Severe mental illness

Severe mental illness remains a threat to society, with new instances being recorded every day. The illness has a high stigma since those affected feel rejected, mistreated, and discriminated against. While most stigma has been reported as external, affected individuals eventually internalize unfavorable perceptions, resulting in internalized stigma. Internalized stigma, according to researchers, leads to low self-esteem, hope, and empowerment. Indeed, it is concerning that around one-third of patients with serious mental illness face internalized stigma, which negatively impacts subjective quality of life.Although some of the patients are unscathed by the discrimination in the society or derive empowerment from the same, the majority of the individuals undergo significant personal costs as they deal with the effects. The growing population of young men at risk of severe mental illness further compounding the issue of internalized stigma as young dreams can be easily defaced by the lost hope. Therefore, there is a need to address internalized stigma by understanding its effects, treatment options as well as expected outcomes to improve the quality of life for the mentally ill.

Societal vs. Internalized Stigma

Societal stigma refers to the negative stereotypes associated with people with a certain condition, say mental illness. The society develops individual labels or negative attitudes that tend to discriminate individuals suffering from severe mental illness. The perception of the society towards mental illness has been mostly negative leading to neglect of the affected. While this is the most studied type of stigma, there is a growing trend in internalized stigma as the people with severe mental illness start to live according to the stereotypes given by the society. As such, internalized stigma comes from within an individual as they start to accept the negative attitudes associated with their condition. Most studies have focused on the external stigma that majorly emanates from the ignorance of the society regarding a condition. However, internalized stigma follows after the societal stigma as the victims tend to accept their fate in the society without opposing the negative stereotypes.
Mashiach-Eizenberg et al. (2013) reported that internalized stigma had more detrimental effects on the individual as compared to societal stigma. As such, the harmful effects of stigma can be experienced through external and internal perceptions that surround the individual. Once a person with severe mental illness starts associating with the negative stereotypes and accepting them, an internal conflict is created leading to deteriorating of the disease. Sibitz et al. (2013) noted the contribution of internalized stigma on the poor outcomes of treatment as the psychological effects barred recovery. Clearly, internalized stigma is worse than societal stigma as the latter takes a longer time to eradicate in an individual (Ritsher & Phelan, 2004). While societal stigma can be alleviated through awareness programs in the community, internalized stigma is more complex requiring personalized interventions for each of the patients.

Effects of Internalized Stigma

Research has indicated that when people eighth mental illnesses believe in the rejection of the society, a wave of despair is created leading to low self-esteem, low medical adherence, and impaired social adoption. Nevertheless, individuals who do not internalize the stigma lead normal lives under proper care. While this may seem like a personal choice, the extent of external influence may be too much making the victims feel isolated and dejected. Over time, internalized stigma leads to alienation, social withdrawal, discrimination, and risks of suicide.
Mashiach-Eizenberg et al. (2013) investigated the association between internalized stigma and subjective quality of life for people living with severe mental illness. Using measures that assessed hope, self-esteem, and quality of life, the study revealed that self-esteem was responsible for hope and internalized stigma. This suggests that individuals with lower self-esteem had a higher propensity of adapting the negative stereotypes. A related study by Sibitz et al. (2013) on schizophrenic patients also reported that people with lowered self-esteem as well as lower education levels were more likely to develop internalized stigma. The result of this is lower medical adherence as the patients begin to identify with the labels given to them. Most skip medication as they lose hope of becoming better. An earlier study to show the contribution of internalized stigma to the erosion of morale among the patients cited depression as a significant consequence (Ritsher & Phelan, 2004). Social withdrawal and alienation were the main indicators of depression as the patients avoid social settings where they expect to be rejected.
As theorized by Corrigan, Bink, Schmidt, Jones, & Rüsch (2014), self-stigma develops through a series of three stages. One, the patient becomes aware of the negative stereotypes associated with mental illness. Two, the patient concurs with the stereotypes and becomes part of it. Three, the patient applies it to themselves by adopting the behaviors associated with their kind. As such, the people with severe mental illness start to experienced reduced self-efficacy using the ""why try"" notion (Corrigan et al., 2014). In this regard, there is low adherence to medication as the inner perceptions convince them that they are beyond repair. Additionally, the morale to pursue life goals burns out leading to overall frustration.
Similarly, most patients with internalized stigma have a high risk of committing suicide or harming themselves in other ways. Referring to the ""why model,"" the patients lose their role in life leading to suicidal thoughts. Indeed, (Corrigan et al., 2014) note that there is diminished the sense of recovery for patients with internalized stigma increasing their risk of having suicidal thoughts. Additionally, spending most of the time in isolation, such patients may feel that they need to punish themselves for being rejected in the society. One study focused on loneliness as a contributing factor to internalized stigma among the mentally ill that could lead to depression and suicide (Switaj, Grygiel, Anczewska, & Wciórka, 2013).
The literature above therefore reveals the effects of internalized stigma that are felt mostly by the individuals and those close to them. Self-esteem has been related to the development of this type of stigma showing the need for interventions aimed at promoting the self-awareness of individuals.

