 She says, she's Kitiera Borgé, she's very new to the Second Light, she joined two weeks ago, so it's all new to her. She is blind and she uses an SL viewer called Radigast, which allows her to access this wonderful virtual world with a screen reader. It's a privilege to introduce you to our speaker today, Dr. Philip Yanos. His topic is, how do people diagnosed with mental illness become written off? How can they overcome it? Dr. Yanos is a professor of psychology at John Jay College City University of New York. He is also the interim director of clinical training for the clinical psychology Ph.D. He is an internationally recognized expert on mental health stigma and its effects on identity, not only through his significant research, but as a published author, editor, and contributor to a multitude of publications. He is co-creator of a treatment approach called Narrative Enhancement and Cognitive Therapy, designed to combat the effects of stealth stigma on people diagnosed with severe mental illnesses. In his new book and his talk today, he aims to make the importance of mental health stigma understandable and accessible to a general interest audience. Thank you for coming today. I'm sure that we will all enjoy this presentation. As a reminder, please refrain from talking or typing while Dr. Yanos is speaking. There will be an opportunity at the end to ask questions. And with that, Kitira is very pleased to present to you Dr. Philip Yanos. Thank you very much. And thank you so much for inviting me to present at this conference. It's very interesting and I'm very impressed by the types of presentations you have today. Really, I think it's quite an exciting event. So the title of my talk is, How do people diagnosed with mental illness become written off? And how can they overcome it? I'm clicking the second slide here. Does everyone see it change? Okay, so that's just my name and my affiliation at John Jay College, Criminal Justice, City University of New York. And this is the cover of my book, which shares a title with this presentation. It's called, Written Off, Mental Health Stigma and the Loss of Human Potential. So if you're interested in the topic I'm talking about, the book goes a little bit deeper into these things, gives you a big overview of this topic. I'm really going to be doing a summary of a lot of different research that I and others have conducted today. So study. In this next slide, I'm just showing a quote from the recent news from singer Mariah Carey, who recently became public with her diagnosis of bipolar disorder. And so she said that the reason why she didn't want to reveal her diagnosis was that I didn't want to carry around the stigma of a lifelong disease that would define me and potentially end my career. And the reason why this really jumped out at me so much that I wanted to include it here is because she's somebody who has a lot of celebrity, has a lot of resources, existing kind of credibility in the world as a result of her fame. And yet she also felt that being associated with this label of bipolar disorder would somehow spread at her and make her not taken seriously by others. The next slide here just gives you an overview of the things I'm going to touch on. So I'm going to review the extent of the endorsement of mental health stigma in society today. I'm going to discuss how stigma impacts the identity of people who have been diagnosed, talk about how identity impacts the recovery process, and then talk about pure lead and professional ways of overcoming the effects of stigma on identity. So the next slide just touches on the topic of what is stigma just to define it. So one of the more commonly accepted definitions of stigma is something that occurs when elements of labeling, stereotyping, separation, status loss, and discrimination co-occur in a power situation. The important part of that definition is the power situation aspect. So stigma occurs when someone with more power attaches negative stereotypes to someone with less power. The essential part here that I want you to connect to is that you have a label, and in this case we're thinking of the label being mental. So the negative stereotypes that are most typically linked to mental illness are expectations of violence, unpredictability, incompetence, and inability to work or function. A little bit of background, when we're thinking about stigma, it can be helpful to try to put it into perspective what it was like less than 100 years ago. So something that was a very powerful impact on the lives of a lot of people with mental illness in the 20th century was the eugenics movement, which led to widespread forced sterilization laws in the United States, and which also inspired a euthanasia, what they called euthanasia program in Nazi Germany, which led to the killing of tens of thousands, maybe 100,000 people with mental illness, which preceded the larger holocaust that all know about. This next slide, sorry, let me... So the next slide is just an image of a piece of material from the American eugenics movement. And you can see, if you're able to see it, it says unfit human traits, such as evil-mindedness, epilepsy, criminality, insanity, alcoholism, pauperism, and many others, running families, and inherited it in exactly the same way as color in guinea pigs. This was intended to promote the eugenics movement that families with more positive traits, as it perceived, should associate. But it also tried to promote the idea that those who had these unfit traits, which included mental illness, should be sterilized. The next slide is an image of a map of the 48 contiguous U.S. states. And