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Stigma as a
Barrier to Recovery: The Consequences of Stigma for the
Self-Esteem of People With Mental Illnesses
Bruce G.
Link, Ph.D., Elmer L. Struening, Ph.D., Sheree Neese-Todd, M.A.,
Sara Asmussen, Ph.D. and Jo C. Phelan, Ph.D.
http://www.psychservices.psychiatryonline.org/cgi/content/full/52/12/1621
Abstract
OBJECTIVE: The objective of this study was to determine
whether stigma affects the self-esteem of persons who
have serious mental illnesses or whether stigma has
few, if any, effects on self-esteem. METHODS:
Self-esteem and two aspects of stigma, namely, perceptions
of devaluation-discrimination and social withdrawal
because of perceived rejection, were assessed among
70 members of a clubhouse program for people with
mental illness at baseline and at follow-up six and
24 months later. RESULTS: The two measures of
perceptions of stigma strongly predicted self-esteem at
follow-up when baseline self-esteem, depressive
symptoms, demographic characteristics, and diagnosis
were controlled for. Participants whose scores on the
measures of stigma were at the 90th percentile were
seven to nine times as likely as those with scores at the
10th percentile to have low self-esteem at follow-up.
CONCLUSIONS: The stigma associated with mental
illness harms the self-esteem of many people who have
serious mental illnesses. An important consequence of
reducing stigma would be to improve the self-esteem
of people who have mental illnesses.
Introduction
One of the most tragic consequences of the stigma of mental
illness is the possibility that it engenders a significant
loss of self-esteem—specifically, that the stigma of
mental illness leads a substantial proportion of
people who develop such illnesses to conclude that
they are failures or that they have little to be
proud of.
Stigma can
affect people through mechanisms of direct discrimination,
such as a refusal to hire the person; structural
discrimination, such as the availability of fewer
resources for research and treatment; or social
psychological processes that involve the stigmatized
person's perceptions (1).
In this study, we empirically examined the
association between stigma and self-esteem by using a
social psychological theory about stigma.
According to
the stigma theory we used, people develop conceptions
of mental illness early in life (2,3,4,5)
from family lore, personal experience, peer
relations, and the media's portrayal of people with
mental illnesses (6,7,8,9,10).
On the basis of these conceptions, people form
expectations about whether most people will reject an
individual who has a mental illness as a friend, an
employee, a neighbor, or an intimate partner and
whether most people will devalue a person who has a mental
illness as being less trustworthy, less intelligent,
and less competent.
For a person
who never develops a serious mental illness and never
experiences psychiatric hospitalization, these beliefs
have little personal relevance. In sharp contrast, such
beliefs have an especially poignant relevance for a
person who develops a serious mental illness. If a
person believes that others will devalue and reject
people who have mental illnesses, that person must
now fear that this possibility of rejection applies personally.
The person may wonder, "Will others stereotype me, look
down on me, and reject me because I have been
identified as having a mental illness?"
A fear of
rejection can have serious negative consequences. It
is undoubtedly threatening and personally disheartening to
believe that one has developed an illness that others are
afraid of. Expecting and fearing rejection, people
who have been hospitalized for a mental illness may
act less confidently or more defensively, or they may
simply avoid contact altogether. The result may be
strained and uncomfortable social interactions with potential
stigmatizers (11),
more constricted social networks (3),
poorer life satisfaction (12),
unemployment, and loss of income (2,4).
When performance is impaired in these ways, self-esteem is
challenged, because the individuals affected may
conclude that they are less able and less worthy than
others.
But does the
stigma of mental illness put people at risk of having
low self-esteem? Some reports downplay the importance
of stigma (13,14,15),
indicating that it is "transitory and does not appear
to pose a severe problem" (13)
or that former patients "enjoy nearly total
acceptance in all but the most intimate
relationships" (14).
If stigma is really inconsequential, one would expect
it to have little—if any—impact on self-esteem. From
such a vantage point, any observed association
between stigma and self-esteem would be suspect—the product
of biased perception through which people with low
self-esteem view the world around them, including
stigmatization by others, in a negative and
pessimistic light. According to this view, it is not
so much that stigma influences self-esteem but rather
that self-esteem shapes one's perceptions of and responses to
the experience of stigma. Given this alternative view, the
existence and magnitude of any connection between
stigma and self-esteem, along with an explanation for
this connection, are all in question.
We found only
one empirical study that directly examined the
connection between stigma and the self-esteem of people who
develop mental illnesses (16).
It showed that stigma led to self-deprecation, which
in turn compromised feelings of mastery over life
circumstances. Previous research on attributes other
than mental illness has found that although stigmatized groups
often experience lower self-esteem, this is not always the
case (17).
