Content uploaded by Kristin D Mickelson
Author content
All content in this area was uploaded by Kristin D Mickelson on Mar 10, 2015
Content may be subject to copyright.
Journal of Social and Clinical Psychology, Vol. 27, No. 9, 2008, pp. 903-930
903
MICKELSON AND WILLIAMS
POVERTY AND DEPRESSION
PERCEIVED STIGMA OF
POVERTY AND DEPRESSION:
EXAMINATION OF INTERPERSONAL
AND INTRAPERSONAL MEDIATORS
KRISTIN D. MICKELSON, PH.D.
Kent State University
STACEY L. WILLIAMS, PH.D.
East Tennessee State University
This study examines the perceived stigma of poverty by assessing individuals’
negative feelings about being poor (internalized stigma), and their beliefs about
whether others treat them as stigmatized (experienced stigma). In a combined
sample of low-income women (N = 210), we tested a dual-pathway model to
explain how these perceived stigma dimensions are related to depression among
the impoverished. We proposed that interpersonal (i.e., impaired support avail-
ability and heightened fear of support request rejection) and intrapersonal factors
(i.e., impaired self-esteem) differentially mediate the relationship of internalized
and experienced poverty stigma with depression. Structural equation modeling
partially supported the model: internalized stigma and depression were partially
mediated by self-esteem and fear of rejection, while experienced stigma was re-
lated to depression through fear of rejection only. In other words, internalized
and experienced perceived stigma activate separate and similar mechanisms to
inuence depression among the poor.
Kristin D. Mickelson, Department of Psychology, Kent State University and Stacey L.
Williams, Department of Psychology, East Tennessee State University.
We thank all of the women who participated in both the Women’s HOUR study and
the MOM study for sharing their lives and experiences with us. We also thank Dr. Mary
Ann Stephens, the anonymous reviewers, and Dr. Jay Mohr for providing feedback on
earlier drafts.
Correspondence concerning this article should be addressed to Kristin D. Mickelson,
Department of Psychology, Kent State University, P. O. Box 5190, Kent, Ohio,
44242-0001. E-mail: kmickels@kent.edu.
904 MICKELSON AND WILLIAMS
Poverty carries with it not only economic burdens but also psycho-
social difficulties. Those living in poverty encounter daily struggles
that range from tangible problems (e.g., obtaining basic necessities
for themselves and their families) to intangible one (e.g., impaired
personal relationships and self-cognitions; e.g., Bassuk et al., 1996;
Mirowsky & Ross, 1986). An additional burden for low-income in-
dividuals is the knowledge that society stigmatizes them (or labels
them as deviant) because of their financial situation (Lott, 2002). In
his influential work on stigma, Goffman (1963) proposed that those
with a “deviant” characteristic experience negative reactions from
society at both social and cognitive levels. Not only is the literature
generally silent about perceptions of stigma among the impover-
ished, it is also unclear about the influence of perceived stigma of pov-
erty on social and cognitive outcomes and, subsequently, on mental
health outcomes. In the present study, we examine two potential
mechanisms by which perceived stigma (defined as one’s person-
al feelings about their stigmatized condition and one’s perceived
experience of being stigmatized by others) is related to depression
among the impoverished. Specifically, we argue that interpersonal
factors (i.e., impaired support availability and heightened fear of
support request rejection) and intrapersonal factors (i.e., impaired
self-esteem) mediate the link between perceived stigma of poverty
and depression.
PERCEIVED STIGMA OF POVERTY
The definition of stigma has ranged from having a personal charac-
teristic that deviates from societal norms (Goffman, 1963) to social
stereotyping or categorization (see Jones et al., 1984, for a review).
Stigma has traditionally been defined from the perspective of the
perpetrators’ labeling of the target, rather than the target’s percep-
tions of stigma. In fact, individuals who are stigmatized by society
may not necessarily feel the stigma as intensely as one might expect.
More recently, research has examined the concept of perceived stigma
finding that, regardless of whether society continues to label a con-
dition or characteristic as stigmatizing, individuals who belong to
groups (or have characteristics) that have been traditionally margin-
alized can vary quite dramatically in their perceptions of stigma (e.g.,
Corrigan & Calabrese, 2005; Crandall, 1991). Although research on
POVERTY AND DEPRESSION 905
poverty has shown that society consistently stigmatizes the poor—
either through blaming them for their situation or through stereo-
types (see Waxman, 1983, for a review)—systematic research on the
stigma perceptions of the poor is more limited. In one study, using
a qualitative design, poor women tended to believe others looked
down on them because of their low-income status (Collins, 2005).
