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The evaluation of Beliefs
about the Self
By
Arlette langerak
P.R.Brown
&
R. van Daalen
A thesis submitted in partial fulfillment of the
requirements for the degree of
Master of Science in
Sociology
At the
University of Amsterdam
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Introduction
In the last few decades most research that has been done on the subject of the internalization of stigmatizing views in relation to mental illness, has primarily focused on people with a
persistent mental illness, and have shown that these people belong to one the most stigmatized
groups in society (Corrigan, 2005). Other research has shown that there are many negative public opinions present in society towards people that suffer from a mental illness and that social distance and experiences of stigmatization are common towards this group (Corrigan & Watson, 2002).
The loss of opportunity experienced by people with a mental illness is largely exacerbated by negative public views (Link, Cullen, Struening, & Shrout, 1989; Farina, 1998; Penn, Guynan, Daily, Spaulding, 1994). In his work, Link (1987) showed that employers are less likely to hire people who are labeled mentally ill. Additionally, people are less likely to lease
apartments and to offer others forms of practical support when they are aware of the fact that someone suffers from a mental illness (Alisky & Iczkowski, 1990; Page, 1977).
People with a mental illness are believed to be unpredictable, dangerous, irrational,
incompetent, bizarre and these prejudices have persisted and strengthened from the ‘50s till today, in combination with a desire to keep social distance from these people (Link et al. 1999; Martin, Pescosolido, & Tuch, 2000; Phelan et al. 2000; Rabkin, 1980; Wahl, 1995). Independent of the mental illness a person suffers from, having a label and experiences of stigmatization, can have numerous negative outcomes; less income and higher unemployment (Link, 1982, 1987; Link, Mirotznik, & Cullen, 1991), smaller and less supportive social networks (Link et al. 1989; Perlick et al. 2001); greater demoralization and episodes of depression (Link, 1987; Link et al. 1991, 1997) and lower subjective quality of life and satisfaction (Markowitz, 1998; Rosenfield, 1997).
Hence, The Mental Health Care Organization started a campaign ‘Samen Sterk tegen Stigma’ (together strong against stigma) and emphasized that anti-stigma efforts are necessary to clinical services for enhancing the quality of life for people that suffer from a mental illness. The anti- stigma strategies include education (providing information about mental illnesses to counter the myths around them), contact (establish interactions between the people with a mental illness and the public) and protest (creating moral appeals to stop stigmatization towards people with a mental illness through TV- commercials).
Researchers have studied the phenomenon of stigma and have examined ways of reducing negative public views towards people with a mental illness (Corrigan et al., 2003; Feldman &
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Crandall, 2007) . As I mentioned earlier, public stigma is the most prominent form that is studied and observed, due to the fact that it represents discrimination towards a vulnerable group by the larger population.
Another phenomenon related to public stigma, which has had too little attention, is the occurrence of self- stigma. In making sense of prejudice and social distance experienced by people who suffer from a mental illness, researchers distinguish public stigma from self- stigma (Corrigan & Roa, 2012). Public stigma refers to negative attitudes by the population about people with devaluated characteristics. Self stigma occurs when these people internalize the negative public attitudes and suffer from the consequences.
In short, a large number of studies have given evidence that having a stigmatized label and experiences of social distance and rejection significantly lowers the quality of life, this evidence counters earlier statements that stigma only has minor negative consequences for people with a mental illness (Gove, 1980).
Considering the predictions of labelling theories and the studied negative consequences of stigmatizing experiences, we would expect large differences between people with or without a mental illness and a correlation between experienced stigmatization.
Interestingly, this is not what numerous studies have shown (Corrigan & Watson, 2002; Corrigan, Watson, & Barr, 2006; Hayward & Bright, 1997; Hayward et al. 2002; Kleim et al. 2008; Link et al. 2001, 2002; Link, Castille & Stuber, 2008; Markowitz, 1998; Risenfield, 1997; Wright et al. 2000; Yanos et al. 2002). Almost all studies report a significant negative association between experienced stigmatization and a person’s perceived identity.
Nevertheless, the relation between stigma and self-esteem are in some cases somewhat modest in strength (Link et al. 2008; Hayward et al. 2002; Vauth et al. 2007). This can be explained by the fact that some people who experienced high levels of stigmatization or social distance internalize these events differently than others with a mental illness. The extent to which people internalize these events of stigmatization has influence on the way they form their identity and the way they internalize beliefs about their selves.
Corrigan & Watson (2000) showed that although some people who have a mental illness suffer self-derogation as a result of experienced stigmatization, others respond in a different way such as anger or indifference. They called this “the paradox of self- stigma”.
In contrast to people that suffer from observable illnesses that are not considered as their own responsibility, people known to be diagnosed with a mental illness are at greater risk of being stigmatized (Thoits, 2011).
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about his or her identity it seems sensible to consider the possible ways in which people resist stigma and which resistance might be employed by people with a mental illness.
Understanding the different ways in which people cope with their label requires not only insight in the experiences people had over time in relation to their illness, but also the nature of the mental illness. Research has shown that, higher levels of social distance and
stigmatizing labels are attached to mental illnesses that are more severe. People with Borderline Personality Disorder or Schizophrenia are considered more dangerous,
unpredictable and irrational than people who suffered from episodes of Depression (Koehne, 2012). Differences between internalizing a stigmatised label could therefore possibly be explained by differences between mental illnesses.
The main focus of this research is the analysis of the different ways in which women that are diagnosed with a Borderline Personality Disorder and women diagnosed with Depression internalize beliefs about their selves.
The overarching themes within this research concern the life experiences of the women which indicate uncertainty towards their mental illness, the internalization of negative views towards their label, and the way in which they cope with, and present their label.
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2
Context
Published narratives by people that suffer from a mental illness describe the negative and harmful effects of stigma on self-efficacy and self-esteem (Corrigan, 1989; Holmes & River, 1998). However, a careful consideration of the research literature suggests a paradox. People with a mental illness differ in the way they internalize beliefs about the self and the influence of stigma on these beliefs is not always as strong as might be expected (Chaimberlin, 1978; Deegan, 1990). Research also suggests that, instead of internalizing the negative public beliefs about one’s mental illness, people could become angry because of the prejudice that they experience from society. Anger towards the prejudice and low-self esteem describe a fundamental paradox in the evaluation of beliefs about the self. Models that explain the internalization of self-stigma need to account for people that internalize stigma in a negative way and other people that are energized by the prejudice (Corrigan & Watson, 2002). There is another group that needs consideration in describing the impact of stigma on the self. The sense of self for people with a mental illness is neither energized or hurt by prejudice, instead they show a indifference to it. In this paragraph I will illustrate how the evaluation about the self is influence by public views towards the illness. Stigmatizing experiences do not
necessarily need to lead to feelings of lower sself esteem. Through the discussion of coping strategies in order to resist negative public opinions I will attempt to create an understanding of the different ways people develop their won identity in relation to their mental illness.
