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Stigma Health. Author manuscript; available in PMC 2017 November 01. Published in final edited form as: Stigma Health. 2016 November ; 1(4): 252–262. doi:10.1037/sah0000032.

Emotional Clarity as a Buffer in the Association Between Perceived Mental Illness Stigma and Suicide Risk Katie Wang1, Nicole H. Weiss2, John E. Pachankis3, and Bruce G. Link4 1Center

for Interdisciplinary Research on AIDS, Yale University

2Department

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of Psychiatry, Division of Prevention and Community Research, School of Medicine, Yale University

3Department

of Chronic Disease Epidemiology, Social and Behavioral Sciences Division, School of Public Health, Yale University 4School

of Public Policy, University of California, riverside

Abstract

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Among people living with psychiatric disorders, mental illness stigma has been identified as a major barrier to recovery by contributing to low self-esteem and interfering with treatmentseeking. The present research examined the association between perceived mental illness stigma and suicide risk severity and considered the role of emotional clarity (i.e., the ability to identify and understand one’s emotional experiences), a critical component of emotion regulation, as a moderator of this association. A sample of individuals who had experienced recent psychiatric hospitalizations (N = 184) completed self-report measures of perceived stigma associated with their psychiatric diagnoses, deficits in emotional clarity, and behaviors that have been found to confer risk for suicide. A moderation analysis revealed that perceived mental illness stigma was positively associated with suicide risk severity, but only for individuals who have greater deficits in emotional clarity. These findings highlight the role of emotional clarity as a resource for individuals coping with mental illness stigma and underscore the potential utility of targeting deficits in emotional clarity in prevention and intervention efforts for reducing suicide risk.

Keywords mental illness stigma; emotional clarity; emotion regulation; coping; suicide risk

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Costing more than one million lives per year, suicide is among the leading causes of death worldwide (World Health Organization, 2012). Individuals with serious mental illnesses are particularly vulnerable to suicide risk: More than 90% of people who attempt or commit suicide have a diagnosable psychiatric condition (Nock, Hwang, Sampson, & Kessler, 2010). Although a plethora of research has identified risk factors for suicide (e.g., psychopathology, substance abuse, medical disorders, neurochemical abnormalities, family history, environmental stressors; see Mościcki, 1997, for a review), the role of stigma associated

Corresponding author: Katie Wang, Ph.D., Center for Interdisciplinary Research on AIDS, Yale University, 135 College Street, Suite 200, New Haven, CT 06510, [email protected].

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with one's mental illness as a risk factor for suicidal behaviors remains under-examined. This represents a noteworthy limitation given that stigma has been identified as a significant barrier to recovery by contributing to low self-esteem and interfering with treatment seeking (Corrigan, Druss, & Perlick, 2014; Link, Strenuing, Nesse-Todd, Asmussen, & Phelan, 2001). Utilizing a sample of individuals who have experienced psychiatric hospitalizations, the present research therefore examined the association between mental illness stigma and suicide risk severity. Additionally, we considered one’s ability to identify and understand emotional experiences (i.e., emotional clarity), a critical component of emotion regulation that has been previously linked to suicidal behaviors (Gratz & Roemer, 2008; Weinberg & Klonsky, 2009), as a moderator of this association.

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As summarized by Corrigan and colleagues (2014), stigma can impact the lives of people with serious mental illnesses in a number of ways, including prejudice and discrimination across various life domains (e.g., employment, housing), fear of interpersonal rejection, and shame and self-doubt. Across numerous studies, these stigma-related stressors have been shown to undermine self-esteem (Link et al., 2001), increase social withdrawal and isolation (Perlick et al., 2001), and deter individuals from seeking mental health treatment (Vogel, Wade, & Hakke, 2006). A cross-national epidemiological study further identified mental illness stigma as a predictor of national suicide rates among 25 European countries above and beyond other socioeconomic factors (e.g., unemployment rates, economic inequality; Schomerus et al., 2015). In light of these findings, understanding the association between mental illness stigma and suicide risk severity represents an important area of inquiry.