as of 1935, it shows how many had forced sterilization laws in place. So it just gives you a sense of the scope of it. The majority of states had enacted forced sterilization laws by that time. The next slide is just a picture from Nazi propaganda, which is a picture of people with mental illness that says it translates as meaning life without promoting the T4 program, which was used to conduct this extermination that happened prior to the Holocaust. So we have a pretty dark history here. What is it like now? So the next slide says, sorry, I'm moving ahead so I can see. It says the negative stereotypes of mental illness still exist. So we know about this from surveys that have been conducted. And the first kind of big comprehensive survey of this was conducted in the U.S. in the 1950s. And there was an interesting examination that compared the findings of that to findings in 1996. And there was actually evidence that negative stereotypes had increased to some extent, especially about people diagnosed with schizophrenia. There was also a comparison between 1996 and 2006 that found no decrease, this in the United States. It both in beliefs about dangerousness and desire to maintain social distance. And we also have examinations on a global scale that have not found improvement in attitudes toward people with schizophrenia on a global level. The next slide shows some of the attitudes that are endorsed on a global level and how much they're endorsed. This is from a large study of 16 countries. So likely to be violent to others was endorsed by 53% on average around the world. Not likely to be productive was endorsed by 51% on average. Unpredictable was endorsed by 70% on average and shouldn't care for children was endorsed by 84%. So all of this indicates that stigma is not just a thing of the past. It still exists. It's still with us. So the question then, if we're talking about identity, is do people who have a diagnosis there? If they don't, then it's not going to impact them. But every bit of evidence that we have indicates that people diagnosed with that illness are very aware of these negative stereotypes. So we have large studies that have found that 70% of people with mental illness diagnoses anticipate discrimination from others. And we also have a large number of studies that have found that 60% or 70% of people diagnosed endorse that most people hold these views and reject a person with a mental illness as a friend, co-worker, etc. So this indicates that people are really quite aware. The next question is how do they become aware? And for this, we have a very clear theory called the Modified Labeling Theory that Bruce Link has developed many years ago, and there's really a lot of evidence for it. Basically, what this theory says is that we all grow up in society learning about these stereotypes, and we become aware of them through the socialization process. And then as we grow up and start to develop mental health problems ourselves or start to get an inkling that they might be coming, you get this, oh my god, this is me kind of reaction. So you don't ever really have to be treated badly or in a discriminatory way to kind of link the stereotypes to yourself because you learned about them when you were growing up. But it certainly can make it worse if you do have those negative experiences. This next slide, it says Modified Labeling Perspective. It's just kind of a simplified graphic of that. So you can see it says Diagnosis of Segmental Illness plus Aware of Negative Stereotypes leads to stereotypes take on personal relevance or what I'm calling stigma concern. So if people then become aware of what happens, well, if they start to have social rejection experiences, let's say they decide they're going to open up the people and some people are supportive but others are not supportive and they get those aversive experiences. We find that there are the significant minority of people with mental health reports having had discrimination experiences. So this can definitely impact people. And once you've had one of those discrimination experiences, it can really kind of discourage you strongly from then opening up to others. We also have evidence for something called microaggression from the research that I and some of my partners in my research have done. And so we're probably all familiar with the concept of microaggressions with regard to race ethnicity at this point. But we wanted to kind of see if this applies to people with mental health diagnoses as well as another kind of more subtle form of discrimination experience. And so we did a study where we found that people with mental illness did endorse having these kinds of experiences. And so we kind of categorized the things that they experienced and they fell into the categories of invalidation, assumption of inferiority, what we call second-class citizen, fear of mental illness and shaming of mental. So the next slide just gives you an example of an invalidation of microaggression. Sorry, make sure you change that. A quote from somebody in our focus group. The person said, people in my family, if I actually start being happy, they're like, are you sure you're okay? You look happy today. It's like I'm allowed to be happy sometimes. Or if I do a lot of activities or if I stay up late, I'll have people call me up and say, maybe you're manic, you stayed up really late. Then a lot more things than usual. So the experience of this person was that even normal happiness gets kind of pathologized when you have had manic episodes or you have that diagnosis. And people are kind of not allowing you to have that type of