A Social- Psychological definition of Self- stigma
Many people that have a mental illness are aware of the fact that there exist prejudices about their group (Hayward & Bright, 1997). Nevertheless, the fact that they are aware of the fact that people have negative beliefs about their mental illness does not necessarily mean that they internalize these beliefs (Crocker & Major, 1989). Many people with a mental illness emphasized they are aware of the negative prejudices about their mental illness but did not necessarily agreed with them (Shurka, 1983; Wright, Gronfein, & Owens, 2000). Not only public stigma but also self-stigma includes prejudices. When people agree with the negative prejudices about their mental illness they tend to belief they are incapable of function properly in society which leads to negative emotional reactions such as low esteem and
self-efficacy (Corrigan, Faber, Rashid, & Leary, 1999). Self-self-efficacy is the expectation people have that they can successfully behave in specific situations in society (Bandura, 1977). Thus it seems sensible to consider the two types of stigma resistance can occur among people with
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a mental illness. The two forms of resistance that can be employed are challenging and
deflecting resistnce which have effect on the way people with a mental illness evaluate beliefs about the self (Thoits, 2012).
Challenging & Deflecting Strategies
Resistance towards public prejudice refers to the opposition to negative influences from society. There are two forms of resistance which are commonly used when people experience a negative force from society: challenging and deflecting. Both forms of resistance protect the self of devaluation from society, but challenging can cause the change of others’ negative views and beliefs about mental illnesses while deflecting does not (Thoits, 2012).
In order for people to use resistance strategies some predictions seem necessary. Resistance is a response towards prejudice and devaluation, therefore people first must have acknowledged to themselves that they have a mental illness. In other words, people must acknowledge they have the label of ‘mentally ill’ regardless of the acceptance of the categorization as personal identity. They must also understand that their illness, when revealed, could become a public identity and other could define them as mentally ill (Link et al. 1989). Finally, people must have knowledge of the cultural meanings attached to the mental illness they have, again regardless of whether they accept these meanings. Corrigan et al. (2006) call these three conditions “stereotype awareness”. These conditions distinguish people who se resistace strategies from people who are in denial or unaware of the mental illness they suffer from (Corrigan & Watson, 2002). These conditions make the experiences of stigmatization towards one’s mental illness ‘personallly relevant’ (Link et al. 1987). There are five groups of people who all differ in the way they do or do not internalize negative beliefs about their mental illness, aside people who are in denial of their mental illness or are unaware. At the extreme, people who agree with the negative public beliefs about their mental illness and endorse and internalize these public views (Corrigan et al. 2006). At the other extreme, people that disagree with public views concerning their mental illness and reject them. The other three that are in between reject the negative public views as self-descriptive, even if they agree with the broader public beliefs about people that suffer from a mental illness.
People that show resistance by means of deflection believe that negative public views “do not characterize me” or “I’m not like that”. The potential for harm due to negative public views is recognized but not accepted as threat to the self (Thoits, 2012). Other ways of deflecting include the aversion of devaluation by negative public views with “avoidance”, these people keep their mental illness a “secret” in order to avoid devaluation through interactions with
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people or mainly socialize with people who have the same stigma. Finally, people that have experienced negative events as a result of their mental illness “label” can engage into “self-restoration” (Thoits, 2012). They shift their social comparisons to other people with a mental illness or retreat themselves from situations in which they may fail due to their mental illness (Crocker & Major, 1989). In short, I suggest that people cope in different ways with the possible negative public views towards their mental illness. People undoubtedly use a number of different strategies, but all of these strategies are typified by one of the orientations I described above. In the next paragraph I will focus on the conditions for the use of these strategies.
When people are “labelled” mentally ill, they experience pressure to respond in expected ways (Link & Phelan, 2001). The experiences of pressure may cause that deflecting beliefs like “thats not who I am” may be very hard to maintain. Educating other people about the mental illness may be difficult as well considering the risk of losing credibility, scruntiny and sanctions (Kaiser, 2006). Despite these pressures, there are a number of factors that increase the likelihood of using challenging and deflecting strategies in certain encounters. The first factor is the familiarity with the mental illness in the family or with friends. Many people with family members or friends that deal with mental health problems realize, through interactions, that the symptoms don’t match the negative public views about “crazy people”. People that develop a mental health problems of their own recognize this sooner due to the familiarity with the symptoms and are quicker to recognize that the mental illness does not fit the negative public views (Thoist, 2010; Corrigan, 2006). Additionally, people that have experienced stigma towards other family members or friends due to their mental illness, are more likely to challenge other people’s negative attitudes towards the “label”. The moderating effects of the familiarity with a mental illness also depend on the quality of the relationship with the person. If the relationship was difficult in relation to the mental health problems, people could also have distanced themselves from this person and have developed negative views about the mental illness themselves. Another factor that influences resistance is the past
experience with stigma. People may have experienced stigma prior to the development of
their mental illness. For example, people might have experienced negative public views towards their ethnic, religious or sexual identity, resistance strategies may therefore already been developed previously and can be applied in relation to the mental illness. Through these early experiences with resistance strategies people are more likely to confront negative public views towards their mental illness (Thoits, 2012). Finally, the characteristics of the mental
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illness people suffer from influences the way they internalize negative public views in
interpersonal interaction. People that suffer from a mental illness that is less severe and the better they are in the management of their mental health problems are more likely to perceive negative public views as “they don’t fit me”. However, people that suffer from a severe persistent mental illness they could become less likely to challenge negative public views (Tajfel and Turner, 1986; Corrigan & Lundin 2001). In short, people that have a mental illness that is time- limited or less severe are considered to be more likely to resist negative public views towards their label than those with more severe forms of mental illness. Up to this point I have elaborated on the ways people resist negative public views towards their mental illness and the possible conditions that play a role in this resistance. People with a mental illness use multiple coping strategies and change strategies over time as the social environment changes too (Corrigan & Watson, 2002; Estroff et al. 1991). The resistance strategy of deflection in combination with secrecy is perhaps used most as well as disclosure to familiar others (Goffman, 1963; Link et al. 1989). For people that use challenging
strategies, disclosure and secrecy are no option. Challenging requires the education and confrontation of other people without mental illness.