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According to the stress-coping model of mental illness stigma (Rusch et al., 2009), stigmarelated experiences do not affect all people with psychiatric disorders in the same way. Specifically, individuals with limited coping resources, such as those who are more sensitive to interpersonal rejection and have less support from their social networks, tend to be more vulnerable to the adverse psychological impact of stigma. One potentially effective yet under-examined resource for coping with mental illness stigma is emotion regulation, defined as the ways in which individuals experience, influence, and express their emotions (Gross, 2013). Although no work, to our knowledge, has examined the role of emotion regulation in the context of coping with mental illness stigma, research with other stigmatized groups supports the proposition that effective emotion regulation can buffer against stigma-related stress. In one study, for example, emotion regulation moderated the association between the frequency of racist experiences and anxiety among African Americans, such that the frequency of racist experiences was only positively associated with anxious arousal for individuals with greater difficulty in emotion regulation (Graham, Calloway, & Roemer, in press).

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One aspect of emotion regulation that might be of particular relevance to understanding the impact of mental illness stigma on suicide risk severity is emotional clarity, i.e., the ability to identify and understand one's emotional experiences. Conceptualized as a critical component of emotion dysregulation (Gratz & Roemer, 2004), deficits in emotional clarity have been implicated in a wide range of deleterious health outcomes (for reviews, see Gratz & Tull, 2010; Smidt & Suvak, 2015), including suicidal behaviors (Gratz & Roemer, 2008; Weinberg & Klonsky, 2009). Tentative evidence further suggests that emotional clarity may

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play an important role in the context of responding to stigma-related stress. For instance, in their exploratory analyses involving different dimensions of emotion regulation, Graham and colleagues (in press) found that emotional clarity significantly moderated the association between the frequency of past-year racist events and anxious arousal, such that past-year racist events were positively related to anxious arousal at low (but not high) levels of emotional clarity.

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The present research extended past work by examining the association between perceived mental illness stigma, a major source of stress for many people living with psychiatric disorders, and suicide risk severity and considering the moderating role of emotional clarity. In the current study, we focused on perceived stigma (i.e., the extent to which a person believes that other people will devalue or discriminate against someone with a mental illness), which has been identified as a key ingredient in the conceptualization of mental illness stigma (Link, 1987; Link et al., 2001). We hypothesized that deficits in emotional clarity would moderate the association between stigma and suicide risk severity, such that perceived stigma would be positively associated with suicide risk severity only among those who have greater difficulty identifying and understanding their emotional experiences. We recognize that demographic characteristics (e.g., age, gender, race/ethnicity), psychiatric diagnoses, and psychopathology severity have been associated with suicide risk in previous research (Mosciski, 1997; Nock et al., 2010). Additionally, among individuals with psychotic disorders (who constitute a majority of participants in the current sample), psychotic symptoms have been associated with suicidal behavior (Radonsky, Haas, Mann, & Sweeny, 2014). Thus, we also examined a number of demographic and clinical characteristics as potential covariates in the current study.

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Method Participants and Procedures

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Analyses for this paper were conducted using data from a study assessing the posthospitalization quality of life and community adjustment outcomes of psychiatric patients (see Phelan et al., 2010, for more details about the study and its primary findings). Participants, all of whom experienced a psychiatric hospitalization within three months prior to the beginning of the study, were recruited through treatment facilities in the New York City boroughs of the Bronx and Queens between January, 2003 and January, 2006. In accordance with Institutional Review Board specifications, all participants were screened by a psychiatrist or Ph.D. psychologist for capacity to provide informed consent. Individuals judged to have such capacity and who agreed to participate were enrolled in the study. Study measures were administered by doctoral- and master's-level psychologists, licensed clinical social workers, and doctoral-level social scientists with extensive experiences in conducting clinical assessments with psychiatric populations. Interview data were augmented with psychiatric diagnoses from clinical charts, which were obtained from treatment facilities with patient consent and approval from the relevant IRBs. The analytic sample for this investigation consists of 184 participants who enrolled in the study and completed all baseline interview questions. The demographic and clinical characteristics of the sample are summarized in Table 1. As can be seen, the mean age of the Stigma Health. Author manuscript; available in PMC 2017 November 01.

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sample was 37.0 years (SD = 10.0), and more than half of the participants were men. The majority of participants were people of color and reported low educational attainment and personal income. The most prevalent psychiatric diagnoses were schizophrenia, schizoaffective disorder, bipolar disorder, and major depression. Measures

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Perceived mental illness stigma—Perceived mental illness stigma was assessed using an 8-item version of the Perceived Devaluation-Discrimination Scale (Link, 1987; Link, Castille, & Stuber, 2008), a self-report measure designed to capture the extent to which participants agree that most people devalue or discriminate against psychiatric patients. Example items include “Most people think less of a person after he/she has been hospitalized for a mental illness” and “Most employers will not hire a person who has been hospitalized for mental illness.” Each item was rated on a 4-point scale, ranging from 0 (strongly agree) to 3 (strongly disagree). The internal consistency for this sample was adequate, α = 0.74.

