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This article was downloaded by: [202.67.40.17]On: 09 October 2013, At: 19:50Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH,UK

American Journal of

Psychiatric RehabilitationPublication details, including instructions for

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The Impact of Illness Identity

on Recovery from Severe

Mental IllnessPhilip T. Yanos

a, David Roe

b& Paul H. Lysaker

c

aPsychology Department , John Jay College of

Criminal Justice, City University of New York , New

York, USAb

Department of Community Mental Health, Facultyof Social Welfare and Health Sciences , University of

Haifa , Haifa, IsraelcRoudebush VA Medical Center and the Indiana

University School of Medicine , Indianapolis, Indiana,

USA

Published online: 18 May 2010.

To cite this article:Philip T. Yanos , David Roe & Paul H. Lysaker (2010) The Impactof Illness Identity on Recovery from Severe Mental Illness, American Journal of

Psychiatric Rehabilitation, 13:2, 73-93, DOI: 10.1080/15487761003756860

To link to this article: http://dx.doi.org/10.1080/15487761003756860

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The Impact of Illness Identity onRecovery from Severe Mental Illness

Philip T. Yanos

Psychology Department, John Jay College of CriminalJustice, City University of New York, New York, USA

David Roe

Department of Community Mental Health, Faculty ofSocial Welfare and Health Sciences, University ofHaifa, Haifa, Israel

Paul H. LysakerRoudebush VA Medical Center and the IndianaUniversity School of Medicine, Indianapolis,Indiana, USA

The impact of the experience and diagnosis of mental illness on ones identityhas long been recognized; however, little is known about the impact of illnessidentity, which we define as the set of roles and attitudes that a person hasdeveloped in relation to his or her understanding of having a mental illness.The present article proposes a theoretically driven model of the impact ofillness identity on the course and recovery from severe mental illness andreviews relevant research. We propose that accepting a definition of oneselfas mentally ill and assuming that mental illness means incompetence andinadequacy impact hope and self-esteem, which further impact suiciderisk, coping, social interaction, vocational functioning, and symptom severity.

This work was supported by National Institute of Mental Health grant

R34-MH082161.Address correspondence to Philip T. Yanos, PhD, Associate Professor, John Jay College ofCriminal Justice, City University of New York, Psychology Department, 445 W 59th St.,New York, NY 10019, USA. E-mail: [email protected]

American Journal of Psychiatric Rehabilitation, 13: 7393, 2010

Copyright # Taylor & Francis Group, LLC

ISSN: 1548-7768 print=1548-7776 online

DOI: 10.1080/15487761003756860

73

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Evidence supports most of the predictions made by the model. Implicationsfor psychiatric rehabilitation services are discussed.

Keywords: Identity; Recovery; Stigma

Accumulating evidence from long-term follow-up studies carriedout over the last 2 decades has demonstrated that most people diag-nosed with schizophrenia-spectrum disorders achieve full or partialrecovery (Harding, Zubin, & Strauss, 1992; Hopper, Harrison,

Janca, & Sartorius, 2007). These research findings, along with firstperson accounts (Deegan, 1993) and ideology (Anthony, 1993) havebegun to erode pessimistic and deterministic attitudes regardingsevere mental illness and have brought the vision of recovery intopolicy documents and initiatives (DHHS, 2003). Focus has gradu-ally shifted away from the question of whether people can recoverfrom severe mental illness to what facilitates recovery (Onken,Ridgway, Dornan, & Ralph, 2002). Several important directionshave been taken, including addressing structural (Yanos, Knight,

& Roe, 2007) and stigma barriers (Corrigan et al., 2001; Corrigan& Gelb, 2006), transforming policy (DHHS, 2005), and identifyingand delivering evidence-based practices (Mueser, Torrey, Lynde,Singer, & Drake, 2003). These approaches are important in targetingprocesses that impact the course of recovery, ranging from broadsocietal and system issues of legislation, oppression, and discrimi-nation to more individualized matters such as effective services.

