All posts by Robert F. Mullen, Ph.D.

About Robert F. Mullen, Ph.D.

Robert F. Mullen is director of ReChanneling Inc, an organization focused on alleviating the impact of 'mental' disorders (neuroses) through a wellness model of research, program development, and individual support. Finding one-size-fits-all recovery inadequate in addressing the totality of the unique personality, ReChanneling favors a psychobiographic analysis[1] of the problem before developing a multilayered custom solution. A working platform showing encouraging results for social anxiety disorder is an integration of positive psychology's optimum human functioning with CBT's behavior modification, neuroscience's network restructuring, and other personalized supported and non-traditional approaches (Mullen, 2018). The deficit of self-esteem and motivation due to the disruption in natural human development is addressed by a program called healthy philautia. ReChanneling utilizes Stanislavski's method of memory and emotion retrieval and control[2] and the behavioral ethics of the nine right truths (right choice) of Abhidharma. ReChanneling's custom, life support for remission-recovery, carries the individual client through the process of recovery from program inception through core-work, neural network restructuring, implementation, and onto recovery-remission for as long as it takes. Dr. Mullen is a Doctor of Philosophy; his disciplines include contemporary behavior, modified psychobiography, and method psychology. His most recent published work on social anxiety disorder[3] will soon be featured in Handbook of Love from Springer, available through Amazon and most booksellers. [1] Mullen, R. F. (2019). How an Honorable Psychobiography Embraces the Fluidity of Truth. New Trends in Psychobiography, Chap. 5, Springer. doi:10.1007/978-3-030-16953-4. https://link.springer.com/book/10.1007/978-3-030-16953-4. [2] Mullen, R. F. (2016). The Art of Authenticity: Constantin Stanislavski and Merleau-Ponty. Journal of Literature and Art Studies, 6 (7):790-803 (2016). doi:10.17265/2159-5836/2016.07.010 http://www.davidpublisher.org/ Public/uploads/ Contribute/ 57426420547ed. pdf [3] Mullen, R. F. (2020). Enlisting Positive Psychologies to Challenge Love within SAD's Culture of Maladaptive Self-Beliefs. Handbook of Love in Cultural & Transcultural Cultures, Springer, 2020.

Dysfunction is Evidence of Our Humanness.

Simultaneous mutual interaction of all human system components is required for sustainability.

There is a joke that circulates among mental health professionals. Why do only 26% of people have a diagnosable mental disorder? . . . Because the other 74% haven’t been diagnosed yet.

We are all psychologically dysfunctional in some way. “Mental illnesses are so common that almost everyone will develop at least one diagnosable mental disorder at some point in their life” (Scientific American). 

Why do we treat the mentally ill with contempt, trepidation, and ridicule? We are hard-wired to fear and isolate mental illness, and we have been misinformed by history and the disease model of mental health. There are four common misconceptions about psychological dysfunctions. They are (1) abnormal and selective, (2) a consequence of behavior, (3) solely mental, and (4) psychotic. 

Let us deconstruct these misconceptions, beginning with the latter.

A dysfunctional person is psychotic.

There are two degrees of mental disorder: 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. We are universally neurotic. Since the overwhelming majority of mental disorders are neuroses, we are all dysfunctional to some extent.

A dysfunction is abnormal or selective. 

A neurosis is a condition that negatively impacts our emotional wellbeing and quality of life but does not necessarily impair or interfere with normal day-to-day functions. It is a standard part of natural human development. One-in-four individuals have a diagnosable neurosis. According to the World Health Organization, nearly two-thirds of people who have a neurosis reject or refuse to disclose their condition. Include those who dispute or chose to remain oblivious to their dysfunction, we can conclude that mental disorders are common, undiscriminating, and impact us all in some fashion or another. Many of us have more than one disorder; depression and anxiety are commonly comorbid, often accompanied by substance abuse. 

A dysfunction is the consequence of a person’s behavior. 

Combined statistics prove that 89% of neuroses onset at adolescence or earlier. In the rare event conditions like PTSD or clinical narcissism begin later in life, the susceptibility originates in childhood. Most psychologists agree that a neurosis is a consequence of childhood physical, emotional, or sexual disturbance. Any number of things can cause this. Perhaps parents are controlling or do not provide emotional validation. Maybe the child is subjected to bullying or from a broken home. Behaviors later in life may impact the severity but are not responsible for the neurosis itself. It is never the child’s fault, nor reflective of their behavior. There is the likelihood no one is intentionally responsible. This disputes moral models that we are to blame for our disorder, or it is God’s punishment for sin.  

A dysfunction is solely mental.

To 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, while pharmacology promotes it as chemical or hormonal imbalance. However, the simultaneous mutual interaction of all human system components—mind, body, spirit, and emotions—is required for sustainability and recovery.

The disease model focuses on the history of deficit behavior. The American Psychiatric Association’s (APA) brief definition of neurosis contains the following words: distressing, irrational, obsessive, compulsive, dissociative, depressive, exaggerated, unconscious, and conflicts. The Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the APA, uses words like incapable, deceitful, unempathetic, manipulative, difficult, irresponsible, and incompetent. 

This ‘defective’ emphasis has been the overriding psychiatric perspective for over a century. The disease model is the chief proponent of the notion that the mentally ill are dangerous and unpredictable. We distance ourselves and deem them socially undesirable. We stigmatize them. The irony is, we are them. 

  • Over one-third of family members hide their relationship with their dysfunctional child or sibling to avoid bringing shame to the family. They are considered family undesirable, a devaluation potentially more life-limiting and disabling than the neurosis itself. 
  • The media stereotypes neurotics as homicidal schizophrenics, impassive childlike prodigies, or hair-brained free-spirits. One study evidenced over half of U.S. news stories involving the dysfunctional allude to violence. 
  • Psychologists argue that more persons would seek treatment if psychiatric services were less stigmatizing. There are complaints of rude or dismissive staff, coercive measures, excessive wait times, paternalistic or demeaning attitudes, pointless treatment programs, drugs with undesirable side-effects, stigmatizing language, and general therapeutic pessimism. 
  • The disease model supports doctor-patient power dominance. Clinicians deal with 31 similar and comorbid disorders, 400 plus schools of psychotherapy, multiple treatment programs, and an evolving plethora of medications. They cannot grasp the personal impact of a neurosis because they are too focused on the diagnosis. 

A recent study of 289 clients in 67 clinics found that 76.4% were misdiagnosed. An anxiety clinic reported over 90% of clients with generalized anxiety were incorrectly diagnosed. Experts cite the difficulty in distinguishing different disorders or identifying specific etiological risk factors due to the DSM’s failing reliability statistics. Even mainstream medical authorities have begun to criticize the validity and humanity of conventional psychiatric diagnoses. The National Institute of Mental Health believes traditional psychiatric diagnoses have outlived their usefulness and suggests replacing them with easily understandable descriptions of the issues. 

Because of the disease model’s emphasis on diagnosis, we focus on the dysfunction rather than the individual. Which disorder do we find most annoying or repulsive? What behaviors contribute to the condition? How progressive is it, and how effective are treatments? Is it contagious? We derisively label the obvious dysfunctional ‘a mental case.’

Realistically, we cannot eliminate the word ‘mental’ from the culture. Unfortunately, its negative perspectives and implications promulgate perceptions of incompetence, ineptitude, and unlovability. Stigma, the hostile expression of someone’s undesirability, is pervasive and destructive. Stigmatization is deliberate, proactive, and distinguishable by pathographic overtones intended to shame and isolate. 90% of persons diagnosed with a mental disorder claim they have been impacted by mental health stigma. Disclosure jeopardizes livelihoods, relationships, social standing, housing, and quality of life. 

The disease model assumes that emotional distress is merely symptomatic of biological illness. The Wellness Model focuses on the positive aspects of human functioning that promote our wellbeing and recognize our essential and shared humanity. The Wellness Model emphasizes what is right with us, innately powerful within us, our potential, and determination. Recovery is not achieved by focusing on incompetence and weakness; it is achieved by embracing and utilizing our inherent strengths and abilities. 

Benefits of the Wellness Model

  • Revising negative and hostile language will encourage new positive perspectives
  • The self-denigrating aspects of shame will dissipate, and stigma becomes less threatening. 
  • A doctor-client knowledge exchange will value the individual over the diagnosis.
  • Realizing neurosis is a natural part of human development will generate social acceptance and accommodation. 
  • Recognizing that they bear no responsibility for onset will revise public opinion that  people deserve their neurosis because it is the result of their behavior. 
  • Emphasizing character strengths and virtues will positively impact self-beliefs and image, leading to more disclosure, discussion, and recovery-remission. 
  • Realizing proximity and susceptibility will address the desire to distance and isolate. 
  • Emphasis on value and potential will encourage accountability and foster self-reliance.

The impact of a neurosis begins at childhood; recovery is a long-term commitment. The Wellness Model creates the blueprint and then guides, teaches, and supports throughout the recovery process by emphasizing our intrinsic character strengths and attributes that generate the motivation, persistence, and perseverance to recover. 

The adage, treat others as you want to be treated, takes on added relevance when we accept that we all experience mental disorder. In fact, dysfunction is evidence of our humanness.

A referenced copy of this article is available: rechanneling@yahoo.com.

Dysfunction in the LGBTQ Community

The LBGTQ+ community is 1.5-2.5 times more likely to have anxiety and depression

Establishing a Wellness Model for LGBTQ+ Persons with a Mental Disorder

Abstract. 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 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.  

Introduction

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 wellbeing 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, anxiety. Adolescent numbers fluctuate between 8 and 18 million (CDC, 2020; NIMH, 2017); the actual number 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 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 dysfunctions, impacting the emotional wellbeing 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 is shared among a group of people who possess a common social identity” (p. 140). Culture impacts,

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 similarly 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. 

Transition

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,” whereas the wellness model focuses “on positive aspects of human functioning” (Mayer & May, 2019, p. 159). 

