, & Kubiak, 2003). Self-stigma, also known as internalized stigma, refers to personal shame, withdrawal, and loss of self- esteem experienced by some people with mental ill- ness. Self-stigma is often triggered by applying to ones elf the negative stereotypes held by the public ( Chronister, Chou, & Liao, 2013; Corrigan et al., 2003).

There is no single cause of stigma; instead it has multiple interconnecting sources, though misguided perceptions about mental illness and those who are living with mental illness are believed to be one of the most prominent sources. Previous research has demonstrated that members of the public lack know- ledge of mental illnesses and hold a number of mis- informed beliefs about individuals with mental illnesses. Crisp, Gelder, Rix, Meltzer, and Rowlands (2000) surveyed 1,737 British adults in an effort to determine public opinions about individuals with mental illness. Their findings demonstrated that ap- proximately 70% of respondents believed people with schizophrenia, alcoholism, or drug addiction were dangerous, which has been an ongoing issue with this population ( Csiernik, Forchuk, Speechley, & Ward-Griffin, 2007). Wang and Lai (2008) surveyed 3,047 adults in Canada to obtain attitudes concern- ing depression and found that 45% of participants considered people with depression to be unpredict- able, with over 20% considering them dangerous. Stuart (2003) conducted a review of mental health and violence literature and concluded that the gen- eral public exaggerates the strength of relationship between mental illness and violence and also exag- gerates their own personal risk of being harmed by individuals with mental illness. Some researchers have traced the connection between mental illness and violence to the often unrealistic portrayals of individuals with mental illness in the media ( Blood, Putnis, & Pirkis, 2002; Byrne, 2000; Leff & Warner, 2006). Another common misguided belief about individuals with mental illness is that their illnesses

are self-inflicted, making them blameworthy for their situation ( Corrigan et al., 2003; Corrigan & Watson, 2007; Crisp et al., 2000). Unfortunately, stigmatizing attitudes are not limited to the general public but often occur within individuals’ social circles as well. For example, Moses (2010) interviewed adolescents with mental illness and found that 46% reported stigmatization from their family members and 62% experienced stigmatization from peers. In Crisp et al.’s (2000) study, 50% of respondents reported knowing someone with a mental illness; however, between 70% and 80% of them also reported generalized negative views about individuals with mental illness.

Experiencing stigmatizing attitudes from the pub- lic and within social circles can lead to numerous detrimental effects on an individual’s health and well- being. Livingston and Boyd (2010) conducted a sys- tematic review of 45 stigma and mental health articles and found that the social effects of stigmatization include exclusion, diminished social support, low subjective quality of life, and poor self-esteem. Fur- ther, self-stigma was found to be positively associated with symptom severity and negatively associated with adherence to treatment ( Livingston & Boyd, 2010; Perlick et al., 2001). Wright, Gronfein, and Owens (2000) surveyed 88 individuals with mental illness recently discharged from hospitals and found that stigmatization was associated with increased stress and a weakened sense of mastery among participants. Common consequences of experiencing stigmatiza- tion include shame, secrecy, isolation, social exclu- sion, and feeling like an outsider within one’s family ( Byrne, 2000). Yanos, Roe, and Lysaker (2010) fur- ther found that self-stigma is associated with poorer vocational outcomes. In recent years, policymakers have begun to acknowledge the detrimental effects of stigmatization and programs have been developed to counteract misinformation about mental illnesses among the public. However, individuals continue to experience mental illness stigma within their com- munities and social circles. Stigma has been described as potentially more detrimental than mental illnesses themselves and is considered to be one of the great- est obstacles remaining in the treatment of mental illness ( Cechnicki, Matthias, & Angermeyer, 2011; Chronister et al., 2013).

