The stigma of mental illness: Explanatory models and methods for change

Unraveling the insight paradox: One-year longitudinal study on the relationships between insight, self-stigma, and life satisfaction among people with schizophrenia spectrum disorders

The promotion of insight among people with schizophrenia spectrum disorders has posed a dilemma to service providers as higher insight has been linked to positive clinical outcomes but negative psychological outcomes. The negative meaning that people attached to the illness (self-stigma content) and the recurrence of such stigmatizing thoughts (self-stigma process) may explain why increased insight is associated with negative outcomes. The present study examined how the presence of high self-stigma content and self-stigma process may contribute to the negative association between insight and life satisfaction. A total of 181 people with schizophrenia spectrum disorders were assessed at baseline. 130 and 110 participants were retained and completed questionnaire at 6-month and 1-year follow-up, respectively. Results showed that baseline insight was associated with lower life satisfaction at 6-month when self-stigma process or self-stigma content was high. Furthermore, baseline insight was predictive of better life satisfaction at 1-year follow-up when self-stigma process was low. Findings suggested that the detrimental effects of insight can be a result from both the presence of cognitive content and habitual process of self-stigma. Future insight promotion interventions should also address self-stigma content and process among people with schizophrenia spectrum disorders so as to maximize the beneficial effects of insight.

Self-Stigma in Relatives of people with Mental Illness scale: development and validation

BACKGROUND

Serious mental illness (SMI) is profoundly stigmatised, such that there is even an impact on relatives of people with SMI. Aims To develop and validate a scale to comprehensively measure self-stigma among first-degree relatives of individuals with SMI.

METHOD

We conducted group interviews focusing on self-stigma with first-degree relatives (n = 20) of people with SMI, from which 74 representative quotations were reframed as Likert-type items. Cognitive interviews with relatives (n = 11) identified 30 items for the Self-Stigma in Relatives of people with Mental Illness (SSRMI) scale. Relatives (n = 195) completed the scale twice, a month apart, together with four external correlate scales.

RESULTS

The 30-item SSRMI was reliable, with scores stable over time. Its single-factor structure allowed generation of a 10-item version. Construct validity of 30- and 10-item versions was supported by expected relationships with external correlates.

CONCLUSIONS

Both versions of the SSRMI scale are valid and reliable instruments appropriate for use in clinical and research contexts. Declaration of interest None.

Romeo and Juliet: Perceptions of love of stigmatized relationships

We examined the connection between the perception of love and stigma in relationships and how much stigma needs to be present to elicit a heightened perception of love. Participants in the first study rated several relationships on the degree of stigma each one of them faced, and how much the individuals in each relationship loved each other—the perception of the Romeo and Juliet effect. In the second study, participants read a scenario of a male, gay relationship with various degree of stigma (none, one, two, or three sources), and rated how much the couple loved each other. The results suggest that there is a perception that the Romeo and Juliet effect exists, despite evidence that does not (Sinclair, Hood, & Wright, 2014). Individuals in relationships, which face stigma from multiple sources, are believed to love each other more than those with no stigma. Together, the results suggest that perceived stigma and love in a relationship are positively associated, which runs counter to better supported models of relationship satisfaction (Parks, Stan, & Eggert, 1983).

Antimicrobial stigmatization: Public health concerns about conventional pig farming and pig farmers' experiences with stigmatization

According to the World Health Organization, antimicrobial resistance is one of the most severe threats to public health. Since the 1950's contemporary farming of pigs has been heavily dependent on the use of antibiotics. Recently, concerned experts of public health have become more outspoken, often, criticizing pig farmers for social irresponsibility and gambling with public health. Danish pig farmers are internationally renewed for their relatively low use of antibiotics. Nevertheless, the public criticism aimed at farmers is relatively strong in Denmark. Based on qualitative interviews with 30 pig farmers and 21 public health experts, this article sets out how pig farmers, according to public health experts, threaten public health and how pig farmers, according to the farmers, experience and internalize stigmatization related to their lives as farmers. By focusing on Danish pig farmers' experiencing public condemnation from scientific experts as well as in their local communities, this article proceeds along the line of existing research on health-related stigmatization.

Perceived stigma among non-professional caregivers of people with severe mental illness, Bahir Dar, northwest Ethiopia

BACKGROUND

The stigmatization of mental illness is currently considered to be one of the most important issues facing caregivers of severely mentally ill individuals. There is a dearth of information about the prevalence and associated factors of perceived stigma among caregivers of people with severe mental illness in the study area.

OBJECTIVE

To assess the prevalence and associated factors of perceived stigma among non-professional caregivers of people with severe mental illness, Bahir Dar, northwest Ethiopia.

METHOD

Institutional based cross-sectional study was conducted from May to June, 2016 at Felege Hiwot Referral Hospital among 495 caregivers of people with the severe mental illness. Pre-tested structured family interview schedule questionnaire was used. Binary logistic regression was applied to identify factors associated with perceived stigma and interpreted using odds ratio with 95% confidence interval. Statistical significance was considered at p value < 0.05.

RESULT

The overall prevalence of perceived stigma was found to be 89.3%. Being female, rural residency, lack of social support, long duration of relationship with the patient and currently not married were found significantly associated with the perceived stigma of caregivers.

CONCLUSION

Prevalence of perceived stigma is very high in the current study. Thus, stigma reduction program and expanding of strong social support should better be implemented by different stakeholders for caregivers of people with severe mental illness.

A smart-phone intervention to address mental health stigma in the construction industry: A two-arm randomised controlled trial

Background

High levels of self-stigma are associated with a range of adverse mental health, treatment, and functional outcomes. This prospective study examined the effects of an electronic mental health stigma reduction intervention on self-stigma (self-blame, shame, and help-seeking inhibition) among male construction workers in Australia.

