Psychiatric Rehabilitation Journal 2015, Vol. 38, No. 2, 186 –193

© 2015 American Psychological Association 1095-158X/15/$12.00 http://dx.doi.org/10.1037/prj0000109

Peer Education as a Strategy for Reducing Internalized Stigma Among Depressed Older Adults Kyaien O. Conner

Symone A. McKinnon

University of South Florida

San Diego State University

Christine J. Ward, Charles F. Reynolds III, and Charlotte Brown This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

University of Pittsburgh Objective: This article examines the mechanisms through which peer educator (PE) intervention targets and reduces internalized stigma. There is substantial evidence that internalized stigma negatively impacts the lives of those suffering with mental health concerns, and has been identified as 1 of the most significant barriers to seeking professional mental health services. There has been a push toward identifying interventions and programs that effectively reduce and mitigate the impact of internalized stigma. Research suggests that contact with other individuals who share a stigmatized condition may be a promising approach to targeting and reducing internalized stigma. However, there is a dearth of research that has identified the mechanism through which this contact impacts internalized stigma. Methods: Study participants (n ⫽ 19) completed a 3-month PE intervention. Each participant was matched with an older adult with a history of depression currently in recovery who provided psychoeducation, social support, and motivational interviewing. Participants completed a demographic questionnaire, public stigma (PDD), and internalized stigma (Internalized Stigma of Mental Illness, ISMI) scales pre- and post-PE intervention. They further participated in a brief semistructured qualitative interview to attain in-depth information about their perceptions of stigma and of working with a PE. Results: Overall, internalized stigma scores were significantly reduced after participating in the PE intervention. In addition, participants identified 4 mechanisms through which contact with their PE impacted their stigmatized beliefs: age related concerns, shared understanding, improved mental health literacy, and mutual support. Conclusions and Implications for Practice: This study suggests that PE is a potentially valuable approach toward reducing internalized stigma among older adults with depression. Keywords: internalized stigma, peer education, aging, depression

(2015), stigma ranked 4 out of 10 significant barriers to treatment utilization, and internalized stigma and treatment stigma were most commonly associated with reduced help-seeking behavior. In addition, research suggests that the relationship between stigma and help-seeking is particularly salient among vulnerable groups such as ethnic minorities (Clement et al., 2015; Conner, Copeland, Grote, Rosen et al., 2010; Conner, Copeland, Grote, Koeske et al., 2010; Conner, Koeske, & Brown, 2009; Gary, 2005; Roeloffs et al., 2003) and older adults (Conner, Copeland, Grote, Rosen et al., 2010; Sirey et al., 2001).

Stigma associated with depression and other mental illness continues to be one of the most pervasive barriers to treatment, deterring many individuals who need mental health services from seeking care. Individuals who can benefit from mental health treatment choose not to pursue services, or begin treatment but drop-out prematurely, to avoid the label of “depressed” as well as the stereotypes, prejudice, and discrimination associated with having a mental illness (Roeloffs et al., 2003; Sirey et al., 2001; Thornicroft, 2006; Wahl, 2012). Cooper, Corrigan, and Watson (2003) proposed that 50% to 60% of individuals with a mental health concern choose not to seek treatment due to stigma. In a recent systematic review conducted by Clement and colleagues

Public Stigma and Internalized Stigma Stigma theory posits that the stigma associated with having a mental illness manifests via public stigma and internalized stigma. Public stigma refers to the negative beliefs, attitudes, and conceptions about mental illness held by the general population, which may lead to stereotyping, prejudice, and discrimination against individuals with mental health disorders (Corrigan, 2004). Internalized or self-stigma refers to the devaluation, shame, secrecy, and social withdrawal, which are triggered by applying negative stereotypes about mental illness to oneself (Corrigan, 1998, 2004; Corrigan & Watson, 2002). Living in an environment that sanctions the stigmatization of people with mental illness, an individual

This article was published Online First April 27, 2015. Kyaien O. Conner, LSW, Department of Mental Health Law and Policy, School of Behavioral and Community Sciences, The Florida Mental Health Institute, University of South Florida; Symone A. McKinnon, Department of Psychology, College of Sciences, San Diego State University; Christine J. Ward, Charles F. Reynolds III, and Charlotte Brown, Department of Psychiatry, School of Medicine, University of Pittsburgh. Correspondence concerning this article should be addressed to Kyaien O. Conner, Florida Mental Health Institute, 1301 Bruce B. Downs Boulevard, Tampa, FL 33612. E-mail: [email protected] 186

