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. Author manuscript; available in PMC: 2021 Jun 1.
Published in final edited form as: Psychiatr Rehabil J. 2019 Aug 15;43(2):91–96. doi: 10.1037/prj0000386

Internalized Stigma, Sense of Belonging, and Suicidal Ideation Among Veterans with Serious Mental Illness

Heather Wastler 1, Alicia Lucksted 1, Peter Phalen 1, Amy Drapalski 1
PMCID: PMC7021557  NIHMSID: NIHMS1045354  PMID: 31414842

Abstract

Objective:

There is emerging evidence that internalized stigma increases risk for suicide among individuals with serious mental illness. The purpose of the current study was to evaluate whether sense of belonging moderates the relationship between internalized stigma and suicidal ideation.

Method:

242 veterans with serious mental illness completed measures of internalized stigma, belongingness, and depression. Moderation analysis was used to determine whether sense of belonging interacts with internalized stigma to predict suicidal ideation when accounting for individual differences in depression and relevant demographic variables.

Results:

Consistent with our hypothesis, sense of belonging significantly moderated the relationship between internalized stigma and suicidal ideation. Specifically, the relationship between internalized stigma and suicidal ideation was strongest when sense of belonging was low.

Conclusions and Implications for Practice:

Internalized stigma and belongingness interact to increase risk for suicide. Both constructs should be assessed and included in interventions to reduce suicide risk among veterans with serious mental illness.

Keywords: stigma, belonging, interpersonal psychological theory of suicide, serious mental illness, depression

Internalized stigma refers to the process by which people with serious mental illness endorse and personally apply societal prejudices and stereotypes about mental illness to themselves (e.g. Watson, Corrigan, Larson, & Sells, 2006; Lucksted & Drapalski, 2015). Internalized stigma has profound negative effects, contributing to depression, hopelessness, social isolation, poor self-esteem, as well as reduced quality of life, recovery, and treatment engagement (e.g. Drapalski et al., 2013; Livingston & Boyd, 2010; Yanos, Roe, Markus, & Lysaker, 2008). As many of internalized stigma’s negative outcomes are also well-established risk factors for suicide, internalized stigma has also been discussed as an under-appreciated contributor to suicidal ideation, and therefore an additional target for assessment and intervention (Rüsch, Zlati, Black, & Thornicroft, 2014). The few studies evaluating this relationship have found that internalized stigma is a significant predictor of suicidal ideation among individuals with mental illness broadly defined (Oexle, Waldmann, Staiger, Xu, Rüsch, 2016; Oexle et al. 2017), and among those with serious mental illness (Farrelly, Jeffery, Rüsch, Williams, Thornicroft, Clement, 2015; Sharaf, Ossman, Lachine, 2012; Touriño et al., 2018). Despite this emerging evidence, internalized stigma is rarely considered in suicide risk assessment or intervention, and this area of research is considerably understudied. In fact, little is known about how internalized stigma impacts suicidality among people living with serious mental illness. Social isolation and hopelessness are two potential factors that might influence this relationship, though this work is limited and additional research is needed (Farrelly et al., 2015; Touriño et al., 2018).

At the same time, the suggestion that social isolation and hopelessness may influence the relationship between internalized stigma and suicidality is consistent with one of the predominant theories in the general suicide literature, the Interpersonal Psychological Theory (IPT). This theory suggests that thwarted belongingness, perceived burdensomeness, and acquired capability to act on suicidal thoughts interact to increase risk for suicide (Chu et al., 2017; Joiner, 2005; Van Orden et al., 2010). According to this theory, suicidal ideation develops when people experience self-hatred, perceiving themselves as a liability to others (perceived burdensomeness) and feel lonely/disconnected due to a lack of meaningful relationships (thwarted belongingness). IPT suggests that either experience is sufficient for passive suicidal ideation (e.g. ‘I would be better off dead’), whereas the simultaneous experience of both increases risk for active suicidal ideation (e.g. ‘I want to kill myself’).

Both perceived burdensomeness and thwarted belongingness are particularly relevant to the relationship between internalized stigma and suicidal ideation. Current IPT literature calls for research to understand factors that influence thwarted belonging and perceived burdensomeness to promote more comprehensive and effective assessments and early interventions (Chu et al., 2017; Joiner, 2005; Van Orden et al., 2010). Notably, however, internalized stigma has yet to be considered in the IPT literature. Given the nature and impact of internalized stigma’s negative effects, it might be an important contributor to both thwarted belonging and perceived burdensomeness. This idea is supported by research repeatedly showing a relationship between internalized stigma and social isolation/sense of belonging (e.g. Drapalski et al., 2013; Lysaker et al., 2007; Treichler & Lucksted, 2018; Yanos et al., 2008). Additionally, when individuals with serious mental illness endorse and apply negative stereotypes about mental illness to themselves (e.g. ‘people with mental illness cannot make important contributions to society’), they might then perceive themselves as a burden on others and withdraw from social interactions. Therefore, internalized stigma might be one of many experiences that lead to both thwarted belonging and perceived burdensomeness, and it might serve as an ‘observable indicator’ that adds to established proxies for these constructs (e.g. low self-esteem, self-blame, loneliness, social withdrawal) (Joiner, 2005; Van Orden et al., 2010).