Method

Male construction workers (N = 682) were randomly assigned to receive either the intervention condition or the wait list control over a six-week period. Self-stigma was assessed using the Self-Stigma of Depression Scale at post-intervention. We conducted linear regression to assess the effectiveness of the intervention on self-stigma, adjusting for relevant covariates.

Results

Self-stigma was relatively low in the sample. The intervention had no significant effect on self-stigma, after adjusting for confounders. There were reductions in stigma in both the intervention and control groups at 6-week follow-up. Process evaluation indicated that participants generally enjoyed the program and felt that it was beneficial to their mental health.

Conclusions

These observations underscore the need for further research to elucidate understanding of the experience of self-stigma among employed males.

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Self-stigma is thought to be an important barrier to help-seeking

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There is a need for greater understanding of self-stigma among blue collar males

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A electronic anti-stigma program did not have a beneficial effect on aspects of self-stigma

On shame and voice-hearing

Hearing voices in the absence of another speaker-what psychiatry terms an auditory verbal hallucination-is often associated with a wide range of negative emotions. Mainstream clinical research addressing the emotional dimensions of voice-hearing has tended to treat these as self-evident, undifferentiated and so effectively interchangeable. But what happens when a richer, more nuanced understanding of specific emotions is brought to bear on the analysis of distressing voices? This article draws findings from the 'What is it like to hear voices' study conducted as part of the interdisciplinary Hearing the Voice project into conversation with philosopher Dan Zahavi's Self and Other: Exploring Subjectivity, Empathy and Shame to consider how a focus on shame can open up new questions about the experience of hearing voices. A higher-order emotion of social cognition, shame directs our attention to aspects of voice-hearing which are understudied and elusive, particularly as they concern the status of voices as other and the constitution and conceptualisation of the self.

The Meaning of Stigma for People with Mental Disorders in Brazil

OBJECTIVE

To understand the meaning of stigma for people with mental disorders.

METHOD

A qualitative study with 46 Brazilian adults with mental disorders. Data were collected through semistructured interviews and nonparticipant observation and submitted for a thematic analysis with symbolic interactionism.

RESULTS

Stigma was considered as an experience of incomprehension and suffering. The society has difficulty in empathizing, respecting differences and understanding the extent of the suffering of people with mental disorders. Participants recommended anti-stigma strategies that included promoting knowledge and respecting differences.

CONCLUSIONS

The present study contributes new insights to be addressed in interventions to reduce the suffering and impact of stigma.

Conditional Disclosure on Pathways to Care: Coping Preferences of Young People at Risk of Psychosis

The interrelationship between stigma and help-seeking is under-researched among children and adolescents. This study explored stigma in relation to pathways to care among young people putatively in an early stage of increased risk of developing psychotic disorders. "Pathways to care" was defined as help-seeking and support from informal and formal resources, and increased risk was determined through the presence of persistent psychotic-like experiences and internalizing/externalizing psychopathology. Twenty-nine qualitative interviews were analyzed using thematic analysis. We defined the superordinate theme in these data as "conditional disclosure," a concept reflecting the rules and prerequisites that influenced how/whether participants sought help. Through parallels between these findings and established stigma theory, we examined how these conditions could be interpreted as influenced by stigma. Our findings demonstrate the influence of stigma on young people's perceptions of a range of pre-clinical symptoms, and on how they seek support for these symptoms.

Self-stigma of Patients with Type 1 Diabetes and Their Coping Strategies

BACKGROUND

The purpose of this study was to examine the stigma and coping strategies of patients with type 1 diabetes.

METHODS

Data were collected from 24 adult patients with type 1 diabetes via in-depth semi-structured interviews that took place in clinic waiting rooms. Qualitative and descriptive data analysis was conducted to identify stigma and coping strategies of patients with type 1 diabetes.

RESULTS

Stigma of patients with type 1 diabetes consisted of four categories: (i) "hatred of insulin" due to a treatment-oriented lifestyle after the onset of the disease, (ii) "imperfect body" due to systemic changes caused by the disease, (iii) "social outcast" as a diabetes patient who used to be healthy, and (iv) "poor me," a negative self-image due to the responses and attitudes of others. Regarding the coping strategies for reducing stigma, the following four categories were derived from the analysis: (i) In a stable disease stage, patients coped with stigma by "hiding their disease" or (ii) "pretending to be healthy" by avoiding self-care behaviors in public. When they told others about their disease, they (iii) "gradually spoke out to those around them about their illnesses." (iv) When they could not do either (i) or (ii), they resorted to "limiting their social life" or limiting interactions with others.

CONCLUSION

Patients with type 1 diabetes changed their coping strategies for reducing stigma as the disease progressed because stigma was tied to their disease. Physical, psychological, social, and spiritual coping strategies are required to reduce stigma, and the strategies are interrelated. It is important for nurses to assess patients from various viewpoints, including the viewpoint of stigma.

Bioethical analysis to the therapeutic use of Cannabis: Integrative review

Introduction:

Despite being considered as a contravention under some countries’ legislation, the therapeutic use of Cannabis sativa has been growing in Brazil, due to the promising results observed in many pathologies. Such a scenario has fostered the need to deepen discussions on the subject and possibly revise legislation governing the substance use and access.

Objectives:

Identify the types of stigma related to the therapeutic use of Cannabis and describe the strategies people use to overcome stigma.

Methods:

This integrative review was carried out in the databases PubMed, Scopus, CINAHL, MEDLINE, PsycINFO, Web of Science, and Cochrane Library, with 565 articles being retrieved. Triads’ cross-check were done, first maintaining the “cannabis” and “therapeutic use” pair, added by “stigma,” “bioethics,” “ethics,” “social consequences,” and “legal consequences.” The final selection resulted in six articles.