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with a mental health disorder may accept and internalize these stigmatizing attitudes and beliefs that appear to be endorsed within society (Corrigan, 1998; Link & Phelan, 2001). Individuals with depression may believe they are less valued due to their membership within this stigmatized group, and may suffer negative emotional reactions, such as diminished self-esteem and self-efficacy (Link, Struening, Neese-Todd, Asmussen, & Phelan, 2001), as well as self-imposed barriers to treatment seeking, treatment adherence, and recovery (Yanos, Roe, & Lysaker, 2010).

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Interventions to Reduce Stigma Because of its deleterious impact, researchers have begun advocating for the development of interventions to reduce internalized stigma (Corrigan et al., 2001; Pinfold, Thornicroft, Huxley, & Farmer, 2005; Shor & Sykes, 2002). While recent treatment interventions have been developed, which can target and reduce internalized stigma (Fung, Tsang, & Cheung, 2011; Lucksted, Drapalski, Calmes, DeForge, & Boyd, 2011), additional research may be needed to examine strategies to reduce internalized stigma among individuals not currently in treatment, who are reluctant to seek professional mental health care. Given that research suggests public stigma leads to the development of internalized stigma (Conner, Copeland, Grote, Koeske, et al., 2010; Vogel, Bitman, Hammer, & Wade, 2013), it stands to reason that strategies that impact public stigma may also mitigate internalized stigma. Researchers identified three general approaches for targeting and countering public stigma. These approaches include education, contact, and protest (Corrigan & O’Shaughnessy, 2007; Corrigan et al., 2001). Of the three identified approaches, contact has been proposed as the most promising strategy for reducing public stigma (Corrigan & Penn, 1999). Researchers have examined the benefit of contact with individuals suffering with a mental illness and found that contact led to improved attitudes and behaviors (Corrigan et al., 2001; Desforges et al., 1991; London & Evans-Lacko, 2010) and that antistigma programs involving interactions with an individual with a mental health diagnosis were an effective strategy to decrease stereotypes and mental illness stigma (Corrigan et al., 2001; Pinfold et al., 2003). Despite these gains in public stigma research, there has been a dearth of research that has examined the impact of contact interventions on internalized stigma, and that has investigated the mechanisms through which contact impacts and mitigates internalized stigma (Rüsch, Angermeyer, & Corrigan, 2005; Stuart, 2008).

Peer Educator Interventions Mental health programs are increasingly creating service delivery roles for people who have previously experienced a mental illness. Founded on a rationale of self-help and mutual support, such roles are key strategies for increasing the acceptability and accessibility of mental health services, and making these services more responsive to the needs of vulnerable adults with mental illness (Mowbray, Moxley, & Collins, 1998). Individuals who have personal experience with mental illness and the mental health service delivery system can offer a unique kind of expertise, not typically available within traditional mental health treatment. Peer educators (PE) and support services offer a mechanism for work-

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ing with vulnerable populations, such as older adults or racial and ethnic minorities, who are in need of mental health services, but may feel alienated from the traditional mental health system (Segal, Gomory, & Silverman, 1998). By providing relevant information from a trusted source and improving attitudes about mental health treatment, PEs may serve to reduce the impact of internalized stigma as a significant barrier to service utilization. To date, the research that has examined the benefit of PE programs on targeting and reducing stigma (internalized stigma in particular), and the mechanisms through which contact with a “peer” impacts and mitigates stigma is limited. Rüsch and colleagues (2005) argued for additional empirical studies to examine the strategies and content of public and internalized stigma reduction programs. This paper begins to address this gap by examining a PE intervention designed to help engage depressed elders into a psychosocial treatment for depression by improving attitudes and reducing internalized stigma through contact with a “peer” who is currently in recovery for a previous depressive episode.

