# Presentation: 077143

## Countering Internalized Stigma among People with Mental Illnesses 

**www.stopstigma.samhsa.gov**

**Countering Internalized Stigma among People with Mental Illnesses **

- September 26, 2007

## Survey

**www.stopstigma.samhsa.gov**

**Survey**

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## Contact Us

**www.stopstigma.samhsa.gov**

**Contact Us**

**SAMHSA ADS Center**11420 Rockville PikeRockville, MD  20852
*Toll free*:**  1-800-540-0320***Fax*:**  240-747-5470***Web*:**  www.stopstigma.samhsa.gov***E-mail*:**  stopstigma@samhsa.hhs.gov**

*The Moderator for this call is ****Holly Reynolds****.*

## Questions?

**Questions?**

**www.stopstigma.samhsa.gov**

- At the end of the speaker presentations, you will be able to ask questions.  You may submit your question by pressing **‘01’** on your telephone keypad.  You will enter a queue and be allowed to ask your question in the order in which it was received.  On hearing the conference operator announce your name, you may proceed with your question.

## Speakers

**Speakers**

**www.stopstigma.samhsa.gov**

**Amy Watson, Ph.D., Assistant Professor  at the Jane Addams College of Social Work, University of Illinois at Chicago**

- Amy Watson is on the faculty of the Jane Addams College of Social Work at the University of Illinois at Chicago, where she teaches in the Mental Health Concentration.  She is also an active member and former Project Director of Chicago Consortium for Stigma Research (CCSR), an interdisciplinary group of researchers dedicated to studying mental illness stigma, its consequences, and strategies for attitude change.  Her research focuses on stigma as a barrier to accessing mental health services and the influence of mental illness stigma on how people are processed through the criminal justice system.  Her current NIMH-funded research studies include one examining the experiences of persons with mental illness who have come in contact with police, and another that seeks to understand how youth with mental health problems who are involved with the juvenile justice system make sense of their dual labels and systems involvement.

## Speakers

**Speakers**

**www.stopstigma.samhsa.gov**

**Robert Lundin, Director, *****The Awakenings Review ***
- Robert Lundin became ill with psychosis and depression while a student at Vanderbilt University in the 1970s. He showed signs of mania and psychosis for years after that, but eventually responded well to medications. He worked as a freelance journalist for the Chicago Tribune in the early 1990s, then as a research assistant at the University of Chicago in the 1990s and 2000s. Lundin also worked recently as a case manager for Evanston Northwestern Healthcare. Over the years, stigma has weighed heavily on Lundin and he has written about it in a book he co-authored with Patrick Corrigan, and in an article titled, "The Mind Will Follow" published in Schizophrenia Bulletin. Lundin is also the founder of the Awakenings Project, an arts group for people with mental illness, and editor of their literary magazine, "The Awakenings Review."

## Speakers

**Speakers**

**www.stopstigma.samhsa.gov**

**Patricia E. Deegan, Ph.D. **
- Patricia E. Deegan, Ph.D. is an activist in the disability rights movement, a writer, lecturer and researcher. Pat is also an independent consultant with Pat Deegan & Associates, LLC and an adjunct professor at Sargent College of Health and Rehabilitation Sciences at Boston University. She has many published papers, some of which have been translated into 9 languages.  Pat has lectured on the topics of self-directed recovery and empowerment around the world, and has made three films on disability related topics. Pat’s current projects include developing software to support shared decision-making in psychiatry, researching a recovery-based approach to using psychiatric medications in collaboration with the University of Kansas, developing recovery-based workforce trainings for mental health practitioners, helping to restore forgotten cemeteries at state hospitals, helping consumers win money for new housing through the sale of state hospitals and developing technical assistance materials for people affected by the U.S. Supreme Court’s Olmstead Decision. Pat has lived her own journey of recovery, having first been diagnosed with schizophrenia as a teenager. She received her doctorate in clinical psychology from Duquesne University.

## Self Stigma & Mental Illness

- Amy Watson, Ph.D.
*The work described in this presentation was funded in part by a grant from the National Institute of Mental Health (MH66059) awarded to Patrick Corrigan.*

## Overview

- Internalized stigma-a modified labeling theory perspective
- Model of divergent personal responses to mental illness stigma
- Research on internalized/self stigma

## “Thinking of myself as garbage, I would even leave the side walk in what I thought of as exhibiting the proper deference to those above me in social class.  The latter group, of course, included all other human beings (Gallo, 1994, p 407-408). 

