Research report
Resilience as a response to the stigma of depression: A mixed methods analysis

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Abstract

Background

Stigma has been shown to have a significant influence on help-seeking, adherence to treatment and social opportunities for those experiencing depression. There is a need for studies which examine how the stigma of depression intersects with responses to depression.

Methods

161 telephone interviews with people experiencing depressive symptoms, derived from a longitudinal cohort study, were sampled on the basis of their perceptions of stigma around depression. Interview transcripts were searched for references to stigma and analysed thematically. The frequency of the themes was calculated and cross-referenced, producing a meta-theme matrix.

Results

Stigma was closely linked to ideas about responsibility for causation and/or continuation of depressive symptoms. Stigmatised individuals felt compelled to take steps to develop their resilience including drawing on existing support networks and expanding on positive emotions and personal strengths in order to counteract this stigma. However, such strategies were burdensome for some. These participants gained relief from relinquishing their personal responsibility.

Limitations

The data were briefer than many interview studies. This narrowed its interpretation, but allowed a large sample of participants.

Conclusions

When considering how to tailor therapies for those experiencing depressive symptoms, health professionals should consider the interaction of stigma with coping strategies. Many individuals can build on existing relationships and personal strengths to develop resilience, some however need to first relinquish the expectation of having sufficient pre-existing resilience within themselves.

Introduction

Stigma is a significant phenomenon for people with mental health problems (Corrigan, 2004, Crisp et al., 2001, Dinos et al., 2004, World Health Organisation, 2001). It has been linked to the non-disclosure of emotional problems to health care practitioners (Barney et al., 2005, Prior et al., 2003), non-adherence to treatment regimes (Corrigan, 2004, Weich et al., 2007) as well as problems with self-esteem, social opportunities and participation (Dinos et al., 2004, Link et al., 2001). Stigma has thus been a key concept for researchers exploring the experiences of individuals with mental health problems across disciplines, and continues to occupy a high position on many research agendas (Pescosolido et al., 2008).

The wealth of literature on stigma has yielded a complex picture of its operation. The way in which it is experienced, and the level of stigma attributed to an individual may vary greatly, contingent on factors such as psychiatric diagnosis and severity (Dinos et al., 2004, Pyne et al., 2004), age, gender and ethnicity (Perry et al., 2007). Stigma is linked with the degree to which people are held accountable for the cause of their condition (Albrecht et al., 1982, Chapple et al., 2004, Crocker and Major, 1989). Conditions attributable to factors perceived as ‘controllable’ elicit higher degrees of stigma, negative reactions and hostility than those considered beyond an individual's control, highlighting the role of personal responsibility in the attribution of stigmatised identities (Chapple et al., 2004, Shih, 2004, Weiner et al., 1988). Stigmatised individuals however, may be more or less accepting of the identity attributed to them. Goffman (1963) highlighted the way in which stigmatised individuals internalise their negative identity and thus come to ‘self-stigmatise’, incorporating stigmatised views in their self-perception. However, Shih (2004) suggests a more positive reading of stigmatised identities, as the active rejection of stigmatised identities can produce feelings of achievement and satisfaction. Other forms of stigma have also been identified in the literature, including ‘perceived/felt stigma’ (the anticipated negative views of others, whether or not this is enacted) and ‘personal stigma’ (the stigmatising views of other people held by an individual). The literature thus indicates that the experience of stigma is complex (Alonso et al., 2009, Barney et al., 2005, Griffiths et al., 2008, Scambler and Hopkins, 1989).

In the same way that individuals experience stigma in a variety of different ways, so the experience of depression is responded to in different ways (Dowrick et al., 2008; Hansson et al., 2010, Karp, 1994, Kokanovic et al., 2008, Schreiber et al., 2000, Schreiber and Hartrick, 2002). Dowrick et al. (2008) have suggested that the concept of ‘resilience’ is a key to understanding some of these responses. To manage depression, people draw on the resources available to them in order to generate coping mechanisms and enhance their personal resilience. These practices have been referred to as ‘ordinary magic’ and ‘personal medicine’. ‘Ordinary magic’ refers to the utilisation of personal support networks and resources to deal with times of adversity, whereas ‘personal medicine’ refers to the undertaking of particular activities that expand our positive resources, emotions and strengths, to enhance the meaning, experience and enjoyment of our lives for example, exercise, reading or meditation (Dowrick et al., 2008: 442).

