When Stacy G. was diagnosed with depression, the Calgary mother of two rejected the notion. In her family, mental illness was either a taboo topic or ridiculed with terms like “nut cake” or “nut job.” Stacy blamed her persistent sadness and negativity on a stressful job and pledged to banish this “crappy thing” from her life through sheer determination. Friends told her to think positively, turn herself over to God or push through it.

“You see people every day thinking you should just ‘suck it up’ …,” says Stacy, referring to widely held views that depression is a moral failing or character flaw.

Then a close family friend died, and her “suck it up” strategy stopped working. Once a Type A personality, she became easily fatigued and unable to concentrate or cope with pressure. She couldn’t stop crying. She began to draw away from friends and family, in part from fear of their negative reactions.

“A good friend at work talked to me once after I told her what was going on, and then I never heard from her again,” says Stacy, 42, who took medical leave from her job as a revenue analyst. “I pretty much shut everyone out, because I was afraid of what others would say or think.”

Like many people with depression, Stacy bought into long-held public attitudes toward the condition. Her self-stigma delayed her treatment, increased her isolation, warped her self-image and lowered her self-esteem—a closed-circuit loop that only deepens depression.

A range of research shows that when social stigma becomes internalized as self-stigma, individuals with depression are far less likely to seek treatment.

For example, a 2009 study from Leipzig University in Germany identified internalized stigma as “an important mechanism decreasing the willingness to seek psychiatric help”—and of far more influence than “anticipated discrimination.” Likewise, a U.S. study of college students, published in Medical Care Research and Review in May 2009, found that personal stigma (as opposed to perceived stigma) was “significantly” associated with unwillingness to seek help.

Shaking off the shame and blame of self-stigma, therefore, may be the first step to recovery from depression—and to recovering a positive sense of self.  

Patrick Corrigan, PsyD, director of the National Consortium on Stigma and Empowerment at the Illinois Institute of Technology in Chicago, recommends several strategies for self-empowerment.

Education to replace “mental health myths” with facts about depression can be useful in some circumstances, he says —both for the individual with depression and the people around them.

Pushing back against social stigma through advocacy and activism can counteract internalized stigma, Corrigan says—not to mention attack self-stigma at its source.

Most effective, however, are approaches that help those with depression realize they are not alone, that they have nothing to hide, and that they are not condemned by the condition.

“The concept of recovery needs reintroduction,” says Corrigan. “People need hope, and the fact is that most people do recover.”

Change the story

Stacy ultimately turned to medication and talk therapy to manage her depression, along with lifestyle changes like making sure she gets out of the house every day. She counts on the meds to stabilize her mood so she can benefit from her cognitive-behavioral therapy

(CBT), which uses a kind of reality-check process to retool negative thoughts and hurtful patterns of behavior. CBT and narrative therapy can be powerful tools against self-stigma, according to stigma researcher Philip T. Yanos, PhD, an associate professor of psychology at John Jay College of Criminal Justice of the City University of New York. In studies dealing with how internalized stigma affects vocational rehabilitation, social anxiety and cognitive skills, Yanos has identified hopelessness and low self-esteem as paralyzing by-products of self-stigma. In cognitive-behavioral therapy, he says, “the process of cognitive restructuring … [can] challenge the validity of beliefs” that impede recovery.

Narrative therapy, meanwhile, focuses on recrafting the stories we tell ourselves to explain the events in our lives so as to eliminate themes of powerlessness and illuminate possibilities. As Yanos puts it, the goal is helping people with depression “tell stories about their lives in which their role as a protagonist is developed and transformed and themes of empowerment ... are emphasized.”

Get the message

For nearly 15 years, licensed social worker Mark M.’s narrative was one of shame and inadequacy because he couldn’t just “get over” his depression. Diagnosed in college with major depression and generalized anxiety disorder, he says he was too embarrassed, stubborn and afraid to accept the diagnosis and get help.

