Conducting Successful Interviews

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Authors:
Nok’khanya F. Hadebe1
Tendani S. Ramukumba1

Affiliations:
1Adelaide Tambo School of
Nursing Science, Faculty of
Science, Tshwane University
of Technology, Pretoria,
South Africa

Corresponding author:
Nok’khanya Hadebe,
[email protected]

Dates:
Received: 05 June 2019
Accepted: 28 Oct. 2020
Published: 18 Dec. 2020

How to cite this article:
Hadebe, N.F. &
Ramukumba, T.S., 2020,
‘Resilience and social support
of young adults living with
mental illness in the city of
Tshwane, Gauteng
province, South Africa’,
Curationis 43(1), a2084.
https://doi.org/10.4102/
curationis.v43i1.2084

Copyright:
© 2020. The Authors.
Licensee: AOSIS. This work
is licensed under the
Creative Commons
Attribution License.

Introduction and background
Mental illnesses rank third in their contribution to the burden of disease in South Africa, and
in 2012, approximately one in six South Africans experienced a common mental illness such as
depression, anxiety or substance use illness (Lund et al. 2012:402). Globally, 264 million
people suffer from depression, 50 million suffer from dementia, 45 million suffer from bipolar
and 20 million suffer from schizophrenia and psychosis (World Health Organization [WHO]
2019). Mental illnesses are characterised by a clinically significant disturbance in cognition,
emotion regulation or behaviour that reflects a dysfunction in the psychological, biological or
developmental processes underlying mental functioning (Aftab 2016:11). Mental health, on
the contrary, is a state of well-being in which every individual realises his or her own
potential, can cope with the normal stresses of life, can work productively and fruitfully and
is able to contribute to her or his community (WHO 2014).

Mental illnesses are often accompanied by discrimination. Young adults who already
experience prejudice and discrimination, in particular, suffer doubly when faced with the
burdens of mental illnesses (Collins et al. 2012:2). They face demands, expectations and
challenges that carry larger risks than those experienced by their peers some generations
ago (Rowling 2006:101). Poor mental health is related to other health and development
concerns in young people, such as lower educational achievements, substance abuse, violence,
and poor reproductive and sexual health (Sharan & Sagar 2007). Although they are often
first detected later in life, several mental illnesses have their onset at ages 14–35 years
(WHO 2001). This is the population with the highest prevalence of mental health illnesses,
particularly those young adults aged between 18 and 24 years (Rowling 2006:101).

The negative experiences of this group create vulnerabilities and exert certain constraints
in access to resources, triggering mental illnesses (Rowling 2006:101), which are usually

Background: Young adults living with mental illnesses often experience a flood of
powerful negative emotions, including anger, anxiety and depression. Some of these
young adults remain trapped in their negative emotions long after the stressful events
that caused them have passed, whilst resilient young adults without mental illness are
able to quickly bounce back to their normal emotional state.

Objectives: The objective of the study was to explore the social supports of young adults
living with mental illness in the city of Tshwane.

Methods: This was a qualitative explorative study conducted in the city of Tshwane in 2018
amongst young adults living with mental illness, using a semi-structured interview schedule.

Results: Those young adults living with mental illness who had support from family and friends
were able to cope with stressful challenges and had a better outlook for the future, whilst those
who perceived their relationship with friends and family as not supportive reported low self-
esteem and difficulties dealing with challenging and stressful situations in their lives.

Conclusion: Resilience was seen in those young people living with mental illness with support
from family and friends, who had positive future prospects, those with high self-esteem and
those who were able to adapt to changing situations beyond their control.

Keywords: resilience; social support; young adults; mental illness; family support; supportive
relationships.

Resilience and social support of young adults living
with mental illness in the city of Tshwane,

Gauteng province, South Africa

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associated with significant distress in social, occupational
or other important activities (Maisel 2013:1). These negative
experiences not only affect their mental health but also limit
their capacity to acquire the skills to feel confident in
interpersonal interactions and resilience in case of life
stresses (Rowling 2006:102). Some of the most important
determinants of mental illnesses include lack of social
support and social protection (WHO 2019).

Resilience is the ability of an individual to function
completely in the face of adversity or stress, and it is
considered one of the dimensions of positive mental
health (Murphey, Barry, & Vaughn 2013:1). Resilience is a
combination of personal characteristics and some learned
skills (International Council of Nurses 2016:31). This
concept generally refers to the capacity of people who are
faced with adversity to adapt, cope, rebound, withstand,
grow, survive and define a new sense of self through
situations of adversity, including mental illness
(Deegan 2005:1). Young adults who are resilient are
likely to enter adulthood with a good chance of coping
well when experiencing difficult circumstances in life
(Murphey et al. 2013:1). Young adults with mental illnesses
often experience a flood of powerful negative emotions,
such as anger, anxiety and depression. Some remain
trapped in these negative emotions long after the stressful
events that caused them have passed, whilst emotionally
resilient young adults have the ability to bounce back to
their normal emotional state (Mills & Dombeck 2005).

The demands, expectations, challenges, experiences and
circumstances faced by young adults not only affect
their mental health but also limit their capacity to acquire
the skills to feel confident in interpersonal interactions
and resilience in case of challenges (Rowling 2006:102).
These experiences continue to put them at risk of
social exclusion and discrimination in all facets of life
(Murphey et al. 2013:4). Furthermore, the status quo
leads to young adults living with mental illnesses being
unable to exhibit resilience. Supporting individuals as
they develop their own resilience is of significant benefit
to individuals, families and organisations (International
Council of Nurses 2016:31).

Previous research has indicated associations between
social support and resilience in mental health through
several psychological and behavioural mechanisms
such as the motivation to adopt a healthy lifestyle, high
self-esteem and the use of active coping strategies, amongst
others (Southwick et al. 2016:78). Therefore, this article
reports on the social support of young adults living with
mental illnesses.

Objective of the study
The objective of the study was to explore the social support
of young adults living with mental illnesses in the city of
Tshwane, Gauteng Province, South Africa.

Research methods and design
Research design
A qualitative exploratory research approach was followed
in this study. The purpose of qualitative research is to
explore a phenomenon from the participant’s point of
view (De Vos et al. 2012:64), whilst exploratory studies are
conducted to gain insight into a situation, phenomenon,
community or individual (De Vos et al. 2012:95). A
qualitative research approach is applicable to researchers
who need to examine the quality of human behaviour,
making sense of and interpreting the meanings that
participants attach to their experiences (Austin & Sutton
2014:436). The design of the study enabled the researcher
to explore the resilience of young adults living with mental
illnesses, as well as their ability to establish social
networking and seek social support.