In addition to objectively defined domains, there is just as cruciala need to study subjectively defined domains of recovery such as

core identity and sense of self (Davidson & Strauss, 1992; Estroff,1989; Roe & Davidson, 2005), particularly in light of recoveryunderstood as an inherently personal, subjective, and self-definedprocess (Bellack, 2006; Onken, Ridgway, Dornan, & Ralph, 2007).The impact of the experience and diagnosis of mental illness onones identity has long been recognized (Estroff, 1989; Goffman,1961); however, little is known about the impact of what we hereterm illness identity on the course of and recovery from severemental illness. We define illness identity as the set of roles and atti-

tudes that people have developed about themselves in relation totheir understanding of mental illness. It is thus an aspect of onesexperience of oneself that is affected by both the experience ofobjective aspects of illness and by how each individual makes

74 P. T. Yanos et al.

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meaning of the illness. Our conception of illness identity is

primarily influenced by the sociological concept of identity, whichtypically refers to the social categories that a person uses to describehim- or herself (e.g., patient, father, survivor) as well as thesocial categories others use to describe that person (Thoits, 1999).We use the term illness identity as an alternative to earlier terms,such as engulfment (Lally, 1989), to allow for the multiple waysin which people might make sense of having a mental illness. Thus,our concept includes other ways of making sense of having a men-tal illness, including empowered identities and ones in which

mental illness is irrelevant.No comprehensive theoretical model currently exists of howillness identity impacts important aspects of recovery. The purposeof the present paper is to propose a theoretically driven model ofthe impact of illness identity on the course of and recovery fromsevere mental illness and to review the existing empirical researchthat supports it.

THE MODEL

We hypothesize that illness identity may play a major role in thecourse of severe mental illness, affecting both subjective and objec-tive outcomes related to recovery. As presented in Figure 1, wehypothesize that the impact of any awareness of having a psychi-atric problem is moderated by the meanings that the personattaches to that problem (that is, how the illness is conceptualizedand what that means about the person experiencing it).1 As an illus-tration, consider the following example: With the onset of schizo-

phrenia, a person starts having a broad range of new challengessuch as hearing voices, having unusual beliefs, and having difficult-ies with studies or work, which leads him or her to seek help; after apsychiatric evaluation, that person may be advised by a mentalhealth professional that he or she has a mental illness. At this timethe person has a decision to make. Should the person conclude thatthese experiences are caused by mental illness? We suggest thatonce a person has decided to characterize unusual experiences

1Note that the model presented here is very similar to that presented in Yanos, Roe,Markus, and Lysaker (2008), but differs slightly in that the emphasis on meaningsattached to illness is broader, rather than restricted to the impact of internalizedstigma.

Impact of Illness Identity 75

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at least partly as being the result of mental illness, what that illnessmeans about him or her becomes a key issue. Does the illness, forexample, mean that the person is weak? Is it just another barrierto be overcome? Does the illness have no personal meaning or does

it mean the end of previous dreams?The second step in our model is that illness identity affects hopeand self-esteem. Self-esteem refers to the evaluative aspects of theself, or self-regard (Baker & Gallant, 1984). It is at this point specifi-cally at which stigma becomes an important consideration. Does theperson attach stigmatizing meanings to the characterization of hisor her experiences as mental illness? Does this person acceptthat mental illness is synonymous with dangerousness and incom-petence and, in essence, internalize the stigma, leading to the loss of

a previously held identity (e.g., as student, worker, parent) and toless hope and self-esteem? Does the person, alternatively, believethat what he or she has been diagnosed with is a challenge thatcan be surmounted, allowing for hope and self-esteem to remainintact? At this juncture, group identification may play an impor-tant role in how one assigns meaning to the definition of onesexperience as mental illness (Watson, Corrigan, Larson, & Sells,2007). Specifically, some persons may identify with having a mentalillness and ascribe widely-held stigmatizing views to this status,

while others may make a similar identification but take on a posi-tive identity by way of identification with peers (e.g., believing thathaving a mental illness is a mark of advantage). There are two keyideas here: first, persons diagnosed with severe mental illness do

Figure 1. Impact of illness identity on recovery-related outcomes.