Studies and researchportray the mental healthcare community 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 stereotype 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 the universality, age of onset, and complementarity of mental illness and clearly differentiating 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 standard 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. To 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 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. All human system components must work in concert; they cannot function alone. The simultaneous mutual interaction of all human system components—mind, body, spirit, and emotions—is required to sustain and recover from a mental dysfunction. 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 disorder: 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. A neurosis is a condition that negatively impacts our emotional wellbeing 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-Remission

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 disclose a mental disorder, seek treatment, or accept diagnosis is due to the same attributions that underscore general reticence: stigmatization, victimization, public opinion, media representation, family rejection, and the diagnosis itself. 

Stigmatization 

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 nonconformity. (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. LGBTQ+ persons share the added onus that their sexual and gender-based identity is socially and culturally tribal.

Victimization

“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)

Public Opinion 

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, “between 80-100 percent of respondents . . . favoured 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 believe “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 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. 

Media Representation 

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, 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 images that negatively impact the self-beliefs and image of LGBTQ+ and mentally ill persons. 

Family Rejection

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 a& 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 DSM’s 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. 

Self-Esteem

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

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. As well, “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 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 potentials and become the best that they can be. 

Studies support the utilization of positive psychological constructs, theories, and interventions for enhanced understanding and improvement of mental health. 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 over dysfunction, 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).  

Concluding Thoughts

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-centred 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 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). 

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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.

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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.  

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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

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ONLINE GROUP: STRATEGIZING YOUR PSYCHOLOGICAL DYSFUNCTION

You Deserve to Be Treated with Dignity and Respect

I invite you to join our online family. If you are committed to alleviating those symptoms of neuroses (disorders) that impact your emotional wellbeing and quality of life, contact me. This is a no-fee discussion and support group. 

I have studied, researched, and written about psychological dysfunctions for well over a decade. I have facilitated groups, workshops, and practicums for various dysfunctions. I utilize the Wellness Model of mental healthcare, which focuses on the character strengths and attributes that generate the motivation, persistence, and perseverance that enable recovery. 

My work with individuals and groups emphasizes communication and empathy. As someone who has been dealing with my own dysfunction (social anxiety disorder) for decades, I understand what you are going through on a personal level, and I know how the mental healthcare community functions. 

While each of the 31 dysfunctions listed in the Diagnostic and Statistical Manual of Mental Disorders has its characteristics and symptoms, they are similar in how they affect your emotional wellbeing, affect your self-esteem, image, and self-beliefs. These similarities are how we can relate to and support each other.

Your confidentiality is paramount to this group. Your email is shared only with your permission. We are on a first-name basis during our sessions, and you may choose an alias if that makes you comfortable. 

We want these sessions to be relaxed and joyful experiences where you can share your stories and concerns with others. 

Once you contact us, I will open a channel of dialogue so that I can get to know your needs and concerns before any online participation. That will allow you to get to know me better before you decide to participate.

You are not alone, it is not your fault, and you deserve to be treated with dignity and respect.

Social Anxiety Disorder and Relationships.

Enlisting Positive Psychologies to Challenge Love Within SAD’s Culture of Maladaptive Self-Beliefs.

in C.-E. Mayer and E. Vanderheiden (eds.) International Handbook of Love. Transcultural and Transdisciplinary Perspectives, Springer Publications, 2021. (Pre-order, Amazon).

Social anxiety disorder (SAD) is one of the most common psychophysiological malfunctions, affecting the emotional and mental well-being of over 15 million U.S. adults who find themselves caught up in a densely interconnected network of fear and avoidance of social situations. These observations provide insight into the relationship deficits experienced by people with SAD. Their innate need-for-intimacy is no less dynamic than that of any individual, but their impairment disrupts the ability (means-of-acquisition) to establish affectional bonds in almost any capacity. The spirit is willing, but competence insubstantial. It is the means-of-acquisition and how they are symptomatically challenged by SAD that is the context of this research.

Notwithstanding overwhelming evidence of social incompatibility, there is hope for the startlingly few SAD persons who commit to recovery. A psychobiographical approach integrating positive psychology’s optimum human functioning with CBT’s behavior modification, neuroscience’s network restructuring, and other supported and non-traditional approaches can establish a working platform for discovery, opening  the bridge to the procurement of forms of intimacy previously inaccessible. It is an arduous and measured crossing that only 5% of the afflicted will even attempt in the first year of onset.

Keywords: Love. Social anxiety disorder. Intimacy. Philautia. Means-of-acquisition.

      

59.0 Social Anxiety Disorder

Social anxiety disorder (SAD) is the second most commonly diagnosed form of anxiety in the United States (MHA, 2019). The Anxiety and Depression Association of America (ADAA, 2019a) estimate nearly 15 million (7%) American adults currently experience its symptoms. Ritchie and Roser (2018) report 284 million SAD persons, worldwide, and the National Institute of Mental Health (NIMH, 2017) report 31.1% of U.S. adults experience some anxiety disorder at some time in their lives, Global statistics are subject to “differences in the classification criteria, culture, and gender” (Tsitsas & Paschali, 2014), and “in the instruments used to ascertain diagnosis”(NCCMH, 2013).

Studies in other western nations (e.g., Australia, Canada, Sweden) note similar prevalence rates as in the USA, as do those in culturally westernized nations such as Israel. Even countries with strikingly different cultures (e.g., Iran) note evidence of social anxiety disorder (albeit at lower rates) among their populace. (Stein & Stein, 2008)

SAD is the most common psychiatric disorder in the U.S. after major depression and alcohol abuse (Heshmat, 2014). It is also arguably the most underrated and misunderstood. A “debilitating and chronic” psychophysiological affliction (Castella et al., 2014), SAD “wreaks havoc on the lives of those who suffer from it” (ADAA, 2019a). SAD attacks all fronts, negatively affecting the entire body complex, delivering mental confusion (Mayoclinic, 2017b), emotional instability (Castella et al., 2014; Yeilding, 2017), physical dysfunction (NIMH, 2017; Richards, 2019), and spiritual malaise (Mullen, 2018). Emotionally, persons experiencing SAD feel depressed and lonely (Jazaieri, Morrison, & Gross, 2015). Physically, they are subject to unwarranted sweating and trembling, hyperventilation, nausea, cramps, dizziness, and muscle spasms (ADAA, 2019a; NIMH, 2017). Mentally, thoughts are discordant and irrational (Felman, 2018; Richards, 2014). Spiritually, they define themselves as inadequate and insignificant (Mullen, 2018).

___________________________________

I invite you to join our online group, “Strategizing Your Mental Dysfunction.” If you are committed to alleviating those symptoms that impact your emotional wellbeing and quality of life, contact me. This is a no-fee discussion and support group. You are not alone, it is not your fault, and you deserve to be treated with dignity and respect. ___________________________________

The National Institute of Mental Health estimates that 9.1% of adolescents experience social anxiety disorder, and 1.3% have severe impairment (NIMH, 2017). The onset of SAD is generally considered “to take place between the middle and late teens” (Tsitsas & Paschali, 2014). Like other pathogens, SAD can remain dormant for years before symptoms materialize. Any number of situations or events trigger the initial contact; it could be hereditary, environmental, or the result of some traumatic experience. The LGBTQ community is 1.5–2.5 times as susceptible to SAD “than that of their straight or gender-conforming counterparts” (Brenner, 2019). 39.5% of general anxiety sufferers pursue recovery compared to “5% of SAD persons in the first year of experiencing the malfunction” (Shelton, 2018).

SAD is randomly misdiagnosed (Richards, 2019), and the low commitment-to-recovery (Shelton, 2018) suggests a reticence by those infected to recognize and or challenge their malfunction. Approximately 5% of SAD persons commit to early recovery, reflective of symptoms that manifest maladaptive self-beliefs of insignificance and futility. Grant et al. (2005) state, “about half of adults with the disorder seek treatment,” but that is after 15–20 years of suffering from the malfunction (Ades & Dias, 2013). Resistance to new ideas and concepts transcends those of other mental complications and is justified by,

1. general public cynicism,

2. self-contempt by the afflicted, generated by maladaptive self-beliefs,

3. ignorance or ineptitude of mental health professionals,

4. real or perceived social stigma, and

5. the natural physiological aversion to change.

Many motivated towards recovery are unable to afford treatment due to SAD induced “impairments in financial and employment stability” (Gregory, Wong, Craig, Marker, & Peters, 2018). The high percentage of jobless people experiencing social anxiety disorder in the U.S. is related to “to job inefficiency and instability” (Felman, 2018), greater absenteeism, job dissatisfaction, and or frequent job changes. “More than 70% of social anxiety disorder patients are in the lowest economic group” (Nardi, 2003).

According to leading experts, the high percentage of SAD misdiagnoses are due to “substantial discrepancies and variation in definition, epidemiology, assessment, and treatment” (Nagata, Suzuki, & Teo, 2015). The Social Anxiety Institute (Richards, 2019) reports, among patients with generalized anxiety, an estimated 8.2% had the condition, but just 0.5% were correctly diagnosed. A recent Canadian study by Chapdelaine, Carrier, Fournier, Duhoux, and Roberge (2018) reported, of 289 participants in 67 clinics meeting criteria for social anxiety disorder outlined in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV), 76.4% were improperly diagnosed.

Social anxiety disorder is a pathological form of everyday anxiety. The clinical term “disorder” identifies extreme or excessive impairment that negatively affects functionality. Feeling anxious or apprehensive in certain situations is normal; most individuals are nervous speaking in front of a group and anxious when pulled over on the freeway. The typical individual recognizes the ordinariness of a situation and accords it appropriate attention. The SAD person anticipates it, takes it personally, dramatizes it, and obsesses on its negative implications (Richards, 2014).

