Shame Fades as Recovery Advances in Schizophrenia and Bipolar Disorder, Study Finds

Recovery from serious mental illness has long been described as a journey rather than a destination, but researchers have only recently begun mapping the psychological terrain that people cross along the way. A new cross-sectional study from Turkey adds an important piece to that map, suggesting that the burden of internalized stigma, the quiet process by which patients absorb society’s negative stereotypes about their own conditions, diminishes measurably as people move through the stages of recovery from schizophrenia and bipolar disorder. At the same time, the study found that mindfulness, a psychological trait often promoted as a protective resource in mental health care, did not vary significantly across recovery stages, a finding that challenges some common assumptions about what supports people on the long road back.

The research, conducted by Meryem Fırat and Buse Nur Gedik of the Department of Psychiatric Nursing at Erzincan Binali Yıldırım University together with Papatya Karakurt of the Department of Fundamental Nursing, was published in BMC Psychiatry. The team recruited 104 patients attending a Community Mental Health Center, a setting that serves people living with severe psychiatric conditions in the community rather than in hospital wards. All participants completed a sociodemographic data form along with three standardized instruments: the Stages of Recovery Instrument-30, known as STORI-30; the Internalized Stigma of Mental Illness Scale, or ISMI; and the Mindful Attention Awareness Scale, abbreviated as MAAS. The researchers then analyzed the data using percentage distributions, mean scores, Pearson correlation analysis, and one-way analysis of variance, a statistical technique that tests whether average scores differ across multiple groups.

The STORI-30 is grounded in a widely cited stage model of recovery developed from the firsthand accounts of people living with serious mental illness. In this model, recovery unfolds through five stages. The first, Moratorium, is a period of withdrawal and despair in which the person feels overwhelmed by loss and uncertainty. Awareness follows, when the individual begins to sense that a life beyond illness might be possible. Preparation marks the stage of tentative experimentation, as people start taking small steps toward their goals. Rebuilding involves active work to construct a positive identity and reengage with valued roles. Finally, Growth represents a mature stage in which the person has integrated the experience of illness into a renewed sense of self and looks forward with confidence. The instrument asks respondents to rate statements describing thoughts and feelings characteristic of each stage, allowing researchers to profile where a person sits along this trajectory.

In the new study, the mean scores for the five stages painted a picture of a sample that was, on average, oriented toward the later phases of recovery. Moratorium scored lowest, at 9.48 with a standard deviation of 6.84, followed by Awareness at 13.25, Preparation at 13.49, Rebuilding at 14.84, and Growth at 14.99. Growth was also the largest single stage group, accounting for 28.8 percent of participants. This distribution matters because the community mental health center model is explicitly designed to foster exactly this kind of forward movement, offering structured support, social contact, and rehabilitation activities outside the hospital. The scores suggest that many of the patients in this sample were not merely stabilizing but actively rebuilding their lives.

Against that backdrop, the stigma findings stand out. The mean total score on the Internalized Stigma of Mental Illness Scale was 77.74 with a standard deviation of 14.14, a level indicating a meaningful degree of self-stigma in the sample overall. Yet when the researchers compared stigma scores across the recovery-stage groups, they found a statistically significant difference, with an F statistic of 11.917 and a p value below .001. The pattern was clear and clinically intuitive: internalized stigma was highest among those in the earliest stage of recovery and lowest among those in the most advanced stages. Correlation analysis reinforced the same story. Stigma scores were positively correlated with Moratorium, the stage of withdrawal and despair, and negatively correlated with Rebuilding and Growth, the stages in which people actively reconstruct their identities and futures.

The direction of this relationship is one of the study’s most thought-provoking aspects, and the authors are careful not to overclaim causation from a cross-sectional design. It is plausible that internalized stigma acts as a brake on recovery, keeping people trapped in the shame and social withdrawal that define the Moratorium stage. It is equally plausible, however, that as people progress through recovery, gaining roles, relationships, and a renewed sense of agency, they naturally shed the internalized stereotypes that once defined them. Most likely, the relationship is bidirectional: stigma impedes progress, and progress erodes stigma. What the data do establish is that stigma is not a fixed trait but a dynamic one, tightly linked to where a person stands in the recovery process, and that it deserves attention at every point along the way.

