There is a 900-ton elephant in the counseling room, and it is often not acknowledged by the counselor or the client. As sessions go on and therapeutic alliance builds, this elephant results in a missed opportunity for the counselor to truly know their client. This elephant is known as stigma.
Although stigma associated with mental illness is a well-researched area, there is a paucity of the literature that teaches counselors how to 1) identify stigma and 2) process and address stigma to decrease its impact on the client. This elephant cannot continue to boast proudly from the corner of the counseling room. Counselors must call it out. But how? Now, you’re asking the right question!
Stigmas exist nearly everywhere. Sometimes stigma is associated with things we can see such as ethnicity or a set of behaviors, and other times, it is present in things that are not so obvious such as within systems or laws. Either way, stigma is harmful.
There are two primary types of stigmas: public stigma and self-stigma. According to an article by Graham Davey published in Psychology Today in 2013, public stigma forms from negatively held beliefs that society has about a particular group of people. These beliefs often entail stereotypes, discrimination and prejudice. In a 2002 article published in World Psychiatry, Patrick Corrigan and Amy Watson postulate that self-stigma occurs when an individual internalizes the negative beliefs that society has about them. For example, it is a common belief, and myth, that people with mental illness are dangerous. Self-stigma means the individual believes this narrative even if they are not dangerous and even when there is no evidence to support this claim. Self-stigma is usually a result of public stigma. Both kinds of stigma have been documented to exacerbate symptoms. Stigma also creates an “us versus them” divide between those who have a mental illness and those who do not.
Counselors have been charged with many responsibilities within the counseling session. We attune to the client’s mood, process emotions, help to create the goal of third-order change and create a safe space for clients to explore their most vulnerable selves. One skill, however, that we are not specifically trained to do is to recognize stigma and how it impacts our client’s lives. Furthermore, most counselors are ill-equipped to know how to address stigma once its presence has been recognized. Clients come to session and talk about how their symptoms have created obstacles in their relationships, work and career, but they do not usually name stigma as one of the main culprits. Counselors who are aware of what stigma is, how it presents and how to alleviate it have a better chance at addressing those presenting issues and offering their client a more well-rounded counseling experience by acknowledging stigma’s detrimental role.
Tips for addressing stigma with clients
For the past 10 years, I’ve worked with individuals who have been diagnosed with severe and persistent mental illnesses. Specifically, I have extensive experience working with individuals diagnosed with schizophrenia. Throughout my career, I have learned a great deal about the plague of stigma and how it can often destroy a person’s will to recover. During my doctoral studies, I conducted a case study where I investigated the impact of stigma on self-stigma attitudes of an African American man diagnosed with schizophrenia. This project was profound because it allowed me to witness firsthand how detrimental stigma can be for people who have a mental illness, and most important, I learned how to recognize and address it. This study also put me on a path to share what I know about stigma. Here are three simple tips for how counselors can recognize stigma in the counseling session.
1) Remember that counselor education and awareness are essential components of the counseling process. Stigma can form from biases, so counselors must be aware of their own prejudices. We all have them, and the sooner we can own them, the sooner we can use that information to address the elephant in the room. Ask yourself, “How do I feel about my client and their diagnosis?” Then, ask yourself how others may feel about your client. How would you feel if your partner or parent had this diagnosis? Would there be feelings of shame? Embarrassment? Denial? This process may help to reveal stigmatizing thoughts that perhaps were not as apparent. Stigma can be found in the language that the client uses to describe their mental illness, in the nonverbal communication that the client displays, or in myths and stereotypes that the client unknowingly shares with the counselor. To have the most profound impact on dismantling stigma attitudes, counselors need to have a good understanding of what stigma is and how it may present in a counseling session. Counselors should educate themselves on stigma and then listen attentively for any of these signs so that they can be addressed.
2) Name the elephant in the counseling session. This calls for the counselor to use immediacy to recognize stigma. Calling the elephant out strips it of its power. Identifying stigma and processing how it has an impact on the client not only allows the client to tell their full story but also helps the counselor better understand the obstacles that their clients face. You understand clients in context. This force that lurks in the corner is now identifiable, and when something is identifiable, it can be addressed.
3) Create a collaborative and safe space. A collaborative, safe space is essential for good therapeutic work to happen. When the client and the counselor are working toward the same goal, the synergistic efforts become a force to be reckoned with. This partnership is necessary to effectively address negative stigma attitudes. A safe space is crucial for any therapeutic alliance to blossom, but a space cannot be safe if counselors have not done their part to identify the stigmas that make the client’s condition worse. Clients need to trust their counselor in order to be a change agent in their own recovery. Counselors who address symptoms and the stigma attached to the client’s condition create a comprehensive approach to treatment.