SAD’s culture of maladaptive self-beliefs (Ritter, Ertel, Beil, Steffens, & Stangier, 2013) and negative self-evaluations (Castella et al., 2014) aggravate anxiety and impede social performance (Hulme, Hirsch, & Stopa, 2012). “Patients with SAD often believe they lack the necessary social skills to interact normally with others” (Gaudiano & Herbert, 2003). Maladaptive self-beliefs are distorted reflections of a situation, often accepted as accurate. The cofounder of CBT, Aaron Beck provides three types of maladaptive self-beliefs responsible for persistent social anxiety. Core beliefs are enduring fundamental understandings, often formed in childhood and solidified over time. Because SAD persons “tend to store information consistent with negative beliefs but ignore evidence that contradicts them, [their] core beliefs tend to be rigid and pervasive” (Beck, 2011). Core beliefs influence the development of intermediate beliefs―attitudes, rules, and assumptions that influence one’s overall perspective, which, in turn, influences thought and behavior. Automatic thoughts and behaviors (ANTs) are real-time manifestations of maladaptive self-beliefs, dysfunctional in their irrationality (Richards, 2014; Wong, Moulds, & Rapee, 2013).

Negative self-images reported by patients with social anxiety disorder reflect a working self that is retrieved in response to social threat and which is characterised by low self-esteem, uncertainty about the self, and fear of negative evaluation by others. (Hulme et al., 2012)

Halloran and Kashima (2006) define culture as “an interrelated set of values, tools, and practices that is shared among a group of people who possess a common social identity.” As the third-largest mental health care problem in the world (Richards, 2019), social anxiety disorder is culturally identifiable by the victims’ “marked and persistent fear of social and performance situations in which embarrassment may occur,” and the anticipation “others will judge [them] to be anxious, weak, crazy, or stupid” (APA, 2017). Although studies evidence “culture-specific expression of social anxiety” (Hoffman, Asnaani, & Hinton, 2010), SAD “is a pervasive disorder and causes anxiety and fear in almost all areas of a person’s life” (Richards, 2019). SAD affects the “perceptual, cognitive, personality, and social processes” of the afflicted who find themselves caught up in “a densely interconnected network of fear and avoidance of social situations” (Heeren & McNally, 2018).

The superficial overview of SAD is intense apprehension—the fear of being judged, negatively evaluated, and ridiculed (Bosche, 2019). There is persistent anxiety or fear of social situations such as dating, interviewing for a position, answering a question in class, or dealing with authority (ADAA, 2019a; Castella et al., 2014). Often, mere functionality in perfunctory situations―eating in front of others, riding a bus, using a public restroom—can be unduly stressful (ADAA, 2019a; Mayoclinic, 2017b). This overriding fear of being found wanting manifests in perspectives of incompetence and worthlessness (Richards, 2019). SAD persons are unduly concerned they will say something that will reveal their ignorance, real or otherwise (Ades & Dias, 2013). They walk on eggshells, supremely conscious of their awkwardness, surrendering to the GAZE―the anxious state of mind that comes with the maladaptive self-belief they are the center of attention (Felman, 2018; Lacan, 1978). Their movements can appear hesitant and awkward, small talk clumsy, attempts at humor embarrassing, and every situation reactive to negative self-evaluation (ADAA, 2019a; Bosche, 2019). They are apprehensive of potential “negative evaluation by others” (Hulme et al., 2012), concerned about “the visibility of anxiety, and preoccupation with performance or arousal” (Tsitsas & Paschali, 2014). SAD persons frequently generate images of themselves performing poorly in feared social situations (Hirsch & Clark, 2004; Hulme et al., 2012) and their anticipation of repudiation motivates them to dismiss overtures to offset any possibility of rejection (Tsitsas & Paschali, 2014). SAD is repressive and intractable, imposing irrational thought and behavior (Richards, 2014; Zimmerman, Dalrymple, Chelminski, Young, & Galione, 2010). It establishes its authority through its subjects’ defeatist measures produced by distorted and unsound interpretations of actuality that govern perspectives of personal attractiveness, intelligence, competence, and other errant beliefs (Ades & Dias, 2013).

We are all familiar with the free-association test. The person in the white coat tosses out seemingly random words and the recipient responds with the first word that comes to mind. Consider the following reactions: boring, stupid, worthless, incompetent, disliked, ridiculous, inferior (Hulme et al., 2012). Most people use personal pejoratives daily, but few personalize and take them to heart like a SAD person. These maladaptive self-beliefs, over time, become automatic negative thoughts (Amen, 1998) implanted on the neural network (Richards, 2014). They determine initial reactions to situations or circumstances. They inform how to think and feel and act. The ANT voice exaggerates, catastrophizes, and distorts. SAD persons crave the company of others but shun social situations for fear of being found out as unlikeable, stupid, or annoying. Accordingly, they avoid speaking in public, expressing opinions, or even fraternizing with peers … People with social anxiety disorder are typified by low self-esteem and high self-criticism. (Stein & Stein, 2008)

Anxiety and other personality disorders are branches of the same tree. “There is a significant degree of comorbidity between social anxiety disorder and other mental health problems, most notably depression (19%), substance-abuse disorder (17%), GAD [generalized anxiety disorder] (5%), panic disorder (6%), and PTSD (3%)” (Tsitsas & Paschali, 2014). The Anxiety and Depression Association of America (ADAA, 2019a) includes many emotional and mental disorders related to, components of, or a consequence of social anxiety disorder including avoidant personality disorder, panic disorder, generalized anxiety disorder, depression, substance abuse, eating disorders, OCD, and schizophrenia.

Personality disorders are a group of mental illnesses. They involve long-term patterns of thoughts and behaviors that are unhealthy and inflexible. The behaviors cause serious problems with relationships and work. People with personality disorders have trouble dealing with everyday stresses and problems. (UNLM, 2018)

Personality reflects deep-seated patterns of behavior affecting how individuals “perceive, relate to, and think about themselves and their world” (HPD, 2019). A personality disorder denotes “rigid and unhealthy pattern[s] of thinking, functioning and behaving,” which potentially leads to “significant problems and limitations in relationships, social activities, work and school” (Castella et al., 2014). 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).

59.1.1. SAD and Interpersonal Love

In unambiguous terms, the desire-for-love is at the heart of social anxiety disorder (Alden, Buhr, Robichaud, Trew, & Plasencia, 2018). Interpersonal love relates to communications or relationships of love between or among people. The diagnostic criteria for SAD, outlined in the DSM-V (APA, 2017), includes: “Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others.” SAD persons find it inordinately difficult to establish close, productive relationships (Castella et al., 2014; Fatima, Naizi, & Gayas, 2018). Their avoidance of social activities limits the potential for comradeship (Desnoyers, Kocovski, Fleming, & Antony, 2017; Tsitsas & Paschali, 2014), and their inability to interact rationally and productively (Richards, 2014; Zimmerman et al., 2010) makes long-term, healthy relationships unlikely. SAD persons frequently demonstrate significant impairments in friendships and intimate relationships (Castella et al., 2014). According to Whitbourne (2018), SAD persons’ avoidance of other people puts them at risk for feeling lonely, having fewer friendships, and being unable to take advantage of the enjoyment of being with people who share their hobbies and interests.

There is a death of research directly investigating the relationship between SAD and interpersonal love (Montesi, Conner, Gordon, & Fauber, 2013; Read, Clark, Rock, & Coventry, 2018). A study on friendship quality and social anxiety by Rodebaugh, Lim, Shumaker, Levinson, and Thompson (2015) notes the lack of relative quality studies, and Alden et al. (2018) report on the lack of attention paid to the SAD person’s inability or refusal to function in close relationships. The few studies that do exist report that the SAD person exhibits inhibited social behavior, shyness, lack of assertion in group conversations, and feelings of inadequacy while in social situations (Darcy, Davila, & Beck, 2005). This dominant culture of maladaptive self-beliefs results in the tendency to avoid new people and experiences, making the development of “adequate and close relationships (e.g., family, friends, and romantic relationships)” extremely challenging (Cuming & Rapee, 2010). Experiencing social anxiety disorder translates to less trust and perceived support from close interpersonal relationships (Topaz, 2018).

Although intimately related, the desire-for-love and the means-of-acquisition are binary operations. Most forms of interpersonal love require the successful collaboration of wanting and obtaining. The desire-for-love is the non-consummatory component of Freud’s eros life instinct (Abel-Hirsch, 2010). The means-of-acquisition are the methods and skills required to complete the transaction―techniques that vary depending upon the type of love in the offing. Let us visualize love as a bridge, with desire (thought) at one end and acquisition at the other; the span is the means-of-acquisition (behavior). The SAD person cannot get from one side to the other because the means-of-acquisition are structurally deficient (Desnoyers et al., 2017; Tsitsas & Paschali, 2014). They grasp the fundamental concepts of interpersonal love and are presented with opportunities but lack the skills to close-the-deal. Painfully aware of the tools of acquisition, they cannot seem to operate them.

59.2. Cognitive Behavioral Therapy

CBT purposed for SAD is typically conceptualized as a short-term, skills-oriented approach aimed at exploring relationships among a person’s thoughts, feelings, and behaviors while changing the culture of maladaptive self-beliefs into productive, rational thought and behavior (Richards, 2019). CBT focuses on “developing more helpful and balanced perspectives of oneself and social interactions while learning and practicing approaching one’s feared and avoided social situations over time” (Yeilding, 2017). Almost 90% of the approaches empirically supported by the “American Psychological Association’s Division 12 Task Force on Psychological Interventions” involve cognitive-behavioral treatments, according to Lyford (2017). “Individuals who undergo CBT show changes in brain activity, suggesting that this therapy improves your brain functioning as well” (NAMI, 2019).

Recent meta-analytic evidence suggests that CBT as an effective treatment for SAD compares favorably with other psychological and pharmacological treatment programs (Cuijpers, Cristea, Karyotaki, Reijnders, & Huibers, 2016). There is no guarantee of success, however, and standard CBT is imperfect (David, Cristea, & Hoffman, 2018; Mullen, 2018). The best outcome a SAD sufferer can hope for is mitigation of symptoms through thought and behavior modification and the simultaneous restructuring of the neural network, along with other supported and non-traditional treatments..

