Recovery from social anxiety and related conditions.

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The primary difference between social anxiety and social anxiety disorder is the severity of symptoms. Not everyone is affected in the same way, as the intensity and duration of symptoms can vary greatly from one person to another. Even though these conditions may seem similar in terms of traits and features across different individuals, each person’s experience is shaped by their environment, life events, and the diversity of human thoughts and behaviors.

Furthermore, it is important to note that comorbidities—other mental health conditions that occur alongside social anxiety—are common. This highlights the complexity of social anxiety. Therefore, effective recovery strategies must address not only the causes and effects of the symptoms but also their associated conditions. Throughout this book, when recovery methods are discussed for social anxiety, performance anxiety, social phobia, and social anxiety disorder, they are meant to apply to each.

Anxiety and Depression in the LGBTQ Community

Abstract. Effectively establishing wellness models in mental health demands a fundamental change in language, power dynamics, and perspectives across the mental healthcare community and beyond.

Approximately 65 million U.S. adults and 18.5 million adolescents experience major depression and anxiety. Estimates indicate that 60% of those with anxiety also show depression symptoms, and both conditions often co-occur with substance abuse. The LGBTQ+ community is 1.5 to 2.5 times more likely to experience anxiety and depression than their straight or gender-conforming counterparts. Similar statistics apply to LGBTQ+ individuals with other mental and emotional disorders.

Anxiety and depression are leading causes of the 56% rise in adolescent suicide over the past decade. LGBTQ+ high school students are nearly five times more likely to attempt suicide than their heterosexual peers, and 40% of transgender adults have tried to take their own lives at some point.

Wellness should become the main focus of mental health because the disease model has been very ineffective. Instead of concentrating on disease and weaknesses, wellness models highlight character strengths and virtues that boost motivation, persistence, and perseverance necessary for recovery. Psychological science needs positive application through program integration, thorough evaluation, transparency, and proper information management. Empathy and communication must take precedence over etiology and misdiagnosis.

Wellness influences more than just mental health; it is a framework that also aims to promote complete physical, mental, and social well-being. This paper will demonstrate how the sociological focus of the wellness model on character strengths and attributes not only positively affects the self-beliefs and image of a person with mental illness but also aligns with sexual and gender-based identities and bodes well for the recovery and remission of an LGBTQ+ individual with a mental illness.  

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Introduction

To illustrate the potential impact of the wellness model, this paper focuses on LGBTQ+ individuals with anxiety and depression. “There is an urgent need to develop and disseminate tailored, evidence-based interventions that enhance 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 types of mental health issues affecting millions of U.S. adults who are trapped in a tightly connected cycle of fear and social avoidance. Johns Hopkins (2020) reports that about 25 million U.S. adults have depression, and 45 million experience anxiety. The numbers for adolescents vary between 8 and 18 million (CDC, 2020; NIMH, 2017); the actual figure is unclear.

Data are even less reliable for the LGBTQ+ community because large-scale mental health studies rarely include questions about 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 that the infection rate in the LGBTQ+ community is 1.5 to 2.5 times higher “than that of their straight or gender-conforming counterparts” (Brenner, 2019, p. 1).

Depressive illnesses often occur alongside anxiety and substance abuse (Johns Hopkins, 2020). “Some estimates show that 60% of those with anxiety also have symptoms of depression, and the numbers are similar for those with depression who experience anxiety” (Salcedo, 2018, p. 1). Anxiety and depression are major factors in the 56% rise in adolescent suicide over the past decade (Curtin & Heron, 2019). “High school students who identify as lesbian, gay, or bisexual are nearly 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).

The psychological and sociological impact of anxiety disorders can be overwhelming. Physically, anxiety can result in sweating, trembling, fatigue, and a rapid heartbeat, weaken the immune system, and raise the risk of heart disease. People with depression may go through a lack of interest and pleasure in daily activities, significant weight changes, insomnia or oversleeping, exhaustion, difficulty concentrating, feelings of worthlessness, guilt, and recurring thoughts of death or suicide.

Anxious and depressed individuals often perform poorly in social situations (Hirsch & Clark, 2004; Hulme et al., 2012) due to fear of being perceived as unlikeable, stupid, or annoying. As a result, they tend to avoid speaking in public, sharing their opinions, or even socializing with peers.

