Living with uncertainty: A grounded theory of psychiatric stigma when seeking or maintaining employment
The aim of this study was to investigate stigma for people who have experienced psychiatric disorder. Psychiatric stigma can exclude people both from economic roles and from participation in daily community life. Social and psychological reaction models of stigma adequately explain parts of this process but do not provide an integrated account that addresses the unique illness experience of psychiatric disorder. Nor do they provide an experiential account of psychiatric stigma that reflects its unique difference in a valued life situation - employment. The 31 Participants had all used psychiatric services and comprised 20 men and 11 women ranging in age from 20-59 years. There were 11 Maori, 18 Pakeha and 2 Pacific Islanders. At the time of this study they were all seeking or maintaining employment. Participants completed multiple open-ended interviews over a two year period. The interviews were transcribed and analysed using Glaser’s method of grounded theory. Constant comparison within and between stigmatising events found most of the variance in Participants’ accounts was captured in the core category of uncertainty (See Table 1). Uncertainty ruptured possibilities for health, identity, relationships and positive life trajectories. Consequently, Participants faced the task of managing a stigmatised identity by striving to resolve uncertainty. Yet the process of resolving uncertainty and negotiating a stigmatised identity had the ironic effect of creating uncertainty. This was theorised as a mutually interacting and self-generating process of creating-resolving uncertainty (see Table 2). Utilising a psychiatric service entailed changing from a person to a patient and this was accompanied by a change in social role and personal expectations. Staff monitored their patients for illness. This implicitly trained patients to self-monitor for signs of illness and embedded a medical language to achieve it. Any behaviour or expression was perceived as indicative of their mental health status. When patients tried to become everyday people again, self-monitoring and monitoring by other people suffused any actions with concerns about their mental health. The impact of this and living an illness-mediated life required the continuous constructing of identity. The need to monitor for illness signs ensured that Participants’ lives became marked by and marked out by their disorder, so everyday performance became a performance of mental health. This entailed a vulnerability and caution in every day life where the haunting prospect of their disorder occurring again intruded into both self-concept and self processes. Life became uncertain and this required a vigil to prospect for ‘mad’ signs and sort everyday perceptions for unreality, inappropriateness and illness related events. This was crucial within the workplace where Participants may or may not have disclosed their psychiatric history to their colleagues. Disclosure was fraught with the uncertainty of whether to display or not to display; to tell or not tell; to let on or not let on; to lie or not lie; and, in each case, to whom, how, what, when and where. This study developed an innovative theory of psychiatric stigma that integrates the effects of illness experience on self-concept, the experiential demands of participating in employment and the interpersonal and intra-psychic processes Participants employed to resolve psychiatric stigma. Resolving and creating uncertainty explained the task of negotiating a uniquely stigmatised identity and increased understanding of the stigmatisation that could accompany other illnesses or disorders. The theory can now be used to examine psychiatric stigma in distinct population groupings and to predict its effects in more diverse settings. Future research should aim to develop measures of its dimensions, so that it can be used to distinguish between the stigma experienced by people with psychiatric illness across time and place, among different groups. The effects of variables such as community attitude change and professional intervention could then be investigated. Thus the theory could be used to improve the quality of life for people who experience psychiatric disorder.
Networked Digital Library of Theses and Dissertations