“[M]any patients, although being under drug therapy, remain symptomatic and have recurrence of symptoms,” according to the Brazilian Journal of Psychiatry. “40–50% are better, but still symptomatic, and 20–30% remain the same or worse.” (Manfro, Heldt, Cordiol, & Otto, 2008)

Behavioral and cognitive treatments are globally proven methodologies. There are multiple associations worldwide, “devoted to research, education, and training in cognitive and behavioral therapies” (McGinn, 2019). CBT Conferences (2019) are offered across the globe, “where knowledge transfer takes place through debates, round table discussions, poster presentations, workshops, symposia, and exhibitions.” David et al. (2018) credit CBT

as the best standard we have in the field currently available—for the following reasons: (1) CBT is the most researched form of psychotherapy. (2) No other form of psychotherapy is systematically superior to CBT in the treatment of anxiety, depression, and other disorders; if there are systematic differences between psychotherapies, they typically favor CBT. (3) Moreover, the CBT theoretical models/mechanisms of change have been the most researched and are in line with the current mainstream paradigms of the human mind and behavior (e.g., information processing).

The Association for Behavioral and Cognitive Therapies (ABCT) is “a worldwide humanitarian organization,” fostering the “dissemination of evidence-based prevention and treatments through collaborations with the World Health Organization (WHO) and the United Nations Educational, Scientific and Cultural Organization (UNESCO)” (McGinn, 2019). The World Confederation of Cognitive and Behavioural Therapies (WCCBT) is a global multidisciplinary organization promoting health and well-being through the scientific development and implementation of “evidence-based cognitive-behavioral strategies designed to evaluate, prevent, and treat mental conditions and illnesses” (ACBT, 2019).

Cognitive-behavioral therapy is arguably the gold standard of the psychotherapy field. David et al. (2018) maintain, “there are no other psychological treatments with more research support to validate.” Studies of CBT have shown it to be an effective treatment for a wide variety of mental illnesses including depression, SAD, generalized anxiety disorders, bipolar disorder, eating disorders, PTSD, OCD, panic disorder, and schizophrenia (Kaczkurkin & Foa, 2015; NAMI, 2019). However, David et al. (2018) suggest if the gold standard of psychotherapy defines itself as the best in the field, then CBT is not the gold standard. There is clearly room for further improvement, “both in terms of CBT’s efficacy/effectiveness and its underlying theories/mechanisms of change.”

Lyford (2017) provides two examples of criticism. A 2013 meta-analysis published in Clinical Psychology Review comparing CBT to other therapies, failed to “provide corroborative evidence for the conjecture that CBT is superior to bona fide non-CBT treatments.” An 8-week clinical study by Sweden’s Lund University in 2013, concluded that “CBT was no more effective than mindfulness-based therapy for those suffering from depression and anxiety.”

Another meta-analysis conducted by psychologists Johnsen and Friborg (2015) tracked 70 CBT outcome studies conducted between 1977 and 2014 and concluded that “the effects of CBT have declined linearly and steadily since its introduction, as measured by patients’ self-reports, clinicians’ ratings, and rates of remission.” According to the authors, “Just seeing a decrease in symptoms,” he says, “doesn’t translate into greater well-being.” This is reflective of most one-size-fits-all approaches.

While this study recognizes CBT as the best foundation for addressing the SAD culture of maladaptive self-beliefs, it makes the point standard CBT, alone is not necessarily the most productive course of treatment. New and innovative methodologies supported by a collaboration of theoretical construct and integrated scientific psychotherapy are needed to address mental illness as represented in this era of advanced complexity. A SAD person subsisting on paranoia sustained by negative self-evaluation is better served by multiple non-traditional and supported approaches, including those defined as new (third) wave (generation) therapies, developed through client trust, cultural assimilation, and therapeutic innovation with CBT and positive psychology serving as the foundational platform for integration.

59.3. Categories of Interpersonal Love

In Nicomachean Ethics, Aristotle (1999) encapsulates love as “a sort of excess of feeling.” Utilizing the classic Greek categories of interpersonal love is vital to this study; each classification illustrates how SAD symptoms thwart the subject’s means-of-acquisition in seven of eight categories (with the notable exception of healthy philautia). The three primary categories: (1) philia (comradeship), (2) eros (sexual), and (3) agape (selfless and unconditional), are followed by (4) storge (family), (5) ludus (provocative), (6) pragma (practical), and the two extremes of philautia: (7) narcissistic and, (8) positive self-qualities. Forms of inanimate love are excluded from this study, “including love for experiences (meraki), objects (érōs), and places (chōros)” (Lomas, 2017).

1. Aristotle called philia “one of the most indispensable requirements of life” (Grewal, 2016). Philia is a bonding of individuals with mutual experiences―a “warm affection in intimate friendship” (Helm, 2017). This platonic love subsists on shared experience and personal disclosure. A core symptom of a SAD person is the fear of revealing something that will make them appear “boring, stupid or incompetent” (Ades & Dias, 2013). Even the anticipation of interaction causes “significant anxiety, fear, self-consciousness, and embarrassment” (Richards, 2014) because of the fear of being scrutinized or judged by others (Mayoclinic, 2017b).

2. Eros is reciprocal feelings of shared arousal between people physically attracted to each other, the fulfillment declared by the sexual act. The SAD person’s self-image of unlikability (Stein & Stein, 2008) coupled with the fear of intimacy (Montesi et al., 2013) and rejection (Tsitsas & Paschali, 2014) has significant consequences in terms of acquiring a sexual partner, and satisfaction of the sexual act (Montesi et al., 2013). SAD’s culture of maladaptive self-beliefs poses severe challenges to their ability to establish, develop, and maintain romantic relationships (Cuncic, 2018; Topaz, 2018). A study by Montesi et al. (2013), examining the SAD’s person’s symptomatic fear of intimacy and sexual communication concluded, “socially anxious individuals experience less sexual satisfaction in their intimate partnerships than nonanxious individuals, a relationship that has been well documented in previous research.” The study reported a lacuna of literature, however, examining the sexual communication of SAD persons.

3. Through the universal mandate to love thy neighbor, the concept of agape embraces unconditional love that transcends and persists regardless of circumstance (Helm, 2017). SAD generally infects adolescents who have experienced detachment, exploitation, and or neglect (Steele, 1995). This form of love characterizes itself through unselfish giving; the SAD person’s maladaptive self-belief she or he is the constant focus-of-attention is a form of self-centeredness bordering on narcissism (Mayoclinic, 2017a).

4. Again, the primary cause of SAD stems from childhood hereditary, environmental (Felman, 2018; NAMI, 2019), or traumatic events (Mayoclinic, 2017b). In each case, the SAD person is exploited (unconsciously or otherwise) in the formative stages of human motivational development: those of physiological safety and belongingness and love (Maslow, 1943). As a result, storge or familial love and protection, vital to the healthy development of the family unit, is severely affected. The exploited adolescent (Steele, 1995) faces serious challenges recognizing or embracing familial love as an adolescent   or adult.

5. SAD persons’ conflict with the provocative playfulness of ludus is evident by the fear of being judged and negatively evaluated by others (Mayoclinic, 2017b) as well as themselves (Hulme et al., 2012; Ritter et al., 2013). Persons experiencing SAD do not find social interaction pleasurable (Richards, 2019) and have limited expectation things will work out advantageously (Mayoclinic, 2017b). Finally, SAD persons’ maladaptive self-beliefs generally result in inappropriate behavior in social situations (Kampmann, Emmelkamp, & Morina, 2019).

6. The obvious synonym for pragma is practicality―a balanced and constructive quality counterintuitive to someone whose modus operandi is discordant thought and behavior (Richards, 2014; Zimmerman et al., 2010). Pragma is mutual interests and goals securing a working and endurable partnership, facilitated by rational behavior and expectation. The SAD personality sustains itself though irrationality (Felman, 2018) and maladaptive self-beliefs (Hulme et al., 2012; Ritter et al., 2013). The pragmatic individual deals with relationships sensibly and realistically, conforming to standards considered typical. The overriding objective of a SAD person is to “avoid situations that most people consider “’normal’ ” (WebMD, 2019).

The onset of SAD is a consequence of early psychophysiological disturbance (Felman, 2018; Mayclinic, 2019a). The receptive juvenile might be the product of bullying (Felman, 2018), abuse (NAMI, 2019), or a broken home. Perhaps parental behaviors are overprotective or controlling or do not provide emotional validation (Cuncic, 2018). Subsequently, the SAD person finds it difficult to let his or her guard down and express vulnerability, even with someone they love and trust (Cuncic, 2018). Alden et al. (2018) note that SAD persons “find it difficult, in their intimate relationships, to be able to self-disclose, to reciprocate the affection others show toward them.”

There is a large body of research linking love with positive mental and physical health outcomes (Rodebaugh et al., 2015). Relationships, love, and associations with others lead one to recognition of their value to society “and motivates them towards building communities, culture and work for the welfare of others” (Capon & Blakely, 2007). Love is developed through social connectedness. Social connectedness, essential to personal development, is one of the central psychological needs “required for better psychological development and well-being” (Deci & Ryan, 2000). Social connectedness plays a significant role as mediator in the relationship between SAD and interpersonal love (Lee, Dean, & Jung, 2008) and is strongly associated with the level of self-esteem (Fatima et al., 2018).

59.4. Philautia

The seventh and eighth categories of interpersonal love are the two extremes of philautia: narcissism and positive self-qualities. To Aristotle, healthy philautia is vigorous “in both its orientation to self and to others” due to its inherent virtue (Grewal, 2016). “By contrast, its darker variant encompasses notions such as narcissism, arrogance and egotism” (Lomas, 2017). In its positive aspect, any interactivity “has beneficial consequences, whereas in the latter case, philautia will have disastrous consequences” (Fialho, 2007).

The good man should be a lover of self (for he will both himself profit by doing noble acts, and will benefit his fellows), but the wicked man should not; for he will hurt both himself and his neighbours, following as he does evil passions. (Grewal, 2016)

59.4.1. Unhealthy Philautia

Unhealthy philautia is akin to clinical narcissism―a mental condition in which people function with an “inflated sense of their own importance [and a] deep need for excessive attention and admiration.” Behind this mask of extreme confidence, the Mayoclinic report (2017a) states, “lies a fragile self-esteem that’s vulnerable to the slightest criticism.” SAD persons live on the periphery of morbid self-absorption through their self-centeredness. Their obsession with excessive attention (ADAA, 2019b) mirrors that of unhealthy philautia. In Classical Greece, persons could be accused of unhealthy philautia if they placed themselves above the greater good. Today, hubris has come to mean “an inflated sense of one’s status, abilities, or accomplishments, especially when accompanied by haughtiness or arrogance” (Burton, 2016). The self-centeredness and self-absorption of a SAD person often present themselves as arrogance; in fact, the words are synonymous. The critical difference is that SAD persons do not possess an inflated sense of their own importance but one of insignificance.

