Self-Stigma In Persons With Mental Illnesses
Introduction
Stigma is a psychological phenomenon that can significantly impact the lives of persons affected by it. Although stigma in itself isn’t problematic, it becomes so when it operates to discriminate against affected persons. Contemporary scholarship elucidates three tiers in which this occurs: social, structural, and internalised. This essay will discuss internalised stigma, or self-stigma, with a particular focus on mentally ill persons, a significant proportion of whom report self-stigma.
Definition & causes
There is little consensus within the psychological community as to a clinically functional definition of self-stigma. This is partly due to it being a descriptor of inherently nebulous psychosocial variables. Consequently, psychological literature has tended toward proximate, not precise, definitions of self-stigma consisting of: (i) internalising stigma; and (ii) effects on psychosocial variables. Corrigan, Kerr, and Knudsen (2005, p. 179) define self-stigma as the internalisation of public stigma that reduces self-esteem and self-efficacy. Similarly, Corrigan, Watson, and Barr (2006) define self-stigma as the application of public stigma to people with mental illness generally, or to oneself. Thus, self-stigma may be appropriately described as an application of public stigma to oneself that engenders psychosocial effects.
Recent studies have moved towards describing self-stigma in terms of what causes it to be classified as self-stigma, rather than defining precisely what it is. The pre-eminent classification in this regard is the “three A’s” stage-model of how self-stigma is caused: awareness, agreement, and application. Under this model, one must first be aware of the stereotype that stigmatises them (e. g. , mentally ill people are disgusting) and, second, agree with them (e. g. , correct, mentally ill people are disgusting). Third, and most importantly, they must apply these stereotypes to themselves to experience self-stigma (e. g. , I am mentally ill, therefore I am disgusting). The “application” step differentiates stigma from self-stigma. Whilst the former merely serves as a gateway for marginalisation, the latter is a clinically relevant phenomenon that materially effects mentally ill persons as they become instruments of their own stigma. Accordingly, self-stigma does not have an etiology in a medical sense. That is, whereas an illness such as cancer has an identifiable set of risk factors (e. g. , smoking, genetics, radiation), self-stigma does not. Whether a mentally ill person experiences self-stigma is dependent on whether they fulfil the stage-model criteria. Therefore, to say self-stigma is caused by anything is a misnomer; it is rather a term used to classify the application of public stigma to oneself.
Effects
The effects of self-stigma on the individual don’t manifest until the third criterion— “application” —of the stage-model is met. Although the initial negative effects are psychosocial in nature, they have pernicious subsequent effects on behavioural and psychiatric outcomes. These effects may be characterised under the “why try” model, which refers to the concomitant mental consequences of self-stigma that interfere with life goal achievement. These varied effects on the individual, as well as a novel discussion of their potential negative ramifications on society, will be further discussed below.
A “Why Try” Model
The “why try” model is concerned with a self-stigmatising person’s questioning of their sense of self-worth. This questioning is the result of self-stigma decrementing the person’s psychological wellbeing, as measured across several psychosocial variables. A meta-analyses of 127 scientific articles found self-stigma is strongly negatively correlated with self-esteem (r = –. 55, p <. 001), self-efficacy (r = –. 54, p <. 001), and hope (r = –. 58, p <. 001). These decrements to psychosocial variables significantly detriment the self-stigmatising person’s ability to achieve goals. For example, diminished self-esteem may lead to a mentally ill person questioning their ability to obtain a job due to perceiving themselves as less deserving than a “normal” person. Likewise, diminished self-efficacy and hope may lead to questioning their ability to live independently or treat their illness, respectively, due to perceiving their illness as making them inadequate. Although it may be argued that these pessimistic mental processes aren’t in themselves functionally problematic, their influence on future behavioural and psychiatric outcomes undoubtedly are. For example, if a mentally ill person applied to themselves the stereotype that they’re inadequate, this may reasonably lead to self-discrimination. Self-discrimination derived in this manner often manifests as self-isolation, which is problematic in several ways. First, self-isolation invariably limits the person’s pursuit of employment opportunities, which will in turn impact their ability to live independently. Second, self-isolation leads to decreased healthcare service use in mentally ill persons, as self-stigma is negatively correlated with treatment adherence (r = –. 38, p <. 001).
