Traditional theories of crisis propose that crisis may emerge when people are disturbed from «emotional homeostasis» by external hazards which disrupt the individual’s coping ability (Caplan, 1964). From this point of view crisis is described as leading to personal growth and development of new coping strategies through social interaction. This theory has been criticized for not being applicable for people with severe mental illness as the mental health crises experienced by these persons are often associated with the underlying mental illness, following through different patterns of experiences and trajectories and having different characteristics (Callahan, 1994).

Mental health crises tend to be an iterative process and are characterized by dissimilar needs for the type and length of help (Ball, Links, Strike, & Boydell, 2005; Brennaman, 2012). Bridgett and Polak (2003) describe a crisis as a «failure in adequate coping in relation to acute mental distress». An emphasis here is placed on the social conditions and a person’s everyday life contexts, such as social and economic status and social networks, as exerting an impact on crisis experiences (Borg, Karlsson, Lofthus, & Davidson, 2011). This view is in accordance with a social perspective on mental health in which a crisis is also viewed in a social and contextual perspective, with an assumption that everything in our life affects our situation and development of a social identity (Horwitz, 2002; Szasz, 2007).

Overcoming and dealing with a crisis situation is influenced by several factors, such as individual resources, beliefs and values, social relationships, impression of one-self, and general everyday life situations (Bridgett & Gijsman, 2008; Hoff, 2001; Tew, 2005; Winness et al., 2010). Integration into society on different levels through significant and valued normal roles is critical in recovery from mental health crises and to avoid stigmatization and deviance (Borg et al., 2011; Corrigan, 2005; Deegan, 1988).

Historically, the major social attitude toward mental illness has been stigmatization. Stigma is referred to as «a sign of disgrace or discredit that sets a person apart from others» (Goffman, 1963). This suggests that stigma is about an identity, and seeing others or experiencing oneself as being deviant or «abnormal» according to the current dominant norms and values in the culture and society in which one is situated. Deinstitutionalization of mental health care and prominence of community-based mental health services, with an emergence of recovery-oriented services, social network treatments and anti-stigma programs, have highlighted the experiences of mental health crises in everyday lives and in the public arena (Rüsch, Angermeyer, & Corrigan, 2005). While this has resulted in the demystification of mental illness and a greater public understanding of mental health in the recent decades, discrimination and marginalization through stigmatization are still well-known phenomena and the stigmatization of mental health crises seems to prevail in current social situations (Jenkins & Carpenter‐Song, 2008; Johnstone, 2001; Stuart, 2008; Topor, Borg, Di Girolamo, & Davidson, 2011; World Health Organization (WHO), 2010).

The identity of normalcy («normality») is defined and constituted in societies through formal and residual rules and norms (Becker, 1973; Scheff, 2007; Thoits, 1985). The process of stigmatization, both public and self-stigma, involves three parts: stereotyping (negative belief), prejudice (agreement with belief), and discrimination (response to prejudice) (Corrigan & Watson, 2002). This process in relation to mental health labelling, often based in misconceptions, is revealed in the attitudes and behavior both by the service-users, people in general and mental health providers, as well as in the media (Flanagan, Miller, & Davidson, 2009; Lauber, Nordt, Braunschweig, & Rössler, 2006; Rao et al., 2009; Ssebunnya, Kigozi, Lund, Kizza, & Okello, 2009; Thornicroft, Rose, Kassam, & Norman, 2007).

Stigmas as a result of these processes are complex phenomena which can strongly impact on the persons’ lives. Research on stigma in mental health identifies this phenomenon as an obstacle for social integration of people struggling with disabilities (Björkman, Svensson, & Lundberg, 2007; Link & Phelan, 2001). Stigma often obstructs access to valued roles in the society through prejudice and discrimination leading to segregation, oppression and ostracism in various arenas in social life, both in work and leisure (Björkman et al., 2007; Corrigan, 2004; Corrigan & Watson, 2002; Thomas, 2004; Topor et al., 2011; World Health Organization (WHO), 2010).

Sociological theories have focused on the process of development of self and social identity for decades, the one key theoretical perspective being symbolic interactionism (Roe, Joseph, & Middleton, 2010). In the perspective of symbolic interactionism the «self» is a construct having specific meanings gained through interpretations embedded in social interactions with significant others, and social identity emerges from the self as reflected in others gained through social interaction (Mead, 1913, 1934).

