STIGMA, SELF-CONCEPT AND STIGMA RESISTANCE AMONG INDIVIDUALS
WITH MENTAL ILLNESS
A dissertation submitted
to Kent State University in partial
fulfillment of the degree requirements for the
degree of Doctor of Philosophy
by
Natalie Bonfine
May 2013
Dissertation written by
Natalie Bonfine
B.A., Kent State University, 2003
M.A., Kent State University, 2005
Ph.D., Kent State University, 2013
Approved by
Christian Ritter
Dr. Christian Ritter
, Chair, Doctoral Dissertation Committee
Richard Adams
Dr. Richard Adams
, Members Doctoral Dissertation Committee
Emily Asencio
Dr. Emily Asencio
Kristen Marcussen
Dr. Kristen Marcussen
Kristin Mickelson
Dr. Kristin Mickelson
Sara Newman
Dr. Sara Newman
Accepted by
Richard T. Serpe
Dr. Richard T. Serpe
, Chair, Department of Sociology
James L. Blank
Dr. James L. Blank
, Dean, College of Arts and Sciences
ii
TABLE OF CONTENTS
LIST OF FIGURES ………………………………………………..………………….iv
LIST OF TABLES…………………………………………………..…………………v
ACKNOWLEDGEMENTS…………………………………………..………………vii
CHAPTERS
Page
1
INTRODUCTION AND STATEMENT OF THE PROBLEM………………1
2
THEORETICAL FOUNDATIONS AND RESEARCH QUESTIONS………9
3
DATA AND METHODOLOGY………………………………………….....55
4
RESULTS ……………………………………………………………………80
5
SUPPLEMENTAL ANALYSES AND RESULTS…………….…………..118
6
DISCUSSION AND CONCLUSIONS……………………….…………….134
REFERENCES……………………………………………………….…………......149
APPENDICES……………………………………………………….……………...167
iii
LIST OF FIGURES
FIGURE
Page
2.1
Conceptual Model: Self-esteem………………………………………………53
2.2
Conceptual Model: Mastery………………………………………………….54
5.1
Standardized Estimates for Stigma, Defensive Strategies and
Self-concept.……………………………………………………………..….129
iv
LIST OF TABLES
TABLE
Page
3.1
Sample Characteristics: Means, Proportions, Standard Deviation and
Alpha Reliability………………………………………………….……………...61
3.2
Correspondence of Theoretical Concepts, Research Concepts and
Empirical Indicators………………………………………………….…………..62
3.3
Principal Component Analysis Factor Loadings for Empowerment
Scale (28 items).………………………………………………………………….68
3.4
Rogers et al. (1997) Factor Structure of the Empowerment Scale
(28 items).………………………………………………………………………..69
3.5
Principal Component Analysis Factor Loadings for Empowerment
Scale, Not Including Self-Concept Items (13 items) …………………………....71
4.1
Descriptive Statistics for Control, Independent, Dependent and Intervening
Measures: Means, Proportions, Standard Deviation and Alpha Reliability…..…84
4.2
Correlation Coefficients of Control Variables with Stigma, Self-Esteem and
Mastery…………………………………………………………………………..86
4.3
Correlations of Dependent and Focal Measures…………………………….…...89
4.4
Exploratory OLS Regression Analysis of Self-Esteem on Stigma and Stigma
Responses…………………………………………………………………...…....92
4.5
Exploratory OLS Regression Analysis of Mastery on Stigma and Stigma
Responses…………………………………...……………………………..……..97
4.6
OLS Regression of Self-Esteem on Stigma and Stigma Responses……….…...105
4.7
OLS Regression of Self-Esteem on Interaction Effects of Stigma and Stigma
Responses………………………………………………………………………108
4.8
OLS Regression of Mastery on Stigma and Stigma Responses............………..111
4.9
OLS Regression of Mastery on Interaction Effects of Stigma and Stigma
Responses………………………….……………………………………….…..114
v
4.10
Summary of Research Questions and Evidence of Empirical Support................116
5.1
Post-hoc Regression Analyses of Self-Esteem on Multiple Stigma Response
Measures …………………….…………………………………….…………...121
5.2
Post-hoc Regression Analyses of Mastery on Multiple Stigma
Response Measures …………………….………………………….………...…123
5.3
Post-hoc Regression Analyses of Stigma Response Measures on Control
Measures and Stigma…………………………….………………..……………125
5.4
Unstandardized and Standardized Estimate for Stigma, Defensive Strategies
And Self-concept (N=221)……………………………………………….……..130
A.1
Post-hoc Analyses of Stigma and Self-Esteem without Time 1
Measure of Self-Esteem ……………………………………………….…….…175
A.2
Post-hoc Analyses of Stigma and Mastery without Time 1
Measure of Mastery ……………………………………………………....……177
A.3
OLS Regression of Self-Esteem on Criminal Justice Involvement,
Stigma, and Stigma Responses………...……………………………………….179
A.4
OLS Regression of Mastery on Criminal Justice Involvement,
Stigma, and Stigma Responses………...……………………………………….182
A.5
Bivariate Correlation Matrix of Dependent, Independent and Control
Measures…...………………………………………...……………..…………..187
vi
ACKNOWLEDGEMENT
I am grateful to many individuals for their assistance and support throughout my
graduate career. I would like to thank Dr. Christian Ritter, my mentor and dissertation
director. I am deeply grateful for the time, encouragement and guidance he has provided
throughout the years. His support has helped me become the sociologist I am today. I
would also like to acknowledge the time and thoughtful comments provided by the
members of my dissertation committee: Dr. Richard Adams, Dr. Emily Asencio, Dr.
Kristen Marcussen, Dr. Kristin Mickelson and Dr. Sara Newman. I am thankful to Dr.
Richard Serpe for his guidance over the years, and to Dr. Rebecca Erickson for her
advice, insight and support in graduate school. I would also like to thank Dr. Mark R.
Munetz for his unwavering support and encouragement. I am also appreciative of his help
in shaping my research ideas and interests.
I will be forever grateful to my parents and family for their unfaltering love and
support. I would like to thank my friends for understanding when I needed to focus on
my work, but also for distracting me when I needed that too. Finally, I would like to
thank Shawn Bonfine for believing in me, helping me through this, and for making me
laugh. I cannot express how happy you make me. I am grateful to share this journey with
you.
vii
CHAPTER 1
INTRODUCTION
The stigma of mental illness is “fundamentally a social phenomenon rooted in
social relationships and shaped by the culture and structure of society” (Pescosolido and
Martin 2007: 322). Stigma is a “mark” or attribute that distinguishes one person from
another and links the marked person with socially devalued or undesirable characteristics
(Goffman 1963; Link and Phelan 1995). Ultimately, such categorization will result in the
stigmatized individual being “reduced from a whole and usual person to a tainted,
discounted one” (Goffman 1963: 3). If one is exhibiting behaviors or expressing
emotions that are contrary to the norms for social interaction, the individual will be
viewed as abnormal or deviant.
Stigma associated with mental illness can have far reaching consequences for the
lives of individuals who are labeled. Stigma occurs when such “elements of labeling,
stereotyping, separation, status loss and discrimination co-occur in a power situation that
allows the components of stigma to unfold” (Link and Phelan 2001: 367). Stigma and
discrimination related to mental illness may block certain life goals for individuals, such
as living independently or obtaining stable and meaningful employment (Corrigan, Kerr
and Knudsen 2005; Link 1982; Link and Phelan 2001; Rosenfield 1997). Further, public
attitudes and stereotypes about mental illness may cause people to avoid getting treatment
1
2
that is needed because they do not want to be labeled or experience discrimination
(Corrigan and Wassel 2008; Corrigan et al. 2005).
Sociological theories assume that stigma results in the self-devaluation of
individuals who are stigmatized. However, the evidence supporting this presupposition is
mixed (Crocker and Major 1989). Stigma resistance is an emerging concept that may
explain the conditions under which certain individuals are able to resist devaluation and
discrimination by others (Thoits 2011). While stigma resistance has not received much
theoretical or empirical attention to date, it has the potential to explain how the impact of
stigma varies among those who are labeled.
In this dissertation, I explore the link between stigma and self-concept. I also
examine stigma resistance responses that people may enact or possess to ward off the
potentially negative effects of the stigma of mental illness. Specifically, I examine the use
of defensive strategies as well as empowerment as potential moderators of the
relationship between perceived stigma and self-concept. These relationships are assessed
longitudinally among a population of individuals with severe mental illness.
Evidence of the Impact of Stigma on Self-concept
Theoretical and empirical evidence suggests that there is a harmful link between
stigma and self-concept for individuals with mental illness (Corrigan, Watson and Barr
2006; Link 1987; Link, Mirotznik and Cullen 1991; Rosenfield 1997; and Wright,
Gronfein and Owens 2000). Stigma may negatively impact self-concept by eroding selfesteem and/or self-efficacy (Corrigan et al. 2005; Link et al. 2001). Stigma is linked to
3
psychosocial outcomes, including reduced agency and quality of life, and increased levels
of depression (Camp, Finlay and Lyons 2002; Livingston and Boyd 2010; Lundberg et al.
2009; Rosenfield 1992; Rosenfield 1997; Wright et al. 2000).
Sociological theories provide insight into the process by which stigma may
negatively impact self-concept. According to classic and modified labeling theories,
individuals distinguish and label human differences. The labeled person is linked to
undesirable stereotypes, attitudes or beliefs. From a symbolic interactionist perspective,
individuals recognize the values, attitudes and beliefs of others in society. If the
undesirable stereotypes and attitudes of others about mental illness are internalized,
meaning the individual applies stereotypes to one‟s self, negative self-feelings will occur.
There are two relevant assumptions that explain how stigma may negatively
impact self-concept (Camp et al. 2002; Link et al. 1989). First, it is assumed that people
with mental illness recognize and share the negative representations that others associate
with mental illness. Second, it is assumed that being diagnosed with a mental illness
makes that condition a central component of one‟s identity or self-concept. These
assumptions indicate that individuals are aware of negative cultural values and
representations of mental illness, and that those who identify with these devalued cultural
depictions of mental illness will have more negative self-feelings because they are
representative of one‟s identity.
However, despite this theoretical and empirical evidence, other evidence suggests
that the harmful effects of stigma on self-concept are not as strong or as lasting as might
be predicted (Camp et al. 2002; Corrigan et al. 2005; Crocker and Major 1989; Gove
4
2004; Thoits 2011). Compared to stigma associated with other social characteristics (e.g.
sexual orientation) or physical health conditions or disabilities, stigma associated with
mental disorders has been shown to have the weakest association to mental health
outcomes including self-esteem, quality of life and depression (Mak et al. 2007). That is,
stigma associated with mental disorders may not have as strong of an impact on internal
self-feelings as expected by labeling theories when compared to the stigma associated
with other characteristics or conditions. This finding suggests that there is variability in
the impact of stigma, as well as in the ways in which individuals respond to stigma, that
results in differential impact of stigma on self-concept.
Further, Corrigan and Watson (2002) discussed a paradox of stigma that suggests
that there is much variation in the impact of stigma. The authors found that, while many
individuals with mental illness suffer self-derogation as a consequence of internalizing
stigma and discrimination, there is a subset of individuals who react energetically with
anger or become empowered to advocate on behalf of themselves and others, while still
others are indifferent to the effects of stigma with no apparent impact on self-concept
(Corrigan and Watson 2002). The paradox, then, is that given these different responses,
stigmatized individuals in general do not differ from non-stigmatized persons in selfesteem and they may even have higher levels of self-esteem (Corrigan and Watson 2002).
This paradox suggests that there is a need to examine the degree that stigma experiences
influence social psychological processes and the wide variation in responses to stigma.
5
Stigma Resistance Responses
There are a number of responses that individuals with mental illness may use to
reduce the impact of stigma. Some may react to stigma by internalizing the negative
reactions of others, applying these negative attitudes towards one‟s self. Internalizing
stigma in this way ultimately results in a devalued sense of self-concept and adopting an
identity associated with mental illness (Corrigan et al. 2005; Corrigan, et al. 2006;
Goffman 1963; Livingston and Boyd 2010). Others may react by engaging in defensive
strategies, meaning those attempts to protect oneself from the negative attitudes and
discrimination of others. Such strategies include hiding the fact that one has a mental
illness, at least to the degree possible, or withdrawing from social interaction (Link et al.
2002; Link et al. 1989; Link et al. 1991). Such strategies are defensive because the
individual is actively trying to avoid or limit exposure to negative attitudes, stereotypes,
and discrimination that have been perceived or are anticipated.
Still others may react to the threat of stigma by engaging in proactive resistance
strategies. Stigma resistance strategies are “intentional, agentic responses to possible
harm” that challenge or confront the negative attitudes of others (Thoits 2011: p. 11).
Such strategies may be behavioral, such as rebuking someone for a tasteless joke or
seeking to educate others about mental illness, or more cognitive, such as in the
deflection of stigma by reducing threats to self-regard (e.g. saying to one‟s self, “that‟s
not me”) (Thoits 2011). Stigma resistance strategies may be social as well, bringing
people together in a collective effort to challenge negative attitudes about mental illness.
Collective action increases social resources, promotes advocacy and activism and
6
legitimizes feelings of anger and injustice (Thoits 2011). Individual and social
empowerment are critical components of proactive stigma resistance strategies because
they represent an attempt of individuals or groups to gain power and control, where
individuals may benefit from membership in a devalued social group. It is the process by
which individuals may improve self-concept by actively confronting the sources of
stigma. Resistance strategies may be the key to more fully understanding how stigma
impacts the self-concept of individuals with mental illness.
Research Aims
Given the contradictory evidence around a persistent negative link between
stigma and self-concept, further investigation of these relationships is essential to
understand how the stigma of mental illness may have a detrimental effect for some
individuals with certain conditions, but not for everyone in the same way to the same
degree. Sociological theory and research must continue to examine both positive and
negative effects of labeling mental health conditions. I propose three general research
aims to examine the relationship between stigma and self-concept among individuals
with mental illness, and how individual responses to stigma impact this possible
relationship.
The first research aim is to examine the relationship between stigma and selfconcept, as measured by both self-esteem and mastery. Most research has typically
focused on self-esteem, a measure of one‟s attitudes about oneself. This study will also
focus on mastery as a measure of self-concept because it incorporates attitudes and
7
feelings of personal power and control over one‟s environment. Mastery may be of
particular importance with regards to the second research aim, which is to better
understand how individuals enact strategies that may ward off or resist the potentially
negative effects of stigma on self-concept. Specifically, I will examine the use of
defensive strategies (e.g. secrecy and social withdrawal) as a moderator in the theorized
relationship between stigma and self-concept.
Studies that have examined the use of defensive strategies report mixed results in
their ability to reduce the negative effects of stigma on self-concept. As such, recent
theoretical and empirical work has shifted towards a focus on other forms of coping with
stigma that may enhance one‟s sense of power. Empowerment has been described as
antithetical to stigma and represents a process by which individuals seek to build strength
from identifying as a member of a stigmatized group. The third research aim is to
critically examine empowerment and its underlying constructs to assess their applicability
as measures of proactive responses to stigma and as protective factors for the self-concept
of individuals with mental illness.
Summary of Dissertation by Chapter
This dissertation is divided into six chapters. This present chapter (Chapter 1)
introduces the issues under investigation and briefly discusses the research aims for this
study. In Chapter 2, I review relevant theoretical perspectives that contribute to our
understanding of the relationship between public stigma and self-concept. Chapter 2 also
presents a discussion of stigma resistance in general, and provides theoretical support for
8
the use of defensive strategies and empowerment as stigma resistance responses. Chapter
2 concludes with a statement of the research questions. Chapter 3 describes the sample
and methodology used to examine the research questions. Chapter 4 presents the results
of initial, exploratory analyses, as well as the results of the main analyses related to the
research questions. Chapter 5 contains a summary of results from post hoc analyses that
further explore findings from the primary analysis. Chapter 6 contains a discussion of the
key findings of this study, along with a summary of limitations of the study. I conclude
with a discussion of future research directions.
CHAPTER 2
THEORETICAL FOUNDATIONS AND RESEARCH QUESTIONS
In this chapter, I discuss the theoretical perspectives that explain the impact of
stigma on self-concept. This review of relevant literature is divided into six sections.
First, I draw from a symbolic interactionist perspective to define and contextualize the
self-concept. I begin by providing a brief overview of the symbolic interactionist
conceptualization of the self as it relates to the evaluative process that occurs within
social interaction. I also describe two components of self-concept, self-esteem and
mastery, and discuss how they may be impacted through a process of labeling that occurs
within social interaction. Second, I provide a definition of public stigma as the negative
attitudes of others towards individuals with a socially devalued social status. I contrast
public, perceived stigma from self-stigma, meaning that stigma which has been
internalized by individuals. Third, I discuss classic and modified labeling theories. In the
fourth section of this chapter, I discuss principles from symbolic interactionist and
labeling theories that relate to the relationship between stigma and self-concept.
The focus of this dissertation is to further elucidate the mechanisms that enable or
disallow public, perceived stigma to impact the self-concept of individuals with mental
illness. In the fifth section of this chapter, I provide a brief overview of resistance
strategies that individuals enact when confronted with stigma. This discussion includes a
9
10
comparison of the plight of individuals with mental illness to other similar groups who
are also stigmatized, and how membership or identification with such stigmatized groups
is not necessarily prescriptive of damaged or devalued self-concept, and may be
beneficial. Sixth, I discuss the use of defensive strategies and empowerment as resistant
responses to stigma. I conclude this chapter with a statement of the research questions.
Symbolic Interactionist Conceptualizations of the Self
The symbolic interactionist perspective is an explanatory framework that provides
insight into the definition and development of the self. The symbolic interactionist
perspective views both society and the self as a fluid and negotiated process in which
individuals define and interpret the meaning of actions of others through social
interaction (Blumer 1969; Goffman 1959; Mead 1934; Thoits 1999). Individuals
communicate through a system of shared symbols (e.g. language, gestures, and signals).
Through communication, individuals are able to reflect on how others view the self
(Mead 1934). Similar to the looking-glass self, we derive self-meanings by reflecting on
others‟ reactions to our self (Cooley 1902). In this way, the self is developed through a
reflexive process that provides feedback to the actor of the consequences of how others
view and respond to the self (Burke 1980; Rosenberg 1979).
Goffman (1959) focused on the ritualistic nature of interaction in which
individuals are both the process and products of social interaction. In The Presentation of
Self in Everyday Life, Goffman (1959) described a dramaturgical approach that likened
social interaction to a staged drama in which and all individuals are simultaneously actors
11
and audience to others. The dramaturgical perspective suggests that individuals engage in
impression management by carefully selecting and controlling appearance, manner and
personal behaviors. If successful, the individual presents a portrayal of him or herself
within the interaction that he or she wishes to be conveyed to others. Acting is an attempt
of the individual to control the information that is available to others and to define the
situation in a way that is preferred by each actor (Cahill 2001).
It is important to note that, from a symbolic interactionist perspective, the
individual is a conscious and reflective actor, not a passive and predetermined object of
larger social forces (Blumer 1969). The central mechanism for human interaction is the
interpretation of one‟s own and others‟ behaviors (Blumer 1969; Mead 1934). This
interpretation occurs through communication, a process by which we observe and
interpret others‟ signals (e.g. language, gestures, facial expressions, etc.), and then
reciprocate with our own (Turner 1986). This interpretation involves giving meaning to
other social objects, judging the suitability of that meaning as it relates to one‟s self, and
making decisions based on that judgment that affect oneself and others because of its
influence on the interaction. Through this process, individuals are active in the
development and maintenance of the self.
The self may be conceptualized as consisting of three features that are developed
and maintained within social interaction. These features include: 1) the self, that is, the
social object that engages in interactive processes; 2) self-concept, meaning the
individuals‟ understanding and interpretation of self; and 3) self-esteem, or one‟s
12
evaluation of self. I briefly describe each of these three features of the self in the
following sections.
The Self
Symbolic interactionism suggests that by taking the perspective of others, that is,
viewing the self from the standpoint and values of others, we develop a sense of self
based on reflected appraisals (Mead 1934). In this way, the self may be defined as a
social object in an environment that is affected and impacted by the individual, as well as
by other social agents (Mead 1934). This role-taking process allows us to see ourselves as
we perceive others to see us. Through such reflection, “the individual experiences
himself, as such, not directly, but only indirectly, from the particular standpoints of other
individual members of the same social group as a whole to which he belongs” (Mead
1934: 138).
Role-taking occurs during social interaction, as well as during imagined
interaction and internal, cognitive processing within the mind (Mead 1934). The mind,
defined as symbolic interaction toward the self, allows us to envision how others view
ourselves, and it is through the mind that one reflects on and understands the meaning of
other people‟s words and actions (Mead 1934; Rosenberg 1979).
The self is a reflexive dialectic between Mead‟s (1934) concepts of the “I” and the
“me.” The “I” represents the active agent that experiences, thinks and acts. The “I”
incorporates the aspect of individuals that is unlearned, unplanned and innate. The “me”
represents the perspective of oneself that one assumes when taking to role of specific
13
others or of the general community. It represents the conceptions of self that individuals
adopt when describing the self (Gecas 1982; Mead 1934). This reflexive exchange
between the “I” and the “me” is a process that produces the self, suggesting that the self
is not an object that is shaped entirely at the hands of others, but that individuals are
capable of choosing actions with consideration for social context. Both the “I” and the
“me” must be present to reflect on one‟s self as an object, and also to engage in actions
that cause activity. In this way, Mead viewed the self as a process requiring action, then
reflection, then action.
The self incorporates the perspectives of all those who come in contact with us.
Mead (1934) defined this general perspective as follows: “the organized community or
social group which gives to the individual his unity of self may be called „the generalized
other.‟ The attitude of the generalized other is the attitude of the whole community” (p.
154). In taking the role of the generalized other, we incorporate the attitudes,
dispositions, meanings, expectations and collective representations for situations within
an orienting perspective for our own experiences (Turner 1986). That is, as we interact
with others beyond the circle of significant others to whom we are closest, we incorporate
the viewpoints of general others into our own conceptualization of our selves.
Within Goffman‟s dramaturgical approach, the self is developed anew within
each interaction (Goffman 1959). For Goffman, “self is not something that an individual
owns but something others temporarily lend him or her” (Cahill 2001: 192). Thus,
individuals attempt to control the impression that others have in order to present a self
that is consistent with the individuals‟ self views. In doing so, individuals strive for
14
authentic interaction when possible. Further, individuals learn to have emotions and
feelings attached to the selves that are presented to others. Goffman (1959) called this
“face,” and he discussed how individuals feel shame if the face is not adequately
represented or is inauthentic. The emotional attachment to one‟s projected self regulates
one‟s conduct within interaction (Cahill 2001).
There are social implications for those who are unable to control all aspects of
one‟s projected self. If an individual has a visible, stigmatized condition (e.g. physical
deformity), he or she will be challenged in presenting the self that he or she desires to
maintain within interaction. Thus, he or she may alter the way that he or she interacts
with others by limiting the people that he or she comes in contact with or by restricting
the information that is shared. The individual may also make attempts to conceal the
stigmatizing condition. Goffman (1959) describes the potential consequences to social
interaction as follows:
“When the individual employs these strategies and tactics to protect his own
projections, we may refer to them as „defensive practices‟; when a participant
employs them to save the definition of the situation projected by another, we
speak of „protective practices‟ or tact. Together, defensive and protective
practices comprise the techniques employed to safeguard the impression fostered
by an individual during his presence before others” (p. 13-14).
In sum, the self may be defined as an object that develops through social
interaction through communication among individuals who use a system of symbolic
language and shared meanings (Blumer 1969; Cooley 1902; Goffman 1959; Mead 1934;
Rosenberg 1979). Through interaction, participants make reference to each other and
attribute characteristics to each other. During actual or imagined interactions, one gauges
the reactions of others towards oneself. Thus, the self is a process of reflexive action.
15
Self-concept
If the self is understood to be the aspect of a person that has experiences, reflects
on those experiences and acts upon self-understandings, self-concept, then, may be
considered as the product of this cognitive and reflexive activity as it results in a
conception of oneself as a physical, social and moral being (Gecas 1982; Thoits 1999).