## How does Stigma Operate?

**Public Stigma**
- - **Stereotype:**    Negative belief about a group	       e.g., dangerousness                incompetence                character weakness**-  Prejudice:**    Agreement with belief and/or     negative emotional reaction         e.g., anger                 fear**-  Discrimination:**    Behavior response to prejudice       e.g., avoidance of work and                housing opportunities                without help

**Self-Stigma**
**Stereotype:**    Negative belief about the self	       e.g.,  character weakness                incompetence
**-  Prejudice:**    Agreement with belief      Negative emotional reaction         e.g., low self-esteem                 low self-efficacy**-  Discrimination:**    Behavior response to prejudice       e.g., fails to pursue work                and housing     			opportunities

**Notes:**
In our work we distinguish between public & self stigma

## Labeling Theory & Self Stigma

- LABEL

- Internalized
- Stigma

- Perceived
- Devaluation &
- Discrimination

- Loss of Self Esteem/
- Self Efficacy
- Adverse Impact on
- Recovery

- Culturally shared conceptions of mental illness

**Notes:**
Bruce Link & colleagues discuss self stigma from a labeling theory perspective-which examines the negative impact of stigma on the self—basically via 2 paths

## Labeling Theory & Self Stigma

- Internalized stigma and perceived devaluation & discrimination have been linked to:
- Diminished self esteem & self efficacy (even once) symptoms have remitted
- Diminished adherence to treatment
- Diminished pursuit of rehabilitation goals (employment, housing, social networks)

**Notes:**
Typically these studies have measured perceived devaluation & discrimination and self esteem/self efficacy

## Alternative Responses to Stigma

- Indifference
- Empowerment/righteous anger
- What accounts for these varied responses to mental illness stigma?

**Notes:**
However, there is evidence that not everyone experiences these negative impacts, or experiences to a lesser degree
Research on empowerment suggest some people are engergized to fight the stigma

## Self Stigma

- Typically, what is measured and loosely referred to as “self stigma” is perceived devaluation and discrimination.
- This is the first component of our model of self stigma that attempts to account forvaried responses.

## Components of Self Stigma

- 1. Stereotype awareness (perceived discrimination & devaluation)
- 2. Stereotype agreement
- 3. Stereotype self-concurrence
- 4. Self esteem decrement

**Notes:**
Our model has 4 components

## Factors That Influence the Process

- Further development of our model of self stigma...factors that influence the process
- Group identification
- Perceived legitimacy of stigma
- Awareness/illness insight

**Notes:**
Group identification-individuals who identify may internalize OR develop positive identity thru interactions with peers—this buffers them from negative effects of public stigma.  This has been supported in research on other groups-and is our hypothesized effect
If people believe the negative outcomes legitimate, stereotype is accurate—loss of SESE
Perceived legitimacy of stigma and discrimination >>greater self stigma
Awareness/insight “lack of insight” may be protective.  Insight may also be necessary for group identification

- Group Identification

- Legitimacy

- Stereotype Awareness

- Self Concurrence

- Stereotype Agreement

- Self Esteem

- Self Efficacy

- FIGURE 1: Theoretical Model of Self Stigma

- STEREOTYPE

- Empowerment

**Notes:**
71 individuals with serious mental illness receiving services in a community support program
SSMI (Corrigan, et al)
Group Identification (adapted from Jetten, et al 1996)
Perceived Legitimacy (adapted from Schmader, et al 2001)
Disease Awareness (SUMD, Amador, 1993)
Self Esteem (Rosenberg, 1965)
Self Efficacy (Sherer, 1983)
Empowerment (Rogers, et al 1997)

## Factors Influencing the Self Stigma Process: Findings

- The more aware of MI stigma        the less it is perceived as legitimate. Awareness also reduces self concurrence****
- Stereotype agreement is positively associated with self concurrence.
- Self concurrence negatively associated with self esteem and self efficacy

**Notes:**
****our model holds that awareness is necessary to agreement and self concurrence, however it was not sig associated with agreeemt, and neg to self concurrence.  Perhaps awareness is necessary to have any opinion-thus cancelled effect out

