Internalized stigma and quality of life among persons with severe mental illness: The mediating roles of self-esteem and hope

Abstract

Research has revealed the negative consequences of internalized stigma among people with serious mental illness (SMI), including reductions in self-esteem and hope. The purpose of the present study was to investigate the relation between internalized stigma and subjective quality of life (QoL) by examining the mediating role of self-esteem and hope. Measures of internalized stigma, self-esteem, QoL, and hope were administrated to 179 people who had a SMI. Linear regression analysis and structural equation modeling (SEM) were used to analyze the cross-sectional data. Self-esteem mediated the relation between internalized stigma and hope. In addition, hope partially mediated the relationship between self-esteem and QoL. The findings suggest that the effect of internalized stigma upon hope and QoL may be closely related to levels of self-esteem. This may point to the need for the development of interventions that target internalized stigma as well as self-esteem.

Introduction

Internalized stigma (or self-stigma) within the context of mental health refers to the process by which a person with a serious mental illness (SMI) loses previously held or hoped for identities (e.g., self as student or worker) and adopts stigmatizing views held by many members of the community (e.g., self as dangerous, self as incompetent) (Corrigan and Watson, 2002, Ritsher and Phelan, 2004, Yanos et al., 2010). It is estimated that about a third of people with SMI experience high levels of internalized stigma (Brohan et al., 2010, Yanos et al., 2011) that constitute a significant barrier to recovery (Yanos et al., 2010, Yanos et al., 2011).

The rapidly growing body of research on internalized stigma has shown that self-stigma is associated with low self-esteem, low sense of empowerment, low social support, low hope, poor adherence to treatment and low subjective quality of life (QoL) (Corrigan et al., 2006a, Corrigan et al., 2006b, Lysaker et al., 2007, Werner et al., 2008, Livingston and Boyd, 2010). Corrigan et al. (2009) described the following three processes of internalized stigma: awareness of the stereotype, agreement with the stereotype and applying it to oneself. In addition, Corrigan et al. (2009) proposed a “why try?” model that presents a chain of internalized stigma consequences. The “why try?” model suggests that, as a result of internalized stigma, persons with SMI experience reduced self-esteem and self-efficacy, which might lead them to avoid pursuing life goals (Corrigan et al., 2009). Thus, persons with SMI who are aware of public stigma toward mental illness, and agree with and adopt the public's stigmatizing attitudes, may feel unworthy and question their ability to achieve their personal goals (Corrigan et al., 2009). Both the capacities and routes one has toward desired goals are conceptualized as hope (Snyder et al., 1991). Hope is not a single response to an event but rather involves a general orientation one has towards the future (Snyder et al., 1991). In the psychiatric empirical literature, as well as in personal narratives of persons with SMI, hope is often thought to be an important contributor to recovery and QoL (Deegan, 1988, Anthony, 1993, Jacobson and Greenely, 2001, Hasson-Ohayon et al., 2009). Research has shown that persons with SMI express significantly less hope than the general population (Landeen and Seeman, 2000, Landeen et al., 2000) and that low levels of hope are related to low QoL (Hasson-Ohayon et al., 2009) and avoidant coping strategies (Lysaker et al., 2008).

Yanos et al. (2010) proposed a model for how internalized stigma may have a major impact on both subjective and objective outcomes related to recovery. The model posits that identity that is influenced by internalized stigma negatively affects hope and self-esteem. Hopelessness and low self-esteem, in turn, may increase depression and create a risk for suicide. They may also influence social interaction, as individuals with low self-esteem drift away from others and become isolated. Recent research has supported many of the predictions of the model. Specifically, path analysis supported the hypothesis that internalized stigma was associated with avoidant coping, active social avoidance, and depressive symptoms, and that these relationships were mediated by the impact of internalized stigma on hope and self-esteem (Yanos et al., 2008). A prospective study found that changes in internalized stigma were closely linked to changes in self-esteem (Lysaker et al., 2012). Work by other researchers has also indicated that internalized stigma is associated with low levels of self-esteem (Corrigan et al., 2006b, Werner et al., 2008), avoidant coping, (Kleim et al., 2008), and impaired social functioning (Muñoz et al., 2011).

Internalized stigma, hope and self-esteem are highly related to the QoL of persons with SMI (Hansson, 2006, Hasson-Ohayon et al., 2009, Staring et al., 2009). Achievement of enhanced QoL presents a goal in psychiatric rehabilitation, consisting of both subjective and objective dimensions, and it is of particular value to understand how QoL relates to other important factors.

Based on the above-reviewed literature, the current study examined a mediation model in which internalized stigma affects self-esteem, self-esteem affects hope, and hope affects QoL. Accordingly, its assumptions are consistent with both the “why try?” model (Corrigan et al., 2009) and the path model of self-stigma (Yanos et al., 2008, Yanos et al., 2010). However, the current study differed from the path model by examining hope and self-esteem as two related but different phenomena along the process of the internalization of stigma. Fig. 1 presents the model. According to the current model, internalized stigma is related to hope through self-esteem, and self-esteem is related to QoL thorough hope. Based on this model, we hypothesized that (1) internalized stigma would be negatively related to self-esteem; (2) self-esteem would be positively related to hope; (3) internalized stigma would be negatively related to hope; (4) controlling for self-esteem would reduce the relation between internalized stigma and hope; (5) self-esteem would be positively related to QoL; (6) hope would be positively related to QoL; and (7) controlling for hope would reduce the relation between self-esteem and QoL.