The Effect of Psychiatric Diagnosis on Young People’s Sense of Self and Social Identity

A new review highlights the effects that psychiatric diagnosis has on children and adolescents’ social relationships and views of self.

Rebecca Troeger
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A systemic review of research on the role that psychiatric diagnosis plays in shaping young people’s self-understanding and social identity was recently published in the journal Social Science & Medicine. The multidisciplinary review, led by Dr. Cliodhna O’Connor of University College Dublin’s School of Psychology, found that psychiatric diagnosis plays a complex role in the lives of children and adolescents, both helping and harming their budding sense of self and social relationships. For example, while diagnosis subjects some young people to stigma and social isolation, it can also serve to encourage greater interpersonal acceptance and heightened connection with “similar others.” The researchers found that “different orientations to a diagnosis” were present not only between participants but also within young people over time, as attitudes towards their diagnosis shifted.

“Diagnoses are not purely clinical judgments that occur in a vacuum,” the authors write, “they have pragmatic repercussions, which are central to real-world diagnostic decisions.”

Photo Credit: Nuria LV, Model: Sergio C. (Flickr)

The authors begin their paper by introducing the role psychiatric diagnosis plays in clinical treatment, and the various practical, psychological, and social repercussions diagnosis can have in the lives of individuals who receive them.  Practically, a diagnosis serves an explanatory function, offers a potentially beneficial “common language,” and serves as an entryway to treatment and other resources. However, diagnoses with bleak prognoses can also prompt pessimism or resignation amongst health care providers and clients, and serve to limit treatment choices.

Research has documented a wide variety of psychosocial effects of psychiatric diagnosis. Diagnosis can sometimes offer a relief, validation, and bolstering of one’s self-concept by “externalizing the disorder from a person’s ‘true’ self.” Regarding potential harms to self-concept and social identity, psychiatric diagnosis can cause be invalidating and rob individuals of personal agency. Diagnosis often also carries a stigma that can result in unwelcome differential treatment and discrimination.

Recognizing the significant influence psychiatric diagnosis has on recipients’ personal and social selves, and given that childhood and adolescence represent a particularly “critical period in the development of self and identity,” O’Connor and her team chose to focus their research on individuals under 18. The researchers conducted a systemic literature review of original qualitative research exploring how psychiatric diagnosis affects children and adolescents’ selves and social identities. After screening 3,892 articles, they selected 38 based on pre-determined inclusion and exclusion criteria. A thematic synthesis was then used to code the included studies, which resulted in 11 analytic themes and four ‘super-themes’: benefits for self-concept, risks for self-concept, benefits for social identity, and risks for social identity:

Benefits for self-concept

Under this super-theme, the researchers found three primary themes: self-understanding, self-legitimation, and self-enhancement. Self-understanding is characterized by an experience of “self-insight” following diagnosis. For example, one participant response within this theme was, “I’ve never really fit in, I always felt different, and now I know why.” Self-understanding was found to be valuable in and of itself and as a pathway to “self-management and clinical intervention.”

Self-legitimation refers to the sense of validation, relief, and hope that some young people experienced after receiving a diagnosis. Self-enhancement is a phenomenon in which participants presented a view of self that was positive and independent of their diagnosis. In some instances, particularly in the case of those with autism spectrum disorder (ASD), the diagnosis itself was viewed as a source of positive feelings (e.g., seeing ASD as a ‘gift’).

Risks for self-concept

The dangers of diagnosis to self-concept included self-threat (i.e., diagnosis as a threat to one’s view of self) and self-devaluation (i.e., diagnosis harming self-esteem). Within the self-threat theme, the researchers found that participants in 14 of the reviewed articles experienced strong negative emotional responses (e.g., shock, grief, distress) upon first receiving a diagnosis; some subsequently resisted or rejected their diagnosis.

Within the self-devaluation theme, present in 16 of the reviewed studies, participants were found to possess a negative view of self (e.g., seeing themselves as “inferior,” “inadequate,” “damaged and incomplete,” “unintelligent” and “undeserving of happiness”). Similarly disconcerting is the finding that youth in 11 of the studies reported that being given a psychiatric diagnosis “had restricted their opportunities in education, career, and relationships.”

