The relationship between internalized stigma and quality of life among people with mental illness: are self-esteem and sense of coherence sequential mediators?

People with mental illness are frequent targets of public stigma, i.e., negative stereotypes, prejudice, and discrimination [1]. Many individuals turn these stigmatizing societal attitudes against themselves, which may result in internalized stigma (also referred to as self-stigma). Internalized stigma can be defined as “a subjective process, embedded within a socio-cultural context, which may be characterized by negative feelings (about self), maladaptive behaviour, identity transformation, or stereotype endorsement resulting from an individual’s experiences, perceptions, or anticipation of negative social reactions on the basis of their mental illness” [2, p. 2151]. This detrimental process may hamper the recovery of service users, limit their life chances and substantially reduce their quality of life (QoL) [1, 3].

However, although the negative impact of the internalized stigma of mental illness on QoL is well established [2, 4], the precise mechanism of this effect has not been fully explained. Some previous research has indicated that self-esteem may play a mediating role in this relationship. More specifically, in a study including 179 people with serious mental illness, Mashiach-Eizenberg et al. [5] found that self-esteem fully mediated the relation between internalized stigma and hope, whereas hope partially mediated the relationship between self-esteem and QoL. In another study, based on data obtained from 403 persons with mental illness, Oliveira et al. [6] demonstrated that self-esteem fully mediated the relation between internalized stigma and the physical and the social relationships domains of QoL, and partially mediated the relationship between internalized stigma and psychological, environment, and level of independence domains.

Building and expanding on these findings, we propose a model of the impact of internalized stigma on QoL including sense of coherence (SOC) as another potential mediating factor, in addition to self-esteem. SOC is the term coined by Antonovsky, who defined it as “a global orientation that expresses the extent to which one has a pervasive, enduring though dynamic feeling of confidence that (1) the stimuli deriving from one’s internal and external environments in the course of living are structured, predictable, and explicable; (2) the resources are available to one to meet the demands posed by these stimuli; and (3) these demands are challenges, worthy of investment and engagement” [7, p. 19]. These three interrelated components of SOC are called comprehensibility, manageability and meaningfulness. The SOC construct is the core of Antonovsky’s theory of salutogenesis, which seeks to explain the origins of health. The theory posits that high SOC reflects a greater capacity to cope with stressful situations and predicts good health and QoL.

Importantly, according to Antonovsky the development of a strong SOC requires the presence of so-called generalized resistance resources (GRRs). These include “any characteristic of the person, the group, or the environment that can facilitate effective tension management” [8, p. 99]. In other words, within the salutogenic framework, GRRs are biological, material, or psychosocial factors that lead to life experiences which contribute to seeing the world as more comprehensible, manageable, and meaningful.

Self-esteem is regarded as one of the typical GRRs promoting SOC [9]. This view was supported empirically by the studies performed on adolescent [10], adult [11], and elderly [12] populations, which revealed that better self-esteem predicted higher SOC. Hence, given that both cross-sectional and longitudinal research [2] consistently demonstrate a negative association of internalized stigma of mental illness with self-esteem, it seems reasonable to presume that self-esteem may mediate the relationship between internalized stigma and SOC. Furthermore, since there is a vast body of empirical evidence from studies on various samples (mainly disease-specific groups of patients) showing the positive influence of SOC on QOL [13], one can expect that SOC may act as a mediator between self-esteem and QoL.

Against this background, in the current study, we tested a theoretical model which assumed that self-esteem and SOC sequentially mediate the relationship between internalized stigma and QoL among people with mental illnesses. Specifically, we hypothesized that more severe internalized stigma is related to lower self-esteem, which is associated with weaker SOC, which in turn relates to worse QoL.

Descriptive statistics and intercorrelations of the measures used in the study are presented in Table 2. Internalized stigma, QoL, self-esteem, and SOC were all significantly correlated in the expected direction, whereas psychiatric symptoms showed significant (positive) association only with internalized stigma.

The results of the mediation analysis are shown in Fig. 2 and in Tables 3 and 4.

After accounting for socio-demographic and clinical factors, all individual paths between the key variables in the model turned out to be significant, with the exception of the direct effect of internalized stigma on QoL when controlling for the effects of the mediators (i.e., self-esteem and SOC). There was a significant sequential indirect effect of internalized stigma on QoL through self-esteem and SOC [path a₁d₂₁b₂: beta = –0.06, SE = 0.02; 95% CI (−0.11, −0.03)]. Also significant were simple mediation paths from internalized stigma to QoL via self-esteem [path a₁b₁: beta = –0.11, SE = 0.03; 95% CI (−0.18, –0.05)] and from internalized stigma to QoL through SOC [path a₂b₂: beta = −0.06, SE = 0.03; 95% CI (−0.12, −0.02)]. Examination of the pairwise contrasts of the indirect effects (see Table 4) revealed that the three indirect effects cannot be distinguished in terms of magnitude (zero is contained in the interval).

