2. Int. J. Environ. Res. Public Health 2023, 20, 5570 2 of 24
it corresponds with the categorization proposed by Livingston and Boyd. Internalized
stigma has great inhibitory effects on the intention of seeking help [6,7].
Schizophrenia is a renowned, serious mental illness that affects a large number of peo-
ple in society. According to the WHO in early 2022, schizophrenia affected approximately
24 million people, or 1 in 300 people (0.32%) worldwide [8]. Males and females are equally
affected; however, the peak ages of onset differ: males are affected between the ages of
10 and 25 years, while females are affected between the ages of 25 and 35 years [9]. Suicide
accounts for 4 to 10% of all deaths among those diagnosed with schizophrenia, predomi-
nantly affecting young males [10]. This could be due to a variety of factors, including the
reaction to the psychosis and the experience of stigma.
The World Health Organization has identified three main points regarding stigma
and mental illness: (1) stigma is the primary reason for discrimination against and rejec-
tion of people with mental illness; (2) stigma has negative effects on both the prevention
of mental health problems and the treatment and care of those who suffer from them;
and (3) stigma violates human rights [11]. According to several studies, people with
schizophrenia are more likely to experience and suffer from self-stigma than people with
other mental illnesses [12,13]. Forty-one percent of a sizable European sample of adults
with a schizophrenia-spectrum diagnosis reported high levels of internalized stigma, while
69 percent reported moderate or severe perceived discrimination [14]. A systematic review
conducted on persons with schizophrenia spectrum disorders found that approximately
65% of participants felt stigmatized, and 56% had experienced it [15]. Stigmatization of
those diagnosed with schizophrenia is widespread, and it may stem from skewed assump-
tions regarding their physical appearance and inconsistent acts that are associated with
altered thoughts, perceptions, and behaviors [16]. Individuals having schizophrenia may
experience exclusion by members of society and misconduct displayed against them re-
garding their emotions, thoughts, and behaviors [17]. Debilitating symptoms associated
with the condition are labelled as “madness” by society, which leads to stigmatization, dis-
crimination, and a decrease in productivity, all of which have a significant negative impact
on the patient’s emotional, social, and economic well-being [18]. The majority of people
diagnosed with schizophrenia reported having a low level of perceived social support, with
support from significant others ranking the lowest, followed by support from friends and
family [19]. Even when functional remission is reached, there is still a high unemployment
rate among people with schizophrenia [20]. Prior research demonstrated that people with
schizophrenia are disproportionately affected by internalized stigma [21,22]. The impaired
functioning that is common in schizophrenia presents significant difficulties for both the
affected person’s family and the surrounding society. Hence, among the vital goals of
treatment for people with schizophrenia is to enhance their capacity to function and become
self-sufficient through enhanced social adaptation [23,24].
Psychological interventions aiming to reduce the detrimental effects of internalized
stigma on individuals with schizophrenia spectrum disorders have garnered considerable
attention in recent years. The results of several systematic reviews and meta-analyses
published in the last few years on interventions to diminish internalized stigma are still
inconsistent [25–28]. This might be due to a lack of prior experimental trials that have
been conducted to establish the efficacy of a certain intervention. Consequently, it is
impossible to reliably verify the pooled effect sizes. In the early stages of an intervention,
the lack of research from various locations around the world may reduce our understanding
of its potential overall efficacy. At present, various psychological interventions have
been developed and tested to reduce internalized stigma in patients with schizophrenia
spectrum disorders, such as Group Psychoeducation [29–32] and Narrative Enhancement
and Cognitive Therapy (NECT) [33,34]. Such treatments are crucial because they can
target a wide variety of factors that relate to the psychological process of the production
of internalized stigma, which was mentioned previously. The outcomes of interventions
at different time intervals or in different regions varied greatly. This might be because of
numerous variables such as small sample sizes, variation in intervention implementation,
3. Int. J. Environ. Res. Public Health 2023, 20, 5570 3 of 24
and anecdotal definitions of stigma. Considering this discrepancy, further study on this
topic is still necessary to learn more about the therapies that have been developed so far,
and including newer studies may lead to a more definitive conclusion.
Aims
The aim of this study is to perform an updated systematic review and meta-analysis
of the evidence for the effectiveness of interventions for internalized stigma among adults
with schizophrenia spectrum disorders and to determine the efficacy of interventions on
internalized stigma reduction among adults with schizophrenia spectrum disorders.
2. Materials and Methods
The systematic review and meta-analysis have been carried out in compliance with
the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guide-
line [35,36]. It was registered in the International Prospective Register of Systematic Reviews
(PROSPERO) on 26 August 2021, with registration number CRD42018106359 [37].
2.1. Search Strategy
The search was conducted across four electronic databases: EMBASE, MEDLINE,
PsycINFO, and the Cochrane Central Register of Controlled Trials. Materials that ex-
isted from inception until 8 September 2022 were obtained from the selected electronic
databases by using their own designed search strategy made from phrases with accept-
able truncation (indicated with asterisks) and Boolean operators of AND and OR. The
related search terms were “adults”, “Not adolescents, elderly”, “schizophrenia”, “psy-
chosis”, “delusional”, “schizoaffective”, “mental illness”, “mental disorder”, “perceive
stigma*”, “perceived stigma*”, “selfstigma”, “self stigma”, “internalized stigma”, “inter-
nalised stigma”, “shame”, “stigma intervention*”, “stigma reduction”, “antistigma”, “anti-
stigma”, “destigmatisation”, “destigmatization”, “educat*”, “attitude change”, “NECT”,
“CBT”, “photovoice”, “coming out proud”, “self disclosure”, “psychoeducat*”, “depres-
sion literacy”, “pamphlet*”, “brochure*”, “booklet”, “contact-base*”, “video-base contact”,
“video-based contact”. The search method was restricted to English-language publications
and research involving human participants. No geographical limitations were imposed. A
bibliographic search from relevant systematic reviews and acceptable studies was carried
out at the start of the research to maximize the likelihood of finding relevant studies.
2.2. Eligibility Criteria
Studies included in the review met the following criteria: (1) used a randomized
controlled trial or similar type study design (pseudorandomized controlled trial and non-
randomized experimental trial); (2) includes individuals ranging in age from 18 to 65 years
old; (3) evaluated interventions for reducing internalized stigma; (4) quantitatively assessed
the reduction in internalized stigma; and (5) published full papers in the English language.
The exclusion criteria were (1) non-English language papers, (2) case reports, reviews,
unpublished research, conference abstracts, trial protocols, and proceedings, and (3) studies
that did not include people from the diagnoses of schizophrenia spectrum and other
psychotic disorders.
2.3. Selection Process
All of the collected search results were subsequently transferred to reference manage-
ment software [Covidence systematic review software, Veritas Health Innovation, Mel-
bourne, Australia. www.covidence.org (accessed on 8 August 2022)]. This program will
automatically sort out any duplicate studies upon import, making it much simpler for
two independent reviewers to examine the titles and abstracts of the research. Thereafter,
the eligibility of the entire texts was meticulously examined based on the inclusion and
exclusion criteria that had been established previously. When there were discrepancies
4. Int. J. Environ. Res. Public Health 2023, 20, 5570 4 of 24
between the two reviewers (SJ and other members of the team), a third reviewer or the
group’s consensus was used to reach a decision.
2.4. Methodological Quality
The McMaster Critical Appraisal Tool for Quantitative Studies was utilized in order
to conduct an evaluation on the level of quality present in each of the studies that were
included [38]. It consists of 15 questions that evaluate the subject areas of research purpose,
literature, design, samples, outcomes, interventions, results, conclusions, and therapeutic
implications. Each question was given a grade of “Yes”, “No”, or “Not Addressed”, and
a score of one point was awarded for “Yes” responses. A maximum score of 15 is possi-
ble. The Australian National Health and Medical Research Council (NHMRC) evidence
hierarchy was utilized to ascertain the level of evidence possessed by each study that was in-
corporated into the review [39]. The five aspects that were evaluated were (i) evidence base;
(ii) consistency of findings across included studies; (iii) clinical impact; (iv) generalizability;
and (v) applicability. In order to assist in providing direction for the overall weighting of
the suggestion, each component was assigned a grade ranging from “A” to “D”.
2.5. Data Extraction and Management
The data extraction was carried out by two independent reviewers (SJ and TI) using
spreadsheets created in Microsoft Excel (Microsoft Corporation, Redmond, WA, USA).
The descriptive data that were extracted from the included studies include the following:
country of origin; study setting; sample size and characteristics (diagnoses, gender, age
group); exposure, comparator, and characteristics of interventions (type, frequency, dura-
tion); outcome measures and its relevant results. If further information was required, the
respective authors were contacted. Any discrepancies that were found in the data that was
extracted were resolved by a third reviewer (SS).
2.6. Statistical Analysis
A meta-analysis was carried out in order to compare the interventions that have
been utilized with the purpose of lowering levels of internalized stigma. The RevMan
software program (Review Manager (RevMan). Version 5.4, The Cochrane Collaboration,
2020) was used to analyze the data. For continuous outcomes measured on a variety of
scales, the pooled effect was computed as a standardized mean difference (SMD). The
confidence intervals (CI) were set at 95%. The I2 index statistic was utilized in order to
provide an expression of the heterogeneity that existed among the studies. A value of
0% for the I2 index showed that there was no observable heterogeneity; a value of 25%
indicated low heterogeneity, 50% indicated moderate heterogeneity, and 75% indicated
high heterogeneity [40]. Because of the diversity of the studies that were incorporated into
the analysis, a random-effect model was used so that any potential heterogeneity could be
accounted for. A p-value of ≤0.05 was used to indicate statistical significance. Moreover,
publication bias was investigated using a funnel plot.
3. Results
3.1. Systematic Review
3.1.1. Study Selection
Searches conducted using online databases yielded a total of 681 studies, of which
21 were duplicates. There was a total of 276 studies retrieved from EMBASE, 79 studies
from MEDLINE, 105 studies from PsycINFO, 105 studies from the Cochrane Library,
and 116 studies sourced from additional records discovered through the reference list.
Following the removal of studies that were found to be duplicates and a screening of the
titles and abstracts, a total of 638 studies were excluded. A total of 43 studies with full-text
manuscripts were evaluated for eligibility. The overall selection process is illustrated in
Figure 1. Finally, a total of 27 studies were included in the systematic review.
5. Int. J. Environ. Res. Public Health 2023, 20, 5570 5 of 24
were duplicates. There was a total of 276 studies retrieved from EMBASE, 79 studies from
MEDLINE, 105 studies from PsycINFO, 105 studies from the Cochrane Library, and 116
studies sourced from additional records discovered through the reference list. Following
the removal of studies that were found to be duplicates and a screening of the titles and
abstracts, a total of 638 studies were excluded. A total of 43 studies with full-text manu-
scripts were evaluated for eligibility. The overall selection process is illustrated in Figure
1. Finally, a total of 27 studies were included in the systematic review.
Figure 1. Flowchart based on the PRISMA 2020 statement [36] that describes the movement of in-
formation through the various stages of conducting this systematic review.
3.1.2. Quality Assessment
The level of evidence provided by the included studies was evaluated with the use
of the NHMRC evidence hierarchy. Eighteen studies were rated level II (a randomized
controlled trial) [29,30,32–34,41–53], while three were III-1 (a pseudorandomized con-
trolled trial) [41–43]; and six were III-2 (a comparative study with concurrent controls—
non-randomized, experimental trial) [31,44–48]. The McMaster Critical Appraisal Tool for
Quantitative Studies was used to evaluate the risk of bias, and the results were expressed
in percentage based on the number of criteria that were met (refer to Table S1 of Supple-
mentary Materials). Nine studies were rated >90% [32,33,41,49–54], sixteen studies were
rated 80–90% [30,31,34,47–52,55–61], while two studies were rated 50–60% [29,55]. The
manner in which randomization was conducted was described in each of the included
RCTs. All of the studies also stated their findings in terms of statistical significance, and
the analysis methods were appropriate. Avoidance of contamination (item 9) and avoid-
ance of cointervention (item 10) were not reported in most of the included studies.
