Self-stigma among mental health activists: a mixed method

evaluation of the Obertament training

Isabela Sibuet Ruiz (i6133183)

Faculty of Psychology and Neuroscience - Maastricht University

&

Facultat de Psicologia - Universitat de Barcelona

SELF-STIGMA AMONG MENTAL HEALTH ACTIVISTS

Abstract

Self-stigma is the process by which individuals diagnosed with mental illnesses accept

and incorporate the negative stereotypes held against their condition into their identity.

Self-stigma has been consistently linked to detrimental consequences and modern

research is concerned with finding effective interventions to reduce it. Activism

trainings such as the one designed by Obertament have the potential to contribute to

self-stigma reduction. Thus, the aim of this study is to evaluate self-stigma by means of

a mixed method (qualitative and quantitative) in participants of the Obertament activism

training. 84 individuals were assessed with a self-stigma scale (ISMI-10) and wrote self-

characterisation narratives, both before and after the training. Both qualitative and

quantitative data was analysed by means of a mixed method design. Quantitative

variables were generated from the narratives after a content analysis of the material and

analysed using non-parametric repeated measures analysis of variance and non-

parametric correlations together with quantitative data. The results of the quantitative

data indicated a reduction of self-stigma in those individuals that started the training

with high self-stigma. The results of the qualitative data indicated the presence of six

common themes (relationships, activities, traits, optimism/pessimism, others and

disorder), which were engulfed in two supracategories (positive themes and negative

themes). As a conclusion, this study demonstrated a decrease in self-stigma among

participants with high basal self-stigma and how participants spontaneously report

themes in their narratives that are common to self-stigma dimensions to describe

themselves.

Keywords: self-stigma, activist training, mental health, ISMI-10, mixed method

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Introduction

Self- or internalized stigma is a term coined by Corrigan et al. (Corrigan, 2005;

Corrigan & Watson, 2002) used to define “the phenomenon by which negative

stereotypes about mental illness are accepted and incorporated into the identity of

people who have been diagnosed with severe mental illnesses” (Yanos, Lucksted,

Drapalski, Roe, & Lysaker, 2015). The interest in the concept of self-stigma is,

however, older than its conceptualization; Goffman (1963) already considered the

existence of the phenomenon of self-stigma embedded in the more general concept of

mental illness stigma. Later research following Goffman’s tradition led to the

distinction of three interacting levels within mental illness stigma, of which self-stigma

constitutes one: individual (self-stigma), interpersonal (social stigma) and structural

(institutional stigma; Livingston & Boyd, 2010). The particular relevance of self-stigma

lies in the fact that the harm that it produces comes from an internal source, opposite to

social and institutional stigma, where the harm has an external origin (Krajewski,

Burazeri, & Brand, 2013). Following this train of thought, what is fundamental to the

acquisition of self-stigma and to the appearance of its detrimental consequences is, thus,

the change in the patient’s identity, which is substituted by the identity of the illness

(Link & Phelan, 2001; Pinto-Foltz & Logsdon, 2008).

Given that self-stigma influences individuals’ perception of themselves, the

possibility of self-stigmatisation having negative effects upon psychosocial or illness

outcomes is not farfetched. Therefore, research on the field has widely focused on

unravelling the relationship between self-stigma and a number of relevant variables

(Livingston & Boyd, 2010). The results of this research have consistently revealed an

association between self-stigma and self-esteem, self-efficacy and hope. The direction

of the association is the same for the three variables: higher self-stigma is associated

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with a lower score in any of them (Karakaş, Okanlı, & Yılmaz, 2016; Livingston &

Boyd, 2010; Olçun & Şahin Altun, 2017; Picco et al., 2016). Most of the studies

reported in the literature are cross-sectional, implying that causal relationships should

not be extracted. However, some recent longitudinal data appears to also support these

associations, particularly that of self-esteem (Livingston & Boyd, 2010). The effects of

self-stigma are not reported only in the personal psychosocial field, but also in the

vocational, since higher self-stigma has also been consistently associated with decreased

life goal attainment and lack of life goals (Corrigan, Larson, & Rüsch, 2009) and worse

vocational outcome (Yanos, Lysaker, & Roe, 2010). A detrimental influence against

personal and vocational areas of people’s lives could, potentially, have severe

consequences for their quality of life. Following this line of thought, the relationship

between the abovementioned variables has been researched, and support for decreased

quality of life in highly self-stigmatized individuals has been regarded as a robust

finding (Holubova et al., 2016; Livingston & Boyd, 2010; Picco et al., 2016; Vrbova et

al., 2017). Not surprisingly after the described findings, high self-stigma has also been

reported to be associated with increased suicide risk (Sharaf, Ossman, & Lachine, 2012)

and suicidal ideation (Oexle et al., 2017). Finally, on top of these results pertaining to

psychosocial variables, self-stigma has also been studied in relation to clinical variables.

Increased psychiatric symptom severity and poorer treatment adherence have been

consistently reported in association with high self-stigma (Assefa, Shibre, Asher, &

Fekadu, 2012; Kamaradova et al., 2016; Livingston & Boyd, 2010; Vrbova et al., 2016).

All the aforementioned results have led to the postulation of several models

aimed at explaining self-stigma acquisition and its negative outcomes. The most

outstanding example is the “why try effect” model, which describes the path from

public stereotypes to decreased life goal attainment in self-stigmatized individuals

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(Corrigan et al., 2009). Nevertheless, and although most of the models tested show good

fit, none has been able to capture the complete picture yet, and some may even

contradict each other (Aukst Margetić, Jakovljević, & Margetić, 2012; Chan & Mak,

2016; Corrigan, Bink, Schmidt, Jones, & Rüsch, 2016; Corrigan, Rafacz, & Rüsch,

2011; Drapalski et al., 2013; Muñoz, Sanz, Pérez-Santos, & Quiroga, 2011; Schrank,

Amering, Hay, Weber, & Sibitz, 2014; Yanos, Roe, Markus, & Lysaker, 2008). Part of

the responsibility of the contradictions found in self-stigma literature may be the use of

different assessment instruments; measuring discrepancies could also be the reason why

self-stigma has not been successfully and robustly associated to any demographic data

(Livingston & Boyd, 2010).

In order to produce quality research, it is fundamental to use well-designed

measure instruments that appropriately capture the construct of interest. Self-stigma

research is not an exception. Precisely, the development of the Internalized Stigma of

Mental Illness (ISMI) scale has subserved this purpose. ISMI scale was designed by

Ritsher, Otilingam, & Grajales (2003) and its creation largely fostered research in the

self-stigma field. ISMI conceptualized self-stigma as a construct engulfing five

subcomponents, which are reflected in the items of the scale. The latter subcomponents

are Alienation, Discrimination Experience, Social Withdrawal, Stereotype

Endorsement, and Stigma Resistance (Boyd Ritsher et al., 2003). On top of having

optimal psychometric characteristics and capturing the concept of self-stigma

appropriately, it allows for the exploration of associations with the different

subcomponents of the scale. Moreover, ISMI scale has been translated into more than

50 languages, with good consistency and reliability in the resulting instruments (Boyd,

Adler, Otilingam, & Peters, 2014). Recently, a brief version of the scale, ISMI-10,

became available. According to the developers, ISMI-10 is particularly suited to detect

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reductions in self-stigma after participation in psychosocial rehabilitation programmes

as a result of the reduction in respondent burden from ISMI to ISMI-10 (Boyd,

Otilingam, & DeForge, 2014).

