Stigma Resistance and Well-Being in the Context of the Mental Illness Identity

Abstract

We use a perceptual control model of identity to examine the relationship between stigmatized appraisals (from self and other) and well-being among individuals with serious mental illness. We also examine the role of stigma resistance strategies in the identity process. Using in-depth interviews with active clients of a community mental health center (N = 156), we find that deflection, or distancing oneself from mental illness, is associated with greater self-esteem and fewer depressive symptoms. Challenging others through education is associated with higher self-esteem, and challenging stigma through activism is associated with fewer depressive symptoms. Activism also moderates the relationship between identity discrepancy (the difference between appraisals from self and other) and well-being; however, the extent to which activism is helpful or harmful depends on whether appraisals from others are more or less stigmatizing than self-views. We discuss the implications of these findings for identity and stigma research.

Keywords

identity mental illness stigma stigma resistance strategies well-being

The negative impacts of stigma for individuals with mental illness are widespread and well documented. In various forms, stigma has been shown to compromise self-esteem and mastery (e.g., Drapalski et al. 2013; Livingston and Boyd 2010; Marcussen, Ritter, and Munetz 2010; Ritsher and Phelan 2004; Rosenfield 1997), social functioning (Yanos, Roe, and Lysaker 2010), and subjective quality of life (Livingston and Boyd 2010; Marcussen et al. 2010; Marcussen and Ritter 2016; Rosenfield 1997). Stigma is also negatively associated with health-related behaviors such as treatment seeking and compliance, in part due to its damaging impact on self-evaluation (Corrigan and Watson 2002). A central focus of stigma research is identifying how negative perceptions associated with deviant behaviors or statuses become self-relevant and subsequently harmful.

Theories rooted in symbolic interactionism have advanced various mechanisms through which negative self-views arise from deviant behaviors, including secondary deviance (Lemert 1951), self-fulfilling prophecies (Scheff 1966; Tannenbaum 1938), and role-taking with generalized or significant others (Mead 1934; Thoits 1985). A key feature of much of this research is the relevance of societal perceptions to self-definitions for individuals who hold a stigmatized status (e.g., Becker 1963; Link 1987; Link et al. 1989). Identity scholars similarly focus on the relationship between how individuals believe they are perceived by others (reflected appraisals) and how they perceive themselves (self-views) in the context of social roles and group memberships (e.g., Burke 1991, 1996; Stets and Burke 2014).

Despite convincing theoretical arguments for the negative association between perceived stigma and well-being, empirical support for this relationship is mixed (Corrigan and Watson 2002; Crocker and Major 1989; Thoits 2011). Thoits (2011) argued this may be due to stigma resistance efforts, such as deflecting and challenging negative stereotypes associated with mental illness. Deflection occurs when individuals distance themselves from the mental illness label and associated stereotypes (Thoits 2011, 2016; Thoits and Link 2016). Individuals may choose instead to challenge stereotypes by educating others about mental illness. This strategy might include sharing information (e.g., Link, Mirotznik, and Cullen 1991) or correcting those who voice inaccurate perceptions about mental illness. Challenging mental illness stigma can also take the form of public engagement or activism, such as supporting organizations or joining established networks that work to combat stigma (Thoits 2011). Taken together, these strategies offer cognitive and behavioral mechanisms for resisting the internalization of negative societal perceptions, thereby weakening the relationship between stigma and well-being.

This study draws on stigma and identity theories to examine the relationship between stigmatized reflected appraisals and stigmatized self-views as they affect well-being. Following recent research (Marcussen, Gallagher, and Ritter 2019), we use a perceptual control model of identity to study these relationships. The perceptual control model (Burke 1991, 1996) provides an ideal platform for integrating stigma and identity research. The model conceptualizes identities as dimensions of meaning that individuals attach to roles they hold (e.g., a mental health consumer), groups to which they belong (e.g., a support group), or personal characteristics (e.g., a moral person). Like stigma theories, the focus of this model is on attributes that are applied to a status or role and meanings that are considered personally relevant. The perceptual control model also emphasizes the relational nature of identities, acknowledging that self-meanings are a result of how individuals view themselves and how they perceive they are viewed by others. As such, stigmatized identities incorporate aspects of both social stigma (perceptions of stigma from others) and internalized stigma (stigmatizing perceptions of oneself). According to Burke (1991, 1996), individuals seek consistency between reflected appraisals and self-perceptions. Failure to verify identity meanings, also referred to as identity discrepancy, is damaging to self-evaluation and mental health. This is true whether feedback from others is more positive or less positive than one’s self-views.

The negative impact of identity discrepancies on well-being has received empirical support with respect to normative social roles (e.g., partner, worker, friend). Studies have only recently applied the model to stigmatized identities (Marcussen et al. 2019), and have yet to determine whether and to what extent stigma resistance plays a role in the identity process. In this article, we propose a model that examines the relationships among identity, stigma resistance, and well-being. We expect deflection and challenging strategies to be positively associated with self-esteem and negatively associated with depressive symptoms. We also propose that these cognitive and behavioral strategies buffer the relationship between identity based stressors (i.e., stigmatized reflected appraisals and identity discrepancies) and well-being for individuals with serious mental illnesses (SMI).

Backround

Stigma and Well-Being

Stigma is characterized as “an attribute that links a person to undesirable stereotype,” which results in discrediting, devaluing, and discriminating against individuals who hold the stigmatized status (Goffman 1963:11). Stigma can also be linked to group membership whereby negative attributes associated with a group become attached to individual members of the group (Allport 1958; Goffman 1963). Those who experience or perceive stigma are exposed to and/or have reason to anticipate negative attitudes and unfair treatment. An expansive body of research suggests that stereotypes of individuals with mental illness as dangerous, helpless, and irresponsible are pervasive (e.g., Link et al. 1999; Martin, Pescosolido, and Tuch 2000; Phelan et al. 2000; Wahl 1995) and culturally shared (Crocker, Major, and Steele 1998). Studies that have examined the relationship between perceived social stigma and well-being have found it to be detrimental to self-evaluation (e.g., Link et al. 1989; Markowitz 1998; Rosenfield 1997; Wright, Gronfein, and Owens 2000) and mental health (Marcussen et al. 2010; Marcussen and Ritter 2016; Rosenfield 1997) for individuals who identify as having a mental illness.

