Establishing a Wellness Model for LGBTQ+ Persons with Anxiety, Depression, and Comorbid Emotional Dysfunction
Robert F. Mullen, Ph.D.
Firmly establishing wellness models in mental health requires nothing less than a reformation of language, power structure, and perspective throughout the mental healthcare community and beyond.
65 million U.S. adults and 18.5 million adolescents have major depression and anxiety. Estimates show that 60% of those with anxiety also have depression symptoms, and both are comorbid with substance abuse. The LBGTQ+ community is 1.5-2.5 times more likely to have anxiety and depression than their straight or gender-conforming counterparts. Similar numbers hold for LGBTQ+ persons with other mental and emotional disorders. Anxiety and depression are the primary causes of the 56% increase in adolescent suicide over the last decade. High school LGBTQ+ students are almost five times as likely to attempt suicide than their heterosexual peers, and 40% of transgender adults have attempted suicide in their lifetime.
Wellness must become the central focus of mental health because the disease model has provided grossly unsatisfactory results. Rather than obsessing on disease and deficits, wellness models emphasize the character strengths and virtues that generate motivation, persistence, and perseverance essential to recovery. Psychological science is there, but it needs positive implementation through program integration, positive evaluation, transparency, and information management. Empathy and communication must supersede etiology and misdiagnosis.
Wellness impacts more than mental health; it is a paradigmatic perspective that seeks to promote a state of complete physical, mental, and social well-being. This paper will show how the wellness model’s sociological emphasis on character strengths and attributes not only positively impacts the self-beliefs and image of a mentally ill person but resonates in sexual and gender-based identities and portends well, the recovery-remission of an LGBTQ+ person with a mental illness.
To illustrate the wellness model’s potential impact, this paper focuses on LGBTQ+ persons with anxiety and depression disorders, which comprise 42% of diagnosable dysfunctions in the current Diagnostic and Statistical Manual of Mental Disorders (DSM). It posits what is learned can be applied to the remaining 58% of mental disorders that impact an LGBTQ+ person’s emotional well-being and quality of life. “There is an urgent need to develop and disseminate tailored evidence-based interventions that improve the health of lesbian, gay, bisexual, transgender, and queer (LGBTQ) youth. (Wilkerson et al., 2016, p. 358).
Depression and anxiety are the two most common forms of mental dysfunction impacting millions of U.S. adults who find themselves caught up in a densely interconnected network of fear and avoidance of social situations. Johns Hopkins (2020) reports that around 25 million U.S. adults have a depressive illness, and 45 million have anxiety. Adolescent numbers fluctuate between 8 and 18 million (CDC, 2020; NIMH, 2017); the actual number is indeterminate. Statistics are even less reliable for the LGBTQ+ community because large-scale mental health studies rarely include sexual and gender identity (NAMI, 2020b). “Federally funded surveys only recently have begun to identify sexual minorities in their data collections” (Medley et al., 2020, p. 1). Experts estimate the infection rate in the LBGTQ+ community is 1.5 to 2.5 times higher “than that of their straight or gender-conforming counterparts” (Brenner, 2019, p. 1).
Depressive illnesses tend to co-occur with anxiety and substance abuse (Johns Hopkins, 2020). “Some estimates show that 60% of those with anxiety will also have symptoms of depression, and the numbers are similar for those with depression also experiencing anxiety” (Salcedo, 2018, p. 1). Anxiety and depression are the primary causes of the 56% increase in adolescent suicide over the last decade (Curtin & Heron, 2019). “High school students who identify as lesbian, gay or bisexual are almost five times as likely to attempt suicide compared to their heterosexual peers,” and “40% of transgender adults have attempted suicide in their lifetime” (NAMI, 2020b, p. 1).
Anxiety is the most common mental dysfunction, impacting the emotional well-being and quality of life of adults and children who find themselves caught up in a densely interconnected network of fear, worry, and apprehension. The psychological and sociological toll can be overwhelming. Physically, anxiety can cause sweating, trembling, fatigue, and rapid heartbeat, lower the immune system and increase the risk of heart disease risk. Persons with depression may experience a lack of interest and enjoyment of daily activities, significant weight fluctuation, insomnia or excessive sleeping, enervation, inability to concentrate, feelings of worthlessness, guilt, and recurrent thoughts of death or suicide. Anxious and depressed persons frequently generate images of themselves performing poorly in social situations (Hirsch & Clark, 2004; Hulme et al., 2012) for fear of being found out as unlikeable, stupid, or annoying. Accordingly, they avoid speaking in public, expressing opinions, or even fraternizing with peers. Symptoms can be repressive and intractable, imposing irrational thought and behavior (Richards, 2014; Zimmerman et al., 2010) that govern perspectives of personal attractiveness, intelligence, and competence (Ades & Dias, 2013). Over time, these self-beliefs become automatic negative thoughts (Amen, 1998) that determine initial reactions to situations or circumstances.
Mental Health and LGBTQ+ Culture
Halloran and Kashima (2006) define culture as “an interrelated set of values, tools, and practices that are shared among a group of people who possess a common social identity” (p. 140). Culture determines how mental illness is perceived or diagnosed, how services are organized, and how they’re funded. It also affects how patients express their symptoms…and how they cope in the range of their community and family supports. (Daw, 2001, p. 1)
Studies and research indicate that mental health culture is underscored by the same interrelated attributions to mental health stigma: public opinion, media representation, family rejection, distancing, and the diagnosis itself. These attributions are also LGBTQ+ cultural influences along with heterosexualism and victimization. Both are impacted by history, while the disease model remains the primary contributor to mental health culture.
LGBTQ+ culture is defined by its sexual and gender identity as distinct from the heterosexual and cisgender community (NAMI, 2020b). Subcultures within the community comprise “a diverse set of groups, including distinct groups based on sexual orientation and gender identity” (Lewis et al., 2017, p. 861), each struggling to develop their recognition. LGBTQ+’s social identity is shaped by oppression and its role in overcoming it. The community faces “numerous challenges and instances of heterosexism and homophobia in their daily lives” (UW-Madison, 2020, p. 1), including “discrimination, prejudice, denial of civil and human rights, harassment, and family rejection” (NAMI, 2020b, p. 1). The contrast in social culture is underscored by 26 countries with legalized same-sex marriage versus 73 countries where homosexual activity between consenting adults is illegal (Equaldex, 2020) and 8 countries where it is punishable by death (ILGA, 2019). LGBTQ+ people worldwide are confronted by “violence, arbitrary arrest, imprisonment, torture, and execution, according to Amnesty International” (WEF, 2018, p. 1). Because of this cultural disparity, this paper limits its focus to LGBTQ+ mental health issues in the United States.
Working within a wellness model of mental health has become a central focus of international policy (Slade, 2010). As psychologist Kinderman (2014) writes, “we need wholesale and radical change, not only in how we understand mental health problems but also in how we design and commission mental health services” (p. 1). Decades of pathographic focus in psychological research and studies, negative diagnostic attributions, stereotyping and stigma, public and institution resistance, and a doctor-client power dominance factor in the need to transition to a wellness paradigm.
Firmly establishing wellness models in mental health requires nothing less than a reformation of language, power structure, and perspective throughout the mental healthcare community and beyond. Rather than obsessing on disease and deficits, wellness models emphasize the character strengths and virtues that generate motivation, persistence, and perseverance to recovery. Psychological science is there but needs implementation through program integration, positive evaluation, transparency, and information management. Empathy and communication must supersede etiology. This paper does not endorse a total dissolution of medical model approaches, but a review of their efficacy and the psychological effectiveness of their pathographic dominance is highly warranted.