3.1.3. Study Characteristics
Records identified from
Databases and Registers
(n = 565)
• EMBASE (n =276)
• MEDLINE (n =79)
• PsycINFO (n =105)
• Cochrane (n =105)
Records removed before
screening:
• Duplicate records removed
(n = 8)
Title and Abstract screened
(n = 557)
Records excluded
(n = 510)
Reports sought for retrieval
(n = 47)
Reports not retrieved (n = 22)
• Wrong study design (n = 3)
• not schizophrenia spectrum
disorders (n = 19)
Reports assessed for eligibility
(n = 25)
Reports excluded (n = 4)
• Repeating study (n = 1)
• Wrong study design (n = 2)
• Full text not in English (n = 1)
Records identified from other
sources:
• Citation searching (n = 116)
Reports assessed for eligibility
(n = 18)
Studies included in review
TOTAL (n = 27)
Identification of studies via databases and registers Identification of studies via other methods
Identification
Screening
Included
Reports sought for retrieval
(n = 40)
Records excluded based on Title
and Abstract screened
(n = 63)
Records removed before
screening:
• Duplicate records removed
(n = 13)
Reports not retrieved (n = 22)
• non RCT/similar type (n = 9)
• not schizophrenia spectrum
disorders (n = 13)
Reports excluded (n = 12)
• Wrong study design (n = 5)
• Full text not in English (n = 7)
Figure 1. Flowchart based on the PRISMA 2020 statement [36] that describes the movement of
information through the various stages of conducting this systematic review.
3.1.2. Quality Assessment
The level of evidence provided by the included studies was evaluated with the use
of the NHMRC evidence hierarchy. Eighteen studies were rated level II (a randomized
controlled trial) [29,30,32–34,41–53], while three were III-1 (a pseudorandomized controlled
trial) [41–43]; and six were III-2 (a comparative study with concurrent controls—non-
randomized, experimental trial) [31,44–48]. The McMaster Critical Appraisal Tool for
Quantitative Studies was used to evaluate the risk of bias, and the results were expressed in
percentage based on the number of criteria that were met (refer to Table S1 of Supplementary
Materials). Nine studies were rated >90% [32,33,41,49–54], sixteen studies were rated
80–90% [30,31,34,47–52,55–61], while two studies were rated 50–60% [29,55]. The manner
in which randomization was conducted was described in each of the included RCTs.
All of the studies also stated their findings in terms of statistical significance, and the
analysis methods were appropriate. Avoidance of contamination (item 9) and avoidance of
cointervention (item 10) were not reported in most of the included studies.
3.1.3. Study Characteristics
Study characteristics are summarized in Table 1. Studies from fifteen different coun-
tries, including the United States of America, Canada, China, Vietnam, Japan, Taiwan,
Turkey, Jordan, Israel, England, Sweden, Croatia, Finland, Spain, and Germany, were
included in this review. Twenty-two studies (81.5%) were published in the last 10 years
(2013–2022), with nine of those studies published since the year 2020. This review included
a total of 2975 participants, the majority of whom fell into the age range of 30 to 50 years
old; the number of male participants was slightly higher compared to female participants,
as well as the vast majority of the participants possessed at least secondary education.
6. Int. J. Environ. Res. Public Health 2023, 20, 5570 6 of 24
Table 1. Study characteristics [29,30,32–34,41–62].
Study Country
Study
Design
Setting Diagnosis Sample Size Intervention
Intervention
N
Type Frequency Duration Control
Control
N
Type Frequency Duration
Outcome
Measures
Main Result
Significance and Test
Used
Shin S. &
Lukens E.P.
2002 [29]
USA RCT outpatient Schizophrenia 48
Group
Psychoedu-
cation
24 group
total 10
sessions
(90
min/session)
10 weeks
Supportive
Sessions
24 individual
total 10
sessions
(45
min/session)
10 weeks
• SDS
• BPRS
• FCOPES
EG > CG
SoS = 2049.35; F = 376.10;
df = 1,45; p < 0.001
ANCOVA
Aho-
Mustonen
K. et al. 2011
[30]
Finland RCT inpatient
Schizophrenia,
Schizoaffective
39
Group
Psychoedu-
cation
19 group
total 8
sessions
(45–60
min/session)
8 weeks TAU 20 NA NA NA
•PSQ
• KASQ
• SUMD
• CRS
• DAI-10
• BPRS
• NOSIE-30
• BDI-II
• RSE
• 15D
CG > EG
p = 0.08
Cohen’s d = −0.59
Student’s t-tests
Fung K.M.T
2011 [57]
China RCT outpatient Schizophrenia 66
Self-Stigma
Reduction
Programme
34
group +
individual
total
12group +
4 individual
(2 group ses-
sions/week)
NA
Newspaper
reading
32
group +
individual
total
12group +
4 individual
(2 group
sessions per
week)
NA
• CSSMIS
• PTCS
• BPRS
• GAF
•
CAQ-SPMI
• SUMD
• CGSS
EG > CG
F = 2.204; p = 0.096
Effect size = 0.096
Repeated measures
ANOVA/ANCOVA with
Bonferroni correction
Uchino T.
et al. 2012
[58]
Japan NRCT outpatient
Schizophrenia,
Schizoaffective
56
Group
Psychoedu-
cation
29 group
total 6
sessions
(1 ses-
sion/week)
6 weeks TAU 27 NA NA NA
• SDS-J
• KIDI
• DAI-10
• BPIS
• GAF
EG > CG
p < 0.01
Mann-Whitney U-test
Yanos P.T.
et al. 2012
[33]
USA RCT outpatient
Schizophrenia,
Schizoaffective,
BMD, MDD
35 NECT 15 group
(1 h/session
1 ses-
sion/week)
20 weeks TAU 20 NA NA NA
• ISMI
• BHS
• RSES
• CSC
• QLS
• PANSS
• SUMD
EG = CG
F = 1.06; p = 0.312
Cohen’s d = 0.37
ANOVA
Silverman
M.J. et al.
2013 [42]
USA pseudo-RCT inpatient
MDD, BMD,
Schizophrenia,
Psychosis, Anxiety,
PTSD
78
Music
therapy
(Mental
Illness
Stigma
Educational
Group
Songwriting
Session)
29 group
total 24
sessions
(45
min/session
×1/week)
6 months
Group
No-Music
Educational
Mental
Illness
Stigma
Talk-based
Session
(Active
Control
Group)
Wait-list
Control
Group
(rock and
roll bingo)
17
32
group
group
total 8
sessions
(45
min/session)
total 8
sessions
(45
min/session)
6 months
6 months
• SS
EG > WLCG
EG = ACG
(df)F = (2,75)5.09;
p = 0.008
ηp2 = 0.120
F test, Bonferroni
inequality
Roe D. et al.
2014 [48]
Israel NRCT NA SMI 119 NECT 63 group
total 20
sessions
(1 h/session
×1/week)
6 months TAU 56 NA NA NA
• ISMI
• MANSA
• ADHS
• RSE
EG > CG
F = 7.81; p = 0.006
ηp2 = 0.06
ANOVA
Russinova
Z. et al. 2014
[52]
USA RCT NA
Schizophrenia
spectrum disorder,
BMD, MDD,
Others
82
Antistigma
Photovoice
Program
40 group
total 10
sessions
(90
min/session)
10 weeks Waiting List 42 NA NA NA
•ISMI
•ACS
•ES
•GPSES
•PGRS
•CES-D
EG > CG
p = 0.03
Cohen’s d = 0.55
mixed-effects linear
regression
7. Int. J. Environ. Res. Public Health 2023, 20, 5570 7 of 24
Table 1. Cont.
Study Country
Study
Design
Setting Diagnosis Sample Size Intervention
Intervention
N
Type Frequency Duration Control
Control
N
Type Frequency Duration
Outcome
Measures
Main Result
Significance and
Test Used
Morrison
A.P. et al.
2016 [59]
England RCT outpatient
Schizophrenia
spectrum disorder,
Schizoaffective
disorder, BMD
with psychotic
features, FEP, EIS
27
Cognitive
Therapy
14 individual
total 12
sessions
(1 h/session)
over a 4
month
period
TAU 13 NA NA NA
• ISMI-R
• SIMS
• SS
• QPR
• BDI-7
• BHS
• SIAS
• SERS-S
• ISS
EG = CG
F = 0.052; p = 0.822
Cohen’s d = 0.09
ANCOVA
Ngoc T.N.
et al. 2016
[55]
Vietnam RCT inpatient Schizophrenia 49
Family
Schizophre-
nia
Psychoedu-
cation
Program
(FSPP)
26 individual
total 3
sessions
(1.5
h/session)
1.5 week TAU 23 NA NA NA
• STS
• QLESQ
• MCI
• CS
EG > CG
F(1,45) = 6.67; p <
0.05
R2 = 0.13
ANCOVA
Hansson L.
et al. 2017
[34]
Sweden RCT mixed SMI 87 NECT 41 group
total 20
session
(1 h/session)
NA Waiting List 46 NA NA NA
• SSMIS-SF
• RSES
• MANSA
EG > CG
95% CI = 0.04–0.89;
p = 0.013
Cohen’s d = 0.5
ANOVA
Ivezić S.S.
et al. 2017
[41]
Croatia pseudo-RCT outpatient Schizophrenia 80
Group
Psychoedu-
cation
40 group
total 12
sessions
12 weeks Waiting List 40 NA NA NA
• ISMI
• BUES
• PDD
EG > CG
F/t = 8.18; p =
0.005
ηp2 = 0.097
sample t-test
Lucksted A.
et al. 2017
[51]
USA RCT outpatient
Schizophrenia,
BMD, Recurrent
major depressive,
Schizotypal,
Borderline
personality, Other
delusional or
psychotic disorder
253
Ending Self-
Stigma
Psychoedu-
cational
intervention
122 group
total 9
sessions
(90
min/session)
9 weeks
TAU
(minimally
enhanced by
a brochure
about
internalized
stigma)
131 NA NA NA
• ISMI-29
• SSMIS
• MARS
• GSES
• SOBI
• BSI
• ESS
• BCI
• R-BANS
EG > CG
df = 252; p = 0.131
Effect size = –0.139
repeated measures
mixed model
Wood L.
et al. 2017
[53]
England RCT inpatient
Schizophrenia,
Schizoaffective
Schizophreniform,
Delusional
disorder, Psychotic
disorder NOS, EIS
30 CBT 15 individual
total 1–2
sessions
(2 h/session)
2 weeks Psychoeducation 15 individual
total 1–2
sessions
(2 h/session)
2 weeks
• ISMI-S
• SS
• SERS
• QPR
• BDI-PC
• AMHP
EG = CG
F = 0.306; p = 0.585
Cohen’s d = −0.238
ANCOVA
Li J. et al.
2018 [50]
China RCT outpatient Schizophrenia 327
• SASD
• Psycho-
education
• SST
• CBT
169 individual
total 8
sessions
(2 h/session)
9 months
Face-to-face
Interview
158 individual NA 9 months
• ISMI
• DISC-12
• GAF
• SQLS
• SES
• BPRS
• PANSS-N
CG > EG
OR(95%CI) =
−0.04(−0.14 to
0.06); p = 0.440
ICC = 0.1235
Linear Mixed
Models
Yilmaz E.
and Kavak F.
2018 [44]
Turkey NRCT outpatient Schizophrenia 69
Mindfulness-
Based
Psychoedu-
cation
34 group
total of 12
sessions
2
days/week
6 weeks TAU 35 NA NA NA • ISMI EG > CG
p = 0.001
Mann–Whitney
U = 98.000
Independent-
samples t
test
8. Int. J. Environ. Res. Public Health 2023, 20, 5570 8 of 24
Table 1. Cont.
Study Country
Study
Design
Setting Diagnosis Sample Size Intervention
Intervention
N
Type Frequency Duration Control
Control
N
Type Frequency Duration
Outcome
Measures
Main Result
Significance and Test
Used
Gaebel W.
et al. 2019
[56]
Germany RCT mixed
Schizophrenia
spectrum
disorders,
Depression
462
Psychoeducational
Group
Therapy +
STEM
+ Booster
session
227 group
total 12
sessions
(8 + 3 + 1)
4 to 11
weeks +
6w later
booster
psychoeducational
group
therapy
+ booster
session
235 group
total 12
sessions
(11 + 1)
4 to 11
weeks +
6w later
booster
• ISMI
• HAM-D
• PANSS
• CGI
• GAF
• KCS
• WHO-
QOL-BREF
• BUES
• RSES
• SCL-27
EG = CG
p = 0.83
d = 0.3
mixed models analyses
and t tests
Yanos P.T.
et al. 2019
[54]
USA RCT mixed
Schizophrenia,
Schizoaffective
118 NECT 65 group
total 20
sessions
20 weeks
Supportive
Group
Therapy
52 group
total 20
session
20 weeks
• ISMI
• RSES
• BHS
• QLS
• MSIF
• PANSS
• CSC
• STAND
EG > CG
F = 2.19; df = 3347;
p = 0.09
Effect Size = 0.25
(small-to-moderate)
mixed-effects modeling,
GPower3
Díaz-
Mandado O.
& Perianez J.