The mindfulness results tell a different and more surprising story. The mean score on the Mindful Attention Awareness Scale was 50.80 with a standard deviation of 12.74, but unlike stigma, mindfulness did not differ significantly across recovery stages, with an F statistic of 1.377 and a p value of .247. Correlation analysis confirmed the null finding: mindfulness was not significantly associated with any stage of recovery. For a field that has invested heavily in mindfulness-based interventions for psychosis and mood disorders, this is a notable result. It suggests that trait mindfulness, at least as measured by this instrument, may be relatively stable across individuals regardless of their recovery position, and that it may not be the stage-sensitive variable that stigma is. The finding does not diminish the potential value of mindfulness training, but it does caution against assuming that mindful attention automatically deepens as people recover, or that it maps neatly onto the recovery trajectory.

The methodological context deserves attention when weighing these results. The study was descriptive and correlational, capturing a single moment in time for a modest sample of 104 people drawn from one community mental health center in Erzincan, Turkey. Cross-sectional designs cannot establish whether stigma falls because recovery advances or vice versa, and the stage model itself, while clinically rich, relies on self-reported agreement with stage-characteristic statements. The researchers also note that the study received no specific grant funding and that the authors declare no competing interests. Ethical approval was obtained from the Ethics Committee of Erzincan Binali Yıldırım University Faculty of Health Sciences in August 2022, and all participants gave written informed consent, with procedures conducted in accordance with the Declaration of Helsinki.

Even with those limitations, the clinical implications are concrete. The authors conclude that integrating recovery-oriented and stigma-sensitive approaches into psychiatric nursing care may help support patients through the recovery process. In practice, that means screening for internalized stigma rather than assuming it will resolve on its own, tailoring interventions to the patient’s current recovery stage, and recognizing that people in the Moratorium stage may need intensive help with shame and social reconnection before they can engage with rehabilitation goals. Peer support programs, psychoeducation that directly addresses self-stigma, and narrative approaches that help people reframe their illness experiences all become more targeted when clinicians know that stigma is concentrated in the early stages of the journey.

The study also carries a broader message about how mental health systems measure success. Recovery, in the modern sense, is not simply the absence of symptoms but the presence of hope, identity, and a meaningful life, and the instruments used here, STORI-30, ISMI, and MAAS, give clinicians and researchers a vocabulary for tracking those dimensions. The finding that the largest group of patients at this center had reached the Growth stage offers an encouraging counterpoint to fatalistic views of schizophrenia and bipolar disorder. At the same time, the persistence of substantial internalized stigma in the sample, averaging above 77 points on a scale where higher scores reflect greater self-stigma, is a reminder that the social environment surrounding people with mental illness shapes their inner lives in ways that medication alone cannot touch. As community mental health services expand worldwide, this research suggests that the fight against stigma, both external and internalized, belongs at the center of recovery-oriented care, stage by stage, patient by patient.

Subject of Research: Internalized stigma, mindfulness, and recovery stages in schizophrenia and bipolar disorder

Article Title: Internalized stigma and mindfulness in the context of recovery stages in schizophrenia and bipolar patients: a cross-sectional study

Article References: Fırat, M., Gedik, B. N., & Karakurt, P. (2026). Internalized stigma and mindfulness in the context of recovery stages in schizophrenia and bipolar patients: a cross-sectional study. BMC Psychiatry. https://doi.org/10.1186/s12888-026-08692-9

Image Credits: AI Generated

DOI: 10.1186/s12888-026-08692-9

Keywords: schizophrenia, bipolar disorder, internalized stigma, mindfulness, recovery stages, STORI-30, ISMI, MAAS, psychiatric nursing, community mental health, self-stigma, cross-sectional study