Redefining Mental Health
Government agencies define mental illness as a “diagnosable mental, behavioral, or emotional disorder of sufficient duration to meet diagnostic criteria” that can “result in functional impairment which substantially interferes with or limits one or more major life activities” (Salzer et al., 2018, p. 3). This ‘defective’ emphasis has been the overriding psychiatric perspective for centuries.
The pathographic or disease perspective of diagnosis and recovery focuses on the history of an individual’s suffering to facilitate diagnosis. Schioldann (2003, p. 303) defines pathography as a historical biography from a medical, psychological, and psychiatric viewpoint. It analyses a single individual’s biological heredity, development, personality, life history and mental and physical pathology, within the socio-cultural context of his/her time, in order to evaluate the impact of these factors upon his/her decision-making, performance, and achievements. (Kőváry, 2011, p. 742)
One only needs the American Psychological Association’s (APA, 2020) definition of neurosis to comprehend the mental health community’s pathographic focus. The 90-word overview contains the following words: distressing, irrational, obsessive, compulsive, dissociative, depressive, exaggerated, unconscious, conflicts, anxiety, disorders. DSM-3 abandoned the word ‘neurosis’ in 1980, but it remains the go-to term in the mental health community. Coined by a Scottish physician in 1776, neurosis defined itself as functional derangement of the nervous system. Pathography focuses “on a deficit, disease model of human behaviour (sic),” whereas the wellness model focuses “on positive aspects of human functioning” (Mayer & May, 2019, p. 159).
Studies and research portray the mental healthcare community as drowning in pessimism (Henderson et al., 2014; Khesht-Masjedi et al., 2017; Pryor et al., 2009). “There is evidence to indicate the problem may be endemic in the medical health community” (Gray, 2002, p. 3), and universally systemic (Knaak et al., 2017). Noted psychologist Alison Gray (2002) argues that more disordered persons would seek treatment if psychiatric services were less stigmatized and stigmatizing. Patients commonly report instances where a staff member was inordinately rude or dismissive. They cite coercive measures, excessive wait times, paternalistic or demeaning attitudes, treatment programs revolving around drugs with undesirable side effects, stigmatizing language, and general therapeutic pessimism (Henderson et al., 2014; Huggett et al., 2018). Clients with more severe complications or illnesses are often deemed “difficult, manipulative, and less deserving of care” (Knaak et al., 2017, p. 2). Nurses and clinicians cite a lack of collegial support, insufficient knowledge and training, and the fear of client self-harm (Henderson et al., 2014), leading them to over-diagnose and over-prescribe (Huggett et al., 2018).
Transitioning from the disease model’s pathographic language to the optimistic and encouraging language of wellness models is everyone’s responsibility in the mental health community―its institutions, associations, practitioners, researchers, media, and clients. In the growing opinion of clinical psychologists, empathy and communication must take precedence over etiology.
We must move away from the disease model, which assumes that emotional distress is merely symptomatic of biological illness, and instead embrace a model of mental health and well-being that recognizes our essential and shared humanity. Our mental health is largely dependent on our understanding of the world and our thoughts about ourselves, other people, the future, and the world. (Kinderman, 2014, p. 3
Language and Perspective
Language generates and supports perspective, and linguists agree that the relationship between language and power is mutual (Ng & Deng, 2017). Language influences thought and action. Terms like incapacity, deceit, unempathetic, manipulative, and irresponsible describe DSM-5 traits for various disorders. The argument is not that these descriptions are invalid; they are overwhelmingly negative and perceptually hostile. Judging by public opinion, media representation, and mental health stereotypes and stigma, these words help frame the perception of a person with a mental disorder (DeMare, 2016; Pinfold et al., 2005; Pryor et al., 2009).
Realistically, we cannot eliminate the word ‘mental’ from the culture. The disease model’s guide for 70 years is called the Diagnostic and Statistical Manual of Mental Disorders. Unfortunately, the word ‘mental’ is a limited description of a disorder, and its negative implications support perceptions of incompetence, unworthiness, and undesirability. It is the dominant source of stigma, shame, and self-denigration. Psychologically, the word mental defines a person or their behavior as somehow extreme or illogical. Adolescents derisively assign the term to the unpopular, different, and socially inept. The urban dictionary defines mental as someone silly or stupid.
Hostile and demeaning language is pervasive throughout mental healthcare promulgated by the disease or medical model’s pathographic undercurrent. This perspective influences public opinion, study and research, media representation, the doctor-patient power structure, community interrelationships, and client self-beliefs and image. Transitioning from the disease model to wellness models requires constructing a more reasonable mental health perspective by addressing misunderstanding, misinformation, and the overriding focus of the disease model on diagnosis, disorder, deficit, and denigration.
Misinformation is generated by the psychological community’s difficulty finding agreement due to changing criteria, “substantial discrepancies and variation in definition, epidemiology, assessment, and treatment” (Nagata et al., 2015, p. 724), and the intractability of the American Psychiatric Association. There are four common misconceptions about mental disorders. They are (1) abnormal and selective, (2) a consequence of behavior, (3) solely mental, and (4) psychotic. These are corrected by universality, age of onset, complementary, and the clear differentiation of psychosis from neurosis.
Universality. A recent article in Scientific American speculates that “mental illnesses are so common that almost everyone will develop at least one diagnosable mental disorder at some point in their life” (Reuben & Schaefer, 2017, p. 1). It is a part of natural human development. One-in-four individuals have a diagnosable mental disorder. According to the World Health Organization, nearly two-thirds of people who believe they have a mental disorder reject or refuse to disclose their condition. Include those who dispute or chose to remain oblivious to their dysfunction, and we can conclude that mental disorders are common, undiscriminating, and universally impacting.
Age of Onset. The onset of a disorder is a consequence of early psychophysiological disturbance, according to Mayoclinic (2019). Perhaps parental behaviors are overprotective or controlling or do not provide emotional validation (Cuncic, 2018). The receptive juvenile might be the product of bullying, abuse, or a broken home. “LGBT youths experience greater stressors from childhood into early adulthood, such as child abuse and unstable housing, that exacerbate mental health problems” (Mustanski et al., 2016, p. 527). LGBTQ+ youth experience disproportionately high rates of verbal and physical harassment and other types of peer victimization (Berlan et al., 2010; Reisner et al., 2015). “Gender minority youth had approximately four-fold higher odds of experiencing any bullying or harassment in the past year” (Reisner et al., 2015, pp. 35-36).
Childhood/adolescent exploitation or abuse are generic terms to describe a broad spectrum of experiences that interfere with a youth’s optimal physical, cognitive, emotional, and social development (Steele, 1995). Any number of situations or events can trigger the susceptibility to onset; it could be hereditary, environmental, or some traumatic experience (Mayoclinic, 2019; NIH, 2019). Statistically, the LGBTQ+ community is at “a higher risk than their heterosexual counterparts for traumatic life experiences such as childhood physical, psychological, and sexual abuse” (Bandermann, 2014, p. 3).
Despite the implication of intentionality in the words’ abuse’ and ‘exploitation,’ a toddler might sense abandonment and develop emotional issues when a parent is preoccupied (Lancer, 2019). The child/adolescent is not accountable for their dysfunction; there is the likelihood no one is intentionally responsible. Similarly, with the scientific affirmation that, while sexual and gender-based identities may have a genetic or biological basis, they are not chosen, and the LGBTQ+ person is not accountable; unlike mental illness, there is no implicit or explicit responsible party.
Undoubtedly, this sociological model conflicts with moral models that claim, “mental illness is onset controllable, and persons with mental illness are to blame for their symptoms” (Corrigan 2006, p. 53), and sexual and gender-based orientation is a choice.
