Download Effects of the Label “Schizophrenia” on Causal Attributions of Violence

Effects of the Label "Schizophrenia" on
Causal Attributions of Violence
by Charles M. Boisvert and David Faust
Research shows that labels can lead to biases in interpreting behavior. Darley and Gross (1983) found that a
label of high versus low socioeconomic status altered
undergraduates' perception of a child's academic functioning. In a study by Bromfield et al. (1988), teachers
predicted less future success and urged less task persistence for a child labeled sexually abused versus an unlabeled child. Goodyear and Parish (1978) found that
undergraduates viewed individuals seeking counseling
more negatively when they were labeled a "patient" or
"client" versus a "typical person."
Research further suggests that biasing effects of
labels may extend to professionals. In one study, nurses
demonstrated more affective involvement and made fewer
belittling statements in response to hypothetical statements made by "schizophrenia" patients versus "borderline personality disorder" patients (Gallop et al. 1989).
Fryer and Cohen (1988) found that hospital staff rated
patients labeled "psychiatric" as less likable and as having
more unfavorable traits and fewer favorable traits than
patients labeled "medical." In a study by Langer and
Abelson (1974), psychoanalytic and behavioral therapists
observed a videotape of a person labeled as either a
patient or a job applicant. The psychoanalysts, unlike the
behavior therapists, described the "patient" as significantly more disturbed than the "job applicant."
Abstract
We investigated the relation between the label of
"schizophrenia" and causal attributions of violence.
Undergraduates read 1 of 10 scenarios in which two
variables were manipulated: a psychiatric label and
environmental stress. The scenario described an
employee who acted violently toward his boss.
Subjects made causal attributions for the employee's
behavior by completing an adapted version of the
Causal Dimension Scale II. Subjects also completed a
questionnaire designed to explore several issues concerning the effects of the schizophrenia label on perceptions of behavior. Contrary to the primary hypothesis, the schizophrenia label did not lead subjects to
make significantly more personality causal attributions for violent behavior. With increasing environmental stress, subjects did make significantly fewer
personality attributions. A follow-up study using practicing clinicians as subjects yielded similar findings.
The results of these studies are discussed in light of
perceived stereotypes of persons with schizophrenia
and conceptual issues in attribution research.
Key words: Attributions, Causal Dimension Scale
II, stereotypes, violence.
Schizophrenia Bulletin, 25(3):479-491,1999.
Stereotypes
Labels can exert powerful effects on perception; thus, to
the extent they have the potential to facilitate understanding, they have the potential to impede it as well. Labels
may be applied incorrectly, may describe pseudoconglomerations of symptoms versus genuine syndromes, or may
lead to stereotyping or extreme tendencies to incorporate
nonrelated phenomena under the label or diagnosis. As
Mirowsky and Ross (1989) have argued, diagnosis may
hinder understanding, treat attributes as entities, and
ignore the structure of causal relations among the variables on which it is based.
Various mechanisms or processes may be involved in the
biasing effects of labels. Psychiatric labels may function
as a stereotype through which behavior is narrowly interpreted. At the foundation of stereotypes is what the
Chapmans (1967, 1969) identified as "illusory correlations," that is, the false association between two variables
Reprint requests should be sent to Dr. CM. Boisvert, 1184 Mendon
Rd., Cumberland, RI02864.
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Schizophrenia Bulletin, Vol. 25, No. 3, 1999
CM. Boisvert and D. Faust
or an overperception of that association. In the case of
stereotyping, an illusory correlation represents the false
pairing of person and behavior (Hamilton and Gifford
1976; Hamilton and Rose 1980). For example, we may
believe that individuals with schizophrenia are violent far
more often than members of the general population
because of stereotypic perceptions of the mentally ill.
However, epidemiological research shows that the association between mental disorder and violence is slight and
may be present only when individuals are experiencing
psychotic symptoms (Link et al. 1992; Monahan 1992).
Others have suggested that schizophrenia predisposes a
person to homicidal behavior particularly when the schizophrenia coexists with alcoholism (Eronen at al. 1996)
and that symptom acuity in schizophrenia may contribute
to an increased tendency toward criminality (Modestin
andAmmann 1996).
this phenomenon the "fundamental attribution error."
Research, in fact, shows that professionals display dispositional biases (Batson 1975; Batson and Marz 1979;
Batson et al. 1982; Jordan et al. 1988; Dumont 1993;
Donnan and Pipes 1985).
Limited research has examined the effects of labels
on attribution. Snyder et al. (1976) found that undergraduate females made more personality attributions regarding
the locus of a client's problem when told that the client
was a chronic patient as opposed to someone being seen
for the first time. In Shenkel et al.'s (1979) study, female
social welfare students made more personality-based attributions when they had access to a pre-existing diagnosis.
Snyder (1977) found that psychoanalytic therapists compared with behavioral therapists made significantly more
personality attributions when identifying the locus of a
person's problem when the person was labeled a
"patient." However, when the person was labeled a "job
applicant," no significant attributional differences were
found between the two therapist groups (Snyder 1977).
Pious and Zimbardo (1986) reported that psychoanalytic
therapists compared with behavioral therapists were more
likely to provide dispositional explanations for hypothetical client problems.
In turn, much of the research that examined psychiatric labels focused on the negative effects experienced by
the labeled person (Farina et al. 1971; Rosenhan 1973;
Scheff 1974; Link 1987; Retzinger 1989; Parish et al.
1992) and the degree to which the labeled person is
accepted socially (Bentz and Edgerton 1971; Loman and
Larkin 1976; Link 1987; Link et al. 1987, 1989). Other
research has examined attitudes toward the mentally ill
(Phillips 1964; Segal 1978; Arkar and Eker 1994) and
labeling theory as it relates to mental disorder (Link and
Cullen 1990).
Given the limited research that examines the impact
of psychiatric labels on causal attributions and the potential importance of labels in shaping our judgments, this
study was designed to explore the relation between the
label of schizophrenia and causal attribution. We hypothesized that this label would lead individuals to make more
personality causal attributions for violent behavior. We
also hypothesized that as the strength of possible environmental causes for behavior increased, the degree to which
individuals made personality causal attributions for violent behavior would decrease. This hypothesis was
derived from the discounting principle in attribution theory, which states that "the social observer 'discounts' the
role of any causal candidate in explaining an event to the
extent that other plausible causes or determinants can be
identified" (Ross 1977, p. 180). In Study 1, we examined
our hypotheses using undergraduates as subjects. Study 2
extended this research to practicing clinicians.
