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Self-Stigma in Schizophrenia: A Concept Analysis Yoshimi Omori, RN, MSN, Chizuru Mori, RN, PhD, and Ann H. White, RN, PhD, MBA, NE-BC Yoshimi Omori, RN, MSN, was Doctoral Student, University of Tsukuba, Tsukuba, Ibaraki, Japan, and is Undergraduate Student, University of Southern Indiana, Evansville, Indiana, USA; Chizuru Mori, RN, PhD, is Professor, University of Tsukuba, Tsukuba, Ibaraki, Japan; and Ann H. White, RN, PhD, MBA, NE-BC, is Professor and Dean of College of Nursing and Health Professions, University of Southern Indiana, Evansville, Indiana, USA Keywords Holistic health, psychiatric/mental health, rehabilitation Correspondence Yoshimi Omori, RN, MSN, University of Tsukuba, Tsukuba, Ibaraki, Japan E-mail: yoshimi_ohmori@ yahoo.co.jp
Omori
PURPOSE. This study aimed to clarify the phenomenon and definition of self-stigma in schizophrenia. CONCLUSION. Self-stigma in schizophrenia affects patients’ well-being and attitudes to treatment. Although stigma and self-stigma have interactive and different characteristics, theses definitions are not clearly distinguished. Mental illnesses may have different stereotypes but are treated equally in some studies. Lack of awareness of illness is a common feature in schizophrenia but has not been focused in self-stigma studies. PRACTICE IMPLICATION. Further studies are needed to clarify the phenomenon of self-stigma in people with schizophrenia and to develop interventions targeted at reducing self-stigma.
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Introduction The nursing and psychiatric literature defines the concept of “self-stigma” in people with mental illnesses as stereotyping, prejudice, and discrimination toward oneself (Corrigan & Watson, 2002a). These studies have improved and deepened our understanding of the concept of “self-stigma.” However, self-
stigma as a concept remains unclear, owing to the different stereotypes that exist for different mental illnesses and, in cases of people with schizophrenia, to the lack of awareness of illness often observed in these people. Nevertheless, people with schizophrenia may also suffer from self-stigma. For example, individuals who deny their mental illness may feel uncomfortable when treated as psychiatric patients. They may have 259
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Self-Stigma in Schizophrenia negative stereotypes, prejudice, or discrimination toward mental illness or they may have experienced uncomfortable interactions with people who have negative attitudes toward mental illnesses. Therefore, analyzing the concept of self-stigma in schizophrenia is important to further understand the illness. The purpose of this concept analysis was to analyze the concept of self-stigma in people with schizophrenia who also have negative emotions, beliefs, and attitudes toward schizophrenia and other forms of mental illness. Literature Review To clearly understand self-stigma, a review of the literature addressing the concept of stigma will be first presented. We believe that only with a basic understanding of stigma can the concept of self-stigma be properly analyzed. We conducted the literature review by using the PubMed, CINAHL, and MEDLINE databases. Articles published from 2000 to 2010 with the keywords stigma, mental illness, and schizophrenia were collected. Articles were excluded if they dealt with specific mental illnesses other than schizophrenia. Goffman’s article published in 1963 was also included in this concept analysis because it is considered a seminal work in the entire discussion of stigma and self-stigma associated with the diagnosis of schizophrenia. Link and Phelan (2001) wrote that the term “stigma” should be applied “when elements of labeling, stereotyping, separation, status loss, and discrimination co-occur in a power situation that allows the components of stigma to unfold” (p. 367). They further defined the “stigmatized person” as someone expected to be rejected as a friend, employee, neighbor, or intimate partner, and to be devalued as less trustworthy, intelligent, and competent by most people owing to his or her mental illness (Link & Phelan, 2001). Pinto-Foltz and Logsdon (2008) also suggested the interactive aspects of stigma and used the term stigma to describe both phenomena: the stigmatizing and the stigmatized. Pinto-Foltz and Logsdon believed that an unpleasant personal experience in interpersonal relationships with others who are in an influential social position is one of the essential factors for self-stigma. Link and Phelan (2001) and Pinto-Foltz and Logsdon tried to explain the phenomenon of stigma as a twoway interpersonal relationship. However, having 260 © 2014 Wiley Periodicals, Inc. Nursing Forum Volume 49, No. 4, October-December 2014
Y. Omori et al. negative beliefs and attitudes toward mental illnesses are different from being afraid that negative beliefs and attitudes are applied to oneself. Moreover, people who do not perceive association with a stigmatized group may not think that negative beliefs and attitudes would be applied to them. The negative beliefs and attitudes that developed in childhood based on the social norms could cause self-stigma when people start to perceive personal association with mental illnesses (Corrigan & Watson, 2002a). Individuals expect that these beliefs and attitudes will be applied to them and that other people will reject and devalue them (Corrigan & Watson, 2002a; Link & Phelan, 2001; Pinto-Foltz & Logsdon, 2008). Therefore, stigma becomes self-stigma when an individual perceives association of the self with the group. Also, focusing on the impact of mental illness on the individual helps to narrow the focus of the discussion to the concept of self-stigma. A significant difference between stigma and self-stigma is harmfulness to the identity (Goffman, 1963; Pinto-Foltz & Logsdon, 2008). It is known that self-stigma decreases the individual’s self-esteem, self-efficacy, and confidence in the future (Corrigan & Watson, 2002a). To understand the phenomenon clearly and to try to define the concept, it is important to divide the concept into two different but interactive phenomena. Some studies on stigma were conducted in people with mental illness, while others focused on individuals with specific mental illnesses such as schizophrenia and depression. Since stereotyping is one of the basic elements of stigma (Corrigan & Watson, 2002a; Link & Phelan, 2001), different stereotypes for different mental disorders affect the impact of stigma. Ben-Zeev, Young, and Corrigan (2010) suggested an impact on diagnosis labeling in stigma. In addition, since people with schizophrenia are thought to have an impaired perception of self (Kicher & David, 2003), the size of the impact of self-stigma and perception of self-stigma in people with schizophrenia may be different from those in people with other mental illnesses. Therefore, there is a need to focus on the differences in diagnoses and how the disease affects self-stigma. Corrigan and Watson (2002a) and Corrigan, Watson, and Barr (2006) also reported that group identities affect self-stigma. They showed that agreement of stereotypes did not correlate with declines in self-esteem or self-efficacy but showed that selfconcurrence with stereotypes correlated negatively
Y. Omori et al. with decrements of self-esteem and self-efficacy (Corrigan et al., 2006). These results indicate that self-stigma occurs when an individual perceives some associations with negative stereotypes of mental disorders. However, how individuals associate themselves with stereotypes remains to be determined. Corrigan and Watson (2002a) thought that group identification is one way to associate self with the group’s negative stereotypes. However, how people with schizophrenia recognize their own disease has been the subject of heated debate. Lack of awareness of illness is a common phenomenon in schizophrenia. This lack of awareness of illness is believed to be correlated with cognitive deficits in individuals with schizophrenia (Cooke, Peters, Kuipers, & Kumari, 2005). However, this lack of awareness is not an allor-nothing phenomenon but is regarded as a continuous and categorical phenomenon (Amador et al., 1993; David, 1990). Even if individuals with schizophrenia do not clearly recognize their illness, they may have a partial understanding of themselves and their illness (Amador, Strauss, Yale, & Gorman, 1991). Moreover, even if they deny their illness, their experiences of hospitalization, treatment, and interaction with other people may lead them to associate themselves with mental illness. As a result, even though they deny their illness, they suffer from self-stigma. Markova and Berrios (1992) explained the lack of awareness of one’s illness as a form of “selfdeception.” They described self-deception as “a failure of self-knowledge” and explained that “it is unclear, for example, what is meant by the oft-made claim that patients do not ‘want to know the truth’ about their illness or that they are denying their problems” (p. 856). Therefore, self-stigma may exist in people with schizophrenia when they do not fully recognize their illness and also when they are not aware of their self-stigma. Not only lack of awareness but also cognitive impairment is a common clinical feature of schizophrenia. Some psychotic symptoms such as delusions and hallucinations affect perception, and perceiving stigma was reported to be affected by the severeness of such symptoms (Ertugrul & Ulug˘, 2004). People with severe delusion and suspiciousness are more likely to perceive stigma. In contrast, people with severe emotional withdrawal and passive/apathetic social withdrawal are less likely to perceive stigma. Also, Jenkins and Carpenter-Song (2008) reported individuals with schizophrenia started to perceive
