ORIGINAL ARTICLE
Does Humor Influence the Stigma of Mental Illnesses? Patrick W. Corrigan, PsyD, Karina J. Powell, MS, J. Konadu Fokuo, BA, and Kristin A. Kosyluk, MS Abstract: Public stigma is a barrier for people with mental illness. Humor may have the potential to decrease stigmatizing attitudes in the context of disclosure. Participants completed measures on stigmatizing attitudes and humor style and were then randomized to one of three conditions (self-disclosure comedy sketch, the same comedy sketch with no disclosure, and a control comedy sketch). After reviewing the comedy sketch, the participants repeated the attitude measures and provided perceptions of the comic. Humor styles and perceptions significantly interacted with condition to reduce stigma. Perceptions of the self-disclosed comic were associated with reduced stigma. People exhibiting affiliative humor style (i.e., they enjoy making others laugh) were shown to have significantly greater stigma changes in the disclosed condition compared with the nondisclosed and control conditions. Affiliative humor endorsers also interacted with the nondisclosed condition, suggesting that mental health comedy might generally reduce stigma in people who use humor to improve relationships. Key Words: Stigma, humor, mental illness (J Nerv Ment Dis 2014;202: 397Y401)
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ublic stigmaVthat is, the population’s endorsement of prejudice about mental illnessVis a barrier to the personal goals of many people with psychiatric illness including opportunities related to good jobs, satisfactory living arrangements, and quality health care (Sartorius et al., 2012). Public stigma has been defined as stereotypes about mental illness that lead to discrimination (Corrigan, 2005). One stereotype is blame: the belief that people ‘‘choose’’ to have a mental illness. According to attribution theory, people who are perceived as responsible for a condition (such as their mental illness) are disparaged and shunned (Corrigan, 2000; Weiner, 1985). Given stigma’s pernicious effects, advocacy groups have developed a variety of antistigma programs meant to reduce its egregious impact. Results of a recent meta-analysis identified 71 empirical studies, with 13 using randomized controlled trials that showed contact-based approaches (i.e., in which people with lived experiences share stories of recovery with the public), that yielded the best effect sizes (Corrigan et al., 2012). One group, Stand Up for Mental Health, uses comedy to enhance its impact on stigma change. Stand Up for Mental Health, founded in 2004, is an organization of Canadians with mental illness who use comedy as a way to build confidence and fight stigma. Humor might seem to be an unlikely aid in reducing stigma. Research fairly consistently shows that humor and comedy are often associated with endorsing negative stereotypes about social groups (Ford and Ferguson, 2004; Maio et al., 1997; Thomas and Esses, 2004), with the relationship between jokes and sexism especially well documented (Ford et al., 2008; Greenwood and Isbell, 2002). The connection between humor and prejudice has been extended to people with disabilities in general (Anderson, 1988) and those with mental illness (Ne´meth, 2009). However, humor does not always seem to exacerbate
Department of Psychology, Illinois Institute of Technology, Chicago, IL. Send reprint requests to Patrick W. Corrigan, PsyD, Department of Psychology, Illinois Institute of Technology, 3424 S. State St, Chicago, IL 60616. E-mail: [email protected]. Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0022-3018/14/20205Y0397 DOI: 10.1097/NMD.0000000000000138
The Journal of Nervous and Mental Disease
stigma; for example, a randomized controlled trial on the effects of Starved, a 2005 situation comedy about four people with eating disorders, showed no worsening in stereotypes (Katterman and Klump, 2010; Shaeffer, 2005). Theorists have wondered whether humor can be used to assuage the shame of stigma related to health conditions (Ruiz-Mellott, 2004), an assumption supported in a qualitative study with more than 250 service providers for people with human immunodeficiency virusYacquired immunodeficiency virus showing gallows humor as an effective approach for dealing with the related self-stigma (Makoae et al., 2008). Social scientists have opined that some television (TV) shows have lessened the stigma of homosexuality, citing Will and Grace, a 2001 to 2005 comedy about gay lawyer, Will Truman (Castiglia and Reed, 2004), and the 1997 comedy, Ellen, in which character Ellen Morgan disclosed that she was a lesbian shortly after DeGeneres publically came out (Ryan and Boxer, 1998). The last example is especially relevant to the goals of this study; how does humorous discussion of one’s own ‘‘stigmatized condition’’ affect public stigma? We were unable to find any research that tested this kind of disclosure in the empirical literature. In this study, we examine the impact of Stand Up for Mental Health founder David Granirer’s 2-minute YouTube routine in which he discusses experiences with his illness and the public’s reaction to the introduction of a local mental health clinic. We sought to distinguish the effects of his first-person story from the humor per se. Hence, people were randomized to Mr Granirer’s routine with or without selfdisclosure, that is, knowing whether the comic did or did not have experience with mental illness himself. We hypothesize that the self-disclosing sketch will significantly reduce mental illness stigma in viewers, consistent with the assumptions about TV shows discussing gay and lesbian subject matter referenced above. However, stripping out disclosures will translate the piece to humor alone, which we think will undermine any benefits. Authenticity of the comic, operationalized as perceiving a comic as knowing about what he/she speaks because of his/her lived experience, will likely be an important moderator in antistigma effects. We hypothesize that comics viewed as having a mental illness will seem more authentic and hence yield bigger reductions in stigma. Similarly, we expect sketches in which the comic is viewed as funnier, more similar to the viewer, and more sincere to yield greater impact for the self-disclosure condition. Research suggests that comedy’s effects are impacted by humor style, defined as individual differences in the way people react to humor that vary across several domains (Hodson et al., 2010a). For example, those who endorse an aggressive style (‘‘I often use humor or teasing to put others down’’) may perceive slapstick humor as funny and support notions of social dominance (‘‘It is a good thing that some groups are at the top and others at the bottom’’; Hodson et al., 2010b). We hypothesize that effects of comedy sketches will interact with a person’s individual humor styles. Two styles are incorporated into this study: a) aggressive style, those higher in aggressive style will show less benefit from the authentic comic, and b) affiliative style (‘‘I enjoy making others laugh’’), the opposite of aggressive, will lead the viewer to empathizing with the comedian, causing greater reduction in stigma.