A. 2020 [60]
Spain RCT outpatient
Schizophrenia,
Schizotypal,
Persistent
delusional
disorder,
Schizoaffective,
Other non organic
psychotic
disorders, BMD,
Recurrent
depressive
disorder, OCD
54
“Coping
Internalized
Stigma
Program”
(PAREI)
29 group
total 8
sessions
(2 h/session
×1/week)
8 weeks TAU 25 NA NA NA
• ISMI
• PL
• GI
• RAS-41
• BPRS
• SFS
EG > CG
F = 2.88; p = 0.1
ηp2= 0.06
ANOVA
Drapalski
A.L. et al.
2020 [61]
USA RCT outpatient
BMD,
Schizophrenia,
Schizoaffective,
MDD with
psychotic features
216
Ending
Self-Stigma
106 group
total 9
session
(75–90
min/session
×1/week)
9 weeks
Health &
Wellness
Intervention
110 group
total 9
session
(75–90
min/session
×1 ses-
sion/week)
9 weeks
• ISMI
• SOBI
• GSES
• MARS
• SSMIS
EG = CG
t = 0.72; p = 0.470
repeated-measures,
mixed effects model
Konsztowicz
S. et al. 2020
[43]
Canada pseudo-RCT mixed
Schizophrenia,
Schizoaffective,
Other psychotic
disorder, MDD
with psychotic
features, BMD with
psychotic features,
Unspecified
schizophrenia
spectrum and other
psychotic disorder
35
Self-concept
and
Engagement
in LiFe
(SELF)
18 individual
50
min/session
×1/week
average of
4.6 weeks
TAU 17 NA NA NA
• ISMI
• MES
• RSQ
• SERS
• CDS
•
Q-LES-Q-18
• STQ
• CSQ
EG > CG
F = 1.23; df = (1, 31);
p = 0.28
ηp2 = 0.04
ANCOVA
Young
D.K.W. et al.
2020 [45]
China NRCT outpatient
Depression,
Schizophrenia,
BMD, Anxiety,
Others
78
Destigmatized
Group
Intervention
36 group
total 10
sessions
(90
min/session
×1 ses-
sion/week)
10 weeks TAU 42 NA NA NA
• ISMI
• RAS
• BDI
EG > CG
t(p) = −0.812(0.417);
F(p) = 7.482(0.008)
ηp2= 0.099
ANCOVA
Alhadidi M.
et al. 2022
[32]
Jordan RCT inpatient Schizophrenia 122
Group
Psychoedu-
cation
66 group
total 7
sessions
(45–60
min/session)
3 weeks TAU 56 NA NA NA
• ISMI-10
• KASQ
• BIS
EG > CG
F = 13.29, p < 0.001
d = –0.8
Repeat Measure
ANCOVA
9. Int. J. Environ. Res. Public Health 2023, 20, 5570 9 of 24
Table 1. Cont.
Study Country
Study
Design
Setting Diagnosis Sample Size Intervention
Intervention
N
Type Frequency Duration Control
Control
N
Type Frequency Duration
Outcome
Measures
Main Result
Significance and Test
Used
Çiftçi M.C.
& Budak
K.F. 2022
[47]
Turkey NRCT outpatient Schizophrenia 100
CBT-based
Psychoedu-
cation
Program
50 group
total of 8
sessions
(45–60
min/session
×2/week)
4 weeks TAU 50 NA NA NA
• ISMI
• FROGS
EG > CG
t = 2.672; p = 0.009
Effect Size = 0.8
power analysis, t test
Erdoğan E.
& Demir S.
2022 [49]
Turkey RCT outpatient Schizophrenia 39
Solution-
Focused
Group
Psychoedu-
cation
Program
20 group
total 6
sessions
(90
min/session
×2/week)
6 weeks TAU 19 NA NA NA
• ISMI
• RSES
• SubRAS
EG > CG
p < 0.001
W = 0.810
Spearman’s correlation
analysis, Kendall W
coefficient (effect size)
Hasan A.A
& Alasmee
N. 2022 [62]
Jordan RCT outpatient
Schizophrenia
spectrum disorder
278
Self-Stigma
Reduction
Programme
140 individual
total 13
sessions
(biweekly)
26 weeks TAU 138 NA NA NA
• ISMI
• PANSS
• PTCS
• CGSS
EG > CG
F = 187.75; p < 0.001
Effect Size = 0.59 (large)
ANOVA
Shih C. et al.
2022 [46]
Taiwan NRCT inpatient Schizophrenia 70
Against
Stigma
Program
35 group
60
min/session
×1/week
6 weeks TAU 35 NA NA NA
• ISMI
• RES
EG > CG
p = 0.012
Effect Size = 0.760
Generalized estimating
equation
RCT: randomized controlled trial; NRCT: non-randomized, experimental trial; NA: not available; BMD: Bipolar Mood Disorder; OCD: Obsessive–Compulsive Disorder; MDD: Major
Depressive Disorder; SMI: Severe Mental Illness (majority had psychotic disorder); FEP: First Episode Psychosis; EIS: Early Intervention Service; NOS: not otherwise specified; STEM:
a psycho-educational group therapy module to promote stigma coping and empowerment; NECT: Narrative Enhancement and Cognitive Therapy; TAU: Treatment As Usual; EG:
Experimental Group; CG: Control Group; WLCG: Wait-list Control Group; ACG: WLCG (Active Control Group); SDS:Link’s Stigma-Devaluation Scale; BPRS: Brief Psychiatric Rating
Scale; FCOPES: Family Crisis Oriented Personal Evaluation Scales; PSQ: Perceived Stigma Questionnaire; KASQ: Knowledge about Schizophrenia Questionnaire; SUMD: Scale to Assess
Unawareness of Mental Disorder; CRS: Compliance Rating Scale; DAI-10: Drug Attitude Inventory-1; NOSIE-30: Nurses’ Observation Scale for Inpatient Evaluation; BDI-II: Beck
Depression Inventory-II; RSES: Rosenberg Self-Esteem Scale; 15D: 15D instrument of health-related quality of life; CSSMIS: Chinese Self-stigma of Mental Illness Scale; CAQ-SPMI:
Change Assessment Questionnaire for People with Severe and Persistent Mental Illness; PTCS: Psychosocial Treatment Compliance Scale; GAF: Global Assessment of Functioning Scale;
CGSS: Chinese General Self-efficacy Scale; SDS-J: Japanese version of the Social Distance Scale; KIDI: Knowledge of Illness and Drugs Inventory; BPIS: Birchwood’s Psychosis Insight
Scale; ISMI: Internalized Stigma of Mental Illness Scale; BHS: Beck Hopelessness Scale; CSC: Coping with Symptoms Checklist; QLS: Quality of Life Scale; PANSS: Positive and Negative
Syndrome Scale; MANSA: Manchester Short Assessment of Quality of Life; ADHS: Adult Dispositional Hope Scale; ACS: Approaches to Coping with Stigma scale; CES-D: Center for
Epidemiological Studies Depression Scale; ES: Empowerment Scale; GPSES: Generalized Perceived Self-Efficacy Scale; PGRS: Personal Growth and Recovery Scale; ISMI-R: Internalized
Stigma of Mental Illness Scale—Revised; SIMS: Semi-Structured Interview Measure of Stigma; QPR: Process of Recovery Questionnaire—Short Form; BDI-7: Beck Depression Inventory
7; SIAS: Social Interaction Anxiety Scale; SERS-S: Self-Esteem Rating Scale—Short Form; ISS: Internalized Shame Scale; QLESQ: Quality of Life Enjoyment and Satisfaction Questionnaire;
STS: Stigma Towards Schizophrenia scale; MCI: Medication Compliance Inventory; CS: Consumer Satisfaction Scale; SSMIS-SF: Self-Stigma of Mental Illness Scale—Short Form; BUES:
Boston University Empowerment Scale; PDD: Perceived Devaluation and Discrimination Scale; MARS: Maryland Assessment of Recovery in People with Serious Mental Illness; GSES:
General Self-Efficacy Scale; SOFBI: Sense of Belonging Instrument; BSI: Brief Symptom Inventory; ESS: Experiences of Stigma Survey; BCI: Beck Cognitive Insight; R-BANS: Repeatable
Battery of Neuropsychological Status; ISMI-S: Internalized Stigma of Mental Illness Inventory–Shortened; SS: Stigma Scale; SERS: Self-Esteem Rating Scale; BDI-PC: Beck Depression
Inventory–Primary Care; AMHP: Attitudes towards Mental Health Problems; DISC-12: Discrimination and Stigma Scale; SQLS: Schizophrenia Quality of Life Scale; SES: Self-Esteem
Scale; HAM-D: Hamilton Depression Rating Scale; CGI: clinical global status; KCS: Kemp Compliance Scale; WHO-QOL-BREF: World Health Organization Quality of Life Brief Version;
SCL-27: symptom checklist; MSIF: Multidimensional Scale of Independent Functioning; STAND: Illness Awareness subscale of the Scale to Assess Narrative Development; PL: Perceived
Legitimacy; GI: Group Identification; RAS: Recovery Assessment Scale; SFS: Social Functioning Scale; SSMIS: Self-Stigma of Mental Illness Scale; MES: Modified Engulfment Scale; RSQ:
Recovery Style Questionnaire; CDS: Calgary Depression Scale; Q-LES-Q-18: Abbreviated Quality of Life Enjoyment and Satisfaction Questionnaire; STQ: Satisfaction with Therapy
Questionnaire; CSQ: Client Satisfaction Questionnaire; BDI: Beck Depression Inventory; BIS: Birchwood Insight Scale; ISMI-10: Internalized Stigma of Mental Illness Inventory–10-Item
Version; FROGS: Functional Remission of General Schizophrenia Scale; SubRAS: Subjective Recovery Assessment Scale.
10. Int. J. Environ. Res. Public Health 2023, 20, 5570 10 of 24
There were 15 studies composed of individuals who were treated as
outpatients [29,31,33,41,43,45,47–50,52,54,57,58,60]. There were six studies conducted on
participants who were inpatients [30,32,42,46,53,55]. Four studies encompassed partici-
pants from both inpatient and outpatient settings [34,43,54,56], while two studies did not
address this [48,52].
There were 10 studies that only included people who had the diagnosis of schizophre-
nia in their participant pool [29,32,41,44,46,47,49,50,55,57]. Three studies had samples
that have either schizophrenia or schizoaffective disorder as their diagnosis [30,31,54].
Nine studies had the majority of patients diagnosed with a condition that falls within the
schizophrenia spectrum disorder [33,43,51–53,59–62]. Two studies used samples that met
the criteria for serious mental illness (SMI); however, exact diagnosis was not stated but
claimed that the majority of the participants had a psychotic condition [34,48]. A total
of three studies had a larger number of samples consisting of individuals with affective
disorders [42,45,56].
3.1.4. Characteristics of Interventions Used
Group Psychoeducation was by far the most common type of intervention employed,
with a total of five studies. [29–32,41]. Narrative Enhancement and Cognitive Therapy
(NECT) was the second most common type of intervention utilized (total of four stud-
ies) [33,34,48,54]. Two studies reported on the Ending Self-Stigma (ESS) psychoeduca-
tional intervention [51,61]. Another two studies utilized the Self-stigma Reduction Pro-
gram [57,62].
In terms of the mode of delivery, there were a total of 20 studies that involved sessions
that were carried out in groups [29–34,41–43,46,49–51,54,55,57–61], six studies involved
sessions conducted individually [43,50,53,55,59,62], and only one study involved a combi-
nation of both [57].
As for the controls utilized, a total of 19 studies compared the interventions with
Treatment as Usual or a Waiting List, which consisted of patients receiving their stan-
dard psychiatric or psychosocial treatments [30–34,41–43,48,50,52–54,56–61]. However,
one of the studies also acknowledged that their Treatment as Usual was minimally en-
hanced by a brochure about internalized stigma [51]. The following were among the
controls used: Health and Wellness Intervention [61], Newspaper Reading [57], Group
Psychoeducation [56], Face-to-face Interview [50], Supportive Sessions [29], Individual
Psychoeducation [53], and Supportive Group Therapy [54]. One study used an Active Con-
trol Group which consisted of a No-Music Educational Mental Illness Stigma Talk-based
Session, and Wait-list Control Group which consisted of rock and roll bingo [42].
3.1.5. Characteristics of Outcome Measures Used
Table 1 provides the list of outcome measurements that were utilized in each study.
There were 20 studies that used The Internalized Stigma of Mental Illness (ISMI) Scale to
examine the changes in the participants’ internalized stigma [32,33,41–46,48–52,54,56–61].