Complementarity. In early civilizations, mental illness was the domain of supernatural forces and demonic possession. Hippocrates and diagnosticians of the 19th century looked at the relative proportions of bodily fluids. Lunar influence, sorcery, and witchcraft are timeless culprits. In the early 20th century, it was somatogenic. The biological approach argues that neuroses are related to the brain’s physical functioning (McLeod, 2018), while pharmacology promotes it as a chemical or hormonal imbalance. Carl Roger’s study of the cooperation of human system components to maintain physiological equilibrium produced the word ‘complementarity’ to define simultaneous mutual interaction. Mind, body, spirit, and emotions work in concert. The same mutual interaction is evident in sexual and gender-based identities as it is in all persons.
Psychosis and Neurosis. There are two degrees of mental disorders: neuroses and psychoses. When someone sees, hears, or responds to things that are not actual, they are having a psychotic episode. While few persons experience psychosis, everyone has moderate-and-above levels of anxiety, stress, and depression. Neurosis is a condition that negatively impacts our emotional well-being and quality of life but does not necessarily impair or interfere with normal day-to-day functions. Since the overwhelming majority of mental disorders are neuroses, humans are all dysfunctional to some extent.
“Language reveals power, reflects power, maintains existing dominance, unites and divides . . . and creates influence.” (Ng & Deng, 2017, p. 15). The similar impact of the wellness model on the mentally ill and the LGBTQ+ person is evident. Revising negative and hostile language to embrace a positive dialogue of encouragement and appreciation generates new perspectives that positively contribute to self-beliefs and image, leading to more disclosure, discussion, and, in the case of mental illness, recovery-remission. The self-denigrating aspects of shame should dissipate; stigma becomes less threatening.
Accepting that mental illness and sexual and gender-based identities are ubiquitous and non-discriminating should make it easier to embrace the subject within the family structure. Realizing their proximity and general susceptibility should mitigate the desire to distance and isolate. Accepting their social pervasiveness should alleviate the prejudice, ignorance, and discrimination attached to mental illness (Khesht-Masjedi et al., 2017; Pescosolido, 2013; Pinfold et al., 2005; Wood & Irons, 2017), as well as sexual and gender-based identities (Adamczyk & Liao, 2018; Dodge et al., 2016; Lewis et al., 2017). Recognizing that neither the mentally ill nor the LGBTQ+ person is accountable disputes the belief that they are weak or amoral and their condition a reflection of behavior. (Condition is herein defined as the state of something with regard to its quality.)
Resistance to Recovery
The term stigma-avoidance defines those who fear that public disclosure could, potentially, stigmatize and discredit them. Statistics from the National Bureau of Economic Research “find that survey respondents under-report mental health conditions 36% of the time when asked about diagnosis” (Bharadwaj et al., 2017, p. 3). A recent study by Salzer et al. (2018) reveals that only one-third of disordered persons were in recovery-remission in 2017. The lower recovery-remission rates may be partly due to the inability to afford treatment due to anxiety-induced financial and employment instability (Gregory et al., 2018). More than 70% of social anxiety disorder patients, for example, are in the lowest economic group (Nardi, 2003).
The LGBTQ+ community’s resistance to disclosing a mental disorder, seeking treatment, or accepting a diagnosis is due to the same attributions that underscore general reticence: stigmatization, victimization, public opinion, media representation, family rejection, and the diagnosis itself.
Mental health stigma is the hostile expression of the abject undesirability of the afflicted. 90% of survey respondents with a mental disorder claim they have been impacted by mental health stigma (NAMI 2020a). Stigmatization is deliberate and proactive, distinguishable by pathographic overtones intended to shame and isolate (Pryor et al., 2009). Disclosure of a mental disorder jeopardizes livelihoods, relationships, social standing, housing, and quality of life (Huggett et al., 2018; Pinfold et al., 2005; Sowislo et al., 2016; Wood & Irons, 2017). “The deleterious effects of stigma and prejudice on the health of sexual minority individuals have been well-documented across both physiological and psychological domains” (Dodge et al., 2016, p. 1).
For LGBTQ youth, the minority stress theory posits that their health is affected by the degree to which their social environment stigmatizes sexual and gender minorities and the extent to which LGBTQ+ youth in these environments are expected to hide their non-conformity. (Wilkerson et al., 2016, p. 359)
Mental health stigma is expressed within three categories:
- Tribal stigma devalues.
- Moral character stigma implies amorality and weakness.
- Abominations of the body stigma refers to physical deformity or disease (Pryor et al., 2009).
Mental disorder occupies the last two categories. Ignorance equates a mental disorder with weakness or contributing behavior, while the medical model focuses on the disease and deformity aspect. The LGBTQ+ community’s sexual and gender-based identity is socially and culturally tribal.
“Community-based samples of LGBT youths have shown that as many as 30% may experience psychological distress at clinically significant levels” (Mustanski et al., 2016, p. 527). A study of the effects of cumulative victimization on LGBTQ+ youth’s mental health found that they “experience greater mental health problems, such as depression, anxiety, suicide attempts, and posttraumatic stress disorder (PTSD) . . . than do heterosexual and cisgender individuals” (Mustanski et al., 2016, p. 527). Contributors include internalized homophobia, stigma consciousness, identity concealment, and experiences of heterosexism and victimization. (Heterosexism is the sociological term for discrimination or prejudice against gay people by heterosexuals who assume heterosexuality is the normal sexual orientation). Sexual and gender-identity minorities are disproportionally subject to bullying, harassment, and other peer victimization (Berlan et al., 2010; Reisner et al., 2015). The LGBTQ+ community is “one of the most targeted communities by perpetrators of hate crimes in the country” (NAMI, 2020b, p. 1).
Because of the greater risk of victimization in LGBT individuals compared with heterosexuals starting as early as adolescence, research is needed that examines how trajectories of sexual orientation-based victimization across development influence the risk for mental health problems for LGBT people. (Mustanski et al., 2016, p. 528)
“Although recognition, attributions, and service use may reflect prejudice associated with mental illness, the heart of stigma lies in social acceptance” (Pescosolido, 2013, p. 8). The image of the dangerous, unpredictable, mentally ill person is still widely endorsed by the public (Corrigan & Watson, 2002; Pinfold et al., 2005). Stuart and Arboleda-Flórez (2012) analysis of two surveys (1990/2006) on public perception found, that “between 80-100 percent of respondents . . . favored involuntary hospitalization for that disorder when they thought that violence was an issue” (p. 7).
Attitudes toward sexual and gender-based identity became substantially more accepting between the 1970s, the most significant shift among 18- to 29-year-olds (Adamczyk & Liao, 2018; Dodge et al., 2016). “It is clear that Americans have become more accepting of same-sex sexual behavior and relationships, but it is unclear how universal those changes are and whether they are due to age, time period, or cohort” (Twenge et al., 2016, p. 10).
Persons tend to be more supportive, in part, “because gay men and lesbians are then seen as less responsible for their orientation” (Adamczyk & Liao, 2018, p. 4). An overwhelming share (92%) of the U.S. LGBTQ+ community believes “society has become more accepting of them in the past decade and expect it to grow even more accepting in the decade ahead” (Pew, 2020, p 1). However, many rights and benefits afforded to LGBTQ+ individuals depend on region, race and ethnicity, political persuasion, educational attainment, economics, and religiosity (Adamczyk & Liao, 2018; Dodge et al., 2016; UW-Madison, 2020). Religion is strongly associated with negative beliefs about the justifiability of LGBTQ+ “sexual behavior and marriage” (Twenge et al., 2016, p. 8). The degree of intolerance is denominational and subject to the frequency of attendance. Jews and moderate-to-liberal protestants are more tolerant than Baptists, fundamentalists, and Catholics (Adamczyk & Liao, 2018; Schnabel, 2016). The Pew (2020) study shows that 29% of LGBTQ+ persons have felt unwelcome in a place of worship;
Heterosexual women consistently demonstrate more positive attitudes toward sexual and gender minority groups than heterosexual men who are “traditionally expected to more rigidly conform to gender explicitly heteronormative norms and stereotypes” (Dodge et al., 2016, p. 4). Attitudes toward lesbians and gay men are significantly more positive than attitudes toward transgender people (Adamcyzk & Liao, 2018; Lewis et al., 2017), whereas “bisexual individuals commonly report experiencing stigma, prejudice, and discrimination from both heterosexual and gay/lesbian individuals” (Dodge et al., 2016, p. 1).