Labels and Causal Attribution
To the extent that psychiatric labels lead the observer to
focus on internal causes of behavior that are indeed internally caused and to otherwise focus externally, they shape
judgment properly. Certainly, in some cases, behaviors
may arise in substantial part from disturbances within the
person. If identical twins reared apart and in highly contrasting environments both develop the belief that they are
the Messiah, we are probably justified in believing that
the problem, in good part, lies within them. Forming personality attributions for a behavior that is symptomatic of
a person's illness may also be justified. For example,
auditory hallucinations are experienced more often by
people with schizophrenia than by members of the general
population. Thus, one might well be justified in making
internal causal attributions for this behavior (i.e., attributing the voices to the schizophrenia). However, if someone
with schizophrenia is observed to be violent and is not
currently experiencing psychotic symptoms, we probably
would not be justified in attributing the behavior to the
schizophrenia because those subjects without active psychotic symptoms apparently show no increased tendency
toward violence compared with individuals without schizophrenia (Link et al. 1992; Monahan 1992).
Research suggests that individuals are more inclined
to attribute their own behavior to external (situational)
causes, whereas an observer is more inclined to attribute
the person's behavior to internal (dispositional) causes
(Jones and Nisbett 1972; Ross 1977). According to Jones
and Nisbett (1972), there is a "pervasive tendency for
actors to attribute their actions to situational requirements,
whereas observers tend to attribute the same actions to
stable personal dispositions" (p. 2). Ross (1977) coined
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Effects of the "Schizophrenia" Label
Schizophrenia Bulletin, Vol. 25, No. 3, 1999
Study 1
Method
Subjects. A total of 282 undergraduate students
(127 males, 153 females, 2 subjects who did not indicate
gender) from psychology classes at the University of
Rhode Island participated voluntarily and received extra
course credit for participating. Subjects were given a
packet consisting of one page providing instructions and
requesting demographic information, a one-page scenario,
and a two-page questionnaire.
Scenarios. The scenario described a divorced person who had two kids and a history of counseling and was
an employee at a manufacturing company. In the scenario
the employee was called into his boss's office. All information in the scenarios was kept the same except for (1)
the presence or absence of a psychiatric label and (2) the
level of environmental stress. Half the subjects evaluated
an employee who had a label of schizophrenia, and half
evaluated an employee who had no psychiatric label.
Selection of the label condition. The label condition read as follows: "At the beginning of his treatment
Mike underwent a series of interviews and thorough psychological, testing and was diagnosed with schizophrenia.
Mike, fortunately, has not experienced psychotic symptoms since he was diagnosed." We selected the label of
schizophrenia because of common stereotypes linking
such disorders to dangerousness (Rabkin 1974; Link and
Cullen 1986; Link et al. 1987; Wahl and Harman 1989).
In addition, we selected a potentially strong but false
association between a label and behavior (i.e., schizophrenia and violence). To be confident that the association was
indeed false, we described the individual with schizophrenia in a nonacute stage of the disorder, and in particular in
the absence of active, psychotic symptoms. This description was necessary because research suggests that under
certain circumstances the association between schizophrenia and violence may be potentially true when individuals
are experiencing acute psychotic episodes (Link et al.
1992; Monahan 1992). One disadvantage to describing
the person in the scenario as not experiencing psychotic
symptoms is that individuals with schizophrenia at such
points, during which they may show relatively adequate
functioning (Childers and Harding 1990; Ram et al. 1992;
Eggers and Bunk 1997), may not and probably do not
elicit the most powerful types of associations with violence. Furthermore, we needed to achieve a reasonable
balance with the nonlabel condition. Describing an individual with acute psychotic features might lead the reader
to adopt the label of schizophrenia whether explicitly
mentioned or not. Thus, clearly the choice was a compromise between a powerful label that might, by itself, elicit
stereotypic associations and an individual so labeled and
481
described in the vignette. Our description, while still
potentially falling within the rubric of schizophrenia, certainly would appear to be a considerably less severe case
and a higher functioning individual than is generally
imagined. We did incorporate behavioral descriptors associated with schizophrenia, such as restricted social contacts and emotional isolation. Finally, we also indicated
that the diagnosis had been firmly established to
strengthen perceptions that the diagnosis was correct,
even though some may have questioned this because of
the "favorable characteristics" ascribed to the person in
the scenario.
It was expected that the schizophrenia label would
lead subjects to shift attributions toward the person rather
than the situation. Within each group, the level of environmental stress ranged from negligible to extreme along
five conditions. In each condition, the boss conveyed different information to the employee. Subjects evaluated the
employee's behavior of pushing the boss (see the appendix for a copy of the exact scenarios).
Measures
Causal Dimension Scale II. After reading a scenario, subjects completed an adapted version of the
Causal Dimension Scale II (CDS-II; McAuley et al.
1992), a self-report instrument consisting of 12 items
scored on a nine-point semantic differential scale. The
CDS-II is designed to measure how individuals perceive
causes along four factors: locus of causality, stability,
external control, and personal control. The three questions
per factor are rated on a scale from one to nine, and factor
scores vary from 3 to 27. Factor analytic studies have
yielded internal consistency ranging from 0.60 to 0.92 for
the four factors; average internal consistencies are as follows: locus of causality, 0.67; stability, 0.67; personal
control, 0.79; and external control, 0.82 (McAuley et al.
1992).
The CDS-II was initially developed to assess personal causal attributions. An extensive literature review,
as well as contact with a researcher directly involved in
creating the CDS and CDS-II (D. Russell, personal communication, March 29, 1994), did not uncover any standardized scales for observer causal attributions. This led
us to adopt the CDS-II to assess observer causal attributions. The authors were aware of only a few studies that
examined observer causal attributions using the original
CDS (Abraham 1987; Herr et al. 1990; Royce and
Muehlke 1991). Also, a prominent attribution researcher
believed that the CDS-II could be adapted to measure
observer causal attributions (B. Weiner, personal communication, November 24, 1993). Finally, the CDS-II has
been shown to be a more reliable and valid measure of
causal dimensions than other methods (McAuley et al.