Some strategies will appear and disappear from someone’s repertoire as the mental illness career unfolds (Tajfel & Turner, 1986). Changes in social interactions over time and familiarity with ones mental illness influence the way people internalize beliefs about theirselves and form identity around their mental illness. With this in mind I present the following research question;
How do people with the diagnosis of Borderline Personality Disorder and people with the diagnosis of Depression differ in the ways they evaluate beliefs about their selves?
- How do people with BPD and Depression differ in defining and internalizing experiences of social stigmatization?
- How do these beliefs about the self differ in outcomes of self-stigmatization? In the context I discussed that people with a mental illness do not necesseraly internalize negative opinions about their mental illness. In the following paragraph I will discuss the importance of narratives in people’s lives in the conceptualization of identity.
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Theory
In this paragraph I will discuss the narrative conception of life experiences in relation to the conceptualization of identity. The idea behind the narrative conceptualization of the self is based on the fact that people create self- stories through which they form their identity (Goffman, 1963). Negative experiences in life can have a strong influence on the way people form beliefs about their identity and is therefore an important aspect in the narratives of people with a mental illness. A narrative identity provides a subjective sense of self continuity as it symbolically integrates the events of lived experience in the plot of the story a person tells about his or her life (Ezzy, 239:1998). In this paragraph I will explain the importantce of narratives in the conception of identity by discussing George Herbert Mead on the conception of temporal and intersubjective nature of the self and Paul Ricoeur on Hermeneutic theory of narrrative identity. The importance of the conception of identity through narratives will be discussed through an analysis of Goffman in relation to Links Modified Labeleing theory.
G.H.Mead’s Theory of Time
While sociologists have mainly focused on Meads’s (1934) social psychology of the self , Mead’s (1932) theory of time tends to have been linked more often to philosophical concerns. “A narrative conception of a person’s identity provides a framework for the
integration and extension of Mead’s conception of time and his social psychology of the self” (Ezzy, 1998:240). Norbert Wiley (1994:43) ones pointed out, that there is a temporal
dimension in Mead’s conception of the “I” and the “me” in that both the “I” and the “me” are discovered experientially in memory images of the things individuals have done in the past. In short, experiences in the past form memories which have influence on the way people view their selves now. One section of Mead’s The philosophy of the Present (1959) describes the importance of temporality for the concept of the self. He describes that consciousness arises when organisms include their own organized attitudes “among the objects that shape their action”. “Life becomes conscious at those points at which the organism’s own responses enter as part of the objective field to which it reacts” (p.73). Past behaviour and responses
influence the actions in the present.
There is a large difference in experiences between people that suffer from a mental illness. Whereas some experienced negative views towards their label, others did not or experienced this in another way. These experiences, which include behaviour and responses towards those experiences in the past, influence the narrative identity and sense of self in the present.
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Both memories of the past and anticipations of the future are symbolically organized and manipulated to provide a coherent self-concept that serves to direct current action.
Mead’s analysis of the construction of past and future through anticipating and remembering one’s own responses produces the idea of “taking the role of the other”. In the same way that persons pass from the present into their own remembered actions, they also pass into the remembered or anticipated responses of others. The meanings of past and anticipated events change as a consequence of reframing- effects of role taking during the passage of interaction (Ezzy, 1998:241). Considering self-stigma, through the process of re-framing and role taking, people that suffer from a mental illness can create negative opinions about the mental illness in general as well. People that suffer from a mental illness are part of the same society as the people that have negative opinions about their illness. Thus, it is possible that people with a mental illness were raised with the same negative views about mental illnesses before they actually got developed a mental illness theirselves. These negative opinions about one’s own illness could encourage self-stigma.
The temporal nature of the understanding of the self has been central to the work of many other symbolic interactionists like Strauss (1969) describing the different types and
trajectories of the understanding of the self and McCall & Simmons (1966) discussing life plans or strategies for interaction. Nevertheless, Mead not only implies that self-concept has an temporal aspect, but rather that temporality is integrated into the concept of the self in a more fundamental way (Ezzy, 1998). Interpreting people’s life events and experiences in the past, can explain the identity of the self in the present.
Mead’s interpretation of events
Mead argues that the events of the present appear as continually novel and discontinuous with the past (1959). In the Philosophy of the Present Mead argues that:
“Before the emergent has occurred, and at the moment of its occurrence, it does not follow from the past. That past relative to which it was novel cannot be made to contain it. But after it has occurred we endeavour to reconstruct experience in terms of it, we alter our interpretation and try to conceive a past from which the recalcitrant element does follow and thus to eliminate the discontinuous aspects of its present status”(1959:17).
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Mead considers the events that will occur in the present as discontinuous, the reconstructed past is considered to be inevitable and continuous. Continuity in narratives about the past are a very important aspect in the development of a sense of self and identity (Ezzy, 1998). In the following section I will discuss Ricoeur’s theory which explains how this continuity is
achieved and why it is so important.
David Maines (1983) provides an analysis of Mead’s conception of the relationship between the objective mental images people have of the past which influence the present. Maines (1983) describes four dimensions of the past within Mead’s theory which can be divided into two dimensions of the ‘objective’ events of lived experiences and the symbolic interpretation people ascribe to them.
First, Mead describes an “implied objective past”. This means that a certain event needs to have taken place in the past in order to exist as a past experience in the present (Maines, 1983:164). This objective past is linked to the “social structural past”, this refers to the conditioning effects of the past on the structures of experience of the present. These two dimensions could be referred to as events of the lived experiences.
Secondly, the past is symbolically reconstructed in the present. Mead argues that the past conditions action by its reality in the present (1959:17).
Mead’s temporal conception of the self- concept suggests two central issues that require further explanation. First, there is a distinction between history and fiction. A careful examination is important in order to understand the link between objective events of lived experiences and their symbolic interpretation by the people that experienced them. Secondly, the formation of the sense of self must be clarified. The formation of someone’s identity is changeable and links past and future in the present, the main concept in this process, according to Mead, is role taking.
To understand the concept of role taking and the development of identity through past experiences, I will discuss Ricoeur’s theory of time and narrative to complement Mead.
Ricoeur’s interpretation of events
Ricoeur’s analysis of time examines the differences between history and fiction. Through the concept of history we learn how we can interpret events as ‘tragic’ or ‘enjoyable’. Ricoeur argues that history, fiction and interpretive imagination, shape the narratives of people. In his work Time and Narrative, he explains the way history and fiction are linked to each other. History can be distinguished from fiction because it refers to an ‘actual’ or ‘real’ past
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(Ricoeur, 1988:5). Nevertheless, the past is impossible to understand without the fictive imagination, Ricoeur therefore argues that historical events and imaginative interpretation are intertwined together in establishing the narrative identity of a person. The experienced events in the past lead to the symbolic, fictive narrative interpretation. Ricoeur’s hermeneutics emphasize the reality of lived experience even though they are subject to subjective interpretations of certain experiences of people.