normal happiness or trust that it could be that. The next slide just shows an example of kind of microaggression from the wider media, which is this is a candy bar wrapper that I actually saw in San Francisco, in the San Francisco airport after I attended a anti-stigma conference, ironically. And so it says Alcatraz, like a ward bar, nuts. And so this is a kind of thing, a sort of subtle kind of discounting or treating it like this is an okay thing to do to make light of people's experiences. And this is something that I think is a lot more common than many people realize. A little more about microaggressions is we created a scale that can assess it among community members. And so we polluted the scale with general community members. And I can give you some info on the endorsement of that. So it has three sub-scales. The first is assumption of inability. And so it has a sample item is if someone I'm close to told me they had a mental illness diagnosis, I would try to talk more slowly because they wouldn't get confused. And we have patronization. If someone I'm close to told me they had a mental illness diagnosis, I would frequently remind them that they need to take their medication. And the fear of mental illness sub-scale has an item. If I saw a person who I thought had a mental illness in public, I would keep my distance. So these are some of the items that we put in there based on what we heard from our focus group participants, people who had experienced these types of things. And we found relatively high endorsement of them. It's in that a lot of community members will be willing to endorse the new training. Okay, so the next slide just touches on that social rejection experiences seem to have an impact and to increase stigma awareness and concern. And sorry, I'm just trying to make sure I'm on the right thing. And so then the next question is how does this impact a person when they're aware of negative stereotypes in society based on what they've grown up with and what they've experienced? So Pat Corrigan, who's a very important researcher in this area and Amy Watson, they developed this model that basically there's three possible, let's call them indifference, righteous anger, and the last one I'm going to call self-stigma. They use a different term. So my graphics here will just kind of try to explain what leads to each one in a simplified way. So you can see from this graphic it says indifference. And we have low or high perceived stereotype legitimacy and low group identification leads to indifference. What does this mean? Basically that it could happen if you don't really think of yourself as a part of the group, you don't identify with this group of people with mental illness. If that's the case, then you could be indifferent. It could also be that you do identify, but you really dismiss these stereotypes and you don't really give them much credence. And as a result, your response is sort of like, it doesn't matter, I don't care about it. The second possible response that they talked about is what they call righteous anger. And in this case, people do have identification with the group. Identify as being a person who's been diagnosed. Maybe they identify as having a disorder as well. But they reject the stereotypes. They think that they're wrong. And as a result, they kind of feel that this is an injustice and they have to oppose it and maybe do what they can to change people's minds about it. In the last possible response, which I'm calling self stigma, people are aware of being in the group and they have identified with it. But they believe that these stereotypes are legitimate. They think that it's true that people with mental illness are dangerous or incompetent. So in this case, we have a toxic combination of believing that you're a member of the group and believing that these negative stereotypes are true. But this is where we kind of get into this area of identity. Because if you believe that you're a member of a group and you believe that the stereotypes are true, it's going to start to affect how you define yourself. So what do we mean by identity? This next slide just kind of gives a simple definition. Identity refers to the social categories people use to describe themselves and others used to describe them. We have our own identity, but we're also influenced by the categories that others impose on us. So I may define myself as a father and a professional and a nice person. Other people may think of me as a boring teacher, as a blowhard. If I don't know about that, it's not going to affect me. But if I am, it's going to affect me, and I'm probably going to feel a little less good about myself if I know people think of me as a... So in the next slide, it basically states that when we talk about this idea of self-stigma, we're really talking about people developing a stigmatized identity. And what this means is that through a variety of processes, the identity of having a mental illness and that being something that's associated with negative things takes over and supersedes other identity categories. So people who've been diagnosed with mental illness have many identities. They're musicians, they're spiritual people, veterans, spouses, parents. But the mental illness identity, when it's become linked to these negative stereotypes, can come to overtake these other things and become prime. The next slide tries to touch to some extent on how this can connect. It doesn't happen overnight. It's a gradual process. There was an interesting study that was done back in the 80s by someone named, I think, Joseph Lally. And he kind of interviewed people