The mental health consequences of perceived stigma may be muted without internalization (Goffman 1963; Link 1987; Link et al. 1989; Thoits 2011). Perceptions of stigma do not inevitably become self-relevant, and social stigma is not tantamount to self-stigma (Corrigan and Watson 2002). Corrigan and colleagues (Corrigan and Watson 2002; Corrigan, Watson, and Barr 2006; Watson et al. 2007) suggest that applying public stigma to self-conceptions is more likely to be associated with self-esteem than either stereotype awareness (having a general knowledge of stereotypes) or stereotype agreement (acceptance of stereotypes as applied to the group). Yanos et al. (2010) similarly argued that attaching stigmatized meanings to oneself results in the reduction of self-esteem and hope. Accordingly, when stereotypes about mental illness become part of one’s self-view, they may be more consistently associated with self-evaluation and depression.

Resisting Stigma

Although stigma research has emphasized the consequences of internalizing negative stereotypes, researchers have also made a case for the rejection of social stigma. Rather than accept public perceptions, individuals may respond with anger or indifference (Corrigan and Watson 2002), or with empowerment and resistance (e.g., Corrigan and Watson 2002; Thoits 2011). For some, perceived stigma may be energizing, rather than demoralizing (Corrigan and Watson 2002). Additionally, individuals may not identify with the stigmatized group (e.g., others with mental illness), in which case, they may accept public stereotypes as accurate, but not apply them to themselves (Corrigan and Watson 2002). Conversely, identification with a group will sometimes encourage individuals to embrace their mental illness status (Crocker and Major 1989). In an effort to avoid identity threat, coping mechanisms such as engagement (approach or fight) or disengagement (avoidance or flight) can diminish the relationship between a stigmatized status and self-concept (Crocker and Major 1989; Miller and Kaiser 2001; Thoits 2011).

Thoits (2011) identified several potential responses to cultural stereotypes, including stigma endorsement and internalization on the one hand and stigma rejection through challenging, educating, and confronting stereotypical beliefs on the other hand. Between these responses lies a middle ground, where individuals are aware of cultural views about mental illness but attempt to minimize their effect using strategies such as distancing themselves from definitions of illness (deflection), avoiding social situations and interactions with others who have mental illnesses (withdrawal), or pulling back from behaviors or interactions based on previously experienced devaluation and discrimination (self-restoration). Thoits (2011) suggested that strategies such as deflection are likely to maintain well-being, whereas challenging strategies may increase agency, and therefore improve well-being. This is consistent with previous research that shows that advocacy and confronting others about their misperceptions are self-enhancing coping responses for individuals with mental illnesses and have the most potential for reducing stigma (Link et al. 2002; Wahl 1995).

Thoits and colleagues show some support for the relationship between stigma resistance and well-being. In a study of individuals diagnosed with psychosis, Thoits and Link (2016) found that the efficacy of resistance and coping strategies varied based on the type of stigma measured (e.g., perceived social stigma, discrimination experiences, and internalized stigma) and the type of strategies used (deflection, challenging, and concealment) but that both challenging and deflection were associated with higher self-esteem and quality of life. Thoits (2016) similarly found that deflection (measured as denial of having an emotional or mental disability) was positively associated with well-being for individuals regardless of the severity of their symptoms.

Drawing on these initial studies, our first set of hypotheses addresses the relationship between stigma resistance strategies and well-being for individuals with SMI. Given our interest in identity processes, we focus on cognitive strategies such as minimizing the relationship between self-definitions and mental illness stereotypes (deflection) and behavioral strategies that aim to reduce negative appraisals from others (challenging).

Hypothesis 1: Deflecting stigma will be positively associated with self-esteem.

Hypothesis 2: Deflecting stigma will be negatively associated with depressive symptoms.

Hypothesis 3: Challenging stigma with (a) education and (b) activism will be positively associated with self-esteem.

Hypothesis 4: Challenging stigma with (a) education and (b) activism will be negatively associated with depressive symptoms.

Mental Illness as a Stigmatized Identity

Identity theory offers an explanation for how individuals create and maintain identity meanings attached to social roles and positions. These meanings may be constructed in response to actual or imagined feedback (Cooley 1902; Mead 1934). The perceptual control model of identity, in particular, focuses on the relationship between self-perceptions (referred to as an identity standard or self-view) and the perceptions of others (reflected appraisals from generalized or specific others) in the context of role identities (Burke 1991, 1996), group identities, and person identities (Stets and Burke 2014; Stets and Serpe 2013). Self-views are personal meanings related to a given identity, typically measured as attributes such as trustworthy, responsible, independent, and moral. Reflected appraisals represent perceptions of how the identity is viewed by others based on the same set of attributes.

To maintain well-being, individuals seek to verify identities through a process of continuously comparing perceived feedback to their own set of meanings in the identity. Consistency between self-views and reflected appraisals is associated with well-being, whereas discrepancy between self-views and reflected appraisals is associated with lower levels of self-esteem (Asencio 2013; Burke and Harrod 2005; Cast and Burke 2002; Marcussen 2006) and higher levels of distress (Burke and Harrod 2005; Marcussen and Gallagher 2017). Because a fundamental assumption of this model is that individuals seek consistency between reflected appraisals and self-views, any discrepancy (whether more positive or more negative relative to self-views) will result in an interruption to the identity process (Burke 1991, 1996).