Self-Stigma in Schizophrenia stigma after their condition improved. Moreover, Jenkins and Carpenter-Song (2009) reported that individuals with schizophrenia who currently have a job perceived more stigma than the individuals who do not have a job. These studies suggest that individuals with schizophrenia tend to perceive stigma when their perceptions are less affected by symptoms, and also suggested that interaction between a person and social environment affect how they perceive stigma. However, this suggestion cannot apply to selfstigma. There is no clear evidence to support that self-stigma is affected by severeness of symptoms and of cognitive impairment. Kicher and David (2003) reported that the impaired perception of self is related to hallucinations, delusions, and lack of awareness of illness. So, symptoms and cognitive impairment may relate to self-stigma. Nevertheless, self-stigma may be caused by negative stereotypes and attitudes which a person already internalizes in the self. Even though a person experiences severe symptoms and cognitive impairment, he or she may be able to perceive association of the self with schizophrenia and may suffer from self-stigma. Therefore, further research will be needed about relations between symptoms and self-stigma. Jenkins and Carpenter-Song (2008) reported that nearly half of the subjects refused to participate in the study. Individuals with self-stigma tend to avoid situations in which they may face stigma (Goffman, 1963; Pinto-Foltz & Logsdon, 2008), and this may make it difficult to get cooperation from individuals who have self-stigma. Therefore, there is a great possibility that studies about self-stigma reveal a small part of the phenomenon because of difficulty of collecting participants to studies. As severeness of disease is different in individuals in any disease, severeness of lack of awareness, impaired perception of self, cognitive deficit, and positive and negative symptoms is different in individuals with schizophrenia. There are many people with schizophrenia who are well aware of themselves and their environment, and those people have built up great knowledge about stigma and self-stigma. This paper focuses on individuals with schizophrenia who are not fully aware of their illness but who still suffer from self-stigma. Method of Concept Analysis Concept analysis is the process of examining the structure, function, and basic elements of a concept; 261
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Self-Stigma in Schizophrenia
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Figure 1. Concept Map Self-Stigma in Schizophrenia
Antecedents Labeling and Stereotyping Hierarchy/Power of the Group in Society Awareness of Association of the Self with the Group Negative Emotional Reaction Harmfulness to the Identity
Defining Attributes Stereotyping Prejudice and Discrimination Emotional Reactions Harmfulness to the Identity
Self-Stigma in People with Schizophrenia
Consequences Fear of Rejection and Discrimination Isolation from Society Spoiling of the Identity Low Self-Esteem and Self-Efficacy Negative Attitudes to Participation and Adherence to the Treatment Plan
Theoretical Definitions 1. Stigma exists when elements of labeling, stereotyping, separating, emotional reactions, status loss, and discrimination occur together in a power situation (Link and Phelan, 2001; Link et al., 2004). “The stigmatized person” is a person who believes that others will devalue and reject him/her because of stereotypes (Link and Phelan, 2001). 2. Self-stigma consists of three components: stereotype, prejudice, and discrimination. Self-stigma arises when people with mental illness are aware of the stereotypes, agree with the belief leading to negative emotional reactions, and have a behavior response to prejudice (Corrigan & Watson, 2002a; 2002b). Operational Definitions 1. Self-stigma has three levels: stereotype agreement, self-concurrence, and self-esteem decrement (Corrigan et al., 2006; Watson et al., 2007). 2. Internalized stigma is an inner subjective experience of stigma and its psychological effects (Ritsher et al., 2003).
Empirical References Awareness of Self-Stigma Structure of Self-Stigma Depressive Symptoms VS Self-Stigma Low Self-Esteem Low Self-Efficacy Low Adherence/Compliance Effects of Self-Stigma Reduction Program Over a short period : Interactive Relationship : One Way Relationship
it helps us to distinguish the concept from concepts that are similar to, but not the same (Walker & Avant, 2011). The interrelationship of the concept of self-stigma with the concept of stigma presents a challenge when developing a concept analysis. This interactive relationship complicates our understanding of the structure of the phenomenon. Moreover, some researchers use the term stigma to explain both concepts. Therefore, concept analysis is useful for examining the basic elements of the concept of self-stigma and for distinguishing clearly between these two interactive concepts. The methodology developed by Walker and Avant will be used in the current concept analysis. Figure 1 graphically depicts this concept analysis of self-stigma. 262 © 2014 Wiley Periodicals, Inc. Nursing Forum Volume 49, No. 4, October-December 2014
Concept Analysis Defining Attributes Defining attributes are the cluster of attributes that are the most frequently associated with the concept and that allow the broadest insight into the concept (Walker & Avant, 2011). The defining attributes for the concept of self-stigma in people with schizophrenia are stereotyping, emotional reaction toward the stigmatized group, prejudice and discrimination, as well as harmfulness to the identity of the person. Stereotyping, prejudice, and discrimination are fundamental elements for both concepts of stigma and self-stigma (Corrigan & Watson, 2002a; Link & Phelan,
Self-Stigma in Schizophrenia
Y. Omori et al. 2001). Labels create an environment in which other people believe they understand the person’s actual social identity when a person possesses an attribute that makes him or her different from others (Goffman, 1963). However, features of the group are socially selected, and these features would differ dramatically according to time and place (Link & Phelan, 2001). In other words, labeling is affixed and does not have fixed meanings behind the word (Link & Phelan, 2001). When labeling links to negative attributes and to devaluation, stereotyping occurs (Link & Phelan, 2001). Linking a person to undesirable attributes and devaluating him or her with an undesirable social label are precursors toward stigmatization of that person. Also, when an individual believes and is afraid that this linking is applied to the self, labeling becomes a precursor toward self-stigma. However, stereotyping is also believed as one of the elements of defining attributes. People with selfstigma expect to be rejected by other people because of prejudice (Link & Phelan, 2001). This expectation arose because they do not only understand stereotypes but also think these stereotypes would be applied to them. Therefore, people with self-stigma have stereotypes and believe they are stereotyped. Also, emotional reactions, such as fear, are reported to be related to self-stigma and to cause negative attitudes toward those who belong to the stigmatized group (Corrigan & Watson, 2002a). Emotional reactions to self-stigma are observed in different ways. Corrigan and Watson (2002a) reported that one group of individuals with mental disorders showed anger at being treated differently and that they believed that this righteous anger gave them power to resist self-stigma. In contrast, a second group showed no emotion at being treated differently, but the reasons for this lack of overt emotion were unclear. Link and Phelan (2001) believe people with self-stigma are afraid of being rejected by society. This fear isolates them from society. Moreover, when they concur with the notion that they will be treated differently owing to their mental illness, the self-stigma becomes harmful to their identity (Corrigan & Watson, 2002a; Goffman, 1963; Pinto-Foltz & Logsdon, 2008). Prejudice and discrimination are defined as having negative attitude and behavior associated with low social evaluation (Leary, 2010). Perceiving and believing that an individual will face prejudice and discrimination from others lead the individual to perceive that he or she is devalued by society. Individuals who think this devaluation applies to themselves are considered