Self-concept is the product of reflexive cognitive action rooted in one‟s personal
experiences while interacting with the social world, and represents the totality of an
individual‟s thoughts and feelings towards oneself. Self-concept consists of the essential
parts of the self, meaning our own understanding of our self as an object (e.g. as a man,
optimist) (Gecas 1982; Rosenberg 1979; Thoits 1999). The self-concept is “not the „real
self‟ but, rather, the picture of the self” (Rosenberg 1979: 7, emphasis in original),
meaning that self-concept is understood to us as we perceive others to view our selves.
Self-concept is developed through a process of reflected appraisals and social
comparisons (Gecas 1982). Reflected appraisals are those that are adopted by taking the
role of specific or general others. Social comparisons are those comparisons that
individuals make to assess one‟s own abilities and qualities in comparison to others
(Gecas 1982). Because self-concept is developed through personal interpretations of
others‟ perceptions, it is an inherently social phenomenon, even though it is cognitive and
internal. As Gecas (1982) suggested, “the content and organization of the self-concept
reflects the content and organization of society” (p. 10).
To impose order onto one‟s self-concept, individuals develop social identities
based on social classification and self-definition (Rosenberg 1979; Thoits 1999). Social
16
identities are often rooted in the structural locations of the individual, such as one‟s race
or gender, on are based on roles that individuals enact. Roles are positions that carry
normative behavioral expectations and scripts for carrying out normative behaviors, and
they connect individuals to cultural values and norms (Gordon 1976). Roles provide
individuals with meaning which helps them to make sense of themselves. Individuals
develop self-concept around these roles, also called role-identities.
Stryker (1979) suggested that self-concept is a salience hierarchy of these roleidentities. Individuals adopt multiple role-identities and commit to each to varying
degrees. The level of commitment to a specific role-identity depends on the degree that
one is enmeshed within social relationships that depend on that identity (Stryker 1979).
The level of salience depends on one‟s readiness to invoke various role-identities in given
situations (Stryker and Serpe 1994). Thus, those role-identities that are more salient to an
individual will have greater commitment and comprise the individual‟s self-concept to a
greater degree. When others recognize and legitimize one‟s role-identity enactments, selfconcept is maintained (Thoits 1999).
Self-esteem: Evaluation of Self
Self-esteem is the individual‟s overall evaluation or appraisal of the self (Cast and
Burke 2002: Gecas 1982; Thoits 1999). Individuals engage in a process of selfverification in which they assess the degree to which feedback from social situations
matches or confirms one‟s self-concept (Cast and Burke 2002). Individuals evaluate
themselves based on their ability to achieve a match between an identity goal or ideal
17
(known as an identity standard) and perceptions drawn from the environment about the
actual performance of the self (Burke 1991; Cast and Burke 2002; Swann, Stein-Seroussi
and Giesler 1992). Thus, self-verification processes help individuals reconcile their
perceived self-concept with the feedback that is received from others.
Swann et al. (1992) contend that individuals seek a stable self-concept in order to
maintain a predictable and negotiable social reality. Verifying an identity produces
feelings of competency and self-worth, increasing one‟s sense of self-esteem. However,
when the self-verification process is inconsistent with an individual‟s view of him or
herself, individuals make attempts to reduce the disturbance in the self-verification
process (Cast and Burke 2002). Individuals extricate themselves from social situations or
shed the identity in order to avoid the negative feelings that arise from persistent
discrepancies between situational meanings and identity standards (Cast and Burke 2002:
1048).
There are multiple conceptualizations of self-esteem. First, self-esteem is
conceptualized using both a global and a domain-specific approach. General or global
self-esteem incorporates both positive and negative attitudes toward the self (e.g.
Rosenberg‟s (1965) self-esteem scale). Global measures of self-esteem, such as
Rosenberg‟s (1965) self-esteem scale, refer to overall positive and negative feelings
about the self, and are explicitly designed not to be domain specific or conceptually
unidemensional (Robins, Hendid and Trzesniewski 2001). Others have focused attention
on the bideminsional nature of self-esteem which separates a positive dimension that
examines self-affirming, self-confidence measures from a negative dimension which
18
focuses on self-deprecation or self-denigration (Owens 1993). The global self-esteem
scale as constructed by Rosenberg (1965) has high construct validity and does not appear
to be superior to versions of the scale that focus on positive or negative dimensions
(Greenberger et al. 2003).
Second, self-esteem is conceptualized as representing two different aspects of
self-evaluations: self-esteem that is based on one‟s sense of worth or value (worth-based
self-esteem) and self-esteem that is based on one‟s sense of power, efficacy and
competency to exert agency, control or causality within one‟s environment (efficacybased self-esteem) (Gecas 1982; Cast and Burke 2002). This evaluation of efficacy may
also be global (e.g. Pearlin and Schooler‟s (1978) mastery scale) or it may be specific to
one‟s efficacy in a certain domain (e.g. the health-related locus of control scale as a
measure of one‟s ability to control health behaviors, such as diet and exercise (Wallston
et al. 1976)). I discuss both worth-based self-esteem and efficacy-based self-esteem in
greater detail below.
Self-esteem. Self-esteem is viewed as the degree to which an individual feels that
he or she is a person of value. Rosenberg (1965) described self-esteem as the evaluation
that individuals maintain towards him or herself, and which typically expresses approval
or disapproval towards oneself. It is a concept grounded in social norms and values
concerning interpersonal conduct (Gecas 1982). An individual receives feedback from
others about the degree to which he or she is accepted and valued through reflected
appraisals and social comparison. The more that one feels valued based on the feedback
of this process, the more that worth-based self-esteem will be improved. A person with
19
high self-esteem will believe that he or she possesses many positive qualities and will
have positive attitudes toward the self. However, worth-based self-esteem will be most at
risk when an individual is faced with possible exclusion or devaluation from others (Cast
and Burke 2002).
Mastery. Efficacy-based self-esteem is the degree to which people see themselves
as capable and efficacious (Cast and Burke 2002; Gecas 1982; 1989). It refers to the
motivation of individuals to engage in certain actions, and is relevant to their expectation
of the efficacy of such actions (Bandura 1977; Gecas 1989; Gecas and Schwalbe 1983).
As individuals interact with others, they evaluate their effectiveness, abilities and causal
agency (Gecas 1989). This process is realized through self-verification within interaction
that provides feedback to individuals as to the efficacy of his or her actions. This
component of self-esteem is more responsive to perceived effectiveness on the part of the
individual in maintaining consistency between situational meanings (reflected appraisals
from others) and identity standards (Cast and Burke 2002; Gecas and Schwalbe 1983).
Efficacy is akin to mastery, which is the component of self-concept that reflects
one‟s sense of power or personal control (Gecas 1989; Pearlin and Schooler 1978; Wright
et al. 2000). This definition is compatible with a symbolic interactionist view of self as
“active, creative and agentive” (Gecas 1982: 18). Gecas and Schwalbe (1983) discuss
how individuals derive a sense of self “from the consequences and products of behavior
that are attributed to the self as an agent in the environment” (emphasis added) (p. 79).
Like self-esteem, mastery is an evaluation of one‟s self-concept. It differs from selfesteem because it focuses on one‟s abilities and competencies to enact various desired
20
effects on social outcomes. A person with a high sense of mastery would feel that he or
she has power over things that happen to him or her. Thus, conceptualizing mastery as an
evaluative measure of self-concept incorporates dimensions of agency and power, both of
which may be integral to one‟s ability to overcome and resist negative effects of stigma
and perceived discrimination.
Self-esteem and Mastery as Outcome Measures
When examining self-concept as an outcome, researchers examine the processes
that produce or inhibit self-esteem and mastery (Rosenberg 1979). While this is the focus
of some empirical studies (see Bengtsson-Tops 2004), much work that focuses on a stress
process framework views self-concept as an intervening concept in the process by which
social stressors affect physical stress outcomes. Based on the stress process framework,
self-esteem and mastery are viewed as personal coping resources that individuals have to
reduce the harmful effects of stressors (Mirowsky and Ross 2003; Schieman 2002;
Pearlin and Schooler 1978; Thoits 1995). Self-concept is thus conceptualized as a
mediator in the process by which stressors impact health and psychological well-being
outcomes, or as a moderator which exacerbates or inhibits the effects of stress on
outcomes (Pearlin et al. 1981; Thoits 1999).
The limitation with this approach as it relates to this study is that it does not
examine how “the success or failure of coping strategies might enhance or undermined
self-concept” (Thoits 1999: 358). To better understand self-concept‟s role in the stress
process and the means by which it serves as a coping strategy, we need to examine those
21
factors that influence self-concept. While this dissertation is not a sociological assessment
of the stress process itself, the findings may influence our understanding of the ways in
which social stressors (e.g. stigma) impact self-esteem and mastery.
In sum, the self develops through interaction, while the self-concept is the
conception of oneself as a social being. The self-concept is ordered by social roles that
provide meaning about who an individual is and what behaviors and actions are expected
in social situations. Self-esteem is the evaluation or appraisal of the self-concept.
Individuals engage in a process of self-verification to match self-feelings with the
feedback received from others. Successful self-verification will result in positive selfevaluations, while negative self-verification will result in the individual making attempts
to reduce discomfort that disconfirmation causes.
There are two aspects of self-esteem: worth-based and efficacy-based self-esteem.
Both aspects may be impacted by stigma, but the impact may occur in different ways.
Worth-based self-esteem, meaning the feelings that one is a person of value, may be
negatively affected by anticipated or experienced devaluation. Efficacy-based self-esteem
is the evaluation of oneself as efficacious, agentive and in control. Efficacy-based selfesteem may relate to various strategies that individuals enact when confronted with
stigma. In the following sections, I define stigma, discuss the social origins of stigma,
and describe public, social stigma in comparison to internalized, self-stigma. I will then
review classic and modified labeling theories which link the discussion on self-concept
with the literature on stigma.
22
Defining Stigma
Stigma is conceptualized as a mark or discrediting characteristic of an individual
that is devalued by others with whom the individual interacts (Goffman 1963). In
defining stigma, Goffman (1963) wrote,
“The term, stigma, then, will be used to refer to an attribute that is deeply
discrediting, but it should be seen that a language of relationships, not attributes,
is really needed. An attribute that stigmatizes one type of possessor can confirm
the usualness of another, and therefore is neither creditable nor discreditable as a
thing in itself… stigma is a special kind of relationship between attribute and
stereotype” (p.3-4).
Thus, stigma exists within social interaction, and represents the separation of one
individual (or group of individuals) from others based on cultural meanings of a
devalued, discredited characteristic.
Because stigma occurs through social interaction, the formation of stigma is
inherently a social process. A stigmatizer perceives a mark or characteristics that is
socially devalued or perceived as negative. Certain marks or cues may be more visible
than others, such as those cues marked by physical deformity, while others may be more
invisible or hidden, including the stigma of mental illness (Corrigan and O'Shaughnessy
2007; Goffman 1963). Once a stigmatizer perceives a mark, he or she endorses negative
stereotypes that are learned and culturally sustained through a process of socialization
(Balsam and Mohr 2007; Link et al. 1987; Stuber, Meyer and Link 2008; Thoits 2011).
These stereotypes are knowledge structures that reflect the cultural beliefs and categories
of a dominant social group (Corrigan and O'Shaughnessy 2007).
23
Often, stereotypes are formed around neutral observations about a certain group
of individuals. However, they may also be formed around negative feelings or
perceptions about individuals. If certain individuals behave in ways that are contrary to
social norms for appropriate behavior, individuals may draw upon certain stereotypical
beliefs to explain and understand the situation. If these stereotypes are enacted and
endorsed by a stigmatizer, he or she may develop prejudicial attitudes towards the
individual or may change behaviors to discriminate against the individual (Corrigan and
O'Shaughnessy 2007; Stuber et al. 2008). Individuals rely on social cues to make these
determinations within social interaction. However, for certain conditions, a label is
needed for hidden stigmatizing conditions to become known. In this way, labeling of a
condition by a person with authority or power to make such a determination plays an
important role in the degree to which one will be stigmatized by others.
Stigma operates at the structural, interpersonal and individual levels of society. At
the structural level, stigma exists within institutional policies that allow for patterns of
structural discrimination, exclusion and prejudice (Goldberg and Smith 2011; Link and
Phelan 2001; Livingston and Boyd 2010). At an interpersonal level, social or public
stigma is the negative attitudes of the general population held towards a group of
individuals who are viewed as having a negative mark that links those individuals to
undesirable characteristics (Link and Phelan 2001). Public stigma is the social
endorsement of negatively held beliefs about stigmatizing characteristics or towards
individuals who possess such characteristics. These negative beliefs are held by the
generalized other and are endorsed through acts and portrayals of public discrimination
24
and prejudice (Livingston and Boyd 2010). Self-stigma occurs at the individual level and
represents the loss of self-esteem or self-efficacy that occurs when people internalize
public stigma (Corrigan et al. 2005).
This dissertation will focus on a conceptualization of stigma as public or social
stigma. Given the importance of social interaction in the creation of the self from a
symbolic interactionist approach, I seek to better understand the degree to which negative
feelings and attitudes of the generalized other impact the self-concept of people who are
labeled with a stigmatizing condition. I do not focus on internalized stigma (or selfstigma). Internalized stigma relies too heavily on the assumption that public stigma, in
fact, does have a negative impact on self-concept, and ignores the potential influence of
moderators in the process by which stigma may affect self-concept.
In sum, stigma may be defined as a discrediting mark or characteristic that is
given to an individual who is expressing behavior or emotion that is counter to the
culturally accepted expectations for normative behavior, thoughts or emotions. The
individual will be viewed as deviant or abnormal, and will be labeled with a devalued
social status. Mental illness is stigmatized because of public sentiments that individuals
with mental illness are unpredictable, unkempt, irrational or dangerous (Link et al. 1999;
Pescosolido et al. 1999, 2010; Phelan et al. 2000). If this public stigma negatively
impacts the way that an individual views him or herself, then stigma becomes
internalized and affects the self-concept. In the following section, I discuss classic and
modified labeling theories that further explain this process.
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Labeling Theories
Labeling theories posit that individuals recognize and react to societal conceptions
of mental illness (Link et al. 1989; Scheff 1963). Per Scheff (1963), labeling theory
suggests that individuals who have been categorized by other people as deviant come to
view themselves as deviant. Such categories are applied primarily by agents of social
control, resulting in an official label that is attached to the individual. This label results in
negative responses from others, which in turn causes the individual to adopt the expected
social role of a person with mental illness. Thus an identity shift occurs for the labeled
individual (Scheff 1963; Scheff 1974; Link et al. 1989).
Labeling theory emphasizes the role of deviance in our conceptualization of
mental illness. Scheff (1963) categorized mental illness as a form of residual deviance,
meaning that the deviant behaviors do not violate a specific social rule, but represent a
category of behaviors that appear wrong or culturally different. When the behavior gains
sufficient public recognition to be viewed as problematic, or when a professional labels
the behavior (e.g. by applying a diagnosis), the cultural definitions associated with mental
illness take over and bring about the social consequences of being labeled, including
social rejection and discrimination (Scheff 1963). Gove (1970) rejected this contention
that the label is the reason for social rejection. Gove (1970) discussed that individuals are
socially rejected because of deviant and norm-breaking behavior, not because they have
been officially labeled. Social norms reflect the goals, priorities, and definition of
26
constructs and commonly held beliefs in society, and when these norms are violated by
an individual exhibiting deviant behavior, social processes of rejection are enacted.
Mental illness may also be viewed as deviant because it is counter to the dominant
social norms of health. Illness in general is defined by deviance from a norm, which is
based on social definitions and constraints, such as morality (Szasz 1960). The
terminology previously used to describe mental illness has shifted from having a moral
connotation, such as a manifestation of sin or demonic behavior, to a well/sick
classification (Aneshensel and Phelan 1999; Ausubel 1961; Mechanic 1999). That is, the
medical model now emphasizes a definition of mental illness as “sick” rather than “bad.”
However, as Aneshensel and Phelan (1999) describe, the medical model emphasizes
internal processes within individuals and diverts attention from social sources of stigma.
While a label of sick may be preferable to a label of bad or evil, the medical model still
shapes “sick” as a deviant status, which potentially results in stigma and negative social
consequences.
Modified Labeling Theory
Like labeling theory, modified labeling theory explains the process by which
social labels, specifically the label of mental illness, impact self-concept. In discussing
modified labeling theory, Link et al. (1989) proposed a 5-step process in which this
occurs. First, societal conceptions of mental illness lead to general feelings of devaluation
and discrimination towards mental illness, and through socialization, individuals learn
these societal conceptions of mental illness (Link et al. 1987; Thoits 2011). Second, when
27
an individual is officially labeled with a mental illness the negative societal conceptions
about mental illness become personally relevant to that individual (Link et al. 1989).
Third, individuals respond to this label in a number of ways to mitigate the harmful
effects of the negative label. Fourth, the negative consequences of others‟ reactions to the
label of mental illness ultimately impact one‟s self-concept and social resources, and
fifth, this process results in increased vulnerability to repeated or prolonged disorder and
the continuation of the mental illness label (Link et al. 1989).
Unlike classical labeling theory, modified labeling theory does not assume that
the stigmatized individual accepts their categorization as self-descriptive (Thoits 2011).
However, stigmatized individuals who do not accept the label are still exposed to the
negative attitudes and perceptions of others, and the label may still negatively impact
self-concept. Thus, the key element of labeling is that stigmatization and social rejection
follow from a label that carries a negative connotation (Link et al. 1987). According to
Link et al. (1987), “a label is a starting point that activates an array of beliefs about the
designated person that may ultimately affect the level of acceptance or rejection such a
person experiences” (p. 1474). Labeled individuals may take the perspective of others
and define him or herself as others would, adjusting behavior to conform to the
expectations of others. This self-fulfilling prophecy suggests that people with negative
views alter behavior towards members of stigmatized groups so that a stigmatized
individual behaves and ultimately views him or herself in a manner consistent with the
negative stereotypes of the larger group (Crocker and Major 1989). Ultimately, this
process may result in a shift in one‟s self-concept by affecting self-esteem or mastery.
28
Source of the Label
An important consideration within classic and modified labeling theories is the
source of the label. In describing labeling theory, Scheff (1963), suggested that a formal
agent of social control is the primary source of labels. These include the doctors,
psychiatrists or other professionals who assign psychiatric diagnoses (Phelan and Link
1999). However, others may also participate in the labeling process, such as lay persons
who perceive behavior to be deviant, or even the individual who engages in self-labeling
of one‟s own behavior (Gove 1970; Horwitz 1982; Thoits 1985).
For instance, Thoits (1985) posited that “public, official labeling of one‟s rule
breaking is not necessary for the emergence of a deviant identity; there can be private
self-labeling” (p. 222). Thus, a formalized label of a mental disorder may not be
necessary in order to experience the effects of being labeled. Drawing from Mead‟s
(1934) concept of the generalized other, Thoits (1985) suggested that, even if others are
not present, individuals may imagine the reactions of others and internalize these
imagined responses. Self-labeling assumes then, that individuals recognize social values
and norms for behavior, that there are cultural labels for the categories of norms for
acceptable behavior that can be applied to oneself, and that there is motivation to
conform to these norms (Thoits 1985). As individuals engage in self-reflection, they can
imagine the reaction of others and may alter their self-conceptions accordingly.
While self-labeling may occur, there is evidence that individuals are resistant to
applying self-labels even when receiving mental health services. This unwillingness or
uncertainty about self-labeling reflects a conception of mental illness as a dynamic
29
process, with symptoms that are transitory, variable or ambiguous (Moses 2009). Further,
self-labeling is based on the assumption that individuals want to conform to social norms,
which may not be the case for individuals who are seeking to clearly define, develop and
understand one‟s self, such as adolescents (Moses 2009). Whether the resistance to
engage in self-labeling is a reflection of the shifting nature of mental illness itself, or is a
hesitancy to incorporate mental illness within one‟s self-concept, the process itself can be
transformative for the individual.
Summary of Theoretical Principles Related to Stigma and Self-concept
Thus far, I have presented the theoretical arguments that would suggest that
stigma has a pervasive and negative influence on the self-concept of individuals with
mental illness. While this may be true for certain individuals, there is evidence that
stigma does not influence others in the same way or to the same degree. In this section, I
summarize the key theoretical principles that may explain variation in the experience of
stigma and its effects on self-concept.
Specifically, I draw three themes from the above discussion of the impact of
stigma on the development of self-concept. First, I discuss how processing the norms and
values of the generalized other may result in the adoption of deviant identity; however,
there is selectivity in the degree to which individuals adopt the perspective of the
generalized other. Second, I discuss how self-concept focuses on certain role-identities
that carry different weights or degrees of importance to the individual. I discuss how this
may have an impact on the salience of a stigmatized identity. Third, I discuss the
30
importance and value placed on the agency of individuals in defining self-concept, and
how this may relate to differential responses to stigma.
Rejecting the Views of the Generalized Other
One of the key extensions of a symbolic interactionist approach is how the
attitudes and perspectives of the generalized other plays a central role in the definition
and labeling of a deviant status. By taking the perspective of others, or viewing one‟s self
from the standpoint of the community and its social values, we see ourselves as others do
(Blumer 1969; Mead 1934). According to Rosenberg (1979), “when the language of
verbs becomes a language of nouns, either through formal certification procedures or
general social recognition, the labeling process occurs, and produces additional elements
of social identity” (p. 10-11).
Thus, as individuals are classified and defined by others within social interaction,
they take on labels given by others and incorporate them into self-concept or roleidentities. These labels may have positive or negative connotations, as in the case of a
deviant or stigmatized label. Given this, it is assumed that possessing a stigmatized
attribute that is not valued by the generalized other would have a negative effect on one‟s
self-evaluation (Camp et al. 2002). However, evidence exists that individuals vary in the
degree that they concur with others‟ views. Such disagreement may result in anger,
defensive reactions or proactive responses to try to change the others‟ perspective (Camp
et al. 2002; Fine and Asch 1988; Mak et al. 2007). As such, the negative impact of stigma
on self-concept is not inevitable.
31
The Importance of a Stigmatized Identity to Self-concept
The second theoretical principle that relates to the relationship between stigma
and self-concept concerns the importance of the stigmatized condition to one‟s sense of
self. The self-concept consists of the relationship of its parts, that is, the roles or
identities, that individuals have. Those role-identities are organized hierarchically in a
system of self-values, meaning the role-identities that people have are not of equal
importance to individuals (Rosenberg 1979). Certain role-identities that comprise the
self-concept have unequal centrality to the individual, and it is possible that identities
related to a stigmatized condition are not incorporated within self-concept.
There is a theoretical assumption that evaluations about one‟s role-identities are
additive, combining to represent one‟s global sense of self-esteem (Thoits 1999). For
instance, if one views oneself as witty, attractive, a hard worker and a good listener, all
positive attributes, the assumption is that the positive self-evaluations of each of these
specific aspects of self contribute to global self-esteem. While this may be true, this
assumption does not take into account the importance of each component to one‟s selfconcept. We derive global self-esteem from qualities that matter to us as individuals, or
those that are rated as central to our conceptualization of our self (Rosenberg 1979). In
other words, “if we attempt to understand persons‟ global self-esteem, we must
appreciate the differential contribution to global self-esteem of the esteem attached to
self-components which themselves are regarded by persons as more or less central”
(Stryker and Serpe 1994: 18). If this is so, then those aspects of self-concept (roleidentities) that are most highly valued will contribute most to global self-esteem. Those
32
aspects of self-concept that are deemed less important will not impact self-esteem as
much.
If an individual does not view the status of mental illness as an important or
central component of their self-concept, that individual may not incorporate the
stigmatized identity within his or her self-concept. Goffman (1961) purported that a
patient of a mental hospital will convert his or her self-concept to match the institutional
definition of self as a mental patient. Thus, patients who have been institutionalized for a
long period of time will adopt a self-concept as one who is sick, dependent and in need of
care. However, while there may be acceptance of the patient role and the presence of
symptomatic behavior, this does not necessarily translate into acceptance of being a
person with mental illness within one‟s self-evaluation (Townsend 1976). Individuals
may protect or preserve self-concept by minimizing the emphasis on oneself as a person
with mental illness. This would reduce the ability of the mental illness label (and all of its
negative connotations) to harm self-concept.
Personal Agency in Defining the Self-concept
A third theoretical principle that may illuminate how stigma has a differential
impact on self-concept is the role of personal agency in defining self-concept.