METHODS Research participants completed pretests of stigmatizing attitudes and humor style and were then randomized to one of three conditions: a comedy sketch in which the comic discloses his mental illness, the same
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sketch in which all allusion to the comic’s mental illness is omitted, and a control comedy sketch with no reference to mental illness. The research participants then repeated the measures of stigmatizing attitudes and reported their perceptions of the comic. Recruitment was conducted via advertising on the Chicago, Illinois, Volunteers section of Craigslist (www.craigslist.org/chicago/volunteers). The participants accessed the study via hyperlink to a secure online survey site called Qualtrics (www.qualtrics.com). The only exclusion criterion was age; only adult participants (aged Q18 years) were permitted to participate in the study. The participants were informed that this was a study about humor and mental illness and were given a $5.00 Amazon gift card for completing research tasks. An overall concern of online research such as this is keeping the task relatively brief so subjects do not prematurely terminate. Hence, short versions of tests and single-item proxies of our constructs were selected; the total task took approximately 15 minutes in all. To assess public stigma in terms of blame and attributions, we used the short form of the Attribution Questionnaire (AQ); in the measure, participants are presented a short vignette about Harry, a 35-year-old person with schizophrenia who lives alone and works full time as a clerk at a legal firm. In the full AQ (Corrigan et al., 2003; Reinke et al., 2004), participants answer 27 items (e.g., ‘‘I think that it was Harry’s own fault that he is in the present condition’’) on a 9-point agreement scale (9 = very much). The AQ-27 has strong reliability, construct validity, and sensitivity to change after antistigma program participation. Given that the original AQ is long for many outcome studies, a short form with nine items was tested and found to have similar strong reliability, validity, and sensitivity to change (Corrigan et al., 2003, 2013). A total score from the AQ is used in this study. We used items from the Humor Styles Questionnaire (HSQ; Martin et al., 2003) to assess this construct. The HSQ comprises items to which participants respond using a 9-point agreement scale (1 = extremely disagree; 9 = extremely agree). We selected items that represent aggressive and affiliative humor. People were randomized to one of three comedy sketches (approximately 2 minutes each). The index sketch by Stand Up for Mental Health founder, David Granirer, has more than 12,000 YouTube views. In this disclosed comic sketch, Granirer shares his ironic perceptions about the ‘‘threats’’ of a mental health center opening up in the community. The sketch begins with Granirer disclosing his mental illness and experiences with symptoms and medication. This condition is contrasted to a nondisclosed comic condition in which Mr Granirer does the same material except all reference to his mental illness is omitted. The control condition consisted of a 2-minute sketch in which a sex-, race-, and age-matched comic discussed his lack of understanding of women’s fashion. There was no mention of issues related to mental health in the control condition. The participants completed the AQ before and immediately after the comic sketch. They also completed five statements about the comic on a 9-point agreement scale (9 = extremely agree). Statements assessed participant perceptions about the comic as being humorous, aggressive, with/without a mental illness, ‘‘like me,’’ and sincere. The research participants also completed demographic questions.
Statistical Plan First, we examine frequencies and means (standard deviations) of demographics, humor styles, and perceptions of comics across the three research conditions. We then examine change in AQ scores from preassessment to postassessment to test the hypothesis about disclosed and nondisclosed comedy sketch effects on stigma change. Before examining moderating effects of humor styles and perceptions of comics, we provide Pearson’s product moment correlations to describe their association with AQ scores. We then tested moderator effects as planned multiple regression analyses representing the relationship between posttest AQ scores and intervention-humor style (or perceptions of comic) interactions after partialling out baseline 398
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AQ scores. Intervention represents two planned contrasts of conditions: disclosure versus no disclosure and control (1, 0, 0) or no disclosure versus disclosure and control (0, 1, 0). Hence, Table 3 represents a series of equations of the form as follows: AQ post ¼ þ AQ post ¼ þ
AQ pre þ contrastð1;0;0Þ humor style n contrastð0;1;0Þ humor style n or AQ pre þ contrastð1;0;0Þ comic perception n contrastð0;1;0Þ comic perception n
RESULTS Examination of AQ distributions revealed seven participants showing significant floor effects, that is, endorsing almost no stigmatizing attitudes. Hence, these outliers were removed from additional analyses, reducing N fairly evenly across conditions to 342. The total sample was 70.8% men and ethnically diverse. They were 65.8% white, 20.8% African-American, 9.5% Asian, and 2.9% Native American. A total of 45.3% of the participants reported themselves to be Hispanic or Latino. It was a fairly educated group, with 48.5% reporting at least some college, 32.7% having earned a bachelor’s degree, and 3.2% having earned a graduate degree. Almost all participants (95.9%) reported currently working full time. Table 1 summarizes demographics across conditions, in which no significant differences were found. Table 1 also summarizes humor styles and perceptions of the comic across conditions, again with no significant differences emerging. Finally, Table 1 lists pretest and posttest AQ scores by condition, with nonsignificant main effects and interaction. These last analyses failed to show a humor effect on stigma change. Table 2 summarizes relationships among AQ pretest and posttest scores, humor styles, and perceptions of the comic. Both pretest and posttest AQ scores were negatively related to affiliative humor. The more participants enjoy humor, the less likely they were to endorse stigmatizing attitudes. Effect sizes for these relationships were greater than 12.5%. Although affiliative and aggressive humor were significantly inversely associated (r = j0.22, p G 0.001), aggressive humor was not associated with pretest or posttest AQ scores. Table 2 also summarizes the relationship between pretest and posttest AQ scores and perceptions of the comic. All of these relationships were significant; the participants viewing comics as having a mental illness and relatively more humorous, aggressive, ‘‘like me,’’ and sincere showed diminished stigma on the AQ. Effect sizes for these relationships range from 4.8% to 22.1%. Finally, an affiliative humor style was found to be significantly associated with all perceptions of the comic. An aggressive humor style was significantly related to viewing the comic as only humorous or aggressive. Although we found no significant group by trial interactions, suggesting no stigma change due to comic condition, we examined interaction effects between individual conditions and measures of humor styles or perceptions of the comic to independently test these hypotheses. Table 3 provides the results of multiple regression analyses. The first two rows examined the interaction of humor style with contrasted comic sketch conditions. Results for an affiliative humor style showed significant betas for both interactions. People assigned to the disclosed comic and the nondisclosed comic condition showed significant reductions in posttest stigma on the AQ as they endorsed greater affiliative humor. Significant effects for the interactions of aggressive humor and antistigma interventions were not found with either condition. The bottom half of Table 3 summarizes interactions between antistigma comic sketch conditions and perceptions of the comic. Perceptions of the comic when the comic self-disclosed were associated with greater reductions in stigma from pretest to posttest. This occurred when the comic was viewed as humorous, having a mental illness, ‘‘like me,’’ and sincere. The self-disclosed comic who was viewed as less aggressive also showed significantly better change in stigma on the AQ. * 2014 Lippincott Williams & Wilkins
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DISCUSSION Humor is used by some advocates with lived experience as a strategy to diminish public stigma toward mental illness. In this study, we attempted to examine the effects of humor on stigma change when the comic had or had not publicly disclosed his mental health status. The results failed to show a significant change in stigma due to either of the two comic sketch conditions. Given the relatively short time between pretest and posttest, an AQ memory effect or social desirability effect may have undermined significant change. Alternatively, comic effects may occur only when examined by moderators such as humor style and perceptions of the comic. In fact, significant stigma change was found when examining the interaction of comic conditions with humor style and perceptions of the comic. Stigma as measured on the AQ was shown to significantly decrease for the disclosed comic condition among the participants who endorsed an affiliative humor style.