## Factors Influencing the Self Stigma Process: Findings

- The more identified with the group, the less likely to agree and self concur with stereotypes and have higher self efficacy
- The more stigma is perceived as legitimate, the more likely to agree & self concur and have lower self efficacy
- Illness insight associated with greater stereotype agreement and lower self esteem, self efficacy, self esteem and empowerment.****

## Other Recent Studies

- Lysaker, Roe & Yanos (2006) Illness Insight & Internalized Stigma
- Group 3:insight paired with internalized stigma>poorer self esteem and less hope than other two groups, Group 2 faired the best, group 3 in the middle
*..”it is as important to assist in developing a sense of mastery as it is to help enhance insight.”*
- Ritsher & Phelan (2004) Internalized Stigma & Morale
- Stereotype Endorsement,  Social Withdrawal & **Alienation**** dimensions predicted  depression and lowered self esteem
*	**	*
*	**	**“**What is needed is an antidote for alienation.”*

**Notes:**
Lysaker—et al—pushing insight is not always desirable for functioning-when stigma is moderate of high, recovery oriented services—with providers that provide a sense of hope –and assist with mastery and countering stigma may help.  Changing what the “meaning” of mental illness is
Ritcher & Phelan—suggest interpersonal engagement, fellowship of self help groups, role recovery (SE) psychotherapeutic alliance

## Discussion

- Protective factors
- stereotype awareness
- group identification (this may reduce alienation)
- Harmful factors
- perceived legitimacy of stigma
- alienation
- disease awareness absent positive group identification

**Notes:**
Discuss implications for interventions

## Implications

- Identify and evaluate mechanisms that
- promote positive group identification
- support interpersonal engagement and fellowship
- enhance stigma awareness
- challenge the legitimacy of stigma
- support role recovery and mastery
- instill hope

## Self-StigmaA Fall From Grace?

**www.stopstigma.samhsa.gov**

- Self-StigmaA Fall From Grace?

- Robert Lundin

## Can you call self-stigma “disgrace?”

- We are unable to achieve other people’s or society’s goals or meet their expectations
- Many of us fail in reaching our own life’s plan (which is dictated in large part by other people’s expectations)
- Where there are shortcomings there are often feelings of disgrace, e.g. failure and negative self-image

## My fall from grace

- Having to quit graduate school in 1979
- Being fired from a university admissions department in 1980
- A ruinous psychosis in 2007
- Leaving my last job 2007

## How do you cope with disgrace?

- Realign one’s values
- Keep trying
- Understand that disgrace is put upon you, you need not accept it

## Healing From Self-Stigma

- To inquire about use contact Pat@patdeegan.com

- Patricia E. Deegan, PhD
- http://www.patdeegan.com

## Macro-aggression

- Examples
- Take-downs and physical restraint
- Macing by police and attendants
- Solitary confinement
- Homelessness in an affluent country
- Lack of access to healthcare resulting in premature mortality
- Illegal locked units in nursing homes such as in New York State
- Involuntary shock treatment

- Copyright 2000 © Pat Deegan PhD & Associates, LLC
- To inquire about use contact Pat@patdeegan.com

## Micro-aggression

- More subtle and stunning
- More consistent and difficult to “prove”
- Less like a club striking you down and more like sandpaper wearing you down

- Copyright 2000 © Pat Deegan PhD & Associates, LLC
- To inquire about use contact Pat@patdeegan.com

## Micro-Aggression

- “Brief and commonplace daily verbal, behavioral, and environmental indignities, whether intentional or unintentional, that communicate hostile, derogatory or negative racial slights to the target person or group.”
*Sue, Capodilupo, Torino, et al. 2007, “Racial Microaggressions in Everyday Life: Implications for everyday practice, *_*American Psychologist*_.

- Copyright 2000 © Pat Deegan PhD & Associates, LLC
- To inquire about use contact Pat@patdeegan.com

## The Origins of Self-Stigma

- What language and symbols define reality and what is normal/abnormal?

- Discrimination, bigotry, prejudice, scapegoating,

- For diagnosed person: self-hatred and shame
- For non-diagnosed person: privilege

**Cultural**

**Interpersonal**
-  **Personal**

- Who makes/enforces decisions and controls access to resources?

