Hostname: page-component-848d4c4894-ttngx Total loading time: 0 Render date: 2024-05-19T10:19:01.231Z Has data issue: false hasContentIssue false
  • English
  • Français

An Integrative Cognitive Model of Internalized Stigma in Psychosis

Published online by Cambridge University Press:  10 May 2017

Lisa Wood ,
Rory Byrne  and
Anthony P Morrison
Lisa Wood*
Affiliation:
North East London Foundation Trust, Goodmayes Hospital, Barley Lane, Ilford IG3 8XJ and Division of Psychology and Mental Health, University of Manchester, School of Health Sciences, Zochonis Building, ManchesterM13 9PL
Rory Byrne
Affiliation:
Psychosis Research Unit, Greater Manchester West NHS Foundation Trust, Rico House, Prestwich, ManchesterM25 9WL
Anthony P Morrison
Affiliation:
Division of Psychology and Mental Health, University of Manchester, School of Health Sciences, Zochonis Building, Manchester M13 9PL and Psychosis Research Unit, Greater Manchester West NHS Foundation Trust, Rico House, Prestwich, ManchesterM25 9WL
*
*Correspondence to Lisa Wood, North East London Foundation Trust, Goodmayes Hospital, Barley Lane, IlfordIG3 8XJ. E-mail: lisawood3@nhs.net
Get access Rights & Permissions [Opens in a new window]

Abstract

Background: Internalized stigma is a significant difficulty for those who experience psychosis, but it has never been conceptualized using cognitive theory. Aims: The aim of this paper is to outline a cognitive model conceptualizing internalized stigma experienced by people who also experience psychosis. Method: Previous literature is reviewed, critiqued and synthesized to develop the model. It draws upon previous social cognitive models of internalized stigma and integrates cognitive behavioural theory and social mentality theory. Results: This paper identifies key cognitive, behavioural and emotional processes that contribute to the development and maintenance of internalized stigma, whilst also recognizing the central importance of cultural context in creating negative stereotypes of psychosis. Moreover, therapeutic strategies to alleviate internalized stigma are identified. A case example is explored and a formulation and brief intervention plan was developed in order to illustrate the model in practice. Conclusion: An integrative cognitive model is presented, which can be used to develop individualized case formulations, which can guide cognitive behavioural interventions targeting internalized stigma in those who experience psychosis. More research is required to examine the efficacy of such interventions. In addition, it is imperative to continue to research interventions that create change in stigma at a societal level.

Keywords

Cognitivepsychosisinternalized stigmasocial mentality theory
Type
Research Article
Information
Behavioural and Cognitive Psychotherapy , Volume 45 , Issue 6 , November 2017 , pp. 545 - 560
Copyright
Copyright © British Association for Behavioural and Cognitive Psychotherapies 2017 

