Amy L. Drapalski

Interventions targeting mental health self-stigma: A review and comparison.

OBJECTIVE With growing awareness of the impact of mental illness self-stigma, interest has arisen in the development of interventions to combat it. The present article briefly reviews and compares interventions targeting self-stigma to clarify the similarities and important differences between the interventions. METHOD We conducted a narrative review of published literature on interventions targeting self-stigma. RESULTS Six intervention approaches (Healthy Self-Concept, Self-Stigma Reduction Program, Ending Self-Stigma, Narrative Enhancement and Cognitive Therapy, Coming Out Proud, and Anti-Stigma Photo-Voice Intervention) were identified and are discussed, and data is reviewed on format, group-leader backgrounds, languages, number of sessions, primary mechanisms of action, and the current state of data on their efficacy. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE We conclude with a discussion of common elements and important distinctions between the interventions and a consideration of which interventions might be best suited to particular populations or settings.

Perceived Barriers to Medical Care and Mental Health Care Among Veterans With Serious Mental Illness

OBJECTIVES This study examined perceived barriers to mental health care and medical care and the relationship between demographic and clinical characteristics and perceived barriers among veterans with serious mental illness. METHODS Veterans diagnosed as having serious mental illnesses, hospitalized for psychiatric concerns, and at risk for treatment dropout (N=136) completed an interview as part of a larger study of a critical time intervention. RESULTS Many participants perceived barriers to accessing mental health care (67%) and medical care (60%). Personal factors were cited most often as barriers; overall, however, personal barriers were more likely to be perceived to impede mental health care (56%) than medical care (43%). Psychiatric symptoms were associated with greater perceived barriers to mental health care and medical care. CONCLUSIONS Veterans with serious mental illness at risk of treatment dropout perceived barriers to mental health care and medical services. Strategies to overcome barriers are needed and should target illness-related factors that may impede service use.

Assessing recovery of people with serious mental illness: development of a new scale.

OBJECTIVES The authors describe the development of the Maryland Assessment of Recovery in People with Serious Mental Illness, or MARS, a 25-item self-report instrument that measures recovery of people with serious mental illness, and report a study of its psychometric properties. METHODS Doctoral-level scientists with expertise in serious mental illness drafted a set of survey items about the recovery process. Items reflected recovery domains outlined by the Substance Abuse and Mental Health Services Administration. After consultation with a panel of experts on recovery that included consumers and clinical scientists and with a small group of consumers, the instrument was narrowed to 67 items and administered to 166 individuals recruited from outpatient mental health clinics in two states. Item response theory and classical item analysis were used to select best-fitting items, reduce item redundancy, and improve the psychometric properties of the scale. Principal components analysis and confirmatory factor analysis were conducted to further examine dimensions of recovery measured by the scale. RESULTS The MARS is quite practical for use with individuals with serious mental illness. It demonstrated excellent internal consistency (Cronbachs α=.95) and test-retest reliability (r=.898) and good face and content validity. CONCLUSIONS The data provide initial support for use of the MARS to measure recovery of people with serious mental illness.

Issues and developments on the consumer recovery construct

The consumer recovery model has had increasing influence on mental health practices in the United States, Western Europe, and several other countries. However, adoption of the model has reflected political decisions rather than empirical evidence of the validity of the model or its value for treatment services. The recovery construct is poorly defined, and until recently there has been no reliable and valid measure with which to base a research program. We have developed an empirical measure that is well-suited for both research and clinical applications: the Maryland Assessment of Recovery in Serious Mental Ill-ness (MARS). We briefly describe the MARS and present preliminary data demonstrating that recovery is not a simple by-product of traditional outcome do-mains, but seems to be a distinct construct that may have important implications for understanding consumers with serious mental illness and for evaluating the outcome of treatment programs.

Self-stigma regarding mental illness: Definition, impact, and relationship to societal stigma.