These symptoms can be suppressive and difficult to change, leading to irrational thoughts and behaviors (Richards, 2014; Zimmerman et al., 2010) that influence perceptions of personal attractiveness, intelligence, and competence (Ades & Dias, 2013). Over time, these self-beliefs turn into automatic negative thoughts (Amen, 1998) that shape initial reactions to various 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 influences 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 within their community and family supports. (Daw, 2001, p. 1)

Research shows that mental health culture is shaped by related factors like public opinion, media portrayal, family rejection, distancing, and diagnosis. LGBTQ+ culture is characterized by its sexual and gender identities, which are different from those of the heterosexual and cisgender majority (NAMI, 2020b). Smaller groups within the community include “a diverse set of groups, including distinct groups based on sexual orientation and gender identity” (Lewis et al., 2017, p. 861), each working to gain 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).

Transition

Working within a wellness model of mental health has become a key 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 emphasis on pathology in psychological research and studies, negative diagnostic labels, stereotyping and stigma, public and institutional resistance, and the power imbalance between doctors and clients highlight the need to shift to a wellness paradigm.

Firmly establishing wellness models in mental health requires nothing less than a reformation of language, power structures, and perspectives throughout the mental healthcare community and beyond. Instead of focusing on disease and deficits, wellness models highlight character strengths and virtues that promote motivation, persistence, and perseverance for recovery.

This paper does not advocate for a complete dissolution of medical model approaches, but a review of their effectiveness and the psychological impact of their pathographic dominance is strongly warranted.

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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 dominant psychiatric view for centuries. The pathogenic or disease perspective of diagnosis and recovery centers on a person’s history of suffering to aid in diagnosis. Schioldann (2003, p. 303) describes 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)

We only need the American Psychological Association’s (APA, 2020) definition of neurosis to understand the mental health community’s pathographic focus. The 90-word overview includes terms such as: distressing, irrational, obsessive, compulsive, dissociative, depressive, exaggerated, unconscious, conflicts, anxiety, and disorders. DSM-3 abandoned the word ‘neurosis’ in 1980, but it still remains the go-to term in the mental health community. Coined by a Scottish physician in 1776, neurosis was defined as a functional derangement of the nervous system. Pathography focuses “on a deficit, disease model of human behaviour,” whereas the wellness model emphasizes “positive aspects of human functioning” (Mayer & May, 2019, p. 159).

Studies and research show that the mental health care community is 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 it is also 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 often report instances where staff members were excessively rude or dismissive.

They mention coercive measures, long wait times, paternalistic or demeaning attitudes, treatment programs focused on drugs with undesirable side effects, stigmatizing language, and overall therapeutic pessimism (Henderson et al., 2014; Huggett et al., 2018). Clients with more serious complications or illnesses are often considered “difficult, manipulative, and less deserving of care” (Knaak et al., 2017, p. 2). Nurses and clinicians point to a lack of collegial support, inadequate knowledge and training, and the fear of client self-harm (Henderson et al., 2014), which leads them to over-diagnose and over-prescribe (Huggett et al., 2018).

Shifting from the disease model’s pathographic language to the hopeful and supportive language of wellness models is everyone’s responsibility in the mental health community―its institutions, associations, practitioners, researchers, media, and clients. Among clinical psychologists, there is a growing belief that empathy and communication should come before 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 shapes perspective, and linguists agree that the relationship between language and power is reciprocal (Ng & Deng, 2017). Language influences thought and behavior. Terms such as incapacity, deceit, unempathetic, manipulative, and irresponsible describe DSM-5 traits for various disorders. The point is not that these descriptions are invalid; rather, they are overwhelmingly negative and perceptually hostile. Based on public opinion, media portrayal, and mental health stereotypes and stigma, these words help shape how people with mental disorders are perceived (DeMare, 2016; Pinfold et al., 2005; Pryor et al., 2009).

Realistically, we cannot remove the word ‘mental’ from the culture. For 70 years, the disease model has been shaped by the Diagnostic and Statistical Manual of Mental Disorders. Unfortunately, the word ‘mental’ is a limited way to describe a disorder, and its negative connotations reinforce perceptions of incompetence, unworthiness, and undesirability. It is the main source of stigma, shame, and self-criticism. Psychologically, the word ‘mental’ frames a person or their behavior as somehow extreme or illogical. Adolescents often mockingly use the term for those who are unpopular, different, or socially awkward. The Urban Dictionary defines ‘mental’ as someone silly or stupid.