Schizophrenia Bulletin, Vol. 25, No. 3, 1999
CM. Boisvert and D. Faust
1992). (A copy of the CDS-II adapted version can be
obtained from the authors.)
Exploratory questionnaire. Subjects also completed an exploratory questionnaire, developed by the
researchers, that consisted of five items rated along a
seven-point Likert scale. The items addressed the severity
of the behavior, the degree to which the behavior was justified, the cause of the behavior, the degree to which the
behavior was characteristic of the person, and the likelihood that the behavior had occurred previously. (A copy
of the exploratory questionnaire is available from the
authors.)
ational than did subjects in any of the other groups; subjects in the negligible stress group attributed the cause of
the employee's behavior to be significantly more dispositional than did subjects in any of the other groups; and
subjects in the high stress group attributed the cause of the
employee's behavior to be significantly more situational
than did subjects in the mild stress group (see table 1).
Follow-up univariate analysis of variance for variable
ES yielded significant group differences for four of the
five items from the exploratory questionnaire. These four
items were "How would you rate the severity of Mike's
[the protagonist in the scenario] behavior?" (F = 11.85,
df = 4,270, p < 0.01); "How would you rate the degree to
which Mike was justified in behaving as he did?" (F =
30.13, df = 4,270, p < 0.01); "How would you best
explain the cause of Mike's behavior?" (F = 27.01, df =
4,270, p < 0.01); and "How likely is it that Mike has acted
violently in other situations?" (F •= 12.03, df = 4,270, p <
0.01).
Post hoc Tukey HSD tests at the p < 0.05 level for the
exploratory questionnaire items indicated that with
increasing environmental stress, subjects were less likely
to rate violent behavior as severe, but more likely to rate
the person as justified in acting violently, the cause of
behavior as more situational, and the person as less likely
to have a history of acting violently. Interestingly, subjects
perceived violent behavior similarly regardless of the
presence or absence of the schizophrenia label.
Results did not support the primary hypothesis: the
label of schizophrenia did not lead subjects to make more
personality causal attributions for behavior. Results did
support the secondary hypothesis: as the strength of possible environmental causes for behavior increased, the
degree to which subjects made personality causal attributions for behavior decreased (figure 1).
Several possibilities may explain the negative results
for the primary hypothesis. The undergraduates in this
study may have taken (or possibly were taking) psychology courses that "debiased" them and challenged common stereotypes concerning the relationship between
mental illness and violence. In addition, professionals
may be more inclined than laypersons to make personality
attributions for another person's behavior, as some
research has suggested (Batson 1975; Batson and Marz
1979). To explore the latter possibility, we extended our
research to practicing clinicians.
Procedure. The design was a randomized 2 X 5 factorial with the following variables: schizophrenia label (present or absent) and environmental stress (negligible, mild,
moderate, high, or extreme). Subjects read and signed an
informed consent and then were tested in small groups
ranging from 2 to 30. Subjects read the scenario and
answered first the CDS-II and then the exploratory questionnaire. Subjects were debriefed in small groups.
Results. The results were analyzed using a 2 X 5 multivariate analysis of variance (MANOVA). A significant
multivariate main effect was found for environmental
stress (ES). Wilk's Lambda was 0.49, F = 5.75, df =
36,983, p < 0.01. The MANOVA analysis produced no
other main or interaction effects, suggesting that the
schizophrenia label, compared with no label, did not lead
subjects to make more personality causal attributions for
behavior. The power of our design to detect group differences for the label variable was approximately 0.96
(Cohen 1988). In addition, personality causal attributions
for the schizophrenia label group, compared with the nolabel group, did not decrease at a reduced rate across the
increasing levels of stress.
Follow-up univariate analysis of variance for ES
found significant group differences for three of the four
CDS-n factors: the locus factor (F = 28.10, df = 4,270,
p < 0.01), the external control factor (F = 3.46, df =
4,270, p < 0.01), and the personal control factor (F = 3.17,
df = 4,270, p < 0.01). The stability factor did not yield
significant results F = 1.59, df = 4,270, p > 0.05). Post
hoc Tukey honestly significant difference (HSD) tests at
the p < 0.05 level for the locus of causality factor (the
researchers' primary interest) indicated that the extreme
stress group and negligible stress group were significantly
different from all the other groups, and the high stress
group was significantly different from the mild and negligible stress groups. Regardless of the presence or absence
of the schizophrenia label, subjects in the extreme environmental stress group attributed the cause of the
employee's violent behavior to be significantly more situ-
Study 2
Method
Subjects. Eighty mental health professionals from
a community mental health center in New England were
randomly selected to participate in the study. This group
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Schizophrenia Bulletin, Vol. 25, No. 3, 1999
Effects of the "Schizophrenia" Label
Figure 1. Study 1 (Undergraduates): group means for CDS-II locus of causality factor
Person 27
(A
o
O
Situation
Negligible
Mild
Moderate
Stress
Note.—CDS-II = Causal Dimension Scale II; SCZ = schizophrenia.
483
High
Severe
Schizophrenia Bulletin, Vol. 25, No. 3, 1999
CM. Boisvert and D. Faust
was selected because of geographical convenience.
Subjects were assured of anonymity, and participation
was voluntary. Fifty-eight subjects returned the questionnaire: 4 psychiatrists, 10 registered nurses, 18 master'slevel clinicians, 2 clinicians with certificates of advanced
graduate studies degrees, 20 bachelor's-level clinicians, 1
associate's-level clinician, 1 certified case manager, 1 person without a postsecondary degree, and 1 who did
notindicate a degree. The subjects' years of clinical experience ranged from 1 to 10 or more years.
Subjects received a packet consisting of one page
providing instructions and requesting demographic information, a one-page scenario, a two-page questionnaire,
and one page requesting professional information (i.e.,
degree, years of clinical experience, and theoretical orientation).
Scenarios. The scenarios were identical to those
used with the undergraduates. Half the subjects evaluated
an employee who had a label of schizophrenia, and half
evaluated an employee who had no psychiatric label.
