Asian Journal of Psychiatry 73 (2022) 103171

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Asian Journal of Psychiatry

journal homepage: www.elsevier.com/locate/ajp

Anti-stigma psychosocial intervention effects on reducing mental illness

self-stigma and increasing self-esteem among patients with schizophrenia in
Taiwan: A quasi-experiment
Chieh-An Shih a, Jiun-Hau Huang a, b, c, *, Man-Hua Yang d, **
a
Institute of Health Policy and Management, College of Public Health, National Taiwan University, Taipei, Taiwan
b
Institute of Health Behaviors and Community Sciences, College of Public Health, National Taiwan University, Taipei, Taiwan
c
Department of Public Health, College of Public Health, National Taiwan University, Taipei, Taiwan
d
College of Nursing, National Yang Ming Chiao Tung University, Taipei, Taiwan

A R T I C L E I N F O A B S T R A C T

Keywords: Previous studies have noted that as self-stigma in patients with schizophrenia increases, their quality of life and
Schizophrenia self-esteem decrease. Considering the cultural differences and scarcity of self-stigma intervention research in
Against Stigma Program Asia, the purpose of this study was to evaluate the intervention effects of the Against Stigma Program on reducing
Intervention
self-stigma and increasing self-esteem among patients with schizophrenia. In this study, 70 patients with
Self-stigma
Self-esteem
schizophrenia were recruited from 3 community psychiatric rehabilitation institutions in Taiwan and assigned to
Taiwan the experimental and control groups. Controls received their usual treatment, and those in the experimental
group participated in the Against Stigma Program (60-minute weekly sessions for 6 weeks). The participants
were assessed at baseline, post-intervention, and 1-month follow-up, using the Internalized Stigma of Mental
Illness Scale (ISMIS) and Rosenberg Self-Esteem Scale (RES). Generalized estimating equations (GEE) were used
to analyze the changes in scores over time and differences between the experimental and control groups. Self-
stigma significantly decreased and self-esteem significantly increased after participation in the Against Stigma
Program. The GEE analysis revealed significant group and time interactions such that self-stigma reduction effect
(B = − 0.291) was stronger in the experimental group at post-intervention, and self-esteem promotion effects at
post-intervention (B = 0.823) and 1-month follow-up (B = 0.543) were both greater in the experimental group.
In conclusion, these findings suggest that the Against Stigma Program can help reduce self-stigma and increase
self-esteem of patients with schizophrenia. This study can be used as an empirical reference to inform future
clinical care of patients with schizophrenia in Taiwan.

1. Introduction
People with mental illness are prone to suffer from stigma and
discrimination from society, even friends and family members (Mental
Health Foundation, 2018). As noted by the WHO: (1) stigma is the main
cause of discrimination against and rejection of people with mental
illness; (2) stigma not only affects the prevention of mental health
problems but also hinders the treatment and care of mental illness; (3)
stigma is a violation of human rights (World Health Organization,
2015). An online survey of nearly 600,000 Internet users from 229
countries further revealed that stigma toward mental illness has become
a critical global mental health issue (Seeman et al., 2016). Specifically,
the general public still had some stereotypes regarding people with
schizophrenia, such as a tendency toward violence and incompetence
(Durand-Zaleski et al., 2012). According to a systematic review,
22.5–96.0% of patients with schizophrenia experienced stigma and
41.7% reported self-stigma (Gerlinger et al., 2013).
Self-stigma encompasses negative stereotypes, prejudice, and self-
discrimination toward people with mental illness, and hence, self-
stigmatization could be defined as endorsing prejudicial stereotypes
that diminish feelings of self-worth (Corrigan and Rao, 2012). In regard
to its mechanism, researchers proposed a three-stage progressive model

* Correspondence to: Institute of Health Behaviors and Community Sciences, College of Public Health, National Taiwan University, 17 Xu-Zhou Road, Taipei
10055, Taiwan.
** Correspondence to: College of Nursing, National Yang Ming Chiao Tung University, No. 155, Section 2, Li-nong Street, Taipei 11221, Taiwan.
E-mail addresses: jhuang@ntu.edu.tw (J.-H. Huang), mhyang@nycu.edu.tw (M.-H. Yang).

https://doi.org/10.1016/j.ajp.2022.103171
Received 7 February 2022; Received in revised form 9 May 2022; Accepted 11 May 2022
Available online 16 May 2022
1876-2018/© 2022 Elsevier B.V. All rights reserved.