Hostile and demeaning language is widespread in mental healthcare, driven by the disease or medical model’s pathographic bias. This view influences public opinion, research, media portrayals, the doctor-patient power dynamic, community relations, and clients’ self-beliefs and self-image. Moving from the disease model to wellness approaches requires building a more balanced mental health perspective by addressing misunderstandings, misinformation, and the disease model’s heavy focus on diagnosis, disorder, deficit, and stigma. 

Misinformation stems from the psychological community’s difficulty in reaching consensus due to shifting 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 misconceptions are addressed by the universality, age of onset, and complementarity of mental illness, as well as by clearly distinguishing psychosis from neurosis. 

Universality 

A recent article in Scientific American suggests 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 typical aspect of natural human growth. One in four people has a diagnosable mental disorder.

According to the World Health Organization, nearly two-thirds of those who believe they have a mental disorder either reject or refuse to disclose their condition. Including those who deny or ignore their issues, we can conclude that mental disorders are widespread, affecting all groups, and have a universal impact.

Age of Onset

The origins of a disorder, according to Mayo Clinic (2019), is mainly due to early psychophysiological issues, although genetics and environment also contribute. Parental behaviors may be overprotective or controlling, or they might not provide emotional support (Cuncic, 2018). The affected juvenile could result from bullying, abuse, or coming from 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 face disproportionately high levels of verbal and physical harassment, as well as other forms of peer victimization (Berlan et al., 2010; Reisner et al., 2015). “Gender minority youth had approximately four times higher odds of experiencing any bullying or harassment in the past year” (Reisner et al., 2015, pp. 35-36).

Childhood and adolescent exploitation or abuse are general terms that describe a wide range of experiences disrupting a young person’s optimal physical, cognitive, emotional, and social development (Steele, 1995). Numerous situations or events can increase vulnerability; these may be hereditary, environmental, or a result of a traumatic incident (Mayoclinic, 2019; NIH, 2019). Statistically, the LGBTQ+ community faces “a higher risk than their heterosexual counterparts for traumatic life experiences such as childhood physical, psychological, and sexual abuse” (Bandermann, 2014, p. 3).

Although the words ‘abuse’ and ‘exploitation’ imply intent, a toddler may still feel abandoned and develop emotional problems when a parent is distracted (Lancer, 2019). The child or adolescent is not to blame for their issues; no one may be intentionally responsible. Similarly, scientific research supports that while sexual and gender identities may have a genetic or biological basis, they are not chosen, and LGBTQ+ individuals are not at fault; unlike mental illness, there is no accountable person involved.

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 that sexual and gender-based orientation is a choice.

Complementarity 

To early civilizations, mental illness was seen as caused by supernatural forces and demonic possession. Hippocrates and 19th-century diagnosticians focused on the relative levels of bodily fluids. Lunar influence, sorcery, and witchcraft are longstanding explanations. In the early 20th century, it was considered somatogenic.

The biological approach suggests that neuroses are linked to the brain’s physical functioning (McLeod, 2018), while pharmacology highlights chemical or hormonal imbalances. Carl Rogers’ study of how human system components work together to maintain physiological balance introduced the term ‘complementarity’ to describe their simultaneous mutual interactions..

All components of the human system must work together; they cannot operate independently. The interconnected interaction of all parts—mind, body, spirit, and emotions—is essential for maintaining mental health and recovery. This same mutual interaction is present in sexual and gender identities, just as it is in all individuals.

Psychosis versus Neurosis

When someone sees, hears, or responds to things that are not real, they are experiencing a psychotic episode. Although few people experience psychosis, everyone has moderate to high levels of anxiety, stress, and depression. A neurosis is a condition that negatively affects our emotional well-being and quality of life but does not necessarily disrupt normal daily functions. Since most mental disorders are neuroses, humans are all somewhat dysfunctional.

Language reveals power, reflects power, maintains existing dominance, unites and divides… and creates influence” (Ng & Deng, 2017, p. 15). The wellness model has a similar impact on the mentally ill and LGBTQ+ individuals. Replacing negative and hostile language with a positive dialogue of encouragement and appreciation fosters new perspectives that boost self-belief and self-image, leading to increased disclosure, discussion, and, in the case of mental illness, recovery and remission. The self-critical aspects of shame should fade; stigma becomes less intimidating.