The perceptual control model has been applied most often to normative and positively viewed identities (Stets and Serpe 2013). More recently, identity research has expanded to include deviant identities (e.g., Asencio and Burke 2011; Carter and Mireles 2016; Granberg 2011; Kaufman and Johnson 2004; Lee and Craft 2002), including studies that focus on aspects of the mental illness identity (e.g., Kroska and Harkness 2006; Marcussen and Asencio 2016; Marcussen et al. 2019; Markowitz, Angell, and Greenberg 2011). These studies have demonstrated a negative relationship between stigmatized appraisals (from the perspective of self and other) and well-being. Discrepancies between stigmatized self-views and reflected appraisals have also been shown to be negatively associated with self-evaluation and positively associated with depressive symptoms. Marcussen et al. (2019) found that identity processes for stigmatized identities and normative identities are similar, particularly when reflected appraisals and self-views are considered in tandem. The question remains: Can this process be interrupted by efforts to resist stigma?

In this study, we consider the role of stigma resistance in identity processes for individuals with SMI. In line with identity theory, we view stigmatized meanings associated with the mental illness identities as comprised of self-views and reflected appraisals. Unlike measures of perceived stigma that assess common stereotypes or expectations regarding individuals with mental illness, reflected appraisals assess how individuals believe others view them in the context of their identities. This is an important distinction because it increases the potential for self-relevance of negative stereotypes associated with social roles, group membership, and personal characteristics.

Hypothesis 5: The negative relationship between stigmatizing reflected appraisals and self-esteem will be weaker at higher levels of deflection.

Hypothesis 6: The positive relationship between stigmatizing reflected appraisals and distress will be weaker at higher levels of deflection.

Hypothesis 7: The negative relationship between stigmatizing reflected appraisals and self-esteem will be weaker at higher levels of challenging with (a) education and (b) activism.

Hypothesis 8: The positive relationship between stigmatizing reflected appraisals and distress will be weaker at higher levels of challenging with (a) education and (b) activism.

We also examine the relationship between stigmatized reflected appraisals and stigmatized self-views. According to the perceptual control model, when dissonance occurs between how individuals perceive themselves and how they believe they are perceived by others, they will seek to reduce the discrepant feedback and avoid associated distress. We suggest that stigma resistance may take the form of cognitive and/or behavioral strategies that reduce the negative impact of discrepancy on well-being.

Hypothesis 9: The negative relationship between identity discrepancy and self-esteem will be weaker at higher levels of deflection.

Hypothesis 10: The positive relationship between identity discrepancy and distress will be weaker at higher levels of deflection.

Hypothesis 11: The negative relationship between identity discrepancy and self-esteem will be weaker at higher levels of challenging with (a) education and (b) activism.

Hypothesis 12: The positive relationship between identity discrepancy and distress will be weaker at higher levels of challenging with (a) education and (b) activism.

Data And Methods

Sample

The study sample was comprised of active clients of a community mental health center located in a Midwestern city. Active clients were those who received at least one unit of service within the previous 120 days. Research partners at the mental health services board randomly selected 1,500 of the approximately 2,500 active clients to be contacted about the study between November 2011 and April 2012. Staff at the community mental health center mailed letters to each randomly selected client that included information about the study and a form to return to the research team if they were interested in being contacted about potentially participating in the study. Data were collected during face-to-face interviews that lasted approximately 90 minutes. Of the clients who were contacted, 262 returned the form indicating that they were interested in participation, for a response rate of 17%. Although the response rate was lower than expected, when sample characteristics (gender, Medicaid eligibility, age, ethnicity, units of mental health services used in the preceding year) were compared to the full population of active clients, we found only two significant differences: gender and Medicaid eligibility. Our sample was 60% female (vs. 44% in the remaining population) and 88% Medicaid eligible (vs. 80% in the remaining population). Interviews were scheduled with 223 clients (85% of those who expressed interest in the study; 15% of those who were originally contacted).¹

The analytic sample for the present study comprised 156 individuals who were reinterviewed during Wave 2 of the original study, approximately 18 months after Wave 1. Stigmatizing self-views and reflected appraisals were only included in the Wave 2 interview.2 Demographic characteristics of the analytic sample are displayed in Table 1. On average, the sample was approximately 50 years old, 62% female, and 57% white. Fifty-three percent of respondents received less than $10,000, 43% received between $10,000 and $19,999, and 5% received more than $19,999 per year from all sources. Ninety-one percent of respondents were single, 14% were employed, 59% lived alone, and 10% lived with children under the age of 18. Respondents had been in mental health treatment for an average of about 22 years. In terms of primary diagnosis, schizophrenia (51%) was the most common, followed by depressive (22%), bipolar (19%), and other (8%) diagnoses. Additionally, 49% of respondents had been diagnosed with a substance abuse disorder, and 12% had been diagnosed with posttraumatic stress disorder (PTSD).

Table 1.

Descriptive Statistics for All Study Variables, Community Mental Health Survey, 2011-2013.

	n/f	Mean/Proportion	SD	Range	α
Demographic/control variables
Age (years)	146	49.53	9.286	28–72
Sex (1 = female)	146	.62		0–1
Race (1 = minority)	146	.43		0–1
Income	152
<$10,000	80	.53		0–1
$10,000-$19,999	65	.43		0–1
>$19,999	7	.05		0–1
Marital status (1 = single)	145	.91		0–1
Employment status (1 = working)	146	.14		0–1
Living situation (1 = live alone)	145	.59		0–1
Children (1 = live with children < 18)	145	.10		0–1
Time in treatment (years)	141	21.65	11.845	0–49
Principal diagnosis	146
Schizophrenia diagnosis	75	.51		0–1
Depressive diagnosis	32	.22		0–1
Bipolar diagnosis	27	.19		0–1
Other diagnosis	12	.08		0–1
Co-occurring diagnosis	146
Substance abuse diagnosis	146	.49		0–1
PTSD diagnosis	146	.12		0–1
Identity variables
Identity discrepancy	131	.83	2.325	0–14.23
Linear discrepancy	131	.21	.887	–3.77–3.64
Zero discrepancy (sv = ra)	11	.08
Negative discrepancy (sv > ra)	55	.42
Positive discrepancy (sv < ra)	65	.50
Stigma resistance variables
Deflection (4 items)	139	2.70	.487	1–4	.668
Challenging education (2 items)	153	.52	.456	0–1	.795
Challenging activism (4 items)	154	.25	.302	0–1	.672
Well-being variables
Self-esteem (10 items)	147	2.84	.542	1–4	.889
Depressive symptoms (7 items)	152	3.01	2.102	0–7	.884

Note: PTSD = post-traumatic stress disorder; SD = standard deviation; RA = reflected appraisals; SV = self-views.