In general, this scale possesses good construct validity, content validity, internal consistency,
and test–retest reliability. However, it is necessary to take into consideration the fact that
several versions and translations were utilized across these studies.
Among the other main scales used to measure the efficacy of the interventions were the
following: Perceived Stigma Questionnaire [30]; the Chinese Self-stigma of Mental Illness
Scale [57]; the Self-Stigma of Mental Illness Scale-Short Form and the Rosenberg Self-Esteem
Scale [34]; the Stigma Towards Schizophrenia scale [55]; the Link’s Stigma-Devaluation
Scale [29]; the Stigma Scale [42]; and the Japanese version of the Social Distance Scale [31].
In each of these studies, the validity and reliability of these measures were acknowledged
as being sound.
11. Int. J. Environ. Res. Public Health 2023, 20, 5570 11 of 24
3.1.6. Results of the Interventions
The findings of the interventions for internalized stigma are summarized in Table 2.
Overall, 15 out of 27 studies presented statistically significant outcomes. Four out of the
five studies found that Group Psychoeducation was effective in achieving a statistically
significant reduction in internalized stigma. One study compared Group Psychoeducation
with Supportive Session, and the results favored Group Psychoeducation [29]. Another
three studies that compared Group Psychoeducation with Treatment as Usual or a Waiting
List produced significant reductions in internalized stigma as well [31,32,41]. However,
one study that compared this intervention with Treatment as Usual provided results of
lowering stigma in both groups, but considerably more so in the control group, which
appeared to be a negative treatment effect for this intervention [30].
In the case of NECT, two out of the four studies revealed findings that were favorable
to this intervention in comparison to Treatment as Usual or the Waiting List [34,48]. One
study showed that NECT was not more effective than Treatment as Usual [33], while
another study that compared this intervention with Supportive Group Therapy yielded
results that favored the intervention; however, it was not statistically significant [54].
One study that compared ESS to Treatment as Usual generated data that showed that
ESS was beneficial in helping to lessen essential features of internalized stigma; however, it
was not statistically significant [51]. In another study, the findings indicated that ESS was
not more beneficial than the Health and Wellness Intervention [61].
One study that compared the Self-stigma Reduction Program to Newspaper Reading
found results that favored the intervention, although the difference was not statistically
significant [57], while the findings of another study that compared this intervention to Treat-
ment as Usual provided statistically significant results that favored this intervention [62].
Other studies that resulted in significant findings involve the following types of in-
terventions: Antistigma Photovoice Program [52]; Family Schizophrenia Psychoeducation
Program [55]; Mindfulness-based Psychoeducation [44]; Destigmatized Group Interven-
tion [45]; CBT-based Psychoeducation Program [47]; Solution-focused Group Psychoe-
ducation Program [49]; and Against Stigma Program [46]. These studies compared the
intervention to Treatment as Usual or the Waiting List. Another study found substantial
results when comparing Group Music Therapy to the Waiting List, but found no differences
when compared to the Active Control condition of Group Education [42].
In terms of the effect size, 21 studies contributed their findings. However, four of
them did not elaborate on the type of effect size they employed. Small effect sizes were
found in three studies [53,55,59]; small to medium effect sizes were found in four stud-
ies [33,43,54,56]; medium effect sizes were found in five studies [30,34,48,52,60]; medium
to large effect sizes were found in three studies [41,42,45]; and large effect sizes were found
in two studies [32,62].
As for specific principal targets, Group Psychoeducation showed significant improve-
ments in Perception [29], Knowledge about illness [31], and Insight [32], whereas NECT
showed significant improvements in Social Withdrawal [48,54], Stereotype Endorsement,
Alienation [48], Stereotype Agreement, Awareness, Application, and Self-esteem [34]. ESS
showed significant improvements in Stigma Resistance, Recovery, Alienation, Stereotype
Agreement, and Self-concurrence [51], while the Self-stigma Reduction Program showed
significant improvements in Self-esteem, Readiness of Change, Participation [57], Percep-
tion, Self-efficacy, and Compliance [62].
12. Int. J. Environ. Res. Public Health 2023, 20, 5570 12 of 24
Table 2. Summary of the findings of interventions for internalized stigma [29,30,32–34,41–62].
Study Quality of Study
Experimental
Group
Control
Group
Main
Result
Internalized
Stigma
Stereotype
Endorsement
Stigma
Resistance
Insight
Empowerment
Recovery
Self-Esteem
Anticipated
Discrimination
Perceived
Discrimination
Social
Withdrawal
Readiness
of
Change
Participation
Stereotype
Agreement
Self-Concurrence
Awareness
Application
Disclosure
Knowledge
about
Illness
Alienation
Internalised
Shame
Hope
Engulfment
Social
Functioning
Perception
Self-Eficacy
Compliance
Shin S. & Lukens
E.P. 2002 [29]
II
A randomised
controlled trial
60% GP SS EG > CG ↑*** 3***
Aho-Mustonen K.
et al., 2011 [30]
II
A randomised
controlled trial
87% GP TAU CG > EG ↔ 3↔ 3↔ 3↔
Fung K.M.T., 2011
[57]
II
A randomised
controlled trial
87% SRP NR EG > CG ↔ 3* 3* 3* 3↔ 3↔
Uchino T. et al.,
2012 [58]
III-2
A comparative study
with concurrent
controls:
n Non-randomised,
experimental trial
80% GP TAU EG > CG ↑** 3**
Yanos P.T. et al.,
2012 [33]
II
A randomised
controlled trial
100% NECT TAU EG = CG ↔ 3↔ 3↔ 3↔
Silverman M.J.
et al., 2013 [42]
III-1
A pseudorandomised
controlled trial
87% GMT
GE,
WL
EG >
WLCG
EG =
ACG
↑** 3* 3*
Roe D. et al., 2014
[48]
III-2
A comparative study
with concurrent
controls:
n Non-randomised,
experimental trial
80% NECT TAU EG > CG ↑** 3** 3* 3*
13. Int. J. Environ. Res. Public Health 2023, 20, 5570 13 of 24
Table 2. Cont.
Study Quality of Study
Experimental
Group
Control
Group
Main
Result
Internalized
Stigma
Stereotype
Endorsement
Stigma
Resistance
Insight
Empowerment
Recovery
Self-Esteem
Anticipated
Discrimination
Perceived
Discrimination
Social
Withdrawal
Readiness
of
Change
Participation
Stereotype
Agreement
Self-Concurrence
Awareness
Application
Disclosure
Knowledge
about
Illness
Alienation
Internalised
Shame
Hope
Engulfment
Social
Functioning
Perception
Self-Eficacy
Compliance
Russinova Z. et al.,
2014 [52]
II
A randomised
controlled trial
93% APP WL EG > CG ↑* 3* 3**
Morrison A.P. et al.,
2016 [59]
II
A randomised
controlled trial
87% CT TAU EG = CG ↔ 3** 3* 3*
Ngoc T.N. et al.
2016 [55]
II
A randomised
controlled trial
53% FSPP TAU EG > CG ↑* 3**
Hansson L. et al.,
2017 [34]
II
A randomised
controlled trial
87% NECT WL EG > CG ↑* 3** 3* 3* 3*
Ivezić S.S. et al.,
2017 [41]
III-1
A pseudorandomised
controlled trial
93% GP WL EG > CG ↑** 3↔
Lucksted A. et al.,
2017 [51]
II
A randomised
controlled trial
93% ESS TAU EG > CG ↔ 3* 3* 3** 3** 3*
Wood L. et al., 2017
[53]
II
A randomised
controlled trial
93% CBT PE EG = CG ↔ 3* 3*
Li J. et al., 2018 [50]
II
A randomised
controlled trial
93%
SASD
PE
SST
CBT
FTF CG > EG ↔ 3*
14. Int. J. Environ. Res. Public Health 2023, 20, 5570 14 of 24
Table 2. Cont.
Study Quality of Study
Experimental
Group
Control
Group
Main
Result
Internalized
Stigma
Stereotype
Endorsement
Stigma
Resistance
Insight
Empowerment
Recovery
Self-Esteem
Anticipated
Discrimination
Perceived
Discrimination
Social
Withdrawal
Readiness
of
Change
Participation
Stereotype
Agreement
Self-Concurrence
Awareness
Application
Disclosure
Knowledge
about
Illness
Alienation
Internalised
Shame
Hope
Engulfment
Social
Functioning
Perception
Self-Eficacy
Compliance
Yilmaz E. and
Kavak F. 2018 [44]
III-2
A comparative study
with concurrent
controls:
n Non-randomised,
experimental trial
87% MBP TAU EG > CG ↑*** 3*** 3*** 3*** 3***
Gaebel W. et al.,
2019 [56]
II
A randomised
controlled trial
87% STEM GP EG = CG ↔ 3↔ 3↔
Yanos P.T. et al.,
2019 [54]
II
A randomised
controlled trial
93% NECT SGT EG > CG ↔ 3↔ 3*
Díaz-Mandado O. &
Perianez J. A. 2020
[60]
II
A randomised
controlled trial
87% PAREI TAU EG > CG ↔ 3↔ 3↔ 3* 3↔ 3** 3*
Drapalski A.L. et al.
2020 [61]
II
A randomised
controlled trial
87% ESS HW EG = CG ↔ 3↔ 3↔ 3↔
Konsztowicz S. et al.
2020 [43]
III-1
A pseudorandomised
controlled trial
87% SELF TAU EG > CG ↔ 3↔ 3↔ 3*
Young D.K.W. et al.
2020 [45]
III-2
A comparative study
with concurrent
controls:
n Non-randomised,
experimental trial
87% DGI TAU EG > CG ↑** 3↔ 3* 3** 3**
Alhadidi M. et al.
2022 [32]
II
A randomised
controlled trial
93% GP TAU EG > CG ↑*** 3*** 3NA
15. Int. J. Environ. Res. Public Health 2023, 20, 5570 15 of 24
Table 2. Cont.
Study Quality of Study
Experimental
Group
Control
Group
Main
Result
Internalized
stigma
Stereotype
Endorsement
Stigma
Resistance
Insight
Empowerment
Recovery
Self-esteem
Anticipated
Discrimination
Perceived
Discrimination
Social
Withdrawal
Readiness
of
Change
Participation
Stereotype
Agreement
Self-concurrence
Awareness
Application
Disclosure
Knowledge
about
illness
Alienation
Internalised
Shame
Hope
Engulfment
Social
Functioning
Perception
Self-eficacy
Compliance
Çiftçi M.C. & Budak
K.F. 2022 [47]
III-2
A comparative study
with concurrent
controls:
n Non-randomised,
experimental trial
87% CBPP TAU EG > CG ↑** 3** 3* 3↔ 3**
Erdoğan E. &
Demir S. 2022 [49]
II
A randomised
controlled trial
100% SFGPP TAU EG > CG ↑*** 3*** 3*** 3** 3*** 3***
Hasan A.A &
Alasmee N. 2022
[62]
II
A randomised
controlled trial
87% SRP TAU EG > CG ↑*** 3* 3*** 3***
Shih C. et al. 2022
[46]
III-2
A comparative study
with concurrent
controls:
n Non-randomised,
experimental trial
87% ASP TAU EG > CG ↑* 3***
↑ = statistically reduces internalized stigma; * = p < 0.05; ** = p ≤ 0.01; *** = p ≤ 0.001; ↔ = statistically no difference; 3 = noted improvement in principal; GP = Group Psychoeducation;
SS = Supportive Sessions; TAU = Treatment As Usual; SRP = Self-stigma Reduction Program; NR = Newspaper Reading; NECT = Narrative Enhancement and Cognitive Therapy;
GMT = Group Music Therapy; GE = Group Education; WL = Waiting List; APP = Antistigma Photovoice Program; CT = Cognitive Therapy; FSPP = Family Schizophrenia Psychoeducation
Program; ESS = Ending Self-Stigma psychoeducational intervention; CBT = Cognitive Behavioral Therapy; PE = Psychoeducation; SASD = Strategies Against Stigma and Discrimination;
SST = Social Skills Training; FTF = Face-to-face interview; MBP = Mindfulness-based Psychoeducation; STEM = a psycho-educational group therapy module to promote stigma coping
and empowerment; SGT = Supportive Group Therapy; SELF = Self-concept and Engagement in LiFe; PAREI = Coping Internalized Stigma Program; DGI = Destigmatized Group
Intervention; HW = Health and Wellness Intervention; SFGPP = Solution-focused Group Psychoeducation Program; ASP = Against Stigma Program; CBPP = CBT-based Psychoeducation
Program; EG = Experimental Group; CG = Control Group; WLCG = Wait-list Control Group; ACG = Active Control Group.