In line with the aforementioned knowledge about the consequences of self-

stigma and the new research tools available, modern lines of research are moving

towards interventional approaches designed to reduce self-stigmatisation in its

participants. According to meta-analyses, several interventional approaches have been

found efficacious in reducing self-stigma among their participants (Mittal, Sullivan,

Chekuri, Allee, & Corrigan, 2012; Tsang et al., 2016; Yanos et al., 2015). Even though

each of the approaches has its particularities, they appear to share some characteristics:

using psychoeducation to counteract myths about mental illness, using cognitive

techniques to improve participants’ skills in fighting self-stigma, emphasising the use of

narration to help participants make sense of their past and regain control over their own

life again, and using behavioural decision-making (Yanos et al., 2015).

The shared profile of the interventional approaches reported in the literature

reminds of that of the activism training programme of the Catalan association

Obertament. Obertament is a project intended to fight against the stigma and

discrimination suffered by individuals with mental health problems, and one of the aims

of the organization is to train mental illness sufferers into activists against social and

institutional stigma. Prior research has highlighted the capacity of this training to

increase empowerment in the participants, and, consequently, to decrease their stigma

and discrimination perception (Aznar-lou, Rubio-valera, & Serrano-blanco, 2015).

Moreover, Obertament activism training has been also linked to increases in well-being

in those participants who had high baseline self-stigma (Eiroa-Orosa & Lomascolo,

n.d.). Being this the case, self-stigma undeniably plays an important role in determining

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if the training is or not beneficial for participants; this variable should be further

characterised in relation to Obertament activism training. In addition, even though it has

been suggested that qualitative studies could be highly informative for self-stigma

research, this type of research is scarce or not properly evaluated (Livingston & Boyd,

2010); it has not been addressed in the context of interventional research either.

The use of a qualitative method to obtain subjective information about the self-

stigma status of participants of the activist training could be highly beneficial to widen

the scope of self-stigma research. Moreover, if qualitative data is mixed with

quantitative data, the results could be highly informative since it would mix more

subjective with more objective data. The reasons for the use of a mixed method in such

a field of study are various (J. Creswell & Plano Clark, 2010). The first reason is Offset,

which refers to the fact that combining quantitative and qualitative research methods

can allow to offset each method’s weaknesses and draw on the strengths of each one.

The second reason is Completeness, which refers to the creation of a more

comprehensive account of the field of study thanks to the use of quantitative and

qualitative methods simultaneously. Finally, the third reason is Diversity of views,

which remarks that the mixed use of both methods can lead to combining researchers’

and participants’ perspectives and to uncovering relationships between variables while

revealing meanings among research participants at the same time (Bryman, 2006).

Following the aforementioned, the aim of the present study is to evaluate self-

stigma by means of a mixed method (qualitative and quantitative) in participants of the

Obertament activism training. The quantitative evaluation method will entail the

assessment of ISMI-10 pre and post training, and the qualitative method will consist on

writing self-characterisation narratives, also pre and post training. The themes perceived

in the narratives analysis will be associated to self-stigma scores. We hypothesise that

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self-stigma, as assessed by ISMI-10, will be reduced after participating in the training.

A second hypothesis is that participants will spontaneously report themes that reflect the

presence of self-stigma in their narratives. We also hypothesise that certain elements

found in the narratives will correlate with higher or lower levels of self-stigma, and

reflect a relationship with self-stigma in a qualitative perspective.

Methods

Participants

Participants were recruited from those who voluntarily enrolled in the

Obertament activist trainings through their website, distribution email list or related

consumer and survivor groups. All individuals enrolled to training programmes

scheduled for the second half of 2017 and the first half of 2018 were offered to

participate in the study. The trainings incorporated to the present study included editions

carried out at three different locations in Catalonia: Barcelona, Santa Coloma and

Granollers.

Inclusion criteria for the study coincided with inclusion criteria for activist

training eligibility: a) present or past experience of a stabilized mental illness, b)

communicative and social abilities (assertiveness, listening ability), c) being able to

engage in teamwork and to assume responsibility and compromise, d) being

comfortable with the use of IT tools (email), e) leadership and problem solving abilities,

f) interest and wish to talk about the own mental illness experience and about

discrimination, and g) willingness to appear in the media and/or talk in front of an

audience. Participants also had to be older than 18 years old.

The sample size of the study initially aimed at 50 individuals based on a prior

study that used a similar mixed method (Castellano-Tejedor et al., 2015). Finally, the

number of individuals recruited was of 84 individuals. This number is higher since it

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was contemplated that data would not be complete for all the participants, and thus,

more participants would be needed to attain an adequate number of valid observations

for the analysis.

Intervention

The Obertament activism training consists of several formative sessions, which

are designed to empower people with a past or present history of mental illness into

leading the cause against stigma and discrimination of psychopathology. For instance,

instructed activists engage in anti-stigma activities like sensitization programmes or

becoming media spokespersons. The formative sessions also include social contact

activities, sensitization of particular groups and analysis of media mental illness

messages (Aznar-lou et al., 2015).

The training was conducted by an Obertament participation and activism

promotion technician together with a media and spokesperson technician and consisted

of five six-hour training sessions. As a main objective, the training intends to provide

the skills necessary for the individuals to fight against stigma and discrimination

through their stories of self-experience. The training is divided into three blocks:

introduction, awareness and communication. During the introduction, psychoeducation

about concepts related to mental health, stigma and discrimination is provided and

participants learn to visualize and identify the various manifestations of discrimination

and stigma. In the awareness block, participants are instructed on the various strategies

to combat stigma and discrimination. Finally, on the communication block, participants

interact with mass media as a tool to fight against stigma and to normalize the vision of

mental illness (Eiroa-Orosa & Lomascolo, n.d.).

Measures

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Socio-demographic data. Information regarding gender, age and association

from which they came from before accessing Obertament was collected by means of a

questionnaire. Information regarding the diagnoses of participants was not collected,

since it was not in accordance with the ethical practice of the association.

Measure of self-stigma. The Brief version of the Internalized Stigma of Mental

Illness Scale (ISMI-10) is an abbreviated variant of the ISMI scale (Boyd Ritsher et al.,

2003) developed by Boyd, Otilingam, & DeForge (2014). The scale consists of ten

items selected from the original 29 items that conform the full scale (i.e. items 2, 7, 9,

17, 20, 21, 22, 23, 27, and 28). Each item is rated in a four-point Likert-scale (1 =

strongly disagree, 2 = disagree, 3 = agree, 4 = strongly agree). The five subscales of the

full scale (i.e. Alienation, Discrimination Experience, Social Withdrawal, Stereotype

Endorsement, and Stigma Resistance) are still represented in the brief version, with two

items per subscale. The item selection was performed taking into account the

psychometric characteristics of the items and the correlation with the overall ISMI score

and similar scales, and according to the construct validity. Since ISMI-10 only includes

two items per subscale, the output of this instrument should be handled as an overall

scale score and not divided into independent subscale scores, which is possible in ISMI.