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Deficits in emotional clarity—The 20-item Toronto Alexithymia Scale (TAS-20; Bagby, Parker, & Taylor, 1994) consists of three subscales that assess difficulty in identifying and describing emotions as well as differentiating them from bodily sensations. In the current study, the 6-item Difficulty in Identifying Feelings subscale from the TAS-20 was used to assess emotional clarity, i.e., participants’ ability to identify and understand their emotional experiences. Example items include “I am often confused about what emotion I am feeling” and “When I am upset, I don’t know if I am sad, frightened, or angry.” Each item was rated on a 4-point scale, ranging from 0 (strongly disagree) to 3 (strongly agree), with higher total scores indicating greater deficits in emotional clarity. The internal consistency for this sample was adequate, α = .85.

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Suicide risk severity—Suicide risk severity was assessed using four items. Taken from the Youth Risk Behavior Survey (CDC, 2001) and utilized by Phelan and colleagues (2010), these items captured past 12-month suicidal behavior (“During the past 12 months, did you ever seriously consider attempting suicide?”, “During the past 12 months, did you make a plan about how you would attempt suicide?”, “During the past 12 months, how many times did you actually attempt suicide?”, “If you attempted suicide during the past 12 months, did any attempt result in an injury, poisoning, or overdose that had to be treated by a doctor or nurse?”). Suicide risk severity items are dichotomous in nature (present = 1, absent = 0), with the exception of the continuous variable assessing the number of suicide attempts in the past 12 months. A dichotomous score was created for this variable by assigning a score of “1” to participants who reported at least one suicide attempt in the past 12 months. All other participants were assigned a score of “0” on this variable. Scores for each of the four items were summed to create a continuous variable reflecting past 12-month suicide risk severity. Illness-related social functioning—The Illness-related Social Functioning Scale (Swartz, Swanson, & Hannon, 2003) is a 7-item self-report measure that asks respondents how difficult it was to complete tasks such as “make routine decisions,” “control the symptoms of your illness,” “deal with day to day stresses,” and “concentrate long enough to

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complete tasks.” Participants rated the extent to which each item applies to them on a 3point scale, ranging from 0 (not difficult) to 2 (very difficult). The Illness-related Social Functioning Scale has been shown to demonstrate adequate psychometric properties (Swartz et al., 2003). Internal consistency for the current sample was adequate, α = 0.80.

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Psychotic symptoms—The Structured Clinical Interview for DSM-IV (SCID-IV; First & Gibbon, 2003) was used to assess the presence of psychotic symptoms occurring in the past three months (e.g., persecutory delusions, delusions of control, thought broadcasting, and grandiose delusions). The SCID-IV is a well-established and widely used diagnostic interview with good inter-rater and test-retest reliability (First & Gibbon, 2003). Symptoms considered present in the past three months were scored as 1; symptoms considered absent in the past three months were scored as 0. Scores for each of the psychotic symptoms were then summed to create a continuous variable reflecting the total number of psychotic symptoms in the past three months. Data Analysis As recommended by Tabachnick and Fidell (2007), all study variables were assessed for assumptions of normality. Given the small number of participants in several of the education, marital status, and diagnostic categories, these variables were recoded into variables of less than high school diploma (39.7%) versus some education beyond high school (60.3%); not married (90.7%) versus married (9.3%); and mood (26.1%) versus psychotic (73.4%) disorder (one participant was hospitalized for opioid dependence and thus not classified).

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Following this, Pearson product-moment correlations among perceived stigma, deficits in emotional clarity, suicide risk severity, and demographic variables and clinical characteristics that have been linked to suicide risk in the extant research, including age, gender, race/ethnicity, education, income, marital status, mood versus psychotic disorder diagnosis, psychotic symptoms, and illness-related social functioning, were calculated to explore their bivariate associations. To address the question of whether perceived stigma, emotional clarity, and/or their interaction predict suicide risk severity, a moderation analysis was conducted utilizing the PROCESS SPSS macro as recommended by Hayes (2013). The PROCESS procedures use ordinary least squares regression and bootstrapping methodology, which confers more statistical power than standard approaches to statistical inference and does not rely on distributional assumptions. Bootstrapping was done with 1,000 random samples generated from the observed covariance matrix to estimate bias-corrected 95% confidence intervals (CIs) and significance values. Variables were mean-centered (i.e., transformed from raw- to deviation- score scaling by subtracting the mean from observations; Aiken & West, 1991) and simultaneously entered into the model. Next, following the methods described by Aiken and West (1991), regression slopes were plotted at one standard deviation above and below mean levels of deficits in emotional clarity, and follow-up analyses were conducted to examine whether the slopes of the regression lines differed significantly from zero. Bauer and Curran’s (2005) J-N technique was then used to delineate the point in the range of the continuous moderator (i.e., deficits in emotional clarity) at which the effect of the IV (i.e., perceived stigma) on the DV (i.e., suicide risk