Ethical Consideration:

However, the ethical issues that pervade and regulate decisions on this subject must be considered.

Results:

Different dimensions and types of stigma related to the therapeutic use of Cannabis have been identified. The bioethical principle of autonomy was an expression of citizenship and human rights, mitigating internal conflicts related to self-stigma and the effects of external stigma on the person’s life.

Conclusion:

It was possible to identify the types of stigma related to the therapeutic use of Cannabis is an internal dimension represented (self-stigma) and an external dimension, represented (social and structural stigmas) and to identify strategies adopted to face this stigma: skills training group for users, elaboration of laws and specific programs to clarify the therapeutic use of Cannabis with a greater social scope, and support for family members. Thus, contributing to the building of people’s autonomy in a broader context of decision-making autonomy and executive autonomy will provide the development of people’s capacity to perform complex tasks of self-management and, consequently, to continue promoting and preserving their decision-making process and their capacity to plan and perform tasks associated with managing their lives and their treatments.

Association between mental health-related stigma and active help-seeking: systematic review and meta-analysis

BackgroundMental disorders create high individual and societal costs and burden, partly because help-seeking is often delayed or completely avoided. Stigma related to mental disorders or mental health services is regarded as a main reason for insufficient help-seeking.AimsTo estimate the impact of four stigma types (help-seeking attitudes and personal, self and perceived public stigma) on active help-seeking in the general population.MethodA systematic review of three electronic databases was followed by random effect meta-analyses according to the stigma types.ResultsTwenty-seven studies fulfilled eligibility criteria. Participants' own negative attitudes towards mental health help-seeking (OR = 0.80, 95% CI 0.73-0.88) and their stigmatising attitudes towards people with a mental illness (OR = 0.82, 95% CI 0.69-0.98) were associated with less active help-seeking. Self-stigma showed insignificant association (OR = 0.88, 95% CI 0.76-1.03), whereas perceived public stigma was not associated.ConclusionsPersonal attitudes towards mental illness or help-seeking are associated with active help-seeking for mental problems. Campaigns promoting help-seeking by means of fighting mental illness-related stigma should target these personal attitudes rather than broad public opinions.

Attitudes Towards the Mentally Ill: A Study with Health Workers at a University Hospital in Rio de Janeiro

As there are few studies about evaluation of attitudes of health care workers to people with mental disorders in Brazil, a cross-sectional study was carried out to assess the health professionals' attitudes working in a university hospital in Rio de Janeiro and also examine the proportion of negative and positive attitudes endorsed by healthcare professionals in Brazil towards people with mental illness in comparison with other parts of the world. Data were collected using the Community Attitudes towards the Mentally Ill (CAMI) in a random sampling frame of health professionals (n = 246) working in a University Hospital in Rio de Janeiro between April 2013 and June 2013. The CAMI consists of four sub-scales: Authoritarianism, Benevolence, Social Restrictiveness and Community Mental Health Ideology. The results showed attitudes that range from neutral to positive, with the Benevolence and Social Restrictiveness sub-scales showing the least stigmatizing results. The following individual characteristics were associated with negative attitudes: lower levels of education and less clinical experience. In general, health workers attitudes towards service users are characterized as positive when compared with other international studies. However, educational programs for health workers should be reinforced to further promote pre-existing positive attitudes towards people with mental health and the implementation of Brazilian Mental Health Policies.

Internalized stigma among psychiatric outpatients: Associations with quality of life, functioning, hope and self-esteem

This study aimed to: (i) determine the prevalence, socio-demographic and clinical correlates of internalized stigma and (ii) explore the association between internalized stigma and quality of life, general functioning, hope and self-esteem, among a multi-ethnic Asian population of patients with mental disorders. This cross-sectional, survey recruited adult patients (n=280) who were seeking treatment at outpatient and affiliated clinics of the only tertiary psychiatric hospital in Singapore. Internalized stigma was measured using the Internalized Stigma of Mental Illness scale. 43.6% experienced moderate to high internalized stigma. After making adjustments in multiple logistic regression analysis, results revealed there were no significant socio-demographic or clinical correlates relating to internalized stigma. Individual logistic regression models found a negative relationship between quality of life, self-esteem, general functioning and internalized stigma whereby lower scores were associated with higher internalized stigma. In the final regression model, which included all psychosocial variables together, self-esteem was the only variable significantly and negatively associated with internalized stigma. The results of this study contribute to our understanding of the role internalized stigma plays in patients with mental illness, and the impact it can have on psychosocial aspects of their lives.

The Impact of a Rights-Based Counselling Intervention to Reduce Stigma in People Affected by Leprosy in Indonesia

Background

This paper assesses the impact of a counselling intervention on reducing leprosy-related stigma in Cirebon District, Indonesia. The unique features of this intervention are its rights-based approach, the underlying Cognitive Behavioural Therapy (CBT) model, the three types of counselling and the lay and peer counsellors who were involved.

Methodology/principal findings

Mixed methods (e.g. three scales, interviews, focus group discussions and reflection notes) were used to assess the impact of the intervention, which ran over a two-year period. There was a control area with no interventions. The study participants were people affected by leprosy and other key persons (e.g. family members). The sample size differs per method, for example, data regarding 67 counselling clients and 57 controls from a cohort, and notes from 207 counselling clients were examined. The notes showed that most clients faced stigma on a daily basis, whether internalized, anticipated and/or enacted. A significant reduction was found between the before and after total scores of the SARI Stigma Scale (p-value < 0.001), Participation Scale Short (p-value < 0.001) and WHO Quality of Life score (p-value < 0.001) among the counselling clients. While there is also an effect in the control group, it is much larger in the intervention group. Qualitative data indicates that knowledge and rights trigger change. Clients took steps to improve their life such as re-connecting with neighbours, helping in household activities and applying for jobs. Challenges include the wish to conceal their condition.