Strong skepticism about the importance of the stigma of
mental illness and the fact that relatively little
research has been conducted on the connection between
stigma and self-esteem indicate the need for more
research in this area.
Methods
Setting
Our study was conducted between 1995 and 1997 in a clubhouse
program modeled on the Fountain House prototype (18).
Club members were recruited by invitation to
participate in the study, and 88 members agreed to be
randomly assigned to one of two conditions: an
intervention designed to facilitate coping with stigma and
a no-intervention control group. Members who were assigned
to the control group were offered the intervention
after a six-month follow-up assessment. The
intervention had no measurable effect on
participants' perceptions of stigma, depressive symptoms,
or self-esteem (19).
Approval for
the study was obtained from the New York State
Psychiatric Institute's institutional review board. We report
data for 70 of the 88 persons who were recruited at
baseline, who had valid stigma and self-esteem
measures at six-month follow-up.
The mean±SD
age of these 70 participants was 41.3±10.7 years, and
most (45, or 64 percent) were male. Fifty-nine (84
percent) were white, eight (11 percent) were African American,
and three (4 percent) were members of other racial or
ethnic groups. Twelve (17 percent) had less than a
high school education, 46 (66 percent) had completed
high school but had not graduated from college, and
12 (17 percent) were college graduates. The median
number of hospitalizations that study participants experienced
was five, with a range of none to 50. The most common
diagnosis was schizophrenia (25 patients, or 36
percent), followed by other nonaffective psychotic
disorders (11 patients, or 16 percent), depressive
disorder (six patients, or 9 percent), bipolar disorder
(five patients, or 7 percent), and other (23 patients, or
33 percent).
Of the initial
88 persons, 70 (80 percent) and 55 (63 percent) were
reinterviewed at the six- and 24-month follow-ups, respectively.
In comparing the patients who were lost to follow-up with
those who were reinterviewed, we found no significant
differences in age, sex, marital status, education,
diagnosis, baseline depressive symptoms, baseline
stigma, or baseline self-esteem at either the six- or
24-month follow-up.
Measures
Self-esteem. We used a version of Rosenberg's scale to
measure self-esteem (20).
Study participants were asked whether they strongly
agreed, agreed, disagreed, or strongly disagreed with
ten statements such as "At times, you think you are no good
at all." Each item was coded so that a high score on the
item reflected high self-esteem. The items were then
summed and divided by ten to create a self-esteem
scale score. The reliability of the scale was .85 at
baseline, .83 at six months, and .87 at 24 months.
Stigma.
Perceived devaluation-discrimination was measured with
a 12-item instrument that asks about the extent of
agreement with statements indicating that most people
devalue current or former psychiatric patients by
perceiving them as failures, as less intelligent than
other persons, and as individuals whose opinions need
not be taken seriously (4,21).
The measure captures a key ingredient of our stigma
theory—the extent to which a person believes that
other people will devalue or discriminate against
someone with a mental illness. The scale is balanced
such that a high level of perceived devaluation-discrimination
is indicated by agreement with six of the items and by
disagreement with six others. Items are appropriately
recoded so that a high score reflects a strong
perception of devaluation-discrimination. The scale
is constructed by summing the items and dividing by
12 to produce a scale score that varies from 1 to 4. The
reliability of the scale was .88, .86, and .88 at
baseline and at the six- and 24-month follow-ups,
respectively.
Stigma-withdrawal (18)
was used to assess a key component of our stigma
theory by quantifying the extent to which participants
endorse withdrawal as a way to avoid rejection. Our
nine-item instrument assesses the degree of agreement
with statements such as "If a person thought less of
you because you had been in psychiatric treatment,
you would avoid him or her." All items are scored so
that a high score indicates a high level of stigma-withdrawal.
The item scores are summed and divided by nine to produce
a score that varies from 1 to 4. The reliability of
the scale was .70, .69, and .70 at baseline and at
the six- and 24-month follow-ups, respectively.
Although the
stigma scales are conceptually distinct, the Pearson
correlation between them was .45 at baseline. Respondents who
believed that current and former psychiatric patients are
devalued and discriminated against were also likely
to endorse withdrawal as a way of coping with the
possibility of rejection. Consequently, we examined
both the combined effects and the unique effects on
self-esteem of these two measures.
