Group Identity, Self-Disclosure, and the Self-Stigma
of Mental Illness

Mental illness strikes with a double-edged sword. On
one side are the symptoms, distress, and disabilities
that result from the mental illness; on the other is
the public stigma that robs people of rightful
opportunities, such as work, housing, and healthcare.
Internalizing this stigma leads to self-stigma, which
can further impede a person's life goals. One of the
best ways to challenge self-stigma is by associating
with peers who have mental illness. This paper focuses
on group-identity and self-disclosure as a way of
controlling self-stigma.

We have distinguished the phenomenon of stigma into
public and self forms. Public stigma occurs when
members of the general public endorse stigmatizing
attitudes, or stereotypes, about mental illness (eg,
"All people with mental illness are dangerous") and
act in a discriminatory manner (eg, "I want to avoid
these people, so I will not hire them or rent an
apartment to them"). People who endorse these
stereotypes about themselves experience
self-stigma.[1-4]

People with self-stigma agree with the stereotype,
"All people with mental illness are to blame for their
illness," and apply it to themselves (eg, "I am
mentally ill so I must be responsible for my symptoms
and disabilities"). This kind of self-talk leads to
decrements in self-esteem (eg, "I am a bad person
because I am to blame for my illness") and
self-efficacy (eg, "I can't meet the demands of daily
living"). The entire process results in a "Why try?"
effect: "Why should I even try to get a job? A person
like me is neither worthy of such a position nor able
to take advantage of it."

"Why try?" clearly hinders a person's life
opportunities. If someone is convinced that he or she
is inept and unworthy, this person will not try to get
a good job, rent a nice apartment, or obtain
satisfactory healthcare. Ironically, the "Why try?"
effect also undermines individuals' participation in
the very treatments that can help them manage life
goals in light of their illness, eg, "Why try the
treatments for mental illness? I will not benefit from
it." Given this state of being, it is important to
identify strategies that address self-stigma and teach
them to those who can benefit.


Challenging Self-Stigma

Research suggests that instead of being overwhelmed by
stigma, many people become righteously angry because
of the prejudice they experience.[5,6] This kind of
reaction can empower people to change their role in
the mental health system and become more active
participants in their own treatment plans and push for
improvements in the quality of services they receive.
In addition, there is a third group that needs to be
considered in describing the impact of self-stigma:
individuals who seem to be indifferent to it
altogether, ie, those whose sense of self is neither
hurt, nor energized, by social stigma.[7]


Beating Stigma Through Empowerment

Personal empowerment is viewed as the opposite of
self-stigma. Being empowered means having control over
one's treatment and one's life.[8] Persons who have a
strong sense of personal empowerment usually have high
self-efficacy and self-esteem. Communities and health
service providers can foster this personal empowerment
in a variety of ways that involve giving consumers
greater control over their own treatments and over
their reintegration into the community.[9-11] At its
most general level, fostering empowerment involves
adopting a collaborative approach to treatment
planning, in which a consumer ceases to be a mere
passive recipient of services. This places the
emphasis on the strengths and potential of a consumer
rather than his or her weaknesses. Treatment programs
should also form a partnership and seek feedback from
consumers regarding service satisfaction and
suggestions for improvement.

Beyond this, true empowerment services promote a
consumer's self-determination in relation to
employment opportunities, housing, and other areas of
social life. Rather than a stigmatizing and coercive
removal from the community, these new approaches
provide community-based support for the consumer's
continuing efforts to adapt to community living. This
approach is typified by the 1980 Assertive Community
Treatment (ACT) model of Stein and Test,[11] in which
services are brought directly to the consumer's home,
workplace, or other meaningful community setting.
Supported employment and education are also methods
used to facilitate integrating persons with mental
illness into the fabric of society. These approaches,
which were given increased priority with the passage
of the American with Disabilities Act in 1990,
encourage the prompt placement of clients into
employment and/or educational settings and provide
supportive services for their continuing success in
these settings.[12]

Consumers can also empower themselves by becoming
staff members of traditional treatment programs[13] or
they can create and run their own services. These may
include lodges and clubhouses as well as self-help and
mutual assistance groups. The Fountain House in New
York is a paradigmatic example of consumer empowerment
through mutual help. Fountain House does not focus on
providing "treatment" for mental illness but rather on
helping to develop the skills and talents of its
"members," as participants are called -- a much less
stigmatizing and more empowering label than "patient."
It also implies an element of responsibility, as
members are expected to take supportive and leadership
roles in groups and in teams to accomplish the tasks
required to maintain the clubhouse.[14] Members and
staff have equal status and work together to serve the
clubhouse community. Services like these greatly
increase consumers' sense of power, thereby
challenging any stigma against which they may be
struggling.