Measures

Dependent measures

We focused on two measures of well-being: self-esteem and depression. Self-esteem was measured using the 10-item Rosenberg Self-Esteem scale (Rosenberg 1965). Items included “I feel that I am a person of worth, at least on an equal basis with others” and “I feel that I have a number of good qualities.” Responses ranged from 1 (strongly agree) to 4 (strongly disagree) and were coded so that higher scores indicate greater self-esteem. All items were summed and divided by the number of items in the scale (Cronbach’s α = .889).

Depressive symptoms were measured using an abbreviated seven-item version (Mirowsky and Ross 1992) of the Center for Epidemiological Studies-Depression scale (Radloff 1977). Respondents were asked, “On how many days in the past seven days have you . . . ?” Items include “felt you could not get going,” “felt that you couldn’t shake the blues,” and “felt sad.” Items were summed and divided by the number of items in the scale, with higher scores indicating more depressive symptoms (Cronbach’s α = .884).

Independent measures

The independent variables for the study were identity discrepancies, reflected appraisals, and three stigma resistance strategies (deflection, challenging education, and challenging activism). Identity discrepancies were calculated using measures of self-views and reflected appraisals. Self-views and reflected appraisals were measured by asking respondents to fill out a handout containing 11 pairs of semantic differentials (adapted from Markowitz et al. 2011) that represent the positive and negative poles of stigmatizing characteristics associated with the mental illness identity. Respondents were shown a scale that ranges from 1 to 7, with negative characteristics on one pole and their positive equivalents on the other pole, and were instructed, "Mark on the scale where you think you best fit in your mind, saying before each item, ‘I am . . . ’” for self-views and “ . . . others think I am . . . ” for reflected appraisals. The semantic differentials include “unfriendly–friendly,” “dangerous–safe,” “unintelligent–intelligent,” “incompetent–competent,” “disorganized–organized,” “unstable–stable,” “unpredictable–predictable,” “unreliable–reliable,” “irrational–rational,” “childlike–adult,” and “irresponsible–responsible.” Items were summed and divided by the number of items in the scale, with higher scores representing more stigmatizing self-views or reflected appraisals, respectively.

We created a discrepancy score by subtracting the self-view scale from the reflected appraisal scale. This linear discrepancy scale (which includes negative and positive scores) was then squared to reflect the underlying assumption in identity theory that the relationship between identity discrepancy and emotional outcomes such as psychological distress is theoretically curvilinear, where zero discrepancy is expected to produce zero distress and increasing discrepancy in either a positive (i.e., the reflected appraisal is higher than the self-view) or negative (i.e., the reflected appraisal is lower than the self-view) direction should increase distress (Burke and Harrod 2005; Stets and Burke 2014). Following Dawson (2014), we include both linear and squared terms in each model to accurately interpret the squared discrepancy term.³ The term identity discrepancy used in our hypotheses and analyses, however, refers to the squared term only. As shown in Table 1, 8% of respondents had no discrepancy. Among those with a discrepancy, 42% had a negative discrepancy (i.e., self-views are more stigmatizing than reflected appraisals), and 50% had a positive discrepancy (i.e., self-views are less stigmatizing than reflected appraisals).

Stigma resistance was measured using 10 items developed to capture theoretical components of deflection and challenging described in previous research (Thoits 2011). Deflection was measured using four items, including “I am not like most people with mental illness” and “My mental illness is only a small part of who I am.” Responses ranged from 1 (strongly agree) to 4 (strongly disagree) and were coded so that higher scores indicate more use of deflection as a stigma resistance strategy. Items were summed and divided by the number of items in the scale (Cronbach’s α = .668). Challenging was measured using six items that represent educating others about mental illness and involvement in activities and events related to mental health advocacy/activism, including “Told someone their ideas about mental illness were incorrect” and “Spoken about your mental illness at a public event.” Respondents were asked whether they had participated in each challenging activity by indicating yes (coded 1) or no (coded 0). Based on factor analysis of the stigma resistance items, we found that the challenging items represented two separate constructs: challenging education (two items) and challenging activism (four items). Stigma resistance items and their factor loadings are presented in Table 3 and discussed in more detail in the Results section. For both challenging education (r = .795) and challenging activism (Cronbach’s α = .672), all items were summed and divided by the number of items in the scale, with higher scores representing more participation in each respective stigma resistance strategy.

Control variables

As shown in Table 1, we included several variables that are theoretically and empirically relevant to our study in the analyses. We measured age (years), sex (1 = female), race (1 = minority), income (1 = <$10,000, 2 = $10,000–$19,999, 3 = >$19,999), marital status (1 = single), employment status (1 = working for pay), living situation (1 = living alone), dependent children (1 = live with children <18), time in treatment (years), principal diagnosis (1 = schizophrenia, depression, bipolar, or other diagnosis, respectively), and co-occurring diagnoses (1 = substance abuse or PTSD, respectively).

