Journal of Psychiatric and Mental Health Nursing, 2008, 15, 5965

The evaluation of a short group programme to reduce self-stigma in people with serious and enduring mental health problems
D. L. MACINNES1 phd msc bsc (hons) pg dip arm rmn & M. LEWIS2 msc rmn Reader in Mental Health, Centre for Health and Social Care Research, Faculty of Health, Canterbury Christ Church University, Canterbury, Kent, and 2Nurse Consultant (Assertive Outreach), Dorset Healthcare NHS Foundation Trust, Hahnemann House, Westcliff, Bournemouth, UK
1

Correspondence: D. L. MacInnes Centre for Health and Social Care Research Faculty of Health Canterbury Christ Church University Canterbury Kent CT1 1QU UK E-mail: douglas.macinnes@ canterbury.ac.uk

MACINNES D. L. & LEWIS M. (2008) Journal of Psychiatric and Mental Health Nursing 15, 5965 The evaluation of a short group programme to reduce self-stigma in people with serious and enduring mental health problems The concept of stigma has been acknowledged as being an important factor in the way that people with mental health problems are viewed and treated. Some authors suggest that stigma should be viewed as a multifaceted rather than a single concept. One part of this multifaceted concept has been called self-stigma which has been dened as the reactions of stigmatized individuals towards themselves. This study examined the impact of a 6-week group programme designed to reduce self-stigma in a group of service users with serious and enduring mental health problems. Twenty participants were assessed prior to the commencement of the group and immediately following its cessation. In addition to self-stigma, assessments for self-esteem, self-acceptance and psychological health measures were also undertaken. The results record a signicant reduction in the stigma following the group and also non-signicant increases in the participants levels of self-esteem, self-acceptance and overall psychological health. However, there was only a negligible correlation recorded between the reduction in self-stigma and the increase in self-esteem, self-acceptance and psychological health. The paper discusses the possible explanations for these ndings. Keywords: cognitive therapy, group work, psychological health, self-acceptance, selfesteem, self-stigma
Accepted for publication: 24 September 2007

Introduction
The concept of stigma is increasingly viewed as an important issue within mental health. Mental health professionals have been encouraged to develop interventions that reduce the amount of stigmatization faced by mental health service users. The Mental Health National Service Framework (Department of Health 1999) Standard One proposed that mental health practitioners should combat discrimination
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against individuals and groups with mental health problems, and promote their social inclusion. It also positively endorsed the use of developing an evidence base with which to support interventions. Additionally, there have been recent programmes instigated by the World Psychiatric Association and the Royal College of Psychiatrists in the UK that have aimed to reduce mental health stigma (Warner 2005, Byrne 2006). Although the association between having a mental illness and stigma has been recognized for
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many years, Lee (2002) noted there have been few empirical studies examining ways of reducing stigmatization with Angermeyer (2004) advocating that more research is undertaken that looks at self-stigmatization (stigma from the perspective of the service user).

Stigma
Byrne (1999) described the main attribute of stigma as a mark of disgrace or discredit that sets a person aside from others while Hayward & Bright (1997) added that it is the negative effects of a label placed on any group. It can be related to many different characteristics including race, age, gender, religion and sexuality as well as mental health. According to Byrne (1997), most mental health professionals and service users acknowledge that stigma plays a negative role at every stage of mental illness presentation, diagnosis, treatment and outcome. Much research on stigma was done in the sixties and seventies and there has been a resurgence of interest in the subject since the 1990s due to the interest in community care (Hayward & Bright 1997, Angermeyer & Holzinger 2005). Early studies conclude that the general public disliked and feared the mentally ill and wanted to avoid them at all costs while a survey by Crisp et al. (2000) found that the public still viewed people with severe mental health problems as unpredictable and dangerous.

Reducing stigma
The majority of interventions designed to reduce stigma related to overt discrimination have focused on three areas detailed by Corrigan & Penn (1999): protest, education and contact; protest involves the suppression of stigmatizing attitudes through moral indignation, education involves replacing half-truths with more accurate conceptions about mental health disorders, while contact challenges public attitudes through direct interactions with people who have a mental illness. Corrigan et al. (2002) suggest that contact and, to a lesser extent, education have had some effect on generating more positive views in the general public.

