Self-stigma: An added burden in mental health problems

Moses, T. (2010). Adolescent mental health consumers’ self-stigma: Associations with parents’ and adolescents’ illness perceptions and parental stigma. Journal of Community Psychology, 38(6), 781-798. doi: 10.1002/jcop.20395

Summarized by Jessica Cunningham

Background:

Previous studies have shown that mental illness is highly stigmatized in the United States, but little research has been done on predictors of self-stigmatization (or the degree to which a member of a stigmatized group views themselves in the same negative light that society does) among children and adolescents who have been diagnosed with mental illness.

Self-stigmatization is problematic for a number of reasons, the first being that it lowers self-confidence and self-efficacy, which in turn makes it more difficult to treat a number of common problems such as depression and anxiety. Self-stigmatization also decreases the likelihood of seeking treatment, which can prove to be fatal for those with suicidal ideation among their symptoms.

Therefore, it is important for researchers to identify predictors of self-stigmatization among mentally ill adolescents in order to form interventions to help reduce these factors. Parents may play a key role in self-stigmatization among their mentally ill children, if they believe that their behaviors are controllable and stable, they are more likely to be harshly critical and less empathetic, and this may be compounded by the stigma that their parents might feel from society at large (e.g. blaming the parent for the illness of the child).

Methods:

This researcher recruited a sample of sixty adolescents from the ages of 12-18 and sixty parents/guardians from a wraparound program serving youth with one or more mental illnesses at risk for restrictive placements. Participants had to have been in the above mentioned age bracket, involved in the program for at least 8 weeks, speak English, and have a parent/guardian willing to participate. Exclusion criteria included an intellectual disability or a pervasive developmental disorder. Parents/guardians consisted of 88% mothers and 12% fathers.

Interviewers measured adolescents’ self-stigma; this measure included questions about embarrassment, shame, and worry about others’ responses to their mental illness. The interview also included a measure of causality to determine where the adolescent felt the “blame” for their mental health problems belonged: biology, personality, family problems, social problems, trauma, or economic problems. Adolescents were also asked about perceived controllability of their disorder, or the extent to which they believed their mental illness was illness versus controllable behavior. Finally, interviewers asked adolescents about perceived chronicity or stability of their illness over time (e.g. “I expect to have mental illness for the rest of my life”).

Parents were asked about the extent to which they believe “most people” look down on or shun families of children with mental health problems, as well as experiences with disapproval, criticism, or insult from others based on their child’s mental health problems. Additionally, parents were assessed on the degree to which they felt shame and the inclination to conceal their child’s mental illness, with shame addressing worry about the judgements of others, and the inclination to conceal addressing the desire to outright hide their child’s mental illness from others. Parents were also asked to explain their beliefs about causality, controllability, and chronicity along the same lines as their children.

The researcher then used hierarchical regression analyses to determine the set of factors significantly related to adolescents’ self-stigma ratings.

Participants:

Adolescents were 14.8 years old on average, mostly Caucasian (56.7%), and with over half being previously hospitalized. 61.7% of participants were male, 70% had been diagnosed with a mood disorder, 71% had been diagnosed with at least one disruptive behavior disorder, and 20% had a diagnosis of PTSD. Over 70% of parents were biological parents, the remaining were either kinship guardians or adoptive parents. The majority of parents were female, Caucasian, and over one third had an education of a high school equivalency or less. There were no significant differences between types of parents for outcomes, although biological parents were more likely to score higher on measures of personal stigma, and perceived devaluation of families who have mental illness.

Results:

Twenty-three percent of adolescents reported feelings of self-stigma often or very often, and Caucasian youth who had been receiving services from a young age were more likely to report these feelings than others.

On average, parents stated that they did not feel a sense of shame or need to conceal their child’s mental illness; only 22% agreed they felt ashamed, and only 30% felt like they should conceal their child’s illness.

A greater portion of the sample (50%) felt that they were criticized or blamed for their child’s mental illness by others, and 58% said that families of children with mental health problems are stigmatized. In terms of illness perceptions, adolescents tended to be fairly neutral in their ratings of the stability and controllability of their illnesses but leaning towards the idea that they could control their behavior and that it would not last for their entire lifetimes, but parents tended to be less optimistic.

In terms of causality, adolescents were more likely to believe their problems were the result of personality, whereas parents were more likely to believe their problems were the result of biology.

Adolescents perceiving less control over their thoughts and feelings and those anticipating that their MH problems are likely to be life-long scored higher on self-stigma. Adolescents who identified any of five causal explanations for their MH problems (except economic deficits) were more likely to experience self-stigma than adolescents who denied these or were uncertain, and endorsing more causal factors was correlated with higher ratings of self-stigma.

In terms of parents’ influence on their adolescents’ self-stigma, youth reported less self-stigma when parents reported more optimism about their child’s future and their ability to control their behavior. Adolescents were more likely to report higher levels of self-stigma when parents felt the need to conceal their mental illness, and when their parents felt that families of children with mental illness were devalued.

The positive relationship between adolescents’ self-stigma ratings and parents’ reported sense of shame also demonstrated a trend toward statistical significance. Parents’ causal perceptions were not significantly correlated with adolescents’ self-stigma, and much of the variance in the model is best explained by adolescent factors, not parent factors. However, two adolescent causal perceptions emerged as the most powerful correlates of higher self-stigma: social skill deficits and trauma.

The only parent factor that remained significant in the model was parents’ desire to conceal their child’s mental health problems; these three factors accounted for 59% of the variance of adolescents’ self-stigma ratings, and they remained statistically significant when demographic/clinical factors significant (age, age at first treatment, race, and diagnosis of a disruptive behavior disorder) were included in the model.

Discussion & Conclusion:

Self-stigma is an additional burden that anyone seeking treatment for mental health problems must bear, but this may be particularly difficult for adolescents. A smaller proportion of adolescents and parents in this sample reported concerns about self-stigma than the typical adult population, but this may be due to the small sample size and relative homogeneity of it.

Future studies should aim to replicate the findings with a more ethnically and socioeconomically diverse sample. Similarly, parents of children seeking treatment for mental health problems may, by virtue of seeking treatment, be more open and accepting of mental illness than those who are not seeking treatment for their child.

Adolescents with parents who report more desire and attempts to conceal their child’s mental health status from others report more self-stigma, this may be a case of a contagion effect on the part of the parents. This finding in particular is important for mentoring programs and practitioners to note, as part of the self-stigma that mentally ill mentees might face is tied up in their parents’ perceptions, but mentors might be able to act as a buffer against these negative ideas. If mentors instead model tolerance and openness for neurodivergence, it might be possible for them to help mentees to reduce some of their self-stigma.

In addition, the author notes that adolescents’ perceptions of social skill deficits and trauma as causal factors for their mental illness were strong correlates of self-stigma. And, she writes “given the salience of social assimilation in adolescence, it makes sense that adolescents reporting having trouble making or keeping friends as part of what causes or perpetuates their MH problems would be the same adolescents who report more embarrassment, self-consciousness, and fear of rejection on account of MH problems. In fact, this finding may reflect a conceptual overlap between social impairment and self-stigma.”

Similarly, trauma often causes feelings of shame and guilt that may overlap with mental illness related self-stigma. Mentors and program coordinators should keep these factors in mind when challenging mentee’s negative self-perceptions, and focus on helping mentees to develop a sense of self-efficacy in social skills.

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