The central concept in symbolic interactionism and the development of a person’s social identity is the notion of a «looking-glass self» (Cooley, 1902). This means that the shaping of self and social identity develop in social processes and through the experiencing of oneself as a normal and significant person in relationships with others or being labelled as a deviant if the behavior is not appropriate to structural circumstances as residual rules and norms in the specific society (Becker, 1973; Corrigan, Markowitz, & Watson, 2004; Mead, 1913; Scheff, 2007). Individuals see themselves through the eyes of others, even to the extent of incorporating others’ views into their own self-concepts; if providers, family, friends, and people in general label a person as mentally incapacitated, the person may come to perceive him- or herself that way and behave accordingly (Jenkins & Carpenter‐Song, 2008; Norvoll, 2013).

In this regard being in mental health crisis situations might lead to experiencing oneself as deviant from what is defined as «normal» and bring about more manifest marginalization and social exclusion (Corrigan, 2005; Giddens & Sutton, 2013; Scheff, 2007). While the literature is rich in describing social processes of stigma for mental health, there is a paucity of this phenomenon from the personal perspective. In this study it has been of high importance to promote the subjectivity of the informants.

The following research question was explored: What are the subjective experiences of mental health crises and being a service-user in relation to social identity and social relationships? The focus of our attention is on people who struggle with long-term mental health problems and repeated mental health crises.

Methods

The study is a part of the research project, «Crisis Resolution and Home Treatment (CR/HT) in Community Mental Health Service: Development, Practice, Experiences» (Karlsson, Borg, & Kim, 2008), and is a qualitative study applying in-depth interviews to address the research aims. The context of the study is a Norwegian county. In an area with a population of approximately 150,000 inhabitants and is rural with the exception of a town of 70,000 inhabitants.

The purpose of the study is to gain insights into the first person knowledge about mental health crisis and social identity. The nature of the method used implicates that the findings were from a small sample of people who had experienced mental health crisis and described their experiences of the implication for and changes in their social identity. The findings provided in-depth understandings of the phenomena and the participants’ own life world, which is the essence of the phenomenological-hermeneutical method (Lindseth & Norberg, 2004).

Participants. The purposeful selection of study participants was carried out from February 2008 to August 2009 among mental health service-users of one specific CR/HT team in Norway. All service users were adults over 18 years. The selection was accomplished by the chief psychiatrist at the CR/HT. The inclusion criteria were: (a) severe mental illness according to scores on the Global Assessment of Functioning (GAF), with a score below 50 (American Psychiatric Association, 1994; Hall, 1995); (b) at least two contacts with a CR/HT team, but no recent contact during the previous three months before receiving the invitation to participate in the study; (c) at least one inpatient treatment in an acute psychiatric ward during the past three years; and (d) no admittance to inpatient acute services during the past six months.

We first identified those service users of the CR/HT team who have made at least two contacts in the past but not within the past three months before the recruitment. A total of 381 persons received help from the CR/HT during the period, and of those 161 service users were identified as potential participants in the study. After applying the inclusion criteria (a, b, c, and d), 30 persons were identified and contacted by mail which included an information letter, a responding letter with informed consent and a stamped envelope. Seven persons accepted. One man and six women, between the ages of 34 and 74 years participated in the interviews. All of them experienced mental health illness and crisis for several years and had comprehensive knowledge about living and coping with the life challenges of an iterative mental health crisis. We have no information from the 23 persons who rejected the invitation regarding their reasons for non-acceptance. Furthermore, given the dominance of female participants, we acknowledge the possibility of a variation of experiences by gender.

Ethics – approval and considerations. The study was approved in advance by the Regional Committee for Medical Research Ethics, Eastern Norway Regional Health Authority (S-07329a). The participants were given both written and verbal information before agreeing to participate. The interviewer was aware of the informants potential vulnerability both in the interview situations and afterwards. Therefore, the participants were informed about the opportunity to contact the crisis resolution team or interviewer if necessary. Nobody used this opportunity as far as we know. All names of the participants given in the findings are pseudonyms chosen by the first author. The participants were given the opportunity to read the written interviews, but none of the participants took up this option.

