Evidence for the Effectiveness of Psychological Interventions for Internalized Stigma among Adults with Schizophrenia Spectrum Disorders: A Systematic Review and Meta-Analyses

In recent years, psychological interventions have been used to alleviate internalized stigma in people with schizophrenia spectrum disorders, but outcomes have been inconsistent. The aim of this review was to examine the existing evidence regarding this matter. Four electronic databases (EMBASE, MEDLINE, PsycINFO, and the Cochrane Central Register of Controlled Trials) were searched from inception until 8 September 2022, using appropriate strategies. The eligibility, quality, and strength of evidence of each study were all evaluated against the predetermined standards. Further quantitative analyses were performed using the RevMan software. A total of 27 studies were included in the systematic review. Eighteen studies with extractable data for meta-analysis yielded a statistically significant overall effect (Z = 3.00; p = 0.003; 95% CI: −0.69 [−1.15, −0.24]; n = 1633), although there was considerable heterogeneity (Tau2 = 0.89; Chi2 = 303.62, df = 17; p < 0.00001; I2 = 94%). Subgroup analyses for Narrative Enhancement and Cognitive Therapy (NECT) produced a statistically significant and highly homogenous effect (Z = 3.40; p = 0.0007; 95% CI: −0.44 [−0.70, −0.19]; n = 241; Tau2 = 0.00; Chi2 = 0.14, df = 2 (p = 0.93); I2 = 0%). In conclusion, the majority of the psychological interventions are successful in lowering levels of internalized stigma, especially NECT, and interventions that integrate multiple therapies may be more beneficial.


Introduction
Internalized stigma occurs when an individual with a mental health condition adopts stigmatizing attitudes about their condition as their own. This acceptance can have a negative impact on the person's sense of self-worth and ability to recover from their illness [1][2][3]. Included in the category of internalized stigma are both felt/perceived stigma and self-stigma [4]. This is consistent with the regressive model of self-stigma proposed by Corrigan, which comprises four stages [5]. First, one becomes aware of the stigma of mental illness (also called "perceived stigma"), then one agrees with the stigma, one subsequently applies the stigma to oneself, and finally one experiences the negative effects of the stigma on one's self-esteem and self-efficacy, which leads to shame (also known as "self-stigma"). Thus, according to this model, perceived stigma is the first stage of self-stigma formation. Both perceived stigma and self-stigma are involved in the internalization of public stigma. Thus, both perceived stigma and self-stigma are classified as internalized stigma. Therefore, 2 of 24 it corresponds with the categorization proposed by Livingston and Boyd. Internalized stigma has great inhibitory effects on the intention of seeking help [6,7].
Schizophrenia is a renowned, serious mental illness that affects a large number of people in society. According to the WHO in early 2022, schizophrenia affected approximately 24 million people, or 1 in 300 people (0.32%) worldwide [8]. Males and females are equally affected; however, the peak ages of onset differ: males are affected between the ages of 10 and 25 years, while females are affected between the ages of 25 and 35 years [9]. Suicide accounts for 4 to 10% of all deaths among those diagnosed with schizophrenia, predominantly affecting young males [10]. This could be due to a variety of factors, including the reaction to the psychosis and the experience of stigma.
The World Health Organization has identified three main points regarding stigma and mental illness: (1) stigma is the primary reason for discrimination against and rejection of people with mental illness; (2) stigma has negative effects on both the prevention of mental health problems and the treatment and care of those who suffer from them; and (3) stigma violates human rights [11]. According to several studies, people with schizophrenia are more likely to experience and suffer from self-stigma than people with other mental illnesses [12,13]. Forty-one percent of a sizable European sample of adults with a schizophrenia-spectrum diagnosis reported high levels of internalized stigma, while 69 percent reported moderate or severe perceived discrimination [14]. A systematic review conducted on persons with schizophrenia spectrum disorders found that approximately 65% of participants felt stigmatized, and 56% had experienced it [15]. Stigmatization of those diagnosed with schizophrenia is widespread, and it may stem from skewed assumptions regarding their physical appearance and inconsistent acts that are associated with altered thoughts, perceptions, and behaviors [16]. Individuals having schizophrenia may experience exclusion by members of society and misconduct displayed against them regarding their emotions, thoughts, and behaviors [17]. Debilitating symptoms associated with the condition are labelled as "madness" by society, which leads to stigmatization, discrimination, and a decrease in productivity, all of which have a significant negative impact on the patient's emotional, social, and economic well-being [18]. The majority of people diagnosed with schizophrenia reported having a low level of perceived social support, with support from significant others ranking the lowest, followed by support from friends and family [19]. Even when functional remission is reached, there is still a high unemployment rate among people with schizophrenia [20]. Prior research demonstrated that people with schizophrenia are disproportionately affected by internalized stigma [21,22]. The impaired functioning that is common in schizophrenia presents significant difficulties for both the affected person's family and the surrounding society. Hence, among the vital goals of treatment for people with schizophrenia is to enhance their capacity to function and become self-sufficient through enhanced social adaptation [23,24].
Psychological interventions aiming to reduce the detrimental effects of internalized stigma on individuals with schizophrenia spectrum disorders have garnered considerable attention in recent years. The results of several systematic reviews and meta-analyses published in the last few years on interventions to diminish internalized stigma are still inconsistent [25][26][27][28]. This might be due to a lack of prior experimental trials that have been conducted to establish the efficacy of a certain intervention. Consequently, it is impossible to reliably verify the pooled effect sizes. In the early stages of an intervention, the lack of research from various locations around the world may reduce our understanding of its potential overall efficacy. At present, various psychological interventions have been developed and tested to reduce internalized stigma in patients with schizophrenia spectrum disorders, such as Group Psychoeducation [29][30][31][32] and Narrative Enhancement and Cognitive Therapy (NECT) [33,34]. Such treatments are crucial because they can target a wide variety of factors that relate to the psychological process of the production of internalized stigma, which was mentioned previously. The outcomes of interventions at different time intervals or in different regions varied greatly. This might be because of numerous variables such as small sample sizes, variation in intervention implementation, and anecdotal definitions of stigma. Considering this discrepancy, further study on this topic is still necessary to learn more about the therapies that have been developed so far, and including newer studies may lead to a more definitive conclusion.

