540147 research-article2014
ISP0010.1177/0020764014540147International Journal of Social PsychiatryMoses
E CAMDEN SCHIZOPH
Article
What helps or undermines adolescents’ anticipated capacity to cope with mental illness stigma following psychiatric hospitalization
International Journal of Social Psychiatry 2015, Vol. 61(3) 215–224 © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0020764014540147 isp.sagepub.com
Tally Moses
Abstract Background: Better understanding of the individual and environmental factors that promote adolescents’ use of more or less adaptive coping strategies with mental illness stigma would inform interventions designed to bolster youth resilience. Aims: This cross-sectional study draws on data from research on adolescents’ well-being after discharge from a first psychiatric hospitalization to explore the relationships between anticipated coping in reaction to a hypothetical social stigma scenario, and various factors conceptualized as ‘coping resource’ and ‘coping vulnerability’ factors. Focusing on coping strategies also identified in the companion article, we hypothesize that primary and secondary control engagement coping would relate to more coping resource and less coping vulnerability factors, and the opposite would be true for disengagement, aggression/confrontation and efforts to disconfirm stereotypes. Methods: Data were elicited from interviews with 102 adolescents within 7 days of discharge. Hypothesized coping resource factors included social resources, optimistic illness perceptions, better hospital experiences and higher selfesteem. Vulnerability factors included more previous stigma experiences, desire for concealment of treatment, more contingent self-worth, higher symptom levels and higher anticipated stress. Multivariate ordinary least squares (OLS) regression was used to analyze associations between coping strategy endorsement and correlates. Results: Although some coping correlates ‘behaved’ contrary to expectations, for the most part, our hypotheses were confirmed. As expected, youth anticipating reacting to the stigmatizing situation with greater disengagement, aggression/ confrontation or efforts to disconfirm stenotypes rated significantly lower on ‘coping resources’ such as self-esteem and higher on vulnerability factors such as symptom severity. The opposite was true for youth who anticipated exercising more primary and secondary control engagement coping. Conclusions: This study begins to identify factors that promote more and less adaptive coping strategies among youth at high risk for social stigma. Some factors that can be modified in the shorter term point to useful directions for clinical interventions. Keywords Adolescents, mental illness, stigma, coping, correlates, cross-sectional
Mental illness stigma involving prejudice and discrimination, and the related experience of self-stigma, undermines the social functioning and personal well-being of youth above and beyond the effects of mental illness (Harris, Milich, Corbitt, Hoover, & Brady, 1992; Hinshaw, 2005; Moses, 2010). While youth may have little control over others’ stigmatizing behavior, they can strengthen or develop coping strategies to mitigate the effects of these negative experiences. Indeed, in the companion article (Moses, 2015), we found that anticipated coping strategies endorsed by youth following a recent psychiatric hospital discharge (Time 1) predicted reported self-stigma following 6 months (Time 2). These findings, general knowledge
about the negative ramifications of both stigma and maladaptive coping for adolescents with mental health (MH) conditions (Spirito & Esposito-Smythers, 2006), raise the following question: what explains youths’ inclination to use more and less adaptive coping strategies to deal with
School of Social Work, University of Wisconsin-Madison, Madison, WI, USA Corresponding author: Tally Moses, School of Social Work, University of Wisconsin-Madison, 1350 University Ave., Madison, WI 53706, USA. Email: [email protected]
216 stigma-related stress? Responses to stress are to some extent tied to innate or fixed characteristics (e.g. temperament, intelligence), but such responses are also highly dependent on situational and environmental factors (Calvete & Connor-Smith, 2006; Cohen & Wills, 1985; Newman, 2008). For instance, youth who have a smaller group of friends seem to avoid asking for help (Newman, 2008), pointing to social network size as a potentially important correlate of coping responses. In this study, we approach this question by examining how adolescents’ anticipated coping responses to a hypothetical social stigma scenario with a friend relate to individual attributes, and environmental factors that we classify as either ‘coping resource factors’ or ‘coping vulnerability factors’ (Taylor & Stanton, 2007). The study population involves youth just discharged from a first psychiatric hospitalization, a time when anticipated or actual mental illness stigma is a salient source of stress, often necessitating explicit coping efforts (Miller, Levin, & van Laar, 2006).
