Expanded-Coming-Out-Proud Group on Reducing Self-stigma for People With a Severe Mental Illness- A Randomized Control Trial With Six-month Follow-up

Control Group, Expanded Coming Out Proud Group

Expanded Coming Out Proud group, Self-stimga, Empowerment, Cognitive Behavioural Therapy, Honest Open and Proud, Depression

Globally, approximately one-third of people with severe mental illness report self-stigma. Self-stigma negatively affects recovery by lowering quality of life, self-esteem, and self-efficacy, and reducing treatment adherence, which can lead individuals to refuse psychiatric medication, experience increased psychiatric symptoms, and relapse. Multi-component interventions, which combine several single interventions, have been found to produce better outcomes than single interventions alone, but few studies have been conducted in this area. To address this research gap, this study aimed to develop and evaluate the longer-term impact of a 12-session Expanded Coming Out Proud (ECOP) group delivered by a social worker and a peer support worker, with skills in empowerment and transforming negative self-stigmatising beliefs, to reduce self-stigma in people with severe mental illness in Hong Kong. This study was a multicentre, randomised controlled trial with 6-month follow-up. The intervention group received ECOP in addition to treatment as usual (TAU), which included interest classes and recreational activities, while the control group received TAU.

This study was a multicentre randomized controlled trial. Participants were recruited from four community-based mental health centres in Hong Kong through open recruitment via promotional activities and referrals from these centres. Those who consented to participate were randomly assigned to either the treatment or control group using computer software administered by a research team member who was not involved in data collection or implementation of the ECOP group. Block randomisation was used to ensure equal numbers in the treatment and control groups. The control group received treatment as usual (TAU) provided by a community mental health centre, including interest classes and recreational activities. In addition to TAU, the intervention group received an ECOP group led by an experienced social worker and a peer social worker from a community mental health centre. A research assistant who was blinded to the randomized allocation of participants conducted data collection and outcome assessment with standardized assessment tools at baseline, post-treatment, and at 3-month and 6-month follow-ups The ECOP incorporated the advantages of both cognitive behavioural therapy and the Coming Out Proud. On one hand, the ECOP, based on the cognitive behavioural therapy, helped participants learn skills to transform self-stigmatising beliefs to reduce self-stigma. On the other hand, the ECOP, adapted from the Coming Out Proud, empowered them to face social stigma effectively by disclosing their mental illness to appropriate social systems, such as peers, support groups, and the media, with an appropriate level of self-disclosure. The ECOP consisted of 12 group sessions, one per week, each lasting one and a half hours, led by an experienced social worker and a peer support worker. Participants in the control group received TAU, including interest classes and leisure activities provided by collaborating community mental health centres, which were the same as those received by the intervention group. For all analyses, two-tailed p values of \< 0.05 is considered statistically significant. Data analyses will be performed using SPSS 29.0 (IBM Corporation, 2024). For hypotheses (1) and (2), within group intervention effects on all outcome assessment scores were investigated by using repeated measures of analysis of variance (ANOVA), while between group intervention effects were investigated by using group x time repeated measures of ANOVA. Effect sizes were calculated using partial η2, with values of 0.01, 0.06 and 0.14 considered small, moderate and large effects, respectively (Cohen, 1988). For hypothesis (3), the predictive power of the improved ISMI and PESAS scores from pre-intervention to post-intervention on the improved BDI and RSE score were investigated and compared using multiple linear regression analysis, using stepwise selection procedure to investigate the relative predictive power of the improved ISMI score and PESAS score.

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