Therefore, the purpose of the current study was to examine the relationship between internalized stigma, sense of belonging, and suicidal ideation in a sample of veterans with serious mental illness, a population that is particularly high risk for suicide (e.g. Ilgen et al., 2010; Jahn et al., 2018). We hypothesized that sense of belonging would moderate the relationship between internalized stigma and suicidal ideation. More specifically, we hypothesized that there would be a strong positive relationship between internalized stigma and suicidal ideation when sense of belonging is low and little to no relationship between internalized stigma and suicidal ideation when sense of belonging is high.

Method

Participants

The current study used baseline data from a randomized control trial of a group-based intervention for self-stigma. The parent study was pre-approved by the University of Maryland Baltimore and the VA Research & Development IRB. Participants were recruited via clinician referrals, review of clinic rosters, and flyers posted in outpatient mental health clinics at three VA medical centers in the DC Metro area. Baseline data was collected for 248 veterans with chart diagnoses of schizophrenia, schizoaffective disorder, bipolar disorder, or major depression with psychotic features. Our sample included 242 veterans, as six participants were excluded due to missing data. Demographic characteristics are reported in Table 1.

Table 1.

Participant Characteristics

Demographic n (%)
Diagnosis
 Bipolar 101 (41.7%)
 Schizophrenia 61 (25.2%)
 Schizoaffective 64 (26.4%)
 Depression with psychosis 16 (6.6%)
Age (M ± SD) 53.49 ± 9.05
Years of Education (M ± SD) 13.14 ± 2.28
Sex
 Male 209 (86.4%)
 Female 33 (13.6%)
Race
 African American 140 (57.9%)
 Caucasian 80 (33.1%)
 Biracial 14 (5.8%)
 Other 6(2.4%)
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Note: Other= Asian (2), American Indian or Alaska Native (3), and Native Hawaiian or other Pacific Islander (1)

Measures

The Internalized Stigma of Mental Illness Inventory served as our measure of internalized stigma (ISMI; Ritsher, Otilingam, & Grajales, 2003). The ISMI is a valid and reliable measure of internalized stigma that consists of 29-items on a 4-point Likert response scale (1= strongly disagree to 4= strongly agree) with higher scores indicating greater internalized stigma. The ISMI has five subscales assessing alienation, stereotype endorsement, discrimination experiences, social withdrawal, and stigma resistance. The current study utilized a 24-item total score that excludes Stigma Resistance, as this subscale reduces the internal consistency of the measure (Lysaker, Roe, Yanos, 2007); Cronbach’s alpha for the ISMI Total without Stigma Resistance in our sample was α=0.925, which was reduced to α=0.885 when stigma resistance items were included.

The Sense of Belonging Inventory (SOBI; Hagerty & Patusky, 1995) served as our measure of thwarted belongingness. The SOBI is a valid and reliable measure of belonging that consists of 32-items on a 4-point Likert response scale (1= strongly disagree to 4= strongly agree) with higher scores indicating greater sense of belonging. The SOBI consists of two subscales measuring antecedents that must be present for developing a sense of belonging (SOBI-A) and one’s psychological experience of being valued in personal relationships (SOBI-P). Sense of belonging measured by the SOBI-P is theoretically aligned with IPT’s description of thwarted belongingness as an unmet need to belong and connect with others through meaningful relationships (Joiner, 2005; Van Orden et al., 2010). The Cronbach’s alpha for the SOBI-P in our sample was α= 0.921.

The Brief Symptom Inventory (BSI; Derogatis & Melisaratos, 1983) served as our measure of depression and suicidal ideation. The BSI consists of 53-items assessing distress from various psychological domains (e.g. depression, anxiety, somatic concerns). Items are measured using a 5-point Likert response scale (0 = not at all and 4 = extremely) with higher scores indicating greater severity and distress from symptoms. The current study used the BSI Item 9 (BSI-9), “Thoughts of ending your life,” as a measure of suicidal ideation. Additionally, the depression subscale (with the suicidal ideation item removed) was included as a covariate in the analysis.

