In Australia, at any given time, one in five people experience mental illness, including anxiety, depression, post-traumatic stress disorder, bipolar disorder and schizophrenia (Australian Bureau of Statistics, 2018). Although psychological treatments are available that successfully reduce symptom severity of these illnesses, individuals often do not seek help (Bernstein, 2016; Corrigan, Druss & Perlick, 2014; Corrigan, Larson & Rusch, 2009). Discrimination by society, stigma and a lack of motivation are just some of the reasons why care and treatment do not reach those in need. To understand the challenges faced by people affected by mental illness and their decision to not access care or treatment, we need to consider the issue of stigma.
Different researchers focus on different aspects of stigma and its subsidiary self-stigma. I will outline some examples below. Prevalent within society is the belief that people with mental illness are weak and dangerous, when compared to the rest of the population (Corrigan & Rao, 2012; Livingstone & Boyd, 2010). Such societal stereotyping stigmatises individuals affected by mental illness. Furthermore, the stereotyping leads to discriminatory and prejudicial behaviour, as these individuals are treated differently, often experiencing exclusion and social isolation (Corrigan, Druss & Perlick, 2014; Corrigan & Rao, 2012; Livingstone & Boyd, 2010). Individuals affected by mental illness are very vulnerable and can start to believe in the way that society perceives them. If an individual agrees with the negative stereotype and internalises it, it can culminate in self-stigma. Self-stigma occurs when individuals with mental illness identify the social or public stigma as their self-concept, which can affect their behaviour and attitudes towards seeking help and treatment (Corrigan & Rao, 2012).
Corrigan & Rao (2012) consider self-stigma to be a progressive process. It begins with awareness of the public stigma that people with mental illness are weak, incompetent, different and dangerous (Corrigan & Rao, 2012). This awareness may lead to the second stage agreement, that is that the public stigma is true amongst all individuals suffering from mental illness. The third stage, called the application phase, occurs when the individual applies such stereotypes to him/herself. It is important to know which stage the person is currently experiencing, because each stage greatly helps to determine the main cause of the self-harming behaviours of the individual, and correctly assess if the negative feelings are manifestations of self-stigma or may be due to other emotional and psychological problems (Corrigan & Rao, 2012).
Self-stigma has been found to significantly influence health outcomes and quality of life for those living with mental illness. Individuals with high-levels of self-stigma exhibit symptoms such as hopelessness, low self-esteem, poor self-efficacy, social isolation, unemployment, poor health outcomes, and lower social support networks (Livingstone & Boyd, 2010). Self-stigma is considered to be one of the main challenges to people with mental illness seeking professional treatment and help (Corrigan, Druss & Perlick, 2014; Corrigan & Rao, 2012; Livingstone & Boyd, 2010).
One of the most disempowering effects of self-stigma is the why try effect. The why try effect only happens if self-stigma goes through the application stage and is where the greatest harm to the individual occurs (Corrigan & Rao, 2012). When an individual who self-stigmatizes loses the will to reach out and access help or treatment, research shows it is because of diminished self-esteem and self-efficacy (Corrigan, Larson & Rusch, 2009). Low-self-esteem and self-efficacy have been correlated with poor treatment adherence, higher psychiatric symptom severity, failure to carry out daily life activities, pursue goals (educational attainment, gainful employment, independent living), decreased quality of life and social support (Corrigan, Larson & Rusch, 2009; Livingstone & Boyd, 2010).
Some form of intervention is needed to help ameliorate the effects of self-stigma. There is still no single approach that is demonstrably more successful, due to differences in sociodemographic, psychosocial and psychiatric variables (Livingstone & Boyd, 2010). Psychoeducational interventions are the most common type of intervention used (Corrigan & Rao, 2012; Mittal, Sullivan, Chekuri, Allee & Corrigan, 2012). It is often done in groups where a professional facilitator educates participants about self-stigma, its consequences, and how to minimize its effects. Within the literature on reducing the effects of self-stigma are two differing approaches (Mittal et al., 2012). The first approach focuses on challenging stigmatising attitudes and beliefs. In contrast, the second is based on a completely different theoretical framework, one where emphasis is placed on accepting that negative stereotypes exist without trying to change them, while developing coping strategies for self-stigma by improving the individual’s self-esteem, empowerment and help-seeking behaviour (Mittal et al., 2012).