Education and interpersonal contact mitigate prejudicial attitudes and behaviors towards both the mentally disordered and LGBTQ+ individuals. Contact-based education has emerged as the most influential factor in public attitude and behavior towards people with mental health problems (Pinfold et al., 2005; Corrigan, 2006). “Multiple studies have found that knowing someone who is LGBTQ+ is associated with more supportive attitudes” (Adamczyk & Liao, 2018, p. 10), and “may increase knowledge, reduce anxiety, and increase empathy” (Lewis et al., 2017, p. 862). This benefit has not crossed over to transgender people, likely, because “personal contact is relatively small” (Lewis et al., 2017 p. 871).
According to the Pew Research Center (Pew, 2020), 30% of the LGBTQ+ community reported they have been threatened or physically attacked, 21% treated unfairly by an employer, and 58% the target of slurs or jokes. Heterosexism inflicts itself on individual, familial, institutional, employment, political, and cultural levels, and openly occurs in educational, career, religious, and social settings (Bandermann, 2014; Lewis et al., 2017).
While public opinion has drastically improved for the LGBTQ+ community, the perception of the dangerous and unpredictable mentally disordered person who should be isolated has not changed substantially in decades (Stuart & Arboleta-Flórez, 2012). A primary goal of wellness models is mitigating mental health stigma by changing the public perspective.
A 2011 study revealed that nearly half of U.S. media stories on mental illness mention or allude to violence (Pescosolido, 2013). News and social media, propelled by far-right politics, fundamentalism, and other fringe organizations, contribute to discrimination and prejudice. Analysis of film, television, and tabloid presentations identify three common misconceptions: people with mental illness are homicidal maniacs, they have childlike perceptions of the world that should be marveled at, or they are rebellious, free spirits (Corrigan, 2006). Portrayals of sexual and gender-based identity in the latter half of the 20th century were, generally, stereotypical exaggerations. “Beginning in the 1990s, some highly likable gay and lesbian television and media characters began to appear in the media” (Adamczyk & Liao, 2018, p. 10). Still, there is an abundance of gay-themed portrayals designed to arouse feelings of shock, betrayal, and titillation. Media coverage commonly promotes disinformation that negatively impacts the self-beliefs and image of LGBTQ+ persons.
Family stigmatization is the rejection of an LGBTQ+ or mentally dysfunctional child or sibling. A 2008 literature review found around 38% of family members “attempt to hide their relationship in order to avoid bringing shame to the family” (Stuart & Arboleda-Flórez, 2012, p. 8). Another study showed that 34% of LGBTQ+ persons reported rejection by family members, 49% reported unfair treatment, and “52% were subject to anti-gay remarks from family members” (Bandermann, 2014, p. 3). The implication of familial undesirability impacts a mentally disordered and LGBTQ+ person’s sense of positive self, a devaluation more potentially “life-limiting, and disabling than the illness itself” (Stuart & Arboleda-Flórez, 2012, p. 3). “The difficulties of living with psychiatric distress are magnified by the experience of rejection” (Gray, 2002), which can lead to psychological and physiological health issues, substance abuse, and addiction.
Etiology and Misdiagnoses
Etiology and diagnosis drive the disease model. Which disorder do people find most repulsive, and which poses the most threat? What behaviors contribute to the disorder? How progressive is the disorder, and how effective are treatments? (Corrigan, 2006). It is essential to recognize how these attributions affect public perception, treatment options, and client self-beliefs and image.
“Until the 1950s, most homosexual persons studied by psychologists and others were prisoners or mental patients, so it was easy to conclude that these were linked” (McFarland, 2018, p. 1). In 1973, the APA announced homosexuality was no longer an illness. DSM diagnostic criteria change dramatically from one edition to the next. Lynam and Vachon (2012) cite therapists’ concern that criteria are “added, removed, and rewritten, without evidence that the new approach is better than the prior one” (p. 483). The social fears described in the DSM-II in 1968 became social phobia in the DSM-III (1980), and social anxiety disorder in 1994’s DSM-IV, resulting in the nickname, the ‘neglected anxiety disorder.’
Revisions, substitutions, and contradictions between DSMs are never universally accepted. Even under the best circumstance with a knowledgeable and caring clinician, it is difficult to obtain a proper mental disorder diagnosis. In addition to the nine types of depression, four anxieties, and eight obsessive-compulsive disorders, the current DSM lists five types of stress response and ten personality disorders, each sharing similar traits and symptomatology with varying degrees of impact. Bipolar personality disorder, for example, shares characteristics and symptoms with generalized anxiety disorder, social phobia, obsessive-compulsive disorder, posttraumatic stress disorder, and panic disorder (Sagman & Tohen, 2009). The most common comorbidities associated with anxiety are major depression, panic disorder, posttraumatic stress disorder, and alcohol abuse/dependence. For example, social anxiety disorder is often comorbid with avoidant personality disorder, eating disorders, schizophrenia (Cuncic, 2018; Vrbova et al., 2017), ADHD, and agoraphobia (Koyuncu et al., 2019).
The Social Anxiety Institute (Richards, 2019) reports that an estimated 8.2% of patients had generalized anxiety, but just 0.5% were correctly diagnosed. A recent Canadian study by Chapdelaine et al. (2018) reported, of 289 participants in 67 clinics meeting DSM-4 criteria for social anxiety disorder, 76.4% were improperly diagnosed.
Maslow’s (1943/1954) hierarchy of needs reveals how childhood disturbance can disrupt natural human development. Healthy growth requires satisfying fundamental physiological and psychological needs. The experience of detachment, exploitation, or neglect may disenable the subject from satisfying their physiological and safety needs and or the need to belong and experience love, which can impact the acquisition of self-esteem.
If the child is criticized, overly controlled, or not given the opportunity to assert itself, it begins to feel insecure in its ability to survive, and may then become overly dependent on others, develop low self-esteem, and experience a sense of shame or doubt in its own abilities. (Vanderheiden & Mayer, 2017, p. 15)
Research on persons with depression and anxiety reveals how the disease model “diminishes hope, self-esteem, self-efficacy, empowerment, and quality of life.” (Garg and Raj, 2019, p. 124). LGBTQ+ youth rejected because of their identity have much lower self-esteem, are more isolated, and have less support than those accepted by their families (House, 2018).
Self-esteem determines one’s relation to self, to others, and the world. Self-esteem is the umbrella for all the positive self-qualities that structure optimal functioning, e.g., self -respect -resilience, -efficacy, -reliance, -compassion, -value, -worth, and other intrinsic wholesome attributes. Self-esteem provides the recognition that one is consequential and worthy of love. A grassroots poll by Unite UK (2016) found that 62% of LGBTQ+ persons believe they have low self-esteem. Exposure to historical alienation, ambiguous public opinion, adolescent bullying, heterosexualism, and other harmful elements, in time, will have an impact on an LGBTQ+ person’s self-beliefs and image (Unite UK, 2016).
Recovery is an individual process. Humans have unique DNA and disparate sensibilities, memories, and abilities. One-size-fits-all approaches are inadequate to fully address the personality’s dynamic complexity and its owner’s uniqueness. Mental illness is ubiquitous and non-discriminating; dysfunction embraces every walk of life. Indeed, “the LGBTQ+ community encompasses a wide range of individuals with separate and overlapping challenges regarding their mental health” (NAMI, 2020b, p. 1).
