Abstract
Self-stigma in people with schizophrenia significantly predicts psychosocial treatment compliance in which those with higher level of self-stigma have poorer compliance to psychosocial interventions (Fung, Tsang, & Corrigan, 2008). Person with schizophrenia being self-stigmatized is self-discredited through internalizing negative stereotypes induced to him and/or his illness group (Corrigan, 1998; Corrigan & Watson, 2002; Fung, Tsang, Corrigan, Lam, & Cheung, 2007). Stereotype agreement (with the public perceived negative characteristics of people with schizophrenia such as being dangerous and violent), self-concurrence (believing those negative stereotypes induced to them) and self-esteem decrement (via further internalization of what they believe about those stereotypes) are the three tiers of the mechanism of the self-stigmatization process (Corrigan, Watson, & Barr, 2006). Those more severely self-stigmatized endorse their feeling of hopelessness (a negative stereotype) more and thus more tend to think that they cannot benefit much from any treatment and so is their adherence.
In macro level, measures to address public stigma about mental illness need to be incorporated into mental health policy (Jenkins, 2003). This stigma puts disadvantages to the social status of individuals with schizophrenia, which undermine their life opportunities (such as education, work or marriage), social contact and self-esteem, and eventually quality of life (Thara, Taj, & Tirupati, 2008). The resulting social exclusion is likely to viciously reinforce the public stigma. Campaigns to tackle public stigma can hence be regarded as one of the interventions to alleviate the stereotype agreement (the first of the three-tier mechanism of the self-stigmatization process) and thus improve treatment compliance. Nonetheless, the cost-effectiveness of these campaigns is a concern. On one hand, their large-scale nature necessitates high costs. On the other hand, a number of complex variations (such as the need of precise match of mass media tactics with target audiences) affect the outcomes of the programs (Li, Tsui, & Cheng, 2013). The effects may then not be promising.
While macro-level interventions in tackling public stigma (the root cause of self-stigma and hence poor treatment compliance) may not work well, micro-level interventions targeting on individuals with schizophrenia being self-stigmatized may be a way out. As those with higher level of self-stigma have poorer compliance to psychosocial interventions, reducing self-stigma may help to improve their treatment compliance. A self-stigma reduction program has been developed in Hong Kong, which is the first of its kind there and in the whole mainland China (Fung, 2011). Some strategies were adopted, including psychoeducation (using relevant facts to challenge self-stigma), cognitive behavioral therapy (disputing irrational ideas on self-concept and self-abilities, reconstructing and normalizing self-stigmatized beliefs, enhancing positive self-esteem), social skills training (polishing skills on assertiveness and social problem solving to tackle difficult stigmatizing situations), motivational interviewing (motivating the change of problematic behaviors and hence higher motives to start being engaged in treatment regimes) and Goal Attainment Program (motivating behavioral change via instilling hope and setting realistic life goal). Its preliminary effects were shown in a randomized controlled trial (Fung, Tsang, & Cheung, 2011) in which self-stigma of the participants was reduced and their readiness for alleviating problematic behaviors was enhanced. Further research should be conducted to investigate how much such effects contribute to improving the engagement and adherence to the treatment protocols (including psychosocial interventions and even psychopharmacology). Upon some adaptations (e.g. on cultural relevancy), this innovative self-stigma reduction program can be implemented in other regions. Review of the results of future studies evaluating the effects would add further evidence on the roles and priority of this self-stigma reduction intervention in promoting the compliance to other psychosocial interventions. It may guide the clinical decisions by, for instance, having self-stigma reduction program implemented prior to (or concurrently with) other interventions (such as vocational rehabilitation training) to enhance the cost-effectiveness.