Accepting that mental illness and sexual and gender identities are common and non-discriminatory should make it easier to discuss these topics within the family. Recognizing their closeness and general vulnerability should reduce the urge to distance or isolate. Accepting their widespread presence should help reduce prejudice, ignorance, and discrimination related to mental illness (Khesht-Masjedi et al., 2017; Pescosolido, 2013; Pinfold et al., 2005; Wood & Irons, 2017), as well as sexual and gender identities (Adamczyk & Liao, 2018; Dodge et al., 2016; Lewis et al., 2017).

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Resistance to Recovery

The term stigma-avoidance describes individuals who fear that public disclosure could lead to stigmatization and discredit. Statistics from the National Bureau of Economic Research show 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) indicates that only one-third of individuals with a disorder were in recovery or remission in 2017. Lower recovery-remission rates may be partly due to the inability to afford treatment, which is driven by anxiety-related financial and employment instability (Gregory et al., 2018).

For example, more than 70% of patients with social anxiety disorder are in the lowest economic group (Nardi, 2003). The LGBTQ+ community’s reluctance to disclose a mental disorder, seek treatment, or accept a diagnosis comes from the same reasons that lead to general hesitation: stigmatization, victimization, public opinion, media representation, family rejection, and the diagnosis itself

Stigmatization

Mental health stigma is the hostile expression of the extreme undesirability of individuals with mental health issues. Ninety percent of survey respondents with a mental disorder report being affected by mental health stigma (NAMI 2020a).

Stigmatization is deliberate and proactive, often characterized by overtones that aim to shame and isolate (Pryor et al., 2009). Revealing a mental disorder can threaten livelihoods, relationships, social status, housing, and overall 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 manifests in three categories:

• Tribal stigma devalues individuals.
• Moral character stigma suggests amorality and weakness.
• Abominations of the body stigma pertains to physical deformity or disease (Pryor et al., 2009).

Mental disorders are categorized in the last two groups. Ignorance links mental disorders to weakness or problematic behavior, while the medical model emphasizes the disease and deformity aspects. LGBTQ+ individuals face the added challenge that their sexual and gender identities are social and cultural constructs.

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 on 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 disproportionately subject to bullying, harassment, and other forms of 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 related to mental illness, the core of stigma lies in social acceptance. The public still widely endorses the image of the dangerous, unpredictable mentally ill person (Corrigan & Watson, 2002; Pinfold et al., 2005). Stuart and Arboleda-Flórez (2012) analyzed two surveys (1990/2006) on public perception. They 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 identities became significantly more accepting during the 1970s, with the biggest change seen 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).

People tend to be more supportive, partly because ‘gay men and lesbians are then seen as less responsible for their orientation” (Adamczyk & Liao, 2018, p. 4). An overwhelming majority (92%) of the U.S. LGBTQ+ community believes that “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 available to LGBTQ+ individuals depend on factors such as region, race and ethnicity, political beliefs, education, economic status, and religiosity (Adamczyk & Liao, 2018; Dodge et al., 2016; UW-Madison, 2020).

Religion is strongly linked to negative attitudes toward the legitimacy of LGBTQ+ “sexual behavior and marriage” (Twenge et al., 2016, p. 8). The level of intolerance varies by denomination and correlates with attendance frequency. Jews and moderate-to-liberal Protestants are generally more tolerant than Baptists, fundamentalists, and Catholics (Adamczyk & Liao, 2018; Schnabel, 2016). The Pew (2020) study indicates that 29% of LGBTQ+ individuals have felt unwelcome in a place of worship.

Heterosexual women consistently show 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 toward transgender people (Adamcyzyk & Liao, 2018; Lewis et al., 2017), while “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 reduce prejudicial attitudes and behaviors toward both the mentally ill and LGBTQ+ individuals. Contact-based education has become the most influential factor in shaping public attitudes and behaviors toward people with mental health issues (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 extended 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 being threatened or physically attacked, 21% experienced unfair treatment from an employer, and 58% were the target of slurs or jokes. Heterosexism functions at individual, family, institutional, employment, political, and cultural levels and is openly evident in educational, career, religious, and social environments.

While public opinion has significantly improved for the LGBTQ+ community, the perception of people with mental health issues as dangerous and unpredictable, who should be isolated, has not changed much in decades (Stuart & Arboleta-Flórez, 2012). A main goal of wellness models is to reduce mental health stigma by shifting public perceptions. 