Conclusion/significance

The findings show that the counselling intervention was effective in reducing stigma, promoting the rights of people with leprosy and facilitating their social participation. More research is needed on how to create a more sustainable intervention, preferably structurally embedded in the health or social services.

Can building knowledge, increasing the awareness of rights and developing confidence through counselling empower people affected by leprosy and reduce the stigma that surrounds them? In this paper the authors describe the impact of a counselling module designed to address the widespread issue of stigma in Cirebon District, Indonesia. The module ran for a two-year period and has some unique features. For example, it integrates three different types of counselling: individual, family and group. During the counselling, medical information about leprosy was provided and awareness of rights (e.g. right to healthcare, right to education) was raised. The counselling was offered by lay and peer counsellors, the latter having been affected by leprosy, to a total 260 people. This study showed that counselling can be effective in reducing stigma. The authors recommend its application on a larger scale.

Patients' perceptions of barriers to self-managing bipolar disorder: A qualitative study

BACKGROUND

Self-management of bipolar disorder (BD) is challenging for many individuals.

MATERIAL

Interviews were used to assess perceived barriers to disease self-management among 21 high-risk patients with BD. Content analysis, with an emphasis on dominant themes, was used to analyze the data.

RESULTS

Three major domains of barriers emerged: individual barriers (psychological, knowledge, behavioral and physical health); family/community-level barriers (lack of support and resources); and provider/healthcare system (inadequate communication and access to care).

CONCLUSION

Care approaches providing social and peer support, optimizing communication with providers and integrating medical and psychiatric care may improve self-management of BD in this vulnerable population.

Mixed-methods analysis of internalized stigma correlates in poorly adherent individuals with bipolar disorder

BACKGROUND

Internalized stigma, which occurs when stigmatized individuals accept society's assessment and incorporate this assessment into their sense of self, is prevalent in individuals with bipolar disorder (BD). This study explored the correlates of internalized stigma in a research sample of patients with BD who were poorly adherent to their medications.

METHODS

Both quantitative and qualitative analyses were performed. Scores of 115 individuals with BD on the Internalized Stigma of Mental Illness (ISMI) scale were correlated with scores on the General Self-Efficacy (GSE) Scale, Brief Psychiatric Rating Scale (BPRS), Montgomery-Asberg Depression Rating Scale (MADRS), and Young Mania Rating Scale (YMRS). Regression was run for GSE (dependent variable) and ISMI (independent variable). In-depth qualitative interviews were conducted on a representative subsample (N=21).

RESULTS

Internalized stigma levels were moderately high. Internalized stigma and self-efficacy correlated, and internalized stigma related to self-efficacy after adjusting for demographic variables (age, gender, years of education), comorbidities, and symptom severity (BPRS and MADRS). Internalized stigma was also associated with the BD symptoms of depression, anxiety, guilt feelings, suspiciousness, and hallucinogenic behaviors. No association was found with mania.

CONCLUSIONS

Because internalized stigma has strong psychosocial and psychiatric symptom associations, it is recommended that clinicians address both societal stigma and internalized stigma. Strategies such as cognitive-behavioral therapy may help modify BD patients' internalized stigma.

The Stigma of Suicide Survivorship and Related Consequences-A Systematic Review

Background

considerable proportion of the population experiences major life disruptions after losing a loved one to suicide. Social stigma attached to suicide survivors adds to complications occurring in the course of suicide bereavement. Despite its known risks, stigma related to suicide survivors has been sparsely investigated.

Methods

We conducted a systematic literature search in PubMed, Web of Science, PsycInfo and PsyArticles, of studies indexed up through August 2015. Articles were eligible for inclusion if they addressed experiences of stigma in suicide survivors, compared them to other bereavement populations, or investigated stigmatizing attitudes within the public. The search was restricted to English-language studies.

Results

25 records matched inclusion criteria. Study designs were heterogeneous, making comparisons difficult. Results demonstrated that suicide survivors experience stigma in the form of shame, blame, and avoidance. Suicide survivors showed higher levels of stigma than natural death survivors. Stigma was linked to concealment of the death, social withdrawal, reduced psychological and somatic functioning, and grief difficulties. Only one study investigated stigmatizing attitudes towards suicide survivors among the general population.

Limitations

Internal and external validity of the studies was restricted by a lack of valid measures and selection bias.

Conclusions

More methodologically sound research is needed to understand the impact of stigma on suicide survivors’ grief trajectories and to separate it from other grief aspects. Clinicians and grief-counselors as well as the public should be educated about the persistent stigma experienced by suicide survivors.

The right location? Experiences of refugee adolescents seen by school-based mental health services

Access to needed mental health services can be particularly difficult for newly arrived refugee and asylum-seeking adolescents, although many attend school. This study examined young refugees' impressions and experience of mental health services integrated within the school system. Semi-structured interviews were conducted with 40 adolescent refugees discharged by three school-based mental health services across the United Kingdom. Two-thirds preferred to be seen at school. Rumination and worry about insecurity in the asylum process had a negative impact particularly on the adolescents' social functioning and ability to focus at school. The important role played by teachers in supporting and mediating contact with mental health services was valued by those interviewed. The study confirms that schools offer an important location for mental health services for adolescent refugees and provide an important portal for integration of services.