stigma. The concept of self-stigma (which has also been called internal stigma or perceived stigma) has been noted by other authors. King et al. (2007) suggested it could be viewed as the reactions of stigmatized individuals towards themselves. Link & Phelan (2001) suggested peoples social psychological processes (shame, lower self-esteem) inuence the stigmatized persons perceptions while Gilbert (2003) stated it arises from the belief that if someone has mental health problems they cannot elicit positive emotions from other people but that anxiety, anger, contempt, ridicule and disgust will be elicited. The effect of this perceived response is to increase the sense of inferiority and generate negative emotions such as anxiety and depression. This also leads on to limited social interactions (Link et al. 1989), poorer relationships (Corrigan & Penn 1999), poorer life satisfaction (Rosenberg 1979) and unemployment (Link 1987). Other studies have concluded that higher levels of stigma were associated with lower levels of self-esteem (Wright et al. 2000, Link et al. 2001). Interestingly, both Link et al. (2001) and Teachman et al. (2006) also found that service users with mental illness had stigmatizing views similar to the general population. This may help explain the ndings of Farina et al. (1971) that the behaviour of people with mental illness deteriorated if they believed that the person they were interacting with knew about their illness. Hayward & Bright (1997) also stated that people avoided seeking help for mental health or emotional problems because they were afraid of a mental illness label. It is suggested that designing an intervention that focuses on the reduction of self-stigma would be able to explicitly target the specic processes underpinning the maintenance of this type of stigma.

Reducing self-stigma
Hayward & Bright (1997) suggested an approach to help in reducing self-stigma. Three main elements were detailed: 1. Using a cognitive approach to assess and combat service users specic stigmatizing beliefs. One approach utilizes the concept of Unconditional Self-Acceptance (USA). Unconditional Self-Acceptance leads the individual with mental health problems to accept themselves as fallible human beings and therefore not become disturbed or distressed by their interactions with other people (Ellis 1994, Dryden 2001). It is proposed that the development of USA beliefs would help to reduce self-stigma. 2. Sharing a holistic conception of mental illness with the service user incorporating biological and psychological factors and emphasizing the role of psychosocial factors. This offers the service user a greater sense that
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Self-stigma
However, there have been several authors who suggest that to view stigma as a single concept is unhelpful and that there are, in fact, different types of stigma. Byrne (2001) detailed that to be marked as mentally ill carries both internal (secrecy, lower self-esteem and shame) and external (social exclusion, prejudice and discrimination) consequences, all of which are considered under the heading of
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steps can be taken to reduce the effects of the illness and of the stigma. 3. Avoiding any demarcation between health and illness, emphasizing that they lie on a continuum. The emphasis being on managing a particular set of problems rather than managing a diagnosis. This helps to normalize the mental health problem within this continuum and reduces the sense of abnormality reported by some individuals with mental health problems.

Aims and objectives

The research aims to ascertain whether a six-session programme using cognitive approaches (with a specic emphasis on developing unconditional self-acceptance) would reduce self-stigma within a group of service users with serious mental health problems. The specic objectives being: 1. To ascertain levels of self-stigma, self-acceptance, selfesteem and psychological well-being in a cohort of mental health inpatients. 2. To examine the effect of a structured programme on self-stigma, self-acceptance beliefs, self-esteem, psychological well-being and within the cohort. 3. To examine the correlation between self-stigma and the three other measures (self-acceptance, self-esteem and psychological well-being).

The reasons for these exclusion criteria were that it was necessary for the participants to be able to consciously evaluate the relationship between their thoughts, feelings and behaviours as well as understand the psychoeducational material presented during the group. Initially, discussions with members of the clinical team in each of the clinical areas were held to ascertain the appropriateness of inviting service users to participate in the study. Once agreement was reached, potential participants were approached and invited to participate in the study. It was expected that the sample would consist of three groups of between six to eight subjects (1824 subjects in all). Power calculations suggested that 19 participants would be sufcient based on a power calculation of 80% and a signicance level of 5% (Cohen 1972).

Data collection
The demographic characteristics of the participants were recorded. It was decided to use four well-validated selfreport measures to examine self-stigma, self-acceptance beliefs, self-esteem and psychological well-being. Self-stigma was evaluated using the devaluationdiscrimination scale (Link et al. 1989). The measure examines the extent to which a person believes that people will devalue or discriminate against someone with mental health problems. The measure has 12 items scored on a 6-point Likert scale. The item scores are summed and divided by 12 to produce a mean score of between 1 and 6. Higher scores reect a higher perception of devaluation and discrimination. Self-esteem was measured using Rosenbergs SelfEsteem Scale (Rosenberg 1965). It is a 10-item unidimensional Likert response scale and has been widely used in various settings (Bowling 1999). Scores range from 0 to 30, with higher scores reecting higher levels of self-esteem. Self-acceptance beliefs were assessed on a subscale of the Shortened General Attitude and Belief Scale (Lindner et al. 1999). The self-downing subscale has been found to have high reliability and validity as a measure of self-acceptance by Lindner et al. (1999) and MacInnes (2003). Its subscale scores range from 4 to 20 with lower scores indicating stronger self-acceptance beliefs. Psychological well-being was measured by the General Health Questionanire-28 (GHQ) (Goldberg 1984). It is the most widely applied self-completed measure of psychiatric disturbance in the UK (Bowling 1999). The overall GHQ scores is the sum total of the item scores. These scores range from 0 to 28 with scores of 6 or over indicating poor psychological health.
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Methods
Design
The study utilizes a quantitative approach using a pre-test/ post-test design with the participants assessed prior to an intervention (the six-session group) and following the cessation of the group.