Data collection. This qualitative, explorative study is based on in-depth interviews following a semi-structured guide (Kvale & Brinkmann, 2009). The interviews began with the opening question «what do you consider that a mental health crisis is about?». All interviews were carried out as conversation, and the guide was used as a check list in the last part of the interview to ensure that all planned topics were mentioned. The aim was to explore reflections on the experiences of mental health crises, social relationships and social identity from the service user’s perspective, using the following questions as the lead-in questions in the interviews:

• Can you say something about how mental health crisis experiences impact your relations to others? (partner, children, parents, sibling, friends and colleagues)
• Can you say something about your meetings with the mental health services?

Each participant made the decision about where the interview should take place. Five wanted the interview to take place in their homes, and two interviews were carried out at the interviewer’s workplace in a neutral meeting room.

Analysis. Following the description of analysis by Kvale and Brinkmann (2009), as the first step the transcribed texts from the interviews were systematically read through in a naïve manner several times by the first author. The aim, according to the phenomenological-hermeneutical method, was to grasp and interpret the participants’ descriptions and patterns of their lived experiences with social identity and stigma attached to mental health crises. This naïve reading and first interpretation can be based on Ricer’s philosophy of hermeneutic, which emphasizes that there is a dialectic movement between understanding and explaining the data-material (Ricoeur, 1976). This was done with as much reflexive, open-minded and inductive reading as possible, as well as grasping the intuitive sense of the meaning of the text as a whole. This also led to the next step in the process of analysis, the structured review of the transcribed interviews. Following the initial in-depth reading of the interview texts, meaning units according to social identity, social relations and crisis were identified. Then the meaning units were categorized and grouped together to identify important themes for the participants (Table 1). The themes in the analysis arose in an iterative process between reading and interpreting to help find meaning units and then themes according to the research question (Kvale & Brinkmann, 2009; Pope, Ziebland, & Mays, 2000). The first author conducted the analysis and reflected on the findings with the third author. Author two contributed with comments to the writing of the background and the discussion, and revised the paper.

Findings

Explicit in the findings is the experience of the existence of stigmatization attached to mental health crises and mental «illness». During the interviews the participants revealed that a consequence of their experiences of mental health crises was that they often felt isolated and excluded in different ways from both public and private arenas. The informants described situations of stigma as having a serious impact on their everyday lives in various ways. Family, close friends and an extended network of colleagues and mental health providers were mentioned in relation to these. Common for the participants was that they felt a huge difference in how they saw themselves in social contexts before and after a mental health crisis, and how they perceived others viewed them socially.

The experience of being looked down on. The main theme, «the experience of being looked down on», was identified based on the following four sub-themes in the analysis: «once mentally ill, always mentally ill», «labelled by oneself», «labelled by social networks» and «labelled in mental health services» (see Table 1).

It is difficult, very difficult being mentally ill (…) because you get looked down on… I will never… I believe, I hope I can do it, but I think I will never say that today a somatic or mental illness is the same. It’s just nonsense, really nonsense, that people look down their noses at people with such problems.

This statement reveals the experience of one participant in this study regarding his social identity as a person who has experienced a mental health crisis.

1. Once mentally ill, always mentally ill. The participants have experienced iterative mental health crises over the years. For some of them this indicates that it is difficult to get away from the role of a mentally ill person. Sarah experienced that the problem was that people around her thought that «once mentally ill, always mentally ill»:

(…) even if things have improved, I think, in recent years in relation to mental illness, that there is more openness about it, which there is, probably, but still a lot of taboos and stigmas associated with it. That is, one time mentally ill, always mentally ill. (…) Like if you have a depression when you’re 25 and have another when you’re 45, then it’s sort of like «yeah, well, I remember that she was ill, and she has probably been ill all the time», but if you catch the flu when you’re 25 and again when you’re 45 nobody will say that you have a chronic flu. Right?

Sarah said that she was highly embarrassed by her mental health state over the years and wanted not to be seen as a mentally ill person. She was really ashamed of it and worked hard to hide it from her family, friends and colleagues to get rid of the stigma.

Nora experienced a change from being a proud employee with an adequate education, which was of great importance to her, to becoming insecure and struggling with how to act and present herself in various social contexts throughout the years of her life from the time of her first mental illness episode to the present age of mid-seventies – and maybe for the rest of her life:

I should be defeated since you get fired that way. (…) I was shocked to be straightforward. I was incapable of acting. I was out of my self and could not talk with anybody about it. Yes, not any human, they would not believe it. It was the worst thing you could do to me; it was like breaking my back, so I could not keep my back up.

