Psychiatric Rehabilitation Journal 2015, Vol. 38, No. 2, 158 –163
© 2015 American Psychological Association 1095-158X/15/$12.00 http://dx.doi.org/10.1037/prj0000121
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Retrospective Accounts of Self-Stigma Experienced by Young People With Attention-Deficit/Hyperactivity Disorder (ADHD) or Depression Lynn McKeague and Eilis Hennessy
Claire O’Driscoll and Caroline Heary
University College Dublin
National University of Ireland
Objective: Little is known about self-stigma experienced by young people with mental health problems, despite the fact that research has demonstrated its existence. In the present study, we sought to investigate the experiences of self-stigma in childhood and adolescence, and particularly the nature of change in self-stigma across this developmental period. Young adults diagnosed with attention-deficit/hyperactivity disorder (ADHD) or depression before their 18th birthdays were interviewed about their experiences within their peer groups during childhood and adolescence. Methods: This qualitative study involved open-ended interviews with 16 young adults aged 18 –30 years. Interviews focused on the experience of stigmatization, responses to stigma, and how these changed over time. Results: Three main themes pertaining to self-stigma emerged: (a) being different, (b) peer stigmatization and associated experiences of self-stigma, and (c) selective disclosure and a move toward greater openness. The findings also suggested that the passing of time and changes in young people’s social networks and/or degrees of recovery were associated with changes in their experiences of self-stigma. Conclusions and Implications for Practice: During childhood and adolescence, self-stigma is characterized by a sense of being different from peers and negative self-evaluation as a consequence of that difference. However, our findings also demonstrated that some young people were prepared to challenge the stigma they experienced. Further research is needed to understand the factors that contribute to these differing responses and to develop antistigma interventions that facilitate the inclusion of young people with mental health problems in their peer groups. Keywords: attention-deficit/hyperactivity disorder (ADHD), depression, self-stigma, mental health, youth
lems internalize stigma in this way, this suggests that it is important to investigate whether stigma experiences are similarly internalized by children and adolescents. An additional reason for research on self-stigma during adolescence relates to the importance of establishing personal identity during this developmental stage (Erikson, 1968) and the centrality of the peer group in this process. For example, Newman and Newman (2001) speak about an intense preoccupation with group belonging during adolescence and Kroger (2007) emphasized the importance of friends and peers for testing “identity-related skills” (p 54). This focus on the peer group is linked to cognitive development and a newfound ability to think about groups and relationships among and within groups. Newman and Newman (2001) note that even the process of self-evaluation in adolescence takes place within this group context. In keeping with this, Moses (2010) found that among adolescents with mental health problems, the strongest correlate of self-stigma was the perception of having a social skills deficit. We know of no research to date on self-stigma in childhood, and research on self-stigma in adolescence is much more limited than in adulthood, although there are notable exceptions. For example, Moses (2009, 2010) explored the correlates of self-stigma and Kranke et al. (Kranke, Floersch, Kranke, & Munson, 2011) identified “differentness” as central to the experience in self-stigma in adolescence. The need for more research on this topic is evident, given that so many young people with mental health problems
Children and adolescents with mental health problems are more likely to be excluded from their peer groups and to have negative peer experiences than children and adolescents who don’t experience these problems (Hay, Payne & Chadwick, 2004). In addition, we know that researchers have identified the existence of stigma toward peers with mental health problems throughout childhood and adolescence (O’Driscoll, Heary, Hennessy & McKeague, 2012). It is now widely recognized that adults with mental health problems who have been stigmatized by others may also experience self-stigma (Krajewski, Burazeri, & Brand, 2013). Self-stigma occurs when individuals with mental health problems recognize the negative attitudes that exist among others, endorse these views, and believe that they are personally applicable, thus causing a loss in self-esteem (Corrigan & Watson, 2002). If adults with mental health prob-
This article was published Online First March 23, 2015. Lynn McKeague, BA, PhD and Eilis Hennessy, BA, PhD, School of Psychology, University College Dublin; Claire O’Driscoll, BA, MSc, PhD and Caroline Heary, BA, MPsychSc, PhD, Department of Psychology, National University of Ireland. Lynn McKeague and Claire O’Driscoll are now at the Institute of Psychiatry, King’s College London. Correspondence concerning this article should be addressed to Eilis Hennessy, School of Psychology, University College Dublin, Belfield, Dublin 4, Ireland. E-mail: [email protected] 158
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RETROSPECTIVE ACCOUNTS OF SELF-STIGMA
appear to struggle with peer relationships and may therefore be prone to internalize the stigma they experience within their peer groups. Despite concern about self-stigma, it is now increasingly acknowledged that not all persons with mental health problems react to experiences of being stigmatized by developing self-stigma, some may respond with indifference, righteous anger, or empowerment (Corrigan & Lundin, 2001; Corrigan & Watson, 2002). To date, none of the studies on adolescents with mental health problems have reported on such responses. Although researchers have established the existence of selfstigma in adolescence, we know nothing of self-stigma in childhood or of the developmental trajectory of self-stigma. It is also possible that children and adolescents are unable to accurately identify when they are being stigmatized (Mukolo, Heflinger, & Wallston, 2010) and this makes the identification of the onset and developmental course of self-stigma even more difficult. The present study was designed to add to our understanding of the developmental origins of self-stigma in childhood and/or adolescence. To achieve this end, we interviewed young adults who reflected on their childhood and adolescent years. These represent developmental periods during which we might expect stigma to be internalized. In addition, the centrality of peers for identity formation in late childhood and adolescence would suggest that such experiences might be particularly significant for the development of self-stigma. Thus, we chose to confine our focus to accounts of experiences within the peer group. The present study was part of a larger research project that also involved investigating experiences of self-stigma as reported by children and adolescents (10 –16 years of age) currently diagnosed with mental health problems and their parents. The overarching research questions that guided the present study were: (a) Do young adults recall experiencing stigmatization during childhood/ adolescence? (b) Do young adults recall internalizing the stigmatizing views of others during childhood/adolescence? (c) Do young adults report a change in the nature of stigmatization or self-stigma over time?
Method Ethical Approval Ethical approval for the study was granted by the University College Dublin, Human Research Ethics Committee - Humanities (HREC-HS).
Recruitment The recruitment strategy and number of participants was determined a priori. The intention was to ensure that data were collected from equal numbers of participants who had either ADHD or depression in childhood or adolescence, and to include both men and women with each condition. Because of high levels of comorbidity of anxiety with depression, those with a dual diagnosis were also included. Throughout this paper, we refer to this group as having a diagnosis of depression. The target sample size was 20 participants aged between 18 and 23, however difficulties with reaching this target resulted in broadening the age range to 18 to 30 years.
