(p. 90) Acceptance of Mental Illness Among Women: Intersectional Stigma
The issue of gender figures prominently in the acceptance of serious mental illness.1 Women encounter unique barriers and facilitators to the acceptance process. Women are over-represented among people diagnosed with mental illness in general (Gove, 1980; Mowbray, Herman, & Hazel, 1992). Recent estimates suggest women are 20% to 50% more likely to have a mental illness (Freeman & Freeman, 2013; Substance Abuse and Mental Health Services Administration [SAMHSA], 2013). Gender-related oppression is one of the key factors believed to account for differences in rates, onset, and symptoms of mental illness among women as opposed to men (Gove, 1980).
As we have discussed in earlier chapters, acceptance of mental illness is facilitated by the presence of various resources needed to deal with the stigma, prejudice, and discrimination that tend to accompany mental illness. Women with mental illness experience heightened levels of stigma and intersectional oppression, which can affect the acceptance process. This phenomenon is represented in higher rates of victimization, unemployment, poverty, homelessness, and disparities in care than the rest of the population (Artacoz, Benach, Borrell, & Cortés, 2004; Jonikas, Laris, & Cook, 2003; Mowbray, Nicholson, & Bellamy, 2003). Logie and colleagues (2011) referred to this notion of overlapping, multiple levels of stigma and discrimination as intersectional stigma.
Some of the risk factors that women experience in the development of mental illness pertain to physical and sexual violence (Gove, 1980; Mowbray et al., 2003). It is estimated that as many as 51% to 97% of women with mental illness have a physical and/or sexual assault history (Goodman et al., 2001). Women in general are at risk (p. 91) of sexual abuse during childhood, which has been found to be associated with psychiatric symptoms in adulthood (Meyer, Muenzenmaier, Cancienne, & Struening, 1996). Women with mental illness also experience vulnerability to sexual exploitation (Padgett, Leibson Hawkins, Abrams, & Davis, 2006; Weinhardt, Carey, Carey, & Verdecias, 1998). Violence toward women with mental illness contributes to psychiatric symptom severity, as well as substance abuse and homelessness (Benbow, Forchuk, & Ray, 2011; Goodman, Rosenberg, Mueser, & Drake, 1997).
Women with serious mental illnesses experience a number of clinical disparities. Women are known to have twice the rate of depression as men, likely due to gender role strain, vulnerability to stress, victimization, and other adverse life events (Nolen-Hoeksema, 2001). This population has also historically encountered insensitivity and prejudice from the mental health professionals they have sought out for help (Ussher, 2011). Although overall rates of mental illness are generally the same for men and women, gender differences have emerged in diagnostic practices. Women are often judged by providers harshly when not conforming to gender stereotypes (Eriksen & Kress, 2008). This gender bias includes pathologizing of women’s emotional reactions and overdiagnosis of histrionic, borderline, or dependent personality disorders (Eriksen & Kress, 2008; Reich, Nduaguba, & Yates, 1988).
Once in therapy, clinicians may overlook the specific needs of women with serious mental illnesses (Mowbray et al., 2003). There is a high incidence of mothers among women with mental illness (Joseph, Joshi, Lewin, & Abrams, 1999), and many of these women seek mental health services for support with custody problems or other parenting stressors that may result from the challenges of the mental illness. Nonetheless, a parenting focus is often lacking in psychiatric interventions (Joseph et al., 1999). Although overt discrimination toward women with mental illness in clinical settings may be on the decline today, subtle forms of stereotyping, lack of awareness, and various microaggressions occur (Mowbray, 2003).
The additional levels of oppression faced by women with mental illnesses reflect the intersectional stigma encountered by this group. This term stems from the theory of intersectionality, which refers to the multiple social, political, and cultural identities within an individual that lead to compounded experiences of oppression (Benbow et al., 2011; Crenshaw, 1993). This construct can be used to examine combined levels of privilege and oppression based on race, ethnicity, religion, age, class, gender, sexual orientation, and (dis)ability (Benbow et al., 2011). Various aspects of one’s identity may lead to privilege (i.e., unearned societal advantages) or oppression (Shields, 2008). For example, one may be disadvantaged in terms of racial identity in the broader society, but privileged with regard to socioeconomic status. Intersectional identities, therefore, are contextual and not static (Collins, 2000; Shields, 2008).