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severity) was statistically significant. Finally, we reran the moderation analysis controlling for demographic variables and clinical characteristics that were significantly associated with suicide risk severity.

Results The variable of suicide risk severity exhibited a non-normal distribution and was square-root transformed. Descriptive data for the primary study variables and covariates, as well as their zero-order correlations, are presented in Table 2. As expected, deficits in emotional clarity and suicide risk severity were significantly related, r = .20, p = .02. Perceived stigma and suicide risk severity were also positively associated, though the correlation was only marginally significant, r = .14, p = .06.

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A moderation analysis was conducted to examine the main and interactive effects of perceived stigma and deficits in emotional clarity on suicide risk severity (see Table 3). The final model accounted for 9% of the variance in suicide risk severity, F (3, 131) = 4.17, p = . 01. A significant main effect was found for emotional clarity, b = .10, SE = .05, t = 2.03, p = .04, 95% CI: 0.003, 0.19, but not for perceived stigma, b = .08, SE = .05, t = 1.60, p = .11, 95% CI: −0.02, 0.19. Further, the interaction between perceived stigma and deficits in emotional clarity significantly predicted suicide risk severity, b = .10, SE = .05, t = 2.26, p = .03, 95% CI: 0.01, 0.19. As illustrated in Figure 1, analysis of simple slopes revealed that perceived stigma was significantly positively associated with suicide risk severity when deficits in emotional clarity were high (+1 SD), b = 0.19, SE = .07, t = 2.55, p = .01, 95% CI: 0.04, 0.33, but not when they were low (−1 SD), b = −0.02, SE = .07, t = −0.31, p = 76, 95% CI: −0.15, 0.11. Using Bauer and Curran’s (2005) J-N technique, perceived stigma was found to predict suicide risk severity significantly at emotional clarity deficits values of 1.42 (approximately 0.5 standard deviations above the mean) and greater.

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As supplementary analyses, we reran the moderation analyses after entering demographic variables and clinical characteristics that were significantly correlated with suicide risk severity (i.e., Black race/ethnicity, Latino race/ethnicity, mood versus psychotic disorder diagnosis, and illness-related social functioning; see Table 2). The pattern of results obtained was consistent with our findings from the main analysis (see Table 3). The perceived stigma × deficits in emotional clarity interaction term approached significance, b = .08, SE = .05, t = 1.77, p = .08, 95% CI: −0.01, 0.18. Further, simple slopes analyses revealed that the relation between perceived stigma and suicide risk severity approached significance when deficits in emotional clarity were high (+1 SD), b = 0.13, SE = .08, t = 1.76, p = .08, 95% CI: −0.02, 0.28, but not when they were low (−1 SD), b = −0.03, SE = .07, t = −0.49, p = . 62, 95% CI: −0.16, 0.10. Finally, to determine which of these covariates were responsible for lowering the significance of the perceived stigma × deficits in emotional clarity interaction, moderation analyses were conducted controlling for Black race/ethnicity, Latino race/ethnicity, mood versus psychotic disorder diagnosis, and illness-related social functioning separately (see Table 3). Though each of the aforementioned variables were significantly correlated with suicide risk severity at zero-order (see Table 2), illness-related social functioning was the

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only covariate that was significant in the separate moderation models. Moreover, the perceived stigma × deficits in emotional clarity interaction was significant in each of the separate moderation models, except for the model containing illness-related social functioning. Notably, however, the perceived stigma × deficits in emotional clarity interaction did approach significance in the model controlling for illness-related social functioning, b = .08, SE = .05, t = 1.83, p = .07, 95% CI: −0.01, 0.17. Further, illness-related social functioning did not alter the perceived stigma × deficits in emotional clarity interaction appreciably (bs = .10 and .08 for the model without covariates and the model with illness-related social functioning, respectively).