Coping resource factors Coping resource factors are expected to promote effective stress-reduction efforts, and a greater sense of mastery, while minimizing the use of presumably maladaptive or harmful efforts to cope. In this study, the set of coping resource factors examined include social support, number of friends, optimistic illness perceptions, perceptions of having benefitted from hospitalization and self-esteem. Youth struggling with MH concerns make frequent mention of social connections and support as critical to their efforts to reduce and manage symptoms and deal with life challenges (McCarthy, Downes, & Sherman, 2008; Wisdom & Barker, 2006; Woodgate, 2006). Perceptions of social support and a larger network of friends provide a platform for feeling loved, cared for and valued, which would induce more confidence, positive thinking and available instrumental help (Cohen & Wills, 1985; Taylor & Stanton, 2007; Verhaeghe, Bracke, & Bruynooghe, 2008). Optimistic perceptions of their MH problems (i.e. as controllable and temporary) as well as positive perceptions of treatment are also potential coping resources. Research informed by the Self-Regulation Model (Leventhal, Weinman, Leventhal, & Phillips, 2008) demonstrates that individuals’ cognitive perceptions of their illness in terms of timeline and controllability of symptoms are associated with more engaged and positive coping strategies among individuals with mental illness (Fortune, Barrowclough, & Lobban, 2004; Valentiner, Holahan, & Moos, 1994). Less research on the relevance of treatment perceptions as a coping resource is available. However, since inpatient (and outpatient) psychiatric services focus primarily on teaching coping skills (Grossoehme & Gerbetz, 2004; Marriage & Cummins,
International Journal of Social Psychiatry 61(3) 2004), it is interesting to explore if perceived benefits from hospitalization relate to more engaged and proactive coping strategies. Finally, self-esteem may also determine coping strategies. A rich literature attests to the critical role of self-esteem in moderating the effect of stressors (including stigma) on well-being (Crocker, Garcia, Levin, & van Laar, 2006; Taylor & Stanton, 2007).
Coping vulnerability factors Coping vulnerability factors are expected to relate to less adaptive or effective coping responses and more harmful efforts to resolve or minimize stress. The set of coping vulnerability factors examined in this work include more previous exposure to stigma relating to MH problems or treatment, greater desire to conceal MH status, anticipation of greater stress in relation to stigmatizing event, higher symptom ratings and greater reliance on others’ approval as a basis for self-worth. Prior experiences with MH-related prejudice or rejection can be a resource if these lead to the acquisition of stigma coping skills (Miller & Kaiser, 2001; Miller, Myers, Swim, & Stangor, 1998). Yet, for adolescents with psychiatric problems, more exposure to stigma in the presumably indicates inadequate social support and eroding psychological resources (e.g. self-esteem, optimism) that would otherwise bolster more adaptive coping (Sandstrom, 2004). Moreover, individuals more highly motivated to conceal MH problems or treatment from others may experience more distress and cope less effectively with social stigma. In fact, Ilic et al. (2012) found that, among people with mental illness, secrecy or selective disclosure related to lower self-esteem. Based on research indicating links between secrecy, lower self-esteem and withdrawal among adult MH consumers (Kleim et al., 2008; Link, Mirotznik, & Cullen, 1991; Vauth, Kleim, Wirtz, & Corrigan, 2007), we expect greater desire for secrecy will relate less adaptive coping. Anticipated levels of stress in reaction to a peer-stigmatizing event are expected to be inversely associated with adaptive coping. ‘Stress reactivity’ is related to both adjustment problems as well as less adaptive coping strategies such as aggression or resignation (Finkelstein, Kubzansky, Capitman, & Goodman, 2007; Hampel & Petermann, 2006; Seiffge-Krenke, Aunola, & Nurmi, 2009). Likewise, higher ratings on symptom scales typically bode ill for positive coping strategies among youth (Reijntjes, Stegge, & Terwogt, 2006; Sandstrom, 2004). Finally, youths with a greater propensity to rely on external validation (i.e. others’ approval) for a sense of self-worth are expected to feel more threatened by a social stigma encounter (Crocker et al., 2006). Based on research on contingencies of self-worth and self regulation, we anticipate that more externally focused youth would cope with a stigma incident in less adaptive ways, such as disengaging
217
Moses from others, in order to protect against further social vulnerability and stress (Burwell & Shirk, 2006; Crocker & Park, 2004).