In both Mead’s and Ricoeur’s approach the focus is on the process of interpretation and scrutinizing how the past and the future are shaping the present. For Ricoeur, people’s narratives have two aspects that are both important in understanding events of lived experiences. The experiences of people over time create narratives, it is exactly those narratives that influence present actions and shaping of identity (Ezzy, 1998).
Lived experiences are in no way separate from narration and actions of people are always symbolically mediated. Ricoeur uses his analysis of narrative to establish a conception of self-identity. He argues that the concept of self-identity is discovered through people’s own narrational acts (Ricoeur, 1992).
The story that people tell about themselves become their actual history (1988:247).
The sense of self-continuity in identity is a product of narratives of self-consistency through life’s changes. Narratives are integrally temporal due to the fact that they combine the events of the past, present and the future into a narrative whole (Ricoeur, 1992). Narratives can change but this does not mean that they cannot give us a sense of self-sameness and give a persistent view of someone’s preferences and motivations.
The term narrative identity suggests that “what we call subjectivity is neither an incoherent series of events nor an immutable substantiality, impervious to evolution”. “Narrative identity is coherent but changeable, historically grounded but “fictively” reinterpreted, constructed by an individual but constructed in interaction and dialogue with other people” (Ricoeur,
1991:32). To summarize Ricoeur, narrative identities describe lived time which is still ongoing in the present and future, they are in-process and unfinished, continuously made and remade as episodes happen (Ezzy, 1998:247).Self-narratives may appear confused and chaotic due to the disordered nature of life and uncertainty of how the “story” will end. Nevertheless, this does not mean they cannot tell us anything or give us insight in the perceived identity of people and future behaviour.
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Labeling Theory
As reflected in the former paragraphs, the self- narratives people have are highly important in the construction of identity. There is a large difference between people that have a mental illness in the way that they internalize experiences and construct their own identity. In his work, Goffman emphasizes the way in which people reinterpret the past in order to use it in ‘present situations’, in the same way that Mead underlined the process of reinterpretation of the past to make sense of people’s actions in the present. Interestingly, Goffman argues that the influence of societal opinions and stigma is highly important in the construction of someone’s identity and the way they present their selves to the world.
Goffman (1963) argued that mental illness is a ‘moral stigma’, which indicates a ‘weak’ character or a failure of self-control. People who have been labeled mentally ill have a stigma that is characterized as more discrediting than other forms of stigma such as membership (religious, ethnic) (Corrigan, 2000; Goffman, 1963).
Most theorists assumed that experiences with stigmatization in the past and present, almost inevitably result in a devaluated identity (Crocker & Major, 1989; Major & O’Brien, 2005). Symbolic interactionism and Labeling theories suggest that social devaluation will eventually lead to devaluation of the self (Thoits, 2012). The central process in linking society and the self in this approach is, as Mead mentioned earlier, “taking the role of the other” (Mead, 1934). An undesirable label applied by other people becomes an undesirable identity, this identity results in self-devaluation or produces self-stigma (Goffman, 1963; Corrigan & Watson, 2002; Corrigan & Calabrese, 2005). Classic labelling theory arrives at the same prediction as symbolic interactionism. Classic labeling theory states that people who have been labeled by others as deviant come to see themselves as deviant too (Becker, 1963). The acceptance of the deviant identity occurs due to the fact that they take over the perspective of others and define themselves as others do (Goffman, 1963). In different words, labeling can cause a self-fulfilling prophecy that results in the adoption of the identity. Once people are labeled mentally ill, stereotypes become activated in the imagination of other people. The stereotypes people have are learned early in life and are reinforced through interaction and media. When people have stereotyped thoughts about mental illnesses they block the labeled individuals from returning to conventional activities (Goffman, 1961). Labeled people decide they must be mentally ill and then accept the label as a part of their identity. Labeling by other people produces a ‘mentally ill’ identity and can cause self-devaluation.
Link introduced a modified labeling theory (Link, 1987; Link et al. 1989) which extends the traditional approach. Link argues that ‘labeled’ people can construct a self-fulfilling process.
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When people enter mental health care because of their mental health problems, they become labeled as “mental health patients”. From this moment the prejudices and stigma become relevant and even threatening because now the attitudes and beliefs of the label can be applied to themselves. The fear of devaluation and rejection by others can cause people to ward off the consequences by using coping strategies. One way of coping with their label, as discussed before, is by keeping their mental illness a secret ( “passing” as normal (Goffman, 1963)), Coping strategies can ofcourse backfire which might increase more social distance and isolation. Attempts to avoid social distance and stigma can create dramatic social circumstances which in turn may undermine people’s self-worth.
In contrast to the classical labeling theory, Link’s modified labeling theory does not automatically assume that people with a mental illness accept the official categorization as self-descriptive. Goffman (1963), argued that stigmatized people do not necessarily identify with a social label personally, but still need to deal with interpersonal difficulties which are caused by a discrediting public identity created by others. Additionally he argues that encounters with ‘normal’ people cause anxiety due to the fact that people with a label experience limits to the acceptance of ‘normal’ people, which in turn reminds them that they are different and have a negative label (Goffman, 1963). In order to understand the
development of identity in relation to a mental illness it seems sensible to carefully analyse tha narratives of people’s lived experiences.
In the next paragraph I will discuss the methods used in order to conduct this research
followed by the analysis of the narratives of women with Borderline Personality Disorder and Depression.
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Methods
This research uses qualitative analysis. The qualitative approach is adopted as it is judged to be the most appropriate method to study the narratives of women with a mental illness. The aim was to include participants with different forms of borderline personality disorders and people varying in amount of depression episodes in order to study a wide range of
experiences. In this light, there are no limits placed on, severity, recurrence, duration of depression, nature and type of treatment. In order to participate the study, the participants all had to be female and between age 18- 65 and having been diagnosed with depression or some form of borderline personality disorder. I decided to only use women in this research in order to avoid gender influence in the analysis. A number of studies have provided evidence that of differences between gender related to depression and borderline, arguing that both the
biological and social factors could influence the analysis (Goodwin &Gotlib, 2004; Kessler, 2003; Piccinelli& Wilkinson, 2000).
