Reducing self-stigma and supporting disclosure in adults with mental illness

In The Lancet Regional Health Europe, Rüsch and colleagues¹ report the results of a pragmatic multicentre randomised controlled trial of Honest, Open, Proud, a peer-led group program developed by the pioneering stigma researcher Patrick Corrigan to support decisions about disclosure of a mental illness. Self-stigma was chosen as the primary outcome based on the premise that empowerment about disclosure drives improvements in how people apply mental illness stereotypes to themselves (e.g. “because I have a mental illness, I will not recover or get better”). These beliefs may harm the pursuit of life goals through effects on self-esteem and self-efficacy. Honest, Open, Proud program doesn't directly challenge these beliefs. Instead, it builds stigma-coping self-efficacy, supporting participants to move from reflexive secrecy toward considered, selective disclosure. It is also plausible that contact with peer facilitators visibly in recovery may help reduce self-stigma beliefs in participants.

Compared to treatment as usual, Honest, Open, Proud participants showed significantly less self-stigma at 6 weeks (−1.83, 95%-CI −2.96 to −0.70, d = −0.24, p = 0.0015) and also at 6-month follow-up (−1.20, 95%-CI −2.36 to −0.05, d = 0.16, p = 0.042). There were also significant positive effects on stigma stress, depressive symptoms, help-seeking intentions, quality of life, recovery and shame, at 6 weeks.

A key strength of the research was its peer-led approach, with lived experience input also incorporated into the design and conduct of the study. Several systematic reviews have evaluated peer-led interventions in mental health, with meta-analyses showing small but consistent effects on clinical and personal recovery.² However, these generally note modest study quality, short follow-up, and limited evaluation of social outcomes. The pragmatic multi-site design of Rüsch and colleagues' trial, with broad inclusion criteria, longer follow-up, transdiagnostic delivery, and measurement of social inclusion and employment outcomes, represents a meaningful advance on this evidence base. Encouragingly, the authors also reported high demand for trial participation, pointing to the likely sustainability of the program.

However, disclosure decisions depend on more than self-stigma and often include a consideration of the environment in which a person might disclose. Reducing self-stigma is likely to always be desirable but increasing disclosure may not be. Supportive environments play a key role in both the disclosure itself and its consequences.³ There, the picture is somewhat less encouraging. Evidence from a number of countries, including Germany, suggests that despite some stigmatising beliefs diminishing over time, willingness to interact with people with mental illness has not improved in recent years.^4,5 If stigmatising beliefs in broader society are not decreasing, it is challenging for people with mental illness not to continue to internalize them.

Moreover, in parallel with studies showing lack of improvement in stigmatising attitudes, recent population surveys in Australia suggest that reported experiences of discrimination have increased since 2014,⁶ while in most domains, disclosure has decreased, including to friends, partners, family members, and people in the neighbourhood.⁷ Workplace disclosure did not change significantly in the period, with most people not disclosing to supervisors or colleagues. While variations in factors such as social safety nets, employment protections and public mental health services limit generalisability to some extent, these findings point to the need for new approaches to reducing stigma and discrimination, including those that tackle structural and interpersonal discrimination, have a focus on inclusive stakeholder engagement, including with people with lived experience, employers, health professionals and others in positions of power.⁸ Context-specific adaptations are also likely to be required, particularly for lower-income countries where social protections may be more limited. Measures of disclosure norms, anticipated discrimination, and perceived organisational support, as well as self-stigma, could usefully be incorporated into evaluations of stigma-reduction programs.

Thus, improving social inclusion outcomes for people with mental health conditions is likely to require a wider roll out of programs such as Honest, Open, Proud as well as strategies to reduce stigmatising beliefs in broader society and improve supportive behaviours by individuals responding to disclosures Population-level education to friends and family on how to provide non-stigmatising, non-judgemental support to those who disclose is likely to play a key role. Better quality support from friends and family has been linked with better mental health in help recipients, better relationships and help seeking, as well as reductions in self-stigma over time.⁹ Improving organisational policies and practices that support those who disclose in workplaces, health, educational, welfare and other settings is also likely to be vital, particularly when economic conditions become more challenging. Low anticipated discrimination, visible resources and social support have been positively associated with willingness to disclose, actual disclosure and better mental health and work outcomes.¹⁰

Contributors

Nicola Reavley: Writing—original draft; Amy Morgan: Writing—review and editing.

Declaration of interests

NR declares no competing interests. AM has received funding from Mental Health First Aid Australia.