As assessed by Boyd, Otilingam, & DeForge (2014), the English version of ISMI-10

possesses satisfactory internal consistency, with a Cronbach alpha of 0.75, excellent

correlation to the full version (r = 0.94, p < .01), and satisfactory convergent validity. A

reassessment of the psychometric properties with a bigger and more diverse sample

yielded a ordinal alpha of 0.86, demonstrating a good internal consistency, and,

moreover, it indicated an almost perfect correlation with the full version (r = 0.95, p <

.001; Ociskova, Prasko, Kamaradova, Marackova, & Holubova, 2016). The

reassessment lead to the validation of ISMI-10 as a useful method for measuring the

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self-stigma among adults with a mental disorder (Ociskova et al., 2016). Moreover,

Boyd et al. highlighted the potential use of the scale in interventional research since it

“should reduce respondent burden in program evaluation projects that seek to determine

whether participation in psychosocial rehabilitation programming reduces internalized

stigma” (Boyd, Otilingam, et al., 2014).

Self-characterisation. Participants of the study were asked to write self-

characterisation narratives. The instructions given to them were broad, so as not to

condition them in what to write. The technician who conducted the training said

something in the lines of “Write a picture of who you are at the present moment”. The

narratives were written by hand and were no longer than one page (A4). All narratives

were digitalised literally, for posterior treatment and analysis procedures, which were

conducted as described in the Data analysis section.

Procedure

All recruited participants ideally attended the five sessions that conform the

Obertament activism training. Depending on the location of the training (Barcelona,

Santa Coloma or Granollers), it took place on different dates (between October 2017

and February 2018), for which different participant cohorts resulted. Prior to the first

session, participants completed the ISMI-10, and after the first session took place (S1),

embedded in the dynamics of the training, participants wrote the pre self-

characterisation narrative. After the last session of the training, participants wrote the

post self-characterisation narrative and they completed the ISMI-10 again (S5; figure 1).

In the last session, participants were asked to complete the narrative before the

administration of the ISMI-10. In the case that in the last session there was not enough

time for both the questionnaire and the self-characterisation completion, the narrative

was given priority and participants were asked to complete the questionnaire online.

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Figure 1. Evaluation chronogram.

Prior S1 S2 S3 S4 S5

ISMI-10

Self-characterisation

Data analysis

Demographic data was explored prior to data analysis to obtain a descriptive

picture of the sample and for potential use as covariate during the following analyses.

The description of the sample was performed using frequencies, means and standard

deviations.

The analysis of the quantitative data obtained from the ISMI-10 scale was

performed with non-parametric repeated measures analysis of variance, particularly

with the test Wilcoxon Signed Ranks Test. A non-parametric test was used due to lack

of availability of post ISMI-10 data. With this analysis we aimed at confirming the

hypothesis of a decrease in self-stigma scores after the training.

For the qualitative analysis of the self-characterisation narratives a thematic

analysis approach was used (Braun & Clarke, 2006). Thematic analysis is used to

identify, analyse and report recurrent themes within the data. It allows to describe the

data set in rich detail. Prior to the proper thematic analysis of the data, all the narratives

of the participants were digitalised. The thematic analysis was structured in 6 phases

(Braun & Clarke, 2006): familiarisation with the data, generation of initial codes, search

for themes, review of the themes, definition and naming of the themes, production of

the report. As a result of the content analysis performed on the narratives, several

themes arose, which gave qualitative sense to the results. The number of times and

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percentage of appearance of each theme was reported. Moreover, those themes were

used for the mixed treatment of the data.

Finally, data was analysed using a mixed methods approach. The characteristics

of the mixed method of choice were the following (J. Creswell & Plano Clark, 2010):

fixed (the use of qualitative and quantitative methods was planned beforehand as part of

the design of the study), interactive (qualitative and quantitative methods were mixed

before the final interpretation), with equal priority of the two methods, concurrent

timing (both implemented at a single phase) and mixing of the methods during data

analysis. The category of the mixed method used is a convergent parallel type of

analysis (the results of the two methods converge in an overall interpretation), and,

particularly, the data transformation variant. In order to perform the mixed methods

analysis with data transformation, the themes detected during the content analysis were

dichotomised into quantitative variables (absence of theme = 0 vs. presence of theme =

1), allowing for the statistic comparison with the quantitative data. Further variables

were created with various computations of the dichotomous variables derived from the

content analysis. The data transformation allowed for the qualitative treatment of all the

data using non-parametric repeated measures analysis of the variance and for non-

parametric correlation analysis to relate both qualitative and quantitative data. Again,

Wilcoxon Signed Ranks Test was the analysis of choice for the repeated measures

analysis, and Kendall’s Tau-b was for the correlation analysis.

All analyses were carried using IBM SPSS Statistics version 23 (SPSS, Inc.,

Chicago, IL). A 95% confidence interval was used for all analyses.

Results

A total of 84 individuals participated in the 3 activist trainings associated to the

study. All the participants in the trainings agreed to participate in the study. Almost all

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of the participants were able to complete the baseline ISMI-10 test. However, the ISMI-

10 post-training was asked to be completed online, due to lack of time at the end of the

session. This procedure highly limited the availability of the post score, since the online

completion was quite scarce. From an initial pool of 84 participants, a total of 14 could

be included in the longitudinal calculations involving ISMI-10 score. The narratives

were part of the training and, thus, there is also high participation, both pre and post.

The longitudinal calculations of the narratives could include a total of 30 individuals.

Only a total of 7 individuals have all 4 measurements simultaneously, which are the

completers of the programme. Thus, each computation was performed with the

maximum of individuals possible.

Demographic characteristics

Demographic characteristics are shown in table 1. As can be seen in the table,

56% of the participants were women and 44%, men. The mean age of the sample was

40.66 years, with a standard deviation of 11.72 years, a minimum age of 18 and a

maximum age of 66. Comparing the three training groups between them, there is no

statistical difference in the age distribution, however they statically differ in sex

distribution: Granollers has a higher percentage of men, Santa Coloma of women and

Barcelona of women. When the sample is divided into high and low self-stigma

according to the median of the basal ISMI-10 score (1.9), the two groups do not

statistically differ in age or sex distribution. Completers and non-completers did not

differ either in sex or age distribution.

Table 1. Demographic data of the participants in the total sample and in the sample divided into high or

low basal self-stigma, and statistical comparison between the two groups.