Acknowledgement of the attempts of individuals to reject or resist such labels reflects a
theoretical trend that focuses on an assertive and agentive self to create and maintain
positive self-concepts (Gecas 1982). According to Rosenberg (1979), individuals
selectively choose which other social actors are significant others, which social
33
comparisons are made, and which aspects of one‟s self-concept are central or most salient
to the individual. This selectivity implies an active choice on the part of the individual to
create or maintain a self-concept that is desirable to that individual. The degree to which
one is successful at this will impact how one evaluates self-concept, and may relate to
feelings of self-worth or efficacy.
Given the importance of agency in shaping one‟s self and self-evaluations, it is
necessary to examine both self-esteem (worth-based self-esteem) and mastery (efficacybased self-esteem) as central components of self-concept (Rosenfield 1992; Wright et al.
2000). Mastery represents the extent that one feels in control or powerful over one‟s life
circumstances, and it is an essential concept to the investigation of how individuals draw
upon personal resources and paradigms to respond to stress, including stigma (Thoits
2011). Compared to studies that examine self-esteem, a focus on mastery incorporates
one‟s feelings of control and ability to change one‟s situation. Mastery may be
particularly important when examining the effects of stigma on self-concept, or in the
assessment of approaches that individuals enact to reduce or limit negative effects of
stigma.
In sum, while the symbolic interactionist perspective and labeling theories suggest
that negative cultural values related to mental illness will be viewed as self-descriptive,
there is also theoretical support that the degree to which this process occurs varies.
Individuals may be aware of negative stereotypes held by the generalized other, but they
may also not define themselves by these cultural depictions. Further, individuals may
cognitively reframe the degree of importance of the mental illness identity, thus reducing
34
the potential threat of stigma associated with a deviant category. Finally, individuals
enact a degree of agency in selecting which aspects of self-concept are most central. In
the following sections, I discuss how stigma resistance is a critical theoretical and
empirical construct in fully understanding the effect of stigma.
Resisting the Negative Effects of Stigma
As discussed, there is theoretical and empirical evidence to suggest that the
stigma of mental illness may have a detrimental impact on self-concept (Corrigan et al.
2006; Livingston and Boyd 2010; Munoz et al. 2011). However, there is also evidence
that suggests that some individuals are not as negatively affected by stigma as might be
predicted or expected based on symbolic interactionist and labeling theory frameworks,
and that the negative effects of stigma are not felt by all individuals with mental illness
(Thoits 2011). In other words, there is wide variation in the degree to which stigma exerts
a negative impact on an individual‟s sense of self.
Personal agency and choice of responses to stigma have not been thoroughly
examined, and much is unknown about how individuals enact strategies to counter the
effect of stigma. Thoits (2011) observed that there are multiple, unexplored responses to
stigma that may explain the modest effect of stigma on self-concept for certain
individuals. Such responses may have either beneficial or detrimental consequences, but
an individual‟s use of resistance strategies should not be ignored. As such, additional
research is needed to more fully understand how individuals respond to perceived stigma.
35
In this section, I discuss two stigma resistance orientations that individuals may adopt in
response to stigma: defensive strategies and empowerment.
Stigma Resistance: Defensive Strategies
As discussed, people with mental illness are likely to be aware of negative
cultural representations of mental illness. Once labeled, these negative representations
become personally relevant (Link et al. 1989). In response, some individuals adopt
defensive strategies to overcome the negativity associated with a stigmatized condition
(Camp et al. 2002; Link et al. 1991; Markowitz 1998; Thoits 2011). Link et al. (1991)
and Link and colleagues (1989) discussed withdrawal and secrecy as coping responses to
stigma. Withdrawal involves limiting social interactions to those who know about and
tend to accept one‟s stigmatized condition, and secrecy involves concealing one‟s
condition from others (Link et al. 1991: 304). From a modified labeling perspective,
secrecy and withdrawal are self-protective strategies that are designed to distance oneself
from the stigmatizing attitudes of others.
There is mixed evidence as to the effectiveness of secrecy and social withdrawal
on reducing the harmful influence of stigma. For instance, Link and colleagues (1991)
reported that social withdrawal had a detrimental effect on demoralization (an internal
feeling state) and unemployment (an objective social condition), and that neither secrecy
nor withdrawal diminished negative labeling effects on psychological distress or
demoralization. Others found no evidence of the effectiveness of social withdrawal as a
strategy that protects self-esteem (Ilic et al. 2011; Wright et al. 2000), while others have
36
found that secrecy has a strong, negative impact on self-esteem (Ilic et al. 2011). Link et
al. (1991) suggest that the use of defensive coping strategies hurts individuals‟ selfconcept because it inadvertently limits social opportunities and induces psychological
malaise among those who invoke such responses.
Stigma Resistance: An Empowerment Approach
Further examining the interplay of personal agency and social empowerment is
one theoretical direction that may explain the relationship between stigma and self. While
some coping responses to the stress posed by stigma may be defensive reactions, other
responses indicate agentive, proactive measures that individuals take to assuage the
effects of stigma. Empowerment has been described as the antidote to or opposite of
stigma (Corrigan et al. 2005; Lundberg et al. 2008), and may be an effective stigma
resistance response. However, it is unknown how empowerment affects the potential
relationship between stigma and self-concept.
Empowerment is defined as the means to gain control over one‟s life conditions
and critically understand and influence the structural constraints in which one lives
(Perkins and Zimmerman 1995; Rogers et al. 1997). It is a multi-level construct that
operates at the individual, organizational and social or community levels (Zimmerman
1995). According to Rappaport (1987), “empowerment conveys both a psychological
sense of personal control or influence and a concern with actual social influence, political
power, and legal rights” (p. 121). With regards to mental illness, the goals of
37
empowerment are to diminish stigma and discrimination, overcome illness and promote
recovery from illness (Corrigan and Garman 1997).
The empowerment ideology emerged from the self-help and community
psychology movements which followed deinstitutionalization (Dickerson 1998; Segal,
Silverman and Temkin 1995). This empowerment ideology developed, in part, as a
response against the domination of the psychiatric professional establishment, and it
encourages persons with mental illness to take control over their lives, reduce reliance on
professionals and develop support networks with other similar individuals who also have
mental illness (Dickerson 1998). An empowerment approach has been incorporated into
treatment and service programs by increasing client decision-making in the treatment
process, improving social skills and networking opportunities, encouraging supportive
peer interactions, and framing service providers as partners or collaborators instead of as
authoritative experts (Corrigan and Garman 1997; Perkins and Zimmerman 1995; Segal
et al. 1995).
Empowerment is a broad construct distinct from self-concept. In developing a
theory of empowerment, Rappaport (1987) described it as “not only an individual
psychological construct, it is also organizational, political, sociological, economic and
spiritual” (p. 130). To Rappaport (1987), empowerment is inherent in racial and
economic justice, legal rights, human needs, health care, education and community. It is
as relevant to organizations, neighborhoods and communities as it is to individuals
(Rappaport 1987: 130). Empowerment, however, has primarily received attention in the
psychological literature because of its emphasis on internal, psychological processes (e.g.
38
sense of personal control, self-efficacy and self-esteem) and because of its popularity in a
variety of mental health services and programs. This focus has downplayed some of the
social components of empowerment, such as group advocacy, and ignores social context
and forces that exert influence over individuals (Peterson and Zimmerman 2004; Riger
1993). This is problematic because it focuses attention on or within individuals and
detracts focus from the collective actions of groups of individuals.
Empowerment theory, research and interventions link individuals to the larger
social environment (Perkins and Zimmerman 1995). While empowerment is at the
forefront of many treatment programs, it has been understudied as a social phenomenon
that influences and is influenced by social forces. Empowerment has been cited as an
essential element to ward off or combat stigma, yet research on empowerment has not
focused on how individuals who have successfully overcome stigma have achieved this
outcome (Corrigan and Garman 1997; Shih 2004).
Empowerment is similar to the process of coping as both are concerned with
gaining control over one‟s environment to mitigate the influence of stress (Gutierrez
1994). However, the concept of empowerment goes beyond coping. The focus on coping
is on how individuals themselves adjust to the effects of stress, either through the use of
social support resources or by enlisting psychosocial resources to buffer the effects of
stress. The empowerment perspective, however, is concerned with how individuals
actively attempt to adjust or eliminate stressful situations (Gutierrez 1994). Feelings of
control are significantly associated with better health outcomes, goal setting and problem
solving, as well as reducing uncontrollable stressors (Gutierrez 1994; Thoits 2006).
39
Coping processes seek to avoid or prevent negative consequences, whereas the
goal of an empowerment perspective is to enact processes that change the social world
and create positive outcomes (Shih 2004). If coping is a reactive response to adversity
that drains available coping resources, empowerment is an active attempt to overcome
adversity by drawing strength from the experience of adversity (Shih 2004). The
empowerment perspective looks at the relationship of individuals to their social
environments, yet from the perspective of how the environment is impacted by the
individual. From this perspective, “empowering interactions can be an important
mediator of stressful life experiences by encouraging health and action oriented responses
to the social environment” (Gutierrez 1994: 208).
Illness and identity: Developing an empowered self. When facing a chronic or
stigmatized illness, individuals may define new roles and identities for themselves based
on the illness condition (Crossley 1997; Onken and Slaten 2000). The link between an
illness condition and its impact on self-concept is based on an assumption that the
debilitating condition is central to one‟s self-concept, leading to social comparisons
between sick and well social groups (Fine and Asch 1988). Such social comparisons
make illness synonymous with helplessness, dependency, and passivity.
The connection between illness and identity extends Parson‟s (1951) concept of
the sick role. In brief, the sick role is a set of “institutionalized expectations” around the
social condition of illness (Parsons 1951: 436). There are four exemptions and
obligations of the sick individual. First, the individual is exempt from normal social role
responsibilities. Second, the sick individual is exempt from responsibility for the illness,
40
meaning that the individual is expected to recognize that his or her condition “must be
taken care of” (Parsons 1951: 437). Third, the individual must express a desire to get
well, as the illness itself must be viewed as undesirable. Fourth, the sick individual is
obligated to seek professional help to correct the condition.
Implicit in the sick role model is that the illness is an undesirable state that limits
the abilities of the afflicted individual, and that professional or outside help must be
sought to correct the situation. Individuals who are ill are then removed from social
interaction and are viewed as separate and distinct from healthy, normal others. This
distinction may have some positive effects, particularly if the adoption of the sick role
increases empathy and social support from close network ties (Perry 2011). However,
there are likely simultaneous negative effects of being categorized as ill. In terms of the
effects of stigma of mental illness on self-concept, it is possible that adoption of the sick
role for individuals with chronic health conditions may negatively influence self-concept
as individuals who are stigmatized may internalize negative reactions of a healthy
generalized other.
Conversely, empowerment in the development of an illness identity challenges
the traditional attitudes about illness and its impact on self-concept. An empowerment
perspective suggests that individuals seek to build strength from identifying as a person
with a certain illness or condition. This encourages the individual to accept labels but
refute the negative stigma associated with such labeling. Crossley (1997) discussed the
development of an “empowered self” as a possible response of individuals who reject the
41
traditional model of the sick role, particularly if the illness condition is stigmatized or
misunderstood by others (p. 1870).
In developing an empowered self, individuals enact strategies that build strength
and derive power from the otherwise discredited identity as an ill person. Individuals
become empowered to define their conditions in ways that overcome stigma of a
devalued status. For example, constructing oneself as a “survivor” or “fighter” has
positive, moralistic connotations suggesting agency, hard work and determination of this
achieved status (Crossley 1997: 1866). The empowered self may improve the selfconcept of the individual and limit the negative influence of social devaluation.
Given the above discussion, social empowerment may be advantageous for
individuals with mental illness as it suggests the exercise of personal agency in
developing an identity around an illness condition. This identity promotes in-group social
connectivity, which leads to better self-esteem, self-efficacy, resiliency in the face of
adversity, adaptability and optimism (Balsam and Mohr 2007; Shih 2004; Thoits 2011).
The process of identifying with a stigmatized group may eliminate stress-inducing
tension around hiding one‟s condition from others, reduce the shame associated with the
disabling condition, and it may reduce negative attitudes of others (Corrigan 2003; Lee
and Craft 2002; Onken and Slaten 2000). As Link and Phelan (1995) state, “to the extent
that people with mental illness are empowered to „come out‟ and challenge stereotypes,
the broader public may come to view mental illness differently than they do now” (p.
375). This strategy has been effective for other marginalized groups that have sought to
overcome diversity and establish equality, such as those seeking racial and gender
42
equality, as well as within the gay, lesbian, bisexual and transgendered movement
(Balsam and Mohr 2007; Corrigan and Garman 1997; Gershon, Tschann and Jemerin
1999; Quinn and Earnshaw 2011).
Strategies that shift power from the dominant group to the stigmatized group may
reduce the influence of stigma. Thus, stigma may be negated through proactive
approaches to change or reduce stigma, such as community activism, protest, education
and interpersonal contact (Corrigan et al. 2005; Link and Phelan 1995). Individuals who
self-identify as a person with mental illness may also turn to similar others and peers to
gain understanding, acceptance and support related to the condition. As individuals make
connections with one another to reduce the effects of stigma, they may also begin to
develop an identity as a collectivity (Thoits 2011). By creating a social collective,
individuals with mental illness may become empowered to challenge negative stereotypes
and discrimination and advocate for social justice. This process could have broad social
consequences and may also improve the self-concept of individuals involved.
In sum, empowerment is a concept that has been under-studied by sociologists.
Empowerment is distinct from one‟s sense of self-concept, and goes beyond internal
coping processes. Individuals develop a sense of resiliency by overcoming adversity and
creating positive outcomes (Shih 2004). Examining empowerment as a social activist
movement will inform social research on the influence and power of the social
collectivity of disadvantaged groups. Further research will also improve our
understanding on how empowerment operates across different social characteristics, in
different social contexts, and across the life span (Zimmerman 1995). Finally, from a
43
social psychological perspective, we may better understand empowerment as it
contributes to the development of self-concept and identity.
It is important to understand empowerment as a social process by which
individuals draw strength and power. Thus, incorporating measures of empowerment
within sociological analyses of stigma resistance strategies may help researchers explain
why some individuals with mental illness do not have negative or adverse reactions to
social stigma. In this study, I posit that an empowerment orientation may mitigate the
impact of stigma on self-concept. However, I must first discuss some measurement issues
related to empowerment that must be addressed in order to understand its impact on the
relationship between stigma and self.
Measuring empowerment. Empowerment is typically conceptualized as a
psychological construct that incorporates self-oriented measures to examine internal,
social psychological orientations (Peterson and Zimmerman 2004; Riger 1993; Segal et
al. 1995; Thoits 2011). Empowerment is closely related to self-concept as those who have
a strong sense of empowerment can be expected to have high levels of self-esteem. Also,
empowerment is by definition a construct that integrates perceptions of personal control
(mastery) with one‟s behaviors to exert control because it is related to “control over one‟s
treatment and one‟s life” (Corrigan et al. 2005).
While empowerment is often viewed as an individual construct, it is distinct from
one‟s sense of self or personality (Segal et al. 1995). In developing a valid measure of
empowerment, it is necessary to examine the correlation of measures of self-concept (e.g.
self-esteem, self-efficacy and mastery) and empowerment (Segal et al. 1995). However,
44
common operationalizations of empowerment incorporate measures of self-concept as
underlying components within the construction of empowerment measures. This blurs our
understanding of how empowerment may be manifested within the everyday lives of
individuals with mental illness.
Incorporating self-concept within the construction of empowerment measures is
problematic in two ways. First, such an emphasis may not fit with the realities of many
people with mental illness. Low personal regard, negative self-feelings and lack of insight
into an illness condition may be definitional characteristics of certain mental illness
conditions (Dickerson 1998; Shih 2004). Thus, measures of empowerment may be
inaccurate or inadequately defined if they, by definition, rely on the presence of a certain
level of self-esteem, mastery, or awareness of the illness condition. Second, and most
relevant to the present analysis, incorporating self-concept measures within the concept
of empowerment masks important differences between self-oriented and socially-oriented
aspects of empowerment and confounds any assessment of the relationship among
stigma, empowerment and self-concept.
This measurement issue is apparent when examining the construction of a
commonly used measure of empowerment- the Boston University Empowerment Scale
(Rogers et al. 1997). This measure was developed with input from a group of individuals
with mental illness who were engaged in mental health services and who were active in
the self-help movement. Rogers et al. (1997) held meetings to get input on the
psychological components of empowerment (e.g. assertiveness, having decision-making
power, having access to information and resources). These groups developed consensus
45
of certain dimensions of empowerment, including control over one‟s life, achievement of
goals, self-esteem and self-efficacy (Rogers et al. 1997).
Rogers et al. (1997) developed survey items to represent these dimensions by
drawing upon other commonly used valid and reliable measures, including Rosenberg‟s
(1965) self-esteem scale and Rotter‟s (1966) locus of control scale. The authors created a
28-item scale consisting of five factors: self-esteem/self-efficacy; power/powerlessness;
community activism and autonomy; optimism and control over the future; and righteous
anger (See “Appendix A: Measurement of Self-concept, Stigma and Responses to
Stigma” for the individual items). These factors represent self-oriented as well as general
or community-oriented aspects of empowerment.
The process used to develop Rogers et al.‟s (1997) measure of empowerment
reflects the tendency of current research to focus on self-concept oriented measures,
including self-esteem and mastery, as definitional components of empowerment.
However, this process confounds these concepts with others that are embedded within the
same measure, which may mask the effects of these underlying concepts or may
misattribute the driving mechanism within empowerment.
Community activism and righteous anger. An empowerment orientation may
reduce the harmful effects of stigma on self-concept. However, because it is a broad
concept with many different definitions, conceptualizations and measurements, research
is needed to determine which components of empowerment relate to stigma and selfconcept. Two measures from Rogers et al.‟s (1997) Empowerment Scale, community
46
activism and righteous anger, are theoretically predicted to relate to stigma resistance, but
have received little empirical research to date. I briefly discuss each concept below.
First, when constructing the Empowerment Scale, Rogers et al. (1997) included
items pertaining to an individual‟s orientation towards the ability of social others (or
social collectives) to overcome obstacles. This measure of community activism may
explain differential responses among individuals with mental illness to the threat of
stigma on self-concept. Corrigan and Watson (2002) and Thoits (2011) discussed three
possible responses to stigma. These responses included: 1) acceptance and internalization
of the stigmatized status, 2) ignoring the stigma, and 3) challenging stigma. This third
response incorporates one‟s identification with similar others in a collectivity to engage
in efforts to change the perception of others. Such an approach towards community
activism may empower individuals to challenge others and to advocate on behalf of
themselves (Corrigan and Watson 2002; Thoits 2011). This may in turn affect self-esteem
and mastery (Corrigan et al. 1999). However, as Sibitz et al. (2011) suggest, “further
research should focus on the development of a more robust measure of stigma resistance,
possibly extending the range of measurements, e.g. toward the impact of community
activism” (p. 321).
A second concept included within the Empowerment Scale that relates to stigma
resistance is righteous anger (Rogers et al. 1997). Corrigan and Watson (2002) noted that
certain individuals will respond “forcefully” to stigma with righteous anger (p. 36).
However, other stigmatized individuals will not internalize stigma because they either
may not be aware of it or because they believe that the stigmatization is illegitimate (Mak
47
et al. 2007). If stigma is viewed as illegitimate, individuals may react with righteous
anger towards the prejudice or discrimination that is experienced or perceived (Deegan
1990; Mak et al. 2007). Such a response may empower people to become active
participants in their own treatment or in challenging negative stereotypes about mental
illness (Corrigan and Watson 2002; Thoits 2011). However, further specification of the
concept of righteous anger is needed, particularly as it may represent an active orientation
towards stigma resistance.
To better understand what is at the core of the concept of empowerment, it is
necessary to critically examine how empowerment is constructed and to assess
meaningful conceptual differences between concepts that are (or may be) conflated
within one measure. This is of particular importance when trying to disentangle the effect
of stigma and empowerment on psychological processes, including self-concept. In this
dissertation, I present exploratory analyses of the impact of two measures derived from
Rogers et al.‟s (1997) Empowerment Scale. This study will assess an orientation towards
community activism as a measure of stigma resistance, as well as an orientation towards
righteous anger. Both empowerment measures are conceptualized as possible resistance
responses to the threat of stigma. This study is an empirical assessment of these
theoretical suppositions.
Understanding Stigma Resistance among Community Mental Health Samples
Most studies have focused on empowerment among mental health service utilizers
who are participants in client-run, self-help programs, also known as a “clubhouse”
48
model of mental health services (Dickerson 1998). The clubhouse model developed out
of client dissatisfaction with professionally-led treatment programs (Corrigan and
Garman 1997). These programs are typically developed and operated by individuals with
mental illness who are clients of the mental health system (Link, Castille and Stuber
2008; Markowitz 1998; Rosenfield 1992, 1997; Thoits 2011), although there is variation
in the degree that professionals without mental illness are included within the treatment
model (Corrigan and Garman 1997). Underlying this model is the assumption that,
because of lived experiences, the client has unique insight about mental illness and how it
should be treated (Corrigan and Garman 1997).
In addition to providing for a variety of services to meet the basic needs of clients,
empowerment-oriented clubhouse programs offer vocational, psychosocial and social
opportunities for participants (Mowbray et al. 2006; Rosenfield 1997). The clubhouse
model encourages participants to take an active role in planning treatment-oriented
programs, such as group therapy meetings, as well as in planning various social activities,
daily maintenance of the facility and developing skills related to self-care. However,
research on the clubhouse model of mental health services is still needed. Although there
is some evidence that the clubhouse model reduces hospitalizations, increases
independent living skills, helps clients find jobs and improves feelings of self-efficacy
and self-esteem (Corrigan and Garman 1997; Mowbray et al. 2006), little is known about
which components of the clubhouse model drive these findings.
The clubhouse model is a highly specialized form of mental health services, and
clubhouse programs may be markedly different from traditional models of community
49
mental health care. The clubhouse model emphasizes support, self-sufficiency and
personal empowerment, and these values may not be as apparent within a traditional
community mental health context, and many users of traditional mental health services
may feel disenfranchised from participating in treatment decisions (Dickerson 1998).
Traditional mental health centers exist within a fragmented system of care and often lack
adequate funding and resources, which limits the mental health system from offering an
array of services that encourage a recovery-based approach to mental health care
(Mechanic and Rochefort 1990; Torrey 2008). Thus, the clubhouse model may not be
representative of mental health service utilizers in an outpatient, community setting.
Participation in a clubhouse model may also be dependent upon a number of
factors. For instance, Mowbray et al. (2006) reported that the majority of clubhouse
participants were male, white, and middle aged. Other factors, such as adherence to a
treatment program, the degree of psychiatric disability, presence of co-occurring
substance use issues, and/or financial resources, may also signal differences between the
population of mental health service clients who engage in clubhouse programs and those
in the general population of mental health service users.
This study broadens this research by assessing aspects of empowerment among
individuals with mental illness who vary in level of disability, who are engaged in
general community mental health services and are not necessarily affiliated with a
clubhouse or other empowerment-oriented program. Such research addresses a gap in
knowledge related to the construction of empowerment measures, but also to their
50
applicability among a sample of individuals engaged with a traditional model of mental
health services.
Research Questions
In this chapter, I have summarized theoretical approaches that may explain the
link between stigma and self-concept. I have also discussed stigma resistance responses
to stigma, including defensive strategies and empowerment. These mechanisms may be
used to explain how some stigmatized individuals eschew or overcome the effects of
negative labels that are applied. Further, I have provided a brief critique of the
construction of empowerment and have made suggestions for further research in this
area. In this section, I propose several research questions to examine these relationships.
This dissertation focuses on the relationship between stigma and self-concept
among individuals with mental illness, while also considering the role of stigma
resistance responses that individuals enact to ward off the potentially negative effect of
stigma. My primary conceptual relationship of interest is to better understand the effect of
stigma on self-concept, which I operationalize as two outcome measures- self-esteem and
mastery. Thus, I have research questions that focus on self-esteem as the primary
outcome, and questions related to mastery. I first discuss the research questions that focus
on self-esteem as the primary dependent variable of interest, and follow this with a
statement of the questions related to mastery.
Theoretical assertions and empirical findings suggest that stigma has a negative
impact on self-concept by reducing self-esteem. However, additional research is still
51
needed to document this theoretical claim. Given this, a primary research question for
this study is:
Research question 1: Does perceived, public stigma have a negative effect on
self-esteem?