Method Research Design Self-report questionnaires were utilized to assess demographic information, public stigma, and internalized stigma before and after participating in the PE engagement intervention. Semistructured interviews were used after the PE intervention was completed to collect qualitative descriptive data to identify and explore the unique experiences these older adults had while working with a PE and to better understand the mechanisms through which contact with this “peer” impacted their internalized stigma. The data presented in this study comes from a larger study that included a PE intervention to reduce internalized stigma followed by an optional cognitive– behavioral therapy intervention to reduce symptoms of depression. For the purpose of this investigation, only information regarding participant experiences working with the PE, and their levels of depression, public, and internalized stigma is presented. Data regarding the overall study outcomes and the PE training will be included in a forthcoming manuscript.

Setting and Participants Study participants were recruited from two community-based primary care health centers and a social service agency located in a predominantly low-income and African American community within an eastern U.S. city. Agency or clinic physicians, nurses, and social workers referred adults aged 60 or older with depression. Upon contact with our study, a research associate screened respondents by phone using the Patient Health Questionnaire-9 (PHQ-9; Kroenke, Spitzer, & Williams, 2001). Respondents endorsing at least moderate symptoms of depression (PHQ-9 score ⱖ 10), and who were not currently being treated for a mental health issue were invited to participate in an in-person interview to determine study eligibility. Eligibility criteria (presence of a depressive episode, rule-out bipolar disorder, significant substance abuse, and any psychotic disorders) were assessed using the Primary Care Evaluation of Mental Disorders (PRIME MD; Spitzer, Kroenke, & Williams, 1999). Eligible respondents completed writ-

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ten informed consent, and were assigned a PE who contacted them within 1 week.

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PE Intervention PEs included 7 older adults (1 male, 7 female, aged 61–91), recruited from the above community sites. All had a prior history of depression and received treatment to remission, but were not currently depressed. They were selected based upon their interest in sharing their experiences with depression and treatment with another older adult, and the presence of good communication skills. The PEs completed a comprehensive training program before being assigned to study participants. The PE training program consisted of a five-session, 20-hr, manualized training protocol comprised of lectures, role play, and group discussion. PEs did not function as mental health counselors, and this was emphasized in the training. It was hypothesized that contact with a “peer” in their age group, from their community, and who had also experienced depression will have a mitigating effect on internalized stigma among study participants. PE’s were matched to study participants on the following criteria: age, neighborhood, and participants’ preference for gender and race. PEs were instructed to contact their peer to set up an initial visit immediately upon participant entry to the study and were required to meet with them a minimum of three times (at least once in person) over a 3-month period. There was no upper limit to the amount of contacts, and all contacts above and beyond three meetings were completely at the initiation of study participants. On average, PEs met with their peers nine times over 3 months. There was no set structure to the PE sessions with participants. PEs were trained to use motivational interviewing techniques to assess the participants needs, provide accurate information about depression and depression treatment, discuss their own experience with depression and road to recovery, and provide social and emotional support. PEs created contact notes that outlined in detail their interaction with participants, which were turned in and reviewed. PEs attended biweekly supervision meetings with project researchers/clinicians to discuss current cases, gain critical feedback, and receive additional education. PEs were paid modestly for their interactions with participants ($25 for in person visit, $15 for telephone contact). Participants were not paid for their contacts with their PE.

Procedures Study participants (n ⫽ 19) completed several brief questionnaires immediately following successful screening into the study before their first contact with their PE, and then again following completion of the 3-month PE intervention: Demographic characteristics. Self-reported demographic characteristics included: age, gender, race, marital status, education, and employment status. Clinical characteristics. The PHQ-9 (Kroenke et al., 2001) was used to assess the severity of depressive symptoms at screening, baseline, and follow-up. This instrument has excellent sensitivity and specificity as a screener and is sensitive to change in depressive symptomatology over time. A higher score indicates more severe depressive symptoms. Perceived public stigma was assessed with a revised version of the Devaluation Discrimination Scale (Link, 1982). This 12-item,

6-point Likert scale (1 ⫽ strongly agree to 6 ⫽ strongly disagree) evaluates the extent to which the respondent believes that others will devalue or discriminate against persons with a mental illness. The scale was adapted so that items referring to “having a mental illness” were changed to “had depression” (see Brown et al., 2010) for adapted scale. Possible scores range from 12 to 48; higher scores indicating more public stigma. Internalized stigma was assessed with the Internalized Stigma of Mental Illness Scale (ISMI; Ritsher, Otilingam, & Grajales, 2003), which focuses on the individual’s beliefs about themselves as an individual with mental illness. This 29-item, 4-point Likert scale (1 ⫽ strongly agree to 4 ⫽ strongly disagree) was also adapted so that items referred to “depression” instead of “mental illness” (see Brown et al., 2010). Possible scores range from 29 to 126; higher scores indicate more internalized stigma.