In the early 1900s Cooley’s concept of the “looking glass self” (Cooley, 1902, 1909) articulated that ideas about ourselves are profoundly shaped by how we believe others see us—that one’s self concept is socially constructed. As a result, negative judgments from others are often incorporated into one’s self concept (Allport, 1954; Crocker & Major, 1989; Link, Cullen, Struening, et al., 1989; Mead, 1934), resulting in ‘shame’ (Allport, 1954; Crocker & Major, 1989; Goffman, 1961; Scheyett, 2005). Later, Allport (1954); Goffman (1961, 1963) and others expanded this by highlighting the inherently social aspect of stigmatization, defining stigma as negative judgments we levy against each other based on devalued group identities (e.g., “the mentally ill”; Scheyett, 2005). These concepts have been applied to the social-distancing and discrimination often faced by people experiencing or labeled with mental illnesses (Link, Cullen, Struening, et al., 1989; Scheff, 1966; Wahl, 1999), drawing in part on theory regarding other marginalized identities (e.g., Meyer, 2003). One result has been the idea of “internalized stigma” or “self-stigma” (shortened from ‘stigmatization’), the incorporation of others’ prejudices and stereotypes about people with mental illnesses into beliefs about oneself. Previous research has documented internalized stigma’s many harms, while also clarifying that stigmatized individuals are often resilient and paths between societal stigmatization and individual impacts are diverse (Corrigan & Watson, 2002; Crocker & Major, 1989; Watson, Corrigan, Larson, & Sells, 2007). Resistance to internalizing stigmatization is also persistent, if too rarely documented (Beers, 1908; Grobe, 1995; Jefferson, 1947). Nonetheless, that many people with mental health problems experience significant negative effects from internalized stigma is now well documented in research (Ritsher & Phelan, 2004; West et al., 2011) and first person accounts (Deegan, 1993; Gallo, 1994; Shimrat, 1997). These include reduced self-esteem, empowerment, hope, and sense of recovery, as well as exacerbated psychiatric symptoms and a greater reluctance to engage in treatment and other supports (Livingston & Boyd, 2010; Ritsher & Phelan, 2004). Such proximal effects, in turn, have potential distal consequences, such as impeding pursuit of life goals, reducing community participation and hindering social relationships and support (Lysaker, Roe, & Yanos, 2007; Yanos, Roe, Markus, & Lysaker, 2008). Much like breathing in polluted air, it is very hard to not take in at least pieces of societal prejudices like racism, sexism, classism, homophobia, and mental illness stigmatization (e.g., Bearman, Korobov, & Thorne, 2009; Meyer, 2003; Williams & Williams-Morris, 2000). When one then also belongs to the stigmatized group, internalizing the messages is often impossible to entirely avoid (Conde & Gorman, 2009; David, 2013) Thus, people who find themselves experiencing self-stigma are not at fault— but are left with the effects. In October 2013, we brought together 30 researchers in the area of mental illness self-stigma to discuss the current state of the field and to identify future priorities (“Reducing Internalized Stigma of Mental Illness: Mapping Future Directions,” Baltimore Maryland). These included the differences between and relationships among self-stigma and related constructs; exploring models or theories of the development, maintenance, and amelioration of self-stigma; validating new and existing measures of self-stigma with a variety of populations; and advancing strategies and programs designed to prevent, reduce, or eliminate self-stigma. That small working meeting was the impetus for this special issue. A call for papers was circulated widely, and final authors include both conference attendees and others. The resulting articles push forward our knowledge about and inquiry into the effects and dynamics of internalized stigma associated with mental illness as well as potential avenues and strategies for intervening to reduce it. Several seek to clarify our understanding of the concept of self-stigma and the interrelationships between it and other constructs (e.g., public stigma, anticipated stigma). For example, Quinn, Williams, and Weisz (2015) explore the relationship between discrimination experiences, anticipated stigma, and selfstigma in an effort to understand how self-stigma might develop. Their findings suggest that because of prior experiences of discrimination, individuals with mental illness may come to expect and anticipate that they will be stigmatized, which, in turn, may contribute to believing that the stereotypes involved are true. Further, Jennings et al. (2015) examine the role of perceived need Alicia Lucksted, Department of Psychiatry, University of Maryland School of Medicine; Amy L. Drapalski, VA Capitol Health Care Network (VISN 5) Mental Illness Research, Education, and Clinical Center (MIRECC), Baltimore, Maryland. Correspondence concerning this article should be addressed to Alicia Lucksted, Department of Psychiatry, Division of Psychiatric Services Research, University of Maryland School of Medicine, 737 West Lombard Street, Room 528, Baltimore MD 21201. E-mail: aluckste@psych .umaryland.edu Psychiatric Rehabilitation Journal

Gender Differences in Substance Use, Consequences, Motivation to Change, and Treatment Seeking in People With Serious Mental Illness

Gender differences in patterns and consequences of substance use, treatment-seeking, and motivation to change were examined in two samples of people with serious mental illness (SMI) and comorbid substance use disorders (SUDs): a community sample not currently seeking substance abuse treatment (N = 175) and a treatment-seeking sample (N = 137). In both groups, women and men demonstrated more similarities in the pattern and severity of their substance use than differences. However, treatment-seeking women showed greater readiness to change their substance use. Mental health problems and traumatic experiences may prompt people with SMI and SUD to enter substance abuse treatment, regardless of gender.

