Stigmatizing beliefs and attitudes about mental illness are prevalent and exposure to stigma is common among people with mental illness. The negative effects of stigma are compounded when a veteran with Serious Mental Illness (SMI) internalizes these stigmatizing assumptions and stereotypes. Internalized stigma refers to the process in which a person with mental illness cognitively or emotionally absorbs negative messages or stereotypes about mental illness and comes to believe them and apply them to him/herself. Internalized stigma is evident among veterans with SMI and can lead to decreased self-efficacy, increased depression, social withdrawal, and curtailed pursuit of recovery goals.
We developed Ending Self Stigma (ESS), a 9-session group intervention to assist veterans with SMI to develop skills to effectively cope with stigma and minimize the internalization of stigmatizing beliefs and stereotypes. The primary objectives of this project are to compare the effects of ESS to a general health and wellness group in: 1) reducing internalized stigma and 2) improving proximal psychosocial outcomes (e.g., self-efficacy, belonging, recovery orientation). Secondary objectives include assessing the effects of ESS on improving distal psychosocial outcomes (e.g., quality of life, social functioning) and examining if improvements are maintained 6-months post-treatment.
This study is a randomized trial of veterans with SMI receiving outpatient mental health services from 3 different VA Medical Centers. Two hundred and fifty two participants were enrolled in the study. Of those, 249 completed baseline assessments and were randomly assigned to ESS (N=125) or a general health and wellness group (HW; N=124). One participant assigned to ESS was later deemed ineligible, leaving a total of 248 participants (N= 124 in each group). ESS focused on teaching strategies/tools to help participants address self-stigma. The HW group focused on providing information/ education to help participants better manage health-related concerns (e.g. physical activity, nutrition, sleep issues). Both groups were held once a week for 9 weeks. Participants completed assessments at baseline, post-treatment, and 6-months post-treatment. 87% (216/248) completed post-treatment assessments and 79% (197/248) completed 6-month follow-up assessments. A repeated measure mixed effects model with adjustment for baseline response was used to address the primary and secondary aims. Qualitative interviews were conducted with a subset of veterans (N=45) from both conditions in order to gain a better understanding of veterans' experiences of and strategies for coping with internalized stigma, to compare experiences of veterans in both groups, and to explore any reasons for ESS drop-out.
Most participants were male (87%), African-American (58%) or Caucasian (34%), and had 12 or more years of education (93%). The mean age of participants was 53.4 +/- 9.2. With regards to diagnosis, 51% had a diagnosis of schizophrenia or schizoaffective disorder, 42% bipolar disorder, and 7% major depression with psychotic features. On average, Veterans reported mild levels of self-stigma at baseline (M=2.2 +/- .4). Veterans across both groups showed significant but modest reductions in self-stigma (p=0.016), and increases in the psychological experience of belonging (p=0.045), satisfaction with social relationships (p=0.01), and general life satisfaction (p=0.016) from baseline to post treatment. Improvements in self-stigma and general life satisfaction were maintained at 6-months post-treatment. There were no differences between the ESS and the HW group in reductions in self-stigma or increases in belongingness, self-efficacy, recovery, quality of life or social functioning from baseline to post-treatment (p>0.05 for all).
Mental illness stigma and self-stigma negatively impact treatment seeking and adherence and pose significant barriers to the recovery of Veterans with serious mental illness (SMI). There may be multiple ways to assist Veterans with serious mental illness in addressing self-stigma, including interventions that directly target self-stigma and interventions or programs that may address self-stigma more indirectly.
- Yanos PT, Lucksted A, Drapalski AL, Roe D, Lysaker P. Interventions targeting mental health self-stigma: A review and comparison. Psychiatric Rehabilitation Journal. 2015 Jun 1; 38(2):171-8.
- Drapalski AL. Reducing internalized stigma among veterans with serious mental illness through Ending Self Stigma. In A. Drapalski (Chair), Ending self stigma: A skill building approach to reducing the impact of self stigma. Paper presented at: Together Against Stigma International Conference; 2015 Feb 1; San Francisco, CA.