Intersectionality is an important concept for clinical work with women with serious mental illnesses. Depending on one’s social identity, these women may experience intersecting oppression, such as stigma toward mental illness, sexism, racism, homelessness, and poverty (Benbow et al., 2011). Little research, however, (p. 92) has been conducted to examine the compounded levels of discrimination and oppression experienced by this group. A study by Logie and colleagues (2011) is among the few that have focused on issues of intersectionality in the lives of women with mental illness. These authors coined the term intersectional stigma to describe overlapping, marginalized identities among these women with regard to HIV-related stigma, mental illness stigma, sexism, racism, transphobia, and homophobia.
We selected the following two case narratives to address this gap in the literature and highlight issues of intersectionality in the process of acceptance among women with serious mental illness. We begin these case narratives by describing the women’s stories of developing mental illness. Next, we explore their experiences with intersectional stigma, that is, compounded encounters with stigma and oppression in addition to mental illness stigma. We explore their personal definitions of acceptance and the related barriers and facilitators to this process that they encountered. Presenting these women’s stories in this way helps to highlight the complex interplay of acceptance and gender in the lives of women with serious mental illness.
“Clara” is a biracial woman in her thirties of African American and South Asian heritage. Throughout her life, she was diagnosed with a number of psychiatric and physical problems, such as post-traumatic stress disorder (PTSD), severe major depression, fibromyalgia, and chronic fatigue syndrome (CFS). Her mother died when she was a child, and her father was unable to care for her because of his mental illness. Clara and her brothers went to live with extended family where she was sexually abused by a family member. Her extended family members soon lost their housing and she became homeless. Clara began to engage in sex work to provide for herself and her siblings, as well as to support an opiate addiction that lasted throughout her teens. To add to these struggles, Clara reported a number of experiences of stigma and mistreatment by the providers she had sought out for help, including racially derogative remarks and an incident of sexual assault by a former therapist. In middle-adulthood, Clara accessed a number of support networks that she found helpful in dealing with these injustices. She decided to use her mental health experiences to help others and became a peer specialist.
Clara discussed a number of experiences of oppression related to her multiple identities in terms of race, class, gender, and mental health. “I feel more of an akin and an identity as someone who’s poor than I do as someone who’s mentally ill… . Having to deal with not having money … felt a lot more pressing than my mental illness.” In Clara’s case, her experiences of intersectional oppression at times led one oppressed identity, such as being poor, to take precedence over others.
(p. 93) She also spoke about multiple experiences of abuse as interfering with treatment. “When I was younger, I was sexually abused by one of my therapists when I was in juvenile for a weekend. Because I got picked up for prostitution, and I was sexually abused by the first person I ever opened up to about what happened between me and my [family member]… . I think it’s been why I have a really safe professional distance from my providers… . It makes therapy something that I’ve been in and out of, and in and out of, and in and out of since I was 12. It makes me not trust people and not want to stick around.” Clara’s abuse history reflects the barriers to treatment encountered by many women with mental illness, for whom elevated risks of violence and mistreatment contribute to intersectional oppression.
When asked about the meaning of acceptance, Clara responded, “It’s part of my identity… . To me it means coming out and it means being able to advocate for others … I accept [my other psychiatric problems] as a part of my fibro and my PTSD. I don’t think I look at my depression that much as a separate component. I mean, it just feels like it’s just one more thing that I have. So, I never had a big deal about it. I mean, accepting it was more like finding a reason for my pain, than trying to accept a label.” Clara defined acceptance of mental illness as a part of her identity. Her acceptance of mental illness was made less difficult by her acceptance of other psychiatric and medical conditions. Developing a role as an advocate was also central to her acceptance process; it highlighted multiple ways in which various aspects of her identity were vital to her acceptance process.
When she was asked to comment on barriers to accepting her mental illness, Clara described a lack of public acceptance. “I just think that our society has a hard time dealing with depression as a real thing. As a disease and as—well, not a disease, but as something that’s more than just a part of someone’s personality.” Clara identified another barrier to acceptance as access to mental health resources. “I mean, how helpful is it [to accept mental illness] to a person who has absolutely no money, who can’t go to a therapist?” These responses underscore the impact of socioeconomic status and mental illness stigma on acceptance of mental illness.