Study setting
The study was conducted in a low-resource area located
on the peripheries of the city of Tshwane in what was
formerly called ‘townships’. Low-resource settings are
characterised by limited finances to cover healthcare costs
on an individual or societal basis, leading to limited access
to medication, equipment, supplies and devices and less
developed infrastructure, including transportation
(Washington University 2014). The ‘city of Tshwane’ refers to
the City of Tshwane Metropolitan Municipality in Pretoria,
Gauteng province. Pretoria is the administrative capital city
of the Republic of South Africa (South African Government
2020). In this city, mental healthcare services are provided
through a provincial hospital on the south-western side of
the city and two other private hospitals, as well as through
provincial clinics, City of Tshwane Municipality clinics, and
public and private rehabilitation centres.

Study population and sampling
The researcher approached five clinics offering mental
healthcare services in the city of Tshwane; however, only two
were willing to assist. With assistance from the mental
healthcare nurses, the researcher identified those individuals
who fit the inclusion criteria and were willing and able to
give consent and participate in the study. These included
young adults aged between 18 and 34 years living with
mental illnesses, residing and utilising the mental health
clinics in the city of Tshwane. Purposive sampling was used
to recruit 21 participants between March and June 2018.
However, four participants withdrew from the study without
giving a reason.

Young adults living with schizophrenia, mood disorders,
anxiety and depression who were stable on treatment were
included, whilst young adults with substance abuse,
intellectual disability and those who were not in touch with
reality and were unable to give informed consent were
excluded from the study. Data collection ceased after the
10th participant, when no new codes were generated,

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suggesting that the researcher had reached data saturation
(Majid et al. 2018:67). According to Creswell (2014), data
saturation is reached when no new information is discovered
in the data during the data analysis or there is enough
information to replicate the study. This is when the ability to
obtain additional new information has ended and when
further coding is no longer feasible.

Data collection
Data gathering was done through self-report using face-to-face
semi-structured interviews. An interview guide was used
to guide the interview. An interview guide was designed
with the help of experts and was pretested with the first
two interviews to ensure that the questions elicited
appropriate responses and confirmed the reliability of the
data collection instrument. The interviews were carried out
in English, which was a preferred language of communication
for all participants. The Robertson Cooper model of resilience
guided the questions and probing during the interviews
(International Council of Nurses 2016:30). Face-to-face
interviews allowed the researcher to collect data on
individuals to explore sensitive issues of relationships and
support that involved personal histories, as well as the
individuals’ perspectives on resilience; this was useful
particularly because the researcher was aware of exploring a
sensitive topic (Family Health International 2005:2). Other
advantages of using interviews in this study included that
the researcher was able to clarify questions where there were
misunderstandings, the researcher was able to observe some
non-verbal behaviours and mannerisms, and the researcher
was able to obtain in-depth responses (Brink, Van der Walt &
Van Rensburg 2018:153). Questions related to the participants’
sense of confidence, social support and ability to establish
social networks, purposefulness and adaptability were
included in the interview guide, with additional probes
posed to the participants. The interviews were recorded
using an audio-recording device, and reflective notes were
taken during the interviews.

To ensure rigour, the researcher used Lincoln and Guba’s
criteria of credibility, dependability, confirmability and
transferability (Lincoln & Guba 1986). According to Forero
et al. (2018:3), the purpose of dependability is to ‘establish
confidence that the results are true, credible and believable’.
To ensure credibility, the researcher spent more than
12 weeks with the setting and participants, and to pretest
the interview guide, interviews were conducted with two
participants. The researcher further developed a detailed
draft of the study protocol and a detailed track record of the
data collection process, and an independent coder was also
used to code the data and then compare and discuss the
codes with the researcher in order to ensure dependability
(Forero et al. 2018:3). A reflexive journal was also kept,
ensuring that the results would be confirmed by other
researchers (Forero et al. 2018:3). Transferability was
ensured by purposefully selecting participants who fit the

criteria for inclusion in the study and ensuring that data
were collected until saturation was reached.

Data collection procedure
The researcher visited two clinics that had already indicated
their availability for the research to proceed. Potential
participants were identified from those clinics during
the days that they had an appointment with the doctor. The
purpose of the study and the procedure involved in
the participation were explained by the researcher to the
potential participants. Those who were willing to participate
were given an information leaflet to further familiarise
themselves with the research objectives and procedure
before written consent was obtained. After informed
consent had been obtained, the research participants were
interviewed on the clinic premises in a separate private
room after their appointments with the doctors. Each
interview lasted for 30–45 min. Only one interview was
conducted per session as the researcher did not want to
disrupt the treatment flow. The interviews were later
transcribed verbatim to begin the data analysis. Data were
collected until saturation was reached.

Data analysis
The data were transcribed verbatim from audiotapes to
paper. Using Tesch’s approach to content analysis, the
verbatim transcriptions were analysed until data saturation
was reached. Tesch’s approach involves categorising
verbatim transcriptions into themes for analysis (Creswell &
Creswell 2018:192). The transcriptions were carefully read,
making notes of ideas that emerged from the data whilst
arranging similar topics into groups. The researcher then
abbreviated the topics as codes and wrote the codes next to
the appropriate segments of text, using the most descriptive
wording for the topics and then grouping together topics that
were related to each other. The data material belonging to
each category was put together in one place, and a preliminary
analysis was performed. The organisation of data was
observed to check whether new categories or codes emerged.
Recoding of the data was done where necessary.

Ethical considerations
The ethical standards for nurse researchers and fundamental
research principles serve as a framework for nurses
conducting and participating in research; therefore, the
research was based on the ethical standards for nurse
researchers (Brink et al. 2018:34).

Approval from the relevant research committee
The Departmental Research and Innovation Committee,
Faculty Higher Degree Committee, Faculty Research Ethics
Committee of the Tshwane University of Technology (FCRE
2017/10/08 [SCI] [2]), and the Tshwane Research Committee
(GP_201711_015) approved the study and granted permission
to the researcher to carry it out in the community.

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The right to self-determination
Informed consent was obtained from each participant before
data collection could commence. Transparency was upheld
in terms of the objectives of the research, the type of data to
be collected, the method of data collection and the benefits
of the research. The potential respondents were approached
by the researcher on the day of follow-up at the clinic, where
they were invited to take part in the study after a thorough
explanation and an information leaflet had been provided.

Principle of beneficence
The researcher ensured the well-being of all participants,
who have a right to protection from discomfort and harm –
be it physical, psychological, emotional, spiritual, economic,
social or legal.

Principle of justice
The researcher treated all participants fairly and equally
during the study. The researcher ensured that there was no
victimisation or loss of benefits for those participants who
refused to participate in the study or those who withdrew
their participation from the study.