Prediction of Changes in Self-Stigma Among Veterans Participating in Partial Psychiatric Hospitalization: The Role of Disability Status and Military Cohort

OBJECTIVE Interventions addressing internalized stigma are a new area of research, and it is important to identify the types of clientele who derive benefit from existing interventions. METHOD Information was provided by 235 veterans attending a partial psychiatric hospitalization program, regarding their levels of internalized stigma on admission and discharge from a 3-week program that included interventions targeting internalized stigma. RESULTS Upon discharge, veterans receiving disability benefits demonstrated less reduction in internalized stigma than those not receiving disability benefits. Time of service moderated the relationship between disability status and change in internalized stigma, such that veterans serving in the more recent Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND) cohort who received disability benefits had a more difficult time resolving internalized stigma. Further analyses suggested that OEF/OIF/OND cohort veterans receiving disability benefits have more difficulty developing effective stigma resistance, and more difficulty resolving stigma-related alienation, than other veterans. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE Based on this research, particular attention should be devoted to internalized stigma among OEF/OIF/OND veterans.

Outcomes of a Psychoeducational Intervention to Reduce Internalized Stigma Among Psychosocial Rehabilitation Clients

OBJECTIVE This community-based randomized controlled trial was carried out to test the Ending Self-Stigma (ESS) psychoeducational intervention, which is designed to help adults with serious mental illnesses reduce internalization of mental illness stigma and its effects. METHODS A total of 268 adults from five different mental health programs in Maryland took part. After baseline interview, consenting participants were randomly assigned to the nine-week ESS intervention or a minimally enhanced treatment-as-usual control condition. Participants were assessed by using symptom, psychosocial functioning, and self-stigma measures at baseline, postintervention, and six-month follow-up. Demographic characteristics were assessed at baseline. RESULTS Compared with participants in the control condition, ESS group participants showed significant decreases on the stereotype agreement and self-concurrence subscales of the Self Stigma of Mental Illness Scale, significant improvement on the alienation and stigma resistance subscales of the Internalized Stigma Mental Illness measure, and a significant increase in recovery orientation from baseline to postintervention. None of these differences were sustained at six-month follow-up. CONCLUSIONS Results indicate that ESS was useful in helping to reduce key aspects of internalized stigma among individuals with mental illnesses and that advances in the delivery, targeting, and content of the intervention in the field may be warranted to increase its potency.

Trauma exposure and PTSD in women with schizophrenia and coexisting substance use disorders: Comparisons to women with severe depression and substance use disorders

The present study compared rates of trauma exposure and PTSD among three groups of women at high trauma risk: those with substance use disorders (SUD) and schizophrenia (n=42), those with SUD and severe, nonpsychotic depression (n=38), and those with SUD and no other DSM-IV Axis I condition (n=37). We hypothesized that exposure to traumatic stressors and current diagnosis of PTSD would be more common in women with schizophrenia and SUD, when compared to the other two groups. Results indicate that women with schizophrenia and SUD had a more extensive trauma history than women with SUD only, and were also more likely to have PTSD. Women with schizophrenia had a fourfold greater likelihood of meeting criteria for current PTSD than were women with severe, nonpsychotic depression when potential confounds of age, race, education, severity of trauma history, and childhood trauma exposure were controlled. These results lend support to the possibility that women with psychosis have an elevated vulnerability to PTSD symptomology when exposed to life stressors that is distinct from the vulnerability associated with coexisting nonpsychotic SMI. The psychological sequelae of trauma are substantial and should be addressed in women seeking treatment for schizophrenia and problematic substance use.

Family member engagement with early psychosis specialty care

Family members of individuals with early psychosis (EP) play critical roles in their engagement with EP services, but family member experiences of those roles are insufficiently understood.