Control
variables. In addition
to the standard demographic variables of age,
education, and sex (male=1, female=0), we also controlled
for random assignment to the experimental group (coded as
1) versus the control group (coded as 0), diagnosis
(schizophrenia and other nonaffective psychotic
disorders=1, other diagnoses= 0), and baseline
depressive symptoms. We measured depressive symptoms
with a shortened 14-item version of the Center for
Epidemiological Studies Depression Scale (CES-D) (alpha=.83),
a self-report measure that asks a person how often during
the previous week he or she experienced each symptom.
Possible scores on this scale range from 0 to 42,
with higher scores indicating a greater number of and
more frequently experienced depressive symptoms.
Analysis
We present descriptive results to illustrate levels of
self-esteem and stigma experienced by the study
participants. We used regression analysis to test
hypotheses about the effects of stigma on self-esteem
in our longitudinal design. The analyses included only the
control variables that were predictive of at least
one of the outcome variables of interest—stigma or
self-esteem. Finally, we tested for the consistency
of the effect of stigma on self-esteem across groups
defined by age, sex, education, diagnosis, and
depressive symptoms by assessing evidence for interactions
between these variables and stigma.
Results
Descriptive results for self-esteem and stigma
Baseline responses to items in the self-esteem scale indicated
that low self-esteem was a significant problem for a
substantial minority of study participants. For
example, 38 participants (54 percent) agreed or
strongly agreed with the statement "You feel useless
at times," and 26 (37 percent) agreed or strongly
agreed with "All in all, you are inclined to feel that you are
a failure." In comparison, a study of a nationally
representative sample of the general U.S. population
(N= 487) used the same questions and showed that 29
percent felt useless at times and 10 percent felt
that they were failures (22).
The mean±SD score on the ten-item self-esteem scale
was 2.7±.47, significantly higher than the midpoint
of 2.5, indicating that, on average, participants
expressed positive self-esteem (t=3.76, df=69,
p<.05). Nevertheless, a substantial minority (17 patients,
or 24 percent) had scores below the midpoint, and most
participants (51, or 73 percent) indicated low
self-esteem on two or more items.
Baseline
responses to the measure of perceived devaluation-discrimination
indicated that most study participants believed that
current and former psychiatric patients experience
rejection. When participants who agreed and those who
strongly agreed were grouped together, 52 (74
percent) expressed a belief that employers will discriminate
against former psychiatric patients; 57 (81 percent) and
46 (66 percent) had similar expectations about dating
relationships and close friendships, respectively; 48
(69 percent) expressed a belief that former
psychiatric patients will be seen as less
trustworthy, 41 (59 percent) that they will be seen as less
intelligent, and 47 (67 percent) that their opinions will
be taken less seriously. The mean±SD score on the
12-item scale was 2.76±.50, which is significantly
above the midpoint of 2.5, indicating that most study
participants believed that psychiatric patients will
face rejection in numerous ways (t=4.34, df=69,
p<.001).
The results
also indicate that study participants endorsed withdrawal
as a means of coping with the possibility of rejection.
When the participants who agreed and those who
strongly agreed were grouped together, 44 (63
percent) indicated they would avoid a person if they
believed that person thought less of them because
they had received psychiatric treatment, 47 (67 percent)
indicated that they found it easier to be friendly
with people who had been psychiatric patients, and 50
(71 percent) indicated that people with serious
mental illnesses will find it less stressful to
socialize with other people who have a serious mental illness.
The mean±SD score on the nine-item scale was 2.82±.42,
significantly above the midpoint of 2.5, indicating that
most study participants endorsed stigma-withdrawal
(t=7.07, df=69, p<.001).
Self-esteem and
perceived stigma
Table 1
presents the results of regression analyses indicating
the importance of self-esteem in determining perceptions
of stigma. Baseline self-esteem uniquely explained
7.6 percent of the variance in perceived
devaluation-discrimination at six months. No
significant effects of self-esteem on stigma-withdrawal
at either follow-up point were observed, and no
significant effect of self-esteem on perceived
devaluation-discrimination was observed at 24-month
follow-up. This latter finding is important in that
it suggests that the effect of self-esteem on perceived
devaluation-discrimination at six months had eroded by 24
months.
Table 1. Results of regression analyses of baseline self-esteem
on stigma variables at six- and 24-month follow-up among members
of a clubhouse program for persons with mental illness
Stigma and self-esteem
Table 2
presents the results of regression analyses indicating
the importance of stigma in determining self-esteem. Four
regression equations are shown for each of the two
follow-up periods. In the first equation, baseline
self-esteem, sex, diagnosis, and depressive symptoms
were entered as predictors of self-esteem at
follow-up. In equations 2 and 3, each of the stigma variables
was added separately. In equation 4, the two stigma
variables were added together to allow their combined
effects on self-esteem to be determined. As equations
2 and 3 show, both perceived
devaluation-discrimination and stigma-withdrawal were
significantly associated with self-esteem at each
follow-up point. Beyond the variance accounted for by
the other variables, the two stigma variables, taken
together, explained 12.6 percent of the variance in
self-esteem at six months and 18.8 per cent at 24 months  .
