Group Identity, Self-Disclosure, and the Self-Stigma of Mental Illness
Mental illness strikes with a double-edged sword. On one side are the symptoms, distress, and disabilities that result from the mental illness; on the other is the public stigma that robs people of rightful opportunities, such as work, housing, and healthcare. Internalizing this stigma leads to self-stigma, which can further impede a person's life goals. One of the best ways to challenge self-stigma is by associating with peers who have mental illness. This paper focuses on group-identity and self-disclosure as a way of controlling self-stigma.
We have distinguished the phenomenon of stigma into public and self forms. Public stigma occurs when members of the general public endorse stigmatizing attitudes, or stereotypes, about mental illness (eg, "All people with mental illness are dangerous") and act in a discriminatory manner (eg, "I want to avoid these people, so I will not hire them or rent an apartment to them"). People who endorse these stereotypes about themselves experience self-stigma.[1-4]
People with self-stigma agree with the stereotype, "All people with mental illness are to blame for their illness," and apply it to themselves (eg, "I am mentally ill so I must be responsible for my symptoms and disabilities"). This kind of self-talk leads to decrements in self-esteem (eg, "I am a bad person because I am to blame for my illness") and self-efficacy (eg, "I can't meet the demands of daily living"). The entire process results in a "Why try?" effect: "Why should I even try to get a job? A person like me is neither worthy of such a position nor able to take advantage of it."
"Why try?" clearly hinders a person's life opportunities. If someone is convinced that he or she is inept and unworthy, this person will not try to get a good job, rent a nice apartment, or obtain satisfactory healthcare. Ironically, the "Why try?" effect also undermines individuals' participation in the very treatments that can help them manage life goals in light of their illness, eg, "Why try the treatments for mental illness? I will not benefit from it." Given this state of being, it is important to identify strategies that address self-stigma and teach them to those who can benefit.
Research suggests that instead of being overwhelmed by stigma, many people become righteously angry because of the prejudice they experience.[5,6] This kind of reaction can empower people to change their role in the mental health system and become more active participants in their own treatment plans and push for improvements in the quality of services they receive. In addition, there is a third group that needs to be considered in describing the impact of self-stigma: individuals who seem to be indifferent to it altogether, ie, those whose sense of self is neither hurt, nor energized, by social stigma.
Beating Stigma Through Empowerment
Personal empowerment is viewed as the opposite of self-stigma. Being empowered means having control over one's treatment and one's life. Persons who have a strong sense of personal empowerment usually have high self-efficacy and self-esteem. Communities and health service providers can foster this personal empowerment in a variety of ways that involve giving consumers greater control over their own treatments and over their reintegration into the community. [9-11] At its most general level, fostering empowerment involves adopting a collaborative approach to treatment planning, in which a consumer ceases to be a mere passive recipient of services. This places the emphasis on the strengths and potential of a consumer rather than his or her weaknesses. Treatment programs should also form a partnership and seek feedback from consumers regarding service satisfaction and suggestions for improvement.
Beyond this, true empowerment services promote a consumer's self-determination in relation to employment opportunities, housing, and other areas of social life. Rather than a stigmatizing and coercive removal from the community, these new approaches provide community-based support for the consumer's continuing efforts to adapt to community living. This approach is typified by the 1980 Assertive Community Treatment (ACT) model of Stein and Test, in which services are brought directly to the consumer's home, workplace, or other meaningful community setting. Supported employment and education are also methods used to facilitate integrating persons with mental illness into the fabric of society. These approaches, which were given increased priority with the passage of the American with Disabilities Act in 1990, encourage the prompt placement of clients into employment and/or educational settings and provide supportive services for their continuing success in these settings.
Consumers can also empower themselves by becoming staff members of traditional treatment programs or they can create and run their own services. These may include lodges and clubhouses as well as self-help and mutual assistance groups. The Fountain House in New York is a paradigmatic example of consumer empowerment through mutual help. Fountain House does not focus on providing "treatment" for mental illness but rather on helping to develop the skills and talents of its "members," as participants are called -- a much less stigmatizing and more empowering label than "patient." It also implies an element of responsibility, as members are expected to take supportive and leadership roles in groups and in teams to accomplish the tasks required to maintain the clubhouse. Members and staff have equal status and work together to serve the clubhouse community. Services like these greatly increase consumers' sense of power, thereby challenging any stigma against which they may be struggling.
Group Identity and Coming Out
Programs like Fountain House are effective because they promote a sense of the "groupness" of people with mental illness. One variable that mitigates self-stigma's effects on self-esteem and self-efficacy is group identity. One might think that persons who belong to stigmatized groups would internalize the negativity that is aimed at that group, thereby provoking worse effects to self-stigma. Research shows, however, that persons who develop a positive identity by interacting with other members of the group will develop more positive self-perceptions. Moreover, persons who are involved in advocacy or self-help groups related to the stigma seem to develop better self-esteem.  Hence, participation in groups that promote identification counters the effects of self-stigma. Research on the effects of group identity on people with mental illness show clear patterns: participation in consumer-operated, mutual support groups produces more empowerment and less self-stigma.