Total sample (n=84) Low (n=35) High (n=39) Comparison

N % N % N % χ 2, d p
(n=32)
Sex (% females) 47 56 20 57 23 59 .025, 1 .873
M SD M SD M SD t, d p

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Age (M±SD) 40.66 11.72 40.85 11.2 39.17 12.43 .354, 1 .554

Quantitative analysis

When analysing the sample as a whole, there was no significant difference

between the pre and the post scores of the ISMI-10 scale. This difference was analysed

using a non-parametric repeated measures analysis of variance (Wilcoxon Signed Ranks

Test). However, if the sample is split according to the median of baseline ISMI-10 score

into high and low self-stigma, the difference between ISMI-10 pre and ISMI-10 post is,

then, significant, but only for those with high baseline self-stigma (n = 7; Z = -2.03; p <

.042). There was no significant difference in mean score of ISMI-10 pre and post

between sex and between age. Similarly, there were no significant differences in ISMI-

10 pre between completers and non-completers.

Self-characterisation narratives analysis

A thematic content analysis was performed on all the pre and post self-

characterisation narratives as described in the Data analysis section. As a result of the

process, 6 themes were found to recurrently appear in the narratives: relationships,

activities, traits, view of the future, others and disorder. The themes could appear with

either a positive or a negative valence in any of the cases. Due to this, two

supracategories were defined: positive themes and negative themes; consequently, the

themes were split according to this. Thus, the final 12 variables have a representation in

both the positive and the negative side, and are: relationships positive, relationships

negative, activities positive, activities negative, positive traits, negative traits, optimism,

pessimism, others positive, others negative, disorder positive, disorder negative. A

definition of each of the categories, together with the number of times they appeared in

pre and post narratives and the percentage that this represents can be found in table 2. A

compilation of examples of each category can be found in table 3. In order to produce

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dichotomous variables and transform qualitative data into quantitative data, in each of

the narratives, the absence of a category was coded as 0 while the presence was coded

as 1. From all these dichotomous variables, only the presence versus absence of

“negative traits” in the post narratives differed significantly between those with high

basal self-stigma and those with low basal self-stigma (n = 35; χ2 = 5.536; p < .019). For

“negative traits” in the pre narratives there was a trend towards significance but without

reaching it (n = 41; χ2 = 3.186; p < 074). In both cases there was more presence than

absence of the category “negative traits” in the high baseline self-stigma group than in

the low one.

From the abovementioned categorisation, several variables were computed to

perform the analysis. First, 4 new variables were created using the sum of each

participant’s mention to any positive theme and using the sum of each participant’s

mention to any negative theme (a positive and a negative sum for pre and a positive and

a negative sum for post). These variables could go from 0 to 6, depending if the

participants did not mention any of the themes of interest (0) or if they mentioned all of

them (6), and all the in-between numbers. Using the newly created variables, a second

computation was performed, which lead to the variable pre-post difference of the

abovementioned sums, which aimed at analysing the change in the mention of positive

and negative themes from the start to the end of the intervention. This was computed as

the subtraction of the mentioned variables, leading to a difference for positive themes

and a difference for negative themes. Moreover, a third computation was performed to

obtain a variable reflecting positive attributes minus negative attributes in order to

analyse conflict in the valence of self-characterisation (simultaneity of positive and

negative self-description). Two variables were created from this computation, a pre and

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a post one. Means and standard deviations of the abovementioned variables are reported

in table 4.

The change from pre to post analysed in the computed variables using a non-

parametric repeated measure variance analysis (Wilcoxon Signed Ranks Test) did not

yield any significant results. However, when analysing the sample separated in high and

low baseline self-stigma, the change in the sum of positive attributes became

significant, but only in the low baseline self-stigma group (n= 15; Z = -1.98; p < .048).

The low baseline self-stigma group had more presence of positive themes in the pre

narratives than in the post. The rest of the computed variables did not change from pre

to post and were not different in high and low groups either.

On top of the aforementioned 12 variables derived from the content analysis,

another variable was directly derived from the narratives analysis. Opposite to the first

ones, this one was extracted from the contrast between pre and post narratives for each

participant, instead of from the analysis of all the narratives together. The variable was

“empowerment”, which was coded as presence (1) or absence (0) according to whether

participants mentioned a feeling of empowerment caused by the training in the post

narrative as compared to the pre. The number of empowered individuals and the

percentage that this implies are reported in table 2, while examples of the variable are

reported in table 3. The number of self-reportedly empowered individuals is

significantly higher among those with low self-stigma (n = 28; χ2 = 5.038; p < .025).

Table 2. Definition and frequency of the categories derived from the content analysis.

Categories Definition N pre % pre N post % post

Positive

Fragment in which participants express

Positive
involvement and positive influence of 22 50 15 38.5
relationships
personal relationships with others.

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Fragment in which participants express being

Positive
active or engaging in activities that motivate 28 63.6 22 56.4
activities
them.

Positive Fragment in which participants highlight

33 75 28 71.8
traits positive qualities that they have.

Fragment in which participants have a positive

Optimism 14 31.8 15 38.5
view of their future.

Others Fragments in which participants recall having

1 2.3 0 0
positive been viewed by people in a positive way.

Fragments in which participants highlight

Disorder
positive contributions of their disorder to their 2 4.5 2 5.1
positive
lives.

Negative

Fragment in which participants express

Negative
withdrawal and difficulties in establishing 11 25 6 15.4
relationships
personal relationships with others.

Negative Fragment in which participants express having

3 6.8 1 2.6
activities no will to engage in an active lifestyle.

Negative Fragment in which participants highlight

14 31.8 10 25.6
traits negative qualities that they have.

Fragment in which participants have a

Pessimism 1 2.3 2 5.1
negative view of their future.

Others Fragments in which participants recall having

8 18.2 1 2.6
negative been viewed by people in a negative way.

Fragments in which participants highlight

Disorder
negative contributions of their disorder to their 15 34.1 15 38.5
negative
lives.

Mention to a feeling of empowerment caused

Empowerment by the training in the post narrative as - - 19 63.3

compared to the pre.

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Table 3. Examples of the content that qualifies for each of the categories derived from the content

analysis.

Categories Examples

Positive

Positive - I like to spend time with my family and friends.

relationships - I’m an extrovert. I like to talk to people.

Positive - She likes to read, explore and spend time with people she loves.

activities - I’m a 30 year old girl, dynamic, who wants to do lots of things, with

lots of projects.

Positive traits - I’m a responsible, sensitive and creative person.

- I’m responsible and a hard worker. I like to do interesting things […].

Optimism - He has a fulfilling and happy life and is stable from 9 years ago.

- My main goal is to build myself and see grow something beautiful in

my world.

Others positive - I’ve always had my family’s support.

Disorder - I’m proud of the life I have and of the process that brought me where I

positive am now.

- After this training I feel more confident to face [my illness],[…].

Moreover, I think I would be or could be a good activist.

Negative

Negative - I’m also a bit of a loner.

relationships - I’m an introvert and I have trouble maintaining social relationships.

Negative - I’ve had many different jobs because it has always been difficult for

activities me to work.

- Incapable of following her vocational profession

Negative traits - I’m very nervous and I lose control easily

- When I get angry I’m extremely wicked. Antisocial […].

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Pessimism - A person with problems that she doesn’t know how to solve, dreams

that will take long to achieve or will never achieve.

- I’m a person whose insecurities bring them to a feeling of abysmal

inferiority.

Others negative - When I say I have autism […], they see me as I weren’t able do

anything, I become a problem.

