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Empirical Studies of Self-Stigma Reduction Strategies: A Critical Review of the Literature

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Objective: The purpose of this article was to comprehensively review published literature about strategies to reduce self-stigma among people with mental illness. Recommendations and implications for research also are discussed. Methods: The electronic databases of Ovid, PubMed, and PsycINFO were searched for peer-reviewed articles published between January 2000 and August 2011 by using the key words “self-stigma,” “internalized stigma,” “perceived stigma,” and “stigma intervention.” The search was further narrowed to studies that described a detailed intervention and that used self-stigma as a primary or secondary outcome, tested the intervention among individuals with a psychiatric illness, and analyzed data quantitatively with acceptable statistical tools. Results: Fourteen articles met inclusion criteria, and eight reported significant improvement in self-stigma outcomes. Participants predominantly had schizophrenia and related disorders or depression. Six self-stigma reduction strategies were identified. Psychoeducation was the most frequently tested intervention. Self-stigma definitions, measurements, and conceptual frameworks varied considerably across these studies. Several studies lacked a theoretical framework for their intervention. Six different scales were used to measure self-stigma. Conclusions: Two prominent approaches for self-stigma reduction emerged from our review: one, interventions that attempt to alter the stigmatizing beliefs and attitudes of the individual; and two, interventions that enhance skills for coping with self-stigma through improvements in self-esteem, empowerment, and help-seeking behavior. The second approach seems to have gained traction among stigma experts. Targeting high-risk groups to preempt self-stigma appears to be a promising area for future research.
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Empirical Studies of Self-Stigma Reduction
Strategies: A Critical Review of the Literature
Dinesh Mittal, M.D.
Greer Sullivan, M.D., M.S.P.H.
Lakshminarayana Chekuri, M.D.
Elise Allee, M.A.
Patrick W. Corrigan, Psy.D.
Objective: The purpose of this article was to comprehensively review
published literature about strategies to reduce self-stigma among people
with mental illness. Recommendations and implications for research also
are discussed. Methods: The electronic databases of Ovid, PubMed, and
PsycINFO were searched for peer-reviewed articles published between
January 2000 and August 2011 by using the key words self-stigma,
internalized stigma,”“perceived stigma,and stigma intervention.
The search was further narrowed to studies that described a detailed
intervention and that used self-stigma as a primary or secondary out-
come, tested the intervention among individuals with a psychiatric ill-
ness, and analyzed data quantitatively with acceptable statistical tools.
Results: Fourteen articles met inclusion criteria, and eight reported
significant improvement in self-stigma outcomes. Participants pre-
dominantly had schizophrenia and related disorders or depression. Six
self-stigma reduction strategies were identified. Psychoeducation was the
most frequently tested intervention. Self-stigma definitions, measure-
ments, and conceptual frameworks varied considerably across these
studies. Several studies lacked a theoretical framework for their in-
tervention. Six different scales were used to measure self-stigma. Con-
clusions: Two prominent approaches for self-stigma reduction emerged
from our review: one, interventions that attempt to alter the stigmatizing
beliefs and attitudes of the individual; and two, interventions that en-
hance skills for coping with self-stigma through improvements in self-
esteem, empowerment, and help-seeking behavior. The second approach
seems to have gained traction among stigma experts. Targeting high-risk
groups to preempt self-stigma appears to be a promising area for future
research. (Psychiatric Services 63:974981, 2012; doi: 10.1176/appi.
ps.201100459)
People with mental illness, such
as schizophrenia, may internal-
ize negative stereotypes about
mental illness and respond by self-
stigmatization (16). High levels of
self-stigma are associated with low
levels of hope (7), self-esteem (810),
self-efficacy (11), and quality of life
(12). Self-stigma may undermine ad-
herence to treatment recommendations
(1315) and decrease help-seeking be-
havior (16,17). It also may interfere
with rehabilitation goals, such as pur-
suing employment (18), independent
living, and having a full social life
(7,8,19).
The concept of self-stigma has been
described by various terms, including
internalized stigma, perceived stigma,
and enacted stigma. Using a sociolog-
ical perspective, Link and Phelan (2)
postulated that perceived stigma con-
sists of five elements (labeling, stereo-
typing, separation, status loss, and
discrimination). These elements un-
fold when a less powerful, stigmatized
group encounters a more powerful,
stigmatizing group. On the basis of
this conceptualization, they devel-
oped the 12-item Perceived Devalu-
ation and Discrimination (PDD) Scale
and Links Perceived Stigma Question-
naire (LPSQ), a 29-item scale (2022).