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Allot, P., Loganathan, L. and Fulford, K. W. M. (2002). Discovering hope for recovery. Canadian Journal of Community Mental Health, 21, 1–22.Google Scholar
Andreasen, R., Oades, L. and Caputi, P. (2003). The experience of recovery from schizophrenia: towards an empirically validated stage model. Australian and New Zealand Journal of Psychiatry, 37, 584–594.Google Scholar
Angermeyer, M. C., Holzinger, A., Carta, M. G. and Schomerus, G. (2011). Biogenetic explanations and public acceptance of mental illness: systematic review of population studies. British Journal of Psychiatry, 199, 367–372.CrossRefGoogle ScholarPubMed
Beck, A. (1979). Cognitive Therapy of Depression. New York: Guilford Press.Google Scholar
Birchwood, M., Trower, P., Brunet, K., Gilbert, P., Iqbal, Z. and Jackson, C. (2007). Social anxiety and the shame of psychosis: a study in first episode psychosis. Behaviour Research and Therapy, 45, 1025–1037.Google Scholar
Braehler, C., Gumley, A., Harper, J., Wallance, S., Norrie, J. and Gilbert, P. (2013). Exploring change processes in compassion focused therapy in psychosis: results of a feasibility randomized controlled trial. British Journal of Clinical Psychology, 52, 199–214.Google Scholar
Brohan, E., Elgie, R., Sartorius, N. and Thornicroft, G. (2010a). Self-stigma, empowerment and perceived discrimination among people with schizophrenia in 14 European countries: the GAMIAN-Europe study. Schizophrenia Research, 122, 232–238.Google Scholar
Brohan, E., Slade, M., Clement, S. and Thornicroft, G. (2010b). Experiences of mental illness stigma, prejudice and discrimination: a review of measures. BMC Health Services Research, 10, 80.Google Scholar
Chronister, J., Chou, C. and Lao, H. (2013). The role of stigma coping and social support in mediating the effect of societal stigma on internalized stigma, mental health recovery, and quality of life among people with serious mental illness. Journal of Community Psychology, 41, 582–600.Google Scholar
Clark, D. M. (1986). A cognitive approach to panic. Behaviour Research and Therapy, 24, 461–470.Google Scholar
Clark, D. M. (2001). A cognitive perspective on social phobia. In Crozier, R. and Alden, L. E. (eds), International Handbook of Social Anxiety: Concepts, Research and Interventions Relating to the Self and Shyness. London: John WIley and Sons Ltd.Google Scholar
Clark, D. M. and Wells, A. (1995). A cognitive model of social phobia. In Liebowitz, M., Hope, D. A. and Schneier, F. R. (eds), Social Phobia: Diagnosis, Assessment and Treatment. New York: Guilford Press.Google Scholar
Corrigan, P. W., Kosyluk, K. A. and Rusch, N. (2013). Reducing self-stigma by coming out proud. American Journal of Public Health, 103, 794–800.Google Scholar
Corrigan, P. W. and Watson, A. C. (2002). The paradox of self-stigma and mental illness. Clinical Psychology: Science and Practice, 9, 35–53.Google Scholar
Corrigan, P. W., Watson, A. C. and Barr, L. (2006). The self-stigma of mental illness: implications for self-esteem and self-efficacy. Journal of Social and Clinical Psychology, 25, 875–884.Google Scholar
Corstens, D., Longden, E., McCarthy-Jones, S., Waddingham, R. and Thomas, R. (2014). Emerging perspectives from the Hearing Voices Movement: implications for research and practice. Schizophrenia Bulletin, 40, 285–294.Google Scholar
Crisp, A. H., Gelder, M. G., Goddard, E. and Meltzer, H. (2005). Stigmatizaiton of people with mental illnesses: a follow-up study within the Changing Minds Campaign of the Royal College of Psychiatrists. World Psychiatry, 4, 106–113.Google ScholarPubMed
Crocker, J., Major, B. and Steele, C. (1998). Social stigma. In Gilbert, D. T. and Fiske, S. T. (eds), The Handbook of Social Psychology. Boston, MA: McGraw-Hill.Google Scholar
Dellar, R., Curtis, T. and Leslie, E. (2003). Mad Pride: A Celebration of Mad Culture. UK: Chipmunkapublishing.Google Scholar
Dinos, S., Stevens, S., Serfaty, M., Weich, S. and King, M. (2004). Stigma: the feelings and experiences of 46 people with mental illness. British Journal of Psychiatry, 184, 176–181.Google Scholar
Drapalski, A. L., Lucksted, A., Perrin, P. B., Aakre, J. M., Brown, C. H., DeForge, B. R. and Boyd, J. E. (2013). A model of internalized stigma and its effects on people with mental illness. Psychiatric Services, 64, 264–269.Google Scholar