Media Representation 

A 2011 study showed that nearly half of U.S. media stories about mental illness mention or hint at violence (Pescosolido, 2013). News and social media, driven by far-right politics, fundamentalism, and fringe groups, contribute to discrimination and bias. Analyzing films, TV shows, and tabloids reveals three common myths: people with mental illness are dangerous maniacs, they have childlike perceptions of the world that should be admired, or they are rebellious, free spirits (Corrigan, 2006).

Portrayals of sexual and gender identity in the second half of the 20th century were mostly stereotypical exaggerations. “Beginning in the 1990s, some highly likable gay and lesbian TV and media characters started to appear” (Adamczyk & Liao, 2018, p. 10). Still, many gay-themed portrayals aim to shock, betray, or titillate. The media often promotes images that harm the self-esteem and image of LGBTQ+ and mentally ill people.

Family Rejection

Family stigma involves rejecting an LGBTQ+ or mentally ill child or sibling. A 2008 review found that about 38% of family members “attempt to hide their relationship to avoid bringing shame to the family” (Stuart & Arboleda-Flórez, 2012, p. 8). Another study showed that 34% of LGBTQ+ individuals reported rejection by family, 49% faced unfair treatment, and “52% were subject to anti-gay remarks from family members” (Bandermann, 2014, p. 3).

The sense of family rejection can negatively affect both mental health and self-esteem, which can be more life-limiting and disabling than the illness itself (Stuart & Arboleda-Flórez, 2012, p. 3). “The experience of rejection magnifies the difficulties of living with psychiatric distress” (Gray, 2002), potentially leading to mental and physical health problems, substance abuse, and addiction.

Etiology and Misdiagnoses

Etiology and diagnosis shape the disease model. Which disorder do people find most repulsive, and which presents the greatest threat? What behaviors contribute to the disorder? How progressive is it, and how effective are treatments? (Corrigan, 2006). It is crucial to understand how these beliefs influence public perception, treatment choices, and client self-image.

Until the 1950s, most homosexual individuals studied by psychologists and others were prisoners or mental patients, making it easy to link the two. In 1973, the APA declared that homosexuality was no longer classified as an illness. DSM diagnostic criteria have changed significantly from one edition to the next. Lynam and Vachon (2012) highlight 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 listed in the DSM-II in 1968 evolved into social phobia in the DSM-III (1980), and later became social anxiety disorder in DSM-IV (1994), earning it the nickname, the ‘neglected anxiety disorder.’

Revisions, substitutions, and contradictions among DSMs are never universally accepted. Even with a knowledgeable and caring clinician under optimal conditions, it can be challenging to obtain an accurate mental disorder diagnosis. Besides the nine types of depression, four anxiety disorders, and eight obsessive-compulsive disorders, the current DSM lists five types of stress responses and ten personality disorders, each sharing similar traits and symptoms with varying degrees of severity.

Bipolar 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 include major depression, panic disorder, posttraumatic stress disorder, and alcohol abuse or 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).

Self-Esteem

Maslow’s (1943/1954) hierarchy of needs illustrates how childhood disturbances can disrupt natural human development. Healthy growth depends on satisfying essential physiological and psychological needs. Experiences of detachment, exploitation, or neglect may prevent individuals from meeting their physiological and safety needs or the need to belong and feel loved, which can hinder the development 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 people with depression and anxiety indicates that 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 lower self-esteem, are more isolated, and receive less support than those accepted by their families (House, 2018). 

Self-esteem shapes a person’s relationship with themselves, others, and the world. It acts as an umbrella for all positive self-qualities that support healthy functioning, such as self-respect, resilience, efficacy, reliance, compassion, value, worth, and other intrinsic wholesome attributes. Self-esteem affirms that one is important and deserving of love.

 A grassroots poll by Unite UK (2016) found that 62% of LGBTQ+ individuals believe they have low self-esteem. Exposure to historical alienation, ambiguous public opinion, adolescent bullying, heterosexualism, and other harmful influences can, over time, affect an LGBTQ+ person’s self-beliefs and self-image.

Recovery

Recovery is a personal process. Humans have unique DNA, diverse sensitivities, memories, and abilities. One-size-fits-all methods are inadequate to fully address the complex and individual nature of a person’s personality and their specific needs. Mental illness is widespread and does not discriminate; dysfunction affects people from all walks of life. Additionally, “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 flexible, integrating multiple traditional and non-traditional approaches developed through client trust, cultural understanding, and therapeutic innovation.