Thompson (1998), showed that there are differences in female and male narratives and analyses of gender differences in the experience of depression. Excluding gender differences from allows more focus on other differences that might influence different participant narratives. Women rather than men were chosen because depression rates are reported to be twice as high for women than for men (Weissman & Klerman, 1977; Angst et al. 2002). An in-depth interview was considered to be the most appropriate way of collected the data from the participants because it is used when researcher seek information on the individual and personal expriences. An in-depth interview is a one-to-one method of data collection that involves an interviewer and a respondent that discuss specific topics in depth. These
interviews could be considered as a conversation with a purpose (Hennink, 2011). By using a semi-structured interview guide it was possible to gain insight into certain issues. An in-depth interview is not a two way dialogue because it is only the respondent that shares her story and the interviewer will elicit the story. Therefore, in-depth interviewing is described as ‘a
meaning- making partnership between interviewer and their respondents’ which means that
in-depth interviews are ‘a special kind of knowledge- producing conversation’ (Hebbe-Biber & Leavy, 2006:128). The in-depth aspect within an interview is important because it
reinforces the purpose of retrieving a detailed insight into the research issues through the eyes of the participants themselves. The in-depth interviews are therefore primarily used to capture people’s individual voices and narratives. In-depth interviews are also used in order to
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lifestyle context of the participant (Hennink, 2011).
The participants were recruited through a contact within a mental health care organization in Utrecht the Netherlands. The organization focuses on people with a borderline personality disorder and people with experiences of episodes of Depression by giving specialized treatment and guidance in order to help them re- enter society. The organization has an outpatient service which made it possible to take in- depth interviews with women that participate within society. Due to the fact that the organization focuses mainly on young adolescents, the women in the sample were quite young of age, around their twenties. The limitation should be kept in mind considering the generalisability of the findings. Eventually 6 women with the diagnosis of Depression were interviewd and 3 women with a diagnosis Borderline Personality Disorder. Initially 3 more women with a Borderline Personality Disorder were revruited but eventually declined cooperation to the interview due to private reasons. One woman from the diagnosed BPD group and three from the diagnosed Depression group insisted they did not want their interviews included in the Appendix, reasons were that some women discussed their participation to the research among eachother and did not want the ‘others’ to read their full interview. Some of these women knew each other very well and were afraid some of the sories would me recognized by the others.
The data was retrieved through a semi-structured interview guide. The guide included somme introductory points as reminder what to tell the participants at the beginning of the interview (Appendix I). During the introduction the participants were informed about the purpose of the research and what would be done with the data collected. The participants were informes about ethical issues, such as the confidentiality and the anonymity of the data. At the start of the interview the participants were asked for permission for audio-recording the interview and were informed that after transcription the recording would be erased. When all information was given to the participants, they were asked if they were willing to be interviewed. After the introduction some general questions about the background of the participant were asked. This information considered questions about age and educational level. These questions were closed questions and provide some contextual background. After the introduction the
interview proceeded with some opening questions that were broadly related to the key topics of the interview guide. These opening questions were followed by the key questions which relate the core information to answer the research questions. The key questions were placed in the middle of the interview in order to build up rapport between the interviewer and the participant. Rapport enables the participants to feel safe and free to tell their stories and experiences. The interview also included closing questions. After the information needed for
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the study was collected closing questions were asked in order to slowly reduce the rapport that was established. After the data was collected, the audio- recordings were chaged into written transcripts. These written transcript were then coded. Coding is a process that includes labeling all data using codes.This enables researcher to use these codes to search and analyse all segments of the text where a code is mentioned (Hennink, 2011). In order to code the interviews, carefull reading is necessary. Important is to continually identify what the participants say by assessing the context of the discussion. After coding the interviews an analysis was done in order to give answer to the research questions.
Ethical considerations
An important aspect of this research concerns the processing and retrieval of highly sensitive information about the participants. The Ethical considerations are therefore of paramount importance in this research. The principles for ethical conduct are nowadays well recognized. The principles were initially established for medical science, but are now used for all types of research, including qualitative research (Hennink, 2011). The World Medical association (WMA) released the Declaration of Helsinki in 1964, this declaration includes a statement about the ethical principles concerning mediacal research that involves the human as a subject (WMA, 2008). In 1979 The Belmont Report was created by the National Commission for the Protection of Humn Subjects of Behavioral Research to serve as a reference on ethical principles. The Belmont Report underlines three core principles when conducting research which involves human subjects; respect of persons (participants’ welfare should always take precedence over the interests of science), Benefice (maximize benefits of research for society, minimize risks for participants), Justice (research procedures are done in a non-exploitative , and well considered way).
These principles lead to the following important considerations when conducting research;
informed consent, confidentiality, anonymity, minimization of harm and self- determination.
Ethical considerations in qualitative research are the same as in any other research. Nevertheless, ethical considerations may be more pronounced in qualitative research than other because of the nature of qualitative research (Hennink, 2011). Qualitative research methods are known for the fact that they are used to investigate beliefs, perceptions and feelings of people, in order to retrieve that information the researchers establish rapport (trust). This temporal closeness between interviewer and participant demands a careful consideration of the ethical principle of ‘doing no harm’, this is only possible by keeping the information secure and make sure the data is anonymous.
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On the subject of ‘anonymity’ and ‘confidentiality’ people are often confused and use the terms interchangeably. However, both terms are distinct in terms of ethical issues. Anonymity refers to the fact that all information that might identify the participant is removed from the transcripts (Ellis, 2007) . In this research all respondents are anonymised through the use of pseudonyms and all other identifying details will be changed. Although being informed about the anonymity of the data, some women still emphasized the importance of not included th whole interview in the research. Confidentiality refers to sharing information with others that was discussed between the interviewer and participant. This is difficult considering the fact quotes were used in order to explain certain events and analyse the findings but by the use of anonymity this is possible (Parry & Mauthner, 2004).
Seeking permission is a very important part, in this research permission and recruitment was asked through the Head of the mental health care organization through which the participants were gained. After the participants agreed to cooperate to the ineterview they were, after the explanation of the aim and procedure of the interview, asked to give their consent again.
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5
Findings
In this section I will discuss three main themes that are central in the analysis of the
interviews. Through presentation, interpretation and discussion of verbatim quotations from the interviews I will attempt to give a broader understanding of the participants narratives around the development of the mental health problems in relation to defining the self – as emerged within my data analysis The analysis of the biographical path these women walked concerning their mental illness is important in order to understand their experiences of uncertainty, the presence or absence of social distance and the way their identity is formed. Secondly, I will elaborate further on the views the women had of their diagnosis and to what extent having a ‘label’ could have a positive or negative effect on creating identity.
