Layla Bouzoubaa, Hyung Wook Choi, Milan Varghese +2cs.CL
Objectives: To develop a codebook for self-stigma across cognitive, affective, and behavioral domains, and to estimate the prevalence, co-occurrence, and temporal patterns of these indicators in Reddit posts by people who use drugs. Methods: We developed a ten-indicator codebook through consensus-based abductive coding spanning cognitive (self-labeling, pessimism/self-defeatism, deservingness/worthlessness), affective (shame, guilt/self-blame, despair/hopelessness), and behavioral (concealment, anticipated rejection, desire to quit, ambivalence) domains; two coders reached substantial agreement (Cohen's k = 0.72). We then scaled classification with a large language model validated against expert coding (k = 0.73, F1 = 0.80), analyzing 72,115 thread-initiating posts from 1,660 English-language users (2006-2025). Results: 3,838 posts (5.3%) from 1,228 users (74.0%) contained self-stigma; all ten indicators discriminated self-stigma posts (RR 3.6 to 86.2), led by self-labeling (56.0%) and despair/hopelessness (48.5%). Self-stigma was integrated: core and behavioral indicators were strongly associated at the user level (OR = 4.65, 95% CI 3.12-6.94, p < 0.001), and 87.0% of posts with behavioral indicators also contained a core indicator. Contrary to progressive models, behavioral indicators emerged earlier than core ones (desire to quit at median position 0.08 vs. shame at 0.38). Nine of ten indicators were stable across posting trajectories; only pessimism increased (OR = 1.62, 95% CI 1.25-2.10). Conclusion: Among people who use drugs online, self-stigma is an integrated phenomenon in which behavioral indicators rarely appear without internalized ones and often precede them. Most expressions remain stable over time, but pessimism about change deepens, marking a target for early digital intervention and showing that progressive stage models do not map directly onto textual disclosure.
Self-stigma predicts treatment avoidance and disengagement among people who use drugs (PWUD), yet conversational systems aiming to provide support typically treat self-stigma expression as a uniform signal. We present a three-phase, proof-of-concept study of a persona-aware approach to LLM support. Latent Profile Analysis (LPA) on indicator-level features from 1,174 self-stigma expressors on Reddit yields a four-persona typology validated against held-out behavioral and linguistic features. Sequential Bayesian and recurrent neural classifiers recover these personas from limited posting histories, substantially outperforming batch and few-shot LLM baselines (macro-F1 = 0.74 at 30 posts). Evaluation by eight clinical experts across three contemporary LLMs revealed a misalignment: persona-matched responses successfully achieved targeted behavioral shifts, yet raters holistically preferred the generic empathy of the persona-neutral baseline. Our findings suggest that holistic empathy judgments and clinically-aligned response design can pull in opposite directions, and that evaluating LLM-based stigma support requires rubrics capable of decomposing the two.
Simulating patients with large language models (LLMs) is a promising tool for mental health training, but existing approaches fail to capture a key clinical reality: self-stigma. Patients experiencing self-stigma, the internalization of negative stereotypes, often exhibit context-sensitive resistance, such as avoidance, denial, or self-blame, which current models render as static or uniformly compliant behavior. To address this, we introduce a novel simulation framework grounded in the psychological 3A1H model of self-stigmatization. Our core innovation is the creation of a \textbf{Stigmatized Self-Reflection} (\textbf{SSR}) dataset, where we augment mental health dialogues with internal monologues that reflect stigma-aware reasoning. By fine-tuning LLMs with this data using a chain-of-thought approach, we train patient agents to dynamically adjust their level and expression of stigma based on conversational triggers. Evaluations demonstrate that our approach significantly outperforms specialized baselines, generating more authentic and situationally appropriate patient responses. This work provides a crucial step towards realistic stigma simulation for clinical training and empathetic dialogue systems.