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Recruitment took place in 12 third-level educational facilities and through two support groups. One of these groups provided support specifically for young adults with ADHD and the other group provided support for individuals with depression. Recruitment strategies included online and hard copy advertisements (on notice boards) and distribution of information sent directly by student disability support services. The study inclusion criteria were: (a) received a diagnosis of depression or ADHD before the age of 18 years, and (b) currently aged 18 –30 years. The study exclusion criteria were: (a) participants with ADHD must not have received a comorbid diagnosis of depression in childhood or adolescence, and (b) participants with depression must not have received a comorbid diagnosis of ADHD during childhood or adolescence. All participants were given an information leaflet about the study and provided written consent. They did not receive compensation. All recruitment was completed before data analysis commenced, though transcription of recordings took place as soon after interviews as possible.
Participants In total, 16 young adults (nine women) who had a self-reported childhood diagnosis of ADHD or depression took part. The mean age of participants was 22.58 years (SD ⫽ 4.67 years), with an age range of 18 –30 years. All participants were White, reflecting the racial homogeneity of the institutions and country where they were recruited. Data available for each individual included sociodemographic characteristics, age at diagnosis and nature of diagnosed condition, current mental health status and medication, and duration of treatment. Details of participants are provided in Table 1.
Interview Schedule A semistructured interview with open-ended questions was used to generate qualitative data. A detailed schedule of questions was
Table 1 Characteristics of Young Adult Participants Variable
Mean
N
%
Age in years at data collection Gender Female Male Diagnosis Depression Attention-deficit/hyperactivity disorder Medication (in childhood/adolescence) Yes No Medication (at present) Yes No Age category in years 18–25 26–30 Highest level of education Secondary school completion Degree Completing degree at present
22.58
—
—
— —
9 7
56.25 43.75
— —
10 6
62.5 37.5
— —
13 3
81.25 18.75
— —
12 4
75 25
— —
12 4
75 25
— — —
1 1 14
6.25 6.25 87.5
MCKEAGUE, HENNESSY, O’DRISCOLL, AND HEARY
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developed; however, the open-ended nature of the questions allowed participants the freedom to describe experiences that were most pertinent to them (Barbour, 2001). To commence the interview, participants were asked to describe the time when they were first diagnosed. The remaining questions related to domains that were deemed relevant to self-stigma (e.g., peer relationships, disclosure to peers, reactions to stigma) and how experiences changed over time. The interview schedule did not explicitly refer to the issue of stigma. This ensured that participants were not induced to talk about stigma, and only did so if this it was something that was of personal relevance to them. Prompting was used to ensure that all necessary details were obtained on each topic. Questions included, “What particular difficulties do you think you faced in dealing with [condition] as a child . . . as an adolescent?” “Do you think the challenges that you faced changed at all as you moved from childhood to adolescence?” “Did you tell your classmates or friends that you had a diagnosis of [condition]?” “Describe your experiences of friendship as a child . . . as a teenager.” Interviews were conducted by the first author, who was in her early 20s at the time they took place. Interviews were scheduled for a time and place convenient to participants. These included the universities where they were studying, their own homes, and at the university where the study was based. Interviews ranged in length from 13 min to 1 hr, 27 min. All interviews were audio recorded and subsequently transcribed verbatim, and the names used in quotations below were generated by a random name generator.
The initial coding frame therefore reflected the raw data generated during interviews, the research questions relating to this study, and the literature. Following its initial development, the coding frame continued to be modified (e.g., by collapsing or merging codes) as subsequent transcripts were coded until each code represented a conceptually distinct aspect of stigmatization, which was then identified as a theme. Modifications to the coding frame were made based on discussion between the first author and the second author, who acted as the “analytical auditor.” When the final coding frame was agreed upon, the interview transcripts were saved to NVivo 10 (QSR International) and codes drawn from the coding frame were applied to each transcript. Data unrelated to the issue of stigma were not coded. The final revised version of the coding frame was subsequently applied to all transcripts. To capture how participants’ experiences of stigma changed over time, the first author relied on emerging observations from the data, i.e., differences in participants’ interpretation of their experiences at different points in their lives, but she also noted where participants reported change. Interrater reliability analysis was conducted on 10% of data within each of the themes that emerged and were drawn from across all transcripts by the first two authors. Internal reliability was acceptable, ⫽ 0.72, p ⬍ .001, 95% CI [0.66, 0.78]. The final stage of data analysis involved careful selection of extracts from the data to illustrate each theme (Elliott, Fischer, & Rennie, 1999).
Results Data Analysis Interviews were transcribed verbatim by the first author. Transcripts consisted of approximately 137, 000 words of text. During the process of familiarization with the data, the first author made detailed notes about each interview. Following this, the interviews were analyzed using thematic analysis (Braun & Clark, 2006). A hybrid approach of inductive and deductive coding (Fereday & Muir-Cochrane, 2006) was used, whereby the coding frame was developed by examination of the interview transcripts (inductive) as well as consideration of study research questions (deductive) and knowledge of existing literature (deductive). Four interview transcripts were selected as the basis for the formation of the initial coding frame. These transcripts were purposefully selected to represent participants who met different criteria (one male and one female with depression; one male and one female with ADHD). These interviews had been identified as capturing a broad range of issues relating to stigma, as their accounts seemed representative of perspectives provided by the sample as a whole.
Interviews provided accounts of living with ADHD or depression during childhood and/or adolescence. Our focus in this paper has been on accounts of peer stigmatization and whether young people reported internalizing such stigma. In addition, the analysis focused on evidence of changing responses over time and of responses that challenged stigma. Three main themes pertaining to self-stigma emerged: (a) being different, (b) responses to peer stigmatization, and (c) selective disclosure and a move toward greater openness. Sample quotations from each theme are presented in Table 2.
Being Different The dominant characterization of the experience of having a mental health problem during childhood and/or adolescence was of being “different” to others. The narratives on being different are relevant to self-stigma because for these participants, being different was interpreted negatively and contributed to negative selfevaluation. For example, Allyson (27, depression) recalled that, “I felt maybe different, or broken, or damaged.”
Table 2 Key Themes From Thematic Analysis of Young Adult Interviews Themes 1. Being different 2. Responses to peer stigmatization
3. Selective disclosure
Example quote “I felt maybe different, or broken, or damaged.” “I do remember socially having a lot of problems, and not being able to figure out what was wrong, and just kind of being like, ‘well why don’t they like me?’ I couldn’t figure it out. But looking back now, I can see that it was because I was kind of like always butting in and I was very bossy and stuff like that, which I think is very annoying for kids.” “I’m completely open, when I would have been really closed.”