about how did you come to believe you that you're a mentally ill person? And that there was a bunch of things that were kind of sort of important transitional events. For some people, it was hearing the diagnosis. For other people, it was applying for disability, which I don't know if this is a predominantly U.S. audience, but in the United States, when you apply for disability, you basically have to proclaim that you're permanently unable to work. It's kind of this dance that people have to go through where they claim that even if they don't believe it's true. But what we found is that, at least what Lally found, is that a lot of times people start to believe it's true because they've got to claim it so strongly. Other things that can occur, maybe when professionals say, you know, you have to give up on your dreams. You're not going to be able to do the things that you wanted to do. And this hasn't really been studied, but it's been reported in a lot of personal accounts that people have written. So I think it's something else that we have to take a seat. The next slide is a quote from the first personal account that talked about self-stigma. It was titled Self-Stigmatization by Kathleen Gallo. And so I'm just going to read it to you. She said, I perceive myself quite accurately, unfortunately, as having a serious mental illness, and therefore has been relegated to what I call social garbage heap. I tortured myself with the persistent and repetitive thought that people I would encounter, even total strangers, not like me and wished that mentally ill people like me did not exist. Thus, I would do things such as standing away from others at bus stops and hiding and cringing in the bar corners of subway parks. I think I give myself as garbage. I would even leave the sidewalk in what I thought as exhibiting the proper difference to those above me in social class. A lot of group, of course, included all other human beings. So really a very negative self-image, feeling that she's beneath others. So now those of us who are interested in this, how do we know if it's happening? Well, we use scales. There's a number of scales that have been developed. The most commonly used one is called the internalized stigma of mental illness inventory. There's also the self-stigma of mental illness inventory. And there's some other less frequently used scales such as the self-stigma of depression scale and the modified engulfment scale. Just to give you a sense of what the internalized stigma of mental illness scale touches on, the next slide shows some sample items. So mentally all people tend to be violent, very simple. If people endorse that, they're endorsing stereotype. I'm embarrassed or ashamed that I have a mental illness is indicative of what's called alienation. There's some positively worded items such as people with mental illness make important contributions to society. And so those are in the opposite direction. They kind of the counterpoint to self-stigma. Another item would be the cause I have a mental illness. I need others to make the most decisions for another endorsement of the same. So we use this scale. I already told you that there are those three theoretically responses. So how many people endorse having this stigmatized identity? So what the next slide shows is just kind of what we tend to find in research. What we tend to find is that about 20 to 40 percent of people with severe mental disorders show what we might consider elevated or clinically significant self-stigma. And the biggest study that was done was that in Europe with over a thousand people across 14 European countries, and it found that people with schizophrenia, spet from disorders were more likely to have this elevated self-stigma. There were 40 percent that were in that elevated range, but it was still common among people with bipolar disorder and depression where 22 percent had the elevated self-stigma. There's been a lot of other studies that have been done. So really there's really pretty strong evidence that it's a pretty common phenomenon. So the next slide is particularly prone to it. Interestingly, there's not a lot of evidence for variation between people, not really by gender or age. We have evidence or ethnicity. We have evidence for it being more common among people with the schizophrenia, spet from diagnosis. We also have some interesting findings regarding the country of origin. So I'm a recarriage, you might have guessed by my name. So it was interesting to me, but not a big surprise based on what I know from my culture that self-stigma was most highly endorsed in Greece, in these European countries that they examined. It seemed that there's an association between the community attitudes and the extent to which people endorse these views and take them into their identity. But that's something that really needs to be studied for. So now we're getting into the crux of what I want to talk about, how does this affect people? So they have, you know, endorsed self-stigma, but what does it do to them? How does it affect the trajectory of their recovery, let's say? So this is where I've kind of gotten most into the research. And so with my colleagues, David Rowan, Paul Lysacker, we came up with a conceptual model. So just quickly, the next slide is a screenshot of the article where we proposed this illness identity model. And I'm just shifting to the next model, the next slide, which is just a picture of the month, a diagram. Basically what this diagram shows is that we predict that when you have this combination of internalized stigma and an awareness that you have a mental illness, it has