Shannon Gu

Instructor Danny Nolan

SOC 240

16 August 2017

Surrounded but alone:

Depression, stigma, and identity

The leading cause of disability worldwide may come as a surprise to someit is not a

physical illness, and as such, the general public may be inclined to believe that it is not a disability

at all. Depression is the second most common mental health problem in the world, and among

developed nations, nearly 20% of people will experience at least one depressive episode in their

lifetimes (Cruwys et al., 2014). Despite its recognition as a serious public health problem,

depression is frequently undertreated and underdiagnosed; roughly half of those struggling with

depressive symptoms seek professional help for their condition, and of those who seek help, even

less are formally diagnosed as depressed or provided with adequate treatment plans (Svensson and

Hansson, 2015; Economou et al., 2017). The root of the problem, then, is not that depression lacks

sufficient treatment interventions, but that such treatments often do not reach the people they

intend to benefit. One major barrier to access is insufficient mental health literacy among the

general public, which underpins the stigma associated with mental illnesses such as depression

(Economou et al., 2017). The high incidence of depression, unfortunately, does not appear to

correlate with the acknowledgement that it is a legitimate disorder.

Depression is commonly viewed as an illness of the self, characterized by persistent

negative beliefs about oneself and the world around them (Karp, 1994; Montesano et al., 2017).

The thoughts and feelings that depression generates are so intense that people with depression

frequently link their mental state to stress-inducing physical conditions like drowning or

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suffocating (Karp, 1994). Other symptoms include highly self-critical attitudes, a loss of pleasure

from enjoyable activities, and increased social withdrawal (Cruwys et al., 2014). Viewing

depression solely through the lens of clinical psychology, however, underemphasizes that

depression is an inherently social disorder: social impairment, as either a cause or a symptom, is

far more prevalent in depression than in any other physical or mental illness (Cruwys et al., 2014).

As such, depression is paradoxical in that it leads to the perceived need for withdrawal but also a

desire for social connectedness (Karp, 1994). Another example of the social factor in depression

is the existence of stigma and its effects on individuals with depression; according to the Cooley-

Mead hypothesis, individuals come to see themselves in the way that they think others perceive

them (Lundgren, 2004). Since commonly held beliefs about individuals with depression

characterize them as lazy, weak, and bearing personal responsibility for the illness (Economou et

al., 2017), stigma and subsequent discrimination have the potential to reinforce the individuals

negative self-concepts, effectively worsening their condition. Examining depression from the

perspective of social psychology provides a more nuanced understanding of how the identity of an

individual with depression is shaped by their social environment.

Illness Identity

A change in social connectedness often marks the onset of depression. Depressive episodes

can result from negative events in ones social environment, such as bullying, the end of a

relationship, or the loss of a loved one (Cruwys et al., 2014). Other times, depressive episodes or

moods do not have a specific trigger, and those who experience the symptoms for the first time

may not even attribute them to depression. The extended period of unease is the first of Karps

(1994) stages of depression. Initially, individuals with depression attribute their low moods to the

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structure of their lives as opposed to the structure of their selves, believing that they will start to

feel better if they remove themselves from the problematic situation (Karp, 1994). When their

circumstances change but their mental state does not, however, the individuals consider the

possibility that they may be sickthat their problem is internal instead of situationalthus

shifting their explanations from structural attributions to dispositional attributions (Karp, 1994).

The implication that they are the cause of their own problem may then lead to the development of

a negative self-concept. Research has shown that clinically depressed individuals are significantly

better at connecting and organizing negative self-views than positive self-views (Montesano et al.,

2017).

The second stage, the conclusion that something is seriously wrong, is where the formation

of an illness identity and the loss of ones social identity begin (Karp, 1994; Cruwys et al., 2014).