Other research has primarily focused on perceptions of stigma with
respect to welfare status or use of public assistance or means-tested
government programs (e.g., Aid to Families with Dependent Chil-
dren; e.g., Horan & Austin, 1974; Jarrett, 1996; Kerbo, 1976; Stuber
& Kronebusch, 2004). Stuber and Schlesinger (2006) examined the
sources of stigma for means-tested government programs and found
that participation in these programs is related to two distinct forms
of stigma—namely, identity stigma (which is defined as internaliz-
ing negative stereotypes) and treatment stigma (which is defined as
a fear that others may treat them poorly). This research shows that
poor people feel the stigma of their situation from agency staff as
well as society; and, these perceptions can inhibit their use of social
services. Similarly, we define perceived stigma in the present study
as an individual’s personal negative feelings about their poverty,
such as embarrassment, shame, or deviance (what we term internal-
ized stigma), and the individual’s perception of being stigmatized
by others (which may or may not accurately reflect network mem-
bers’ behaviors and feelings; what we term experienced stigma). We
believe that both internalized and experienced stigma of poverty
will be related to an individual’s depression, but through different
pathways.
PERCEIVED STIGMA AND DEPRESSION
Numerous studies have found a link between perceived stigma
(operationalized as internalized and/or experienced stigma) and
depression or emotional distress (e.g., Baxter, 1989; Coffey, Leit-
enberg, Henning, Turner, & Bennett, 1996; Devins, Stam, & Koop-
mans, 1994; Hermann, Whitman, Wyler, Anton, & Vanderzwagg,
1990; Mansouri & Dowell, 1989). Perceived stigma has been posi-
tively related to depression among leg amputees (Rybarczyk, Ny-
enhuis, Nicholas, Cash, & Kaiser, 1995), HIV/AIDS patients (Cran-
dall & Coleman, 1992), family caregivers of HIV-infected women
906 MICKELSON AND WILLIAMS
(Demi, Bakeman, Moneyham, Sowell, & Seals, 1997), and parents
of children with mental retardation (Baxter, 1989). Two longitudinal
studies have also found that perceived stigma increased depression
over time in mentally ill, substance-abusing men (Link, Struening,
Rahav, Phelan, & Nuttbrock, 1997) and parents of special needs chil-
dren (Mickelson, 2001).
One explanation for the link between perceived stigma and de-
pression is that an individual’s awareness of social stereotypes, and
actual or anticipated experiences with discrimination, negatively
impacts social relationships. Perceived stigma (again, defined as in-
ternalized and/or experienced stigma) has been shown to be relat-
ed in a variety of conditions to negative perceptions of others (Cran-
dall & Coleman, 1992), negative interactions with others (Devins et
al., 1994; Gibbons, 1985; Levinson & Starling, 1981; Link, Cullen,
Struening, Shrout, & Dohrenwend, 1989), as well as perceived and
actual restrictions in social activities (Jacoby, 1994; MacDonald & An-
derson, 1984, respectively). Besides withdrawal from and by one’s
network (which may contribute to impaired perceptions of support
availability), those with high levels of perceived stigma may fear
rejection of support requests by their network. Although not specifi-
cally addressed in prior research as an outcome, anticipated social
rejection by others is often a component of perceived stigma mea-
sures (e.g., Fife & Wright, 2000; Swendeman, Rotheram-Borus, Co-
mulada, Weiss, & Ramos, 2006). And, as stated above, work on per-
ceived stigma and poverty more specifically has found that fear of
negative treatment by professionals (i.e., treatment stigma or what
we term experienced stigma) inhibits utilization of social services
(Stuber & Schlesinger, 2006).
In addition to perceived stigma impairing one’s social relation-
ships, research has found that individuals with higher levels of in-
ternalized and/or experienced perceived stigma (for a variety of
conditions) also report lower levels of self-esteem (e.g., Kahng &
Mowbray, 2005; Kent, 1999; Link, Struening, Neese-Todd, Asmus-
sen, & Phelan, 2001; Westbrook, Bauman, & Shinnar, 1992). Self-es-
teem may be affected by personal feelings of deviance, self-blame,
or acceptance of stereotypes associated with the condition (Corri-
gan & Calabrese, 2005; Goffman, 1963; Jones et al., 1984). However,
others have argued that impairment of self-esteem does not always
occur because not every individual in a stigmatized group accepts
the societal labels or stereotypes (Camp, Finlay, & Lyons, 2002; Wat-
POVERTY AND DEPRESSION 907
son & River, 2005). In fact, Corrigan, Watson, and Barr (2006) re-
cently argued that—whereas public stigma is simply awareness of
stereotypes—self-stigma consists of stereotype agreement, self-con-
currence, and self-esteem decrement. In other words, an individual
with high self-stigma would (1) agree with the stereotypes held by
the public about their situation, (2) believe the stereotypes apply to
them, and (3) experience decreased self-esteem because of the ac-
ceptance of these stereotypes.