Although the PDD is the most fre-
quently used measure of self-stigma,
14 other scales are also used to assess
the personal experience of stigma
related to mental illness (23).
Corrigan and Watson (1,4,6,24)
expanded Link and Phelans (2) con-
ceptualization of self-stigma into a
hierarchy of three As: awareness,
agreement, and application. To expe-
rience self-stigma, one must not only
be aware of the stereotype or stereo-
types that describeastigmatized
groupfor example, people with
mental illness are weak and, there-
fore, are responsible for their disorder
but also agree with the stereotype.
In addition, one must also apply the
stereotype to oneself (I am weak and
Dr. Mittal, Dr. Sullivan, and Ms. Allee are affiliated with the Department of Psychiatry,
Central Arkansas Veterans Healthcare System, Building 58 (152/NLR), 2200 Fort Roots
Dr., Little Rock, AR 72114 (e-mail: dinesh.mittal@va.gov). Dr. Chekuri is with the
Department of Applied Gerontology, University of North Texas, Denton, Texas.
Dr. Corrigan is with the Joint Center for Psychiatric Rehabilitation, Illinois Institute
of Technology, Chicago.
974 PSYCHIATRIC SERVICES 'ps.psychiatryonline.org 'October 2012 Vol. 63 No. 10
have mental illness, so I must be
responsible for my disorder) (4).
Some authors have defined self-
stigma relative to the barriers it may
create (namely decreased help seek-
ing, shame, and negative appraisal).
For example, according to Vogel and
others (16), self-stigma is defined as
the perception of oneself as inade-
quate or weak if one were to seek
professional help.Luoma and others
(25) defined self-stigma as shame,
evaluative thoughts, and fear of en-
acted stigma that results from individ-
ualsidentification with a stigmatized
group that serves as a barrier to the
pursuit of valued life goals.
Development of interventions to
decrease self-stigma is a relatively
new area of research. A recent re-
view by Heijnders and Van Der Meij
(26) highlighted multiple target lev-
els for antistigma programs related
mostly to physical illnesses such
as HIV/AIDS, leprosy, tuberculosis,
and epilepsy. The authors identified
key strategies, including counseling,
cognitive-behavioral therapy (CBT),
empowerment, self help, and support
groups. Far less is known about the
role of these strategies for reducing
self-stigma related to mental illness.
This article reviews published lit-
erature that describes empirical
strategies for reduction of self-stigma
related to mental illness and discusses
implications for research.
Methods
We searched the electronic databases
of Ovid, PubMed, and PsycINFO for
peer-reviewed journal articles pub-
lished in the English language by
using the terms self-stigma,”“inter-
nalized stigma,”“perceived stigma,
and stigma intervention.We chose
these terms because of their com-
mon usage in self-stigma reduction
initiatives. Although the terms self-
stigmaand internalized stigmaare
used interchangeably, the term per-
ceived stigmarelates to the individ-
uals expectation of devaluation and
discriminatory attitudes by the gen-
eral public (stereotype awareness).
For the initial review, we selected
articles that contained these terms in
the title or abstract and were pub-
lished between January 2000 and
August 2011 (N=3,501). We then
screened abstracts to identify inter-
vention studies with self-stigma as
an outcome measure and completed
a full-text review of such articles
(N=87). We included articles that
described or cited in an accessible
source a detailed intervention, in-
cluded an intervention targeting self-
stigma as a primary or secondary
outcome, tested the intervention
among individuals with an existing
psychiatric illness (for example,
schizophrenia, bipolar disorder, sub-
stance use disorder, depression, and
posttraumatic stress disorder) or in
a high-risk group (for example, indi-
viduals exposed to traumatic life
events), and analyzed data quantita-
tively with acceptable statistical tools
to determine the effectiveness of the
interventions. We excluded case re-
ports, qualitative studies, interven-
tions that targeted the general public,
and studies focusing on general med-
ical illness.