In this study, we found evidence for a theoretical model proposing that self-esteem and SOC sequentially mediate the relationship between internalized stigma and QoL among people with mental illness. Our findings are in keeping with previous research which has already convincingly demonstrated a robust association of self-stigma with diminished self-esteem [2, 4] and documented the role of self-esteem in mediating the negative effect of self-stigma on QoL [5, 6]. However, the study results also make an additional contribution to the existing literature by identifying SOC as another important element in the chain of self-stigma consequences and speaking in favor of the idea that self-esteem is a potential GRR for SOC.

It should be emphasized that apart from the two-mediator path, two simple mediation paths with either self-esteem or SOC as single mediators between internalized stigma and QoL were also found to be significant and the three indirect effects did not differ in terms of magnitude. This further corroborates the importance of both of these self-related variables for the QoL and highlights the complexity of the ways in which self-stigma acts on people with mental illness.

Contrary to self-esteem, SOC is a construct that has not been thus far extensively studied in the context of internalized mental health stigma and the harms it causes. This may be somewhat surprising given the well-described role of SOC in coping with stressors or enhancing health and QoL [13, 24, 25] as well as its clear relevance for mental health treatment and rehabilitation [26‐28]. Identifying the mediating effects of SOC is noteworthy as it indicates that the mechanism through which self-stigma affects the QoL of people with mental illness involves the restriction of their capacity to manage stress. Thus, for service users, self-stigma not only is a stressor itself, but also a factor diminishing their ability to mobilize the GRRs and to adapt to stressful situations. Given the harmful effects of stress on the course and outcome of mental disorders [29] and the accumulated evidence that stronger SOC is associated with better health (especially mental health) [24], it can be recommended that future studies investigate whether SOC acts as a mediator in the relationship of internalized stigma not only with QoL, but also with various indicators of health and disability in people receiving psychiatric treatment. This could shed more light on the routes through which self-stigma hinders recovery from mental illness.

Regarding implications for clinical practice, with replication this study may support the need for targeting self-esteem and SOC in therapeutic programs aiming to prevent the harmful impact of internalized stigma on people with mental illness. There is some empirical evidence indicating that these personal resources are modifiable by means of specific group interventions. An example of a method of improving self-esteem may be the “self-esteem module” designed by Lecomte et al. [30]. This is a 12-week structured group intervention, consisting of 24 1-h sessions and divided into five blocks addressing the following key aspects of self-esteem: a sense of security, a sense of identity, a sense of belonging, a sense of purpose, and a sense of competence. A randomized cross-over study by Borras et al. [31] has confirmed the effectiveness of this approach among individuals with severe mental disorders, in particular those receiving case-management care. In turn, an example of a promising intervention promoting SOC is a talk-therapy group program developed by Langeland et al. [27, 32]. It consists of 16 weekly group meetings and homework, with mental health professionals acting as group leaders. Its main purpose is to raise participants’ awareness of their potential, their internal and external resistance resources (such as personal qualities, coping abilities and social support), and their ability to use them, and thus to improve their SOC, coping, and level of mental health. In a randomized controlled trial, this intervention was demonstrated to have a significant positive influence on the SOC of people with mental health problems [32]. In the light of the findings obtained, these types of interventions may have the potential to break the chain of negative effects triggered by self-stigma and leading to the impairment of QoL and may be a useful addition to the interventions directly targeting self-stigmatizing beliefs and attitudes, e.g., through psychoeducation or cognitive behavioral therapy (CBT) techniques [33, 34].

Some limitations of the study are to be mentioned. Most importantly, the cross-sectional design does not allow us to draw any definite conclusions about causality. While there is considerable evidence for the detrimental effect of self-stigma on self-esteem [2], it has also been suggested that enhancing self-esteem may lead to the reduction of self-stigma [33]. Similarly, although it seems reasonable to hypothesize that stigma may weaken SOC, alternative models have also been proposed in which SOC is a predictor of stigma [35, 36]. Clearly, longitudinal studies are needed to further disentangle the complex relationships between internalized stigma, self-esteem, SOC, and QoL. Next, the generalizability of the findings may be restricted by the fact that our participants were a convenience sample recruited from just one psychiatric institution. Furthermore, we cannot rule out the possibility that some unmeasured factors account for the relationships observed in this study. It needs to be noted as well that the stigma instrument utilized in the analyses (the SES) is not a pure measure of internalized stigma. In this respect, however, it is similar to the Internalized Stigma of Mental Illness (ISMI) scale [37], the instrument extensively used for assessing internalized stigma among people with mental illness, which is also a multidimensional, complex measure covering several stigma domains (including, e.g., experienced discrimination). Finally, the validation of the SES against other, more fully tested psychometrically internalized stigma instruments is yet to be performed in order to confirm its measurement properties.

Despite these limitations, this research provides further evidence for the significance of internalized stigma as a barrier to recovery from mental illness and extends the understanding of the mechanism of its impact on service users by showing how it may compromise their QoL through undermining their personal resources (such as self-esteem and SOC).