Although direct literature on perceived stigma of poverty and
self-esteem is lacking, we can look to the broader literature on so-
cial class and self-esteem to understand whether these arguments
apply to perceived stigma of poverty and feelings of self-worth.
Research considering the association between poverty and self-con-
cept is somewhat mixed. Several studies have found lower levels of
income to be related to lower self-esteem (e.g., McMullin & Cairney,
2004; Mirowsky & Ross, 1986). However, Barusch (1997) found that
low-income older women do not necessarily have poor self-con-
cepts, especially if they can redefine poverty to exclude themselves,
compare themselves to those less fortunate, and/or view their pov-
erty as temporary. This latter study corresponds with the argument
above that decrements in self-esteem are not inevitable if a person
does not identify with the stigma (Corrigan, Watson, & Barr, 2006).
In other words, the more individuals internalize the stigma of pov-
erty, the more their self-esteem is impacted.
EXPLANATORY MECHANISMS IN THE
PERCEIVED STIGMA-DEPRESSION PROCESS
Bringing together the research on social and cognitive impacts of
perceived stigma, we propose a mediational model to explain the
process by which perceived stigma is related to depression. Specifi-
cally, we propose a dual pathway model where social support and
self-esteem act as mediators. Link and Phelan (2001) recently called
for more research in stigma that examines the processes underly-
ing stigma and distress. Much of the research on perceived stigma
tends to be basic in its examination of direct relations between per-
ceived stigma (broadly defined as internalized and/or experienced
stigma) and a single outcome. Although this research helps us to
understand the broad impact of perceived stigma on various aspects
908 MICKELSON AND WILLIAMS
of people’s lives, it fails to address the underlying mechanisms or
processes involved.
Existing research on specific explanatory mechanisms is scarce.
With respect to social support, Mickelson (2001) found in parents
of special needs children that perceived stigma (operationalized as
a combination of internalized and experienced stigma) was related
to increased depression over time through decreased perceptions of
support availability and increased negative interactions with net-
work members. With respect to self-esteem, several studies have
found that self-esteem acts as a mediator between perceived stigma
and quality of life (Rosenfield, 1997) and life satisfaction (Markow-
itz, 1998) in the mentally ill (with both studies defining perceived
stigma as experiences with discrimination or devaluation), as well
as distress in a sample of people with vitiligo (a skin condition in-
volving the loss of skin pigmentation; Kent, 1999), which defined
perceived stigma as a combination of internalized and experienced
stigma. No published studies, however, have systematically exam-
ined internalized and experienced stigma with both social support
and self-esteem in the same model.
To understand how social support and self-esteem are each in-
volved, we first return to the discussion of perceived stigma dimen-
sions. One issue in reviewing the literature on perceived stigma is
the plethora of operationalizations that are used in the different
studies. There is no one standard operationalization in these stud-
ies—they range from individuals’ perceptions of how society views
or stereotypes their stigma condition (e.g., Rybarczyk et al., 1995;
Stuber & Kronebusch, 2004) to individuals’ feelings of shame, em-
barrassment, and distress about their stigma condition (e.g., Cof-
fey et al., 1996) to actual or perceived experiences of devaluation
or discrimination (e.g., Kahng & Mowbray, 2005; Link et al., 2001;
Markowitz, 1998; Rosenfield, 1997; Swendeman et al., 2006; West-
brook et al., 1992), or to some combination of these prior operation-
alizations (e.g., Kent, 1999; Levinson & Starling, 1981; MacDonald
& Anderson, 1984; Mickelson, 2001). Furthermore, researchers have
alternately discussed the perceived stigma dimensions in terms of
self versus public stigma (Watson & River, 2005), identity versus
treatment stigma (Stuber & Schlesinger, 2006; see discussions of
both above), or felt versus enacted stigma (Jacoby, 1994). Felt stigma
refers to an internal sense of shame and anticipation of rejection,
whereas enacted stigma refers to actual experiences with discrimi-
POVERTY AND DEPRESSION 909
nation or prejudice. Enacted (or experienced) stigma can be closely
connected with the literature on discrimination for understanding
its antecedents and consequences (see Major, Quinton, & McCoy,
2002, for a review). Scambler and Hopkins (1986) argued, however,
that felt stigma is more distressing than enacted stigma (which they
argue is infrequent) because it is related to a fear of rejection (wheth-
er based on actual or perceived experiences) and, consequently, so-
cial isolation and distress. All of these dimensions are akin to our
constructs. Specifically, internalized stigma has some parallels with
self-stigma, identity stigma, and felt stigma such that it focuses on
the internalization of feelings of shame and/or responsibility. On
the other hand, experienced stigma has some parallels with public
stigma, treatment stigma, and enacted stigma such that it focuses on
either anticipated or perceived experiences of discrimination. Yet,
surprisingly, no one has examined the pathways by which these
two perceived stigma dimensions each influence depression.