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not merely experience symptoms but they also interpret their

experience of having an illness and assign meanings to it whichin turn qualify and affect hope and self-esteem. Second, internaliza-tion of these meanings and, in particular, stigma, can infectpersonal constructions of illness, damaging hope and self-esteem.It is important to note that stigmatizing perceptions reflect largersocietal views that broad population surveys have indicated arestill widespread (Martin, Pescosolido, & Tuch, 2000). These beliefsinclude heightened expectations of violent and disorderly behavioras well as the conviction that persons with severe mental illness

cannot sustain gainful employment or make informed decisionsabout their own welfare (Link, Phelan, Bresnahan, Stueve, & Pesco-solido, 1999; Pescosolido, Monahan, Link, Stueve, & Kikuzawa,1999; Phelan, Link, Stueve, & Pescosolido, 2000).

Next, the model posits that hopefulness and self-esteem in turninfluence three variables central to the process of recovery fromsevere mental illness. First, lack of hope and low self-esteem mayincrease depression and create a risk for suicide, while greater hopemay act as a protective factor against suicide. Continuing with our

example, if a person views the diagnosis as representing a completedisruption of his or her dreams, that person might contemplate sui-cide. Hope and self-esteem may also influence social interaction(though this is likely to be moderated by family support and othersources of existing social support). Individuals with lower self-esteem may drift away from others and become isolated. Degreeof hope and self-esteem may also have an effect on the types ofcoping strategies used in response to symptoms and stressors.Following our example, if hopelessness prevailed, we might expect

the individual to use more avoidant strategies such as removalfrom anxiety-provoking situations or to use alcohol or drugs tonumb unpleasant emotional states.

In the next phase of the model, we suggest that the types ofcoping strategies used can directly affect vocational outcomes,symptom severity, as well as social interaction. Here, as individualsuse more avoidant strategies, they may be more likely to avoid newand challenging work situations (such as those offered throughrehabilitation or supported employment programs). To continue,

if a stigmatized view of mental illness diminished hope and thenled to a preference for avoidant coping, we hypothesize that theperson would be at risk for being unable to manage job-relatedstress and therefore losing his or her job. Conversely, another


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individual who uses more problem-oriented strategies might be

better able to maintain employment by dealing with work-relatedstress in a more adaptive manner. Regarding social interaction, justas hopelessness might lead to withdrawal and isolation, so might agenerally avoidant stance to naturally arising conflict with others.Finally, we hypothesize that the types of coping strategies used,social interactions, and vocational functioning all affect the severityof psychotic symptoms. We are not claiming that psychotic symp-toms are caused by these factors, but rather that psychotic symptomscan be made more severe and disabling if individuals remain socially

isolated, lack the structure of employment, and continue to use avoi-dant coping strategies. Concluding our example, if a stigmatizedview of mental illness were to diminish hope (leading to socialwithdrawal) and promote avoidant coping (leading to job loss), wemight imagine that the combined stress might increase levels ofhallucinations or delusions beyond where they initially began.

Review of Evidence for the Model

General Evidence for Relationship Between IllnessIdentity and RecoveryBefore discussing the evidence for specific relationships predictedby the model, we first discuss the general evidence for a relation-ship between understandings of illness and their effects on personalidentity and recovery-related outcomes. There is substantial evi-dence that transforming identity is an important part of the processof improving outcomes for people with severe mental illness. In aseries of qualitative studies, Davidson and colleagues (Davidson

& Strauss, 1992; Davidson, Sells, Sangster, & OConnell, 2005)described how the process of constructing a new sense of selfis an important part of the process of recovery from mental illness.These studies describe how persons with severe mental illness whodisplayed significant improvement in global functioning expressedthemes of the discovery of ways of recapturing a sense of purposethrough daily activities. A longitudinal qualitative study (Roe,2001) assessing the process of recovery from severe mental illnesshas supported this conclusion, finding that individuals who

improved functioning over a 1-year period showed a progressionfrom the identity of patient to person in their narratives,suggesting that maintaining a patient identity can be detrimentalto recovery. Multiple, quantitative, longitudinal single-case studies


