Randomized controlled trial of the self-stigma reduction program among individuals with schizophrenia
Introduction
Schizophrenia is a severe and prevalent mental illness (Mueser and MuGurk, 2004, Lieberman et al., 2006). Individuals with schizophrenia are commonly undermined by the process of stigmatization (Corrigan, 2000, Corrigan and Watson, 2002, Fung et al., 2007). Mental illness stigma is widely endorsed in society (Phelan et al., 2000, Yang and Pearson, 2002, Tsang et al., 2003, Corrigan, 2004, Fung et al., 2008). Public stigma towards individuals with schizophrenia is mainly due to over-generalization of their dangerousness (Corrigan, 1998, Corrigan, 2004, Hayward and Bright, 1997).
In Chinese societies, public stigma is believed to be more severe than in Western societies, reflecting the collectivistic nature of Chinese culture (Nagayama Hall, 2002, Fung et al., 2007, Lam et al., 2010). Nagayama Hall (2002), Fung et al. (2007) and Lam et al. (2010) suggested that under the collectivistic ideation, deviant behaviors of schizophrenia are regarded as character flaws or low moral standards, an interpretation that in turn results in higher levels of discrimination. A cross-cultural qualitative study conducted by Tsang et al. (2007) in Hong Kong, Beijing, and Chicago revealed that Chinese employers were more prone to be influenced by collectivistic value when they need to make hiring decisions towards individuals with mental illness. The findings support that collectivistic value is likely to exacerbate mental illness stigma.
Under the influences of public stigma, individuals with mental illness who endorse stigma against themselves as legitimate are more likely to internalize it (Corrigan and Watson, 2002). Self-stigmatization is regarded as the self-discredit of individuals via the internalization of negative stereotypes towards themselves and/or their social group (Corrigan and Watson, 2002, Fung et al., 2007). Low perceived legitimacy of discrimination is believed to be a protective factor against self-stigmatization (Rusch et al., 2006, Rusch et al., 2009). Rusch et al. (2010) suggested that automatically activated shame reactions were positively correlated to higher level of perceived legitimacy.
Self-stigmatization constitutes an impediment for individuals with schizophrenia to display treatment adherence (Ludwig et al., 1990, Tsang et al., 2006, Fung et al., 2008, Fung et al., 2010, Tsang et al., 2010) and thus their recovery (Ritsher and Phelan, 2004, Corrigan et al., 2006, Fung et al., 2007). Studies by our team (Fung et al., 2010, Tsang et al., 2010) have adopted the regression and path analyses to investigate the mechanism as to how self-stigma undermines psychosocial treatment adherence among individuals with schizophrenia. One hundred and five adults with schizophrenia in Hong Kong were recruited for a cross-sectional observational study. Findings suggested that individuals with lower level of self-stigma and better readiness for changing own problematic behaviors were more likely to have better adherence. The inadequate coping strategies and feeling of hopelessness adopted by self-stigmatized individuals may be regarded as the possible obstacles causing poor adherence (Tsang et al., 2010). For instance, self-stigmatized individuals may avoid the experience of public stigma by not seeking psychiatric services (Cooper et al., 2003, Corrigan, 2004, Wrigley et al., 2005, Corrigan and Wassel, 2008, Fung et al., 2008). The findings using path analysis (Fung et al., 2010) supported direct and indirect (mediated by insight and readiness for change) effects of self-stigma on reducing adherence. The construct of readiness for change has been commonly adopted in prior studies to explain treatment adherence among individuals with mental illness (Rusch and Corrigan, 2002, Finnell and Osborne, 2006). Following this approach, this construct was also employed and measured in the present study. Although the percentage of variance explaining the mediating effects of insight and readiness for change on psychosocial treatment adherence is not high, the results shed light on a plausible mechanism to explain how self-stigmatization may undermine treatment adherence.
With a deeper understanding on the mechanism explaining how self-stigmatization may undermine treatment adherence, an intervention program which targets at reducing self-stigma, enhancing readiness for change, and promoting psychosocial treatment adherence was formulated. Literature reviews that only two psychoeducational (Wieczynski, 2000, Link et al., 2002) and two cognitive behavioral therapy (Knight et al., 2006, Macinnes and Lewis, 2008) programs are available to help individuals with mental illness combat their negative consequences of self-stigma. Wieczynski (2000) has developed a three-session stigma management group for 27 individuals with mental illness. However, no significant improvement on participants' self-efficacy and stigma coping skills was shown. The 16-session educational group implemented by Link et al. (2002) focused on the discussion of personal stigmatizing experiences, and the recommendation of behavioral strategies to cope with stigma. As Link et al. recruited participants with different diagnoses, an obvious limitation is that the results did not improve our understanding of stigma on specific diagnosis including schizophrenia. Knight et al. (2006) have adopted a waiting-list control design to test the effectiveness of group cognitive behavioral therapy for 21 individuals with schizophrenia. Positive findings on self-esteem enhancement and depression reduction were obtained. Macinnes and Lewis (2008) adopted a strategy of unconditional self-acceptance to help individuals with severe mental illness reduce self-stigmatization. Significant reduction of self-stigma was demonstrated. Unfortunately, the power of the findings was weak based on the single group pre-test and post-test design. To date, the clinical outcomes of these programs remain inconclusive due to the lack of a consistent theoretical framework underpinning the questionable study design. We therefore developed a self-stigma reduction program which was underpinned by a sound theoretical framework. The effectiveness of the self-stigma reduction program was tested via the randomized controlled trial and reported in this paper.
Section snippets
Development of treatment protocol
Fung et al. (2010) and Tsang et al. (2010) have provided a theoretical framework to explain how self-stigma may undermine psychosocial treatment adherence. We proposed that self-stigmatized individuals are more likely to demonstrate poor insight towards the beneficial effects of receiving psychiatric interventions. Their poor insight would further limit their readiness for changing own mental health problems, and thus result in treatment non-adherence. Based on this framework, we formulated a
Attrition rates, dosage, and functioning
The attrition rates for the experimental and comparison groups were 0% and 6.25% respectively. The findings of Chi-square analysis revealed that the attrition rate did not differ significantly between the two groups (χ2 = 2.191, df = 1, p = 0.139).
The findings suggested that participants of the experimental groups on average had received 9.58 (SD = 2.79) group and 3.15 (SD = 0.96) individual follow-up sessions, whereas the comparison participants have received 8.69 (SD = 3.59) group plus 3.03 (SD = 1.40)
Discussion
The findings suggested that the self-stigma reduction program has the active effect to reduce self-esteem decrement, facilitate the readiness for changing own problematic behaviors, and enhance psychosocial treatment participation among individuals with schizophrenia. However, its therapeutic effects were not long lasting and could not be maintained after the completion of the program.
The self-esteem of the self-stigmatized individuals has shown modest improvement after they have engaged in the
Acknowledgment
This study is supported by the Health and Health Services Research Fund of the Health, Welfare and Food Bureau, the HKSAR Government (Reference Number: 04060091). We would also like to acknowledge Baptist Oi Kwan Social Services, Richmond Fellowship of Hong Kong, Stewards Company, and the New Life Psychiatric Rehabilitation Association for their supports of the present study.
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