Sample
The participant groups were all inpatients at a mental health unit within Greater London. The inclusion criteria were that the participants had to be between the ages of 18 and 65, and diagnosed as having a severe and enduring mental illness. The following two exclusion criteria were applied: Service users assessed by the health care team as unable to participate in the study due to their current mental state. Individuals who had limitations in understanding English which would make it difcult for them to fully engage in the group process.
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D. L. MacInnes & M. Lewis

All of the assessment reports were given to the participants in the inpatient unit and completed in a random order 1 week prior to the rst session and at the end of the nal session.

assumed to be signicant (Sackett et al. 2000). Condence intervals were also recorded at 95%.

Results
The demographic characteristics of the participants are recorded in Table 2. The cohort was all male, with a mean age of just under 32 years and a history of mental health problems for an average of almost 9 years. Twenty participants attended the groups (although three did not attend all the sessions). Table 3 records the participants scores. It details the pre-test and post-test scores as well as the t-test scores, statistical signicance and condence intervals. The mean pre-test score recorded for the devaluation-discrimination scale was 4.33 (SD 0.82). The results also show a statistically signicant improvement in the post-test self-stigma score by 0.73 to a mean score of 3.6. The mean self-acceptance score (11.05) was below the mid-point score of 12.5 indicating levels of above-average self-acceptance. The self-acceptance score also reduced by 2.08 to a mean score of 8.97 following the intervention and although non-signicant certainly indicated a strong tendency towards an increase in these beliefs. The self-esteem scale recorded a pre-programme mean of 20.07. There was a non-signicant increase in levels of self-esteem following the group with a post-group score of

Programme
A structured programme was developed using a cognitive therapy approach with psycho-educational input. The content of the programme utilized the works of Kemp et al. (1996) on illness beliefs, Dryden (1999) regarding selfacceptance and Hayward & Bright (1997) on examining stigmatization. The content of the groups is detailed in Table 1. The groups were closed sessions with six to eight patients attending and held weekly for 6 weeks.

Data analysis
Descriptive statistics examined the levels of the various assessment tools noted above. t-Tests were employed to examine differences in pre-group and post-groups scores. In addition, Pearson correlation coefcients were used to examine associations between self-stigma, beliefs, selfesteem and well-being. Any results where P = <0.05 were

Table 1 Programme overview Learning about mental health problems Discussing experiences diagnosis and symptoms Impact of having mental health problems Stress Vulnerability Model stressors/coping Descriptions/denitions of stigma Experiences and effects of stigma Introduction to ABC model Detailing principles of self-acceptance Challenging specic beliefs about stigma Promoting involvement in service users own care

Table 2 Demographic details Participants Number Age (mean) Gender Admission age (mean) Years of illness (mean) 20 31.8 (SD 7.2) All male 23.1 (SD 5.3) 8.7 (SD 3.7)

Table 3 Pre- and post-intervention scores of the participants Subject Dev-disc Self-acceptance SES GHQ Pre-group score (SD) 4.33 (0.82) 11.05 (3.46) 20.07 (4.57) 2.40 (4.21) Post-group score (SD) 3.60 (0.74) 8.97 (3.40) 21.24 (1.71) 1.99 (2.67) t-test 2.93 1.89 -1.05 0.36 Sig 0.01 0.07 0.31 0.72 Condence interval (95%) 0.231.23 -0.354.15 -1.151.10 -1.782.84

GHQ, General Health Questionanire; SES, Rosenbergs Self-Esteem Scale.

Table 4 Correlation between self-stigma, self-acceptance, self-esteem and psychological health Devaluation-Discrimination Devaluation-Discrimination n/a Self-acceptance Pearson correlation -0.03 P = 0.85 SES Pearson correlation 0.03 P = 0.87 GHQ- 28 Pearson correlation -0.09 P = 0.60

GHQ, General Health Questionanire; SES, Rosenbergs Self-Esteem Scale.