However, few studies have explored the way in which individual coping strategies such as ‘ordinary magic’ and ‘personal medicine’ are influenced by experiences, or perceptions, of stigma. As Schreiber et al. (2000) and Schreiber and Hartrick (2002) have suggested, these responses may present a means by which to better understand the stigma of depression itself. Schreiber et al.'s work (2000) and Schreiber and Hartrick (2002) on black West-Indian Canadian women's management of depression and its stigma, for example, revealed that conceptualisations of depression and its causation formed part of the stigma of depression. The concept of ‘being strong’, or drawing on personal resilience, was used by these women to divert the stigma of depression in a socially acceptable way, specifically by drawing on cultural stereotypes of black women as ‘strong’ and ‘robust’. However, this strategy, as a response to stigma, could simultaneously lead to the adoption of burdensome or counter-productive approaches to its management, or even be a precursor to depression (Schreiber et al., 2000, Schreiber and Hartrick, 2002).

Using the concept of resilience, this paper will explore the way in which stigma informs responses to depression through a mixed-methods analysis of data yielded from structured computer assisted telephone interviews (CATI) with 161 participants. Whilst the stigma surrounding depression and its impact has been well documented, particularly in small scale qualitative studies (Prior et al., 2003, Sims, 1993), few large scale surveys have been conducted to explore how stigma is experienced and responded to. Where large scale surveys have been conducted, these have been designed to measure public attitudes and perceptions of mental illness (e.g. Highet et al., 2002, Martin et al., 2000, Priest et al., 1996, Wang et al., 2007) rather than exploring directly the perspectives of people experiencing mental health conditions (e.g. Alonso et al., 2009, Hansson et al., 2010). This mixed methods study benefits from the analysis of qualitative data from 161 participants, a much larger sample than is usually found in qualitative research, which is enhanced through quantitative analysis.

Section snippets

Methods

The benefits of using mixed methods approaches to explore complex phenomena such as depression have been acknowledged in the literature (Andrews and Halcomb, 2009, De Gruy, 2005, Wittink et al., 2006). These methods allow not only for the analysis of complex concepts, such as the meanings and experiences around depression, but also for their contextualisation within large scale quantitative findings and their linkage with demographic information/standard measures of depression (Hansson et al.,

The origins of depression, blame and stigma

In this study, participants were all asked the following open-ended questions ‘In your own words and experience, what do you think depression is?’ and ‘what do you believe causes people to become depressed?’, which elicited a variety of views regarding the nature and origins of depression. For 17 (11%) participants, developing symptoms of depression in the first instance (regardless of the circumstances surrounding it) and the degree to which the symptoms interfered with everyday life were

Discussion

Our analysis of structured interview data of people living with depression supports the findings from previous studies that stigma is an important factor in how people experience and respond to depression. Our analysis suggests that the way this plays out is complex. Although many individuals consider the cause of depression to be beyond their control, they nevertheless consider the problem of depression as their inability to deal with themselves and their life situation. Personal

Role of funding source

The funders of this study had no role in the data collection, analysis or reporting of this paper.

Conflict of interest

The named authors have no conflicts of interest to declare.

Acknowledgement

The named authors submit this publication on behalf of the diamond study investigators which include: Professor Jane Gunn, Professor Helen Herrman, Professor Mike Kyrios, A/Professor Kelsey Hegarty, Professor Christopher Dowrick, Dr Gail Gilchrist, Associate Professor Grant Blashki, Professor Dimity Pond, Ms Patty Chondros, Associate Professor Renata Kokanovic and Dr Victoria Palmer. The diamond study was initiated with pilot funding from the beyondblue Victorian Centre of Excellence and the

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