Exploring the Paradoxical Effects of Insight and Stigma in Psychological Recovery

Recovery among people with serious mental illness (SMI) is an evolving concept that is recognized as a personalized unique process (Deegan, 1988; Leete, 1989), and has been recognized as the most important goal within a consumer-centered mental health system (President's New Freedom Commission, 2003; Surgeon General, 1999). While the literature contains over 100 empirical definitions of recovery (Bonney & Stickley, 2008; Brennaman & Lobo, 2011), the conceptual framework of this study is grounded in a consumer-derived definition of psychological recovery: "The establishment of a fulfilling, meaningful life and a positive post-diagnostic sense of identity founded on hopefulness and self-determination" (Andresen, Caputi, & Oades, 2006; p. 588). As mental health systems transition toward a recovery orientation, further empirical and conceptual refinement of current recovery models is needed. Insight and Recovery Intrapersonal awareness that one has SMI (i.e., insight; Amador et al., 1993) is an important factor in recovery and is also a common clinical concern among practitioners (Davidson, O'Connell, Tondora, Styron, & Kangas, 2006; Frese, Knight, & Saks, 2009). Limited insight has been identified as highly prevalent among persons with SMI (Amador et al., 1994) and considerable research has identified paradoxical effects associated with insight (Lysaker, Roe, & Yanos, 2007). For instance, evidence suggests that higher insight predicts improvements in many domains, such as adherence to psychological (Brent, Giuliano, Zimmet, Keshavan, & Seidman, 2011; Byerly, Fisher, Carmody, & Rush, 2005) and medication treatments (Beck, Cavelti, Kvrgic, Kleim, & Vauth, 2011; Mohamed et al., 2009), symptomatology (Gharabawi, Lasser, Bossie, Zhu, & Amador, 2006), post-diagnostic identity (Williams, 2008), and community functioning (e.g., work performance; Lysaker, Bryson, & Bell, 2002). Unfortunately, higher insight is also associated with unwanted outcomes such as increased hopelessness (Carroll, Pantelis, & Harvey, 2004; Hasson-Ohayon, Kravertz, Meir, & Rozencwaig, 2009), depressive symptomatology (Cavelti, Kvrgic, Beck, Rusch, & Vauth, 2012; Smith et al. 2004), suicidal risk (Evren & Evren, 2004; Sharaf, Lachine, & Ossman, 2012), as well as decreased self-esteem (Staring, Van der Gaag, Van der Berge, Duivenvoorden, & Mulder, 2009) and quality of life (QoL; Boyer et al., 2012). Such findings have been referred to as 'the insight paradox' (Lysaker et al., 2007). Experienced Stigma and Recovery An additional important factor in recovery is the stigma associated with having a mental illness (Davidson et al., 2007; Wahl, 2012). The World Health Organization (2001) defines stigma as "a mark of shame, disgrace, or disapproval which results in an individual being rejected, discriminated against, and excluded from participating in a number of different areas of society" (p. 16). SMI stigma is a cross-cultural phenomenon (Angermeyer, Buyantugs, Kenzine, & Matschinger, 2004; Corry, 2008) and is considered the greatest concern facing mental health communities (Surgeon General, 1999). People with SMI may experience harmful stereotypes, prejudice, and discrimination (Hinshaw & Stier, 2008; Phelan, Link, & Dovidio, 2008) which may detrimentally impact all life domains (Dovidio, Major, & Crocker, 2000; Jones et al., 1984). Labeling theories suggest that people with SMI may internalize stigmatizing beliefs and perceive themselves as having lower social value which negatively impacts their post-diagnostic identity (Link, Cullen, Struening, Shrout, & Dohrenwend, 1989; Williams, 2008). However, while the majority of individuals with SMI experience stigma, experience is not synonymous with internalization (Crocker & Major, 1989; Jenkins & Carpenter-Song, 2008). Still, previous research has almost exclusively focused on how internalized stigma impacts persons with SMI. …