Confidentiality and anonymity
The researcher ensured confidentiality and anonymity
through the protection of participants’ identities. The
researcher ensured the privacy, worth and dignity of the
participants during the study by conducting the interviews
with participants in a private area with minimal disturbances.
The researcher used fictitious names when reporting to
ensure that no link could be made between the individual
identities of the participants and the research reports and
publications generated from the results.

Findings
Demographic information
Table 1 presents the demographic information of all
participants, including their age, gender, nature of illness,
highest educational level achieved, employment status and
relationship status. The participants were aged between
19 and 34 years. Seven participants were male, and the
three others were female. In terms of the highest educational

level achieved, two participants had diplomas and four
participants had completed grade 12. None of the participants
were married, but four were in relationships. The participants
included in the study were living with mental illness such as
anxiety disorder, depression, schizophrenia, bipolar and
epilepsy. Although epilepsy is not classified as a mental
illness in the literature, people living with epilepsy may
experience changes in personality, display extreme emotional
changes or exhibit behaviours that are not considered socially
acceptable, leading to them being mental healthcare users
(Sadock, Sadock & Ruiz 2015:723).

Social support
During the data analysis, multiple themes emerged,
including social support, adaptability, purposefulness and
confidence. However, for the purpose of this article, only one
theme (i.e. social support) and the three categories that
emerged under it are discussed (see Table 2).

The theme of social support emerged during analysis of
the responses to a question that aimed to explore the
participants’ ability to seek and secure social support
from effective networks and build good relationships to
help them overcome adverse situations. Questions relating
to the participants’ relationships with their families and
friends were posed. The participants reflected on their
relationships with their families and friends, and some
even reflected on their relationships with colleagues.
Categories that emerged from the theme were poor
relationship with family, good relationship with family and
good relationship with friends.

Poor relationship with family
Under the category of poor relationship with family, the
participants reported a lack of support, loneliness and

TABLE 1: Demographic information.
Participant
number

Name Gender Age Illness Education Employment Relationship status

1 Mahlatse Male 31 Depression Grade 10 Unemployed Single
2 Lehlogonolo Male 19 Anxiety Grade 11 Scholar Single
3 Tsietsi Female 34 Schizophrenia Diploma Unemployed Single
4 Paulus Male 34 Schizophrenia Grade 12 Unemployed Relationship
5 Dorah Female 29 Epilepsy Grade 10 Self-employed Single
6 Beauty Female 28 Depression, bipolar Grade 12 Employed Relationship
7 David Male 29 Schizophrenia Diploma Part-time Relationship
8 Lebogang Male 23 Depression Grade 12 Scholar Single
9 Jeffrey Male 32 Schizophrenia Grade 12 Unemployed Single
10 Thabo Male 27 Schizophrenia Grade 11 Unemployed Relationship

TABLE 2: Social support.
Theme Category Subcategory

Social support Poor relationship with family Lack of support
Loneliness
Alienation

Good relationship with family Supportive relationship
Family involvement
Financial support
Therapeutic relationship

Good relationships with friends Spending time together
Understanding and empathy
Tolerance and compassion

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alienation from family members. One participant reported a
lack of support that led to feelings of loneliness. It appears
that those participants who had poor relationships with
their families also lacked support from them. The narratives
to support this subcategory are as follows:

‘Like, when I do something useful or looking for their [family]
help when I have problems … maybe in a relationship or anything
like that, you see? There is no one that stands by me; I feel like
I am alone in this world, which is true, you see?’ (Mahlatse,
31 years old, depression)

‘I am on my own, I do everything by myself. No one at home
helps me.’ (Dorah, 29 years old, epilepsy)

Good relationship with family
Some participants reported that they had good relationships
with their families. Participants mentioned supportive
relationships, involvement in their treatment, financial
support and therapeutic relationships with their families.
Narratives to support this category are as follows:

‘They are supportive … sometimes my sister comes with me to
the clinic, for follow-up and check-ups.’ (Paulus, 34 years old,
schizophrenia)

‘My sister used to take me to the doctor’s appointment, and she
would sometimes fetch my treatment.’ (Beauty, 28 years old,
bipolar and depression)

‘Well, it’s amazing, and I’m grateful to have them in my life.
They are very supportive and help me with my studies.’
(Lebogang, 23 years old, depression)

‘It is okay; if I want something, they give me money; they are
supportive.’ (Tsietsi, 34 years old, schizophrenia)

Good relationship with friends
Participants reported that they spent most of their time
with their friends, and some described their relationship
with friends as understanding and empathetic, whilst
other friends were seen as tolerant and compassionate.
Narratives to support this category are as follows:

‘We are very close; it’s people I actually grew up with. So,
we understand each other very well.’ (Lebogang, 23 years old,
depression)

‘They are there for me when I need people to spend time with.’
(Lehlogonolo, 19 years old, anxiety)

‘They are supportive; even when I’m sick, they come to visit me.
They pray with me, and they have good words that encourage
me.’ (Tsietsi, 34 years old, schizophrenia)

‘They treat me with respect; they do not isolate me.’ (Paulus,
34 years old, schizophrenia)

The participants described their relationships with friends as
good; they also mentioned that their friends were
encouraging, did not isolate them and spent time with them.

Discussions
Half of the participants in this study were unemployed.
There has also been a general increase in the unemployment
rates in South Africa (StatsSA 2019). Unemployment has
been associated with poor general health and some poor

health behaviours, such as smoking, cannabis use and
harmful drinking habits (Carlin et al. 2011:21). Furthermore,
unemployed people are twice as likely to experience
anxiety and depression, more than twice as likely to
engage in harmful consumption of alcohol and smoking,
and five times as likely to use cannabis (Carlin et al. 2011:7).
The longer unemployment goes on, the more social networks
are lost (Carlin et al. 2011:21), with a loss of an important
tenet of resilience (Blunt 2016). Unemployment is also
associated with experiences such as stigma, anger
and frustration, and loss of social roles Guintoli et al. 2011:2).

In a cross-sectional study examining the association and
interaction between education and physical and mental
health with unemployment in early, mid, and late work life,
Van Zon et al. (2017) found that low educational achievement
and poor physical and mental health exacerbate each
other’s impact on unemployment. The study concluded that
addressing unemployment may account for the physical and
mental health status of adults during some phases of their
lives (Van Zon et al. 2017). Although age is also a significant
predictor of resilience, especially in emotional regulation in
the general population (Gooding et al. 2012:268), in this study
age did not have any significance. Thus, social support is a
more important predictor of resilience than age.