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RETROSPECTIVE ACCOUNTS OF SELF-STIGMA
Some participants placed the feeling of difference within a specific developmental context, particularly in reference to adolescence. Joanne (25, depression) said, “. . . and a lot of teenagers are kind of paranoid about that, you know, being seen as weird or overly different, in a bad way.” Colm (22, depression) also referred to the teenage years as a time when it was important to avoid being viewed as different: “. . . as a teenager, you don’t want to be judged or classified or be thought of as in some way defective.” Within the context of avoiding feeling different as an adolescent, receiving a diagnosis of ADHD or depression was perceived as helpful by some participants because they could see that their experiences were more common than they had previously assumed. For Colm (22, depression), being diagnosed allowed him to view what he was going through as a “condition” and this helped him to see that the difficulties he was facing were not unique: “. . . it was a condition, and one that a lot of people suffer from.” For Allyson (27, depression), coming to the realization that the condition did not make her “special” or “unique” was an important turning point. She recalled coming to terms with the fact that “. . . there’s loads of people, there’s hundreds of people with depression or with manic depression, I’m not special for having this.” None of the participants reported a negative response to the experience of being diagnosed, although Tim (21, ADHD) reported that at age 8, he did not know about his diagnosis: “Well I wasn’t really aware of it at that stage, so I’d been diagnosed but I wouldn’t have known about it” and that as a teenager, he had not fully understood what it meant. “. . . In secondary school I can’t see how it would have come up. And again I wouldn’t have fully understood . . .”. Participants recalled that as they became older they developed a better understanding of their mental health problem and found ways to cope with the symptoms. Some reported that they now feel a sense of self-acceptance and have a new perspective on what it means to them to be “different” or “strange.” For example, Dylan (18, ADHD) reported that he no longer cared if others thought he was strange, because he had become confidant in the fact that he was his own person and felt accepted by the friends in whom he has confided. “. . . It doesn’t bother me if someone calls me strange.” Similarly, Tim (21, ADHD) said that he had come to appreciate the fact that he is different to others. “. . . I was strange, I am strange, I completely get that, and I love that now.”
Responses to Peer Stigmatization The potential path from peer stigmatization to self-stigma was evident in narratives of participants’ responses to their peers. These experiences caused some to become upset or to reinforce the experience of being different. For example, Tim (21, ADHD) said that, “With the bullying, it brought up all sorts of questions . . . under the stress, you question why are you different or why are you strange.” Dylan (18, ADHD) also described the negative implications of peer stigmatization. “. . . It kind of made me feel quite low at times.” Colm (22, depression) felt that the impact of peer victimization was more pervasive during adolescence than it had been in childhood. In primary school, just because you’re a child and you want the friendship and compassion of your peers, it just wasn’t nice not to be very popular and have these insults hurled at you on an almost daily basis. So I suppose as a child it was just upsetting and that’s about the
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extent of it, but then in secondary school I suppose it becomes psychologically effective.
He explained that as an adolescent being insulted was very difficult because . . . it made me feel like there was something very wrong with me. You know, that people thought it was hilarious and “Oh God, that’s embarrassing.” That’s the word, “embarrassed.” It made me feel very embarrassed. Like, “Why am I different than other people?” And it obviously is something to be derided, if they’re deriving humor from it, you know, instead of something to be taken seriously.
Leo (30, depression) also experienced persistent peer problems and feelings of isolation for much of his childhood and early adolescence. He said that his peers regarded him as “a weirdo” but his account also labeled his depression as a “weakness.” “They wouldn’t have known it was depression. I suppose they just recognize the weakness in you.” Gina (30, depression) also recalled feeling left out, but felt that this was self-inflicted. I felt like I was separate. I didn’t feel like people were leaving me out, I felt like it was me who was doing it. . . . I felt like there was a big, big circle around me, and that everyone was outside that circle.
However, alternative responses to victimization were also apparent. Some described how, over time, they began to retaliate against peers who victimized them. For example, Julia (19, depression) remembered standing up to the people who were bullying her. “I kind of snapped. . . . I had so much going on anyway, when I started being bullied, like she [the bully] really started to wreck my head [irritate me], and I stood up to her, and that’s all I’ll say. I didn’t beat her up or anything, but I stood up to her.” Jenna (19, depression) also recalled standing up to a friend who was treating her unfairly. “. . . At one point I just stopped her and I said ‘I think you’re treating me like shit, and I don’t like it.’” Another tactic for dealing with social difficulties was to befriend peers who were facing similar emotional or behavioral issues. It is possible that these peers were considered less likely to stigmatize. Colm (22, depression) believed that having depression influenced his choice of friends. “It affected my core group of friends. I became friends with people who were rather sensitive as I was, or who felt very hurt when they were insulted like I did, or who were just very emotional.” A number of participants with ADHD also befriended peers who were facing similar issues. For example, Dylan (18, ADHD) described how his limitless energy was difficult for the majority of peers to deal with but said that it was “. . . helpful finding people who were energetic and wouldn’t find me strange.” Amy (18, depression) described her ability to identify peers who were facing something similar. “I feel when you have it [a mental health problem] it’s like you just kind of hone in to other people that have it.” However, unlike other participants in this study, she was ambivalent about finding similar peers and recalled feeling that befriending these individuals would be counter to the process of recovery. I was kind of afraid . . . I’m low and they’re low . . . I didn’t know what that could lead to. And I was kind of thinking like if that led to me like trying to commit suicide again . . . I was like “I can’t go
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through that again, and I can’t put anyone else through that again.” So then I tried to kind of stay away from them.
Selective Disclosure
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Examination of participants’ narratives about disclosure provides insight into their awareness of societal stigma, particularly during their adolescent years. One way that some avoided stigma was by hiding the stigmatized identity (their disorder and associated behavior and emotions) from others by keeping it a secret. For example, Colm (22, depression) said that: . . . It’s different now. I’ve no problem with people knowing that I have these issues or conditions or whatever you like to call them, because I’m an adult. But as a teenager, you know, you don’t want to be judged or classified or be thought of as in some way defective, you know, so it was embarrassing.