This article is a systematic narrative
review of articles that met our selec-
tion criteria. We analyzed articles for
the demographic profile of partici-
pants; target disorders; self-stigma
definition; conceptual basis; scale or
measures used; type, length, and
content of intervention; mode of de-
livery; study design; and self-stigma
outcomes and effect sizes.
Results
Fourteen articles were identified by
our search. Table 1 describes the ar-
ticles in terms of sample size, popu-
lation studied, design, and research
setting. In general, the studies were
small. Six had sample sizes of 50
persons or fewer, four had sample
sizes between 50 and 100, and only
four had sample sizes larger than 100.
Eight studies focused on persons with
schizophrenia or serious mental ill-
ness, three on persons with depres-
sion, one on persons with substance
use disorders, and two on groups at
risk to develop a mental disorder
(college students with symptoms of
depression or anxiety and veterans in
postdeployment transition). The race
of the participants varied considerably
across studies. Only half of the stud-
ies were conducted in the United
States. All but two were conducted
predominantly in outpatient clinical
settings. The methodological design
employed by the studies varied: ten
were randomized controlled trials, one
had a wait-list control group, and three
used a pretest-posttest design.
Table 2 presents details about the
content, design, measurement, and
outcomes of the self-stigma interven-
tions. Six articles (2732) did not
clearly describe a stigma definition
or a conceptual framework, three (33
35) alluded to Corrigan and Watsons
self-stigma conceptualization (1,4,6),
and two (36,37) referred to Link and
otherssociological perspective of
stigma (2,22). The remaining three
articles (25,38,39) offered only con-
textual definitions with no theoret-
ical framework. Only five articles
(25,33,3638) developed an interven-
tion that was based on a conceptual
model. Of the 14 articles, nine articles
(25,30,31,3338) described an inter-
vention targeting self-stigma as a pri-
mary outcome and five (2729,32,39)
described interventions with self-
stigma as a secondary outcome.
Types and content of
intervention strategies
The most common type of interven-
tion strategy was psychoeducation or
psychoeducation combined with cog-
nitive restructuring. Some investiga-
tors examined the effect of printed
material only, such as brochures (31,39),
or of materials on the Internet (30),
and others examined educational
sessions delivered by a trainer or
a therapist. These psychoeducational
interventions were most often con-
ducted in a group format. The num-
ber of educational sessions ranged
from one to 23. The content and
processes used for the educational
interventions varied widely. For ex-
ample, Link and others (37) evaluated
an intervention in which a trainer
stressed the effects and consequences
of stigma and encouraged participants
to share personal experiences and
discuss behavioral strategies. McCay
and colleagues(36) intervention sought
to educate participants to interpret
the illness experience, minimize self-
stigmatizing attitudes, develop hope,
and pursue meaningful life goals. Shin
and Lukens (32) utilized a more med-
ically oriented approach, educating
participants about illness, medication
PSYCHIATRIC SERVICES 'ps.psychiatryonline.org 'October 2012 Vol. 63 No. 10 975
effects, stigma, relapse prevention,
crisis management, communication
and stress-management skills, self help,
and community resource utilization.
They also used visual aids, such as charts
and handouts, to reinforce didactic
materials. Alvidrez and others (31)
evaluated an intervention tailored
for African-American adults, includ-
ing use of a psychoeducational book-
let, ‘‘Getting Mental Health Treatment:
Advice From People Whove Been
There.’’ Information included experi-
ences and advice of black mental
health consumers on treatment en-
gagement, challenges in seeking men-
tal health treatment, and strategies to
overcome those challenges.
One study (25) evaluated the effect
of acceptance and commitment ther-
apy, a contemporary behavioral analytic
theory of language and cognition (40) in
which participants are instructed to
watch their thoughts mindfully and feel
their feelings completely. Participants
were also taught to respond to their
stigmatizing attitudes and behaviors
by applying principles such as accep-
tance,”“diffusion,and contact.
Three studies (28,29,38) evaluated
interventions that combined psycho-
education with elements of CBT.
MacInnes and Lewis (38) encouraged
participants to share illness experi-
ences and educated them about symp-
toms, stress, coping, self help, and
stigma and its impact. Principles of
self-acceptance and CBT challenged
specific beliefs about stigma. Knight
and others (28), using cognitive-
behavioral elements, tested an inter-
vention to improve self-esteem by
increasing stigma awareness. Partici-
pants also received psychoeducation
about stigma and myths and realities
about mental illness. Aho-Mustonen
and others (29) indirectly targeted
self-stigma through improving self-
esteem. Their intervention included
education about schizophrenia and its
symptoms, epidemiology, and course of
illness as well as stress and medication
effects. Participants received home-
work that was based on cognitive-
behavioral principles.
