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Running Head: RESEARCHED ARTICLE

Researched Article

University of Central Florida

Lauren Parquette
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Mental health was never something that was simply swept under the rug in my house

growing up. It was rather something my family was very vocal about: “Are you feeling

anxious?” “How are you feeling today?” “I need to take a mental health day.” None of these

phrases were out of sort in the least in my household; we were all quite communicative about

any mental trial we were facing. I was diagnosed with generalized anxiety disorder as well as

obsessive compulsive disorder (commonly known as OCD) at the ripe age of nine years old

(though my parents claim they knew much earlier). It was not until a few years, many

therapy sessions, and medication trials later that I began showing symptoms of both

depression and attention deficit disorder (ADD). I am always pretty upfront about the cards I

have been dealt, especially because—due to these illnesses—I am all too familiar with the

feeling of isolation that they can at times present. For someone with all of these diagnoses I

am easily considered highly functioning, though this was not always the case. I have been

able to reach this point for a variety of reasons including a solid support system, medical

support (and the means to receive it—something so many people are not as fortunate to

have), and about a decade of therapy. Within this time I have learned something that I had

not expected to: language plays a vital role in the realm of mental health.

Downs (n.d.) describes rhetoric as being “a set of principles that explain and predict

how people make meaning and interact” in his article Rhetoric: Making Sense of Human

Interaction and Meaning-Making. Both inside and outside of this group, rhetoric plays a vital

role. In Johns’ (1997) article Discourse Communities and Communities of Practice:

Membership, Conflict, and Diversity, she explains that group-specific rhetoric is not atypical

within a discourse community, that it is rather a pillar of membership as a whole; this being

the principle of effective communication.

It is fairly well known that outside of the community there still lies a thick cloud of

stigma; therapy, mental illness, and the medication used to treat it are still very much
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considered taboo. This stigma is often internalized by those affected. This is exemplified in

a study performed by Kranke and Floersch (2009a) in which they examined stigma within the

adolescent demographic. They found that teens often felt a good amount of shame and

tended to use words with negative connotations when discussing their diagnosed illnesses and

their experience with them, this being perpetuated through stigmatic language around mental

illness. The researchers coded their data and found these trends to be evident. Another

researcher who decided to analyze stigma’s effects was Molloy (2015). Prior to this research,

Molloy had recognized that oftentimes societal stigma diminishes the opinions and overall

contributions of those with mental illness, believing that their illness impairs them from doing

anything credible. She used a “hybrid field-based study . . . as well as ethnographic methods”

where she performed the field portion at outpatient facilities with patients affected by chronic

mental illnesses. She later coded her data and examined “recuperative ethos” and “agile

epistemologies.” In Corrigan’s (2007c) article, he discusses how individuals needing

treatment will often go as far to avoid seeking it due to the surrounding stigma. Corrigan

chose to use his article to draw more comprehensive conclusions from existing research.

Through his research he found that stigma threatened individuals who believed themselves to

be affected by mental illness through “label avoidance, blocked life goals, and self-stigma.”

Zembylas and Fendler (2007f) take a different perspective on the issue of patient perception.

Thee researches chose to examine the role of “emotions in education;” they offered that

obsolete concepts being taught to us can be creating these kinds of emotions within the

discourse. Zembylas and Fendler show the role through the two most common perspectives,

“the psychological strand” and “the cultural feminist strand,” before explaining the value and

potential benefits of the use of “parrahesia” instead.

This phenomenon is not solely affecting patient impression and esteem. The concept

of stigma has so largely impacted the community that professionals, like Linhorst and Eckert
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(2003), are having to change methods of treatment in order to account for it. In their research

they experimented at a public psychiatric hospital in which the mental health professionals

used language intended to empower. Ramon, Shera, Healy, Lachman, and Renouf (2009b)

take this worldwide change in therapeutic and linguistic practices as an opportunity to look at

the different mental health policies of four different countries. They also examine the impact

these new implementations, such as the “language of recovery,” have had. Therapy and other

treatment tactics commonly used also show the power held by rhetoric. Particular texts use

language to carve and mold one’s idea of the concept while therapy itself uses specific

terminology and connotations to allow for more productive sessions and effective results.

With all of these things considered, it is important to recognize that more research is needing

to be done regarding stigma and its effects on the discourse.