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have also suggested that as persons progress toward recovery, one

of the first steps tends to be the reclamation of a sense of oneselfas active agent (Lysaker, Davis, Eckert, Strasburger, Hunter, &Buck, 2005; Lysaker, Davis, Jones, Strasburger, & Hunter, 2007).

Qualitative research on the impact of participation in the mentalhealth consumer movement (i.e., organizations run by and forpersons diagnosed with mental illness that provide advocacy andself-help services) has also supported that participation in theseorganizations can facilitate recovery by encouraging participants,through rituals of self-disclosure and advocacy, to transform

identities of mental patient to consumer advocate (McCoy &Aronoff, 1994; Onken & Slaten, 2000). This transformation enabledconsumers to reframe the experience of mental illness so that itno longer carried a negative connotation but instead was seen assomething that was OK, or even a mark of social advantage.These studies and those described above suggest that an essentialpart of the recovery process involves transforming undervaluedidentities associated with internalized stigma and replacing themwith more individualized empowered identities.

Studies supporting the theory that identity transformationis an important part of the recovery process provide a generalframework of empirical support for our conceptual model. Wenow discuss the research evidence supporting specific relationshipshypothesized by the model.

Relationship Between Illness Identity andHope=Self-EsteemAs is indicated in the conceptual model represented in Figure 1,

we hypothesize that the nature of illness identity directly impactsthe hope and self-esteem of people diagnosed with severemental illness. Specifically, we hypothesize that individuals whoboth identify themselves as having a mental illness and acceptstigmatizing attitudes regarding this identity will have diminishedhope and self-esteem, while the opposite will be true of individualswho accept that they have a mental illness but do not accept stigma-tizing attitudes.

There is good evidence in the literature on the relationship

between insight and self-esteem, and internalized stigma. Cross-sectional studies have found that greater insight is associated withhigher levels of dysphoria (Mintz, Dobson, & Romney, 2003),lowered self-esteem (Warner, Taylor, Power, & Hyman, 1989),


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and decreased well-being and quality of life (Hasson-Ohayon,

Kravetz, Roe, & Weiser, 2006). Several studies have also establishedthat there is a relationship between internalized stigma and dimin-ished self-esteem and hope (Watson et al., 2007). One cross-sectional study found that engulfment of the mental patient role(similar to internalization of stigma) was strongly negatively asso-ciated with hope and self-esteem (McCay & Seeman, 1998), whileanother (Corrigan, Watson, & Barr, 2006) found that internalizedstigma was strongly negatively associated with both self-esteemand self-efficacy, even when controlling for depressive symptoms.

Link and colleagues research (Link, Struening, Neese-Todd,Asmussen, & Phelan, 2001) on a modified labeling perspective,though not explicitly addressing internalized stigma, has alsoprovided considerable support for the impact that internalizingthe label of being mentally ill can have on a variety of subjectiveoutcomes related to recovery. Links research and related studieshave measured incorporation of stigmatizing attitudes by using ascale that measures the extent to which a person with mental illnessagrees that most people have devaluing and discriminating

attitudes toward the mentally ill. There is evidence from a bodyof studies that the degree to which one believes that others havedevaluing and discriminating attitudes is related to diminishedself-esteem (Link et al., 2001) and a decreased sense of mastery(Wright, Gronfein, & Owens, 2000), even when controlling forsymptoms. Consistent with this is research on personal narrativesof self and illness that found that participants with greater levelsof self-stigma tended to tell stories about their lives that werescored by blinded raters as having lesser themes of social worth

