Blythe A. Buchholz and Patrick W. Corrigan, Illinois Institute of Technology
Mistaken beliefs about mental illness and the resulting discrimination (together known as stigma) can be as harmful to the person as the illness itself. One form of stigma called public stigma happens when the general public agrees with stereotypes and socially disapproves of the person. This public stigma causes pain that acts as a barrier to the person’s pursuit of life goals. Sometimes, the person with mental illness believes the false stereotypes about their experience with mental illness. This is called self-stigma and causes a significant decrease in the person’s belief that they are good and able and that there is hope for recovery. These false ideas about mental illness and recovery can leave people believing they are not able to achieve their life goals. For these people, seeking therapeutic services is also less likely.
An interesting way to reduce self-stigma is doing what might seem most threatening - sharing one’s experiences with mental illness. Telling someone about your mental illness can be empowering and may actually increase self-esteem for some people. This can be tricky, however, and it would be good for the advocacy community to develop effective guidance and supports for people wanting to tell their story about their experiences with mental illness. There are some specific practices that people with mental illness could adopt should they decide to “come out proud.”
The Problem of Self-Stigma
Social psychologists have described stigma in terms of:
· Stereotypes - usually negative beliefs about a group: “people with mental illness are dangerous”
· Prejudice - agreement with these beliefs leading to a negative feelings about the person: “that’s right; they’re dangerous and I’m afraid of them”
· Discrimination - the behavior in response to these beliefs and feelings: “because I’m afraid of them, I’m not going to hire them”
When people with mental illness take these ideas, feelings and behaviors and apply them to themselves, it may undermine the pursuit of goals, including those related to education and employment. This has been called the “why try” effect. “Why try to seek out a job? I am not worthy of it.” “Why attempt to learn math? I don’t have the skills to focus and learn.” Additionally, people may avoid situations where they believe there is public stigma, which often include academic and work settings, which makes it even harder to achieve life goals and independence.
Identity and Disclosure
One approach to resolving self-stigma is to identify with others who have mental illnesses. Individuals who identify with their stigmatized group may report less stress related to prejudice and better self-esteem. This has been found to be true in studies of African Americans, older adults, women, and gay men and lesbians. Sexual orientation is helpful to look at because, like mental illness, it does not show in outward appearance. It is easier to keep it a secret. Keeping this secret and covering up such important aspects of one’s identity can have negative effects on mental and physical health, relationships, employment, and general well-being. Thoughtful and careful sharing of one’s closet secrets seems to not only reduce these harmful effects, but often leads to a greater sense of personal empowerment and improved self-esteem, while at the same time helping to break down the barrier of public stigma.
Identifying with Mental Illness
The relationship between personal identity and self-stigma is complex. One may think that to identify with a mental illness would lead to more stress, but this is not necessarily true. Many researchers have found that it may not be identifying with one’s mental illness that leads to more stress, but that the person believes the ideas that others hold are true. Identifying with one’s mental illness can pull together the central experiences of mental illness into the whole of one’s self-image. When the person holds a definition of recoverythat includes a sense of hope, capability, goal attainment, and community, the identification with mental illness can be quite positive.
Pride and Mental Illness Identity
Pride emerges from a sense of who one is. In this context, mental illness is an identity in which a person might be proud. For some people, “I am a person with mental illness,” describes much of their daily experience. This kind of identity promotes a feeling of authenticity. Authentic people often have pride in their authenticity and may experience greater self-esteem and well-being.
Some people view mental illness as a central part of their identity, while others may not. An individual identifying as a member of this group risks being discriminated against (one of the downsides of disclosure); but, at the same time, can lessen the effects of self-stigma on the person with mental illness by offering sources of support and solidarity to cope with any negative or emotionally difficult experiences.