Livingston and Boyd (2010) also found that diminished self-esteem and self-efficacy correlated strongly with symptom severity (r = –. 41, p <. 001). Drapalski et al. (2013) corroborate this association between self-stigma and poor psychiatric outcomes, finding a strong negative correlation between self-stigma and recovery orientation (r = –. 54, p <. 001). Thus, self-stigma’s initial psychosocial effects lead to behavioural and psychiatric problems for people with mental illness.
Societal Effect
Although much literature focuses on the individual clinical effects of self-stigma, a nuanced perspective reveals that they may operate on a societal level. As discussed above, the psychosocial effects of self-stigma have concomitant behavioural responses, most notably self-discrimination and isolation. Though not clinically abnormal, this behavior may nonetheless be construed as such by those lacking an informed awareness of mental illness. Self-isolationist behaviour may then be socially reinforced as synonymous with mental illness. As such, persons exhibiting this behaviour may be wrongly designated as mentally ill by much of society. This is self-evidently problematic; not only would existing stigma be reinforced, but it would attach to traits that are not in fact indicative of mental illness. This would further entrench incumbent social structures that systemically marginalise and oppress people with mental illness. This may manifest in increased unconscious bias against mentally ill persons vis-à-vis employment or policy-making. This hypothetical progression — from individual, socially abnormal behaviours to increased public bias against mentally ill people — has in fact eventuated in the United States. According to Hirschtritt and Binder (2018), the US government has sought to attribute the increase in mass shootings to a supposed epidemic of mental illness, as opposed to overly liberal gun policies. This occurs despite the fact that only about 4% of criminal violence perpetrators are in fact mentally ill. In light of this, falsely imputing blame for such criminal acts to people with mental illness is clearly discriminatory and serves to increase stigma against them. In addition, considering self-stigmatising persons suffer severe decrements to their self-esteem, they are likely to reciprocate this public stigma and thereby intensify their self-stigma. Thus, though self-stigma operates predominantly on an individual basis, it may nonetheless influence societal attitudes that further oppress mentally ill persons.
Intervention strategies
Although numerous intervention strategies have been shown to mitigate the negative effects of self-stigma, the common denominator amongst these strategies is empowerment. This seems to be because empowerment’s association with measurable psychosocial and psychiatric variables is the obverse of self-stigma’s association with the same variables. Thus, cultivating a healthy sense of personal empowerment is necessary to successful self-stigma intervention. Five factors constitute a sense of empowerment: self-esteem and self-efficacy; actual power or control; community activism; righteous anger; and optimism about the future. Accordingly, a strategy that addresses as many of these factors simultaneously would lead to optimal empowerment. Consequently, the most important factors must be determined. The pre-eminence of self-esteem and self-efficacy in assessing self-stigma means they are likely essential, and so any strategy must address that factor. As for the others, strong theoretical evidence supports the notion that community activism and control would best cultivate empowerment.
Indeed, Peterson (1999, pp. 256–257) extols the value of voluntarily adopting responsibility, to both oneself and others, by mediating one’s individuality with healthy group identification. Pursuant to this idea, community activism allows a mentally ill person to adopt responsibility to assist others within a group setting, thereby simultaneously cultivating their sense of control and worth. Therefore, the most effective self-stigma intervention strategies will seek to empower a mentally ill person’s self-esteem and self-efficacy, community activism, and sense of control. Accordingly, strategies involving both voluntary disclosure and community engagement would be optimal. To this end, an optimal strategy would be akin to the “Ending Self-Stigma” intervention. This intervention comprised 9 sessions in which mentally ill people met to share materials covering education about mental health, cognitive behavioural strategies, and methods to strengthen interpersonal ties. However, two additions may improve the “Ending Self-Stigma” intervention: (i) assigning suitable mentally ill people as helper figures within the group; and (ii) including those who aren’t mentally ill. Assigning capable, mentally ill persons as helpers would cultivate their sense of responsibility and control within this community setting in a healthy manner. Likewise, including non-mentally ill persons would provide self-stigmatised persons the opportunity to build their self-esteem and self-efficacy as they learn they are more than capable of frequent, voluntary, and informative dialogue with people they likely perceive as “normal”.
Conclusion
Self-stigma is a complex phenomenon with various pernicious effects on psychosocial, behavioural, and psychiatric outcomes that impede recovery and treatment. Consolidating personal empowerment in people with mental illness is vital to intervention strategies. However, a significant limitation of previous studies is the lack of intersectional analysis, longitudinal design, and standardised measurement frameworks. Thus, future research would benefit from a longitudinal experiment investigating intersecting self-stigmas, and how this affects the efficacy of intervention strategies.