(Lysaker, Buck, Taylor, & Roe, 2008).Lysaker, Roe, and Yanos (2007) attempted to link findingsregarding both awareness and internalized stigma by exploringthe hypothesis that the effects of awareness of illness of schizo-phrenia on self-esteem and hope might be moderated by the degreeto which the person internalizes stigmatizing views about mentalillness. A cluster analysis of persons in a stable phase of illnessrevealed two groups of persons who were relatively aware of hav-ing a mental illness: persons who did, and did not, endorse having

internalized stigmatizing beliefs about their condition. Persons withhigh insight who endorsed internalized stigma beliefs (roughly athird of the sample) had lower levels of self-esteem and hope,and fewer interpersonal relationships than those with insight who


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rejected stigmatizing beliefs. The cluster analyses also produced

a third group that had low insight into illness and also endorsedstigmatizing beliefs, though to a lesser degree than did the highinsight=high stigma group. This group also had higher levels ofself-esteem and hope than the group with high insight and highstigma, but did not differ from them in social functioning. This lastfinding may suggest that both the acceptance of stigma and denialof mental illness may lead to social isolation. Taken together, thesefindings support the view that the meanings a person attributes tohaving a mental illness can have important implications for how

awareness or insight into illness impacts outcomes.

Impact of Hope and Self-Esteem on Suicide Risk,Coping, and Social IsolationAs indicated in Figure 1, we also hypothesize that hope andself-esteem impact suicide risk, the choice of coping strategies usedto deal with symptoms and stressors, and the social interactions ofpersons with severe mental illness. There is evidence supporting allthree of these hypothesized relationships.

There is good support for the relationship between hopelessnessand suicide risk among persons with severe mental illness. In theirrecent review of the predictors of suicidal behavior among peoplediagnosed with schizophrenia, Bolton, Gooding, Kapur, Barrow-clough, and Tarrier (2007) identified eight studies finding supportfor a relationship between hopelessness and suicide risk=behavioramong people with schizophrenia. In discussing the reasons someindividuals with schizophrenia experience more hopelessness, thereview discussed the hypothesis that negative self-evaluation

related to the meaning attributed to having a mental illness canincrease risk for hopelessness. This hypothesis is supported bythe work of Birchwood, Iqbal, and Upthegrove (2005), who haveresearched what they termed post-psychotic depression, whichthey hypothesized results from the loss of social goals, roles andstatus and social shame that accompanies the realization thatone has a psychotic disorder. They found that roughly 35% of asample of persons with psychotic disorders showed evidence ofpostpsychotic depression and that these individuals had feelings

of shame and humiliation (which are very consistent with the con-struct of internalized stigma), along with high levels of awarenessof having a mental illness (in separate research, Rusch et al.[2006] have also found shame to be related to internalized stigma).


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In a related study, Tarrier, Barrowclough, and Andrews (2004)

found that suicidal ideation and behavior were strongly predictedby hopelessness, which was in turn greatly predicted by negativeself-evaluation. A more recent study by Fialko et al. (2006) alsofound that both diminished self-esteem and belief in decreasedcontrol over ones illness were related to suicidal ideation amongpersons with psychotic disorders. Collectively, these findingssuggest that diminished hope and self-esteem impact suicidal idea-tion among people with severe mental illness, and that diminishedhope and self-esteem are likely impacted by illness identity factors.

With regard to the relationship between hope=self-esteem andcoping, three cross-sectional studies have found support for thisrelationship. Lysaker, Campbell, and Johannsen (2005) found thatindividuals with greater insight and hope were more likely to useproblem-centered coping strategies and less likely to use avoidantcoping strategies than both individuals with high insight but lowhope and individuals with high hope and low insight. Cooke et al.(2007) found that poor self-esteem was significantly associatedwith the use of avoidant coping strategies (specifically behavioral

disengagement). Similarly, Hoffman, Kupper, and Kunz (2000)found that poor self-concept was significantly associated with theuse of depressive-resigned coping among persons with schizo-phrenia participating in vocational rehabilitation.