Semistructured Interview Interviews were conducted with study participants (n ⫽ 19) immediately following their last visit with their PE. Interviews lasted approximately 45 min and followed a semistructured format with additional items for further probing, if necessary. Questions asked about the benefit of working with their PE, how working with a PE impacted their view of depression and treatment as well as their dissatisfaction with the intervention. No questions specifically asked about stigma, as to not bias study results; rather, the issue of stigma was brought up and discussed organically by study participants. Probes were used to gather more information about stigma when participants identified it themselves.

Data Analysis Simple correlations were utilized to examine the relationship between demographic characteristics and the main study variables of interest (public and internalized stigma). Paired sample T tests were utilized to examine prepost differences in scores on the public stigma (PDD) and internalized stigma (ISMI) scales. Before analysis, the data were tested for the absence of outliers and multicollinearity, homoscedasticity of residuals, and independence of error terms. Thematic analysis, a qualitative data analysis technique suggested by Braun and Clark (2006) was utilized to ensure a systematic and rigorous analysis of the semistructured interviews. Thematic analysis involves identifying, analyzing, and reporting patterns observed within data, and attempting to understand it through encoding and interpretation. Following the six guidelines suggested by Braun and Clark (2006), the thematic analysis process involved first becoming familiar with the data. During this process, the principal investigator and research staff read and reread all the written transcripts from the interviews to attain a general understanding of the data, and to develop an initial list of interesting ideas that emerged. Second, codes were developed from the important ideas, expressions, terms, and phrases of participants. Codes were given line by line through each transcript and reflect the actual language used by participants. Third, codes were clustered to identify broader patterns and potential themes. Forth, potential themes were reevaluated and refined. Fifth, selected themes were further defined and named. For each theme, we created a detailed theme analysis to identify how each theme was

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related to other themes and how they fit into the overall purpose of the study. Initially, members of the research team followed this process separately for each interview, and then combined results to ensure accuracy of the analysis. If there were discrepancies in how research team members coded certain phrases, these phrases were discussed until consensus was reached. After reviewing the 18th interview, we found that no new information was being presented, and comments were becoming increasingly redundant. Despite reaching saturation of data at 18 interviews, we analyzed the final interview to be thorough.

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Results Sample Characteristics As shown in Table 1, the majority of the sample was female, non-Hispanic White, aged 60 –70 years, and married. Most were retired or spent time volunteering or in school, but many continued to work full- or part-time. Most participants had completed high school and had at least attended college. The majority of participants endorsed moderate or moderately severe depressive symptoms and had sought mental health treatment in the past. However,

Table 1 Sample Characteristics Characteristics (n ⫽ 19) Gender Female Male Race Non-Hispanic White African American Age 60–65 66–70 71–75 75⫹ years Marital status Married Single Divorced Widowed Education High school graduate Completed some college Employment Retired Volunteer/school Working full-time Working part-time ⴱ PhQ-9 scores 10–14 15–19 20⫹ Treatment Currently in treatment Had sought treatment in the past Had not seen anyone in ⬎7 months

n (%)

Mean

12 (63) 7 (37) 14 (74) 5 (26)

67 (SD ⫽ 5.02)

6 (32) 6 (32) 5 (26) 2 (10) 7 (37) 5 (26) 4 (21) 3 (16) 18 (95) 15 (78) 6 (32) 6 (32) 4 (21) 3 (16)

14 (SD ⫽ 2.10)

13 (69) 4 (21) 2 (10) 0 (100) 14 (74) 10 (53)

Note. PhQ-9 ⫽ Patient Health Questionnaire-9. PhQ depression symptoms: minimal (score 1– 4), mild (score5–9), moderate (score 10 –14), moderately severe (score 15–19), and severe (score 20 –27).