THE STIGMA SCALE The Stigma Scale was developed by King et al. (2007) as a standardized measure of the stigma of mental illness. Items for the scale were developed on the basis

of results from an earlier study by Dinos, Stevens, Serfaty, Weich, and King (2004). In the initial study, 46 patients from community and day mental health services in North London, United Kingdom (UK), participated in qualitative one-on-one interviews concerning their feelings and experiences with men- tal illness. King et al. (2007) reviewed the results and developed a 42-item scale using participant phrases regarding stigma experiences; the process of item development involved adapting participant phrases to make them more general and applicable to other people’s experiences. The scale was pilot-tested with 193 mental health services users, 93 of whom were asked to complete the scale once at baseline and again two weeks later. Items with low test–retest reliability were dropped, resulting in a final scale with 28 items. The final version contains three subscales determined by factor analysis of the pilot results: discrimination, disclosure, and potential positive aspects of mental ill- ness ( King et al., 2007).

We conducted an extensive search of literature by reviewing all articles that have cited King et al. (2007) and searching the PsycINFO, CINAHL, and Social Sciences Abstracts databases for the key words “Stigma Scale.” Through this review we found that the Stigma Scale has been used in a small number of studies, but mostly in modified or adapted form. Schwenk, Davis, and Wimsatt (2010) conducted a cross- sectional Web- based survey study with 769 medical students at the University of Michigan to evaluate their levels of de- pression, stigma, and suicidal ideation; some state- ments for the survey were drawn from the Stigma Scale but were adapted to reflect the population of medical students and specific depression experiences. Sanders (2012) ran a mixed methodology study to investigate how women with drug addiction use mu- tual support to counteract stigma in Maryland. She distributed surveys to women attending Narcotics Anonymous meetings that included items adapted from the Stigma Scale to reflect the specific issue of drug addiction. Further, the Stigma Scale has been used in three graduate theses from U.S. universities: Conrad-Garrisi (2011) administered the full Stigma Scale during a correlation study examining the rela- tionship between a number of variables and mental health recovery with 143 members of psychiatric re- habilitation “clubhouses”; Hall (2012) adapted the Stigma Scale during a vignette-based survey study examining intimate partner violence with 250 male and female undergraduate student participants; and Walston (2012) used the positive aspects of mental

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illness subscale from the Stigma Scale to investigate illness acceptance as a mediator to schizophrenia re- covery in 100 participants diagnosed with schizophre- nia receiving outpatient mental health treatment.

PURPOSE OF STUDY To date, the Stigma Scale or sections of it have been used in a small number of studies and theses within the United States and the UK. The purpose of our study was to examine stigma experiences for indi- viduals living with mental illness in London, Ontario, Canada, and provide a direct comparison between a Canadian sample and the King et al. (2007) results. To our knowledge, this study is the first one to use the Stigma Scale in a Canadian context.

METHOD Design The findings from this study are part of a five-year Community-University Research Alliance (CURA) program funded by the Social Sciences and Human- ities Research Council of Canada on the topics of poverty and social inclusion for psychiatric survivors (that is, individuals with lived experience of mental illness). The CURA used a participatory-action re- search approach to longitudinally collect quantitative and qualitative data on the issues of concern. This study used a cross-sectional descriptive comparative research design. Data from the first year of the CURA were obtained and analyzed to describe stigma experiences for the sample as well as compared with those from the Stigma Scale pilot sample. Re- search ethics approval was obtained from the research ethics board at Western University, London, Ontario.

Setting and Sample This study was conducted in London, Ontario, Canada, a midsize city with a population of approxi- mately 365,000 ( Statistics Canada, 2012). Although specific rates of mental illness for London are un- available, it is estimated that 20% of Canadians ex- perience a mental health problem or illness in any given year; however, only one in three people ex- periencing mental health problems or illnesses re- port seeking and receiving services and treatment ( Mental Health Commission of Canada, 2012).

A total of 380 psychiatric survivors participated in the study. Individuals were recruited to participate if they had been diagnosed with a mental illness for a minimum of one year prior to participation (self- reported), were between the ages of 18 and 75, spoke

and understood English, and provided informed consent. Quota sampling was used to ensure equal representation by gender (male and female) and housing status (homeless, residing in a group living setting, unemployed housed, and employed housed). Sample sites included homeless shelters, group living settings for psychiatric survivors, community men- tal health agencies, public housing, and hospitals. The study was advertised using a variety of methods, including posters, newspaper advertisements, word of mouth, social media, and identification of inter- ested participants by mental health workers con- nected to the CURA program. Participants were recruited over a six-month period in the summer and fall of 2011. Interviews took place at locations chosen by participants.