Aims
The aim of this study is to perform an updated systematic review and meta-analysis of the evidence for the effectiveness of interventions for internalized stigma among adults with schizophrenia spectrum disorders and to determine the efficacy of interventions on internalized stigma reduction among adults with schizophrenia spectrum disorders.

Materials and Methods
The systematic review and meta-analysis have been carried out in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline [35,36]. It was registered in the International Prospective Register of Systematic Reviews (PROSPERO) on 26 August 2021, with registration number CRD42018106359 [37].

Eligibility Criteria
Studies included in the review met the following criteria: (1) used a randomized controlled trial or similar type study design (pseudorandomized controlled trial and nonrandomized experimental trial); (2) includes individuals ranging in age from 18 to 65 years old; (3) evaluated interventions for reducing internalized stigma; (4) quantitatively assessed the reduction in internalized stigma; and (5) published full papers in the English language. The exclusion criteria were (1) non-English language papers, (2) case reports, reviews, unpublished research, conference abstracts, trial protocols, and proceedings, and (3) studies that did not include people from the diagnoses of schizophrenia spectrum and other psychotic disorders.

Selection Process
All of the collected search results were subsequently transferred to reference management software [Covidence systematic review software, Veritas Health Innovation, Melbourne, Australia. www.covidence.org (accessed on 8 August 2022)]. This program will automatically sort out any duplicate studies upon import, making it much simpler for two independent reviewers to examine the titles and abstracts of the research. Thereafter, the eligibility of the entire texts was meticulously examined based on the inclusion and exclusion criteria that had been established previously. When there were discrepancies between the two reviewers (SJ and other members of the team), a third reviewer or the group's consensus was used to reach a decision.

Methodological Quality
The McMaster Critical Appraisal Tool for Quantitative Studies was utilized in order to conduct an evaluation on the level of quality present in each of the studies that were included [38]. It consists of 15 questions that evaluate the subject areas of research purpose, literature, design, samples, outcomes, interventions, results, conclusions, and therapeutic implications. Each question was given a grade of "Yes", "No", or "Not Addressed", and a score of one point was awarded for "Yes" responses. A maximum score of 15 is possible. The Australian National Health and Medical Research Council (NHMRC) evidence hierarchy was utilized to ascertain the level of evidence possessed by each study that was incorporated into the review [39]. The five aspects that were evaluated were (i) evidence base; (ii) consistency of findings across included studies; (iii) clinical impact; (iv) generalizability; and (v) applicability. In order to assist in providing direction for the overall weighting of the suggestion, each component was assigned a grade ranging from "A" to "D".