ⴱ

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none were currently in treatment, and more than one half had not been in treatment for the preceding 7 months.

Pre-Postsurvey Analysis Before the PE intervention, mean scores of perceived public stigma were 31.5 (min 24, max 44, SD ⫽ 5.87), indicating that perceptions of public stigma were moderate to high among this sample. Mean scores of internalized stigma were 63.3 (min 52, max 89, SD ⫽ 11.00), suggesting that levels of internalized stigma were also moderate to high among this population. After the PE intervention, scores on the PHQ-9 were significantly reduced, Mean Change ⫽ 6. 285, t ⫽ 3.667, p ⫽ .010. Stigma scores were also positively impacted by the PE intervention. Postintervention, perceived public stigma scores were significantly reduced, Mean Change ⫽ 4. 14, t ⫽ 2.691, p ⬍ .05, and internalized stigma scores were significantly reduced, Mean Change ⫽ 8.142, t ⫽ 2.566, p ⬍ .05. The relationship between depression severity and the stigma measures was not significant pre- or postintervention.

Semistructured Interviews Participants identified four broad themes that helped to elucidate how a contact intervention might facilitate a change in internalized stigma among depressed older adults. These themes include: agerelated concerns, shared understanding, improved mental health literacy, and mutual support. These themes are discussed below. Specific quotes from participants that highlight these themes are presented in Table 2. Pseudonyms are utilized to protect the identities of study participants. Age-related concerns. Study participants felt that people in their age cohort did not share how they felt mentally and emotionally, although they were able to comfortably talk about having diabetes, cancer, or their upcoming surgeries. Conversations around physical health issues helped participants identify a group with which they could belong, feel safe, ask questions, and give and receive support. This level of support, however, did not exist among members of their age cohort surrounding issues of depression. Participants suggested that while they could talk openly and unrestrictedly about their physical health concerns, mental health problems were an issue that was not discussed. Participants also felt that older adults are not comfortable talking to psychologists and psychiatrists, and believed that seeking professional mental health treatment would not be helpful and was a waste of time and money. Participants strongly acknowledged the benefit of talking to someone from their age group with whom they could truly relate. However, participants were fearful that most members within their age cohort would further stigmatize their experience by endorsing the belief that depression was something that should be hidden and not discussed. Working with a PE was a way to talk to someone within their age group without fear of misunderstanding and further stigmatization. Shared understanding. Study participants felt that working with a PE created an opportunity for shared understanding. They enjoyed being able to talk to someone who had a history of dealing with depression. Participants valued hearing about their PEs’ experiences with the mental health service delivery system and information concerning their previous diagnoses with depression, seeking treatment, and recovery. Hearing the stories of their PEs

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Table 2 Themes That Emerged From the Semistructured Interviews (n ⫽ 19)

