Background: Stigma and fear of stigma are widespread among Veterans with PTSD1-2 and both have pernicious effects on Veterans' well-being and participation in mental health treatment2-4. Internalized stigma is a harmful consequence of societal stigma, and has been associated with decreased hope, self-esteem, personal motivation, morale, self-regard, and persistence regarding illness management among individuals with a range of mental illnesses5-14. Internalized stigma also has negative impacts on the recovery and well- being of Veterans with PTSD specifically15, but no evidence-based interventions are currently available to assist Veterans with PTSD in combatting the impact of internalized stigma. Therefore, the purpose of this proposal is to develop and pilot-test an intervention to provide Veterans with PTSD the skills to cope effectively with stigma and to mitigate the internalization of stigmatizing beliefs and stereotypes. To that end, we will modify Ending Self Stigma (ESS), an intervention composed of evidence-based strategies for combating internalized stigma for mental illness16, to specifically serve the needs of Veterans with PTSD.
Aims : The two aims of this proposed two-year pilot are to 1) modify the existing ESS intervention to address internalized and societal stigma experienced by Veterans with PTSD and 2) conduct a randomized pilot trial of ESS-P for 64 Veterans with PTSD diagnoses, to test our hypotheses that a) feasibility of ESS-P will be satisfactory, as demonstrated by adequate rates of recruitment, initial intervention engagement, attendance at intervention sessions, and acceptability of the intervention reported by participants; b) when compared to a control group receiving an informational brochure, ESS-P participants will have significantly reduced internalized stigma at immediate post-treatment, c) when compared to a control group receiving an informational brochure, ESS-P participants will show significantly increased self-efficacy, increased sense of belonging, and increased recovery orientation at immediate post-treatment, and d) compared to controls, ESS-P participants will demonstrate increased participation in mental health treatment during the three months post-treatment versus the three months before baseline. Methods: Our proposal will be conducted in two phases that map onto our two study Aims. In Phase I, we will produce an intervention and accompanying manual for the PTSD version of ESS (ESS-P), based upon the strategies and structure of the existing ESS intervention. To this end, we will interview Veterans with a PTSD diagnosis to learn more about their experience with societal and internalized stigma associated with PTSD, plus other considerations and issues in addressing internalized stigma with such Veterans. Information gleaned in these qualitative interviews will form the basis of our adaption of the ESS intervention to specifically address the needs of Veterans with PTSD. In Phase II, we will pilot-test ESS-P with Veterans who have PTSD, to evaluate the feasibility and acceptability of the intervention. In addition, we will preliminarily estimate the effects of ESS-P through comparison to a control group receiving an informational brochure on internalized stigma associated with PTSD. These feasibility, implementation and pilot outcome data will be used to further refine the intervention, towards the goal of conducting a future larger scale study of ESS-P within the VA system. Impact: Given the severe effects of societal and internalized stigma and the lack of interventions to help Veterans with PTSD overcome stigmas associated with PTSD symptoms, experiences, diagnoses or treatment, this proposal has the potential for high and lasting impact. In keeping with pilot effects of the core ESS curriculum, we anticipate that Veterans participating in the tailored ESS for PTSD (ESS-P) may experience increased empowerment and behavioral activation regarding a variety of life goals. Such benefits would further the VA's commitment to improving the mental health, Recovery, and community reintegration of Veterans detailed in the 2010-2014 VHA Strategic Plan42.
Veterans with PTSD report that stigma and fear of stigma have a chilling effect on their participation in mental health treatment. Despite the widely-documented effects of stigma on the recovery of individuals with mental illnesses and research demonstrating harmful consequences of internalized stigma, including decreased hope, self-esteem, personal motivation, and persistence regarding illness management, no interventions are currently available to assist Veterans with PTSD in combating the impact of internalized stigma. The goal of this research is to develop and pilot-test an intervention to provide Veterans with PTSD the skills to cope effectively with stigma and to mitigate the internalization of stigmatizing beliefs and stereotypes To accomplish this purpose, Ending Self Stigma (ESS), an intervention composed of evidence-based methods for combating internalized stigma for serious mental illness, will be modified and tested to address issues particular to PTSD.