59.4.2. Healthy Philautia

Aquinas’ (1981) response to demons and disorder states, “evil cannot exist without good.” The Greeks believed that the narcissism of unhealthy philautia would not exist without its complementary opposition of healthy philautia, which is commonly interpreted as the self-esteeming virtue―an unfortunate and wholly incomplete definition. Rather than self-esteem only, philautia incorporates the broader spectrum of all positive self-qualities.

Rather, we are concerned here with various positive qualities prefixed by the term self, including -esteem, -efficacy, -reliance, -compassion, and -resliance. Aristotle argued in Nichomachean Ethics that self-love is a  precondition for all other forms of love. (Lomas, 2017)

Positive self-qualities determine one’s relation to self, to others, and the world. They provide the recognition that one is of value, consequential, and worthy of love. “Philautia is important in every sphere of life and can be considered a basic human need” (Sharma, 2014). To the Greeks, philautia “is the root of the heart of all the other loves” (Jericho, 2015). Gadamer (2009) writes of philautia: “Thus it is; in self-love one becomes aware of the true ground and the condition for all possible bonds with others and commitment to oneself.” Healthy philautia is the love that is within oneself. It is not, explains Jericho (2015) “the desire for self and the root of selfishness.” Ethicist John Deigh (2001) writes:

Accordingly, when Aristotle remarks that a man’s friendly relations with others come from his relations with himself … he is making the point that self-love (philautia), as the best exemplar of love … is the standard by which to judge the friendliness of the man’s relations with others.

Positive self-qualities are obscured by SAD’s culture of maladaptive self-beliefs and the interruption of the normal course of natural motivational development. Positive psychology embraces “a variety of beliefs about yourself, such as the appraisal of your own appearance, beliefs, emotions, and behaviors” Cherry, 2019). It points to measures “of how much a person values, approves of, appreciates, prizes, or likes him or herself” (Blascovich & Tomaka, 1991). Ritter et al. (2013) conducted a study on the relationship of SAD and self-esteem. The research concluded that SAD persons have significantly lower implicit and explicit self-esteem relative to healthy controls, which manifest in maladaptive self-beliefs of incompetence, unattractiveness, unworthiness, and other irrational self-evaluations.

Healthy philautia is essential for any relationship; it is easy to recognize how the continuous infusion of healthy philautia into a SAD person supports self-positivity and interconnectedness with all aspects of interpersonal love. “One sees in self-love the defining marks of friendship, which one then extends to a man’s friendships with others” (Deigh, 2001). Self-worthiness and self-respect improve self-confidence, which allows the individual to overcome fears of criticism and rejection. Risk becomes less potentially consequential, and the playful aspects of ludus less threatening. Self-assuredness opens the door to traits commonly associated with successful interpersonal connectivity―persistence and persuasiveness, optimism of engagement, a willingness to vulnerability. A SAD person’s recognition of her or his inherent value generates the realization that they “are a good person who deserves to be treated with respect” (Ackerman, 2019). A good person is, spiritually, one that is loved by God; reciprocation is instinctive and effortless. “To feel joy and fulfillment at being you is the experience of philautia” (Jericho, 2015). The philautia described by Aristotle, “is a necessary condition to achieve happiness” (Arreguín, 2009) which, as we continue down the classical Greek path, is eudemonic. In the words of positive psychologist Stephen (2019), eudaimonia

describes the notion that living in accordance with one’s daimon, which we take to mean ‘character and virtue,’ leads to the renewed awareness of one’s ‘meaning and purpose in life’.

Aristotle touted the striving for excellence as humanity’s inherent aspiration (Kraut, 2018). He described eudaimonia as “activity in accordance with virtue” (Shields, 2015). Eudaimonia reflects the best activities of which man is capable. The word eudaimonia reflects personal and societal well-being as the chief good for man. “The eudaimonic approach … focuses on meaning and self-realization and defines well-being in terms of the degree to which a person is fully functioning” (Ryan & Deci, 2001). It is through recognition of one’s positive self-qualities and their potential productive contribution to the general welfare that one rediscovers the intrinsic capacity for love. Let us view this through the symbolism of Socrates’ tale of the Cave (Plato, 1992). In it, we discover SAD persons chained to the wall. Their perspectives generate from the shadows projected by the unapproachable light outside the cave. They name these maladaptive self-beliefs: useless, incompetent, timid, ineffectual, ugly, insignificant, stupid. The prisoners have formed a subordinate dependency with their surroundings and resist any other reality until, one day, they find themselves loosed from their bondage and emerge into the light. Like the cave dwellers, the SAD person breaks away from maladaptive self-beliefs into healthy philautia’s positive self-qualities, which encourage and support connectivity to all forms of interpersonal love.

A study published in Cognitive Behaviour Therapy (Hulme et al., 2012) looked at the effect of positive self-images on self-esteem in the SAD person. Eighty-eight students were screened with the Social Interaction Anxiety Scale (SIAS) and divided between the low self-esteem group or the high self-esteem group. The study had two visions. The first was to study the effect of positive and negative self-beliefs on implicit and explicit self-esteem. The second was to investigate how positive self-beliefs would affect the negative impact of social exclusion on explicit self-esteem, and whether high socially anxious participants would benefit as much as low socially anxious participants. The researchers used a variety of measures and instruments. The Social Interaction Anxiety Scale is standard in SAD therapy and CBT workshops; the Implicit Association Test (IAT) reveals the strength of the association between two different concepts. The Rosenberg Self-Esteem Scale (RSES) is a 10-item self-report measure of explicit self-esteem; the State-Trait Anxiety Inventory-Trait (STAI-T) is a 20-item scale that measures trait anxiety; and the Depression Anxiety Stress Scale-21 (DASS-21) is a self-report scale measuring depression, anxiety, and general distress.

Social exclusion is inherently aversive and reduces explicit self-esteem in healthy individuals … the effect of exclusion has been measured in terms of its impact on positive affect and on four fundamental need scores (self-esteem, control, belonging, and meaningful existence) which contribute to psychological well-being. (Hulme et al., 2012)

The study’s results were consistent with evidence based on implicit self-esteem in other disorders; it found that negative self-imagery reduces positive implicit self-esteem in both high and low socially anxious participants. It provided supporting evidence of the effectiveness of promoting positive self-beliefs over negative ones, “because these techniques help patients to access a more positive working self” (Hulme et al., 2012). It also demonstrated that positive self-imagery maintained explicit self-esteem even in the face of social exclusion.

59.5. Conclusion

For 25 years, since the appearance of SAD in DSM-IV, the cognitive-behavioral approach has reportedly been effective in addressing social anxiety disorder. It is structurally sound and would conceivably remain the foundation for future programs, however it is not the therapeutic gestalt it claims to be. Productive cognitive-behavioral approaches emphasize the replacement of SAD’s automatic negative thoughts and behaviors (ANT’s) with automatic rational ones (ARTs). As defined by UCLA psychologists Hazlett-Stevens and Craske (2002), CBT approaches treatment with the assumption that a specific central or core feature is responsible for the observed symptoms and behavior patterns experienced (i.e., lawful relationships exist between this core feature and the maladaptive symptoms that result). Therefore, once the central feature is identified, targeted in treatment, and changed, the resulting maladaptive thoughts, symptoms, and behaviors will also change.

Clinicians and researchers have reported the lack of clear diagnostic definition for social anxiety disorder; features overlap and are comorbid with other mental health problems (ADAA, 2019a; Tsitsas & Paschali, 2014). Experts cite substantial discrepancies and disparity in the definition, epidemiology, assessment, and treatment of SAD (Nagata et al., 2015). More specifically, according to a study published in the Journal of Consulting and Clinical Psychology (Alden et al., 2018), “there is not enough attention paid in the literature to the ability to function in the close relationships” required for interpersonal love.

Standard CBT also lacks methodological clarity. Johnsen and Friborg (2018) cite the varying forms of CBT used in study and therapy over the years. Experts point to two predominant types of CBT: “the unadulterated CBT created by Beck and Ellis, which reflects the protocol-driven, highly goal-oriented, more standardized approach they first popularized,” and the more integrative and collaborative approaches of “modern” CBT (Wong et al., 2013). This study maintains neither faction should be ignored if we are to effectively challenge address the evolving complexities of positive self-qualities and their importance to the individual’s psychological well-being.

The deficit of positive self-qualities in individuals impaired by SAD’s symptomatic culture of maladaptive self-beliefs combined with the interruption of the natural course of human motivational development is a new psychological concept in our evolving conscious complexity. Cognitive-behavioral therapies focus on resolving negative self-imaging and irrationality through programs of thought and behavioral modification.  Positive self-qualities in healthy philautia is not a new concept; it was being discussed in symposia almost two-and-a-half centuries ago. The psychological ramifications and methods to address it, however, are in their formative stages. There is a need for innovative psychological and philosophical research to address the broader implications of healthy philautia’s positive self-qualities, which could deliver the potential for self-love and societal concern to the SAD person, opening the bridge to the procurement of all forms of interpersonal love.

Kashdan, Weeks, and Savostyanova (2011) cite the “evidence that social anxiety is associated with diminished positive experiences, infrequent positive events, an absence of positive inferential biases in social situations, fear responses to overtly positive events, and poor quality of life.” Models of CBT that attempt only to reduce the individual’s avoidance behaviors would benefit from addressing more specifically the relational deficits that such people experience, as well as positive psychological measures to counter SAD’s culture of maladaptive self-beliefs. Non-traditional and supported approaches, including those defined as new (third) wave (generation) therapies, with CBT serving as the foundational platform for integration, would widen the scope and perspective in comprehending SAD’s evolving intricacies.