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Age-related concerns “People in my age group tend to have some odd misconceptions, some stereotypical thoughts and behaviors when it comes to mental health. And there is a negative cloud that surrounds mental health issues. You know like depression is a mark.” (Paul, 66-year-old White man) “I felt like I really belonged with my peer educator. With therapists not one of them comes from my age group, but my peer educator did. It really makes a difference talking to someone my age. It’s just easier for older people to relate.” (Lisa, 69-year-old White woman) “Ageism is a part of it, no offense. I think at a certain point you just want to be with someone you can relate to who has had the hands-on experience instead of the book learning. I work with young people and love them dearly, but I felt more comfortable with my peer educator.” (Jessica, 65-yearold African American woman) “People in my age group feel more comfortable talking to a peer educator than to a therapist or psychologist because a lot of us in our age group think that psychiatrists and psychologists are quacks.” (Marshall, 75-year-old White man) Shared understanding—(having a relatable PE) “My peer educator talked to me about her situation with depression and her therapist, so I know she understands. And she always seemed like she wanted to listen when I called. It was nice to talk to someone who could understand me for once.” (Mary, 72-year-old White woman) “I never talked to my friends and family, or my pastor about mental health. They all just thought I was crazy. Most folks think I am crazy in an odd way. That’s why I liked talking to my peer educator. He could understand me and what I’m going through.” (Marshall, 75-year-old White man) “It’s the shared lifetime experience. I trusted her because of knowing of her life experiences, and I could trust that she had been through similar things, like been there done that. That made me feel better about what I’m going through. I don’t feel so bad about being depressed anymore.” (Jessica, 65-year-old African American woman) Improved mental health literacy—(information provided from a trusted source) “I learned a lot from my PE about depression and treatments. She knew because she had learned, but also because she had been through it before herself. I don’t usually like talking about mental health stuff, but I was comfortable to learn about it from her.” (Patty, 64-year-old African American woman) “I’d rather talk to my peer educator than a therapist because she didn’t have any preconceived notions or an education about how to deal with depression. Professionals go by the book. It was good to have a nonprofessional point of view.” (Jane, 67-year-old White woman) “It was good to see that my peer educator got over her depression and that she is doing well. We talked about therapy directly, and I see now that my depression is not something I caused and that I can get help and be better too.” (Jane, 67-year-old White woman) Mutual support—(reciprocal support between the PE and participants) “I got to see myself in my PE. He been where I am, and he got through it. I respect him, and seeing that he could do it means I can do it too. And he told me he respected me, and sometimes he even would let me be there for him. That made me feel important.” (Darryl, 69-year-old African American man) “I could call up my peer educator anytime, happy or sad. She would help me and be there for me, but I could be there for her too. I learned a lot from her, but she learned a lot from me too. That made me feel good about myself. To be able to help someone else.” (Jane, 67-year-old White woman) “I enjoyed working with my peer educator a lot. I called her more than I thought I would. It was just like having a friend. It was like a buddy system.” (Lisa, 69-year-old White woman)

helped participants to feel more comfortable talking about their own mental health concerns and their fears about getting treatment. These conversations with their PEs helped participants feel less stigmatized by their own experience with depression and treatment. For the first time, study participants reported that they were talking to someone who truly understood them. Their PE was a person who looked like them, from their community, who had stood in their shoes and could fully understand what they were going through. This shared understanding helped study participants to recognize how common being depressed can be and that this was not an experience to be ashamed of. Study participants felt that having someone who could fully understand them was a key factor in helping them to feel less stigmatized by their depression. Improved mental health literacy. All 19 study participants acknowledged that working with a PE improved their knowledge about depression and depression treatments. PEs were trained to talk to study participants about the causes and symptoms of depression, unique features of depression among older adults, and the different treatment options available to them. Participants felt that this information was presented in a manner that they were comfortable with, from someone they could trust and who had gone through this themselves. Learning from PEs who had their own

personal experiences with depression and mental health treatment added a sense of credibility that the study participants valued. Participants identified that they were more receptive to learning from the PE than from a mental health professional. Participants gravitated toward receiving information from the PE and the personal experiences their PEs shared rather than receiving scholarly knowledge from a professional. In fact, some participants went as far as to state that they were not comfortable talking to a mental health clinician at all and would only disclose their problems to a PE. Through the accurate information about depression and depression treatment shared by their PE, participants learned that they were not a contributor to the onset of their depression but rather it is a common physical illness that is feasible to treat, even for older adults—thus mitigating feelings of shame and guilt. Mutual support. Study participants also stated that the support they received from their PE was instrumental in their path toward recovery. The convenience and accessibility of having a PE prompted participants to use them more frequently than anticipated. In addition to receiving support from their PEs, a rewarding and impactful outcome for study participants was the opportunity to reciprocate the support. The PEs experienced some less favorable days; however, this was a perfect opportunity for study

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participants to return the favor to their PEs and be supportive to them. This process aided in connecting the participants with their PEs, strengthened the trust in the relationship, and provided an opportunity for shared growth and understanding. This mutual support also helped study participants to recognize their ability to help others irrespective of their personal issues. This process helped participants to feel better about themselves overall.