Studies were conducted on the interaction between
low educational achievement with health outcomes,
health-seeking behaviours, health disparities and unhealthy
behaviours. However, there are no previous studies that
examined any form of relationship between educational
achievement and resilience in young adults living with
mental illness. In contrast, other studies concluded that low
educational achievement and poor physical and mental
health exacerbate each other’s impact on unemployment
(Van Zon et al. 2017). This study found that the common
traits amongst those participants with resilience were
good social bonds with family and friends and a higher
educational achievement compared to the others. These
participants reported good relationships with their families
and friends. The two participants who were not resilient, on
the contrary, had some similarities, such as lower educational
achievement compared with the rest of the participants and
poor relationships with their families. Van Zon et al. (2017)
showed that low education and mental illness were
associated with unemployment, whilst unemployment was
associated with a loss of social networks (Carlin et al. 2011:21),
poor health and harmful health behaviours.

Social support is about building good relationships with
others and seeking support when needed (International
Council of Nurses 2016:31). When it comes to resilience,
having this network allows people to overcome difficult
situations rather than trying to cope on their own (Blunt 2016).
Robertson Cooper identified five types of social support
(Blunt 2016): emotional – reassurance and support; esteem –
showing encouragement; network – a feeling of
social connection; tangible – assisting with material help;
and informational – providing facts and advice. The importance

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of the support provided by family, friends or networks, based
upon shared cultural, economic or recreational interests, is
strongly emphasised by Buikstra et al. (2010) as a foundation of
both community and individual resilience. A supportive social
network helps individuals to cope during hard times, and
positive and caring individuals strengthen their networks
(Buikstra et al. 2010).

Social support is important for maintaining physical and
psychological health, and the harmful consequences of
poor social support in mental illness are well documented
(Ozbay et al. 2007:35). Southwick, Vythilingam and Charney
(2005:256) also support this by stating that social support is
essential for individuals to maintain good physical and
mental health. Lack of support from family, a sense of
alienation and loneliness meant that participants experienced
challenges in securing social support and establishing
social networks, which are essential constituents of resilience
(Blunt 2016). Research has also indicated that threats to social
connectedness, such as rejection and loneliness, trigger
neurobiological systems associated with mental instability
(Southwick et al. 2016:78). Those resilient participants also
reflected tolerance, compassion, understanding and empathy
from their friends and families.

Good social support has been identified as having a positive
impact on moderating and enhancing resilience to stress in
patients with mental illnesses (Ozbay et al. 2007:35). Those
participants who reported that they had good relationships
with their families and friends expressed support, family
involvement in their treatment regimens and financial
support. Tlhowe, Du Plessis and Koen (2017:33), in their
study about the power of families to limit relapse in mentally
ill family members, note family involvement in the daily
activities of patients with mental illnesses as a strength that
contributes to limiting relapses.

Loneliness and alienation were identified as traits that
indicated the participants’ lack of resilience in this study.
Loneliness or isolation may be experienced because of an
individual’s departure from society or exclusion from the
community, whilst alienation is seen as an interpersonal
phenomenon resulting from the lack of social acceptance
towards mental illness (Erdner et al. 2005). An alienated
person does not have any sense of belonging and love and
remains isolated and estranged (Anju 2015). This condition
emerges as a result of a lack of capacity to fit into the social
structure, unfulfilled expectations and poor mental health.
Therefore, people living with mental illnesses who lack social
support are likely to find it difficult to become resilient.

Strengths and limitations
In the beginning of the study, the researcher identified five
clinics that offered mental healthcare services where data
could be collected; however, because of a lack of interest and
lack of clear protocol in terms of obtaining ethical clearance
to conduct research in these facilities, the researcher ended

up with only two clinics where data could be collected.
The findings emanating from this study may also not be
generalised to other contexts.

Implications and recommendations
Based on the findings from this study, recommendations
emerged for nursing practice, nursing education and
nursing research. Mental healthcare nurses should include
the families of the mental healthcare users during
psychotherapy to increase awareness, harness support
from significant others and enhance resilience. Community-
based mental health programmes should assist mental
healthcare users to blend into their communities well and
enhance resilience. Furthermore, research has to assess the
feasibility of incorporating skills to enhance adaptability,
purposefulness, self-esteem, social support and
networking amongst mental healthcare users to enhance
resilience.

Conclusion
The main objective of this research study was to explore
the social support of young adults living with mental
illnesses in the city of Tshwane, Gauteng Province,
South Africa. The results indicated that the presence of
social support from family and friends led to participants
being resilient in the face of adversity. Recommendations
to facilitate resilience amongst young adults living
with mental illnesses were outlined. This study also
provided a direction for future research and mental health
education to include the tenets of resilience in an effort to
help young adults living with mental illnesses to build
and sustain resilience.

Acknowledgements
N.F.H. would like to acknowledge Tshwane University of
Technology for their continuing support.

Competing interests
The authors have declared that no competing interests exist.

Authors’ contributions
N.F.H. was the principal investigator and authored the
manuscript. T.S.R. was the study’s supervisor and reviewed
the manuscript.

Funding information
This research received no specific grant from any
funding agency in the public, commercial or not-for-profit
sectors.

Data availability statement
Data sharing is not applicable to this article as no new
data were created or analysed in this study.

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Disclaimer
The views and opinions expressed in this article are those
of the authors and do not necessarily reflect the official
policy or position of any affiliated agency of the authors.

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J Ment Health, 2019; 28(3): 304–311
� 2019 Informa UK Limited, trading as Taylor & Francis Group. DOI: 10.1080/09638237.2018.1487537

O R I G I N A L A R T I C L E

Secrecy versus disclosure of mental illness among adolescents: II. The
perspective of relevant stakeholders

Nadine Mulfinger1, Nicolas Rüsch1, Philipp Bayha1, Sabine Müller2, Isabel Böge3, Vehbi Sakar4, and Silvia Krumm1

1Department of Psychiatry II, Ulm University and BKH Günzburg, Ulm, Germany, 2Department of Child and Adolescent Psychiatry, University

Hospital Ulm, Ulm, Germany,
3

Department of Child and Adolescent Psychiatry, Centre for Psychiatry Ravensburg Weissenau, Ravensburg, Germany,
4Department of Child and Adolescent Psychiatry, Josefinum, Augsburg, Germany

Abstract

Background: The burden of mental illness (MI) is exacerbated when adolescents with MI are
confronted with stigma and social exclusion. Adolescents face the difficult decision whether or
not to disclose their MI. Focus groups (FGs) were conducted with parents of adolescents with
MI as well as with teachers, mental health professionals (MHPs) and adolescents without MI.
Aim: To collect information from relevant stakeholders on secrecy versus disclosure of MI
among adolescents.
Methods: Thirteen FG sessions with 87 participants were recorded, transcribed and analyzed
using qualitative content analysis to identify major themes.
Results: Selective disclosure and social media as a potential way of disclosure emerged as
dominant themes. Negative aspects of disclosure on social media were discussed. Stigma and
labeling were seen as disadvantages of disclosure. Social support was perceived as one
advantage of disclosure. Distinctive features of adolescence, such as self-discovery, appeared as
specific problems. Parents, teachers, MHPs and adolescents without MI were considered
important for disclosure. Participants discussed how to help adolescents with their dilemma
between disclosure and secrecy.
Conclusions: The findings suggest that disclosure decisions are personal and influenced by the
individual’s environment. Implications for interventions that aim to support adolescents with MI
in this regard are discussed.