as having low self-esteem (Corrigan et al., 2006). Perceiving stereotypes and expecting to face prejudice and discrimination lead the individual to devalue himself or herself, and this in turn will spoil and harm his or her identity. Therefore, a spoiled or harmed identity is regarded as one of the characteristics of self-stigma (Goffman, 1963; Pinto-Foltz & Logsdon, 2008). Antecedents Antecedents are those events or incidents that must occur or be in place for the occurrence of the concept (Walker & Avant, 2011). The following antecedents are fundamental to the understanding of self-stigma. Self-stigma is mostly affected by labeling and stereotyping. A person is stereotyped when society labels individuals to socially selected features and devaluates them. Labeled differences are typically linked to negative characteristics that then form into stereotypes (Link & Phelan, 2001). Due to labeled features that are selected in the social and cultural contexts of the time (Link & Phelan, 2001), the hierarchy/power of the group in society is also needed in the process of stereotyping. However, the process by which this hierarchy is established and affects self-stigma is unclear. Leary (2010) describes the targets of prejudice and discrimination as “people whose relational value is perceived to be low” (people do not discriminate against those whose relationships they value). On the other hand, Link and Phelan (2001) suggested that stigmatization results in loss of status. Once a lowhierarchy group is labeled and associated with negative values, this group becomes more likely to be the target of discrimination. An individual linked to this group is more likely to be discriminated against and to lose status. Awareness of the association of the self with the group is essential in the process of development of self-stigma. Recognizing the group identity is important to perceiving self-stigma (Corrigan & Watson, 2002a). However, as mentioned above, lack of awareness of illness is a common phenomenon in schizophrenia. Also, even when individuals with schizophrenia deny their illness, psychiatric hospitalization and treatment may make them feel that they are being treated as a person with mental illness. Recognizing and believing that a person is associated with the stigmatized group and that other people may treat the person as less valuable cause negative emotions, such as fear (Link & Phelan, 2001). Finally, when an 263
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Self-Stigma in Schizophrenia individual believes that he or she is undergoing treatment only because he or she has a mental illness, the fact that he or she is somehow associated with mental illness becomes harmful to his or her identity. Cases Model Cases A model case is an example of the use of the concept that demonstrates all the defining attributes of the concept. That is, the model case should be a pure and paradigmatic example. Basically, the model case is one that we are absolutely sure is an instance of the concept (Walker & Avant, 2011). John is a 35-year-old man who was diagnosed as having schizophrenia and discharged from a psychiatric hospital 6 months previously. He lives in a group home and is supposed to go to an adult day-care facility three times a week. Recently, he has not gone to the facility. When the day-care staff visited him, he told them “I am busy looking for a job. I was in a psychiatric hospital, but I don’t think I should have been. The doctors and nurses and my family forced me to be hospitalized. I was there for 6 months although I am not such a psychiatric patient. I don’t need to go to an adult day-care facility. I just need to have a job. Please do not come here again. I don’t want the neighbors to know that I’ve been in a psychiatric hospital.” This case represents a model case. John has a negative stereotypical view of mental illness and psychiatric hospitals. Although he does not have sufficient awareness of his illness to fully associate himself with schizophrenia or mental illness, he shows negative emotion toward being associated with mental illness. Furthermore, he recognizes and fears that other people will associate him with mental illness and treat him differently. He also tries to distance himself from an event that associates him with a mental disorder. This behavior demonstrates harmfulness to his identity and self-stigma. Borderline Cases Borderline cases are those examples or instances that contain most of the defining attributes of the concept being examined but not all of them. They may contain most or even all of the defining characteristics but differ substantially in one of them, such as the 264 © 2014 Wiley Periodicals, Inc. Nursing Forum Volume 49, No. 4, October-December 2014
Y. Omori et al. length of time or intensity of the occurrence. These cases are inconsistent in some way from the concept under consideration, and, as such, they help us see why the model case is not inconsistent. In this way, our thinking about the defining attributes of the concept of interest is clarified (Walker & Avant, 2011). John is a 35-year-old man who was diagnosed as having schizophrenia and discharged from a psychiatric hospital 6 months previously. He lives in a group home and is supposed to go to an adult day-care facility three times a week. He comes to the facility as ordered by his doctor. One day, he says to a member of the staff, “I was very upset when my neighbor and his wife talked to each other after I said hello to them. I think they don’t like me because I have schizophrenia. I always try to be nice to people and never to hurt them. So I wish they would treat me the same as other people.” This case represents a borderline case. John recognizes the stereotypes of schizophrenia and of mental illness and thinks other people may treat him differently because of his illness. In addition, he associates himself with schizophrenia. However, he is upset at being treated differently and thinks he is different from these stereotypes and resists being regarded in this stereotypical way. While this case demonstrates the aspect of self-stigma, John does not totally perceive himself as stigmatized by his illness.
Contrary Cases Contrary cases are clear examples of “not the concept” (Walker & Avant, 2011). John is a 35-year-old man who was diagnosed as having schizophrenia and discharged from a psychiatric hospital 6 months previously. He lives in a group home and goes to an adult day-care facility three times a week. A member of the staff offered him the opportunity to join an employment program. He replies, “Well, 6 months ago, my condition was much more severe, but now I’ve recovered. I think it may be difficult to work full-time, but after the program I will be able to get a full-time job. I’d like to join the program.” This case represents a contrary case. John thinks he can join the new program because he thinks he has recovered from his mental illness. He does not perceive any negative stereotypes or prejudice toward mental illness, and therefore, he does not perceive any self-stigma.
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Y. Omori et al. Consequences
Variables
Stigmatized individuals expect that most people will reject having close relationships with them and that other people will devalue them as less trustworthy, intelligent, and competent (Link & Phelan, 2001). When these individuals believe that others will reject and devalue them because of their mental illness, they fear that this rejection and devaluation will be applied to themselves (Link & Phelan, 2001). Therefore, these perceptions and fear not only spoil their identity (Corrigan & Watson, 2002a; Goffman, 1963; Pinto-Foltz & Logsdon, 2008), but also discourage people with mental illness from having relationships with others and isolate them from society (Holmes & River, 1998; Jenkins & Carpenter-Song, 2009). Empirical studies also showed that self-stigma correlates with low self-esteem and low self-efficacy in people with mental illnesses (Corrigan et al., 2006; Werner, Aviv, & Barak, 2008). Corrigan and Watson (2002a) believed that not only concurrence with negative stereotypes but also self-concurrence with negative stereotypes cause declines in selfesteem and self-efficacy (Corrigan et al., 2006). Moreover, self-stigma correlated negatively with participation and attitudes to psycho-education and adherence in people with mental illness (Fung, Tsang, & Corrigan, 2008; Fung, Tsang, Corrigan, Lam, & Cheng, 2007). Jenkins and Carpenter-Song (2009) reported that approximately one-half of the study participants with schizophrenia stated that they took medication secretly from others because they feared rejection and discrimination. Therefore, selfstigma significantly affects the lives of people with schizophrenia.