Benefits for social identity

Benefits of diagnosis for young participants’ social identity included social identification, social acceptance, and social comparison. The theme of social identification is based on the finding that in 13 studies, young people indicated having gained a sense of social identity from their diagnosis, including valued connections with similarly diagnosed peers and improved relationships with former acquaintances and family members.

In some cases, participants stated that the diagnosis had contributed to improved interpersonal relationships (social acceptance theme). In others, diagnosis prompted individuals to make downward social comparisons (e.g., “I’m not as bad as the others here”) that served to boost self-esteem.

Risks for social identity

Risks for social identity included social alienation, social invalidation, and social stigmatization. Social alienation refers to young people’s sense of feeling “different” from their peers as a result of their diagnosis. For example, one participant stated:

“I kind of just feel, I feel like I am just marked. Like people just have, some people just kind of treat me different, and I don’t want to be treated different, I just want to be treated how I was.”

In some cases, this difference was reported to be seen by others as “abnormal,” or “weird,” and it resulted in social isolation, rejection, or victimization (i.e., bullying).

Another identified risk for social identity was social invalidation or others’ lack of awareness about or acceptance of the legitimacy of one’s diagnosis. Lastly, the researchers found reports of “direct experience of stigma” in 23 of the included articles. Participants experienced stigma from their peers, family, school officials, and the media, and dealt with this stigma in a variety of ways, including internalizing it, fighting against it, and avoiding it.

“Acknowledging the active, pragmatic ways children negotiate diagnoses and therapies is critical to ensure that debates about youth psychiatric diagnosis avoid perpetuating paternalistic views of children,” the authors write.

Limitations of the study include the disproportionate representation of “diagnostic populations” in the review (i.e. overrepresentation of those with ADHD and ASD diagnoses, and underrepresentation of those with psychotic, affective, and anxiety disorders), as well as “demographic imbalances” (e.g. imbalanced gender breakdown and the reviewed studies’ overall lack of explicit focus on racial, cultural, sexual orientation, and gender identity factors).

The authors call for future research that investigates which variables might help “predict adaptive and detrimental outcomes,” such as a child’s age, gender, familial and cultural characteristics, and specific diagnosis. Finally, they call attention to the complexity of responses to diagnosis documented in the review, which has important clinical implications:

“Deciding whether to give, seek or accept a diagnosis requires complex calculations that weigh up the costs and benefits it is likely to afford for a certain individual in a certain context. It is particularly important to raise awareness of this complexity among clinicians: while clinical rationale may remain paramount in diagnostic decisions, clinical outcomes will undoubtedly be compromised if a diagnosis impairs a young person’s self-worth or social relationships. Clinical benefits must therefore be balanced against psychological and social risks.”

 

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O’Connor, C., Kadianaki, I., Maunder, K., & McNicholas, F. (2018). How does a psychiatric diagnosis affect young people’s self-concept and social identity? A systematic review and synthesis of the qualitative literature. Social Science & Medicine212, 94-119. (Link)

23 COMMENTS

  1. I was “Diagnosed” myself as a young person. I recovered many years ago as a result of carefully not taking medication “suitable” for “Schizophrenia” – but I very nearly didn’t make it.

    I didn’t use the skills of Professional Mental Health workers to recover – because in the main, these people do not possess these skills.

    By Recovery I mean I no longer cost anything in Mental Health terms, and I was none the worse for this.

  2. If there is no human meaning behind dehumanising nominalism, diagnoses will be just a judgements. If someone give you a diagnose in nowadays meaning, it means he is using you. Materialistst and scientist are too stupid for using DSM. They are not human enough to use it, they condemned the true language of the psyche, they are just pretending they know something.