Discussion

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The current investigation examined the impact of perceived mental illness stigma, a major source of stress for many people living with psychiatric disorders, on suicide risk severity. Additionally, it considered the role of emotional clarity, a critical component of effective emotion regulation, as a potential moderator of the association between perceived mental illness stigma and suicide risk severity. Consistent with our hypotheses, we found that the relation between perceived stigma and suicide risk severity was moderated by emotional clarity, such that perceived stigma was only significantly positively associated with suicide risk severity among individuals with greater difficulty identifying and understanding their emotional experiences. This finding was further supported by supplementary analyses that included demographic and clinical characteristics associated with suicide risk severity as covariates (i.e., race/ethnicity, diagnosis, illness-related social functioning). Although the interaction between perceived stigma and emotional clarity became marginally significant in this analysis, the reduction in statistical significance might be attributable to reduced power (as a result of including a greater number of variables in the regression model) or the overlap in variance among perceived stigma, emotional clarity, and identified covariates.

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Although mental illness stigma has been linked to a wide range of adverse psychological consequences (e.g., Corrigan et al., 2014; Link et al., 2001; Perlick et al., 2001), its association with suicidal behaviors has remained largely unexamined. Our findings illuminate the role of perceived mental illness stigma as a potential risk factor for suicidal behaviors among people living with psychiatric disorders. Because mental illness stigma may impede individuals from seeking or fully engaging in mental health treatment (Corrigan, 2014) and may therefore limit opportunities for addressing mental illness stigma at the individual level, anti-stigma efforts have historically focused on larger systems (e.g., organizations, communities) that may influence individuals’ experiences of mental illness stigma (Thornicroft, Brohan, Kassam, & Lewis-Holmes, 2008). Nevertheless, as noted by Mittal and colleagues (2012), stigma reduction interventions that promote adaptive coping and empowerment among treatment-seeking individuals living with a psychiatric diagnosis have gained traction among stigma experts, thus underscoring the need for research that identifies candidate individual levels factors that may reduce mental illness stigma and its related negative outcomes (e.g., suicide risk severity). To this end, the present research demonstrated that emotional clarity can serve as an important buffer against the adverse impact of perceived mental illness stigma. These results

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are especially noteworthy because emotional clarity has been implicated both as a predictor of suicidal behaviors (e.g., Gratz & Roemer, 2008; Weinberg & Klonsky, 2009) as well as maladaptive responding to stigma-related stress (Graham et al., in press). Whereas most of the mental illness stigma coping interventions to date have combined psychoeducation and cognitive restructuring exercises (Mittal et al., 2012), addressing individuals’ deficits in emotional clarity might serve as a promising treatment target for future interventions. Indeed, observing and describing one’s emotions, a core element of mindfulness- and acceptance-based psychotherapy, has received initial support as one component of a larger or more comprehensive treatment in reducing stigma (e.g., Luoma, Kohlenberg, Hayes, Bunting, & Rye, 2008) and suicidal behaviors (e.g., Linehan et al., 2006).

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The present investigation has several limitations. First, the cross-sectional nature of our data precluded predictive, causal conclusions. Future research could further clarify the relations among perceived mental illness stigma, emotional clarity, and suicide risk severity by utilizing longitudinal and experimental methodologies. For example, prospective designs that include measures of these constructs at repeated assessment points over time could help elucidate the long-term and causal effects of perceived stigma on suicidality and the buffering role of emotional clarity. Furthermore, determining whether an intervention designed to improve emotional clarity can alleviate the negative impact of perceived stigma on suicide risk represents another promising direction for future research.

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Second, we acknowledge that the suicide risk severity measure used in the current study was relatively limited in scope. Although the items used in the present research were taken from the Youth Risk Survey (CDC, 2001) and largely resembled many other standard measures of suicide risk, such as those used by the National Comorbidity Survey (Nock et al., 2010), the dichotomous scoring and narrow temporality limited their sensitivity. Future research should carefully examine the replicability of the current results using more sophisticated suicide risk measures, such as those recommended by Batterham and colleagues (2015) in their systematic review of the suicide risk assessment literature.