More and less adaptive coping strategies The five coping strategies examined are detailed in the companion piece, so they are reviewed briefly here. Three types of coping are derived from the Responses to Stress Model and measurement tool (Responses to Stress Questionnaire or RSQ; Compas, Connor-Smith, Saltzman, Thomsen, & Wadsworth, 2001; Connor-Smith, Compas, Wadsworth, Thomsen, & Saltzman, 2000): primary control engagement coping (PCEC), secondary control engagement coping (SCEC) and disengagement coping (DISENG). PCEC involves proactive efforts to resolve the stressor or seek support in relation to it. PCEC was the most commonly anticipated coping strategy in this sample but it was not tied to adolescents’ self-stigma ratings. SCEC entails cognitive reframing to better adjust to objective conditions. SCEC was the coping strategy most robustly predictive of (lower) self-stigma at Time 2 (controlling for baseline self-stigma). DISENG involves cognitively or physically withdrawing from the source of the stress or suppressing reaction to it. In this study, DISENG at Time 1 predicted higher self-stigma ratings in Time 2, but also higher ratings of self-stigma at Time 1 predicted greater DISENG endorsement at Time 2. This indicates a significant bi-directional relationship between DISENG and self-stigma. Two additional coping strategies are explored to reflect research, suggesting other ways people may react to the stress of social stigma: verbal or physical aggression or confrontation (AGGRESS), and efforts to disconfirm stereotypes (DISCONF) by intentionally acting ‘normal’ to dispel negative stereotypes. In this sample, AGGRESS was not associated with self-stigma, while DISCONF was found to have a bi-directional relationship with self-stigma (similar to DISENG).
This study For study hypotheses, we draw on the study findings reviewed in the companion piece, as well as the broader social psychological literature, indicating an advantage in exercising PCEC and SCEC, and fewer benefits in exercising DISENG, DISCONF and AGGRESS to cope with stressors such as stigma. Accordingly, we expect that youth anticipating greater use of PCEC and SCEC will report significantly more coping resource factors and less coping vulnerability factors. Conversely, youth anticipating greater use of DISENG, AGGRESS and DISCONF will rate coping vulnerability and resource factors significantly higher and lower, respectively.
Methods The self-selected study sample is comprised of 102 youth (ages 13–18 years) hospitalized in a voluntary inpatient psychiatric program for the first time (mean = 7.6 days (standard deviation (SD) = 4.2)). Majority (72% or 70.6%) were admitted following suicidal ideation or attempts and the most common discharge diagnosis was depression (68% or 66.7%). The youth were recruited with the help of hospital admissions staff, a process entailing the informed consent of each adolescent’s legal guardian and youths’ assent. Participants were engaged in in-home interviews occurring within 7 days of each youth’s discharge. Interviews were conducted by trained graduate students and followed a semi-structured format. Although this study also included 6-month follow-up interviews, the data utilized in this article are taken from baseline interviews exclusively. This study received approvals from the University and Hospital Institutional Review Board (IRB) committees. The companion article (page#) includes additional details regarding study procedures.