Any analysis must consider the subject’s environment, hermeneutics, history, and autobiography alongside their wants, beliefs, and aspirations. Otherwise, the complexity of personality is not appreciated, and the treatment becomes insufficient.

Positive Psychology and the Wellness Model

In 2004, the World Health Organization started promoting the benefits of a wellness perspective, defining health as “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 highlight, “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 primary driver of the wellness model is positive psychology (PP), which began with Maslow’s (1943/1954) influential works on humanism; APA president Seligman endorsed it in 1998. Positive psychology and other optimistic methods emphasize the natural 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 goal 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 strive to realize their potential and become the best they can be.

Research supports using positive psychological constructs, theories, and interventions to improve understanding and 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 field of positive psychology continues to develop evidence-based interventions that aim to evoke positive feelings, thoughts, 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 initial challenges of positive psychology was its neglect of the negative aspects of character. Recognizing this, psychologists promoted a more holistic approach that includes the dialectical opposition of human experiences. As one psychologist stated, “people are not just pessimists or optimists. They have complex personality structures” (Miller, 2008, p. 598). Positive Psychology 2.0 (PP 2.0) was developed as a response to the narrow focus on optimism, adopting a more inclusive and balanced outlook (Rashid et al., 2014).

The disease model of mental health views recovery as the remission of symptoms or the reduction of significant interference or limitations (ADAMHA, 2012; Salzer et al., 2018). In contrast, the wellness model asserts that individuals with a mental disorder can lead satisfying and fulfilling lives regardless of symptoms or impairments related to their diagnosis (Slade, 2010).

Schrank et al. (2014) describe recovery as people “(re-) engaging in their life based on their own goals and strengths and finding meaning and purpose through constructing and reclaiming a valued identity and valued social roles” (p. 98).

By focusing on wellness rather than dysfunction, the positive psychology movement seeks 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) and has declared that traditional psychiatric diagnoses have outlived their usefulness (Kinderman, 2014). NIMH is transforming diagnosis based on emerging research data and the doctor-patient communication dynamic rather than on 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 wellness, recovery remission is the sustained, long-term alleviation of symptoms. Wellness influences more than just mental health; it is a paradigmatic approach that aims to promote a state of complete physical, mental, and social well-being. Its sociological focus on optimal human functioning, designed to counter the pathographic emphasis of other models, not only positively affects the self-beliefs and image of a person with mental illness but also resonates in sexual and gender identities and suggests a hopeful outlook for the recovery and remission of an LGBTQ+ individual with mental health challenges.

There are many approaches to recovery. Psychology author Farreras (2020) cites 400 different schools of psychotherapy. Mayer and May (2019) describe current positive psychology as “a balanced, interactive, meaning-centered and cross-cultural perspective” (p. 156) that considers equally “positive emotions and strengths and negative symptoms and disorders” (Rashid et al., 2014, p. 162).

Positive psychology works best when combined with other programs, and its mental health interventions have been successful in reducing 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 can be valuable additions to targeted interventions. Behavioral exercises improve the practice of resilient and generous social skills. Positive affirmations also hold significant subjective value. Evidence supports mindfulness and acceptance-based approaches to re-engage and foster positive thoughts, feelings, and memories.

Castella et al. (2014) propose motivational enhancement strategies to help clients overcome resistance. Ritter et al. (2013) highlight the benefits of positive autobiography in countering destructive thoughts and behaviors. The significance of thoroughly examining the nuanced and unique dynamics in the relationships among emotional expression, intimacy, and overall relationship satisfaction for dysfunctional individuals and LGBTQ+ persons should be recognized (Montesi et al., 2013).

However, this paper avoids throwing out the baby with the bathwater, suggesting that the current diagnostic system should be part of a more comprehensive analysis that includes communication and highlights the character strengths that foster motivation, persistence, and perseverance toward recovery and remission. All “patients with mental disorders deserve better” (Insel, 2013, p. 2).

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INDIVIDUAL RECOVERY. The symptoms of social anxiety make it challenging for some to participate in a collective workshop. Dr. Mullen works one-on-one with a select group of individuals uneasy in a group setting. ReChanneling offers scholarships to accommodate the costs. What is absent in group activities is provided in our monthly, no-cost Graduate Recovery Group. In this supportive community, graduates interact with others who have completed the program.  Contact ‘rmullenphd@gmail.com’.        

Committing to recovery is one of the hardest things you will ever do.
It takes enormous courage and the realization that you are of value,
consequential, and deserving of happiness.