Analytic Strategy

We first conducted a factor analysis to determine the extent to which the stigma resistance strategies of deflection, challenging education, and challenging activism are empirically distinct. We then estimated two sets of structural equation models (SEMs) to investigate (1) the main and multiplicative effects of reflected appraisals and stigma resistance strategies on self-esteem and depressive symptoms and (2) the main and multiplicative effects of identity discrepancy and stigma resistance strategies on those same outcomes. We estimate separate models for each respective stigma resistance strategy. SEM is ideal for concurrently estimating relationships among multiple correlated independent and outcome variables. The SEMs employ maximum likelihood with missing values (MLMV) estimation to retain as many cases as possible in the analyses. MLMV produces unbiased estimates when missing data are missing at random and potential correlates of missingness are included in the model.⁴ Robust standard errors were used to correct for the autocorrelation of errors.

We conducted factor analysis on the stigma resistance strategy items using maximum likelihood estimation, promax rotation, and mean substitution for missing values. We estimated preliminary SEMs that included all control variables. The final models presented here omit all control variables that were not significantly associated with any of the focal independent or dependent variables, leaving only diagnoses and the statistically significant structural pathways between them and the other exogenous and endogenous variables. Results were substantively identical in the preliminary and final models. We standardized variables prior to computing interaction terms.

Results

Bivariate correlations between independent and dependent variables are displayed in Table 2. Stigmatizing reflected appraisals are significantly associated with identity discrepancy (r = .387, p < .001), linear discrepancy (r = .685, p < .001), self-esteem (r = –.504, p < .001), and depressive symptoms (r = .399, p < .001), but they are not significantly associated with the stigma resistance strategies. Identity discrepancy is significantly associated with depressive symptoms (r = .191, p < .05). In terms of stigma resistance strategies, deflection is significantly associated with self-esteem (r = .423, p < .001) and depressive symptoms (r = –.192, p < .05), and challenging education is significantly associated with self-esteem (r = .200, p < .05), but challenging activism is not significantly associated with well-being. Challenging education and activism are positively associated with each other (r = .336, p < .001) but not deflection. Finally, self-esteem is negatively associated with depressive symptoms (r = –.546, p < .05).

Table 2.

Correlations between Independent, Moderating, and Dependent Variables, Community Mental Health Survey, 2011-2013.

	(1)	(2)	(3)	(4)	(5)	(6)	(7)	(8)
(1) Stigmatizing reflected appraisals	1.000
(2) Identity discrepancy	.387***	1.000
(3) Linear discrepancy	.685***	.444***	1.000
(4) Deflection	–.140	.096	.085	1.000
(5) Challenging education	.066	.159	.048	.128	1.000
(6) Challenging activism	–.009	–.039	.009	–.100	.336***	1.000
(7) Self-esteem	–.504***	–.127	–.160	.423***	.200*	.036	1.000
(8) Depressive symptoms	.399***	.191*	.148	–.192*	–.022	–.157	–.546***	1.000

Note: Correlations were estimated using pairwise deletion. The number of cases for each cell ranges from 119 to 154.

p ≤ .05, ***p ≤ .001, two-tailed.

Stigma Resistance Strategies

The stigma resistance measures used in this study represent extensions of previous theoretical and empirical work (Marcussen and Asencio 2016; Thoits 2011). As shown in Table 3, the results of our factor analyses indicate that stigma resistance strategy items load on separate factors representing challenging activism (Factor 1), deflection (Factor 2), and challenging education (Factor 3), respectively. Additionally, none of the items cross-load, providing further evidence of discriminant validity.

Table 3.

Factor Analysis of Stigma Resistance Strategy Items (N = 155), Community Mental Health Survey, 2011-2013.

	Factor 1	Factor 2	Factor 3
Deflection
I am not like most people with mental illness.	–.153	.565	.043
When I see how mental illness is portrayed in the media, I think “that’s not me.”	.028	.474	.013
My mental illness is a small part of who I am.	–.002	.577	.130
My mental health issues are not serious.	.069	.664	–.116
Challenging education
Confronted someone about inappropriate things they have said regarding mental illness.	–.031	–.068	.999
Told someone their ideas about mental illness were incorrect.	.089	.132	.625
Challenging activism
Spoken about your mental illness at a public event.	.361	–.124	.121
Contributed to organizations that educate about mental illness.	.655	–.022	–.050
Participated in antistigma campaigns around issues of mental illness.	.582	–.018	.003
Participated in organized activities supporting mental illness awareness.	.686	.091	.035
Eigenvalues	2.525	2.094	1.137
Cronbach’s α	.672	.668	.795

Note: Factor analysis was conducted using maximum likelihood estimation, promax rotation, and mean substitution for missing values. Factor 1 and Factor 2 r = –.150; Factor 2 and Factor 3 r = .096; Factor 1 and Factor 3 r = .397. Item loadings for each factor are bolded.

It is noteworthy that most of the sample engaged in some form of stigma resistance. Regarding deflection, 91% of respondents agreed or strongly agreed with at least one of the four items (36%–80% across items), with “My mental illness is only a small part of who I am” (80%) and “When I see how mental illness is portrayed in the media, I think ‘that’s not me’” (78%) being the most highly endorsed. A majority of respondents (61%) also engaged in at least one of the two types of challenging education by confronting someone about inappropriate things they have said about mental illness (52%) and/or telling someone their ideas about mental illness were incorrect (53%). Similarly, over half of the respondents (53%) participated in at least one of the four types of challenging activism (13%–33% across items). Contributing to organizations that educate about mental illness (33%) and participating in organized activities supporting mental illness awareness (32%) were the most common forms of challenging activism.

Effects of Stigmatizing Reflected Appraisals and Stigma Resistance on Well-Being

In the first set of SEMs (Table 4), we estimated the main and multiplicative effects of stigmatizing reflected appraisals and stigma resistance strategies on self-esteem and depressive symptoms in separate models for deflection (Model 1), challenging education (Model 2), and challenging activism (Model 3).

Table 4.