To provide an alternative indicator of the strength of the
connection between stigma and self-esteem, we
dichotomized the self-esteem scale at its midpoint
(2.5) and used logistic regression to calculate the
odds that stigma was associated with low self-esteem.
When baseline self-esteem, sex, and diagnosis were controlled
for, a person who had a score at the 90th percentile on
the devaluation-discrimination scale was estimated to
be 8.8 times as likely to have low self-esteem at
follow-up as a person who had a score at the tenth
percentile. A similar comparison for
stigma-withdrawal indicated that a person who had a score at
the 90th percentile was seven times as likely to have low
self-esteem at follow up as a person who had a score
at the tenth percentile.
We also tested
for interactions between the stigma variables and
age, sex, diagnosis, and depressive symptoms. Only one
interaction was significant, and, given that we
tested 16, this one may have occurred by chance. We
conclude that the baseline stigma measures were
consistently related to self-esteem at follow-up and
that the magnitude of the effect was relatively constant
across subgroups of the sample.
Discussion
Some people
have theorized that stigma is harmful to the self-esteem
of persons who have mental illnesses. Others have claimed
that the stigma of mental illness is relatively
inconsequential and should therefore play only a very
small role—if any—in shaping the self-esteem of
people with mental illnesses. Our results sharply
contradict the latter claim. Baseline measures of
perceived devaluation-discrimination and stigma-withdrawal
strongly predicted self-esteem at both the six- and the
24-month follow-up, even with adjustment for baseline
self-esteem and depressive symptoms.
Our study had
some potential limitations. Participants' symptomatic
states or personality orientations may have influenced their
reports of perceptions of stigma. For example, if a person
was so depressed that all his or her perceptions were
colored in a negative way, that person might have
reported both low self-esteem and stigma without
there being any causal relation between the two. Two
considerations lead us to question this possibility.
First, controlling for baseline self-esteem sharply reduced
the possibility of contamination. This control removed
from the perception of stigma at baseline all sources
of correlation that were due to baseline self-esteem,
including any correlation due to contaminated
measurement. Second, the effect of stigma remained
robust when we controlled for depressive symptoms,
which is contrary to the hypothesis that depressive symptoms
colored perceptions to produce an artifactual association
between stigma and self-esteem. Taken together, this
evidence makes it unlikely that contaminated
measurement accounts for our results.
It is also
possible that some unmeasured confounding variable
accounted for the association between stigma and self-esteem.
However, the longitudinal associations between stigma and
self-esteem were very strong. As a result, any
unmeasured confounder would need to have very strong
associations with both the stigma measures and
self-esteem in order to reduce the associations between
these variables to the null value. Given that we
controlled several potential confounding variables
that accounted for substantial proportions of
variance in self-esteem at follow-up—for example,
baseline self-esteem, depressive symptoms, and diagnosis—it
is highly unlikely that some heretofore unspecified
confounder would have sufficiently strong
associations with both baseline stigma and follow-up
self-esteem to render their strong association
spurious.
Because we
tested our theory in a clubhouse for persons with
severe mental illness, the results are generalizable only to
similar populations. Nevertheless, stigma was both
consistently related to self-esteem and relatively
constant in the magnitude of its effects across
subgroups of the sample defined by age, sex,
diagnosis, and depressive symptoms. Although the
generalizability of the effect in our sample does not
prove that it is also generalizable to other
populations, it does raise our confidence that the
effect is not limited to a particular subgroup. On the contrary,
our results suggest that the effect of stigma on
self-esteem was present in very diverse subgroups of
the sample we studied.
Conclusions
The results of
this study contribute to our understanding of the
role that stigma plays in the lives of people who have mental
illnesses, in several ways. First, contrary to the claim
that stigma is relatively inconsequential, our
results suggest that stigma strongly influences the
self-esteem of people who have mental illness.
Second, we used a social-psychological theory that
identified and tested one important mechanism through which
stigma affects people. Because stigma can affect people
through many different mechanisms (1),
it is important to identify exactly what those
mechanisms are so that effective interventions can be
developed.
Third,
although the existence of a connection between stigma
and self-esteem may not be surprising to some readers, the
magnitude of the association that we uncovered is
startling and disturbing. As our results show, a
person who strongly endorsed the two stigma scales
was seven to nine times as likely to have low
self-esteem at follow-up as a person who had a low score on
these scales. The strength of this association highlights
the importance of stigma in the lives of people who
have mental illness and indicates why it is critical
for mental health research and policy to address
stigma with fervor.