Measures Coping with stigma. Drawing on the RSQ (Connor-Smith et al., 2000), participants were asked to ‘Imagine a situation where someone you considered to be a good friend started making fun of your being hospitalized at [hospital name], calling you all sorts of names in front of other people that you know’. Subsequently, participants were asked how they anticipate responding (32 items). As noted, we elicited three coping subscales from the RSQ: PCEC, SCEC and DISENG. Two additional stigma-coping subscales were developed for this study: AGGRESS and DISCONF. Coping scales’ alpha coefficients ranged between .68 and .86 for this sample. See page# in the companion article for a more detailed account of the RSQ; Table 1 (p. x) lists the items that comprise each subscale. Coping correlates.1 1. Coping resource factors – perceived social support. This scale includes nine items from the Inventory of Parent and Peer Attachment (IPPA; Armsden & Greenberg, 1987), assessing communication, trust and alienation with one’s group of friends as a whole. An example item is ‘I can count on my friends when things go wrong’ (5-point scale, α= .89). 2. Number of friends. To capture youths’ friendship network size, adolescents were asked to list up to 10 friends defined as ‘someone outside of the family that you hang out with, feel comfortable with, from whom you can ask for help, or tell personal information to’. (This variable reflects a sum of individuals listed.)
218
International Journal of Social Psychiatry 61(3)
Table 1. Inter-correlations among coping correlates.
1. Social support 2. No. of friendships 3. Perceived control 4. Expected short-term 5. Perceived hosp. benefits 6. Self-esteem 7. Previous rejection 8. Secrecy/conceal. 9. Need external approval 10. YSR internalizing 11. YSR externalizing 12. Perceived stress
1
2
3
4
5
6
7
8
9
10
11
12
–
.53 *** –
.27 ** .12 –
.29 ** .13 .55 *** –
.38 *** .34 ** .25 * .12 –
.37 *** .15 .51 *** .52 *** .08 –
−.30 ** −.07 −.26 ** −.34 *** .11 −.39*** –
−.15 .01 −.03 −.14 .05 −.23 * .29 ** –
−.33 ** −.01 −.33 ** −.22 * −.09 −.41 *** .24 * .39*** –
−.25 * .00 −.53 *** −.46 *** .01 −.72*** .52 *** .15 .22 –
−.11 −.09 −.23 −.41*** .17 −.34 ** .42 *** −.02 .12 .43 *** –
−.05 −.03 −.12 .00 .19 −.24 * .15 .38 *** .34 *** .08 −.04
YSR: Youth Self-Report. *p
ISP0010.1177/0020764014540147International Journal of Social PsychiatryMoses
E CAMDEN SCHIZOPH
Article
What helps or undermines adolescents’ anticipated capacity to cope with mental illness stigma following psychiatric hospitalization
International Journal of Social Psychiatry 2015, Vol. 61(3) 215–224 © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0020764014540147 isp.sagepub.com
Tally Moses
Abstract Background: Better understanding of the individual and environmental factors that promote adolescents’ use of more or less adaptive coping strategies with mental illness stigma would inform interventions designed to bolster youth resilience. Aims: This cross-sectional study draws on data from research on adolescents’ well-being after discharge from a first psychiatric hospitalization to explore the relationships between anticipated coping in reaction to a hypothetical social stigma scenario, and various factors conceptualized as ‘coping resource’ and ‘coping vulnerability’ factors. Focusing on coping strategies also identified in the companion article, we hypothesize that primary and secondary control engagement coping would relate to more coping resource and less coping vulnerability factors, and the opposite would be true for disengagement, aggression/confrontation and efforts to disconfirm stereotypes. Methods: Data were elicited from interviews with 102 adolescents within 7 days of discharge. Hypothesized coping resource factors included social resources, optimistic illness perceptions, better hospital experiences and higher selfesteem. Vulnerability factors included more previous stigma experiences, desire for concealment of treatment, more contingent self-worth, higher symptom levels and higher anticipated stress. Multivariate ordinary least squares (OLS) regression was used to analyze associations between coping strategy endorsement and correlates. Results: Although some coping correlates ‘behaved’ contrary to expectations, for the most part, our hypotheses were confirmed. As expected, youth anticipating reacting to the stigmatizing situation with greater disengagement, aggression/ confrontation or efforts to disconfirm stenotypes rated significantly lower on ‘coping resources’ such as self-esteem and higher on vulnerability factors such as symptom severity. The opposite was true for youth who anticipated exercising more primary and secondary control engagement coping. Conclusions: This study begins to identify factors that promote more and less adaptive coping strategies among youth at high risk for social stigma. Some factors that can be modified in the shorter term point to useful directions for clinical interventions. Keywords Adolescents, mental illness, stigma, coping, correlates, cross-sectional