Data Extraction and Management
The data extraction was carried out by two independent reviewers (SJ and TI) using spreadsheets created in Microsoft Excel (Microsoft Corporation, Redmond, WA, USA). The descriptive data that were extracted from the included studies include the following: country of origin; study setting; sample size and characteristics (diagnoses, gender, age group); exposure, comparator, and characteristics of interventions (type, frequency, duration); outcome measures and its relevant results. If further information was required, the respective authors were contacted. Any discrepancies that were found in the data that was extracted were resolved by a third reviewer (SS).

Statistical Analysis
A meta-analysis was carried out in order to compare the interventions that have been utilized with the purpose of lowering levels of internalized stigma. The RevMan software program (Review Manager (RevMan). Version 5.4, The Cochrane Collaboration, 2020) was used to analyze the data. For continuous outcomes measured on a variety of scales, the pooled effect was computed as a standardized mean difference (SMD). The confidence intervals (CI) were set at 95%. The I 2 index statistic was utilized in order to provide an expression of the heterogeneity that existed among the studies. A value of 0% for the I 2 index showed that there was no observable heterogeneity; a value of 25% indicated low heterogeneity, 50% indicated moderate heterogeneity, and 75% indicated high heterogeneity [40]. Because of the diversity of the studies that were incorporated into the analysis, a random-effect model was used so that any potential heterogeneity could be accounted for. A p-value of ≤0.05 was used to indicate statistical significance. Moreover, publication bias was investigated using a funnel plot.

Study Selection
Searches conducted using online databases yielded a total of 681 studies, of which 21 were duplicates. There was a total of 276 studies retrieved from EMBASE, 79 studies from MEDLINE, 105 studies from PsycINFO, 105 studies from the Cochrane Library, and 116 studies sourced from additional records discovered through the reference list. Following the removal of studies that were found to be duplicates and a screening of the titles and abstracts, a total of 638 studies were excluded. A total of 43 studies with full-text manuscripts were evaluated for eligibility. The overall selection process is illustrated in Figure 1. Finally, a total of 27 studies were included in the systematic review. were duplicates. There was a total of 276 studies retrieved from EMBASE, 79 studies from MEDLINE, 105 studies from PsycINFO, 105 studies from the Cochrane Library, and 116 studies sourced from additional records discovered through the reference list. Following the removal of studies that were found to be duplicates and a screening of the titles and abstracts, a total of 638 studies were excluded. A total of 43 studies with full-text manuscripts were evaluated for eligibility. The overall selection process is illustrated in Figure  1. Finally, a total of 27 studies were included in the systematic review.

Included
Reports sought for retrieval (n = 40) Records excluded based on Title and Abstract screened (n = 63) Records removed before screening: • Duplicate records removed (n = 13) Reports not retrieved (n = 22) • non RCT/similar type (n = 9) • not schizophrenia spectrum disorders (n = 13) Reports excluded (n = 12) • Wrong study design (n = 5) • Full text not in English (n = 7) Figure 1. Flowchart based on the PRISMA 2020 statement [36] that describes the movement of information through the various stages of conducting this systematic review.

Study Characteristics
Study characteristics are summarized in Table 1. Studies from fifteen different countries, including the United States of America, Canada, China, Vietnam, Japan, Taiwan, Turkey, Jordan, Israel, England, Sweden, Croatia, Finland, Spain, and Germany, were included in this review. Twenty-two studies (81.5%) were published in the last 10 years (2013-2022), with nine of those studies published since the year 2020. This review included a total of 2975 participants, the majority of whom fell into the age range of 30 to 50 years old; the number of male participants was slightly higher compared to female participants, as well as the vast majority of the participants possessed at least secondary education.        There were 15 studies composed of individuals who were treated as outpatients [29,31,33,41,43,45,[47][48][49][50]52,54,57,58,60]. There were six studies conducted on participants who were inpatients [30,32,42,46,53,55]. Four studies encompassed participants from both inpatient and outpatient settings [34,43,54,56], while two studies did not address this [48,52].
There were 10 studies that only included people who had the diagnosis of schizophrenia in their participant pool [29,32,41,44,46,47,49,50,55,57]. Three studies had samples that have either schizophrenia or schizoaffective disorder as their diagnosis [30,31,54]. Nine studies had the majority of patients diagnosed with a condition that falls within the schizophrenia spectrum disorder [33,43,[51][52][53][59][60][61][62]. Two studies used samples that met the criteria for serious mental illness (SMI); however, exact diagnosis was not stated but claimed that the majority of the participants had a psychotic condition [34,48]. A total of three studies had a larger number of samples consisting of individuals with affective disorders [42,45,56].

