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Internalized Stigma Erodes Morale

By Jennifer Ritsher and Jennifer Bernstein

The stigma of mental illness is strong in our society and causes harm to many people with severe mental illness (SMI). The most obvious form of stigma is when people reject, put down, or discriminate against those with mental illness because of negative stereotypes. Previous research has found that when people with SMI believe that most people reject and devalue people with mental illnesses, they may suffer a number of negative outcomes, such as demoralization, lowered self-esteem, impaired social adaptation, unemployment, income loss, and reduced psychiatric medication adherence. People with SMI who do not hold these beliefs as strongly suffer fewer of these negative consequences.

It is important to recognize that the harmful effects of stigma may work not only through the external effects of discrimination by others, but also through the internal perceptions, beliefs and emotions of the stigmatized person. Thus, our group set out to research internalized stigma. Internalized stigma means that the person actually believes the stereotypes. We would expect a person who has internalized negative stereotypes to have lower self-esteem than someone who is aware of negative stereotypes held by others but who does not personally accept them.

In our research project, we measured the intensity and prevalence of internalized stigma among 82 outpatients with SMI and tested whether internalized stigma predicted deterioration in morale (self-esteem and depressive symptoms) four months later. We studied people who had already been living with SMI for many years. We wanted to know if stigma had already done its work on them, or if we could actually detect even more deterioration in morale over this short time in this group. To answer this, we developed a questionnaire that measures five dimensions of internalized stigma: Alienation, Stereotype Endorsement, Discrimination Experience, Social Withdrawal and Stigma Resistance. Participants responded on a scale from "strongly agree" to "strongly disagree" to 29 statements, which include, for example, "Having a mental illness has spoiled my life," "Mentally ill people tend to be violent," "I avoid getting close to people who don't have mental illness to avoid rejection," and "I can have a good, fulfilling life, despite my mental illness."

The results confirmed that internalized stigma does erode morale over time-even in this group of people who had already been coping with stigma and mental illness for years. The most consistently harmful consequences were those of alienation. People who experienced alienation related to their SMI were likely to deal with more distress four months later, as their morale worsened further. This suggests that feeling different and divided from others may be a powerful component of internalized stigma. The fact that alienation worsens the reduced self-esteem and increased depressive symptoms caused by stigma speaks to the difficulty of pulling oneself out of this vicious cycle without help.

Endorsing stereotypes about mental illness also predicts a deepening of depressive symptoms. Stigma pervades society, and those who become mentally ill are typically well aware of the stereotypes associated with their condition. Thus it is but a short step for people with SMI to apply those stereotypes to themselves, adding to their sense of helplessness, hopelessness, and demoralization.

Another way stigma adversely impacts people is through social withdrawal. Although, for many, social withdrawal represents a coping mechanism, it is a costly one. We found that SMI-related social withdrawal predicted increased depressive symptoms four months later.

It is noteworthy that we found that perceptions of current discrimination do not predict a decrease in morale. This supports the idea that it is the internalization of stigma, not the discrimination itself, that is the most psychologically damaging aspect of stigmatizing experiences. If experiences occur but one does not internalize the stigma, one will be less emotionally damaged (although one's objective life situation, housing, etc, may well be adversely affected).

Future studies should explore ways that internalized stigma can be resisted. For example, our previous work showed that about one third of those with SMI who know they have the diagnosis do not agree that they have a mental illness. Future work might investigate whether or not accepting the label provides any protection against the destructive aspects of internalized stigma. It may also be that more social momentum and greater numbers of stigma resisters working together are needed for stigma resistance to work. Increasing anti-stigma activism may grow into an empowering social movement like those that radically transformed the ėstigmaî of being an African American or being gay or lesbian. The scientific literatures on internalized racism and internalized homophobia emphasize the importance of combating both the discrimination in society and the way that it is internalized within individuals.

Internalized stigma impedes recovery from SMI by dragging people down. Treatment approaches that focus on reducing internalized stigma may be able to prevent this by helping clients overcome the aspect of stigma that is within themselves. This would help them more effectively fight the aspects of stigma that are external. What is needed to overcome internalized stigma is the antidote for alienation: interpersonal engagement, such as that provided by self-help groups, the role recovery inherent in supported employment, or the healing power of psychotherapy. Of course, stigma in society is unjust and harmful, and must be reduced. In the meantime, this internal approach in treatment may help lessen the impact of stigma on individuals with SMI.

For more information

Dr. Jennifer Ritsher
Department of Psychiatry
University of California, San Francisco
San Francisco VA Medical Center
4150 Clement Street (116A)
San Francisco, CA 94121
Email: Dr. Jennifer Ritsher


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