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C.-A. Shih et al.
of self-stigma: (1) Awareness: a person with an undesired condition is
aware of the negative stereotypes and develops negative feelings and
emotional reactions toward their certain conditions; (2) Agreement: the
person may agree and believe that these negative stigmatizing stereo­
types are true; (3) Application: the person concurs that these stereotypes
apply to themselves, thereby harming their self-esteem (Corrigan and
Rao, 2012). As has been found in most previous studies, self-stigma was
significantly associated with lower self-esteem (Horsselenberg et al.,
2016; Karakaş et al., 2016).
Compared with Western culture, the notion of stigma in Eastern
culture not only affects the patients but also results in family members
experiencing negative criticism and the perception that the highly
valued elements in Asian culture, such as marriage, children, and family
structure, are more likely to be damaged. Therefore, when a family
member has a mental illness, the patient and their family members
undergo “social death” (Yang et al., 2007). In light of such cultural
differences, some researchers proposed that the concept of self-stigma in
Asian society should include fear of social ostracism, predictions of
marital preclusion, and self-deprecation (Han and Chen, 2008).
People with mental health problems have often been found to be in
denial of their illness and reluctant to seek treatment owing to fear of
being labeled by others, thus delaying necessary medical treatment
(Clement et al., 2015). As such, self-stigma not only can affect patients’
social life, but can also lead to further deterioration of their mental
health (The Lancet, 2016). Especially among patients with schizo­
phrenia, a qualitative study in Taiwan reported that they suffered from
discrimination and rejection at work, within their family, and by society,
causing them to question their value in life and creating a sense of
worthlessness and helplessness (Ku and Hong, 2016). Such self-stigma
has been found to cause great social anxiety and reduce self-esteem,
quality of life, hope, vocational functioning, and treatment compliance
(Gerlinger et al., 2013). Clearly, self-stigma has far-reaching conse­
quences and could cause a tremendous negative impact on patients with
schizophrenia. In Asia, it is particularly concerning that self-stigma ap­
pears to be a pervasive issue. For instance, among people with schizo­
phrenia in India, internalized forms of self-stigma were found to be more
common than actual experiences of discrimination (Koschorke et al.,
2014). Further, a recent study in India showed that self-stigma was
overall the most important predictor of recovery, highlighting the
pivotal role of self-stigma reduction among patients with schizophrenia
(Singla et al., 2020).
In an effort to reduce mental illness self-stigma, psychosocial in­
terventions have been developed in Western as well as Eastern countries
(Wood et al., 2016). For example, some of the current interventions for
self-stigma reduction were devised by Western researchers, including
Ending Self-Stigma (Lucksted et al., 2011), psycho-education group
(MacInnes and Lewis, 2008; Uchino et al., 2012), vocational rehabili­
tation program (Lysaker et al., 2012), and Narrative Enhancement and
Cognitive Therapy (NECT) (Yanos et al., 2012). Most of these in­
terventions involved cognitive restructuring and attitudinal change to­
ward mental illness as the basic components, followed by self-esteem
enhancement and change of attitude toward themselves. The duration of
these interventions ranged from 6 to 40 weeks with varying degrees of
improvement in self-stigma reduction. For instance, the
psycho-education program by MacInnes and Lewis (2008) was a 6-week
group therapy based on the ABC Model (Activating event, Belief,
Consequence). This program first provided information to help the pa­
tients understand mental health problems, followed by discussions of
their experiences and the impact of mental illness on their life, and
finally, definitions of stigma and the ABC Model were introduced to help
them reconstruct their attitudes toward their disease, correct their ir­
rational beliefs, and positively accept their disease. After the 6-week
group intervention, self-stigma was found significantly reduced.
Notably, there have also been a few intervention programs for
reducing self-stigma among people with schizophrenia in Hong Kong
and Mainland China. For example, Fung et al. (2011) adopted an
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Asian Journal of Psychiatry 73 (2022) 103171
integrative approach, including psycho-education, cognitive behavioral
therapy, motivational interviewing, social skills training, and goal
attainment, and developed a program consisting of 12 group and 4 in­
dividual follow-up sessions. The findings of their RCT suggested that,
compared with the newspaper reading group (N = 32), the self-stigma
reduction program (N = 34) had potential to reduce self-esteem decre­
ment, promote readiness for change, and enhance treatment adherence.
In Guangzhou, China, Li et al. (2018) conducted an RCT of internalized
stigma and discrimination reduction, which adopted a
community-based comprehensive approach and found a significant
reduction in anticipated discrimination and an elevation in overcoming
stigma among patients with schizophrenia. In brief, a systematic review
of anti-stigma interventions among people with mental illness in China