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Third, because participants in the current study were recruited for a project that was designed to assess post-hospitalization community adjustment of psychiatric patients, all participants had experienced a psychiatric hospitalization immediately prior to the beginning of the study. The range of psychiatric diagnoses represented was also limited, with most of the sample being diagnosed with schizophrenia or schizoaffective disorder. Given that individuals with psychotic disorders tend to experience more stigma than those with other psychiatric conditions (Angermeyer et al., 2004), these sample characteristics enabled us to test our hypotheses with a group of individuals who were particularly vulnerable to stigmarelated stress. Nevertheless, future research should carefully examine the generalizability of our findings with more representative samples characterized by a wider range of psychiatric diagnoses and treatment histories. Lastly, we acknowledge that the current study only assessed specific components of stigma and emotion regulation, both of which are complex, multifaceted constructs. Specifically, although we believe that perceived stigma represents an important antecedent of adverse stigma-related consequences (i.e., participants who perceived more devaluation/

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discrimination from the public would be more inclined to anticipate interpersonal rejection and internalize the negative stereotypes about people with mental illnesses; Link, 1987), we did not directly assess participants’ personal experiences of stigma-related stress (e.g., selfstigma) or their coping orientations (e.g., secrecy, withdrawal) because these measures were not included in the dataset on which the present analyses were based. Furthermore, whereas emotional clarity represents a highly relevant construct to understanding the impact of mental illness stigma on suicide risk severity, other dimensions of emotion regulation, such as emotional acceptance and access to different emotion regulation strategies, have also been closely linked to suicidal behaviors (e.g., Gratz & Roemer, 2008; Weinberg & Klonsky, 2009) and thus might influence the stigma-suicidality association in important ways. Given that individuals must be able to identify and understand their emotions before they can effectively manage them, our focus on emotional clarity represents an important first step towards illuminating the role of emotion regulation as a resource for coping with mental illness stigma. Building on the current investigation, future research could productively examine how different stigma and emotion regulation processes might interact to predict suicidality and other behavioral health outcomes among psychiatric populations.

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Deficits in emotion regulation have been implicated in a wide range of psychopathology symptoms and self-destructive behaviors (for reviews, see Gratz & Tull, 2010; Weiss, Sullivan, & Tull, 2015). Furthermore, a small yet growing body of research has demonstrated the importance of considering emotion regulation in understanding maladaptive responding to stigma-related stress (e.g., Graham et al., in press; Hatzenbuehler, 2009; Perez & Soto, 2011). The present research contributes to the existing literature by providing initial support for the moderating role of deficits in emotional clarity in the relation between perceived mental illness stigma and suicide risk severity among people living with psychiatric disorders. Further, findings underscore the potential utility of targeting deficits in emotional clarity in prevention and intervention efforts for reducing suicide risk.

Acknowledgments The data used in the present research were collected as part of the Community Outcomes of Assisted Outpatient Treatment study (PI: Bruce G. Link) funded by the New York State Department of Mental Health. Katie Wang was supported by a training fellowship from National Institute of Mental Health (T32-MH020031). Nicole H. Weiss was supported by a training fellowship from the National Institute on Drug Abuse (T32-DA019426). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. We thank Trace Kershaw and members of the CIRA HIV Prevention Training Fellowship for their feedback on an earlier version of this manuscript.

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Perez CR, Soto JA. Cognitive reappraisal in the context of oppression: Implications for psychological functioning. Emotion. 2011; 11:675–680. [PubMed: 21534660] Perlick DA, Rosenheck RA, Clarkin JF, Sirey JA, Salahi J, Struening EL, Link BG. Stigma as a barrier to recovery: Adverse effects of perceived stigma on social adaptation of persons diagnosed with bipolar affective disorder. Psychiatric Services. 2001; 52:1627–1632. [PubMed: 11726754] Phelan JC, Sinkewicz M, Castille DM, Huz S, Muenzenmaier K, Link BG. Effectiveness and outcomes of assisted outpatient treatment in New York State. Psychiatric Services. 2010; 61:137–143. [PubMed: 20123818] Radomsky ED, Haas GL, Mann JJ, Sweeney JA. Suicidal behavior in patients with schizophrenia and other psychotic disorders. American Journal of Psychiatry. 2014; 156:1590–1595. Rusch N, Corrigan PW, Wassel A, Michaels P, Olschewski M, Wilkniss S, Batia K. A stress-coping model of mental illness stigma: Predictors of cognitive stress appraisal. Schizophrenia Research. 2009; 110:59–64. [PubMed: 19269140] Schomerus G, Evans-Lacko S, Rusch N, Mojtabai R, Angermeyer MC, Thornicroft G. Collective levels of stigma and national suicide rates in 25 European countries. Epidemiology and Psychiatric Sciences. 2015; 24:166–171. [PubMed: 24576648] Smidt KE, Suvak MK. A brief, but nuanced, review of emotional granularity and emotion differentiation research. Current Opinion in Psychology. 2015; 3:48–51. Thornicroft G, Brohan E, Kassam A, Lewis-Holmes E. Reducing stigma and discrimination: Candidate interventions. International Journal of Mental Health Systems. 2008; 2:3. [PubMed: 18405393] Tobachnick, BG., Fidell, LS. Using Multivariate Statistics. Boston, MA: Pearson Education; 2007. Vogel DL, Wade NG, Haake S. Measuring the self-stigma associated with seeking psychological help. Journal of Counseling Psychology. 2006; 53:325–337. Weinberg A, Klonsky ED. Measurement of emotion dysregulation in adolescents. Psychological Assessment. 2009; 21:616–621. [PubMed: 19947794] Weiss NH, Sullivan TP, Tull MT. Explicating the role of emotion dysregulation in risky behaviors: A review and synthesis of the literature with directions for future research and clinical practice. Current Opinion in Psychology. 2015; 3:22–29. [PubMed: 25705711] World Health Organization. WHO Global Health Estimates. 2012. http://www.who.int/mental_health/ prevention/suicide/suicideprevent/en/

