Understanding the Public Stigma of Mental Illness: A Mixed-Methods, Multi-Level, Exploratory Triangulation Study.

Abstract Background: This study examines the role of themata in understanding mental health-related stigma. It is motivated by the need for alternative theoretical-methodological approaches beyond the dominant frameworks in education and contact-based anti-stigma public health efforts, which have shown mixed and unintended consequences. Specifically, it addresses the need for a more nuanced framework in stigma research, one that is sensitive to the dialogues through which people relate themselves to mental health and stigma in context. Methods: The research employs an exploratory mixed-methods approach, including the analysis of 529 news reports, 20 focus group discussions, and 19 one-to-one interviews, all concerning representations of shared living arrangements with someone perceived to have experiences of mental illness. Thematic analysis and natural language processing are used within a convergent triangulation design to analyze the data. Results: We found that mental health and illness were communicated through an overarching Self/Other thema and five subordinate themata: normal/abnormal, harm/non-harm, bounded/non-bounded, and moral/immoral. Despite familiarity with psychological distress and 'modern' explanations of mental illness, concerns about social identity motivated representations of mental illness as a predominantly permanent, negative form of personhood marked by abnormality, harm, distance, and immorality. Additionally, concerns about personal vulnerability, including historically rooted fears of contagion, motivated distancing representations of mental illness, rather than neutral portrayals. Conclusions: Themata have under-developed theoretical and methodological potential for addressing mental health-related stigma, particularly in their ability to describe the dynamic ways in which culture motivates people to both resist and reproduce stigma, partly through ambivalences, absences, tensions, and ambiguities in representation. A critical discussion is provided on how themata may support ecological strategies in mental health campaigns over generic models, emphasizing the need to understand group knowledge and contact dynamics to mitigate adverse effects.