The two contrasting interventions also correspond to two types of psychological treatments: cognitive-behavioural therapy (CBT) and acceptance and commitment therapy (Bernstein, 2016). These therapies treat different conditions and therefore one cannot be considered as more reputable than the other. However, empirical research shows self-esteem and empowerment is a more effective method to reduce the effects of self-stigma for individual’s with mental illness (Corrigan, Larson & Rusch, 2009; Mittal et al., 2012). Accordingly, the approach that focuses on acceptance and coping strategies is associated with increased self-esteem, empowerment, self-efficacy, quality of life and goal attainment (Corrigan, Larson & Rusch, 2009). Consequently, stigma specialists are increasingly adopting this approach and recommend focusing on high-risk groups such as survivors of natural disasters and other traumatic life events (Mittal et al., 2012).
As mentioned previously, evaluation of interventions to reduce self-stigma have been problematic because of sociodemographic, psychosocial and psychiatric variables (Corrigan & Rao, 2012; Mittal et al., 2012). Psychoeducational interventions, which usually target one group of individuals with mental illness, such as anxiety, depression, bipolar disorder, schizophrenia, post-traumatic stress disorder and other psychiatric illnesses, have evaluated either short-term or long-term effects, but not one against the other, and as a high proportion of studies did not specify the length of illness at the time when the intervention began, it is hard to conclusively demonstrate the effectiveness of a specific program. Despite these limitations, psychoeducational interventions coupled with social and life coping skills are usually considered the first-step in a line of interventions. Furthermore, due to their flexible nature it is possible to combine them with other therapeutic approaches such as CBT or acceptance and commitment-therapy (Mittal et al., 2012).
We will now consider a recent addition to self-stigma reduction treatments. One that aims to improve self-esteem and bases its results on the wellbeing of participants. An example of this intervention is the Inquiry-Based Stress Reduction of Byron Katie (Ferris France et al., 2019). This 12-week program incorporates face-to-face workshops, self-inquiry, and peer and mentor methods. The intervention starts by encouraging participants to be more aware of their negative thoughts and behaviours, and their self-stigmatizing beliefs through self-inquiry. Participants then go through a process of finding their own answers to their questions and are thus more aware of their behaviours when the self-stigmatizing thoughts occur. When the participant is fully aware of their attitudes, thoughts, and behaviours, they go through a turnaround stage, whereby the participant turns the negative thoughts into empowering and positive ones. They then apply this to their everyday lives. This assists participants to cope better during stressful situations (Ferris France et al., 2019).
Change and coping strategies include building acceptance of the individual’s current mental condition and getting support through one’s self and one’s community. The intervention is also more about building a positive perception and overcoming negative thoughts. Compared to other evidence-based interventions which measure the results quantitatively, this approach reports qualitative outcomes such as determining the effect on the wellbeing of the participant. Participants who go through this kind of program have shown improvements across many areas in their lives (Ferris France et al., 2019). The limitation of this approach is that it is not widely used among large groups, and that the measurements used are arbitrary. This is because they are not focused on the reduction of negative attributes, but more on measuring the positive attributes shown by the participants.
In conclusion, people experiencing mental illness are often subjected to the detrimental effects of stigma and self-stigma. Such stereotypical overgeneralisations are correlated with poor treatment adherence, higher psychiatric symptom severity, diminished quality of life and social support, self-efficacy and goal attainment. There is still no uniform approach in self-stigma intervention because of differences between sociodemographic, psychosocial and psychiatric variables. The most common self-stigma intervention is psychoeducational treatment. Earlier, this essay considered new approaches to self-stigma reduction, such as the Inquiry-Based Stress Reduction of Byron Katie. This approach differs to previous approaches because it encourages participants to accept their condition but at the same time overcomes the self-stigmatizing attitudes by noticing it when it occurs and carrying out positive actions to cope with difficult situations. Coping strategies are correlated with long-term changes due to their holistic approach and effect on the wellbeing of participants.
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