Addressing stigma from a theoretical framework
Some counselors may not feel equipped to try these tips. Perhaps it seems daunting to address something that the counselor only recently realized. Because counselors learn to conceptualize and treat clients using a theoretical lens, this approach might be one of the best ways for counselors to meet the responsibility of addressing negative stigma attitudes.
My theory of choice is rational emotive behavior therapy (REBT), which was developed by Albert Ellis in the 1950s. One of the primary premises of REBT is that we are not disturbed by life events. Instead, it is our belief about the event that makes all the difference. If our beliefs are irrational, then our emotions and behaviors will be irrational as well. Counselors who use REBT aim to change faulty beliefs into beliefs that are more productive and aligned with reality. The result is less self-disturbance.
I tested this theory in my doctoral case study that I mentioned earlier. In this study, I applied REBT techniques to the negative self-stigma attitudes of an African American male, Ike (pseudonym), diagnosed with schizophrenia. I found that many of the techniques that are unique to REBT also helped the client gain awareness of the impact of stigma. Ike learned ways to discount irrational ideas that stemmed from stigma.
REBT is built on the philosophy of universal acceptance, which means that we accept things for how they are. This does not mean we have to like the situation. It does not mean we agree with it. It does not mean it is fair or we condoned it. It just means that in this moment, the situation is the way it is and we have little to no control to change it. There are three primary types of universal acceptance: universal self-acceptance, universal other acceptance and universal life acceptance.
Universal self-acceptance acknowledges that we are all a work in progress, and even with our human flaws, we are still worthy. We have to be kind and patient with ourselves as we continue to work toward self-improvement each day. Excepting one’s flaws and shortcomings without criticism but with the goal of improvement is the premise of universal self-acceptance. When clients struggle with this concept, I ask them to think of their most favorite person. Then, I have them envision telling this person the things they say to themselves in times of high criticism and negative self-talk. Most clients admit they would never say such things to the other person. So, I ask clients to think of that person every time they engage in negative self-talk. I create a rule: If they would not say these things to that loved one, they are not allowed to say it to themselves. Over time, the goal is that the client learns to talk to themselves with kindness and compassion without the need to imagine they are speaking to their loved one. Many of my clients have found this approach to be effective, and it is how I begin the process of teaching clients about universal self-acceptance.
Universal other acceptance posits that we meet people where they are and accept them “as is.” We cannot control others, and it is not our jobs to judge them. Each person has their own way of going through life, and if we can just learn to accept this (even if we don’t necessarily like it), then we can avoid feeling overly upset when others do not behave in the ways we think they should. When clients learn to practice universal other acceptance, they can also accept other individuals who may have the same or similar mental health challenges. Practicing universal other acceptance has both indirect and direct advantages toward negating negative connotations and stigma attitudes around mental illness.
Universal life acceptance suggests that life is going to happen whether we want it to or not. This does not mean that we should just “lie down and take it” and that our problems will be solved by inertia. Instead, universal life acceptance stresses that we have to change our thinking about the life event because being upset and angry about it will not change the circumstances. Rather than experiencing intense emotions such as rage or deep depression, we can accept the situation and strive to change it by doing so within our locus of control. We cannot control life events; we can control only our reactions to them. Essentially, we can control only ourselves, not anything or anyone else. Universal life acceptance helps clients learn to focus on what they can control (primarily themselves) and relinquish control of everything else.
Counselors can gain a comprehensive understanding of universal acceptance by practicing it themselves. Firsthand experience puts counselors in a better position to teach these concepts to clients. Additionally, understanding how universal acceptance works in their own lives gives them insight into how to apply this to a client’s presenting problems. Counselors can teach clients to apply universal acceptance to negative stigma attitudes that emerge from deep exploration into stigma’s presence and impact.
REBT interventions for addressing stigma
As mentioned previously, REBT has the potential to be a go-to theory for addressing self-stigma attitudes. Although REBT has a plethora of interventions, I want to suggest three interventions that I personally used in my research and found to be effective in addressing Ike’s self-stigma attitudes and beliefs that caused him significant stress.
1) The ABC situational model. The ABC situational model, which is a foundation of REBT, allows for clients to see how their irrational thinking leads to self-disturbance. If they can change their thinking, then the emotion that follows will change as well. The A in the ABC situational model stands for activating event, which is the incident or event that happened. The B stands for belief or what you tell yourself about the event. The C stands for consequence, which is how you feel as a result of the belief that you have about the event.
Ellis believed that this formula captures how most people get to the point of distress. People get overly distraught when their belief is faulty or illogical. For example, Ike had been at the same company for the past three years. He felt good about his work and was finally making ends meet. When he was hired, Ike self-disclosed that he had a mental health diagnosis of schizophrenia disorder. He figured it was good practice to let his employer know just in case he experienced any challenges managing symptoms. One afternoon, the executives called for an emergency meeting, and Ike learned that he and several others would be laid off from their jobs. The executives said it was due to the hardships brought on by the pandemic. Ike took in the news and had a panic attack. He was convinced that this was the worst thing that could ever happen to him and that he was chosen to be let go because of his mental illness. He was sure word would spread among future employers and he would be excluded.