Group Identity and Coming Out

Programs like Fountain House are effective because
they promote a sense of the "groupness" of people with
mental illness. One variable that mitigates
self-stigma's effects on self-esteem and self-efficacy
is group identity.[15] One might think that persons
who belong to stigmatized groups would internalize the
negativity that is aimed at that group, thereby
provoking worse effects to self-stigma. Research
shows, however, that persons who develop a positive
identity by interacting with other members of the
group will develop more positive self-perceptions.[16]
Moreover, persons who are involved in advocacy or
self-help groups related to the stigma seem to develop
better self-esteem.[15] Hence, participation in groups
that promote identification counters the effects of
self-stigma. Research on the effects of group identity
on people with mental illness show clear patterns:
participation in consumer-operated, mutual support
groups produces more empowerment and less
self-stigma.[17]

People who are in the closet about their mental
illness cannot easily participate in groups; they are
concerned about such group affiliations because it can
disclose the history of their mental illness. However,
being in the closet also deprives a person of the kind
of peer-to-peer interactions that can help them
overcome this stigma.

Coming out is by no means an easy process. There are
both costs and benefits to disclosing one's
experiences with mental illness.[18,19] Benefits may
include feeling less shame and being able to find
peers with whom to share experiences of mental illness
and its treatment. The costs to coming out may include
contact with someone who is rejecting of a person with
mental illness because of their fear of the mental
illness, or it may include contact with healthcare
professionals who feel that people of this group are
incapable of making important medical decisions and
therefore will treat them as children. Costs and
benefits are likely to vary by situation and by role.

Coming out at work is different than doing so with
neighbors or fellow churchgoers. Given the list of
possible consequences, opting to disclose and how to
disclose are not transparent decisions that all people
stigmatized with mental illness should pursue in a set
manner. Rather, individuals should weigh the costs
involved against the benefits.

Disclosure is not a monolithic phenomenon but varies
in several ways. Based on a review of the limited
literature[20] (Herold KPP, unpublished doctoral
dissertation, 1995; Thampanichawat W, unpublished
doctoral dissertation, 1999), we have been able to
identify 4 levels of disclosure: social avoidance,
secrecy, selective disclosure, and indiscriminant
disclosure.

(1) Social Avoidance. One way to handle disclosure is
to not tell anyone. This can be accomplished by
avoiding situations where the public may find out
about one's mental illness. People who are victimized
by stigma may choose to not socialize with, live near,
or work alongside persons without disabilities. They
may prefer this kind of situation because they feel
protected against people who might treat them cruelly
because of their mental illness. Unfortunately,
persons who choose to avoid the "normal" world lose
out on all the benefits it can bring: free access to a
broader set of opportunities and citizens who may be
supportive of one's experience with mental
illness.[20] Moreover, social avoidance in some ways
promotes stigma and discrimination, as it endorses the
idea that persons with mental illness should be kept
away from the rest of the world. Social avoidance may
be a useful strategy during times when one's symptoms
are intense and there is a need for respite from the
demands of society. However, avoiding the "normal"
world altogether will most likely prevent the
achievement of life goals.

(2) Secrecy. Instead of avoiding work or community
situations in order to keep one's experiences with
mental illness private, many persons choose to enter
the normal world but not share their experiences with
others. They keep all aspects of their psychiatric
experiences a secret -- both the impact of their
illness and the interactions with the mental health
system in its various manifestations. Some may argue
that mental illness is readily apparent and can be
inferred from a person's symptoms, dysfunctions, and
disabilities; however, many of the experiences that
are commonly associated with mental illness are not
readily perceived and labeled by the public.[21]

There are 2 strategies to keeping experiences with
mental illness a secret. The first seems easy: Don't
tell anyone.[20] A person does not share a history of
hospitalizations, doctors, medications, and symptoms.
If the first strategy for keeping experiences secret
is an act of omission, the second strategy is an act
of commission. Whether of not to explain the gaps in a
past and current experience, or the work resumes with
blank years because of hospitalizations, or the photo
albums that don't include pictures from the time when
they were actively coping with their illness, becomes
part of a decision about how to disclose their mental
illness. Without explanations, these gaps may cause
coworkers or neighbors to wonder about other things,
such as, "Why do they leave early to see a doctor
every month?" or "What are those medicines they take
at lunch?"

(3) Selective Disclosure. Keeping experiences with
mental illness a secret prevents a person from taking
advantage of the support and resources that may be
available to them when they do need to disclose.
Hence, many people decide to disclose their
experiences with mental illness to a select set of
friends and acquaintances (Bradmiller MA, unpublished
doctoral dissertation, 1997). Choosing to disclose to
some people and not others has its risks; those who
find out may shun them. However, with the risk comes
opportunity: finding others who are supportive. A
decision to disclose to someone does not mean one must
tell everything; choosing to disclose does not mean
giving up all of one's privacy. Just as people can
decide whom they may wish to disclose to, they can
also decide the content of the disclosure.