Nora never started to work again after this process, and the consequence of this was the loss of a critical social network and years of struggling with loneliness.

2. Labelled by one-self. Low self-esteem and the feeling of not being «normal» were described by the participants. Philip experienced in general that it is difficult to suffer a mental illness and hard to be pictured as a person with those kind of problems. He felt that being mentally ill was something totally different from having a somatic disease. He stated that he was ashamed when he had a beer in a public place, and mentioned this situation from last summer.

We were going to a concert, my wife and I, then my wife says: «Fancy a pint?». (…) So I sit there with my pint, and I start thinking: «Good Lord, if anyone should see me now», me with my disability pension, problems with the upstairs compartment and then he sits there drinking.

His social life and experience of self-identity changed following the crisis. He used to enjoy having a beer with his friends, but now he felt that was not a proper thing to do anymore. Cathrine stated that contempt was the best word to describe her experience; she did not respect herself because of her mental health crisis and said so.

Yes, it is mostly characterized by the contempt I feel for my own weakness, and that I am very angry at myself, because, there it…, yeah there it happens again, I am so hellishly weak.

Cathrine described that while she was in the mental health crisis, she felt weak and that this led to a loss of respect for herself.

3. Labelled by social network. This theme is based on the informants’ interpretations of how people acted and felt toward them in relation to mental health problems. Philip felt that people he had been in good relationships with previously now looked down on him because of the mental health crisis, mentioning one concrete situation in which he and his wife met a friend while they were out walking.

(…) I’ll tell you one thing, I had a colleague, we met him in town; my wife, me and him are standing there, and he’s talking to my wife for at least 10 minutes, without speaking a word to me.

One of his coping strategies to avoid the feeling of being labelled by his acquaintances was for him and his wife to travel abroad, which made him feel safe.

Yeah, we spent a week on the Costas. It worked real fine. And then I think, like, how come that I feel real good when I’m down there and not when I’m at home? And I’ve found out that it’s because of the sense of security that I had when I was down there. An’ I could just walk around, didn’t need to be afraid of looking around, or of meeting other people I knew.

Sarah thinks that people do not in general understand what it means to have a bipolar disorder and how it affects people’s lives both personal and social. She pointed out that she might experience prejudiced because she has a bipolar disorder.

(…) I think that not very many people know what it is, and that it sounds a little scary. (…) It’s sort of how you have to face up to … some strange looks and people scrape their feet and start speaking of something else when you … or like when you’ve been on sick leave people ask: «So why are you on sick leave, then?» (hawks) «Ehh, well, I have a mental illness…», then just «Yeah», and then they change the topic. That it … it is, I’ve seen it many times, and there are many others I’ve talked to whom also, then, people sort of go silent. (…) And then people don’t know.

Being labelled as mentally ill by others may also lead to social isolation. Lisa used to love her social life, and several evenings during the week she was at concerts, pubs and restaurants. She told about a particular restaurant she used to go, which she knew the people working there. She now felt that she could read their lips, and that they were almost pointing their fingers at her.

I don’t go… I don’t go out anymore, (…) I can’t bear going to concerts anymore, I can’t bear anything. Because I … uhh (sighs heavily) everybody’s going to look at me now, they stand there murmuring and whispering, because people are just like that.

Lisa felt stamped and had withdrawn from the social arenas she previous inhabited, hence her peripheral network was considerably narrowed because she felt that they looked down on her. She pulled back from her network when she felt most down because she did not want to be looked down upon.

4. Labelled in mental health services. Another finding is about the experience of being labelled by mental health service providers in the context of being a «mental health patient». One should expect understanding and caring from mental health professionals and the mental health services, however, this is by no means always the case. For instance, Nora felt she was not being taken seriously or competently at all in the mental health hospital unit. During one admission, she fell and broke her leg; nobody believed her and it took several hours before she was taken to the emergency unit. When she was finally transferred to a somatic hospital, she had the same feeling of not being trusted, and that she was seen as an incompetent person.