Characteristics of Interventions Used
Group Psychoeducation was by far the most common type of intervention employed, with a total of five studies. [29][30][31][32]41]. Narrative Enhancement and Cognitive Therapy (NECT) was the second most common type of intervention utilized (total of four studies) [33,34,48,54]. Two studies reported on the Ending Self-Stigma (ESS) psychoeducational intervention [51,61]. Another two studies utilized the Self-stigma Reduction Program [57,62].

Characteristics of Outcome Measures Used
Among the other main scales used to measure the efficacy of the interventions were the following: Perceived Stigma Questionnaire [30]; the Chinese Self-stigma of Mental Illness Scale [57]; the Self-Stigma of Mental Illness Scale-Short Form and the Rosenberg Self-Esteem Scale [34]; the Stigma Towards Schizophrenia scale [55]; the Link's Stigma-Devaluation Scale [29]; the Stigma Scale [42]; and the Japanese version of the Social Distance Scale [31].
In each of these studies, the validity and reliability of these measures were acknowledged as being sound.

Results of the Interventions
The findings of the interventions for internalized stigma are summarized in Table 2. Overall, 15 out of 27 studies presented statistically significant outcomes. Four out of the five studies found that Group Psychoeducation was effective in achieving a statistically significant reduction in internalized stigma. One study compared Group Psychoeducation with Supportive Session, and the results favored Group Psychoeducation [29]. Another three studies that compared Group Psychoeducation with Treatment as Usual or a Waiting List produced significant reductions in internalized stigma as well [31,32,41]. However, one study that compared this intervention with Treatment as Usual provided results of lowering stigma in both groups, but considerably more so in the control group, which appeared to be a negative treatment effect for this intervention [30].
In the case of NECT, two out of the four studies revealed findings that were favorable to this intervention in comparison to Treatment as Usual or the Waiting List [34,48]. One study showed that NECT was not more effective than Treatment as Usual [33], while another study that compared this intervention with Supportive Group Therapy yielded results that favored the intervention; however, it was not statistically significant [54].
One study that compared ESS to Treatment as Usual generated data that showed that ESS was beneficial in helping to lessen essential features of internalized stigma; however, it was not statistically significant [51]. In another study, the findings indicated that ESS was not more beneficial than the Health and Wellness Intervention [61].
One study that compared the Self-stigma Reduction Program to Newspaper Reading found results that favored the intervention, although the difference was not statistically significant [57], while the findings of another study that compared this intervention to Treatment as Usual provided statistically significant results that favored this intervention [62].
Other studies that resulted in significant findings involve the following types of interventions: Antistigma Photovoice Program [52]; Family Schizophrenia Psychoeducation Program [55]; Mindfulness-based Psychoeducation [44]; Destigmatized Group Intervention [45]; CBT-based Psychoeducation Program [47]; Solution-focused Group Psychoeducation Program [49]; and Against Stigma Program [46]. These studies compared the intervention to Treatment as Usual or the Waiting List. Another study found substantial results when comparing Group Music Therapy to the Waiting List, but found no differences when compared to the Active Control condition of Group Education [42].
In terms of the effect size, 21 studies contributed their findings. However, four of them did not elaborate on the type of effect size they employed. Small effect sizes were found in three studies [53,55,59]; small to medium effect sizes were found in four studies [33,43,54,56]; medium effect sizes were found in five studies [30,34,48,52,60]; medium to large effect sizes were found in three studies [41,42,45]; and large effect sizes were found in two studies [32,62].