In the present study, we argue that among impoverished indi-
viduals, internalized stigma of poverty will be related to depres-
sion primarily through lower self-esteem; in other words, if an in-
dividual self-identifies with the stigma, feelings of self-worth will
be impaired by one’s acceptance of the stereotypes. On the other
hand, experienced stigma of poverty will be related to depression
primarily through lower perceived support availability (of friends,
relatives, and professionals); in other words, reporting discrimina-
tory experiences (or even believing they are likely to occur) by one’s
network will be related to less positive support perceptions of net-
work members. Finally, we argue that fear of support request rejec-
tion (by friends, relatives, and professionals) will act as a mediator
for both internalized and experienced stigma. Our rationale is that
anticipation of rejection has been tied to both acceptance of stereo-
types (internalized stigma) and the actual or believed experience of
discrimination (experienced stigma). See Figure 1 for a depiction of
our proposed mediational model.
Note that the dual-pathway model presents only the primary
means by which each dimension of perceived stigma is related to
depression. We recognize that it is possible for experienced stigma
to be associated with self-esteem and internalized stigma to be as-
sociated with perceived support availability; however, we believe
these associations would be indirect and occur through the rela-
tion between internalized and experienced stigma. For example,
910 MICKELSON AND WILLIAMS
past research has shown that self-stigma mediates the link between
perceived public stigma and attitudes towards counseling (Vogel,
Wade, & Hackler, 2007), suggesting that experienced stigma may be
related to decrements in self-esteem indirectly through internalized
stigma.
Considering dimensions of stigma, poverty is often a shared
stigma (i.e., others within an individual’s network are also poor)
and, compared to other stigmatizing conditions such as AIDS or
being overweight, is more ambiguous in its visibility and perceived
controllability. However, we still believe that the personal sense of
embarrassment and perceived inequalities will be strong enough to
elicit variability on both internalized and experienced stigma. Due
to the taboo of discussing money/finances with others, people may
be less aware of the extent of financial difficulties experienced by
other network members. As a result, although the social stigma of
poverty is shared by the network, an individual may not perceive
their network as sharing in the stigma—or, at least, to the same de-
gree or for the same reasons (i.e., responsibility attributions). Thus,
we argue, because of this discrepancy in perspective, perceived
poverty stigma will be related to less perceived support availability
and greater fear of rejection from family and friends even though
they may be in similar financial straits.
Finally, because an alternative model is plausible, we will also test
the competing hypothesis that internalized and experienced stigma
may act as mediators between perceived support availability, fear of
Self-
Esteem
Fear of
Rejection
+
+
_
_
_
_
Perceived
Support
Availability
+
Depression
Internalized
Stigma
Experienced
Stigma
FIGURE 1. Proposed Mediational Model.
POVERTY AND DEPRESSION 911
rejection, self-esteem and depression. This model makes theoretical
sense in that those with low social support and self-esteem may be
more likely to internalize and experience stigma with their finan-
cial situation which, in turn, would be related to their depression.
However, due to the scarcity of causal research on perceived stigma
and the focus in prior studies on the correlates or effect of perceived
stigma on social support and self-esteem, this alternative media-
tional model has not been empirically tested in prior studies.
In order to test our proposed mediational model, we assessed in-
ternalized and experienced perceptions of poverty stigma in low-
income women. Our rationale for focusing on women only is two-
fold. First, poverty is qualitatively and quantitatively different for
men and women. For example, education, income, and occupation
are differentially correlated between men and women. Specifically,
there are lower correlations between women’s income and educa-
tion and income and occupation than between men’s (Ostrove &
Adler, 1998). Moreover, poor women are more likely to be caring
for children; whereas poor men are more likely to be dealing with
mental illness and substance abuse (US Census Bureau, 2006). Sec-
ond, our outcome variable of interest, depression, is more common
in women than men (Nolen-Hoeksema, 2001). Because of these dif-
ferences, we chose to focus only on women to limit the confound-
ing issue of gender. Our goal is to begin to understand the process
of poverty-related stigma on women’s mental health in the present
study and, then in future research, to determine if these processes
generalize to men.
METHOD
SAMPLE
For the present study, two datasets on low-income women were
combined (N = 210). The two studies were conducted using the
same recruitment strategies. Based on the income eligibility criteria
for many social services, poor women in the present study were de-
fined as having an annual income 220% or less of the federal poverty
threshold for their household size (US Census Bureau, 2006). These
912 MICKELSON AND WILLIAMS
women were recruited from government and social service agen-
cies in Northeast Ohio. The only difference in eligibility between
the two studies is that women in the second study were required
to have at least one child between 1 year and 16 years of age living
with her at the time of the interview. Even so, 84% of women in the
first study also had children 16 years or younger. The two studies
were conducted approximately five years apart, with the first one
being conducted in early 2000 and the second study in late 2005.