16. Int. J. Environ. Res. Public Health 2023, 20, 5570 16 of 24
Other notable interventions were Solution-focused Group Psychoeducation Program
which showed significant improvements in Stereotype Endorsement, Stigma Resistance,
Perceived Discrimination, Social Withdrawal, and Alienation [49]; Mindfulness-based
Psychoeducation which showed significant improvements in Stereotype Endorsement,
Perceived Discrimination, Social Withdrawal, and Alienation [44]; Coping Internalized
Stigma Program (PAREI) which showed significant improvements in Recovery, Alienation,
and Social Functioning [60]; Destigmatized Group Intervention which showed significant
improvements in Perceived Discrimination, Social Withdrawal, and Alienation [45]; and
CBT-based psychoeducation program which showed significant improvements in Stereo-
type Endorsement, Perceived Discrimination, and Alienation [47]. There were also other in-
terventions that showed improvements in fewer principal targets [29,42,43,50,52,53,55,59].
3.2. Meta-Analysis
As this review is about determining the effectiveness of interventions for internalized
stigma, a meta-analysis was conducted so that the significance of the link between the
interventions that were utilized and their effectiveness in decreasing internalized stigma
could be further investigated. Because the purpose of this review is not to ascertain which
intervention is superior to the other, but rather to determine whether or not a particular
intervention is effective when it is employed, studies that compared interventions to
Treatment as Usual or a Waiting List were used. A total of 21 studies fit this description;
however, only 18 of them were included in the analysis since 2 studies did not provide
adequate extractable data. See Figure 2 for details.
Int. J. Environ. Res. Public Health 2023, 20, x FOR PEER REVIEW 23 of 31
intervention is superior to the other, but rather to determine whether or not a particular
intervention is effective when it is employed, studies that compared interventions to
Treatment as Usual or a Waiting List were used. A total of 21 studies fit this description;
however, only 18 of them were included in the analysis since 2 studies did not provide
adequate extractable data. See Figure 2 for details.
The overall effect was statistically significant (Z = 3.00; p = 0.003; 95% CI: −0.69 [−1.15,
−0.24]; n = 1633), although there was considerable heterogeneity (Tau2 = 0.89; Chi2 = 303.62,
df = 17; p < 0.00001; I2 = 94%). This indicates that on the whole, the interventions that were
utilized were effective in lowering internalized stigma in comparison to Treatment as
Usual or the Waiting List; nevertheless, there was a significant amount of variation across
these studies [40]. In view of the significant level of heterogeneity that exists across the
studies, we moved on to the subgroup analysis [63,64].
Figure 2. Meta-analysis and forest plot illustrating the efficacy of the overall interventions that were
utilized in reducing internalized stigma in comparison to Treatment as Usual (TAU) or the Waiting
List (WL) [30−34,41,43,45−48,51,52,55,58,59,61,64].
3.2.1. Subgroup Analysis
Due to the high I2, we conducted subgroup analyses in studies utilizing the same type
of interventions.
Narrative Enhancement and Cognitive Therapy (NECT)
There were three studies that evaluated the effectiveness of Narrative Enhancement
and Cognitive Therapy (NECT) to that of Treatment as Usual (TAU) or the Waiting List
(WL) [33,34,48]. See Figure 3 for details. The summary effect was statistically significant
(Z = 3.40; p = 0.0007; 95% CI: −0.44 [−0.70, −0.19]; n = 241), as well as it was highly homog-
enous (Tau2 = 0.00; Chi2 = 0.14, df = 2 (p = 0.93); I2 = 0%).
Figure 2. Meta-analysis and forest plot illustrating the efficacy of the overall interventions that were
utilized in reducing internalized stigma in comparison to Treatment as Usual (TAU) or the Waiting
List (WL) [30–34,41,43,45–48,51,52,55,58,59,61,64].
The overall effect was statistically significant (Z = 3.00; p = 0.003; 95% CI: −0.69
[−1.15, −0.24]; n = 1633), although there was considerable heterogeneity (Tau2 = 0.89;
Chi2 = 303.62, df = 17; p < 0.00001; I2 = 94%). This indicates that on the whole, the inter-
ventions that were utilized were effective in lowering internalized stigma in comparison
to Treatment as Usual or the Waiting List; nevertheless, there was a significant amount of
17. Int. J. Environ. Res. Public Health 2023, 20, 5570 17 of 24
variation across these studies [40]. In view of the significant level of heterogeneity that
exists across the studies, we moved on to the subgroup analysis [63,64].
3.2.1. Subgroup Analysis
Due to the high I2, we conducted subgroup analyses in studies utilizing the same type
of interventions.
Narrative Enhancement and Cognitive Therapy (NECT)
There were three studies that evaluated the effectiveness of Narrative Enhancement
and Cognitive Therapy (NECT) to that of Treatment as Usual (TAU) or the Waiting List
(WL) [33,34,48]. See Figure 3 for details. The summary effect was statistically significant
(Z = 3.40; p = 0.0007; 95% CI: −0.44 [−0.70, −0.19]; n = 241), as well as it was highly
homogenous (Tau2 = 0.00; Chi2 = 0.14, df = 2 (p = 0.93); I2 = 0%).
Int. J. Environ. Res. Public Health 2023, 20, x FOR PEER REVIEW 24 of 31
Figure 3. Subgroup analysis of Narrative Enhancement and Cognitive Therapy (NECT) in compar-
ison to Treatment as Usual (TAU) or the Waiting List (WL) [33,34,48].
Group Psychoeducation
Four studies compared the effectiveness of Group Psychoeducation to that of Treat-
ment as Usual (TAU) or the Waiting List (WL) [30–32,41]. See Figure 4 for details. The
summary effect was not statistically significant (Z = 1.55; p = 0.12; 95% CI: −0.51 [−1.15,
0.13]; n = 297), as well as there was considerable heterogeneity (Tau2 = 0.36; Chi2 = 20.22,
df = 3 (p = 0.0002); I2 = 85%). Even after further segmentation according to age, gender,
duration of illness, and level of education, there was still high levels of heterogeneity.
Figure 4. Subgroup analysis of Group Psychoeducation (GP) in comparison to Treatment as Usual
(TAU) or the Waiting List (WL) [30–32,41].
3.3. Publication Bias
There was no indication of publication bias in any of the papers that we chose to
include in the meta-analysis, as can be seen in the funnel plot that is shown in Figure 5.
Figure 3. Subgroup analysis of Narrative Enhancement and Cognitive Therapy (NECT) in comparison
to Treatment as Usual (TAU) or the Waiting List (WL) [33,34,48].
Group Psychoeducation
Four studies compared the effectiveness of Group Psychoeducation to that of Treat-
ment as Usual (TAU) or the Waiting List (WL) [30–32,41]. See Figure 4 for details. The sum-
mary effect was not statistically significant (Z = 1.55; p = 0.12; 95% CI: −0.51 [−1.15, 0.13];
n = 297), as well as there was considerable heterogeneity (Tau2 = 0.36; Chi2 = 20.22, df = 3
(p = 0.0002); I2 = 85%). Even after further segmentation according to age, gender, duration
of illness, and level of education, there was still high levels of heterogeneity.
Int. J. Environ. Res. Public Health 2023, 20, x FOR PEER REVIEW 24 of 31
Figure 3. Subgroup analysis of Narrative Enhancement and Cognitive Therapy (NECT) in compar-
ison to Treatment as Usual (TAU) or the Waiting List (WL) [33,34,48].
Group Psychoeducation
Four studies compared the effectiveness of Group Psychoeducation to that of Treat-
ment as Usual (TAU) or the Waiting List (WL) [30–32,41]. See Figure 4 for details. The
summary effect was not statistically significant (Z = 1.55; p = 0.12; 95% CI: −0.51 [−1.15,
0.13]; n = 297), as well as there was considerable heterogeneity (Tau2 = 0.36; Chi2 = 20.22,
df = 3 (p = 0.0002); I2 = 85%). Even after further segmentation according to age, gender,
duration of illness, and level of education, there was still high levels of heterogeneity.
Figure 4. Subgroup analysis of Group Psychoeducation (GP) in comparison to Treatment as Usual
(TAU) or the Waiting List (WL) [30–32,41].
3.3. Publication Bias
There was no indication of publication bias in any of the papers that we chose to
include in the meta-analysis, as can be seen in the funnel plot that is shown in Figure 5.
Figure 4. Subgroup analysis of Group Psychoeducation (GP) in comparison to Treatment as Usual
(TAU) or the Waiting List (WL) [30–32,41].
3.3. Publication Bias
There was no indication of publication bias in any of the papers that we chose to
include in the meta-analysis, as can be seen in the funnel plot that is shown in Figure 5.
18. Int. J. Environ. Res. Public Health 2023, 20, 5570 18 of 24
Int. J. Environ. Res. Public Health 2023, 20, x FOR PEER REVIEW 25 of 31
SE: Standard Error; SMD: Standardized Mean Difference.
Figure 5. The funnel plot for meta-analysis on the overall interventions that were utilized in reduc
ing internalized stigma in comparison to Treatment as Usual or the Waiting List.
3.4. NHRMC Evidence Statement Matrix
This review found that certain interventions may be effective methods for reducing
internalized stigma; however, variations in these interventions needed to be considered
as well. The overall rating of B for the NHRMC Evidence Statement Matrix was given
This indicates that there is some evidence in support of the recommendations, but caution
should be exercised while implementing them. Table S2 of the Supplementary Materials
provides a summary of the evidence matrix.
4. Discussion
This study explores a number of various psychological interventions that have the
potential to reduce internalized stigma in individuals who have been diagnosed with
schizophrenia spectrum disorders. To the best of our knowledge, this is the largest review
to date on psychological therapies for internalized stigma in schizophrenia spectrum dis
orders, encompassing a total of 27 studies with a combined sample size of 2975 individu
als from 15 different countries. Overall, the findings suggest that a variety of psychologica
therapies may be effective in reducing internalized stigma in people with schizophrenia
spectrum disorders. A systematic review of studies revealed that 15 out of 27 trials yielded
statistically significant results in favor of psychological therapies for decreasing internal
ized stigma. This is further supported by the meta-analysis of 18 trials, which demon
strated a significant effect of the therapies in reducing internalized stigma compared to
Treatment as Usual or the Waiting List.
According to the findings, not only was Narrative Enhancement and Cognitive Ther
apy (NECT) somewhat effective from the standpoint of the systematic review, but it was
also efficacious from the perspective of the meta-analysis that we conducted. These results
are consistent with those of previous research that came to the conclusion that NECT is
Figure 5. The funnel plot for meta-analysis on the overall interventions that were utilized in reducing
internalized stigma in comparison to Treatment as Usual or the Waiting List.
3.4. NHRMC Evidence Statement Matrix
This review found that certain interventions may be effective methods for reducing
internalized stigma; however, variations in these interventions needed to be considered
as well. The overall rating of B for the NHRMC Evidence Statement Matrix was given.
This indicates that there is some evidence in support of the recommendations, but caution
should be exercised while implementing them. Table S2 of the Supplementary Materials
provides a summary of the evidence matrix.
4. Discussion
This study explores a number of various psychological interventions that have the
potential to reduce internalized stigma in individuals who have been diagnosed with
schizophrenia spectrum disorders. To the best of our knowledge, this is the largest review to
date on psychological therapies for internalized stigma in schizophrenia spectrum disorders,
encompassing a total of 27 studies with a combined sample size of 2975 individuals from
15 different countries. Overall, the findings suggest that a variety of psychological therapies
may be effective in reducing internalized stigma in people with schizophrenia spectrum
disorders. A systematic review of studies revealed that 15 out of 27 trials yielded statistically
significant results in favor of psychological therapies for decreasing internalized stigma.
This is further supported by the meta-analysis of 18 trials, which demonstrated a significant
effect of the therapies in reducing internalized stigma compared to Treatment as Usual or
the Waiting List.
According to the findings, not only was Narrative Enhancement and Cognitive Ther-
apy (NECT) somewhat effective from the standpoint of the systematic review, but it was
also efficacious from the perspective of the meta-analysis that we conducted. These results
are consistent with those of previous research that came to the conclusion that NECT
is beneficial in reducing self-stigma as well as other subjective components of recovery
such as hope and self-esteem in people who have suffered from psychotic-related ill-
nesses [34,48,54]. NECT is a structured, group-based intervention that combines narrative
19. Int. J. Environ. Res. Public Health 2023, 20, 5570 19 of 24
therapy focused on enhancing one’s ability to narrate one’s life story, psychoeducation to
help replace stigmatizing views about mental illness and recovery with empirical findings,
and cognitive restructuring geared toward teaching skills to challenge negative beliefs
about the self [34]. The length of time that the intervention was carried out ranged from
five to six months. Since it has been seen phenomenologically that people with severe
mental illness typically have a diminished capacity to narrate the unfolding tale of their
own lives, NECT’s primary focus is on supporting the change in personal narratives. The
ability to alter one’s narrative is seen as crucial in this context for the purpose of altering
one’s sense of self. By having participants write or dictate tales about themselves and then
receiving comments from the facilitator and group members on alternate viewpoints about
the topics contained in their stories, NECT aims to assist individuals in reshaping their
narratives. This intervention is effective because it is sensitive to the particular patient’s
experiences and beliefs, and it also provides multiple tailored approaches to diminishing
the internalized stigma in them.