Clara was asked about what facilitated her process of acceptance of mental illness. She replied, “My depression advocacy group [for women of color] … Because, being a person of color, it’s not something that’s culturally talked about… . Because so many … women in this culture end up taking care of everybody else other than themselves.” Clara’s response emphasized the importance of the support of others with shared experiences of intersectional oppression related to mental illness, race, gender, and class. In addition, she indicated that other medical disabilities increased her ability to accept her mental illness. She stated, “I kind of figure my depression is part of, I mean, it’s part of having fibro and chronic fatigue, so it’s just one more … thing that you get when you get the whole like, range of crap which is CFS and fibro.”
Clara’s narrative highlights how intersecting identities related to gender, race, ethnicity, socioeconomic status, and medical disability impact the process of acceptance of mental illness. As a woman with mental illness, Clara experienced increased risk of violence and mistreatment. And yet, awareness of these intersecting (p. 94) identities increased her acceptance of mental illness and allowed her to connect with women with shared experiences of intersectional oppression. Moreover, her class identity often took precedence over her mental illness identity, further influencing her sense of self and acceptance process surrounding mental illness.
“Rita” is a white American woman of Jewish heritage. Rita was diagnosed with Asperger’s Syndrome, currently identified in the DSM-5 as mild autism spectrum disorder. She also was diagnosed with epilepsy and learning disabilities as a child. She wrote depressive notes to teachers during middle school and believed she had undiagnosed depression throughout childhood and adolescence. She received her first diagnosis of depression in college in a student health center and became interested in mental health services. After college, Rita began to work as a case manager in a group home for adults with development disorders. Her depression began to interfere with her ability to go to her job every day, and she decided to apply for welfare support. To cope with her struggles, Rita joined a depression support group for low-income women. She also became an advocate for people with autism and worked to change state policy.
Rita’s background highlights intersectionality in the number of experiences of oppression related to physical disability, mental illness, and gender identities. Rita described public stigma toward physical versus psychiatric disabilities. She stated, “As long as you’re obviously disabled, people are fine with you… . But if you have anything invisible, and all of mine are invisible … Nobody wants to accommodate that … And then, the media constantly plays up that crazies are violent by definition … So you’ve got that sort of double whammy.” Rita spoke to the impact of an “invisible disability” on her acceptance process. Her term, “double whammy,” parallels the meaning of double stigma in her experience as a woman with mental illness and other disabilities.
When asked to define acceptance, Rita indicated, “Trying to work with it, figuring out how to realize when I’m beginning to slide when things aren’t going well and such, and figuring out what to do… . I’m a big believer in radical acceptance… . That you need to completely accept yourself for who you are, and that you need to accept others, too. But before you can accept other people and not judge them you need to do the same thing for yourself.” Implicit in her definition is a sense of acceptance as a process of identity development and developing a positive sense of oneself.
When asked about barriers to acceptance, Rita described her age as being a barrier given that she was diagnosed during a time when little was known about depression and she did not receive treatment. “Well, because of my age … I think I was depressed as a child. But I think in the seventies it wasn’t really a concept. I don’t think they thought children could be depressed, really.”
She also cited public dismissal of invisible identities like psychiatric disabilities and stereotypes of violence in the media surrounding mental illness as (p. 95) additional barriers to acceptance. “As long as you’re obviously disabled, people are fine with you … because with that kind of attitude running around it can feel to you like it’s not real, as real as if you were in a wheelchair or as if you had crutches or whatever. It can run the risk for some people of feeling, ‘It’s just all in my head,’ or dismissing it as something that you just need to fight, or you just need to get over.”
Rita described public notions of coping with depression and disabilities as a barrier to acceptance. “Everyone says you have to fight depression and all of this… . And that that was the whole picture that everyone has of disabilities—the brave fight against your disability. The picture everyone has of the brave disabled person bravely fighting their disability and overcoming it, and that’s the wonderful, lovely picture.” Rita’s comment was notably tinged with sarcasm over the pressures to conform to heroic narratives of overcoming mental illness.
When asked about facilitators to acceptance of mental illness, Rita replied: “Talking to other people about stuff. I went for like three years to a weekly low-income women’s group, and that was really good… . I learned a lot about asking for help at this group.” Rita also described the impact of other psychiatric conditions on this process. Because of her experience of Asperger’s, she found that, “I care less than a lot of people about what other people think… . It’s helped me do what I want in life. I’ve always known a lot about who I am, and I’ve not been influenced that much—to some extent, but not that much—by other people.” She also described acceptance of mental illness as: “Just one more disability on the long list, I guess. The laundry list is being added to, I suppose.”