Mental illness stigma involving prejudice and discrimination, and the related experience of self-stigma, undermines the social functioning and personal well-being of youth above and beyond the effects of mental illness (Harris, Milich, Corbitt, Hoover, & Brady, 1992; Hinshaw, 2005; Moses, 2010). While youth may have little control over others’ stigmatizing behavior, they can strengthen or develop coping strategies to mitigate the effects of these negative experiences. Indeed, in the companion article (Moses, 2015), we found that anticipated coping strategies endorsed by youth following a recent psychiatric hospital discharge (Time 1) predicted reported self-stigma following 6 months (Time 2). These findings, general knowledge
about the negative ramifications of both stigma and maladaptive coping for adolescents with mental health (MH) conditions (Spirito & Esposito-Smythers, 2006), raise the following question: what explains youths’ inclination to use more and less adaptive coping strategies to deal with
School of Social Work, University of Wisconsin-Madison, Madison, WI, USA Corresponding author: Tally Moses, School of Social Work, University of Wisconsin-Madison, 1350 University Ave., Madison, WI 53706, USA. Email: [email protected]
216 stigma-related stress? Responses to stress are to some extent tied to innate or fixed characteristics (e.g. temperament, intelligence), but such responses are also highly dependent on situational and environmental factors (Calvete & Connor-Smith, 2006; Cohen & Wills, 1985; Newman, 2008). For instance, youth who have a smaller group of friends seem to avoid asking for help (Newman, 2008), pointing to social network size as a potentially important correlate of coping responses. In this study, we approach this question by examining how adolescents’ anticipated coping responses to a hypothetical social stigma scenario with a friend relate to individual attributes, and environmental factors that we classify as either ‘coping resource factors’ or ‘coping vulnerability factors’ (Taylor & Stanton, 2007). The study population involves youth just discharged from a first psychiatric hospitalization, a time when anticipated or actual mental illness stigma is a salient source of stress, often necessitating explicit coping efforts (Miller, Levin, & van Laar, 2006).
Coping resource factors Coping resource factors are expected to promote effective stress-reduction efforts, and a greater sense of mastery, while minimizing the use of presumably maladaptive or harmful efforts to cope. In this study, the set of coping resource factors examined include social support, number of friends, optimistic illness perceptions, perceptions of having benefitted from hospitalization and self-esteem. Youth struggling with MH concerns make frequent mention of social connections and support as critical to their efforts to reduce and manage symptoms and deal with life challenges (McCarthy, Downes, & Sherman, 2008; Wisdom & Barker, 2006; Woodgate, 2006). Perceptions of social support and a larger network of friends provide a platform for feeling loved, cared for and valued, which would induce more confidence, positive thinking and available instrumental help (Cohen & Wills, 1985; Taylor & Stanton, 2007; Verhaeghe, Bracke, & Bruynooghe, 2008). Optimistic perceptions of their MH problems (i.e. as controllable and temporary) as well as positive perceptions of treatment are also potential coping resources. Research informed by the Self-Regulation Model (Leventhal, Weinman, Leventhal, & Phillips, 2008) demonstrates that individuals’ cognitive perceptions of their illness in terms of timeline and controllability of symptoms are associated with more engaged and positive coping strategies among individuals with mental illness (Fortune, Barrowclough, & Lobban, 2004; Valentiner, Holahan, & Moos, 1994). Less research on the relevance of treatment perceptions as a coping resource is available. However, since inpatient (and outpatient) psychiatric services focus primarily on teaching coping skills (Grossoehme & Gerbetz, 2004; Marriage & Cummins,
International Journal of Social Psychiatry 61(3) 2004), it is interesting to explore if perceived benefits from hospitalization relate to more engaged and proactive coping strategies. Finally, self-esteem may also determine coping strategies. A rich literature attests to the critical role of self-esteem in moderating the effect of stressors (including stigma) on well-being (Crocker, Garcia, Levin, & van Laar, 2006; Taylor & Stanton, 2007).