Based on the findings of previous studies, Group Psychoeducation was the most
commonly used psychological intervention for reducing internalized stigma [25,26,28].
These results coincide with the results of our study since we found that this intervention had
been looked into in a total of five different studies [29–32,41]. In general, this intervention’s
goal is to educate participants on a variety of important topics, such as gaining a better
understanding of their condition, avoiding future relapses, discussing their experiences
with stigma, and learning coping techniques to help them overcome stigma. The treatment
not only combines psychodynamic strategies for coping with emotional reactions to the
disease and stigma, but it also encompasses cognitive strategies for addressing attitudes
and ideas about the illness. Previous research has demonstrated that psychoeducation is an
effective method for helping people with schizophrenia to obtain a deeper understanding
of their condition and its implications [65]. There are a few key distinctions between the
use of this intervention among the trials that we studied, most notably with regard to the
duration and frequency with which it is implemented. The shortest was seven sessions
in three weeks [32], while the longest was twelve sessions in three months [41]. Despite
positive findings from the systematic review on the effectiveness of this intervention,
we discovered from our meta-analysis that the summary effect was not significant and
that the heterogeneity was large. One possible explanation for this discrepancy is that
the intervention was performed differently in various studies, with varied length and
methodology. Consequently, this finding should be interpreted with caution due to the
requirement to account for the variations in intervention.
It was discovered that among the most effective interventions were those that in-
cluded a few different therapies. Combinations across therapies such as psychoeducation,
cognitive behavioral therapy, social skills training, mindfulness, problem-solving skills,
communication skills, and support groups were common. Among the interventions that
had such multi-faceted elements were Self-stigma Reduction Program [62], Antistigma
Photovoice Program [52], Mindfulness-based Psychoeducation [44], Destigmatized Group
Intervention [45], CBT-based Psychoeducation Program [47], Solution-focused Group Psy-
choeducation Program [49], and Against Stigma Program [46]. Because of the many
dimensions of the stigma, it addresses and the variety of approaches it provides, it appears
that such therapies are advantageous in helping patients overcome internalized stigma.
However, due to the limited number of studies that have been conducted to investigate
their efficacy, accepting these conclusions has to be approached with caution.
Another notable matter is that the majority of the available interventions are carried
out in groups rather than individually or in a combination of the two. This trend may
have arisen for a variety of reasons, including the fact that group therapy is commonly
viewed as more efficient financially and time-wise; patients gain comfort in knowing they
are not alone in their struggles [66]; individuals gain insight through reflection on the
experiences of others; and therapeutic alliances are strengthened through interactions with
peers and facilitators during group sessions [67]. However, it is crucial not to overlook the
20. Int. J. Environ. Res. Public Health 2023, 20, 5570 20 of 24
possible advantages of interventions that are carried out individually, which may include a
more intensive therapeutic experience, an individualized approach, and the maintenance
of confidentiality. In light of this, it is essential to keep in mind that the effectiveness of
an intervention may only be obtained to the fullest extent possible when the treatment is
specifically adapted to the experiences and requirements of the patient.
Furthermore, internalized stigma is a multifaceted phenomenon that is comprised
of a variety of components. One of the most effective strategies for overcoming it is
to first identify the relevant principal targets that are involved, followed by prescribing
interventions that are designed to explicitly address those targets while also taking into
account many other aspects of the patient’s capabilities and requirements. For instance, we
may use the Internalized Stigma of Mental Illness (ISMI) Scale to determine which parts of
internalized stigma are primarily impacted in a patient. This can be carried out by analyzing
the patient’s responses to the various questions on the scale. If Stereotype Endorsement and
Alienation are a problem, then interventions such as NECT [48], Solution-focused Group
Psychoeducation Program [49], Mindfulness-based Psychoeducation [44], or CBT-based
psychoeducation program [47] that are known to effectively improve these targets may be
utilized. Such tailored care may result in the following outcomes: an improved patient
experience as a result of treatment decisions that take into account patients’ care needs and
preferences; an improved population’s health and quality of life as a result of tailored care
being supported; and a reduction in the per capita cost of care as a result of a reduction
in the overuse, underuse, and misuse of healthcare services [68]. Furthermore, prior to
implementing the intervention, it is essential to have a discussion about the options that are
suitable and available, as well as the pros and cons of each, and to apply shared decision
making between the patient and the doctor, as this may have many positive outcomes.
Strength and Limitations
Among the strengths of this study is that, to the best of our knowledge, this is the
largest review to date on psychological interventions for internalized stigma in schizophre-
nia spectrum disorders. In addition, this is also the first meta-analysis to examine the
effectiveness of Narrative Enhancement and Cognitive Therapy (NECT) in lowering in-
ternalized stigma in people with schizophrenia spectrum disorders. However, there were
some limitations to our study. Firstly, we limited our search to only include studies that
had been published in English. As a result, we are unable to include the findings of other
research that was published in a variety of languages, which leaves open the potential
for publication bias. Secondly, the studies that were included in our research at times
employed varying definitions of internalized stigma to some extent and also assessed it
using different questionnaires that each had their unique method of ascertaining it.
Recommendations for future research include conducting more clinical trials testing
the efficacy of each psychological intervention. This would allow for the measurement of
pooled effects for each intervention, so providing a clearer picture of each’s effectiveness.
After that, head-to-head comparisons of successful interventions might be conducted,
yielding the most effective intervention. In addition, we also recommend that future
research focus on the patient-tailored strategy of prescribing therapies based on the detected
elements of internalized stigma.
5. Conclusions
According to this systematic review and meta-analysis, the majority of the psychologi-
cal interventions evaluated are successful in lowering levels of internalized stigma, the use
of NECT shows promise, and interventions that mix several therapies may be more benefi-
cial. The strength of our research is that it is the largest review to date on psychological
interventions for internalized stigma in people with schizophrenia spectrum disorders, as
well as the first meta-analysis to evaluate the effectiveness of Narrative Enhancement and
Cognitive Therapy (NECT) in lowering internalized stigma in people with schizophrenia
spectrum disorders.
21. Int. J. Environ. Res. Public Health 2023, 20, 5570 21 of 24
Insights from this study have the potential to give mental health practitioners more
effective alternatives for implementing psychological therapies to reduce internalized
stigma. Moreover, we recommend that future research focus on the patient-tailored strategy
of prescribing therapies based on the detected elements of internalized stigma. In addition,
we urge that future studies concentrate on the patient-tailored method of prescribing
therapies based on the detected elements of internalized stigma.
Supplementary Materials: The following supporting information can be downloaded at: https://
www.mdpi.com/article/10.3390/ijerph20085570/s1, Table S1: Quality assessment of included studies;
Table S2: Summary of the NHRMC Evidence Statement Matrix.
Author Contributions: Conceptualization, S.J., T.I.M.D. and L.C.C.; methodology, S.J., T.I.M.D.,
S.M.S., L.C.C. and N.E.-T.; software, S.J.; validation, S.J., L.C.C., T.I.M.D., S.M.S. and M.M.; formal
analysis, S.J.; resources, S.J., T.I.M.D. and S.M.S.; data curation, S.J. and L.C.C.; writing—original draft
preparation, S.J.; writing—review and editing, S.J., T.I.M.D. and S.M.S.; visualization, S.J.; supervision,
S.J., T.I.M.D., S.M.S., M.M. and S.R.; funding acquisition, T.I.M.D. All authors have read and agreed
to the published version of the manuscript.
Funding: This research was funded by the Dana Fundamental PPUKM (Project Code: FF-2018-351).
Institutional Review Board Statement: The study was approved by the Research Ethics Committee,
The National University of Malaysia (UKM PPI/111/8/JEP-2018-430).
Informed Consent Statement: Not applicable.
Data Availability Statement: Not applicable.
Conflicts of Interest: The authors declare no conflict of interest.
References
1. Link, B.G.; Struening, E.L.; Neese-Todd, S.; Asmussen, S.; Phelan, J.C. Stigma as a Barrier to Recovery: The Consequences of
Stigma for the Self-Esteem of People with Mental Illnesses. Psychiatr. Serv. 2001, 52, 1621–1626. [CrossRef] [PubMed]
2. Corrigan, P.W.; Watson, A.C.; Barr, L. The Self–Stigma of Mental Illness: Implications for Self–Esteem and Self–Efficacy. J. Soc.
Clin. Psychol. 2006, 25, 875–884. [CrossRef]
3. Sartorius, N.; Schulze, H. Global Programme of the World Psychiatric Association. Reducing the Stigma of Mental Illness: A Report from a
Global Programme of the World Psychiatric Association; Cambridge University Press: Cambridge, UK, 2005.
4. Livingston, J.D.; Boyd, J.E. Correlates and Consequences of Internalized Stigma for People Living with Mental Illness: A
Systematic Review and Meta-Analysis. Soc. Sci. Med. 2010, 71, 2150–2161. [CrossRef] [PubMed]
5. Corrigan, P.W.; Druss, B.G.; Perlick, D.A. The Impact of Mental Illness Stigma on Seeking and Participating in Mental Health
Care. Psychol. Sci. Public Interes. 2014, 15, 37–70. [CrossRef] [PubMed]
6. Barney, L.J.; Griffiths, K.M.; Jorm, A.F.; Christensen, H. Stigma about Depression and Its Impact on Help-Seeking Intentions. Aust.
N. Z. J. Psychiatry 2006, 40, 51–54. [CrossRef]
7. Brown, C.; Conner, K.O.; Copeland, V.C.; Grote, N.; Beach, S.; Battista, D.; Reynolds, C.F. Depression Stigma, Race, and Treatment
Seeking Behavior and Attitudes. J. Community Psychol. 2010, 38, 350–368. [CrossRef]
8. World Health Organization Mental Health 2022. Available online: https://www.who.int/news-room/fact-sheets/detail/
schizophrenia (accessed on 18 December 2022).
9. Sadock, B.J. Kaplan & Sadock’s Synopsis of Psychiatry, 11th ed.; Wolters Kluwer: Philadelphia, PA, USA, 2015.
10. American Psychiatric Association. The American Psychiatric Association Practice Guideline for the Treatment of Patients with Schizophre-
nia; American Psychiatric Association Publishing: Maine Avenue SW, Washington, DC, USA, 2020; ISBN 0-89042-484-5.
11. World Health Organization. Mental Health. 2015. Available online: http://www.euro.who.int/en/health-topics/
noncommunicable-diseases/mental-health/priority-areas/stigma-and-discrimination (accessed on 18 December 2022).
12. Holzinger, A.; Beck, M.; Munk, I.; Weithaas, S.; Angermeyer, M.C. Stigma as Perceived by Schizophrenics and Depressives.
Psychiatr. Prax. 2003, 30, 395–401. [PubMed]
13. Reneses, B.; Sevilla Llewellyn-Jones, J.; Vila-Badia, R.; Palomo, T.; Lopez-Mic´o, C.; Pereira, M.; Jos´e Regatero, M.; Ochoa, S. The
Relationships between Sociodemographic, Psychosocial and Clinical Variables with Personal-Stigma in Patients Diagnosed with
Schizophrenia. Actas Esp. Psiquiatr. 2020, 48, 116–125.
14. Brohan, E.; Elgie, R.; Sartorius, N.; Thornicroft, G. Self-Stigma, Empowerment and Perceived Discrimination among People with
Schizophrenia in 14 European Countries: The GAMIAN-Europe Study. Schizophr. Res. 2010, 122, 232–238. [CrossRef] [PubMed]
15. Gerlinger, G.; Hauser, M.; De Hert, M.; Lacluyse, K.; Wampers, M.; Correll, C.U. Personal Stigma in Schizophrenia Spectrum
Disorders: A Systematic Review of Prevalence Rates, Correlates, Impact and Interventions. World Psychiatry 2013, 12, 155–164.