concluded that such interventions demonstrated promise to reduce
stigma’s negative impact, but also indicated that there is a need for more
intervention research in the future (Xu et al., 2017).
Consistent with the aforementioned conclusion, another systematic
review and meta-analysis of interventions specifically for self-stigma
reduction in people with schizophrenia also corroborated that, while
the results showed promise in alleviating internalized stigma among
these patients, more interventions are needed to further expand the
empirical evidence base of self-stigma reduction (Wood et al., 2016).
Moreover, as has been the case in Taiwan, previous studies concerning
the stigma of schizophrenia have mostly been qualitative investigations
to understand the experience of the patients (Ku and Hong, 2016).
Hence, it remains largely unknown whether a brief intervention would
be effective in reducing self-stigma among these patients. In addition, it
is worth noting that the duration of many stigma reduction interventions
reviewed above appeared to be 12 weeks or longer. However, consid­
ering the cost and time constraints of a group therapy, a shorter-term
intervention might be more feasible and sustainable for widespread
dissemination in the future such that more patients could benefit from
this evidence-based intervention program. Therefore, to address this
research gap, the current study drew on the 6-week psycho-education
program by MacInnes and Lewis (2008) and adopted a
quasi-experimental design to evaluate the group intervention effects of a
6-week anti-stigma program on reducing self-stigma and increasing
self-esteem among patients with schizophrenia in Taiwan.
2. Methods
2.1. Study design and sampling
This study employed a quasi-experimental design. The participants
in the control group received treatment as usual, and those in the
experimental group participated in the Against Stigma Program, which
was a group course involving a 60-minute session per week for 6 weeks.
Prior to recruitment, power analysis and sample size calculation were
first performed to determine that the optimal number of participants to
recruit at baseline was 70. Next, considering that in Taiwan each psy­
chiatric rehabilitation institution generally has an average of 25–30
residents, this study needed to recruit 3 institutions. Accordingly, a
random selection was performed from the list of psychiatric rehabilita­
tion institutions in northern Taiwan. After we successfully obtained
approval from 3 institutions, consenting participants were then
randomly assigned to either the experimental or the control group, using
coin tosses. The group intervention was conducted within the institution
in an enclosed room for residents’ group activities, such as occupational
therapy sessions and rehabilitation training classes. As a result, not
knowing to which group they were randomized, the participants might
think the 2 groups were simply taking turns engaging in therapy sessions
as usual. Besides, before the implementation of the study, each partici­
pant was reminded not to discuss group activities with other patients in
the institution to avoid affecting the results of this study.
C.-A. Shih et al.
2.2. Participants and procedures
The inclusion criteria for the participants in this study were: (1) a
schizophrenia diagnosis (DSM-V); (2) residence in the community psy­
chiatric rehabilitation institution for more than 10 weeks; (3) ages
20–65; and (4) willingness to participate in this study. The exclusion
criteria were: persons with cognitive impairment, alcoholism, brain
injury, mental retardation, personality disorders, or a history of sub­
stance abuse.
To ensure sufficient statistical power for this study, the sample size
was carefully calculated and pre-determined before recruitment. First,
based on the estimated effect size of 0.321 of a randomized controlled
trial of self-stigma reduction among patients with schizophrenia in Hong
Kong (Fung et al., 2011), this study used G*Power 3.1 for power anal­
ysis, and with an alpha of 0.05 and a power of 80%, the total sample size
required for this experiment was calculated to be 54. Next, drawing on
the empirical findings of a self-stigma reduction intervention in India
(Amaresha et al., 2018), this study set the attrition rate to be 22%. As
such, the planned number of participants to recruit at baseline was
estimated to be 70. Fortunately, no participants dropped out of the study
and the final sample size remained at 70, achieving a power of 90% for
this study in the end.
The study protocol was reviewed and approved by the Institutional
Review Board of National Yang Ming Chiao Tung University. The ethical
approval of this study was officially granted on March 27, 2019
(approval number: YM108027F). Accordingly, this study started
recruiting participants from March 28 through April 19, 2019 by
verbally advertising and disclosing the full content of the study’s non-
therapeutic sessions in the social hall of the institution. Those patients
who expressed interest in seeking more information would be provided
with detailed consent form information. After all their queries were
responded to and they were well informed about this study, they then
decided whether to officially consent to participate. The recruited
sample consisted of 70 patients, with 35 in the experimental group and
35 in the control group.
2.3. Measures
2.3.1. Internalized Stigma of Mental Illness Scale (ISMIS)
The self-rated ISMIS contains 29 items concerning self-stigma in 5
subscales (alienation, stereotype endorsement, discrimination experi­