Numerous studies have established scales for discrimination, social distances, and stigma, but only a few reports have been published on measurement of self-stigma. Ritsher, Otilingam, and Grajales (2003) developed a new scale, the “Internalized Stigma in Mental Illness (ISMI)” scale. This is a 29-item scale rated on a fourpoint Likert scale (1 = strongly disagree, 2 = disagree, 3 = agree, 4 = strongly agree). They defined “internalized stigma” as the inner subjective experience of stigma and its psychological effects, including alienation, stereotype endorsement, perceived discrimination, social withdrawal, and stigma resistance. The Self-Stigma of Mental Illness Scale (SSMIS) (Corrigan et al., 2006) has four subscales (stereotype awareness, stereotype agreement, stereotype selfconcurrence, and self-esteem decrement) with 40 items. Each item is rated on a nine-point agreement scale. Corrigan et al. (2006) considered that selfstigma arose when stereotype awareness, stereotype agreement, self-concurrence, and self-esteem decrement were all represented.
Empirical References Empirical references are classes or categories of actual phenomena that by their existence or presence demonstrate the occurrence of the concept itself (Walker & Avant, 2011). As mentioned below, some measures that attempt to scale self-stigma are available. Still, those scales were established without discussion about awareness of illness. Moreover, it is very difficult to recruit people with schizophrenia who are not aware of their illness as subjects of research studies. In clinical situations, many patients who are not aware of their illness may also be unaware of self-stigma.
Implications for Nursing Practice Self-stigma in people with schizophrenia significantly influences their lives and affects their participation in treatment. Self-stigma decreases self-esteem and self-efficacy in people with mental illnesses (Corrigan et al., 2006; Werner et al., 2008). Also, self-stigma was reported to be related to negative participation and negative attitudes toward psychoeducation and adherence to the treatment plan in people with mental illness (Fung et al., 2007, 2008). Jenkins and Carpenter-Song (2009) reported that approximately one-half of the study participants with schizophrenia stated that they took medication secretly from others because they feared rejection and discrimination. Therefore, diminution of self-stigma in people with schizophrenia is important not only to improve self-esteem and self-efficacy in people with schizophrenia but also to support their participation in treatment and to decrease their fears and worries. However, the term stigma is used to describe both concepts—stigma and self-stigma—and the definition of stigma is varied in studies. Therefore, further discussion and research is needed to grasp and to measure the whole phenomenon of self-stigma. 265
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Self-Stigma in Schizophrenia Moreover, nurses are integral to patients’ education and medication administration in people with schizophrenia. There are many opportunities for the nurse to decrease self-stigma related to stereotypes of the disease and to medication. It is important for nursing to find effective interventions to decrease self-stigma, to clarify the phenomenon of self-stigma, and to develop a tool which clearly measures the phenomenon of self-stigma. References Amador, X. F., Strauss, D. H., Yale, S. A., Flaum, M. M., Endicott, J., & Gorman, J. M. (1993). Assessment of insight in psychosis. American Journal of Psychiatry, 150(6), 873–879. Amador, X. F., Strauss, D. H., Yale, S. A., & Gorman, J. M. (1991). Awareness of illness in schizophrenia. Schizophrenia Bulletin, 17(1), 113–132. Ben-Zeev, D., Young, M. A., & Corrigan, P. W. (2010). DSM-V and the stigma of mental illness. Journal of Mental Health, 19(4), 318–327. Cooke, M., Peters, E., Kuipers, E., & Kumari, V. (2005). Disease, deficit or denial? Models of poor insight in psychosis. Acta Psychiatrica Scandinavica, 112, 4–17. Corrigan, W. P., & Watson, C. A. (2002a). The paradox of self-stigma and mental illness. Clinical Psychology: Science and Practice, 9(1), 35–53. Corrigan, W. P., & Watson, C. A. (2002b). Understanding the impact of stigma on people with mental illness. World Psychiatry, 1(1), 16–20. Corrigan, W. P., Watson, C. A., & Barr, L. (2006). The selfstigma of mental illness: Implications for self-esteem and self-efficacy. Journal of Social and Clinical Psychology, 25(9), 875–884. David, S. A. (1990). Insight and psychosis. British Journal of Psychiatry, 156, 798–808. Ertugrul, A., & Ulug˘, B. (2004). Perception of stigma among patients with schizophrenia. Social Psychiatry and Psychiatric Epidemiology, 39, 73–77. doi: 10.1007/s00127-0040697-9 Fung, M. T. K., Tsang, W. H. H., & Corrigan, W. P. (2008). Self-stigma of people with schizophrenia as predictor of their adherence to psychosocial treatment. Psychiatric Rehabilitation Journal, 32, 95–104.
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Y. Omori et al. Fung, M. T. K., Tsang, W. H. H., Corrigan, W. P., Lam, S. C., & Cheng, W. (2007). Measuring self-stigma of mental illness in China and its implications for recovery. International Journal of Social Psychiatry, 53(5), 408–418. Goffman, E. (1963). Stigma: Note on the management of spoiled identity. Englewood Cliffs, NJ: Prentice-Hall Holmes, P. E., & River, P. L. (1998). Individual strategies for coping with the stigma of severe mental illness. Cognitive and Behavioral Practice, 5, 231–239. Jenkins, J., & Carpenter-Song, E. (2008). Stigma despite recovery: Strategies for living in the aftermath of psychosis. Medical Anthropology Quarterly, 22(4), 381– 409. Jenkins, J., & Carpenter-Song, E. (2009). Awareness of stigma among persons with schizophrenia: Marking the contexts of lived experience. Journal of Nervous and Mental Disease, 197(7), 520–529. Kicher, T., & David, A. (2003). The self in neuroscience and psychiatry. Cambridge, UK: Cambridge University Press. Leary, R. M. (2010). Fifth edition handbook of social psychology. T. S. Fiske, T. D. Gilbert, & G. Lindzey (Eds.). Hoboken, NJ: John Wiley & sons. Link, G. B., & Phelan, C. J. (2001). Conceptualizing stigma. Annual Review of Sociology, 27, 363–385. Link, G. B., Yang, H. L., Phelan, C. J., & Collis, Y. P. (2004). Measuring mental illness stigma. Schizophrenia Bulletin, 30(3), 511–541. Markova, I., & Berrios, E. (1992). The assessment of insight in clinical psychiatry: A new scale. Acta Psychiatrica Scandinavica, 86, 159–164. Pinto-Foltz, D. M., & Logsdon, C. M. (2008). Stigma towards mental illness: A concept analysis using postpartum depression as an exemplar. Issues in Mental Health Nursing, 29, 21–36. Ritsher, J. B., Otilingam, P. G., & Grajales, M. (2003). Internalized stigma of mental illness: Psychometric properties of a new measure. Psychiatry Research, 121(1), 31–49. Walker, O. L., & Avant, C. K. (2011). Fifth edition strategies for theory construction in nursing. Cranbury, NJ: Pearson Education. Watson, C. A., Corrigan, P., Larson, E. J., & Sells, M. (2007). Self-stigma in people with mental illness. Schizophrenia Bulletin, 33(6), 1312–1318. doi: 10.1093/schbul/sb1076 Werner, P., Aviv, A., & Barak, Y. (2008). Self-stigma, self-esteem and age in persons with schizophrenia. International Psychogeriatrics, 20(1), 174–187.