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Discussion This study provides a preliminary examination of the mechanisms through which contact with a PE mitigates internalized stigma. We learned from the pre-postsurvey analysis that participants had lower perceptions of public stigma, as well as reduced internalized stigma after working with a PE. Through contact with a PE, study participants had a unique opportunity to work with a skilled and empathetic peer from their age group whom did not stigmatize them and whom freely and proudly shared their own experience with mental illness and treatment. This interaction helped participants to be more optimistic in their perceptions about the attitudes held about depression among society; and specifically members of their own community. This also had impact on participants’ internalized feelings of guilt and shame. This finding is logical given research suggesting that perceived public stigma is a precursor to the development of internalized stigma among individuals currently dealing with a mental illness (Vogel et al., 2013). Thematic analysis of participant interviews yielded interesting results that propose potential mechanisms through which contact with a PE influences internalized stigma. Overall, participants identified 4 broad themes that elucidate how contact interventions may facilitate a change in internalized stigma among depressed older adults. Participants felt that people in their age group do not discuss mental health issues. Further, they felt older adults tended to have negative beliefs regarding depression and seeking treatment, which further stigmatized participants’ experiences. Working with a PE who was in their age cohort, and had a history of depression, helped participants identify themselves with a group and feel a sense of belonging. Crocker and Major (1989) discussed the self-protective properties of stigma, and the benefit of in-group identification to experience a buffering effect. In the current study, participants were eager to identify someone with whom they could affiliate, feel safe, be vulnerable, and talk to about their mental health concerns. Contact with their PE provided them an opportunity for within-group membership, which offers self-protective properties and helped them to view their depression in a less stigmatized fashion and to be more optimistic about their own recovery. Participants trusted the information they received from PEs because they were receiving first-hand information from someone who had personally experienced the mental health service delivery system themselves. Moreover, study participants identified being more receptive to receiving mental health information from their PE than from a professional mental health practitioner. This finding is critical given that research suggests individuals who possess more information about mental illness hold less stigmatizing attitudes toward others and feel less stigmatized themselves (Corrigan & Penn, 1999). Therefore, it is important that we ensure we are delivering information in a way that individuals can most success-

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fully receive it, and contact with a PE may be an avenue for doing so among older adults with depression. Participants also highlighted the importance of mutual support in their relationship with their PE. Having the ability to receive nonjudgmental and consistent support from their PE was important; however, the opportunity for study participants to provide support back to their PE was also emphasized. Corrigan, Sokol, and Rüsch (2013) found that mutual support programs have positive effects on quality of life and a negative impact on self-stigma for individuals with mental illness. Similarly, in this study, mutual support gave study participants an opportunity for enhanced connection with their PE, to establish trust, and to recognize their own strengths. This seemed to have a positive impact on participants’ self-esteem and helped to combat the negative effects of internalized stigma.

Limitations The results of this study should be viewed within the context of its limitations. It is likely that the individuals who chose not to participate in the current study had greater perceived public and internalized stigma, which led to their reluctance to be involved. In addition, this sample of older adults was uniquely highly educated. As higher education is often correlated to lower perceptions of stigma (Nadeem et al., 2007), it is likely that the older adults in this current study may have endorsed less stigma than the eligible population. Without a control condition, it is impossible to determine whether the changes in public and internalized stigma were due solely to the PE intervention. Despite this limitation, our analysis of participant interviews and the detailed information provided about the impact of working with the PEs on internalized stigma leads us to confidently assert that the PE intervention was the significant change agent. Future research should, however, examine the impact of peer-led programs on stigma using randomized controlled trial methodology. Given the limitations, this study has several strengths and provides a unique look at the mechanisms through which internalized stigma is reduced by a contact intervention, which has not been adequately addressed in the literature.

Implications This study highlighted mechanisms through which working with a PE can reduce internalized stigma, a significant deterrent to treatment utilization. Given that study participants identified a preference for receiving information from a PE over a traditional mental health care provider, this suggests that more opportunities for peer-led support, education, and treatment engagement programs may help reach populations of individuals in need of mental health services not currently receiving treatment. Particularly, those who may feel alienated from the traditional mental health service delivery system may benefit from PE interventions. Although this was a small sample of older adults from an urban city, we believe, given the benefit of within-group identification, that peer-led programs may be a beneficial strategy for working with a broader range of individuals dealing with mental illness. More research is needed to examine the effectiveness of peer-led programs on stigma, attitudes, and treatment engagement in diverse populations.

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REDUCING INTERNALIZED STIGMA

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Received April 2, 2014 Revision received November 13, 2014 Accepted January 5, 2015 䡲