Instrument The Stigma Scale contains 28 items rated on a five- point Likert scale ranging from 1 = strongly disagree to 5 = strongly agree. Item wording alternates between positive and negative statements to avoid response set bias, with negative statements undergoing reverse scoring during analysis ( King et al., 2007). Thirteen items on the scale pertain to discrimination experi- ences (that is, “perceived hostility by others or lost opportunities because of prejudiced attitudes”), 10 items evaluate a person’s willingness to disclose men- tal health information to others, and five items con- cern a person’s acknowledgment of the positive aspects of their mental illness ( King et al., 2007, p. 250). The scale can be analyzed to yield one total score and three subscale scores.

A total stigma score can be determined by adding all responses; the lowest possible total score is 0 and the highest possible total score is 112, with higher scores indicating more mental illness stigma. A dis- crimination subscale score can be determined by add- ing responses to the 13 discrimination items; the lowest possible discrimination score is 0 and the high- est possible discrimination score is 48, with higher scores indicating more discrimination experiences due to mental illness. A disclosure subscale score can be obtained by adding responses to the 10 disclosure items; the lowest possible disclosure score is 0 and the highest possible disclosure score is 44, with a higher disclosure score indicating a lower likelihood of dis- closing mental illness information. A positive aspects subscale score can be determined by adding responses to the five positive aspects items; the lowest possible positive aspects score is 0 and the highest possible

Meier, Csiernik, Warner, and Forchuk / The Stigma Scale: A Canadian Perspective 215

positive aspects score is 20, with higher scores indicat- ing a lower likelihood of seeing the positive aspects of mental illness.

Previous analyses have shown the Stigma Scale to have good reliability. In the original study by King et al. (2007), Cronbach’s alpha was determined to be .87 for the total score, with alphas for the sub- scales being .87 (discrimination), .85 (disclosure), and .64 (positive aspects). The overall Stigma Scale was also shown to be negatively correlated with the Self-Esteem Scale, demonstrating its concurrent validity ( King et al., 2007).

Data Collection Each of the 380 participants completed one-on-one interviews with trained research assistants. Research assistants read all items of the Stigma Scale out loud to participants, and participants rated their responses verbally or by pointing at the instrument. Responses were recorded using paper-and-pencil methods and entered into electronic databases after the interview. An honorarium of $20 was given at the end of each interview to compensate for time and travel.

Data Analysis Frequencies and percentages of sample characteristics were calculated. Responses to items in the Stigma Scale were scored according to the guidelines set out by King et al. (2007). These were then used to de- termine the scores for each of the three subscales and an overall total scale score. Reliability of the Stigma Scale was assessed through a Cronbach’s alpha for the final scale and each of the subscales. This was also assessed for the individual items, examining the Cronbach’s alpha with each item removed.

Measures of central tendency were calculated for each item, and t tests were used to determine if significant differences existed between the measures calculated for the current sample and those reported by King et al. (2007). Measures of central tendency were also calculated for the subscales and compared with those found in the King et al. (2007) article through t-test analyses. As the original King et al. (2007) article did not contain sample sizes for the subscales, these were estimated by summing the number of missing responses from each of the indi- vidual items. Using this conservative method, sample sizes were calculated to be 150 (discrimination sub- scale), 164 (disclosure subscale), 172 (positive aspects subscale), and 100 (total score). Mean differences for the subscales were then standardized using the pooled standard deviation. All mean differences (individual items and subscales) were calculated so that a positive value indicated higher stigma in the Canadian sample. A Bonferroni correction was ap- plied to account for the multiple testing, lowering the threshold from p < .05 to p < .0016.

RESULTS Description of Sample Characteristics for both the UK and Canadian samples are presented in Table 1. There was little difference in age (42.9 years for UK sample, 40.7 years for Canadian sample), though the UK sample had a slightly greater percentage of men (57.1% versus 50.0%), and a slightly lower proportion of individuals currently employed (17.0% versus 24.7%). Ethnicity could not be directly compared due to differences in data collection, though it did appear that the UK sample contained a slightly higher percentage of Caucasians (87.4% versus 75.5%).

