by R.J. Barna
Stigma is a harmful disconnection caused by prejudging others: thinking, speaking, and acting on what we “know” before taking the time to learn the truth. We’ve all experienced it, prejudging others and being prejudged to varying degrees and for various reasons. It can be intentional or unintentional. It may be rooted in rumor, past experience, or even partial fact. It could be well-intentioned (“Oh, you’re X? My cousin is too, and they just needed Y.”), but even then, it’s still harmful.
Stigma occupies the space where people might be received and truly known. When prejudgment of another overshadows that person’s value, it makes genuine connection between the perceiver and the perceived impossible. Stigma keeps us strangers. And if you start to believe the stigma, you can even become a stranger to yourself.
Stigma and Self-Stigma
Remember that classic Western setup? Townsfolk are gathered around tables, having a great time while a piano plays. The doors swing open, and heavy bootsteps signal the arrival of a stranger. The music and laughter stop. All eyes turn. It is quite clear that this new person is unwelcome. This person is prejudged as a source of trouble. The townsfolk have made up their minds before a word is spoken that this person does not belong.
In a good fiction, the stranger marches in and finds an opportunity to prove them wrong (usually by running off an evil baron, rescuing some lost townsfolk, or finding a forgotten treasure). But imagine that person doesn’t have an opportunity or wasn’t given one. Wouldn’t they start to believe the townsfolk and just go home?
According to Corrigan and Rao (2012), self-stigma (or internalized stigma) is a process of harm that moves from awareness of perceived beliefs (the stranger senses the tension in the room) to agreement with them (I don’t belong here) and eventual self-application (Why try to prove them wrong?). While it starts with what others think, it can eventually become how we see ourselves and even how we start to act.
The Harms of Self-Stigma
In addition to the immediate disconnection from one’s self and those around them, self-stigma’s impact can be compounded and long-lasting. Loss of faith in oneself could prevent someone from applying for a good job, exploring new interests, or maintaining social relationships. Self-stigma can also interfere with recovery and worsen the severity of behavioral health challenges, leading people to believe they will never get better, aren’t worthy of help, or tragically, even have worth at all.
Speaking Out
Facing stigma is possible. As it turns out, the stranger that rolled into town isn’t as unfamiliar as the townsfolk think. According to Mental Health America (2022), 19.86% of adults in the U.S. have reported a mental health challenge, and SAMHSA (2021) reports 46.3 million Americans (12 years +) meet the DSM-5’s diagnostic criteria for substance use disorder: 13.76%.
Because behavioral health challenges are so common, many advocate for speaking openly about them, but that may not be the right choice for everyone. A 2019 national poll from the American Psychiatric Association (APA) - for example - found that “millennials were almost twice as likely as baby boomers to be comfortable [62% vs. 32%] discussing their mental health.” It really depends on the person and the townsfolk.
Familiarity isn’t something that usually happens all at once either. Just because we may want to discuss our behavioral health situation doesn’t mean we are necessarily ready or even know the best way to do so with any particular person. Some folks like to listen. Some folks like to talk. Some folks are activated by words, phrases, or even how they’re said (too direct or indirect, tone, situation of the speaker, etc.). We often need to peel away the layers of prejudgement and expectation in order to find the best approach.
It may take time and varying degrees of disclosure to build a healthy connection with others. Sometimes we avoid broaching a topic until we hear a person suggest they may be open to it. Other times we may hint at it a few times until that person seems ready. It might also be something we talk about proudly every time. Corrigan and Rao (2012) detail a spectrum of “disclosure,” ranging from social avoidance (riding right through town) to broadcasting (kicking the doors wide open) with secrecy (telling no one), selective disclosure (telling those who might understand), and indiscriminate disclosure between (sharing with anyone, but only if they ask).
Obviously, these kinds of disclosure vary in degree of risk and reward, and that will be unique to every situation. Not telling everyone I meet about my behavioral health challenges carries very little risk, while keeping that information secret from my partner could be harmful to our relationship. Similarly, standing up to someone I overhear sharing stigmatizing comments about “people like me” may risk my safety more than challenging the same comments of a loved one (or vice versa). And if the reward - connecting with another person - isn’t worth that risk, it may be better for us to connect or reconnect with ourselves instead.