Standardized (β) and Unstandardized (b) Coefficients and Robust Standard Errors (SE) for Stigmatizing Reflected Appraisals and Stigma Resistance Structural Equation Models (N = 155), Community Mental Health Survey, 2011-2013.

	Model 1 ^a				Model 2 ^b				Model 3 ^c
	Self-Esteem		Depressive Symptoms		Self-Esteem		Depressive Symptoms		Self-Esteem		Depressive Symptoms
	b (SE)	β	b (SE)	β	b (SE)	β	b (SE)	β	b (SE)	β	b (SE)	β
Stigmatizing reflected appraisals	–.185***(.028)	–.461	.616***(.125)	.388	–.209***(.030)	–.512	.644***(.125)	.404	–.212***(.031)	–.514	.645***(.118)	.405
Deflection	.385***(.083)	.353	–.517(.324)	–.120	—		—		—		—
Challenging education	—		—		.247***(.080)	.208	–.142(.357)	–.031	—		—
Challenging activism	—		—		—		—		.022(.129)	.012	–1.027* (.423)	–.148
Stigmatizing reflected appraisals × Deflection	.024(.062)	.030	–.027(.243)	–.009	—		—		—		—
Stigmatizing reflected appraisals × Challenging education	—		—		.027(.061)	.030	.155(.274)	.045	—		—
Stigmatizing reflected appraisals × Challenging activism	—		—		—		—		–.147(.113)	–.102	.160(.320)	.029

Note: Structural pathways from psychiatric diagnoses to stigmatizing reflected appraisals, stigma resistance, and interaction terms are included in the models but not shown here.

Model 1: Chi-square 8.12(8df), p = .422; root mean square error of approximation =.010; root mean square error of approximation = .999.

Model 2: Chi-square 6.03(8df), p = .643; root mean square error of approximation =.000; comparative fit index = 1.000.

Model 3: Chi-square 8.08(8df), p = .426; root mean square error of approximation = .008; root mean square error of approximation = .999.

p ≤ .05, ***p ≤ .001, two-tailed.

As shown in Table 4, we find that deflection is significantly and positively associated with self-esteem (b = .385, p < .001) and marginally negatively associated with depressive symptoms (b = –.517, p = .111), supporting Hypothesis 1 and marginally supporting Hypothesis 2. We find mixed support for our hypotheses involving challenging. Challenging education is significantly and positively associated with self-esteem (b = .247, p < .001), and challenging activism is significantly and negatively associated with depressive symptoms (b = ‒1.027, p < .05). Thus, we find support for Hypothesis 3a (for challenging education) and Hypothesis 4b (for challenging activism).

Turning to stigmatizing reflected appraisals, we find that they are significantly and negatively associated with self-esteem and significantly and positively associated with depressive symptoms across all three models. None of the interactions between stigmatizing reflected appraisals and stigma resistance strategies are statistically significant, failing to support Hypotheses 5 through 8. In other words, stigmatizing reflected appraisals are negatively associated with self-esteem and positively associated with depressive symptoms, but stigma resistance strategies do not significantly weaken those associations.⁵

Effects of Identity Discrepancies and Stigma Resistance on Well-Being

In the second set of SEMs, we estimated the main and multiplicative effects of identity discrepancy and stigma resistance strategies on self-esteem and depressive symptoms in separate models for deflection (Model 1), challenging education (Model 2), and challenging activism (Model 3). All associations between stigma resistance and well-being are substantively identical in the reflected appraisal and discrepancy analyses, with one exception. Deflection is significantly associated with depressive symptoms (b = –.837, p < .05) in the discrepancy model but marginally significant in the reflected appraisal model. Together, these findings generally support Hypothesis 2.

Consistent with previous research, we find identity discrepancy is negatively associated with self-esteem in Model 1 (b = –.036, p < .001) and positively associated with depressive symptoms in Model 1 (b = .200, p < .001) and Model 3 (b = .231, p < .05).

As shown in Table 5, interactions between identity discrepancy and deflection are not significantly associated with self-esteem or depressive symptoms, failing to support Hypotheses 9 and 10. Similarly, interactions between identity discrepancy and challenging education are not significantly associated with either outcome, failing to support Hypotheses 11a and 12a. It appears that neither deflection nor using education to challenge mental illness stigma modifies the association between identity discrepancy and well-being.

Table 5.

Standardized (Beta) and Unstandardized (b) Coefficients and Robust Standard Errors (SE) for Identity Discrepancy and Stigma Resistance Structural Equation Models (N = 155), Community Mental Health Survey, 2011-2013.

	Model 1 ^a				Model 2 ^b				Model 3 ^c
	Self-Esteem		Depressive Symptoms		Self-Esteem		Depressive Symptoms		Self-Esteem		Depressive Symptoms
	b (SE)	β	b (SE)	β	b (SE)	β	b (SE)	β	b (SE)	β	b (SE)	β
Identity discrepancy	–.036***(.011)	–.151	.200***(.048)	.217	.003(.035)	.014	.196(.139)	.216	–.050(.026)	–.220	.231* (.092)	.261
Deflection	.462***(.092)	.407	–.837* (.344)	–.191	—		—		—		—
Challenging education	—		—		.223* (.094)	.188	–.177(.376)	–.038	—		—
Challenging activism	—		—		—		—		.042(.140)	.023	–1.005* (.485)	–.144
Identity discrepancy × Deflection	.085(.065)	.243	–.327(.225)	.113	—		—		—		—
Identity discrepancy × Challenging education	—		—		–.060(.069)	–.123	–.152(.281)	–.080	—		—
Identity discrepancy × Challenging activism	—		—		—		—		–.278**(.091)	–.369	.610* (.289)	.208

Note: Structural pathways from psychiatric diagnoses to identity discrepancy, linear discrepancy, stigma resistance, and interaction terms are included in the models but not shown here. Models also control for linear discrepancy and interactions between linear discrepancy and stigma resistance. Pathways (not shown) involving linear discrepancy are generally nonsignificant, with the exception of the association between linear discrepancy and self-esteem in Model 1(b = –.101, p < .05).