One such step is the integration of positive psychology within the cognitive behavioral therapy model which, “despite recent scientific attention to the positive spectrum of psychological functioning and social anxiety/SAD … has yet to be integrated into mainstream accounts of assessment, theory, phenomenology, course, and treatment” (Kashdan et al., 2011). CBT would continue to modify automatic maladaptive self-beliefs, thoughts, and behaviors, and positive psychology would replace them with positive self-qualities.

Training in prosocial behavior and emotional literacy might be useful supplements to typical interventions. Behavioral exercises can be used to practice the execution of considerate and generous social skills. Positive affirmations have enormous subjective value as well. Data provide evidence for mindfulness and acceptance-based interventions, where the goal is not only to respond to the negativity of maladaptive self-beliefs but to pursue positive self-qualities despite the presence of unwanted negative thoughts, feelings, images, or memories. Castella et al. (2014) suggest motivational enhancement strategies to help clients overcome their resistance to new ideas and concepts. Ritter et al. (2013) tout the benefits of positive autobiography to counter SAD’s association with negative experiences, and self-monitoring helps  SAD persons to recognize and anticipate their maladaptive self-beliefs (Tsitsas & Paschali, 2014). Finally, the importance of considering the “nuanced and unique dynamics inherent in the relationships among emotional expression, intimacy, and overall relationship satisfaction for socially anxious individuals” should be thoroughly considered (Montesi et al., 2013). As positive psychology turns its attention to the broader spectrum of philautia’s positive self-qualities, integration with CBT’s behavior modification, neuroscience’s network restructuring, and other non-traditional and supported approaches would establish a working platform for discovery.

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There Is No Shame in Mental Illness

What is shame? The painful feeling of humiliation or distress that comes from the sense of being or doing a dishonorable, ridiculous, or immodest thing; the feeling that you are less than, unbefitting, or undesirable. 

What causes shame of a mental dysfunction. History, culture, the disease model of mental healthcare, and mental health stigma (MHS).

Why you should not be ashamed. History is crude and inconsistent, culture is misinformed, the disease model is exploitive and archaic, and MHS is generated and sustained by prejudice, ignorance, and discrimination based on disinformation.

The most famous definition of shame is “feeling ridiculous, embarrassed, humiliated, chagrined, mortified, shy, reticent, painfully self-conscious, inferior, and inadequate.”[i] There are many aspects and degrees of shame; volumes have been written about shame’s types and complexities. Here is what some of the experts write. “Shame is painful, [ii] incapacitating,[iii] and uncontrollable.[iv] Shame makes you feel powerless,[v] inferior, and worthless.[vi] “To feel shame is to feel seen, acutely diminished.[vii]

Shame makes you want to escape, to become invisible. It elicits self-defensive reactions that can make you feel inadequate or become hostile and aggressive. Shame is inescapable, embracing every aspect of the human experience.[viii] 

Shame is not all bad. Shame alerts you to wrongness. You have done something wrong (you are bad), someone has wronged you (they are bad), or you feel wrong (you are inadequate). Shame can be revealing, cathartic and motivational, promoting change, growth, and broadened self-awareness. 

Right now, I am only concerned about the shame you feel because of your mental dysfunction. Everyone has some degree of psychological disturbance. It is a universal and undiscriminating condition; it infects during childhood rendering you unaccountable. So why do you feel shame? Because mental illness is historically denigrating and culturally feared and scorned – beliefs perpetuated by the disease model of mental health and reinforced by MHS claims that you are disgusting, distressing, frightening, and undesirable. 

The disease model of mental health focuses on what is wrong with you. It labels you by your diagnosis, and you cease to be a person. You are then lumped in with others similarly diagnosed and labeled as schizophrenics, paranoiacs, depressive persons, persons with anxiety. You are then stereotyped by the most descriptive symptoms and characteristics of your dysfunction using terms utilized by the Diagnostic and Statistical Manual of Mental Disorders (e.g., incapable, deceitful, unempathetic, manipulative, irresponsible). Then and ignorant (misinformed) and prejudiced (fearful) society stigmatizes or brands you as personifications of that stereotype.

Labels, stereotypes, and stigma are inaccurate representations because of the “implied expectations of how people with mental health problems may behave.” [ix] You may share or resemble symptoms or characteristics of a dysfunction (who doesn’t), but the sum of the label and stereotype is not the sum of the person. You are not your dysfunction.

_________________________

I invite you to join our online group, Strategizing Your ‘Mental’ Disorder. If you are committed to alleviating those symptoms that impact your emotional wellbeing and quality of life, contact me. This is a no-fee discussion and support group. You are not alone, it is not your fault, and you deserve to be treated with dignity and respect.

________________________

Mental Health Stigma is the hostile expression of the abject undesirability of a human being who has a mental illness. Stereotypes of mental illness “often include an exaggerated sense of dangerousness.” [i] (Ironically, the early asylums in Spain and Egypt were built to protect the mentally ill from the dangerous and violent members of society.)[ii] The stigma or branding does not need to be true or accurate; it just has to be believed. Its only purpose is to separate you from the rest of society, which assumes they are normal, and you are not. 

What are the factors or attributes in MHS? Mental health stigma is formed facilitated by ignorance (misinformation), prejudice (fear), and discrimination (false superiority). Stigma supports and is supported by public opinion, media misrepresentation, the mental healthcare industry, and the disease model of mental health. 

First of all, studies show that the aversion to mental illness is socially hard-wired. Society considers you dangerous, unpredictable, and socially undesirable. Society wants to distance themselves and isolate you because of their deep-rooted fear and realization of their own susceptibility. 

The media stereotypes anyone with a dysfunction as an unpredictable, hysterical, and dangerous schizophrenic. Half of news stories on ‘mental’ illness allude to violence. A person with a mental illness is either a homicidal maniac, autistic, or a rebellious, hair-brained, free spirit. 

Healthcare professionals are often undertrained and inflexible. You know how your disorder impacts your emotional wellbeing and quality of life far better than your doctor. Clinicians deal with 31 similar and comorbid disorders, over 400 schools of psychotherapy, multiple treatment programs, and an ever-increasing plethora of medications. 

The mental healthcare community is drowning in pessimism. There is evidence to indicate the problem is endemic in the medical health community and universally systemic, which means that it impacts you personally, and the current model of healthcare is the culprit. 

Clients report instances where staff members are rude or dismissive. Complaints include coercive measures, excessive wait-times, paternalistic or demeaning attitudes, one-size-fits-all treatment programs, medications with undesirable side-effects, and stigmatizing language. 

The ‘defective’ or disease emphasis has been the overriding psychiatric perspective for over a century. By the 1952 publication of the first DSM, the focus had drifted from pathology (the science of the causes and effects of your dysfunction) to pathography (the breakdown of your psychological shortfalls, categorizing them to facilitate diagnosis). Pathography focuses on a deficit, disease model of human behavior. Which disorder poses the most threat? What behaviors contribute to the disorder? Are you contagious? What sort of person has a mental illness? It is these attributions that form public opinion, stigma, and your self-beliefs and image. 

The disease model and the DSM’s diagnostic system is under increasing scrutiny for its misdiagnosis, constant criteria revisions, symptom comorbidity, one-size-fits-all recovery programs, and general negativity. The Wellness Model of mental health focuses on your character strengths and virtues that generate the motivation, persistence, and perseverance to recover. A battle is not won by focusing on incompetence and weakness; it is won by knowing and utilizing your strengths and attributes. That is how you recover―with pride and self-reliance and determination―with the awareness of what you are capable. 

Why you should not be ashamed   

(History is crude and inconsistent, culture is misinformed, the disease model is exploitive and archaic, and MHS is generated and sustained by prejudice, ignorance, and discrimination based on disinformation.)

Recognizing that shame is a fundamental part of human nature allows you to confront it and realize, while others may attempt to shame you, it is up to you whether you chose to be shamed. No one can make you feel shame; it is entirely of your own volition. What is there to be ashamed of? Mental illness is universal and undiscriminating. Everyone is dysfunctional in one way or another. You are not responsible for being infected. You did not deal yourself the cards. You should only feel shame if your dysfunction negatively impacts your emotional wellbeing and quality of life, and you refuse to do something about it.

_____________________

i Goldberg C. (1991). Understanding shame. New Jersey/London: Jason Aronson.

ii Benda, J., Kadleĉík, P., Loskotová, M. (2018). Differences in self-compassion and shame in patients with anxiety disorders, patients with depressive disorders and healthy controls. Československá psychologie / ročník LXII (6), 520-541.

iii Keen, N., George, D., Scragg, P., Peters, E. (2017). The role of shame in people with a diagnosis of schizophrenia. British Journal of Clinical Psychology 56, 115–129 (2017). doi:10.1111/bjc.12125.

iv Camp, A.R. (2018). Pursuing Accountability for Perpetrators of Intimate Partner Violence: The Peril (and Utility?) of shame. Boston University Law Review, 98: 1677-1736.

v  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

vi Murphy, S.A., & Kiffin-Petersen, S. (2017). The Exposed Self: A Multilevel Model of Shame and Ethical Behavior. Journal of Business Ethics, 141, 657–675 (2017). doi:10.1007/s10551-016-3185-8.

vii Miceli, M., & Castelfranchi, C. (2018). Reconsidering the Differences Between Shame and Guilt. Europe’s Journal of Psychology, 14(3), 710-733 (2018). doi:10.5964/ejop.v14i3.1564.

viii Okano, K. (1994). Shame and Social Phobia: A Transcultural Viewpoint. Bulletin of the Menninger Clinic, 58(3), .http://enlight.lib.ntu.edu.tw/FULLTEXT/JR-MDL/oka.htm

ix 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

x 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

xi Stuart, H., & Arboleda-Flórez, J. (2012). A Public Health Perspective on the Stigmatization of Mental Illnesses. Public Health Reviews, 34: Epub ahead of print.

You Deserve to Be Treated with Dignity and Respect.

This is a personal message to those of you whose emotional wellbeing and quality of life are impacted by a ‘mental’ disorder. I write as someone who knows what you are going through, and who understands the system. I have dealt with social anxiety disorder throughout my life. I have spent the last 16 years researching and developing methods to alleviate the impact of mental dysfunctions. I know the disease model of mental health has been ineffective and demeaning, and I emphasize the importance of adopting a Wellness Model that treats you with dignity and appreciation for your abilities and potential. 