In this article I intend to explain and examine the impact of stigma on the community

of those living with mental illness and how this affects treatment. I have done a number of

textual analyses in order to determine these findings. I evaluated and annotated text within

the community for treatment. These include The Dialectal Behavior Therapy Workbook

(2007d-e) and I Thought It Was Just Me (But It Isn’t) (2007a-b). I found that stigma

impacted practices in more ways than previously recognized by others in the field. It

permeated into the language used within these texts in a number of ways.

Methods

Initially I had a number of research questions I wanted to explore and plenty of

sources and methods of primary research that I thought would be relevant. The ideas of both

interviews and surveys with mental health professionals to discuss how they use language

and writing within treatment came to mind. I also pondered on the idea of anonymously

surveying people with mental illness to discuss their own use of rhetoric in the same area as

well as its effectiveness. After further analyzation, it became evident that these would not
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work due to the vulnerability of the population as well as patient privacy. Additionally

considered was the use of a mulit-modal approach to look at apps designed for meditation

and tracking common in mental health. As if all of these were not already more than

sufficient, I intended on using Instagram pages intended to inspire and uplift those with

mental illness as well. But unfortunately, due to the constraints of time, circumstance, and

vulnerable population most of my previously conceptualized notions were not able to come

into fruition.

However, I decided to use texts aimed at treatment. I took excerpts from the

aforementioned books that are aimed at treatment and betterment. From these texts I decided

to use the primary method of rhetorical analysis to examine the purposeful language related

to treatment. With these selections I went through and found recurring codes in the material.

I then examined the rhetoric specifically and marked instances in which these were exhibited.

I coded terms within the areas of Tools, Tactics, and Exercises; Emotions; Breakdown of

Concepts and Examples; Goals and Commitment; Positive Language and Affirmation;

Ability to Handle Situations/Putting Power in the Patient’s Hands; Things You Know But

Need to Hear; and Point of View.

Results
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As discussed earlier, rhetoric is integral in all aspects of our lives. Be it conscious or

not, rhetorical devices and canons are evident in all forms of communication. Discourse

communities and their specific lexis of course allow for more specified and pertinent

conversations. Through my research I was able to recognize the intentional and meticulous

sculpting of language in texts used by those within the greater discourse. Evidence of

specified rhetoric could be seen in all of the sources I examined. The codes I found within

these texts have been listed above, though I feel perhaps the most pertinent are emotions,

concept breakdowns, goals, affirming language, and allowing patients to be in control.

Emotions tie back into perceptions of pathos within rhetoric. These texts not only articulated

feelings commonly expressed and felt within the community but also validate them.

Conceptual breakdowns allow for a wider and more comprehensive knowledge of a subject,
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particularly when new phrasing or exercises are brought forth; it allows for an understanding

of the ‘why.’ The category of goals is particularly important because its inspiring change

within patients. This type of language is motivating when combined with affirming language

which is also necessary when trying to break stigma. This is key in empowering people to

push past preconceived barriers. Allowing patient autonomy is also a huge aspect. It

provides options and can affect self-esteem. This breaks stigma by allowing a patient-lead,

just as what would be done in the physical medical field. I found that these concepts kept

recurring within the documents. That said, I made sure to take note of these concepts in my

coding of the resources. I have included all of the works I analyzed in my research, including

my own coding of the documents in an appendices. Appendix A can be used as a legend for

the markups within Appendices B-E.

The first source I will discuss is the Chapter 1 Excerpt (2007d) from The Dialectal

Behavior Therapy Workbook (Appendix B). This selection discusses the basic coping skills

of “Distress Tolerance.” The piece is aimed at explaining what McKay et. al. refer to as

“overwhelming emotions” as well as coping mechanisms. The authors are also explicit in

expressing that not all mechanisms are healthy. In the text the most central codes are the

articulating of things the patient already knows, the use of positive language, and use of

exercises. The repeating of things the patient already knows is somewhat of a difficult

concept to explain. In a way I think of it as being similar to a sort of ‘tough love’ approach,

exhibited in phrasing such as “self-destructive coping strategies…lead[s] to your pain being

prolonged into long-term suffering.” This code can also serve as a ‘reality check’ like how