this direct effect on hope and self-esteem, and that this has an effect on increasing risk of suicide. We know that hope and self-esteem impact a likelihood of suicidal thoughts at least. It also has a negative impact on coping and engagement in treatment. Basically people who don't have hope are more likely to feel like, what's the point? Why should I try to really put effort into treatment? This has a further impact on vocational outcomes. People are less likely to go back to work or to best effort into working. There's also an effect on social interaction where people become more isolated, withdraw more from others. And finally there's this effect on symptom severity. So we don't think that this has a direct effect on symptoms, but we do know that when people are more socially isolated it can make symptoms, even psychotic symptoms like delusions and hallucinations, worse. So this is what we propose, and we did a few studies where we tried to test them. So I'm just kind of going to zoom through that a little bit because I don't want to get bogged down in the stats and things like that, but I hope because I've just explained it. The next slide is just a screenshot of our first paper on this that we did where we proposed that there was this interaction between awareness or insight and internalized stigma that impacted hope, social functioning and self-esteem. And so a summary of it is that we wanted to know, when does it happen that insight has negative impact? We believe that it does when it's combined with this self-stigma. So we felt that insight can have negative impacts on people when it's combined with elevated self-esteem, whether that if you don't endure self-esteem then insight can have very positive effects. So the next slide is just a picture of the table from our study which is pretty simple. If you understand what we're doing here, we just divided a group of people with schizophrenia spectrum diagnoses into three groups. There was the low-insight, low-stigma group, high-insight, low-stigma group, and high-insight, high-stigma. If you want to think about it, we could think of the last group as sort of the self-stigma group, the middle group which as being kind of the wages anger group. And the first group is being kind of indifferent. They basically didn't believe that they had mental disorders because they had low insight. So what you can just see from the numbers, the specific numbers don't matter, but what matters is the differences between them. And basically what it shows is that the high-insight, high-stigma group had the lowest self-esteem, the lowest hope. They had social relationships that were just as impaired as those in the low-insight, low-stigma group, and their symptoms were just as high as people in the low-insight, low-stigma group. The interesting thing was that there seemed to be some benefits to having low insight if you didn't endorse self-stigma in that you had better self-esteem and better hope. The one group that had high-insight and low self-stigma. The thing that we took from this is that there's no benefit to having insight if it's going to be combined with self-stigma. So I'm going to move on now. I just shifted to my new set of slides, so I hope that you see them. I'm going to click... Hold on. Do you see the first slide that says take home message? I'm going to make sure that's working. Okay, you see it. Thank you. So basically it summarized what I just said, is that the advantage of insight is lost when it's combined with self-stigma. We did another study, which is just a screenshot of the journal page is the next slide. And basically there's something that's called a path analysis, which is a statistical analysis looking at the association between variables. I'm going to go ahead to the diagram of it, which is a slide with a bunch of boxes. And so basically what it shows is that we had these significant and pretty substantial relationships between things that we thought would be related in large part. So the little asterisk means that it was statistically significant. So there was this strong relationship between internalized stigma and hope and self-esteem, less hope and self-esteem, if you had more self- internalized stigma, that this impacted coping, it impacted depressive symptoms, it impacted social avoidance. And there was this indirect effect where social avoidance was related to more psychotic symptoms. So this suggested that we were onto something. What we weren't able to test in this study was the vocational part, because we didn't have data on that. We did another study, which the screenshot of the journal article is the next slide that I just put up. But we looked at people who were in a vocational rehab program over time, and so we had data on what their level of self-stigma endorsement was at the beginning. And we were able to see if it impacted how much they improved over time. So this was kind of giving us a better read on that. So skipping ahead to the findings from this, essentially what we found was that people who had more endorsement of self-stigma at the beginning, and this is even when controlling for their symptom severity, improved less five months later in their vocational. This suggested that this does have an impact on work to the extent that people who think that being a mental illness is associated with inability to get better are less likely to actually get better even when they're offered opportunities to work. And just a quick shot of the take-home message from that slide. You might wonder if we're the only ones who have found this, but this has actually been studied by a lot of people around