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Self-Stigma in Schizophrenia: A Concept Analysis Yoshimi Omori, RN, MSN, Chizuru Mori, RN, PhD, and Ann H. White, RN, PhD, MBA, NE-BC Yoshimi Omori, RN, MSN, was Doctoral Student, University of Tsukuba, Tsukuba, Ibaraki, Japan, and is Undergraduate Student, University of Southern Indiana, Evansville, Indiana, USA; Chizuru Mori, RN, PhD, is Professor, University of Tsukuba, Tsukuba, Ibaraki, Japan; and Ann H. White, RN, PhD, MBA, NE-BC, is Professor and Dean of College of Nursing and Health Professions, University of Southern Indiana, Evansville, Indiana, USA Keywords Holistic health, psychiatric/mental health, rehabilitation Correspondence Yoshimi Omori, RN, MSN, University of Tsukuba, Tsukuba, Ibaraki, Japan E-mail: yoshimi_ohmori@ yahoo.co.jp
Omori
PURPOSE. This study aimed to clarify the phenomenon and definition of self-stigma in schizophrenia. CONCLUSION. Self-stigma in schizophrenia affects patients’ well-being and attitudes to treatment. Although stigma and self-stigma have interactive and different characteristics, theses definitions are not clearly distinguished. Mental illnesses may have different stereotypes but are treated equally in some studies. Lack of awareness of illness is a common feature in schizophrenia but has not been focused in self-stigma studies. PRACTICE IMPLICATION. Further studies are needed to clarify the phenomenon of self-stigma in people with schizophrenia and to develop interventions targeted at reducing self-stigma.
Mori
White
Introduction The nursing and psychiatric literature defines the concept of “self-stigma” in people with mental illnesses as stereotyping, prejudice, and discrimination toward oneself (Corrigan & Watson, 2002a). These studies have improved and deepened our understanding of the concept of “self-stigma.” However, self-
stigma as a concept remains unclear, owing to the different stereotypes that exist for different mental illnesses and, in cases of people with schizophrenia, to the lack of awareness of illness often observed in these people. Nevertheless, people with schizophrenia may also suffer from self-stigma. For example, individuals who deny their mental illness may feel uncomfortable when treated as psychiatric patients. They may have 259
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Self-Stigma in Schizophrenia negative stereotypes, prejudice, or discrimination toward mental illness or they may have experienced uncomfortable interactions with people who have negative attitudes toward mental illnesses. Therefore, analyzing the concept of self-stigma in schizophrenia is important to further understand the illness. The purpose of this concept analysis was to analyze the concept of self-stigma in people with schizophrenia who also have negative emotions, beliefs, and attitudes toward schizophrenia and other forms of mental illness. Literature Review To clearly understand self-stigma, a review of the literature addressing the concept of stigma will be first presented. We believe that only with a basic understanding of stigma can the concept of self-stigma be properly analyzed. We conducted the literature review by using the PubMed, CINAHL, and MEDLINE databases. Articles published from 2000 to 2010 with the keywords stigma, mental illness, and schizophrenia were collected. Articles were excluded if they dealt with specific mental illnesses other than schizophrenia. Goffman’s article published in 1963 was also included in this concept analysis because it is considered a seminal work in the entire discussion of stigma and self-stigma associated with the diagnosis of schizophrenia. Link and Phelan (2001) wrote that the term “stigma” should be applied “when elements of labeling, stereotyping, separation, status loss, and discrimination co-occur in a power situation that allows the components of stigma to unfold” (p. 367). They further defined the “stigmatized person” as someone expected to be rejected as a friend, employee, neighbor, or intimate partner, and to be devalued as less trustworthy, intelligent, and competent by most people owing to his or her mental illness (Link & Phelan, 2001). Pinto-Foltz and Logsdon (2008) also suggested the interactive aspects of stigma and used the term stigma to describe both phenomena: the stigmatizing and the stigmatized. Pinto-Foltz and Logsdon believed that an unpleasant personal experience in interpersonal relationships with others who are in an influential social position is one of the essential factors for self-stigma. Link and Phelan (2001) and Pinto-Foltz and Logsdon tried to explain the phenomenon of stigma as a twoway interpersonal relationship. However, having 260 © 2014 Wiley Periodicals, Inc. Nursing Forum Volume 49, No. 4, October-December 2014
Y. Omori et al. negative beliefs and attitudes toward mental illnesses are different from being afraid that negative beliefs and attitudes are applied to oneself. Moreover, people who do not perceive association with a stigmatized group may not think that negative beliefs and attitudes would be applied to them. The negative beliefs and attitudes that developed in childhood based on the social norms could cause self-stigma when people start to perceive personal association with mental illnesses (Corrigan & Watson, 2002a). Individuals expect that these beliefs and attitudes will be applied to them and that other people will reject and devalue them (Corrigan & Watson, 2002a; Link & Phelan, 2001; Pinto-Foltz & Logsdon, 2008). Therefore, stigma becomes self-stigma when an individual perceives association of the self with the group. Also, focusing on the impact of mental illness on the individual helps to narrow the focus of the discussion to the concept of self-stigma. A significant difference between stigma and self-stigma is harmfulness to the identity (Goffman, 1963; Pinto-Foltz & Logsdon, 2008). It is known that self-stigma decreases the individual’s self-esteem, self-efficacy, and confidence in the future (Corrigan & Watson, 2002a). To understand the phenomenon clearly and to try to define the concept, it is important to divide the concept into two different but interactive phenomena. Some studies on stigma were conducted in people with mental illness, while others focused on individuals with specific mental illnesses such as schizophrenia and depression. Since stereotyping is one of the basic elements of stigma (Corrigan & Watson, 2002a; Link & Phelan, 2001), different stereotypes for different mental disorders affect the impact of stigma. Ben-Zeev, Young, and Corrigan (2010) suggested an impact on diagnosis labeling in stigma. In addition, since people with schizophrenia are thought to have an impaired perception of self (Kicher & David, 2003), the size of the impact of self-stigma and perception of self-stigma in people with schizophrenia may be different from those in people with other mental illnesses. Therefore, there is a need to focus on the differences in diagnoses and how the disease affects self-stigma. Corrigan and Watson (2002a) and Corrigan, Watson, and Barr (2006) also reported that group identities affect self-stigma. They showed that agreement of stereotypes did not correlate with declines in self-esteem or self-efficacy but showed that selfconcurrence with stereotypes correlated negatively
Y. Omori et al. with decrements of self-esteem and self-efficacy (Corrigan et al., 2006). These results indicate that self-stigma occurs when an individual perceives some associations with negative stereotypes of mental disorders. However, how individuals associate themselves with stereotypes remains to be determined. Corrigan and Watson (2002a) thought that group identification is one way to associate self with the group’s negative stereotypes. However, how people with schizophrenia recognize their own disease has been the subject of heated debate. Lack of awareness of illness is a common phenomenon in schizophrenia. This lack of awareness of illness is believed to be correlated with cognitive deficits in individuals with schizophrenia (Cooke, Peters, Kuipers, & Kumari, 2005). However, this lack of awareness is not an allor-nothing phenomenon but is regarded as a continuous and categorical phenomenon (Amador et al., 1993; David, 1990). Even if individuals with schizophrenia do not clearly recognize their illness, they may have a partial understanding of themselves and their illness (Amador, Strauss, Yale, & Gorman, 1991). Moreover, even if they deny their illness, their experiences of hospitalization, treatment, and interaction with other people may lead them to associate themselves with mental illness. As a result, even though they deny their illness, they suffer from self-stigma. Markova and Berrios (1992) explained the lack of awareness of one’s illness as a form of “selfdeception.” They described self-deception as “a failure of self-knowledge” and explained that “it is unclear, for example, what is meant by the oft-made claim that patients do not ‘want to know the truth’ about their illness or that they are denying their problems” (p. 856). Therefore, self-stigma may exist in people with schizophrenia when they do not fully recognize their illness and also when they are not aware of their self-stigma. Not only lack of awareness but also cognitive impairment is a common clinical feature of schizophrenia. Some psychotic symptoms such as delusions and hallucinations affect perception, and perceiving stigma was reported to be affected by the severeness of such symptoms (Ertugrul & Ulug˘, 2004). People with severe delusion and suspiciousness are more likely to perceive stigma. In contrast, people with severe emotional withdrawal and passive/apathetic social withdrawal are less likely to perceive stigma. Also, Jenkins and Carpenter-Song (2008) reported individuals with schizophrenia started to perceive