Within each of these groups, the level of stress ranged
along two conditions (negligible or moderate). We chose
only two stress conditions partly because we had access to
a relatively small sample size. We chose the negligible
condition because we believed it would elicit dispositional attributions more easily than the other stress conditions would (as evidenced by results from Study 1) and
the moderate stress condition because we believed it was
the most ambiguous and thus would be most sensitive to
the effects of stereotypes (Hamilton et al. 1990).
Procedure. The design was a randomized 2 X 2 factorial with the following variables: schizophrenia label (present or absent) and environmental stress (negligible or
moderate). Subjects received the research packet via
interoffice mail. They read and signed an informed con-
sent and forwarded it to the researcher, then read a scenario and answered the CDS-II and the exploratory questionnaire. Subjects sent completed materials anonymously
through interoffice mail to the researcher. Following the
study, subjects received a summary of the results and
were given the option of contacting the researcher to be
debriefed.
Results. The results were analyzed using a 2 X 2
MANOVA. A significant multivariate main effect was
found for ES (Wilk's Lambda = 0.51, F = 5.01, df = 9,46,
p < 0.01). The MANOVA analysis produced no other
main or interaction effects, suggesting that practicing clinicians did not perceive the cause of violent behavior to be
more dispositional than situational when the person was
given a label of schizophrenia as opposed to no label. The
power of our design to detect group differences for the
label variable was approximately 0.36 (Cohen 1988).
Follow-up univariate analysis of variance for ES
found significant group differences for the locus factor
(F = 26.10, df = 1,54, p < 0.01). The external control factor also yielded significant results (F = 9.79, df = 1,54,
p < 0.01). Neither the personal control factor nor the stability factor yielded significant results (see table 2).
Follow-up univariate analysis of variance for variable
ES yielded significant group differences for two of the
five items from the exploratory questionnaire. These two
items were "How would you rate the degree to which
Mike was justified in behaving as he did?" (F = 17.77,
df = 1,54, p < 0.01); and "How would you best explain
the cause of Mike's behavior?" (F = 6.42, df = 1,54, p <
0.01). These results suggested that with increasing environmental stress, professionals were more likely to rate
the person as justified in acting violently and the cause of
behavior as more situational.
Table 1. Study 1 (Undergraduates): group mean scores on the CDS-II locus of causality factor
Label condition
No label
Schizophrenia
Stress
Negligible
Mild
Moderate
High
Extreme
CDS-II Mean
Group mean
SD
Group mean
SD
21.70
16.52
15.81
13.39
11.96
15.91
3.34
4.59
4.72
5.01
6.16
—
21.33
18.68
16.63
15.47
11.43
16.71
4.31
4.70
4.68
4.13
6.01
—
CDS-II mean
21.521
17.60
16.30
14.432
11.703
—
Note.—Scores range from 3, maximal situational attribution, to 27, maximal personal attribution. CDS-II = Causal Dimension Scale
SD = standard deviation.
1
2
3
p < 0.05 for Negligible group > Mild, Moderate, High, and Extreme groups.
p < 0.05 for High group < Mild and Negligible groups.
p < 0.05 for Extreme group < High, Moderate, Mild, Negligible groups.
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Schizophrenia Bulletin, Vol. 25, No. 3, 1999
Effects of the "Schizophrenia" Label
Table 2. Study 2 (Clinicians): group mean scores on the CDS-II locus of causality factor
Label condition
Schizophrenia
Stress
Group mean
No label
Group mean
SD
SD
CDS-II mean
Negligible
20.24
20.86
4.82
20.531
4.10
Moderate
13.58
16.27
3.53
4.03
14.931
CDS-II Mean
16.91
18.55
Note.—Scores range from 3, maximal situational attribution, to 27, maximal personal attribution. CDS-II = Causal Dimension Scale
SD = standard deviation.
1
p < 0.01 for Negligible group > Moderate group.
nonbiased judgment in the face of stimuli (e.g., the label
of schizophrenia) potentially expected to create biasing
effects. However, as noted, our particular vignette
description of a person with schizophrenia may have been
less likely to elicit strong stereotypes.
Regardless of the presence or absence of the schizophrenia label, subjects in the moderate environmental
stress group, compared with the negligible stress group,
attributed the cause of the employee's violent behavior to
be significantly more situational. These results suggest
that as the strength of environmental causes for behavior
increased, subjects made fewer personality causal attributions (figure 2). However, the results did not suggest that
the label of schizophrenia led practicing clinicians to
make more personality causal attributions.
Methodological Concerns. The null result for the label
variable, on the other hand, may have resulted from
methodological limitations, which raises issues related to
experimental design and measurement; in particular, is the
analogue approach, which measures perceptions of hypothetical situations, a proper test of the research hypotheses? However, analogue approaches of the type applied in
this study are commonly used to investigate the effects of
labels on clinical judgment (Link 1987; Link et al. 1987;
Loring and Powell 1988; Penn et al. 1994). Moreover, a
clear trend was detected regarding the ES variable, indicating that our attempts to manipulate this variable were
successful. Nevertheless, reactions, stereotypic or otherwise, that are elicited from an analogue study may be different from reactions elicited in more naturalistic settings.
Thus, although our findings suggest that some stereotypes
of schizophrenia may be attenuated under certain circumstances and given specific measurement conditions (e.g.,
using vignettes to elicit perceptions of causality), generalizing the result to naturalistic conditions and circumstances across which they apply requires further study.
Discussion
The significant main effect for environmental stress in
both studies suggests that attempts to manipulate perceived level of stress were successful. Overall, there was
a clear and consistent trend toward increasing situational
attributions with increasing degrees of environmental
stress. At the same time, both the undergraduates and the
practicing clinicians perceived the situation as a substantial contributor to behavior even when the degree of situational stress was mild, which may suggest something
about attributions toward and attitudes about violent
behavior. Extreme environmental stress was not required
for subjects to believe that violent behavior was justified.
Although environmental stress influenced the degree to
which undergraduates and practicing clinicians made personality causal attributions, the schizophrenia label did
not; nor was there evidence for an interaction between the
two variables.