Further, there is evidence that individuals engage in strategies to defend against
negative reactions of others to protect or preserve one‟s self-concept. If that is the case,
such strategies would have a moderating effect on the primary focal relationship between
stigma and self-concept. In other words, the effect of stigma on self-concept (e.g. selfesteem, mastery) would vary in relation to the presence or absence of stigma resistance
strategies. However, the evidence of the effectiveness of such strategies to lessen
negative effects of stigma on self-concept is limited (Link et al. 1991). Given this, I pose
several research questions to determine the moderating effect of resistance strategies on
the potential relationship between stigma and self-concept.
If individuals use defensive strategies, the effect of stigma on self-concept would
be different for those individuals than if defensive strategies are not used. Since defensive
strategies, which include strategies of hiding one‟s mental illness from others and
withdrawing from social interaction, may have a negative impact on self-concept, the use
of such strategies should exacerbate the harmful impact of stigma. Thus, a related
research question is as follows:
Research question 2: Do social withdrawal and secrecy moderate the potential
relationship between perceived stigma and self-esteem?
52
Empowerment may be another means of resisting stigma, although this theoretical
assumption has not been tested. Further, one of the research aims of this study is to
provide a critical assessment and more in-depth analysis of the concept of empowerment.
I have argued that commonly used conceptualizations of empowerment confound related
constructs within one measure. This is particularly problematic for this assessment of the
effects of stigma on measures of self-concept as the dependent variables of this analysis
are embedded within the measure of empowerment as it has been traditionally
conceptualized. This may mask the effect of other important aspects of empowerment
that may be indicators of stigma resistance strategies. Given these concerns, I examine
two factors related to the construct of empowerment, community activism and righteous
anger, as proactive and energetic empowerment orientations that may impact the link
between stigma and self-concept.
If empowerment is a positive or beneficial means of coping with stigma, then it
would be expected that dimensions of empowerment, community activism and righteous
anger, would have ameliorative effects on the relationship between stigma and selfconcept. In other words, the adoption of an empowerment orientation that focuses on
community activism and righteous anger by some individuals should mitigate negative
effects of stigma on self-concept. Thus, additional research questions are:
Research question 3: Does community activism moderate the relationship
between perceived stigma and self-esteem?
Research question 4: Does righteous anger moderate the relationship between
perceived stigma and self-esteem?
53
The research questions pertaining to self-esteem are depicted in Figure 2.1.
Figure 2.1. Conceptual Model: Self-esteem
In addition to using self-esteem as an outcome measure in this relationship, I
assess the effect of stigma on mastery because this concept incorporates an individual‟s
sense of personal power to overcome adversity. Below are the related research questions
that focus on mastery as the primary outcome measure. See also Figure 2.2.
Research question 5: Does perceived, public stigma have a negative effect on
mastery?
Research question 6: Do social withdrawal and secrecy moderate the potential
relationship between perceived stigma and mastery?
Research question 7: Does community activism moderate the relationship
between perceived stigma and mastery?
Research question 8: Does righteous anger moderate the relationship between
perceived stigma and mastery?
54
Figure 2.2. Conceptual Model: Mastery
The proposed analyses will examine the moderating effects of defensive
responses and empowerment measures on the relationship between stigma and selfconcept. Given the recent theoretical assumptions related to stigma resistance, it is
assumed that the use of such strategies would fundamentally alter the effect of stigma on
self-concept for those individuals who engage in defensive strategies or adopt an
empowerment approach. Specifically, empowerment approaches may lessen or
ameliorate negative effects of stigma on self-concept, while the use of defensive
strategies may exacerbate or worsen the effects of stigma. These relationships will be
assessed in the following chapters.
CHAPTER 3
DATA AND METHODOLOGY
In this chapter, I describe the data and sample used for this study. First, I begin
with an overview of the data collection process, and discuss how the sample was
generated and the characteristics of the sample. I then provide information about the
measures used within this analysis. I conclude by discussing the plan for analysis for
examining the research questions set forth in the previous chapter.
Data and Sampling
Data Source
The data used for this project are from a longitudinal study of individuals living
with mental illness who are engaged in community-based mental health services in an
urban area in Northeast Ohio (“The Quality of Life of People with Mental Illness”
Principal Investigators: Christian Ritter and Mark R. Munetz). This study sample is
comprised of over 200 individuals with a broad range of psychiatric diagnoses. Thus, this
study presents a more representative sample of individuals with mental illness, and will
allow for the examination of the extent to which the effect of stigma on self-concept may
differ for those who have been diagnosed with different mental disorders.
55
56
One of the original aims of the Quality of Life of People with Mental Illness study
(I will refer to this study as Quality of Life, in short) was to examine the consequences of
jail diversion programs on a population of individuals living with mental illness who had
had some contact with the criminal justice system. In general, there is a high level of
involvement of individuals with mental illness and the criminal justice system. A study
conducted by the National Alliance on Mental Illness found that 44 percent of individuals
with severe mental illness in their sample had been arrested or detained by police (Hall et
al. 2003). Further, approximately 10 percent of jail inmates have a mental disorder
(Treatment Advocacy Center 2009). This issue is the focus of a body of research beyond
the scope of this dissertation that examines how individuals may be diverted from the
criminal justice system and linked to the mental health system.
However, this aim did direct the recruitment processes for the Quality of Life
study which has implications for the present study. Specific jail diversion programs of
interest in the original Quality of Life study include Crisis Intervention Team (CIT)
training for law enforcement officers and Mental Health Court (MHC) specialty court
docket programs, and some individuals within the sample were recruited from these
sources.
The sample consists of individuals who had had encounters with the criminal
justice system, either through interaction with a CIT officer or via referral to or
participation in the MHC program, and a control group of individuals with mental illness
who had no involvement with the criminal justice system at the outset of the study.
Approximately 52 percent of the final sample for this present study became eligible to
57
participate in this study as a consequence of some degree of suspected criminal activity
that resulted in criminal justice involvement. The majority of these became known to the
research team via their eligibility for or participation in the MHC program (46 percent),
while a small percentage of the final sample (6 percent) had been referred to a
community mental health emergency center by CIT-trained law enforcement officers.
Still others who did not have contact with the criminal justice system (48 percent of the
final sample for this dissertation) were recruited by study personnel reaching out to
clients of a community-based mental health center (30 percent) and by reaching out to
those who were referred to the community mental health emergency center by a referral
source other than the police (18 percent). Thus, this sample is not a random sample of
individuals with mental illness, and the recruitment sources were a function of the
sampling parameters for the original Quality of Life study.
The Quality of Life study provides an opportunity to better understand
psychosocial processes of a sample of individuals with severe mental illness who are
engaged in community mental health treatment and who may or may not have had some
contact with the criminal justice system. While it is an important topic, criminal justice
involvement of individuals with mental illness is not a focal issue for this present study as
I am seeking to investigate how stigma associated with mental illness relates to selfconcept regardless of criminal justice involvement. I will, however, examine the potential
effect of prior contact with the criminal justice system on the research questions posed
previously (see “Appendix B: Supplemental Technical Data Analyses” for additional
detail).
58
Sample Recruitment and Data Collection Activities
All eligible and potential participants who were recruited for possible
participation in the Quality of Life study were contacted by members of the research team
who provided information about the study and assessed the level of interest in
participating. If potential participants were interested, trained members of the research
team followed-up to schedule an appointment for interview at a community mental health
treatment facility. The research team arranged for cab service if transportation to the
interview was needed. Interviewers met each participant and escorted them to a private
interview room to review the consent process and conduct the interviews. Each
interviewer was certified in human subjects research and trained in the medical
emergency and privacy protocols required by the mental health treatment agency. Each
interview itself lasted approximately 60 minutes.
Interviews were conducted with 370 individuals from September 2002 through
November 2005. 262 individuals participated in a follow-up interview approximately 6
months after the initial interview (February 2003 through March 2006). This resulted in a
71 percent retention rate between the first and second interviews. Participants were
compensated $20 for participating at Time 1, and $25 for participating at Time 2.
The Quality of Life interviews focused on multiple concepts to assess participant
well-being and quality of life. The interview included measures to assess perceived
stigma, self-concept (e.g. mastery, self-esteem), perceptions about mental illness, social
support and social networks, empowerment and use of services. This interview also
contained items to assess one‟s general life satisfaction and satisfaction across different
59
domains, including satisfaction with living situation, leisure activities, family, social
relations, finances, work (or school), safety, and physical health (Lehman 1997). The
measures relevant to this study are further described in the sections that follow.
In addition to conducting interviews, a team of clinical supervisors employed by
the research team reviewed medical charts of all participants in the study in order to
obtain all psychiatric diagnoses, including co-occurring substance use diagnoses. If there
was more than one diagnosis within the chart, the clinical supervisor then made a
determination about which diagnosis was the principal, or primary, diagnosis. Each
medical chart was reviewed by two clinical supervisors to determine inter-rater
reliability. Medical charts with discrepancies among reviewers were assessed by a
psychiatrist who made the final determination of the principal diagnosis. Even with this
careful check, there will still a number of study participants where no diagnosis was
available. Thus, while the sample of those who participated in the Time 2 survey
administration was 262, the final sample size for this study was reduced to 221 due to
cases that were missing on psychiatric diagnosis.
All study participants provided informed consent for all aspects of the study,
including the interview and medical chart review. The Institutional Review Boards (IRB)
of Kent State University and the Northeastern Ohio Universities College of Medicine
(NEOUCOM, now Northeast Ohio Medical University) approved this study (initial study
protocol numbers: 02-250 (KSU); 02-032 (NEOUCOM)). The original study protocol has
been approved as an exempt study by the IRB at Northeast Ohio Medical University
(protocol # 10-066). The IRB at Kent State University has approved the present study as
60
a project involving secondary data analysis (protocol #12-299). Please see Appendix C
for copies of the notices of IRB approval.
Sample Description
Demographic characteristics of this sample can be found in Table 3.1. The
average age of the sample is just over 40 years old. Thirty nine percent of the sample is
female. Half of the sample (50 percent) is white, 42 percent is African American, and 8
percent is of another race, primarily Hispanic. On average, the sample has completed
fewer than 12 years of education ( ̅ = 11.87, SD = 1.983), and the average monthly
income of the study participants is approximately $675, or $8,100 annually.
Given that this sample consists of individuals with mental illness, I included
several binary measures for psychiatric diagnoses. Over half of the sample have a
principal diagnosis of schizophrenia (51 percent), and 19 percent have a principal
diagnosis of depressive disorder. Seventeen percent of the sample have a diagnosis of
bipolar disorder, and 13 percent have a principal diagnosis of “other,” representing an
inclusive category of all other psychiatric diagnoses that may have been a principal
diagnosis, including anxiety disorders, substance use diagnoses, and post-traumatic stress
disorder, among others.
I include control measures that relate to various roles held by members of the
sample, particularly as role statuses may be of particular importance to the self-concept of
individuals (Camp et al. 2002; Simon 1997). As shown in Table 3.1, 22 percent of the
sample is employed either on a part-time or full-time basis. The majority of the study
61
participants are not married, with 55 percent never married, and an additional 37 percent
formerly married (either divorced or widowed). Only 8 percent of the sample is currently
married or partnered. Finally, 58 percent of the sample has children.
Table 3.1. Sample Characteristics: Means, Proportions, Standard Deviation and Alpha
Reliability (N = 221)
Variable
Mean
S.D.
Range
Demographic factors
Age
40.26
10.203
18 – 64
Gender (1=female)
.39
.489
0–1
White
.50
.501
0–1
African American
.42
.495
0–1
Other race
.08
.274
0–1
Education (years completed)
11.87
1.983
7 – 18
Income (monthly)
675.48 487.701
0 – 3200
Psychiatric diagnoses
Schizophrenia
.51
.501
0–1
Depressive disorders
.19
.393
0–1
Bipolar disorder
.17
.374
0–1
Other diagnoses
.13
.333
0–1
Role-based statuses
Employed
.22
.413
0–1
Never married
.55
.498
0–1
Formerly married
.37
.483
0–1
Currently married/cohabiting
.08
.274
0–1
Respondent has children
.58
.495
0–1
Measures
This section briefly describes the primary concepts of interest for this study,
including self-concept (dependent measures), perceived stigma (independent measure)
and potential moderating measures related to stigma resistance response items, as well as
demographic and control measures, including psychological functioning and social
resources. The conceptualization for these measures is further detailed in Table 3.2.
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Table 3.2. Correspondence of Theoretical Concepts, Research Concepts and
Empirical Indicators
Theoretical
concepts
Research concepts
Empirical indicator
Self-concept
Self-esteem
Self-Esteem Scale
Rosenberg (1965)
Mastery
Personal Control / Mastery Scale
(Pearlin and Schooler 1978)
Stigma
Perceptions of public
endorsement of negative
views towards people with
mental illness
Perceived Devaluation and
Discrimination Scale (Link 1987)
Stigma resistance
responses
Defensive coping
orientation/strategies
Social withdrawal
Secrecy
(scale adapted from Link et al. 1991
and Wright et al. 2000)
Empowerment
Righteous anger
Community activism
(scales adapted from Rogers et al.
1997)
Gender
Dichotomous measure (Female = 1)
Race
African American, white, other
Age
Age (coded in years)
Education
Number of years of education
Financial resources
Monthly income
Psychiatric diagnosis
Primary Axis I psychiatric diagnosis
at time of entry into study (per
medical chart)
[Primary categories: schizophrenia;
bipolar disorder; major depression;
other diagnoses (including substance
use disorders)]
Role-based statuses
Employment status (1=working)
Marital status
Parental status
Sample
characteristics
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Table 3.2 (continued). Correspondence of Theoretical Concepts, Research
Concepts and Empirical Indicators
Psychological
Stability of psychological
Depression (CES-D) at time 1
functioning
distress
Anxiety (SDS) at time 1
(functionality)
Participant‟s level of
Interviewer appraisal: Level of
comprehension
difficulty in comprehending
questions
Interviewer observation: significant
problem during the interview
Interviewer observation: significant
problem was comprehension
Interviewer observation: significant
problem was some other concern
Social resources
Social support
Frequency of contact with family
members (Lehman)
Frequency of contact with social
relations (Lehman)
Social embeddedness
Extensiveness of network (Fischer)
Number of social ties
Self-concept
Self-esteem. Self-esteem is assessed using Rosenberg‟s (1965) measure of selfesteem. This 10-item measure incorporates two dimensions of self-esteem based on the
respondent‟s positive (self-worth) and negative (self-deprecation) attitudes towards self
(per Wright et al. 2000). The positive self-esteem indicators include “I feel that I am a
person of worth, at least the equal of others,” “I feel that I have a number of good
qualities,” “I am able to do things as well as most other people,” “I take a positive
attitude toward myself,” and “On the whole, I am satisfied with myself.” The negative
self-esteem items include “At times I think I am no good at all,” “I feel I do not have
much to be proud of,” “I certainly feel useless at times,” “I wish I could have more
respect for myself,” and “All in all, I feel that I am a failure.” The self-esteem scale is
64
coded using a six-item Likert scale ranging from “strongly disagree” to “strongly agree,”
and items were coded such that higher scores indicate higher levels of positive selfesteem. The alpha reliability for this scale is .875.
Mastery. Mastery is measured by a seven item scale (Pearlin and Schooler 1978).
Items in this scale relate to the control one feels over his or her life, ability to solve
problems in one‟s life, feeling helpless, feeling pushed around, belief in control over
one‟s future and belief in one‟s ability to accomplish things. The response categories for
this scale range from “strongly disagree” to “strongly agree”. The range for this scale is
from 7, indicating low levels of mastery, to 42, indicating high levels of mastery. The
alpha reliability for mastery at Time 2 is .866.
Stigma
Devaluation/ discrimination is included as a measure of perceived, public stigma.
This is a 12-item scale (α = .875) assessing the extent to which an individual believes
most people will devalue or discriminate against a person with mental illness (Link
1987). Response categories are a Likert scale ranging from “strongly disagree” to
“strongly agree” for questions related to how “most people” view people with mental
illness. The range for this scale is from 12, indicating low levels of perceived devaluation
or discrimination, to 72, indicating high levels perceived devaluation or discrimination.
Sample items include “Most people feel that having a mental illness is a sign of personal
failure” and “Most employers will pass over the applications of a former mental patient in
65
favor of another applicant.” This measure is the primary independent measure as it is
conceptualized to have deleterious effects on the self-concept of individuals.
Stigma Resistance Responses
Defensive strategies. This study uses Wright et al.‟s (2000) measure of defensive
strategies. This is an 11-item scale to measure an individual‟s tendency to cope with
stigma by keeping their illness secret or withdrawing from potentially stigmatizing
situations. Respondents answered “yes” (1) or “no” (0) to a series of statements assessing
whether they would use particular defensive strategies, meaning those strategies that
would minimize possible stigmatization or discrimination through withdrawal or inaction,
in a variety of situations. Sample items are “When you meet people for the first time do
you ever tell them that you were once mentally ill?” and “Do you think it is a good idea
to keep your history of mental illness a secret?” This measure is adapted from Link and
colleagues (1991) and includes items related to withdrawal and secrecy coping responses
(See Appendix A for the individual items that are drawn from Link et al. (1991)). Items
are coded so that higher scores indicate greater use of defensive strategies of secrecy and
withdrawal (α = .614).
Empowerment. The Boston University Empowerment Scale incorporates 28-items
to assess overall personal empowerment. This measure was developed by Rogers et al.
(1997) based on input from a group of individuals with mental illness who were involved
in the self-help movement. The measure incorporates internally-oriented factors related to
self-esteem, self-efficacy and autonomy. However, other items within the scale indicate a
66
more external or socially-based orientation and focus on power and community activism.
Finally, there are attitudinal measures related to optimism and righteous anger.
For this dissertation, I specifically focus on two dimensions of empowerment
discussed by Rogers et al. (1997): community activism and righteous anger. These
dimensions represent active or energetic aspects of empowerment that are conceptually
distinct from self-esteem and mastery. Further, each of these concepts has been suggested
as either the antithesis of stigma or as an expected reaction to stigma that is perceived to
be unjust (Corrigan and Watson 2002).
The scale assessing community activism (α = .704) includes four measures such
as “people working together can have an effect on their community” and “working with
others in my community can help to change things for the better.” The measure of
righteous anger include three items: “Getting angry about something never helps,”
“People have no right to get angry just because they do not like something” and “making
waves never gets you anywhere” (reverse coded) (α = .687). Response categories for
items in both scales range from strongly disagree to strongly agree (6-point Likert scale).
The variables are coded such that higher scores indicate agreement, and negatively
worded items were reverse coded for consistency.
To arrive at these measures, I conducted analyses on the factor structure of the
full empowerment scale to disentangle the self-concept oriented measures from other
constructs. I examined the inter-item reliability and correlations among items after
removing the self-concept (self-esteem and mastery) measures from the full scale. To do
this, I conducted Principal Component Analysis (PCA), an exploratory factor analysis
67
data reduction technique, with Varimax rotation for the 28-items of the full
empowerment scale.
Given that my sample is of comparable size and make-up to Rogers et al.‟s (1997)
initial study sample (e.g. individuals with mental illness who are engaged in mental
health services), it could be expected that the factor structure would be similar. For these
preliminary analyses, all 28 items loaded onto one or more factors with a factor loading
of .40 or greater. Table 3.3 lists the 28-item factor analysis with the factor loading score.
Eigenvalues and the total variance explained are also shown for each factor. The data
sorted into seven factors. While there are similarities among the factor structure of my
data and that reported by Rogers et al. (1997), my results did not replicate an identical
factor structure. For comparison, Table 3.4 shows the factor structure reported by Rogers
et al. (1997).
As I have argued, a measure that incorporates self-concept items within the
construct of empowerment may be misleading and confounding, particularly within a
social psychological analysis of the impact of stigma on one‟s self-concept. As such, I
conducted additional exploratory factor analyses of the empowerment scale by removing
those items that are indicative of self-concept (self-esteem and mastery). To do this, I
removed all items that ask the respondent to think of their sense of self within the context
of the question. Many of these items are derived from Rotter‟s (1966) Locus of Control
scale (e.g. “When I make plans, I am almost certain to make them work”), Rosenberg‟s
(1965) self-esteem scale (“I have a positive attitude about myself”) and the Self-Efficacy
Scale (“I see myself as a capable person”) (Sherer and Adams1983).
68
69
70
By removing these self-oriented items in this exploratory way, I am able to
disentangle those items within the concept of empowerment that may confound our
understanding of any relationship between stigma and self-concept. Removing the selforiented items from the empowerment scale maps onto Rogers et al.‟s (1997) in that the
items from the Self-esteem/Self-efficacy (Factor 1) and the self-oriented items from the
Power/Powerless (Factor 2) factors are removed (see Table 3.4). This analysis of the
remaining 13 items yielded a 4-factor structure. Table 3.5 lists the 13-item factor analysis
and factor loading scores of these items.
Based on this factor analysis, I examined the items associated with each factor.
Items that loaded onto the first factor are those measures that relate to Rogers et al.‟s
(1997) factor of “community activism.” However, the items measuring autonomy did not
load onto the community activism factor as they did for Rogers et al. (1997), with the
exception of one item (“People should try to live their lives the way they want to”),
which had a factor loading of .41. Other items related to autonomy (e.g. “People have a
right to make their own decisions, even if they are bad ones”) did not load onto this
factor. This suggests that the measure of community activism represents one concept,
community activism, and not a blended concept of community activism and autonomy as
suggested by Rogers et al. (1997). Reliability analyses of these five items further suggests
that community activism and autonomy are separate constructs because the scale
reliability would be improved if the item assessing autonomy (“People should try to live
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Table 3.5. Principal Component Analysis Factor Loadings for Empowerment Scale, Not
Including Self-Concept Items (13 items)
Factor and Scale Item
Loading
Factor 1
Working with others in my community can help to change things for the
.82
better
People working together can have an effect on their community
.70
a
People have more power if they join together as a group
.67
Very often a problem can be solved by taking action
.65
People should try to live their lives the way they want to
.41
1
3
Factor 2
Making waves never gets you anywhere
Getting angry about something never helps
People have no right to get angry just because they don‟t like something
You can‟t fight city hall (authority)
.75
.73
.71
.61
Factor 3
Getting angry about something is often the first step toward changing it
People are only limited by what they think is possible
People have more power if they join together as a group a
.73
.70
.40
Factor 4
People have a right to make their own decisions, even if they are bad ones
Experts are in the best position to decide what people should do or learn
.79
.70
Eigenvalue = 2.47, variance explained = 19.0 percent; 2 Eigenvalue = 2.24, variance explained = 17.3 percent;
Eigenvalue = 1.29, variance explained = 10.0 percent; 4 Eigenvalue = 1.29, variance explained = 9.9 percent
their lives the way they want to”) is dropped from the scale (Cronbach‟s α is improved
from .668 to .704). Thus, reliability analyses of the four community activism items
support this assertion of construct validity, as these items have adequate internal
consistency.
The items that loaded onto the second factor are indicative of the “righteous
anger” construct described by Rogers et al. (1997). Four items had sufficient factor
loading scores to indicate adequate consistency among the items. When scaled,
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Cronbach‟s α was improved by dropping one item (“you cannot fight city hall
(authority)”). Removing this item increased the Cronbach‟s α score to .686.
The items that loaded onto the third factor are suggestive of perceptions about
one‟s ability to bring about change. However, these items also did not hold up to
reliability testing and could not be incorporated into one scale item. The items that loaded
on the fourth factor are indicative of measures of autonomy (per Rogers et al. (1997)).
Again, however, reliability analyses indicated that these items did not have adequate
internal consistency or validity.
These exploratory findings using PCA factor analysis suggest that there are two
aspects of empowerment, righteous anger and community activism, that are conceptually
different from other items included within the full empowerment measure. These two
measures are not significantly correlated with each other (r = -.085, p= .207), providing
further evidence that they represent two distinct dimensions of the concept of
empowerment that merit further analytical and theoretical consideration.
Psychological Functioning
As each member of the sample lived independently in the community at the time
of the interview, and was not in a psychiatric hospital, it is assumed that there is some
level of social and psychological functioning despite the presence of a severe mental
illness. I assess psychological functioning to control for any possible effect related to the
study participant‟s level of ability or capacity to engage with the research process. While
a measure of global psychological functioning, such as the Global Assessment of
73
Functioning or the Multnomah Community Ability Scale (MCAS) would have served to
assess the participant‟s degree of social and psychological functioning (Barker et al.