Keywords

Mental illness, mental health condition,
adolescents, stakeholders, disclosure, focus
groups

History

Received 7 June 2017
Revised 22 January 2018
Accepted 16 April 2018
Published online 15 November 2018

Introduction

Youth with mental illness (MI) often anticipate or experience

stigma. As MIs are often stigmatized but concealable

conditions, adolescents with MI can decide whether or not

to disclose their MI. Although coming out can result in further

discrimination, disclosure can challenge stigma and have a

positive impact on well-being and empowerment (Corrigan

et al., 2010, 2013).

Decisions about disclosure include various considerations.

In their Disclosure Processes Model, Chaudoir & Fisher

(2010) found that disclosure affects people’s lives in two

ways: (1) people who disclose information about their MI

expose themselves to social evaluation which can result in

support or stigmatization. According to Sentenac et al.

(2012), school-aged children with chronic conditions were

subjected to higher levels of victimization in comparison with

healthy children. Here, victimization occurred more often

among children with psychiatric diagnoses than among those

with chronic physical diseases. In another study among

college students, age and familiarity with MI were found to

predict MI stigma (Feeg et al., 2014). (2) The information

disclosed can change social interactions as it influences

perceptions and behaviors in the social context.

Furthermore, the environment is affected by disclosure

decisions (DDs). Mothers of children with disruptive

behaviors reported blaming themselves for their child’s

behavior and feeling stigmatized by others (Fernández &

Arcia, 2004). Goffman (1963) referred to this phenomenon as

‘‘courtesy stigma’’. On the other hand, the environment can

influence adolescents’ decisions to disclose: Hartman et al.

(2015) showed that parenting style influenced self-conceal-

ment and alcohol use among university students. Levels of

parental authoritarianism, whether on the part of the father or

mother, were directly linked to self-concealment.

Generally, adolescence is a challenging developmental

period as the establishment of relationships with other

adolescents becomes more important and young people

begin to build new interpersonal relationships (Bukowski

et al., 1993). In addition, children and adolescents are

embedded in different social contexts such as family and

Correspondence: Nadine Mulfinger, Department of Psychiatry II, Ulm
University and BKH Günzburg, Parkstrasse 11, 89073 Ulm, Germany.
Tel: þ49 731 500 618 72. E-mail: [email protected]

school. Each of these can affect the impact of the child’s

illness (Matza et al., 2004).

In summary, DDs among adolescents with MI are both

influenced by and have a bearing on the immediate environ-

ment such as parents, friends, school and health care

providers. As far as we know, the only existing qualitative

research examining relevant stakeholder views on secrecy and

disclosure was conducted in the US (Buchholz et al., 2015).

Results may therefore not be applicable to other countries.

Moreover, perspectives of mental health professionals

(MHPs) have not been examined.

In order to better understand the complexity of DDs among

youth diagnosed with MI, the aim of our study was to

explore the views of different stakeholders on secrecy and

disclosure of MI among adolescents. A better understanding

of contextual factors can inform interventions to support

adolescents in their DDs.

Methods

In order to address the research question, focus groups (FGs)

were conducted because of their emphasis on dynamic group

interaction (Vaughn et al., 1996). In part I of this two-part

article, we presented results of FGs with adolescent service

users (Mulfinger et al., 2018b). In the present study, part II,

FGs with stakeholders representing important actors in the

adolescents’ social environment (parents of adolescents with

MI, teachers, MHPs and adolescents without MI) were

conducted to explore their views on secrecy versus disclosure

of adolescents’ MI. The study was approved by the ethics

committee of Ulm University.

Recruitment

Participants were recruited via self-help groups, sports clubs,

youth centers and schools between December 2014 and May

2015. Inclusion criteria were defined for adolescents without

MI (aged 13–18) and for parents of adolescents with MI

(child’s MI in adolescence). Participants aged 18 years or

older provided written informed consent, while participants

under the age of 18 needed the written consent of their

guardian in addition to their own. Adolescent participants

received a gift voucher; adult participants were compensated

with cash for their effort.

Procedure

Based on the literature, a semi-structured interview guideline,

similar to the interview guideline for adolescents with MI,

was developed (Table 1). Each group consisted of 2–8

participants and lasted 30–110 minutes. FGs took place in

schools, at the Departments of Child and Adolescent

Psychiatry, in the facilities of Ulm University and in the

facilities of self-help groups. The language used was German.

All interviews were conducted by a moderator (NM) and a co-

moderator (PB).

Analysis

All discussions were recorded and transcribed verbatim

(Dresing et al., 2015). Qualitative content analysis

(Kuckartz & McWhertor, 2014) was used to identify and

code major themes with both deductive and inductive

approaches. The qualitative analysis software package

MAXQDA (Kuckartz & McWhertor, 2014) was used for

qualitative data analysis. This software enables both an

inductive and a deductive text coding. The first interview of

each stakeholder group was simultaneously coded by two

researchers (PB and NM), the remaining interviews were

coded by one researcher and subsequently cross-checked by

the second researcher. The further analysis procedure was the

same as in part I (Mulfinger et al., 2018b). For a detailed

description of the analysis procedure, see Figure 1. Results

were periodically discussed in qualitative research workshops

and with other team members. In case no consensus could be

reached, a third and senior researcher (SK or NR) was

consulted. The first author translated the quotations into

English; these were reviewed by the research team and a

bilingual translator.

Results

A total of 87 participants were recruited for 13 FGs composed

of 24 adolescents without MI (three FG; aged 14–17), 26

teachers (four FG; aged 29–65), 22 MHPs (three FG; aged

25–56) and 15 parents (three FG; aged 44–74). The charac-

teristics of all participants are shown in Table 2.

The following three main categories were generated based

on the research questions and subcategories emerged from the

transcripts: (1) uncertainties and problems in dealing with MI;

Table 1. Focus group interview guideline.

1. Common perceptions of adolescents with MI among the public:
‘‘What do other people think about adolescents with mental illness in your opinion?’’

2. Communication about MI
‘‘With whom do adolescents talk about their mental illness in your opinion?’’

3. Advantages and disadvantages of disclosure
‘‘Do you think adolescents should talk openly about their mental illness or should rather keep it secret?’’

4. Consequences of being labeled ‘mentally ill’ by others
‘‘What does it mean to an adolescent, in your opinion, when the environment knows about his or her mental illness?’’