(4) Indiscriminant Disclosure. Selective disclosure
means there are select groups of people with whom
information is shared and groups from whom this
information remains a secret.[20] People who choose
indiscriminant disclosure abandon secrecy altogether.
They no longer worry who finds out about their mental
illness or treatment history. People choosing this
option are relieved of the burden posed by keeping
part of their lives underground.

Despite its benefits, indiscriminant disclosure
requires a fairly hardy personality. Many people who
find out about the disclosed information may react
negatively to the revelation. Hence, people opting for
indiscriminant disclosure need to assess whether or
not they can cope with the disapproval that can result
from bigoted reactions.


Conclusions

Self-stigma can be an additional burden to people with
mental illness, but it is not an inevitable result of
psychiatric disorder. Some people rally against stigma
by choosing personal empowerment instead.
Participation in programs that foster group
identification and cohesion among peers helps to
minimize self-stigma. There are several strategies for
disclosure, but they vary in terms of their impact,
and can precipitate both positive and negative
effects. Ultimately, it is an individual's decision
whether or not to disclose a history of mental
illness.


References

Corrigan PW, Watson AC. Paradox of self-stigma and
mental illness. Clin Psychol Sci Pract. 2001;9:35-53.
Link BG, Struening EL, Neese-Todd S, Asmussen S,
Phelan JC. Stigma as a barrier to recovery:
consequences of stigma for the self-esteem of people
with mental illnesses. Psychiatr Serv.
2001;52:1621-1626. Abstract
Markowitz FE. The effects of stigma on the
psychological well-being and life satisfaction of
persons with mental illness. J Health Soc Behav.
1998;39:335-347. Abstract
Rosenfield S. Labeling mental illness: the effects of
received services and perceived stigma on life
satisfaction. Am Sociol Rev. 1997;62:660-672.
Chamberlin J. On Our Own: Patient-Controlled
Alternatives to the Mental Health System. New York,
NY: McGraw-Hill; 1978.
Deegan PE. Spirit breaking: when the helping
professions hurt. Hum Psychol. 1990;28:194-209.
Rapp CA, Goscha RJ. The Strengths Model: Case
Management With People With Psychiatric Disabilities.
2nd ed. Oxford, UK: Oxford University Press; 2006.
Rappaport J. Terms of empowerment/exemplars of
prevention: toward a theory for community psychology.
Am J Community Psychol. 1987;15:121-148. Abstract
Corrigan PW, Faber D, Rashid F, Leary M. The construct
validity of empowerment among consumers of mental
health services. Schizophr Res. 1999;38:77-84.
Abstract
Rogers ES, Chamberlin J, Ellison M, Crean T. A
consumer-constructed scale to measure empowerment
among users of medical health services. Psychiatr
Serv. 1997;48:1042-1047. Abstract
Stein LI, Test MA. Alternative to mental hospital
treatment. I. Conceptual model, treatment program, and
clinical evaluation. Arch Gen Psychiatry.
1980;37:392-397. Abstract
Becker DR, Drake RE. A Working Life for People With
Severe Mental Illness. New York, NY: Oxford Press;
2003.
Mowbray CT, Moxley DP, Collins ME. Consumer as mental
health providers: first-person accounts of benefits
and limitations. J Behav Health Serv Res.
1998;25:397-411. Abstract
Beard JH, Propst RN, Malamud TJ. The Fountain House
model of psychosocial rehabilitation. Psychosoc
Rehabil J. 1982;5:47-53.
Frable DE, Wortman, C, Joseph J. Predicting
self-esteem, well-being, and distress in a cohort of
gay men: the importance of cultural stigma, personal
visibility, community networks, and positive identity.
J Pers. 1997;65:599-624. Abstract
Porter JR, Washington RE. Minority identity and
self-esteem. Annu Rev Sociol. 1993;19:139-161.
Corrigan PW. Impact of consumer-operated services on
empowerment and recovery of people with psychiatric
disabilities. Psychiatr Serv. 2006;57:1493-1496.
Abstract
Chin D, Krosen KW. Disclosure of HIV infection among
Asian/Pacific Islander American women: cultural stigma
and support. Cultural Diversity Ethnic Minority
Psychology. 1999;5:222-235.
Hays RB, McKusick L, Pollack L, Hilliard R, Hoff C,
Coates TJ. Disclosing HIV seropositivity to
significant others. AIDS. 1993;7:425-431. Abstract
Corrigan PW, Lundin RK. Don't Call Me Nuts! Coping
With the Stigma of Mental Illness. Tinley Park, Ill:
Recovery Press; 2001.
Corrigan PW. Mental health stigma as social
attribution: Implications for research methods and
attitude change. Clinical Psychology: Science and
Practice. 2000;7:48-67.




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