Administrative information
Title {1} | Compassion-focused therapy (CFT) for the reduction of the internalized stigma of mental disorders: a multi-center, prospective, randomized, controlled study |
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Trial registration {2a and 2b} | Registered on January 26, 2023: clinicaltrials.gov NCT05698589 |
Protocol version {3} | Version 1 of 01-3-2022 |
Funding {4} | Funding to finance this study has been requested after a public invitation to tender from the General Directorate for Healthcare Provision (DGOS) (national PHRC). |
Author details {5a} | M. Riebel: Laboratoire de Psychologie des Cognitions (Unistra), France O. Rohmer: Laboratoire de Psychologie des Cognitions (Unistra), France E. Charles: Strasbourg University Hospital (SUH), France S. Weibel: Strasbourg University Hospital (SUH), France L. Weiner: Strasbourg University Hospital (SUH), France; Laboratoire de Psychologie des Cognitions (Unistra), France |
Name and contact information for the trial sponsor {5b} | Strasbourg University Hospital (SUH) 1, place de l’Hôpital, F-67 091 STRASBOURG cedex DRCI@chru-strasbourg.fr |
Role of sponsor {5c} | The funders played no role in the design of the study; collection, analysis, and interpretation of the data; and writing the manuscript. |
Introduction
Background and rationale {6a}
Objectives {7}
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1. To evaluate the maintenance of effects on self-stigma scores in the three groups of treatment (CFT, ESS, and TAU) at 6-month follow-up (V2)
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2. To assess the effects of treatment (CFT, ESS, and TAU) at baseline (V0), post-treatment (V1), and at 6 months follow-up (V2) on target psychological dimensions (shame, self-compassion, emotional regulation, automatic avoidance tendencies toward mental illness)
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3. To assess the effects of treatment (CFT, ESS, and TAU) at baseline (V0), post-treatment (V1), and at 6 months follow-up (V2), on social functioning and psychiatric measures (psychiatric symptoms, depression, anxiety and stress, social functioning, access to care, recovery, functional remission)
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4. To assess the psychological factors mediating (shame, self-compassion, and emotional dysregulation) the efficacy of CFT on the self-stigma measure (V1)
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5. To evaluate the acceptability of the active interventions (CFT and ESS): pretreatment (V0) via a treatment credibility measure, during treatment via attrition rate, session attendance and group cohesion, and post-treatment (V1) via patient satisfaction and treatment side effects In addition, in the coordinating center, qualitative interviews will assess the acceptability of the active interventions.
Trial design {8}
Methods
Study setting {9}
Participants
Eligibility criteria {10}
Inclusion criteria
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- Patients≥ 18 years of age
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- Patient affiliated to a social health insurance plan (beneficiary or beneficiary’s family)
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- Patient with one or several diagnoses of chronic psychiatric disorder (schizophrenia, schizoaffective disorder, bipolar disorder, recurrent major depression, borderline personality disorder) or a neurodevelopmental disorder (autism spectrum disorder) treated as an outpatient or in a day hospital
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- CGI-Severity score < 6, assessed by the psychiatrist [49]
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- ISMI score indicating moderate to high self-stigma (> 2) [50]
Non-inclusion criteria
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- Patient in an exclusion period determined by a previous or ongoing study
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- Patient participating in an interventional study involving psychotherapy or an experimental drug
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- Patient in acute episode of their disorder according to the CGI Severity score
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- Patient in a medical emergency or immediate life-threatening situation
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- Patients with an intellectual disability (IQ < 70) estimated via the fNART [51]
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- Legal issues: care under constraint or patient deprived of freedom because of a judicial - measure
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- Patient who does not speak and read French sufficiently
Inclusion criteria for individuals who will perform the interventions
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- The facilitators of both psychotherapies are mental health professionals or peer support worker.
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- In each psychotherapy group of 8 patients, one of the facilitators is a senior psychologist.