Finally, in relation to the former two themes, I will discuss how these women live and cope with their label and how the presence or absence of stigma influences the way in which they present their selves towards their social environment.
Biographical uncertainty – Long term experiences
What became clear from the narratives of the experiences of these women is that in almost all cases the mental health problems started at a very young age. The data showed that a young age had a huge effect on the process of making sense of the mental health problems the women suffered from. In only a few cases women were slightly more aware of their mental health problems. This could be explained by the fact that there were other family members who had experienced the same or some other forms of mental health problems through which they developed some familiarity with mental health problems. Mead and Ricoeur, as
discussed earlier, underlined that narratives can change over time through the influence of experiences. The fact that the women started their mental illness “career” at such a young age could therefore have a strong impact on the eventual conceptualization of their identity through their narratives.
Overall most women in the sample came in contact with some form of mental health care in their early adolescence. Although the women from the sample include both the diagnosis of Borderline Personality Disorder and Depression, in all cases it was feelings of depression, gloominess and not being ‘happy’ which made them get into contact with mental health care for the first time. The data showed that at this young age the women suffered from high levels
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of uncertainty towards their mental health problems which in turn caused more distress. The interview started with questions about the women’s first experiences with mental health care and what made them decide to get in contact with mental health care. The cases that I present in the analysis are cases that clearly reflect the overall lived experiences and thoughts these women had. They represent a clear view for both the group diagnosed with Borderline Personality Disorder and the group diagnosed with Depression.
The first case I present reflected the first experiences with mental health problems and the experienced uncertainty at that time in life for both groups.
Lotte (BPD); I was depressed, my parents had just separated, uhmmm ... well I was twelve, thirteen when they separated. I've always noticed that my father had a relationship with another woman for years ... I have known since I was ten that my father was cheating on my mother. But nobody talked about that. This caused me to become a bit ‘weird’and I have had anxiety since I was very Young, I was born three months too early so we think something went wrong there uhmm…Yes, it was mainly anxiety and I was very insecure due to this anxiety. I had feelings of uncertainty all the time, but I know that now. And that’s how it all started, and then I got the diagnosis Dysthymic disorder. Eventually when they (mental health care
organization) wanted to include my parents in the process I quit going. I wanted to discuss ‘me’ not ‘them’.
Lotte suggested that she had experiences of anxiety and depression at a very young age. Interestingly she believed that this was, on one hand, partly caused by the fact that there were certain ‘family issues’ which might have lead to feelings of anxiety and on the other hand the fact that she believed that during her birth something biological went wrong. At this time in life she mainly showed feelings of uncertainty and could not yet make sense of her mental health problems. Below, Sandy’s case showed feelings of uncertainty too when she was young which resulted in the fact that she came in contact with mental health care.
Sandy (BPD); It took me quite a while before I did something (refers to mental health problems getting too severe), I have to think real hard to but it all must have started when I was 13. And that’s really difficult because of puberty and all, that makes it more difficult to keep everything on track en boundaries fade away.But I needed help, so thats when I went to some kind of Child ccare agenecy or something… but that felt really ‘ridiculous’. After that I said ‘mom, whatever, just leave it’. I really didn’t feel the urge to talk to this woman. After that I just let it be for a while…I don’t know… just… I didn’t know what was going on anyway.
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Nobody at home supported me anyway and nobody ever took action or asked: “kid, are you oké?, shouldn’t you get some help”. So I’ve always been quite lost in this. My mother always said ‘there’s nothing wrong with my child’.
Due to uncertainty Sandy didn’t procceed with mental health care. Her social environment didn’t support her to find mental health care and the fact that Sandy’s mother emphasized that there is ‘nothing wrong with her child’ this showed that there are negative beliefs present towards the possibilty that Sandy could have had a mental illness which was denied. The narratives of the women in the sample show somewhat similar experiences of lack of support from their families at their young age. In many cases parents did not acknowledge the
possibility of a mental illness with their child which made the process of contacting mental health care, which they very much needed, more difficult for these women.
It seems sensible to consider the time in which people grew up as a possible explanatory factor for the lack of support that was received by these women. Their family members grew up in a another time in which public views of mental illness were different that now. This difference in views of the label ‘mentally ill’ will become more clear later in the analysis of the narratives of the women.
An example of the difference in views and understanding of mental illnesses is shown below. The story presented is that of Janny. What makes the narratives of Janny so interesting is that she is slightly older them the rest of the women which therefore included the presence of another timeframe. The fact that she was raised in the ‘60s might have influenced the process of making sense of her mental health problems and the way she formed an identity around her diagnosis.
Janny (DP); I think I was 20 or 21 years old when someone advised me to contact mental health care. She thought I wasn’t doing well and no.. I knew that too but I never really thought of getting help for my problems, but I just went. I didn’t really think I had a Depression at that time or something but the woman thought I didn’t have my life on track….and she was right ofcourse.. so that was the first time (she got in contact with mental health care).. I couldn’t work, because I had asthmatic
bronchitis so I didn’t have a job anymore now, and I had no money to pay the rent so I lost all perspective and that played an important role (in why she experienced
depressive feelings). So that I wasn’t happy and that I had worries, yeah that was right, and … what are you going to do now?
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Janny did not speak in terms of mental health problems or ascribed words as ‘Depression’, anxiety and/or distress, she merely mentioned she knew she ‘wasn’t doing very well’ and probably needed to go and talk to someone when someone she knew mentioned it. As I mentioned above, there is a possibility concerning the timeframe she lived in, that mental health problems weren’t discussed or recognized in the way they are now. This could have had a strong influence on the consideration to get into contact with mental health care organizations and the way people made sense of their mental health problems.
Lois’ narrative was interesting because, just like Lotte and Sandy, she did not proceed with mental health care eventhough she was in need of it, only she represented the group of women that suffered from a Depression.
Lois (DP): I was 17(when she suffered from her first episode of Depression) and uhmmmm…. My parents separated when I was 16 and a lot happened after that in one year. Ik moved from Utrecht centre to Vleuten blablabla… and then I got my first Depression and I went to a social worker. I suffered from constant anxiety and I wasn’t capable of doing ANYTHING. I didn’’t want to go to work, I didn’t want to see my friends, I didn’t want to go bed or come out of bed, nothing. I was completely numb and I decided to go to Indigo to get help.
I: Did you get intensive mental health care?