Stigma Change and Humor
People who seem to enjoy humor and making people laugh were shown to have significantly larger changes in the disclosed comic condition compared with the nondisclosed and the control condition. An affiliative style was also found to interact with the nondisclosed comic condition, which suggests that comedy about mental health in general might reduce stigma in a person who enjoys laughing. An aggressive humor style was not found to interact with either comic condition, a notable finding that suggests that offense at a comic’s statement about mental illness does not seem to impede attitude change. The sketch’s effect on attitude change also significantly interacted with perceptions of the comic. These effects were found only for the comic who self-identified with a mental illness. The participants who viewed the disclosed comic as more humorous yielded greater reductions in stigmatizing attitudes. A specific hypothesis of the study was that the comic viewed as more authentic would produce greater stigma reduction
TABLE 1. Differences in Demographics, Humor Style, Comic Ratings, and Stigma Measures by Condition Sketch With Disclosed Comic, n = 117 Variable
Mean
Demographics Sex (female), % Age Race White African-American Asian Native American Pacific Islander Hispanic ethnicity Education Some HS HS diploma AA/AS Some college BA/BS Graduate degree Other Employment Full time Part time Humor style Affiliative Aggressive Perceptions of comic Humorous Aggressive Has mental illness Like me Sincere AQ Pretest Posttest
SD
Sketch With Nondisclosed Comic, n = 108 Mean
35.9% 33.2
SD
Control Sketch, n = 117 Mean
28.7% 6.8
32.5
SD
Group Differences
7.4
W22 = 4.67, NS F(2,339) = 0.34, NS
23.1% 5.4
32.9
69.2% 17.1% 1.7% 6.8% 5.1% 47.0%
59.3% 25.0% 5.6% 8.3% 1.9% 44.4%
68.4% 20.5% 2.6% 6.8% 1.7% 44.4%
W28 = 8.73, NS
0.0% 1.7% 6.0% 54.7% 32.5% 2.6% 2.6%
0.9% 2.8% 13.9% 43.5% 33.3% 3.7% 1.9%
0.9% 0.0% 13.7% 47.0% 32.5% 3.4% 2.6%
W212 = 10.2, NS
95.7% 4.3%
95.4% 4.6%
96.6% 3.4%
W22 = 0.22, NS
W22 = 0.20, NS
1.99 2.66
1.14 2.06
2.07 2.72
1.05 2.13
2.09 2.78
1.03 2.13
F(2,339) = 0.26, NS F(2,339) = 0.10, NS
2.97 2.82 2.85 2.50 2.46
2.28 2.08 2.10 1.97 1.67
3.28 2.79 2.90 3.06 2.85
2.25 2.02 2.10 2.33 1.95
3.18 2.79 2.77 2.87 2.71
2.28 1.97 1.95 2.03 1.93
F(2,339) = F(2,339) = F(2,339) = F(2,339) = F(2,339) =
55.3 54.2
8.1 11.2
53.0 52.9
9.6 10.4
54.6 54.7
9.1 10.0
0.56, 0.01, 0.11, 2.11, 1.29,
NS NS NS NS NS
Condition: F(2,339) = 1.35, NS; trial: F(1,339) = 0.93, NS; interaction: F(2,339) = 0.43, NS
Frequencies (percentages) are reported for categorical variables. AA indicates Associate of Arts; AS, Associate of Science; BA, Bachelor of Arts; BS, Bachelor of Science; HS, high school; NS, not significant.
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TABLE 2. Pearson’s Product Moment Correlations Among AQ Pretest Scores, Humor Styles, and Perceptions of the Comics Humor Styles
AQ pretest AQ posttest Affiliative Aggressive Humorous Aggressive Has MI Like me
Perceptions of the Comic
Affiliative
Aggressive
Humorous
Aggressive
Has MI
Like me
Sincere
j0.36*** j0.41***
0.04 0.03 j0.22***
j0.31*** j0.32*** 0.15** j0.28***
j0.41*** j0.42*** 0.30*** j0.11* 0.23***
j0.47*** j0.45*** 0.20*** j0.09 0.38*** 0.58***
j0.29*** j0.22*** 0.19*** j0.08 0.20*** 0.30*** 0.34***
j0.45*** j0.44*** 0.30*** j0.06 0.31*** 0.47*** 0.47*** 0.42***
*p G 0.05; **p G 0.01; ***p G 0.001. MI indicates mental illness.