Recovery is “about seeing people beyond their problems – their abilities, possibilities, interests, and dreams – and recovering the social roles and relationships that give life value and meaning” (Slade, 2010, p. 2). Recovery programs must be fluid, integrating multiple traditional and non-traditional approaches developed through client trust, cultural assimilation, and therapeutic innovation. Any analysis must consider the subject’s environment, hermeneutics, history, and autobiography in conjunction with their wants, beliefs, and aspirations. Otherwise, the personality complexity is not valued, and the treatment is inadequate.
Positive Psychology and the Wellness Model
In 2004, the World Health Organization began promoting the advantages of the wellness perspective, declaring health “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (Slade, 2010, p. 1). The World Psychiatric Association states, “the promotion of well-being is among the mental health system” (Schrank et al., 2014, p. 98). As psychologists point out, “psychological well-being is viewed as not only the absence of mental disorder but also the presence of positive psychological resources” (Sin & Lyubomirsky, 2009, p. 468).
The wellness model’s chief facilitator is positive psychology (PP), which originated with Maslow’s (1943/1954) seminal texts on humanism; APA president Seligman legitimized it in 1998. Positive psychology and other optimistic approaches focus on the inherent ability, “not only to endure and survive but also to flourish” (Mayer & May 2019, p. 160).
Positive psychology is a relatively new field (since 1998) that, ostensibly, complements rather than replaces traditional psychology. Defined as the science of optimal functioning, PP’s objective is “to study, identify and amplify the strengths and capacities that individuals, families, and society need to thrive” (Carruthers & Hood, 2004, p. 30). Cultural psychologist Levesque (2011) describes optimal functioning as the study of how individuals attempt to achieve their potential and become the best they can be.
Studies support the utilization of positive psychological constructs, theories, and interventions for enhanced mental health understanding and improvement. PP interventions have “improved wellbeing and decreased psychological distress in mildly depressed individuals, in patients with mood and depressive disorders, [and] in patients with psychotic disorders” (Chakhssi et al., 2018, p. 16). As Carruthers and Hood (2004) point out, “The things that allow people to experience deep happiness, wisdom, and psychological, physical and social wellbeing are the same strengths that buffer against stress and physical and mental illness” (p. 30).
The academic discipline of positive psychology continues to develop evidence-based interventions that focus on eliciting positive feelings, cognitions, or behaviors (Schotanus-Dijkstra et al., 2018). Positive psychology offers promising interventions “to support recovery in people with common mental illness, and preliminary evidence suggests it can also be helpful for people with more severe mental illness” (Schrank et al., 2014, p. 99).
Positive Psychology 2.0.
One of the early challenges of positive psychology was its inattention to the negative aspects of character. Recognizing this, psychologists advocated a more holistic approach to embrace the dialectical opposition of human experience. As one psychologist put it, “people are not just pessimists or optimists. They have complex personality structures” (Miller, 2008, p. 598). Positive Psychology 2.0 (PP 2.0) evolved as a correction to the singular focus on optimism to embrace a more inclusive and balanced perspective (Rashid et al., 2014).
The disease model of mental health bases recovery on the remission of symptoms or the suspension of substantial interference or limitation (ADAMHA, 2012; Salzer et al., 2018). The wellness model maintains that individuals with a mental disorder can live satisfying and fulfilling lives regardless of symptoms or impairments associated with the diagnosis (Slade, 2010). Schrank et al. (2014) describe recovery as people “(re-) engaging in their life on the basis of their own goals and strengths, and finding meaning and purpose through constructing and reclaiming a valued identity and valued social roles” (p. 98). By emphasizing wellness, the positive psychology movement aims to destigmatize mental illness by emphasizing “the positive while managing and transforming the negative to increase wellbeing” (Mayer & May, 2019, p. 163). Perkins and Repper (2003, p. 3) write:
People with mental illness who are in recovery are those who are actively engaged in working away from Floundering (through hope-supporting relationships) and Languishing (by developing a positive identity), and towards Struggling (through Framing and self-managing the mental illness) and Flourishing (by developing valued social roles).
Thomas Insel (2013), director of the National Institute of Mental Health, is “re-orienting its research away from DSM categories” (p. 2), declaring that traditional psychiatric diagnoses have outlived their usefulness (Kinderman, 2014). NIMH is transforming diagnosis based on emerging research data and a doctor-patient communication dynamic rather than on the current symptom-based categories. Kinderman (2014) suggests replacing traditional diagnoses with easily understandable descriptions of the issues.
A simple list of people’s problems (properly defined) would have greater scientific validity and would be more than sufficient as a basis for individual care planning and the design and planning of services. (1)
In mental health, recovery-remission is a realized, long-term mitigation of symptoms. Wellness impacts more than mental health; it is a paradigmatic perspective that seeks to promote a state of complete physical, mental, and social well-being. Its sociological emphasis on optimal human functioning, designed to counter the pathographic focus of other models, not only positively impacts the self-beliefs and image of a mentally ill person but resonates in sexual and gender-based identities and portends well, the recovery-remission of an LGBTQ+ person with a mental illness.
There are many approaches to recovery. Psychology textbook author, Farreras (2020) cites 400 different schools of psychotherapy. Mayer and May (2019) characterize current positive psychology as “a balanced, interactive, meaning-centered and cross-cultural perspective” (p. 156) that considers equally “positive emotions and strengths and negative symptoms and disorders” (Rashid et al., 2014, p. 162). Positive psychology works best in conjunction with other programs (CBT, for example), and its mental health interventions have proved successful in mitigating symptoms of depression, anxiety, and other disorders. “Growing research suggests that a positive psychological outlook not only improves ‘life outcomes’ but enhances health directly” (Easterbrook, 2001, p. 23).
Training in prosocial behavior and emotional literacy might be useful supplements to specific interventions. Behavioral exercises enhance the execution of resilient and generous social skills. Positive personal affirmations have enormous subjective value as well. Data supports mindfulness and acceptance-based interventions to re-engage and regenerate positive thoughts, feelings, and memories. Castella et al. (2014) suggest motivational enhancement strategies to help clients overcome resistance. Ritter et al. (2013) tout the benefits of positive autobiography to counter destructive thoughts and behaviors. The importance of considering the nuanced and unique dynamics inherent in the relationships among emotional expression, intimacy, and overall relationship satisfaction for dysfunctional individuals and LGBTQ+ persons, should be thoroughly investigated (Montesi et al., 2013).
However, this paper balks at throwing out the baby with the bathwater, positing that the current diagnostic system should be utilized as a part of a more thorough analysis that embraces communication and emphasizes the character strengths that generate motivation, persistence, and perseverance towards recovery-remission. All “patients with mental disorders deserve better” (Insel, 2013, p. 2).
WHY IS YOUR SUPPORT SO IMPORTANT? ReChanneling develops and implements programs to (1) moderate symptoms of emotional dysfunction and (2) pursue personal goals and objectives – harnessing our intrinsic aptitude for extraordinary living. Our paradigmatic approach targets the personality through empathy, collaboration, and program integration utilizing scientific and clinically practical methods including proactive neuroplasticity, cognitive-behavioral modification, positive psychology, and techniques designed to reinvigorate self-esteem. All donations support scholarships for groups, workshops, and practicums.