Lois: No not at all actually, I went 8 times and then I quit and didn’t get any form of help till I was 19. I thought I was doing okey so … yeahh things would be alright
Lois’ narrative showed that although he suffered from anxiety and uncertainty she eventually thought that “things would be alright”. At this point she did not have a clear understanding yet of the severity of her mental illness. The narratives of Lois, Sandy and Lotte, although all through different triggers, have in common that they contacted mental health care
organizations or a form of mental health care at a very young age and they all didn’t proceed after while. The overall idea behind not proceeding was the belief that “things would be alright, eventually” this emphasized a belief that their mental health problems were temporarily. Additionally, the women’s family members did not seem to actively support them in terms of making sense of their mental health problems. Almost all cases showed this phenomenon of lack of support for mental health care from family members.
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Judith’s case is one of the cases in which slightly lesser feelings of uncertainty were shown. This needs some explanation because less uncertainty does not necessarily mean that people can make better sense out of their mental health problems. At age 14 Judith suffered from her first episode of Depression and immediately started therapy which she did till age 19 when the trajectory was over and she was considered adult and had tools enough to deal with her
mental health problems. She experienced less uncertainty towards her mental health problems due to the fact that other family members had had episodes of Depression or other forms of mental health problems too. As I explained earlier, familiarity with a mental illness can have positive effect in internalizing beliefs about the mental illnes. The only difficulty for her was to make sense concerning the negative effect her mental health problems had on her (social) life and not uncertainty towards what was ‘happening’ to her mentally.
I: When was the first time you came in contact with mental health care?
Judith (DP); I think it was when I was in the first or second grade of highschool. And I came in contact with a psychologist that my parents knew, because my brother had already been treated by him as well as my mother. After that they sent me to the UMC (hospital) to the psychiatric ward and there I got diagnosed with Depression
I was already familiar with the diagnosis of Depression because of my mother and brother. But I only understood the symptoms as being part of Depression
As reflected by the narratives above, most women from the sample showed forms of mental health problems at a very young age. Due to different circumstances and influences most women decided not to proceed with mental health care which can also partly be explained by the fact that they cannot make sense out of the their mental health problems yet, and hope for the best. Other factors that are important in proceeding with mental health care are also the amount of support that is given from parents or other family members. In hardly any of the cases, apart from the cases were familiarity of the mental illness was present, parents seemed to play an important role in the sense- making process of the mental illness. This could be explained by the fact that parents share the same negative public views towards mental
illnesses and are not very eager to get that child labeled ‘mentally ill’. At that point the mental illness stigma becomes relevant and threatening and negative beliefs can be applied to their children (Link et al. 1987).
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Ongoing uncertainty
As the women got older, making sense out of the mental health problems they suffered from and the effect the problems had on their lives started to become very problematic.The following narratives reflected the ongoing experiences of uncertainty of some women from the sample towards their mental health problems. Up until this point none of the women I discussed were diagnosed with a mental illness. Due to ongoing mental health problems most of the women eventually contacted mental health care again. Lotte’s narrative reflected the first respons when she was diagnosed.
Lotte (BPD): and then I got in contact with a mental health care organization and I told my story and they immediately said uhmmmm…. I’m going to put you on a
waiting list because you need to be included in an institution or else you are not going to make it. I was really shocked by that. Thats not how it’s supposed to happen. We’re not gonna do that!!
I: Why not?
Lotte:Because I thought “I’m not crazy, am I?”that’s what I thought. Im just who I am and I don’t consider myself to be crazy. I’m not dangerous to other people and all… anyway… I myself a pretty strong judgement about people that are mentally ill. He also told me he thought I had a Borderline Personality Disorder and that I would never get rid of that if I wasn’t going to do anything about that. When I went outside after the meeting it felt like my whole world had collapsed underneath me.
Lotte’s experience with being diagnosed with Borderline Personality Disorder is fascitnating because it reflected the way all women responded within this group. She explained that she had a judgment about people that are in need of intensive therapy, this was emphasized by the thought ‘I’m not dangerous’. She also emphasized that being labeled with Borderline was difficult for her since she didn’t think she was ‘crazy’. As I discussed before, in relation to deflecting strategies, at this point she doesn’t consider her own negative views of people with a mental illness to be ‘personally relevant’. The potential harm to her identity caused by negative views towards being ‘mentally ill’ is recognized but immediatley dismissed as a threat to the self, “I’m not like that”. As discussed earlier, Classic labeling theory states that people who have been labelled by others as deviant come to see themselves as deviant too (Becker, 1963). The acceptance of the deviant identity occurs because they take over the
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perspective of others and define themselves as others do (Goffman, 1963). In different words, labeling can cause a self-fulfilling prophecy that results in the adoption of the identity.
Lois’ narratives were interesting because, after her first episode of Depression, she suffered from a second major Depression two years later. At this point she started trying to make more sense of why she felt the way she did. She also tried to develop more meaning around reasons for her Depression. The narratives of Lois are relevant in this context because the represented the difference between the response towards getting a diagnosis for both groups. Whereas the women that got diagnosed with Borderline Personality Disorder struggled to accept the fact that they were now labelled with a highly stigmatized label and showed signs of
self-stigmatization, the group of women that got diiagnosed with Depression were overall trying to make sense of ‘why’ they were depressed instead of struggling with their identity.
I: why did you decide to ge tinto contact with mental health care again?
Lois (DP); because I suffered from another episode of Depression when I was 19. I went on a internship to Aruba and everything went wrong there. It took me 5 years to finish my MBO and twice I didn’t do anything for 6 months. So…. The first time when I started school I was 17 and I was able to manage everything a bit better…and in the two years after that everything went wrong and I go tinto a major Depression when I was 19.
Lois (DP):The only thing is I never really understood what it exactly was that I was suffering from, why am I depressed? Everything was about ‘being depressed’ but not ‘where does it come from’. Who are you? And I didn’t understand it myself either so…
When I asked Janny if she ever decided to contact a mental health care organziation again, she explained that she did, although much later in life. She worked as a nurse in psychiatry and found out there were many women with a Depression and she knew her grandmother had manic depression. There she learned there was a strong hereditary component in the illness and she herself already knew she had ‘darker’ episodes. She strongly kept emphasizing that the time she grew up in (1970) does have an influence on the way people dealt with mental health issues. She explained that in the ‘70s mental health problems didn’t really ‘exist’. This kept her from searching for help earlier because she had simply never realized that it could be a mental illness she suffered from the last decade. In therapy she found out that due to
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traumatic life events in the past (being away from her parents for months while being extremely ill, and suffering from a deadly kidney disease) she started to realize she got ‘damaged’.