[CrossRef]
22. Int. J. Environ. Res. Public Health 2023, 20, 5570 22 of 24
16. Clark, C.M. Psychosocial Treatments for Schizophrenia: An Evaluation of Theoretically Divergent Treatment Paradigms, and
Their Efficacy. Clin. Schizophr. Relat. Psychoses 2016, 10, 41–50. [CrossRef] [PubMed]
17. Valery, K.-M.; Prouteau, A. Schizophrenia Stigma in Mental Health Professionals and Associated Factors: A Systematic Review.
Psychiatry Res. 2020, 290, 113068. [CrossRef] [PubMed]
18. Midin, M.; Ruzanna, Z.Z.; Rosdinom, R.; Wan Salwina, W.I. The Road to Recovery from Schizophrenia. Malaysian J. Psychiatry
2007, 16, 70–71.
19. Munikanan, T.; Midin, M.; Daud, T.I.M.; Rahim, R.A.; Bakar, A.K.A.; Jaafar, N.R.N.; Sidi, H.; Baharuddin, N. Association of Social
Support and Quality of Life among People with Schizophrenia Receiving Community Psychiatric Service: A Cross-Sectional
Study. Compr. Psychiatry 2017, 75. [CrossRef]
20. Dahlan, R.; Midin, M.; Shah, S.A.; Nik Jaafar, N.R.; Abdul Rahman, F.N.; Baharudin, A.; Das, S.; Sidi, H. Functional Remission
and Employment among Patients with Schizophrenia in Malaysia. Compr. Psychiatry 2014, 55, S46–S51. [CrossRef] [PubMed]
21. Lampropoulos, D.; Wolman, A.; Apostolidis, T. Analyzing the Presentation and the Stigma of Schizophrenia in French Newspapers.
Soc. Psychiatry Psychiatr. Epidemiol. 2017, 52, 1541–1547. [CrossRef] [PubMed]
22. Yamaguchi, S.; Mizuno, M.; Ojio, Y.; Sawada, U.; Matsunaga, A.; Ando, S.; Koike, S. Associations between Renaming Schizophrenia
and Stigma-Related Outcomes: A Systematic Review. Psychiatry Clin. Neurosci. 2017, 71, 347–362. [CrossRef]
23. Hanssen, E.; Balvert, S.; Oorschot, M.; Borkelmans, K.; van Os, J.; Delespaul, P.; Fett, A.-K. An Ecological Momentary Intervention
Incorporating Personalised Feedback to Improve Symptoms and Social Functioning in Schizophrenia Spectrum Disorders.
Psychiatry Res. 2020, 284, 112695. [CrossRef]
24. Nemoto, T.; Uchino, T.; Aikawa, S.; Matsuo, S.; Mamiya, N.; Shibasaki, Y.; Wada, Y.; Yamaguchi, T.; Katagiri, N.; Tsujino, N.; et al.
Impact of Changes in Social Anxiety on Social Functioning and Quality of Life in Outpatients with Schizophrenia: A Naturalistic
Longitudinal Study. J. Psychiatr. Res. 2020, 131, 15–21. [CrossRef]
25. Wood, L.; Byrne, R.; Varese, F.; Morrison, A.P. Psychosocial Interventions for Internalised Stigma in People with a Schizophrenia-
Spectrum Diagnosis: A Systematic Narrative Synthesis and Meta-Analysis. Schizophr. Res. 2016, 176, 291–303. [CrossRef]
26. Alonso, M.; Guillén, A.I.; Muñoz, M. Interventions to Reduce Internalized Stigma in Individuals with Mental Illness: A Systematic
Review. Span. J. Psychol. 2019, 22, E27. [CrossRef]
27. Mills, H.; Mulfinger, N.; Raeder, S.; Rüsch, N.; Clements, H.; Scior, K. Self-Help Interventions to Reduce Self-Stigma in People
with Mental Health Problems: A Systematic Literature Review. Psychiatry Res. 2020, 284, 112702. [CrossRef]
28. Luo, H.; Li, Y.; Yang, B.X.; Chen, J.; Zhao, P. Psychological Interventions for Personal Stigma of Patients with Schizophrenia: A
Systematic Review and Network Meta-Analysis. J. Psychiatr. Res. 2022, 148, 348–356. [CrossRef]
29. Shin, S.-K.; Lukens, E.P. Effects of Psychoeducation for Korean Americans with Chronic Mental Illness. Psychiatr. Serv. 2002, 53,
1125–1131. [CrossRef]
30. Aho-Mustonen, K.; Tiihonen, J.; Repo-Tiihonen, E.; Ryynänen, O.-P.; Miettinen, R.; Räty, H. Group Psychoeducation for Long-
Term Offender Patients with Schizophrenia: An Exploratory Randomised Controlled Trial. Crim. Behav. Ment. Health 2011, 21,
163–176. [CrossRef] [PubMed]
31. Uchino, T.; Maeda, M.; Uchimura, N. Psychoeducation May Reduce Self-Stigma of People with Schizophrenia and Schizoaffective
Disorder. Kurume Med. J. 2012, 59, 25–31. [CrossRef]
32. Alhadidi, M.; Al Hadid, L.A.R.; Danaee, M.; Abdullah, K.L.; Yoong, T.L. Effects of Psychoeducation on People with Schizophrenia
in Long-Term Care: An Intervention Study. J. Psychosoc. Nurs. Ment. Health Serv. 2023, 61, 9–18. [CrossRef] [PubMed]
33. Yanos, P.T.; Roe, D.; West, M.L.; Smith, S.M.; Lysaker, P.H. Group-Based Treatment for Internalized Stigma among Persons with
Severe Mental Illness: Findings from a Randomized Controlled Trial. Psychol. Serv. 2012, 9, 248–258. [CrossRef] [PubMed]
34. Hansson, L.; Lexén, A.; Holmén, J. The Effectiveness of Narrative Enhancement and Cognitive Therapy: A Randomized
Controlled Study of a Self-Stigma Intervention. Soc. Psychiatry Psychiatr. Epidemiol. 2017, 52, 1415–1423. [CrossRef] [PubMed]
35. Liberati, A.; Altman, D.G.; Tetzlaff, J.; Mulrow, C.; Gotzsche, P.C.; Ioannidis, J.P.A.; Clarke, M.; Devereaux, P.J.; Kleijnen, J.;
Moher, D. The PRISMA Statement for Reporting Systematic Reviews and Meta-Analyses of Studies That Evaluate Healthcare
Interventions: Explanation and Elaboration. BMJ 2009, 339, b2700. [CrossRef]
36. Page, M.J.; McKenzie, J.E.; Bossuyt, P.M.; Boutron, I.; Hoffmann, T.C.; Mulrow, C.D.; Shamseer, L.; Tetzlaff, J.M.; Akl, E.A.;
Brennan, S.E.; et al. The PRISMA 2020 Statement: An Updated Guideline for Reporting Systematic Reviews. BMJ 2021, 372, n71.
[CrossRef] [PubMed]
37. Booth, A.; Clarke, M.; Dooley, G.; Ghersi, D.; Moher, D.; Petticrew, M.; Stewart, L. The Nuts and Bolts of PROSPERO: An
International Prospective Register of Systematic Reviews. Syst. Rev. 2012, 1, 2. [CrossRef] [PubMed]
38. Law, M.; Stewart, D.; Letts, L.; Pollock, N.; Bosch, J.; Westmorland, M. Guidelines for Critical Review of Qualitative Studies.
McMaster University Occupational Therapy Evidence-Based Practice Research Group. 1998, pp. 1–9. Available online: https://s6
6fd5096a1c9453a.jimcontent.com/download/version/1440700114/module/9639616752/name/qualresearchreviewguide.pdf (ac-
cessed on 3 September 2022).
39. National Health and Medical Research Council. A Guide to the Development, Implementation and Evaluation of Clinical Practice
Guidelines; Commonwealth of Australia: Canberra, Australia, 1999; ISBN 1864960485.
40. Higgins, J.P.; Thomas, J.; Chandler, J.; Cumpston, M.; Li, T.; Page, M.J.; Welch, V.A. Cochrane Handbook for Systematic Reviews of
Interventions; John Wiley & Sons: Chichester, UK, 2019.
23. Int. J. Environ. Res. Public Health 2023, 20, 5570 23 of 24
41. Erdoğan, E.; Demir, S. The Effect of Solution Focused Group Psychoeducation Applied to Schizophrenia Patients on Self-Esteem,
Perception of Subjective Recovery and Internalized Stigmatization. Issues Ment. Health Nurs. 2022, 43, 944–954. [CrossRef]
42. Russinova, Z.; Rogers, E.S.; Gagne, C.; Bloch, P.; Drake, K.M.; Mueser, K.T. A Randomized Controlled Trial of a Peer-Run
Antistigma Photovoice Intervention. Psychiatr. Serv. 2014, 65, 242–246. [CrossRef] [PubMed]
43. Lucksted, A.; Drapalski, A.L.; Brown, C.H.; Wilson, C.; Charlotte, M.; Mullane, A.; Fang, L.J. Outcomes of a Psychoeducational
Intervention to Reduce Internalized Stigma Among Psychosocial Rehabilitation Clients. Psychiatr. Serv. 2017, 68, 360–367.
[CrossRef]
44. Wood, L.; Byrne, R.; Enache, G.; Morrison, A.P. A Brief Cognitive Therapy Intervention for Internalised Stigma in Acute Inpatients
Who Experience Psychosis: A Feasibility Randomised Controlled Trial. Psychiatry Res. 2018, 262, 303–310. [CrossRef] [PubMed]
45. Li, J.; Huang, Y.-G.; Ran, M.-S.; Fan, Y.; Chen, W.; Evans-Lacko, S.; Thornicroft, G. Community-Based Comprehensive Intervention
for People with Schizophrenia in Guangzhou, China: Effects on Clinical Symptoms, Social Functioning, Internalized Stigma and
Discrimination. Asian J. Psychiatr. 2018, 34, 21–30. [CrossRef]
46. Yanos, P.T.; Lysaker, P.H.; Silverstein, S.M.; Vayshenker, B.; Gonzales, L.; West, M.L.; Roe, D. A Randomized-Controlled Trial of
Treatment for Self-Stigma among Persons Diagnosed with Schizophrenia-Spectrum Disorders. Soc. Psychiatry Psychiatr. Epidemiol.
2019, 54, 1363–1378. [CrossRef]
47. Fung, K.M.T.; Tsang, H.W.H.; Cheung, W. Randomized Controlled Trial of the Self-Stigma Reduction Program among Individuals
with Schizophrenia. Psychiatry Res. 2011, 189, 208–214. [CrossRef]
48. Morrison, A.P.; Burke, E.; Murphy, E.; Pyle, M.; Bowe, S.; Varese, F.; Dunn, G.; Chapman, N.; Hutton, P.; Welford, M.; et al.
Cognitive Therapy for Internalised Stigma in People Experiencing Psychosis: A Pilot Randomised Controlled Trial. Psychiatry Res.
2016, 240, 96–102. [CrossRef]
49. Drapalski, A.L.; Lucksted, A.; Brown, C.H.; Fang, L.J. Outcomes of Ending Self-Stigma, a Group Intervention to Reduce
Internalized Stigma, Among Individuals with Serious Mental Illness. Psychiatr. Serv. 2021, 72, 136–142. [CrossRef] [PubMed]
50. Díaz-Mandado, O.; Periáñez, J.A. An Effective Psychological Intervention in Reducing Internalized Stigma and Improving
Recovery Outcomes in People with Severe Mental Illness. Psychiatry Res. 2021, 295, 113635. [CrossRef]
51. Gaebel, W.; Zäske, H.; Hesse, K.; Klingberg, S.; Ohmann, C.; Grebe, J.; Kolbe, H.; Icks, A.; Schneider, F.; Backes, V.; et al. Promoting
Stigma Coping and Empowerment in Patients with Schizophrenia and Depression: Results of a Cluster-RCT. Eur. Arch. Psychiatry
Clin. Neurosci. 2020, 270, 501–511. [CrossRef] [PubMed]
52. Hasan, A.A.; Alasmee, N. Evaluation of the Impact of a Self-Stigma Reduction Programme on Psychosocial Outcomes among
People with Schizophrenia Spectrum Disorder. J. Ment. Health 2022, 31, 83–91. [CrossRef] [PubMed]
53. Ngoc, T.N.; Weiss, B.; Trung, L.T. Effects of the Family Schizophrenia Psychoeducation Program for Individuals with Recent
Onset Schizophrenia in Viet Nam. Asian J. Psychiatr. 2016, 22, 162–166. [CrossRef]
54. Ivezić, S.Š.; Alfonso Sesar, M.; Mužinić, L. Effects of a Group Psychoeducation Program on Self-Stigma, Empowerment and
Perceived Discrimination of Persons with Schizophrenia. Psychiatr. Danub. 2017, 29, 66–73. [CrossRef]
55. Silverman, M.J. Effects of Music Therapy on Self- and Experienced Stigma in Patients on an Acute Care Psychiatric Unit: A
Randomized Three Group Effectiveness Study. Arch. Psychiatr. Nurs. 2013, 27, 223–230. [CrossRef]
56. Konsztowicz, S.; Gelencser, C.R.; Otis, C.; Schmitz, N.; Lepage, M. Self-Concept and Engagement in LiFe (SELF): A Waitlist-
Controlled Pilot Study of a Novel Psychological Intervention to Target Illness Engulfment in Enduring Schizophrenia and Related
Psychoses. Schizophr. Res. 2021, 228, 567–574. [CrossRef]
57. Yılmaz, E.; Kavak, F. Effects of Mindfulness-Based Psychoeducation on the Internalized Stigmatization Level of Patients with
Schizophrenia. Clin. Nurs. Res. 2020, 29, 496–503. [CrossRef]
58. Young, D.K.W.; Ng, P.Y.N.; Cheng, D. Destigmatized Group Intervention on Promoting Hope of Recovery: A Quasi-Experiment
Study. Res. Soc. Work Pract. 2020, 30, 54–64. [CrossRef]
59. Shih, C.-A.; Huang, J.-H.; Yang, M.-H. Anti-Stigma Psychosocial Intervention Effects on Reducing Mental Illness Self-Stigma and
Increasing Self-Esteem among Patients with Schizophrenia in Taiwan: A Quasi-Experiment. Asian J. Psychiatr. 2022, 73, 103171.
