Social functioning mediates the relationship between psychiatric symptoms and recovery among veteran and community service users with serious mental illness.

OBJECTIVE: Previous research has established the impact of psychiatric symptoms on social functioning, while there is a paucity of research examining how social functioning relates to personal recovery, an individual's self-assessment of their mental health recovery. This study examined the mediating effect of social engagement, interpersonal communication, and satisfaction with support in the relationship between distinct psychiatric symptom clusters and perceived mental health recovery. METHODS: In a cross-sectional study, both patient self-report and provider assessment data were collected for 250 patients with serious mental illness (SMI) across four mental health service sites. Parallel mediation analytic models were used. RESULTS: Interpersonal communication partially mediated the relationship between positive and negative symptom clusters and personal recovery. Satisfaction with social supports partially mediated the relationship between excited symptoms and personal recovery. Both interpersonal communication and satisfaction with social supports partially mediated the relationship between general psychological distress and depressive symptoms and personal recovery. Collectively, social functioning mediators explained nearly half of the relationship between general psychological distress and excited symptoms and personal recovery and nearly all of the relationship between positive symptoms and personal recovery. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Clinical providers working with persons with SMI should regularly assess social functioning in addition to assessing psychiatric symptoms and personal recovery factors and should incorporate social skills education into SMI group and individual treatments. Social functioning as a target of treatment may be especially beneficial for patients who are dissatisfied with other interventions or feel they have experienced the maximum benefit from treatment and are seeking additional methods to support personal recovery. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Self-Stigma and PTSD: Conceptualization and Implications for Research and Treatment.

Preliminary empirical evidence suggests that self-stigma may be a significant problem for those with posttraumatic stress disorder (PTSD). Although research on self-stigma for persons with PTSD is limited, some PTSD symptoms, such as negative thoughts about oneself, feelings of shame, and avoidance-particularly of social interactions-may be conceptually related to self-stigma, potentially explaining the co-occurrence and relevance of self-stigma in PTSD. This Open Forum reviews how the social cognitive model may explain the co-occurrence of self-stigma and PTSD, considers how this model may inform treatment approaches for self-stigma in PTSD, and identifies next steps to empirically test the proposed theory.

Even mild internalized stigma merits attention among adults with serious mental illness.

Internalized or self-stigma can be damaging to psychological and social functioning and recovery, especially for people with serious mental illness. Most studies have focused on the effects of high self-stigma, which has included both moderate and high self-stigma, versus low levels of self-stigma which has included no, minimal, or mild self-stigma. Therefore, little is known about the variation within these categories (e.g., minimal versus mild self-stigma) and its impact on recovery. This article examines differences in the demographic, clinical, and psychosocial variables associated with different levels of self-stigma severity. Baseline data (N = 515) from two concurrent randomized controlled trials of a psychosocial intervention aimed at reducing internalized stigma, and its effects among adults with serious mental illnesses were examined. We found that participants with greater psychological sense of belonging, and greater perceived recovery were significantly less likely to have mild or moderate/high internalized stigma than minimal stigma. Those reporting a greater frequency of stigma experiences, however, were more likely to have mild or moderate/high internalized stigma than minimal stigma. Our findings further underscore the multifaceted nature and impact of self-stigma, particularly in interpersonal relationships and interactions, and demonstrate the importance of attending to even mild levels of self-stigma endorsement. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Support for the social-cognitive model of internalized stigma in serious mental illness.

One prominent social-cognitive model of internalized stigma by Corrigan and his colleagues (2012; 2002) proposes that individuals are exposed to societal stereotypes about mental illness, at least tacitly agree with them, and may apply them to oneself, engendering harmful self-beliefs. There is limited empirical support for this model in serious mental illness. Moreover, it is not clearly established how internalized stigma and its associated factors impact recovery in this population. The current study uses structural equation modeling (SEM) to assess the social-cognitive model's goodness of fit in a sample of Veterans with serious mental illness (Veteran sample, n = 248), and then validates the model in a second and independent sample of individuals receiving community-based psychiatric rehabilitation services (community sample, n = 267). Participants completed the Self-Stigma of Mental Illness Scale (SSMIS; Corrigan et al., 2006) and measures of self-esteem, self-efficacy, and recovery attitudes. Consistent with Corrigan and colleagues' formulation of internalized stigma, SEM analyses showed a significant indirect pathway from stereotype awareness, to stereotype agreement, to application to self, to self-esteem decrement, to poorer recovery attitudes. Additionally, there was a significant direct effect from stereotype awareness to self-esteem. This study shows that individuals with serious mental illness experience psychological harm from stigma in two ways: (1) through perceived public prejudice and bias, and (2) through internalizing these negative messages. In particular, stigma harms individuals' self-esteem, which then reduces their recovery attitudes.