Cognitive therapy for internalised stigma in people experiencing psychosis: A pilot randomised controlled trial

We aimed to evaluate the feasibility of Cognitive Therapy (CT) as an intervention for internalised stigma in people with psychosis. We conducted a single-blind randomised controlled pilot trial comparing CT plus treatment as usual (TAU) with TAU only. Participants were assessed at end of treatment (4 months) and follow-up (7 months). Twenty-nine participants with schizophrenia spectrum disorders were randomised. CT incorporated up to 12 sessions over 4 months (mean sessions=9.3). Primary outcome was the Internalised Stigma of Mental Illness Scale - Revised (ISMI-R) total score, which provides a continuous measure of internalised stigma associated with mental health problems. Secondary outcomes included self-rated recovery, internalised shame, emotional problems, hopelessness and self-esteem. Recruitment rates and retention for this trial were good. Changes in outcomes were analysed following the intention-to-treat principle, using ANCOVAs adjusted for baseline symptoms. There was no effect on our primary outcome, with a sizable reduction observed in both groups, but several secondary outcomes were significantly improved in the group assigned to CT, in comparison with TAU, including internalised shame, hopelessness and self-rated recovery. Stigma-focused CT appears feasible and acceptable in people with psychosis who have high levels of internalised stigma. A larger, definitive trial is required.

Ethical implications of the perception and portrayal of dementia

The way we perceive and portray dementia has implications for how we act towards people with dementia and how we address the issue of dementia within society. As a multi-disciplinary working group, established within the framework of the European Dementia Ethics Network of Alzheimer Europe, we aimed to describe the different ways that people with dementia are perceived and portrayed within society and to consider the moral implications of this. In the current paper, we address perceptions of dementia as reflected in explanatory models of its cause and nature, descriptions of characteristics of people with dementia, the use of language, media portrayals and the views of people living with dementia. Academics and professionals could use this exploration to reflect on their behaviour and their use of language regarding people with dementia.

The Effects of Stigma on Recovery Attitudes in People With Anorexia Nervosa in Intensive Treatment

Self-stigma in individuals with anorexia nervosa (AN) may affect engagement in intensive treatment. The objective of this study was to test a Model of Self-Stigma to identify the influence of public stigma, internalized stigma, self-esteem, and self-efficacy on recovery attitudes in individuals in inpatient treatment for AN. Using a cross-sectional design, 36 female participants with AN completed questionnaires during the first week of intensive inpatient treatment. Better attitude towards recovery was positively correlated with higher self-esteem and self-efficacy and negatively correlated with greater internalized stigma and perceptions of others devaluing families of individuals with AN. Together, these factors accounted for 63% of the variance in recovery attitudes. Findings demonstrate the adverse effects perceived stigma towards families, self-stigma, and self-esteem have on recovery attitudes in individuals with AN. Clinical interventions are needed to challenge internalized stigma and bolster self-esteem to enhance individuals' recovery efforts.

Exploring the relationship between stigma and help-seeking for mental illness in African-descended faith communities in the UK

Background

Stigma related to mental illness affects all ethnic groups, contributing to the production and maintenance of mental illness and restricting access to care and support. However, stigma is especially prevalent in minority communities, thus potentially increasing ethnically based disparities. Little is known of the links between stigma and help‐seeking for mental illness in African‐descended populations in the UK.

Objective and study design

Building on the evidence that faith‐based organizations (FBOs) can aid the development of effective public health strategies, this qualitative study used semi‐structured interviews with faith groups to explore the complex ways in which stigma influences help‐seeking for mental illness in African‐descended communities. A thematic approach to data analysis was applied to the entire data set.

Setting and participants

Twenty‐six men and women who had varying levels of involvement with Christian FBOs in south London were interviewed (e.g. six faith leaders, thirteen ‘active members’ and seven ‘regular attendees’).

Results

Key factors influencing help‐seeking behaviour were as follows: beliefs about the causes of mental illness; ‘silencing’ of mental illness resulting from heightened levels of ideological stigma; and stigma (re)production and maintenance at community level. Individuals with a diagnosis of mental illness were likely to experience a triple jeopardy in terms of stigma.

Discussion and conclusion

‘One‐size‐fits‐all’ approaches cannot effectively meet the needs of diverse populations. To ensure that services are more congruent with their needs, health and care organizations should enable service users, families and community members to become active creators of interventions to remove barriers to help‐seeking for mental illness.

The Effects and Stigma of Mental Illness in Turkey

This study was planned to determine internalized stigma of patients who were monitored in the psychiatry clinics due to mental problems. It was determined that there was significant difference between the patients' mean internalized stigma total scores between subscale scores and their gender, job, the place that the patient was raised in, educational status, working status, income level, the period spent after the diagnosis, hospitalization status, the hospital monitoring the patient and the diagnosis. It is suggested that counseling services should be planned in order to identify negative impact of the factors that influence coping with internalized stigma.

'People like me don't make things like that': Participatory video as a method for reducing leprosy-related stigma

The Stigma Assessment and Reduction of Impact project aims to assess the effectiveness of stigma-reduction interventions in the field of leprosy. Participatory video seemed to be a promising approach to reducing stigma among stigmatized individuals (in this study the video makers) and the stigmatisers (video audience). This study focuses on the video makers and seeks to assess the impact on them of making a participatory video and to increase understanding of how to deal with foreseeable difficulties. Participants were selected on the basis of criteria and in collaboration with the community health centre. This study draws on six qualitative methods including interviews with the video makers and participant observation. Triangulation was used to increase the validity of the findings. Two videos were produced. The impact on participants ranged from having a good time to a greater sense of togetherness, increased self-esteem, individual agency and willingness to take action in the community. Concealment of leprosy is a persistent challenge, and physical limitations and group dynamics are also areas that require attention. Provided these three areas are properly taken into account, participatory video has the potential to address stigma at least at three levels - intrapersonal, interpersonal and community - and possibly more.