ADAMHA. (2012). S. 1306 (102nd): ADAMHA Reorganization Act. 102nd Congress (1991–1992). [Online.] https://www.congress.gov/bill/102nd-congress/senate-bill/1306/text
Adamczyk, A. & Liao, Y.-C. (2018). Examining Public Opinion About LGBTQ+-Related Issues in the United States and Across Multiple Nations. Annual Review of Sociology, 45(1): 1-27 (2018). doi: 10.1146/annurev-soc-073018-022332
Ades, T. & Dias, S. (2013). Social Anxiety Disorder: Recognition, Assessment and Treatment. (Online.) NICE Clinical Guidelines, No. 159. https://www.ncbi.nlm.nih.gov/books/NBK327649/.
APA. (2020). Neurosis. (Online definition.) Dictionary of Psychology. American Psychological Association. Washington, DC: American Psychological Association. https://dictionary.apa.org/neurosis
Bandermann, K. M. (2014). “Exploring Coping Mediators between Heterosexist Oppression and Post-Traumatic Stress Symptoms among Gay, Lesbian, and Bisexual Persons. ” Ph.D. Dissertation: University of Tennessee, 2014. https://trace.tennessee.edu/utk_graddiss/3108
Berlan, E. D., Corliss, H. L., Field, A. E., Goodman, E., & Austin, S. B. (2010). SEXUAL ORIENTATION AND BULLYING AMONG ADOLESCENTS IN THE GROWING UP TODAY STUDY. Journal of Adolescent Health, 46(4): 366–371 (2010). doi: 10.1016/j.jadohealth.2009.10.015
Bharadwaj, P., Pai, M. M., & Suziedelyte, A. (2017). Mental Health Stigma. Economics Letters, 159 (57-60). doi: 10.3386/w21240
Carruthers, C., & Hood, C. D. (2004). The Power of Positive Psychology. Parks and Recreation. .file:///C:/Users/rober/ OneDrive/ Pending/New%20Psychobiography/carruthers%20x.pdf
Castella, K. De., Goldin, P., Jazaieri, H., Ziv, M., Heimberg, R. G., & Gross, J. L. (2014). Emotion beliefs in social anxiety disorder: Associations with stress, anxiety, and well-being. Australian Journal of Psychology, 66:139–148 (2014). doi: 10.1111/ajpy.12053.
CDC. (2020). Data and Statistics on Children’s Mental Health. [Online.] Atlanta, GA: Centers for Disease Control https://www.cdc.gov/ childrensmentalhealth/ data.html
Chakhssi, F., Kraiss, J. T., Sommers-Spijkerman, M., & Bohlmeijer, E.T. (2018). The effect of positive psychology interventions on well-being and distress in clinical samples with psychiatric or somatic disorders: a systematic review and metaanalysis. BMC Psychiatry 18:211: 1-17 (2018). https://doi.org/10.1186/s12888-018-1739-2..
Chapdelaine A., Carrier J-D., Fournier L., Duhoux A. Roberge P. (2018) Treatment adequacy for social anxiety disorder in primary care patients. PLoS ONE 13(11): (2018). doi.org/ 10.1371/journal.pone.0206357.
Corrigan, P. (2006). Mental Health Stigma as Social Attribution: Implications for Research Methods and Attitude Change. Clinical Psychology Science and Practice, 7(1): 8-67 (2006). doi: 10.1093/clipsy.7.1.48
Corrigan, P. W., & Watson, A. C. (2002). Understanding the impact of stigma on people with mental illness. World Psychiatry, 1: 16-20 (2002).
Cuncic, A. (2018). How Social Anxiety Affects Dating and Intimate Relationships. verywellmind. https://www.verywellmind.com/adaa-survey-results-romantic-relationships-3024769.
Curtin, S. C. & Heron, M. (2019). Death Rates Due to Suicide and Homicide Among Persons Aged 10–24: United States, 2000–2017. (Online.) National Center for Health Statistics. https://www.cdc.gov/nchs/data/databriefs/db352-h.pdf
Daw, J. (2001), Culture counts in mental health services. (Online.) American Psychological Association. https://www.apa.org/monitor/dec01/culture
DeMare, N. (2016). Exaggerations and Stereotypes of Schizophrenia in Contemporary Films. Elon Journal of Undergraduate Research in Communications, 7(1):1/1. http://www.inquiriesjournal.com/articles/1474/exaggerations-and-stereotypes-of-schizophrenia-in-contemporary-films.
Dodge, B., Herbenick, D., Friedman, M. R., Schick, V., Fu, T.-C., Bostwick, W., Bartelt, E., Muñoz-Laboy, M., Pletta, D., Reece, R., & Sandfort, T. G. M. (2016). Attitudes toward Bisexual Men and Women among a Nationally Representative Probability Sample of Adults in the United States. PLoS One, 11(10). doi: 10.1371/journal.pone.0164430
Easterbrook, G. (2001). Psychology discovers happiness. I’m OK, You’re OK. The New Republic, Article 27, p. 136
Equaldex. (2020). Status of LGBT Laws by Country. Equaldex. https://www.equaldex.com/
Farreras, I. G. (2020). History of mental illness. In R. Biswas-Diener & E. Diener (Eds), Noba textbook series: Psychology. Champaign, IL: DEF publishers. http://noba.to/65w3s7ex
Garg, R., & Raj, R. (2019). A cross-sectional study of self-stigma and discrimination among patients with depression. Open Journal of Psychiatry & Allied Sciences, 10(2): 124-127 (2019). doi: 10.5958/2394-2061.2019.00027.2.
Gregory. B., Wong, Q. J. J., Craig, D., Marker, C. D., & Peters, L. (2018). Maladaptive Self-Beliefs During Cognitive Behavioural Therapy for social anxiety disorder: A Test of Temporal Precedence. Cognitive Therapy and Research, 42(3): 261–272 (2018). doi.org/10.1007/s10608-017-9882-5
Halloran, M., & Kashima, E. (2006). Culture, social identity, and the individual. In Individuality and the group: Advances in Social Identity. London: Sage. doi:org/10.4135/9781446211946.n8.
Henderson, C., Noblett, J., Parke, H., Clement, S., Caffrey, A., Gale-Grant, O., Schulze, B., Druss, B., Thornicroft, G. (2014). Mental health-related stigma in health care and mental health-care settings. Lancet Psychiatry, 1(6): 467-482 (2014). doi: 10.1016/S2215-0366(14)00023-6.
Hirsch, C. R. & Clark, D. M. (2004) Information-processing Bias in Social Phobia. Clinical Psychology Review, 24(7): 799-825 (2004). doi: 10.1016/j.cpr.2004.07.005.
House, Harris. (2018). LGBTQ+ Addiction Factors: The Importance of Self-Esteem, (Online). Harris House. https://www.harrishousestl.org/LGBTQ+-addiction-factors-the-importance-of-self-esteem/
Huggett, C., Birtel, M. D., Awenat, Y. F., Fleming, P., Wilkes, S., Williams, S., Haddock, G. (2018). A qualitative study: experiences of stigma by people with mental health problems. Psychology and Psychotherapy: Theory, Research and Practice, 91: 380–397 (2018). doi: 10.1111/papt.12167
Hulme, N., Hirsch, C., & Stopa, L. (2012). Images of the Self and Self-Esteem: Do Positive Self-Images Improve Self-Esteem in Social Anxiety? Cognitive Behaviour Therapy, 41(2): 163–173 (2012). doi.org/10.1080/16506073.2012.66455
ILGA. (2019). State-Sponsored Homophobia report. (Online.) ILGA World. https://ilga.org/state-sponsored-homophobia-report
Insel, T. (2013). Post by Former NIMH Director Thomas Insel: Transforming Diagnosis. (Online.) Washington, DC: National Institute of Mental Health. https://www.nimh.nih.gov/about/directors/thomas-insel/blog/2013/transforming-diagnosis.shtml
Johns Hopkins. (2020). Mental Health Disorders Statistics. (Online.) The Johns Hopkins University, The Johns Hopkins Hospital, and The Johns Hopkins Health System.https://www.hopkinsmedicine.org/health/wellness-and-prevention/mental-health-disorder-statistics
Khesht-Masjedi, M.F., Shokrgozar, S., Abdollahi, E., Golshahi, M., & Sharif-Ghaziani, Z. (2017). Exploring Social Factors of Mental Illness Stigmatization in Adolescents with Mental Disorders. Journal of Clinical and Diagnostic Research, 11(11) :(2017). doi: 10.7860/JCDR/2017/27906.1083.