Outcomes of Ending Self-Stigma, a Group Intervention to Reduce Internalized Stigma, Among Individuals With Serious Mental Illness.

OBJECTIVE: Ending Self-Stigma is a nine-session group intervention designed to teach individuals experiencing mental illness a set of tools and strategies to effectively deal with self-stigma and its effects. The authors examined the efficacy of Ending Self-Stigma with an active comparison group focused on general health and wellness education (the Health and Wellness intervention) in a cohort of veterans. METHODS: Veterans with serious mental illness (N=248) were randomly assigned to either the Ending Self-Stigma or the Health and Wellness intervention. Participants completed assessments of symptoms, internalized stigma, recovery, sense of belonging, and other aspects of psychosocial functioning at baseline, posttreatment, and 6-month follow-up. Repeated-measures, mixed-effects models were used to examine the effects of group × time interactions on outcomes. RESULTS: Individuals in both groups experienced significant but modest reductions in self-stigma and increases in psychological sense of belonging after the treatments. The Ending Self-Stigma and Health and Wellness interventions did not significantly differ in primary (self-stigma) or secondary (self-efficacy, sense of belonging, or recovery) outcomes at posttreatment. Significant psychotic symptoms moderated treatment effects on self-stigma, such that among individuals with significant psychotic symptoms at baseline, those who participated in Ending Self-Stigma had a significantly greater reduction in internalized stigma than those in the Health and Wellness intervention. CONCLUSIONS: Interventions directly targeting self-stigma and those that may address it more indirectly may be helpful in reducing internalized stigma. Individuals experiencing psychotic symptoms may be more likely to benefit from interventions that specifically target self-stigma.

The Ending Self-Stigma for Posttraumatic Stress Disorder (ESS-P) Program: Results of a Pilot Randomized Trial.

Experiences of and concerns about encountering stigma are common among veterans with posttraumatic stress disorder (PTSD). One common and serious consequence is self-stigma, which is when an individual comes to believe that common negative stereotypes and assumptions about PTSD are true of oneself. The current study was a pilot randomized trial that evaluated the feasibility, acceptability, and preliminary outcomes of the Ending Self-Stigma for PTSD (ESS-P) program, a nine-session group intervention that aims to assist veterans with PTSD learn tools and strategies to address stigma and self-stigma. Veterans (N = 57) with a diagnosis of PTSD who were receiving treatment in U.S. Veterans Health Administration outpatient mental health programs were recruited. Participants were randomized to either ESS-P or minimally enhanced treatment as usual and assessed at baseline and after treatment on clinical symptoms, self-stigma, self-efficacy, recovery, and sense of belonging. Information on mental health treatment utilization for the 3 months before and after group treatment was also collected. Compared to controls, there was a significant decrease in self-stigma, d = -0.77, and symptoms of depression, d = -0.76, along with significant increases in general and social self-efficacy, ds = 0.73 and 0.60, respectively, and psychological experience of belonging, d = 0.46, among ESS-P participants. There were no differences regarding recovery status or changes in treatment utilization. The results of the pilot study suggest that participation in ESS-P may help reduce self-stigma and improve self-efficacy and a sense of belonging in veterans with PTSD.

The influence of experiences of stigma on recovery: Mediating roles of internalized stigma, self-esteem, and self-efficacy.

OBJECTIVE: Experiencing stigmatization regarding mental illness has harmful effects on recovery from serious mental illness (SMI). Stigma experiences can also lead to internalized stigma, the cognitive and emotional internalization of negative stereotypes, and application of those stereotypes to one's self. Internalized stigma may lead to additional harms, including decrements in self-esteem and self-efficacy. Therefore, this study examined the effects of stigmatization experiences on recovery-related outcomes through internalized stigma, self-esteem, and self-efficacy in a single comprehensive model. METHODS: Adults with SMI (n = 516) completed standardized measures assessing the variables of interest during baseline assessments for 2 randomized controlled trials. In a secondary analysis of the trial data, separate serial mediation models were tested for recovery orientation, perceived quality of life, and social withdrawal as outcomes, with experiences of stigma as the predictor variable and internalized stigma, self-esteem, and self-efficacy as serial mediators in that order. Alternate order and parallel mediation models were also tested to evaluate directionality. RESULTS: The serial mediation model was the best fit, although self-efficacy was not found to be a critical mediator. Experiences of stigma led to internalized stigma, which influenced self-esteem and recovery-related outcomes, consistent with the social-cognitive model of internalized stigma. CONCLUSION: This indicates that internalized stigma is an essential target for reducing the negative impact of stigmatization on recovery. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Stigma and discrimination as correlates of mental health treatment engagement among adults with serious mental illness.