Fowler, D., Freeman, D., Smith, B., Kuipers, E., Bebbington, P., Bashforth, H. et al. (2006). The Brief Core Schema Scale (BCSS): psychometric properties and associations with paranoia and grandiosity in non-clinical and psychosis samples. Psychological Medicine, 36, 749–759.Google Scholar
Franz, L., Carter, T., Leiner, A. S., Bargner, E., Thompson, N. J. and Compton, M. T. (2010). Stigma and treatment delay in first-episode psychosis: a grounded theory study. Early Intervention in Psychiatry, 4, 47–56.Google Scholar
Freeman, D., Garety, P. and Kuipers, E. (2001). Persecutory delusions: developing the understanding of belief maintenance and emotional distress. Psychological Medicine, 31, 1293–1306.Google Scholar
Freeman, D., Garety, P. A., Kuipers, E., Fowler, D., Bebbington, P. E. and Dunn, G. (2007). Acting on persecutory delusions: the importance of safety seeking. Behaviour Research and Therapy, 45, 89–99.Google Scholar
Gerlinger, G., Hauser, M., De Hert, M., Lacluyse, K., Wampers, M. and Correll, C. U. (2013). Personal stigma in schizophrenia spectrum disorders: a systematic review of revalence rates, correlates, impact and interventions. World Psychiatry, 12, 155–164.Google Scholar
Gilbert, P. (2000). The relationship of shame, social anxiety and depression: the role of evaluation of social rank. Clinical Psychology and Psychotherapy, 7, 174–189.Google Scholar
Gilbert, P. (2010). Compassion Focused Therapy. Hove: Routledge.Google Scholar
Gilbert, P. and Allan, S. (1998). The role of defeat and entrapment (arrested fight) in depression: an exploration of an evolutionary view. Psychological Medicine, 28, 584–597.Google Scholar
Gilbert, P. and Procter, S. (2006). Compassionate mind training for people with high shame and self-criticism: overview and pilot study of a group therapy approach. Clinical Psychology and Psychotherapy, 13, 353–379.CrossRefGoogle Scholar
Green, G. (2009). The End of Stigma? Changes in the Social Experience of Long-Term Illness. London: Routledge.Google Scholar
Gumley, A., Braehler, C., Laithwaite, H. M., MacBeth, A. and Gilbert, P. (2010). A compassion focused model of recovery after psychosis. International Journal of Cognitive Therapy, 3, 186– 201.Google Scholar
Gumley, A. and Schwannauer, M. (2006). Staying Well after Psychosis. London: John Wiley and Sons.Google Scholar
Hasson-Ohayon, I., Ehrlich-Ben Or, S., Vahab, K., Amiaz, R., Weiser, M. and Roe, D. (2012). Insight into mental illness and self-stigma: the mediating role of shame proneness. Psychiatry Research, 30, 802–806.Google Scholar
Henderson, C. and Thornicroft, G. (2013). Evaluation of the Time to Change Programme in England 2008–2011. British Journal of Psychiatry, 202, 45–48.Google Scholar
Hinshaw, S. P. (2007). The Mark of Shame: Stigma of Mental Illness and an Agenda for Change. Oxford: Oxford Univeristy Press.Google Scholar
Iqbal, Z., Birchwood, M., Chadwick, P. and Trower, P. (2000). A cognitive approach to depression and suicidal thinking in psychosis. II: Testing the validity of a social ranking model. British Journal of Psychiatry, 177, 522–528.Google Scholar
Kleim, B., Vauth, R., Adam, G., Stieglitz, R., Hayward, P. and Corrigan, P. W. (2008). Perceived stigma predicts low self-efficacy and poor coping in schizophrenia. Journal of Mental Health, 17, 482–491.Google Scholar
Link, B. and Phelan, J. C. (2001). Conceptualizing stigma. Annual Review of Sociology, 27, 363–385.Google Scholar
Link, B. G. (1987). Understanding labelling effects in the area of mental disorders: an assessment of the effects of expectations of rejection. American Sociological Review, 52, 96–112.CrossRefGoogle Scholar
Link, B. G., Struening, E. L., Neese-Todd, S., Asmussen, S. and Phelan, J. C. (2001). Stigma as a barrier to recovery: the consequences of stigma for the self-esteem of people with mental illness. Psychiatric Services, 52, 1621–1626.Google Scholar
Link, B. G., Yang, L. H., Phelan, J. C. and Collins, P. Y. (2004). Measuring mental illness stigma. Schizophrenia Bulletin, 30, 511–541.Google Scholar
Livingston, J. D. and Boyd, J. E. (2010). Correlates and consequences of internalized stigma for people living with mental illness: a systematic review and meta-analysis. Social Science and Medicine, 71, 2150–2161.Google Scholar
Lysaker, P., Yanos, P., Outcalt, J. and Roe, D. (2010). Association of stigma, self-esteem, and symptoms with concurrent and prospective assessment of social anxiety in schizophrenia. Clinical Schizophrenia and Related Psychoses, 4, 41–48.Google Scholar