Self-Stigma in Schizophrenia stigma after their condition improved. Moreover, Jenkins and Carpenter-Song (2009) reported that individuals with schizophrenia who currently have a job perceived more stigma than the individuals who do not have a job. These studies suggest that individuals with schizophrenia tend to perceive stigma when their perceptions are less affected by symptoms, and also suggested that interaction between a person and social environment affect how they perceive stigma. However, this suggestion cannot apply to selfstigma. There is no clear evidence to support that self-stigma is affected by severeness of symptoms and of cognitive impairment. Kicher and David (2003) reported that the impaired perception of self is related to hallucinations, delusions, and lack of awareness of illness. So, symptoms and cognitive impairment may relate to self-stigma. Nevertheless, self-stigma may be caused by negative stereotypes and attitudes which a person already internalizes in the self. Even though a person experiences severe symptoms and cognitive impairment, he or she may be able to perceive association of the self with schizophrenia and may suffer from self-stigma. Therefore, further research will be needed about relations between symptoms and self-stigma. Jenkins and Carpenter-Song (2008) reported that nearly half of the subjects refused to participate in the study. Individuals with self-stigma tend to avoid situations in which they may face stigma (Goffman, 1963; Pinto-Foltz & Logsdon, 2008), and this may make it difficult to get cooperation from individuals who have self-stigma. Therefore, there is a great possibility that studies about self-stigma reveal a small part of the phenomenon because of difficulty of collecting participants to studies. As severeness of disease is different in individuals in any disease, severeness of lack of awareness, impaired perception of self, cognitive deficit, and positive and negative symptoms is different in individuals with schizophrenia. There are many people with schizophrenia who are well aware of themselves and their environment, and those people have built up great knowledge about stigma and self-stigma. This paper focuses on individuals with schizophrenia who are not fully aware of their illness but who still suffer from self-stigma. Method of Concept Analysis Concept analysis is the process of examining the structure, function, and basic elements of a concept; 261
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Figure 1. Concept Map Self-Stigma in Schizophrenia
Antecedents Labeling and Stereotyping Hierarchy/Power of the Group in Society Awareness of Association of the Self with the Group Negative Emotional Reaction Harmfulness to the Identity
Defining Attributes Stereotyping Prejudice and Discrimination Emotional Reactions Harmfulness to the Identity
Self-Stigma in People with Schizophrenia
Consequences Fear of Rejection and Discrimination Isolation from Society Spoiling of the Identity Low Self-Esteem and Self-Efficacy Negative Attitudes to Participation and Adherence to the Treatment Plan
Theoretical Definitions 1. Stigma exists when elements of labeling, stereotyping, separating, emotional reactions, status loss, and discrimination occur together in a power situation (Link and Phelan, 2001; Link et al., 2004). “The stigmatized person” is a person who believes that others will devalue and reject him/her because of stereotypes (Link and Phelan, 2001). 2. Self-stigma consists of three components: stereotype, prejudice, and discrimination. Self-stigma arises when people with mental illness are aware of the stereotypes, agree with the belief leading to negative emotional reactions, and have a behavior response to prejudice (Corrigan & Watson, 2002a; 2002b). Operational Definitions 1. Self-stigma has three levels: stereotype agreement, self-concurrence, and self-esteem decrement (Corrigan et al., 2006; Watson et al., 2007). 2. Internalized stigma is an inner subjective experience of stigma and its psychological effects (Ritsher et al., 2003).
Empirical References Awareness of Self-Stigma Structure of Self-Stigma Depressive Symptoms VS Self-Stigma Low Self-Esteem Low Self-Efficacy Low Adherence/Compliance Effects of Self-Stigma Reduction Program Over a short period : Interactive Relationship : One Way Relationship
it helps us to distinguish the concept from concepts that are similar to, but not the same (Walker & Avant, 2011). The interrelationship of the concept of self-stigma with the concept of stigma presents a challenge when developing a concept analysis. This interactive relationship complicates our understanding of the structure of the phenomenon. Moreover, some researchers use the term stigma to explain both concepts. Therefore, concept analysis is useful for examining the basic elements of the concept of self-stigma and for distinguishing clearly between these two interactive concepts. The methodology developed by Walker and Avant will be used in the current concept analysis. Figure 1 graphically depicts this concept analysis of self-stigma. 262 © 2014 Wiley Periodicals, Inc. Nursing Forum Volume 49, No. 4, October-December 2014
Concept Analysis Defining Attributes Defining attributes are the cluster of attributes that are the most frequently associated with the concept and that allow the broadest insight into the concept (Walker & Avant, 2011). The defining attributes for the concept of self-stigma in people with schizophrenia are stereotyping, emotional reaction toward the stigmatized group, prejudice and discrimination, as well as harmfulness to the identity of the person. Stereotyping, prejudice, and discrimination are fundamental elements for both concepts of stigma and self-stigma (Corrigan & Watson, 2002a; Link & Phelan,
Self-Stigma in Schizophrenia
Y. Omori et al. 2001). Labels create an environment in which other people believe they understand the person’s actual social identity when a person possesses an attribute that makes him or her different from others (Goffman, 1963). However, features of the group are socially selected, and these features would differ dramatically according to time and place (Link & Phelan, 2001). In other words, labeling is affixed and does not have fixed meanings behind the word (Link & Phelan, 2001). When labeling links to negative attributes and to devaluation, stereotyping occurs (Link & Phelan, 2001). Linking a person to undesirable attributes and devaluating him or her with an undesirable social label are precursors toward stigmatization of that person. Also, when an individual believes and is afraid that this linking is applied to the self, labeling becomes a precursor toward self-stigma. However, stereotyping is also believed as one of the elements of defining attributes. People with selfstigma expect to be rejected by other people because of prejudice (Link & Phelan, 2001). This expectation arose because they do not only understand stereotypes but also think these stereotypes would be applied to them. Therefore, people with self-stigma have stereotypes and believe they are stereotyped. Also, emotional reactions, such as fear, are reported to be related to self-stigma and to cause negative attitudes toward those who belong to the stigmatized group (Corrigan & Watson, 2002a). Emotional reactions to self-stigma are observed in different ways. Corrigan and Watson (2002a) reported that one group of individuals with mental disorders showed anger at being treated differently and that they believed that this righteous anger gave them power to resist self-stigma. In contrast, a second group showed no emotion at being treated differently, but the reasons for this lack of overt emotion were unclear. Link and Phelan (2001) believe people with self-stigma are afraid of being rejected by society. This fear isolates them from society. Moreover, when they concur with the notion that they will be treated differently owing to their mental illness, the self-stigma becomes harmful to their identity (Corrigan & Watson, 2002a; Goffman, 1963; Pinto-Foltz & Logsdon, 2008). Prejudice and discrimination are defined as having negative attitude and behavior associated with low social evaluation (Leary, 2010). Perceiving and believing that an individual will face prejudice and discrimination from others lead the individual to perceive that he or she is devalued by society. Individuals who think this devaluation applies to themselves are considered