The null result for the label variable may reflect the
true state of nature; that is, at least in the context studied,
the label of schizophrenia may not distort or bias attribution. Such a result runs contrary to other research suggesting that psychiatric labels skew lay and, particularly, professional judgment. The findings in this study raise the
possibility that judgmental biases of this type might not
be as broad or pervasive as is sometimes assumed. This
study, then, may provide a contrary example of proper or
Another possible reason for the null result is that the
manipulation of the label may not have been strong
enough to yield group differences. Even in the no-label
condition, subjects may have perceived the person as a
"mental patient" simply by virtue of involvement in psychotherapy. Past studies, in fact, have shown that labels
such as "patient" or "client" can be stigmatizing (Parish et
al. 1992) and that information such as "a history of treatment" can lead to dispositional biases (Snyder et al.
1976). However, the subjects, at least in making causal
attributions for violent behavior, did not differentiate significantly between a "maladjusted divorced person" and
someone "diagnosed with schizophrenia."
485
CM. Boisvert and D. Faust
Schizophrenia Bulletin, Vol. 25, No. 3, 1999
Figure 2. Study 2 (Clinicians): group means for CDS-II locus of causality factor
Person
27
24
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El No Label
21
18
15
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12
6
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Situation
^
^
^
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^
^
^
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, • . . / ; : . • .;::;.• ..,;:,.•:• , ;
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Moderate
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Negligible
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Note.—CDS-II = Causal Dimension Scale II; SCZ = schizophrenia.
486
<
Schizophrenia Bulletin, Vol. 25, No. 3,1999
Effects of the "Schizophrenia" Label
with schizophrenia or borderline personality disorder to
dispositional factors. However, these dispositional attributions may represent different judgments that are not easily
distinguishable if measured on a dichotomous situationaldispositional scale. Furthermore, these dispositional attributions may be influenced by the degree to which clinicians perceive the person to have control over the
behavior. For example, clinicians may understand various
features of schizophrenia as a biological problem, certainly residing in the person but over which the person has
little control. Alternatively, clinicians may understand
borderline personality disorder as a personality problem,
also residing within the person but over which the person
does have control. Thus, clinicians may be less inclined to
evoke personality attributions to explain the behavior of
an individual with schizophrenia than to explain the
behavior of an individual with borderline personality disorder.
Penn et al. (1994) similarly suggested that labels may
be stigmatizing to the extent that they suggest the person
has control over the behavior and subsequently could be
"blamed" for the behavior. As some research has suggested, attributional biases (differences) may be modified
by other variables. For example, professionals' theoretical
orientation can contribute to attributional biases (Snyder
1977; Pious and Zimbardo 1986) and may influence attributions of responsibility for problems (McGovern et al.
1986). Considering past attribution research and preliminary findings from this study, it seems reasonable to suggest that causal attributions ultimately may be arrived at
through an understanding of dispositional and situational
factors as phenomena that are not static, dichotomized,
and easily predictable occurrences, but fluid, dynamic,
and influenced potentially by multiple variables (e.g., psychiatric labels, setting, particular behavior, theoretical orientation, sociocultural factors).
Research findings suggesting that professionals display attributional biases are based on only a few studies
(Batson 1975; Batson and Marz 1979; Donnan and Pipes
1985). Additionally, in the context of these studies, the
claim of "professional bias" may be questionable. Professionals may be justified in attributing a client's problem to dispositional characteristics, particularly when
given ambiguous information (Davis 1979). A Bayesian
would argue that the prior odds should inform the
appraisal of information, and base rates for dispositional
characteristics need to be considered before concluding
that clinicians display dispositional biases. For example, a
clinician may be asked to identify the cause of a client's
social withdrawal, which may be co-occurring with stressful events. If the client has a diagnosis of schizophrenia
and if social withdrawal is far more common in those with
schizophrenia in comparison to those without this label,
Schizophrenia Stereotypes. It is notable that the label
of schizophrenia itself, compared with no label, did not
significantly alter subjects' causal attributions of violence.
Such a finding raises questions about whether the label of
schizophrenia, by itself, is enough to evoke stereotypes
and to what extent information beyond the label contributes to stereotypic perceptions. Penn et al. (1994) studied the effect that various levels of information about a
recovered person with mental illness had on emotional
and social reactions to that person. They found that those
who had had previous contact with the mentally ill perceived them as less dangerous and that descriptions of
previous symptomatology in the acute phase of schizophrenia were more stigmatizing than the label of schizophrenia alone.
The apparent public stereotype of the mentally ill as
dangerous (Segal 1978; Link and Cullen 1986; Landrine
1992; Monahan 1992) may have attenuated over recent
years (Skinner et al. 1995), possibly as a result of the
community mental health and consumer-organized movements to counter erroneous perceptions of the mentally ill.
The "dangerousness" stereotype may have been mollified
in the study because the person in the scenario was
assuming an acceptable role in society (i.e., employee),
possibly a role not perceived as stereotypic of an individual with schizophrenia. Some research suggests, indeed,
that stereotypes of the mentally ill are evoked more easily
when an individual is observed in a role presumably associated with the mentally ill (Segal 1978).
In our study we might have found a label effect had
we described the person with schizophrenia as experiencing psychotic symptoms and distress. However, such a
description would have added surplus meaning connecting the individual to violent behavior, and subjects may
have been more justified in attributing the behavior to the
person (see Link et al. 1992; Monahan 1992; Junginger
1996). Moreover, we recognize at the same time that our
description may have vitiated some stereotypes of schizophrenia and that other descriptions of a person with schizophrenia may not have aroused the same perceptions.
Ultimately, subjects may have perceived the person with
schizophrenia as relatively unimpaired compared with the
average person with schizophrenia, and consequently
were less inclined to make personality attributions for
behavior.
Conceptual Issues in Attribution Research. Causal
attributions may, in fact, represent cognitive processes
that are not understood easily through traditional concepts
(i.e., the fundamental attribution error) or easily measured
through the available methodology (Solomon 1978;
Miller et al. 1981; Watkins 1986; White 1991). For example, clinicians could attribute the behavior of someone
487
Schizophrenia Bulletin, Vol. 25, No. 3, 1999
CM. Boisvert and D. Faust
then the clinician would be justified in shifting attributions about social withdrawal in the direction of individual versus situational factors. Research suggesting that
professionals display fundamental attributional errors
may be inconclusive and possibly misleading.