Social identity is a part of ones self-concept obtained from memberships in social groups; Cruwys

et al. (2014) argue that social identities play a crucial role in psychological well-being by producing

feelings of belongingness, establishing social support and collective values, and acting as a source

of motivation for the individual. Depression, however, hinders the benefits of social identities. For

one, the mental state generated by depression cannot be understood by those who have not

experienced it, so the meanings from depression cannot be properly conveyed to others (Karp,

1994). Furthermore, to talk about the problem with friends and family means presenting a new

identity to them, which the individual may be unwilling to do because of the potential for

stigmatization and the difficulty of accepting a negative identity (Karp, 1994). An illness identity

is also unlikely to have a role that fits in ones existing social groups. Therefore, the barriers to

communication lead to social withdrawal and further internalization of negative thoughts.

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Depression can be seen as a mental state derived from a perceived lack of belonging, social support,

and control over ones life (Cruwys et al., 2014).

The last three stages of depressioncrisis, acceptance of the illness identity, and

overcoming depressionare related to the concepts of self-verification and salience. Unlike in

typical cases of self-verification, however, the illness identity is not desirable to have, particularly

because it arises from a seemingly uncontrollable fault of the self. During the crisis stage,

individuals with depression become exposed to the world of mental health care, which confirms

their beliefs that their condition originated from within themselves (Karp, 1994). Exposure to this

new context has its benefits and drawbacks: receiving a diagnosis, for instance, provides

individuals with a name for their incoherent thoughts and feelings and implies that the condition

can be treated, but it also labels them as deviant and puts them into the stigmatized group of those

with mental illnesses (Karp, 1994). Upon confirmation of the illness identity, individuals begin to

more actively understand the meanings behind their new identity by seeking the causes of their

condition, reinterpreting past experiences based on their current condition, and creating coping

mechanisms (Karp, 1994). Finally, understanding more about ones illness identityin essence, a

part of the self that needs to be fixed or replacedenables individuals to construct and work

towards fully functional possible selves (Karp, 1994). While overcoming depression can be

achieved alone, the most effective means of recovery often involve regaining social support and

connectedness (Cruwys et al., 2014). The effects of forming social networks with others who are

stigmatized, however, are still up for debate.

Mental Illness Stigma

From a social perspective, the biggest obstacle to recovering from depression is stigma.

Stigma is a social construct consisting of negative perceptions and behaviors toward a specific

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group (Sheehan et al., 2017). Svensson and Hansson (2015) identified four major components of

stigma: 1) people perceive and label differences between other people; 2) cultural beliefs,

combined with negative stereotypes, harm the labelled people; 3) the labelled people are separated

from the rest of society to distinguish us versus them; 4) the labelled people experience further

discrimination and status loss. As for how mental illness stigma develops, psychological well-

being is a critical element of what behaviors are considered normal in society; the behaviors of

those who are mentally unwell are seen as deviant, leading to negative stereotypes of individuals

with mental illnesses as being dangerous, unintelligent, or worthless (Phelan et al., 1997). Stigma

then becomes internalized when individuals in stigmatized groups apply public stigma to

themselves (Sheehan et al., 2017). The fear of others negative judgments, which is pervasive in

individuals with depression, is not unfoundedits roots are in the immediate social environment.

A survey of the American public found that mental illness not only prompts negative responses

such as distrust and a desire for increased social distance, but is also a more stigmatizing condition

than that of ex-criminal status, physical disability, and homosexuality (Phelan et al., 1997).

Considering the intensity of mental illness stigma, it is of little surprise that in all age groups,

stigma is the primary impediment to seeking help (Sheehan et al., 2017; Dolphin and Hennessy,

2017).

One objective for reducing public stigma is to improve the general publics mental health

literacy, which is knowledge about mental illnesses that assists in their identification and

prevention (Economou et al., 2017). Having a high degree of mental health literacy, however, does

not guarantee a lack of stigmatizing attitudes. For instance, although peoples ability to identify

mental illnesses has improved over the years, the publics attitudes towards mentally ill individuals

have not (Svensson and Hansson, 2015). In addition, even those with a high degree of mental

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health literacy are not free of stigma. A study by Economou et al. (2017) showed that psychology

students, while better able to identify depression than the general population, held attitudes similar

to the general populationsthat is, the students did not acknowledge depression as a serious

condition and considered discussing depression with a friend as more helpful than counseling or

therapy. They also firmly held the belief that people with depression could easily snap out of

their condition, despite their extensive clinical knowledge on depression (Economou et al., 2017).