as having low self-esteem (Corrigan et al., 2006). Perceiving stereotypes and expecting to face prejudice and discrimination lead the individual to devalue himself or herself, and this in turn will spoil and harm his or her identity. Therefore, a spoiled or harmed identity is regarded as one of the characteristics of self-stigma (Goffman, 1963; Pinto-Foltz & Logsdon, 2008). Antecedents Antecedents are those events or incidents that must occur or be in place for the occurrence of the concept (Walker & Avant, 2011). The following antecedents are fundamental to the understanding of self-stigma. Self-stigma is mostly affected by labeling and stereotyping. A person is stereotyped when society labels individuals to socially selected features and devaluates them. Labeled differences are typically linked to negative characteristics that then form into stereotypes (Link & Phelan, 2001). Due to labeled features that are selected in the social and cultural contexts of the time (Link & Phelan, 2001), the hierarchy/power of the group in society is also needed in the process of stereotyping. However, the process by which this hierarchy is established and affects self-stigma is unclear. Leary (2010) describes the targets of prejudice and discrimination as “people whose relational value is perceived to be low” (people do not discriminate against those whose relationships they value). On the other hand, Link and Phelan (2001) suggested that stigmatization results in loss of status. Once a lowhierarchy group is labeled and associated with negative values, this group becomes more likely to be the target of discrimination. An individual linked to this group is more likely to be discriminated against and to lose status. Awareness of the association of the self with the group is essential in the process of development of self-stigma. Recognizing the group identity is important to perceiving self-stigma (Corrigan & Watson, 2002a). However, as mentioned above, lack of awareness of illness is a common phenomenon in schizophrenia. Also, even when individuals with schizophrenia deny their illness, psychiatric hospitalization and treatment may make them feel that they are being treated as a person with mental illness. Recognizing and believing that a person is associated with the stigmatized group and that other people may treat the person as less valuable cause negative emotions, such as fear (Link & Phelan, 2001). Finally, when an 263
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Self-Stigma in Schizophrenia individual believes that he or she is undergoing treatment only because he or she has a mental illness, the fact that he or she is somehow associated with mental illness becomes harmful to his or her identity. Cases Model Cases A model case is an example of the use of the concept that demonstrates all the defining attributes of the concept. That is, the model case should be a pure and paradigmatic example. Basically, the model case is one that we are absolutely sure is an instance of the concept (Walker & Avant, 2011). John is a 35-year-old man who was diagnosed as having schizophrenia and discharged from a psychiatric hospital 6 months previously. He lives in a group home and is supposed to go to an adult day-care facility three times a week. Recently, he has not gone to the facility. When the day-care staff visited him, he told them “I am busy looking for a job. I was in a psychiatric hospital, but I don’t think I should have been. The doctors and nurses and my family forced me to be hospitalized. I was there for 6 months although I am not such a psychiatric patient. I don’t need to go to an adult day-care facility. I just need to have a job. Please do not come here again. I don’t want the neighbors to know that I’ve been in a psychiatric hospital.” This case represents a model case. John has a negative stereotypical view of mental illness and psychiatric hospitals. Although he does not have sufficient awareness of his illness to fully associate himself with schizophrenia or mental illness, he shows negative emotion toward being associated with mental illness. Furthermore, he recognizes and fears that other people will associate him with mental illness and treat him differently. He also tries to distance himself from an event that associates him with a mental disorder. This behavior demonstrates harmfulness to his identity and self-stigma. Borderline Cases Borderline cases are those examples or instances that contain most of the defining attributes of the concept being examined but not all of them. They may contain most or even all of the defining characteristics but differ substantially in one of them, such as the 264 © 2014 Wiley Periodicals, Inc. Nursing Forum Volume 49, No. 4, October-December 2014
Y. Omori et al. length of time or intensity of the occurrence. These cases are inconsistent in some way from the concept under consideration, and, as such, they help us see why the model case is not inconsistent. In this way, our thinking about the defining attributes of the concept of interest is clarified (Walker & Avant, 2011). John is a 35-year-old man who was diagnosed as having schizophrenia and discharged from a psychiatric hospital 6 months previously. He lives in a group home and is supposed to go to an adult day-care facility three times a week. He comes to the facility as ordered by his doctor. One day, he says to a member of the staff, “I was very upset when my neighbor and his wife talked to each other after I said hello to them. I think they don’t like me because I have schizophrenia. I always try to be nice to people and never to hurt them. So I wish they would treat me the same as other people.” This case represents a borderline case. John recognizes the stereotypes of schizophrenia and of mental illness and thinks other people may treat him differently because of his illness. In addition, he associates himself with schizophrenia. However, he is upset at being treated differently and thinks he is different from these stereotypes and resists being regarded in this stereotypical way. While this case demonstrates the aspect of self-stigma, John does not totally perceive himself as stigmatized by his illness.
Contrary Cases Contrary cases are clear examples of “not the concept” (Walker & Avant, 2011). John is a 35-year-old man who was diagnosed as having schizophrenia and discharged from a psychiatric hospital 6 months previously. He lives in a group home and goes to an adult day-care facility three times a week. A member of the staff offered him the opportunity to join an employment program. He replies, “Well, 6 months ago, my condition was much more severe, but now I’ve recovered. I think it may be difficult to work full-time, but after the program I will be able to get a full-time job. I’d like to join the program.” This case represents a contrary case. John thinks he can join the new program because he thinks he has recovered from his mental illness. He does not perceive any negative stereotypes or prejudice toward mental illness, and therefore, he does not perceive any self-stigma.
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Variables
Stigmatized individuals expect that most people will reject having close relationships with them and that other people will devalue them as less trustworthy, intelligent, and competent (Link & Phelan, 2001). When these individuals believe that others will reject and devalue them because of their mental illness, they fear that this rejection and devaluation will be applied to themselves (Link & Phelan, 2001). Therefore, these perceptions and fear not only spoil their identity (Corrigan & Watson, 2002a; Goffman, 1963; Pinto-Foltz & Logsdon, 2008), but also discourage people with mental illness from having relationships with others and isolate them from society (Holmes & River, 1998; Jenkins & Carpenter-Song, 2009). Empirical studies also showed that self-stigma correlates with low self-esteem and low self-efficacy in people with mental illnesses (Corrigan et al., 2006; Werner, Aviv, & Barak, 2008). Corrigan and Watson (2002a) believed that not only concurrence with negative stereotypes but also self-concurrence with negative stereotypes cause declines in selfesteem and self-efficacy (Corrigan et al., 2006). Moreover, self-stigma correlated negatively with participation and attitudes to psycho-education and adherence in people with mental illness (Fung, Tsang, & Corrigan, 2008; Fung, Tsang, Corrigan, Lam, & Cheng, 2007). Jenkins and Carpenter-Song (2009) reported that approximately one-half of the study participants with schizophrenia stated that they took medication secretly from others because they feared rejection and discrimination. Therefore, selfstigma significantly affects the lives of people with schizophrenia.