Altering Beliefs and Enhancing Skills
Facing self-stigma is also possible. Another 2012 study on self-stigma reduction strategies that “reported significant improvement in self-stigma outcomes,” found 2 common methods for possible success: “one, interventions that attempt to alter the stigmatizing beliefs and attitudes of the individual; and two, interventions that enhance skills for coping with self-stigma through improvements in self-esteem, empowerment, and help-seeking behavior” (Mittal, et al.).
For those who find conventional therapy helpful to their individual recovery, Cognitive Behavioral Therapy (CBT) may be worth considering. VA psychologists (2019) and Veterans have found a reduction of self-stigma stemming from common, “You’re stronger than that,” attitudes through exercises like roleplay and problem-solving skill development. An important part of the process is to “delegitimize stigmatizing messages as untrue, ignorant, and harmful,” by training a reflexive “Why not try?” whenever a “Why try?” thought emerges (VA News). Instead of being overwhelmed by the burden of justifying an action, it instead becomes easier and perfectly reasonable to weigh its potential outcomes.
Other forms of positive thinking and visualizing success have long been common tools of wellness. For those who are spiritually inclined, meditation may be a powerful experience to be grounded by personal affirmations or connected with higher powers and ideals. Utilitarian approaches may include journaling or focusing: allowing oneself the time and space to feel and taking some control over those feelings by naming them and/or putting an experience into words. Challenging self-stigma is possible when we remind ourselves that a.) self-stigma is not our fault, b.) we are more than a diagnoses, and c.) our awareness of self can promote positive change.
Connection Counters Stigma
Connection counters stigma, because making space to learn from, with, and about others helps us to see them as more than strangers and overcome the harmful impact of prejudgement. Connection is a skill we can practice through many forms of disclosure - what to say and when. And even though we may be working on ourselves, the Mayo Clinic (2017) reminds us that support from friends, groups, and organizations reduces the negative impacts of isolation while also helping us learn about ourselves by being open to other perspectives, so it’s equally important to seek out those connections as well.
Whether external or internal, stigma is all too common in our lives and presents a substantial barrier to behavioral health recovery. It’s hard not to feel “strange” when everyone treats you like a stranger. We can face self-stigma by challenging our beliefs and practicing empowerment skills, but really, “curing it lies with the community in which one lives,” because that’s where the stigma began (Corrigan & Rao, 2012).
We need to face it together. In our towns and with our folks, we need to make space for others and challenge stigma before it does damage, including the internalization of those messages. We can create change through increased awareness of our unique situations; education about beliefs and skills; and contact with those we hope to better understand.
References:
Corrigan PW, Rao D. On the self-stigma of mental illness: stages, disclosure, and strategies for change. Can J Psychiatry. 2012 Aug;57(8):464-9. doi: 10.1177/070674371205700804. PMID: 22854028; PMCID: PMC3610943.
Mayo Foundation for Medical Education and Research. (2017, May 24). Mental health: Overcoming the stigma of mental illness. Mayo Clinic. Retrieved April 3, 2023, from https://www.mayoclinic.org/diseases-conditions/mental-illness/in-depth/mental-health/art-20046477
Minot, D. (2022, July 14). There is hope. Behavioral Health News. Retrieved April 3, 2023, from https://behavioralhealthnews.org/there-is-hope/
Mittal, D., Sullivan, G., Chekuri, L., Allee, E., & Corrigan, P. W. (2012). Empirical studies of self-stigma reduction strategies: A critical review of the literature. Psychiatric Services, 63(10), 974–981. https://doi.org/10.1176/appi.ps.201100459
National Survey on Drug Use and health. SAMHSA.gov. (n.d.). Retrieved April 3, 2023, from https://www.samhsa.gov/data/data-we-collect/nsduh-national-survey-drug-use-and-health
Stigma, prejudice and discrimination against people with mental illness. Psychiatry.org - Stigma, Prejudice and Discrimination Against People with Mental Illness. (n.d.). Retrieved April 3, 2023, from https://www.psychiatry.org/patients-families/stigma-and-discrimination
VA psychologists help veterans overcome self-stigma. VA News. (2019, August 26). Retrieved April 3, 2023, from https://news.va.gov/64887/va-psychologists-help-veterans-overcome-self-stigma/
https://www.samhsa.gov/data/sites/default/files/2022-12/2021NSDUHFFRHighlights092722.pdf