If we apply Ike’s situation to the ABC situational model, the activating event in this scenario is Ike being laid off. The belief is Ike thinking that he was let go because of his illness and that things could not get any worse. Ike was convinced that there was no way he would be able to find another job. He generalized the situation and thought to himself, “This always happens to me. I’m never going to keep a job if I tell people I have this condition.” The consequence in this scenario is extreme anxiety — to the point of panic — and thoughts of hopelessness.
Ike’s self-disturbance comes from his irrational beliefs. If Ike believes he was laid off because of his mental illness but there is no real evidence, proof or situation that corroborates this idea, then his emotional response would be at the same level of severity as his thoughts. This leads to self-disturbance. Counselors can intervene at the belief level and help clients to change their irrational beliefs into thoughts that are more aligned with the reality of the situation. Challenging Ike’s unfounded thoughts about being fired because of his mental illness would be a good place to start. The clinician could help Ike realize that although the situation is not ideal and will be hard, it is not the end of the world, and it is not the most terrible thing that could ever happen. He has no concrete reason to believe he was laid off because of his illness. He was not the only person the company let go, and he did not know whether others had mental illnesses. Furthermore, there is no evidence to support that his employer will share his condition with others. This approach can help to reduce the severity of emotions and bring about a different, less traumatic, emotional experience. Ike would learn to see the layoff as an unfortunate event, but a bearable one. His distress would be more aligned and more in proportion to the actual circumstance, which would likely reduce self-disturbance.
The ABC situation model is the cornerstone of REBT. Counselors can use this approach to gain an understanding of the origins of the clients’ faulty thinking. It is also a useful teaching tool for clients as well. The more they understand how to use this model, the more they can begin to use it outside of the counseling room, leading to third-order change.
2) Disputation. Another technique used in REBT is disputation. Ellis believed that we must vigorously and consistently challenge irrational thoughts through disputation. Not only must we challenge them, but we must also replace them with ones that are more realistic. In my case study, Ike believed he was not capable of being loved or cared for by anyone because he had a diagnosis of schizophrenia. Although he felt this way often, I was able to get Ike to share about many instances where he experienced good relationships with others who knew about his condition. These relationships were the exception, but when there is an exception, the irrational beliefs are hard, if not impossible, to uphold. Disputation helped Ike to recognize that not all his relationships were bad and that he had experienced healthy relationships with others. Counselors who use REBT believe that the more we get into the habit of identifying and then challenging our faulty thinking, the easier it will be to replace those beliefs with thoughts that are more in proportion with reality.
3) Reality testing. Reality testing is another fundamental intervention used in REBT, and it helps the client to use evidence to negate thoughts that are irrational. Ike, for example, often did not feel safe because of the way society had treated him in the past because of his mental illness. These negative experiences led Ike to believe that others in the community could tell he had schizophrenia just by looking at him. The stigma of what someone with a mental illness is perceived to look like was prominent in Ike’s worldview.
Ike practiced reality testing by putting his theory into practice. I gave him a homework assignment to go for a short walk in the community and identify who had a mental illness and who did not based solely on how the person looked. After completing the assignment, Ike reported that he was not able to say for sure who had a mental illness. He said he could not tell by just looking at them and that the other person would have needed to “do something” for him to make that decision. Ike and I applied this new information to his own thoughts about how he is perceived by others. He concluded that if he were just going to the store or taking a stroll in the neighborhood, there was no way someone could pinpoint that he had schizophrenia. This exercise was repeated many times to help Ike to disprove his thoughts about this idea.
In summary, stigma continues to wreak havoc upon those with mental illness. There is not enough focus on this issue within most counseling programs, so many counselors are not aware of stigma’s impact on symptoms and clients in general. Counselors can be change agents by gaining an understanding of the impact of stigma. And then they can educate the client by addressing stigma and its impact on the client in the counseling session. Counselors can also offer interventions to help clients learn to cope with and combat negative self-stigma attitudes. Stigma can make a condition that is already hard to manage worse, but if counselors can learn to recognize it, they can empower their clients to do the same with the added benefit of teaching clients how to cope.
Tina C. Lott is a licensed clinical professional counselor, certified alcohol and other drug counselor, national certified counselor, approved clinical supervisor, and board-certified telemental health provider. She is a core faculty member with Walden University. In addition, she is an independently contracted therapist at PATH mental health, a mother of two fantastic kids and a life partner to her fiancée. Contact her at firstname.lastname@example.org.
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