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Figure 1.

Perceived Mental Illness (MI) Stigma by Deficits in Emotional Clarity Interaction for Suicide Risk Severity

Author Manuscript Stigma Health. Author manuscript; available in PMC 2017 November 01.

Wang et al.

Page 13

Table 1

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Demographic and Clinical Characteristics of the Sample Mean age (SD)

37.0 (11.0)

Gender (% male)

59.1%

Race/ethnicity Black/African American

53.3%

Hispanic

28.8%

White

7.6%

Other race/ethnicity

10.3%

Educational Attainment No formal schooling

0.5%

Some grade school

2.2%

Completed grade school

9.2%

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Some high school

27.7%

Completed high school

31.0%

Some college

23.4%

Completed college

5.4%

Completed graduate school

0.5%

Past-year household income < $5,000

47.5%

$5,000 to $9,999

44.8%

$10,000 to $14,999

6.0%

$15,000 to $24,999

1.6%

Marital status Never married

70.5%

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Married

9.3%

Divorced

11.5%

Separated

6.0%

Widowed

2.7%

Mean weeks unemployed in the past year (SD)

47.0 (11.7)

Chart diagnoses Schizophrenia

40.1%

Schizoaffective

32.2%

Bipolar

18.6%

Major depressive disorder

7.3%

Other

1.7%

Author Manuscript Stigma Health. Author manuscript; available in PMC 2017 November 01.

Author Manuscript

Author Manuscript -----------

6. White (yes/no)

7. Black (yes/no)

8. Latina (yes/no)

9. Education

10. Marital Status

11. Weeks Unemployed

12. Household Income

13. Mood vs. Psychotic

14. Psychotic Symptoms

15. Illness-Related

Stigma Health. Author manuscript; available in PMC 2017 November 01. 0.38

SD 0.56

1.29

--

--

--

--

--

--

--

--

--

--

--

--

--

--

.14

2

−.14

.20**

1.11

0.45

--

--

--

--

--

--

--

--

--

--

--

--

11.06

37.00

--

--

--

--

--

--

--

--

--

--

--

--

−.09

−.06

.14†

--

4

3

--

--

--

--

--

--

--

--

--

--

--

--

--

.19*

.07

.02

−.09

5

--

--

--

--

--

--

--

--

--

--

--

--

.01

.19*

−.05

.01

.21**

6

--

--

--

--

--

--

--

--

--

--

--

--

--

--

--

--

--

--

--

--

--

--

--

--

--

--

--

--

--

−.07

−.003

−.68***

--

.11

−.18*

−.31***

.14

−.07

.11

.04

.13

.14

9

.004

−.11

−.18*

−.17* .18*

.06

.17*

8

−.13

−.24**

7

--

--

--

--

--

--

--

--

−.01

−.04

.03

−.02

.04

.14*

.04

−.01

−.01

10

11.73

46.97

--

--

--

--

--

−.07

−.02

.04

−.03

−.05

−.01

.11

−.03

.07

−.08

11

--

--

--

--

--

--

−.02

−.04

.11

.04

−.10

.10

.01

.08

.01

.03

.05

12

--

--

--

--

--

.05

−.03

−.02

.05

.12

−.22**

1.02

0.59

--

--

−.08

−.03

.02

−.06

.03

−.06

−.05

.14

.01

.21** .02

.004

.07

.34***

.07

14

−.002

.19**

.15

.13

13

0.44

1.52

--

−.31***

−.09

−.07

.08

−.10

−.01

−.15

.20**

−.10

.02

.07

−.31***

−.42***

−.16*

15

Sex (1= male, 2 = female). Education (0 = less than a high school diploma, 1 = some education beyond high school). Marital Status (0 = not married, 1 = married). Household Income (1 = $0–$4,999, 2 = $5,000–$9,999, 3 = $10,000–$14,999, 4 = $15,000–$24,999, 5 = $25,000–$34,000, 6 = $35,000–$49,999, 7 = ≥ $50,000). Mood vs. Psychotic Disorder (0 = psychotic disorder, 1 = mood disorder).

p ≤ .06.



p ≤ .001.