Joanne (25, depression) said that as an adult, she is “not really ashamed” of her mental health difficulties. She recalled that this was not the case when she was an adolescent, when she had perceived her disorder as “embarrassing” and did not tell her peers because she wished to avoid being viewed as different. “You feel very isolated when you’re depressed and kind of don’t want to make yourself further ostracized, and that kind of thing, so you don’t want to feel any more different. You don’t want people to see you even more different.” However, a greater willingness to disclose was not universal and there were also narratives of selectivity, usually tied directly to negative experiences during childhood or early adolescence. Reasons for current reluctance to disclose were generally related to past experience. Amy (18, depression) reported that as a teenager she had been very forthcoming to her peers about her attempted suicide. However, instead of fostering supportive reactions by sharing this information, she found herself abandoned by her friends. This experience made her resolve to only tell people whom she could trust: “. . . it’s really not a good idea to tell everyone everything.” In fact, Amy had not told anyone about her mental health difficulties since starting university. “I felt like college was such a fresh start and I loved that no one knows anything about you. You know, so I just want to kind of keep it that way.”
Discussion In keeping with accounts of self-stigma development proposed by Corrigan and Watson (2002), participants recalled being aware of peer-group negative attitudes during their childhood and adolescence. Although the participants did not overtly endorse the stigmatizing views they experienced from their peers, they reported responding with negative self-evaluation, and in some cases, with self-blame. However, not all participants reported responding in this way. Some described a sense of injustice at being treated differently and stood up for themselves when they encountered differential treatment. Research with adults who have mental health problems have reported that reactions of empowerment and righteous anger are common responses to discrimination (Corrigan & Lundin, 2001; Corrigan & Watson, 2002). Our research builds on this work by demonstrating that such reactions may emerge during the teenage years. The narratives of being different that permeated participants’ interview transcripts are consistent with Newman and Newman’s
(2001) account of the intense desire for peer-group belonging in the adolescent years. Concern about being different is normative during the teenage years, so for these young people who were overtly different from their peers, either behaviorally or affectively, the sense of isolation was much more intense and they used words like “broken,” “damaged,” and “weak” to describe themselves. For some, having a diagnosis was positive, as it provided proof that others shared their experiences. This finding contrasts with the work of Moses (2009), who found that young people were unhappy with being labeled as having a mental health problem. However, the participants in Moses’ study were younger, were currently attending an integrated mental health service, and may have had more severe functional impairment. Analysis of how disclosure decisions changed from childhood or adolescence to adulthood proved particularly insightful. Consistent with the existing literature, a number of factors appear to have facilitated greater openness, including having established a stable group of friends (Rubin, Bukowski, Parker, & Bowker, 2008) as well as reduced concern about the image of themselves that they projected to others (Vrij, Paterson, Nunkoosing, Soukara, & Oosterwegel, 2003). The move toward greater openness was not ubiquitous for this sample, with anticipation of stigmatizing reactions standing between some young adults and the fulfillment of their desire to disclose.
Limitations This study has several limitations. The sample was small, was ethnically homogeneous, and included a high proportion of women with depression. However, given the exploratory nature of the study, these limitations should not be seen as detracting from our findings, as many of the issues relating to self-stigma that emerged may serve to encourage further investigation with larger and more diverse samples. Another limitation of the sample is the overrepresentation of young adults who had reached third-level education. Research has suggested that having a mental health problem in childhood or adolescence is associated with higher odds of early termination of education, particularly for termination prior to completion of secondary education, thus limiting progression to thirdlevel college (Lee et al., 2009). Thus, our participants may be among the most resilient of those who experienced mental health problems in childhood or adolescence, or may have experienced milder symptoms than peers with the same diagnoses, as the majority of them had successfully completed secondary school and transferred to college. There are also potential biases inherent in the use of retrospective recall (Brewin, Andrews, & Gottlieb, 1993), which may have influenced the participants’ accounts of their experiences. Our decision to include retrospective narratives was designed to allow for the analysis of change in stigma experiences throughout time. We were also concerned that children and adolescents might not recognize public stigma directed toward them. It is possible that participants’ interpretation of their childhood or adolescent experiences were influenced by subsequent experiences, such as recovery or relapse or success vs. failure within the education system, although recent research has confirmed the stability over time of retrospective accounts of childhood experiences (Pinto, Correia, & Maia, 2014).
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Conclusion and Implications In this research project, young adults provided narrative accounts of living with a mental health problem in childhood or adolescence. Their accounts suggest that they were aware of being stigmatized by their peers; reactions to this stigma included feelings of being different from everyone else, personal distress, negative self-evaluation and, in some young people’s accounts, were directly linked to self-blame. These are all responses that have been associated with self-stigma. Not all participants reported such feelings, though, which is important to note, and there was also evidence of anger toward those who stigmatized them. Participants spoke about using selective disclosure because of their anticipation of stigma during childhood and/or adolescence, though some spoke of greater openness as they got older. These findings reinforce the need identified by many other authors for antistigma interventions during the school years to reduce or eliminate stigma toward peers with mental health problems. Our findings also highlight the need for additional research to investigate why children and adolescents respond in different ways to the stigmatizing actions of their peers. Further research is also needed on the advantages and disadvantages of disclosure and the contexts in which disclosure can be helpful to young people with mental health problems.