A few cross-sectional studies have examined the link betweenhope=self-esteem and social isolation among persons with severemental illness. Lysaker, Davis, and Hunter (2004) examined thecorrelates of hopelessness and found evidence supporting the viewthat persons with both diminished levels of hope linked to personal

agency and expectations of the future had fewer social interactionsthan persons with greater hope of either type. Tarrier et al.(2004) found that, in a sample of individuals with recent onsetschizophrenia, hopelessness was related to greater social isolation.Similarly, using data from a large multicenter study of Scandina-vian countries, Sorgaard et al. (2002) found that self-esteem waspositively related to size of the social network and frequency ofsocial interaction.

Impact of Hope, Self-Esteem, and Coping onVocational OutcomesAs is indicated in the conceptual model represented in Figure 1, wealso hypothesize that hope=self-esteem will impact vocational


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outcomes. There is limited evidence for this relationship, as few

studies have addressed the relationship between psychologicalvariables and vocational outcomes. In their review of theperson-related predictors of employment outcomes for adultswith severe mental illness, Michon, van Weeghal, Kroon, andSchene (2005) did not identify any studies examining the impactof hopelessness or self-esteem on employment outcomes, althoughthey did identify three studies finding support that work-relatedself-efficacy (or positive expectations regarding work success)was a predictor of good work outcomes. More specifically with

regard to hope, Davis, Neese, Hunter, and Lysaker (2004) foundthat different dimensions of hopelessness were related to differentaspects of subsequent work performance. Specifically, loss ofmotivation was related to poorer social skills and work cooperation,suggesting that individuals who have given up on working as apossibility do not invest the effort in behavior necessary for goodjob success. Of related interest is the work of Hoffman, Kupper,Zbinden, and Hirsbrunner (2003), which, while not directly asses-sing the impact of hope or self-esteem on vocational outcomes,

found evidence supporting the hypothesis that external locus ofcontrol (a related construct) predicted impaired work behavior invocational rehabilitation and reduced the likelihood of eventuallyobtaining competitive employment.

The relationship between coping and vocational outcomes hasbeen relatively unstudied. One prospective study (Yau, Chan,Chan, & Chui, 2005), however, found that avoidant coping (depres-sive resignation) was related to impaired work skills among Club-house (Model of Psychosocial Rehabilitation) participants with

severe mental illness, and that reductions in avoidant coping overtime predicted improvements in work skills. While this study doesnot necessarily support a relationship between coping and competi-tive employment, it indicates that coping affects skills related toemployment success. In addition, two qualitative studies (Cunning-ham, Wolbert, & Brockmeir, 2000; Becker, Whitley, Bailey, & Drake,2007) have examined the variables perceived as being related to jobsuccess among persons with severe mental illness who had foundand maintained employment. In both studies, participants high-

lighted the importance of using effective coping skills to deal withwork-related stress. Of note, Cunningham et al. (2000) comparedgroups of mental health consumers who had and had not been suc-cessful in finding gainful employment, and found differences in the


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way employed and unemployed consumers talked about coping,

with employed consumers discussing more problem-orientedcoping.

Impact of Coping, Vocational Outcomes, and SocialIsolation on Symptoms. As indicated in Figure 1, we alsohypothesize that coping, vocational outcomes, and social interac-tions impact symptom severity among persons with severe mentalillness. There is evidence supporting all three of these hypothesizedrelationships.

While considerable research has explored the relationshipbetween coping and outcomes such as social functioning and qual-ity of life, little research has addressed the relationship betweencoping and symptom severity. Nevertheless, there is cross-sectional(Lysaker , Davis, Lightfoot, Hunter, & Strasburger, 2005) evidencethat the types of coping strategies typically used by persons withsevere mental illness are related to symptom severity. Similarly,Strous, Ratner, Gibel, Ponizovsky, and Ritsner (2005) found thatchanges in coping strategies were associated with changes in symp-

tom severity over time. In both cases, the direction of the relation-ship is unclear, and plausible interpretations could be made ineither manner. However, one prospective study, conducted byMeyer (2001), found support that coping may influence symptoms;specifically, the author found that preferences for adaptive copingat baseline predicted fewer psychotic symptoms at follow-up.