OBJECTIVE: The negative impacts of stigma on mental health treatment initiation are well established, but the relationship of stigma to proactive engagement in mental health treatment (e.g., actively working toward therapy goals) is largely unexamined. This study examined the relationship between mental health treatment engagement and stigma experiences, discrimination experiences, and internalized stigma among adults with serious mental illness. Age, race, gender, and education were tested as moderators of the relationships between stigma-related variables and treatment engagement. METHOD: Data were collected from 167 adults with serious mental illnesses who were receiving services at 5 psychosocial rehabilitation programs. Treatment engagement was assessed by participants' primary mental health care providers, using the Service Engagement Scale. The relationship between treatment engagement, stigma, and discrimination as well as potential demographic moderators were tested with Pearson's correlations and multiple linear regressions. RESULTS: Treatment engagement was not correlated with experiences of stigma, experiences of discrimination, or application of stigmatizing beliefs to self. Gender, race, and age were not significant moderators but education was. Experiences of stigma were associated with greater treatment engagement in those with a higher level of education (p = .007), whereas application of stigma to one's self was associated with poorer treatment engagement in those with a higher level of education (p = .005). CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Among individuals with higher levels of education, efforts to prevent internalization of public stigma may be crucial to promote proactive mental health treatment. Replication studies are needed to confirm these findings. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Person-Oriented Recovery of Individuals With Serious Mental Illnesses: A Review and Meta-Analysis of Longitudinal Findings.

OBJECTIVE: Although there is significant literature examining changes over time in the functional recovery of people with serious mental illnesses, relatively little is known about the longitudinal nature of person-oriented recovery. The purpose of this review and meta-analysis is to synthesize findings pertaining to the study of person-oriented recovery constructs over time and concomitants of change. METHODS: Systematic searches up to February 2017 were conducted and were supplemented by hand-searching of reference lists and by contacting study authors. Twenty-three independent studies that included a sample of individuals with serious mental illnesses and that quantitatively measured person-oriented recovery, empowerment, or hope over at least two time points were included in the review. Of these, seven were randomized controlled trials that were included in the meta-analysis. Data were independently extracted by two reviewers. Aggregate effect sizes for person-oriented recovery outcomes were calculated, and individual, intervention, and methodological characteristics served as moderators in meta-regression analyses. RESULTS: The meta-analysis (N=1,739 participants) demonstrated that consumers experience greater (and sustained) improvement in person-oriented recovery outcomes when they are involved in recovery-oriented mental health treatment versus usual care or other types of treatment. Only type of intervention provider was a significant moderator; a study of an intervention that was delivered by both mental health professionals and peer providers demonstrated the greatest differences between treatment and control groups. CONCLUSIONS: Recovery-focused interventions, especially those that involve collaborations between mental health professionals and peer providers, may serve to foster increased recovery, hope, and empowerment among individuals with serious mental illnesses.

Family Involvement in the Clinical Care of Clients With First-Episode Psychosis in the RAISE Connection Program.

OBJECTIVE: This study described how families were involved in the RAISE Connection Program for clients with first-episode psychosis (FEP) and examined factors that predicted family involvement. METHODS: Presence of family members at clinical visits for 65 clients with FEP was described. Multiple regressions were conducted to determine whether demographic characteristics, clinical factors, or client-provider discussions regarding family predicted family involvement during the first six months of the program. RESULTS: Most participants (95%) had at least one family member attend a clinical visit during program involvement. Age of the client with FEP, psychiatric symptoms, and substance use predicted the number of days family members attended visits during the first six months of program participation; client-provider discussions about family did not. CONCLUSIONS: Family involvement in the ongoing care of clients with FEP is common when efforts are made to engage clients with FEP and their families.

Differences in suicide and death ideation among veterans and nonveterans with serious mental illness.

Individuals with serious mental illness and veterans are two populations at elevated risk for suicide; however, research has not examined whether veterans with serious mental illness may be at higher suicide risk than nonveterans with serious mental illness. Additionally, overlapping risk factors for suicide in these populations may account for differences in suicide-related outcomes between these groups. Therefore, the aim of this study was to identify differences in death ideation and suicide ideation among veterans and nonveterans with serious mental illness. We also aimed to explore these effects after adjusting for potentially shared risk factors. We found that veterans with serious mental illness reported death ideation and suicide ideation more than twice as often as nonveterans with serious mental illness. After adjusting for demographic, psychiatric, and theory-driven risk factors, the effect of veteran status on death ideation remained significant, though the effect on suicide ideation was no longer significant. Depressive and psychotic symptoms were significant predictors of death ideation; depressive symptoms and hostility were significant predictors of suicide ideation. Clinicians should particularly monitor death ideation and suicide ideation in veterans with serious mental illness, as well as associated clinical risk factors such as depression, psychotic symptoms, and hostility. (PsycINFO Database Record

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.

