BACKGROUND Population surveys indicate that people generally hold distorted views and
negative stereotypes about individuals suffering from mental disorders. For example, 60%
of the population believes that patients with mental disorders are aggressive or violent,
and 50% believe they are incapable of working. Research has also found that most
individuals with mental disorders are aware of the presence of these stereotypes in
society, and over 70% expect to be treated unjustly by others because of their condition.
Additionally, 60-70% of patients with mental disorders believe that most people would
refuse to have someone with a mental disorder as a friend, neighbor, colleague, or
partner. While some individuals with mental disorders may react to these stereotypes with
indifference or anger, most end up accepting these stereotypes as true, internalizing
them and attributing them to themselves; this phenomenon is known as internalized stigma
or self-stigma. One of the largest studies in this field estimated that 41% of
individuals with schizophrenia spectrum disorders experience high levels of self-stigma.
Other studies have reported similar rates. The literature has found that self-stigma is
associated with worse recovery outcomes. A recent meta-analysis reports significant
correlations between self-stigma and a lack of hope, self-esteem, and self-efficacy,
poorer subjective quality of life, greater symptom severity, and lower treatment
adherence. Self-stigma can be both a consequence and a cause of negative outcomes. When
self-stigma plays a causal role, it can become a target for treatment. Yanos and
colleagues proposed the illness identity model which provides a set of detailed and
testable hypotheses regarding the potential causal role that self-stigma plays in
influencing recovery outcomes in individuals with mental disorders. This model suggests
that when identity is influenced by self-stigma, individuals believe that recovery is not
possible, reducing hope (i.e., expectations about one future) and self-esteem. Despair
and low self-esteem, in turn, increase the risk of suicide, reduce social interaction,
lead to the use of passive coping strategies for symptoms, and reduce treatment
adherence. As patients use avoidant coping strategies, they may also lose their jobs.
Finally, avoidant coping, social isolation, and reduced social functioning can increase
the severity of psychotic symptoms. Empirical support for this model comes from the
findings of two studies conducted by different research groups. Building on the evidence
of the role that self-stigma plays in recovery processes, Narrative Enhancement and
Cognitive Therapy (NECT) was developed as a treatment protocol aimed at reducing
self-stigma in individuals with mental disorders. NECT is a structured group treatment
that combines psychoeducation (to help participants challenge stigmatizing beliefs about
mental illness and recovery with empirical and scientific data), cognitive restructuring
(aimed at teaching skills to modify negative beliefs about oneself related to stigma),
and narrative enhancement (designed to help participants improve their ability to
integrate themes like trust and self-worth into their narratives). To date, five studies
have tested the effectiveness of NECT. The first, conducted in the United States with a
small group of 39 patients, failed to highlight significant effects of NECT on
self-stigma, likely due to the small sample size; however, the intervention was found to
be feasible and well-tolerated by participants. A study conducted in Israel with 119
patients showed that participation in the NECT program was associated with significant
improvements in self-esteem, quality of life, and hope. Similarly, a randomized
controlled trial with a 6-month follow-up conducted in Gothenburg, Sweden, found that the
NECT intervention was associated with significant improvements in self-esteem and
self-stigma, and that these improvements were maintained at six months. A subsequent
randomized controlled study conducted in the United States with 170 patients with
schizophrenia spectrum disorders demonstrated that NECT could produce significant
improvements in self-stigma and other variables, including avoidant coping, compared to
the supportive control intervention. Finally, a randomized controlled trial implemented
in Taiwan showed more significant results from NECT in improving self-esteem and reducing
perceived discrimination compared to the control intervention. These studies demonstrate
that NECT's effectiveness is supported by robust empirical evidence, qualifying it as an
evidence-based intervention and suggesting its large-scale implementation. Unfortunately,
in Italy, interventions against self-stigma in individuals with mental disorders are not
regularly provided. Where anti-self-stigma interventions are offered, they are generally
not based on solid evidence of effectiveness. This delay is due to the unavailability of
manualized interventions, such as NECT, in our language. Moreover, the anti-self-stigma
interventions published in the literature have so far been tested in geographical
contexts and within healthcare organizations very different from those in our country.
Therefore, it is unclear how these interventions, if made available in Italian, could be
applicable within our healthcare settings.
OBJECTIVES The objectives of this study are: (1) to evaluate the effectiveness of this
approach in the clinical routine of mental health centers; (2) to test the feasibility of
the new Italian version of the NECT treatment in patients who seek care at mental health
centers in a large area of north-eastern Italy. Overall, this project will enhance
knowledge of optimal treatments for patients with mental disorders burdened by high
self-stigma, with the aim of improving their recovery outcomes. The study is a pragmatic,
multicenter, randomized controlled trial with two parallel arms: intervention group and
control group.
INTERVENTIONS The intervention group will receive Narrative Enhancement and Cognitive
Therapy (NECT), a structured group therapy aimed at reducing self-stigma in individuals
with severe mental disorders. NECT, originally developed by Philip Yanos and colleagues,
has been adapted into Italian for this study and consists of 20 sessions divided into
five parts: orientation, psychoeducation, cognitive restructuring, narrative enhancement,
and conclusion. Each part is designed to help participants reflect on their experiences,
challenge self-stigmatizing beliefs, and foster a new, positive identity. The control
group will continue with their usual care, which typically involves a combination of
pharmacological treatment and psychosocial interventions provided by public mental health
services. The study will systematically collect information about the care received by
participants during the trial.
STUDY DURATION AND RANDOMIZATION PROCEDURE NECT sessions during approximately one hour,
structured into an introduction, a central discussion, and a conclusion. The NECT
intervention is considered an add-on treatment, meaning participants will continue
receiving their standard care in addition to the group therapy. The control group will
continue with their usual treatment, which may include medication, symptom management,
and psychiatric rehabilitation. Staff involved in delivering the NECT intervention will
undergo specific training to ensure consistent and effective implementation.
Treatment fidelity will be monitored through audio recordings of selected sessions,
evaluated using the NECT Fidelity Scale.
The study also includes a feasibility assessment, measuring participant engagement,
session completion rates, and feedback from both participants and facilitators to
identify factors that may impact the implementation of NECT in clinical settings.
The study is designed to be completed over 12 months. It begins with protocol approval,
followed by a two-month recruitment phase to enroll eligible participants. Once
recruitment is complete, a five-month intervention phase will take place, during which
participants will undergo the NECT treatment. The final five months are allocated for
data entry, analysis, and the preparation of results for publication.
The study involves 26 community mental health centers (CMHCs) across the Veneto region,
the Trento province, and the city of Bolzano.
The randomization process is crucial for ensuring the validity of the trial. Each CMHC
will recruit 16 patients, for a total of 416 participants. They will be randomly assigned
to either the NECT intervention group or a control group, maintaining a 1:1 allocation
ratio.
This stratified randomization by CMHC ensures that the unique characteristics of each
center are accounted for, contributing to the robustness of the study's findings. The
randomization will be carried out using specialized software to ensure fairness and
consistency across all centers.