- Due to mental health problems I feel limited by society.

Disorder - I have bipolar disorder and I have problems in my daily life.

negative - Sometimes I suffer from anxiety crisis and I am not myself.

- I’m much more than my anxiety. I’m many things left to discover.

Empowerment - I like to know what is done in mental health campaigns and get

personally involved.

Table 4. Variables computed form the original 12 variables of the narratives content analysis with their

mean and standard deviation.

Variable Mean Standard deviation

Total of positive themes pre 2.27 1.042

Total of positive themes post 2.10 0.821

Total of negative themes pre 1.18 1.040

Total of negative themes post 0.90 0.940

Difference in positive themes -0.20 1.24

Difference in negative themes -0.27 0.83

Conflict in themes pre 1.09 1.64

Conflict in themes post 1.21 1.36

Mixed analysis

Non-parametric correlation analyses (Kendall’s Tau-b, due to its

conservativeness) were performed in order to relate the mean of pre and post ISMI-10

scores (quantitative) to the variables derived from the content analysis of the narratives

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(total of positive themes pre, total of positive themes post, total of negative themes pre,

total of negative themes post, conflict in themes pre, conflict in themes post, and

empowerment; qualitative). Most of the correlations were non-significant. However, the

significance of some correlations is noteworthy (table 5). First, the mean of ISMI-10

post positively correlated with “total of positive themes post”. Moreover, total of

positive themes pre positively correlated with “empowerment”. “Total of negative

themes pre” positively correlated with “total of negative themes post”. Finally, “conflict

in themes pre” positively correlated with “empowerment”.

When the correlations were repeated separately for the low and the high baseline

self-stigma groups there were some remarkable changes. In the low basal self-stigma

group, the correlation that remained significant was that of “total of positive themes

pre” and “empowerment”. Moreover, a new significant correlation appeared between

ISMI-10 pre and “conflict post”. However, in the high basal self-stigma group the

significant correlations were between “total of negative themes pre” with “total of

negative themes post”, as well as the first one with “empowerment”, the latter

relationship in negative direction.

Table 5. Correlations between quantitative and transformed qualitative data in the total sample and in the

sample divided into low and high baseline self-stigma groups.

Correlated variables Statistic p value N

ISMI-10 post - Total of positive themes post 0.534 .044 11

Positive themes pre - empowerment 0.381 .026 30

Negative themes pre - Negative themes post 0.577 .000 30

Conflict pre - empowerment 0.363 .027 30

Low baseline self-stigma

ISMI-10 pre - Conflict post 0.386 .049 18

Positive themes pre - empowerment 0.517 .041 15

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High baseline self-stigma

Negative themes pre - Negative themes post 0.584 .020 13

Negative themes pre - empowerment -0.634 .019 13

Discussion

Nowadays, the awareness of the detrimental consequences of self-stigma on

mental illness sufferers is leading to the creation of new interventions aimed at reducing

this self-stigma. Obertament activism training has the profile to act as such an

intervention and, indeed, prior research demonstrated that this training significantly

reduced self-stigma in the whole group of participants and that it improved wellbeing

among those who started the training with high self-stigma (Eiroa-Orosa & Lomascolo,

n.d.). However, being self-stigma such a subjective matter, it is also important to

acknowledge the opinions that the participants have about themselves without the

conditioning of a scale. Following the aforementioned arguments, our study was

innovative in using a mixed-methods analysis aimed at incorporating objective

information and subjective information about the effect of Obertament activism training

on self-stigma.

In the present study, the sample had slightly more females than males and most

participants were in their middle age. No differences were found among completers and

non-completers of the training. No differences were found in demographic

characteristics between low and high baseline self-stigma groups.

When analysing solely the data on the objective measure of self-stigma (ISMI-

10 scale), we did not exactly replicate the results found in Eiroa-Orosa & Lomascolo

(n.d.), as was expected. The change in self-stigma scores from pre to post was not

significant in the sample as a whole, as opposed to the mentioned study. However it was

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significant in those who started the training with a high self-stigma score. Although the

result for self-stigma change is not the same, the methodology of splitting the sample

according to the median of the baseline self-stigma score and obtaining different results

based on this dichotomisation was reproduced from that in Eiroa-Orosa & Lomascolo

(n.d.). In fact, the median score for the dichotomisation was 1.9 in the present study and

1.89 in the mentioned study, reinforcing the validity of this procedure. This finding

could be explained by a floor effect in those with lower scores, either of the instrument

or of the intervention. A floor effect in the instrument would mean that it is easy to have

a low score in the test, and thus, even if the intervention did decrease self-stigma in

those with a low baseline, this would not be reflected in the scale because there would

be no room for a decrease in score. Similarly, a floor effect of the intervention would

mean that participants who already started with a low self-stigma would not have room

for a decrease in it, since it would be very difficult to decrease it further, and, thus, the

intervention would not be so effective. Nevertheless, the finding is important since it

shows that, even if the change is not manifest in the sample as a whole, some

participants (particularly those more in need of an intervention) still benefit from the

training. Moreover, the results can lead to the implementation of improvements to the

intervention. For instance, some of its elements could be different for those who start

with high self-stigma versus those who are low at baseline.

Regarding the self-characterisation narratives analysis, important results were

obtained. After following the six steps of the content analysis process (Braun & Clarke,

2006), the themes that were derived from the narratives were divided into two

supracategories: positive themes and negative themes. Moreover, the themes pertained

to 6 recurrent categories that appeared both in negative and in positive formats. Those

categories were: relationships (how participants interact with others and if they view

23
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these interactions as valuable), activities (if participants engage in an active lifestyle or

not), traits (the qualities that participants use to describe themselves),

optimism/pessimism (how participants view their futures), others (how participants

consider that others view themselves) and disorder (how participants consider that their

disorder has influenced their lives). Even though the names of the aforementioned

categories do not coincide with those of the subscales in the ISMI-10 scale (Alienation,

Discrimination Experience, Social Withdrawal, Stereotype Endorsement, Stigma

Resistance), they have a lot in common. In fact, it is not surprising that the categories of

ISMI-10 scale reflect an alteration of the main functional domains of a person, and that

participants report on similar categories in the self-characterisation narratives; not in

vain, self-stigma consists of an internalisation of the illness stereotypes into one’s

identity (Yanos et al., 2015).

Regarding the aforementioned overlap in categories, the negative relationship

domain can be considered to be directly equivalent to ISMI-10 items of the Social

Withdrawal subscale i.e. “I don’t socialize as much as I used to because my mental

illness might make me look or behave “weird”.” (item 3) and “I stay away from social

situations in order to protect my family or friends from embarrassment.” (item 5). In

this regard, some of the participants reported similar statements, such as “At the present

moment I’m on sick leave and I have more trouble talking to people”. Another

coincidence is how the domain of negative activities overlaps widely with Alienation

items i.e. “Having a mental illness has spoiled my life.” (item 4) and “People without

mental illness could not possibly understand me” (item 6). This is the case with

contributions such as “Incapable of following her vocational profession”. Negative traits

may fall in the category of Stereotype Endorsement i.e. “Mentally ill people tend to be

violent.” (item 1) and “I can’t contribute anything to society because I have a mental

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illness.” (item 8), especially when participants remark negative traits such as “He has a

lot of tension” or “I am a very nervous person and I become upset easily”. Pessimism

reflects some traits of Stereotype endorsement, especially equivalent to item 8, in

contributions such as “With unstable affective state, which prevents her from doing

everything she would like to do and to accomplish all her duties”. The category of

others negative clearly falls upon the subscale of Discrimination Experience, i.e.