5. Consequences of self-labeling as ‘mentally ill’
‘‘What do you think: How does it feel for adolescents to identify themselves as persons with mental illness?’’

6. Coping of adolescents with stigma and discrimination
‘‘How should adolescents deal with stigmatization or discrimination because of their mental illness in your opinion?’’

7. Recommendations to support adolescents in their disclosure decisions
‘‘What could be helpful for adolescents in their decision whether or not to disclose their mental illness?’’

DOI: 10.1080/09638237.2018.1487537 Secrecy versus disclosure of mental illness II 305

(2) perspectives on disclosure versus secrecy; (3) recommen-

dations for decision making (Table 3).

Uncertainties and problems in dealing with MI

Insecurity in contact with adolescents with MI

At the level of everyday experiences, teachers reported being

insecure when dealing with students’ MIs.

I recognize when someone sits apathetically in the

classroom and does nothing and keeps silent [. . .].

I recognize when someone has an emotional outburst and

cries and sobs [. . .]. But I don’t feel competent to say that
they [students with MI] are mentally ill. (Teachers # 1; <)

Adolescence was seen as an ambiguous and vulnerable

period, when adolescents are in a phase of self-discovery

and ‘normal’ problems, not necessarily related to MI, are

frequent.

They [adolescents] are in a phase of self-discovery. And

they often feel weak, which also affects their personality.

Figure 1. Development of main and subcategories.

Table 2. Participants’ characteristics.

Teachers MHP Parents Adolescents without MI
Participants 26 22 15 24

Age (years) 46.3 (12.0) 40.4 (8.7) 55.5 (8.7) 15.9 (1)
M (SD)
Sex (female), N (%) 16 (61.5) 15 (68.2) 13 (86.7) 15 (62.5)
Married N (%) 17 (65.4) 12 (54.5) 9 (60) –
Educational degree (adolescents: in school

leading to this degree), N (%)
12th/13th grade higher education entrance qualification 26 (100) 18 (81.8) 2 (13.3) 14 (58.4)
9th/10th grade secondary school graduation – 4 (18.2) 13 (86.7) 10 (41.6)
Work experience (years), M (SD) 17.1 (11.5) 11.6 (10) – –
Job title (%) Psychologist¼32

Educator¼23
Child and adolescent psychiatrist¼27
Social worker¼9
Music therapist¼9

306 N. Mulfinger et al. J Ment Health, 2019; 28(3): 304–311

And when this personality is also a mental burden. . ..
(Teachers # 2; <)

A teacher described her insecurity arising from the

dilemma of perceiving a student’s need for help and sensing

her own profound lack of knowledge:

We observe things that we can’t classify. On the one hand

we think we should do something, but then we don’t

actually say anything because we are insecure [about MI].

(Teachers # 2; ,)

Parents and MHPs largely echoed teachers’ comments.

Many of them stressed that the environment felt helpless and

overburdened with the MI of adolescents, resulting in an

inability to act. Adolescents without MI emphasized they

could not cope with the MI of their friends and did not know

how to respond.

You notice when your friend has a problem. But to put up

with it and to support the friend when she is feeling

down. . . this becomes a burden for yourself. (Adolescents
# 1; ,)

Some adolescents without MI mentioned they often faced

the fact that parents had the last word regarding help-seeking

and forms of treatment.

Friends feel overwhelmed by it [a friend’s MI]. They can’t

help by taking [the adolescent with MI] to the doctor, that’s

what parents mostly do. (Adolescents # 1; ,)

In one FG of adolescents without MI, participants equated

MIs with intellectual disabilities; one young man referred to

his experiences with choir members of a social institution who

‘‘sing much more passionately than normal people’’

(Adolescents # 3; <).

Stigmatization

Stigmatization emerged as an important topic across all FGs.

Both parents and MHPs described that MIs among adoles-

cents were more stigmatized than other conditions. Parents,

MHPs and teachers mentioned that parents were often blamed

for the MI of their child.

People say my son has just become like this because his

father died so early and I can’t get my act together. There is

enormous prejudice in society [. . .]. (Parents # 1; ,)

Participants across all FGs reported discrimination against

adolescents with MI, especially in school and from adoles-

cents without MI. Teachers referred to colleagues who were

ignorant or unaware of MI among students.

There are also teachers who just make rash judgments

about the behavior of students [with MI] – that they’re just

out of place for example. Or that they just do nothing at all.

(Teachers # 3, <)

MHPs reported that teachers accused adolescents of using

their MI as an excuse to avoid doing things such as

homework. Some MHPs described a general lack of aware-

ness of MI:

I remember when I was a teacher, I was shocked by how

many teachers simply neglected it [MI], [. . .]. Really
obvious mental health problems simply weren’t taken into

consideration. Generally they either just observed [it] or

looked the other way. (MHPs # 2; ,)

Table 3. Main categories and subcategories with number of quotes (n).

Main category Selected subcategory Major themes

Uncertainties and problems in
dealing with MI (n¼480)

Insecurity in contact with
adolescents with MI (n¼75)

Helplessness of environment in dealing with adolescents, special features of
adolescence: higher incidence of problems not necessarily connected to MI,
limited sources of help as parents decide for children regarding help-seeking,
lack of knowledge: MI were equated with intellectual disabilities

Stigmatization (n¼122) Negative attitudes towards adolescents with MI in the public; immediate
environment also affected

School setting Teachers: unawareness of MI, students use MI as excuse; but also positive
discrimination

Adolescents without MI Indifference towards adolescents with MI
Working environment Poor chances to get a job, impairment of professional development
Family Family members cannot accept MI

Perspectives on disclosure
versus secrecy (n¼1249)

Benefits of disclosure (n¼93) Understanding, environment knows how to react, simplifies respectful inter-
action, relief

Risks of disclosure (n¼107) Risk of stigmatization, social exclusion in different contexts, label can stick,
consequences for environment (burden), disclosure decisions not always
controllable by affected adolescents, deterioration of symptoms possible

Risks of secrecy (n¼37) Burden, social withdrawal, environment cannot react adequately
Benefits of secrecy (n¼8) Avoidance of stigmatization, normal treatment
Internal and external criteria for

disclosure (n¼117)
Internal: Self-confidence, courage; external: trust and discretion

Ways to disclose (n¼140) ‘Testing out’ disclosure in a small group of people, selective disclosure preferred,
social media as chance and risk

Recommendations for decision
making (n¼83)

Communication (n¼52) Communication with reliable people or people with lived experiences of MI;
moderated group discussions, talking about consequences of disclosure,
testing out disclosure

DOI: 10.1080/09638237.2018.1487537 Secrecy versus disclosure of mental illness II 307

Parents felt hurt because they did not receive any reaction

to or comments on their child’s MI. Some parents mentioned

the difficulties of professional development for adolescents

with MI.