Statistical Analyses

Analyses were conducted using SPSS Version 24.0. Bivariate Pearson correlations were conducted among our psychological variables of interest (ISMI, SOBI-P, and BSI-9). Covariates were selected based on significant correlations between demographic variables and suicidal ideation; years of education was the only variable significantly related to suicidal ideation (r = 0.157, p = 0.014; other values available upon request). Additionally, depression was included as a covariate given the substantial body of literature establishing depression as a risk factor suicide (e.g. Bostwick & Pankratz, 2000; Goldney, Dal Grande, Fisher, & Wilson, 2003; Nock et al., 2009; Ribeiro, Huang, Fox, & Franklin, 2018) and the significant relationship between depression and suicidal ideation in our sample (r = 0.332, p < 0.01). Prior to analysis, sense of belonging and internalized stigma were mean centered. The SPSS PROCESS MACRO Model 1 (Hayes, 2018) was then used to test whether sense of belonging moderated the relationship between internalized stigma and suicidal ideation when accounting for individual differences in depression and education. An analysis of simple effects was used to probe the interaction (e.g. Rogosa, 1980; Bauer & Curran, 2005). Additionally, the Johnson-Neyman technique was used to identify values of the moderator at which sense of belonging had a significant effect on the relationship between internalized stigma and suicidal ideation (Johnson & Fey, 1950).

Results

Bivariate correlations between internalized stigma, sense of belonging, and suicidal ideation were significant in the expected directions (see Table 2). The overall regression model was significant, explaining 15.16% of the variance in suicidal ideation, F(5,236)= 8.432, p <0.001. The main effects for internalized stigma (b= 0.0932, t= 0.845; p = 0.399; 95% CI [−0.124, 0.311]) and sense of belonging (b= −0.0006, t= −0.1102, p = 0.912, 95% CI [−.0110, .0098]) were not statistically significant. Sense of belonging significantly interacted with internalized stigma to predict suicidal ideation even when accounting for individual differences in depression and education (b= −0.0150, t= −2.3721, p = 0.0185, 95% CI [−0.0275, −0.0025]).

Table 2.

Internalized Stigma, Sense of Belonging, and Suicidal Ideation Correlation Matrix

1 2 3
1. ISMI —
2. SOBI- P −0.651** —
3. BSI-9 0.239** −0.229** —
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**

p < 0.01

Note: ISMI = Internalized Stigma of Mental Illness Inventory total score without stigma resistance. SOBI-P = Sense of Belonging Instrument- Psychological Experiences subscale. BSI-9 = Suicidal ideation item of the Brief Symptom Inventory

To further explore this interaction, we used simple effects of internalized stigma on suicidal ideation at three levels of belonging (see Figure 1): low (−1SD), moderate (mean), and high (+1SD). Results suggest that the relationship between internalized stigma and suicidal ideation is strongest when sense of belonging is low (b= 0.256, t= 1.94, p = 0.054, 95% CI [−0.0046, 0.516]). For individuals who report moderate (b= 0.093, t=0 .845, p= 0.399, 95% CI [−0.124, 0.311]) to high (b= −0.069, t= −0.542, p= 0.589, 95% CI [−0.321, 0.182]) sense of belonging, there is no relationship between internalized stigma and suicidal ideation. The Johnson-Neyman technique revealed that the relationship between internalized stigma and suicidal ideation was significant when sense of belonging was in the bottom 15% of our sample.

Figure 1.

Figure 1.

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The effects of internalized stigma on suicidal ideation at low, moderate, and high levels o belonging. To enhance interpretability this graph uses raw, non-mean centered values.

Discussion

Our finding that sense of belonging moderates the relationship between internalized stigma and suicidal ideation is consistent with the Interpersonal Psychological Theory of suicide (Chu et al., 2017; Joiner, 2005; Van Orden et al., 2010). IPT suggests that passive suicidal ideation (e.g. ‘I would be better off dead’) develops when people experience either perceived burdensomeness or thwarted belongingness, whereas the simultaneous experience of both increases risk for active suicidal ideation (e.g. ‘I want to kill myself;’ Joiner, 2005; Van Orden et al., 2010). Our findings support this theory, as we found that internalized stigma was related to increased thoughts of suicide when sense of belonging was low, even when controlling for depression and education. That is, the simultaneous experience of internalized stigma and low sense of belonging increases risk for suicidal ideation. Additionally, the lack of relationship between internalized stigma and suicidal ideation when sense of belonging is high suggests that belongingness/connectedness might buffer against the negative effects of internalized stigma, serving as a potential protective factor against suicidal ideation. It should also be noted that, among participants with low sense of belonging, where self-stigma did have a significant exacerbating effect on suicidal ideation, the impact was relatively small; participants with a standard deviation increase in internalized stigma scored just 0.3 higher on the suicidal ideation item’s 5-point Likert scale.