Self-reported stigma and its association with socio-demographic factors and physical disability in people with intellectual disabilities: results from a cross-sectional study in England

PURPOSE

The aim of this study was to investigate whether socio-demographic variables and physical disability (e.g. sensory impairment and mobility problems) were associated with self-reported stigma in people with intellectual disabilities (ID), and to examine whether age, sex and ethnicity modified the relationship between severity of intellectual disability and self-reported stigma.

METHODS

229 participants with mild or moderate intellectual disabilities were recruited from 12 centres/sites in England from community intellectual disability services, day centres, supported housing schemes, voluntary organisations and invitation letters. Information on physical disability and socio-demographic variables were obtained using a structured data collection form. Self-reported stigma was measured using a validated questionnaire.

RESULTS

Age was associated with self-reported stigma, with older adults reporting more stigmatising experiences. Participants with moderate intellectual disabilities were more likely to report being treated differently such as being made fun of and being treated like children. Physical disability such as sensory, mobility and speech problems were not associated with self-reported stigma. Gender modified the relationship between severity of ID and self-reported stigma as participants who were male and had moderate ID were more likely to report stigma compared to females with moderate ID. Categorical age also modified the relationship between severity of ID and self-reported stigma as older participants who had moderate ID were more likely to report stigma compared to younger people with moderate ID.

CONCLUSIONS

Older adults and those with moderate ID are potentially at higher risk of being targets of public stigma or are more likely to report stigma. Interventions to help individuals cope with stigma could be targeted to this group.

Resilience, internalized stigma, self-esteem, and hopelessness among people with schizophrenia: Cultural comparison in Austria and Japan

Resilience is becoming an important topic in people with schizophrenia since there is evidence that it increases the probability for long-term recovery. The current study investigated transcultural differences in resilience across schizophrenia patients from two different geographical regions, Austria and Japan. Another objective was to examine transcultural differences in internalized stigma, self-esteem, and hopelessness, which can be expected to be relevant in this context, as well as the interrelations between these subjective elements of recovery and symptom severity. To this end, patients from outpatient mental health services in Innsbruck, Austria (N=52) and Tokyo, Japan (N=60) as well as 137 healthy comparison subjects from both countries were included into this cross-sectional study. Notably, we detected a significant country effect with markedly lower resilience (F=74.4, p<0.001) and self-esteem scores (F=226.0, p<0.001) as well as higher hopelessness scores (F=37.4, p<0.001) among Japanese subjects in general. In addition, both Austrian and Japanese patients indicated significantly lower degrees of resilience (F=57.5, p<0.001), self-esteem (F=51.8, p<0.001), and hope (F=29.5, p<0.001) compared to healthy control subjects. The inter-correlations between subjective elements of recovery were comparable in size in the two patient samples, but the inter-correlations between these issues and residual symptoms of schizophrenia as objective domains of recovery were markedly higher in Austrian subjects. This suggests that schizophrenia patients from Western European and Japanese cultures may have different needs to achieve recovery. In conclusion, it will be critical to develop culture-specific psychosocial programs and to examine their feasibility and effectiveness among these patients.

The effects of a documentary film about schizophrenia on cognitive, affective and behavioural aspects of stigmatisation

BACKGROUND AND OBJECTIVES

Stereotypes about schizophrenia may lead to prejudicial attitudes and discrimination with debilitating effects on people diagnosed with schizophrenia. There is thus a need to develop interventions aiming to prevent, reduce or eliminate such stereotypes. The aim of this study was to evaluate the effects of a documentary film on schizophrenia on cognitive, affective and behavioural aspects of stigmatisation.

METHODS

Forty-nine participants were assessed on measures of stereotypes and social distance, and on the Model of Stereotype Content, which includes measures of stereotypes, emotional reactions and behavioural tendencies. Participants were randomly assigned into either a condition in which they viewed the documentary film (Film group), or into a control condition in which no intervention was conducted (Control group).

RESULTS

Only participants in the Film group revealed a significant decrease of negative stereotypes (Dangerousness and Unpredictability) and desired Social distance, and a significant increase in the perception of sociability in persons with schizophrenia.

LIMITATIONS

Small sample size and its reduced generalizability are the main limitations in this study.

CONCLUSIONS

These findings suggest that a documentary film promoting indirect contact with people diagnosed with schizophrenia is a promising tool to prevent and reduce stigmatisation regarding schizophrenia..

Gaining approvals for mental health research in the NHS

When embarking on mental health research it is often necessary to apply for approvals from one or more review bodies to ensure that the research is ethical and that the safety and well-being of participants are safeguarded. This can be complicated and time consuming, particularly to those unfamiliar with the process. In this article we describe the approvals commonly required for National Health Service-based research involving patients and endeavour to clearly explain what is involved at each stage. We then highlight some of the main considerations, including ethical aspects, which are particularly pertinent to conducting research in the field of mental health, and finish with general advice and considerations for future developments in the area.