You are not alone.

  • 1 in 5 adults and 1 in 6 children (ages 6-17) have a diagnosable mental illness.
  • 20 million adults and 5 million adolescents experience mild to major depression.
  • Anxiety disorders impact 45 million adults and 13 million adolescents .
  • 60% of those have both anxiety and depression. Substance abuse is often comorbid.
  • The estimated rate of infection for minorities is 1.5-2.5 times higher.
  • Anxiety and depression are the primary causes of the 56% increase in adolescent suicide over the last decade.
  • Sexual and gender-based adolescents are almost five times more likely to attempt suicide.

There are four essential facts I want you to recognize.

Number 1: You are not abnormal. A disorder, or what they used to call a neurosis, is a common part of natural human development. Mental health professionals have a saying. Question: Why do 26% of American adults have a diagnosable mental disorder? Answer: Because the other 74% haven’t been tested.  Scientific American speculates that mental disorders are so common, almost everyone will develop at least one diagnosable disorder at some point in their life. It is, simply, a condition that negatively impacts your emotional wellbeing and quality of life. 

Number 2: It is not your fault. You were infected, most likely, during your childhood. In the rare event onset happened later in life, the susceptibility originated in your childhood. The infection is a consequence of some physical, emotional, or sexual disturbance. It could be hereditary, environmental, or the result of trauma. Any number of things could have caused it. Perhaps your parents were controlling or did not provide emotional validation. Perhaps you were bullied, or you are from a broken home. It is never your fault and it may be no one’s fault.

Number 3: Forget what you have been told. You have been negatively informed by the disease model of mental health, and influenced by mental health stigma. The disease model focuses on diagnosis, deficit, and denigration. Through its diagnostic process, you cease to be an individual and become your disorder. The Wellness Model emphasizes your character strengths and virtues that generate the motivation, persistence, and perseverance to recover.

You are not ‘mental.’ Not only is the description inaccurate, it promotes hostile perceptions of incompetence, unworthiness, and undesirability. It is the dominant source of stigma, shame, and self-loathing. It feeds the pervasive public stereotype of the dangerous and unpredictable, deranged person who should be isolated in an institution. 

They once thought mental illness was demonic possession. They blamed it on the moon, sorcery, witchcraft, and bodily fluids. In the early 20th century, it was your cellular structure. The biological approach says it is in your brain; the pharmacological approach pushes drugs to balance your chemistry and hormones. The fact is that simultaneous mutual interaction of your human system components is required for sustainability of life and your disorder.

Your dysfunction is not ‘mental,’ biologic, hygienic, neurochemical, or psychogenic, but all of these things facilitated by all your human system components – your mind, body, spirit, and emotions working in concert. 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. So, we have to change the common perception of the word. The Wellness Model’s primary objective is the reformation of language, power structure, and perspective throughout the mental healthcare community and beyond.

And finally, number 4: You deserve better ― from the ‘mental’ healthcare industry, your doctor, family, peers, media, and community. ‘Mental’ illness is a stigma, formed by ignorance, prejudice, and discrimination. It is supported by public opinion, family rejection, a misinformed community, media misrepresentation, and the disease model of mental health. No wonder so many avoid treatment, reject diagnosis, or refuse to disclose their condition.

General public opinion considers you dangerous, unpredictable, and socially undesirable.

37% of family members hide their relationship with their child or sibling in order to avoid bringing shame to the family. Many disordered are family undesirable, a devaluation more life-limiting, and disabling than the illness itself.

The media stereotypes you as a hysterical, unpredictable, and dangerous schizophrenic. Half of news stories on ‘mental’ illness allude to violence. You are either a homicidal maniac, an emotionally challenged childlike prodigy, or a rebellious, hair-brained, free spirit.

Healthcare professionals are often undertrained, misinformed, and inflexible. You know how your disorder impacts your emotional wellbeing and quality of life far better than your doctor. Clinicians deal with 31 similar and comorbid disorders, over 400 schools of psychotherapy, multiple treatment programs, and a constantly evolving plethora of medications, but they do not know the personal impact of your disorder.

The mental healthcare community is drowning in pessimism. There is evidence to indicate the problem is endemic in the medical health community, and universally systematic, which means that it impacts you personally, and the disease model is the culprit. Clients report instances where staff members are inordinately rude or dismissive. Complaints include coercive measures, excessive wait-times, paternalistic or demeaning attitudes, one-size-fits-all treatment programs, medications with undesirable side-effects, stigmatizing language, and general therapeutic pessimism.

The etiology-driven, disease model defines you as incapable, deceitful, unempathetic, manipulative, difficult, irresponsible, and incompetent. These descriptions are straight from the manual. This ‘defective’ emphasis has been the overriding psychiatric perspective for over a century. By the 1952 publication of the first DSM, the focus had drifted from pathology (the science of the causes and effects of diseases) to pathography (the breakdown of an individual’s problems, categorizing them to facilitate diagnosis). Pathography focuses on a deficit, disease model of human behavior, Which disorder poses the most threat? What behaviors contribute to the disorder? Are you contagious? What sort of person has a mental illness? It is these attributions that form your self-beliefs and image.

To iterate, the current Diagnostic and Statistical Manual of Mental Disorders describes 31 dysfunctions. Most share symptomatology and are comorbid. Estimates show that 60% of those with anxiety also have symptoms of depression, and both are comorbid with substance-abuse. The following are closely related to or comorbid with social anxiety: major depression, panic disorder, alcohol abuse, PTSD, avoidant personality disorder, generalized anxiety disorder, substance abuse, eating disorders, schizophrenia, ADHD, and agoraphobia.

Diagnostic criteria change dramatically from one edition to the next. Causes and symptoms are added, removed, and rewritten without evidence that the new approach is better than the prior one. Researchers cite substantial discrepancies and variation in definition, epidemiology, assessment, and treatment. One clinic reports that 8.2% of their clients had generalized anxiety; 0.5% were correctly diagnosed. A study of 67 clinics reported that 76.4% of social anxiety clients were improperly diagnosed.

That is why the Wellness Model focuses on the individual over the diagnosis. The disease model focuses on the diagnosis. The Wellness Model emphasis your character strengths and attributes that generate the motivation, persistence, and perseverance to recover. A battle is not won by focusing on incompetence and weakness; it is won by knowing and utilizing our strengths, and attributes. That is how we recover―with pride and self-reliance and determination―with the awareness of what we are capable.

Recoveryis an individual process. There is no one right way to do or experience recovery. You are not toasters, mass-produced in a factory. You have unique DNA. There has never been a single human being with your sensibilities, memories, and abilities. Your personality is comprised of distinct phenomena generated by everything experienced in your lifetime. It formed itself by core-beliefs and developed through social, cultural, and environmental experiences. It is your current being and the expression of that being―your inimitable way of thinking, feeling, and behaving.

One-size-fits-all approaches have never been able to address the complexity of your individual personality. Any evaluation and treatment program must comprehensively address your individual complexity. Recovery programs must be innovative, fluid, and targeted.

Clinicians must assimilate your culture and earn your trust. They do not have to become you; they must attempt to understand your culture in order to relate to you. An LGBTQ+ person will not be served well by a fundamentalist Baptist psychotherapist. Any clinician or program must consider your environment, history, and autobiography in conjunction with your wants, needs, and aspirations.

You deserve to be treated with dignity, and appreciation.

Your dysfunction has impacted your life since childhood; recovery is a long-term commitment. The Wellness Model creates the blueprint then guides teaches and supports you throughout the process of recovery, but you must do the work. The Wellness Model helps you reengage your intrinsic character strengths and attributes that generate the motivation and persistence and perseverance to recover.

Any suggestion of undesirability is a devaluation more life-limiting and disabling than the illness itself. You deserve to be treated with dignity and appreciation. 

Video: Wellness Model

The Wellness Model of Mental Health in the 21st Century

The disease or medical model has been the approach towards mental health since the dawning of civilization. It is called the pathographic perspective. Pathography is the history of our suffering. The Wellness Model focuses, not on our disease and deficits, but on our character strengths, virtues, and achievements. A disorder, condition, or dysfunction is what used to be called a neurosis. A neurosis is a common part of natural human development. It is, simply, a condition that negatively impacts our emotional wellbeing and quality of life. 

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Positive Psychology and the Wellness Model

The Disease Model focuses on the problem; the Wellness Model emphasizes the solution.

The disease or medical model of ‘mental’ health focuses “on a deficit, disease model of human behavior.” The wellness model focuses “on positive aspects of human functioning.”[i] This disease model ‘defective’ emphasis has been the overriding psychiatric perspective for well over a century.

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.[ii]

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.”[iii] The World Psychiatric Association agrees, stating, “the promotion of well-being is among the goals of the mental health system.”[iv] As positive psychologists point out, “psychological wellbeing is viewed as not only the absence of mental disorder but also the presence of positive psychological resources.”[v]

The wellness model’s chief facilitator is positive psychology (PP), which originated with Maslow’s[vi] seminal texts on humanism, and was legitimated by Seligman as American Psychological Association president in 1998. The focus of positive psychology and other optimistic approaches, is on virtues and strengths “not only to endure and survive, but also to flourish.”[vii]  PP describes 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.”[viii]

Positive psychology is a relatively new field (since 1998) that ostensibly complements and supports rather than replaces traditional psychology. “Positive psychology serves as an umbrella term to accommodate research investigating positive emotions and other positive aspects such as creativity, optimism, resilience, empathy, compassion, humor, and life satisfaction.”[ix]

PP has been defined as the science of optimal functioning, its objective “to study, identify and amplify the strengths and capacities that individuals, families and society need to thrive.”[x] Cultural psychologist Levesque[xi] describes optimal functioning as the study of how individuals attempt to achieve their personal potentials and become the best that they can be.