the world at this point. So the next slide is just a summary of some of the studies that have been done around the world and some of the different countries that have been involved. So you can see there are studies that have been done in Israel, Germany, in Nigeria, in the developing world, China, Spain, Switzerland. I've seen studies from Ethiopia, from Taiwan, Korea. So really it's really being replicated in large part everywhere and not just in the studies that we're doing. So it seems clear that there's definitely something going on here with self-stigma having an impact on it. So the next slide also just reports findings from something called a meta-analysis. This was done back in 2010. There's a lot of new studies now, but as of then it kind of combined findings from different studies and it looked at the pooled relationships between self-stigma and these other variables. And so it's found this strong relationship with hope, self-esteem, self-efficacy, which has to do with sort of confidence and your ability to do things in your life, but also things like quality of life, symptom severity, and then weaker but also notable relationships with treatment adherence and social support. So again, this indicates that self-stigma does have a substantial impact and there's something going on here from this, is that evidence is accumulating for the impact of self-stigma and we need to do something about it. The studies are mostly cross-sectional, meaning most of the data has been collected at one point in time, but there are some studies where the data is collected over time and you can see that this also plays out when you look at it over time. So now we're getting to the part about, well, what can we do about this? So the first thing I wanted to touch on is, is it even possible to change identity? Back in the early 90s when I was getting into this area, I was strongly influenced by an article by Larry Davidson and John Strauss, who's called Sense of Self in the Recovery Process and they weren't specifically talking about identity, but they were touching on a similar thing and basically what they found was that as people improved over time, their sense of self tended to change and evolve in a way where they had a greater sense of agency in their life. And my friend David Rowe also did an analysis of the same data set. This was actually his dissertation back in 2001 and he found that as people improved, they evolved from having an identity of patient to person in the interview narrative. This suggested that people do change over time as they get better and identity kind of goes along with this positive change process. We also have evidence from quantitative studies that there can be improvement in self-sticking over time. So all of this suggests that there is hope. How can we kind of step in and try to help it along to facilitate the change process? The first thing that has been around in the field is peer support. And this is where people with lived experience of mental illness step in to try to help others who are maybe in the same position. And all has to go to the peer support movement for really starting this conversation. I wouldn't be talking about it if the peer movement hadn't initiated this discussion. So back in the 80s and 90s, people were talking about how peer support really put a big emphasis on changing identity and helping people move from the identity of being a patient to an advocate or being more empowered, maybe even seeing the positive impacts of having diagnosis. The next slide is just a diagram from the what we call the Icarus project, which has this diagram of you are not alone. It's an example of the kind of thing that the peer movement emphasized. So we decided to study if there were changes in self-stigma over time with participation and peer support. So the next slide is just a screenshot of our paper called participation in peer support services and outcomes related to recovery. What we did is we looked at people who were beginning in participation in peer-led service setting and we followed them over the course of six months. So basically what we found is that people who were we tried to study only people who were new sort of just as they had just started. We found that people who regularly attended services showed significant decrease in self-stigma over time and an increase in self-esteem. And this was in comparison to those who did not regularly attend. So we can't say anything about those who never came at all. We didn't have any data on them. But we do know that the people who came just kind of showed up and left. We tried to follow them and they didn't really show the improvement in self-esteem and reduction in self-stigma that those who had stuck around it. This suggested that there is some impact of participation in peer support. Next we wanted to see if there's something that we can do in the pro. Basically this is where I sort of have tried to make my contribution by developing a treatment approach with my colleagues David Rohr and Paul Lysacker that we called Narrative Enhancement and Cognitive Therapy. And it wasn't that we didn't think that peer support can do the job, but we just know that not everybody sticks around or even ever goes. So we wanted to offer something that could be available in the professional settings where so many people get their services. So what is Narrative Enhancement Cognitive Therapy? The next slide gives a summary of what the elements of it are. It's a 20-session manualized group intervention and it has three main elements. There's psychoeducation, which is really trying to help replace stigmatizing