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Hay, D. F., Payne, A., & Chadwick, A. (2004). Peer relations in childhood. Journal of Child Psychology and Psychiatry, 45, 84 –108. http://dx.doi .org/10.1046/j.0021-9630.2003.00308.x Krajewski, C., Burazeri, G., & Brand, H. (2013). Self-stigma, perceived discrimination and empowerment among people with a mental illness in six countries: Pan European stigma study. Psychiatry Research, 210, 1136 –1146. http://dx.doi.org/10.1016/j.psychres.2013.08.013 Kranke, D. A., Floersch, J., Kranke, B. O., & Munson, M. R. (2011). A qualitative investigation of self-stigma among adolescents taking psychiatric medication. Psychiatric Services, 62, 893– 899. http://dx.doi .org/10.1176/ps.62.8.pss6208_0893 Kroger, J. (2007). Identity development: Adolescence through adulthood. London, UK: Sage. Lee, S., Tsang, A., Breslau, J., Aguilar-Gaxiola, S., Angermeyer, M., Borges, G., . . . Kessler, R. C. (2009). Mental disorders and termination of education in high-income and low- and middle-income countries: Epidemiological study. The British Journal of Psychiatry, 194, 411– 417. http://dx.doi.org/10.1192/bjp.bp.108.054841 Moses, T. (2009). Self-labeling and its effects among adolescents diagnosed with mental disorders. Social Science & Medicine, 68, 570 –578. http://dx.doi.org/10.1016/j.socscimed.2008.11.003 Moses, T. (2010). Being treated differently: Stigma experiences with family, peers, and school staff among adolescents with mental health disorders. Social Science & Medicine, 70, 985–993. http://dx.doi.org/ 10.1016/j.socscimed.2009.12.022 Mukolo, A., Heflinger, C. A., & Wallston, K. A. (2010). The stigma of childhood mental disorders: A conceptual framework. Journal of the American Academy of Child & Adolescent Psychiatry, 49, 92–103. Newman, B. M., & Newman, P. R. (2001). Group identity and alienation: Giving the we its due. Journal of Youth and Adolescence, 30, 515–538. http://dx.doi.org/10.1023/A:1010480003929 O’Driscoll, C., Heary, C., Hennessy, E., & McKeague, L. (2012). Explicit and implicit stigma towards peers with mental health problems in childhood and adolescence. Journal of Child Psychology and Psychiatry, 53, 1054 –1062. http://dx.doi.org/10.1111/j.1469-7610.2012 .02580.x Pinto, R., Correia, L., & Maia, Â. (2014). Assessing the reliability of retrospective reports of adverse childhood experiences among adolescents with documented childhood maltreatment. Journal of Family Violence, 29, 431– 438. http://dx.doi.org/10.1007/s10896-014-9602-9 Rubin, K. H., Bukowski, W. M., Parker, J. G., & Bowker, J. C. (2008). Peer interactions, relationships, and groups. In W. Damon & R. M. Lerner (Eds.), Child and adolescent development: An advanced course (pp. 141–180). Hoboken, NJ: Wiley. Vrij, A., Paterson, B., Nunkoosing, K., Soukara, S., & Oosterwegel, A. (2003). Perceived advantages and disadvantages of secrets disclosure. Personality and Individual Differences, 35, 593– 602. http://dx.doi.org/ 10.1016/S0191-8869(02)00221-0
Received March 26, 2014 Revision received January 6, 2015 Accepted January 6, 2015 䡲
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Retrospective Accounts of Self-Stigma Experienced by Young People With Attention-Deficit/Hyperactivity Disorder (ADHD) or Depression Lynn McKeague and Eilis Hennessy
Claire O’Driscoll and Caroline Heary
University College Dublin
National University of Ireland
Objective: Little is known about self-stigma experienced by young people with mental health problems, despite the fact that research has demonstrated its existence. In the present study, we sought to investigate the experiences of self-stigma in childhood and adolescence, and particularly the nature of change in self-stigma across this developmental period. Young adults diagnosed with attention-deficit/hyperactivity disorder (ADHD) or depression before their 18th birthdays were interviewed about their experiences within their peer groups during childhood and adolescence. Methods: This qualitative study involved open-ended interviews with 16 young adults aged 18 –30 years. Interviews focused on the experience of stigmatization, responses to stigma, and how these changed over time. Results: Three main themes pertaining to self-stigma emerged: (a) being different, (b) peer stigmatization and associated experiences of self-stigma, and (c) selective disclosure and a move toward greater openness. The findings also suggested that the passing of time and changes in young people’s social networks and/or degrees of recovery were associated with changes in their experiences of self-stigma. Conclusions and Implications for Practice: During childhood and adolescence, self-stigma is characterized by a sense of being different from peers and negative self-evaluation as a consequence of that difference. However, our findings also demonstrated that some young people were prepared to challenge the stigma they experienced. Further research is needed to understand the factors that contribute to these differing responses and to develop antistigma interventions that facilitate the inclusion of young people with mental health problems in their peer groups. Keywords: attention-deficit/hyperactivity disorder (ADHD), depression, self-stigma, mental health, youth
lems internalize stigma in this way, this suggests that it is important to investigate whether stigma experiences are similarly internalized by children and adolescents. An additional reason for research on self-stigma during adolescence relates to the importance of establishing personal identity during this developmental stage (Erikson, 1968) and the centrality of the peer group in this process. For example, Newman and Newman (2001) speak about an intense preoccupation with group belonging during adolescence and Kroger (2007) emphasized the importance of friends and peers for testing “identity-related skills” (p 54). This focus on the peer group is linked to cognitive development and a newfound ability to think about groups and relationships among and within groups. Newman and Newman (2001) note that even the process of self-evaluation in adolescence takes place within this group context. In keeping with this, Moses (2010) found that among adolescents with mental health problems, the strongest correlate of self-stigma was the perception of having a social skills deficit. We know of no research to date on self-stigma in childhood, and research on self-stigma in adolescence is much more limited than in adulthood, although there are notable exceptions. For example, Moses (2009, 2010) explored the correlates of self-stigma and Kranke et al. (Kranke, Floersch, Kranke, & Munson, 2011) identified “differentness” as central to the experience in self-stigma in adolescence. The need for more research on this topic is evident, given that so many young people with mental health problems
Children and adolescents with mental health problems are more likely to be excluded from their peer groups and to have negative peer experiences than children and adolescents who don’t experience these problems (Hay, Payne & Chadwick, 2004). In addition, we know that researchers have identified the existence of stigma toward peers with mental health problems throughout childhood and adolescence (O’Driscoll, Heary, Hennessy & McKeague, 2012). It is now widely recognized that adults with mental health problems who have been stigmatized by others may also experience self-stigma (Krajewski, Burazeri, & Brand, 2013). Self-stigma occurs when individuals with mental health problems recognize the negative attitudes that exist among others, endorse these views, and believe that they are personally applicable, thus causing a loss in self-esteem (Corrigan & Watson, 2002). If adults with mental health prob-
This article was published Online First March 23, 2015. Lynn McKeague, BA, PhD and Eilis Hennessy, BA, PhD, School of Psychology, University College Dublin; Claire O’Driscoll, BA, MSc, PhD and Caroline Heary, BA, MPsychSc, PhD, Department of Psychology, National University of Ireland. Lynn McKeague and Claire O’Driscoll are now at the Institute of Psychiatry, King’s College London. Correspondence concerning this article should be addressed to Eilis Hennessy, School of Psychology, University College Dublin, Belfield, Dublin 4, Ireland. E-mail: [email protected] 158
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RETROSPECTIVE ACCOUNTS OF SELF-STIGMA
appear to struggle with peer relationships and may therefore be prone to internalize the stigma they experience within their peer groups. Despite concern about self-stigma, it is now increasingly acknowledged that not all persons with mental health problems react to experiences of being stigmatized by developing self-stigma, some may respond with indifference, righteous anger, or empowerment (Corrigan & Lundin, 2001; Corrigan & Watson, 2002). To date, none of the studies on adolescents with mental health problems have reported on such responses. Although researchers have established the existence of selfstigma in adolescence, we know nothing of self-stigma in childhood or of the developmental trajectory of self-stigma. It is also possible that children and adolescents are unable to accurately identify when they are being stigmatized (Mukolo, Heflinger, & Wallston, 2010) and this makes the identification of the onset and developmental course of self-stigma even more difficult. The present study was designed to add to our understanding of the developmental origins of self-stigma in childhood and/or adolescence. To achieve this end, we interviewed young adults who reflected on their childhood and adolescent years. These represent developmental periods during which we might expect stigma to be internalized. In addition, the centrality of peers for identity formation in late childhood and adolescence would suggest that such experiences might be particularly significant for the development of self-stigma. Thus, we chose to confine our focus to accounts of experiences within the peer group. The present study was part of a larger research project that also involved investigating experiences of self-stigma as reported by children and adolescents (10 –16 years of age) currently diagnosed with mental health problems and their parents. The overarching research questions that guided the present study were: (a) Do young adults recall experiencing stigmatization during childhood/ adolescence? (b) Do young adults recall internalizing the stigmatizing views of others during childhood/adolescence? (c) Do young adults report a change in the nature of stigmatization or self-stigma over time?
