Get involved Eating Disorders Awareness Week Dr Anthony Natt THE LONG SHAMING SHADOW OF SELF-STIGMA I developed severe anxiety and associated depression when confronted by the challenges of family illness and medical school studies. Inexplicably, anorexia nervosa swiftly established itself as my coping strategy to negotiate these threatening aspects of my life. I overvalued its benefits and blinded myself to its increasing dominance and the damage it was causing me. Over the next 7 years, I concealed it from intervention, isolating me from care and support. Finally I sought help, more out of desperation than hope. 4 decades later, I can still recall the almost overpowering sense of guilt, shame and failure that accompanied this crucial first ambivalent, faltering step towards recovery. Early intervention in mental illness reduces suffering and favours more positive outcomes. However, sufferers often sense public stigma or experience prejudice and discrimination and then as now, healthcare and allied professionals were not immune to this culture of stigma. The experience of uncompassionate, judgemental engagement with such professionals by these sufferers has long been recognized to be particularly harmful to already fragile individuals – how much more damaging must it be to an already diminished self esteem and efficacy when the sufferer then condemns themselves in this way? Self-stigma develops when sufferers internalize these publically held attitudes or censor themselves even in their absence. Like public stigma this can swiftly progress from self-directed stereotypical thoughts to self-directed prejudicial beliefs to harmful or even fatal self-directed discriminatory behaviour e.g., social withdrawal, self-neglect, dependency syndromes, self-harm/suicide. The testimonies of those who have experienced mental illness often reveal how frequently self stigma compounds their suffering and inhibits the sharing of such painful information with those who might help and support them. More research is required into this under reported consequence of mental illness and significant, contributory cause of late presentations and interventions with poor outcomes. Neither does (self) stigma necessarily fade when recovery begins. Indeed, it also constitutes a potent barrier to recovery. I completed 7 months of inpatient treatment and left hospital in much improved health and fully committed to continuing out patient supervision to minimize the risk of relapse. Now I faced the challenge of occupational rehabilitation. Fortunately, a 6 months junior hospital post had been reserved for me by a supportive and far sighted consultant who I had worked for previously. He had anticipated the obstacles to occupational rehabilitation that I might face. Towards the successful completion of this post, I submitted well over one hundred applications with CVs responsibly detailing my past medical history and treatment – not one interview was offered. I was shocked that these written details of past but recovering mental illness eliminated me from further assessment. I had been a valued, well-qualified junior clinician prior to voluntary admission to hospital but these outright rejections communicated to me that I was now considered too great a liability. Recovery from mental illness is sufficiently challenging without painful recurring reminders of prejudicial judgements and/or frank discrimination which risk precipitating / perpetuating self-stigma and jeopardizing or compromising recovery. On my consultant psychiatrist’s recommendation I omitted the relevant medical history from my supporting CV, and the following applications all received offers of interviews. The first interview was successful and I promptly shared my medical details with the occupational health department to further safeguard my progress and 3 months later confided in my lead consultant who, despite my temporary subterfuge, reaffirmed his full confidence in me. 5 years later, I succeeded to a single handed general practice, but discovered I was considered uninsurable for all the mental health related illnesses covered by medical sickness insurance. It was only after a further 10 years without such cover or any evidence of mental health problems and the added responsibilities of a growing family, that such restrictions were finally lifted. This formal endorsement that I was indeed in recovery was both a significant personal and professional milestone for me and thereafter I enjoyed full cover until retirement 20 years later. In my first 5 years in retirement, I have lectured to a variety of undergraduate and postgraduate healthcare and allied professionals on behalf of a mental health charity, First Steps Eating Disorders. The verbal and written feedback from audiences consistently confirms that lived experiences are the most memorable and valued educational content of these presentations. Research also suggests that exposure to members of stigmatized groups effectively challenges and counters stereotypical thoughts, prejudicial beliefs and discriminatory behaviour. Affected individuals who feel comfortable to share their narratives may also experience benefit and progress in their recovery. Only those closest to me knew of my illness prior to retirement. The decision and ability to share such details with a wider audience marked a final transition from the long shadow of self-stigma to a brighter if much belated self-acceptance and means that this personal narrative need not now remain anonymous.