Rita’s case demonstrates how acceptance of mental illness is impacted by intersectional identities. Like Clara, her previous acceptance of her other disabilities, such as epilepsy or Asperger’s Syndrome, facilitated her acceptance of mental illness. Connecting with other low-income women with serious depression supported her process of acceptance. Stigma she faced as an American of her generation interfered with her acceptance of her mental illness. Although she did not discuss her Jewish background in detail, it is possible that this religious and ethnic identity further contributed to her mental health experiences. Jews have a long history of marginalization, and higher rates of depression have been found among this group (McCullough & Larson, 1999). This case demonstrates that multiple, overlapping identities may lead to oppression as well as offer resources that impact the process of acceptance of mental illness. Similarly to Clara, Rita’s advocacy work also became an important role and a means to developing a sense of acceptance.
Understanding Acceptance for Women with Serious Mental Illnesses
As evidenced by these case narratives, women with mental illness may face intersectional levels of oppression as a result of sexism and mental illness stigma. (p. 96) When these women encounter other types of marginalization such as racism, disability, abuse, or poverty, they may experience added struggles and stress. These compounded levels of intersectional stigma may interfere with acceptance of mental illness.
These women’s stories also highlight areas of resilience and strength among women with mental illness. Women’s awareness of the impact of systemic discrimination, prejudice, and oppression surrounding intersectional identities can increase empowerment and acceptance of one’s mental illness. Research has found that training people with mental illness about the nature and effects of stigma can reduce internalization of the stigma while increasing proactive coping and perceived recovery and growth (Russinova et al., 2014). The advocate role appears to be particularly effective for women’s acceptance of mental illness and helps to promote recovery among other women facing intersectional stigma. The intersectional barriers and facilitators to the process of acceptance of mental illness among women are summarized in Table 6.1.
Table 6.1. Intersectional Barriers and Facilitators in the Process of Acceptance Among Women with Serious Mental Illness
Barriers: Intersectional Oppression
Facilitators: Identity-related Resources and Strengths
Mental illness stigma
Awareness of intersectional stigma
Racial-ethnic cultural supports
Findings of these case narratives extend prior research in this area. For one, these stories provide narrative evidence of intersectional stigma in the lives of women who encounter both sexism and mental illness stigma (Logie et al., 2011). They illustrate previous findings that women with mental illness may be at risk of poverty, sexual and physical violence, mistreatment in the mental health system, homelessness, and unemployment (Jonikas et al., 2003; Mowbray et al., 2003). One study found people with congenital psychiatric or physical disabilities had higher levels of acceptance than those with acquired disabilities (Li & Moore, 1998). These women’s stories confirm that prior physical or psychiatric conditions may facilitate the acceptance of later diagnoses of mental illness. Women with mental illness may be particularly aware of the impact of intersectional stigma on the acceptance process and may benefit from identity-congruent supports and resources, such as support groups for women with mental illness.
(p. 97) Applications to Clinical Work
These case narratives suggest the importance of some specific practices for clinical work with women with mental illness. First, providers can ask clients about the impact of intersectional oppression, and support clients’ experiences with mental illness. It is important to learn of mistreatment in mental health services or other forms of mistreatment that might add to intersectional stigma and affect the therapeutic relationship. Clinicians should investigate the client’s definition of acceptance of mental illness and identity-related barriers and facilitators in order to encourage acceptance and empowerment. Pamela Hays’s (2008) model of ADDRESSING cultural complexities in clinical practice (Age, Developmental and acquired Disabilities, Religion, Ethnicity, Socioeconomic status, Sexual orientation, Indigenous heritage, National origin, and Gender) is one guide for integrating intersectional views of the person’s identities into mental health services. The American Psychological Association’s Guidelines for Psychological Practice with Girls and Women (2007) is another valuable resource for clinical care that attends to the role of gender in mental health for women.
This research raises a number of clinical considerations for therapists. For one, therapists can be agents of social change in raising awareness of the ways oppression affects the lives of women with mental illness. Clinical training may be a valuable space to enhance awareness of intersectional stigma. Due to diagnostic stigma and the history of labeling women as “mad,” therapists might experience tension when assigning pathological diagnoses of mental illness to women. Therapists can work with clients in a collaborative manner to find names for the problem in order to reduce power differentials in diagnosis. Helpers can explore community resources and opportunities that might further facilitate the acceptance process and evaluate the effectiveness of these resources with the client. For example, practitioners can support women with mental illness in accessing women’s support groups and becoming advocates for other women. The stories in this chapter also suggest the importance of referring female clients to academic or vocational counseling as well as women’s support groups. These resources may be effective in helping women with mental illness to increase self-esteem, academic and vocational motivation, and socioeconomic mobility (Jonikas et al., 2003).