1994; Hall 1995), such measures were not available in the data. As such, I use several
proxy measures to assess the level of psychiatric functioning and the potential impact that
may have on the validity of the data collected.
First, I included the participant‟s level of anxiety and depression at the Time 1
survey administration. These measures provide an assessment of the stability of mental
well-being over time and are relevant to measures of self-concept. The measure for
anxiety is the Symptoms of Distress Scale, which is adapted from the Symptom
Checklist-90 (SCL-90) and the Brief Symptom Inventory (BSI) (Derogatis 1975; 1977).
The Symptoms of Distress Scale was developed by the Behavioral Health Services
Division and is part of the Mental Health Statistics Improvement Program (MHSIP)
(Ganju 1999). This scale consists of items which ask the respondent to report the extent
to which he or she was bothered by symptoms experienced within the past week. The
scale consists of 15 items, such as “feeling nervousness or shakiness inside,” “being
suddenly scared for no reason” and “feeling so restless you couldn‟t sit still.” Response
categories range from 1 (“not at all”) to 5 (“extremely”). Cronbach‟s α score = .930.
Depression was measured using the 20-item Center for the Epidemiologic
Studies-Depression (CES-D) scale (Radloff 1977). This measure asks respondents to
report how frequently within the past week he or she experienced a variety of feelings
and emotions, such as “felt depressed,” “felt lonely,” or “felt happy.” Several behavioral
items are included as well, such as “had restless sleep” or “had crying spells.” The
74
response categories for these items are 0 (“rarely or never”), 1 (“some or a little of the
time”), 2 (“a lot of the time”) and 3 (“most or all of the time”). Cronbach‟s α for this
scale is .933.
Second, as a means of assessing functionality, I also included some measures
provided by the interviewer about his or her perceptions of the respondent during the
course of the interview. These measures include the interviewer‟s assessment of the level
of difficulty of the participant in comprehending the questions, whether or not there was a
significant problem during the interview, and if so, if that problem was related to
comprehension or some other concern (e.g. a health issue that may have impacted the
progression of the interview). At the conclusion of the interview, the interviewer noted
the level of difficulty the respondent had in comprehending the questions. Response
categories are none, slight, a fair amount, and a lot (range 1 – 4). I also included a binary
measure indicating whether or not the interviewer perceived a significant problem during
the interview (1=yes). For those cases where a significant problem was reported, I
include two binary measures to determine if the problem was related to the respondent
comprehending the questions (1=yes), or if the problem was related to some other
concern that arose during the course of the interview (e.g. participant became physically
ill during the interview) (1=yes).
Social Resources
In order to better understand the possible relationships among the primary
measures of interest (stigma, self-concept and stigma resistance responses) it is necessary
75
to incorporate a more complete understanding of the array of social resources that one has
that may impact the relationship among my focal measures. Social networks and social
support are vital components of sociological research and refer to one‟s connectedness to
others in society (Barrera 1986; Turner and Marino 1994). Social networks are comprised
of those ties an individual may go to as a source of social support, and considers the
availability of ties to provide aid. Social support refers to aspects of support, either
received or perceived, from individuals in the network. Network theorists posit that it is
the number of ties, or the perceived level of availability of those ties, that is beneficial to
health and well-being, while a support perspective would argue that it is the strength of
those ties that is beneficial (Barrera 1986; Lin and Peek 1999; Smith and Christakis
2008).
In this study, I examine the social embeddedness and social networks aspects of
social support. Social embeddedness is a relevant construct for this analysis because it
represents the “flip side of social isolation” and relates to a psychological sense of
community (Barrera 1986: 415). There is a potential connection between social
embeddedness and adopting stigma resistance strategies. Lack of embeddedness, that is,
social isolation, may correlate with the use of defensive strategies, including social
withdrawal and secrecy, while social engagement may be linked to community activism.
I included several control measures to assess one‟s level of social engagement
and embeddedness. First, I include a measure of the frequency of contact with one’s
family members, including how often the respondent talks to family on the telephone and
how often the respondent gets together with family. Response categories ranged from 1
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(“not at all”) to 5 (“at least once a day”). Respondents who reported there were no family
members to contact were given a code of 1 to indicate no contact. These two items were
summed and were correlated (r= .312; p< .001).
I also included a measure to assess the frequency of contact with social relations.
This measure includes seven items assessing how frequently the respondent has contact
with other people who are not in his or her family. This item combines the frequency in
which the respondent does things with a close friend, visits with someone outside of the
respondent‟s home, calls someone (other than a relative), writes a letter to someone,
emails someone, does something that was planned ahead of time, and how often the
respondent spends time with someone who is considered a special or close friend.
Response categories ranged from 1 (“Not at all”) to 5 (“at least once a day”). These seven
items were summed, with an alpha reliability of .748.
I also included two measures to assess one‟s degree of social embeddedness. First,
I included a count of the number of social network ties the respondent named ( ̅ = 4.23,
SD = 2.66). Second, I included a measure of the extensiveness of one‟s social network
(Fischer 1982). This item is created by summing the total number of persons available in
one‟s social network who are available to the respondent, either to provide different types
of assistance or social support (e.g. “In the past six months, who has helped you with
household tasks?” Or “In the past six months, with whom have you discussed personal
worries?”) or by serving an important role to the respondent (e.g. “In the past six months,
who has been a partner?”). The measure is calculated by subtracting the number of areas
where there is no one to provide support from 9 (the total number of areas to be covered),
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and then combining this with the number of areas where the respondent has named
multiple persons who provide support. For each area where there is more than one
supporter named, a value of .5 is added. Thus, a measure is created that summarizes the
extent of availability of one‟s social network.
Sample Characteristics
All analyses included demographic variables as controls, including age, gender,
race, education, and income. Age is measured in years. Gender is coded as a dummy
variable with 1=female, 0=male. Race is coded into three dummy measures, with 1=white
(0=all other races), 1=black (0= all other races), and 1=other race (0=white and black).
The level of education is coded as the number of years of school completed. Income is a
self-report measure of one‟s monthly income in U.S. dollars. As this sample consists of
individuals with severe and persistent mental illness, I included the primary psychiatric
diagnosis. All clients of the community mental health agency have a primary Axis I
diagnosis, with the possibility that there are other co-occurring Axis I or II diagnoses.
Psychiatric diagnoses were collected by a team of clinical supervisors employed by the
research team as previously described. For this study, primary psychiatric diagnosis is
assessed by a series of dummy variables representing schizophrenia, depressive disorders,
bipolar disorder, and all other diagnoses.
I also included role-based statuses, including marital status, parental and
employment statuses. Marital status is coded as three dummy measures representing
1=never married (0=all other categories), formerly married (including divorced and
78
widowed) =1 (0=all other categories) and currently married or cohabitating=1, 0=all
other categories). Parental status is coded as a dummy variable to assess if the respondent
has any children (1=yes, 0=no). Employment status is a dummy variable to indicate
whether the respondent is employed, either full- or part-time, or not (1=yes, 0=no).
Analytic Strategy
Using this longitudinal survey data, I explore the primary, focal relationships
among stigma and self-concept by examining the effects of perceived devaluation/
discrimination on self-esteem, as well as its effect on mastery. Because of the
longitudinal nature of the data, I am able to control for Time 1 levels of self-esteem and
mastery. While I do not anticipate a change in each measure over a six month time
period, particularly since there was no intervention, including the Time 1 measure of each
dependent variable provides a stability measure and reduces potentially spurious
variability.
I use these two dependent measures because each represents a separate dimension
of self-concept, with self-esteem assessing general, positive and negative feelings
towards oneself, and mastery assessing feelings towards one‟s sense of efficacy, power
and control. I then examine the moderating effects of defensive strategies, community
activism and righteous anger on the relationships between stigma and self-concept as
such responses to stigma may impact the relationship between stigma and self-concept.
One goal of this study is to better understand the use of defensive strategies and
empowerment as stigma resistance responses. Defensive strategies relates to withdrawal
79
from social connections and hiding aspects of oneself from others. Empowerment in
general and the measures used for this study, community activism and righteous anger,
are conceptually related to feeling in control and eliciting change in one‟s environment.
Given this, it is conceivable that each stigma response may impact self-esteem and
mastery in different ways.
Further, I will use a variety of analytical approaches to test the research questions
outlined above. I will report descriptive statistics (e.g. mean, median, range) for all
measures for the sample, as well as correlations among all measures. I use factor analysis
and scale construction techniques to assess the reliability of the proposed measures. For
the multivariate analyses, I utilize ordinary least squares (OLS) regression and structural
equation modeling. All analyses are conducted using SPSS Version 19 and AMOS
Version 21.
It is possible that relationships beyond those suggested by the research questions
may persist. Such relationships will be assessed and modeled in post-hoc analyses if their
presence is detected, but these relationships are not predicted by the initial research
questions posed for this study. I organize the analyses presented in the next chapters by
focusing first on the research questions with self-esteem as the outcome measure, and
then with mastery as the dependent measure.
CHAPTER 4
RESULTS
In this chapter, I present the results of data analyses to address the central research
questions for this study. I review the descriptive statistics and correlations for the various
measures that I have included. I discuss results related to the Ordinary Least Squares
(OLS) regression analyses examining the relationships between stigma and self-esteem
and stigma and mastery. I also test for interactive effects of stigma resistance responses
on these potential relationships.
A Note on the Presentation of Results
I have organized the discussion of findings from the correlation and OLS
regression analyses into three sections: (1) Descriptive Statistics (beginning on page 81):
In this section, I present sample characteristics and describe correlations for the various
control, independent and dependent measures for this analysis.
(2) Initial Exploratory Analyses (beginning on page 90): In this section, I
discuss exploratory analyses among all control measures that theoretically may impact
the relationship between stigma and self-concept. The goal of these initial exploratory
analyses is to determine the demographic and control measures that are most closely
related to the key measures of interest in this study, which I then use in all subsequent
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81
analyses. However, given the number of measures under consideration, and the
correlation of these items, there are considerable threats of multicollinearity present
within these exploratory analyses. I address these concerns and correct for them in the
following section.
(3) Analysis of Research Questions (beginning on page 101): This section
contains the research analyses of the research questions outlined in Chapter 2.
Specifically, I examine the effect of public stigma on self-esteem and mastery, as well as
the possible moderating effect of defensive strategies, community activism and righteous
anger. I examine these relationships while holding constant the demographic and other
control measures that were significantly correlated with the key measures of interest.
It should also be noted that, given the exploratory nature of these analyses, I have relaxed
the probability threshold to include p-values of .10 to identify statistically weak yet
theoretically meaningful relationships.
Part 1. Descriptive Statistics
In addition to the sample‟s demographic characteristics described in Chapter 3
(See Table 3.1), I examined several other factors that may influence the theorized
relationships among my focal measures. Specifically, I included control measures to
assess psychological functionality and the participant‟s level of comprehension at the
time of the interview, as well as the social resources an individual has that may influence
the effect of stigma. Descriptive statistics for these items are presented in Table 4.1.
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For anxiety (Time 1), the average score on the Symptoms of Distress Scale was
32.99 (SD = 13.035), with a range of 15 – 75, a moderate score. The average score for
depression at Time 1, as measured by the CES-D, was 23.03 (SD = 13.031) with a range
of 0 – 60. This average is higher than the established threshold for depression among the
general population, which is a score of 16 (Radloff 1977). This indicates a high degree of
depressive symptoms at the first administration of the survey among this sample.
To assess the respondent‟s level of difficulty in comprehending the questions
asked, I included items based on the interviewer‟s observations immediately following
the interview. There was no reported difficulty in the respondent comprehending the
questions for 193 cases (87 percent). Further, there were no interviews that were rated
with a level of difficulty in comprehension as “a lot.” Twenty one (10 percent) interviews
were rated as “slight” difficulty, and seven (3 percent) were rated as a “fair amount” of
difficulty in comprehension. The presence of any significant problem occurring during
the interview was reported among 9 percent of interviews (n=20). Of these incidents,
comprehension was a significant problem for 12 cases, and some other concern (e.g.
participant was not feeling well) accounted for 15 cases (categories are not mutually
exclusive).
Table 4.1 further presents the descriptive data regarding the availability of social
resources. Respondents reported relatively frequent contact with family members, with a
mean of 7.18 (SD=2.023; range: 2 – 10). The mean score for frequency of contact with
social relations was 20.33 (SD=5.530; range: 7 – 35). With regards to the number of
social network ties, the majority of respondents (85 percent) named between 1 and 6
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persons who were available to assist them in a number of different areas ( ̅ = 4.23).
Three percent named “no one” and 12 percent named seven or more. The range for this
measure is 0 to 18. The mean score for Fischer‟s (1982) measure assessing extensiveness
of network is 8.03 (SD=1.250; range: 4.5 = 13), indicating a moderate level of depth
within one‟s social network.
I included the Time 1 measures for the two dependent variables for this studyself-esteem and mastery. It is important to adjust for the Time 1 measure of the dependent
variables because the Time 1 measure of each is the variable that would be most highly
correlated with the Time 2 measure. Including the Time 1 stability measures as controls
reduces extraneous variability from those relationships that may exist among Time 2
independent variables affecting the Time 2 dependent variable. In other words, the Time
1 stability measure is included to highlight actual variability that is occurring among the
independent and dependent measures net of the effect of the Time 1 measure, and reduces
or eliminates spurious variability that does not truly exist. The Time 1 measure of selfesteem had a mean score of 40.74 (SD=10.524). For Time 2, the mean score is 41.48
(SD=10.010). Thus, the mean score of self-esteem is relatively high and stable across
survey administrations. The mean of mastery at Time 1 is 28.74 (SD=6.648) and at Time
2 is 28.73 (SD=6.429), also suggesting a relatively high and stable score across time.
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Table 4.1. Descriptive Statistics for Control, Independent, Dependent and Intervening
Measures: Means, Proportions, Standard Deviation and Alpha Reliability (N = 221)
Variable
Mean
S.D.
Range
Alpha
Psychological functioning
Anxiety (T1)
32.99
13.035
15 – 75
.930
Depression (T1)
23.03
13.031
0 – 60
.933
Difficulty in comprehending Qs
1.16
.444
1–4
Interviewer observation: sig. problem
.09
.288
0–1
Comprehension is sig. problem
.05
.227
0–1
Other concern is sig. problem
.07
.252
0–1
Social resources
Frequency of contact (family) (T2)
7.18
2.023
2 – 10
.475
Frequency of contact (social) (T2)
20.33
5.530
7 – 35
.748
Number of network ties
4.23
2.662
0 – 18
Extensiveness of network
8.03
1.250
4.5 – 13
Focal measures
Self-esteem (T1)
40.74
10.524
10 – 60
.908
Self-esteem (T2)
41.48
10.010
10 – 60
.875
Mastery (T1)
28.74
6.648
7 – 42
.812
Mastery (T2)
28.73
6.429
7 – 42
.866
Devaluation/discrimination (T2)
46.98
10.258
12 – 72
.875
Defensive strategies (T2)
6.29
2.581
0 – 11
.614
19.24
2.678
4 – 24
.704
Empowerment: community activism
(T2)
9.45
3.275
3 – 18
.687
Empowerment: righteous anger (T2)
The primary independent measure for public stigma, perceived devaluation/
discrimination, had a mean score of 46.98 (SD=10.258). I included three measures to
assess stigma resistance responses among the sample. The measure of defensive
strategies has a mean score of 6.29 (SD=2.581), indicating that participants reported
engaging an average of just over six different defense strategies during interactions with
others. Community activism had a mean score of 19.24 (SD=2.678), and righteous anger
had a mean score of 9.45 (SD=3.275).
Table 4.2 presents Pearson‟s correlation coefficients (r) for the demographic and
psychological functioning measures with the primary independent (devaluation/
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discrimination) and dependent measures (self-esteem and mastery). No demographic
factors are significantly correlated with either self-esteem or mastery. However, being
female and years of education are both positively correlated with devaluation/
discrimination (r=.15, p<.05 and r=.12, p<.10, respectively). Having a diagnosis of
schizophrenia is positively correlated with self-esteem (r=.14, p<.05) and negatively
correlated with stigma (r= -.16, p<.05). A diagnosis of depressive disorders was
significantly and negatively correlated with self-esteem (r= -.21, p<.01). Having a
diagnosis of bipolar disorder or all other disorders did not correlate with self-esteem,
mastery or stigma.
These results suggest that those with a primary diagnosis of schizophrenia may be
better off compared to others, at least in that they experience higher levels of self-esteem.
Further, these results suggest that these individuals perceive less stigma than those with
other psychiatric diagnoses. With regards to the role-based status, I found that being
employed is significantly and positively correlated with self-esteem (r=.19, p<.01).
Further, being currently married or cohabitating is significantly and negatively correlated
with devaluation/ discrimination (r= -.11, p<.10). No role-based statuses correlated with
mastery.
Table 4.2 presents correlations between measures assessing comprehension or
other problems during the interview and stigma and measures of self-concept. The level
of difficulty in comprehending questions during the interview was negatively and
significantly correlated with mastery (r= -.15, p<.05) and with stigma (r= -.19, p<.01).
These results suggest that those participants who may have had some difficulty in
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comprehending the questions perceived lower levels of stigma, as well as lower levels of
mastery. It may be interpreted that, if an individual has difficulty in comprehension, he or
she may not be able to perceive subtle social cues related devaluation or discrimination.
If that is so, then any results that suggest an effect of stigma on self-concept may be
interpreted conservatively as the effect may not be present among individuals with
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comprehension difficulties. A significant problem during the interview was also
negatively correlated with devaluation/ discrimination (r= -.15, p<.05). Of those cases
where a problem existed, problems unrelated to comprehension also significantly
correlated with stigma (r= -.11, p<.10).
Two measures, anxiety at Time 1 and depression at Time 1, were significantly
and highly correlated with self-esteem, mastery and stigma. Anxiety was negatively
correlated with self-esteem at Time 2 (r= -.55, p<.001) and mastery at Time 2 (r= -.39,
p<.001), and positively correlated with stigma (r=.20, p<.01). Depression at Time 1 was
negatively correlated with self-esteem and mastery (r= -.63, p<.001 and r= -.44, p<.01,
respectively) and positively correlated with stigma (r=.28, p<.01).
Table 4.3 presents the Pearson correlation coefficients for the primary focal
measures of this analysis. Self-esteem is positively correlated with mastery (r=.72,
p<.001). Self-esteem is also significantly and negatively correlated with the primary
independent measure, devaluation/ discrimination (r= -.31, p<.001), as is mastery (r= .22, p<.001). These correlations suggest inverse relations between stigma and self-esteem
and stigma and mastery where higher scores of stigma associate with reduced levels of
self-esteem and mastery. While these correlations are significant and are in the
theoretically-predicted direction, note that the strength of these associations is moderate,
and is similar to others‟ studies examining stigma and self-esteem and self-efficacy
(Hayward et al. 2002, Kleim et al. 2008, Link et al. 2008, Vauth et al. 2007). Thoits
(2011) suggested that such modest correlations “indicate that some individuals who
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perceive high levels of societal rejection nevertheless have high self-worth while others
who see little societal rejection have low self-regard anyway” (p. 9).
The measures of stigma resistance are also significantly correlated with the
measure of stigma and with self-concept. Defensive strategies is negatively correlated
with self-esteem (r= -.39, p<.001) and with mastery (r= -.34, p<.001). It is positively
correlated with devaluation/ discrimination (r=.30, p<.001), such that higher scores of
perceived stigma correlate with increased use of defensive strategies. Community
activism is positively correlated with self-esteem (r=.37, p<.001) and with mastery
(r=.34, p<.001); however, it is not significantly correlated with stigma. Righteous anger is
negatively correlated with self-esteem (r= -.12, p<.10), suggesting that increases in
righteous anger correlate with decreases in self-esteem. The direction of this relationship
is counter to what would be expected if righteous anger is an empowering response to
perceived justice. Righteous anger is not significantly correlated with mastery. There is a
significant positive correlation between righteous anger and devaluation/ discrimination
(r=.22, p<.001), suggesting that as perceived stigma increases, so does one‟s sense of
righteous anger.
Bivariate correlations among all measures, including demographic, psychological
functioning, social support, self-concept, stigma and stigma resistance response measures
are presented in Appendix D (“Bivariate Correlation Matrix of Dependent, Independent
and Control Measures”).
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Table 4.3. Correlations of Dependent and Focal Measuresa (N=221)
1
2
3
4
1. Self-esteem
1
2. Mastery
.72***
1
a
+
3. Devaluation/discrimination
-.31***
-.22*** 1
4. Defensive strategies
5. Community activism
6. Righteous anger
-.39***
.37***
-.12+
-.34*** .30***
.34*** -.11
-.06
.22***
1
-.16*
-.07
5
1
-.09
6
1
All measures are Time 2 administration
p<.10; *p <.05; **p<.01; ***p<.001
Note that there are 34 measures proposed to be examined in the analyses that
follow. This presents a problem as there are potentially more measures than the analyses
can support given the sample size (N=221). A general rule of thumb is to have 10
observations per parameter estimated in order to reasonably detect size-effects with
confidence (Harrell 2001). Given this rule, an appropriate number of independent
variables for the multivariate analysis would be about 22. To address this issue, I
removed several items that assess psychological functioning. Specifically, I removed
those items that were not significantly correlated with the primary independent measure
(devaluation/ discrimination) and the two dependent measures, self-esteem and mastery
(see Table 4.2).
The items that were removed are: if the interviewer noted a significant problem
during the interview, and if so, whether or not it was related to comprehension or if it was
related to some other concern. These items were not significantly correlated with
devaluation/ discrimination, self-esteem or mastery. The items removed are significantly
correlated with one another and with the measure I kept to assess the respondent‟s level
of difficulty in comprehending the questions asked. Pearson‟s bivariate correlation
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coefficient between the level of difficulty in comprehending questions and whether there
was a significant problem is .44 (p<.001), and is .41 (p<.001) and .27 (p<.001) with the
measures assessing if the significant problem is due to comprehension or due to some
other concern, respectively. The total number of items remaining is still potentially
problematic, and further data reduction may be necessary to avoid this concern. The
results of the initial OLS regression analyses with all remaining measures are discussed
in the following section.
Part 2. Initial Exploratory Analyses
In this section, I present the full analysis with all theoretically predicted control
measures. It should be noted that these analyses are exploratory because of the potential
problem of having more covariates than can be supported based on the sample size and
because of possible issues of multicollinearity. However, these analyses will inform the
main analysis presented in Part 3 below by highlighting the key predictor variables that
may relate to the primary research questions of this study.
Multivariate Analyses: Self-esteem
I conducted ordinary least squared (OLS) regression analyses of self-esteem
regressed on the demographic, control and independent measures. The results of these
analyses are presented in Table 4.4. Model 1 of Table 4.4 shows the demographic
measures, psychological functioning and control measures of social resources regressed
on self-esteem. In this analysis, the only demographic measure that has a statistically
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significant effect on self-esteem is being African American (b=2.092, p<.10), indicating
that African Americans in this sample report higher scores on self-esteem compared to all
other races. The only measure of psychological functioning that relates to self-esteem and
the measure with the strongest association overall is the level of Depression at Time 1
(b= -.383, p<.001, β= -.499). This significant, negative association is interpreted such that
higher scores of depression at Time 1 associate with lower scores on self-esteem at Time
2. Two measures of social resources, frequency of contact with friends and the number of
network ties, were positively associated with self-esteem (b=.192, p<.10; b=.542, p<.10).
Table 4.4, Model 2 added the measure for self-esteem at Time 1, which has a
significant and positive relationship with self-esteem at Time 2 (b=.614, p<.001),
suggesting that this measure is relatively stable over time. Not surprisingly, self-esteem at
Time 1 is the strongest predictor of self-esteem at Time 2, as noted by the change in the
amount of variance explained (R2) from Model 1 to 2. The adjusted R2 for Model 1 is
.410, and for Model 2 is .545, which represents the largest increase in variance explained
across all models of Table 4.4. Recall also that self-esteem at Time 1 is highly correlated
with depression at Time 1 (r= -.79, p<.001), as well as with anxiety at Time 1 (r= -.73,
p<.001). These high correlations, as well as a VIF greater than 4.0 and tolerance scores
less than .20 signals possible issues of multicollinearity (O‟Brien 2007). In this model,
the VIF for the depression item is 5.372, and for anxiety the VIF score is 4.244
(tolerance=.186 and .236 for depression and anxiety, respectively).
