Elsevier

Social Science & Medicine

Volume 71, Issue 12, December 2010, Pages 2150-2161
Social Science & Medicine

Correlates and consequences of internalized stigma for people living with mental illness: A systematic review and meta-analysis

https://doi.org/10.1016/j.socscimed.2010.09.030Get rights and content

Abstract

An expansive body of research has investigated the experiences and adverse consequences of internalized stigma for people with mental illness. This article provides a systematic review and meta-analysis of the extant research regarding the empirical relationship between internalized stigma and a range of sociodemographic, psychosocial, and psychiatric variables for people who live with mental illness. An exhaustive review of the research literature was performed on all articles published in English that assessed a statistical relationship between internalized stigma and at least one other variable for adults who live with mental illness. In total, 127 articles met the inclusion criteria for systematic review, of which, data from 45 articles were extracted for meta-analyses. None of the sociodemographic variables that were included in the study were consistently or strongly correlated with levels of internalized stigma. The review uncovered a striking and robust negative relationship between internalized stigma and a range of psychosocial variables (e.g., hope, self-esteem, and empowerment). Regarding psychiatric variables, internalized stigma was positively associated with psychiatric symptom severity and negatively associated with treatment adherence. The review draws attention to the lack of longitudinal research in this area of study which has inhibited the clinical relevance of findings related to internalized stigma. The study also highlights the need for greater attention on disentangling the true nature of the relationship between internalized stigma and other psychosocial variables.

Introduction

Stigma is an insidious social force that has been associated with an endless number of attributes, circumstances, health conditions, and social groups – with the literature primarily concentrated on race, sexuality, mental illness, and HIV/AIDS (Manzo, 2004). The focus of this paper is on the stigma of mental illness. More specifically, it investigates the correlates and consequences of internalized stigma, also known as self-stigma, for people living with mental illness.

Conceptual clarity regarding ‘stigma’ is lagging behind the burgeoning body of research regarding its effects. As others have highlighted (Link and Phelan, 2001, Parker and Aggleton, 2003), social scientists too often study stigma without an apparent understanding, or explicit articulation, of its conceptual ingredients and boundaries. Manzo (2004) asserted that stigma is consistently “underdefined and overused” (p. 401). In a similarly critical fashion, Prior, Wood, Lewis, and Pill (2003) highlighted the adverse consequences of using stigma as an all-encompassing concept: “Stigma, we suggest, is creaking under the burden of explaining a series of disparate, complex and unrelated processes to such an extent that use of the term is in danger of obscuring as much as it enlightens” (p. 2192). This is particularly problematic as governments and professional organizations mobilize resources toward preventing and managing “this thing called stigma” (Manzo, 2004, p. 413).

Erving Goffman’s conceptualization of ‘stigma’ has germinated over forty years of a blossoming body of theory and research. In his seminal work, Stigma: Notes on the Management of Spoiled Identity, Goffman (1963) referred to stigma as: “an attribute that is deeply discrediting” (p. 3), “an undesired differentness” (p. 5), and something that reduces the bearer “from a whole and usual person to a tainted, discounted one” (p. 3). The utility of Goffman’s conceptualization for understanding health-related stigma within the context of contemporary society has been challenged (Sayce, 1998, Scambler, 2006). For example, Weiss, Ramakrishna, and Somma (2006) have outlined several shortcomings in Goffman’s formulation, including: the outdated language and concepts, the over-generalized application of stigma to an array of circumstances unrelated to health, the failure to account for variability in stigma experiences, the incompatibility of his analytic framework with today’s multicultural or pluralistic societies, and the over-emphasis of dyadic social interactions at the expense of structural considerations. More recently, authors have reframed the concept to improve its relevance for studying the social dimensions of public health problems in the context of modern globalization and multiculturalism (Corrigan, Kerr et al., 2005, Corrigan et al., 2006, Herek, 2004, Herek, 2007, Herek et al., 2009, Link and Phelan, 2001). In particular, contemporary conceptualizations have paid greater attention to the socio-cultural processes and structures that sustain stigma, as well as the factors (including features of the disease) that produce variability in how it is experienced and expressed (Herek, 2007, Parker and Aggleton, 2003, Scambler, 2009; Weiss et al., 2006).

The literature articulates three interacting levels of stigma: social, structural, and internalized (Corrigan, Kerr et al., 2005, Herek, 2007, Herek et al., 2009). Social stigma, also known as public or enacted stigma, exists at the group (i.e., meso) level and describes “the phenomenon of large social groups endorsing stereotypes about and acting against a stigmatized group” (Corrigan, Kerr et al., 2005, p. 179). Structural stigma, also called institutional stigma, exists at the systems (i.e., macro) level and refers to the rules, policies, and procedures of private and public entities in positions of power that restrict the rights and opportunities of people with mental illness (Corrigan, Kerr et al., 2005, Corrigan, Watson et al., 2005). In this form of stigma, “cultural ideology [is] embodied in institutional practices” (Herek, 2007, p. 907) so that differentials in power and status are legitimated, and disadvantage and social exclusion are perpetuated (Corrigan, Kerr et al., 2005, Herek, 2007, Herek et al., 2009).