effects. The results showed that the disclosed comic who was viewed as having a mental illness, ‘‘like me,’’ and sincere yielded better stigma change. Although an aggressive humor style was not found to interact with comic condition, perceiving the comic as aggressive did interact with condition. Namely, perceiving the disclosed comic as aggressive or offensive led to less change in stigma. These findings suggest that researching comedy about mental health person-level variables needs to be considered in crafting these approaches. We began with humor styles here as natural moderators of the way comedy routines are experienced. There are additional humor styles in this area that might be relevant including self-defeating (e.g., ‘‘I get carried away in putting myself down’’) and self-enhancing (e.g., ‘‘My humor keeps me from getting overly depressed about things’’) humor (Martin et al., 2003). These might be especially relevant because the person weighs his/her own personal experiences with mental illness when viewing the comedy sketch. In this light, one’s familiarity with mental illness is likely to mediate the comedy routine. One study showed that familiar experiences with mental illness (e.g., having a family member with mental illness) mediated reductions in stigma that occurred after an education about stigma (i.e., contrasting myths and facts of mental illness) program (Holmes et al., 1999). Interestingly, those with greater familiarity showed significantly less improvement. The study also examined moderating effects of mental health literacy in the education program and found that those who were more knowledgeable about
mental illness were also less likely to decrease stigma after the education program. Both of these findings might reflect a floor effect; those personally familiar with and knowledgeable about mental illness are already likely at the floor of stigma measures with little room to improve. Regardless, future studies need to include measures of person-specific variables in their design. Limitations of the study need to be considered when interpreting findings. Failure to support the main hypotheses per se is the most significant. We were unable to directly determine whether comedy and comic disclosure impact stigma. In part, this might have occurred because of selection of the study measure. The 9-item version of the AQ is much shorter than the original 27-item, which might have yielded greater power. Despite this, showing significant interaction effects definitely suggest a positive role for comedy in stigma change. Findings were also limited to decreasing stigma rather than increasing its obverse, affirming attitudes (Corrigan et al., 2013). Future research should examine the effects of comedy on positive attitudes about mental health, including recovery, self-determination, and personal empowerment. An additional limitation is that only pretests and posttests were examined in the study. We were unable to determine whether a 2-minute comedy sketch yielded any changes that maintained over time. Future studies should include follow-up assessment. This research may have implications for future humor programs attempting to change stigma. Perceptions about the comic were especially
TABLE 3. Results of Multiple Regression Analyses Examining Relationship Between Posttest Scores, Pretest Scores, and Interactions (Planned Contrasts Comic Rating or Humor Style) Interactions
EQ
AQ-Pretest
Humor styles 1 2 Perceptions of 3 4 5 6 7
0.74*** 0.74*** comic 0.74*** 0.74*** 0.74*** 0.74*** 0.74***
Planned Contrast
Humor Style or Comic Perception (Interaction)
Disclosed vs. Nondisclosed, Control (1, 0, 0)
Nondisclosed vs. Disclosed, Control (0, 1, 0)
R2
Affiliative Aggressive
j0.13** j0.02
j0.09* j0.01
0.571 0.557
Humorous Aggressive Has MI Like me Sincere
j0.09* 0.08* j0.09* j0.08* j0.09*
j0.01 0.04 j0.02 j0.02 j0.08*
0.563 0.563 0.564 0.562 0.565
All values are betas (standardized coefficients). *p G 0.05; **p G 0.01; ***p G 0.001. EQ indicates empowerment questionnaire; MI, mental illness.
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important moderators, with sincere and authentic comics seeming to have greater impact. These findings support assertions of Stand Up for Mental Health that authentic comics talking about their experiences with mental health can be a powerful vehicle for stigma change. What other variables might add to this poignancy? Future research needs to examine the relative impact of videotaped versus in vivo sketches. Findings from the meta-analysis on stigma change programs found that face-to-face contact leads to the greatest change (Corrigan et al., 2012). Hence, in vivo comedy sketches are expected to yield better stigma reduction. Still, videotaped and online contact improved stigma significantly, albeit less than face-to-face contact. Videotaped comedy has the potential of penetrating a much bigger audience than in vivo approaches. Hence, future research needs to consider the breadth of impact of different kinds of comedy routines. DISCLOSURE The authors declare no conflict of interest. REFERENCES Anderson PM (1988) American humor, handicapism, and censorship. J Read Writ Learn Disabil Int. 4:79Y87. Castiglia C, Reed C (2004) ‘‘Ah, yes, I remember it well’’: Memory and queer culture in Will and Grace. Cultural Critique. 56:158Y188. Corrigan PW (2000) Mental health stigma as social attribution: Implications for research methods and attitude change. Clin Psychol. 7:48Y67. Corrigan PW (2005) Changing stigma through contact. Adv Schizophr Clin Psychiatry. 1:614Y625. Corrigan PW, Markowitz F, Watson A, Rowan D, Kubiak MA (2003) An attribution model of public discrimination towards persons with mental illness. J Health Soc Behav. 44:162Y179. Corrigan PW, Morris SB, Michaels PJ, Rafacz JD, Ru¨sch N (2012) Challenging the public stigma of mental illness: A meta-analysis of outcome studies. Psychiatr Serv. 63:963Y973. Corrigan PW, Powell KJ, Michaels PJ (2013) The effects of news stories on the stigma of mental illness. J Nerv Ment Dis. 201:179Y182. Ford TE, Boxer C, Armstrong J, Edel JR (2008) More than ‘‘just a joke’’: The prejudice-releasing function of sexist humor. Pers Soc Psychol Bull. 34:159Y170.