Table 1: Comparison of Demographics in the UK and Canadian Samples

UK Sample (n = 193) Canadian Sample (n = 380) Demographic Characteristic M (SD) n (%) M (SD) n (%)

Age (years) 42.9 (12.4) 40.7 (14.0) Gender Male 109 (57.1) 190 (50.0) Female 82 (42.9) 190 (50.0) Ethnicity Caucasian 159 (87.4) 287 (75.5) African American 11 (6.0) 4 (1.1) Indian/Bangladeshi 18 (9.0) NR Native American NR 45 (11.8) Other 25 (13.7) 44 (11.6) Currently employed 34 (17.0) 94 (24.7)

Note: NR = not relevant.

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In addition, psychiatric diagnoses were classified slightly differently, although in both samples each in- dividual could report more than one dia gnosis. Both samples reported similar rates of mood and anxiety disorders, and the UK sample reported slightly higher rates of schizophrenia and personality disorders.

Reliability of the Stigma Scale Table 2 highlights the results of the reliability testing in the Canadian sample and the comparison data from King et al. (2007). Cronbach’s alpha for the total scale score in the Canadian sample was .86, which was similar to .87 in the UK sample. When examining how this changed with item deletion, the alphas ranged from .86 to .87 in the Canadian sample. The alphas for the subscales were all calculated to be lower in the Canadian sample than in the UK sample.

TOTAL STIGMA SCORES Total stigma scores for the Canadian sample ranged from 9 to 99 (possible range was 0 to 112). In com- parison with the UK sample, the Canadian sample scored lower on both the total stigma score (56.0 ver- sus 62.6, p < .0016) and the discrimination subscale (25.0 versus 29.1, p < .0016) (see Table 3). Although this trend was repeated for the disclosure subscale (22.9 versus 24.7) and positive aspects subscale (8.0 versus 8.8), neither of these differences were found to be statistically significant. These results indicate that the

UK sample was experiencing a higher level of dis- crimination and stigma in general than the Canadian sample.

ISSUES IN THE UK UK participants experienced more stigma on 12 items of the Stigma Scale (see Table 4 for the full list of items). Significantly more UK participants re- ported feeling bad about having mental health prob- lems (mean difference –0.69, p < .0016), feeling alone because of their mental health problems (mean difference –0.53, p < .0016), and feeling embar- rassed because of their mental health problems (mean difference –0.51, p < .0016). UK participants indicated that they worried about telling people they received psychological treatment (mean differ- ence –0.51, p < .0016) and that they took medicine/ tablets for mental health problems (mean difference –0.67, p < .0016) significantly more than Canadian participants.

In terms of disclosure, UK participants indicated that they were significantly more scared of how people would react if they found out about their mental health problems (mean difference –0.57, p < .0016), avoided telling people about their mental health problems (mean difference –0.39, p < .0016), minded if people in their neighborhood knew about their mental health problems (mean difference –0.45, p < .0016), felt the need to hide their mental health problems from their friends (mean difference –0.42, p < .0016), and generally found it hard to tell others about their mental health problems (mean difference –0.60, p < .0016). Finally, significantly fewer UK participants agreed with the notion that having a mental illness made them a stronger person (mean difference –0.43, p < .0016), and significantly more UK participants felt that having mental health problems made them feel like life was unfair (mean difference –0.47, p < .0016). The results demon- strate that individuals in the UK feel more negatively about their mental illnesses and are more hesitant to disclose mental illness information to friends and

Table 2: Summary of Reliability Analysis Results for the UK and Canadian

Samples

UK Sample Canadian Sample

Cronbach’s Alpha

Range of Alphas

When Items Removed

Disclosure .85 .79 .76–.81 Discrimination .87 .83 .81–.83 Positive aspects .64 .46 .26–.60 Total .87 .86 .86–.87

Table 3: Summary of Stigma Scale Scores for the UK and Canadian Samples

Subscale

UK Sample Canadian Sample

M Difference Standardized

DifferenceResponse (n) M (SD) Response (n) M (SD)

Discrimination 150 29.1 (9.5) 371 25.0 (9.0) –4.1 –0.49* Disclosure 164 24.7 (8.0) 367 22.9 (7.6) –1.8 –0.23 Positive aspect 172 8.8 (2.8) 375 8.0 (3.1) –0.8 –0.27 Total score 100 62.6 (15.4) 362 56.0 (15.8) –6.6 –0.42*

*p < .0016.