“There’s powerful internal pressure for men to be perfect,” reflects Mark, 43, who lives in Minneapolis. “Guilt and a sense of worthlessness conflict with the ‘Marlboro man’ image.”

Meanwhile, he ended up in the ER with what felt like a heart attack, lost a top counseling job in a health care network, performed poorly at another job, quit playing sports with friends, and neglected his wife and three young children.

His unwillingness to seek treatment, coupled with alcohol abuse as he tried to self-medicate, compromised his career and relationships.

“Self-stigma gave me an ingrained sense of failure,” Mark says of the days before he understood that his drinking and other problems linked back to his depression.

It wasn’t until he hit rock-bottom and landed in a psychiatric hospital that Mark finally got the help he needed to see that having depression wasn’t his fault and did not make him a bad person. Once he began to accept depression as an illness, not an indictment of character, he started on medication and entered psychotherapy.

“(Depression’s) ‘normalization’ helped me,” says Mark. “I realized that on the journey of life, depression can just happen—to adolescents, seniors, anyone.”

Educate & advocate

Mark took on the mission of spreading that message as both a personal and career goal. He founded the advocacy organization Face It to make sure other men, and the people who love them, understand that depression isn’t something you just “get over.” He teaches a course on mood disorders at the University of Minnesota’s Graduate School of Social Work. He also tells his story to workplace audiences as a consultant for businesses wanting to organize in-house depression programs.

Due to his advocacy work, Mark can now see himself as a leader, not a failure—someone who helps others rather than someone who couldn’t even help himself.

Apart from the personal benefits, advocates like Mark who get out in the community and challenge public perceptions play a powerful role in making depression less of a shameful secret, striking at the heart of self-stigma.

“The more ordinary Joes who come forward,” he says, “the better.”

It also helps when celebrities go public with their stories, says former Vancouver psychiatrist Janet Taylor, MD, MPH, who is now based at Columbia University in New York City. Media coverage of athletes and entertainers who have sought treatment for depression, social anxiety and other disorders makes the option more “doable” for the rest of us.

Connect with peers

“Normalization” takes place on a more private basis, too, through peer support: sharing stories with, and hearing stories from, others who are experiencing depression.

“When you identify with similar people, you feel less beat-up and lousy from stigma,” says Corrigan.

Stacy G. champions the healing properties of “peer power.” For example, she describes hearing someone complain about letting his worries snowball and feeling relieved to know she isn’t the only one to experience what she calls “brain spirals.”

Stacy organized a peer support group at her local church, which, she says, “has been a savior for many people.” Members exchange humorous slang for mental illness and coping techniques such as laughter, yoga, and volunteer work.

She also regularly posts on self-help forums.  

“Speaking openly about depression to people who are experiencing it helps you know you’re not alone,” she says.

Share the truth

Corrigan endorses peer support as a means of counteracting self-stigma, but he especially recommends disclosure—that is, coming out into the open about your illness, to whatever extent is comfortable.

“As we’ve seen with gays, keeping a secret is stressful because you perceive it as shameful,” says Corrigan. “But telling a peer or someone else dissipates tension and improves self-esteem as well as physical health.”

Amy K. of Prairie Village, Kansas, was diagnosed with depression, anxiety and PTSD while still in high school and remembers being afraid of how her friends would react if they found out. For years, she lived with self-doubt and a sense of failure as her chronic depression persisted despite counseling and different medications.

“It is difficult to form a healthy self-image when you feel flawed or defective,” says Amy, now a 36-year-old wife and mother.

Amy withdrew from college twice due to poor concentration and learning difficulties. She had trouble working because of fatigue, anxiety and physical ailments, including headaches, gastrointestinal complaints, and fibromyalgia. Her self-esteem was further eroded by the reactions of unsympathetic or skeptical relatives, including her husband.

“The knowledge that others may perceive you as less of a person because you are challenged with these issues is very daunting,” says Amy.