Model 1: Chi-square 21.82(10df), p = .016; root mean square error of approximation = .087; comparative fit index = .964.

Model 2: Chi-square 12.10(10df), p = .278; root mean square error of approximation = .037; comparative fit index = .993.

Model 3: Chi-square 15.31(10df), p = .121; root mean square error of approximation = .059; comparative fit index = .975.

p ≤ .05, ***p ≤ .001, two-tailed.

The interaction of identity discrepancy and challenging activism, however, is significantly associated with self-esteem (b = –.278, p < .01) and depressive symptoms (b = .610, p < .05). For respondents who engage in challenging activism, the association between discrepancy and well-being differs, depending on the direction of discrepancy.⁶ As shown in Figures 1 and 2, challenging activism weakens (buffers) the association between discrepancy and self-esteem and depressive symptoms for those with reflected appraisals that are more stigmatizing than self-views, but challenging activism exacerbates the impact of identity discrepancy on self-esteem and depressive symptoms for those with self-views that are more stigmatizing than reflected appraisals. Hypotheses 11(b) and 12(b) are partially supported in that challenging activism strategies improve the well-being of those who think others see them in more stigmatizing ways than they see themselves, but those same strategies harm the well-being of those who see themselves in more stigmatizing ways than they think others see them.

Figure 1.

Identity Discrepancy × Challenging Activism Interaction on Self-Esteem.

Figure 2.

Identity Discrepancy × Challenging Activism Interaction on Depressive Symptoms.

Discussion

We examined the role of stigma resistance in the identity process among individuals with SMI. Building on previous theory and research, we suggested that engaging in stigma resistance strategies such as deflection, challenging through education, and challenging through activism would be associated with higher levels of self-esteem and lower levels of depressive symptoms. We further proposed that stigma resistance strategies would buffer the negative relationship between stigmatized feedback and well-being. An advantage of the perceptual control model we draw on is its focus on more proximal feedback relative to broader conceptions of social stigma, thereby considering stigma that is necessarily self-relevant. By examining identity discrepancies, the model takes into account the relationship between stigmatizing feedback and self-views, the latter of which has been shown to be more strongly associated with well-being than public stigma (Corrigan et al. 2006; Livingston, Rossiter, and Verdun-Jones 2011; Watson et al. 2007).

Consistent with our expectations and previous research (Thoits and Link 2016), we found that stigma resistance was positively associated with well-being. This pattern was most clearly demonstrated with deflection strategies. Distancing oneself from negative stereotypes regarding mental illness was associated with higher self-esteem and fewer depressive symptoms. Our findings regarding challenging strategies were mixed. We found that confronting misconceptions about mental illness (education) was associated with greater self-esteem and that community engagement (activism) was associated with fewer depressive symptoms among individuals with SMI. Consistent with Thoits and Link (2016), these findings highlight the importance of distinguishing forms of resistance, as well as mental health outcomes, when assessing the relationship between resistance and well-being. We acknowledge the possibility that the relationship between resistance strategies and well-being is likely reciprocal; however, in analyses not shown, we do not see evidence that such a pattern alters our findings (see Note 2).

Our primary goal in this article was to assess the protective role of resistance strategies in the relationship between stigma and well-being. Previous research shows that stigmatizing reflected appraisals, as well as inconsistencies that arise between reflected appraisals and self-views, are associated with higher levels of depressive symptoms for individuals with SMI (Marcussen et al. 2019). We examined whether deflection and challenging strategies buffered the relationship between each of these stressors and well-being. We found that neither deflection nor challenging efforts buffered the relationship between stigmatizing reflected appraisals and well-being. Similarly, deflection strategies and challenging through education did not moderate the negative relationship between identity discrepancy and well-being. Thus, although deflection and challenging through education are positively associated with well-being in our sample, these strategies do not appear to protect them in the face of stigmatizing or identity-discrepant feedback. Although not consistent with our hypotheses, these findings—particularly with respect to deflection—support the suggestion that active strategies may be more efficacious when attempting to combat stigma (Link et al. 2002; Thoits 2011; Wahl 1995).

Indeed, challenging stigma through activism showed promise in our study. As hypothesized, this form of stigma resistance moderated the relationship between discrepancy and both self-esteem and depressive symptoms. However, contrary to the assumptions of the perceptual control model, the direction of the discrepancy mattered. Specifically, we found that when reflected appraisals were more stigmatizing than self-views, activism was associated with higher levels of self-esteem and lower levels of depressive symptoms. Conversely, when self-views were more stigmatizing than reflected appraisals, engaging in activist strategies was associated with lower self-esteem and higher levels of depressive symptoms. These results suggest that perceived stigma may be offset by challenging strategies such as activism when individuals perceive that others see them in a more negative light than they see themselves. When self-stigma is greater than perceived stigma, engaging in activism is associated with more negative outcomes.

Implications for Stigma and Identity Research

Studies examining responses to stigma have shown some support for empowerment (Corrigan et al. 1999, 2006) and resistance (Thoits 2016; Thoits and Link 2016) in terms of their implications for well-being, yet few have examined the efficacy of resistance strategies in more diverse diagnostic samples. Moreover, measures of resistance in previous research are somewhat limited in terms of dimensions of deflection and challenging strategies. Our study uses resistance measures that reflect deflection as distancing oneself from mental illness stereotypes and challenging in terms of both correcting inaccurate perceptions and community engagement. Unlike previous research (Thoits 2016; Thoits and Link 2016), we did not find that stigma resistance was associated with perceived stigma when measured as stigmatized reflected appraisals. This may be a result of differences in our sample as well as how we measure stigmatizing feedback and resistance strategies.