Costs and Benefits of Disclosing
There are many benefits to disclosure; namely, the improved self-esteem and self-efficacy that promote emotional and mental health,which in turn may improve physical health and well-being. Disclosing might improve relationships and expectations in social and occupational settings. It can promote understanding, present opportunities for support, assistance, and reasonable accommodations, or simply relieve the stress and guilt connected to keeping a secret. There are costs to be considered as well. Just a few are listed here and vary greatly by person and their environment: risk for physical or emotional harm (hate crimes), discrimination, disapproval or exclusion from others, and self-consciousness. Costs and benefits can be assessed as both short and long-term outcomes. The balance of costs and benefits varies greatly for each individual and the setting. For example, coming out at work likely has a different pattern of costs and benefits compared to coming out among one’s friend group. Weighing the costs and benefits to coming out is a very complex, unique, and personal process; as such, this process, and ultimately his or her decision on whether to come out or not, is one that can really only be made by that individual.
Strategic Approaches to Disclosure
Disclosure has different levels from people who choose to stay out of social situations (Social Avoidance), to those who choose to socialize with a variety of people but not share their experiences (Secrecy), to taking a chance and disclosing their mental illness to selected co-workers or neighbors (Selective Disclosure), to those that make no active efforts to try to conceal their mental health history and experiences (Open Disclosure), and finally those who choose to broadly tell their story as a way of educating people about mental illness and reducing stigma (Broadcasting). The goal of the final type of disclosure is to seek out people or groups to share past history and current experiences with mental illness. People who broadcast their experiences foster their sense of empowerment over the experience of mental illness and related stigma.
Questions to consider when one has decided to disclose their mental illness include: Who do I want to tell? Why do I want this person to know? What about my experience do I want to tell them? What are some possible outcomes of my disclosure- negative and positive, short- and long-term? One strategy to “test out” whether a person is potentially a good receiver of disclosure is for the person considering disclosure to strike up a conversation about a recent television show, movie, or other media event that portrayed mental illness in a positive light. They then ask the person what they thought about it, rate the response, and decide if this individual will handle their personal information with respect, understanding, and sensitivity.
Coming Out Proud as a Public Health Program
Coming Out Proud is a program developed for people to work through the process of disclosure and issues related to identity. It is a three part program run by facilitators with lived experience, that addresses key issues related to disclosure: (1) weighing the costs and benefits of coming out; (2) considering the range of strategic approaches to disclosing; and (3) learning a good approach for formulating personal stories about experiences with mental illness. Finally, the program presents resources, namely consumer-operated services, which may be great support systems during this process.
The public health value of a coming out program is likely to go beyond self-reported changes of secrecy-related distress, self-stigma, and empowerment. Since perceptions of and experiences with discrimination lead both to heightened stress responses and poorer health behaviors, it is expected that a successful coming out program may reduce stress responses, including physiological and emotional reactions, with a positive impact on physical health and general well-being. Finally, a broader coming out movement is likely to reduce public stigma and structural discrimination for people with mental illnesses.
For more information about the Coming Out Proud program and to download a copy of the manual and the companion workbook, please visit the website for the National Consortium on Stigma and Empowerment at www.ncse1.org. Go to the resources tab on the home page.
Editing support: Sue McKenzie, Rogers InHealth
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3. Rüsch, N., Lieb, K., Bohus, M., Corrigan, P. W. (2006). Self-stigma, empowerment, and perceived legitimacy of discrimination among women with mental illness. Psychiatric Services, 57, 399-402.
4. Wood, A., Linley, P., Maltby, J., Baliousis, M., Joseph, S. (2008). The Authentic Personality: A Theoretical and Empirical Conceptualization and the Development of the Authenticity Scale. Journal of Counseling Psychology.
Adapted from: Corrigan, P. W. and Sokol, K. A. (In press). Reducing Self-Stigma by Coming Out Proud. American Journal of Public Health.
Please address correspondence to Patrick Corrigan, Illinois Institute of Technology, 3424 S. State Street, Chicago, IL 60616; firstname.lastname@example.org or Sue McKenzie, Rogers InHealth, 34700 Valley Drive, Oconomowoc, WI 53066; email@example.com