THE NARRATED SUBJECTIVE EXPERIENCE OF STIGMA FOR ADOLESCENTS DIAGNOSED WITH A MENTAL ILLNESS AND PRESCRIBED PSYCHIATRIC MEDICATION by DERRICK ALAN KRANKE Submitted in partial fulfillment of the requirements For the degree of Doctor of Philosophy Dissertation Adviser: Dr. Jerry Floersch Mandel School of Applied Social Sciences CASE WESTERN RESERVE UNIVERSITY May, 2009 CASE WESTERN RESERVE UNIVERSITY SCHOOL OF GRADUATE STUDIES We hereby approve the thesis/dissertation of _____________________________________________________ candidate for the ______________________degree *. (signed)_______________________________________________ (chair of the committee) ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ (date) _______________________ *We also certify that written approval has been obtained for any proprietary material contained therein. i Copyright © by Derrick Alan Kranke All rights reserved ii Dedication Page I would like to recognize certain people who were instrumental in the dissertation process. First, I would like to dedicate this dissertation to my late grandmother, Genevieve Alvarez. She instilled the value of an education and always encouraged me to pursue my doctorate. I am forever grateful to my adviser, Dr. Jerry Floersch. I attribute my success and transcendence through the doctoral program to him. He is the greatest mentor I have had in my life, but more importantly, he has inspired me to make a difference and be passionate about the work I do. He always puts his students first and does everything in his power to help others succeed. Thanks for introducing me to the field of adolescent mental health. In addition, I would like to thank my wife, Bridget. She demonstrated her love and dedication to me by moving out to Ohio so I could attain my dream. We have learned so much about ourselves through this experience. You inspire me to be a better man. I cannot reiterate the meaning of your love to me. Thank you for providing love and companionship throughout this process, I could not have done it without you. Furthermore, I would like to acknowledge my parents: Linda, Dave, Gil, Marilyn, Jack and Kerry. I am lucky to have a family that supports me in pursuing my dreams. This upbringing has guided me towards a fulfilling and satisfying life. I will be forever grateful to the late night calls with Jack about developing my ideas and theories. Also, I am grateful to my editor, Ann. She graciously edited this dissertation and provided timely and useful suggestions to make this dissertation a finished product. I greatly appreciate your willingness and patience to make me a better writer. iii Besides my editor, I am thankful for the help and support from Sue and Suzie. I thank you both for the feedback you provided, as well as your reliability checks with the analysis. I hope to continue our relationship for many years to come. Moreover, I would like to acknowledge the adolescents in this study. Their perspectives shed light on an area of research that needs much attention. Thank you for sharing your stories. Finally, none of this would have been possible without the heavenly Father, God. He has blessed me in so many ways. I would like to thank him for guiding me throughout this process, and giving me the strength when I needed it most. 1 Table of Contents List of Tables 2 List of Figures 3 Acknowledgements 5 Abstract 6 Chapter 1: Background and Rationale 8 Chapter 2: Literature Review 16 Chapter 3: Methods 57 Chapter 4: Thematic Analysis 76 Chapter 5: Structural Analysis 120 Chapter 6: Conclusion 178 Appendix 198 References 200 2 List of Tables Table 1: Respondent Demographics 60 Table 2: Respondent Diagnoses 61 Table 3: Demographics by Age Group 74 3 List of Figures Figure 1: Conceptualization of Stigma 21 Figure 2: Data Analytic Strategy of Thematic Analysis 68 Figure 3: Data Analytic Strategy of Structural Analysis 69 Figure 4: Number of Stigma Quotations by Age Group 75 Figure 5: Quotations Referencing Secrecy 12-14 year olds 79 Figure 6: Quotations Referencing Secrecy 15-17 year olds 79 Figure 7: Quotations Referencing Shame 12-14 year olds 84 Figure 8: Quotations Referencing Shame 15-17 year olds 84 Figure 9: Quotations Referencing Disclosing to Trusting Friend 12-14 year olds 87 Figure 10: Quotations Referencing Disclosing to Trusting Friend 15-17 year olds 87 Figure 11: Quotations Referencing Associating with Others in Similar Condition 12-14 year olds 90 Figure 12: Quotations Referencing Associating with Others in Similar Condition 15-17 year olds 90 Figure 13: Quotations Referencing do not Disclose to Friend/Withdraw 12-14 year olds 93 Figure 14: Quotations Referencing do not Disclose to Friend/Withdraw 