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Stigma Change and Humor
Ford TE, Ferguson MA (2004) Social consequences of disparagement humor: A prejudice norm theory. Pers Soc Psychol Rev. 8:79Y94. Greenwood D, Isbell LM (2002) Ambivalent sexism and the dumb blonde: Men’s and women’s reactions to sexist jokes. Psychol Women Q. 26:341Y350. Hodson G, MacInnis CC, Rush J (2010a) Prejudice-relevant correlates of humor temperaments and humor styles. Pers Individ Dif. 49:546Y549. Hodson G, Rush J, MacInnis CC (2010b) A ‘‘joke is just a joke’’ (except when it isn’t): Cavalier humor beliefs facilitate the expression of group dominance motives. J Pers Soc Psychol. 99:660Y682. Holmes EP, Corrigan PW, Williams P, Canar J, Kubiak M (1999) Changing public attitudes about schizophrenia. Schizophr Bull. 25:447Y456. Katterman SN, Klump KL (2010) Stigmatization of eating disorders: A controlled study of the effects of the television show Starved. Eat Disord. 18:153Y164. Maio G, Olson J, Bush J (1997) Telling jokes that disparage social groups: Effects of the joke-teller’s stereotypes. J Appl Soc Psychol. 27:1986Y2000. Makoae LN, Greeff M, Phetlhu RD, Uys LR, Naidoo JR, Kohi TW, Dlamini PS, Chirwa ML, Holzemer WL (2008) Coping with HIV related stigma in five African countries. J Assoc Nurses AIDS Care. 19:137Y146. Martin RA, Puhlik-Doris P, Larsen G, Gray J, Weir K (2003) Individual differences in uses of humor and their relation to psychological well-being: Development of the Humor Styles Questionnaire. J Res Pers. 37:48Y75. Ne´meth E (2009) Correlations between television viewing, attitudes toward the mentally ill and psychiatric professionals, and willingness to seek therapy. Psychiatr Hung. 24:133Y140. Reinke RR, Corrigan PW, Leonhard C, Lundin R, Kubiak MA (2004) Examining two aspects of contact on the stigma of mental illness. J Soc Clin Psychol. 23:377Y389. Ruiz-Mellott K (2004) Review of the book An Egg on Three Sticks. Psychiatr Serv. 55:1459Y1460. Ryan CC, Boxer AM (1998) Coming out in primetime: The mental health impact of Ellen’s debut. Cult Divers Ment Health. 4:135Y142. Sartorius N, Stuart H, Arboleda-Flo´rez J (2012) Paradigms lst: Fighting stigma and the lessons learned. New York: Oxford University Press. Shaeffer E (Director) (2005) Starved [television series]. New York: FX Networks. Thomas CA, Esses VM (2004) Individual differences in reactions to sexist humor. Group Process Intergroup Relat. 7:89Y100. Weiner B (1985) An attribution theory of achievement motivation and emotion. Psychol Rev. 92:548Y573.
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Does Humor Influence the Stigma of Mental Illnesses? Patrick W. Corrigan, PsyD, Karina J. Powell, MS, J. Konadu Fokuo, BA, and Kristin A. Kosyluk, MS Abstract: Public stigma is a barrier for people with mental illness. Humor may have the potential to decrease stigmatizing attitudes in the context of disclosure. Participants completed measures on stigmatizing attitudes and humor style and were then randomized to one of three conditions (self-disclosure comedy sketch, the same comedy sketch with no disclosure, and a control comedy sketch). After reviewing the comedy sketch, the participants repeated the attitude measures and provided perceptions of the comic. Humor styles and perceptions significantly interacted with condition to reduce stigma. Perceptions of the self-disclosed comic were associated with reduced stigma. People exhibiting affiliative humor style (i.e., they enjoy making others laugh) were shown to have significantly greater stigma changes in the disclosed condition compared with the nondisclosed and control conditions. Affiliative humor endorsers also interacted with the nondisclosed condition, suggesting that mental health comedy might generally reduce stigma in people who use humor to improve relationships. Key Words: Stigma, humor, mental illness (J Nerv Ment Dis 2014;202: 397Y401)
P
ublic stigmaVthat is, the population’s endorsement of prejudice about mental illnessVis a barrier to the personal goals of many people with psychiatric illness including opportunities related to good jobs, satisfactory living arrangements, and quality health care (Sartorius et al., 2012). Public stigma has been defined as stereotypes about mental illness that lead to discrimination (Corrigan, 2005). One stereotype is blame: the belief that people ‘‘choose’’ to have a mental illness. According to attribution theory, people who are perceived as responsible for a condition (such as their mental illness) are disparaged and shunned (Corrigan, 2000; Weiner, 1985). Given stigma’s pernicious effects, advocacy groups have developed a variety of antistigma programs meant to reduce its egregious impact. Results of a recent meta-analysis identified 71 empirical studies, with 13 using randomized controlled trials that showed contact-based approaches (i.e., in which people with lived experiences share stories of recovery with the public), that yielded the best effect sizes (Corrigan et al., 2012). One group, Stand Up for Mental Health, uses comedy to enhance its impact on stigma change. Stand Up for Mental Health, founded in 2004, is an organization of Canadians with mental illness who use comedy as a way to build confidence and fight stigma. Humor might seem to be an unlikely aid in reducing stigma. Research fairly consistently shows that humor and comedy are often associated with endorsing negative stereotypes about social groups (Ford and Ferguson, 2004; Maio et al., 1997; Thomas and Esses, 2004), with the relationship between jokes and sexism especially well documented (Ford et al., 2008; Greenwood and Isbell, 2002). The connection between humor and prejudice has been extended to people with disabilities in general (Anderson, 1988) and those with mental illness (Ne´meth, 2009). However, humor does not always seem to exacerbate
Department of Psychology, Illinois Institute of Technology, Chicago, IL. Send reprint requests to Patrick W. Corrigan, PsyD, Department of Psychology, Illinois Institute of Technology, 3424 S. State St, Chicago, IL 60616. E-mail: [email protected]. Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0022-3018/14/20205Y0397 DOI: 10.1097/NMD.0000000000000138
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stigma; for example, a randomized controlled trial on the effects of Starved, a 2005 situation comedy about four people with eating disorders, showed no worsening in stereotypes (Katterman and Klump, 2010; Shaeffer, 2005). Theorists have wondered whether humor can be used to assuage the shame of stigma related to health conditions (Ruiz-Mellott, 2004), an assumption supported in a qualitative study with more than 250 service providers for people with human immunodeficiency virusYacquired immunodeficiency virus showing gallows humor as an effective approach for dealing with the related self-stigma (Makoae et al., 2008). Social scientists have opined that some television (TV) shows have lessened the stigma of homosexuality, citing Will and Grace, a 2001 to 2005 comedy about gay lawyer, Will Truman (Castiglia and Reed, 2004), and the 1997 comedy, Ellen, in which character Ellen Morgan disclosed that she was a lesbian shortly after DeGeneres publically came out (Ryan and Boxer, 1998). The last example is especially relevant to the goals of this study; how does humorous discussion of one’s own ‘‘stigmatized condition’’ affect public stigma? We were unable to find any research that tested this kind of disclosure in the empirical literature. In this study, we examine the impact of Stand Up for Mental Health founder David Granirer’s 2-minute YouTube routine in which he discusses experiences with his illness and the public’s reaction to the introduction of a local mental health clinic. We sought to distinguish the effects of his first-person story from the humor per se. Hence, people were randomized to Mr Granirer’s routine with or without selfdisclosure, that is, knowing whether the comic did or did not have experience with mental illness himself. We hypothesize that the self-disclosing sketch will significantly reduce mental illness stigma in viewers, consistent with the assumptions about TV shows discussing gay and lesbian subject matter referenced above. However, stripping out disclosures will translate the piece to humor alone, which we think will undermine any benefits. Authenticity of the comic, operationalized as perceiving a comic as knowing about what he/she speaks because of his/her lived experience, will likely be an important moderator in antistigma effects. We hypothesize that comics viewed as having a mental illness will seem more authentic and hence yield bigger reductions in stigma. Similarly, we expect sketches in which the comic is viewed as funnier, more similar to the viewer, and more sincere to yield greater impact for the self-disclosure condition. Research suggests that comedy’s effects are impacted by humor style, defined as individual differences in the way people react to humor that vary across several domains (Hodson et al., 2010a). For example, those who endorse an aggressive style (‘‘I often use humor or teasing to put others down’’) may perceive slapstick humor as funny and support notions of social dominance (‘‘It is a good thing that some groups are at the top and others at the bottom’’; Hodson et al., 2010b). We hypothesize that effects of comedy sketches will interact with a person’s individual humor styles. Two styles are incorporated into this study: a) aggressive style, those higher in aggressive style will show less benefit from the authentic comic, and b) affiliative style (‘‘I enjoy making others laugh’’), the opposite of aggressive, will lead the viewer to empathizing with the comedian, causing greater reduction in stigma.