Treatment Option, Target, and Outcomes

Psychosocial support is the major treatment intervention used to decreased internalized stigma among patient with the severe mental illness. Wood, Byrne, Varese, & Morrison (2016) studied the use of psychosocial interventions among schizophrenic patients as they experienced the highest level of stigma leading to pervasive and detrimental internalized stigma. The study identified the use of cognitive behavior therapy, social skills and psychoeducation training as the most effective in increasing self-esteem and consequently reducing internalized stigma among individuals. The results concur with those of Morrison et al. (2013) that reported that cognitive therapy had an impact in reducing negative experiences of stigma witnessed by mentally-ill patients. As such, cognitive therapy was classified as a non-stigmatizing agent as individuals receive training on how to cope with negative stereotypes and improvement of their self-esteem. Cognitive behavior therapy targets thinking and behavior of an individual to cause a change that may influence the perception towards a certain opinion. Most of the internalized stigma emanates from the accepted ideas that the individual has adapted due to external pressure. The philosophy behind cognitive therapy is that people tend to behave according to their thoughts. As such, a negative misinterpretation of a situation may make one adopt a behavior that is detrimental. This is the case for people with internalized stigma as they tend to dissociate from people and fall into depression, self-pity or the negative stereotypes associated with severe mental illness. Using an internalized stigma of mental illness scale, the effectiveness of cognitive therapy as an intervention has been proven.
Indeed, the best intervention for internalized stigma is one that targets a change in perception in the individuals suffering from severe mental illness. The negative stereotypes lead to the adoption of behaviors that cause effects such as alienation, depression, suicidal thoughts among others. As such, cognitive behavior targeting a change in their mindset could lead to improved self-esteem which is the starting point in promoting reduced internalized stigma. As internalized stigma is personal, the talk therapy has been shown to differ in effectiveness between different individuals regarding the time used to recover.

Conclusion

The issue of internalized stigma should be accorded enough attention as the reported effects outdo those of societal stigma. While more studies are necessary to quantify the required level of intervention needed to deal with internalized stigma completely, cognitive therapy has been proven to be effective in reducing stigma. Nevertheless, there is a need for more research on the actual impact of internalized stigma, especially to young people. Additionally, community involvement programs should be assessed to determine their role in reducing stigmatization among those with severe mental illness.

References

Corrigan, P. W., Bink, A. B., Schmidt, A., Jones, N., & Rüsch, N. (2014). What is the impact of self-stigma? Loss of self-respect and the ""why try"" effect. Journal of Mental Health (Abingdon, England), 8237(February), 1-6. http://doi.org/10.3109/09638237.2015.1021902
Mashiach-Eizenberg, M., Hasson-Ohayon, I., Yanos, P. T., Lysaker, P. H., & Roe, D. (2013). Internalized stigma and quality of life among persons with severe mental illness: The mediating roles of self-esteem and hope. Psychiatry Research, 208(1), 15-20. http://doi.org/10.1016/j.psychres.2013.03.013
Morrison, A. P., Birchwood, M., Pyle, M., Flach, C., Stewart, S. L. K., Byrne, R., … French, P. (2013). Impact of cognitive therapy on internalised stigma in people with at-risk mental states. British Journal of Psychiatry, 203(2), 140-145. http://doi.org/10.1192/bjp.bp.112.123703
Ritsher, J. B., & Phelan, J. C. (2004). Internalized stigma predicts erosion of morale among psychiatric outpatients. Psychiatry Research, 129(3), 257-265. http://doi.org/10.1016/j.psychres.2004.08.003
Sibitz, I., Friedrich, M. E., Unger, A., Bachmann, A., Benesch, T., & Amering, M. (2013). Internalized Stigma of Schizophrenia: Validation of the German Version of the Internalized Stigma of Mental Illness-Scale (ISMI). Psychiatrische Praxis, 40(2), 83-91. http://doi.org/10.1055/s-0032-1332878
Switaj, P., Grygiel, P., Anczewska, M., & Wciórka, J. (2013). Loneliness mediates the relationship between internalised stigma and depression among patients with psychotic disorders. The International Journal of Social Psychiatry, 60(8), 733-740. http://doi.org/10.1177/0020764013513442
Wood, L., Byrne, R., Varese, F., & Morrison, A. P. (2016). Psychosocial interventions for internalised stigma in people with a schizophrenia-spectrum diagnosis: A systematic narrative synthesis and meta-analysis. Schizophrenia Research. http://doi.org/10.1016/j.schres.2016.05.001