“People ignore me or take me less seriously just because I have a mental illness.” (item

7) and “Others think that I can’t achieve much in life because I have a mental illness.”

(item 10), with reports such as “I’ve had experiences of discrimination endorsed by my

friends and workmates, with attitudes of mocking and disdain”. Disorder negative also

reflects some traits of Discrimination experience with comments such as “Due to mental

health issues I feel limited by society”, but also traits of Alienation with comments such

as “I have bipolar disorder and I have problems with my daily life”. Finally, most of the

positive categories (relationship positive, activities positive, positive traits, optimism,

others positive and disorder positive) reflect the subscale of Stigma resistance i.e.

“People with mental illness make important contributions to society.” (item 2) and “I

can have a good, fulfilling life, despite my mental illness” (item 9).

It appears to be the case, following the aforementioned, that having negative

perceptions about the self in the mentioned domains and absence of positive ones

reflects self-stigma as described in ISMI-10 scale. However, all participants reported

many positive aspects of themselves in their characterisation. In fact, they reported more

number of positive than of negative themes and there was no change between the pre

and the post narrative neither in this difference nor in the conflict between positive and

negative valence from pre to post.

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SELF-STIGMA AMONG MENTAL HEALTH ACTIVISTS

The tendency to describe oneself using a mixture of attributes of positive and

negative valences is a phenomenon known among the researchers of self-content

descriptions (C. J. Showers, Abramson, & Hogan, 1998). The presence of a higher

number of positive themes than of negative ones in the descriptions does not imply that

self-stigma does not exist in those individuals. Indeed, how people describe themselves

can depend highly on contextual factors, such as mood, or the instructions given for

their self-characterisation (C. J. Showers et al., 1998). The fact that the categories that

appeared in the analysis reflect traits of self-stigma is more relevant than the

quantification of it. Moreover, a quantification of the subjective self-stigma in our

sample would be difficult without a comparison group of general population.

Regarding the mixed data, there were almost no significant correlations between

the ISMI-10 data and the variables derived from the content analysis of the narratives,

as it would have been expected. This lack of correlation between the more objective and

the more subjective self-stigma measures could reflect a disparity in the expression of

reduction of self-stigma. For instance, more critical thinking regarding self-stigma,

which could be reflected in the responses to ISMI-10, may be more accessibly modified

by the training, while the integration of this knowledge to the identity and, thus, to the

narratives, could be a more slow process, resistant to change. The present study is,

however, unable to explore this hypothesis. It is also possible that the thematic content

analysis is not the more adequate method to detect a quantitative relationship with a

self-stigma test. It is also possible that it is not the content of the self-characterisations

itself, but how the participants organize the information that constitutes their self-

concept (C. Showers, 1992) what is dependent on the levels of self-stigma.

Some of the significant relationships that were found are in favour of the

mentioned contradictions in the expression of change in self-stigma in more subjective

26
SELF-STIGMA AMONG MENTAL HEALTH ACTIVISTS

and more objective ambits. For instance, the number of individuals that were self-

reportedly empowered is significantly higher among those with low self-stigma. Since

empowerment is related to decreased self-stigma (Aznar-lou et al., 2015), this seems

contradictory with the fact that participants with low baseline self-stigma did not show a

decrease in self-stigma from pre to post. This result could be in line with the floor effect

mentioned earlier. Similarly, high baseline self-stigma participants mentioned more the

theme “negative traits” in the post narrative than low self-stigma participants. However,

those participants were the ones in which self-stigma decreased significantly. Moreover,

from pre to post, those in the low baseline self-stigma group reported less positive

themes compared to those in the high baseline group, who did not change.

A positive correlation was found between ISMI-10 post and “total of positive

themes post”, which would mean that the more self-stigma after the intervention, the

more positive themes are reported by the individual. This correlation disappears when

the sample is analysed divided in the two groups, for which it could be an artefact

produced by a different relationships in the two groups. A second positive correlation

was that of “total of positive themes pre” with “empowerment”, correlation that was

maintained only in the low baseline self-stigma group. According to this correlation, the

more positive themes reported by participants with low self-stigma at the beginning of

the training, the more empowerment they experienced. This relationship seems

plausible, since it is possible that if participants describe themselves more positively

they are more easily empowered. However, the low self-stigma group did not

experience a decrease in self-stigma, which is associated with an increased

empowerment. “Total of negative themes pre” positively correlated with “total of

negative themes post”, and this correlation was only maintained in the high baseline

self-stigma group. This association implies that the more negative domains mentioned

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SELF-STIGMA AMONG MENTAL HEALTH ACTIVISTS

in the narrative pre, the more mentioned in the narrative post. It is, however, noteworthy

that the relationship is only maintained in the high baseline self-sigma group, the ones

in which self-stigma decreases. This could imply that the presence of negative domains

does not condition a reduction in self-stigma. Finally, “conflict in themes pre”

positively correlated with “empowerment”, correlation that disappears in the analysis

per groups. This relationship could also be an artefact of the disparity of the relationship

in the groups.

Some new significant correlations appeared in the analysis of the two groups,

which were a positive correlation between ISMI-10 pre and “conflict in themes post” in

the low self-stigma group and a negative correlation between “total of negative themes

pre” and “empowerment” in the high baseline self-stigma group. The first, implies that

with higher levels of self-stigma at baseline, the relationship between positive and

negative mention of themes is moved towards the positive themes. This is again

expectable, but occurs only in the low baseline self-stigma group. The latter, implies

that, in the high self-stigma group, the more negative themes are reported at the start of

the training, the less empowerment there is. This association is coherent with the

fostering of empowerment in people who report less negative themes.

What seems apparent from the abovementioned contradictions is that people

with low and high baseline self-stigma seem to function differently, both in the

evolution of self-stigma during the training and with the relationships between the

variables. This difference should be further studied in order to understand its underlying

cause.

Further studies should consider several possibilities to improve research in the

field. For instance, it could be interesting to have follow-up measures some time after

the training is over to asses if the changes are maintained or not, or if new changes

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SELF-STIGMA AMONG MENTAL HEALTH ACTIVISTS

appear. This could be interesting to assess if a slower integration of the acquired

knowledge into the identity of the participants exists. Moreover, the self-

characterisation could be analysed by other methods or by the use of other content

analysis techniques. Another improvement could be assessing trainings of more

duration, and assessing other measures of wellbeing in the participants. In addition, the

use of the full version of ISMI instead of ISMI-10 could be interesting to perform a

deeper analysis with the 5 subscales, which was not possible with ISMI-10 since it has

to be considered as a single score (Boyd, Otilingam, et al., 2014).