Coping vulnerability factors Coping vulnerability factors are expected to relate to less adaptive or effective coping responses and more harmful efforts to resolve or minimize stress. The set of coping vulnerability factors examined in this work include more previous exposure to stigma relating to MH problems or treatment, greater desire to conceal MH status, anticipation of greater stress in relation to stigmatizing event, higher symptom ratings and greater reliance on others’ approval as a basis for self-worth. Prior experiences with MH-related prejudice or rejection can be a resource if these lead to the acquisition of stigma coping skills (Miller & Kaiser, 2001; Miller, Myers, Swim, & Stangor, 1998). Yet, for adolescents with psychiatric problems, more exposure to stigma in the presumably indicates inadequate social support and eroding psychological resources (e.g. self-esteem, optimism) that would otherwise bolster more adaptive coping (Sandstrom, 2004). Moreover, individuals more highly motivated to conceal MH problems or treatment from others may experience more distress and cope less effectively with social stigma. In fact, Ilic et al. (2012) found that, among people with mental illness, secrecy or selective disclosure related to lower self-esteem. Based on research indicating links between secrecy, lower self-esteem and withdrawal among adult MH consumers (Kleim et al., 2008; Link, Mirotznik, & Cullen, 1991; Vauth, Kleim, Wirtz, & Corrigan, 2007), we expect greater desire for secrecy will relate less adaptive coping. Anticipated levels of stress in reaction to a peer-stigmatizing event are expected to be inversely associated with adaptive coping. ‘Stress reactivity’ is related to both adjustment problems as well as less adaptive coping strategies such as aggression or resignation (Finkelstein, Kubzansky, Capitman, & Goodman, 2007; Hampel & Petermann, 2006; Seiffge-Krenke, Aunola, & Nurmi, 2009). Likewise, higher ratings on symptom scales typically bode ill for positive coping strategies among youth (Reijntjes, Stegge, & Terwogt, 2006; Sandstrom, 2004). Finally, youths with a greater propensity to rely on external validation (i.e. others’ approval) for a sense of self-worth are expected to feel more threatened by a social stigma encounter (Crocker et al., 2006). Based on research on contingencies of self-worth and self regulation, we anticipate that more externally focused youth would cope with a stigma incident in less adaptive ways, such as disengaging
217
Moses from others, in order to protect against further social vulnerability and stress (Burwell & Shirk, 2006; Crocker & Park, 2004).
More and less adaptive coping strategies The five coping strategies examined are detailed in the companion piece, so they are reviewed briefly here. Three types of coping are derived from the Responses to Stress Model and measurement tool (Responses to Stress Questionnaire or RSQ; Compas, Connor-Smith, Saltzman, Thomsen, & Wadsworth, 2001; Connor-Smith, Compas, Wadsworth, Thomsen, & Saltzman, 2000): primary control engagement coping (PCEC), secondary control engagement coping (SCEC) and disengagement coping (DISENG). PCEC involves proactive efforts to resolve the stressor or seek support in relation to it. PCEC was the most commonly anticipated coping strategy in this sample but it was not tied to adolescents’ self-stigma ratings. SCEC entails cognitive reframing to better adjust to objective conditions. SCEC was the coping strategy most robustly predictive of (lower) self-stigma at Time 2 (controlling for baseline self-stigma). DISENG involves cognitively or physically withdrawing from the source of the stress or suppressing reaction to it. In this study, DISENG at Time 1 predicted higher self-stigma ratings in Time 2, but also higher ratings of self-stigma at Time 1 predicted greater DISENG endorsement at Time 2. This indicates a significant bi-directional relationship between DISENG and self-stigma. Two additional coping strategies are explored to reflect research, suggesting other ways people may react to the stress of social stigma: verbal or physical aggression or confrontation (AGGRESS), and efforts to disconfirm stereotypes (DISCONF) by intentionally acting ‘normal’ to dispel negative stereotypes. In this sample, AGGRESS was not associated with self-stigma, while DISCONF was found to have a bi-directional relationship with self-stigma (similar to DISENG).