Finally, three studies used even
more complex multimodal interven-
tions. Fung and others (33) created
an intervention that combined five
intervention strategies, including
psychoeducation, CBT, motivational
interviewing, social skills training, and
goal attainment. Lucksted and others
(34) developed Ending Self-Stigma,
a program that involved a combination
of cognitive-behavioral exercises, dis-
cussion, sharing of experiences, group
support, skills training, and problem
solving. Adler and others (27) de-
scribed the effectiveness of Battlemind
debriefing and Battlemind training,
a strategy that combines cognitive and
skills-based approaches to educate
returning military personnel about
their postdeployment transition.
Table 1
Demographic profile of participants in studies of self-stigma reduction strategies
Participants
Author and year N Country
Predominant
diagnosis
Age
(M years)
Males Females
Predominant
race-ethnicity SettingN%N%
Luoma et al.,
2008 (25)
88 U.S. Substance use
disorder
36 41 47 47 53 White Residential
Link et al.,
2002 (37)
88 U.S. Schizophrenia 41 54 61 34 39 White Clubhouse
McCay et al.,
2007 (36)
67 Canada Schizophrenia 26 48 72 19 28 Outpatient
Shin and Lukens,
2002 (32)
48 U.S. Schizophrenia 37 20 42 28 58 Korean
American
Outpatient
Alvidrez et al.,
2009 (31)
42 U.S. Depression and
anxiety disorders
45 13 31 29 69 Black Outpatient
Hammer and
Vogel, 2010 (39)
1,397 U.S. Depression 29 1,397 100 0 White Outpatient
Griffiths et al.,
2004 (30)
525 Australia Depression 36 150 26 375 74 White Outpatient
MacInnes and
Lewis, 2008 (38)
20 United
Kingdom
Serious mental illness 32 20 100 0 —— Inpatient
Knight et al.,
2006 (28)
21 United
Kingdom
Schizophrenia 39 11 52 10 48 White Outpatient
and inpatient
Aho-Mustonen
et al., 2011 (29)
39 Finland Schizophrenia 40 35 90 4 10 Prison
Fung et al.,
2011 (33)
66 China Schizophrenia 45 37 56 29 44 Chinese Outpatient
Luckstead et al.,
2011 (34)
50 U.S. Schizophrenia 53 41 81 9 19 Black Outpatient
Wade et al.,
2011 (35)
263 U.S. Depression and
anxiety symptoms
19 119 45 144 55 White Outpatient
Adler et al.,
2009 (27)
2,297 U.S. At-risk combat veterans 2,202 96 95 4 Outpatient
976 PSYCHIATRIC SERVICES 'ps.psychiatryonline.org 'October 2012 Vol. 63 No. 10
Measures
The articles reviewed used six differ-
ent scales to measure changes in
individualspersonal experience of
stigma (Table 2). The PDDLPSQ
(20,21) was the most commonly used
measure. Even though all six scales
presented information on their psy-
chometric properties (23), only three
scalesthe PDDLPSQ, the Inter-
nalized Stigma of Mental Illness
(ISMI) Scale, and the Self-Stigma of
Mental Illness Scale (SSMIS)were
grounded by a conceptual framework.
Outcomes and effect sizes
Eight studies (25,27,30,32,34,35,38,39)
reported a significant decrease post-
intervention in self-stigma levels. Only
two of the seven studies involving
patients with schizophrenia or a psy-
chotic disorder reported significant
improvement postintervention (32,34).
Effect sizes (Cohensd[41]),were
mostly small (.2) to medium (.5) (Table
2). Large effect sizes, 8.03 and .95, were
reported by only two studies (32,38). If
actual effect sizes (Cohensd)werenot
reported, they were calculated by using
the formula described by Thalheimer
and Cook (42). Because most of these
studies were randomized controlled
trials with small sample sizes, effect
sizes should be interpreted with
caution.
Discussion
Our review identified six different
strategies for intervention to decrease
self-stigma related to mental illness.