This study has, of course, some limitations. First of all, the low participation in

the post ISMI-10 test. The fact that the post ISMI-10 test was offered to be completed

online limited a lot the participation, decreasing the power of the statistical analyses.

Second, the short time that the intervention lasted (5 sessions) may prevent us from

seeing effects in the narratives. The rate at which changes appear may be different for

the scale and for the narratives. Third, this study should be performed in interventions

specially designed to decrease self-stigma. Even though Obertament training shares

most of the strategies used in interventions aimed at reducing self-stigma, it is not

particularly designed for that. For this reason, other interventions may have more power

to reduce self-stigma and to influence self-characterisation narratives. Fourth, the lack

of knowledge of the diagnostic categories (due to the association policies) prevents us

from observing potential differences of the effect of the training on the different

diagnoses.

In conclusion, this study has reported several important results. First of all, it has

been demonstrated how people who start an intervention such as the Obertament activist

training with high self-stigma are the ones in whom the self-stigma decreases

significantly. Moreover, qualitative results demonstrate how the recurrent themes that

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appear among participants of the training are deeply related to themes reflexed in how

self-stigma affects the person. It is, thus, impregnated in the identity of the participants,

even if they also report positive themes that counteract with it. Finally, the mixed

analysis of objective and subjective data regarding self-stigma reports several

contradictory results, which point towards the possibility of different functioning in

people with high self-stigma versus people with low self-stigma.

In definitive, the increased knowledge about how self-stigma is modified,

perceived from both a quantitative and a qualitative view, is highly informative for

future improvements to the activist training and other interventions and to research in

the field of self-stigma.

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References

Assefa, D., Shibre, T., Asher, L., & Fekadu, A. (2012). Internalized stigma among

patients with schizophrenia in Ethiopia: a cross-sectional facility-based study.

BMC Psychiatry, 12(1), 239. https://doi.org/10.1186/1471-244X-12-239

Aukst Margetić, B., Jakovljević, M., & Margetić, B. (2012). Socio–cognitive–

behavioral structural equation model of internalized stigma in people with severe

and persistent mental illness should include personality dimensions. Psychiatry

Research, 196(1), 162–163. https://doi.org/10.1016/j.psychres.2011.04.009

Aznar-lou, I., Rubio-valera, M., & Serrano-blanco, A. (2015). Impacto de la formación

de los activistas de las campañas de OBERTAMENT: Ensayo prospectivo no

controlado. Internal Report of Fundació Sant Joan de Déu per la Recerca i la

Docència.

Boyd, J. E., Adler, E. P., Otilingam, P. G., & Peters, T. (2014). Internalized Stigma of

Mental Illness (ISMI) Scale: A multinational review. Comprehensive Psychiatry,

55(1), 221–231. https://doi.org/10.1016/j.comppsych.2013.06.005

Boyd, J. E., Otilingam, P. G., & DeForge, B. R. (2014). Brief version of the Internalized

Stigma of Mental Illness (ISMI) scale: Psychometric properties and relationship to

depression, self esteem, recovery orientation, empowerment, and perceived

devaluation and discrimination. Psychiatric Rehabilitation Journal, 37(1), 17–23.

https://doi.org/10.1037/prj0000035

Boyd Ritsher, J., Otilingam, P. G., & Grajales, M. (2003). Internalized stigma of mental

illness: psychometric properties of a new measure. Psychiatry Research, 121(1),

31–49. https://doi.org/10.1016/j.psychres.2003.08.008

Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative

Research in Psychology, 3(2), 77–101.

31
SELF-STIGMA AMONG MENTAL HEALTH ACTIVISTS

https://doi.org/10.1191/1478088706qp063oa

Bryman, A. (2006). Integrating quantitative and qualitative research: How is it done?

Qualitative Research, 6(1), 97–113. https://doi.org/10.1177/1468794106058877

Castellano-Tejedor, C., Eiroa-Orosa, F.-J., Pérez-Campdepadrós, M., Capdevila, L.,

Sánchez de Toledo, J., & Blasco-Blasco, T. (2015). Perceived positive and

negative consequences after surviving cancer and their relation to quality of life.

Scandinavian Journal of Psychology, 56(3), 306–314.

https://doi.org/10.1111/sjop.12199

Chan, R. C. H., & Mak, W. W. S. (2016). Common sense model of mental illness:

Understanding the impact of cognitive and emotional representations of mental

illness on recovery through the mediation of self-stigma. Psychiatry Research, 246,

16–24. https://doi.org/10.1016/j.psychres.2016.09.013

Corrigan, P. W. (2005). On the stigma of mental illness: Practical strategies for

research and social change. Washington: American Psychological Association.

https://doi.org/10.1037/10887-000

Corrigan, P. W., Bink, A. B., Schmidt, A., Jones, N., & Rüsch, N. (2016). What is the

impact of self-stigma? Loss of self-respect and the “why try” effect. Journal of

Mental Health, 25(1), 10–15. https://doi.org/10.3109/09638237.2015.1021902

Corrigan, P. W., Larson, J. E., & Rüsch, N. (2009). Self-stigma and the “why try”

effect: impact on life goals and evidence-based practices. World Psychiatry, 8(2),

75–81. https://doi.org/10.1002/j.2051-5545.2009.tb00218.x

Corrigan, P. W., Rafacz, J., & Rüsch, N. (2011). Examining a progressive model of

self-stigma and its impact on people with serious mental illness. Psychiatry

Research, 189(3), 339–343. https://doi.org/10.1016/j.psychres.2011.05.024

Corrigan, P. W., & Watson, A. C. (2002). Understanding the impact of stigma on

32
SELF-STIGMA AMONG MENTAL HEALTH ACTIVISTS

people with mental illness. World Psychiatry : Official Journal of the World

Psychiatric Association (WPA), 1(1), 16–20. Retrieved from

http://www.ncbi.nlm.nih.gov/pubmed/16946807

Creswell, J., & Plano Clark, V. (2010). Choosing a mixed methods design. In J. W.

Creswell & V. L. Plano Clark (Eds.), Designing and conducting mixed methods

research (pp. 53–106). London: SAGE.

Drapalski, A. L., Lucksted, A., Perrin, P. B., Aakre, J. M., Brown, C. H., DeForge, B.

R., & Boyd, J. E. (2013). A Model of Internalized Stigma and Its Effects on People

With Mental Illness. Psychiatric Services, 64(3), 264–269.

https://doi.org/10.1176/appi.ps.001322012

Eiroa-Orosa, F. J., & Lomascolo, M. (n.d.). Training mental health activists increases

the well-being of participants with high baseline levels of self-stigma : results of

the Obertament training evaluation. In Press.

Goffman, E. (1963). Stigma: Notes on a spoiled identity. Englewood Cliffs, NJ: Prentice

Hall.

Holubova, M., Prasko, J., Ociskova, M., Marackova, M., Grambal, A., & Slepecky, M.