Kinderman, P. (2014). Why We Need to Abandon the Disease-Model of Mental Health Care. (Online.) Scientific American. https://blogs.scientificamerican.com/mind-guest-blog/why-we-need-to-abandon-the-disease-model-of-mental-health-care/
Knaak, S., Mantler, E., & Szeto, A. (2017). Mental illness-related stigma in healthcare. Barriers to access and care and evidence-based solutions. Healthcare Management Forum, 30(2): 111-116 (2017). doi: 10.1177/0840470416679413
Kőváry, Z. (2011). Psychobiography as a method. The revival of studying lives: New perspectives in personality and creativity research Europe’s Journal of Psychology, 7(4), 739-777 (2020). doi: 10.5964/ejop.v7i4.162
Koyuncu, A., İnce, E. , Ertekin, E., & Tükel R. (2019). Comorbidity in social anxiety disorder: diagnostic and therapeutic challenges. Drugs in Context 2019, 8. doi:10.7573/dic.212573
Levesque, R. J. R. (2011). Optimal Functioning. In Levesque R. J. R. (eds) Encyclopedia of Adolescence. New York City: Springer. doi:https://doi.org/10.1007/978-1-4419-1695-2
Lewis, D. C., Flores, A. R., Haider-Markel, D. P., Miller, P. R., Tadlock, B. L., & Taylor J. K. (2017). Degrees of Acceptance: Variation in Public Attitudes toward Segments of the LGBT Community. Political Research Quarterly, 70(4): 861–75 (2017). doi/full/10.1177/1065912917717352
Lyliard, R. B. (2001). Social anxiety disorder: comorbidity and its implications. Journal of Clinical Psychiatry, 62(Suppl1): 17-24 (2001).
Lynam, D. R. & Vachon, D. D. (2012). Antisocial Personality Disorder in DSM-5: Missteps and Missed Opportunities. Personality Disorders: Theory, Research, and Treatment, 3(4): 483– 495 (2012). doi: 10.1037/per0000006
Maslow, A. (1943). A Theory of Human Motivation. Psychological Review, 50 (4): 370–396 (1943).
Maslow, A. (1954). Motivations and Personality. New York City: Harper & Brothers; Early edition.
Mayer, C.-H., & May, M. (2019). The Positive Psychology Movement. PP1.0 and PP2.0. In C-H Mayer and Z. Kőváry (Eds.), New Trends in Psychobiography (pp. 155-172). Springer Nature Switzerland. https://doi.org/10.1007/978-3-030-916953-4_9.
Mayoclinic. (2017). Social anxiety disorder (social phobia). Mayo Foundation for Medical Education and Research. https://www.mayoclinic.org/diseases-conditions/social-anxiety-disorder/symptoms-causes/syc-20353561.
Mayoclinic. (2019). Mental Illness. (Online.) Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/mental-illness/symptoms-causes/syc-20374968
McFarland, S. G. (2018). How psychology has helped society accept homosexuality. (Online.) Psychology Teacher Network. Washington, DC: American Psychological Association. https://www.apa.org/ed/precollege/ptn/2018/05/society-accept-homosexuality
McLeod, S. (2018). The Medical Model. (Online.) Simply Psychology. https://www.simplypsychology.org/medical-model.html
Medley, G., Lipari, R. N., Bose, J., Cribb, D. S., Kroutil, L. A., & McHenry, G. (2020). Sexual Orientation and Estimates of Adult Substance Use and Mental Health: Results from the 2015 National Survey on Drug Use and Health. https://www.samhsa.gov/data/sites/default/files/NSDUH-SexualOrientation-2015/NSDUH-SexualOrientation-2015/NSDUH-SexualOrientation-2015.htm
Montesi, J. L., Conner, G. T., Gordon, E. A., Fauber, R. L. (2013). On the Relationship Among Social Anxiety, Intimacy, Sexual Communication, and Sexual Satisfaction in Young Couples. Archives of Sexual Behavior 42: 81–91 (2013). doi: 10.1007/s10508-012-9929-3.
Mullen, R. F. (2018). Social Anxiety Disorder. (Online.). https://rechanneling.org/page-20.html
Mustanski, B., Andrews, R., Puckett, J. A. (2016). The Effects of Cumulative Victimization on Mental Health Among Lesbian, Gay, Bisexual, and Transgender Adolescents and Young Adults. American Journal of Public Health, 106(3): 527–533 (2016). doi: 10.2105/AJPH.2015.302976
NAMI. (2020a). Mental Health by the Numbers. [Online}. National Alliance on Mental Health. https://www.nami.org/mhstats
NAMI. (2020b). LGBTQI. (Online.) National Alliance on Mental Illness. https://www.nami.org/Your-Journey/Identity-and-Cultural-Dimensions/LGBTQI
Nagata, T., Suzuki, F., Teo, A.R. (2015).Generalized Social Anxiety Disorder: A still‐neglected anxiety disorder 3 decades since Liebowitz’s review. Psychiatry and Clinical Neurosciences, 69(12): 724-740 (2015). doi: org/10.1111/pcn.12327.
Nardi, A.E. (2003). The social and economic burden of social anxiety disorder. BMJ, 327 (2003).doi: 10.1136/bmj.327.7414.515
Ng, S. H., & Deng, F. (2017). Language and Power. (Online.) Intergroup Communication. doi:10.1093/acrefore/ 9780190228613.013.436
NIH. (2019).Child and Adolescent Mental Health. (Online.) National Institute of Health. https://www.nimh.nih.gov/health/topics/child-and-adolescent-mental-health/index.shtml
NIMH. (2017). Any Anxiety Disorder. (Online.) National Institute of Mental Health. https://www.nimh.nih.gov/ health/statistics/ any-anxiety-disorder.shtml
Perkins R., & Repper, J. (2003). Social Inclusion and Recovery. London: Baillière Tindall.
Pescosolido, B. A. (2013). The Public Stigma of Mental Illness. What Do We Think; What Do We Know; What Can We Prove? Journal of Health and Social Behavior 54(1): 1-21 (2013), doi: 10.1177/0022146512471197
Pew. (2020). A Survey of LGBT Americans. (Online.) Pew Research Center. https://www.pewsocialtrends.org/2013/06/13/a-survey-of-lgbt-americans/
Pinfold, V., Thornicroft, G., Huxley, P., Farmer, P. (2005). Active ingredients in anti-stigma programmes in mental health. International Review of Psychiatry, 17(2): 123–131 (2005). doi: 10.1080/09540260500073638
Pryor, J. B., Reeder, G. D., Monroe, A. E., Patel, A. (2009). Stigmas and Prosocial Behavior Are People Reluctant to Help Stigmatized Persons in S. Stürner, M. Snyder (Eds.) The Psychology of Prosocial Behavior, (pp.59-80). New York City: John Wiley and Sons. doi: 10.1002/9781444307948.ch3
Rashid, T., Anjum, A., Chu, R., Stevanovski, S., Zanjani, A., & Lennox, C. (2014). Strength based resilience: Integrating risk and resources towards holistic well-being. In G. A. Fava & C. Ruini (eds.), Increasing psychological well-being in clinical and educational settings,8: (Vol. 8, pp. 153–176). Dordrecht, Netherlands: Springer.