People who are in the closet about their mental illness cannot easily participate in groups; they are concerned about such group affiliations because it can disclose the history of their mental illness. However, being in the closet also deprives a person of the kind of peer-to-peer interactions that can help them overcome this stigma.
Coming out is by no means an easy process. There are both costs and benefits to disclosing one's experiences with mental illness.[18,19] Benefits may include feeling less shame and being able to find peers with whom to share experiences of mental illness and its treatment. The costs to coming out may include contact with someone who is rejecting of a person with mental illness because of their fear of the mental illness, or it may include contact with healthcare professionals who feel that people of this group are incapable of making important medical decisions and therefore will treat them as children. Costs and benefits are likely to vary by situation and by role.
Coming out at work is different than doing so with neighbors or fellow churchgoers. Given the list of possible consequences, opting to disclose and how to disclose are not transparent decisions that all people stigmatized with mental illness should pursue in a set manner. Rather, individuals should weigh the costs involved against the benefits.
Disclosure is not a monolithic phenomenon but varies in several ways. Based on a review of the limited literature (Herold KPP, unpublished doctoral dissertation, 1995; Thampanichawat W, unpublished doctoral dissertation, 1999), we have been able to identify 4 levels of disclosure: social avoidance, secrecy, selective disclosure, and indiscriminant disclosure.
(1) Social Avoidance. One way to handle disclosure is to not tell anyone. This can be accomplished by avoiding situations where the public may find out about one's mental illness. People who are victimized by stigma may choose to not socialize with, live near, or work alongside persons without disabilities. They may prefer this kind of situation because they feel protected against people who might treat them cruelly because of their mental illness. Unfortunately, persons who choose to avoid the "normal" world lose out on all the benefits it can bring: free access to a broader set of opportunities and citizens who may be supportive of one's experience with mental illness. Moreover, social avoidance in some ways promotes stigma and discrimination, as it endorses the idea that persons with mental illness should be kept away from the rest of the world. Social avoidance may be a useful strategy during times when one's symptoms are intense and there is a need for respite from the demands of society. However, avoiding the "normal" world altogether will most likely prevent the achievement of life goals.
(2) Secrecy. Instead of avoiding work or community situations in order to keep one's experiences with mental illness private, many persons choose to enter the normal world but not share their experiences with others. They keep all aspects of their psychiatric experiences a secret -- both the impact of their illness and the interactions with the mental health system in its various manifestations. Some may argue that mental illness is readily apparent and can be inferred from a person's symptoms, dysfunctions, and disabilities; however, many of the experiences that are commonly associated with mental illness are not readily perceived and labeled by the public. 
There are 2 strategies to keeping experiences with mental illness a secret. The first seems easy: Don't tell anyone. A person does not share a history of hospitalizations, doctors, medications, and symptoms. If the first strategy for keeping experiences secret is an act of omission, the second strategy is an act of commission. Whether of not to explain the gaps in a past and current experience, or the work resumes with blank years because of hospitalizations, or the photo albums that don't include pictures from the time when they were actively coping with their illness, becomes part of a decision about how to disclose their mental illness. Without explanations, these gaps may cause coworkers or neighbors to wonder about other things, such as, "Why do they leave early to see a doctor every month?" or "What are those medicines they take at lunch?"
(3) Selective Disclosure. Keeping experiences with mental illness a secret prevents a person from taking advantage of the support and resources that may be available to them when they do need to disclose. Hence, many people decide to disclose their experiences with mental illness to a select set of friends and acquaintances (Bradmiller MA, unpublished doctoral dissertation, 1997). Choosing to disclose to some people and not others has its risks; those who find out may shun them. However, with the risk comes opportunity: finding others who are supportive. A decision to disclose to someone does not mean one must tell everything; choosing to disclose does not mean giving up all of one's privacy. Just as people can decide whom they may wish to disclose to, they can also decide the content of the disclosure.
(4) Indiscriminant Disclosure. Selective disclosure means there are select groups of people with whom information is shared and groups from whom this information remains a secret. People who choose indiscriminant disclosure abandon secrecy altogether. They no longer worry who finds out about their mental illness or treatment history. People choosing this option are relieved of the burden posed by keeping part of their lives underground.
Despite its benefits, indiscriminant disclosure requires a fairly hardy personality. Many people who find out about the disclosed information may react negatively to the revelation. Hence, people opting for indiscriminant disclosure need to assess whether or not they can cope with the disapproval that can result from bigoted reactions.
Self-stigma can be an additional burden to people with mental illness, but it is not an inevitable result of psychiatric disorder. Some people rally against stigma by choosing personal empowerment instead. Participation in programs that foster group identification and cohesion among peers helps to minimize self-stigma. There are several strategies for disclosure, but they vary in terms of their impact, and can precipitate both positive and negative effects. Ultimately, it is an individual's decision whether or not to disclose a history of mental illness.