Method Ethical Approval Ethical approval for the study was granted by the University College Dublin, Human Research Ethics Committee - Humanities (HREC-HS).
Recruitment The recruitment strategy and number of participants was determined a priori. The intention was to ensure that data were collected from equal numbers of participants who had either ADHD or depression in childhood or adolescence, and to include both men and women with each condition. Because of high levels of comorbidity of anxiety with depression, those with a dual diagnosis were also included. Throughout this paper, we refer to this group as having a diagnosis of depression. The target sample size was 20 participants aged between 18 and 23, however difficulties with reaching this target resulted in broadening the age range to 18 to 30 years.
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Recruitment took place in 12 third-level educational facilities and through two support groups. One of these groups provided support specifically for young adults with ADHD and the other group provided support for individuals with depression. Recruitment strategies included online and hard copy advertisements (on notice boards) and distribution of information sent directly by student disability support services. The study inclusion criteria were: (a) received a diagnosis of depression or ADHD before the age of 18 years, and (b) currently aged 18 –30 years. The study exclusion criteria were: (a) participants with ADHD must not have received a comorbid diagnosis of depression in childhood or adolescence, and (b) participants with depression must not have received a comorbid diagnosis of ADHD during childhood or adolescence. All participants were given an information leaflet about the study and provided written consent. They did not receive compensation. All recruitment was completed before data analysis commenced, though transcription of recordings took place as soon after interviews as possible.
Participants In total, 16 young adults (nine women) who had a self-reported childhood diagnosis of ADHD or depression took part. The mean age of participants was 22.58 years (SD ⫽ 4.67 years), with an age range of 18 –30 years. All participants were White, reflecting the racial homogeneity of the institutions and country where they were recruited. Data available for each individual included sociodemographic characteristics, age at diagnosis and nature of diagnosed condition, current mental health status and medication, and duration of treatment. Details of participants are provided in Table 1.
Interview Schedule A semistructured interview with open-ended questions was used to generate qualitative data. A detailed schedule of questions was
Table 1 Characteristics of Young Adult Participants Variable
Mean
N
%
Age in years at data collection Gender Female Male Diagnosis Depression Attention-deficit/hyperactivity disorder Medication (in childhood/adolescence) Yes No Medication (at present) Yes No Age category in years 18–25 26–30 Highest level of education Secondary school completion Degree Completing degree at present
22.58
—
—
— —
9 7
56.25 43.75
— —
10 6
62.5 37.5
— —
13 3
81.25 18.75
— —
12 4
75 25
— —
12 4
75 25
— — —
1 1 14
6.25 6.25 87.5
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developed; however, the open-ended nature of the questions allowed participants the freedom to describe experiences that were most pertinent to them (Barbour, 2001). To commence the interview, participants were asked to describe the time when they were first diagnosed. The remaining questions related to domains that were deemed relevant to self-stigma (e.g., peer relationships, disclosure to peers, reactions to stigma) and how experiences changed over time. The interview schedule did not explicitly refer to the issue of stigma. This ensured that participants were not induced to talk about stigma, and only did so if this it was something that was of personal relevance to them. Prompting was used to ensure that all necessary details were obtained on each topic. Questions included, “What particular difficulties do you think you faced in dealing with [condition] as a child . . . as an adolescent?” “Do you think the challenges that you faced changed at all as you moved from childhood to adolescence?” “Did you tell your classmates or friends that you had a diagnosis of [condition]?” “Describe your experiences of friendship as a child . . . as a teenager.” Interviews were conducted by the first author, who was in her early 20s at the time they took place. Interviews were scheduled for a time and place convenient to participants. These included the universities where they were studying, their own homes, and at the university where the study was based. Interviews ranged in length from 13 min to 1 hr, 27 min. All interviews were audio recorded and subsequently transcribed verbatim, and the names used in quotations below were generated by a random name generator.
The initial coding frame therefore reflected the raw data generated during interviews, the research questions relating to this study, and the literature. Following its initial development, the coding frame continued to be modified (e.g., by collapsing or merging codes) as subsequent transcripts were coded until each code represented a conceptually distinct aspect of stigmatization, which was then identified as a theme. Modifications to the coding frame were made based on discussion between the first author and the second author, who acted as the “analytical auditor.” When the final coding frame was agreed upon, the interview transcripts were saved to NVivo 10 (QSR International) and codes drawn from the coding frame were applied to each transcript. Data unrelated to the issue of stigma were not coded. The final revised version of the coding frame was subsequently applied to all transcripts. To capture how participants’ experiences of stigma changed over time, the first author relied on emerging observations from the data, i.e., differences in participants’ interpretation of their experiences at different points in their lives, but she also noted where participants reported change. Interrater reliability analysis was conducted on 10% of data within each of the themes that emerged and were drawn from across all transcripts by the first two authors. Internal reliability was acceptable, ⫽ 0.72, p ⬍ .001, 95% CI [0.66, 0.78]. The final stage of data analysis involved careful selection of extracts from the data to illustrate each theme (Elliott, Fischer, & Rennie, 1999).
Results Data Analysis Interviews were transcribed verbatim by the first author. Transcripts consisted of approximately 137, 000 words of text. During the process of familiarization with the data, the first author made detailed notes about each interview. Following this, the interviews were analyzed using thematic analysis (Braun & Clark, 2006). A hybrid approach of inductive and deductive coding (Fereday & Muir-Cochrane, 2006) was used, whereby the coding frame was developed by examination of the interview transcripts (inductive) as well as consideration of study research questions (deductive) and knowledge of existing literature (deductive). Four interview transcripts were selected as the basis for the formation of the initial coding frame. These transcripts were purposefully selected to represent participants who met different criteria (one male and one female with depression; one male and one female with ADHD). These interviews had been identified as capturing a broad range of issues relating to stigma, as their accounts seemed representative of perspectives provided by the sample as a whole.