METHODS Research participants completed pretests of stigmatizing attitudes and humor style and were then randomized to one of three conditions: a comedy sketch in which the comic discloses his mental illness, the same
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sketch in which all allusion to the comic’s mental illness is omitted, and a control comedy sketch with no reference to mental illness. The research participants then repeated the measures of stigmatizing attitudes and reported their perceptions of the comic. Recruitment was conducted via advertising on the Chicago, Illinois, Volunteers section of Craigslist (www.craigslist.org/chicago/volunteers). The participants accessed the study via hyperlink to a secure online survey site called Qualtrics (www.qualtrics.com). The only exclusion criterion was age; only adult participants (aged Q18 years) were permitted to participate in the study. The participants were informed that this was a study about humor and mental illness and were given a $5.00 Amazon gift card for completing research tasks. An overall concern of online research such as this is keeping the task relatively brief so subjects do not prematurely terminate. Hence, short versions of tests and single-item proxies of our constructs were selected; the total task took approximately 15 minutes in all. To assess public stigma in terms of blame and attributions, we used the short form of the Attribution Questionnaire (AQ); in the measure, participants are presented a short vignette about Harry, a 35-year-old person with schizophrenia who lives alone and works full time as a clerk at a legal firm. In the full AQ (Corrigan et al., 2003; Reinke et al., 2004), participants answer 27 items (e.g., ‘‘I think that it was Harry’s own fault that he is in the present condition’’) on a 9-point agreement scale (9 = very much). The AQ-27 has strong reliability, construct validity, and sensitivity to change after antistigma program participation. Given that the original AQ is long for many outcome studies, a short form with nine items was tested and found to have similar strong reliability, validity, and sensitivity to change (Corrigan et al., 2003, 2013). A total score from the AQ is used in this study. We used items from the Humor Styles Questionnaire (HSQ; Martin et al., 2003) to assess this construct. The HSQ comprises items to which participants respond using a 9-point agreement scale (1 = extremely disagree; 9 = extremely agree). We selected items that represent aggressive and affiliative humor. People were randomized to one of three comedy sketches (approximately 2 minutes each). The index sketch by Stand Up for Mental Health founder, David Granirer, has more than 12,000 YouTube views. In this disclosed comic sketch, Granirer shares his ironic perceptions about the ‘‘threats’’ of a mental health center opening up in the community. The sketch begins with Granirer disclosing his mental illness and experiences with symptoms and medication. This condition is contrasted to a nondisclosed comic condition in which Mr Granirer does the same material except all reference to his mental illness is omitted. The control condition consisted of a 2-minute sketch in which a sex-, race-, and age-matched comic discussed his lack of understanding of women’s fashion. There was no mention of issues related to mental health in the control condition. The participants completed the AQ before and immediately after the comic sketch. They also completed five statements about the comic on a 9-point agreement scale (9 = extremely agree). Statements assessed participant perceptions about the comic as being humorous, aggressive, with/without a mental illness, ‘‘like me,’’ and sincere. The research participants also completed demographic questions.
Statistical Plan First, we examine frequencies and means (standard deviations) of demographics, humor styles, and perceptions of comics across the three research conditions. We then examine change in AQ scores from preassessment to postassessment to test the hypothesis about disclosed and nondisclosed comedy sketch effects on stigma change. Before examining moderating effects of humor styles and perceptions of comics, we provide Pearson’s product moment correlations to describe their association with AQ scores. We then tested moderator effects as planned multiple regression analyses representing the relationship between posttest AQ scores and intervention-humor style (or perceptions of comic) interactions after partialling out baseline 398
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AQ scores. Intervention represents two planned contrasts of conditions: disclosure versus no disclosure and control (1, 0, 0) or no disclosure versus disclosure and control (0, 1, 0). Hence, Table 3 represents a series of equations of the form as follows: AQ post ¼ þ AQ post ¼ þ
AQ pre þ contrastð1;0;0Þ humor style n contrastð0;1;0Þ humor style n or AQ pre þ contrastð1;0;0Þ comic perception n contrastð0;1;0Þ comic perception n
RESULTS Examination of AQ distributions revealed seven participants showing significant floor effects, that is, endorsing almost no stigmatizing attitudes. Hence, these outliers were removed from additional analyses, reducing N fairly evenly across conditions to 342. The total sample was 70.8% men and ethnically diverse. They were 65.8% white, 20.8% African-American, 9.5% Asian, and 2.9% Native American. A total of 45.3% of the participants reported themselves to be Hispanic or Latino. It was a fairly educated group, with 48.5% reporting at least some college, 32.7% having earned a bachelor’s degree, and 3.2% having earned a graduate degree. Almost all participants (95.9%) reported currently working full time. Table 1 summarizes demographics across conditions, in which no significant differences were found. Table 1 also summarizes humor styles and perceptions of the comic across conditions, again with no significant differences emerging. Finally, Table 1 lists pretest and posttest AQ scores by condition, with nonsignificant main effects and interaction. These last analyses failed to show a humor effect on stigma change. Table 2 summarizes relationships among AQ pretest and posttest scores, humor styles, and perceptions of the comic. Both pretest and posttest AQ scores were negatively related to affiliative humor. The more participants enjoy humor, the less likely they were to endorse stigmatizing attitudes. Effect sizes for these relationships were greater than 12.5%. Although affiliative and aggressive humor were significantly inversely associated (r = j0.22, p G 0.001), aggressive humor was not associated with pretest or posttest AQ scores. Table 2 also summarizes the relationship between pretest and posttest AQ scores and perceptions of the comic. All of these relationships were significant; the participants viewing comics as having a mental illness and relatively more humorous, aggressive, ‘‘like me,’’ and sincere showed diminished stigma on the AQ. Effect sizes for these relationships range from 4.8% to 22.1%. Finally, an affiliative humor style was found to be significantly associated with all perceptions of the comic. An aggressive humor style was significantly related to viewing the comic as only humorous or aggressive. Although we found no significant group by trial interactions, suggesting no stigma change due to comic condition, we examined interaction effects between individual conditions and measures of humor styles or perceptions of the comic to independently test these hypotheses. Table 3 provides the results of multiple regression analyses. The first two rows examined the interaction of humor style with contrasted comic sketch conditions. Results for an affiliative humor style showed significant betas for both interactions. People assigned to the disclosed comic and the nondisclosed comic condition showed significant reductions in posttest stigma on the AQ as they endorsed greater affiliative humor. Significant effects for the interactions of aggressive humor and antistigma interventions were not found with either condition. The bottom half of Table 3 summarizes interactions between antistigma comic sketch conditions and perceptions of the comic. Perceptions of the comic when the comic self-disclosed were associated with greater reductions in stigma from pretest to posttest. This occurred when the comic was viewed as humorous, having a mental illness, ‘‘like me,’’ and sincere. The self-disclosed comic who was viewed as less aggressive also showed significantly better change in stigma on the AQ. * 2014 Lippincott Williams & Wilkins
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DISCUSSION Humor is used by some advocates with lived experience as a strategy to diminish public stigma toward mental illness. In this study, we attempted to examine the effects of humor on stigma change when the comic had or had not publicly disclosed his mental health status. The results failed to show a significant change in stigma due to either of the two comic sketch conditions. Given the relatively short time between pretest and posttest, an AQ memory effect or social desirability effect may have undermined significant change. Alternatively, comic effects may occur only when examined by moderators such as humor style and perceptions of the comic. In fact, significant stigma change was found when examining the interaction of comic conditions with humor style and perceptions of the comic. Stigma as measured on the AQ was shown to significantly decrease for the disclosed comic condition among the participants who endorsed an affiliative humor style.
Stigma Change and Humor
People who seem to enjoy humor and making people laugh were shown to have significantly larger changes in the disclosed comic condition compared with the nondisclosed and the control condition. An affiliative style was also found to interact with the nondisclosed comic condition, which suggests that comedy about mental health in general might reduce stigma in a person who enjoys laughing. An aggressive humor style was not found to interact with either comic condition, a notable finding that suggests that offense at a comic’s statement about mental illness does not seem to impede attitude change. The sketch’s effect on attitude change also significantly interacted with perceptions of the comic. These effects were found only for the comic who self-identified with a mental illness. The participants who viewed the disclosed comic as more humorous yielded greater reductions in stigmatizing attitudes. A specific hypothesis of the study was that the comic viewed as more authentic would produce greater stigma reduction
TABLE 1. Differences in Demographics, Humor Style, Comic Ratings, and Stigma Measures by Condition Sketch With Disclosed Comic, n = 117 Variable
Mean
Demographics Sex (female), % Age Race White African-American Asian Native American Pacific Islander Hispanic ethnicity Education Some HS HS diploma AA/AS Some college BA/BS Graduate degree Other Employment Full time Part time Humor style Affiliative Aggressive Perceptions of comic Humorous Aggressive Has mental illness Like me Sincere AQ Pretest Posttest
SD
Sketch With Nondisclosed Comic, n = 108 Mean
35.9% 33.2
SD
Control Sketch, n = 117 Mean
28.7% 6.8
32.5
SD
Group Differences
7.4
W22 = 4.67, NS F(2,339) = 0.34, NS
23.1% 5.4
32.9
69.2% 17.1% 1.7% 6.8% 5.1% 47.0%
59.3% 25.0% 5.6% 8.3% 1.9% 44.4%
68.4% 20.5% 2.6% 6.8% 1.7% 44.4%
W28 = 8.73, NS
0.0% 1.7% 6.0% 54.7% 32.5% 2.6% 2.6%
0.9% 2.8% 13.9% 43.5% 33.3% 3.7% 1.9%
0.9% 0.0% 13.7% 47.0% 32.5% 3.4% 2.6%
W212 = 10.2, NS
95.7% 4.3%
95.4% 4.6%
96.6% 3.4%
W22 = 0.22, NS
W22 = 0.20, NS
1.99 2.66
1.14 2.06
2.07 2.72
1.05 2.13
2.09 2.78
1.03 2.13
F(2,339) = 0.26, NS F(2,339) = 0.10, NS
2.97 2.82 2.85 2.50 2.46
2.28 2.08 2.10 1.97 1.67
3.28 2.79 2.90 3.06 2.85
2.25 2.02 2.10 2.33 1.95
3.18 2.79 2.77 2.87 2.71
2.28 1.97 1.95 2.03 1.93
F(2,339) = F(2,339) = F(2,339) = F(2,339) = F(2,339) =
55.3 54.2
8.1 11.2
53.0 52.9
9.6 10.4
54.6 54.7
9.1 10.0
0.56, 0.01, 0.11, 2.11, 1.29,
NS NS NS NS NS
Condition: F(2,339) = 1.35, NS; trial: F(1,339) = 0.93, NS; interaction: F(2,339) = 0.43, NS
Frequencies (percentages) are reported for categorical variables. AA indicates Associate of Arts; AS, Associate of Science; BA, Bachelor of Arts; BS, Bachelor of Science; HS, high school; NS, not significant.