    We are talking about mythical reality and not the brain issues. And the mythical reality is condemned, because scientists claims that nothing exists beyond the brain. Like I say, Apollonians are slaves of the science and the brain, they want to judge rather than accept something which is beyond medical control – this is to preserve status quo of materialism. They do not accept psychological suffering/reality so they invented mental illness in biological meaning. The sad truth of psychiatry is that they do not believe in the power of EXTERNAL EXISTENCE OF PSYCHE, they think it is brain. They do not feel respect for that reality, they want to rule the small safe space – the brain/the meat – THEIR PROPERTY. The main aim of psychiatry is to believe in that reality and do everything they can for the resurrection of psychological man, it should be the main aim of psychological socialism, which will probably be phenomenon in history of the state. The one step closer to the fourth dimension of existence. I do not accept the low language of people who want to control meat, and refuse too admit the psyche is reality beyond human brain. Imagination is the aim of the soul, not of the brain. We are not animals because we can imagine things,and imagination is the fourth dimension.

    People whe believe in money more than in imagination, they want others to stay on the flesh level, because this is the guarantee of their profit.
    WE ARE MORE THAN FLESH, BECAUSE WE CAN IMAGINE, AND WE ARE BEING IMAGINED BY REALITY WE DO NOT own and CONTROL. The aim task of psychiatry is to resurrect that reality which was killed by apollonian ego cliams, theology, rationalism and so on. Psychological reality is a fact which is not sth the science can prove, because science is NOT ENOUGH, it is nothing without IMAGINATION/EMAPTHY LOVE AND THE BEAUTY WHICH IS THE PSYCHE MAIN TRAIT.

    James Hillman, Re-Visioning psychology should be a handbook for everyone who are thinking about the psychological socialism. We must learn that to serve the psyche is more important than making money in small FLESH /egoic world. The egoic kinds of development are not enough to build a human state, there is also psychological kind of development (todays indolence, impairement). And the highest possible form of PSYCHOLOGICAL human beings are autistics, THE LOWEST ARE EGOIC on the simple flesh level. And autistics as 100% psyche property, should have the status of inviolables gods, because if they won’t, scientists and the scientific parasites from the lowest flesh reality will DESTROY PSYCHOLOGICAL MAN FOR THEIR OWN PROFiT. For the profit of the meat.

    To change sth in psychiatry means to destroy authoritarians and create the society of REAL HUMANS, people who are thinking and talking about the psyche with RESPECT. It is all about the language and the MEANING OF THE mythical reality. Without the acceptance of the mythical reality with psychological hierarchy in it, which is abandoned now, even by psychologists, human are not humans, they are just a meat for the state. And to accept the psychological man means to accept the psychological work which is far more diffcult than simple apollonian ego reality.

  3. It is fascinating how this discussion completely avoids the subjective and speculative nature of these diagnoses as the major reason why their is a discussion of “to diagnose or not to diagnose.” Diagnoses shouldn’t be decided on based on how someone FEELS! They should be decided on by an objective observation of a specific problem that can be accurately identified and potentially intervened upon. No one talks about whether a “cancer” or a “flu” diagnosis has potentially positive or negative social consequences! When you have the flu, you have the freakin’ flu, and we all know what that means (more or less) and what your options are. It is only the subjective and frankly disrespectful and invalidative nature of these diagnoses themselves that lead to such questions. No one feels their identity enhanced or invalidated by a diagnosis of “cancer.” They might be able to connect with other cancer patients because they have something in common, but the diagnosis isn’t given for that purpose. It’s given so they’ll know what they’re up against and have some idea how to attack the problem. It is ridiculous to talk about the social benefits/costs of any real diagnosis. The fact that it is even a discussion for psych diagnosis indicates the complete lack of scientific validity behind the diagnostic process.

      • Loonier than Minnesota in the spring. Many shrinks could easily qualify as “Sociopaths,” “Narcissists,” and “Messiah Complexes” if they would subject themselves to “diagnosis.” But who will label a fellow shrink?

        My case worker accused me of Borderline Personality Disorder. She actually meets more criteria for it than I do. Meets guys in AA or bars and moves them into her house three days later. 😛 At least she did when I knew her.

    • Steve,

      Thanks for injecting a little common sense into this academia that departs to the far end of reality. It’s a sad display of the shoddy intellectualism graduate students are required to display before they get their job tickets. No wonder the field is in such sad shape.

      Best regards,
      Mary Newton

    • Psychiatry do not use diagnoses today, they are using only words without meaning.To use it you must know what is the psyche in human meaning. No one can say anything about the hand if the body is invisible. And the body of the psyche is something they reject. The science which destroyed the psychological world, refuse to admit that there are things beyond scientific measure. Without empathy and psychological/human truth diagnoses means nothing.

    • Actually, many diagnosis carry a stigma with them and have a weight in the perception of social self and identity. See the essay by Susan Sontang “Illness as Metaphor and AIDS and Its Metaphors”.
      In the realm of language, nothing is “immune” to the rhetoric, metaphors and their — very factual — consequences.

      • I agree with you – some medical diagnoses do have their own attached stigma. But I think psychiatric diagnoses are the only field where stigmatization occurs primarily BECAUSE of the label put on a person. “AIDS” is associated with being gay or being a needle-user and those categories are a primary the source of the discriminatory attitudes, although any communicable disease can certainly create anxiety and discrimination (remember leprosy!) My point is that in the realm of psychiatric diagnosis, this trend is avoidable by simply choosing not to toss the label at a person. A person with AIDS has AIDS, and there may be attached discrimination and prejudice, but the person gets the label because they literally have something wrong with their bodies that is observable and undeniable. But someone who feels anxious in social situations – well, they’re ANXIOUS, it’s a normal human emotion, and it’s not necessary to go out of our way to identify that person as “disordered” and bring on additional distancing and discrimination when we could to the opposite by reminding people that everyone is anxious sometimes and that it’s OK to be anxious and that we can all be sensitive to shy people and help create circumstances where they will feel more welcome.

        So yes, I get it, there are stigmatizing labels associated with medical diagnoses. But I see that as different from the CREATED stigma that result from the idiotic practice of labeling people’s behavior or emotions as “disordered” instead of trying to help the person or alter the social circumstances that create such anxiety/depression/distress in the first place.

        I hope that makes some sense!

        • Every diagnosis isn’t “diagnosed” though. Even normal (read not qualified/certified/equipped to diagnose) social workers and therapists must use dsm-5 terminology on all insurance claims and for all clients not paying cash. Otherwise rejected/refused/forced to resubmit,even if they just wanted to talk, are only entitled to 4 visits annually, or similar insurance restriction. Diagnoses are usually just made to cater to whatever policy covers the most hours insurance company of given patient allows. Anxiety and Depression are seen as lighter or less detrimental to peoples medical record but are forced on most practitioners that wouldn’t use them if they weren’t losing so many out-of-pocket clients now. With everyone required to have health insurance of some kind and doubled premiums while cutting benefits, most prefer using already paid for sessions in network. Anyway, it’s not exactly a choice NOT to label. I advise most don’t involve themselves or loved ones with trained professionals if you aren’t absolutely on the edge anyway, basically unless a life is in danger you are having a “1st world issue” and would be better to chat with friends and learn to develop patience.

  4. They didn’t get their hands on me until I was in my sixties and by that time I wasn’t going to be convinced by anything that they told me. I was lucky that I was so old and so set in my ways. And when it is all said and done, the staff of the unit where I was held told me when I became a staff member that they never accepted the diagnosis that came with me from the private hospital where I was held. I found that very interesting. But the damned label is still on my records, no matter what I do or say.

    I was diagnosed by a shrink who never looked at me during the fifteen minutes I was with him. He sat and scribbled on his little pad of paper, taking notes from the notes that my therapist had to give him. Finally, without looking up he asked me how I was doing. I said I wasn’t doing very well because I’d just been told the day before that my beloved and only sister had been murdered in New York City. I stated that it felt like the world was coming down around me. At that he finally looked up at me, lunged towards me across his desk with his finger pointing in my face and screamed “That’s stupid!”. This was the very first psychiatrist I’d dealt with in my entire life and at that point I decided he and the people running the system were the crazy ones.

    Kids don’t have a chance against these idiots and we’ve got to start doing something to protect them from the system and from the drug companies.