Future Directions. Our study raises several questions
about perceived stereotypes of people with schizophrenia
and the potential impact of labels in shaping clinical judgment. Our findings suggest that the label schizophrenia,
alone, may not evoke stereotypic perceptions of violence.
In addition, some stereotypic perceptions may be mollified when a supposed stereotypic label (e.g., schizophrenia) exists in the presence of more favorable characteristics (e.g., a work history, providing for a family).
Although it would be naive to conclude that stereotypes
of people with schizophrenia do not exist, our findings
suggest that stereotypic perceptions may be influenced by
several variables. In some cases the psychiatric label may
be one of those variables, but in other situations, the label
alone may be insufficient to evoke a negative stereotype.
Moreover, given our findings and the dearth of
research examining the relation between psychiatric labels
and causal attribution, research is needed to clarify the
extent to which psychiatric labels influence causal analysis. For example, attribution research may need to include
more detailed inquiries into the cognitive activity of the
perceiver; that is, it may be necessary to assess individuals' decision processes underlying causal attributions.
Although self-reports of causal attributions or cue utilization may be prone to error (Nisbett and Wilson 1977),
methods are available for analyzing and comparing subjective impressions with objective measures of cue utilization (Faust 1984). Research is also needed to develop
a technology to assess observer causal attributions. A first
step may be to examine whether the CDS-II can be
adapted for this purpose.
Considering the potential impact of stereotypic perceptions and judgments on causal analysis and clinical
decision making, research on stereotypes of schizophrenia
seems worth pursuing. In clinical matters in which stereotypic perceptions of people with schizophrenia are likely
to influence the selection of treatment, altering such perceptions becomes critical, particularly when it leads to
improved treatment outcomes. After all, if it is not really
the patient's schizophrenia but rather the loss of a job that
caused his or her agitation, then vocational counseling
rather than psychotropic medication may be indicated.
Although our findings are hopeful in their suggestion
that stereotypic perceptions of people with schizophrenia
as more violent than members of the general population
may not be evoked in some situations, this does not mean
that the label conveys no stereotyped information. The
488
label may evoke other stereotypes (e.g., "unemployable,"
"dependent," "stricken") that influence various perceptions and reactions, including clinicians' selection of treatment. Furthermore, not only psychiatric labels, but other
descriptors (e.g., "mental patient," "on psychiatric medication," "work history") may share a powerful role in
influencing and altering stereotypes and thus also deserve
our attention.
Appendix
Scenarios. Mike has been employed at Fisher
Manufacturing as a line worker for the past 6 years.
Although Mike has had conflicts with his coworkers and
has been described as distant and moody, his job performance has been satisfactory. Mike has maintained a good
work attendance record despite taking a 3-week leave of
absence 4 years ago because of severe marital problems,
which eventuated in a divorce. Mike sought counseling
with a psychologist following his divorce, continued in
treatment for 6 months, and came to accept his divorce.
LABEL: At the beginning of his treatment Mike underwent
a series of interviews and thorough psychological testing
and was diagnosed with schizophrenia. Mike, fortunately,
has not experienced psychotic symptoms since he was
diagnosed. Mike's ex-wife has custody of their two children, a daughter Melissa, age 5, and a son Jeremy, age 7.
Mike, however, sees his children regularly and is a good
provider for them. Mike's social life is limited; except for
membership in the Elks Club, he has few outside interests.
Fisher Manufacturing has a history of episodic financial difficulties, and occasionally employees have been
asked to take a cut in pay or have been laid off temporarily. Upon his arrival at work this morning, Mike's supervisor called him into his office. Mike found this unusual
as his supervisor had never asked to meet with him at an
unscheduled time. Mike did not question his supervisor
and came to his office immediately following his supervisor's request. Upon entering his supervisor's office, Mike
noticed that his personnel file was on his supervisor's
desk. Mike's supervisor invited him to sit down and
informed him that: [one of the five stress conditions followed; see below]. Mike then grabbed his supervisor by
the shirt and forcibly threw him against the wall hard
enough to cause a minor concussion.
The Five Stress Conditions
1. Negligible stress: Despite recent layoffs, he would not
be laid off. In fact, because his work performance had
been so good, he would be receiving a raise, but it would
be delayed a few weeks because of problems at the com-
Effects of the "Schizophrenia" Label
Schizophrenia Bulletin, Vol. 25, No. 3, 1999
pany. Mike then stood up and asked if there was any way
he could receive his raise sooner. His supervisor told him
that there were limits to what he could do.
2. Mild stress: He would be terminated very soon. His
supervisor told him that he was sorry about the circumstances and that the company would do what it could to
help him find another job. Mike then stood up and asked
if he had any options at this time. His supervisor informed
him that unfortunately the decision had been made and
there was nothing he could do.
3. Moderate stress: He would be terminated very soon.
His supervisor told him that he was lucky that he lasted
this long with the company and that he was never considered to be a particularly good worker anyway. Mike then
stood up and asked if he had any options at this time. His
supervisor became noticeably angry, glared directly at
Mike, stood up, clenched his fist, and told him that if he
questioned him further he would be sorry.
4. High stress: He would be terminated very soon. His
supervisor told him that he was lucky that he lasted this
long with the company and that he was never considered
to be a particularly good worker anyway. Mike then stood
up and asked if he had any options at this time. His supervisor became noticeably angry, glared directly at Mike,
stood up, clenched his fist, told him that if he questioned
him further he would be sorry, and pushed Mike back into
his chair.
5. Extreme stress: He would be terminated very soon. His
supervisor told him that he was lucky that he lasted this
long with the company and that he was never considered
to be a particularly worker anyway. Mike then stood up
and asked if he had any options at this time. His supervisor became noticeably angry, glared directly at Mike,
stood up, clenched his fist, told him that if he questioned
him further he would be sorry, grabbed Mike by the throat
and began choking him until his face turned red, and
pushed Mike back into his chair. Mike then proceeded to
leave the room, but his supervisor approached the doorway quickly and stood guarding the door.
References
Abraham, I.L. Causal analysis in the clinical inference of
depression: The influence of general cognitions about
causality. Journal of Human Behavior and Learning,
4:61-66, 1987.
