What Is Self-Stigma and Why Does It Hurt?

Ramya Ramadurai, a Ph.D. graduate student in clinical psychology at American University, contributed to this post.

Stigma is defined as a mark of shame or discredit. Through sociological labelling theory we can conceptualize mental health stigma as mark of shame or discredit applied to those who experience emotional disorders, who are then labeled, stereotyped, and discriminated against.

It is well known that mental health stigma is a widespread public issue. Stereotyped attitudes and prejudices held by the public (Rüsch, Angermeyer, & Corrigan, 2005) is called social stigma and can lead to loss of economic or job opportunities, personal life and educational disadvantage, less access to housing or proper health care for physical health conditions, and discrimination more broadly, for those who experience mental health problems.

Maybe less well-known is what happens when these prejudices and stereotypes become enmeshed within the way an individual sees themselves.

Personal acceptance and agreement with stereotypes and prejudicial beliefs held against oneself is called self-stigma (Corrigan, Watson, & Barr, 2006) or internalized stigma (Watson et al., 2007). In the widely used minority stress model (Meyer, 2003), self-stigma or internalized stigma is a proximal outcome of stress induced by the experience of stigma. The psychological mediation framework (Hatzenbuehler, 2009) acknowledges that proximal outcomes like self-stigma may explain the association between the distal outcomes of social stigma and psychopathology.

Internalized stigma is associated with unique emotional distress, loss of self-esteem, feelings of low self-worth, loss of self-efficacy, and ultimately mental health issues. Self-stigma also comes at a functional cost. For example, internalized stigma may lead someone to not even apply for a job because they believe they aren’t capable.

Patients at McLean Hospital’s Behavioral Health Partial Hospital program often talk about mental health stigma. We conducted a study a few years ago to understand how internalized stigma might impact treatment outcomes. Here is what we found:

• People with higher levels of internalized stigma at admission had greater symptom severity and lower self-reported quality of life, functioning, and physical health at discharge (Pearl et al., 2016).
• During treatment, participants experienced an overall reduction in internalized stigma.
• Those who met the criteria for reliable change in internalized stigma also experienced greater improvements in most symptom outcomes.
• Results were consistent across participant characteristics such as race, sex, age, diagnosis, and suicide history.

We aren’t sure exactly what parts of our treatment helped to reduce patients’ internalized stigma. It could be a lot of things, and vary from person to person. I would predict that supportive and affirming interactions with other patients and staff helped. Perhaps psychoeducation received in our various group therapy sessions also helped to dispel some people’s beliefs about mental health symptoms.

One thing is for sure: As long as mental health stigma remains a societal issue, there is a need for interventions that help people on an individual level with their experience of internalized stigma. Psychologists have begun to develop and test interventions intended to help people better manage and understand the unique stigma-related stress they may experience. Many of these interventions have had promising preliminary results, both in reducing internalized mental health stigma, as well as bolstering associated mechanisms like self-esteem and hope.

A recent systematic review found that most self-stigma interventions are group-based, effectively reduce internalized stigma, and involve psychoeducation, cognitive behavioral theory, disclosure-focused interventions, or some combination of the three (Alonso et al., 2019).

For example, Coming Out Proud (Corrigan et al., 2013) is a 3-session group-based manualized protocol that is led by peers (individuals with lived experience with mental illness). Its emphasis is on the exploration and encouragement of an adaptive attitude towards disclosure of mental illness, as a means by which to fight self-stigma. They suggest there is a time and place for secrecy and a time and place for disclosure, and the course is designed to empower individuals to make choices with that in mind. This protocol may be especially powerful for fighting stigma because it is peer-led.

Another example is Narrative Enhancement and Cognitive Therapy (NECT; Yanos et al., 2011), a 20-session group-based manualized protocol led by a therapist. It is founded on the idea that many people with mental illness feel the need to reclaim and rediscover their identity and values, that may have been tainted by the societal perspective of their diagnosis. This treatment involves sharing experiences related to psychiatric illness, feedback from group members, psychoeducation around self-stigma, cognitive restructuring, and ultimately “narrative enhancement” wherein individuals are encouraged to construct, share, and perceive their narrative through a new lens.

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The strengths of group-based self-stigma interventions are clear: They facilitate peer interaction and open group conversations that may untangle and dispel shared negative stereotypes. However, as fear of being stigmatized, and the internalization of stigma have been highlighted as barriers to seeking mental health care, this format may also prove challenging to the accessibility of the intervention. Delivery of self-stigma interventions via other mediums, such as smartphones, may help reach individuals feeling reluctant to seek services or who live in areas where groups are not available. Regardless of the delivery method, it is clear that forming a strong community with people who share lived experiences of mental illness, can be healing.