Self-efficacy as a mediator of the relationship between social support and recovery in serious mental illness.

OBJECTIVE: The purposes of this research were to assess relationships between social support and objective and subjective recovery in a sample of adults with serious mental illness and to examine self-efficacy as a potential mediator of these relationships. METHODS: In this cross-sectional study, a sample of 250 individuals completed measures tapping social support network size, satisfaction with social support, perceived support from the mental health system, self-efficacy, objective recovery (i.e., psychiatric symptoms, social functioning), and subjective recovery. Pearson product-moment correlations and multiple linear regression analyses examined relationships among social support, self-efficacy, and recovery. A bootstrapping procedure was used to estimate the magnitude and significance of indirect effects in mediation analyses. RESULTS: All social support domains (i.e., social support network size, satisfaction with support, perceived support from the mental health system) were significantly related to at least 1 objective recovery outcome and to subjective recovery. Self-efficacy was a mediator of all relationships between social support and objective and subjective recovery. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: The present study aids in better understanding the relationship between social support and recovery in individuals with serious mental illness and paves the way for future research. Particularly relevant to mental health service providers, it highlights the importance of establishing and maintaining an effective therapeutic relationship as well as assisting consumers with developing supportive relationships with others. (PsycINFO Database Record

The reliability and validity of the Maryland Assessment of Recovery in Serious Mental Illness Scale.

The current study aims to further evaluate the psychometric properties of the Maryland Assessment of Recovery in Serious Mental Illness (MARS), a relatively new instrument designed to assess personal recovery status in individuals with serious mental illness. Two hundred and fifty individuals with serious mental illness receiving outpatient mental health treatment completed a baseline assessment which included the MARS and measures to assess recovery-related constructs, clinical outcomes, and social and community functioning. The MARS demonstrated excellent internal consistency and test-retest reliability. Good construct validity was evidenced by strong positive relationships between the MARS and recovery-related constructs (e.g. hope, empowerment, self-efficacy, and personal agency) and a strong negative relationship with self-stigma. Divergent validity was demonstrated by weaker relationships with cognitive and social functioning. The confirmatory factor analysis did not confirm the unitary factor structure found in previous research. Given the equivocal result of the CFA, additional exploratory work is needed to determine if a more complex factor structure is present. This study provides addition support for the psychometric soundness of the MARS and subsequently, its potential use as a measure of personal recovery status in people with serious mental illness.

Personal Recovery as a Protective Factor Against Suicide Ideation in Individuals With Schizophrenia.

Suicide rates are elevated in individuals with schizophrenia, yet evidence is mixed regarding the roles of positive and negative symptoms as risk factors for suicide in this population, suggesting that there may be other influential variables. One such variable may be personal recovery. Therefore, the purpose of this study was to test the hypothesis that personal recovery would moderate the relationship between symptoms of schizophrenia and suicide ideation. This hypothesis was tested in a sample of 169 individuals diagnosed with schizophrenia or schizoaffective disorder using a Poisson regression model. Results suggested that there was no significant interaction between recovery and symptoms of schizophrenia. However, recovery was a significant predictor of suicide ideation after controlling for psychiatric symptoms. These findings indicate that recovery is associated with lower suicide ideation and thus may protect against it. Thus, recovery should be assessed, and potentially intervened upon, to reduce suicide risk in individuals with schizophrenia.

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.

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.

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.

Outcomes of a brief program, REORDER, to promote consumer recovery and family involvement in care.

OBJECTIVE: The Recovery-Oriented Decisions for Relatives' Support (REORDER) intervention is an innovative, manualized protocol utilizing shared decision-making principles with persons who have serious mental illnesses to promote recovery and encourage consideration of family involvement in care. This study compared REORDER to enhanced treatment as usual in a randomized design. METHODS: Participants included 226 veterans with serious mental illness whose relatives had low rates of contact with treatment staff. REORDER involved up to three consumer sessions followed by up to three relative educational sessions if the consumer and relative consented. Individuals were assessed at baseline and six months later. RESULTS: Eighty-five percent of the 111 randomly assigned REORDER participants attended at least one REORDER consumer session; of those, 59% had at least one family session. REORDER participants had significantly reduced paranoid ideation and increased recovery at follow-up. CONCLUSIONS: Participation in REORDER led to marked increases in family participation and improved consumer outcomes.