views about mental illness with empirical reported findings about rates of recovery and associations between mental illness and violence and things like that. I'm teaching cognitive restructuring skills to challenge negative beliefs about the self. And lastly, engaging people in storytelling exercises which are geared toward improving their ability to integrate empowering themes into their life story. So the next slide is just a picture of the manual cover for Narrative Enhancement Cognitive Therapy for the English version. The slide after that is the Swedish version. So it's been translated into a few different languages but Swedish is one of them. Why do we pick this narrative part? I don't have time to really go into that, but there's a lot of evidence that narrative is a really important part of how we define ourselves or the stories that we tell about ourselves have a big impact on our identity. So that's why we wanted to bring that in. And the next slide is just a screenshot of sort of a classic book on this topic called Actual Minds, Possible Worlds. And the next is a screenshot of something called the It's a Friendly Oral History Project where people actually record and put in many narratives of their experience. So I think I'm running out of time. So what I'm going to do now is just give you a quick summary of the evidence for narrative enhancement cognitive therapy and just let people then ask for it. It just indicates the studies that have been done on narrative enhancement cognitive therapy. So there was what's called a quasi-experimental study that was done in Israel. A small randomized controlled trial, that's what RCT stands for in the United States. An uncontrolled follow-up study in Sweden and then a larger randomized controlled trial that was done in Sweden as well. So we have an ongoing study that we haven't published or findings from yet that's happening in the U.S. So I'm just going to move forward because I think I'm running out of time. And let's move to a little summary where the slide should say Conclusions regarding NEC. I'm going to move to that. So essentially what these studies have found is that moving forward to the one that says Conclusions regarding NEC. We have evidence that it works in reducing self-stigma and increasing self-esteem. And kind of the most compelling evidence comes from this Swedish study which was a randomized controlled trial. Sorry, still moving forward. Okay, so you should see the slide says Conclusions regarding NEC. And the type of effect that it has is what they would call a medium to large effect in this kind of, in this field. What we don't really know yet is does it have an impact on things that are maybe even more important like social function and relationships. We really only know now that it impacts self-image and self-esteem. We also don't know if it works when you're comparing it to a more active control group. So that's sort of what, that would be a higher bar and that's what our current study is trying to answer. So it does seem like it is, there is something to it and it can help people. And I'm told that it's now being considered one of sort of part of the standard care that's offered in Sweden, positioned in the United States, but we're a much bigger country. The last thing I just want to give you is just a peek at some other interventions that exist. So narrative enhancement kind of therapy is something that I've developed, but there are others that have been developed kind of in parallel. So one that is called ending self-stigma. It's also group-based intervention a little shorter. There's the anti-stigma photo voice intervention, also group-based, also involved narratives, but in this case, they're linked to taking pictures about your experience. And then there's honest, open and proud, which was developed by my friend, Pat Horgan, who really focuses on helping people to disclose about having a mentalist to other people and really tries to focus on disclosure as the main way of diminishing the effects of self-stigma. The next slide is just the logo for honest, open and proud that Pat has developed. So I'm now going to the take-home message, really the conclusion here, which should kind of reiterate what we talked about in the beginning. So basically, stigma impacts the lives of significant number of people with mental illness, and it restricts opportunities for community participation, but it also impacts identity. Identity and identity change play key roles in the recovery process. So it seems that you can't really have recovery without transformation of identity, but there's evidence that we can impact this through peer-led and professional means. So there is hope. There are ways to undo this stigmatized idea. So I feel I've covered a lot of ground, but I hope that you've been able to follow me and I welcome hearing your question. Dr. Enos, thank you. This has been amazing. We have quite a few things coming out here in the chat. Okay. Oh, okay, let me pull one out. Luke has asked a question. She says, self-stigma on the average would not take effect with one negative event. It is unlikely to be a singular imprinting. Such a change of self-image takes sustained repetition, repeated occasions to take hold. Can reduction or reversal of self-stigma through therapy be maintained if the person continues living in the same environment and encouraged self-stigma in the first place? Well, that's a great question, which is that, you know, if we're trying to help the person develop more positive views of themselves, but they keep getting this invalidation in the world, is it going to work? I can only say