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21.24. The GHQ-28 also showed a non-signicant reduction in psychological ill health. Table 4 notes the correlation between self-stigma and self-acceptance, self-esteem and psychological health. It shows that there is very little correlation between selfstigma and the other three measures.

Discussion
The results indicate that, during the 6 weeks of the programme, there was a signicant reduction in the self-stigma experienced by the participants as well as an increase in self-acceptance beliefs, an increase in self-esteem and an improvement in general psychological health. The pre-test devaluation-discrimination score is higher than most previous studies. Link et al. (1989) recorded scores ranging from 4.03 for those service users who were in their rst contact with services to 4.14 for those who had several contacts. A similar score was recorded by Berge & Ranney (2005) in their study of community outpatients while other outpatient studies by Link et al. (2001) and Graf et al. (2004) both recorded mean scores of 3.31. This suggests that this group of service users had high levels of self-stigma prior to commencing the programme and these had reduced to levels that were comparable to equivalent populations. The self-acceptance scores were similar to those found by MacInnes (2006) on a sample of mental health inpatients while the self-esteem scores were comparable to a range of scores of 16.7 and 23.04 recorded by Ritsher & Phelan (2004) and Berge & Ranney (2005). No differences were found between the participants age or length of mental health difculties and their self-stigma scores. Previous studies have recorded similar ndings. Link et al. (1989) and Graf et al. (2004) had concluded that the level of self-stigmatization was not inuenced by age nor length of mental health problems and, additionally, gender had little effect on self-stigma scores. Link et al. (1997) also assessed level of self-stigma in a cohort of mental health patients at entry into treatment and after a year of treatment. They found similar levels of self-stigma between the two time points indicating that self-stigma does not appear to naturally reduce over time. It supports the view that the group approach was instrumental in reducing levels of self-stigma. However, the results also signify there is little correlation between the self-stigma scores and scores for selfacceptance, self-esteem or psychological health. This is contrary to what was found in some previous studies. Link et al. (2001), Berge & Ranney (2005) and Rsch et al. (2006) reported signicant inverse correlations between self-stigma and self-esteem though Ritsher et al. (2003) found little correlation between the two in their study.
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Additionally, Yen et al. (2005) and Pyne et al. (2004) described that an increase of levels of self-stigma was associated with increased depression severity. The reasons for these apparently contradictory results could be explained by Corrigan & Watson (2002) who suggested that some individuals with mental health problems react personally to stigmatization by becoming more withdrawn and their self-esteem is lowered while others become angry with the prejudicial actions. They also noted a third group who did not have either response but seemed to ignore the effects of the prejudice altogether. Their view was that the individuals perception of the situation governed their reaction to potential stigma. Individuals with mental illness who believe the negative actions of others are legitimate will have lowered self-esteem and less selfacceptance while those who view the negative responses of others as either unjust or irrelevant will not have their self-esteem affected and will respond with indifference or righteous anger. Recent empirical evidence has shown partial support for this assumption (Watson et al. 2007). This could explain why there is no clear association between self-stigma and self-esteem, self-acceptance and psychological health even though all improved during the programme. It may have been that the content of the programme allowed the participants to challenge the perceived legitimacy of the stigmatization. The use of a group approach may also have been benecial in helping to develop a consensus between the individual participants regarding beliefs and responses to self-stigma. Unfortunately, no measures were used in the study to measure the concepts of legitimacy or identication with the target group. Further work examining these concepts and their relationship to self-stigma would be helpful and may help to identify which features of the 6-week course were the most important in developing beliefs that were consistent with reducing self-stigma.

Limitations of study
The sample size was small and so generalizations to the wider mental health population would be unwise. There was no assessment of a comparative group which could have indicated whether the proposed benets were due to other extraneous factors. Finally, post-intervention assessments were carried out immediately at the end of the programme. It would have been helpful to follow participants up and reassess to see if the benets were maintained after a longer period.

Conclusion
The study found that during the period of the programme there was a signicant reduction in the self-stigma experi63

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enced by the participants as well as an increase in levels of self-acceptance, self-esteem and psychological well-being. However, there was no real correlation between selfstigma, and these three variables. It is suggested that the programme allowed the participants to challenge the perceived legitimacy of the stigmatization. Further work would be helpful in these areas in ascertaining which areas of the programme were most important in developing beliefs that were consistent with viewing negative stigmatizing actions as illegitimate and what helped in developing appropriate responses to these actions.

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