How stigma impacts on people with psychosis: The mediating effect of self-esteem and hopelessness on subjective recovery and psychotic experiences

This study aimed to examine how stigma impacts on symptomatic and subjective recovery from psychosis, both concurrently and longitudinally. We also aimed to investigate whether self-esteem and hopelessness mediated the observed associations between stigma and outcomes. 80 service-users with psychosis completed symptom (Positive and Negative Syndrome Scale) and subjective recovery measures (Process of Recovery Questionnaire) at baseline and 6-months later, and also completed the King Stigma Scale, the Self-Esteem Rating Scale and the Beck Hopelessness Scale at baseline. In cross sectional regression and multiple mediation analyses of the baseline data, we found that stigma predicted both symptomatic and subjective recovery, and the effects of stigma on these outcomes were mediated by hopelessness and self-esteem. When the follow-up data were examined, stigma at baseline continued to predict recovery judgements and symptoms. However, self-esteem only mediated the effect of stigma on PANSS passive social withdrawal. Self-esteem and hopelessness should be considered in interventions to reduce the effects of stigma. Interventions that address the current and long-term effects of stigma may positively affect outcome for people being treated for psychosis.

A Cluster-Randomized Controlled Intervention Study to Assess the Effect of a Contact Intervention in Reducing Leprosy-Related Stigma in Indonesia

Background

Can deliberate interaction between the public and persons affected by leprosy reduce stigmatization? The study described in this paper hypothesises that it can and assesses the effectiveness of a ‘contact intervention’.

Methods/Principal Findings

This cluster-randomized controlled intervention study is part of the Stigma Assessment and Reduction of Impact (SARI) project conducted in Cirebon District, Indonesia. Testimonies, participatory videos and comics given or made by people affected by leprosy were used as methods to facilitate a dialogue during so-called ‘contact events’. A mix of seven quantitative and qualitative methods, including two scales to assess aspects of stigma named the SDS and EMIC-CSS, were used to establish a baseline regarding stigma and knowledge of leprosy, monitor the implementation and assess the impact of the contact events. The study sample were community members selected using different sampling methods. The baseline shows a lack of knowledge about leprosy, a high level of stigma and contrasting examples of support. In total, 91 contact events were organised in 62 villages, directly reaching 4,443 community members (mean 49 per event). The interview data showed that knowledge about leprosy increased and that negative attitudes reduced. The adjusted mean total score of the EMIC-CSS reduced by 4.95 points among respondents who had attended a contact event (n = 58; p <0.001, effect size = 0.75) compared to the score at baseline (n = 213); for the SDS this was 3.56 (p <0.001, effect size = 0.81). About 75% of those attending a contact event said they shared the information with others (median 10 persons).

Conclusions/Significance

The contact intervention was effective in increasing knowledge and improving public attitudes regarding leprosy. It is relatively easy to replicate elsewhere and does not require expensive technology. More research is needed to improve scalability. The effectiveness of a contact intervention to reduce stigma against other neglected tropical diseases and conditions should be evaluated.

Stigma plays an important role in several neglected tropical diseases such as leprosy, Buruli ulcer, lymphatic filariasis, onchocerciasis and leishmaniasis. It negatively impacts individuals affected, and often also their families, and even communities. There are different ways to address stigma. One promising intervention is called ‘contact’. The principle is that personal contact between persons affected by a stigmatized condition and the public will demystify incorrect information, break the stereotypes and generate empathy. This in turn is believed to reduce stigma. In this paper the authors report a study that investigated the effect of a contact intervention that aimed to reduce leprosy-related public stigma in Cirebon District, Indonesia. During this intervention 91 so called ‘contact events’ were organized at a local level, for instance, in schools, villages, halls and mosques. The results show that through education, testimonies (direct contact), videos and comics made by people affected by leprosy (in-direct contact) knowledge about leprosy increased and personal attitudes improved substantially.

Social affiliation and negative symptoms in schizophrenia: Examining the role of behavioral skills and subjective responding

Schizophrenia is characterized by profound impairment in the motivation for social affiliation. Negative symptoms are associated with such impairment but the contribution of behavioral skill deficits is unclear. In this study we utilized a novel video paradigm to assess performance-based affiliative behavioral skills in individuals with schizophrenia (N=48) and community controls (N=29). Individuals with schizophrenia displayed significant impairment in behavioral affiliative skills compared to controls; however, in response to the affiliative interaction the groups did not differ on self-reported affective responding, appraisal of the interaction partner, or desire to interact with the partner in the future. Importantly, within the patient group more severe negative symptoms (particularly those related to motivation and pleasure) were associated with poorer affiliative social skills and this relationship was independent of instrumental (non-social) skills, depression or positive symptoms. More severe negative symptoms were also associated with less positive affect in response to the interaction and less positive appraisals of the interaction partner. Self-reported social anhedonia was related to patients' diminished willingness to interact with the partner in the future. These results demonstrate that negative symptoms in schizophrenia are related to both affiliative skill deficits and less affiliative subjective responses to interaction partners.

Association between perceived social stigma against mental disorders and use of health services for psychological distress symptoms in the older adult population: validity of the STIG scale

OBJECTIVES

To document the reliability, construct and nomological validity of the perceived Social Stigmatisation (STIG) scale in the older adult population.

DESIGN

Cross-sectional survey.

SETTING

Primary medical health services clinics.

PARTICIPANTS

Probabilistic sample of older adults aged 65 years and over waiting for medical services in the general medical sector (n = 1765).

MEASUREMENTS

Perceived social stigma against people with a mental health problem was measured using the STIG scale composed of seven indicators.

RESULTS

A second-order measurement model of perceived social stigma fitted adequately the observed data. The reliability of the STIG scale was 0.83. According to our results, 39.6% of older adults had a significant level of perceived social stigma against people with a mental health problem. RESULTS showed that the perception of social stigma against mental health problems was not significantly associated with a respondent gender and age. RESULTS also showed that the perception of social stigma against the mental health problems was directly associated with the respondents' need for improved mental health (b = -0.10) and indirectly associated with their use of primary medical health services for psychological distress symptoms (b = -0.07).