that from the research, there's evidence that it does, but I would also certainly think that a person's environment, whether it's family environment or work environment, is going to be a complicating factor. So I think that it's important to understand that we're not trying to deny that stigma exists. We're not trying to give people the belief that it's not real. What we're trying to do is help them see themselves differently to not internalize those messages and perhaps to develop strategies to respond to it when they encounter it. The most common response is concealment and basically kind of avoidance. So we have generalized social avoidance among a lot of people who have adopted self-stigma. We try to help people to develop strategic disclosure approaches with trusted people that can perhaps discount some of the expectations they might have, but you can't control what other people are going to do. So I guess that's one of the reasons why some people are scared off by Pat Corgan's Honest, Open, and Crowd, which really puts this emphasis on disclosure. What we often say is it's an empirical question. So, you know, let's... Ptyar, your introduction says, as a blind individual, she really appreciates that you were very descriptive of your slides, she respects that, and she said it's been a huge honor to meet you. Thank you so much. Are there other questions? Yeah, Buona has a question for you. I just have to grab them. I'm sorry. Buona says, how do people like her with bipolar identity, with bipolar identify with the stigma thing you were discussing? She wants to know how bipolar reacts with stigma. Well, bipolar disorder is one of the more highly stigmatized disorders, perhaps less than schizophrenia, but it does... Self-stigma does occur among people with bipolar disorder. To some extent, it depends on what one's history is with the mental health system. You know, there are two types of bipolar disorder. There's bipolar one and bipolar two, right? And so bipolar one tends to include... There's often psychotic experiences during the manic phase. This can lead to involuntary hospitalization and things like that. Those kinds of experiences tend to be more associated with the stigmatizing experiences. So it does depend on the, I guess, the presentation and whether psychotic experiences are occurring, which don't occur for everybody with bipolar disorder. Okay. Buona says, he does suffer from spells of mania and depression. It's like flipping a life switch at times. Yes. It is very difficult with people with bipolar disorder. I often want to try to see an integration of those two sides, both sides of the person, but the shifting between extremes is a big challenge. And Zombie says, she's noticed that fellow disabled people have a tendency to come together and are more accepting of friendships with each other. Do you think it's because we know the feeling of stigma or because we are disabled? We have a tendency to be more accepting and understanding of other people's disability, even if it's different? I think so. I think that was certainly borne out historically where the Americans with Disabilities Movement and ACT and the movement that helped it lead to its creation required a unified coalition of people with disabilities, including psychiatric and physical and other kinds of disabilities. So I think there is a fair amount of support in unity. It's not always the case. Sometimes within organizations there can be kind of a hierarchy and sometimes mental illness tends to be looked down upon even within the disability community, but I'd say usually that's not the case and there has been unity, and that's led to very positive results, again, such as the Americans with Disabilities. And we have point for only one more of the many questions. I think we're going to have to have you come back, Dr. Yannos, and talk. Anytime. I'm going to ask Marley's question. Marley says she is wondering about cultural differences. Some society norms lead to naturally self-deprecating behaviors and some are just the opposite. We've got so many good questions. I'm sorry you can't answer them all. Right. So the issue of culture is an interesting one that's been understudied. There is a little bit of discussion of it in my book if you're interested, but not so much about self-stigma, more about the association between culture and stigma on the community side. And I guess my colleague, Larry Yang, has studied this in the Chinese community. And the focus on face and reputation seems to have a big impact on the experience of feeling like you've sort of failed your family or failed to maintain the reputation that your family expects in communities that place a lot of emphasis on reputation. There can be advantages certainly in terms of family support in those types of communities, but it has its downside in this regard. I think it's not that different in the Greek community where we put so much emphasis on the family and wanting to kind of elevate the status of the family through your achievements. When you are not able to do everything that's expected of you or do it in the way that's expected of you, there's a heavy sense of having failed that can really be, I think, compound the self-stigma. I know I haven't directly answered your question, but it's an interesting area that needs to be studied further. I'm afraid we're going to have to change out for the next presentation. We're just going to have to ask Dr. Yanos to return. We've got so many questions. He's got an awful lot to tell us. Thank you, Dr. Yanos. This has been really wonderful. Thanks so much. We will post the transcript on our website.