Acknowledgments
This study was supported by a senior investigator award to Dr.
Link and Dr. Struening from the National Alliance for
Research on Schizophrenia and Affective Disorders.
Footnotes
Dr. Link and Dr. Struening are affiliated with the
Mailman School of Public Health of Columbia
University in New York City and with the New York
State Psychiatric Institute. Ms. Neese-Todd is
with the University of Medicine and Dentistry of New Jersey
in New Brunswick. Ms. Asmussen is with the
Beginning With Children Foundation in New York City.
Dr. Phelan is with the Mailman School of
Public Health of Columbia University. Send correspondence
to Dr. Link at Epidemiology of Mental Disorders,
100 Haven Avenue, Apartment 31D, New York, New York
10032 (e-mail,
bgl1@columbia.edu ). This paper is part of a special section on stigma as a
barrier to recovery from mental illness.
References
- Link BG, Phelan
JC: Conceptualizing stigma. Annual Review of Sociology
27:363-385, 2001
- Link BG:
Understanding labeling effects in the area of mental
disorders: an assessment of the effects of expectations of
rejection. American Sociological Review 52:96-112, 1987
- Link BG, Cullen
FT, Struening E, et al: A modified labeling theory approach
in the area of mental disorders: an empirical assessment.
American Sociological Review 54:100-123, 1989
- Link BG: Mental
patient status, work, and income: an examination of the
effects of a psychiatric label. American Sociological Review
47:202-215, 1982
- Link BG,
Struening EL, Rahav M, et al: On stigma and its
consequences: evidence from a longitudinal study of men with
dual diagnoses of mental illness and substance abuse.
Journal of Health and Social Behavior 38:177-190, 1997
- Wahl OF: Media
Madness: Public Images of Mental Illness. New Brunswick, NJ,
Rutgers University Press, 1995
- Scheff TJ:
Being Mentally Ill: A Sociological Theory. Chicago, Aldine
de Gruyter, 1966
- Angermeyer MC,
Matschinger H: The effect of violent attacks by
schizophrenic persons on the attitude of the public towards
the mentally ill. Social Science and Medicine 43:1721-1728,
1996
- Furnham A,
Bower P: A comparison of academic and lay theories of
schizophrenia. British Journal of Psychiatry 161:201-210,
1992
- Angermeyer M,
Matschinger H: Lay beliefs about schizophrenic disorder: the
results of a population study in Germany. Acta Psychiatrica
Scandinavica 89:39-45, 1994
- Farina A,
Felner RD: Employment interviewer reactions to former mental
patients. Journal of Abnormal Psychology 82:268-272, 1973
- Rosenfield S:
Labeling mental illness: the effects of received services
and perceived stigma on life satisfaction. American
Sociological Review 62:660-672, 1997
- Gove WR: The
current status of the labeling theory of mental illness, in
Deviance and Mental Illness. Edited by Gove WR. Beverly
Hills, Calif, Sage, 1982
- Crocetti G,
Spiro H, Siassi I: Contemporary Attitudes Towards Mental
Illness. Pittsburgh, Pa, University of Pittsburgh Press,
1974
- Aubry T, Tefft
B, Currie R: Public attitudes and intentions regarding
tenants of community mental health residences who are
neighbours. Community Mental Health Journal 31:39-52, 1995
- Wright ER,
Gronfein WP, Owens TJ: Deinstitutionalization, social
rejection, and the self-esteem of former mental patients.
Journal of Health and Social Behavior 41:68-90, 2000
- Crocker J:
Social stigma and self-esteem: situational construction of
self-worth. Journal of Experimental Social Psychology
35:89-107, 1999
- Beard J: The
rehabilitation services of Fountain House, in Alternatives
to Mental Hospital Treatment. Edited by Stein LI, Test MA.
New York, Plenum, 1978
- Link BG,
Struening E, Neese-Todd S, et al: A clubhouse-based
intervention designed to address the stigma of mental
illness. New York, Columbia University, in press
- Rosenberg M:
Conceiving the Self. New York, Basic Books, 1979
- Link BG,
Mirotznik J, Cullen FT: The effectiveness of stigma coping
orientations: can negative consequences of mental illness
labeling be avoided? Journal of Health and Social Behavior
32:302-320, 1991
Link BG,
Phelan JC, Bresnahan M, et al: Lifetime and five-year prevalence
of homelessness in the United States: new evidence of an old
debate. American Journal of Orthopsychiatry 65:347-354, 1995
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