15-17 year olds 93 Figure 15: Quotations Referencing do not Understand Diagnosis 12-14 year olds 96 Figure 16: Quotations Referencing do not Understand Diagnosis 15-17 year olds 96 Figure 17: Quotations Referencing Family Perceptions 12-14 year olds 99 Figure 18: Quotations Referencing Family Perceptions 15-17 year olds 99 Figure 19: Quotations Referencing School Environment 12-14 year olds 102 Figure 20: Quotations Referencing School Environment 15-17 year olds 102 4 Figure 21: Stigma Effects on Adolescent Relationships 108 Figure 22: Adolescents Endorsing no Themes 113 Figure 23: Adolescents Endorsing all Themes 117 Figure 24: Dimensions of Adolescent Stigma Plot 167 Figure 25: Adolescent in First Dimension of Stigma Plot 169 Figure 26: Adolescent in Second Dimension of Stigma Plot 171 Figure 27: Adolescent in Third Dimension of Stigma Plot 173 Figure 28: Genres by Dimensions 177 5 Acknowledgements This work was supported by funding from The National Institute of Mental Health, #KMH068584A1 (Principal Investigator: Jerry Floersch, Ph.D.) and the Eli Lilly Reintegration Scholarship. 6 The Narrated Subjective Experience of Stigma for Adolescents Diagnosed with a Mental Illness and Prescribed Psychiatric Medication Abstract by DERRICK ALAN KRANKE The rate of mental illness diagnoses and use of psychiatric medications among adolescents has increased dramatically (Safer, Zito, & dosReis, 2003). The intended consequence of treatment is to improve functioning and reduce symptoms. However, the unintended consequence of treatment is stigmatization. Minimal research has been conducted on adolescent experience of mental health stigma (Hinshaw, 2007). The extant empirical literature suggests that adults suffer harmful effects of stigma. Research consistently documents that adults who experience mental health stigma have limited opportunities in employment, housing, and intimate relationships. However, adolescents have different developmental tasks, and adolescent experience of stigma therefore may be different. In addition, research suggests adolescents reach developmental milestones at different rates (Kroger, 2007). Younger and older adolescents experience different pressures, demands, and peer interactions, raising the question whether the experience of stigma differs by conceptually developed ages. The aim of this qualitative study was to explore stigma effects among adolescents who have been prescribed psychiatric medication for a mental illness. The purpose was to answer the following questions: (a) Do adolescents experience stigma effects similar to 7 that of adults? (b) Do adolescents experience distinctive/additional effects of stigma? (c) Do younger and older adolescents experience stigma differently? The experience of stigma among younger and older adolescents was compared using thematic and structural analysis. Results indicated that younger and older adolescents do experience stigma effects similar to those of adults—secrecy, shame, and limiting interaction—though context varies across the life span. In addition, qualitative analysis revealed several new effects pertaining to both groups of adolescents: not understanding diagnosis, family perception affecting attitudes toward mental health, and school environment affecting perceptions toward mental health. Stigma experience was contextual and was influenced by adolescent developmental concerns about fitting in, peer perceptions, and social interaction. The findings have implications for mental health needs in schools and raise particular concerns about the negative effect of stigma on peer relationships. Although the findings revealed similarities between the groups of adolescents and adults, the analysis was cross-sectional and thus one must be cautious about the interpretation. 8 Chapter 1: Background & Rationale The Surgeon General (2000) has stated that “both the promotion of mental health in children and the treatment of mental disorders should be major public health goals.” The present dissertation investigates stigma among adolescents prescribed psychiatric medications for treatment of a diagnosed mental illness. The study examines the research literature and scholarship on adult experiences of stigma related to mental illness and applies these findings to adolescents diagnosed with a psychiatric illness and prescribed a psychiatric medication. Stigmatization is a social and psychological process that distinguishes and recognizes human differences, which are then linked to negative stereotypes through labels. Labels place people in separate categories as possessing undesirable characteristics (Link & Phelan, 2001). Stigma research has identified secrecy, shame,