She learned the hard way, however, that buying into the “shame game” can have life-threatening consequences. To stay on the path of wellness, she says, “I have to remove any sense of shame or judgment from my life. When I am free from that, I am empowered and make better, healthier choices.”

In addition to finding effective medications, Amy has embraced life-style changes such as exercising more, eating better and practicing relaxation techniques. In turn, as a blogger and community supervisor for the depression forum on WeGoHealth—a self-help website whose slogan is, “empowering health activists to help others”—she encourages other people with depression to make healthier choices.

Her husband still isn’t entirely comfortable about having her depression out in the open, she says, “but I try to … let him know that I am not embarrassed about it, so therefore he doesn’t need to be embarrassed for me.”

She credits BreakThrough, a program offered by HeartConnexion Ministries in Kansas to help participants rethink their life stories, for giving her the insight she needed to see herself in a new way and fully accept who she is.

“It takes a long time to get there,” she says, “but I finally understand that I am no less of a person because of my health issues. I share my diagnosis pretty publicly, and it’s been incredibly therapeutic.”

Be the change

Stepping out of secrecy can be liberating, but sharing the truth with friends, co-workers and supervisors sometimes has unfortunate consequences. Therefore, Corrigan explains, disclosure can be a selective process. For instance, it may be more comfortable to confide in a friend who already knows someone dealing with depression.

“It’s an individual decision because you do risk something,” Corrigan says.

Manon Charbonneau, MD, a Quebec psychiatrist and past president of the Canadian Psychiatric Association (CPA), decided to take the risk big-time. After weighing the possible costs to her career, she revealed her history of depression before hundreds of colleagues at a CPA convention.

Her change of heart was a long time coming. When Charbonneau first developed depression as a psychiatric resident some 20 years ago, she was careful to keep her diagnosis and treatment a secret.

Stigma in the medical community—an educated population that might be supposed to know better—hasn’t improved, judging by results of a 2009 study of University of Michigan (UM) medical students. Of the UM students who reported high levels of depressive symptoms, about half worried that revealing their illness would be prejudicial to their careers and almost 62 percent said asking for help would mean their coping skills were inadequate.

Established psychiatrists share similar fears. A survey done by the Michigan Psychiatric Society revealed that more than half of the 500-plus members who responded would rather treat themselves for a mental illness than obtain help that would leave a paper trail.

Charbonneau adopted an even more extreme approach when her second major depression hit in 2008: denial. It wasn’t until her college-age son returned home on a visit and urged her to get help that Charbonneau realized how internalized stigma had prevented her from acknowledging her depression and reaching out for psychiatric care.

“It’s the biggest barrier to treatment,” says Charbonneau, who now takes antidepressants to maintain her mental health.

For Charbonneau, eliminating self-stigma ultimately means tackling the larger issue of social stigma. She says she made her dramatic disclosure “to lead the way” in the fight against the insidious enemy that delayed her recovery.

“Your internal stigma is linked with society’s,” says Charbonneau. “You must first attack stigma on the personal level, then the societal level, as we did with AIDS and cancer. We must remake the culture to allow for discussion about mental health.”  

-----
Janice Arenofsky writes health and other nonfiction articles for national magazines such as Miller-McCune and Scientific American.

Steps against stigma

These strategies can help build your sense of personal empowerment and combat not only self-stigma, but the wider social stigma that feeds it.

Explore therapy to help you reframe your life experience, improve your self-image and replace negative self-talk with more positive language.

Use the Internet for peer support. Twitter with others who have depression, trade recovery stories with Facebook friends, or join an online mental health forum (such as esperanza’s new peer-to-peer forum at hopetocope.com or hopetocope.ca).

Practice strategic disclosure. Tell your story to a peer or person with a realistic view of depression.

Get involved in outreach. Join advocacy groups. Participate in or help organize a walkathon or mental health fair. Write protest letters to media outlets or companies that spread negative