Who will take informed consent? {26a}
Additional consent provisions for collection and use of participant data and biological specimens {26b}
Interventions
Explanation for the choice of comparators {6b}
Intervention description {11a}
Experimental arm (CFT)
Active control arm (psychoeducation-ESS)
Session number | Session title | Session content | Home practice |
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1 | Welcoming and creating a safe place Definition of compassion and personal goals | • Introducing members of the group and therapists • Collective reflection on a safe place agreement for the group • Exercise: step in/me too • Exploration of what is (and what is not) compassion • Identification of personal objectives for the therapy • Short introducing to soothing rhythm breathing (SRB) | Soothing rhythm breathing (SRB) |
2 | Compassion wisdom: the tricky brain and the social construction of self | • SRB • Tricky brain problem • How and why we are different to other animals: our unique capacity for self-consciousness and self-judgment (“not our fault”) • We are only one version of the infinite possible versions of self • Understanding the influence of our social environment on our construction (“not our fault”) | Soothing rhythm breathing (SRB) Identifying my own tricky brain loops |
3 | Compassion wisdom: three emotional regulation systems | • SRB • Introducing the three circles model: threat, drive, and soothing • Evolutionary function of emotions | Soothing rhythm breathing (SRB) Drawing my three circles and identifying triggers |
4 | Compassion wisdom: stigma and self-stigma | • SRB • Introduction stigma and self-stigma • Understanding the path from public stigma to self-stigma (“not our fault”) through the social construction of self and the tricky brain • Consequences of self-stigma through the lens of the 3-circle model | Soothing rhythm breathing (SRB) Filling the self-stigma model and tricky brain loops associated |
5 | Compassionate engagement: thinking, imagery, and body postures can influence our physiology | • SRB • Introducing the mindfulness circle • Thoughts and imagination can impact our physiology: experiencing with attention, postures, tones of voice, SRB • Safe place imagery • Ideal compassionate other imagery | Safe place imagery |
6 | Compassionate engagement: the compassionate self | • Experiencing with the compassionate self (postures, tone of voice, feelings of warmth, actions) | Compassionate self-imagery |
7 | Compassionate courage: multiple selves | • Embodying the compassionate self to respond to the threat system thoughts and emotions | Compassionate self-imagery |
8 | Compassionate courage: how to respond to the self-stigmatizing self | • Exploration of self-stigma and self-critic: reasons to be and consequences • Using compassionate self to respond to self-stigma | Compassionate self-imagery |
9 | Compassionate courage: dealing with difficult emotions | • Understanding of shame and guilt • Responding to difficult emotions with compassion | Embodying compassionate self in everyday life |
10 | Compassionate courage: compassionate assertiveness | • Understanding the components of compassionate assertiveness compared to submissive and aggressive expression • Practicing compassionate assertiveness through role plays | Compassionately asking something we need |
11 | Compassionate courage: cultivating the compassionate self | • Writing a compassionate letter • Sharing of compassionate letters | Compassionate letter |
12 | Continuing my journey with compassion | • Reflection on the last 12 weeks • Building my personal compassionate tool bag • Plans for continuing practicing compassion • Gratefulness and compassion wish |
Session number | Session title | Session content | Home practice |
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1 | What is stigma regarding mental illness, where does it come from; what are its impacts? | Self-reflections regarding stigma. Myths and facts about mental illness | Identifying negative ideas and assumptions about mental illness |
2 | What is internalized stigma and what are its impacts? | Self-reflections regarding internalized stigma Common stereotypes and their connections to internalized stigma | Identifying negative ideas and assumptions about myself linked to my mental illness |
3 | “Automatic thoughts” as part of internalized stigma | The 3C’s strategy to ameliorate/challenge them, part 1: catch it | Catching automatic thoughts |
4 | Completing the 3C’s strategy | Part 2: check it and change it. The thoughts behaviors-feelings cycle and internalized stigma | The 3C practice: catch, check, change |
5 | Importance of and strategies for strengthening yourself | “Growing” the positive aspects of yourself that you may have put on the back burner due to mental illness and other challenges | Facets of myself Reclaiming and strengthening parts of my true self |
6 | Increasing belonging | Part 1: the importance of belonging and positive connections with others in staying strong, resisting internalized stigma, enhancing quality of life, and reducing alienation | Adding to belonging: identifying: activity, value, interest |
7 | Increasing belonging | Part 2: practical strategies for increasing belonging | Adding to belonging: next steps |
8 | Increasing belonging | Part 3: the importance of and strategies for optimizing relationships with family and close friends. Increasing the positive, reducing the negative, taking care of oneself to enjoy the former, and tolerate the latter | Increasing belonging with family and friends |
9 | Responding to stigma, disrespect, or discrimination from others | Part 1: in ways that do not lead to internalized stigma, revisiting the thoughts feelings-behaviors cycle | Managing discrimination related to mental illness |
10 | Responding to stigma, disrespect, or discrimination from others | Part 2: cognitive and behavioral strategies | Managing discrimination related to mental illness |
11 | Course recap | Summary of each session and its accompanying strategies | My tools and strategies |
12 | Next steps | Crafting an action plan for after the class. Course evaluation |
Passive control arm (TAU)
Criteria for discontinuing or modifying allocated interventions {11b}
Strategies to improve adherence to interventions {11c}
Relevant concomitant care permitted or prohibited during the trial {11d}
Provisions for post-trial care {30}
Outcomes {12}
Primary outcomes
Secondary outcomes
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• To evaluate the maintenance of effects on self-stigma in the three groups of treatment (CFT, psychoeducation, and TAU) at 6-month follow-up (V2) the Internalized Stigma of Mental Illness Scale (ISMI) [31] will be applied.