Our results suggest that although resistance strategies do not buffer the relationship between stigmatized appraisals and well-being, when reflected appraisals are taken into consideration in relation to self-views, activism does moderate this relationship. Moreover, the effect of activism depends on the relationship between reflected appraisals and self-views. Challenging behaviors appear to be useful when the goal is changing negative appraisals from others but harmful when attempting to confront negative self-views. This raises two important points about the contributions of the perceptual control model in this research. First, taking into account the relationship between reflected appraisals and self-views (rather than examining the independent effects of each on well-being or on one another) presents a way to study stigmatized identities as a product of the relationship between social and self-stigma. Second, our findings challenge previous research that indicate that the direction of the discrepancy is irrelevant when considering its relationship to well-being. Although that may be true with respect to the direct effects of an identity discrepancy on well-being, it is important to reconsider this relationship when examining how individuals cope with stress associated with discrepancy. In fact, the direction of the discrepancy may make a difference in terms of the efficacy of resistance strategies. This finding raises important questions about ways in which identity processes might differ for normative and stigmatized identities. It also suggests that matching stigma resistance strategies with stigma stressors (in this case, considering the source of stigma) might be an important consideration in future work.

This study makes contributions to stigma and identity literatures; however, it is not without limitations. Data that address these complex relationships among individuals with SMI are rare, in part because of difficulties in interviewing this population. Although our response rate is not unusual for samples of people with SMI, it has implications for generalizing our findings. Our sample likely underrepresents lower functioning individuals, and as a result, our findings may not hold for individuals who are experiencing greater than average mental (and physical) disability. Of particular relevance is the extent to which functioning in our sample is associated with our key theoretical variables (i.e., stigma resistance). For our study, functioning was moderately correlated with deflection strategies and not significantly correlated with challenging strategies (see Note 1).

As previously mentioned, the data used for this study are cross-sectional. Although theoretical assumptions of stigma and identity theories give us some confidence in our predictions, these theories emphasize processes that develop over time. The individuals in our sample have been diagnosed and in treatment for an average of 21 years. As such, their identities are likely to be fairly stable, and resistance strategies may become less likely over time (Thoits 2016). An ideal test of the model would allow us to examine how resistance strategies might work to “correct” reflected appraisals in a way that better aligns them with self-views, thereby reducing identity discrepancies. Although longitudinal data would provide an opportunity to examine identity processes over time, it would need to span numerous years to capture changes in reflected appraisals and/or self-views. Nonetheless, understanding the extent to which resistance strategies buffer the negative association between identity-relevant stressors and well-being provides valuable information for addressing the potentially detrimental impact of stigmatizing feedback.

Similar to previous studies (e.g., Marcussen et al. 2019; Markowitz et al. 2011), our measures of stigmatized reflected appraisals and self-views do not explicitly reference the mental illness identity. Although anchoring questions in the context of specific identities is ideal, there is a case to be made that the mental illness identity can be viewed as an “attribute role” (Thoits 1991:104) or a master status (Becker 1963) that is carried into most interactions. From the perspective of the perceptual control model, the mental illness identity may represent a role, group, and/or a person identity across situations and interactions, all of which are subject to identity verification (Stets and Burke 2014). Related to this point, it is important to consider the context in which these questions were asked. Respondents were recruited from community services for mental health and were aware that their involvement in the agency was the reason they were being interviewed. Finally, centrality of the mental illness identity (i.e., the extent to which individuals define themselves in terms of their mental illness) was quite high in this sample, indicating that mental health status likely played an important role in reported self-views and reflected appraisals.

Focusing on cognitive and behavioral strategies for resisting stigma emphasizes the role of agency in identity processes. It is important to also consider the extent to which structural factors encourage or constrain the use of these strategies (Stuber, Meyer, and Link 2008; Thoits 1995). Access to resources likely promotes resistance, specifically strategies that challenge ideas and behaviors of others who are perceived to have more power (Link and Phelan 2014). At the same time, identification with a stigmatized group can lead to a greater sense of empowerment and self-esteem (Corrigan, Powell, and Rüsch 2012; Crocker and Major 1989), which has implications for treatment seeking and mental health advocacy. Stigma scholarship has increasingly highlighted the connection between structure and agency (e.g., Pescosolido et al. 2008; Watson 2012), including the role of self and identity in illness management and recovery (e.g., Corrigan et al. 2012; Estroff 1989; Markowitz et al. 2011; Yanos et al. 2007). Future research should continue to incorporate theoretical models that articulate the numerous and connected pathways through which stigma impacts well-being, with an eye toward informing policy that seeks to promote stigma resistance on multiple fronts.

Footnotes

Acknowledgements

We thank Community Support Services, Inc. and the County of Summit Alcohol, Drug Addiction and Mental Health Services Board for their assistance with data collection.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by the Northeast Ohio Medical University Office of Research and Sponsored Programs (Christian Ritter, PI) to establish the Reasearch Focus Area in Community Mental Health Research.

ORCID iD

Kristen Marcussen

Notes

Author Biographies

Kristen Marcussen is an associate professor in the Department of Sociology at Kent State University. Her research focuses on the relationship between role-identities and psychological distress, the effects of mental illness stigma and community mental health services on well-being, and the role of stigma resistance in the relationships among identity, self-evaluation, and mental health.

Mary Gallagher is an associate professor in the Department of Sociology at Kent State University at Stark. Her current research is situated within identity theory and examines relationships between identity discrepancy, commitment, centrality, and psychological distress in adult social roles.

Christian Ritter is a medical sociologist with postdoctoral training in psychiatric epidemiology. In addition to stigma processes related to mental illness, recent research has included mental illness and the criminal justice system. He is currently a professor in the Department of Psychiatry and Vice Dean of the College of Graduate Studies at Northeast Ohio Medical University. Prior to 2007, he was in the Department of Sociology at Kent State University.

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