Anticipated Impacts on Veteran's Healthcare: Mental illness stigma negatively impact treatment seeking and adherence and poses a significant barrier to the recovery of veterans with serious mental illness (SMI). As outlined in the VA Mental Health Strategic Plan, the development and implementation of strategies to reduce stigma and promote recovery is a VHA priority. However, to date, there are no empirically tested, evidence-based practices aimed at minimizing the negative effects of stigma and the internalization of stigmatizing beliefs. The current study will examine the effectiveness of a group intervention designed to assist veterans with SMI to develop skills to cope more effectively with stigma and discrimination and minimize the internalization of stigmatizing beliefs and stereotypes about people with mental illness. Project Background: Stigmatizing beliefs and attitudes about mental illness are prevalent and exposure to stigma is common among people with mental illness. The negative effects of stigma are compounded when a veteran with SMI internalizes these stigmatizing assumptions and stereotypes. Internalized stigma refers to the process in which a person with mental illness cognitively or emotionally absorbs negative messages or stereotypes about mental illness and comes to believe them and apply them to him/herself. Internalized stigma is evident among veterans with SMI and can lead to decreased self-efficacy, increased depression, social withdrawal, and curtailed pursuit of recovery goals. Project Objectives: In response, we developed Ending Self Stigma (ESS), a 9-session group intervention to assist veterans with SMI to develop skills to effectively cope with stigma and minimize the internalization of stigmatizing beliefs and stereotypes. Results from pilot testing of the intervention have been promising: ESS was associated with a significant reduction in internalized stigma and a significant increase in recovery-orientation. The primary objectives of this larger scale evaluation are to compare the effects of ESS to a general health and wellness group in: 1) reducing internalized stigma and 2) improving proximal psychosocial outcomes (self-efficacy, belonging, recovery orientation). Secondary objectives include assessing the effects of ESS on improving distal psychosocial outcomes (quality of life, social functioning) and examining if improvements are maintained 6-months post-treatment. We expect that veterans in ESS will evidence a greater reduction in internalized stigma and greater improvements in proximal and distal psychosocial outcomes at post-treatment and that these gains will be maintained at 6-months post-treatment. Project Methods: This study will be a randomized trial of 276 veterans with SMI receiving outpatient services in the VA Maryland Health Care System that compares ESS to a general health and wellness group. All participants will complete assessments at baseline, post- treatment, and 6 months post-treatment. Participants will be randomized to ESS or a general health and wellness group. Participants will attend either the ESS or the general health and wellness group once a week for 9 weeks. A two-level mixed effects model with adjustment for baseline response will be used to address the primary and secondary aims. Qualitative data on veterans'experiences of and strategies for coping with internalized stigma will be collected from a subset of veterans in both conditions to compare experiences of veterans in both groups and explore any reasons for ESS drop-out.

Public Health Relevance

Internalized stigma or self-stigma, the process in which a person with serious mental illness comes to believe and apply negative stereotypes or assumptions about people with mental illness to him or herself, poses a significant barrier to veterans'recovery. This study aims to determine whether a group intervention that assists veterans in developing skills to effectively cope with societal stigma and discrimination, prevent internalization of negative stereotypes and beliefs, and reduce existing self-stigma could minimize the negative consequences of stigma and promote recovery among veterans with SMI.

National Institute of Health (NIH)
Veterans Affairs (VA)
Non-HHS Research Projects (I01)
Project #
Application #
Study Section
HSR-4 Mental and Behavioral Health (HSR4)
Project Start
Project End
Budget Start
Budget End
Support Year
Fiscal Year
Total Cost
Indirect Cost
Baltimore VA Medical Center
United States
Zip Code
Jahn, Danielle R; Muralidharan, Anjana; Drapalski, Amy L et al. (2018) Differences in suicide and death ideation among veterans and nonveterans with serious mental illness. Psychol Serv 15:31-39