Model 3 (Table 4.4) included the primary independent measure, devaluation/
discrimination. This item had a weak negative effect on self-esteem (b= -.095, p<.10) net
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of all control factors, psychological functioning, social resources and self-esteem at Time
1. The effect of the stigma resistance response items may be seen in Models 4-6.
Defensive strategies (Model 4) has a strong negative effect on self-esteem (b= -1.172,
p<.001), and the effect of devaluation/ discrimination is reduced to non-significance (b= .037). Community activism (Model 5) has a strong, positive effect on self-esteem
(b=.801, p<.001), suggesting that an activism approach is beneficial to self-esteem. This
item does not affect the relationship between devaluation/ discrimination and self-esteem,
suggest that community activism has a strong and independent effect on self-esteem.
Righteous anger is added to the analysis in Model 6. This item had a negative
effect on self-esteem (b= -.313, p<.05) and the effect of devaluation/ discrimination on
self-esteem is reduced to non-significance. In the final model (Model 7), the primary
measures that are associated with self-esteem included defensive strategies (b= -1.150,
p<.001), community activism (b=.723, p<.001) and righteous anger (b= -.333, p<.05).
The measure of stigma, perceived devaluation/ discrimination, is not significantly related
to self-esteem, suggesting that the effect of this measure on self-esteem may be
understood in relation to stigma resistance response measures.
Multivariate Analyses: Mastery
I also regressed mastery on demographics, role statuses, psychological
functioning, social resources, perceived devaluation/ discrimination, defensive strategies,
community activism and righteous anger (see Table 4.5). The results of these analyses are
presented below. Table 4.5, Model 1 presents the results of the OLS regression of
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mastery on demographic factors, role based statuses, psychological functioning measures
and social resources. There are no demographic or role-based measures that are
significantly related to mastery. The measure of the level of difficulty in the respondent
answering questions is significantly and negatively associated with mastery (b= -1.774,
p<.10). Anxiety at Time 1 and depression at Time 1 are both negatively associated with
mastery (b= -.108, p<.10 and b= -.127, p<.05, respectively). Several social resources
measures are significantly associated with mastery in Model 1. Frequency of social
contact is positively associated with mastery (b=.202, p<.05), as is number of network
ties (b=.517, p<.05). Extensiveness of social network is negatively associated with
mastery (b= -.970, p<.05).
Table 4.5, Model 2 includes the Time 1 measure for mastery, which has a
significant and positive relationship with mastery at Time 2 (b=.448, p<.001). This
suggests that this measure is stable over time. Mastery at Time 1 is a strong predictor of
mastery at Time 2, as evidenced by the change in variance explained across models 1 and
2 of Table 4.5. The adjusted R2 for model 1 is .235, and for model 2 is .353. Net of the
effect of mastery at Time 1, only the social resources measures remain significantly
associated with mastery (Time 2). However, the VIF= 4.730 for depression and VIF =
4.158 for anxiety, indicative of multicollinearity.
Perceived devaluation/ discrimination is entered into the regression in Model 3 of
Table 4.5. This item has a weak negative relationship with mastery (b= -.069, p<.10), net
of all control measures, psychological functioning and social resource measures and
mastery at Time 1. The effect of the stigma resistance response items may be seen in
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Models 4-6. The use of defensive strategies (Model 4) is negatively related to mastery
(b= -.688, p<.01), and the effect of perceived devaluation/ discrimination is reduced to
non-significance (b= -.033). Community activism (Model 5) has a significant and
positive association with mastery (b=.494, p<.001). The effect of perceived devaluation/
discrimination is reduced slightly from Model 2 (b= -.069) to Model 5 (b= -.063) but
remains significantly associated with mastery (p<.10), suggesting that the effect of
community activism on mastery is independent of stigma. Righteous anger (Model 6) is
not significantly related to mastery.
Table 4.5, Model 7 presents mastery regressed on all measures. Income is
significantly related to mastery (b=.002, p<.05), as is frequency of social contact (b=.142,
p<.05) and extensiveness of network (b= -.064, p<.10). Mastery at Time 1 remains as the
strongest predictor of mastery at Time 2 (β=.360). The weak but significant relationship
of perceived devaluation/ discrimination was diminished to non-significance as the
stigma resistance response measures were included in the model. Defensive strategies has
a persistent, negative effect on mastery (b= -.670, p<.01), while community activism has
a positive effect on mastery (b=.466, p<.001).
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Addressing Threats to Multivariate Analyses
Multicollinearity. While the findings presented above are intriguing, they must be
interpreted with caution. The results presented in Tables 4.4 and 4.5 illustrate a problem
of multicollinearity, meaning that two or more of the predictor measures included within
the analyses are too highly correlated with one another (Lewis-Beck 1980). While a goal
of social research is to increase explanatory power by incorporating as many social
factors theorized to relate to the focal measures as possible, this may become a problem if
these measures are too closely related to one another (e.g. multicollinearity) or if they
reduce the statistical power of the analysis. A review the results of the correlations
analysis (Tables 4.2-4.3 and Appendix D), as well as the results of the OLS regression
presented in Tables 4.4 and 4.5, identify the sources of multicollinearity and suggest
some feasible ways to move forward with the multivariate analyses and reduce the
likelihood that multicollinearity will impact the analyses.
To address this issue, I identified the measures that were causing the problem of
multicollinearity due to their high correlation. These items are the baseline measures for
depression and anxiety at Time 1. These items were included in the analysis because they
represent the respondent‟s level of psychological well-being upon entry into the study,
and provide a measure of stability of the individual‟s well-being for the second wave of
data. However, these measures are very highly correlated with each other (r = .85,
p<.001) and with the measure of self-esteem at Time 1 (r = -.79, p<.001 (depression), r =
-.73, p<.001 (anxiety)). When both depression and anxiety are included in the regression
equation, signs of multicollinearity (e.g. VIF > 4.0; tolerance < .20) emerge as self-
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esteem at Time 1 is entered (see Table 4.4, Model 2) and as mastery at Time 1 is entered
(Table 4.5, Model 2) as previously discussed.
Given the necessity to include self-esteem and mastery at Time 1 as stability
measures for the Time 2 dependent variables, it is not a feasible solution to remove these
items. Further, it is of theoretical importance to include a baseline measure of
psychological well-being. Thus, to reduce the threat of multicollinearity, I removed the
anxiety (Time 1) measure, and only used depression at Time 1 to represent psychological
distress. I chose to keep depression as it had a stronger independent effect on both selfesteem and mastery than did anxiety at Time 1. Therefore, depression at Time 1 is
included in additional multivariate regression analyses discussed in Part 3 of this chapter.
Number of covariates. A second concern that must be addressed is the need to
maintain an appropriate number of covariates given the size of this sample. Thus, I limit
my measures to approximately 22, or roughly one measure for 10 cases within my sample
(Harrell 2001). This is achieved by two approaches to data reduction. First, I removed
those dichotomous control measures that were never significantly associated with either
of the dependent measures (self-esteem or mastery) or my primary independent measure,
perceived devaluation/ discrimination. I removed the measure for parental status as it was
not significantly associated with stigma or self-concept. Further, as Thoits (1991)
suggested, role occupation, in this case, being a parent, is less impactful on one‟s sense of
self if this role is not salient, or of central importance, to the individual. In other words,
the status of being a parent does not necessarily mean that that status is enacted or salient
to one‟s sense of self.
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Second, I removed multiple dichotomous measures that had been included to
represent a particular concept. For instance, I reduced the categories associated with race,
marital status and psychiatric diagnosis by removing all but one dichotomous measure.
Thus, I included one measure for race (1=African American, 0=all other races), marital
status (1=currently married or cohabiting, 0=never or formerly married), and psychiatric
diagnosis (1=schizophrenia, 0=all other diagnoses).
The data reduction steps reduced the number of measures included within each set
of regression analyses to 20, thus preserving the degrees of freedom needed based on the
sample size. The results of the OLS regression analysis with these measures removed are
presented below.
Part 3. Analysis of Research Questions
In the sections that follow, I present the results of the primary analyses of this
study. The OLS regression analyses have been corrected to reduce the threat of
multicollinearity and have a reduced number of covariates. First, I present the results of
the OLS regression analyses of self-esteem regressed on the demographic and control
measures, stigma, and stigma resistance responses. I also examine possible moderating
relationships among these measures. Then, I present the analyses of my second dependent
variable of focus, mastery, regressed on the demographic and control measures, stigma,
and stigma resistance responses, and the possible intervening relationships between
stigma, stigma resistance responses and mastery.
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Self-esteem Regression Results
Table 4.6 presents the analyses for the OLS regression of self-esteem regressed on
select demographic, role-based, psychological functioning and social resources measures,
as well as the primary independent (perceived devaluation/ discrimination) and
moderating measures (stigma resistance responses) of interest to this study. Model 1
shows that the measure of depression at Time 1 is negatively related to self-esteem at
Time 2 (b= -.471, p<.001). Further, frequency of social contact (b=.207, p<.05) is
positively associated with self-esteem, suggesting that increased frequency of contact
with non-family members improves self-esteem. No other demographic factors are
significantly related to self-esteem. Self-esteem at Time 1 has a statistically strong and
positive relationship with self-esteem at Time 2 (b=.603, p<.001, β=.636) (See Model 2).
Table 4.6, Model 3 indicates that, net of the demographic and control measures
and self-esteem at Time 1, perceived devaluation/ discrimination has a negative
relationship with self-esteem (b= -.087, p<.10). This relationship suggests that as
perceived levels of devaluation/ discrimination increase, self-esteem is decreased, thus
providing limited support for my first research question. However, this relationship is
weak. The amount of variance explained by devaluation/ discrimination may be seen by
comparing the adjusted R2 values for Model 3 with those in Models 1 and 2. The total
amount of variance explained for control measures and devaluation/ discrimination
(Model 3) is .558. This is an increase in variance explained of .146 over Model 1
(controls only), but only an increase of .004 once the self-esteem stability measure is
included (Model 2). I will examine this effect while relaxing the requirement for
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including the Time 1 stability measure in Appendix B (“Supplemental Technical Data
Analyses”). However, it is important to note that, overall, stigma is associated with selfesteem, but this relationship is very weak. This finding provides empirical support that
stigma may not be as detrimental to self-esteem as theoretically conceptualized.
The independent effects of three stigma resistance response measures, defensive
strategies, community activism and righteous anger, are included within the regression
analyses (see Table 4.6, Models 4-6). Defensive strategies has a significant and negative
effect on self-esteem (Model 4: b= -1.186, p<.001), signaling that increased reliance on
stigma-response strategies such as secrecy and withdrawal results in lowered levels of
self-esteem. Further, the relationship between perceived devaluation/ discrimination and
self-esteem is reduced to non-significance (b= -.087, p<.10 (Model 3); b=-.030, a 66
percent reduction in the unstandardized coefficient), indicating that the use of defensive
strategies may mediate this relationship.
Community activism is significantly and positively related to self-esteem (Model
5: b= .775, p<.001). This relationship suggests that endorsing an empowerment approach
that focuses on the values of community activism improves self-esteem. This relationship
is quite strong (β=.208) and is independent to the relationship found between stigma and
self-esteem. In other words, the weak, negative effect of perceived devaluation/
discrimination and self-esteem remains marginally significant and is not affected by
community activism. There is a 7 percent reduction in the unstandardized coefficient for
devaluation/ discrimination once community activism is entered into the model (b= -.087
(Model 3); b= -.081 (Model 5).
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Righteous anger is negatively related to self-esteem (Model 6: b= -.287, p<.05),
suggesting that increased feelings of righteous anger result in lower levels of self-esteem.
The relationship between perceived devaluation/ discrimination is reduced to nonsignificance, signaling the possibility that righteous anger may partially explain that
original relationship. The unstandardized coefficient for devaluation/ discrimination is
reduced by 17 percent when righteous anger is included in the model (b= -.087 (Model
3); b= -.072 (Model 6)).
Model 7 of Table 4.6 presents the results of the full regression equation. The
amount of variance explained (adjusted R2) in this model is .632. No demographic, rolebased statuses or psychological functioning measures are related to self-esteem.
Depression at Time 1 is significantly related to self-esteem (b= -.090, p<.10). Frequency
of family contact is significantly related to self-esteem (b=.447, p<.05), such that
increased frequency of contact results in higher levels of self-esteem. Self-esteem at Time
1 remains a strong predictor of self-esteem at Time 2 (b=.517, p<.001, β=.545). However,
net of this relationship, the stigma resistance response measures each have a significant
effect on self-esteem. Defensive strategies has a detrimental effect on self-esteem (b= 1.177, p<.001), as does righteous anger (b= -.318, p<.05) while community activism has
a positive or beneficial effect on self-esteem (b=.701, p<.001). The relationship between
perceived devaluation/ discrimination and self-esteem was reduced to non-significance.
Potential interactive effects will be further tested below.
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Testing for moderation. I tested for interactive effects of the stigma resistance
response measures with stigma on self-esteem. For this analysis, I am testing to see if the
relationship between perceived devaluation/ discrimination and self-esteem can be
explained by the influence of stigma resistance response measures, specifically defensive
strategies (relates to my second research question), and community activism and
righteous anger (per my third and fourth research question, respectively). These results
are presented in Table 4.7.
Model 1 of Table 4.7 includes all demographic, role-based statuses, psychological
functioning measures, social resources, self-esteem at Time 1, and all primary
independent measures for stigma and stigma resistance responses. I computed an
interaction term between perceived devaluation/ discrimination and defensive strategies. I
centered this interaction term to the grand mean in order to reduce the threat of
multicollinearity. Net of all control measures, this interaction term does not have a
statistically significant effect on self-esteem (b= -.032, p=.140). This suggests that the
effect of stigma on self-esteem does not vary as a function of defensive strategies. Thus,
my second research question is not supported.
I computed similar mean-centered interaction measures between perceived
devaluation/ discrimination and the two empowerment measures, community activism
and righteous anger. Table 4.7, Model 2 shows the results of the analysis examining
perceived devaluation/ discrimination and community activism. There is no statistically
significant interaction effect of this item on self-esteem (b=.003, p=.828) and my third
research question is not supported. The lack of significance is not surprising given that
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the effect of community activism on self-esteem appeared to be independent of perceived
devaluation/ discrimination as previously discussed (see Table 4.6, Model 5).
Table 4.7, Model 3 includes the interaction term for perceived devaluation/
discrimination and righteous anger. Again, there is no statistically significant effect of
this term on self-esteem (b= -.013, p=.235), suggesting that the effect of stigma on selfesteem does not vary across level of righteous anger. Thus, my fourth research question is
not supported. Taken together, these results suggest that stigma does not have a
differential effect on self-esteem as a function of defensive strategies, community
activism or righteous anger.
Mastery Regression Results
Table 4.8 presents the results of the OLS regression of mastery on control
measures, stigma and stigma resistance response measures. Model 1 includes all
demographic, role-based status measures, psychological functioning items, and social
resources. There are no significant effects of demographic characteristics or role-based
statuses on mastery. With regards to psychological functioning, I found that difficulty in
comprehending the questions did significantly and negatively impact mastery (b= -1.583,
p<.10), such that greater difficulty in comprehension results in reduced levels of mastery.
In addition, higher scores on the measure of depression at Time 1 corresponded to
reduced scores on mastery at Time 2 (b= -.221, p<.001). With regards to social resources,
frequency of social contact and number of network ties are positively related to mastery,
such that more frequent contact results in greater levels of mastery (b=.192, p<.05), as
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does a larger number of social ties (b=.414, p<.05). Extensiveness of one‟s social
network has a negative impact on mastery (b= -.827, p<.05), suggesting that a larger
social network may reduce levels of mastery.
When controlling for mastery at Time 1 (Model 2), the majority of the
relationships presented in Model 1 remain significant. Net of these effects, mastery at
Time 1 has a strong effect on mastery at Time 2 (b=.459, p<.001), providing evidence for
the stability of this measure over time. The proportional increase in variance explained by
adding in the stability measure of mastery at Time 1 is .125, as calculated by the
difference in adjusted R2 from Model 2 (.361) to Model 1 (.236).
Perceived devaluation/ discrimination was included in the analyses to assess the
effect of devaluation/ discrimination on mastery, with the results presented in Model 3
(Table 4.8). I found that, net of all other control measures and the Time 1 stability for
mastery, perceived devaluation/ discrimination has a weak but negative effect on
mastery, such that increases in perceived stigma have a harmful effect on mastery (b= .068, p<.10), providing limited support for my fifth research question.
Models 4-6 (Table 4.8) reports the direct effects of stigma resistance response
items on mastery. In Model 4, net of the effect of all other measures, I found that
defensive strategies has a negative effect on mastery, such that increased use of secrecy
and withdrawal responses results in lower levels of mastery (b= -.679, p<.01). Further,
the significant, direct effect of stigma on mastery is reduced to non-significance (b= .034, p=.384, a reduction in the unstandardized coefficient of 50 percent).
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Model 5 includes the measure of community activism. Here, I found a strong,
positive effect of community activism on mastery (b=.493, p<.001), suggesting that
higher endorsement of an empowerment orientation towards community activism relates
to improved levels of mastery. This effect remained independent of the relationship
between perceived devaluation/ discrimination and mastery, as evidenced by the
significant devaluation/ discrimination coefficient (b= -.062, p<.10). There was only a
slight reduction in the unstandardized coefficient of devaluation/ discrimination once
community activism was included in the model (9 percent). The measure of righteous
anger (Model 6) is not significantly related to mastery (b= -.098, p=.390).
Model 7 includes all measures regressed on mastery at Time 2. The proportion of
variance explained in mastery by all measures is .424. Devaluation/ discrimination does
not have a significant effect. The item that is most strongly related to mastery at Time 2 is
mastery at Time 1 (b=.363, p<.001, β=.375). Net of this relationship, defensive strategies
has a persistent and negative effect on mastery (b= -.669, p<.01), and community
activism has a persistent and positive effect on mastery (b=.466, p<.01). Righteous anger
is not significantly related to mastery. These findings suggest that defensive stigma
resistance responses are detrimental to one‟s self concept as measured by mastery, while
adopting an orientation towards community activism may improve one‟s sense of
mastery.
Table 4.9, Models 1-3 present the results of analyses aimed at examining the
interactive effects of stigma and defensive strategies, as well as the interactive effects of
stigma and the two measures of empowerment, community activism and righteous anger.
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In Model 1, mastery is regressed on the mean-centered interactive term that was
computed for devaluation/ discrimination and defensive strategies. This interaction term
does not have a significant effect on mastery (b=.003, p=.848), and my sixth research
question is not supported. Model 2 includes the interaction term for devaluation/
discrimination and community activism, which is also not significantly associated with
mastery (b= -.010, p=.359), lending no support for my seventh research question.
Model 3 includes the interaction variable for devaluation/ discrimination and
righteous anger. There is no significant interactive effect of righteous anger and stigma
on mastery (b= -.001, p=.920) and my eighth research question is not supported. These
findings suggest that the modest effect of devaluation/ discrimination on mastery is not
explained by interactive effects of stigma resistance response items on stigma. In other
words, the impact of stigma on mastery is not due to variation in the use of stigma
resistance response measures of defensive strategies, community activism or righteous
anger.
Summary
The analyses presented in this chapter were designed to assess the research
questions stated previously in Chapter 2. The results of this analysis as they relate to the
research questions are summarized in Table 4.10. In general, when accounting for the
Time 1 stability measure of self-concept, I found that my measure of stigma, perceived
devaluation/ discrimination, has a negative, albeit weak, effect on self-concept, thus
providing limited support that stigma does have a detrimental effect on self-concept as
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anticipated. This relationship exists between perceived devaluation/ discrimination and
self-esteem and with mastery. These findings suggest that perceived devaluation from
others has a harmful effect on self-concept by reducing self-esteem and lowering
mastery. These findings are consistent with the empirical results of others that suggest
that stigma has a harmful effect on self-concept. However, the strength of this effect is
quite modest, suggesting that the effects of stigma on self-concept may not be as
detrimental as might be predicted theoretically.
Table 4.10. Summary of Research Questions and Evidence of Empirical Support
Research question
Results
Not supported
1 Stigma will have a negative effect on self-esteem
2 The negative relationship between stigma and self-esteem will be
moderated by the use of defensive strategies
Not supported
3 The negative relationship between stigma and self-esteem will be
moderated by an empowerment orientation focused on community
activism
Not supported
4 The negative relationship between stigma and self-esteem will be
moderated by an empowerment orientation focused on righteous anger
Not supported
5 Stigma will have a negative effect on mastery
Not supported
6 The negative relationship between stigma and mastery will be moderated
by the use of defensive strategies
Not supported
7 The negative relationship between stigma and mastery will be moderated
by an empowerment orientation focused on community activism
Not supported
8 The negative relationship between stigma and mastery will be moderated
by an empowerment orientation focused on righteous anger
Not supported
Further, research would suggest that the association between stigma and selfconcept may be modest in strength because certain individuals enact various response
mechanisms to ward off the deleterious effect of stigma on self-concept. This assertion is
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the focus of my analysis of the moderating effects of stigma resistance responses on the
relationship between stigma and self-concept. I did not find empirical support indicate
that the relationships between devaluation/ discrimination and self-esteem or mastery are
due to differential effects of defensive strategies. I also found no support for moderating
effects of community activism or righteous anger on the relationship between
devaluation/ discrimination and self-esteem or between devaluation/ discrimination and
mastery. The implications of these findings will be discussed in Chapter 6. Supplemental
post-hoc analyses are included in the next chapter to further explore and illuminate the
results presented there.
CHAPTER 5
SUPPLEMENTAL ANALYSES AND RESULTS
The goal of the previous chapter was to address the primary research questions for
this analysis by examining the effect of public, perceived stigma on self-concept. In this
chapter, I conduct supplemental post-hoc analyses to further substantiate and explicate
the nature of the relationships among the measures of interest to this study. These
analyses are supplemental in that there are no direct research questions as there were for
analyses presented in the previous chapter. However, evidence emerged in the analyses
presented in Chapter 4 that would suggest that such post-hoc analyses are merited.
Specifically, I examine the emergent evidence of the existence of mediating relationships
among stigma, stigma resistance response measures and self-concept.
Post-hoc Analyses of Mediating Relationships
In Chapter 4, I tested interactive effects for three stigma resistance responses,
defensive strategies, community activism and righteous anger, on the effect of stigma and
self-concept. While there is theoretical support for examining the presence of
interactions, I found no empirical evidence for moderating relationships as predicted.
However, evidence of potential indirect effects of stigma, stigma resistance measures,
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and self-concept emerged within these analyses. While this is beyond the scope of the
research questions posed for this dissertation, I briefly explore the presence of these
indirect relationships as post-hoc analyses below.
Drawing from labeling theories, it is conceivable that mediating relationships may
exist between stigma, stigma responses, and self-concept. Mediating relationships suggest
that the influence of one measure, stigma in this study, influences the outcome measure
(self-esteem and mastery) through its effect on a third, intervening variable. For this
analysis, the stigma response items, defensive strategies, community activism and
righteous anger, are conceptualized as the intervening measures. Thus, for mediating
relationships, it would be predicted that the presence of perceived stigma would result in
the use of defensive strategies. Since the use of defensive strategies is detrimental to selfconcept, stigma would have a negative effect on self-concept because of its effect on the
use of defensive strategies. Also, given the evidence presented in Chapter 4 that righteous
anger has a negative impact on self-concept, at least on self-esteem, it could be expected
that the effect of stigma on self-esteem is mediated by righteous anger, meaning that
stigma has a negative impact on self-esteem because of its effect on righteous anger.
Mediating relationships for the empowerment measure, community activism, may
explain how stigma has a negative, but only modest impact on self-concept. If the
adaptation of an empowerment approach that incorporates community activism is
positively associated with self-concept, a mediating relationship would suggest that the
stigma affects self-concept only through community activism. It could be expected that
stigma would have a negative effect on community activism, which would in turn exert a
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positive influence on self-concept. Thus, the beneficial effects of community activism
would have beneficial impact on self-concept because it would dampen the harmful effect
of stigma.