Research has shown that positive psychology interventions “improved well-being and decreased psychological distress in mildly depressed individuals, in patients with mood and depressive disorders, [and] in patients with psychotic disorders.”[xii] Studies supports the utilization of positive psychological constructs, theories, and interventions for enhanced understanding and improvement of ‘mental’ health. “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.”[xiii]

A range of approaches promoting wellbeing have been tested in intervention research.  A recent study found positive psychology interventions showed “significant improvements in mental well-being (from non-flourishing to flourishing mental health) while also decreasing both anxiety and depressive symptom severity.”[xiv] Continuing research suggests that a positive psychological outlook not only improves life outcomes but enhances health directly.[xv] A meta-analysis of 51 studies with 4,266 individuals utilizing therapies focusing on mindfulness, autobiography, positive writing, gratitude, forgiveness, or kindness, found PPIs “significantly enhance well-being . . . and decrease depressive symptoms.“[xvi]  

The academic discipline of positive psychology continues to develop evidence-based interventions that focus on eliciting positive feelings, cognitions or behaviors.[xvii] Independent research shows PPIs “decreased psychological distress [in individuals] with mood and depressive disorders [and] patients with psychotic disorders . . . improving quality of life and well-being.”[xviii] 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.”[xix]

Disease (Medical) Model

  • Pathography/etiology
  • DSM intractability
  • Systemic pessimism
  • Disease, deficit and denigration
  • One-size-fits-all recovery programs
  • Doctor-client power relationship
  • Rampant Misdiagnosis

Wellness Model

  • Communication
  • Optimal functioning
  • Emerging research data
  • Positive language, perspective
  • Client strengths and abilities
  • Program integration
  • Individual dynamics

Positive Psychology

  • Optimal human functioning
  • Support and enhance traditional psychology
  • Emphasize character strengths & attributes
  • Evidence-based interventions
  • Balanced, holistic perspective

Positive Psychology 2.0.  One of the early challenges of positive psychology was its inattention to the negative aspects of the individual. Recognizing this imbalance, psychologists advocated a more holistic approach to embrace the dialectical opposition of human experience. Positive Psychology 2.0 (PP 2.0) evolved as a correction to this singular focus on optimism so that it could “move forward in a more inclusive and balanced matter,[xx] incorporating both positive and negative aspects of the holistic individual. As one psychologist put it, “people are not just pessimists or optimists. They have complex personality structures.”[xxi] PP 2.0 recognizes the individual achieves optimal human functioning by living a meaningful life that comes through full engagement. PP 2.0 is a balanced approach, one that “equally considers positive emotions and strengths and negative symptoms and disorders.”[xxii]

The positive psychology perspective maintains that individuals with a ‘mental’ disorder can live satisfying and fulfilling lives regardless of symptoms or impairments associated with the diagnosis.[xxiii] Positive psychology aims “to emphasize the positive while managing and transforming the negative to increase well-being.”[xxiv] 

Positive psychology focuses on enhancing wellbeing and optimal functioning rather than ameliorating symptoms. By emphasizing wellness rather than dysfunction, the positive-psychology movement aims to destigmatize ‘mental’ illness. Positive psychologists believe “the constructive use of positive psychology perspective is generally needed in contemporary research to complement the long tradition of pathogen orientation.”[xxv]

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[i] 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.

[ii] 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/ 

[iii] 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)

[iv] 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).

[v] 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

[vi] Maslow, A.H. (1943). A theory of human motivation. Psychological Review, 50(4): 370-396 (1943). doi.org/10.1037/h0054346; Maslow, A. (1954). Motivations and Personality.  New York City: Harper & Brothers; Early edition.

[vii] 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.

[viii] 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).

[ix] Ibid.

[x] Carruthers, C., & Hood, C. D. (2005).  The Power of Positive Psychology. Parks and Recreation.  .file:///C:/Users/rober/ OneDrive/ Pending/New%20Psychobiography/carruthers%20x.pdf 

[xi] 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

[xii] 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.

[xiii] Carruthers, C., & Hood, C. D. (2005).  The Power of Positive Psychology. Parks and Recreation.  .file:///C:/Users/rober/ OneDrive/ Pending/New%20Psychobiography/carruthers%20x.pdf 

[xiv] 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, pp. 1-11 (2018). https://doi.org/10.1186/s12888-018-1825-5

[xv] Easterbrook, G. (2001). Psychology discovers happiness. I’m OK, You’re OK. The New Republic, Article 27,  6

[xvi] 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

[xvii]  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, pp. 1-11 (2018). https://doi.org/10.1186/s12888-018-1825-5

[xviii] 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.

[xix] 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).

[xx] Wong, P. T. P., & Roy, S. (2017). Critique of positive psychology and positive interventions. In N. J. L. Brown, T. Lomas, & F. J. Eiroa-Orosa (eds.), The Routledge International Handbook of Critical Positive Psychology, pp 142-160. London, UK: Routledge.

[xxi]  Miller, A. (2008). A Critique of Positive Psychology— or ‘The New Science of Happiness.’ Journal of Philosophy of Education, 42(3-4), 591-608 (2008).  

[xxii] 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 (Vol. 8, pp. 153–176). Dordrecht, Netherlands: Springer.

[xxiii]  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)

[xxiv] 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.

[xxv] Ibid.

Why We Should Avoid the Term ‘Mental.’

“everyone will develop at least one diagnosable disorder”

‘Mental’ Disorder

  • Condition that negatively impacts your emotional wellbeing and quality of life.
  • Called a neurosis by DSM prior to 1980.
  • Facilitated by mind, body, spirit, and emotions working in concert.
  • Source of shame, stigma, and self-denigration.
  • Correctible inability to function in a ‘normal’ or satisfactory manner.
  • A normal facet of human development.

Language generates and supports perspective. Language influences thought and action. Not only is the word ‘mental’ inaccurate in describing a disorder, but its negative perspectives and implications promulgate perceptions of incompetence, unworthiness, and undesirability. It is the dominant source of stigma, shame, and self-denigration. Realistically, we cannot eliminate the word ‘mental’ from models of healthcare. Still, we should utilize it sparingly, and only to differentiate a disorder from a physical injury or ailment.

The first descriptions that come to mind when one utilizes the word ‘mental’ are crazy and insane. A person with a disorder is not crazy or insane. She or he is someone who has a common malfunction that negatively impacts their emotional wellbeing and quality of life. Scientific American speculates that ‘mental’ disorders are so common that almost everyone will develop at least one diagnosable disorder at some point in their life.[i] A disorder is a normal facet of human development that infects at adolescence or earlier. A person cannot be held accountable for their disorder. They did not make it happen; it happened to them. 

In political correctness, the word ‘mental’ defines a person or their behavior as extreme or illogical somehow. During our schooldays, anyone unpopular or different was derisively called ‘mental’ or ‘mental’ retard. The urban dictionary defines mental as someone silly or stupid. The word was used for attention, involving nonsensical references and actions, usually involving violent or divisive behavior, resulting in the general amusement and hilarity of onlookers. Add the words illness or disorder onto the adjective, ‘mental,’ and we have the public stereotype of dangerous and unpredictable, deranged persons who cannot fend for themselves, necessitating isolation in an institution. 

Dictionary definitions of the adjective ‘mental’ are: (1) of or relating to the mind or (2) of, relating to, or affected by a disorder of the mind. A disorder is not mental. It is administered and facilitated by the mind, body, spirit, and emotions working in concert.

To the early civilizations, ‘mental’ illnesses were the domain of supernatural forces and demonic possession. Hippocrates and diagnosticians of the 19th century favored the humours (bodily liquids). Lunar influence and sorcery and witchcraft are timeless culprits. In the early 20th century, it was somatogenic.[ii][iii] The biological approach argues that mental disorders are related to the brain’s physical structure and functioning.[iv] The pharmacological approach promotes it as an imbalance in brain chemistry. The first Diagnostic and Statistical Manual of Mental Disorders,[v] created to address the influx of veteran shell shock (PTSD), leaned heavily on environmental and biological causes. 

Carl Roger’s study of the cooperation of human system components to maintain physiological equilibrium produced the word complementarity to define simultaneous mutual interaction. All human system components must work in concert; they cannot function alone. Integrality describes the inter-cooperation of the human system and the environment and social fields. A disorder is not biologic, hygienic, neurochemical, or psychogenic. It is a collaboration of these, and other approaches administered by the simultaneous collaboration of the mind, body, spirit, and emotions.

There is no legitimate argument against mind-body collaboration in disease and wellness. We know that emotions are reactive to the mind and body and vice versa. Spirit is not ethereal or otherworldly, but a natural component of human development. While some suggest spirit as the seat of emotions and character, the three are distinct entities. Spirit forms the definitive or typical elements in the character of a person. Emotions are the expressions of those qualities, responsive to the mind and boy.[vi] 

In deference to a wellness paradigm, focusing on the word disorder (a correctable inability to function healthily or satisfactorily) and avoiding the mental description will help alleviate the healthcare system’s negativity. Changing negative and hostile language to embrace a positive dialogue of encouragement and appreciation will open the floodgates to new perspectives and positively affect the disordered person’s self-beliefs and image, leading to more disclosure, discussion, and recovery-remission. The self-denigrating aspects of shame will dissipate; mental health stigma become less threatening. The concentration on character strengths and virtues, propagated by humanism, PP2.0, and other wellness-focused alliances, will encourage client accountability and foster self-reliance, leading to a confident and energized social identity. 

Transitioning from the disease model’s pathographic language to the optimistic and encouraging perspective of wellness models is everyone’s responsibility in the mental health community―its institutions, associations, practitioners, researchers, media, and clients. When ‘mental’ is essential for focus or differentiation, we recommend utilizing quotation marks (‘mental’) to diffuse its negative and harmful perspectives.

You are not accountable for the hand you have been dealt. You are responsible for how you play the cards.

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[i] 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.

[ii]  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.

[iii] 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

[iv] Gray, A.J. (2002). Stigma in Psychiatry. Journal of the Royal Society of Medicine, 95(2): (2002). doi:10.1258/jrsm.95.2.72

[v] 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

[vi] Mullen, R. F. (2018). Social Anxiety Disorder. (Online.). https://rechanneling.org/page-20.html

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