ence, social withdrawal, and stigma resistance) (Ritsher et al., 2003).
Each item was rated on a 4-point Likert-type scale from 1 (Strongly
disagree) to 4 (Strongly agree), with a total score ranging from 29 to 116.
Following the convention of previous research (Singla et al., 2020), this
study further divided the above ISMIS total score by 29 to create a mean
ISMIS score for each participant, ranging from 1 to 4, with a higher score
indicating more serious stigma. The internal consistency of the original
scale was good (Cronbach’s α = 0.90). The Chinese version of the scale
was developed by Wu and Tang (2012), and the overall Cronbach’s α
value was 0.93, indicating good internal consistency.
2.3.2. Rosenberg Self-Esteem Scale (RES)
This study used the self-esteem scale developed by Rosenberg
(1962); all items are answered using a 4-point Likert-type scale ranging
from strongly disagree to strongly agree. The RES has a total of 10 items,
including 5 positive items and 5 negative items. A higher score corre­
sponds to higher overall self-esteem. The Cronbach’s α of the scale was
0.84 (Piyavhatkul et al., 2011). This study used the 10-item Chinese
version of the RES translated by Wang et al. (1992), which showed good
internal consistency (Cronbach’s α = 0.87).
2.4. Against Stigma Program (ASP)
The ASP drew on the structure of the 6-week group program
designed by MacInnes and Lewis (2008) to reduce self-stigma and their
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Asian Journal of Psychiatry 73 (2022) 103171
application of the ABC Model as a theoretical framework to guide the
arrangement of our group therapy curriculum. As regards the cultural
adaptation for patients in Taiwan, owing to lack of empirical reference
for self-stigma reduction interventions among patients with schizo­
phrenia in Taiwan, this study consulted Mental Health and Counseling
by Yang and Wu (2016) as a reference for intervention strategies geared
toward people with a Chinese cultural background. This book in­
corporates the cultures of Asian countries and provides introduction and
recommendations for mental health group therapy, thereby being a
suitable reference for this study in Taiwan. Table 1 presents the frame­
work of this 6-week ASP, including the focus and main theme of each
weekly session, as well as the specific questions for patients to ponder
and discuss each week. Informed by prior research noted above, the
aforementioned process itself, which entailed psychological motivation,
education, etc., was the intervention strategy designed to reduce
self-stigma and increase self-esteem. It should be noted that, for better
cultural adaptation and optimal program effectiveness, from Week 2
onward, the scenarios for the weekly discussions strategically involved
issues that most people are concerned about in Taiwan culture, such as
marriage, children, family, work, etc.
Also, the implementation of this study strictly followed the protocol
for consistency. Therefore, to ensure that the interventions delivered
across various sessions among participants were comparable, all group
therapy sessions were conducted by the same researcher, who had more
than 3 years of clinical and group therapy experience with people with
mental illness.
2.5. Data collection
After ethical approval was granted and participants consented to
participate in this study, data were collected at 3 time points: 1 week
before the group intervention (T1), immediately after the group
Table 1
Framework of the 6-week Against Stigma Program.
Scenarios in which negative emotions occur (time, place, person, or event)
Week 1 Knowledge education
What is mental illness? What is self-stigma? What obstacles does mental
illness bring to my interpersonal interactions and life?
Week 2 Emotional distress
What are your emotions or feelings when an event occurs?
(For example, real-time feelings, physical responses, and behavioral
changes after the event, especially pertaining to interactions with family
members.)
Cognitive bias
What are your thoughts when you have the above negative emotions or
feelings after an event occurs? (For example, if I cannot get this job, I am
a loser; I cannot get married, start a family, and have my own children,
because of my disease.)
Week 3 Negative core beliefs/self-beliefs
What do the above thoughts mean to you now? Based on the above
thoughts, what do you think of yourself? (Beliefs toward mental illness
and patients with mental illness)
Addressing irrational thoughts
What are the reasons for the formation of negative beliefs? Are these
negative beliefs and thoughts true? (When the patient feels that mental
illness cannot be treated and he/she cannot find a job, the following
questions can be asked of the patient: What are the best outcomes? What
is the worst-case scenario? What are the emotional, physical, and
behavioral responses?)
Week 4 Converting negative core beliefs
If the time/location/event changes, what do you think other people
would say about you? (Imagine that you live a wonderful life after 5 or
10 years.)
Positive core beliefs
After converting the above negative self-beliefs, what positive self-
beliefs do you think you would use to replace the negative self-beliefs?
Weeks Open and positive thoughts
5–6 When using positive core beliefs to face the above events, what are some
open and positive thoughts? When using open and positive thoughts to
face the above events, what are some positive emotions or feelings?
C.-A. Shih et al. Asian Journal of Psychiatry 73 (2022) 103171