Given the high rates of suicide among veterans with serious mental illness (e.g. Ilgen et al., 2010; Jahn et al., 2018), even this modest effect has important implications for suicide risk assessment, prevention, and intervention efforts. Comprehensive suicide risk assessments often occur only after an individual has expressed suicidal ideation. Such assessments typically focus on proximal risk factors (e.g. intent, method, plan, preparatory behavior) rather than risk or protective factors that precede the development of suicidal ideation (e.g. Columbia Suicide Severity Rating Scale; Posner et al., 2011). The assessment of a broader array of risk and protective factors that occur before the expression of suicidal ideation (i.e. internalized stigma, perceived burdensomeness, low sense of belonging) might yield the best outcome for suicide prevention efforts (Chu et al., 2017; Joiner, 2005; Stellrecht et al., 2006; Van Orden et al., 2010) and would certainly complement existing proximal interventions.

Additionally, IPT has important implications for suicide prevention/intervention efforts (Chu et al., 2017; Joiner, 2005). Our findings specifically implicate internalized stigma and sense of belonging as two potential targets for suicide intervention. For example, interventions that focus on the development and maintenance of meaningful, close relationships and/or strengthening and repairing existing relationships, might enhance belongingness and buffer against the negative effects of internalized stigma, including its contribution to suicidal ideation. Such interventions might include a group psychotherapy component that fosters belongingness among members with shared experiences, social skills training, therapeutic family programs, and/or in-vivo community integration components focused on developing meaningful relationships and connections within community organizations. Interventions and strategies specifically aimed to help individuals with serious mental illness reduce or resist internalized stigma (Yanos, Lucksted, Drapalski, Roe, & Lysaker, 2015) could also help reduce risk of suicidal ideation, perhaps especially among people experiencing low or thwarted sense of belonging. However, these predictions about treatment implications are untested, and longitudinal or experimental research is needed to evaluate the hypothesis that reductions in internalized stigma will lead to reductions in suicidality. Clinical trials evaluating the efficacy and effectiveness of self-stigma interventions might consider measuring suicidality as an outcome to further explore this hypothesis.

Several limitations should be considered while interpreting our results. First, the current study involved secondary analysis of baseline data from a randomized control trial of a group-based intervention for self-stigma. Therefore, we used a single-item proxy measure of suicidal ideation, which raises potential concerns about validity and reliability. Given IPT’s specific hypotheses about the development of suicidal ideation versus suicidal behavior, future studies should include more comprehensive measures of suicidality that assess for passive versus active suicidal ideation as well as suicidal behaviors (e.g. Columbia Suicide Severity Rating Scale; Posner et al., 2011). Such work will provide a better understanding of how internalized stigma and sense of belonging interact to influence suicide risk severity, which is used by clinicians to guide clinical decision making. For example, if future studies show that stigma and belonging are primarily related to passive suicidal ideation (i.e. low acute risk), they might best be targeted in outpatient interventions discussed above. However, if they also significantly relate to active suicidal ideation and/or behaviors (i.e. intermediate or high acute risk), then they should also be part of residential and inpatient treatment, which might require additional modifications.

In addition to a more comprehensive assessment of suicidality, future research that utilizes a longitudinal design is essential to validate our conclusions about the implications of the current study. Due to the cross-sectional design of our study, we cannot make inferences about the direction and causal nature of the relationship between internalized stigma, sense of belonging, and suicidal ideation. For example, it is plausible that the relationship between internalized stigma and suicidality is bidirectional, as studies have also shown that people who attempt suicide experience public and internalized stigma (e.g. Batterham, Calear, & Christensen, 2013; Carpiniello, & Pinna, 2017; Hanschmidt, Lehnig, Riedel-Heller, & Kersting, 2016; Rimkeviciene, Hawgood, O’Gorman, & De Leo, 2015; Rimkeviciene, O’Gorman, Hawgood, & De Leo, 2019). Longitudinal research will assess the direction of these relationships and will allow for tests of mediation to validate our findings. Finally, our sample was made of U.S. military veterans who were predominantly men (86%) and mostly African American (58%). Therefore, our findings may not generalize to other populations and further research with a more diverse sample would lend additional support to our findings.

Impact and Implications Statement.

The current study found that the simultaneous experience of self-stigmatizing beliefs and low sense of belonging is related to elevated suicidal ideation. Interventions that focus on the development and maintenance of meaningful, close relationships might increase belongingness, thereby buffering against the negative effects of internalized stigma and reducing suicidal ideation.

Disclosures and acknowledgements

This work was supported by Merit Review Award #1I01HX00279 from the Unites States Department of Veterans Affairs Health Services Research and Development Service, and the VA Capitol Network (VISN5) Mental Illness Research, Education, and Clinical Center. The contents do not represent the views of the U.S. Department of Veterans Affairs or the United States Government. Clinicaltrials.gov identifier: NCT01259427

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