Reisner, S. L., Greytak, E. A., Parsons, J. T., & Ybarra, M. (2015). Gender Minority Social Stress in Adolescence: Disparities in Adolescent Bullying and Substance Use by Gender Identity. Journal of Adolescent Health, 56(3): 243-256 (2015). doi: 10.1016/j.jadohealth.2014.10.275
Reuben, A., & Schaefer, J. (2017). \Mental Illness Is Far More Common Than We Knew. [Online.] Scientific American. Retrieved from https://blogs.scientificamerican.com/observations/mental-illness-is-far-more-common-than-we-knew/
Richards, T. A. (2014). Overcoming Social Anxiety Disorder: Step by Step. Phoenix, AZ: The Social Anxiety Institute Press.
Richards, T. A. (2019). What is Social Anxiety Disorder? Symptoms, Treatment, Prevalence, Medications, Insight, Prognosis. (Online.) The Social Anxiety Institute, Inc. https://socialphobia.org/social-anxiety-disorder-definition-symptoms-treatment-therapy-medications-insight-prognosis.
Ritter, V., Ertel, C., Beil, K., Steffens, M. C., & Stangier, U. (2013). In the Presence of Social Threat: Implicit and Explicit Self-Esteem in Social Anxiety Disorder. Cognitive Therapy & Research, 37(6): 1101-1109 (2013). doi: 10.1007/s10608-013-9553-0.
Salcedo, B. (2018). The Comorbidity of Anxiety and Depression. (Online). National Alliance on Mental Illness. https://www.nami.org/Blogs/NAMI-Blog/January-2018/The-Comorbidity-of-Anxiety-and-Depression
Salzer, M. S., Brusilovskiy, E., & Townley, G. (2018). National Estimates of Recovery-Remission from Serious Mental Illness. Psychiatric Services, 69(5): 523-528 (2018). https://doi.org/10.1176/appi.ps.201700401
Sagman, D., & Tohen. M. (2009). Comorbidity in Bipolar Disorder. (Online.). Psychiatric Times. https://www.psychiatrictimes. com/view/comorbidity-bipolar-disorderSchnabel, L. (2016) Gender and homosexuality attitudes across religious groups from the 1970s to 2014: Similarity, distinction, and adaptation. Social Science Research, 55: 31-57 (2016). doi: 10.1016/j.ssresearch.2015.09.012
Schotanus-Dijkstra, M., Drossaert, C. H. C., Pieterse, M. E., Walburg, J. A., Bohlmeijer, E. T., & Smit, F. (2018). Towards sustainable mental health promotion: trial-based health-economic evaluation of a positive psychology intervention versus usual care. BMC Psychiatry 18:265: 1-11 (2018). https://doi.org/10.1186/s12888-018-1825-5
Schrank, B., Brownell, T., Tylee, A., & Slade, M. (2014). Psychology: An Approach to Supporting Recovery in Mental Illness. East Asian Arch Psychiatry, 24: 95-103 (2014).
Sin, N. L., & Lyubomirsky, S. (2009). Enhancing Well-Being and Alleviating Depressive Symptoms with Positive Psychology Interventions: A Practice-Friendly Meta-Analysis. Journal of Clinical Psychology: In Session, 65(5): 467–487 (2009). doi: 10.1002/jclp.20593
Slade, M. (2010). Mental illness and well-being: the central importance of positive psychology and recovery approaches. BMC Health Service Research 10 (26): 1-17 (2010). https://doi.org/10.1186/1472-6963-10-26 10(26)
Sowislo, J. F., Lange, C., Euler, S., Hachtel, H., Walter, M., Borgwardt, S., Lang, U. E., & Huber, C. G. (2016). Stigmatization of psychiatric symptoms and psychiatric service use: a vignette‑based representative population survey. European Archive of Psychiatry and Clinical Neuroscience, 267(4): 351-357 (2017). doi: 10.1007/s00406-016-0729-y.
Stangl, A. L., Earnshaw, V. A., Logie, C. H., van Brakel, W., Simbayi, L. C., Barré, I., & Dovidio, J. F. (2019). The Health Stigma and Discrimination Framework: a global, crosscutting framework to inform research, intervention development, and policy on health-related stigmas. BMC 17(31): 1-13 (2019).https://doi.org/10.1186/s12916-019-1271-3
Stuart, H., & Arboleda-Flórez, J. (2012). A Public Health Perspective on the Stigmatization of Mental Illnesses. Public Health Reviews, 34: Epub ahead of print.
Twenge, J. M., Sherman, R. A., Wells, B. E. (2016). Changes in American Adults’ Reported Same-Sex Sexual Experiences and Attitudes, 1973–2014. Archives of Sexual Behavior, 45(7): 1713–1730(2016). https://doi.org/10.1007/s10508-016-0769-4
Unite UK. (2016). What is causing Low Self-Esteem in the LGBTQ+ Community? (Online.). Unite UK. https://uniteuk1.com/2018/06/low-self-esteem-LGBTQ+-community/
UW-Madison. (2020). LGBTQ+ Culture and Life in the U. S. (Online.) University of Wisconsin-Madison. https://iss.wisc.edu/resources/LGBTQ+/LGBTQ+-culture-2/LGBTQ+culture/#:~:text=LGBTQ+%20issues%20have%20emerged% 20 as%20a%20 major%20social,on%20geographical%20location%2C%20local%20culture%2C%20and%20individual%20backgrounds.
Vanderheiden, E., & Mayer, C.-H. (2017). An introduction to the value of shame―Exploring a health resource in cultural contexts. In E. Vanderheiden, C-H. Mayer (Eds.) The Value of Shame. Exploring a Health Resource in Cultural Contexts (pp, 1-42). New York City: Springer Publishing. doi: 10.1007/978-3-319-53100-7
Vrbova, K., Prasko, J., Ociskova, M., & Holubova, M. (2017). Comorbidity of schizophrenia and social phobia – impact on quality of life, hope, and personality traits: a cross sectional study. Neuropsychiatric Disease and Treatment, 13: 2073-2083 (2017). doi:10.2147/NDT.S141749
WEF. (2018). This is the state of LGBTI rights around the world in 2018. World Economic Forum. https://www.weforum.org/agenda/2018/06/lgbti-rights-around-the-world-in-2018/
WHO. (2019). Mental disorders affect one in four people. (Online.) World Health Organization. https://www.who.int/whr/2001/media_centre/press_release/en/#:~:text=Mental%20disorders%20affect%20one%20in%20four%20people%20Treatment,neurological%20disorders%20at%20some%20point%20in%20their%20lives.
Wilkerson, J. M., Schick, V. R., Romijnders, K. A., Bauldry, J., & Butame, S. A. (2016). Social Support, Depression, Self-Esteem, and Coping Among LGBTQ+ Adolescents Participating in Hatch Youth. Health Promotion Practice. 18(3): 358-365 (2016). doi: 10.1177/1524839916654461
Wood, L., & Irons, C. (2017) Experienced stigma and its impacts in psychosis: The role of social rank and external shame. Psychology and Psychotherapy: Theory, Research and Practice 90, 419–431 (2017). doi: I:10.1111/papt.12127.
Yeilding, R. (2017). Developing the Positive in Managing Social Anxiety. (Online.) National Social Anxiety Center. https://nationalsocialanxietycenter.com/2017/09/18/developing-positive-managing-social-anxiety/.
Zimmerman, M., Dalrymple, K., Chelminski, I., Young, D., & Galione, J. H. (2010). Recognition of irrationality of fear and the diagnosis of social anxiety disorder and specific phobia in adults: implications for criteria revision in DSM-5. Depression and Anxiety, 27(11): 1044-9 (2010). doi: 10.1002/da.20716.