[CrossRef] [PubMed]
60. Çapar Çiftçi, M.; Kavak Budak, F. The Effect of Cognitive Behavioral Therapy-based Psychoeducation on Internalized Stigma and
Functional Remission in Individuals Diagnosed with Schizophrenia. Perspect. Psychiatr. Care 2022, 58, 2170–2182. [CrossRef]
[PubMed]
61. Roe, D.; Hasson-Ohayon, I.; Mashiach-Eizenberg, M.; Derhy, O.; Lysaker, P.H.; Yanos, P.T. Narrative Enhancement and Cognitive
Therapy (NECT) Effectiveness: A Quasi-Experimental Study. J. Clin. Psychol. 2014, 70, 303–312. [CrossRef] [PubMed]
62. Hafdahl, A.R.; Williams, M.A. Meta-Analysis of Correlations Revisited: Attempted Replication and Extension of Field’s (2001)
Simulation Studies. Psychol. Methods 2009, 14, 24–42. [CrossRef]
63. Field, A.P. Is the Meta-Analysis of Correlation Coefficients Accurate When Population Correlations Vary? Psychol. Methods 2005,
10, 444–467. [CrossRef]
64. Ruzanna, Z.Z.; Midin, M.; Parveen, K.; Cheah, Y.C. Does Psychoeducation Improve Insight of Patients with Schizophrenia.
Malaysian J. Psychiatry 2010, 19, 27–40.
65. Robak, R.W.; Kangos, K.A.; Chiffriller, S.H.; Griffin, P.W. The Working Alliance in Group Counseling: An Exploratory Study.
Psychol. Rep. 2013, 113, 591–604. [CrossRef]
24. Int. J. Environ. Res. Public Health 2023, 20, 5570 24 of 24
66. Johnson, D.P.; Penn, D.; Bauer, D.; Lowman, J. Therapeutic Alliance in Group Therapy for Schizophrenia. Carolina Digital
Repository. 2007. Available online: https://core.ac.uk/download/pdf/210604004.pdf (accessed on 18 December 2022).
67. Dekkers, T.; Hertroijs, D.F.L. Tailored Healthcare: Two Perspectives on the Development and Use of Patient Profiles. Adv. Ther.
2018, 35, 1453–1459. [CrossRef]
68. Ismail, M.A.; Midin, M. Shared Decision-Making and Role Preference Among Patients with Schizophrenia in Malaysia: A
Cross-Sectional Study. Front. Psychiatry 2021, 12. [CrossRef]
Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual
author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to
people or property resulting from any ideas, methods, instructions or products referred to in the content.
![Citation: Jagan, S.; Mohd Daud, T.I.;
Chia, L.C.; Saini, S.M.; Midin, M.;
Eng-Teng, N.; Ratnasingam, S.
Evidence for the Effectiveness of
Psychological Interventions for
Internalized Stigma among Adults
with Schizophrenia Spectrum
Disorders: A Systematic Review and
Meta-Analyses. Int. J. Environ. Res.
Public Health 2023, 20, 5570.
https://doi.org/10.3390/
ijerph20085570
Academic Editors: Chung-Ying Lin
and Hector Tsang
Received: 26 January 2023
Revised: 9 March 2023
Accepted: 12 March 2023
Published: 18 April 2023
Copyright: © 2023 by the authors.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and
conditions of the Creative Commons
Attribution (CC BY) license (https://
creativecommons.org/licenses/by/
4.0/).
International Journal of
Environmental Research
and Public Health
Review
Evidence for the Effectiveness of Psychological Interventions
for Internalized Stigma among Adults with Schizophrenia
Spectrum Disorders: A Systematic Review and Meta-Analyses
Shankar Jagan 1,2,3, Tuti Iryani Mohd Daud 1,2,* , Lip Choy Chia 4, Suriati Mohamed Saini 1,2 ,
Marhani Midin 1,2, Ng Eng-Teng 1,2 and Selvasingam Ratnasingam 3
1 Department of Psychiatry, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre,
Kuala Lumpur 56000, Malaysia
2 Hospital Canselor Tuanku Muhriz, Jalan Yaacob Latif, Bandar Tun Razak, Kuala Lumpur 56000, Malaysia
3 Department of Psychiatry & Mental Health, Sarawak General Hospital, Ministry of Health Malaysia,
Sarawak 93586, Malaysia
4 Department of Psychiatry and Mental Health, Hospital Keningau, Peti Surat 11 Jalan Apin-Apin,
Keningau 89007, Malaysia
* Correspondence: tutimd@ppukm.ukm.edu.my; Tel.: +60-3914-56143
Abstract: In recent years, psychological interventions have been used to alleviate internalized stigma
in people with schizophrenia spectrum disorders, but outcomes have been inconsistent. The aim of
this review was to examine the existing evidence regarding this matter. Four electronic databases
(EMBASE, MEDLINE, PsycINFO, and the Cochrane Central Register of Controlled Trials) were
searched from inception until 8 September 2022, using appropriate strategies. The eligibility, quality,
and strength of evidence of each study were all evaluated against the predetermined standards.
Further quantitative analyses were performed using the RevMan software. A total of 27 studies were
included in the systematic review. Eighteen studies with extractable data for meta-analysis yielded
a statistically significant overall effect (Z = 3.00; p = 0.003; 95% CI: −0.69 [−1.15, −0.24]; n = 1633),
although there was considerable heterogeneity (Tau2 = 0.89; Chi2 = 303.62, df = 17; p < 0.00001;
I2 = 94%). Subgroup analyses for Narrative Enhancement and Cognitive Therapy (NECT) produced
a statistically significant and highly homogenous effect (Z = 3.40; p = 0.0007; 95% CI: −0.44 [−0.70,
−0.19]; n = 241; Tau2 = 0.00; Chi2 = 0.14, df = 2 (p = 0.93); I2 = 0%). In conclusion, the majority of the
psychological interventions are successful in lowering levels of internalized stigma, especially NECT,
and interventions that integrate multiple therapies may be more beneficial.
Keywords: internalized stigma; internalised stigma; psychological interventions; therapies; schizophrenia
spectrum disorders; NECT; systematic review; meta-analyses
1. Introduction
Internalized stigma occurs when an individual with a mental health condition adopts
stigmatizing attitudes about their condition as their own. This acceptance can have a
negative impact on the person’s sense of self-worth and ability to recover from their
illness [1–3]. Included in the category of internalized stigma are both felt/perceived stigma
and self-stigma [4]. This is consistent with the regressive model of self-stigma proposed by
Corrigan, which comprises four stages [5]. First, one becomes aware of the stigma of mental
illness (also called “perceived stigma”), then one agrees with the stigma, one subsequently
applies the stigma to oneself, and finally one experiences the negative effects of the stigma
on one’s self-esteem and self-efficacy, which leads to shame (also known as “self-stigma”).
Thus, according to this model, perceived stigma is the first stage of self-stigma formation.
Both perceived stigma and self-stigma are involved in the internalization of public stigma.
Thus, both perceived stigma and self-stigma are classified as internalized stigma. Therefore,
Int. J. Environ. Res. Public Health 2023, 20, 5570. https://doi.org/10.3390/ijerph20085570 https://www.mdpi.com/journal/ijerph](https://image.slidesharecdn.com/ijerph-20-05570-v3-230504110405-59dfba66/85/ijerph-20-05570-v3-pdf-1-320.jpg)
![Int. J. Environ. Res. Public Health 2023, 20, 5570 2 of 24
it corresponds with the categorization proposed by Livingston and Boyd. Internalized
stigma has great inhibitory effects on the intention of seeking help [6,7].
Schizophrenia is a renowned, serious mental illness that affects a large number of peo-
ple in society. According to the WHO in early 2022, schizophrenia affected approximately
24 million people, or 1 in 300 people (0.32%) worldwide [8]. Males and females are equally
affected; however, the peak ages of onset differ: males are affected between the ages of
10 and 25 years, while females are affected between the ages of 25 and 35 years [9]. Suicide
accounts for 4 to 10% of all deaths among those diagnosed with schizophrenia, predomi-
nantly affecting young males [10]. This could be due to a variety of factors, including the
reaction to the psychosis and the experience of stigma.
The World Health Organization has identified three main points regarding stigma
and mental illness: (1) stigma is the primary reason for discrimination against and rejec-
tion of people with mental illness; (2) stigma has negative effects on both the prevention
of mental health problems and the treatment and care of those who suffer from them;
and (3) stigma violates human rights [11]. According to several studies, people with
schizophrenia are more likely to experience and suffer from self-stigma than people with
other mental illnesses [12,13]. Forty-one percent of a sizable European sample of adults
with a schizophrenia-spectrum diagnosis reported high levels of internalized stigma, while
69 percent reported moderate or severe perceived discrimination [14]. A systematic review
conducted on persons with schizophrenia spectrum disorders found that approximately
65% of participants felt stigmatized, and 56% had experienced it [15]. Stigmatization of
those diagnosed with schizophrenia is widespread, and it may stem from skewed assump-
tions regarding their physical appearance and inconsistent acts that are associated with
altered thoughts, perceptions, and behaviors [16]. Individuals having schizophrenia may
experience exclusion by members of society and misconduct displayed against them re-
garding their emotions, thoughts, and behaviors [17]. Debilitating symptoms associated
with the condition are labelled as “madness” by society, which leads to stigmatization, dis-
crimination, and a decrease in productivity, all of which have a significant negative impact
on the patient’s emotional, social, and economic well-being [18]. The majority of people
diagnosed with schizophrenia reported having a low level of perceived social support, with
support from significant others ranking the lowest, followed by support from friends and
family [19]. Even when functional remission is reached, there is still a high unemployment
rate among people with schizophrenia [20]. Prior research demonstrated that people with
schizophrenia are disproportionately affected by internalized stigma [21,22]. The impaired
functioning that is common in schizophrenia presents significant difficulties for both the
affected person’s family and the surrounding society. Hence, among the vital goals of
treatment for people with schizophrenia is to enhance their capacity to function and become
self-sufficient through enhanced social adaptation [23,24].
Psychological interventions aiming to reduce the detrimental effects of internalized
stigma on individuals with schizophrenia spectrum disorders have garnered considerable
attention in recent years. The results of several systematic reviews and meta-analyses
published in the last few years on interventions to diminish internalized stigma are still
inconsistent [25–28]. This might be due to a lack of prior experimental trials that have
been conducted to establish the efficacy of a certain intervention. Consequently, it is
impossible to reliably verify the pooled effect sizes. In the early stages of an intervention,
the lack of research from various locations around the world may reduce our understanding
of its potential overall efficacy. At present, various psychological interventions have
been developed and tested to reduce internalized stigma in patients with schizophrenia
spectrum disorders, such as Group Psychoeducation [29–32] and Narrative Enhancement
and Cognitive Therapy (NECT) [33,34]. Such treatments are crucial because they can
target a wide variety of factors that relate to the psychological process of the production
of internalized stigma, which was mentioned previously. The outcomes of interventions
at different time intervals or in different regions varied greatly. This might be because of
numerous variables such as small sample sizes, variation in intervention implementation,](data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7)