Seeing that even mental health professionals are not immune to public stigma raises a number of

concerns. Prejudices could prevent mental health professionals from fully understanding their

patients and providing them with high-quality care (Economou et al., 2017; Sheehan et al., 2017).

Furthermore, the authority of mental health professionals suggests that their negative attitudes

towards patients with depression must be justified, since they know more about depression than

the general public does; thus, they are inadvertent contributors to stigma rather than fighters of it.

The pervasiveness of stigma is analogous to a perceived lack of social support. Not

knowing who to reach out to in the general public, even that of significant others, results in turning

towards the stigmatized group for support and strengthening the illness identity.

Identifying with Stigmatized Groups

Social identities usually improve an individuals psychological well-being, as knowing

ones role establishes a sense of belonging and meaning in life, but identities within a stigmatized

group are far more complicated. While identifying with a stigmatized group can provide support

that would otherwise not be found, it also poses a social identity threat, in which a person can

experience a loss of status from expressing their socially devalued illness identity (Cruwys et al.,

2014; Isaksson et al., 2017).

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 The experience of discrimination is one of the strongest predictors of identifying with a

stigmatized group, and identifying with the group can help protect against the effects of stigma

(Cruwys and Gunaseelan, 2016; Isaksson et al., 2017). For instance, Isaksson et al. (2017) found

that among people who were diagnosed with depression, those who considered depression as part

of their self-concept were able to list more resources for coping than those who did not. Stronger

identification with depression, howeverthat is, higher salience of the illness identityis more

associated with negative outcomes than positive ones. Isaksson et al. (2017) found that individuals

with depression who more strongly identified with their stigmatized group tended to have more

depressive symptoms, were more vulnerable to stress, and were more likely to see stigmatizing

incidents as harmful.

Perception of the stigmatized group, however, is the biggest determinant in how strongly

ones identification with the group is correlated with negative outcomes. In other words, the

interaction between identifying with a stigmatized group and well-being is heavily moderated by

ones judgments of the group. According to Cruwys and Gunaseelan (2016), identifying as

depressed was correlated with decreased well-being only if the individuals normalized depressive

thoughts and behaviors. Isaksson et al. (2017) also noted that the association between identification

and stress was far stronger if the individuals with depression perceived their group as having little

value. Furthermore, those who saw the stigmatized group as less cohesive tended to have suffered

depression for a shorter time and were less susceptible to social identity threat (Isaksson et al.,

2017). Understanding the role that cognition has in maintaining well-being for people with

depression could lead to better treatment interventions and speed the path to recovery.

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Future Interventions

Depression has three key obstacles to recoverythe illness identity, the loss of social

connectedness, and stigmawhich interact with each other in numerous complex ways. For

example, having a visible illness identity accentuates the perceived differences between mentally

healthy and mentally ill people, which contributes to public stigma and subsequent repression of

the illness identity. Coming forth with an illness identity can socially isolate an individual due to

stigma, but hiding an illness identity can also lead to isolation due to the shame associated with it.

Social isolation can also be the cause instead of the result of depression; in fact, social isolation is

a significant risk factor even after controlling for variables like stress levels, physical health, and

personality (Cruwys et al., 2014). Effective interventions for depression, therefore, should target

at least one of the three obstacles, for being able to overcome one of them will make it easier to

overcome the other two.