intervention (T2), and 1 month after the group intervention (T3). month follow-up, with p < 0.001 and p < 0.05, respectively.
Research participants were instructed to place the questionnaire in an Table 4 presents the results of the GEE analysis, assessing the group,
envelope and returned it to researchers after completion by themselves. time, and their interaction effects on self-stigma reduction. When T1 was
To ensure participants’ privacy, each questionnaire was coded with an used as the baseline reference, the ISMIS scores measured after the
identifying number instead of name. intervention at T2 and T3 were both found to be significantly lower than
the baseline score (p < 0.05). With all the variables controlled for in the
2.6. Data analysis GEE model, the interaction between group and time showed that the
reduction in the ISMIS self-stigma score between T2 and T1 in the
SPSS 23.0 for Windows/PC was used for analysis in this study. The experimental group was significantly greater than that in the control
mean, standard deviation, and frequency distribution (percentage) were group (B = − 0.291), but the group difference in self-stigma reduction at
used to analyze the demographic data and inferential statistical tests, T3 was not statistically significant. Fig. 1 further illustrates the within-
including independent t-tests and paired t-tests. We also used general­ group and between-group differences in the intervention effects on
ized estimating equations (GEE) to analyze the changes in scores over reducing self-stigma, showing the significant self-stigma reduction ef­
time and the differences between the experimental and control groups. fects in the control group and highlighting the significant group differ­
ence at T2.
3. Results
3.3. The effects of the Against Stigma Program on self-esteem
3.1. Demographics
Table 3 shows that in the control group, the RES self-esteem scores of
The sample consisted of 70 patients in total, with 35 participants the participants remained approximately the same both before the
being assigned to the experimental group and 35 to the control group at intervention (Mean = 3.75) and after the intervention at T2 (Mean =
baseline. As shown in Table 2, no significant difference was found be­ 3.80) and T3 (Mean = 3.80), without significant differences (p > 0.05).
tween the experimental and control groups in the demographic char­ By contrast, in the experimental group, the RES score before the inter­
acteristics of the participants: gender (χ 2 ＜ 0.001, p = 0.999), age (t = vention (Mean = 3.37) significantly increased to Mean = 4.24 at T2 and
0.666, p = 0.508), marital status (χ 2 = 1.061, p = 0.303), education (χ 2 Mean = 3.96 at T3 (both p < 0.001).
= 3.173, p = 0.075), and religion (χ 2 = 0.402, p = 0.526). Table 4 presents the GEE model assessing the intervention effects of
the Against Stigma Program on increasing the RES self-esteem scores of
3.2. The effects of the Against Stigma Program on self-stigma the participants. With all the variables controlled for in the model, the
experimental group was found to be associated with a significantly
Table 3 shows that in the control group, the ISMIS self-stigma score negative effect on the self-esteem score (B = − 0.401) at baseline,
at post-intervention (T2) decreased significantly (Mean = 2.14), compared with the control group. However, the interaction between
compared with the baseline score (Mean = 2.34) (p < 0.05), but the 1- group and time indicated that the intervention effects on increasing self-
month follow-up measurement (T3) (Mean = 2.15) was not significantly esteem at T2 (B = 0.823) and T3 (B = 0.543) were both significantly
lower than the baseline score (p > 0.05). In the experimental group, the greater in the experimental group than in the control group, with
ISMIS baseline score before the intervention (Mean = 2.40) significantly p < 0.001 and p = 0.001, respectively. As illustrated in Fig. 1, while the
decreased to Mean = 1.91 at post-intervention and Mean = 2.19 at 1- experimental group had a negative effect at baseline, the between-group
differences were reversed after the intervention, and the positive and
greater intervention effects of the experimental group were significant at
Table 2
both T2 and T3.
Distributions and comparisons of the demographic characteristics of the par­
ticipants, by group (N = 70).
4. Discussion
Variable All Experimental Control
participants group (N = 35) group (N
(N = 70) = 35) Regarding demographic characteristics in this study, male partici­
2 pants accounted for more than half of the sample, and the average age
n (%) n (%) n (%) χ p
was 49.4 years. These results are similar to those reported in studies of
Gender < 0.999 patients with chronic schizophrenia using mindfulness group therapy in
0.001
Female 30 (42.86) 15 (42.86) 15
Taiwan (Lee and Jiang, 2018). Most participants in this study did not
(42.86) have spouses, the proportion of patients with an education level below
Male 40 (57.14) 20 (57.14) 20 high school was over 50%, and the proportion of people with religious
(57.14) beliefs exceeded 80%. These results are similar to those of studies con­
Married 1.061 0.303
ducted in Taiwan (Yang et al., 2017). Therefore, the distribution of our
No 48 (68.57) 26 (74.29) 22
(62.86) sample characteristics approximates that of intervention studies
Yes 22 (31.43) 9 (25.71) 13 involving schizophrenia in Taiwan.
(37.14) Similar to the results of the systematic reviews by Xu et al. (2017)
Education 3.173 0.075 and Wood et al. (2016), showing significant improvements after
Senior high 47 (67.14) 27 (77.14) 20
and below (57.14)
anti-stigma interventions, this study also demonstrated that the Against
College and 23 (32.86) 8 (22.86) 15 Stigma Program for patients with schizophrenia significantly reduced
university (42.86) their self-stigma. During the group intervention, by providing back­
Religion 0.402 0.526 ground information regarding mental illness and generating plans and
No 12 (17.14) 5 (14.29) 7 (20)
actions to reduce stigma, our program participants were able to perform
Yes 58 (82.86) 30 (85.71) 28 (80)
Mean (SD) Mean (SD) Mean t p in-depth self-reflection. When media constantly broadcast news related
(SD) to both mental illness and crime, by means of group discussion, our
Age (years) 49.4 (11.4) 50.3 (11.4) 48.5 0.666 0.508 program participants can examine the processes that cause their
(11.6) depression, understand the appropriateness and inappropriateness of
Note: The participants (N = 70) were assigned to the experimental group and the news, and determine whether they and others hold unreasonable
control group. beliefs that lead to irrational emotions and behaviors. Then, through

