Stigma is a widely researched concept, with public stigma, courtesy stigma and self-stigma (or internalised stigma) frequently cited as issues for those experiencing mental health issues. Individuals with experiences of psychosis are some of the most stigmatised in society, and yet the consequences of stigma on outcomes in psychosis are unclear. The four studies presented in this doctoral thesis used mixed methods to examine the impacts of stigma on recovery from psychosis, and the psychological mechanisms through which these effects might occur. It addresses two areas lacking in sufficient research within the stigma literature: clarity in the relationship between experiences of stigma and internalised stigma; and the effects of stigma on outcomes in psychosis. In particular it examines the relationship between stigma and internalised stigma with two diagnoses on the psychosis spectrum: schizophrenia and bipolar disorder. The study reported in Chapters 3 and 4, was a qualitative investigation based on interviews with 19 individuals who had received a diagnosis of either schizophrenia or bipolar disorder. The objective of the investigation was to explore how individuals processed receiving a diagnosis of schizophrenia or bipolar disorder, and how perceived, experienced and internalised stigma influenced the participants’ self-perception, interactions and recovery feelings. Three overarching themes were identified which were negatively affected by stigma: reactions and responses; relationships; and recovery. The study reinforced the notion that stigma is a significant concern for service-users with diagnoses of bipolar disorder and schizophrenia, and was pervasive in all spheres of life; ultimately impacting on hopes for the future. An unexpected aspect of the qualitative interviews was the participants’ focus on the role of mental health services and experiences of treatment, particularly antipsychotic medication. As this is clearly an important aspect of the participants’ experiences of living with psychosis, this was written up separately, forming Chapter 4. Five overarching themes were identified: living with medication; reinforcing stigma; involvement in care; unmet needs; and positive aspects of care. The findings from this study indicated that whilst service-users made positive reports of aspects of both medication and clinical services; they had extensive concerns about the use of medication, and felt limited in their choice of alternatives. Moreover, service-users felt they lacked autonomy, were not involved in care decisions, and thought their contact with services lacked the ‘human touch’ and could be both invalidating and frustrating. The study presented in Chapter 5, used an epidemiological, longitudinal dataset (n=80) that formed part of independent research commissioned by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research scheme (RP-PG-0606-1086). This study aimed to examine how stigma impacts on symptomatic and subjective recovery from psychosis, both concurrently and longitudinally. We also aimed to investigate whether self-esteem and hopelessness mediated the observed associations between stigma and outcomes. In cross sectional regression and multiple mediation analyses of the baseline data, we found that stigma predicted both symptomatic and subjective recovery, and the effects of stigma on these outcomes were mediated by hopelessness and self-esteem. When the follow-up data were examined, stigma at baseline continued to predict recovery judgements and symptoms. However, self-esteem only mediated the effect of stigma on passive social withdrawal. The study reported in Chapter 6 utilised a clinical sample of 59 service-users with a diagnosis of either schizophrenia or bipolar disorder. The objectives of the study were to assess the impact of stigma on subjective recovery from psychosis, and whether self-esteem and internalised stigma mediates the observed associations between stigmatizing experiences and outcome, thus clarifying the relationship between stigma, self-stigma and recovery. Diagnosis was a persistently significant factor in all analyses, suggesting a negative effect of the term ‘schizophrenia’ on subjective recovery perceptions. In a multiple serial mediation analysis, experiences of stigma predicated subjective recovery and this effect was mediated through internalised stigma, which consequently impaired self-esteem. Findings from these studies suggest that stigma reduces individual’s perceived ability to recover, impairs individual’s perceptions of their progress in recovery, and negatively impacts on psychosis symptoms. These effects occur predominantly through the internalisation of stigma, causing devaluation of self-image and consequently reducing self-esteem. The findings further suggest that whilst the experiences of individuals diagnosed with bipolar disorder and schizophrenia are predominantly similar, ‘schizophrenia’ is an inherently negative term which affects subjective recovery perceptions even when controlling for symptoms. Finally, it is evident that help-seeking is not always helpful, and there are numerous issues with medication and mental health services that can create feelings of hopelessness and reinforce stigmatising stereotypes of severe mental illness. Overall, the findings have significant clinical implications. Internalised stigma is an important psychological mechanism in recovery, and directly links to experiences of stigma. There is a need for clinical services to work in a stigma-informed way in an effort to reduce the impact of stigma post-diagnosis, as well as the development of interventions aimed at preventing stigma from being internalised. Interventions aimed at improving self-esteem and reducing hopelessness for psychosis-spectrum service-users are needed to further reduce the effects of stigma on recovery. Moreover, there is a need for clinical services to reduce behaviours that reinforce stigma, and work collaboratively and transparently with service-users; ensuring that goals for treatment correspond between clinicians and consumers to provide a more patient-centred approach to care.
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