Meta-Analysis
As this review is about determining the effectiveness of interventions for internalized stigma, a meta-analysis was conducted so that the significance of the link between the interventions that were utilized and their effectiveness in decreasing internalized stigma could be further investigated. Because the purpose of this review is not to ascertain which intervention is superior to the other, but rather to determine whether or not a particular intervention is effective when it is employed, studies that compared interventions to Treatment as Usual or a Waiting List were used. A total of 21 studies fit this description; however, only 18 of them were included in the analysis since 2 studies did not provide adequate extractable data. See Figure 2 for details. intervention is superior to the other, but rather to determine whether or not a particular intervention is effective when it is employed, studies that compared interventions to Treatment as Usual or a Waiting List were used. A total of 21 studies fit this description; however, only 18 of them were included in the analysis since 2 studies did not provide adequate extractable data. See Figure 2 for details. The overall effect was statistically significant (Z = 3.00; p = 0.003; 95% CI: −0.69 [−1.15, −0.24]; n = 1633), although there was considerable heterogeneity (Tau 2 = 0.89; Chi 2 = 303.62, df = 17; p < 0.00001; I 2 = 94%). This indicates that on the whole, the interventions that were utilized were effective in lowering internalized stigma in comparison to Treatment as Usual or the Waiting List; nevertheless, there was a significant amount of variation across these studies [40]. In view of the significant level of heterogeneity that exists across the studies, we moved on to the subgroup analysis [63,64].  The overall effect was statistically significant (Z = 3.00; p = 0.003; 95% CI: −0.69 [−1.15, −0.24]; n = 1633), although there was considerable heterogeneity (Tau 2 = 0.89; Chi 2 = 303.62, df = 17; p < 0.00001; I 2 = 94%). This indicates that on the whole, the interventions that were utilized were effective in lowering internalized stigma in comparison to Treatment as Usual or the Waiting List; nevertheless, there was a significant amount of variation across these studies [40]. In view of the significant level of heterogeneity that exists across the studies, we moved on to the subgroup analysis [63,64].

Subgroup Analysis
Due to the high I 2 , we conducted subgroup analyses in studies utilizing the same type of interventions.

Publication Bias
There was no indication of publication bias in any of the papers that we chose to include in the meta-analysis, as can be seen in the funnel plot that is shown in Figure 5.

Publication Bias
There was no indication of publication bias in any of the papers that we chose to include in the meta-analysis, as can be seen in the funnel plot that is shown in Figure 5.

Publication Bias
There was no indication of publication bias in any of the papers that we chose to include in the meta-analysis, as can be seen in the funnel plot that is shown in Figure 5.

NHRMC Evidence Statement Matrix
This review found that certain interventions may be effective methods for reducing internalized stigma; however, variations in these interventions needed to be considered as well. The overall rating of B for the NHRMC Evidence Statement Matrix was given This indicates that there is some evidence in support of the recommendations, but caution should be exercised while implementing them. Table S2 of the Supplementary Materials provides a summary of the evidence matrix.

Discussion
This study explores a number of various psychological interventions that have the potential to reduce internalized stigma in individuals who have been diagnosed with schizophrenia spectrum disorders. To the best of our knowledge, this is the largest review to date on psychological therapies for internalized stigma in schizophrenia spectrum dis orders, encompassing a total of 27 studies with a combined sample size of 2975 individu als from 15 different countries. Overall, the findings suggest that a variety of psychologica therapies may be effective in reducing internalized stigma in people with schizophrenia spectrum disorders. A systematic review of studies revealed that 15 out of 27 trials yielded statistically significant results in favor of psychological therapies for decreasing internal ized stigma. This is further supported by the meta-analysis of 18 trials, which demon strated a significant effect of the therapies in reducing internalized stigma compared to Treatment as Usual or the Waiting List.
According to the findings, not only was Narrative Enhancement and Cognitive Ther apy (NECT) somewhat effective from the standpoint of the systematic review, but it was also efficacious from the perspective of the meta-analysis that we conducted. These results are consistent with those of previous research that came to the conclusion that NECT is

NHRMC Evidence Statement Matrix
This review found that certain interventions may be effective methods for reducing internalized stigma; however, variations in these interventions needed to be considered as well. The overall rating of B for the NHRMC Evidence Statement Matrix was given. This indicates that there is some evidence in support of the recommendations, but caution should be exercised while implementing them. Table S2 of the Supplementary Materials provides a summary of the evidence matrix.