Meier, Csiernik, Warner, and Forchuk / The Stigma Scale: A Canadian Perspective 217

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acquaintances when compared with Canadian par- ticipants.

Common Issues There were 16 items on the Stigma Scale that elicited similar results between Canadian and UK partici- pants. Both Canadian and UK participants reported that they somewhat agreed they had been talked down to because of their mental health problems and that they had some trouble from other people be- cause of their mental health problems. Neither set of participants agreed or disagreed as to whether they had been insulted because of their mental health problems, whether the reactions of others made them keep their mental illness information to them- selves, or whether they were angry with the way others have reacted to their mental health problems. In terms of specific discrimination, participants re- ported similar rates of discrimination from police, employers, the education system, and health care providers, with results indicating that participants somewhat disagreed to experiencing discrimination from all sources. Both Canadian and UK participants agreed with the notion that some people with men- tal health problems are dangerous. Both sets of par- ticipants agreed that having mental health problems made them more understanding people and more accepting of others. However, both sets of partici- pants also agreed with the statement that they would have had better chances in life if they did not have mental health problems. Canadian participants did not report significantly more stigma than UK par- ticipants on any of the scale items.

DISCUSSION This study was the first in Canada to use the full Stigma Scale ( King et al., 2007) as a measure of men- tal illness stigma. Whereas other studies throughout North America have used excerpts of the scale or modified it to fit other populations, we have used the scale in its entirety for the population in which it was designed. As this was the first study to use this scale in Canada, complete results for both the Canadian sam- ple and the original pilot sample from King et al. (2007) were provided. This direct comparison allowed us to describe similarities and differences between geographic regions concerning participants’ stigma experiences.

Despite the difference in time between the two samples, there were a number of similarities. In gen- eral, both samples reported experiencing degrees of

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Meier, Csiernik, Warner, and Forchuk / The Stigma Scale: A Canadian Perspective 219

mental illness stigma, including being talked down to because they had a mental illness and believing they would have had better chances in life if they did not have mental health problems. Neither sample agreed with statements that they had been discriminated against by police, employers, the education system, or health care providers, groups that have previously been identified as being particularly stigmatizing ( Leff & Warner, 2006; Pinfold et al., 2003; Schulze & Angermeyer, 2003). These results are positive and sug- gest that attitudes toward mental illness may be evolv- ing among various groups of people. Further, both sets of participants agreed with the notions that having mental health problems made them more understand- ing and accepting people. Although the results dem- onstrate that stigma continues to exist, some specific findings indicate that discrimination within certain social groups may be improving and people with men- tal illness are better able to acknowledge the positive impact mental illness has had on their acceptance of others.

There were also a number of differences between samples. UK participants reported significantly more stigma than Canadian participants on close to half of the scale items, including fear of telling others about their mental illness and hesitation to disclose mental illness information. In contrast, Canadian participants did not report significantly more stigma on any scale items, indicating that efforts to reduce stigma in Canada may be particularly effective. There is no established empirical explanation for what has led to differences between Canada and the UK with regard to their distinct experiences with stigma as it pertains to mental health. However, one needs to examine not only policies and educational practices pertaining to mental health and mental illness, but the overall economic and ideological differences in policies be- tween the two nations. Those with mental health issues have routinely been oppressed ( Forchuk, Csiernik, & Jensen, 2011); however, whereas Canada has followed the UK in neoliberal ideology beginning in the latter half of the 20th century, the economic fallout of the 21st century has not been as harsh and thus there has been less need to further marginalize traditional targets. As well, in Canada an active media campaign regarding issues of mental health has fo- cused on workplace mental health issues, sponsored by the Conference Board of Canada and leading cor- porations including Bell Canada and the Toronto Dominion Bank ( Thorpe & Chernier, 2011). As well, changes to occupational health and safety policy

may help to explain the distinction between the na- tions ( Edwards, 2014).