Six women participated in both studies; the decision was made to
retain their data in the first study and exclude their data from the
second study.
For the first study, the Women’s Health Outcomes in Urban and
Rural Environments Study HOUR), 100 poor women aged 18 to 65
(69% White, 22% African American, 9% Hispanic) were interviewed
face-to-face about their social support systems. The average woman
was in her mid-30’s (M = 33.7, SD = 10.1), had a high school educa-
tion (M = 12.3 years, SD = 2.7), and an annual income under $12,000
(M = $11,517.14, SD = $6,514.31; range = 1,236-29,580). Only 34%
were employed, and the majority was not married or cohabiting
(75%).
For the second study, the (Mothers Outcomes Matter Study
(MOM), 110 poor women aged 17 to 54 (53.6% White, 40.9% African
American, 1.8% Hispanic, 3.6% Other) were interviewed face-to-
face about their social support systems. The average woman was in
her mid-30’s (M = 32.3, SD = 8.6), had a high school education (M
= 12.8 years, SD = 1.7), and an annual income under $15,000 (M =
$14,286.22, SD = $8,719.12; range = 0-49,200). Only 41.8% were em-
ployed, and the majority was not married or cohabiting (78.2%).
With respect to demographic variables, women from the two stud-
ies were not significantly different on employment, marital status,
education, or age. The women differed in their racial/ethnic break-
down, such that the Women’s HOUR study had a larger percent-
age of Whites and Hispanics, whereas the MOM Study had close to
double the percentage of African Americans.
Women from the two studies also significantly differed on in-
come, with twomen from the MOM Study reporting on average al-
most $2,800 greater annual income than women from the Women’s
HOUR, F(1,208) = 6.69; p = .01. This difference may be due to the
higher percentage of employed women in the MOM study, or to
the presence of minor children, which makes women eligible for
POVERTY AND DEPRESSION 913
more services and cash assistance. However, women in the two
studies did not differ in the number of children 16 years or younger,
Women’s HOUR = 1.78; MOM Study = 2.02; F(1,208) = 2.21; p = .14.
Another likely explanation of income differences in the two studies
is household size. Women from the MOM Study had, on average,
4.1 people in their households (including themselves); on the other
hand, women from the Women’s HOUR had, on average, 3.3 people
in their households (including themselves) F(1,208) = 6.83; p = .01.
The greater household size may be likely to result in a higher house-
hold income from various sources (e.g., child support, government
assistance, wages).
PROCEDURE
Respondents from both studies were recruited from various gov-
ernment and social service agencies geared to providing services
for low-income individuals in Northeast Ohio. Flyers were posted
within agencies, and stamped postcards were available for any
woman aged 18 to 65 interested in participating. Potential respon-
dents filled in their names and telephone numbers and returned the
postcards to the project office. Each respondent had a face-to-face,
in-home interview with a trained interviewer that lasted an aver-
age of ninety minutes. During this time they answered questions
about demographics, perceived stigma, social support, self-esteem,
and depression. Scale cards containing item response scales were
used to facilitate women’s comfort in answering sensitive ques-
tions. Following participation, women were provided with a list of
community services available to them and compensation ($20) for
their time.
INSTRUMENTS
Potential Covariates. A number of sociodemographic variables were
included in the interviews. Each woman provided her age, marital
status, race/ethnicity, monthly income, highest level of education,
number of people in household, number of children, and employ-
ment status. The items were assessed to obtain a general descrip-
tion of the sample, in addition to being possible statistical control
variables.
914 MICKELSON AND WILLIAMS
Perceived Stigma. Perceived stigma of poverty was measured us-
ing eight items reflecting women’s perceptions of stigma associated
with their financial situation (adapted from Mickelson, 2001). Wom-
en were asked to think about their feelings during the past 6 months
and to respond by indicating the extent to which they agreed or
disagreed with each of the statements using a 5-point scale, ranging
from 1 (definitely disagree) to 5 (definitely agree). The eight items
tap into the two dimensions of perceived stigma (each consisting
of 4 items): internalized stigma (i.e., I feel that I am odd or abnormal
because of my financial situation; There have been times when I
have felt ashamed because of my financial situation; I never feel
self-conscious when I am in public; I never feel embarrassed about
my financial situation—scores on the latter two items were reversed
prior to analyses) and experienced stigma (i.e., I feel that others look
down on me because of my financial situation; People treat me dif-
ferently because of my financial situation; I have found that people
say negative or unkind things about me behind my back because
of my financial situation; I have been excluded from work, school,
and/or family functions because of my financial situation). For ana-
lytic purposes, mean scores were calculated for internalized stigma
(Women’s HOUR: α = .59; M. O. M. Study: α = .70)
1
and experienced
stigma (Women’s HOUR: α = .82; MOM Study: α = .70), with higher
scores indicating greater internalized and experienced stigma, re-
spectively.