Discussion
This study explores a number of various psychological interventions that have the potential to reduce internalized stigma in individuals who have been diagnosed with schizophrenia spectrum disorders. To the best of our knowledge, this is the largest review to date on psychological therapies for internalized stigma in schizophrenia spectrum disorders, encompassing a total of 27 studies with a combined sample size of 2975 individuals from 15 different countries. Overall, the findings suggest that a variety of psychological therapies may be effective in reducing internalized stigma in people with schizophrenia spectrum disorders. A systematic review of studies revealed that 15 out of 27 trials yielded statistically significant results in favor of psychological therapies for decreasing internalized stigma. This is further supported by the meta-analysis of 18 trials, which demonstrated a significant effect of the therapies in reducing internalized stigma compared to Treatment as Usual or the Waiting List.
According to the findings, not only was Narrative Enhancement and Cognitive Therapy (NECT) somewhat effective from the standpoint of the systematic review, but it was also efficacious from the perspective of the meta-analysis that we conducted. These results are consistent with those of previous research that came to the conclusion that NECT is beneficial in reducing self-stigma as well as other subjective components of recovery such as hope and self-esteem in people who have suffered from psychotic-related illnesses [34,48,54]. NECT is a structured, group-based intervention that combines narrative therapy focused on enhancing one's ability to narrate one's life story, psychoeducation to help replace stigmatizing views about mental illness and recovery with empirical findings, and cognitive restructuring geared toward teaching skills to challenge negative beliefs about the self [34]. The length of time that the intervention was carried out ranged from five to six months. Since it has been seen phenomenologically that people with severe mental illness typically have a diminished capacity to narrate the unfolding tale of their own lives, NECT's primary focus is on supporting the change in personal narratives. The ability to alter one's narrative is seen as crucial in this context for the purpose of altering one's sense of self. By having participants write or dictate tales about themselves and then receiving comments from the facilitator and group members on alternate viewpoints about the topics contained in their stories, NECT aims to assist individuals in reshaping their narratives. This intervention is effective because it is sensitive to the particular patient's experiences and beliefs, and it also provides multiple tailored approaches to diminishing the internalized stigma in them.
Based on the findings of previous studies, Group Psychoeducation was the most commonly used psychological intervention for reducing internalized stigma [25,26,28]. These results coincide with the results of our study since we found that this intervention had been looked into in a total of five different studies [29][30][31][32]41]. In general, this intervention's goal is to educate participants on a variety of important topics, such as gaining a better understanding of their condition, avoiding future relapses, discussing their experiences with stigma, and learning coping techniques to help them overcome stigma. The treatment not only combines psychodynamic strategies for coping with emotional reactions to the disease and stigma, but it also encompasses cognitive strategies for addressing attitudes and ideas about the illness. Previous research has demonstrated that psychoeducation is an effective method for helping people with schizophrenia to obtain a deeper understanding of their condition and its implications [65]. There are a few key distinctions between the use of this intervention among the trials that we studied, most notably with regard to the duration and frequency with which it is implemented. The shortest was seven sessions in three weeks [32], while the longest was twelve sessions in three months [41]. Despite positive findings from the systematic review on the effectiveness of this intervention, we discovered from our meta-analysis that the summary effect was not significant and that the heterogeneity was large. One possible explanation for this discrepancy is that the intervention was performed differently in various studies, with varied length and methodology. Consequently, this finding should be interpreted with caution due to the requirement to account for the variations in intervention.
It was discovered that among the most effective interventions were those that included a few different therapies. Combinations across therapies such as psychoeducation, cognitive behavioral therapy, social skills training, mindfulness, problem-solving skills, communication skills, and support groups were common. Among the interventions that had such multi-faceted elements were Self-stigma Reduction Program [62], Antistigma Photovoice Program [52], Mindfulness-based Psychoeducation [44], Destigmatized Group Intervention [45], CBT-based Psychoeducation Program [47], Solution-focused Group Psychoeducation Program [49], and Against Stigma Program [46]. Because of the many dimensions of the stigma, it addresses and the variety of approaches it provides, it appears that such therapies are advantageous in helping patients overcome internalized stigma. However, due to the limited number of studies that have been conducted to investigate their efficacy, accepting these conclusions has to be approached with caution.
Another notable matter is that the majority of the available interventions are carried out in groups rather than individually or in a combination of the two. This trend may have arisen for a variety of reasons, including the fact that group therapy is commonly viewed as more efficient financially and time-wise; patients gain comfort in knowing they are not alone in their struggles [66]; individuals gain insight through reflection on the experiences of others; and therapeutic alliances are strengthened through interactions with peers and facilitators during group sessions [67]. However, it is crucial not to overlook the possible advantages of interventions that are carried out individually, which may include a more intensive therapeutic experience, an individualized approach, and the maintenance of confidentiality. In light of this, it is essential to keep in mind that the effectiveness of an intervention may only be obtained to the fullest extent possible when the treatment is specifically adapted to the experiences and requirements of the patient.
Furthermore, internalized stigma is a multifaceted phenomenon that is comprised of a variety of components. One of the most effective strategies for overcoming it is to first identify the relevant principal targets that are involved, followed by prescribing interventions that are designed to explicitly address those targets while also taking into account many other aspects of the patient's capabilities and requirements. For instance, we may use the Internalized Stigma of Mental Illness (ISMI) Scale to determine which parts of internalized stigma are primarily impacted in a patient. This can be carried out by analyzing the patient's responses to the various questions on the scale. If Stereotype Endorsement and Alienation are a problem, then interventions such as NECT [48], Solution-focused Group Psychoeducation Program [49], Mindfulness-based Psychoeducation [44], or CBT-based psychoeducation program [47] that are known to effectively improve these targets may be utilized. Such tailored care may result in the following outcomes: an improved patient experience as a result of treatment decisions that take into account patients' care needs and preferences; an improved population's health and quality of life as a result of tailored care being supported; and a reduction in the per capita cost of care as a result of a reduction in the overuse, underuse, and misuse of healthcare services [68]. Furthermore, prior to implementing the intervention, it is essential to have a discussion about the options that are suitable and available, as well as the pros and cons of each, and to apply shared decision making between the patient and the doctor, as this may have many positive outcomes.