Women with mental illness face intersectional stigma related to sexism and mental illness stigma. Due to intersectional stigma, women with mental illness may encounter increased risk of trauma, unemployment, poverty, and homelessness. Engaging in advocacy, women’s groups, and peer supports can help women with mental illness to gain an awareness of the effects of intersectional (p. 98) stigma on their lives and promote acceptance of mental illness, recovery, and empowerment.
• Explore the impact of gender on women’s process of acceptance. What unique barriers or resources do they encounter as a result of their gender?
• Inquire as to the multiple marginalized identities that women may experience in addition to the mental illness identity. These identities might include other disabilities (physical, intellectual, psychiatric), poverty, and homelessness. Investigate how intersectional stigma impacts the process of acceptance for female clients.
• Learn about which identities feel particularly salient for clients who are women with serious mental illness. Does one’s identity as a woman, person of color, person with a disability, or other aspects of identity take precedence in certain contexts? Does the prominence of one identity over another affect the process of acceptance in any way? Explore how acceptance might be facilitated in these contexts for them.
• Learn about how intersecting identities uniquely impact the mental health experience of clients who are women with serious mental illnesses. Raise awareness of the role of gender on the process of acceptance.
• Explore the extent to which some of these identities may feel more visible versus invisible. Validate less visible identities.
• Identify potential childcare needs women may have. Facilitate access to parenting resources. Examine the meaning mothers with mental illnesses may attribute to the parenting role. Support mothers with serious mental illness to feel effective and empowered in this role.
• Facilitate engagement in advocacy, community action, and peer mentorship roles to facilitate acceptance and empowerment.
• Assist women with serious mental illnesses to access academic and vocational supports as well as job networking opportunities. Work to maximize resources and overcome potential financial barriers to acceptance and functioning.
• Identify relational sources of support and enhance peer support across social identities of gender, race, class, disability, parenting, or other identities.
• Assess for mistreatment or sexual exploitation and any potential impact of these experiences on the acceptance process. Discuss safety measures and provide related resources.
(p. 99) Discussion Questions
1. A frequent goal of feminist therapy is to explore systemic contributions to mental health problems, particularly in the area of gender, race, and class. For example, a feminist therapist might work with a woman with serious mental illness to identify the role of sexism in her mental health problems, poverty, violence, or mistreatment. Do you agree that this would be an appropriate or useful focus in one’s role as a therapist? Explain why or why not.
2. Proponents of intersectionality theory argue that one is not solely defined by one aspect of one’s sociocultural background (e.g., female, black, or wealthy) but rather, multiple identities combine to uniquely impact experience (e.g., black woman with serious mental illness who is wealthy). Do you agree with this theory, or do you feel that a woman with mental illness is primarily defined by one aspect of her identity (e.g., race or gender)? Explain your ideas.
3. Feminist scholar Peggy McIntosh (1989) defined the concept of privilege to refer to unearned advantages one has in the broader society afforded by a particular sociocultural identity. In the United States, some of these privileges include white privilege, male privilege, and heterosexual privilege. In response to a description of this theory, an attendee at a recovery-oriented conference once replied, “Even though I’m white, I lost all of my privileges once I developed a serious mental illness.” Do you agree or disagree with this claim? How do you understand this person’s perspective?
1. Treatment plan. Make a copy of the case narratives in this chapter and distribute them to a group. Create a treatment plan that includes clinical goals, objectives, and recommendations for working with these women. Trade your treatment plan with another group member. Now answer the following questions:
• What goals did you consider? What did you miss? Reflect on these differences and similarities in your treatment plans and recommendations.
• Based on your list, what do you feel are your clinical strengths and focus? How did these strengths develop in your clinical perspective?
• Based on your list, what blind spots or areas for further clinical development might you identify in your focus? What would you like to do to grow in your clinical work? (p. 100)
2. Women’s mental health. Develop a curriculum outline for a potential women’s mental health group. First, identify several of your goals for the group. Then identify the main topics you would want to address in the group. What potential activities might you include to attain these objectives? Explain how you would facilitate the process of acceptance of mental illness for these women, with attention to intersectional stigma. In a group, compare and contrast these group curricula and combine into one group to pilot.