Perceived Support Availability. Perceived support availability was
adapted from the UCLA Social Support Inventory (Dunkel-Schet-
ter, Feinstein, & Call, 1987) and assessed separately for various sup-
port sources (e.g., friends, relatives, professionals). For each sup-
port source, participants responded to items regarding availability
of emotional support (i.e., love, caring, understanding, or reassur-
ance), informational support (i.e., information and advice), and in-
strumental support (i.e., money, food, etc., or help with day-to-day
tasks). Individuals were asked to consider their perceptions of how
available each support source is with respect to the specific type of
support. For example, “To what extent do you feel the following
1. We believe that the lower alpha on internalized stigma in the Women’s HOUR was
related to a misunderstanding of two reverse-worded items in that scale. The response
options were confusing with the reverse wording. For the MOM study, we adjusted the
interviewer prompt and clarification of the response options on these items to reduce
this confusion and, as a result, the alpha increased substantially for this scale.
POVERTY AND DEPRESSION 915
individuals (friends, relatives, professionals) are available to give
you love, caring, understanding, or reassurance?” A mean score
was obtained for perceived support availability collapsed across
all items and support sources, with higher scores indicating great-
er perceived support availability (Women’s HOUR: α = .83; MOM
Study: α = .86). Because the UCLA-SSI has been adapted and used
in various formats and with varying numbers of indices, it is diffi-
cult to determine criteria for reliability (Wills & Shinar, 2000). How-
ever, the obtained alphas for the present studies are comparable to
prior research using the UCLA-SSI.
Fear of Support Request Rejection. The extent to which women feared
rejection of support requests during the six months prior to the in-
terview was also assessed separately for various support sources
(e.g., friends, relatives, professionals), with a measure created for
the present research. Women rated how worried they were that
their requests for help or support might be rejected or ignored us-
ing a 5-point scale, ranging from 1 (not at all) to 5 (very). A mean
score was calculated for fear of rejection, collapsed across all sup-
port network members, with higher scores indicating greater fear
of rejection (Women’s HOUR: α = .63; MOM Study: α = .80). One
reason for the difference in the alpha levels between the Women’s
HOUR and the MOM Study is that there was a finer distinction in
support sources for the MOM study than the Women’s HOUR. In
the Women’s HOUR, participants rated fear of rejection separately
for friends, relatives, and professionals. In the MOM Study, partici-
pants rated fear of rejections separately for parents, siblings, chil-
dren, other relatives, friends, co-workers/neighbors, and casework-
ers/social workers. Thus, fear of rejection consisted of seven items
for the MOM Study and only three items for the Women’s HOUR.
Moreover, with respect to validity, fear of rejection should be nega-
tively related to perceived support availability and, in fact, they are
significantly, negatively correlated (r = -.25, p < .001).
Self-Esteem. Self-esteem was assessed using the Rosenberg (1965)
Self-Esteem Inventory, which consists of 10 items (e.g., On the whole,
I am satisfied with myself; At times I think that I am no good at all)
rated on 4-point Likert scale (1 = strongly disagree; 4 = strongly
agree). This measure is considered the gold standard for assessing
self-esteem and has been well validated and shown to be highly
reliable in past research (Blascovich & Tomaka, 1991). As necessary,
916 MICKELSON AND WILLIAMS
TABLE 1. Bivariate Correlations of Major Study Variables
1 2 3 4 5 6 7
1 Internalized Stigma —
2 Experienced Stigma 0.50*** —
3 Self-Esteem -0.51*** -0.34*** —
4 Perceived Availability -0.14* -0.17* 0.16* —
5 Fear of Support Rejection 0.30*** 0.31*** -0.30*** -0.21** —
6 Depression 0.48*** 0.37*** -0.65*** -0.13 0.38*** 0.78*** —
*p < .05 **p < .01 ***p < .001
POVERTY AND DEPRESSION 917
items were reverse coded to parallel the other items and summed
to obtain an overall self-esteem score, with higher scores indicating
higher self-esteem (Women’s HOUR: α = .88; M. O. M. Study: α =
.91).
Depression. Depressive symptomatology was assessed using the
Center for Epidemiologic Studies Depression Scale, a well-validated
and reliable measure (CES-D; Radloff, 1977). The CES-D is a 20-item
scale that measures depressive symptoms (e.g., I felt depressed; I
could not get going). Participants reported how often in the past
week they have felt each symptom using a 4-point Likert scale that
ranges from 0 (rarely or none/less than one day) to 3 (most/5 to 7
days). As needed, items were reverse coded and a sum score was
calculated, with higher scores indicating greater depressive symp-
tomatology (Women’s HOUR: α = .93; M. O. M. Study: α = .93).