Internalized stigma, also referred to as self or felt stigma, exists at the individual (i.e., micro) level and, in the context of mental illness, can be described as a process whereby affected individuals endorse stereotypes about mental illness, anticipate social rejection, consider stereotypes to be self-relevant, and believe they are devalued members of society (Corrigan, Kerr et al., 2005, Corrigan and Watson, 2002, Corrigan et al., 2006, Ritsher (Boyd) and Phelan, 2004). Further distinctions have been made between felt and self stigma (Herek, 2007, Herek et al., 2009). Whereas felt stigma describes negative consequences resulting from an individual’s awareness of how society perceives, and will likely act toward, the group to which they belong (e.g., homosexual, mentally ill), self-stigma refers to the process of an individual accepting society’s negative evaluation and incorporating it into his or her own personal value system and sense of self. Similarly, distinctions have been made between perceived stigma (awareness of stereotypes) and self-stigma, with the latter being defined as: “when the person internalizes the stigma and applies it to people with mental illness in general (stereotype agreement) or to him or herself (self-concurrence)” (Corrigan et al., 2006, p. 882). The processes and factors that are involved in internalized stigma for people with mental illness have been elucidated in several models, including Corrigan and Watson’s (2002) situational model and Link, Struening, Cullen, Shrout, and Dohrenwend’s (1989) modified labelling theory.

Weiss et al. (2006) define health-related stigma as: “a social process, experienced or anticipated, characterized by exclusion, rejection, blame, or devaluation that results from experience, perception or reasonable anticipation of an adverse social judgment about a person or group” (p. 280). Drawing primarily from this definition, the present study defines internalized stigma as a subjective process, embedded within a socio-cultural context, which may be characterized by negative feelings (about self), maladaptive behaviour, identity transformation, or stereotype endorsement resulting from an individual’s experiences, perceptions, or anticipation of negative social reactions on the basis of their mental illness. The strength of this definition is that it recognizes the macro-socio-cultural forces that influence this subjective, individualized process (Yang et al., 2007). As well, this conceptualization pays attention to the multi-faceted dimensions of internalized stigma (Link & Phelan, 2001), which involves interacting processes at the individual and societal levels. This definition encompasses the various conceptualizations of internalized stigma embodied in studies that were included in the present review (see below).

An expansive body of qualitative and quantitative research has investigated the experiences of internalized stigma for people with mental illness. The fruition of this effort has manifested in the accumulation of findings regarding the factors and domains that are implicated in the process of internalized stigmatization. It is clear that, by impeding recovery and compounding suffering, internalized stigma presents a serious problem for many people who live with mental illness. In order to learn from this rapidly growing body of literature, it is time to take stock of these findings and identify the existence of trends in research relating to internalized stigma. Reviews have been completed with other stigmatizing conditions, including HIV (Logie & Gadalla, 2009) and a combination of others (Mak et al., 2007, Van Brakel, 2006). As well, narrative reviews have been performed on stigma research relating to mental illness. For example, Link, Yang, Phelan, and Collins (2004) provided a comprehensive review of the tools that researchers have used to assess mental illness stigma among several groups, including the general population, children and youth, health professionals, and people with mental illness. More recently, Brohan, Slade, Clement, and Thornicroft (2010) published a review of measures that are designed to assess stigma experiences among people with mental illness. A narrative review by Overton and Medina (2008) describes the effects of various forms of mental illness stigma (e.g., social, structural); however, the findings related to internalized stigma are not reviewed in a comprehensive or systematic manner.

The present review represents the first systematic synthesis of research findings relating specifically to internalized stigma of mental illness. The present study evaluates the sociodemographic, psychosocial, and psychiatric variables that quantitative research has demonstrated to have an empirical relationship with internalized stigma for people who live with mental illness. In addition to providing a solid foundation for stigma researchers, this advancement will help policy-makers and program-planners to understand the outcomes that they should reasonably expect to affect by targeting internalized stigma. For clinicians, it is important to know the extent to which internalized stigma adversely influences therapeutic outcomes and recovery processes for people with mental illness. Moreover, answering the question of whether internalized stigma of mental illness is particularly prevalent within certain populations is an important consideration for health promotion and prevention strategies.

Section snippets

Study selection

The search strategy included locating relevant articles by searching several electronic databases, including PsychINFO, PubMed, and Web of Science. Web of Science includes the Arts & Humanities Citation Index (1975–present), the Social Citation Index Expanded (1900–present), and the Social Sciences Citation Index (1956–present). An inclusive search strategy that used broad keywords was purposely chosen in order to ensure a comprehensive scan of the literature. In January 2010, the keywords

Research characteristics

The reported characteristics of the 127 studies included in the review and the 45 studies used in the meta-analysis are outlined in Table 1. Additional detail about the studies, including the outcome measures that were used, can be found in Supplementary Tables A and B. The description of study characteristics (below) concentrates on the 45 meta-analysis studies.

Indicative of the growing interest in the topic of internalized stigma for people living with mental illness, 97.8% (k = 44) of the

Discussion

The systematic review uncovered a large body of research that has examined associations between internalized stigma and other sociodemographic, psychosocial, and psychiatric variables. The results from 127 studies produced interesting findings in each of these areas, including a relatively small set of results from longitudinal studies. Regarding sociodemographic variables, the lack of consistency across disparate studies indicates that people with a wide range of characteristics, who also have

Limitations

Several limitations need to be considered when interpreting the findings of the present study. First, although a diverse set of countries and populations were represented in the review, the study did not include published research in languages other than English. This restricts the cross-cultural generalizability of these findings. Second, the review excluded qualitative research studies, which means that internalized stigma in this study has been approached and understood using a quantitative

Conclusion

People who live with mental illness are susceptible to feeling as though they are devalued and discredited members of society. The present study has synthesized the research findings to date regarding the correlates and consequences of internalized stigma for people with mental illness. The most promising avenue for future research inquiry appears to be investigating the longitudinal relationship between internalized stigma and the range of psychosocial variables that were identified in this

Acknowledgements

We are grateful for the valuable feedback on an early draft of this manuscript that was kindly provided by Dr. Steven P. Hinshaw. We would also like to thank the anonymous reviewers of Social Science & Medicine for their thoughtful comments.

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    NOTE: References marked with one asterisk indicate studies included in the systematic review. References marked with two asterisks indicate studies included in both the systematic review and meta-analysis.

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