Acceptability, feasibility, and potencial efficacy of a multicomponent intervention on internalized stigma in people diagnosed with severe mental disorder.

The Internalized Stigma Reduction Program: EncontrándoME, belonging to Igual-Mente: stigma reduction program, considers the levels at which stigma manifests itself. Interventions to reduce stigma and its typology should be by levels since the processes that generate and maintain it differ in each. Since a multilevel or ecological perspective was assumed in understanding stigma, the intervention's impact at the intrapersonal or individual level may have repercussions at other levels. The interventions that served as the basis for the design of EncontrándoME were developed in high-income countries. For this reason, the activities from these interventions that were incorporated into the design of EncontrándoME were contextualized and adapted to the local reality, considering cultural values and meanings. Regarding the latter, what is threatened by stigma in the local context is the possibility of working and the feeling of usefulness that this generates in people with a mental disorder (MD). Therefore, the intervention considers the cultural aspects of mental disorders (MDs) and stigma. Multiple interventional techniques were incorporated into account the integrative approach on which the intervention is based. Among them is narrative development, derived from narrative therapy, which has proven effective in getting individuals with MDs to create new stories that consider the challenges and positive aspects of their lives. Another technique is cognitive restructuring as part of cognitive-behavioral therapy, which was considered because it has been widely used to restructure negative beliefs about oneself and the MD. In addition, self-concept is addressed since it has been suggested that interventions should help individuals with hidden stigmatized identities to develop a positive self-concept. Training in coping strategies for stigma (education, deviance, and disclosure of MD) was incorporated since these are strategies that individuals with MDs have reported as valuable and effective. Finally, work will be done to enhance the recovery process of individuals with MDs because the more they are confident that recovery is possible and feasible, the less stigma will be internalized. Regarding the materials used in the intervention, the facilitators have the administration manuals, pencils, markers, attendance sheets, labels to facilitate the identification of participants, cardboard cards, a ball, and a ball of yarn for the development of some activities, flip charts or a computer with a projector to present the content worked on in some sessions, as well as the certificates of participation that will be delivered at the end of the intervention. On the other hand, participants will be given a folder where they can keep the exercises and tasks of each session for later reference, as well as markers, pencils, erasers, crayons, glue, and scissors, in order to be able to carry out the exercises oriented in the sessions. A more detailed description of these materials can be found in the intervention administration manual for facilitators and co-facilitators. Regarding the procedures, the intervention consists of 10 group sessions lasting 90 minutes each, administered to a group of 17 people once a week and in person (total duration: 2 months and 15 days). The number of sessions and their frequency are fixed. The intervention will take place in a room of the Family Mental Health Community Center (COSAM, for its acronym in Spanish) Leonor Mascayano (public health center belonging to primary care), located in Chile, Biobío Region, Concepción, so that it will take place in the same place as the recruitment of participants and data collection. The sessions have a welcome, homework check, central activity/s, orientation to do the next week's homework, closing, and evaluation. Before each session, the facilitator should review the intervention administration manual and arrive 15 minutes early to set up the space and ensure everything is in order. He/she should set up the chairs in a circular fashion, test the equipment to be used and place the session materials on a table next to the work circle. At the beginning of each session, and as participants enter the meeting room, they should put on a name tag, which they will give to the facilitator at the end of each session to be used at the next session. Participants must complete a minimum of 7 sessions and fulfill the total number of hours required to obtain a certificate of participation at the end of the program (participants may only leave each session 10 minutes before the end of the program). The facilitator must send an email, WhatsApp, or phone call (previously agreed with each participant) one day before the session to remind them of their attendance. Likewise, the facilitator should call those participants who do not attend a session to give them a summary and encourage them to attend the next session. The intervention administration manual details the activities to be carried out in each session. The intervention is administered by two facilitators (psychologist, psychiatrist, nurse, social worker, or other social science professional) with previous experience in group management and psychosocial interventions, as well as in working with individuals with MDs, which will be verified by direct consultation with the facilitators. An experienced expert in mental health (a person diagnosed with a mental disorder) will accompany the facilitators in two sessions. The facilitators and the experienced expert will receive prior training in the administration of the intervention by the responsible researcher, they will be recruited specifically for the study, and they will receive monetary compensation for developing the intervention (this compensation is not necessary to replicate the intervention). Training will be conducted face-to-face in a workshop format in the weeks before the administration of each session. The intervention is planned to be tailored to the characteristics of the participants. This implies that the exercises for each session can be done in written form or through a drawing or collage. Two aspects will assess the fidelity of the intervention delivery; through the observation of each session, using a checklist by a professional external to the research team, and through a semi-structured interview with the facilitators one week after the end of the intervention. The checklists and the semi-structured interview are included in the intervention administration manual.