Overview of Analyses. Preliminary analyses were conducted with
all potential covariates (i.e., marital status, race/ethnicity, income,
education, employment status, age, number of kids 16 years or
younger, number of people in the household, and study) entered
simultaneously into multiple linear regression analyses predicting
each major study variable. Based on these preliminary analyses, the
following variables were retained as covariates because they were
significantly related to at least one of the major study variables:
race/ethnicity (1 = White; 0 = minority), education (continuous
variable of years of education completed), employment status (0 =
unemployed; 1 = employed), and study (0 = Women’s HOUR; 1 =
M. O. M. Study). To test the mediational model proposed in Figure
1, we used structural equation modeling (SEM) (with the software
EQS 6.1; Bentler, 2006) to examine a structural path model based on
our hypothesized relations. SEM allows us to test all components of
the mediational model simultaneously while also modeling mea-
surement error of endogenous variables. Preliminary examination
of the data revealed that all of the assumptions of SEM (e.g., lin-
earity, multivariate normality, random residuals) were met in the
current dataset. Examination of the bivariate correlation matrix also
did not reveal any problems with multicollinearity (see Table 1).
918 MICKELSON AND WILLIAMS
RESULTS
PRELIMINARY AND DESCRIPTIVE ANALYSES
Because the internalized and experienced stigma measures are
relatively new and untested in prior research, we first conducted
a confirmatory factor analysis using structural equation modeling.
In this measurement model, internalized and experienced stigma
were defined as latent factors consisting of four indicators each (i.e.,
the 4 items used to assess each dimension). The indicator path that
accounted for the most variance in the respective latent factor was
fixed at 1.0. The measurement model was an adequate fit to the data,
χ
2
(79, N = 210) = 45.12, p < .001, CFI = .94, SRMR = .05, RMSEA = .08
(CI = .05, .11), with no suggestion of cross-loading indicators. Please
note that the significance of the chi-square test is not a reliable way
to measure fit of a model (Hoyle, 1995; Kline, 2005), due to its sen-
sitivity to sample size, size of correlations in the model, complexity
of the model, and even minor violations of multivariate normality.
Rather, it is more appropriate to examine whether the comparative
fit index (CFI) is above .90, the standardized root mean-square re-
sidual (SRMR) is .05 or lower, and the root mean squared error ap-
proximation (RMSEA) is less than .10 (with an RMSEA of .06 to .08
suggesting an adequate fit and less than .05 suggesting a good fit).
As shown in Table 2, women reported high levels depression. Tra-
ditionally, a score of 16 or higher on the CES-D has been used as a
marker for people who may suffer from clinical levels of depression
(see McDowell, 2006, for a review)—the mean for the women in this
study is 23. Participants from the two studies only differed signifi-
cantly on perceived support availability, with participants from the
Women’s HOUR reporting greater support availability (M = 3.22)
than participants in the MOM study (M = 2.60). For all of the other
major study variables, participants from the two studies did not dif-
fer in their means. Thus, for the remaining analyses, results will be
discussed for the combined samples.
POVERTY AND DEPRESSION 919
TABLE 2. Descriptive Statistics of Major Study Variables
Total Sample Women’s HOUR MOM Study
Mean (SD) Actual Range Mean (SD) Mean (SD) F(1,208)
Perceived Stigma
Internalized 3.43 0.93 (1-5) 3.33 0.88 3.52 0.98 2.14
Experienced 2.91 1.03 (1-5) 2.94 1.10 2.89 0.96 0.09
Self-Esteem 28.82 6.03 (12-40) 28.68 5.74 28.95 6.31 0.10
Social Support
Perceived Availability 2.76 0.82 (1-5) 3.08 0.86 2.48 0.66 32.58*
Fear of Rejection 2.47 1.08 (1-5) 2.57 1.12 2.39 1.03 1.49
Depression 23.09 13.58 (0-56) 23.18 14.23 23.00 13.03 0.01
*p < .001.
920 MICKELSON AND WILLIAMS
EXPLANATORY MECHANISMS IN THE
PERCEIVED STIGMA-DEPRESSION PROCESS
In order to test the mediational model, the data were analyzed us-
ing a structural path model. Based on regression analyses with the
major study variables, race/ethnicity, education, employment sta-
tus, and study were included as exogenous variables and left ini-
tially free to affect all other variables. Employment status was not
significantly associated with any of the study variables and was re-
moved from the model. In the final model, significant paths were
retained for (1) education with self-esteem, (2) race/ethnicity with
internalized and experienced stigma, self-esteem, and depression,
and (3) study with perceived support availability and internalized
stigma. In addition, study and race/ethnicity were correlated. In-
cluding these variables ensured that any initial inequalities among
participants were accounted for by the model, which allowed us to
assess the unique effects of the main study variables. Although we
retained the three covariates and the above paths in the final model,
for ease of presentation, they are not shown in Figure 2.
