Associations of multiple domains of self-esteem with four dimensions of stigma in schizophrenia

Abstract

Research suggests global self-esteem among persons with schizophrenia may be negatively affected by stigma or stereotyped beliefs about persons with severe mental illness. Less clear however, is whether particular dimensions of self-esteem are linked to particular domains of stigma. To examine this we surveyed a range of self-esteem dimensions including lovability, personal power, competence and moral self-approval and four domains of stigma: Stereotype endorsement, Discrimination experience, Social withdrawal and Stigma rejection. Participants were 133 adults with diagnoses of schizophrenia or schizoaffective disorder. Stepwise multiple regressions controlling for a possible defensive response bias suggested that aspects of self-esteem related to lovability by others were more closely linked with lesser feelings of being alienated from others due to mental illness. Aspects of self-esteem related to the ability to manage one's own affairs were more closely associated with the rejection of stereotypes of mental illness. A sense of being able to influence others was linked to both the absence of discrimination experiences and the ability to ward off stigma. Implications for treatment are discussed.

Introduction

Individuals' appraisal of their personal value is closely related to the kinds of groups they perceive themselves as belonging to and the values they and others attach to belonging to those groups (Major and O'Brien, 2005, Mead, 1934). For instance, the self-esteem of someone who is a young female professor at a university will likely be affected by the meanings that she and persons in her community as a whole assign to belonging to the groups of “professor,” “young,” and “female.”

In the case of schizophrenia, many identify themselves and are identified by others as belonging to the group of “persons with schizophrenia” (Frese, 1993, Lally, 1989). Such identification may be helpful to some in various ways. For example, seeing oneself as a person with schizophrenia may allow some to see that they are not the only one who suffers certain terrifying experiences. It may also point to strategies for recovery. Nevertheless, a potential problem associated with belonging to this group is that there are stereotyped beliefs attached to severe mental illness (Martin et al., 2000, Swindle et al., 2000). Categorically referred to as stigma, these beliefs are spread across all levels of society and include expectations of violent and disorderly behavior as well as the conviction that persons with schizophrenia cannot work or make informed decisions about their welfare (Link et al., 1999, Phelan et al., 2000).

As a consequence, while identifying oneself as “a person with schizophrenia” may be linked to greater awareness of illness and possibly treatment adherence, it is also associated with threats to self-esteem, self efficacy and hope for the future (Link et al., 2001, Lysaker et al., in press, Lysaker et al., 2007a, Lysaker et al., 2007b, Markowitz, 1998, Roe, 2003, Ritsher and Phelan, 2004, Wright et al., 2000, Watson et al., in press). In fact research has suggested that stigma may reduce self-esteem regardless of symptom level and cognitive function and lead to poorer outcome including depression, humiliation and shame (Birchwood et al., 2005, Landeen et al., 2007). Tarrier and colleagues (2004), for instance, have found that suicidal ideation among persons with psychosis was linked to hopelessness, which was in turn linked to negative self-evaluation. Speaking to the long-term effects of stigma, several authors have suggested that beyond having an immediately distressing impact, stigma may be internalized (Ritsher and Phelan, 2004), and impede a person's chances of establishing identities unrelated to mental illness (Corrigan and Watson, 2002, Skaff and Pearlin, 1992) paving the way to even more entrenched forms of psychosocial dysfunction (McCay and Seeman, 1998).

While the links between stigma, self-esteem and poorer long-term outcomes have been widely noted, less is known about whether specific aspects of stigma are linked to specific elements of self-esteem. Self-esteem is generally referred to as a singular or global construct which reflects a person's sense of his or her own worthiness (Baker and Gallant, 1985). Yet, evidence suggests that overall self-esteem is a synthesis of a number of components of semi-independent facets which correspond to specific domains of life experience. These different components may covary systematically between different types of persons and may respond differentially to changes in life experiences (O'Brien, 1991, O'Brien and Epstein, 1974). For instance, global sense of self-esteem involves appraisals of the extent to which persons feel they are lovable, competent, morally valuable and able to affect their own lives. Research suggests that there are some components of self-esteem which are especially difficult for persons with schizophrenia to achieve including the sense of personal competence and influence over others (Garfield et al., 1987).

Just as self-esteem in general has multiple components, internalized stigma similarly has multiple elements regardless of the group being stigmatized (Major and O'Brien, 2005). Internalized stigma refers not only to the acceptance or internalization of stigmatizing beliefs, but also a general sense that one does not belong in the social world of others in routine life (Ritsher and Phelan, 2004).

The current study set out to examine the associations of different components of self-esteem with different elements of internalized stigma in a sample of persons meeting criteria for a schizophrenia-spectrum disorder. To assess self-esteem, we chose the Multidimensional Self-Esteem Index (MSEI; O'Brien and Epstein, 1998). This instrument has two subscales which assess components of self-esteem which are defined in a purely relational context: Lovability and Likeability. It also has three scales linked to self-esteem in the context of both relations and the carrying out of regular life tasks: Competence, Personal power and Moral self-approval. Finally it has a validity scale which assesses defensive self-enhancement and thus may identify persons who may present with an inflated view of their self-worth. To assess internalized stigma we chose the Internalized Stigma of Mental Illness Scale (ISMIS; Ritsher et al., 2003). The ISMIS has the benefit of providing separate assessments of discrimination experiences, acceptance of stereotypic beliefs and sense of being fundamentally different from others due to mental illness.

While we considered our analyses to be largely exploratory we did make several initial predictions. We first expected that lower self-esteem in the MSEI domains linked to a person's socially based sense of lovability and likeability would be more closely correlated with the ISMIS scales measuring feelings of alienation and social withdrawal. Here we reasoned that persons who felt a fundamental sense of disconnection with others might expect to be unloved. We secondly expected that lower self-esteem in the MSEI domains linked to persons' abilities to cope and function including competence, personal power and moral self-approval, would be more closely linked to the ISMIS scales that assess scales linked to function such as internalization of stereotyped beliefs and discrimination experiences. We reasoned here that experiences of discrimination and the acceptance of stigma might uniquely erode one's sense of efficacy or the ability to meet one's own needs. Additionally, we planned to use the MSEI defensive self-enhancement validity scale to not only eliminate participants whose responses suggested an invalidly defensive responses style, but additionally, as a covariate to rule out the possibility that any associations were due to a general response style.