A common difficulty in moving away from an illness identity is how central the identity

can become in ones self-concept. Some individuals believe in a biochemical model of depression,

in which their depression is the result of some biochemical or physiological flaw (Cruwys and

Gunaseelan, 2016). Although depression does have some basis in biology and genetics, framing it

as a fundamental flaw suggests that depression is permanent (Cruwys and Gunaseelan, 2016) and

that managing it is beyond ones control (Karp, 1994). As such, interventions should help patients

see that depression is a temporary state and that they can achieve a mentally healthy possible self

(Cruwys and Gunaseelan, 2016; Isaksson et al., 2017). To do so, interventions would need to target

the cognitive conflicts at the heart of depression, where positive and negative self-views conflict

over an individuals core values. Cognitive therapy, in which patients practice challenging their

negative self-views, can help them resolve their internal conflicts (Montesano et al., 2017).

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Interventions and therapies should also emphasize that depression symptoms are on a continuum

to help prevent stronger identification with the illness identity (Isaksson et al., 2017).

Upon decreasing the salience of an illness identity, a reasonable next step would be to

rebuild ones social identity. Weak social identities are greatly implicated in depression: having

lower identification with a valued social group and higher perceived social isolation are associated

with more symptoms of depression (Cruwys et al., 2014). Logically, then, strengthening an

individuals social identification with meaningful groups should produce protective effects; for

example, establishing and engaging in interaction rituals builds group solidarity and generates

positive emotions, which can help individuals with depression override their sense of isolation and

low mood. Indeed, a large amount of research has supported the impact of social identification.

Cruwys et al. (2014) list an array of studies on group-based interventions for depression: in one

study, care home residents who joined gender-based social groups showed a significant decrease

in depression symptoms, while in another, participants in group-based interventions that practiced

developing meaningful social identities improved their well-being more than participants in

interventions like medication or individual therapy. Most strikingly, a study showed that

individuals with depression who joined one meaningful social group reduced their risk of relapse

by over 20%and if they joined three groups, their risk was reduced by over 60% (Cruwys et al.,

2014). Social identities are incredibly powerful in bolstering well-being; they speed up recovery

rates, foster resilience, and buffer against stress responses (Cruwys and Gunaseelan, 2016; Cruwys

et al., 2014). Group-based interventions are fairly recent, which makes it challenging to integrate

them into current treatment options. However, they require less resources, are more widely

accessible, and may be a less stigmatizing option than medication or individual therapy.

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 The final goal for improving interventions for depression is to deconstruct the stigma that

surrounds mental illnesses. Given the scope and the depth of stigma, dismantling it may seem

daunting or even impossible; its negative effects on self-concept and its role in inhibiting access

to treatment, however, make it a crucial target. Acknowledging that stigma is a societal problem

emphasizes that society has a responsibility in supporting individuals with depression. Anti-stigma

campaigns for mental illness have typically revolved around personal contact with individuals with

mental illness, educating the public about stigma, and even protests, but their effects have been

quite small thus far (Svensson and Hansson, 2015). A possible explanation for their low impact is

that the general public may not realize that stigmatizing beliefs are as widespread as they are, so

they have difficulty taking the anti-stigma campaigns seriously. Like any social norm, however,

stigma is learned from ones social environment. Thus, changing the way people learn about

mental illnesses like depression could provide more success. For example, Dolphin and Hennessey

(2017) found that stigma toward depression is more heavily associated with depressions

symptoms rather than the label of depression; mental health professionals, who both identify the

symptoms and attach the label, can use this knowledge to confront their own attitudes when they

diagnose and help patients (Economou et al., 2017). If mental health professionals can overcome

their stigmatizing beliefs, the people who turn to them for their guidance and authoritytheir

pupils and the general publicmay begin to adopt less stigmatizing attitudes as well (Economou

et al., 2017). Another way to lessen stigma could be to introduce continuum beliefs about

depression in place of binary labels (depressed versus non-depressed), which would reduce the

perceived differences between mentally healthy and mentally ill individuals and thus decrease the

desire for social distance (Dolphin and Hennessey, 2017). Lastly, mental health literacy could be

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improved by teaching more about the social side of depression: how social connectedness is related

to depression and how mental illness stigma impacts self-concept and the prognosis of depression.