This study For study hypotheses, we draw on the study findings reviewed in the companion piece, as well as the broader social psychological literature, indicating an advantage in exercising PCEC and SCEC, and fewer benefits in exercising DISENG, DISCONF and AGGRESS to cope with stressors such as stigma. Accordingly, we expect that youth anticipating greater use of PCEC and SCEC will report significantly more coping resource factors and less coping vulnerability factors. Conversely, youth anticipating greater use of DISENG, AGGRESS and DISCONF will rate coping vulnerability and resource factors significantly higher and lower, respectively.
Methods The self-selected study sample is comprised of 102 youth (ages 13–18 years) hospitalized in a voluntary inpatient psychiatric program for the first time (mean = 7.6 days (standard deviation (SD) = 4.2)). Majority (72% or 70.6%) were admitted following suicidal ideation or attempts and the most common discharge diagnosis was depression (68% or 66.7%). The youth were recruited with the help of hospital admissions staff, a process entailing the informed consent of each adolescent’s legal guardian and youths’ assent. Participants were engaged in in-home interviews occurring within 7 days of each youth’s discharge. Interviews were conducted by trained graduate students and followed a semi-structured format. Although this study also included 6-month follow-up interviews, the data utilized in this article are taken from baseline interviews exclusively. This study received approvals from the University and Hospital Institutional Review Board (IRB) committees. The companion article (page#) includes additional details regarding study procedures.
Measures Coping with stigma. Drawing on the RSQ (Connor-Smith et al., 2000), participants were asked to ‘Imagine a situation where someone you considered to be a good friend started making fun of your being hospitalized at [hospital name], calling you all sorts of names in front of other people that you know’. Subsequently, participants were asked how they anticipate responding (32 items). As noted, we elicited three coping subscales from the RSQ: PCEC, SCEC and DISENG. Two additional stigma-coping subscales were developed for this study: AGGRESS and DISCONF. Coping scales’ alpha coefficients ranged between .68 and .86 for this sample. See page# in the companion article for a more detailed account of the RSQ; Table 1 (p. x) lists the items that comprise each subscale. Coping correlates.1 1. Coping resource factors – perceived social support. This scale includes nine items from the Inventory of Parent and Peer Attachment (IPPA; Armsden & Greenberg, 1987), assessing communication, trust and alienation with one’s group of friends as a whole. An example item is ‘I can count on my friends when things go wrong’ (5-point scale, α= .89). 2. Number of friends. To capture youths’ friendship network size, adolescents were asked to list up to 10 friends defined as ‘someone outside of the family that you hang out with, feel comfortable with, from whom you can ask for help, or tell personal information to’. (This variable reflects a sum of individuals listed.)
218
International Journal of Social Psychiatry 61(3)
Table 1. Inter-correlations among coping correlates.
1. Social support 2. No. of friendships 3. Perceived control 4. Expected short-term 5. Perceived hosp. benefits 6. Self-esteem 7. Previous rejection 8. Secrecy/conceal. 9. Need external approval 10. YSR internalizing 11. YSR externalizing 12. Perceived stress
1
2
3
4
5
6
7
8
9
10
11
12
–
.53 *** –
.27 ** .12 –
.29 ** .13 .55 *** –
.38 *** .34 ** .25 * .12 –
.37 *** .15 .51 *** .52 *** .08 –
−.30 ** −.07 −.26 ** −.34 *** .11 −.39*** –
−.15 .01 −.03 −.14 .05 −.23 * .29 ** –
−.33 ** −.01 −.33 ** −.22 * −.09 −.41 *** .24 * .39*** –
−.25 * .00 −.53 *** −.46 *** .01 −.72*** .52 *** .15 .22 –
−.11 −.09 −.23 −.41*** .17 −.34 ** .42 *** −.02 .12 .43 *** –
−.05 −.03 −.12 .00 .19 −.24 * .15 .38 *** .34 *** .08 −.04
YSR: Youth Self-Report. *p