Interventions ranged from psychoedu-
cation alone to psychoeducation com-
bined with cognitive restructuring and
more complex or multimodal interven-
tions. Most interventions involved
patients with schizophrenia and psy-
chotic spectrum disorders or depres-
sion and gave little attention to stigma
related to other psychiatric disorders.
In addition, most of the studies re-
viewed were exploratory or pilot in-
vestigations with significant limitations,
such as small sample size, lack of
randomization, or no control group.
Almost all studies reported only im-
mediate postintervention outcomes
and did not measure any follow-up
outcomes to assess sustainability of
the effect. None of the studies
controlled for mediating variables,
such as level of symptoms, severity of
illness, functional status, and changes
in self-esteem, empowerment, or cop-
ing skills. Many of the studies were
unique and not directly comparable,
and none have been replicated.
Given that the development of self-
stigma interventions research is in its
nascent stages, such limitations are
understandable. Even though these
limitations preclude drawing firm
conclusions, it is encouraging to find
some promising interventions that
merit further evaluation. The effect
sizes provided in Table 2 may serve as
a resource to test these interventions
with more rigorous study designs and
larger representative sample sizes.
Apart from these methodological
limitations, our review identified sev-
eral developmental issues in the
emerging research that warrant care-
ful scrutiny. To a large extent, the
articles reviewed used different defi-
nitions of self-stigma, often alluding to
multiple conceptualizations. Concep-
tual clarity in the definitions of stigma
has been an issue for quite some time
(2,4345). In a recent review article,
Livingston and Boyd (5) concluded,
Conceptual overlap is evident in
leading definitions of internalized
stigma. . . . Measurement overlap is
apparent in several items and sub-
scales that are contained within in-
struments that are designed to
measure internalized stigma. . . .
Perhaps the difficulty of compartmen-
talizing psychosocial variables into
neat categories reflects the messy
and entangled nature of peoples lived
experiences.Moreover, the term
self-stigmais used interchangeably
with internalized stigma,”“perceived
stigma,”“enacted stigma,”“internal
stigma,and personal stigma.
Clearly, a consensus on the definition
and conceptualization of self-stigma
and related terminology would bene-
fit this field of research and could
guide measurement.
Our review also found that the
PDD was the scale used most com-
monly to measure self-stigma.
However, some authors (25,29,36)
expressed reservations about its ap-
propriateness to detect changes in
self-stigma levels. In our review, eight
studies used this scale, and only two
recorded significant improvement in
self-stigma outcomes (32,38). The
PDD measures an individuals aware-
ness of public attitudes, beliefs, and
perceptions toward the stigmatized
group (20). However, awareness of
stereotypes itself is not sufficient to
cause self-stigma. Accepting and ap-
plying these stereotypes are also
necessary (4). The PDD does not
detect changes in these two key
constructs (acceptance and applica-
tion). Further, an increased aware-
ness of the publics stigmatizing views
has been associated with the de-
creased likelihood that public stereo-
types are perceived as legitimate (4).
As such, decreasing perceived stigma
(stereotype awareness) alone may not
be an efficient approach to reduce
self-stigma. The conceptualization of
Watson and colleagues (4) may more
comprehensively capture an individu-
als experience of self-stigma. The
ISMI and SSMIS (46,47) likely rep-
resent the best measures to evaluate
self-stigma. In our review, studies that
measured self-stigma with the ISMI,
the Self-Stigma of Seeking Help
Scale, or the Depression Stigma Scale
reported significant improvements
more frequently (25,30,34,35,39). It is
possible that these scales were more
sensitive to change in self-stigma.