Lysaker, P. H., Davis, L. W., Warman, D. M., Strasburger, A. and Beattie, N. (2007a). Stigma, social function and symptoms in schizophrenia and schizoaffective disorder: associations across 6 months. Psychiatry Research, 149, 89–95.Google Scholar
Lysaker, P. H., Roe, D. and Yanos, P. T. (2007b). Toward understanding the insight paradox: Internalized stigma moderates the association between insight and social functioning, hope, and self-esteem among people with schizophrenia spectrum disorders. Schizophrenia Bulletin, 33, 192–199.Google Scholar
Major, B. and O'Brien, L. T. (2005). The social psychology of stigma. Annual Review of Psychology, 56, 393–421.Google Scholar
Markowitz, F. E. (1998). The effects of stigma on the psychological well-being and life satisfaction of persons with mental illness. Journal of Health and Social Behaviour, 39, 335–347.CrossRefGoogle ScholarPubMed
Michail, M. and Birchwood, M. (2009). Social anxiety disorder in first-episode psychosis: incidence, phenomenology and relationship with paranoia. British Journal of Psychiatry, 195, 234–241.CrossRefGoogle ScholarPubMed
Michail, M. and Birchwood, M. (2013). Social anxiety disorder and shame cognitions in psychosis. Psychological Medicine, 43, 133–142.Google Scholar
Morrison, A., Burke, E., Murphy, E., Pyle, M., Bowe, S., Varese, F. et al. (2016). Cognitive Therapy for Internalised Stigma in People Experiencing Psychosis: a pilot randomised controlled trial. Psychiatry Research, 240, 96–102.Google Scholar
Morrison, A. P. (2001). The interpretation of intrusions in psychosis: An integrative cognitive approach to hallucinations and delusions. Behavioural and Cognitive Psychotherapy, 29, 257–276.Google Scholar
Morrison, A. P., Frame, L. and Larkin, W. (2003). Relationships between trauma and psychosis: a review and integration. British Journal of Clinical Psychology, 42, 331–351.Google Scholar
Pitt, L., Kilbride, M., Nothard, S., Welford, M. and Morrison, A. P. (2007). Researching recovery from psychosis: a user-led project. Psychiatry Bulletin, 31, 55–60.CrossRefGoogle Scholar
Pitt, L., Kilbride, M., Welford, M., Nothard, S. and Morrison, A. P. (2009). Impact of a diagnosis of psychosis: user-led qualitative study. Psychiatric Bulletin, 33, 419–423.Google Scholar
Pyle, M. and Morrison, A. (2013). ‘It's just a very taboo and secretive kind of thing’: making sense of living with stigma and discrimination from accounts of people with psychosis. Psychosis: Psychological, Social and Integrative Approaches. doi: 10.1080/17522439.2013.834458 Google Scholar
Quinn, D., Williams, M. K. and Weisz, B. (2015). From discrimination to internalizes mental illness stigma: the mediating roles of anticipated discrimination and anticipated stigma. Psychaitric Rehabilitation Journal, 38, 103–108.Google Scholar
Read, J. and Harre, N. (2001). The role of biological and genetic causal beliefs in the stigmatisation of ‘mental patients’. Journal of Mental Health, 10, 223–235.Google Scholar
Repper, J. (2013). Peer Support Workers: Theory and Practice. London: Centre for Mental Health.Google Scholar
Ritsher, J. B., Otilingam, P. G. and Grajales, M. (2003). Internalized stigma of mental illness: psychometric properties of a new measure. Psychiatry Research, 121, 31–49.Google Scholar
Rüsch, N., Angermeyer, M. C. and Corrigan, P. W. (2005). Mental illness stigma: concepts, consequences, and initiative to reduce stigma. European Psychiatry, 20, 529–539.Google Scholar
Rüsch, N., Corrigan, P. W., Wassel, A., Michaels, P., Olschewski, M., Wilkniss, S. and Batia, K. (2009). A stress-coping model of mental illness stigma: I. Predictors of cognitive stress appraisal. Schizophrenia Research, 110, 59–64.Google Scholar
Rüsch, N., Lieb, K., Bohus, M. and Corrigan, P. W. (2006). Self-stigma, empowerment, and perceived legitimacy of discrimination among women with mental illness. Psychiatric Services, 57, 399–402.CrossRefGoogle ScholarPubMed
Rüsch, N., Todd, A. R., Bodenhausen, G. V., Olschewski, M. and Corrigan, P. W. (2010). Automatically activated shame reactions and perceived legitimacy of discrimination: a longitudinal study among people with mental illness. Journal of Behavior Therapy and Experimental Psychiatry, 41, 60–63.Google Scholar
Russinova, Z., Rogers, E. S., Gagne, C., Bloch, P., Drake, K. M. and Mueser, K. T. (2014). A randomized controlled trial of a peer-run antistigma photovoice intervention. Psychiatric Services, 65, 242–246.Google Scholar