CONCLUSION

RESULTS lead us to conclude that social stigma against mental disorders perceived by older adults may limit help-seeking behaviours and warrants greater public health and public policy attention. Also, results lead us to conclude that physicians should pay greater attention to their patients' attitudes against mental disorders in order to identify possible hidden mental health problems.

The Internalized Stigma of Mental Illness: Cross-Cultural Adaptation and Psychometric Properties of the Portuguese Version of the ISMI Scale

This study examined the psychometric properties of the Portuguese version of the ISMI scale in a sample of 253 adult psychiatric outpatients. The exploratory factor analysis replicated the five factor structure of the scale. The results revealed good internal consistency. Criterion-related validity supported the variability in response to stigma across clinical diagnoses. Thus, the Portuguese version of the ISMI scale can be considered appropriate to measure and differentiate between stigmatization experiences. Also, in order to design more focused approaches aimed to reduce the negative effects of internalized stigma, its use in institutional and in community-based mental health services is recommended.

Correlates of public support toward federal funding for harm reduction strategies

Background

Historically, US federal policy has not supported harm reduction interventions, such as safe injection facilities (SIFs) and needle and syringe programs (NSPs), which can reduce the burden associated with injection drug use. Given recent increases in abuse of both legal and illegal opioids, there has been a renewed debate about effective ways to address this problem. The current study (1) assessed participants’ support for SIFs and NSPs, and (2) evaluated several demographic factors (e.g., age, gender, race, education, political ideology, and religiosity) and individual differences in stigmatizing beliefs about people who inject drugs (PWID) that might relate to support for these interventions.

Methods

U.S. adults (N = 899) completed a web-based study that assessed self-reported support for NSPs and SIFs, and stigma about PWID.

Results

The majority of participants were at least somewhat supportive of both NSPs and SIFs. Regression analyses indicated greater support for NSPs and SIFs was predicted by more liberal political ideology, more agreement that PWID deserve help rather than punishment, older age, and male gender. Also, participants who endorsed lower stigma about PWID were more supportive of NSPs and SIFs. Race, religiosity, and education did not predict support for NSPs and SIFs.

Conclusions

Most participants tended to report support for harm reduction strategies. Age, political ideology, and individual differences in stigmatizing beliefs about PWID were significantly associated with support. Given the potential malleability of stigmatizing beliefs, efforts that seek to shift stigma about PWID could have important implications for public policy towards harm reduction strategies for PWID.

Personal Stigma in Suicide Attempters

The aim of this study was to explore suicide attempters' experiences of personal stigma. This qualitative study included a focus group of 7 experienced clinicians and semi-structured interviews with 8 suicide attempters. Thematic analysis of the data yielded four main themes: seriousness, care, "badness," and avoidance. Experiences of stigma pervaded all contexts, but were most emotionally upsetting to the participants in interpersonal relationships. The findings show the importance of evaluating stigma for suicide attempters during suicide risk assessment and the need for specifically tailored interventions to combat suicide stigma at the individual level.

The effect of diagnostic labels on the affective responses of college students towards peers with ‘Asperger’s Syndrome’ and ‘Autism Spectrum Disorder’

Given the removal of Asperger’s Syndrome label in Diagnostic and Statistical Manual of Mental Disorders–Fifth Edition, the impact of clinical labels upon the affective responses of college students was explored. A total of 120 college students read two vignettes depicting social interactions typical of a person with autism spectrum disorder. In one vignette, they were informed that the character was a typical college student and in the other, the character had a clinical disorder (either autism spectrum disorder, Asperger’s Syndrome or Schizophrenia). Participants’ affective responses were measured on the Positive and Negative Affect Scale. No significant differences in positive and negative affective responses were found between the clinical labels. However, affective responses were significantly more positive and less negative towards behaviours associated with clinical groups compared to the typical college student. The implications for students disclosing their diagnosis at university are discussed.

Dealing with stigma: experiences of persons affected by disabilities and leprosy

Persons affected by leprosy or by disabilities face forms of stigma that have an impact on their lives. This study seeks to establish whether their experiences of stigma are similar, with a view to enabling the two groups of people to learn from each other. Accounts of experiences of the impact of stigma were obtained using in-depth interviews and focus group discussion with people affected by leprosy and by disabilities not related to leprosy. The analysis shows that there are a lot of similarities in impact of stigma in terms of emotions, thoughts, behaviour, and relationships between the two groups. The main difference is that those affected by leprosy tended to frame their situation in medical terms, while those living with disabilities described their situation from a more social perspective. In conclusion, the similarities offer opportunities for interventions and the positive attitudes and behaviours can be modelled in the sense that both groups can learn and benefit. Research that tackles different aspects of stigmatization faced by both groups could lead to inclusive initiatives that help individuals to come to terms with the stigma and to advocate against exclusion and discrimination.

Healthy young minds: the effects of a 1-hour classroom workshop on mental illness stigma in high school students

This study aimed to test the effects of a 1-h classroom-based workshop, led by medical students, on mental illness stigma amongst secondary school students. Students (aged 14-17) from three public secondary schools in British Columbia participated in the workshop. A questionnaire measuring stigma (including stereotype endorsement and desire for social distance) was administered immediately before (T1), immediately after (T2), and 1-month after the workshop (T3). A total of 279 students met the study inclusion criteria. Total scores on the stigma scale decreased by 23 % between T1 and T2 (p < 0.01). This was sustained 1-month post-workshop with a 21 % stigma reduction compared to pre-intervention (p < 0.01). This effect was primarily due to improvements in scores that measured desire for social distance. There were no significant changes in scores that measured stereotype endorsement. Adolescents' stigmatizing attitudes can be effectively reduced through a 1-h easily implementable and cost-effective classroom-based workshop led by medical students.