Interviews provided accounts of living with ADHD or depression during childhood and/or adolescence. Our focus in this paper has been on accounts of peer stigmatization and whether young people reported internalizing such stigma. In addition, the analysis focused on evidence of changing responses over time and of responses that challenged stigma. Three main themes pertaining to self-stigma emerged: (a) being different, (b) responses to peer stigmatization, and (c) selective disclosure and a move toward greater openness. Sample quotations from each theme are presented in Table 2.
Being Different The dominant characterization of the experience of having a mental health problem during childhood and/or adolescence was of being “different” to others. The narratives on being different are relevant to self-stigma because for these participants, being different was interpreted negatively and contributed to negative selfevaluation. For example, Allyson (27, depression) recalled that, “I felt maybe different, or broken, or damaged.”
Table 2 Key Themes From Thematic Analysis of Young Adult Interviews Themes 1. Being different 2. Responses to peer stigmatization
3. Selective disclosure
Example quote “I felt maybe different, or broken, or damaged.” “I do remember socially having a lot of problems, and not being able to figure out what was wrong, and just kind of being like, ‘well why don’t they like me?’ I couldn’t figure it out. But looking back now, I can see that it was because I was kind of like always butting in and I was very bossy and stuff like that, which I think is very annoying for kids.” “I’m completely open, when I would have been really closed.”
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RETROSPECTIVE ACCOUNTS OF SELF-STIGMA
Some participants placed the feeling of difference within a specific developmental context, particularly in reference to adolescence. Joanne (25, depression) said, “. . . and a lot of teenagers are kind of paranoid about that, you know, being seen as weird or overly different, in a bad way.” Colm (22, depression) also referred to the teenage years as a time when it was important to avoid being viewed as different: “. . . as a teenager, you don’t want to be judged or classified or be thought of as in some way defective.” Within the context of avoiding feeling different as an adolescent, receiving a diagnosis of ADHD or depression was perceived as helpful by some participants because they could see that their experiences were more common than they had previously assumed. For Colm (22, depression), being diagnosed allowed him to view what he was going through as a “condition” and this helped him to see that the difficulties he was facing were not unique: “. . . it was a condition, and one that a lot of people suffer from.” For Allyson (27, depression), coming to the realization that the condition did not make her “special” or “unique” was an important turning point. She recalled coming to terms with the fact that “. . . there’s loads of people, there’s hundreds of people with depression or with manic depression, I’m not special for having this.” None of the participants reported a negative response to the experience of being diagnosed, although Tim (21, ADHD) reported that at age 8, he did not know about his diagnosis: “Well I wasn’t really aware of it at that stage, so I’d been diagnosed but I wouldn’t have known about it” and that as a teenager, he had not fully understood what it meant. “. . . In secondary school I can’t see how it would have come up. And again I wouldn’t have fully understood . . .”. Participants recalled that as they became older they developed a better understanding of their mental health problem and found ways to cope with the symptoms. Some reported that they now feel a sense of self-acceptance and have a new perspective on what it means to them to be “different” or “strange.” For example, Dylan (18, ADHD) reported that he no longer cared if others thought he was strange, because he had become confidant in the fact that he was his own person and felt accepted by the friends in whom he has confided. “. . . It doesn’t bother me if someone calls me strange.” Similarly, Tim (21, ADHD) said that he had come to appreciate the fact that he is different to others. “. . . I was strange, I am strange, I completely get that, and I love that now.”
Responses to Peer Stigmatization The potential path from peer stigmatization to self-stigma was evident in narratives of participants’ responses to their peers. These experiences caused some to become upset or to reinforce the experience of being different. For example, Tim (21, ADHD) said that, “With the bullying, it brought up all sorts of questions . . . under the stress, you question why are you different or why are you strange.” Dylan (18, ADHD) also described the negative implications of peer stigmatization. “. . . It kind of made me feel quite low at times.” Colm (22, depression) felt that the impact of peer victimization was more pervasive during adolescence than it had been in childhood. In primary school, just because you’re a child and you want the friendship and compassion of your peers, it just wasn’t nice not to be very popular and have these insults hurled at you on an almost daily basis. So I suppose as a child it was just upsetting and that’s about the
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extent of it, but then in secondary school I suppose it becomes psychologically effective.
He explained that as an adolescent being insulted was very difficult because . . . it made me feel like there was something very wrong with me. You know, that people thought it was hilarious and “Oh God, that’s embarrassing.” That’s the word, “embarrassed.” It made me feel very embarrassed. Like, “Why am I different than other people?” And it obviously is something to be derided, if they’re deriving humor from it, you know, instead of something to be taken seriously.
Leo (30, depression) also experienced persistent peer problems and feelings of isolation for much of his childhood and early adolescence. He said that his peers regarded him as “a weirdo” but his account also labeled his depression as a “weakness.” “They wouldn’t have known it was depression. I suppose they just recognize the weakness in you.” Gina (30, depression) also recalled feeling left out, but felt that this was self-inflicted. I felt like I was separate. I didn’t feel like people were leaving me out, I felt like it was me who was doing it. . . . I felt like there was a big, big circle around me, and that everyone was outside that circle.
However, alternative responses to victimization were also apparent. Some described how, over time, they began to retaliate against peers who victimized them. For example, Julia (19, depression) remembered standing up to the people who were bullying her. “I kind of snapped. . . . I had so much going on anyway, when I started being bullied, like she [the bully] really started to wreck my head [irritate me], and I stood up to her, and that’s all I’ll say. I didn’t beat her up or anything, but I stood up to her.” Jenna (19, depression) also recalled standing up to a friend who was treating her unfairly. “. . . At one point I just stopped her and I said ‘I think you’re treating me like shit, and I don’t like it.’” Another tactic for dealing with social difficulties was to befriend peers who were facing similar emotional or behavioral issues. It is possible that these peers were considered less likely to stigmatize. Colm (22, depression) believed that having depression influenced his choice of friends. “It affected my core group of friends. I became friends with people who were rather sensitive as I was, or who felt very hurt when they were insulted like I did, or who were just very emotional.” A number of participants with ADHD also befriended peers who were facing similar issues. For example, Dylan (18, ADHD) described how his limitless energy was difficult for the majority of peers to deal with but said that it was “. . . helpful finding people who were energetic and wouldn’t find me strange.” Amy (18, depression) described her ability to identify peers who were facing something similar. “I feel when you have it [a mental health problem] it’s like you just kind of hone in to other people that have it.” However, unlike other participants in this study, she was ambivalent about finding similar peers and recalled feeling that befriending these individuals would be counter to the process of recovery. I was kind of afraid . . . I’m low and they’re low . . . I didn’t know what that could lead to. And I was kind of thinking like if that led to me like trying to commit suicide again . . . I was like “I can’t go
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through that again, and I can’t put anyone else through that again.” So then I tried to kind of stay away from them.