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Table 3
T-test comparisons of the intervention effects on the self-stigma and self-esteem scores, by group (N = 70).
Experimental group (N = 35) Control group (N = 35) t value

T1 T2 T3 T1 T2 T3 t1 t2 t3 t4

Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD)

ISMIS 2.40 (0.37) 1.91 (0.35) 2.19 (0.36) 2.34 (0.40) 2.14 (0.45) 2.15 (0.51) -6.980*** -2.715* -2.567* -1.995
RES 3.37 (0.85) 4.24 (0.73) 3.96 (0.71) 3.75 (0.62) 3.80 (0.49) 3.80 (0.71) 8.914*** 4.751*** 0.606 0.369

ISMIS, Internalized Stigma of Mental Illness Scale; RES, Rosenberg Self-Esteem Scale.
T1: baseline; T2: post-intervention; T3: 1-month follow-up.
*p < 0.05; **p < 0.01; ***p < 0.001.
t1: t value of experimental group in baseline and post-intervention comparison.
t2: t value of experimental group in baseline and 1-month follow-up comparison.
t3: t value of control group in baseline and post-intervention comparison.
t4: t value of control group in baseline and 1-month follow-up comparison.

Table 4
Generalized estimating equation (GEE) models assessing the intervention effects of the Against Stigma Program on reducing self-stigma and increasing self-esteem (N
= 70).
Self-stigma Self-esteem

Variable B SE p ESd B SE p ESd

Intercept 2.375 0.191 < 0.001*** 3.936 0.354 < 0.00***

Group
Experimental groupa 0.069 0.101 0.497 -0.401 0.172 0.019*
Time
Post-test T2b -0.208 0.082 0.011* 0.051 0.082 0.532
Follow-up Test T3b -0.192 0.085 0.024* 0.051 0.118 0.663
Experimental group × post-test T2c -0.291 0.116 0.012* 0.760 0.823 0.116 < 0.001*** 1.079
Experimental group × follow-up Test T3c -0.019 0.120 0.876 0.049 0.543 0.167 0.001** 0.712
Control variables
Male (reference: female) -0.055 0.078 0.486 -0.076 0.147 0.604
Age (years) 0.002 0.004 0.570 -0.007 0.007 0.345
Married (reference: unmarried) -0.017 0.090 0.852 -0.080 0.169 0.637
College or university (reference: senior high or below) 0.033 0.085 0.698 -0.029 0.160 0.858
Having a religion (reference: no religion) -0.138 0.104 0.185 0.274 0.195 0.161

T1: baseline; T2: post-intervention; T3: 1-month follow-up.

*p < 0.05; **p < 0.01; ***p < 0.001.
a
Reference: control group.
b
Reference: baseline.
c
Reference: control group × baseline.
d
ES: effect size, based on the between-group differences in the mean change and the pooled baseline SD of the 2 groups.

mutual support and encouragement, our program participants can
magnify their own advantages and remove their self-labels.
While this study also showed reduced self-stigma after the inter­
vention as some of the studies noted previously, there were other dif­
ferences worth discussing when compared with the Western studies. For
example, as stated in a systematic review by Alonso et al. (2019), the
interventions to reduce internalized stigma in individuals with mental
illness could be grouped into 4 blocks. In terms of the intervention
approach, Western studies appeared to focus more on “psycho-education
and knowledge”, while Eastern studies seemed to put more emphasis on
improving the “cognitive-level” change. However, it should be noted
that this is not an absolute divide. For instance, a study in India reported
that the psycho-educational training about self-stigma was the key to the
successful reduction of self-stigma (Amaresha et al., 2018). Accordingly,
in the first week of our group therapy session, the anti-stigma inter­
vention also focused on knowledge and information about the rela­
tionship between mental illness and self-stigma, as a way to provide
foundational education on this topic to optimize program effectiveness.
An in-depth exploration of the different intervention approaches in
Eastern and Western countries revealed that the reasons behind such
differences might stem from cultural differences. For example, prior
research found that, in Chinese culture, mental illness is often attributed
to immoral experience, while in Western culture, people tend to attri­
bute mental illness to biological factors (Krendl and Pescosolido, 2020).
Hence, in Eastern countries, having a mental illness might be seen as
lack of self-control and violating cultural norms (Krendl and Freeman,
2019; Shin et al., 2013). Such discrimination and prejudice often have a
great impact on the social and economic status of family members,
including family lineage for generations to come and family honor (Yang
et al., 2014a, 2014b). Therefore, it is advisable to pay more attention to
the cultural differences and factor in their influences when conducting
mental illness stigma reduction research in Asian countries in the future.
In the control group, we observed that the self-stigma score at T2
significantly differed from that at T1, which might be due to the Haw­
thorne effect (McCambridge et al., 2014). A possible explanation is that,
not knowing to which group they were assigned, those in the control
group were only informed of the study objectives before they were
offered regular seminars as the group intervention led by the re­
searchers. Therefore, those in the control group would likely feel that
they were the observed subjects, which could have affected their
self-stigma scores at T2. Notably, during the regular seminars for those
in the control group, no discussions regarding experiences and feelings
toward stigma were held, and most patients mentioned only problems
related to life (e.g., use time of the bath and toilet, quality of daily meals,
and cleanliness of rooms). Hence, the significant change observed is
speculated to have resulted from the Hawthorne effect.
The GEE analysis showed that the self-stigma scores at T2 and T3
significantly decreased, which could be attributed to the decrease in the
ISMIS scores in both groups. Regarding the group and time interaction, a
significant difference was noted between the experimental group and