Implications The current results have provided insight into the stigma experiences of Canadian participants and com- pared them with UK results to identify similarities and differences between geographic regions. The overall results are clear: Stigma continues to exist for psychi- atric survivors. Despite recent campaigns to eradicate stigma, such as the Opening Minds campaign in Canada ( Mental Health Commission of Canada, 2014a) and the Time to Change (2014) campaign in the UK, psychiatric survivors continue to be a disen- franchised and marginalized group who feel talked down to, have faced issues with others because of their mental health problems, and who feel their chances in life have been limited by mental illness. There have undoubtedly been some improvements in stigmatizing attitudes in recent years, demonstrated by participants reporting little discrimination from police, employers, the education system, and health care providers. How- ever, participants within both countries reported both public stigma and internalized stigma in their lives. Taken together, these results indicate the need for continued, and perhaps varied, antistigma methods. Many antistigma programs target specific groups; for example, the Opening Minds campaign has targeted youths, employers, health care professionals, and the media ( Mental Health Commission of Canada, 2014a). Based on the current results, the campaign appears to be successful in reaching their target groups. However, other members of the public may be missed within the campaign reach if they are not identified as a target population. Varied methods for the general population and other targeted groups may be required to reduce stigma in areas that continue to be problem- atic for psychiatric survivors.

It is interesting that both sets of participants agreed with the notion that individuals with mental illness can be dangerous. Stuart (2003) concluded his review of mental health and violence literature with the fol- lowing quote: “Members of the public undoubtedly exaggerate both the strength of the relationship between major mental disorders and violence, as well as their own personal risk from the severely mentally ill” (p. 124). Exaggerated beliefs that others with mental illness are dangerous may contribute to per- sonal shame and embarrassment when one has a men- tal illness. Antistigma programs may benefit from working to dispel misguided notions about the

Social Work Research Volume 39, Number 4 December 2015220

connection between mental illness and violence, both for members of the general public and for psychiat- ric survivors who may be misinformed about the connection.

Limitations This study used only cross-sectional data. Whereas the large-scale program is longitudinal, only data from the first year of the program were collected to provide direct comparisons to the King et al. (2007) study. It is possible that stigma experiences vary over time and may be affected by other life circumstances. The cur- rent study extracted data from one point in time, so variations in experiences over time and the factors associated with those changes could not be examined. Furthermore, data were collected from one geographic region in Canada through quota sampling. Generaliza- tion to other regions in Canada is therefore limited based on the sampling strategy used. Although these results provided insight into the stigma experiences of Canadian participants, the results require replication in other Canadian regions before basing interventions and programs on them.

CONCLUSION The current study provided foundational results of the Stigma Scale in a Canadian context. It appears that mental illness stigma continues to exist for Ca- nadian psychiatric survivors. When compared with participants from the UK, Canadian participants re- ported less stigma in a number of areas. These results indicate that Canadian antistigma efforts appear to have had some successes in lessening stigma experi- ences for psychiatric survivors, but continued and varied efforts are necessary to truly eliminate stigma in our society. As Canadian participants reported fewer stigma experiences, antistigma efforts within the UK may benefit from incorporating some Cana- dian methods into their antistigma programs.

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Amanda Meier, MSW, RSW, is research coordinator, Lawson Health Research Institute, 750 Base Line Road, Suite 300, London, N6C2R5 Canada; e-mail: Amanda.Meier@lhsc.on.ca. Rick Csiernik, PhD, MSW, RSW, is professor, School of Social Work, King’s University College at Western University, London, ON. Laura Warner, MS, is research analyst, Lawson Health Research Institute, London, ON. Cheryl Forchuk, PhD, RN, is professor, Arthur Labatt Family School of Nursing, Western University, and assistant director, Lawson Health Research Institute, London, ON.

Original manuscript received July 14, 2014 Final revision received December 9, 2014 Accepted January 5, 2015 Advance Access Publication October 6, 2015

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http://www.time-to-change.org.uk/talk-about-mental-health

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