Both cross-sectional and prospective research support a relation-ship between employment and symptoms. Priebe, Warner,Hubschmid, and Eckle (1998) conducted a study of employed and

unemployed persons with schizophrenia in three countries, findingthat employed participants had significantly fewer symptoms.While this study does not support a causal link between employ-ment and reduced symptoms, experimental evidence from a largerandomized trial of supported employment (Bond et al., 2001),found that participants with severe mental illness who participatedin competitive work showed higher rates of improvement insymptoms over time, in contrast with subjects who did not partici-pate in competitive work. This supports the view that involvement

in work can alleviate symptoms.Although much research has documented an associationbetween degree of social interaction and symptom severity (e.g.,Sorgaard, Hansson, & Heikila, 2001), few studies have examined


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this issue prospectively, making it difficult to evaluate the direction

of this relationship (our model hypothesizes that this is a bidirec-tional relationship). However, strong evidence from studiesemploying the Experience Sampling Method (a method that collectsdata on mood, cognition, and activity at multiple time points dur-ing a day) has found that social interactions with acquaintancesand family members are associated with reductions in the experi-ence of delusions (Myin-Germeys, Nicolson, & Delespaul, 2001).Similar findings were not observed for hallucinations (Delespaul,deVries, & van Os, 2002), however, suggesting that social interac-

tion might reduce the intensity of some types of symptoms butnot others.

Integrative Studies

One recent study (Yanos, Roe, Markus, & Lysaker, 2008) hasattempted to conduct an integrated study of some of the relation-ships discussed above. Using data collected from 102 study parti-cipants with schizophrenia spectrum disorder, a path analysis

supported the hypothesis that internalized stigma affected avoidantcoping, active social avoidance, depressive symptoms, and thatthese relationships were mediated by hope and self-esteem. Therewas also evidence that internalized stigma affects positive symp-tom severity by way of its impact on social avoidance, but apredicted relationship between avoidant coping and symptomseverity was not supported. While causal inferences cannot bedrawn from this cross-sectional study, the data provide preliminarysupport for an integrated conceptualization of the relationship

between internalized stigma, hope and self-esteem, and other out-comes related to recovery.

Limitations of the Existing Evidence andRecommendations for Future Research

There is good empirical evidence for many of the connections pre-dicted by the model. Specifically, there is compelling evidence forthe relationship between hope=self-esteem and suicidality, as well

as for the impact of employment on symptoms and other outcomes.Nevertheless, research has not always been adequate to fully testthe relationships predicted in the model. In some areas, such ashope=self-esteem and employment, research has been mainly either


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exploratory or cross-sectional. Clearly, more prospective research is

needed to address many of the areas we have discussed above. Inaddition, there is a need for research to test multiple facets of themodel in an integrated fashion. This would allow for better esti-mates of the magnitude of the relationships between the variousdomains in the model, since most prior studies of connectionsbetween two of the domains in the model have not controlled formany of the other domains. It would also allow for considerationof the extent to which the effects of illness identity are directversus the extent to which they are mediated by hope=self-esteem

and coping as we hypothesize in our model.

DISCUSSION

Well-documented findings on the heterogeneous outcome of severemental illness have generated efforts to identify variables related topositive outcomes and recovery. However, essential questions forthe mental health field continue to be how and why progress in

moving toward recovery varies between individuals and how ser-vice systems can facilitate the potential for recovery. The purposeof this article is to present a theoretically driven model and toreview the research evidence supporting the model to clarify howillness identity could become an important variable in influencingrecovery among persons diagnosed with severe mental illness.