Conclusion

Depression is a mystery to many because it seems like it only exists in ones mind. Clinical

psychology commonly characterizes depression as an illness of the self but often fails to view

either depression or the self in the context of ones social environment, even though depression is

intrinsically a disorder of sociality. Social withdrawal is a major risk factor for depression, but it

also can be a symptom when individuals with depression find themselves unable to properly

communicate with others about their mental state (Cruwys et al., 2014; Karp, 1994). The fear of

stigma, a powerful, socially constructed negative label, only furthers social withdrawal and

prevents many from receiving the help they need (Sheehan et al., 2017). Ironically, receiving help

such as diagnoses or interventions may increase the salience of an illness identity because they

label individuals as deviant (Karp, 1994), which can strengthen the negative impacts of stigma on

ones self-concept. Isaksson et al. (2017) and Cruwys and Gunaseelan (2016) found that higher

identification with a stigmatized group is associated with more depressive symptoms, a longer

duration of depression, and decreased well-being in general; however, they also found that the way

individuals with depression perceived their stigmatized group influenced the likelihood of

experiencing negative effects. Taking everything into consideration, then, the most effective ways

to improve outcomes for people with depression would be to target their illness identities, rebuild

meaningful social identities, and deconstruct the stigma of mental illnesses.

The process of recovering from depression cannot solely be the responsibility of the people

who suffer from it when societal factors play an enormous role in hindering recovery. As

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mentioned at the beginning, depression is the leading cause of disability worldwide, which

indicates that depression is a major societal problem instead of just a collection of individual

problems. How well an individual recovers from depression not only depends on their own efforts,

but also on others efforts to show them empathy and to see them as more than just a stigmatized

label. It is time for society to make progress in normalizing compassion, not distaste, for

individuals with depression, and it is time to recognize how society can change depression for the

better.

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 References

Cruwys, T., & Gunaseelan, S. (2016). Depression is who I am: Mental illness identity, stigma
and wellbeing. Journal of Affective Disorders, 189, 36-42.
Cruwys, T., Haslam, S. A., Dingle, G. A., Haslam, C., & Jetten, J. (2014). Depression and Social
Identity: An Integrative Review. Personality and Social Psychology Review, 18(3), 215-
238.
Dolphin, L., & Hennessy, E. (2017). Labelling effects and adolescent responses to peers with
depression: an experimental investigation. BMC Psychiatry, 17(1).
Economou, M., Peppou, L., Geroulanou, K., Kontoangelos, K., Prokopi, A., Pantazi, A., Zervakaki,
A., & Stefanis, C. (2017). Attitudes of psychology students to depression and its treatment:
Implications for clinical practice. Psychiatriki, 28(1), 46-53.
Isaksson, A., Martin, P., Kaufmehl, J., Heinrichs, M., Domes, G., & Rsch, N. (2017). Social
identity shapes stress appraisals in people with a history of depression. Psychiatry
Research, 254, 12-17.
Karp, D. A. (1994). Living With Depression: Illness and Identity Turning Points. Qualitative
Health Research, 4(1), 6-30.
Lundgren, David C. (2004). Social Feedback and Self-Appraisals: Current Status of the Mead-
Cooley Hypothesis. Symbolic Interaction 27(2), 267-86.
Montesano, A., Feixas, G., Caspar, F., & Winter, D. (2017). Depression and Identity: Are Self-
Constructions Negative or Conflictual? Frontiers in Psychology, 8, 877.
Phelan, J., Link, B. G., Moore, R. E., & Stueve, A. (1997). The Stigma of Homelessness: The
Impact of the Label "Homeless" on Attitudes Toward Poor Persons. Social Psychology
Quarterly, 60(4), 323.
Sheehan, L., Dubke, R., & Corrigan, P. W. (2017). The specificity of public stigma: A comparison
of suicide and depression-related stigma. Psychiatry Research, 256, 40-45.
Svensson, B., & Hansson, L. (2015). How mental health literacy and experience of mental illness
relate to stigmatizing attitudes and social distance towards people with depression or
psychosis: A cross-sectional study. Nordic Journal of Psychiatry, 70(4), 309-313.

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