Proposal of a socio–cognitive–behavioral structural equation model of internalized stigma in people with severe and persistent mental illness Manuel Muñoz a, ⁎, María Sanz b , Eloísa Pérez-Santos b , María de los Ángeles Quiroga b a Psychology School, Madrid Complutense University, Campus de Somosaguas, s/n, 28223 Madrid, Spain b Psychology School, Madrid Complutense University, Madrid, Spain abstract article info Article history: Received 20 May 2009 Received in revised form 9 June 2010 Accepted 23 June 2010 Available online xxxx Keywords: Stigma Discrimination Self-stigma Schizophrenia Psychosis Structural equation model Schizophrenia outcomes The social stigma of mental illness has received much attention in recent years and its effects on diverse variables such as psychiatric symptoms, social functioning, self-esteem, self-efficacy, quality of life, and social integration are well established. However, internalized stigma in people with severe and persistent mental illness has not received the same attention. The aim of the present work was to study the relationships between the principal variables involved in the functioning of internalized stigma (sociodemographic and clinical variables, social stigma, psychosocial functioning, recovery expectations, empowerment, and discrimination experiences) in a sample of people with severe and persistent mental illness (N = 108). The main characteristics of the sample and the differences between groups with high and low internalized stigma were analyzed, a correlation analysis of the variables was performed, and a structural equation model, integrating variables of social, cognitive, and behavioral content, was proposed and tested. The results indicate the relationships among social stigma, discrimination experiences, recovery expectation, and internalized stigma and their role in the psychosocial and behavioral outcomes in schizophrenia spectrum disorders. © 2010 Published by Elsevier Ltd. 1. Introduction The relation between social stigma (Goffman, 1963) and diverse variables related to mental illness such as psychiatric symptomatol- ogy, psychosocial functioning, self-esteem and self-efficacy, quality of life, and social integration seems to be well established (Link et al., 1997, 2001 Rosenfield, 1997; Wright et al., 2000; Markowitz, 2001; Perlick et al., 2001; Sirey et al., 2001; Dickerson et al., 2002; Ertugrul and Ulug, 2004; Ritsher and Phelan, 2004; Depla et al., 2005; Crespo et al., 2007). However, the process underlying these relations raises some controversy. Various models have been developed with the aim of understanding and explaining the stigmatization processes suffered by people with a mental illness (Link, 1987; Link et al., 1987; Link and Phelan, 2001; Ottati et al., 2005; Sartorius and Aichenberger, 2005) and various authors have underlined that the stigma of mental illness is a complex phenomenon with several levels of comprehension and analysis (Corrigan, 2004; Thornicroft, 2006; Vauth et al., 2007; Yanos et al., 2008). When referring to the stigma associated with mental illness, we must distinguish the stigmatizing attitudes about mental illness endorsed by the general population—social or public stigma—from direct discrimination experiences or social exclusion—experienced stigma—and the stigma endorsed by the people with a mental illness about themselves just for having their mental illness—self-stigma or internalized stigma (Link, 1987; Corrigan, 2000; Corrigan and Watson, 2004; Ritsher and Phelan, 2004; Depla et al., 2005). Thus, the studies on internalized stigma have pointed out that many people with severe mental illness have high levels of self- stigma, and that this is positively related to symptoms of depression and negatively related to self-esteem (Ritsher and Phelan, 2004; Mickelson and Williams, 2008; Werner et al., 2008). Also, a negative correlation with quality of life and self-esteem and a positive correlation with symptoms of depression and anxiety have been identified (Link et al., 1997; Rosenfield, 1997). Werner et al. (2008, 2009) also found a moderate relation with age; older participants with schizophrenia or depression reported lower levels of self- stigma. In some cases, the stigma associated with depression seems to be partially mediated by self-esteem, fear of rejection, and experienced stigma (Mickelson and Williams, 2008). Although some studies report that it has no correlation with psychotic symptoms, (Markowitz, 1998), other works have found that the severity of the psychotic and depressive symptoms and the level of disability are higher among people who perceive stigmatization in comparison to people who do not (Ertugrul and Ulug, 2004; Corrigan 2008a; Staring et al., 2009). The studies that have assessed experienced stigma have revealed that this type of stigma has a negative correlation with quality of life Psychiatry Research xxx (2010) xxx–xxx ⁎ Corresponding author. Tel.: + 34 913943129; fax: + 34 913943189. E-mail address: mmunoz@psi.ucm.es (M. Muñoz). PSY-06537; No of Pages 7 0165-1781/$ – see front matter © 2010 Published by Elsevier Ltd. doi:10.1016/j.psychres.2010.06.019 Contents lists available at ScienceDirect Psychiatry Research journal homepage: www.elsevier.com/locate/psychres Please cite this article as: Muñoz, M., et al., Proposal of a socio–cognitive–behavioral structural equation model of internalized stigma in people with severe and persistent men..., Psychiatry Res. (2010), doi:10.1016/j.psychres.2010.06.019