(2016). Self-stigma and quality of life in patients with depressive disorder: a cross-

sectional study. Neuropsychiatric Disease and Treatment, Volume 12, 2677–2687.

https://doi.org/10.2147/NDT.S118593

Kamaradova, D., Latalova, K., Prasko, J., Kubinek, R., Vrbova, K., Krnacova, B., …

Tichackova, A. (2016). Connection between self-stigma, adherence to treatment,

and discontinuation of medication. Patient Preference and Adherence, Volume 10,

1289–1298. https://doi.org/10.2147/PPA.S99136

Karakaş, S. A., Okanlı, A., & Yılmaz, E. (2016). The Effect of Internalized Stigma on

the Self Esteem in Patients with Schizophrenia. Archives of Psychiatric Nursing,

33
SELF-STIGMA AMONG MENTAL HEALTH ACTIVISTS

30(6), 648–652. https://doi.org/10.1016/j.apnu.2016.02.006

Krajewski, C., Burazeri, G., & Brand, H. (2013). Self-stigma, perceived discrimination

and empowerment among people with a mental illness in six countries: Pan

European stigma study. Psychiatry Research, 210(3), 1136–1146.

https://doi.org/10.1016/j.psychres.2013.08.013

Link, B. G., & Phelan, J. C. (2001). Conceptualizing Stigma. Annual Review of

Sociology, 27(1), 363–385. https://doi.org/10.1146/annurev.soc.27.1.363

Livingston, J. D., & Boyd, J. E. (2010). Correlates and consequences of internalized

stigma for people living with mental illness: A systematic review and meta-

analysis. Social Science & Medicine, 71(12), 2150–2161.

https://doi.org/10.1016/j.socscimed.2010.09.030

Mittal, D., Sullivan, G., Chekuri, L., Allee, E., & Corrigan, P. W. (2012). Empirical

Studies of Self-Stigma Reduction Strategies: A Critical Review of the Literature.

Psychiatric Services, 63(10), 974–981. https://doi.org/10.1176/appi.ps.201100459

Muñoz, M., Sanz, M., Pérez-Santos, E., & Quiroga, M. de los Á. (2011). Proposal of a

socio–cognitive–behavioral structural equation model of internalized stigma in

people with severe and persistent mental illness. Psychiatry Research, 186(2–3),

402–408. https://doi.org/10.1016/j.psychres.2010.06.019

Ociskova, M., Prasko, J., Kamaradova, D., Marackova, M., & Holubova, M. (2016).

Evaluation of the psychometric properties of the brief Internalized Stigma of

Mental Illness Scale (ISMI-10). Neuro Endocrinology Letters, 37(7), 511–517.

Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/28326745

Oexle, N., Rüsch, N., Viering, S., Wyss, C., Seifritz, E., Xu, Z., & Kawohl, W. (2017).

Self-stigma and suicidality: a longitudinal study. European Archives of Psychiatry

and Clinical Neuroscience, 267(4), 359–361. https://doi.org/10.1007/s00406-016-

34
SELF-STIGMA AMONG MENTAL HEALTH ACTIVISTS

0698-1

Olçun, Z., & Şahin Altun, Ö. (2017). The Correlation Between Schizophrenic Patients’

Level of Internalized Stigma and Their Level of Hope. Archives of Psychiatric

Nursing, 31(4), 332–337. https://doi.org/10.1016/j.apnu.2017.03.001

Picco, L., Pang, S., Lau, Y. W., Jeyagurunathan, A., Satghare, P., Abdin, E., …

Subramaniam, M. (2016). Internalized stigma among psychiatric outpatients:

Associations with quality of life, functioning, hope and self-esteem. Psychiatry

Research, 246, 500–506. https://doi.org/10.1016/j.psychres.2016.10.041

Pinto-Foltz, M. D., & Logsdon, M. C. (2008). Stigma Towards Mental Illness: A

Concept Analysis Using Postpartum Depression as an Exemplar. Issues in Mental

Health Nursing, 29(1), 21–36. https://doi.org/10.1080/01612840701748698

Schrank, B., Amering, M., Hay, A. G., Weber, M., & Sibitz, I. (2014). Insight, positive

and negative symptoms, hope, depression and self-stigma: a comprehensive model

of mutual influences in schizophrenia spectrum disorders. Epidemiology and

Psychiatric Sciences, 23(03), 271–279.

https://doi.org/10.1017/S2045796013000322

Sharaf, A. Y., Ossman, L. H., & Lachine, O. A. (2012). A cross-sectional study of the

relationships between illness insight, internalized stigma, and suicide risk in

individuals with schizophrenia. International Journal of Nursing Studies, 49(12),

1512–1520. https://doi.org/10.1016/j.ijnurstu.2012.08.006

Showers, C. (1992). Compartmentalization of positive and negative self-knowledge:

Keeping bad apples out of the bunch. Journal of Personality and Social

Psychology, 62(6), 1036–1049. https://doi.org/10.1037/0022-3514.62.6.1036

Showers, C. J., Abramson, L. Y., & Hogan, M. E. (1998). The dynamic self: How the

content and structure of the self-concept change with mood. Journal of Personality

35
SELF-STIGMA AMONG MENTAL HEALTH ACTIVISTS

and Social Psychology, 75(2), 478–493. https://doi.org/10.1037/0022-

3514.75.2.478

Tsang, H. W. H., Ching, S. C., Tang, K. H., Lam, H. T., Law, P. Y. Y., & Wan, C. N.

(2016). Therapeutic intervention for internalized stigma of severe mental illness: A

systematic review and meta-analysis. Schizophrenia Research, 173(1–2), 45–53.

https://doi.org/10.1016/j.schres.2016.02.013

Vrbova, K., Prasko, J., Holubova, M., Kamaradova, D., Ociskova, M., Marackova, M.,

… Zatkova, M. (2016). Self-stigma and schizophrenia: a cross-sectional study.

Neuropsychiatric Disease and Treatment, Volume 12, 3011–3020.

https://doi.org/10.2147/NDT.S120298

Vrbova, K., Prasko, J., Ociskova, M., Kamaradova, D., Marackova, M., Holubova, M.,

… Latalova, K. (2017). Quality of life, self-stigma, and hope in schizophrenia

spectrum disorders: a cross-sectional study. Neuropsychiatric Disease and

Treatment, Volume 13, 567–576. https://doi.org/10.2147/NDT.S122483

Yanos, P. T., Lucksted, A., Drapalski, A. L., Roe, D., & Lysaker, P. (2015).

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

Psychiatric Rehabilitation Journal, 38(2), 171–178.

https://doi.org/10.1037/prj0000100

Yanos, P. T., Lysaker, P. H., & Roe, D. (2010). Internalized stigma as a barrier to

improvement in vocational functioning among people with schizophrenia-spectrum

disorders. Psychiatry Research, 178(1), 211–213.

https://doi.org/10.1016/j.psychres.2010.01.003

Yanos, P. T., Roe, D., Markus, K., & Lysaker, P. H. (2008). Pathways Between

Internalized Stigma and Outcomes Related to Recovery in Schizophrenia Spectrum

Disorders. Psychiatric Services, 59(12), 1437–1442.

36
SELF-STIGMA AMONG MENTAL HEALTH ACTIVISTS

https://doi.org/10.1176/appi.ps.59.12.1437

37