Numerous studies have established scales for discrimination, social distances, and stigma, but only a few reports have been published on measurement of self-stigma. Ritsher, Otilingam, and Grajales (2003) developed a new scale, the “Internalized Stigma in Mental Illness (ISMI)” scale. This is a 29-item scale rated on a fourpoint Likert scale (1 = strongly disagree, 2 = disagree, 3 = agree, 4 = strongly agree). They defined “internalized stigma” as the inner subjective experience of stigma and its psychological effects, including alienation, stereotype endorsement, perceived discrimination, social withdrawal, and stigma resistance. The Self-Stigma of Mental Illness Scale (SSMIS) (Corrigan et al., 2006) has four subscales (stereotype awareness, stereotype agreement, stereotype selfconcurrence, and self-esteem decrement) with 40 items. Each item is rated on a nine-point agreement scale. Corrigan et al. (2006) considered that selfstigma arose when stereotype awareness, stereotype agreement, self-concurrence, and self-esteem decrement were all represented.
Empirical References Empirical references are classes or categories of actual phenomena that by their existence or presence demonstrate the occurrence of the concept itself (Walker & Avant, 2011). As mentioned below, some measures that attempt to scale self-stigma are available. Still, those scales were established without discussion about awareness of illness. Moreover, it is very difficult to recruit people with schizophrenia who are not aware of their illness as subjects of research studies. In clinical situations, many patients who are not aware of their illness may also be unaware of self-stigma.
Implications for Nursing Practice Self-stigma in people with schizophrenia significantly influences their lives and affects their participation in treatment. Self-stigma decreases self-esteem and self-efficacy in people with mental illnesses (Corrigan et al., 2006; Werner et al., 2008). Also, self-stigma was reported to be related to negative participation and negative attitudes toward psychoeducation and adherence to the treatment plan in people with mental illness (Fung et al., 2007, 2008). Jenkins and Carpenter-Song (2009) reported that approximately one-half of the study participants with schizophrenia stated that they took medication secretly from others because they feared rejection and discrimination. Therefore, diminution of self-stigma in people with schizophrenia is important not only to improve self-esteem and self-efficacy in people with schizophrenia but also to support their participation in treatment and to decrease their fears and worries. However, the term stigma is used to describe both concepts—stigma and self-stigma—and the definition of stigma is varied in studies. Therefore, further discussion and research is needed to grasp and to measure the whole phenomenon of self-stigma. 265
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Self-Stigma in Schizophrenia Moreover, nurses are integral to patients’ education and medication administration in people with schizophrenia. There are many opportunities for the nurse to decrease self-stigma related to stereotypes of the disease and to medication. It is important for nursing to find effective interventions to decrease self-stigma, to clarify the phenomenon of self-stigma, and to develop a tool which clearly measures the phenomenon of self-stigma. References Amador, X. F., Strauss, D. H., Yale, S. A., Flaum, M. M., Endicott, J., & Gorman, J. M. (1993). Assessment of insight in psychosis. American Journal of Psychiatry, 150(6), 873–879. Amador, X. F., Strauss, D. H., Yale, S. A., & Gorman, J. M. (1991). Awareness of illness in schizophrenia. Schizophrenia Bulletin, 17(1), 113–132. Ben-Zeev, D., Young, M. A., & Corrigan, P. W. (2010). DSM-V and the stigma of mental illness. Journal of Mental Health, 19(4), 318–327. Cooke, M., Peters, E., Kuipers, E., & Kumari, V. (2005). Disease, deficit or denial? Models of poor insight in psychosis. Acta Psychiatrica Scandinavica, 112, 4–17. Corrigan, W. P., & Watson, C. A. (2002a). The paradox of self-stigma and mental illness. Clinical Psychology: Science and Practice, 9(1), 35–53. Corrigan, W. P., & Watson, C. A. (2002b). Understanding the impact of stigma on people with mental illness. World Psychiatry, 1(1), 16–20. Corrigan, W. P., Watson, C. A., & Barr, L. (2006). The selfstigma of mental illness: Implications for self-esteem and self-efficacy. Journal of Social and Clinical Psychology, 25(9), 875–884. David, S. A. (1990). Insight and psychosis. British Journal of Psychiatry, 156, 798–808. Ertugrul, A., & Ulug˘, B. (2004). Perception of stigma among patients with schizophrenia. Social Psychiatry and Psychiatric Epidemiology, 39, 73–77. doi: 10.1007/s00127-0040697-9 Fung, M. T. K., Tsang, W. H. H., & Corrigan, W. P. (2008). Self-stigma of people with schizophrenia as predictor of their adherence to psychosocial treatment. Psychiatric Rehabilitation Journal, 32, 95–104.
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Y. Omori et al. Fung, M. T. K., Tsang, W. H. H., Corrigan, W. P., Lam, S. C., & Cheng, W. (2007). Measuring self-stigma of mental illness in China and its implications for recovery. International Journal of Social Psychiatry, 53(5), 408–418. Goffman, E. (1963). Stigma: Note on the management of spoiled identity. Englewood Cliffs, NJ: Prentice-Hall Holmes, P. E., & River, P. L. (1998). Individual strategies for coping with the stigma of severe mental illness. Cognitive and Behavioral Practice, 5, 231–239. Jenkins, J., & Carpenter-Song, E. (2008). Stigma despite recovery: Strategies for living in the aftermath of psychosis. Medical Anthropology Quarterly, 22(4), 381– 409. Jenkins, J., & Carpenter-Song, E. (2009). Awareness of stigma among persons with schizophrenia: Marking the contexts of lived experience. Journal of Nervous and Mental Disease, 197(7), 520–529. Kicher, T., & David, A. (2003). The self in neuroscience and psychiatry. Cambridge, UK: Cambridge University Press. Leary, R. M. (2010). Fifth edition handbook of social psychology. T. S. Fiske, T. D. Gilbert, & G. Lindzey (Eds.). Hoboken, NJ: John Wiley & sons. Link, G. B., & Phelan, C. J. (2001). Conceptualizing stigma. Annual Review of Sociology, 27, 363–385. Link, G. B., Yang, H. L., Phelan, C. J., & Collis, Y. P. (2004). Measuring mental illness stigma. Schizophrenia Bulletin, 30(3), 511–541. Markova, I., & Berrios, E. (1992). The assessment of insight in clinical psychiatry: A new scale. Acta Psychiatrica Scandinavica, 86, 159–164. Pinto-Foltz, D. M., & Logsdon, C. M. (2008). Stigma towards mental illness: A concept analysis using postpartum depression as an exemplar. Issues in Mental Health Nursing, 29, 21–36. Ritsher, J. B., Otilingam, P. G., & Grajales, M. (2003). Internalized stigma of mental illness: Psychometric properties of a new measure. Psychiatry Research, 121(1), 31–49. Walker, O. L., & Avant, C. K. (2011). Fifth edition strategies for theory construction in nursing. Cranbury, NJ: Pearson Education. Watson, C. A., Corrigan, P., Larson, E. J., & Sells, M. (2007). Self-stigma in people with mental illness. Schizophrenia Bulletin, 33(6), 1312–1318. doi: 10.1093/schbul/sb1076 Werner, P., Aviv, A., & Barak, Y. (2008). Self-stigma, self-esteem and age in persons with schizophrenia. International Psychogeriatrics, 20(1), 174–187.