Batson, CD., and Marz, B. Dispositional bias in trained
therapists' diagnosis: Does it exist? Journal of Applied
Social Psychology, 9:476-489, 1979.
Batson, C D . ; O'Quin, K.; and Pych, V. An attribution
theory analysis of trained helpers' inferences about
clients' needs. In: Wills, T.A., ed. Basic Processes in
Helping Relationships. New York, NY: Academic Press,
1982. pp. 59-80.
Bentz, K.W., and Edgerton, W.J. The consequences of
labeling a person mentally ill. Social Psychiatry, 6:29-33,
1971.
Bromfield, R.; Bromfield, D.; and Weiss, B. Influence of
the sexually abused label on perceptions of a child's failure. Journal of Educational Research, 82:96-98, 1988.
Chapman, L.J., and Chapman, J.P. Genesis of popular but
erroneous psychodiagnostic observations. Journal of
Abnormal Psychology, 72:193-204, 1967.
Chapman, L.J., and Chapman, J.P. Illusory correlation as
an obstacle to the use of valid psychodiagnostic signs.
Journal of Abnormal Psychology, 74:271-280, 1969.
Childers, S.E., and Harding, C M . Gender, premorbid
social functioning, and long-term outcome in DSM-IH
schizophrenia. Schizophrenia Bulletin, 16:309-318, 1990.
Cohen, J. Statistical power analysts for the behavioral sciences. 2nd ed. Hillside, NJ: Lawrence Erlbaum
Associates, 1988.
Darley, J.M., and Gross, P.H. A hypothesis-confirming
bias in labeling effects. Journal of Personality and Social
Psychology, 44:20-33, 1983.
Davis, D.A. What's in a name? A Bayesian rethinking of
attributional biases in clinical judgment. Journal of
Consulting and Clinical Psychology, 47:1109-1114, 1979.
Donnan, H.H., and Pipes, R.B. Counselor trainees' explanations of behavior: Attributions to traits, situations, and
interactions. Journal of Clinical Psychology, 41:729-733,
1985.
Dumont, F. Inferential heuristics in clinical problem formulation: Selective review of their strengths and weaknesses. Professional Psychology: Research and Practice,
24:196-205, 1993.
Eggers, C , and Bunk, D. The long-term course of childhood-onset schizophrenia: A 42-year followup.
Schizophrenia Bulletin, 23:105-117, 1997.
Eronen, M.; Tiihonen, J.; and Hakola, P. Schizophrenia
Arkar, H., and Eker, D. Effect of psychiatric labels on attitudes toward mental illness in a Turkish sample. International Journal of Social Psychology, 40:205-213, 1994.
and homicidal behavior. Schizophrenia
Bulletin,
22:83-89, 1996.
Farina, A.; Gliha, D.; Boudreau, L.A.; Allen, J.G.; and
Sherman, M. Mental illness and the impact of believing
others know about it. Journal of Abnormal Psychology,
77:1-5, 1971.
Batson, C D . Attribution as a mediator of bias in helping.
Journal of Personality and Social Psychology, 32:455466, 1975.
489
Schizophrenia Bulletin, Vol. 25, No. 3, 1999
CM. Boisvert and D. Faust
Faust, D. The Limits of Scientific Reasoning. Minneapolis,
MN: University of Minnesota Press, 1984.
Link, B.G.; Andrews, H.; and Cullen, F.T. The violent and
illegal behavior of mental patients reconsidered.
American Sociological Review, 57:275-292, 1992.
Fryer, J.H., and Cohen, L. Effects of labeling patients "psychiatric" or "medical": Favorability of traits ascribed by
hospital staff. Psychological Reports, 62:779-793, 1988.
Gallop, R.; Lancee, W.J.; and Garfinkel, P. How nursing
staff respond to the label "borderline personality disorder."
Hospital and Community Psychiatry, 40:815-819, 1989.
Goodyear, R.K., and Parish, T.S. Perceived attributes of
the terms client, patient, and typical person. Journal of
Counseling Psychology, 25:356-358, 1978.
Link, B.G., and Cullen, F.T. Contact with the mentally ill
and perceptions of how dangerous they are. Journal of
Health and Social Behavior, 27:289-303, 1986.
Link, B.G., and Cullen, F.T. The labeling theory of mental
disorder: A review of the evidence. In: Greenley, J.R., ed.
Research in Community and Mental Health, Vol. 6.
Greenwich, CT: JAI Press, 1990. pp. 203-233.
Link, B.G.; Cullen, F T ; Frank, J.; and Wozniak, J.F. The
social rejection of former mental patients: Understanding
why labels matter. American Journal of Sociology,
92:1461-1500, 1987.
Hamilton, D.L., and Gifford, R.K. Illusory correlation in
interpersonal perception: A cognitive basis of stereotypic
judgments. Journal of Experimental Social Psychology,
12:392^07, 1976.
Link, B.G.; Struening, E.; Cullen, F T ; Shrout, P.E.; and
Dohrenwend, B.P. A modified labeling theory approach to
mental disorders: An empirical assessment. American
Sociological Review, 54:400-423, 1989.
Hamilton, D.L., and Rose, T.L. Illusory correlation and
the maintenance of stereotypic beliefs. Journal of
Personality and Social Psychology, 39:832-845, 1980.
Hamilton, D.L.; Sherman, S.J.; and Ruvolo, C M .
Stereotype-based expectancies: Effects on information
processing and social behavior. Journal of Social Issues,
46:35-60, 1990.
Loman, A.L., and Larkin, W.E. Rejection of the mentally
ill: An experiment in labeling. Sociological Quarterly,
17:555-560, 1976.
Loring, M., and Powell, B. Gender, race, and DSM-III: A
study of the objectivity of psychiatric diagnostic behavior.
Journal of Health and Social Behavior, 29:1-22, 1988.
Herr, P.N.; Perkins, D.V.; and Whitley, B.E. Interpersonal
reactions to a depressed, schizotypal, or normal individual: An attributional perspective. Journal of Research in
Personality, 24:454-467, 1990.
McAuley, E.; Duncan, T.E.; and Russell, D.W. Measuring
causal attributions: The revised Causal Dimension Scale
(CDS-II). Personality and Social Psychology Bulletin,
18:566-573, 1992.