Selective Disclosure
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Examination of participants’ narratives about disclosure provides insight into their awareness of societal stigma, particularly during their adolescent years. One way that some avoided stigma was by hiding the stigmatized identity (their disorder and associated behavior and emotions) from others by keeping it a secret. For example, Colm (22, depression) said that: . . . It’s different now. I’ve no problem with people knowing that I have these issues or conditions or whatever you like to call them, because I’m an adult. But as a teenager, you know, you don’t want to be judged or classified or be thought of as in some way defective, you know, so it was embarrassing.
Joanne (25, depression) said that as an adult, she is “not really ashamed” of her mental health difficulties. She recalled that this was not the case when she was an adolescent, when she had perceived her disorder as “embarrassing” and did not tell her peers because she wished to avoid being viewed as different. “You feel very isolated when you’re depressed and kind of don’t want to make yourself further ostracized, and that kind of thing, so you don’t want to feel any more different. You don’t want people to see you even more different.” However, a greater willingness to disclose was not universal and there were also narratives of selectivity, usually tied directly to negative experiences during childhood or early adolescence. Reasons for current reluctance to disclose were generally related to past experience. Amy (18, depression) reported that as a teenager she had been very forthcoming to her peers about her attempted suicide. However, instead of fostering supportive reactions by sharing this information, she found herself abandoned by her friends. This experience made her resolve to only tell people whom she could trust: “. . . it’s really not a good idea to tell everyone everything.” In fact, Amy had not told anyone about her mental health difficulties since starting university. “I felt like college was such a fresh start and I loved that no one knows anything about you. You know, so I just want to kind of keep it that way.”
Discussion In keeping with accounts of self-stigma development proposed by Corrigan and Watson (2002), participants recalled being aware of peer-group negative attitudes during their childhood and adolescence. Although the participants did not overtly endorse the stigmatizing views they experienced from their peers, they reported responding with negative self-evaluation, and in some cases, with self-blame. However, not all participants reported responding in this way. Some described a sense of injustice at being treated differently and stood up for themselves when they encountered differential treatment. Research with adults who have mental health problems have reported that reactions of empowerment and righteous anger are common responses to discrimination (Corrigan & Lundin, 2001; Corrigan & Watson, 2002). Our research builds on this work by demonstrating that such reactions may emerge during the teenage years. The narratives of being different that permeated participants’ interview transcripts are consistent with Newman and Newman’s
(2001) account of the intense desire for peer-group belonging in the adolescent years. Concern about being different is normative during the teenage years, so for these young people who were overtly different from their peers, either behaviorally or affectively, the sense of isolation was much more intense and they used words like “broken,” “damaged,” and “weak” to describe themselves. For some, having a diagnosis was positive, as it provided proof that others shared their experiences. This finding contrasts with the work of Moses (2009), who found that young people were unhappy with being labeled as having a mental health problem. However, the participants in Moses’ study were younger, were currently attending an integrated mental health service, and may have had more severe functional impairment. Analysis of how disclosure decisions changed from childhood or adolescence to adulthood proved particularly insightful. Consistent with the existing literature, a number of factors appear to have facilitated greater openness, including having established a stable group of friends (Rubin, Bukowski, Parker, & Bowker, 2008) as well as reduced concern about the image of themselves that they projected to others (Vrij, Paterson, Nunkoosing, Soukara, & Oosterwegel, 2003). The move toward greater openness was not ubiquitous for this sample, with anticipation of stigmatizing reactions standing between some young adults and the fulfillment of their desire to disclose.
Limitations This study has several limitations. The sample was small, was ethnically homogeneous, and included a high proportion of women with depression. However, given the exploratory nature of the study, these limitations should not be seen as detracting from our findings, as many of the issues relating to self-stigma that emerged may serve to encourage further investigation with larger and more diverse samples. Another limitation of the sample is the overrepresentation of young adults who had reached third-level education. Research has suggested that having a mental health problem in childhood or adolescence is associated with higher odds of early termination of education, particularly for termination prior to completion of secondary education, thus limiting progression to thirdlevel college (Lee et al., 2009). Thus, our participants may be among the most resilient of those who experienced mental health problems in childhood or adolescence, or may have experienced milder symptoms than peers with the same diagnoses, as the majority of them had successfully completed secondary school and transferred to college. There are also potential biases inherent in the use of retrospective recall (Brewin, Andrews, & Gottlieb, 1993), which may have influenced the participants’ accounts of their experiences. Our decision to include retrospective narratives was designed to allow for the analysis of change in stigma experiences throughout time. We were also concerned that children and adolescents might not recognize public stigma directed toward them. It is possible that participants’ interpretation of their childhood or adolescent experiences were influenced by subsequent experiences, such as recovery or relapse or success vs. failure within the education system, although recent research has confirmed the stability over time of retrospective accounts of childhood experiences (Pinto, Correia, & Maia, 2014).
RETROSPECTIVE ACCOUNTS OF SELF-STIGMA
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Conclusion and Implications In this research project, young adults provided narrative accounts of living with a mental health problem in childhood or adolescence. Their accounts suggest that they were aware of being stigmatized by their peers; reactions to this stigma included feelings of being different from everyone else, personal distress, negative self-evaluation and, in some young people’s accounts, were directly linked to self-blame. These are all responses that have been associated with self-stigma. Not all participants reported such feelings, though, which is important to note, and there was also evidence of anger toward those who stigmatized them. Participants spoke about using selective disclosure because of their anticipation of stigma during childhood and/or adolescence, though some spoke of greater openness as they got older. These findings reinforce the need identified by many other authors for antistigma interventions during the school years to reduce or eliminate stigma toward peers with mental health problems. Our findings also highlight the need for additional research to investigate why children and adolescents respond in different ways to the stigmatizing actions of their peers. Further research is also needed on the advantages and disadvantages of disclosure and the contexts in which disclosure can be helpful to young people with mental health problems.
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Received March 26, 2014 Revision received January 6, 2015 Accepted January 6, 2015 䡲