Another key issue that emerged
from our review was the scarcity of a
conceptual basis for self-stigma inter-
ventions. Only five articles (25,33,36
38) developed an intervention that was
based on a conceptual model. Select-
ing and describing a conceptual frame-
work that underpins an intervention
allow one to understand the specific
targets and promote anticipation of
desired changes in the targeted con-
struct. We recommend that in order to
further systematic research that tar-
gets self-stigma, future studies should
clearly identify and adopt a theoretical
framework for self-stigma interven-
tions. Early evidence from our review
suggests that CBT techniques have
the potential to combat self-stigma
(33,34,38). In a recent article, Roe
and others (48) reported positive out-
comes of narrative-enhancement cog-
nitive therapy among persons with
severe mental illness. Participants
showed improvements in six domains
(experiential learning, positive change
PSYCHIATRIC SERVICES 'ps.psychiatryonline.org 'October 2012 Vol. 63 No. 10 977
Table 2
Intervention strategies targeting self-stigma among individuals with existing psychiatric illness or in high-risk groups
Strategy and
author and
year of study
Manual or
protocol Delivery format Principal targets Scale
a
Effect size
b
Significant
improvement
Existing psychiatric
illness
Acceptance and
commitment
therapy
Luoma et al.,
2008 (25)
Yes 2 to 3 group
sessions
Stigmatizing thoughts
and behaviors
ISMI and PDD .67
c
; .27
d
Yes
Psychoeducation
(face to face)
Link et al.,
2002 (37)
e
Yes 16 group
sessions
Effects and
consequences of
stigma, sharing
personal experiences
LPSQ No
McCay et al.,
2007 (36)
e
Yes 12 group
sessions
Illness experience,
engulfment,
and hope
LPSQ No
Shin and
Lukens,
2002 (32)
e
Yes 10 group
sessions
Cultural sensitivities,
crisis management,
communication,
and stress
management skills
PDD 8.03 Yes
Psychoeducation
booklet or
brochure
Alvidrez et al.,
2009 (31)
f
Yes 1 individual
session
Seeking treatment
and engagement
PDD .13 No
Hammer and
Vogel, 2010
(39)
f
Yes 1 individual
session
Male sensitivities,
illness and its
epidemiology
SSOSH .18 Yes
Psychoeducation
(BluePages Web
site) versus CBT
(MoodGym
Web site)
Griffiths et al.,
2004 (30)
f
Yes Five individual
modules
Illness, symptoms,
and treatment
DSS (personal and
perceived stigma)
.11 (personal stigma)
and 0 (perceived
stigma) (BluePages);
.10 (personal and
perceived stigma)
(MoodGym)
Yes
Psychoeducation
with cognitive-
behavioral
therapy
MacInnes
and Lewis,
2008 (38)
No 6 group
sessions
Stigmatizing beliefs,
stress, and coping
PDD .95 Yes
Knight et al.,
2006 (28)
Yes 6 group
sessions
Low self-esteem,
stigma-myths,
and reality
PDD .01 No
Aho-
Mustonen
et al., 2011
(29)
e
Yes 8 group
sessions
Illness, symptoms,
and epidemiology
LPSQ .59 No
Multimodal
strategies
Fung et al.,
2011(33)
e
Yes 12 group and
4 individual
sessions
Goal attainment
and treatment
adherence
CSSMI .147 No
Lucksted et
al., 2011
(34)
Yes 9 group
sessions
Stigma myths
and reality,
community
integration
ISMI .57 Yes
Continues on next page
978 PSYCHIATRIC SERVICES 'ps.psychiatryonline.org 'October 2012 Vol. 63 No. 10
in experience of self, acquiring cogni-
tive skills, enhanced hope, improved
coping, and emotional change).
According to Watson and colleagues
social-cognitive model (4), internaliza-
tion (acceptance and application) of
awareness of stigmatizing stereotypes
results in the Why try?effect, in
which individuals question why they
should even try treatment, given their
belief that it wontworkforpeoplelike
them (49). The CBT interventions
may be effective in changing these
overgeneralizations. To increase cost-
effectiveness, CBT-based antistigma
initiatives could be incorporated into
the CBT interventions routinely of-
fered to patients with schizophrenia
(5054).
We identified two contrasting self-
stigma reduction approaches: first,
interventions that attempt to alter
stigmatizing beliefs and attitudes, and
second, interventions that encourage
participants to accept the existence of
stigmatizing stereotypes without chal-
lenging them and that enhance stigma-
coping skills through improvements in
self-esteem, empowerment, and help-
seekingbehavior.Thelatterapproach
seems to have gained traction among
stigma experts (25,28,31,33,55). Al-
though the approach needs further
empirical exploration, it appears to
have some theoretical support. In
a recent review of self-stigma, Corrigan
and others (49) conceptualized self-
stigma, empowerment, and self-esteem
as part of a continuum: Personal em-
powerment is a parallel positive phe-
nomenon conceived as a mediator
between self-stigma and behaviors
related to goal attainment.Whereas
empowerment anchored one end of
a self-stigma continuum, self-esteem
and self-efficacy anchored the other
end (49).