They are isolated in our society. [. . .] Try to apply for a job
and say that you are mentally ill. Just forget it. It is almost

a death sentence in society. (Parents # 3; ,)

Contrary to the perception of adolescents without MI,

parents felt most adolescents without MI did not care about

other adolescents’ MI problems and excluded them from

friendship groups. The same applied to relatives: ‘‘[. . .] [My]
brother still treats our son disparagingly because he thinks

it’s his own fault. As though if he had stopped smoking or if he

had taken his medicine, everything would be fine’’ (Parents #

3; ,).
While many adolescents were unable to report concrete

examples of unfair treatment of adolescents with MI, they

discussed social exclusion and prejudice as general represen-

tations within society.

[. . .] People are quick to judge others [. . .], sometimes it’s
just a comment that isn’t meant to be harmful, but at that

moment they can hurt people deeply. (Adolescents # 1; ,)

Perspectives on disclosure versus secrecy

Risks and benefits of disclosure

Across all FGs, risks of disclosure were discussed by

participants slightly more than benefits. Understanding was

described as one of the most important benefits of disclosure.

I think it’s important that people around you know about it

[MI]. Because then they can be much more considerate.

Like when someone is ill and struggles to do as much as he

usually can. Then it is good when people around simply

know [about the MI] and can accept it. (Parents # 3; ,)

Adolescents without MI referred to relief as another

benefit of disclosure, ‘‘a sorrow shared is a sorrow halved’’

(Adolescents # 1; <). Parents and MHPs agreed that after
disclosure, frequent questions about MI could be avoided.

I think if it is clearly phrased, it will simply evaporate. All

the questions. People will still ask questions, but only once,

they won’t bother you further. (MHPs # 2, ,)

One MHP stated that disclosure also promoted personal

growth: ‘‘The adolescents, who have done this [disclosure],

they’ve cleared a major hurdle, because [. . .] [they have]
demonstrated the courage to live. [They are] true to themselves

and once they manage that, it doesn’t matter that much what

particular situations might follow [. . .]’’ (MHPs # 3; ,).
However, it was also stressed that the label ‘mentally ill’

might endure even after recovery.

He will have that label forever [. . .]. Even if he recovers
and feels better, he is always the person who used to be

crazy. (Teachers # 1; <)

In contrast to claims that disclosure might prevent

intrusive questions from others, some parents mentioned

that disclosure could lead to even more attention from

others. A mother reported that her son avoided social events

because of his fear of ‘‘someone broach[ing] the topic [MI]

with him, or [of it coming] up at dinner or a birthday

party’’ (Parents # 1, ,).
Teachers, MHPs and adolescents without MI perceived

parents as a barrier to disclosure. Major discrepancies

regarding disclosure between parents and their children with

MI were observed in all FGs. Participants thought parents

wanted to keep their children’s MI a secret – sometimes

even against their children’s will. The reverse was also

observed: Some parents were willing to disclose their

children’s MI even if their children did not want to reveal

it: ‘‘Disclosure was initiated from the family, but I also

know that the daughter suffered because of it’’ (Teachers #

1; ,).
School appeared as the most significant setting where

adolescents were pushed to decide whether or not to disclose

their MI to justify reasonable accommodations:

There are cases where the student wants to keep it

absolutely private [. . .]. As teachers we are then obliged
to tell our close colleagues about it [MI]. They have to

know why some students are absent a lot [. . .]. (Teachers
# 4; <)

In the therapeutic setting, interaction and open communi-

cation about MI between fellow patients might result in a

deterioration of their condition:

It is also possible that together they make it [MI] worse,

especially in the case of eating disorders. This ‘we are the

club of ascetics’ sort of thing. It’s especially the case for

girls. (MHPs # 2; ,)

Risks and benefits of secrecy

Most participants agreed that secrecy had more disadvantages

than benefits. In their view, keeping MI secret was a barrier to

authentic behavior and placed an additional burden on them.

I think when you always [. . .] try to be ‘normal’, and you
always try to be like others, I think that can cause damage

in the long run. (Adolescents # 1; ,)

Another consequence of secrecy was social withdrawal to

avoid stigmatization. Again, it was stressed that negative

consequences of secrecy did not only affect adolescents

themselves but their social environment, too. Compared to the

risks, benefits of secrecy were only marginally addressed:

Secrecy was assessed as a means to avoid stigmatization and

being treated like ‘‘a toddler’’ (Adolescents # 2; ,). Besides
shame, a desire for normalization was reported as a reason for

secrecy:

[. . .] I wouldn’t like it if my schoolmates knew about it
[MI], especially if I am able to behave rather normally and

if I don’t stand out much. (Adolescents # 3; <)

308 N. Mulfinger et al. J Ment Health, 2019; 28(3): 304–311

Self-confidence, trust and discretion

Participants across all FGs addressed criteria for disclosure

that must be met by adolescents with MI (internal criteria)

and by people to whom adolescents could entrust their MI

(external criteria). Self-confidence and courage, as well as

trust and discretion, were reported to be of exceptional

importance. While adolescents without MI generally sup-

ported the idea of disclosing MI and provided good reasons

for doing so, it was acknowledged that disclosure takes a lot of

courage:‘‘[. . .] I’m not sure if I would have the courage [to
talk about my MI]’’ (Adolescents # 3; <).

Additionally, the fact that the decision between disclosure

and secrecy was a very individual one was emphasized.

I think they [adolescents with MI] should decide for

themselves, whom and how much they want to tell.

(Adolescents # 1; ,)

Ways of disclosing

All participants emphasized that adolescents need a close

person familiar with MI. Especially in school, MHPs and

teachers stressed that it would be helpful if a few teachers

were knowledgeable about MI.

I think it’s helpful to have a minimum of insiders, so that

the family knows and that someone at school [. . .] knows
about it. (MHPs # 1; <)

Parents and MHPs recommended describing MI rather

than using the explicit label when talking to others. Selective

disclosure was often advised: ‘‘disclosure, but not in a public

way’’ (Teachers # 3; <). All respondents recommended
testing the consequences of disclosure in a small group before

revealing a MI to a larger group. Different levels of secrecy

were mentioned, e.g. giving true but incomplete information

in contrast to telling lies. Social media played an important

role.

One positive example is that a student, a patient in the

children’s ward, before his [inpatient] stay he wrote a

WhatsApp message to his classmates: ‘I am going to be

away for a while. I am in hospital.’ He used it as an

information platform which was probably easier for him

than to tell them directly. (MHPs 2; <)

Teachers and MHPs in particular referred to the risk of

losing control on social media. Social contacts became

increasingly superficial and developing trust was more

challenging. Furthermore, social media could encourage

indiscriminate disclosure: ‘‘[. . .] there are also people who
put it [MI] on stage. I’ve seen many pictures of self-injury on

Instagram and stuff like that’’ (MHPs # 1; ,).