And I was laying there in bed and I knew it was broken. (…)(a nurse asked) «Are you sure it’s broken?» (Imitates the voice) «What do you think?» I said, but I came from the mental health hospital, y’ know, so they all thought I was a nutter, right.

Nora also experienced that the staff overlooked her in conversations about her condition, excluding her in discussing about her situation or experiences.

(…) And the worst thing is when people don’t speak directly to me, but when people just talk between them. So that’s what it was, then. Yeah, they talked a little around it and said some diagnoses and stuff.

Jane also told about an experience of being looked down on and not being taken seriously by service providers.

A bad experience is when someone talks bad to me in a sarcastic manner – degrading – such as the last time I spoke with the social service guard.

Cathrine described that she felt labelled when she was admitted to the mental health hospital, feeling humiliated by the fact that she was not handling things well and by the feeling that the staff degraded her because of her mental health crisis.

(…) I don’t like going to a therapy in a hospital, I never liked it. (…) It was, like, then you feel even sicker and labelled when you go there. (…) And to me that’s just like labelling people on the forehead, saying that «oh well, you can’t function in daily life, so now we’ll cook for you and arrange things for you». (…) To me it becomes a sign that you’ve quit, because you give up your own independence, then you’ve just lain down to die.

Emma experienced the attitudes of the providers, as if they saw her as deprived and a kind of subordinate. She had a series of uncomfortable encounters with professionals and systems that in the end made her feel small and unworthy. She also felt that normal people are not treated as nicely as people with a mental health crisis, which gave her a feeling of being patronized.

For we are a bit different, that’s why we have like 10,000 people around us all the time, so if I cry out loud as so, then yes … yes, well, we’ve allowed a ton. And I think that it’s not good then. For that feeds into the self-centered mindset that we have in place (…).

Emma felt that because she was labelled as depressed it made her feel worse, especially since the network she was in treated her in a way that allowed her to become a patient and maintain the role as a patient.

Discussion

The findings extracted in the four sub-themes, «once mentally ill, always mentally ill», «labelled by one-self», «labelled by social networks» and «labelled in mental health services», indicate two sets of intertwined meanings that the participants express in relation to their experiences of mental health crises in the context of their social life – identity and stigma.

Identity is the concept self-formed from how the informants felt they were treated by others in the community and in mental health services as being different, inadequate or unwanted. Stigma is about how they constructed experiences in relation to their mental health status to have a socially «undesirable» label, which gets tied to self-identities. The findings reveal that the participants experienced their social and treatment encounters involving stigma and labelling, while at the same time also attributing self-stigmatization in mental health crises. From the perspective of symbolic interactionism and the theory of «looking-glass self», individuals’ social identities become established through social interactions and at the same time are the base with which social interactions are shaped.

Goffman (Goffman, 1961, 1963) suggests that stigmatization and social labelling related to mental illness are the results of a social process in which the individual often passes through a re-socialization process during experiences of crisis, treatment and hospitalization. This means that social identities of persons with mental illness are often likely to be affected and structured by stigmatization and labelling that occurs through a variety of social interactions, including mental health services (Gove, 2004). Since social identity is structured by both self-concepts and concepts of the person by others that are revealed in social interactions, stigmatization and labelling occur not only by others in social relations but also by selves.

Self-labelling and labelling by others were evident in our findings. All participants in our study described how they saw themselves in relation to the mental illness experiences and how they perceived others viewed and interacted with them. A challenge for the participants in this study was that they both experienced labelling themselves and being labelled by others, which made it difficult for them to deal with and feel comfortable in social situations. Social injustice as a deprivation of access to social roles, and not being accepted in the community as a respected citizen can be a part of the problem, thereby sustaining the labelling and stigma. This represents a deprivation of the opportunity to be included in different levels or groups in society. For example, Philip avoiding having a beer in a public bar, Nora losing her job, and Lisa keeping herself isolated from most social activities. These also support findings from other research, which states that experiencing and living with a mental health crisis, mental health illness or other disability are characterized by the feeling of being labelled and excluded from significant groups (Deegan, 1988; Ekeland & Bergem, 2006; Kleinman, 2009; Link, Struening, Neese-Todd, Asmussen, & Phelan, 2001; Shakespeare, 2006; Topor et al., 2011; Wahl, 1999, 2012). Since the social process seems to enhance the sustaining of stigmatization and labelling that have a negative impact on the quality of social life for individuals with mental illness, there is a need to develop ways to impede such processes.