Salkovskis, P. M., Clark, D. M., Hackmann, A., Wells, A. and Gelder, M. (1999). An experimental investigation of the role of safety-seeking behaviours in the maintenance of panic disorder with agoraphobia. Behaviour Research and Therapy, 37, 559–574.Google Scholar
Schrank, B., Amering, M., Hay, A. G., Weber, M. and 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, 271–279.Google Scholar
Scrambler, G. and Hopkins, A. (1986). Being epileptic: coming to terms with stigma. Sociology of Health and Illness, 8, 26–43.Google Scholar
Shahar, G., Trower, P., Iqbal, Z., Birchwood, M., Davidson, L. and Chadwick, P. (2004). The person in recovery in acute and severe psychosis: the role of dependency, self-criticism, and efficacy. American Journal of Orthopsychiatry, 74, 480–488.Google Scholar
Shelvin, M., Houston, J. E., Dorahy, M. J. and Adamson, G. (2008). Cumulative traumas and psychosis: an analysis of the National Comorbidity Survey and the British Psychiatric Morbidity Survey. Schizophrenia Bulletin, 34, 193–199.Google Scholar
Smith, B., Fowler, D., Freeman, D., Bebbington, P., Bashforth, H., Garety, P. et al. (2006). Emotion and psychosis: links between depression, self-esteem, negative schematic beliefs and delusions and hallucinations. Schizophrenia Research, 86, 181–188.Google Scholar
Taylor Nelson Sofres British Market Research Bureau (2014). Attitudes to Mental Illness 2013 Research Report. London: TNS.Google Scholar
Tully, S., Wells, A. and Morrison, A. (under review). An exploration of the relationship between use of safety seeking behaviours and psychosis: a systematic review and meta-analysis.Google Scholar
Uchino, T., Maeda, M. and Uchimura, N. (2012). Psychoeducation may reduce self-stigma of people with schizophrenia and schizoaffective disorder. The Kurume Medical Journal, 59, 25–31.Google Scholar
Varese, F., Smeets, F., Drukker, M., Lieverse, R., Lataster, T., Viechtbauer, W. et al. (2012). Childhood adversities increase the risk of psychosis: a meta-analysis of patient-control, prospective- and cross-sectional cohort studies. Schizophrenia Bulletin, 11, 1–11.Google Scholar
Vass, V., Morrison, A., Law, H., Dudley, J., Taylor, P., Bennett, K. M. and Bentall, R. P. (2015). How stigma impacts on people with psychosis: the mediating effect of self-esteem and hopelessness on subjective recovery and psychotic experiences. Psychiatry Research. doi: 10.1016/j.psychres.2015.09.042 Google Scholar
Waite, F., Knight, M. T. and Lee, D. (2015). Self-compassion and self-criticism in recovery in psychosis: an interpretative phenomenological analysis study. Journal of Clinical Psychology, 71, 1201– 1217.Google Scholar
Watson, A. C., Corrigan, P. W., Larson, J. E. and Sells, M. (2007). Self-stigma in people with mental illness. Schizophrenia Bulletin, 33, 1312–1318.Google Scholar
Wells, A. (1995). Meta-cognition and worry: a cognitive model of generalised anxiety disorder. Behavioural and Cognitive Psychotherapy, 23, 301–320.Google Scholar
Wells, A. and Matthews, G. (1994). Attention and Emotion: A Clinical Perspective. Hillsdale, NJ: Laurence Erlbaum Associates.Google Scholar
Wood, L., Burke, E., Byrne, R. and Morrison, A. (2016a). Examining service user experiences of a cognitive therapy intervention for self-stigma in psychosis. Psychosis: Psychological, Social and Integrative Approaches, 8, 238–249.Google Scholar
Wood, L., Burke, E., Byrne, R., Pyle, M., Chapman, N. and Morrison, A. (2015). Stigma in psychosis: a thematic synthesis of current qualitative evidence. Psychosis: Psychological, Social and Integrative Approaches, 7, 152–165.Google Scholar
Wood, L., Byrne, R., Enache, G. and Morrison, A. (2016b). Acute inpatients experiences of stigma from psychosis: a qualitative exploration. Stigma and Health. doi: 10.1037/sah0000063 Google Scholar
Wood, L., Byrne, R., Varese, F. and Morrison, A. (2016c). Psychosocial interventions for internalised stigma in psychosis: a systematic narrative synthesis and meta-analysis. Schizophrenia Research, 176, 291–303.Google Scholar
Yanos, P., Roe, D. and Lysaker, P. (2010). The impact of illness identity on recovery from severe mental illness. American Journal of Psychiatric Rehabilitation, 13 (2), 73–93.Google Scholar
Yanos, P., Roe, D., Markus, K. and Lysaker, P. (2008). Pathways between internalized stigma and outcomes related to recovery in schizophrenia spectrum disorders. Psychiatris Services, 59, 1437–1442.Google Scholar
Submit a response

Comments

No Comments have been published for this article.