“many of the coping strategies used by people with overwhelming emotions only…make

their problems worse.” As for positive language, when someone experiences “overwhelming

emotions,” oftentimes they are unable to fully recognize things for how they are which is why

this tool can be so important. Sometimes simple redirecting language can give someone
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experiencing these emotions more clarity. This method is seen in phrases like “[a]t some

point in our lives, we all have to cope with distress and pain” and “we can’t always control

the pain in our lives, we can control the amount of suffering we have in response to that

pain.” These types of comments can allow people to feel heard. The use of exercises can

contribute to increasing the feeling of ‘being in control;’ these are seen in the use of “the Cost

of Self-Destructive Coping Strategies worksheet” and “distract[ing] yourself from the

situations that are causing you emotional pain.” This source shows how language is used in a

coaxing and encouraging way to aid in the treatment of symptoms.

McKay et. al. use the second chapter (2007e) as an opportunity to allow for an

expansion of concepts from the last chapter; within this piece, they offer specific exercises

aimed at harnessing the earlier concepts. The Chapter 2 Excerpt (2007e) showed all of the

same codes that were expressed within the Chapter 1 Excerpt (2007d), however had a greater

focus on concept breakdown and affirming the patient’s capability to overcome (Appendix

C). Much like the Chapter 1 Excerpt (2007d), there was also a central focus on the use of

coping tools. The conceptual breakdown is being provided in phrases like “your brain and

body often can’t tell the difference between what’s really happening to you and what you’re

just imagining” (2007e) to explain to the reader exactly what these exercises do and why they

work. Reaffirmation is also seen repeatedly within the chapter in instances like “you can

soothe yourself” as the authors aim at creating a feeling of safety in trying these new skills.

They also utilize the tactic of providing patient choice with examples like “[o]r, if you would

prefer;” this is very common in the medical field to provide for a heightened sense of

autonomy. As stated earlier, this article also holds a particular focus in explaining specific

skills for increasing “distress tolerance;” these are specifically sectioned off with headers like

“safe-place visualization” and “cue-controlled relaxation.” This source uses specific

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language while ‘prescribing’ a tool to be used as a coping mechanism. It shows specificities

in exercises.

Within the first chapter of Brown’s I Thought It Was Just Me (But It Isn’t) (2007a),

she discusses her journey becoming a shame researcher as she delves into the questions that

brought her to do so. She also reminds the reader that “[s]hame is universal” and that it is

multi-layered. In this selection the uses of emotion, conceptual breakdown, and saying what

we already know is true are the driving forces in its effectiveness. Emotion is perhaps the

greatest theme in this text with repeated mention of shame and how it “remains taboo.”

Throughout the piece she discusses her own observations like “the mental and public health

communities aren’t talking about shame” as well as their effects and how we “[fail] to

recognize how much damage shame does to our spirit.” These give the reader a better

understanding of what exactly she means when discussing shame. With these observations

she includes items we already know like “You cannot shame or belittle people into changing

their behaviors.” This piece in particular shows the impact of pathos as well as how

repetition is important when preconceived ideas brought on by stigma are so far engrained in

the mind.

With a greater understanding of what exactly shame is, Brown (2007b) wants her

readers to understand how to be resilient and the most effective way to combat it (Appendix

E). She uses Chapter Two to explain findings from her own research and bring about

solutions to the questions she asked in the last chapter (2007a). Here she focuses on positive

language and affirmation, goals, and exercises to show evidence and encourage the reader.

The positive language is exhibited through examples of her findings wherein she explains

that a key factor in breaking free from shame is the practice of empathy; there is a “power of

hearing someone say” these things. Brown is also explicit in expressing the goal of this

selection, this being: “build stronger and more meaningful connections with the people in our
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lives.” She uses exercises to show how one can achieve this goal through the use of the

“Shame Resilience Continuum.” This selection places value within empowering a patient

through language and how valuable this is in the recovery process.

Discussion

The social impact and clinical advancements in effective treatment are reflected in

how concepts are presented to readers. This data is able to provide specific examples of how

a number of factors have impacted the language used. These primary sources were actually

all a part of bigger books given to me in assignment from past mental health professionals.

So these are indeed examples of texts that are being used (either directly or indirectly) in

treatment. This data shows that there is indeed a connection between the language used in

treatment-based texts and these external factors.

