Objective-The mechanisms by which internalized stigma affects outcomes related to recovery among people with severe mental illness have yet to be explicitly studied. This study empirically evaluated a model for how internalized stigma affects important outcomes related to recovery.Methods-A total of 102 persons with schizophrenia spectrum disorders completed measures of internalized stigma, awareness of mental illness, psychiatric symptoms, self-esteem, hopefulness, and coping. Path analyses tested a predicted model and an alternative model for the relationships between the variables.Results-Results from model 1 supported the view that internalized stigma increases avoidant coping, active social avoidance, and depressive symptoms and that these relationships are mediated by the impact of internalized stigma on hope and self-esteem. Results from model 2 replicated significant relationships from model 1 but also supported the hypothesis that positive symptoms may influence hope and self-esteem.Conclusions-Findings from two models supported the hypothesis that internalized stigma affects hope and self-esteem, leading to negative outcomes related to recovery. It is recommended that interventions be developed and tested to address the important effects of internalized stigma on recovery.Research has increasingly revealed that outcomes for persons with severe mental illness encompass a wide range of possibilities and challenges. As noted by several authors (1)(2)(3), what is referred to as recovery involves nonlinear changes across several semi-independent domains. Recovery can be manifested in more externally evident and objectively measured changes such as symptoms, frequency of socialization, and employment (2), as well in terms of more internally experienced and subjectively measured domains such as perceived quality of life and sense of purpose in life (3). The personal experience of mental illness and the potential transformation of identity that often accompanies this experience has been identified as a potential facilitator or inhibitor of recovery among people with severe mental illness (4), and there is evidence that transforming identity is an important part of the process of improving both subjective and objective outcomes in this population (5,6). A type of identity transformation that may affect many people with severe mental illness is the internalization of stereotypic or stigmatizing views (7-11). The state in which a person with severe mental illness loses previously held or hoped for identities (self as student, self as worker, self as parent, and so on) and adopts stigmatizing views (self as dangerous, self as incompetent, and so on) is typically referred to as "internalized stigma." As an illustration, a person with a college degree and prior aspirations to become a math teacher might conclude that he or she could never achieve this goal if he or she believes that the diagnosis of mental illness means that one is unpredictable and not to be trusted. Internalized stigma has been found to be...

Poor insight in schizophrenia is prevalent across cultures and phases of illness. In this review, we examine the recent research on the relationship of insight with behavior, mood and perceived quality of life, on its complex roots, and on the effects of existing and emerging treatments. This research indicates that poor insight predicts poorer treatment adherence and therapeutic alliance, higher symptom severity and more impaired community function, while good insight predicts a higher frequency of depression and demoralization, especially when coupled with stigma and social disadvantage. This research also suggests that poor insight may arise in response to biological, experiential, neuropsychological, social-cognitive, metacognitive and socio-political factors. Studies of the effects of existing and developing treatments indicate that they may influence insight. In the context of earlier research and historical models, these findings support an integrative model of poor insight. This model suggests that insight requires the integration of information about changes in internal states, external circumstances, others' perspectives and life trajectory as well as the multifaceted consequences and causes of each of those changes. One implication is that treatments should, beyond providing education, seek to assist persons with schizophrenia to integrate the broad range of complex and potentially deeply painful experiences which are associated with mental illness into their own personally meaningful, coherent and adaptive picture.

Bleuler suggested that fragmentation of thought, emotion and volition were the unifying feature of the disorders he termed schizophrenia. In this paper we review research seeking to measure some of the aspects of fragmentation related to the experience of the self and others described by Bleuler. We focus on work which uses the concept of metacognition to characterize and quantify alterations or decrements in the processes by which fragments or pieces of information are integrated into a coherent sense of self and others. We describe the rationale and support for one method for quantifying metacognition and its potential to study the fragmentation of a person's sense of themselves, others and the relative place of themselves and others in the larger human community. We summarize research using that method which suggests that deficits in metacognition commonly occur in schizophrenia and are related to basic neurobiological indices of brain functioning. We also present findings indicating that the capacity for metacognition in schizophrenia is positively related to a broad range of aspects of psychological and social functioning when measured concurrently and prospectively. Finally, we discuss the evolution and study of one therapy that targets metacognitive capacity, Metacognitive Reflection and Insight Therapy (MERIT) and its potential to treat fragmentation and promote recovery.