Recommendations for decision making

The most frequent advice for youth with MI regarding their

DDs was to communicate with reliable people or people with

lived experience of MI. Consequences of disclosure and

secrecy should be considered together and moderated group

discussions were recommended in this context. MHPs and

parents emphasized that youth should be aware of their

strengths and resources and not only concentrate on problem-

related issues. In particular, self-confidence was seen as a

valuable resource for facilitating disclosure.

They not only have a diagnosis, but also their strengths

[. . .]. Still. We also need to take a look at these things with
them together. They also have to be aware of that

[resources]. (Parents # 1; ,)

MHPs thought they could support adolescents with MI,

e.g. preparing them for disclosure. MHPs could also mediate

between adolescents with MI and others.

Discussion

This study examined a wide range of stakeholder perspectives,

to the best of our knowledge for the first time in Europe and

unlike a previous US study including MHPs (Buchholz et al.,

2015). Across all FGs, special problems in recognizing MIs

and insufficient knowledge about MIs among adolescents

were reported. This led to deep insecurity when dealing with

adolescents with MI. This result is in line with previous work.

Austin et al. (2002) found that young people believed epilepsy

to be a form of MI. Heary et al. (2014) reported that younger

children showed limited awareness of unfamiliar conditions

such as MIs. Uncertainty and lack of knowledge made it more

difficult for friends without MI and teachers to respond

appropriately to the adolescents’ MI. DDs are embedded in

different social and employment contexts, as Brohan and her

colleagues (2014) demonstrated regarding employment.

Across all FGs, it was emphasized that MIs among

adolescents were perceived as stigmatized, hampering pro-

fessional development and causing discrimination especially

in school. This finding is supported by Walker et al. (2008)

who described how adolescents without MI endorsed more

negative attitudes towards adolescents with ADHD and

depression than towards adolescents with asthma. In their

study of college students, Feeg and colleagues (2014) found

younger age and less familiarity with MI to be predictors of

MI stigma.

Unlike a previous qualitative study of stakeholder views on

disclosure of MI among adolescents in the US (Buchholz

et al., 2015), participants across all FGs saw more risks than

benefits of disclosure. The main risk was that the label

‘mentally ill’ might stick after recovery. The main advantage

of disclosure for young people with MI was being understood

and finding relief. Secrecy was considered risky because it

might constitute an additional burden. Again, negative

consequences of secrecy equally applied to the adolescents’

environment.

Trust, discretion and self-confidence were addressed as

critical conditions for disclosure. This is in line with Brohan

et al. (2014) who found trust as a factor for disclosure in the

employment context. The meaning of establishing trust prior

to disclosure was highlighted in this context. In a qualitative

study, Kaushansky et al. (2017) found that adolescents and

young adults with chronic illnesses tended to disclose

their condition to trustworthy people or to those they felt

comfortable with.

DOI: 10.1080/09638237.2018.1487537 Secrecy versus disclosure of mental illness II 309

FG participants recommended selective disclosure. These

findings are consistent with disclosure patterns among adults.

Participants in a Dutch study were open with their partner and

close family members, but less so with colleagues (Bos et al.,

2009). Reavley et al. (2018) found a similar pattern in

Australia: Adults of different ages were more likely to disclose

MIs to intimate partners, some friends and some family

members rather than telling everyone or no one. Soldiers with

MI and their professional environment also recommended

selective disclosure, although opening up to partners and

families was seen as more difficult (Rüsch et al., 2017).

Most participants agreed that communication with people

with lived experience of MI was helpful, and participants

recommended moderated group discussions. These findings

are consistent with a study on disclosure among adolescents

with chronic physical illnesses (Kaushansky et al., 2017)

where patients reported that talking with a peer about their

condition led to increased feelings of acceptance and

understanding.

Limitations need to be considered. We cannot rule out the

possibility that participants with better knowledge of mental

health or more sympathy for adolescents with MI attended our

FGs and that participants may therefore not be representative

of the stakeholder groups. Furthermore, participants’ com-

pensation might also affect the willingness to attend the FGs.

Despite these limitations, our findings have implications for

future research. It became clear that especially teachers felt

insecure how to deal with students’ MI. This might be due to a

lack of knowledge regarding MIs. In this regard, the imple-

mentation of educative approaches aimed at increasing

knowledge about MIs seems appropriate in school settings.

Furthermore, it turned out that teachers hoped to receive

support when dealing with students with MI. The implemen-

tation of school-based health centers (SBHCs) could ensure

better access to mental health care for children and adolescents

(Bains & Diallo, 2016) and could also serve to support

teachers and other professionals. Therapists also played an

important role with respect to DDs. They could prepare

adolescents for a possible disclosure in different contexts.

Finally, our findings helped to better understand the context of

DDs that might inform future interventions. Since communi-

cation and peer support appeared as dominant topics regarding

DDs, adapted group programs facilitated by young people with

lived experience of MI (such as ‘Honest, Open, Proud’/HOP;

Corrigan et al., 2015; Mulfinger et al., 2018a; Rüsch et al.,

2014) can support adolescents in their DDs. Based on the

present findings, the existing HOP adolescent version,

developed by Sue McKenzie, Suzette Urbashich, WISE

Wisconsin (https://wisewisconsin.org/) and Patrick W.

Corrigan in the US, was translated and adapted for the

German context. Results of a pilot randomized controlled trial

among adolescents with MI showed that HOP significantly

reduced stigma stress, self-stigma and increased quality of life

and had positive effects on a variety of other stigma- and

health-related outcomes (Mulfinger et al., 2018a).

Conclusions

Disclosure decisions are individual, complex and influenced

by the environment of the individual. Due to high levels of

uncertainty in dealing with adolescents’ MI, initiatives to

increase knowledge and understanding and to reduce public

stigma are needed. This could be achieved through educa-

tional work in schools, when teachers and other professionals

improve their understanding of MI and learn how to respond

appropriately to students with MI. Contact between adoles-

cents with MI and those without is likely to improve attitudes

towards people with MI (Thornicroft et al., 2016). Thus,

schools can invite adolescents or adults with lived experience

to talk about challenges of MI and about recovery to achieve

mutual understanding among adolescents with MI, teachers

and classmates. Furthermore, peer-led group programs such

as ‘Honest, Open, Proud’ can support adolescents with their

decision whether to disclose their MI and to increase their

empowerment (Corrigan et al., 2015; Mulfinger et al., 2018a;

Rüsch et al., 2014). In the long term, the implementation of

SBHCs could contribute to a supportive surrounding at

school.

Declaration of interest

No potential conflict of interest was reported by the authors.

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