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The Internalized and Externalized Shame Scale (EIS) [53] will be used to measure shame. It consists of 9 items ranging from 1 (not at all) to 4 (a lot).
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The Phenomenological Body Shame Scale – Revised (PBSS-R) [54] will also be used to measure body-related shame. Each of the 8 items is scored on a scale ranging from 1 (not at all) to 5 (extremely).
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The Self-Compassion Scale (SCS) [55] will be applied to measure self-compassion. The 26 items are scored on a scale ranging from 1 (almost never) to 5 (almost always).
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The Difficulties in Emotional Regulation Scale – 16 items version (DERS-16) [56] will be used to measure emotional regulation competencies. Each item is scored on a scale ranging from 1 (almost never) to 5 (almost always).
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The automatic avoidance tendencies toward mental disorders (VAAST) [57, 58] assesses the participants’ automatic avoidance tendencies toward mental disorders. The VAAST simulates the approach and avoidance movements of the whole self by manipulating the visual information provided to the participants. A stimulus first appears in the center of the screen in a simulated street background. Participants have to press the “move toward” or the “move away” key as a function of the stimulus category and the instructions. This complementary measure allows to circumvent some biases (such as social pressures) in the responses to the self-report scales.
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• The Brief Psychiatric Rating Scale (BPRS) [59, 60] will be used to assess psychiatric symptoms. The BPRS is a rating scale which a clinician or researcher may use to measure psychiatric symptoms such as depression, anxiety, hallucinations, psychosis, and unusual behavior. The rater enters a number for each of the 24 symptom constructs that ranges from 1 (not present) to 7 (extremely severe).
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• The Social Functioning Questionnaire (SFQ) [63] will be used to measure social functioning. It consists of 16 items divided into two subscales: (1) the frequency of occurrence for different activities/events and (2) the participants’ satisfaction regarding said activities/events. Items of subscale 1 are rated from 0 (never) to 1 (everyday), and items of subscale 2 are rated from 0 (very unsatisfied) to 4 (very satisfied).
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• The Barriers to Accessing Care (BACES-EN-VI) [64] will be applied to assess participants’ access to care. Only the subscale concerning barriers to accessing care related to the stigma of mental illness will be used. The 12 items of the subscale are scored using a scale ranging from 0 (not at all) to 3 (a lot).
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• The Functional Remission of General Schizophrenia Scale (the mini-FROGS) [67] will assess functional remission. The clinician-researcher will rate the 4 items, using a scale ranging from 1 (does not do it) to 5 (does it perfectly).
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• The Credibility and Expectations Questionnaire [68, 69] will be applied to assess self-reported treatment credibility at V0. This questionnaire contains 6 items rated either from 1 to 9 or from 0 to 100% and evaluates whether the participants “think” or “feel” that their treatment will be efficient.
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• The Group Questionnaire [70] will be used to measure group cohesion 3 times during the intervention (sessions 1, 6, and 12). It consists of 30 items addressing the group leaders, the other group members, and the group in general. Each item is scored using a scale ranging from 1 (not true at all) to 7 (very true).
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• The Consumer Satisfaction Questionnaire for Psychotherapeutic Services (CSQ-8) [71] will be applied as a self-report measure assessing participants’ satisfaction at the end of the 12-week program. The 8 items are scored on a scale ranging from 1 to 4. Higher scores are indicative of elevated satisfaction.
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• The attendance rate will be determined by the number of group sessions attended by the patient, and the drop-out rate will be determined by the number of patients lost to follow-up in each arm. In addition to the Consumer Satisfaction Questionnaire for Psychotherapeutic Services questionnaire (CSQ 8) [71], the avoidance of participants (due to self-stigma) in several social situations during the last 6 months, and the satisfaction with the interventions will be assessed via semi-structured interviews conducted at V2 by clinician-researchers blind to the status of patients (in the Strasbourg center only, for the 3 groups—CFT, ESS, and TAU).
Participant timeline {13}
Information briefing (> D7 before V0)
Inclusion visit (V0)
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• ISMI self-questionnaire score ≥ 2
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• IQ > 70
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• CGI-Severity score < 6
Randomization
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Experimental arm: 12 week-treatment of compassion-focused therapy (CFT) (i.e., psychoeducation on the model, experiential in-session exercises, and in-between session compassion practices, video-guided practices). Sessions cover several topics: psychoeducation on compassion from an evolutionary and neuroscientific perspective, emotion regulation skills (especially shame), and compassion practices.
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Active control arm: 12 week-treatment of the psychoeducation program Ending Self-Stigma (ESS) [29]. Sessions cover topics such as modifying self-stigmatizing thoughts and homework.
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Passive control arm: patients follow their usual care, i.e., TAU (e.g., psychiatric, psychological, day hospital), which will be unchanged during the 12-week period. Following their 10-month participation in the study, they will be given access to the written material used for the ESS.