The data I have gathered on this topic supports earlier writing-related studies within

the discourse. Conclusions by other researchers have shown that stigmatic language does

have an impact on those with mental illness and that this kind of language can even bleed into

texts used within the discourse. However, my findings also make connections between texts

intended for treatment and the external implications of stigma and patient betterment. The

data suggests that the external factors can affect something one might think of as being totally

secular. These texts have shown very explicit and purposeful phrasing in order to facilitate

the intended results of patient betterment. Particularly examining my own research question,

I feel that the most central were: Emotions, Positive Language/Reaffirmation, Ability to

Handle Situations/Putting Power in Patient’s Hands, and Point of view.

Emotions

Any discussion of mental health would be ill-advised if not including emotions. They

are quite central in the conversation (or at least they should be). With this in mind, it is clear

in these texts that the authors were incredibly particular in the language they chose. They
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exhibited usage of pathos relating back to Downs’ article (n.d.) in how they chose to

approach these new ideas and tools. Within the sources, it was also evident that the sculptors

of language were remaining mindful that these pieces are being used for what would be

described as a ‘vulnerable population.’ This is shown through gentle language that weaved

between direct and coaxing. This can be exhibited in Chapter 2 (2007e) with phrases ranging

from the explanatory “[m]ake sure you conduct this exercise in a quiet room” to the

encouraging “[j]ust do your best.”

Positive Language/Reaffirmation

This awareness of their audience also carries over into the category of Positive

Language and Reaffirmation. The impact of stigma can be quite traumatizing and carry into

the lives of people in ways we do not immediately recognize. For this reason, the

incorporation of positive language in treatment-based text is vital. Encouragement and, as

mentioned by Brown (2007b), empathy are integral in the recovery process. This kind of

intent can also be viewed from a rhetorical perspective; because of the authors are wanting a

specific result (a healthier reader), they use their language in a specific way that will be more

likely to elicit the desired outcome.

Ability to Handle Situations/Putting Power in Patient’s Hands

This particular code is incredibly relevant when considering the impact of stigma.

There is language within these texts that is specifically intended to provide a greater self-

esteem in the possession of autonomy and choice. This can provide power where it is

believed to have been lost. Words hold a lot weight and when people living with mental

illness so often experience language that is limiting, there is a strength in regaining choice

and independence. Linhorst and Eckert (2003) even discuss how they found positive effects

when involving patients in their own treatment plans. This is just another example of the

value of giving patients something they have the power to control.

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Point of View

This particular code was not something I discussed at great length, however it is also

quite important when seeing these texts. McKay et. al. (2007d-e) opted for a third-person

approach. This being said, there were many uses of “you” within the excerpts. However,

coupled with this was a gentle, more somber and encouraging voice being put to these tactics.

Unlike the others, Brown (2007a-b) opted for a second-person point of view. She decided to

use the more collective “we.” Through this she was able to create a feeling of familiarity and

community when discussing a topic that can quite often be isolating. Though these

perspectives differed, they both made sense for the topics being covered in their respective

texts.

Conclusions

This research was able to provide me with a new understanding of underlying

intentions within the texts in the discourse of mental health. Stigma has very clearly

impacted the language used within the community as shown in the recurring codes in my

findings. Though the biggest intent is effectively treating patients, there is a certain cadence

in which the information is being delivered that is definitely calculated. There is definitely a

clear connection between treatment-focused texts and external stigma; if nothing else, there is

an obvious awareness of it.

Though these findings are quite exciting, there are a few things to consider when fully

examining my research. I was of course faced with obstacles like time and resources.

Though understandable, it is also somewhat unfortunate that there is a certain sensitivity

surrounding the information within my discourse. Due to this, I unfortunately was unable to

directly communicate with professionals within the field or those with mental illness, for that

matter. They may have been able to speak to how stigma has impacted them. To be

considered as well is the fact that I do have a limited amount of primary sources due to the
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constraints of time and resources; I believe that the study would have benefited from a greater

variety of texts.

With these items considered, there is still much to be uncovered regarding this

correlation. My own research has also brought me to wonder: In what other ways has stigma

affected the discourse in terms of treatment? What are ways it has impacted the discourse in

areas not related to treatment? Further research can be done to fill these gaps. Genres such

as mental health apps, bullet journals, and diagnostic texts could also be looked to in search

of these answers. Future research can examine these questions as well as other genres within

the discourse and the impact of stigma.