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TABLE 2. Pearson’s Product Moment Correlations Among AQ Pretest Scores, Humor Styles, and Perceptions of the Comics Humor Styles
AQ pretest AQ posttest Affiliative Aggressive Humorous Aggressive Has MI Like me
Perceptions of the Comic
Affiliative
Aggressive
Humorous
Aggressive
Has MI
Like me
Sincere
j0.36*** j0.41***
0.04 0.03 j0.22***
j0.31*** j0.32*** 0.15** j0.28***
j0.41*** j0.42*** 0.30*** j0.11* 0.23***
j0.47*** j0.45*** 0.20*** j0.09 0.38*** 0.58***
j0.29*** j0.22*** 0.19*** j0.08 0.20*** 0.30*** 0.34***
j0.45*** j0.44*** 0.30*** j0.06 0.31*** 0.47*** 0.47*** 0.42***
*p G 0.05; **p G 0.01; ***p G 0.001. MI indicates mental illness.
effects. The results showed that the disclosed comic who was viewed as having a mental illness, ‘‘like me,’’ and sincere yielded better stigma change. Although an aggressive humor style was not found to interact with comic condition, perceiving the comic as aggressive did interact with condition. Namely, perceiving the disclosed comic as aggressive or offensive led to less change in stigma. These findings suggest that researching comedy about mental health person-level variables needs to be considered in crafting these approaches. We began with humor styles here as natural moderators of the way comedy routines are experienced. There are additional humor styles in this area that might be relevant including self-defeating (e.g., ‘‘I get carried away in putting myself down’’) and self-enhancing (e.g., ‘‘My humor keeps me from getting overly depressed about things’’) humor (Martin et al., 2003). These might be especially relevant because the person weighs his/her own personal experiences with mental illness when viewing the comedy sketch. In this light, one’s familiarity with mental illness is likely to mediate the comedy routine. One study showed that familiar experiences with mental illness (e.g., having a family member with mental illness) mediated reductions in stigma that occurred after an education about stigma (i.e., contrasting myths and facts of mental illness) program (Holmes et al., 1999). Interestingly, those with greater familiarity showed significantly less improvement. The study also examined moderating effects of mental health literacy in the education program and found that those who were more knowledgeable about
mental illness were also less likely to decrease stigma after the education program. Both of these findings might reflect a floor effect; those personally familiar with and knowledgeable about mental illness are already likely at the floor of stigma measures with little room to improve. Regardless, future studies need to include measures of person-specific variables in their design. Limitations of the study need to be considered when interpreting findings. Failure to support the main hypotheses per se is the most significant. We were unable to directly determine whether comedy and comic disclosure impact stigma. In part, this might have occurred because of selection of the study measure. The 9-item version of the AQ is much shorter than the original 27-item, which might have yielded greater power. Despite this, showing significant interaction effects definitely suggest a positive role for comedy in stigma change. Findings were also limited to decreasing stigma rather than increasing its obverse, affirming attitudes (Corrigan et al., 2013). Future research should examine the effects of comedy on positive attitudes about mental health, including recovery, self-determination, and personal empowerment. An additional limitation is that only pretests and posttests were examined in the study. We were unable to determine whether a 2-minute comedy sketch yielded any changes that maintained over time. Future studies should include follow-up assessment. This research may have implications for future humor programs attempting to change stigma. Perceptions about the comic were especially
TABLE 3. Results of Multiple Regression Analyses Examining Relationship Between Posttest Scores, Pretest Scores, and Interactions (Planned Contrasts Comic Rating or Humor Style) Interactions
EQ
AQ-Pretest
Humor styles 1 2 Perceptions of 3 4 5 6 7
0.74*** 0.74*** comic 0.74*** 0.74*** 0.74*** 0.74*** 0.74***
Planned Contrast
Humor Style or Comic Perception (Interaction)
Disclosed vs. Nondisclosed, Control (1, 0, 0)
Nondisclosed vs. Disclosed, Control (0, 1, 0)
R2
Affiliative Aggressive
j0.13** j0.02
j0.09* j0.01
0.571 0.557
Humorous Aggressive Has MI Like me Sincere
j0.09* 0.08* j0.09* j0.08* j0.09*
j0.01 0.04 j0.02 j0.02 j0.08*
0.563 0.563 0.564 0.562 0.565
All values are betas (standardized coefficients). *p G 0.05; **p G 0.01; ***p G 0.001. EQ indicates empowerment questionnaire; MI, mental illness.
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important moderators, with sincere and authentic comics seeming to have greater impact. These findings support assertions of Stand Up for Mental Health that authentic comics talking about their experiences with mental health can be a powerful vehicle for stigma change. What other variables might add to this poignancy? Future research needs to examine the relative impact of videotaped versus in vivo sketches. Findings from the meta-analysis on stigma change programs found that face-to-face contact leads to the greatest change (Corrigan et al., 2012). Hence, in vivo comedy sketches are expected to yield better stigma reduction. Still, videotaped and online contact improved stigma significantly, albeit less than face-to-face contact. Videotaped comedy has the potential of penetrating a much bigger audience than in vivo approaches. Hence, future research needs to consider the breadth of impact of different kinds of comedy routines. DISCLOSURE The authors declare no conflict of interest. REFERENCES Anderson PM (1988) American humor, handicapism, and censorship. J Read Writ Learn Disabil Int. 4:79Y87. Castiglia C, Reed C (2004) ‘‘Ah, yes, I remember it well’’: Memory and queer culture in Will and Grace. Cultural Critique. 56:158Y188. Corrigan PW (2000) Mental health stigma as social attribution: Implications for research methods and attitude change. Clin Psychol. 7:48Y67. Corrigan PW (2005) Changing stigma through contact. Adv Schizophr Clin Psychiatry. 1:614Y625. Corrigan PW, Markowitz F, Watson A, Rowan D, Kubiak MA (2003) An attribution model of public discrimination towards persons with mental illness. J Health Soc Behav. 44:162Y179. Corrigan PW, Morris SB, Michaels PJ, Rafacz JD, Ru¨sch N (2012) Challenging the public stigma of mental illness: A meta-analysis of outcome studies. Psychiatr Serv. 63:963Y973. Corrigan PW, Powell KJ, Michaels PJ (2013) The effects of news stories on the stigma of mental illness. J Nerv Ment Dis. 201:179Y182. Ford TE, Boxer C, Armstrong J, Edel JR (2008) More than ‘‘just a joke’’: The prejudice-releasing function of sexist humor. Pers Soc Psychol Bull. 34:159Y170.
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