**Structural**

- Systemic
- Mentalism

- Copyright 2000 © Pat Deegan PhD & Associates, LLC
- To inquire about use contact Pat@patdeegan.com

## Survey

- 16 adult residential, supported housing and MH/substance abuse residential treatment programs

- Copyright 2000 © Pat Deegan PhD & Associates, LLC
- To inquire about use contact Pat@patdeegan.com

## Questions for Clients

- Has a staff person in a mental health program or hospital ever said something disrespectful to you or someone you know?  If so, will you give me an example of that? 94 examples were generated
- How do staff show you respect? 123 responses were generated

- Copyright 2000 © Pat Deegan PhD & Associates, LLC
- To inquire about use contact Pat@patdeegan.com

## Questions to Staff

- What are the words, phrases or slurs you have heard used by staff in mental health settings that are stigmatizing, disrespectful or that devalue clients?  85 examples were given

- Copyright 2000 © Pat Deegan PhD & Associates, LLC
- To inquire about use contact Pat@patdeegan.com

## Communicating Disrespect: Survey Results

- To inquire about use contact Pat@patdeegan.com

- Categories of disrespectful communication
- Slurs
- Insults
- Pet Names
- Demoralizing Messages
- Clinical Language
- Verbal Abuse
- Behavior
- Silence

## Healing

- Stop minimizing and validate the harmful impact of macro-aggression and micro-aggression: It’s real!
- “I deserved to put in restraints”
- “He called me low functioning but it didn’t bother me
- Peer support – discovering our self-worth and rejecting internalized self-hatred
- “I don’t go to that program because I don’t want to hang out with low-functioning people”
- Prevention: Changing MH practice

- Copyright 2000 © Pat Deegan PhD & Associates, LLC
- To inquire about use contact Pat@patdeegan.com

## More Information

**More Information**

**www.stopstigma.samhsa.gov**

**Amy Watson, Ph.D., Assistant Professor  at the Jane Addams College of Social Work, University of Illinois at Chicago **
- Email: _[acwatson@gmail.com](mailto:acwatson@gmail.com)_
**Robert Lundin, Director, *****The Awakenings Review ***
- Email: _[rklundin@aol.com](mailto:rklundin@aol.com)_
**Patricia Deegan, Ph.D., Independent Consultant with Pat Deegan & Associates, LLC **
- Email: _[patricia.deegan@comcast.net](mailto:patricia.deegan@comcast.net)_

*For more information, contact:*

## Questions for Discussion 

**Questions for Discussion **

**www.stopstigma.samhsa.gov**

- 1.) What strategies can we use to change the negative values we hold about ourselves?
- 2.) How do the labels, often assessment and program admission categories, like SMI (serious mental illness); moderate mental illness; and, mild mental illness contribute to internalized stigma?
- 3.) What does research show regarding internalized stigma within mental health professionals who have a mental illness?  For example, what is the prevalence of self-reported mental illness in this profession?  What policies exist in mental health workplaces to support symptomatic or non-symptomatic employees?
- 4.) How does our own internal stigma cause us to stigmatize our peers? What can we do when we notice that we are judging our peers because they appear different or "less functional?”

***Questions for discussion are generated by emails sent to the ADS Center. If your question does not appear below, please feel free to contact the ADS Center or the presenters directly.***

***Please note: Questions may have been edited for content and clarity. ***

## Resources

**Resources**

**www.stopstigma.samhsa.gov**

- Corrigan PW. River LP. Lundin RK, et al. Stigmatizing attributions about mental illness. *Journal of Community Psychology*. 2000; 28:91–103.
- Corrigan, PW. Watson AC. Understanding the impact of stigma on people with mental illness***. ****World Psychiatry*. 2002 February; 1(1): 16–20.
- Corrigan PW, Watson AC. Paradox of self-stigma and mental illness. *Clinical Psychology: Science & Practice*. 2001; 9:35-53.
- Deegan PE. Spirit breaking: when the helping professions hurt. *The Humanistic Psychologist. *1990; 18:301–313.
- Kroska A. Harkness SK. Stigma sentiments and self-meanings: Exploring the modified labeling theory of mental illness. *Social Psychology Quarterly. *2006; 69: 325-348*.*

***The views expressed within these resources do not necessarily represent the views, policies, and positions of the Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, or the U.S. Department of Health and Human Services.***** **