Strength and Limitations
Among the strengths of this study is that, to the best of our knowledge, this is the largest review to date on psychological interventions for internalized stigma in schizophrenia spectrum disorders. In addition, this is also the first meta-analysis to examine the effectiveness of Narrative Enhancement and Cognitive Therapy (NECT) in lowering internalized stigma in people with schizophrenia spectrum disorders. However, there were some limitations to our study. Firstly, we limited our search to only include studies that had been published in English. As a result, we are unable to include the findings of other research that was published in a variety of languages, which leaves open the potential for publication bias. Secondly, the studies that were included in our research at times employed varying definitions of internalized stigma to some extent and also assessed it using different questionnaires that each had their unique method of ascertaining it.
Recommendations for future research include conducting more clinical trials testing the efficacy of each psychological intervention. This would allow for the measurement of pooled effects for each intervention, so providing a clearer picture of each's effectiveness. After that, head-to-head comparisons of successful interventions might be conducted, yielding the most effective intervention. In addition, we also recommend that future research focus on the patient-tailored strategy of prescribing therapies based on the detected elements of internalized stigma.

Conclusions
According to this systematic review and meta-analysis, the majority of the psychological interventions evaluated are successful in lowering levels of internalized stigma, the use of NECT shows promise, and interventions that mix several therapies may be more beneficial. The strength of our research is that it is the largest review to date on psychological interventions for internalized stigma in people with schizophrenia spectrum disorders, as well as the first meta-analysis to evaluate the effectiveness of Narrative Enhancement and Cognitive Therapy (NECT) in lowering internalized stigma in people with schizophrenia spectrum disorders.
Insights from this study have the potential to give mental health practitioners more effective alternatives for implementing psychological therapies to reduce internalized stigma. Moreover, we recommend that future research focus on the patient-tailored strategy of prescribing therapies based on the detected elements of internalized stigma. In addition, we urge that future studies concentrate on the patient-tailored method of prescribing therapies based on the detected elements of internalized stigma.
Supplementary Materials: The following supporting information can be downloaded at: https:// www.mdpi.com/article/10.3390/ijerph20085570/s1, Table S1: Quality assessment of included studies; Table S2: Summary of the NHRMC Evidence Statement Matrix.