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C.-A. Shih et al. Asian Journal of Psychiatry 73 (2022) 103171

Fig. 1. Generalized estimating equation (GEE) analysis: comparing the within-group and between-group differences in the intervention effects on reducing self-
stigma and increasing self-esteem (N = 70). ISMIS, Internalized Stigma of Mental Illness Scale; RES, Rosenberg Self-Esteem Scale; T1: baseline; T2: post-
intervention; T3: 1-month follow-up; *p < 0.05; **p < 0.01; ***p < 0.001. The overall reference group for comparison was control group at T1.

the control group in terms of self-stigma reduction at T2, suggesting that
the Against Stigma Program is more likely to reduce self-stigma than
treatment as usual (Yanos et al., 2012). However, the change at T3 in the
experimental group was not significant, which may indicate that the
retention effect was not sustained 1 month after the intervention in this
study.
Rational-emotive behavior therapy (REBT), which not only focuses
on improving patients’ unreasonable beliefs but also attaches great
importance to homework assignments, was used as a reference in this
study (Broder, 2000; Matweychuk et al., 2014). Regarding REBT, Ellis
and Dryden (2007) stated that homework assignments were an impor­
tant factor that affected patient treatment and improvement. Before the
group intervention, the patients were able to record experienced and
observed events in daily life and discuss these events with others in the
group intervention (Palmer and Neenan, 1998). Turner and Barker
(2012) concluded that among the patients receiving REBT, those who
did not complete the homework assignments were unable to maintain
rational beliefs after therapy. To consistently achieve the therapeutic
effects of REBT, the participants needed to have the ability and habit of
refuting their internal thoughts through self-talking and self-motivation;
the participants may also use others to help them challenge their irra­
tional beliefs, such as assigning homework and practising intentional
situations (Cheng et al., 2001). In this study, after each group inter­
vention, the participants were reminded of the topics of the next group
intervention and told to write down the events in their lives that caused
negative emotions such that they could share their experiences in the
next group intervention. However, after the 6-week anti-stigma group
intervention ended, there were no more homework assignments, group
discussions, or analyses among patients regarding the negative emotions
caused by stigma, or group influence on the patients; therefore, the
reduction in self-stigma was not significant after the last time point (T3).
In the vocational rehabilitation program by Lysaker et al. (2012) the
researchers assigned appropriate jobs to patients according to their in­
terests and habits, and the patients were encouraged and supported
during the program. After the rehabilitation program was completed,
most patients still continued rehabilitation by themselves, and there was
significant improvement in self-stigma at follow-up. Therefore, it is
recommended that future studies should blend the program activities
with patients’ habits to enhance their impression of the group experi­
ence and sustain the effects of the intervention.
The current study dealt with the issue of mental illness stigma in
Taiwan. Considering the cultural and regional relevance, further insight
might be gained by discussing some similar efforts in other Asian
countries. For example, in a recent Letter to the Editor, Chinese re­
searchers noted the pressing need to break mental illness-related stigma
and discrimination in China, and urged that in order to alleviate the self-
stigma of patients, it is also important to enhance the knowledge and
reduce the public stigma related to mental illness among family care­
givers and healthcare professionals (Zhou and Xu, 2021). Further, a
recent study focusing on mental illness stigma in low- and
middle-income countries emphasized that cultural factors play a sig­
nificant role in determining various aspects of mental health stigma and
also noted that family caregivers and healthcare professionals could
simultaneously be stigmatizers and stigma recipients as well, signifying
a need to address the various aspects of stigma toward mental illness
(Javed et al., 2021). In an effort to reduce mental illness stigma among
community health and care staff in China, a pilot intervention was
conducted and the “education and contact” group showed greater
improvement in attitudes and behaviors than the “education only”
group (Zhang et al., 2022). A similar effort geared toward medical stu­
dents in India found that the Stigma, Empathy, and Attitude (SEA)
educational module only improved students’ knowledge and attitude
toward mental illness, but was ineffective in changing empathy and
stigma (Praharaj et al., 2021). In sum, a systematic review of in­
terventions to reduce mental health stigma in India concluded that,
regardless of whether it was the self-stigma among patients or public
stigma of medical professionals and caregivers, stigma-reduction in­
terventions should strive to be multi-level, using a combination of