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References

Brown, B. (2007a). One: Understanding Shame. I Thought It Was Just Me (But It Isn’t):

Making the Journey from “What Will People Think?” to “I Am Enough,” 1-4.

Brown, B. (2007b). Two: Shame Resilience and the Power of Empathy. I Thought It Was

Just Me (But It Isn’t): Making the Journey from “What Will People Think?” to “I Am

Enough,” 31-33.

Corrigan, P. (2007c). How Clinical Diagnosis Might Exacerbate the Stigma of Mental

Illness. Social Work, 52(1), 31-39. Retrieved from

http://www.jstor.org/stable/23720705.

Downs, D. (n.d.). Rhetoric: Making Sense of Human Interaction and Meaning-Making.

Writing About Writing: For the University of Central Florida, pp. 457-481.

Johns, A. (1997). Discourse Communities and Communities of Practice: Membership,

Conflict, and Diversity. Writing About Writing: For the University of Central Forida,

pp. 319-341.

Kranke, D., & Floersch, J. (2009a). Mental Health Stigma among Adolescents: Implications

for School Social Workers. School Social Work Journal, 34(1), 28–42. Retrieved

from https://search-ebscohost-com.ezproxy.net.ucf.edu/login.aspx?direct=true&db=

eric&AN=EJ893727&site=ehost-live&scope=site.

Linhorst, D., & Eckert, A. (2003). Conditions for Empowering People with Severe Mental

Illness. Social Service Review, 77(2), 279-305. doi:10.1086/373909.

McKay, M., Wood, J., & Brantley, J. (2007d). Chapter 1: Basic Distress Tolerance Skills.

The Dialectal Behavior Therapy Skills Workbook: Practical DBT Exercises for

Learning Mindfulness, Interpersonal Effectiveness, Emotion Regulation & Distress

Tolerance, 5-9.
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McKay, M., Wood, J., & Brantley, J. (2007e). Chapter 2: Advanced Distress Tolerance

Skills: Improve the Moment. The Dialectal Behavior Therapy Skills Workbook:

Practical DBT Exercises for Learning Mindfulness, Interpersonal Effectiveness,

Emotion Regulation & Distress Tolerance, 31-33.

Molloy, C. (2015). Recuperative Ethos and Agile Epistemologies: Toward a Vernacular

Engagement with Mental Illness Ontologies. Rhetoric Society Quarterly, 45(2), 138–

163. Retrieved from https://search-ebscohost-com.ezproxy.net.ucf.edu/login.

aspx?direct=true&db=mzh&AN=2015872456&site=ehost-live&scope=site.

Ramon, S., Shera, W., Healy, B., Lachman, M., & Renouf, N. (2009b). The Rediscovered

Concept of Recovery in Mental Illness: A Multicountry Comparison of Policy and

Practice. International Journal of Mental Health, 38(2), 106-126. Retrieved from

http://www.jstor.org/stable/41345286.

Zembylas, M., & Fendler, L. (2007f). Reframing Emotion in Education through Lenses of

“Parrhesia” and “Care of the Self.” Studies in Philosophy and Education, 26(4), 319–

333. Retrieved from https://search.ebscohost.com/login.aspx?direct=true&db=eric&

AN=EJ924481&site=ehost-live&scope=site.
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Appendix A

Coding Legend for Appendices B-E

Tools/Tactics/Exercises—Underlined (Straight)

Emotions—Orange

Breakdown of Concepts and Examples—Yellow

Goals and Commitment—Underlined (Jagged)

Positive Language/Reaffirmation—Blue

Ability to Handle Situations/Putting Power in Patient’s Hands—Green

Articulating What You Already Know But Need to Hear—Pink

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Appendix B

The Dialectal Behavior Therapy Workbook Chapter 1 Excerpt: Coded

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(See Appendix A for Coding Legend)

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Appendix C

The Dialectal Behavior Therapy Workbook Chapter 2 Excerpts: Coded

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(See Appendix A for Coding Legend)

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Appendix D

I Thought It Was Just Me (But It Isn’t) Chapter 1 Excerpt: Coded

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(See Appendix A for Coding Legend)

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Appendix E

I Thought It Was Just Me (But It Isn’t) Chapter 2 Excerpt: Coded

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(See Appendix A for Coding Legend)