There are four criteria that must be met for mediation to be present (Baron and
Kenny 1986). First, a direct causal relationship must be established between the two focal
measures of interest (X1Y). Second, there must be a direct relationship between the
predicted intervening measure and the dependent variable (X2Y). Third, there must be
a causal relationship between the two independent measures (X1 X2), and fourth, the
direct effect between the primary focal measures (X1Y) must be reduced to nonsignificance when the mediator is included in the model. In this way, the effect of the
primary independent measure on the dependent measure operates through the third,
intervening measure.
In order to test this process within my analyses, all other potentially intervening
measures must be included as controls. As such, I conducted OLS regression analyses
which included multiple stigma response measures within each model to see if the
presence of the other measures would affect the strength of the relationship on the
dependent measures.
Table 5.1 includes the analyses of self-esteem regressed on controls, devaluationdiscrimination, and the stigma response measures, each entered into the model two at a
time. Model 1 shows that defensive strategies has a negative impact on self-esteem (b= 1.102, p<.001), even while controlling for community activism. Likewise, community
activism also has a significant, positive effect on self-esteem when controlling for
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defensive strategies (b=.728, p<.001). Thus, both potentially intervening measures impact
self-esteem net of the effect of the other measure.
A similar pattern is visible in Table 5.1, Model 2 which shows the effects of
defensive strategies and righteous anger. Again, defensive strategies has a strong,
negative impact on self-esteem (b= -1.267, p<.001) while controlling for righteous anger.
Righteous anger also has a negative effect on self-esteem (b= -.358, p<.05), but this
effect is not as strong. Table 5.1, Model 3 includes community activism and righteous
anger, where community activism has a strong, positive impact on self-esteem (b= .757,
p<.001). Righteous anger had a negative impact on self-esteem, even when controlling
for community activism, yet this effect is quite weak (b= -.249, p<.10). These findings
indicate that each potentially mediating variable has an impact on self-esteem, even with
the presence of other stigma response measures. Thus, one of the criteria for mediation is
fulfilled in that the predicted intervening measures impact the primary dependent
variable. Further, the relationship between devaluation/ discrimination and self-esteem
becomes non-significant when the stigma response measures are included (see Table 5.1,
Models 1-3), which is another criterion for mediation.
Table 5.2 shows the results of the OLS regression analysis of mastery on controls,
devaluation/ discrimination, and the stigma response measures entered into the model two
at a time. Model 1 shows that defensive strategies has a negative impact on mastery (b= .646, p<.01), even as community activism is included in the model. Community activism
has a positive effect on mastery (b= .477, p<.001), net of the effect of defensive strategies
on mastery. Table 5.2, Model 2 includes defensive strategies and righteous anger. In this
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model, only defensive strategies has a significant effect on mastery (b=-.706, p<.01).
Model 3 includes community activism and righteous anger, and here, only community
activism has an effect on mastery (b= .487, p<.001). These results suggest that two of
three potentially intervening measures, defensive strategies and community activism,
impact mastery, even when both are included within the regression model. This is further
evidence that these potential intervening measures impact mastery. The effect of
devaluation/ discrimination on mastery is also reduced to non-significance. Additional
analyses conducted below will test additional criteria for mediation.
The previous analyses have demonstrated that the conditions for mediation are
present. First, the analyses presented in Chapter 4 demonstrated that devaluation/
discrimination has a significant, negative effect on self-esteem and on mastery. Second,
the preceding analyses showed that possible intervening measures, defensive strategies,
community activism, and righteous anger, were each significantly associated with selfesteem, and defensive strategies and community activism were associated with mastery.
Third, when each of the potential intervening measures is included within the analyses,
the significant associations between devaluation/ discrimination and self-esteem and with
mastery are reduced to non-significance.
A final criterion for mediation is to demonstrate that the primary dependent
measure, devaluation/ discrimination, is significantly related to each of the intervening
measures. Table 5.3 shows the OLS regression analyses of the three stigma response
measures regressed on all control measures, the Time 1 stability measure for each
dependent measure (defensive strategies, community activism and righteous anger,
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respectively), other stigma response measures, and devaluation/ discrimination. In Model
1, devaluation/ discrimination is positively related to defensive strategies (b= .037,
p<.001), even while controlling for defensive strategies at Time 1, community activism
and righteous anger. These findings provide evidence for a mediating relationship
between stigma and self-esteem through the use of defensive strategies. They also
indicate that the use of defensive strategies mediates the relationship between stigma and
mastery. In other words, perceived stigma results in the use of defensive strategies, which
in turn reduces self-esteem and mastery.
Table 5.3 also shows the effect of devaluation/ discrimination on the two
empowerment measures. First, Model 2 shows community activism regressed on control
measures, community activism at Time 1, defensive strategies and righteous anger. The
effect of devaluation/ discrimination on community activism is not significant. There is
no evidence that community activism mediates the relationship between stigma and selfesteem or stigma and mastery. The effects of devaluation/ discrimination on self-esteem
and on mastery are independent of the effect of community activism on self-esteem.
Table 5.3, Model 3 shows the effect of devaluation/ discrimination regressed on
righteous anger, net of all control measures, righteous anger at Time 1, and other stigma
response measures. Again, the effect of devaluation/ discrimination on righteous anger is
not significant once all control measures and stigma response measures are included
within the analyses. Thus, the relationship between righteous anger and self-esteem as
discussed in Chapter 4 (Table 4.6) is independent of devaluation/ discrimination. As I
have discussed, there was no relationship between righteous anger and mastery (see
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Table 4.8). Righteous anger does not mediate the relationship between stigma and selfesteem, and it is not related to mastery.
Structural Equation Model Findings
The OLS regression results show that an indirect effect between devaluation/
discrimination and self-esteem and between devaluation/ discrimination and mastery
through the use of defensive strategies. That is, perceived public stigma increases the use
of defensive strategies, which in turn, lowers self-esteem and mastery. I further tested
these indirect findings between stigma, defensive strategies and self-concept by using
structural equation modeling. Testing my previous OLS regression results using
structural equation modeling adds the benefits of simultaneously estimating predicted
relationships among multiple independent, intervening and dependent measures. Further,
structural equation modeling provides information on how well a given theoretical model
fits the patterns of relationships found in the data while taking into account all measures.
Evaluating structural model fit. Before I present the results of the structural
equation modeling analysis, I discuss the measures of fit I used to evaluate the structural
models. First, I assessed the fit of the model with the chi-square statistic test. This tests
the null hypothesis that the data perfectly fit the model being estimated. If the chi-square
test is non-significant, then it can be assumed that the data fits the structural model. If the
chi-square test is significant, it indicates that the relationships found in the data differ
significantly from the null hypotheses of perfect fit, and that the model should be rejected
or modified.
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Second, I use several measures of fit that compare the model being estimated to
the independence model (Garson 2012). I report the adjusted goodness of fit (AGFI)
index in which a score above .95 is considered to be a good model fit. I also report the
normed fit index (NFI delta), which indicates the proportion of improvement of an
estimated model over the null model (Garson 2012). For the NFI, a score of 1 indicates a
perfect model fit, and scores must be above .95 to be considered a good fit for the data. I
also report Bentler‟s comparative fit index (CFI), which reports the proportion of
covariation in the data that can be reproduced in the model. This index ranges from 0 – 1,
and scores higher than .90 are considered a good fit.
A third measure of fit used to assess the structural relationship is the root mean
square of error of approximation (RMSEA). The RMSEA corrects for model complexity.
The RMSEA score should be below .05 to be considered a good fit for the data
(Schumacker and Lomax 1996).
Structural equation model findings. I began the structural equation model analysis
by examining the primary theoretical model of interest which examines the indirect effect
of devaluation/ discrimination on self-esteem and mastery through defensive strategies. I
included the Time 1 measures of each concept as stabilities. The initial model did not fit
the data (χ2= 315.216, df= 19, p=.000; AGFI= .516; NFI= .637; CFI=.648; RSMEA=
.266), but did provide insight into the nature of the relationships. Based on this initial
model, I added direct pathways between the self-esteem (Time 1) measure and
devaluation/ discrimination (Time 2), as well as a pathway between mastery (Time 1) and
defensive strategies (Time 2). The Time 1 measure of self-esteem was significantly
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correlated with the Time 1 measures of mastery, devaluation/ discrimination and
defensive strategies. The Time 1 measure of mastery was also correlated with defensive
strategies (Time 1), and defensive strategies (Time 1) was correlated with devaluation/
discrimination at Time 1. Given this, I included correlations for these measures. The
revised structural model fit the data well (χ2= 15.938, df= 11, p=.143; AGFI= .943; NFI=
.982; CFI=.994; RSMEA= .045). This model is depicted in Figure 5.1 (significant
covariance among independent measures are not drawn but can be seen in Table 5.4).
Figure 5.1. Standardized Estimates for Stigma, Defensive Strategies and
Self-concept
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Table 5.4. Unstandardized and Standardized Estimate for Stigma, Defensive Strategies and
Self-concept (N=221)
b
Key theoretical pathways
devaluation/ discrimination (T2)  defensive strategies (T2)
defensive strategies (T2)  self-esteem (T2)
defensive strategies (T2)  mastery (T2)
Stability pathways
devaluation/ discrimination (T1)  devaluation/ discrimination
(T2)
defensive strategies (T1)  defensive strategies (T2)
self-esteem (T1)  self-esteem (T2)
mastery (T1)  mastery (T2)
mastery (T1)  self-esteem (T2)
self-esteem (T1)  mastery (T2)
Suggested pathways
self-esteem (T1)  devaluation/ discrimination (T2)
mastery (T1)  defensive strategies (T2)
Covariancesb
self-esteem (T2)  mastery (T2)
self-esteem (T1)  mastery (T1)
devaluation/ discrimination (T1)  self-esteem (T1)
defensive strategies (T1)  self-esteem (T1)
defensive strategies (T1)  mastery (T1)
devaluation/ discrimination (T1)  defensive strategies (T1)
a
.026
-1.130
-.620
(SE)
β
(.010) .157
(.266) -.194
(.209) -.164
.684
(.044)
.714
.269
.560
.399
.209
.114
(.044)
(.057)
(.069)
(.088)
(.045)
.377
.582
.415
.141
.183
-.098
-.046
17.236
45.708
-21.487
-8.264
-3.505
8.234
(.046) -.099
(.015) -.182
r
(2.422) .547
(5.446) .673
(5.602) -.198
(1.672) -.341
(1.028) -.223
(1.739) .328
Unstandardized coefficients are reported. Standard errors in parentheses.
b
Correlation coefficient is reported (r)
Bolded coefficients are statistically significant at .05 or better
As shown in Figure 5.1 , when accounting for variation in each of the measures
from Time 1 to Time 2, there is a significant, positive relationship between devaluation/
discrimination and defensive strategies (b=.026, p<.001). Further, there is a negative
relationship between defensive strategies and self-esteem (b= -1.130, p<.001) and
between defensive strategies and mastery (b= -.620, p<. 01). The standardized indirect
effect between devaluation/ discrimination and self-esteem is -.030, and the standardized
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indirect effect between devaluation/ discrimination and mastery is -.026. While these
effects are small, they do confirm the presence of indirect effects between stigma and
self-concept.
I also assessed the fit of a structural model that included the demographic and
control measures related to psychological functionality and social resources along with
the theoretical model shown in Figure 5.1. As a preliminary step for this analysis, I
estimated a model in which all control measures were “free to float,” that is, there were
not structural paths drawn between the control measures and the predictor or dependent
measures. Based on this preliminary model, I found that three control variables (female,
working, and difficulty understanding interview questions) were significantly related to
two measures in the theoretical model. Female and working were positively related to
defensive strategies, while difficulty with comprehension during the interview was
negatively associated with devaluation/ discrimination. The remaining control measures
were significantly correlated with one another, but there were no other suggested paths
between these measures and stigma, defensive strategies, or self-concept.
Given this, I estimated a structural model which contained the control measures
that were predictive of devaluation/ discrimination and defensive strategies (female,
working, and difficulty with comprehension), while dropping the other control variables
from the model. I also included the Time 1 stability measures for each of the primary
theoretical measures of interest (devaluation/ discrimination, defensive strategies, selfesteem and mastery). This model fit the data reasonably well (χ2= 41.168, df= 28,
p=.052; AGFI= .925; NFI= .956; CFI=.985; RSMEA= .046). However, this model did
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not improve upon the fit of the main theoretical model presented in Figure 5.1. That is,
including control measures did not enhance understanding of the relationships, and in
fact, reduced the ability of the model to reflect actual patterns in the data.
As a final examination of the presence of indirect effects between stigma,
defensive strategies and self-concept, I estimated a model assessing direct effects of
stigma on self-concept. I wanted to see if the direct effects model fit the data better than
the indirect effects model which included defensive strategies. For this model, I estimate
direct pathways between devaluation/ discrimination and self-esteem and between
devaluation/ discrimination and mastery. I included the Time 1 stability measures for
each of these variables. This structural model did not fit the data (χ2= 11.701, df= 4,
p=.020; AGFI= .910; NFI= .984; CFI=.989; RSMEA= .094). This finding suggests that
indirect effects are present, and that direct effects of stigma on self-concept are not
present when examining these measures longitudinally. Previous regression analyses
presented earlier had indicated only a modest relationship between devaluation/
discrimination and self-esteem and mastery, and these findings support that earlier
assertion.
In sum, these post-hoc analyses show an indirect effect of perceived stigma and
self-esteem and on mastery such that devaluation/ discrimination results in increased use
of defensive strategies, which in turn affects self-concept by lowering self-esteem and
mastery. The structural equation findings support the OLS regression results. There is no
evidence that empowerment measures act as mediators in the relationship between stigma
and self-concept. However, it is interesting to note that community activism does have a
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positive effect on self-concept, independent of perceived stigma. The implications of
these results will be further discussed in the following chapter.
CHAPTER 6
DISCUSSION AND CONCLUSIONS
This dissertation examined the effect of perceived, public stigma on the selfconcept of individuals with severe mental illness, with specific attention paid to the types
of stigma resistance responses that individuals use. I examined two types of responses to
stigma: defensive strategies and empowerment. Defensive strategies were included
because they represent reactions that individuals use in order to hide their condition or
shield themselves from being confronted with stigma. This strategy may exacerbate the
harmful effects of stigma on self-concept. The empowerment measures used assessed
one‟s orientation towards community activism and righteous anger. Based on the
empowerment literature, it would be predicted that these measures would mitigate the
harmful effects of stigma because those who have such orientations may be in a better
position to respond proactively to stigma by joining as a collective to fight against
stigmatization that is perceived to be unjust. In this chapter, I review the key findings and
discuss the theoretical and empirical contributions of this study. I also discuss the study‟s
limitations and areas for future research directions.
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Key Findings
The Effect of Stigma on Self-Concept
I found limited support of the negative effect that perceived stigma has on selfconcept. While I did find some evidence that stigma is negatively associated with both
self-esteem and mastery, these associations were only of modest strength. In the crosssectional analyses at the Time 2 survey administration, I found that stigma had a negative
effect on self-esteem (p<.01) (see Appendix B). However, when controlling for selfesteem at Time 1, this significant effect is reduced to non-significance (p<.10). For
mastery, the cross-sectional analysis suggested a weak association between stigma and
mastery (p<.10). Once controlling for the Time 1 measure of mastery, the strength of this
association remained relatively unchanged (b= -.068, p<.10 with mastery at Time 1; and
b= -.074, p<.10 without mastery at Time 1 as a control measure). These findings suggest
that stigma may not have as strong of a negative impact on self-concept as may be
predicted by labeling theories, or that individuals have multiple means of reducing the
harmful impact of stigma.
Stigma Resistance: Defensive Strategies
The use of defensive strategies had a strong and negative impact on self-esteem,
suggesting that secrecy about one‟s illness and withdrawing from others because of one‟s
mental illness is damaging to the way that one feels about oneself. This is true also for the
relationship between defensive strategies and mastery, meaning that the use of defensive
strategies reduces one‟s feelings of personal power and control. I predicted that the use of
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defensive strategies would moderate the relationship between stigma and self-concept,
such that the use of defensive strategies would exacerbate or worsen the harmful effects
of stigma. This prediction was not supported by the data. However, stigma did have an
indirect effect on self-concept through defensive strategies. Supplemental analyses
supported this assertion, and it may be concluded that the effect of stigma on both selfesteem and mastery is explained by the use of defensive strategies. In other words,
perceived stigma increases the use of defensive strategies, which in turn, decreases both
self-esteem and mastery. This finding suggests that individuals have experienced or
perceived the threat of stigma and have adopted the use of defensive strategies in
response. This process has detrimental effects on one‟s self-feelings.
Stigma Resistance: Empowerment
I also examined two measures of empowerment as possible moderators of the
relationship between stigma and self-concept. Specifically, I examined two concepts
discussed in the stigma resistance literature as antithetical to stigma: community activism
and righteous anger. It was predicted that these measures of empowerment would buffer
against the harmful effects of stigma. I found that community activism has a strong,
positive effect on both self-esteem and mastery, and that these effects are independent of
stigma. That is, regardless of the level of perceived stigma, an orientation towards
community activism increases both self-esteem and mastery. Given this independent
effect of community activism on self-concept, it is not surprising that I did not find
support that community activism moderates the relationship between stigma and self-
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concept. However, these analyses reflect the importance of examining community
activism as an important factor that improves self-concept. Treatment programs that
foster community activism may also have a beneficial effect on the self-concept of
individuals who are involved.
I also examined righteous anger as an empowerment orientation that was
predicted to ward of the negative effects of stigma. Righteous anger has a weak, negative
effect on self-esteem, meaning that the presence of righteous anger decreased feelings of
self-worth. Righteous anger was not related to mastery. Further, I had predicted that
righteous anger would reduce the harmful effects of stigma on self-concept, but this did
not occur. Righteous anger was positively correlated with stigma, meaning that increases
in perceived stigma correlated with increased righteous anger. However, righteous anger
had a negative impact of self-esteem, rather than a positive one, and no effect on mastery.
Others who have examined the righteous anger subcomponent of the
Empowerment Scale have also found that it has a negative effect on self-esteem (Yamada
and Suzuki 2007). However, these findings are counter to what may be predicted within
the empowerment literature, where righteous anger is believed to incite individual and
collective action to produce social change. Anger in response to stigma is damaging to
self-concept unless the individual has the capacity to channel the anger in a way that
successfully reduces the negative experience of stigma. That is, without a good outlet for
the anger or if positive effects are not achieved, righteous anger does not empower
individuals, and instead may have detrimental effects. If empowerment is a measure that
incorporates one‟s ability to control and influence one‟s surroundings, righteous anger
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may not be consistent with this definition if one is unable or does not have the resources
or power to use righteous anger to achieve influence over the situation. These results
raise additional questions about the concept of righteous anger in the stigma resistance
process. Additional analyses are needed to address these issues.
Theoretical and Empirical Contributions of Study
This study contributes to a literature that examines the impact of public stigma on
self-concept. By examining public stigma, I was able to assess the perceptions of stigma
that stem from the generalized other, and the extent to which such stigma impacts
individuals‟ self-concept. This research is separate from investigations of self-stigma,
which assume that stigma has had a detrimental effect on self-concept, and examines the
main effect relationship between perceived stigma and two dimensions of self-conceptself-esteem and mastery. My results support others‟ findings that stigma does not have as
unequivocal of a negative effect on self-concept once baseline measures of self-concept
are included.
This research contributes to sociological literature by applying an assessment of
conceptualizations of empowerment, specifically those theoretically predicted to relate to
stigma and stigma resistance. I examined two measures of empowerment, an orientation
towards community activism and righteous anger, as empowering responses to stigma.
My results suggest that community activism has a strong and positive impact on both
self-esteem and mastery. However, this relationship occurs regardless of the level of
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stigma that is perceived. This finding suggests that endorsing positive attitudes towards
community activism may increase self-esteem and mastery.
Limitations and Future Research Directions
This study has several methodological limitations. First, the study sample was not
randomly drawn, and so findings reported here may not be representative of the general
patterns found within the total population of individuals with mental illness. This study
examined a population of individuals with mental illness who are engaged in a traditional
model of community-based care. Compared to studies that use convenience samples of
individuals involved in specialized clubhouse programs, this study expands our
knowledge of the relationships between stigma, self-concept and stigma resistance among
a broader population of individuals with mental illness. While the sampling and
recruitment methods used to attain this sample did not significantly alter the findings (see
Appendix C), additional research is needed to examine these relationships among other
samples of individuals with mental illness.
Individuals in this sample have been diagnosed with a severe, chronic mental
illness, primarily schizophrenia, bipolar disorder and major depressive disorder. In order
for studies to be representative of a broader population of individuals with mental illness,
research must examine the impact of stigma on self-concept across a variety of mental
illness conditions. Further, researchers should consider varying degrees or levels of
severity of the mental illness condition.
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It is also important to assess possible effects based on the length of time the
individual has been diagnosed or involved in mental health services. This study did
control for age, which did not relate to the effect of stigma on self-concept, but additional
research is needed to clarify possible differences based on lived experience with the
stigmatized illness. A life-course perspective that examines the experience of illnessrelated stigma by age cohort or by tenure in the mental health system will provide
information on the degree to which stigma impacts individual self-concept, and if so, if
the effect varies throughout the life course.
A second limitation of this study is present within the measures related to stigma
resistance. The questions for the measure of defensive strategies were worded in ways
that specifically refer to one‟s mental illness (e.g. “Do you think it is a good idea to keep
your history of mental illness a secret?”). Thus, this measure assesses defensive strategies
related to mental illness. In contrast, the empowerment measures are not specific to one‟s
status as a person with mental illness. While the scale items were assembled with input
from individuals with mental illness, the wording of the items is more general. That is,
when measuring community activism and righteous anger, the measures used in this
study do not refer to community activism related to one‟s status as a person with mental
illness. Righteous anger is written in general terms, and not necessarily related to anger
stemming from one‟s status as a person with mental illness. This limitation may relate to
the non-significant association between stigma and measures or empowerment, and
future research is needed to assure that the operationalization of these concepts is
appropriate for a study examining the stigma of mental illness.
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Finally, the measures of empowerment are measures assessing one‟s attitudes
about or orientation towards community activism and righteous anger. That is, the
measures assess one‟s beliefs that individuals can form together to achieve larger goals,
or beliefs about people‟s rights to get angry and that such anger can elicit change.
However, these measures are not specific to behaviors that the individual has enacted.
Whereas the measure of defensive strategies captures specific behaviors that the
individual has done to hide one‟s condition or withdraw from interaction, the measures
used to assess empowerment are attitudinal only. While this is not problematic in itself,
future research analyses would benefit by having multiple indicators that assess both
attitudes or orientations and specific behaviors of individuals.
Future Research Directions
Labeling and stigma have been a central aspect of historical and contemporary
theoretical and empirical work on physical and mental illness. Such research continues to
examine the complex process by which labeling impacts self and identity development of
individuals who are labeled, and the consequences of such labeling. The purpose of this
study was to contribute to an expansive literature on stigma, labeling and self by
assessing defensive and proactive stigma resistance responses, including empowerment,
to explain differences in the impact of stigma on self-concept for individuals with mental
illness. The findings presented in this study suggest that additional research is needed to
fully understand how individuals experience stigma within everyday lives. In this section,
142
I describe some potential avenues of future research into the relationships between
stigma, self and identity, and stigma resistance.
Illness identity and stigma. Future research should continue to focus on the impact
of stigma on self-concept in the formation of identities around mental illness. As
discussed previously, there are two main assumptions with regards to how stigma may
affect self-concept (Camp et al. 2002; Link et al. 1989). First, it is assumed that all
individuals share a common representation of mental illness that is negative or devalued,
and that this representation is learned through socialization. Second, it is assumed that,
when diagnosed, the status of mental illness becomes central to one‟s identity.
However, these two assumptions do not allow for variability in responses to the
label of mental illness. While a general, negative depiction of mental illness is prevalent
in society, there is a varying degree to which individuals accept these negative portrayals
as self-descriptive. Further, there are varying representations of what it means to have a
mental illness that individuals may adopt. For instance, if a person with mental illness is
involved in an advocacy group and teaches others about the condition, raises money to
support treatment and research, or advocates for policy changes, such as mental health
care parity, then that individual may have a different understanding of what it means to
be a person with mental illness. In this instance, an identity may develop based on one‟s
illness condition, but that identity may not necessarily encompass the negative
perceptions about mental illness held by generalized others.