Recovery research reveals that overcoming stigma and environmental barriers is as important as dealing with symptoms of the mental health distress (Borg, 2007; Onken, Craig, Ridgway, Ralph, & Cook, 2007). The recovery perspective in which developing skills to maintain and develop an identity connected to valued life roles and maintaining practical and social routines on arenas for work and leisure is one approach to support individuals who experience mental health crises to overcome stigmatization (Davidson, 2005). Although labelling or being diagnosed as having mental illness has been associated with beneficent consequences such as protection and help, there are various ramifications that are detrimental to service users as found in this study. Nora’s complaints of a broken leg were not believed by the mental health care professionals, while Jane, Emma and Cathrine experienced that the providers’ attitudes and use of language kept them in their roles as patients and in a dependent position.

The concept of total institution (Goffman, 1961) does not apply in the current context, as the dynamics of social interactions between service users and mental health professionals are different in community settings from those in in-patient services. The shift in the philosophy of mental health care with a focus on relationship-building, contextualization and recovery orientation may also influence the experience of service users in relation to social identity differently from those in institutional care settings. The recent developments in community-based services such as Crisis resolution/home treatment teams (CR/HT) may be able to strengthen the focus on the everyday and social life of persons in mental health crises, helping to enrich their social lives. CR/HT teams can be an important part of services for people in mental health crisis, both to encourage their roles as «normal» and to avoid hospitalization as much as possible. Even if there are changes in location and organization of mental health services, there is still a risk that structural and institutional discrimination including policies, culture and knowledgebase will continue in new contexts as well (Corrigan et al., 2004; Ekeland, 2011).

During the experience of mental health crisis, loss of practical activities and social support can lead to internalized stigma followed by feelings of shame, emptiness, loss of self-esteem and loss of meaning. In the community, a pervasive public stigma can lead to social avoidance and exclude the individual from getting social roles which are valued in social life (Corrigan & Watson, 2002). This can sustain the feeling of being discriminated against both for the individual, the family and others in the network (Buizza et al., 2007; Heath, 2005; Onken et al., 2007; Phelan, Bromet, & Link, 1998; Thornicroft et al., 2007). A consequence may be an internalization of the «incompetent» role as a mentally ill patient, and helplessness may become persistent (Deegan, 2005; Taylor & Brown, 1988).

There is a need to emphasize the emotional, relational, and contextual aspects of mental health care, and the care and services for persons experiencing mental health crises need to include socio-cultural and psycho-dynamic perspectives (Scheff, 2007; Thoits, 1985). Developments in community-based mental health services need to be focused on integrating a more humanistic and social orientation and relying on the knowledgebase drawing on such as social models, social network and anti-stigma theories, which are critical, especially in the current culture of pharmacotherapy and narrow treatment models (Tew, 2005; Wahl, 2012; Walker & Read, 2002; World Health Organization (WHO), 2010, 2013).

Further research. This research provides an understanding regarding the experiences of being in mental health crises in relation to social identity, labelling and stigma. The findings suggest a need to have more in-depth knowledge regarding whether or not involvement in certain types (such CR/HT or community mental health centers versus acute in-patient care) and modes (such as a case approach, a coordinated approach, or an advocate approach) of mental health services impact differently on the way service users experience social relations and social identity. There also is a need for extended and further understanding regarding the impact of an initial experience on ensuing experiences of mental health crises. Furthermore, it is necessary to develop knowledge regarding the extent to which labelling and stigma influence recovery and the attainment satisfying social life.

Conclusion

The aim of this study was to explore service users’ experiences of mental health crises in relation to their social identity and social relationships. The findings of this study acknowledge our understanding that people experiencing mental health crisis are often seen and met as outsiders by the attitudes of mental health providers, people in their social networks, as well as by the public and press. This discrimination, marginalization and social exclusion threaten the feeling of being a «normal» citizen and integral social identity.

As stated by Davidson (2005), we can hope for the day when people with mental health illness are allowed to focus on their convalescence and recovery without the added burden of stigma and of needing to become someone other than who they already are. There is a need to change both the organizational structures and philosophy for mental health services, shifting its emphasis on control and narrow treatment guidelines to context-oriented recovery care and flexible support.

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