Self-stigma is a neglected but important aspect of mental illness stigma

Lars Harsson
Jun 1
3 min read

Stigma and discrimination are still prominent features of the life situation of people with mental illness, adding to the burden of living with a mental illness. Negative attitudes, stereotypes, and discrimination are still prevalent. In fact, there is evidence that public attitudes have not changed substantially during the last two decades or even turned worse in the case of people with schizophrenia. Stigma and discrimination affect people with a mental illness in many ways causing a lowered self-esteem and quality of life, and affecting possibilities of adequate housing, work, and financial situation in a negative way. It is also a major barrier to help seeking causing delays, drop-out, and nonadherence to treatment. Although anti-stigma programs during recent decades have shown small to moderate short-term positive effects, it is still not clear whether these programs have any long-term impacts.

Lars Hansson

Senior professor in mental health services research at the Department of Health Sciences, Lund University. His main research interests have been the life situation and rehabilitation of people with psychosis, including intervention studies elaborating the scientific evidence of psychosocial interventions for this group. During the last decades studies on stigma and the remediation of stigma has also been a focus of interest. Lars Hansson was for several years the director of Center for Evidence based Psychosocial Interventions (CEPI), which is a national knowledge center in collaboration between 5 Swedish universities.

Self-stigma

The generally expanding scientific literature on mental illness stigma has so far, no correspondence in studies on discrimination and self-stigma, where there still is a relative dearth of studies. The internalization of societal negative stereotypes about mental illness which may occur early in life may lead to the development of self-stigma for people afflicted by mental illness later in life. Self-stigma (or internalized or felt stigma) exists on the individual level and indicates that the individual endorses stereotypes of mental illness, finds these stereotypes relevant and anticipates social rejection. Several studies show that self-stigma is a common phenomenon in people with mental illness. The prevalence is between 25–40 percent in various reviews, which mainly include people with serious mental illness. A systematic review from 2021 showed an average incidence of self-stigma of 31% among people with severe mental illness. Another review points to that self-stigma has a negative relationship with hope for the future, empowerment, self-esteem, perceived quality of life and social support. Self-stigma can also result in refraining from looking for work, not making contact or delaying contacts with care, interrupting treatment or avoiding social contacts A model that has been used as a starting point for interventions aimed at self-stigma has been presented by Watzon and colleagues (Watzon, Corrigan, Larson & Sells, 2007). A first step is to be aware of the prejudices and negative attitudes of those around you, a second step to accept and agree with these and a third step to direct them towards yourself and let them control your life and behavior.

Reducing self-stigma

There are several studies focusing on interventions to reduce self-stigma. A systematic review from 2019 concluded that there are effective efforts to respond to self-stigma and that those who contain psychoeducational components or who are multicomponent interventions have shown the best results. One of the interventions which in systematic reviews has shown positive results is Narrative Enhancement and Cognitive Therapy (NECT), and probably the intervention which has received most attention in Swedish mental health services. NECT was originally Developed in the United States by Philip Yanos and colleagues and the core components are as follows: Psychoeducation, providing participants with information about the inaccuracy of stigmatizing views about SMI); Cognitive restructuring, teaching the basic principles of cognitive restructuring and encouraging participants to apply these techniques to self-stigmatizing cognitions; and Narrative enhancement, where participants are encouraged to write and share stories within the group, while focusing on trying to bring together previously fragmented and isolated aspects of the self.

There are four randomized controlled trials investigating NECT). The first US study by was based on few observations and did not show any positive effects in any of the outcomes assessed. A later Swedish study showed positive effects on self-stigma and self-esteem, remaining after a six-month follow-up. A second US study showed reduced self-stigma compared to the control group and the latest study performed in China also showed reduced self-stigma. There is also an ongoing Italian multicenter study. In addition, there are two quasi-experimental studies also showing a reduction in self-stigma and an improvement in self-esteem. Based on these studies the latest national guidelines for care of schizophrenia issued by the Swedish Board of Health and Welfare, NECT is recommended as an intervention with high priority. □