There is also evidence that mental illness does not necessarily become a central
component of identity for many individuals. One possible explanation for this is the
143
personal control that individuals have to redefine the situation and to construct one‟s
identity based on interpreted meanings (Thoits 2006). There are some individuals who
react to stigma by accepting negative attitudes about mental illness and applying them to
oneself as discussed.
However, others may reduce the importance of the mental illness as a core part of
one‟s identity. Thoits (2011) suggested that individuals may deflect the effects of stigma
by cognitively reducing the salience of the sick or ill identity within an individual‟s
saliency hierarchy. These individuals would not define self as sick, but rather, would
have a self-concept consistent with other role-identities where mental patient is not
considered to be a self-descriptive category. These individuals may have other, more
salient roles that register as self-descriptive, and the status of having a mental illness may
be one of many lesser roles.
Still others may incorporate the mental illness role within one‟s identity, yet draw
strength and power from the stigmatized status. The individual identifies with the group,
draws social support and shared understanding of the illness experience from others who
are also stigmatized. This creates an identity around an illness status, in which other
similar members share experiences, understanding and support. This approach has been
effective for other stigmatized groups, including sexual and racial minorities (Crocker
and Major 1989; Meyer 2003). Status in a minority or stigmatized group increases group
solidarity, cohesion and in-group identity, all which benefit well-being (Meyer 2003).
Affiliation with similar stigmatized others provides a social environment in which people
144
are not stigmatized and it provides support when confronted with negative evaluations
from others (Jones et al. 1984).
Finally, future research in the area of illness and identity should consider insight
into one‟s illness condition. For an illness condition to have an effect on one‟s identity,
the individual must acknowledge that a label or diagnosis is potentially applicable to the
self (Thoits 2011). Insight involves recognizing that others may apply that label to him
or herself. The individual must also have stereotype awareness, that is, knowledge of
culture meanings attached to the label (Corrigan et al. 2006). As such, researchers
examining identity work or the use of stigma resistance strategies need to control for the
amount of insight that the illness condition is present and that it carries a specific label or
diagnosis that could be applied to the self.
Developing an empowered self. While empowerment has been cited as the
opposite of stigma (Corrigan et al. 2005; Lundberg et al. 2008), there has been little
sociological research to date to examine this assertion. Empowerment is a complex and
multifaceted construct, and there is much empirical and theoretical work that must be
done in order to examine empowerment as a stigma resistance strategy. An area of future
research is to examine how empowerment impacts self and identity processes.
Internalized stigma is that stigma which has been incorporated into the selfconcept, and studies that focus on internalized stigma are examining a stigmatized self.
Research must also examine the development of an empowered self, in which orientations
towards individual and community empowerment impact self-concept. If the individual
has embraced the mental illness status within one‟s role identity and adopts an
145
empowered orientation, then he or she may engage in stigma resistance strategies that are
aimed at combating stigma, reducing discrimination or securing equal rights and access
to treatment.
Future research should also compare outcomes among three groups of individuals:
those who have internalized stigma (stigmatized self), those for whom stigma does not
reduce or negatively impact self-concept, and those who have adopted empowering
attitudes within the self-concept (empowered self). Such comparisons may help detail the
differential impact of stigma on individuals, highlight effective resistance strategies that
individuals use to ward off the effects of stigma and expand our knowledge of identity
development among individuals with mental illness. Research in this area would also
increase our knowledge of the complex relationships between stigma, self and other
outcomes, including physical health, service utilization and psychological well-being.
Research should also examine empowerment as a proactive response to stigma.
Empowerment research that focuses on stigma resistant responses that improve selfconcept and increase feelings of power and control will enhance our understanding of
how certain individuals are able to overcome negative effects of stigma. For instance,
research could examine the benefits to self-esteem that one feels from being involved in a
collective, advocating for policy change, public awareness and education about mental
illness. Such research many also examine peer support groups and formal and informal
social advocacy groups to better understand how these groups provide social support and
encourage individual and group empowerment.
146
Future research should also consider the impact of empowerment on social
conditions of devalued groups by examining its impact in reducing stigma, expanding
rights and improving social conditions of individuals with mental illness. Areas of
research include the impact of advocacy in reducing formalized and informalized
discriminatory practices, improving treatment programs, and reducing public stigma by
educating others and normalizing the experience of mental illness. Research in these
areas will advance our understanding of empowerment as a sociological construct.
Righteous anger and emotion management. Another task of future research is to
examine the concept of righteous anger, both as an indicator of empowerment, which
theoretically may improve self-concept, and as an emotional response, which may
negatively impact self-concept and well-being. From an empowerment perspective,
righteous anger is a tool that helps propel the individual to act in ways that confront
stigmatizers and challenge negative stereotypes. If these steps are successfully
accomplished, then righteous anger may serve an empowering purpose. Otherwise, it may
have detrimental effects if one becomes angered at the injustice of stigma but remains
powerless to alter the situation. Future research should consider the emotion management
techniques and social support mechanisms that are necessary for individuals with mental
illness to effectively channel righteous anger towards positive outcomes.
Examining stigma responses by stage of illness. Future research should consider
the use of different stigma response strategies by age of onset of the illness, time since
initial diagnosis, stage of illness, and/or severity of illness. The strong connection
between stigma and a tendency to use defensive strategies suggests that individuals are
147
reacting to actual experiences of rejection, based on past experiences, rather than acting
to an anticipated rejection (Thoits 2011; Wright et al. 2000). In other words, individuals
may have learned to recognize signs of rejection and act defensively to block or deflect
the rejection. Such action assumes learned experience that is developed over time. By
examining a broad range of stages of illness, or severity of illness, researchers may
examine the process by which stigmatized individuals learn to recognize stigma and
explore the use of different responses to stigma, each with varying degrees of
effectiveness.
Conclusions
This study examined the relationship between stigma and self-concept among
individuals with mental illness, while also considering the role of stigma resistance
responses that individuals may enlist when presented with public stigma. My primary
conceptual relationship of interest was to better understand the effect of stigma on selfconcept, which I operationalized as self-esteem and mastery. My findings suggest that
stigma does not have as detrimental of an impact on self-concept as might be predicted
by labeling theories.
One possible theoretical explanation for this finding is that individuals have
options with regards to the types of responses to public stigma. Response strategies may
influence the impact of stigma, either exacerbating its effect or helping to defend against
negative reactions of others to protect or preserve one‟s self-concept. In this study, I
examined the use of defensive strategies and two measures of empowerment, community
148
activism and righteous anger, as moderators that may influence the impact of stigma on
self-concept. My findings suggest that stigma results in increased use of defensive
strategies, which has a negative effect on self-esteem and mastery. I also found that
community activism has a strong and positive impact on self-concept, but that this effect
is independent of the presence of perceived stigma. Righteous anger did not have an
effect on the relationship between stigma and self-concept.
This study is an attempt to link two areas of focus within the sociology of mental
health and illness. That is, I have attempted to connect the body of work that examines
stigma and its impact of self-concept with an emerging literature on the concept of stigma
resistance. I have also incorporated the concept of empowerment as an aspect of stigma
resistance that represents a proactive response to the threat of stigma. Research in this
area will continue to examine the number and array of resources and responses that
individuals have that may change the degree to which stigma impacts individuals. Such
research will enhance our understanding of social factors that influence the experience of
individuals with mental illness. Through this knowledge, we may be better able to
identify ways to reduce prejudice and discrimination that results from being stigmatized,
helping individuals with mental illness to live meaningful, productive and empowered
lives.
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APPENDICES
Appendix A: Measurement of Self-concept, Stigma and Responses to Stigma ….168
Appendix B: Supplemental Technical Data Analyses ……………………………172
Appendix C: Notice of IRB approval ……………………………………………..184
Appendix D: Bivariate Correlation Matrix of Dependent, Independent and Control
Measures …………………………………………………………………………….……186
167
168
APPENDIX A
MEASUREMENT OF SELF-CONCEPT, STIGMA AND
RESPONSES TO STIGMA
Self-concept: Mastery
Mastery items: (strongly disagree to strongly agree)
1.
I have little control over the things that happen to me
2.
There is really no way I can solve some of the problems that I have
3.
There is little I can do to change many of the important things in my life
4.
I often feel helpless in dealing with the problems of life
5.
Sometimes I feel I am being pushed around in life
6.
What happens to me in the future mostly depends on me
7.
I can do just about anything I really set my mind to
Self-concept: Self-esteem
Self-esteem items: (strongly disagree to strongly agree)
1.
At times I think I am no good at all
2.
I feel that I do not have much to be proud of
3.
I certainly feel useless at times
4.
I wish I could have more respect for myself
5.
All in all, I feel that I am a failure
6.
I feel that I am a person of worth, at least the equal of others
7.
I feel that I have a number of good qualities
8.
I am able to do things as well as most other people
9.
I take a positive attitude toward myself
10. On the whole, I am satisfied with myself
Stigma: Devaluation/ discrimination
Devaluation/ discrimination items: (Strongly disagree to strongly agree)
1. Most people would willingly accept a former mental patient as a close friend
2. Most people believe a person who had a mental illness is as intelligent as average
person
169
3. Most people believe that a former mental patient is just as trustworthy as the
average citizen
4. Most people would accept a fully recovered former mental patient as a teacher of
young children in a public school
5. Most people feel that having a mental illness is a sign of personal failure
6. Most people would not hire a former mental patient to take care of their children
7. Most people think less of a person who has a mental illness
8. Most employers will hire a former mental patient if qualified for the job
9. Most employers will pass over the applications of a former mental patient in favor
of another applicant
10. Most people in my community treat a former mental patient as they would treat
anyone
11. Most young people would be reluctant to date a person who has been hospitalized
for a serious mental disorder
12. Once they know a person has a mental illness, most people will take opinions less
seriously
Stigma resistance responses: Defensive strategies
Defensive strategies items (1=yes, 0=no)
1. Is it easier for you to be friendly with people who have been psychiatric patients
(Withdrawal)
2. Would you avoid the kind of person who looks down on people who have mental
illness (withdrawal)
3. Would you apply for a job if you knew the employer was going to ask you about
your history of mental illness (withdrawal)
4. When you meet people for the first time do you ever tell them that you were once
mentally ill (withdrawal)
5. Would you apply for a job if you knew the employer didn‟t like to hire people
who had been mentally ill (withdrawal)
6. Do you sometimes avoid people because you think they might look down on
people who had been mentally ill (withdrawal)
7. Do you sometimes hide the fact that you have been mentally ill (secrecy)
8. Do you think it is a good idea to keep your history of mental illness a secret
(secrecy)
9. Would you advise a close relative who had been treated for a mental illness not to
tell anyone about it (secrecy)
10. Do you wait until you know a person well before you tell them you have been
mentally ill
11. When you look for a job, do you think it is a good idea to tell that you were once
mentally ill
170
Stigma resistance responses: Empowerment
Empowerment items: (strongly disagree to strongly agree)
1.
I can pretty much determine what will happen in my life
2.
People are only limited by what they think is possible
3.
People have more power if they join together as a group
4.
Getting angry about something never helps
5.
I have a positive attitude about myself
6.
I am usually confident about the decisions I make
7.
People have no right to get angry just because they don‟t like something
8.
Most of the misfortunes in my life were due to bad luck
9.
I see myself as a capable person
10. Making waves never gets you anywhere
11. People working together can have an effect on their community
12. I am often able to overcome barriers
13. I am generally optimistic about the future
14. When I make plans, I am almost certain to make them work
15. Getting angry about something is often the first step toward changing it
16. Usually I feel alone
17. Experts are in the best position to decide what people should do or learn
18. I am able to do things as well as most other people
19. I generally accomplish what I set out to do
20. People should live their lives the way they want to
21. You can‟t fight city hall (authority)
22. I feel powerless most of the time
23. When I am unsure about something, I usually go along with the rest of the group
24. I feel I am a person of worth, at least on an equal basis with others
25. People have a right to make their own decisions, even if they are bad ones
26. I feel I have a number of good qualities
27. Very often a problem can be solved by taking action
28. Working with others in my community can help to change things for the better
Stigma resistance responses: Community activism (from empowerment)
Community activism items: (strongly disagree to strongly agree)
171
1. People have more power if they join together as a group
2. People working together can have an effect on their community
3. Very often a problem can be solved by taking action
4. Working with others in my community can help to change things for the better
Stigma resistance responses: Righteous anger (from empowerment)
Righteous anger items: (strongly disagree to strongly agree)
1. Getting angry about something never helps
2. People have no right to get angry just because they don‟t like something
3. Making waves never gets you anywhere
172
APPENDIX B
SUPPLEMENTAL TECHNICAL DATA ANALYSES
I conducted supplemental post-hoc analyses to further substantiate and explicate
the nature of the relationships among the measures of interest to this study. In this
Appendix, I present the results of supplemental analyses related to this study. These posthoc, technical analyses are supplemental in that there are no direct research questions as
there were for analyses presented in previous chapters. However, they provide more
detailed information as to the nature of the data and relationships among measures.
There are two main goals related to these supplemental analyses. My first goal is
to better understand the nature of the relationship between stigma and self-concept,
independent of some of the analytical constraints used in the prior analysis. The second
goal is to see if the referral source for the sample, that is, whether or not the study
participant had contact with the criminal justice system, has an effect on the main
analytical findings of this study as presented in Chapter 4. These post-hoc analytical tasks
and results are further described below.
Post-hoc Analyses of the Effect of Stigma and Self-concept without Time 1 Constraints
The findings presented in Chapter 4 are consistent with the broad literature that
would suggest that stigma has a negative, detrimental effect on self-concept, but that this
173
effect is moderate in strength at best. In fact, the analyses presented above show that,
when all control measures and stability measures needed for this longitudinal relationship
are included in the analysis, the relationship between stigma and self-concept is very
weak, with associations significant only when the probability threshold is relaxed to
include p-values at .10. Thus, in order to more fully understand the effect of stigma on
self-concept, I conducted additional post-hoc analyses to examine this relationship
without the constraints posed by including the Time 1 stability measure for the dependent
variable.
First, I examine the effect of stigma (devaluation/ discrimination) on self-esteem.
Recall from Chapter 4, Table 4.3 that these measures were significantly correlated (r= .31, p<.001), and while this correlation is quite strong statistically, the correlation
coefficient itself is not as strong of an association as might be predicted by labeling
theories (Thoits 2011). Also in Chapter 4, I used OLS regression to examine the effect of
devaluation/ discrimination on self-esteem. Both measures were assessed with the Time 2
data while controlling for self-esteem at Time 1. This provided a stability measure for my
dependent variable so that the effects of other independent measures could be assessed
net of the respondent‟s level of self-esteem at the initial survey administration. As
discussed, it was necessary to include this constraint as a control measure. However, it is
possible that the presence of the Time 1 measure of the dependent variable suppresses or
reduces the effect of the independent measures on the dependent measures.
For this post-hoc analysis, I relax this constraint to see the raw effect of devaluation/
discrimination on self-esteem. Table A.1 presents two regression models, showing the
174
effect of the controls and devaluation/ discrimination regressed on self- esteem (Model
1), and then the full model that includes the stigma resistance measures (Model 2). The
Time 1 measure of self-esteem is not included in these models. Table A.1, Model 1
shows that devaluation/ discrimination has a negative, detrimental effect on self-esteem
(b= -.152, p<.01). This is similar to the results presented in Table 4.6, Model 3 (b= -.087,
p<.10), although the strength of the association between stigma and self-esteem is
stronger without controlling for self-esteem at Time 1. In other words, controlling for
self-esteem at Time 1 depresses the effect of stigma on self-esteem. The magnitude of
this effect is apparent when comparing the strength of association with or without the
Time 1 constant. In Table 4.6, Model 3, the unstandardized coefficient for devaluation/
discrimination is -.087. In Table A.1, Model 1 (without the Time 1 constant), the
unstandardized coefficient is -.152. Thus, including self-esteem at Time 1 reduces the
effect of stigma on self-esteem by 43 percent. This effect is also apparent when
comparing the standardized coefficients (β). In Table 4.6, Model 3, the standardized
coefficient for devaluation/ discrimination is -.090. In Table A.1, Model 1, β= -.156.
Thus, the effect of devaluation/ discrimination on self-esteem is stronger if self-esteem at
Time 1 is not included within the analysis.
Table A.1 also contains the full model examining the effect of devaluation/
discrimination on self-esteem with all control and independent measures included. Again,
a similar pattern emerged between Table A.1, Model 2 and Table 4.6, Model 7, in which
the significant effect of devaluation/ discrimination on self-esteem was reduced to nonsignificance as stigma response items were included within the regression. Again, the size
175
Table A.1. Post-hoc Analyses of Stigma and Self-Esteem without Time 1 Measure of Self-Esteem
SELF-CONCEPT
Model 1
Model 2
β
β
Demographic factors
Age
-.026
-.026
.000
.000
(.056)
(.051)
Gender (1=female)
.323
.016
1.275
.062
(1.133)
(1.040)
African American
1.766
.088
1.522
.075
(1.093)
(1.001)
Education (years)
-.044
-.009
.075
.015
(.277)
(.256)
Income (monthly)
.001
.040
.002
.075
(.001)
(.001)
Schizophrenia
-.488
-.024
.117
.006
(1.137)
(1.037)
Employed
2.281
.094
.523
.022
(1.409)
(1.300)
Currently married/ cohabiting
.784
.022
1.654
.045
(2.015)
(1.833)
Psychological functioning
Difficulty in comprehending Qs
-1.924
-.086
-.803
-.036
(1.239)
(1.135)
Depression (Time 1)
-.438*** -.571
-.386***
-.504
(.044)
(.041)
Social resources
Frequency of contact (family)
.262
.053
.347
.070
(.266)
(.242)
Frequency of contact (social)
.183+
.101
.170+
.094
(.106)
(.096)
Number of network ties
.360
.096
.109
.029
(.264)
(.241)
Extensiveness of network
-.525
-.066
-.433
-.054
(.601)
(.548)
-.152**
-.156
-.056
-.058
Devaluation/ discrimination
(.055)
(.053)
-1.410***
-.242
Defensive strategies
(.305)
.869***
.233
Community activism
(.185)
-.209
-.069
Righteous anger
(.152)
57.856
37.764
Constant
.469
.572
R2
.430
.534
Adjusted R2
+
p<.10; *p <.05; **p<.01; ***p<.001
Unstandardized coefficients are reported. Standard errors in parentheses. All measures are reported at the Time 2 administration
unless otherwise specified.
a
176
of the unstandardized coefficient for devaluation/ discrimination was smaller when selfesteem at Time 1 is included in the analyses (b= -.008 (Table 4.6, Model 7), compared to
-.056 in Table A.1, Model 2).
These post-hoc analyses are repeated to examine the effect of devaluation/
discrimination on mastery. Again, recall from Table 4.3 that these measures were
significantly correlated (r= -.22, p<.001), but that this correlation, while statistically
significant, is not as strong of an association between stigma and self-concept as might be
theoretically predicted (Thoits 2011).
Table A.2 presents the OLS regression of all control measures, with the exception
of mastery at Time 1, and devaluation/ discrimination regressed on mastery at Time 2.
Again, I found that, without controlling for mastery at Time 1, devaluation/
discrimination has a negative effect on mastery (b= -.074, p<.10). Table 4.8, Model 3
showed the unstandardized coefficient to be -.068, p<.10 when mastery at Time 1 is
included as a control measure. Thus, it appears that the effect of devaluation/
discrimination on mastery is reduced when mastery at Time 1 is included. However, this
effect is only reduced by 8 percent. Table A.2, Model 2 has the full model with all control
measures, devaluation/ discrimination and stigma response items regressed on mastery.
The significant effect of devaluation/ discrimination and mastery is reduced to nonsignificance when all measures are included in the model (b= -.015, p=.718), a similar
pattern that was shown in Table 4.8, Model 7.
177
Table A.2. Post-hoc Analyses of Stigma and Mastery without Time 1 Measure of Mastery
MASTERY
Model 1
Model 2
Demographic factors
Age
Gender (1=female)
African American
Education (years)
Income (monthly)
Schizophrenia
Employed
Currently married/ cohabiting
Psychological functioning
Difficulty in comprehending Qs
Depression (Time 1)
Social resources
Frequency of contact (family)
Frequency of contact (social)
Number of network ties
Extensiveness of network
Devaluation/ discrimination
-.025
(.041)
.880
(.840)
1.216
(.810)
-.027
(.2050
.001
(.001)
-1.242
(.843)
-.435
(1.044)
.889
(1.492)
-.040
-1.896*
(.918)
-.204***
(.033)
-.131
.089
(.197)
.181*
(.078)
.387*
(.195)
-.750+
(.445)
-.074+
(.041)
.028
Defensive strategies
Community activism
Righteous anger
+
Constant
R2
Adjusted R2
39.456
.296
.245
.067
.094
-.008
.099
-.097
-.028
.038
-.414
.155
.160
-.146
-.118
-.008
(.038)
1.507*
(.788)
1.120
(.759)
.028
(.194)
.002*
(.001)
-.816
(.786)
-1.581
(.985)
1.531
(1.389)
-.013
-1.105
(.860)
-.170***
(.031)
-.076
.153
(.183)
.176*
(.073)
.221
(.183)
-.729+
(.415)
-.015
(.040)
-.939***
(.231)
.590
(.140)
-.049
(.115)
25.609
.407
.354
.048
.115
.086
.009
.135
-.064
-.102
.065
-.345
.151
.092
-.142
-.023
-.250
.246
-.025
p<.10; *p <.05; **p<.01; ***p<.001
Unstandardized coefficients are reported. Standard errors in parentheses. All measures are reported at the Time 2 administration
unless otherwise specified.
a
178
In sum, these post-hoc analyses suggest that the general effect of stigma on selfconcept is similar to what would be predicted by labeling theories. That is, there is a
significant, negative effect of stigma on self-concept, but that this effect is not
particularly strong. The goal of these post-hoc analyses was to see what the nature of the
effect of stigma on self-concept was without the constraint of using the Time 1 measures
of the dependent variables, self-esteem and mastery. These results show that including
the Time 1 measure as a control reduces the size of the effect of devaluation/
discrimination on both self-esteem and on mastery, and that this phenomenon was more
drastic for the self-esteem model (Table A.1) than for the mastery model (Table A.2).
Post-hoc Analyses of the Effect of Contact with the Criminal Justice System
The second goal of these post-hoc analyses is to see if criminal justice
involvement impacts the findings presented in Chapter 4. Recall that the Quality of Life
sample was not randomly selected, and study participants were recruited to participate
from a number of sources. Just over half of this sample (52 percent) had some known
contact with the criminal justice system, either with law enforcement or through the court
system, as those avenues served as referral sources for the study.
In order to examine if the referral source had an impact on the main findings of
this dissertation, I am conducting additional regression analyses to duplicate those
findings presented in Tables 4.6 (self-esteem as the dependent variable) and 4.8 (mastery
as the dependent variable). These post-hoc analyses included a dichotomous measure to
179
180
181
represent if referral to the study was a result of contact with the criminal justice system.
Table 4.6 and 4.8 are reproduced here (Now Tables A.3 and A.4).
In sum, contact with the criminal justice system had no significant effect on selfesteem (see Table A.3). Further, the relationships presented in Chapter 4 remain the same
when controlling for contact with the criminal justice system. That is, devaluation/
discrimination has a weak but significant effect on self-esteem net of contact with the
criminal justice system. However, this effect is reduced to non-significance when the
stigma resistance response measures are included in the analyses. The use of defensive
strategies continues to have a strong, negative impact on self-esteem, while community
activism has a strong, positive effect on self-esteem that is independent of devaluation/
discrimination. Righteous anger has a negative effect on self-esteem.
The effect of contact with the criminal justice system has a similar effect on the
analyses looking at mastery as the outcome measure (see Table A.4). Here, the analyses
suggest similar patterns as described in Chapter 4, Table 4.8, where devaluation/
discrimination has a weak effect on mastery, which is reduced to non-significance when
defensive strategies is entered into the model. Community activism has a positive effect
on mastery net of the effect of devaluation/ discrimination. Righteous anger does not
have a significant impact on mastery.
Post-hoc analyses indicate that whether or not study participants had contact with
the criminal justice system does not affect the primary research findings of this study.
These results suggest that the referral source for the sample does not bias the results.
182
183
APPENDIX C
NOTICE OF IRB APPROVAL
184
185
APPENDIX D
BIVARIATE CORRELATION MATRIX OF DEPENDENT, INDEPENDENT AND
CONTROL MEASURES
186
187
188