Janny (DP):Because I worked in Psychiatry I got more and more insights. And I sttarted to notice that I suffered some personal damage yes.. and that there is a string hereditary component in mood swings. But I was able to handle myself pretty good so… but after the death of my father my mother got into a severe psychotic Depression and then I thought “I have a crazy mother and a crazy uncle and niece and there is a very strong hereditary component in our family, I want to see a psychiatrist now!”
Other then the former quotations from the sample, Janny did not decide to search for mental health care because her mental health problems had had a negative effect on her life. The explanation could be found in the fact that she thought she ‘might’ end up like other family members. Again, I want to emphasize that being raised with different public views and values towards mental illnesses could have a strong effect on the difference in reasoning why people got in contact with mental health care. In relation to the other women, Janny had a different way of evaluating beliefs about her mental illness.
Making sense of mental health problems
The long term experiences of mental health problems and care eventually influenced the way in which most women made sense of their mental illness. Additionally, as emphasized by Ricoeur, the experiences these women had in their past will be of strong importance in the way they shape their identity later in life. The experienced events in the past lead to the symbolic, fictive narrative interpretation. The following narratives show this process of sense- making and the different ways in which these women experienced it. The narratives showed that when the women started to make sense of their mental health problems they also started to develop an identity around their diagnosis. This identity, as will be discussed later, is influenced by public views of mental illnesses. Lois’ narratives are again reflecting the
respons of the women in the Depression group clearly. They were either desperately searching for a diagnosis in order to explain their mental health problems or finding triggers that caused them.
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Lois (DP): In my second trajectory when I was 19, I was desperately searching for a diagnosis. I got tested on everything, Borderline Personality Disorder, Depression everything! So eventually I thought i’ll just focus on Depression… and that made me calm, to know that I have the diagnosis Depression… .
Two years after the second time she had therapy she suffered again from a major depression. Since this was the third time, and it seemed to occur every two years she decided to enter a more intensive trajectory of mental health care. In contrast to the first and second time she went into therapy, she now considered her traumatic experiences of high influence on the reason for her episodes of Depression. Another interesting change in making sense of her mental health problems is that she was desperately searching for a diagnosis. Although there exist negative public views towards mental illnesses Lois’ was in fact very content to finally be diagnosed with ‘anything’. As noted earlier, the nature of the mental illness is very important. More severe mental illnesses tend to have stronger negative views, Lois’ chose to focus on the diagnosis of Depression in order to make sense.
Judith’s case was especially interesting in the proces of making sense of her mental illness since she had family members which suffered from the same mental illness. Although she was familiar with the symptoms of Depression she also suffered from uncertainty.
Judith: The first moment that I suffered from a Depression I was less aware of what it was that I was experiencing, but now that I am older I am more capable of
recognizing it. There are two sides, I will always have to be careful and pay attention to myself in order to prevent from falling back into a Depression and sometimes I’m just wondering what triggered it. But other times I’’m like… o my God there we go again and feelings of ‘It will never get better with me’.
Discussion
As reflected by the narratives, the process of making sense of a mental illness is a long term process. Mental health problems started at a very young age which made it difficult for these young women to make any sense of the problems they had.
In most cases the women did not proceed with mental health care, there were various reasons for making this decision from feelings of misunderstanding by the mental health care
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mental health problem at that time. Although the reasons behind not proceeding with mental health care all seem to vary, the overarching reason is a lack of making sense of their mental health problems in that early stage. Most argued that they just ‘let it go’ for a while which showed that they did not yet made sense of their mental health problems although there still was a strong feeling of uncertainty.
In time, the mental health problems became more severe, occurred more often or episodes of Depression returned which caused most women to search for mental health care aagain. In most cases the mental health problems became of huge influence in their daily lives that they couldn’t be ignored any longer. This is an important aspect in understanding why most women were in search of a diagnosis to finally understand what it was that caused their problems. In most cases it gave some kind of relief to the women after being diagnosed because now there were tools to work with and feelings of uncertainty started to fade away. In the process of makings sense of their mental health problems it became clear that making sense has an strong influence on uncertainty. The more most women started to make sense of their mental health problems the less uncertainty they experienced towards their mental health problems. Although there is less uncertainty towards their mental health problems they had to define their identity around the diagnosis they received
As some of the women already mentioned, having been diagnosed with a mental illness has both positive and negative effects especially when it comes to making sense of your own personality and behavior. When people have stereotyped thoughts about their mental illnesses they could internalize negative public views which could cause a devaluated identity
(Goffman, 1961). Link (1987) argued that ‘labeled’ people can construct a self-fulfilling process. When people enter mental health care because of their mental health problems, they become labeled as “mental health patients”. As the narratives reflected, the women from the Borderline Personality group showed more deviance towards their diagnosis than did the women from the Depression group
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Views of label – forming identity around a mental illness
In the process of making sense of mental health problems, being diagnosed plays a key role in the presence or absence of uncertainty and forming identity. As reflected by the narratives above, the women had ambivalent experiences and attitudes towards their diagnosistic label. Being diagnosed can have a strong positive effect on people in the light of reduction of uncertainty and making sense but it can also bring negative effects in the forming of the identity of these young women. As discussed earlier, negative public views may lead to self-stigmatization which in turn could lead to lower self-esteem.
In this section I will elaborate further on the effect a diagnosis can have on identity and more importantly how the views of these women on their own diagnosis influences their identity. For example, Lotte was not only diagnosed with a Borderline Personality Disorder, but also with Depression and an Attention Deficit Disorder (ADD) in a later stadium. She explained that having been diagnosed with so many different mental illnesses had an opposite effect on making sense. Shortly after she got these diagnoses she got into a severe Depression again and started to physically damage herself. She argues that she completely lost all sense and got ‘stuck’ because of the enormous amount of diagnoses she got. Although she emphasized there hardly was any uncertainty concerning her mental health problems any longer, she now struggled with forming an identity other than being a combination of so many diagnoses.
Lotte (BPD): uhmmm…. That’s hard to say.. more or less a whole feeling, you get presented with so many puzzle pieces and you have to create a whole piece from that. Also..I found it such nonsense that there were so many different diagnoses put on me. Because they diagnosed me with ADD as well. So I thought… this doesn’t make sense at all… but in a different way it did make sense..
I: You think you got diagnosed with too many mental illnesses?
Lotte: Yes…. Absolutely… I also think that the diagnosis of Borderline is a ‘trashcan’- diagnosis. And I’m absolutely very disappointed in the fact they diagnose people so soon with Borderline that is very damaging for the people that really suffer from Borderline. I never thought or felt like a Borderliner.. maybe that’s demeaning to say. Uhmmm … the term Borderlineris nasty because it seems like that is the only thing you are. And that’s not true… you can have an illness but that doesn’t mean that you