Brohan and others (56) found
a strong inverse relationship between
empowerment and self-stigma. The
authors opined that a focus on em-
powerment may result in self-stigma
reduction. Knight and others (28)
attempted to improve self-esteem
outcomes by educating clients about
stigma and myths and realities about
mental illness. Their intervention did
not try to alter stigma levels. Instead,
the authors used education to in-
crease awareness of and coping with
stigma and self-esteem levels. These
conceptual frameworks and the pre-
liminary empirical evidence suggest
that both self-esteem and empower-
ment could be independently tar-
geted to reduce self-stigma.
Our review revealed a striking pau-
city of research on the reduction of self-
stigma related to anxiety disorders, such
as posttraumatic stress disorder. Indi-
viduals with these disorders experience
not only the devastating effects of the
illness but also self-stigmatization
(57,58). We recommend that future
research target these disorders. Addi-
tionally, targeting high-risk groups to
preempt self-stigma is a promising area
for future research. Public stigma
campaigns have employed a similar
approach (59). Our review identified
two studies that targeted high-risk
groups (college students with psycho-
logical symptoms [35] and returning
military personnel during postdeploy-
ment transition [27]). Further research
could involve other high-risk groups,
such as victims of natural disasters or
other traumatic life events. Moreover,
it would also be prudent to identify the
best time to target such individuals with
antistigma interventions. In our review,
most studies did not indicate the
duration of illness at the time of the
intervention. Although it may seem
logical that early intervention would
be best, this expectation needs empir-
ical validation.
Conclusions
We recommend that researchers eval-
uating self-stigma interventions pay
greater attention to self-stigma con-
ceptualization, measurement tools, and
theoretical frameworks. An approach
that involves cognitive restructuring
merits further evaluation. Last, be-
cause we limited our review to articles
Table 2
Continued from previous page
Strategy and
author and
year of study
Manual or
protocol Delivery format Principal targets Scale
a
Effect size
b
Significant
improvement
High-risk group
Counselor self-
disclosure
Wade et al.,
2011 (35)
e,g
No One group
session
Help seeking SSOSH .51 No
Battlemind
training
Adler et al.,
2009 (27)
f
Yes 23 group
sessions
Postdeployment
transition
Hoge Stigma Scale .13 Yes
a
ISMI, Internalized Stigma of Mental Illness Scale; PDD, Perceived Devaluation and Discrimination Scale; LPSQ, Links Perceived Stigma
Questionnaire; SSOSH, Self-Stigma of Seeking Help Scale; DSS, Depression Stigma Scale; CSSMIS, Chinese Self-Stigma of Mental Illness Scale
b
If actual effect sizes (Cohens d) were not reported, they were calculated by using the formula described by Thalheimer and Cook (42).
c
Effect size for ISMI
d
Effect size for PDD
e
The study was a randomized comparative effectiveness trial.
f
The study was a randomized controlled trial.
g
Group counseling itself had a significant positive effect on self-stigma levels.
PSYCHIATRIC SERVICES 'ps.psychiatryonline.org 'October 2012 Vol. 63 No. 10 979
published in the English language,
it is possible that we have missed
self-stigma work done in other
languages.
Acknowledgments and disclosures
This work was supported, in part, by grant IIR
08-086 to Dr. Sullivan from the Department of
Veterans Affairs Office of Research and De-
velopment. Dr. Mittal was supported by the
Veterans Integrated Service Network 16 Mental
Illness Research and Education and Clinical
Center, Central Arkansas Veterans Healthcare
System, and the Center of Excellence for Mental
Health Outcomes, both in Little Rock. The
authors acknowledge Mary K. Bartnik, M.A.,
Shane Russell, B.A., Amanda Lunsford, M.A.,
and Valorie Shue, B.A., for help with the
literature search and research and editorial
assistance.
The authors report no competing interests.
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... Research on other stigmas can also provide insights for the development of new strategies and the refinement of existing strategies for addressing FD self-stigma (for a critical review on self-stigma reduction strategies, see Mittal et al., 2012). For example, there is substantial evidence showing that Acceptance and Commitment Therapy (ACT) can successfully reduce internalized stigma, both when employed in isolation (Luoma et al., 2008) and when combined with CBT (Pearl et al., 2020). ...
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