Evidence in support of our proposed model suggests thatignoring the importance of illness identity may lead to difficultroadblocks in treatment and rehabilitation for many persons with

severe mental illness. Specifically, some persons who are offeredhigh-quality, evidence-based services such as supported employ-ment or illness management may not take advantage of or benefitfrom them because they lack hope that any progress in treatmentis possible. They may certainly engage in such activities but be athigh risk to fail given the expectation of failure or a lack of sche-mata with which to make sense of and enjoy success. The proposedmodel demonstrates how illness identity appears to be a crucial andcentral intersection influencing various domains of recovery

directly, as well as indirectly, through mediating processes.If illness identity has such important effects, the question israised: how can the illness identity of people with severe mentalillness be transformed to facilitate recovery? We believe that


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treatment specifically focused on illness identity can have a positive

effect on outcomes in this area and can allow persons with severemental illness to benefit from other high-quality services. Spe-cifically, we believe that cognitive-behavioral therapy (CBT)approaches focused on addressing attitudes related to illnessidentity can have a favorable impact in this regard. Theoreticaldiscussions (Corrigan & Calabrese, 2005) and case studies (Holmes& River, 1998) discussing how techniques based in CBT showpromise as methods of altering self-conceptions reflective of illnessidentity. A CBT approach to helping individuals recover their

identity would address self-stigmatizing views as cognitive distor-tions or dysfunctional attitudes, which are major areas of focus inmost CBTs. As Holmes and River discussed, CBT techniques suchas psychoeducation (providing information that counteracts exag-gerated stigmatizing views), teaching skills to conduct cognitiverestructuring (collecting evidence to test and challenge the validityof dysfunctional beliefs), and exposure may all be used to addressinternalized stigma. Coping techniques may also be helpful in facil-itating a process of constructing and negotiating meanings (Roe,

Yanos, & Lysaker, 2006). This process includes not only changesin appraisal of a stressor, but also experiencing and perceiving one-self differently in relation to stressors and the sense of threat or suf-fering they generate. For example, a person may use cognitivecoping efforts to generate an internal dialogue that redefines howhe or she feels about setbacks experienced as a result of having amental illness, and changes how strongly such setbacks impactperceptions of the self.

An additional treatment approach that we believe holds promise

in transforming illness identity is narrative enhancement. Phenom-enological observations suggest that severe mental illness ofteninvolves a profound diminishment in a persons ability to narratehis or her own lifes evolving story (Gallagher, 2003; Lysaker,Wickett, Wilke, & Lysaker, 2003). Helping those with severe mentalillness to accept themselves as sufficiently privileged to constructand develop a meaningful story of ones self and disorder that pro-motes recovery may be crucial to the transformation of ones illnessidentity. Such a process helps clients tell stories about what is

wrong and what is right, hopes and losses, and what could be done(Lysaker, Buck, & Roe, 2007; Roe & Ben-Yishai, 1999). The goal ofsuch a process would be to help clients tell more coherent storiesabout their lives in which their role as a protagonist is developed


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and transformed and in which themes of empowerment and agency

are emphasized (Lysaker, Lysaker, & Lysaker, 2001). Thus, for anindividual whose story stresses themes of being unable to over-come impairments associated with having a mental illness, a narra-tively focused psychotherapy aims to guide a person toward areassessed conceptualization, wherein his or her life story empha-sizes personal strength, change, and success over adversity. In thisway, disempowered narratives in which themes dominated byinternalized stigma prevail can be gradually reframed and revisedso that themes of agency and potential and personal strength come

to predominate.In summary, we have offered a model of how a collection ofsocial, psychological, and clinical forces may interact to create sub-stantial barriers to recovery. In particular, we have suggested thatto begin with a definition of oneself as mentally ill and to assumethat mental illness means incompetence and inadequacy, placespeople at risk of ceasing to try to work and fit into their communi-ties. We have suggested that when stigma leads to an impoverishedsense of self, low self-esteem and suicide risk follow. These, then,

promote not only avoidance and poorer psychosocial outcomesbut may also help sustain symptom severity, leading to a viciouscircle. This model can not only be tested empirically but it mayexpose a chain of thoughts and behaviors that could be individuallytargeted for intervention.

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