***

p ≤ .01.

p ≤ .05.

**

*

Note.

1.57

M

Social Functioning

--

5. Sex

--

3. Suicide Risk Severity --

--

2. Emotional Clarity

4. Age

--

1. Perceived Stigma

1

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Descriptive and Correlational Data for the Primary Study Variables

Author Manuscript

Table 2 Wang et al. Page 14

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Author Manuscript

Author Manuscript 0.10

Perceived Stigma × Deficits in Emotional Clarity

0.05 0.03 0.08

Perceived Stigma

Deficits in Emotional Clarity

Perceived Stigma × Deficits in Emotional Clarity

Stigma Health. Author manuscript; available in PMC 2017 November 01. 0.08 0.09 0.10

Perceived Stigma

Deficits in Emotional Clarity

Perceived Stigma × Deficits in Emotional Clarity

0.01 0.08 0.10 0.10

Latino Race/Ethnicity

Perceived Stigma

Deficits in Emotional Clarity

Perceived Stigma × Deficits in Emotional Clarity

Model with Latino Race/Ethnicity

−0.03

Black Race/Ethnicity

Model with Black Race/Ethnicity

0.06 −0.14

Illness-related Social Functioning

−0.02

Latino Race/Ethnicity

Mood vs. Psychotic Disorder

−0.01

Black Race/Ethnicity

Model with all covariates

0.10

0.08

Deficits in Emotional Clarity

Perceived Stigma

Model without covariates

b

.05

.05

.05

.05

.05

.05

.05

.05

.05

.05

.05

.05

.05

.07

.07

.05

.05

.05

SE

−0.02, 0.19 0.002, 0.19 0.01, 0.19

2.02* 2.16*

−0.09, 0.11

1.55

0.22

0.01, 0.19

2.22*

−0.03, 0.18 −0.003, 0.19

1.97

1.44

−0.13, 0.06

−0.01, 0.18

−0.72

−0.07, 0.13

1.77†

−0.05, 0.16

0.58

0.97

−0.04, 0.15 −0.24, −0.04

−2.68**

−0.15, 0.12

1.23

−0.23

−0.14, 0.12

0.01, 0.19

2.26*

−0.11

0.003, 0.19

−0.02, 0.19

95% CI

2.03*

1.60

t

.09

.09

.15

.09

R2

3.12*

3.25*

3.21**

4.17**

F

Regression Analyses Examining the Role of Perceived Mental Illness Stigma, Deficits in Emotional Clarity, and their Interaction in Predicting Suicide Risk Severity

Author Manuscript

Table 3 Wang et al. Page 15

0.08 0.09 0.10

Perceived Stigma Deficits in Emotional Clarity Perceived Stigma × Deficits in Emotional Clarity

−0.14 0.06 0.04 0.08

Illness-related Social Functioning Perceived Stigma Deficits in Emotional Clarity Perceived Stigma × Deficits in Emotional Clarity

Model with Illness-related Social Functioning

0.07

Mood vs. Psychotic Disorder

p < .08.



p < .10.

**

p < .05.

Note. *

Author Manuscript Model with Mood vs. Psychotic Disorder

.05

.05

.05

.05

.05

.05

.05

.05

SE

0.01, 0.19

2.17*

−0.06, 0.14 −0.01, 0.17

1.83†

−0.05, 0.16 0.73

1.06

−0.25, −0.04

−0.01, 0.18

1.82†

−2.83**

−0.03, 0.18

−0.02, 0.16

95% CI

1.48

1.47

t

R2

.14

.10

Author Manuscript b

5.24***

3.70**

F

Wang et al. Page 16

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Author Manuscript

Stigma Health. Author manuscript; available in PMC 2017 November 01.

Emotional Clarity as a Buffer in the Association Between Perceived Mental Illness Stigma and Suicide Risk.

Among people living with psychiatric disorders, mental illness stigma has been identified as a major barrier to recovery by contributing to low self-e...
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