Internalized stigma -- believing that negative stereotypes about serious mental illnesses (SMI) are true of one's self -- is a common and harmful problem for many adults with SMI. It causes demoralization, depression, hopelessness, and reduced motivation to work toward recovery goals (2-17). It can degrade a person's use of needed mental health services, other assistance, and quality of life (16-20). Yet there are no readily available interventions addressing it. Ending Self Stigma is designed to remedy this - an empowering, 9 session, manualized psycho-educational class that integrates knowledge and tools from diverse domains to offer participants an individualized set of strategies for reducing or eliminating internalized stigma in their own lives. In accord with NIMH Strategic Objectives 2 and 3 (22), ESS is designed to ameliorate internalized stigma as an individual-level risk factor for poor illness course (21) and to address a broad range of functional recovery- oriented outcomes, while helping participants personalize their use of the strategies it offers to best fit their individual needs, backgrounds, and preferences. Following a promising but limited pilot study, this application seeks to rigorously test whether ESS (a) reduces internalized stigma, (b) improves related psychosocial and behavioral outcomes, and (c) gains are retained over six months, via a community-based randomized trial enrolling adults with SMI from two large Maryland psychosocial rehabilitation programs. Following full informed consent, eligible volunteers will be interviewed (Time 1) to assess the variables listed above and demographic characteristics and then immediately randomized (50:50 chance) to either the intervention condition of attending ESS at their home agency -or- to the control condition of continuing with usual care at that agency, minimally enhanced by a brief educational discussion and handout about internalized stigma. Nine weeks later, participants in both conditions will be interviewed again (Time 2;after the conclusion of ESS for the intervention condition participants). Statistically comparing these two groups at these two time points will allow us to ascertain whether ESS has the beneficial effects we have hypothesized. Then, 6 months after Time 2 we will again assess all participants (Time 3) to test whether any benefits of taking ESS are sustained over time. If the proposed trial shows it to be effective, ESS will offer a highly-portable intervention to reduce the human suffering and multi-level risks and harms of internalized stigma. The study team intends to then offer its manual, ancillary materials, and facilitator guidance to interested professional and peer mental health agencies nationally, and internationally. Additionally, once the core intervention is tested, the team will proceed with developing variations tailored to other uniquely-stigmatized (and self stigmatizing) conditions such as dual diagnosis, substance abuse, post-traumatic stress disorder, and a variation designed to help prevent the development of self stigma in recently diagnosed individuals.

Public Health Relevance

Internalized stigma - when a person with a mental illness believes that negative stereotypes about mental illness are true of his/her self -- commonly causes demoralization, depression, reduced motivation to work toward recovery goals, and reduced use of helpful treatments and services among adults with mental illness. Ending Self Stigma is a new class-format intervention to help such individuals reduce or eliminate their own internalized stigma and its harmful effects, using a flexible set of strategies drawn from research and experience. This proposal seeks to test ESS in a community-based randomized study so that it may be made widely available if it proves effective.

National Institute of Health (NIH)
National Institute of Mental Health (NIMH)
Research Project (R01)
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Mental Health Services in MH Specialty Settings (SRSP)
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Juliano-Bult, Denise M
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University of Maryland Baltimore
Schools of Medicine
United States
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