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C.-A. Shih et al.
intra-personal, inter-personal, and community level strategies to target
changes in outcomes of individuals, environments, and community
groups for optimal effectiveness (Kaur et al., 2021).
Specifically, as regards schizophrenia, in an effort to tackle the issue
of mental illness stigma and related consequences, some leading re­
searchers in this field have advocated a name change for schizophrenia
(Tandon, 2022). Meanwhile, it is cautioned that although there has been
a growing consensus to abandon the use of the term “schizophrenia”, the
costs of a name-change at this time might far outweigh the potential
benefits, and none of the suggested alternatives could provide a more
accurate and adequate description, hence better characterization, of the
nature of what we currently call schizophrenia. On the other hand, it is
worth noting that, in response to the proposed name change among
mental health professionals and persons with mental illness, the Taiwan
government changed the official Chinese translation of schizophrenia in
2014, from the original “splitting of the mind” to “dysfunction of
thought and perception”. The new name has been considered to be less
stigmatizing, and as such, it is hoped that the name change may
contribute to the reduction of stigma and discrimination associated with
schizophrenia in Taiwan.
In regard to the effectiveness of the Against Stigma Program on self-
esteem, the differences between T2 and T1 and between T3 and T1 were
both statistically significant in the experimental group, indicating that
the Against Stigma Program not only was helpful during the interven­
tion but also had a retention effect up to 1 month after the intervention.
These results corroborated those reported in other research showing that
patients’ sense of self-esteem significantly increased after intervention
(MacInnes and Lewis, 2008). It is worth noting that the group inter­
vention in this study allowed the patients to rethink their status and
situation, as well as share their past and present events that can make
them and their families proud. This approach of allowing the patients to
describe their past life events or experiences was also found to be
effective in enhancing the self-esteem of other members in prior studies
(Jafari et al., 2015; Poorneselvan and Steefel, 2014). A possible mech­
anism is that because the group members who provided encouragement
and support were residents of the same institution, the positive experi­
ences and feelings could be easily recalled and reinforced through
contact with others even after the group session ended, thereby sus­
taining the significant self-esteem improvement at both post-test and
follow-up.
Lastly, the participants of this study lived in psychiatric rehabilita­
tion institutions in Taiwan. Given the unique context, the findings of this
study need to be interpreted and understood from that perspective. It is
noteworthy that, in Taiwan, the names of psychiatric rehabilitation in­
stitutions contain the element of “home” when translated into Mandarin
Chinese. Hence, both metaphorically and literally, for each patient who
resides there, a rehabilitation institution is not only a place for reha­
bilitation, but also like a “home”, where the residents live and support
each other as family members. Therefore, when residents shared their
past experiences and reflected on their thoughts and feelings during the
intervention, the support and feedback they received from each other
could provide strong social support as if from their own family members.
The above-noted contextual and cultural aspects of the study setting
could explain in large part the significant sustaining effects on increased
self-esteem in this study, when compared with the research findings in
Western countries (Morrison et al., 2016; Yanos et al., 2012).
4.1. Limitations and future directions
The current study had some limitations that should be considered
when the findings are interpreted. First, this study did not control for
symptoms of the participants when evaluating the intervention effects.
However, considering that patients with schizophrenia admitted to
community psychiatric rehabilitation institutions in Taiwan are gener­
ally in a stable phase of illness, it is likely that the symptoms of the
participants in this study were comparable. Nevertheless, in the interest
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Asian Journal of Psychiatry 73 (2022) 103171
of rigor, future research should inquire about symptoms and account for
their potential effects on the study outcomes. Second, this study was
conducted in a country of Asian culture; hence, the results may not be
generalizable to other countries of different cultures. However, as dis­
cussed earlier, our study had some findings that were consistent with
those reported in other countries or cultures, suggesting a robust and
perhaps universal phenomenon across different cultures. Hence, more
research is needed to delve into the cultural differences and influences
on the intervention effects. Third, our research participants were pa­
tients with schizophrenia. While patients with other mental illnesses are
also likely to be affected by self-stigma, our findings may not be directly
applicable to patients with other mental health issues. Therefore, stigma
reduction programs should also be implemented among patients diag­
nosed with other mental disorders in the future for comparison. Lastly,
since the participants in both the experimental and control groups were
all patients with schizophrenia living in the same psychiatric rehabili­
tation institutions, they might have exchanged their experiences after
attending the group intervention, creating a diffusion or imitation effect
(Grove et al., 2013). Nonetheless, this study still found significantly
better improvements in the experimental group, suggesting that the
actual intervention effects might otherwise have been more pronounced.
4.2. Conclusions
The results of this study demonstrated that the Against Stigma Pro­
gram achieved significant improvements in both self-stigma reduction
and self-esteem promotion among patients with schizophrenia. The
follow-up results also revealed sustaining effects of this stigma reduction
program in increasing the self-esteem of patients with schizophrenia
even 1 month after the intervention ended. These findings can be used as
an empirical reference to inform the future clinical care of patients with
schizophrenia in Taiwan. It is also hoped that the success of this Against
Stigma Program can be replicated and disseminated on a larger scale to
benefit more patients with schizophrenia.
Financial disclosure
None.
Acknowledgments
This study was funded in part by a grant #10834 from the Tri-Service
General Hospital Songshan Branch, Taipei, Taiwan. The preparation of
this manuscript was also supported in part by National Taiwan Uni­
versity for language polishing services under the Excellence Improve­
ment Program for Doctoral Students (grant #108-2926-I-002-002-MY4),
sponsored by the Ministry of Science and Technology, Taiwan.
Conflict of interest
None.
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