Jones, E.E., and Nisbett, R.E. The actor and observer:
Divergent perceptions of the causes of behavior. In: Jones,
E.E.; Kanouse, D.E.; Kelley, H.H.; Nisbett, R.E.; Valins,
S.; and Weiner, B., eds. Attribution: Perceiving the
Causes of Behavior. Morristown, NJ: General Learning
Press, 1972. pp. 79-94.
McGovern, M.P.; Newman, F.L.; and Kopta, S.M. Metatheoretical assumptions and psychotherapy orientation:
Clinician attributions of patients' problem causality and
responsibility for treatment outcome. Journal of Consulting and Clinical Psychology, 54:476-481, 1986.
Jordan, J.S.; Harvey, J.H.; and Weary, G. Attributional
biases in clinical decision making. In: Turk, D.C., and
Salovey, P., eds. Reasoning, Inference, and Judgment in
Clinical Psychology. New York, NY: The Free Press,
1988. pp. 90-106.
Miller, F.D.; Smith, E.R.; and Uleman, J. Measurement
and interpretation of situational and dispositional attributions. Journal of Experimental Social Psychology,
17:80-95, 1981.
Junginger, J. Psychosis and violence: The case for a content analysis of psychotic experience. Schizophrenia
Bulletin, 22(l):91-103, 1996.
Mirowsky, J., and Ross, C.E. Psychiatric diagnosis as reified measurement. Journal of Health and Social Behavior,
30:11-25, 1989.
Landrine, H. The Politics of Madness. New York, NY:
Peter Lang Publishing, Inc., 1992.
Modestin, J., and Ammann, R. Mental disorder and criminality: Male schizophrenia. Schizophrenia
Bulletin,
22(l):69-82, 1996.
Langer, E.J., and Abelson, R.P. A patient by another
name...: Clinician group difference in labeling bias.
Journal of Consulting and Clinical Psychology, 42:4-9,
1974.
Monahan, J. Mental disorder and violent behavior:
Perceptions and evidence. American
Psychologist,
47:511-521,1992.
Link, B.G. Understanding labeling effects in the area of
mental disorders: An assessment of the effects of expecta-
Nisbett, R.E., and Wilson, T.D. The halo effect: Evidence
for unconscious alteration of judgments. Journal of
Personality and Social Psychology, 35:250-256, 1977.
tions of rejection. American Sociological Review,
52:96-112, 1987.
490
Effects of the "Schizophrenia" Label
Schizophrenia Bulletin, Vol. 25, No. 3,1999
Parish, T.S.; Grosdidier, L.M.; and Emmerson, G.J.
Psychiatrogenic effects of counseling: Self-concepts and
the negative effects of labeling. College Student Journal,
26:202-204, 1992.
Penn, D.L.; Guynan, K.; Daily, T.; Spaulding, W.D.;
Garbin, C.P.; and Sullivan, M. Dispelling the stigma of
schizophrenia: What sort of information is best?
Schizophrenia Bulletin, 20:567-574, 1994.
Segal, S.P. Attitudes toward the mentally ill: A review.
Social Work, 23:211-217, 1978.
Shenkel, R.J.; Snyder, C.R.; Batson, C D . ; and Clark,
G.M. Effects of prior diagnostic information on clinicians' causal attributions of a client's problems. Journal
of Consulting and Clinical Psychology, 47:404-406, 1979.
Phillips, D.L. Rejection of the mentally ill: The influence
of behavior and sex. American Sociological Review,
29:679-687, 1964.
Skinner, L.J.; Berry, K.K.; Griffith, S.E.; and Byers, B.
Generalizability and specificity of the stigma associated
with the mental illness label: A reconsideration twentyfive years later. Journal of Community Psychology,
23:3-17, 1995.
Pious, S., and Zimbardo, P.G. Attributional biases among
clinicians: A comparison of psychoanalysts and behavior
therapists. Journal of Consulting and Clinical Psychology,
54:568-570, 1986.
Snyder, C.R. "A patient by another name" revisited:
Maladjustment or attributional locus of problem? Journal
of Consulting and Clinical Psychology, 45:101-103,
1977.
Rabkin, J. Public attitudes toward mental illness: A review
of the literature. Schizophrenia Bulletin, 1 (Experimental
Issue No. 10):9-33, 1974.
Snyder, C.R.; Shenkel, R.J.; and Schmidt, A. Effects of
role perspective and client psychiatric history on locus of
problem. Journal of Consulting and Clinical Psychology,
44:467-472, 1976.
Ram, R.; Bromet, E.J.; Eaton, W.W.; Pato, C ; and
Schwartz, J.E. The natural course of schizophrenia: A
review of first-admission studies. Schizophrenia Bulletin,
18:185-207,1992.
Solomon, S. Measuring dispositional and situational attributions. Personality and Social Psychology Bulletin,
4:589-594, 1978.
Wahl, O.F., and Harman, C.R. Family views of stigma.
Schizophrenia Bulletin, 15:131-139, 1989.
Retzinger, S.M. A theory of mental illness: Integrating
social and emotional aspects. Psychiatry, 52:325-335,
1989.
Watkins, D. Assessing causal dimensions. Australian
Psychologist, 21:467-472,1986.
Rosenhan, D.L. On being sane in insane places. Science,
179:250-258, 1973.
White, P.A. Ambiguity in the internal/external distinction
in causal attribution. Journal of Experimental Social
Psychology, 27:259-270, 1991.
Ross, L. The intuitive psychologist and his shortcomings:
Distortions in the attribution process. In: Berkowitz, L.,
ed. Advances in Experimental Social Psychology, Vol. 10.
New York, NY: Academic Press, 1977. pp. 173-220.
The Authors
Royce, W.S., and Muehlke, C.V. Therapists' causal attributions of clients' problems and selection of intervention
strategies. Psychological Reports, 68:379-386, 1991.
Charles M. Boisvert, Ph.D., received his doctorate in
Clinical Psychology and David Faust, Ph.D., is a
Professor of Psychology at the University of Rhode
Island, Kingston, RI.
Scheff, T.J. The labeling theory of mental illness.
American Sociological Review, 39:444-452, 1974.
491