Maximum likelihood (ML) estimation method was used, as the
multivariate normality assumption was not violated. Only four
women (1.9%) had missing data (one for depression, two for fear
of rejection, and one for an item on experienced stigma); in the first
three cases, sample mean imputation was used as the participants
were missing data on all items that composed the specific mea-
sure. For the participant who was missing one item on experienced
stigma, a mean imputation was used based on her completed expe-
rienced stigma items. Based on the sample size recommendations
by Bentler (2006), the present sample size (N = 210) is sufficient to
test our proposed model including covariates with a 7.5:1 N:q ratio
(where q represents the number of free parameter estimates)—the
recommended ratio is between 5:1 and 10:1 (i.e., 5 to 10 cases for
every parameter estimate). The N:q ratio is considered a good as-
sessment of power because it considers the complexity of model
to be estimated, rather than simply the number of observed/mea-
sured variables in the model (Jackson, 2003). Finally, the model was
properly overidentified, with 45 known parameters to 28 unknown
parameters.
POVERTY AND DEPRESSION 921
Due to sample size and power issues, we tested our hypothesized
model as a structural path model, with the predictors, mediators,
and outcome all represented as observed variables. Additionally,
direct pathways were added from internalized and experienced
stigma to depression in order to determine whether mediation was
complete or partial. Our hypothesized model fit the data well, χ
2
(21,
N = 210) = 23.08, p = .15, CFI = .98, SRMR = .05, RMSEA = .04 (CI =
.00, .08). We next conducted separate tests for each of the individual
mediators using the Sobel test of indirect effects. In these tests with
the direct effects included, self-esteem emerged as a highly signifi-
cant mediator (z = 6.35, p < .001) between internalized stigma and
Perceived
Support
Availability
Fear of
Support
Rejection
Self-Esteem
Depression
-.18
**
-.50
***
-.54
***
.17
**
.94
.91
.80
.72
.19
**
-.22
**
.18
*
.48
***
.96
.99
Experienced
Stigma
Internalized
Stigma
.22
**
FIGURE 2. Final Trimmed Mediational Model.
Note. Race/ethnicity, education, and study were included in the final
model, but are not represented in the figure for ease of presentation (the
authors will provide the model with these variables and their pathways
represented, upon request). The disturbance terms between Internalized
Stigma and Experienced Stigma and between Perceived Support Availability
and Fear of Support Rejection were allowed to correlate because it is
assumed that they share at least one common omitted cause (Kline,
2005). Standardized parameters estimates are presented in the model;
significance levels for these paths are based on the unstandardized
estimates as EQS does not provide standard errors to conduct significance
tests for standardized estimates. Parameters with a significance of p >
.05 were deleted from the final model. *p ≤ .05 **p ≤ .01 ***p ≤ .001.
922 MICKELSON AND WILLIAMS
depression, whereas fear of rejection of support requests was only
marginally significant for both internalized stigma (z = 1.95, p =
.05) and experienced stigma (z = 2.09, p = .04). Perceived support
availability was not a significant mediator (z = -0.42, p = ns) of the
relationship between experienced stigma and depression. More-
over, the paths from experienced stigma to depression and from
perceived support availability to depression were not significant.
A “trimmed” model that eliminated the paths from experienced
stigma to depression and from perceived support availability to de-
pression fit the data the same as the original model, χ
2
(19, N = 210) =
26.21, p = .12, CFI = .98, SRMR = .05, RMSEA = .04 (CI = .00, .08). The
change in chi-square from the original model was not significant
(∆χ
2
= 3.13, p = .22), suggesting no significant change in fit. The stan-
dardized estimates for the final trimmed model are shown in Figure
2. This structural equation model suggests that the relation between
internalized stigma and depression was partially mediated by im-
paired self-esteem and fear of rejection of support requests, whereas
experienced stigma was related to depression only through fear of
rejection of support requests. Experienced stigma had a direct asso-
ciation with perceived support availability, but this social support
variable did not act as a mediator.
Although the model is theoretically based, the direction of me-
diation cannot be determined because the data are cross-section-
al. As suggested by Kline (2005), an alternative model was tested
to potentially rule out other plausible models. In this alternative
model, both internalized and experienced stigma were modeled as
mediators between perceived support availability, fear of rejection,
self-esteem and depression. In other words, those with low social
support and self-esteem may be more likely to internalize and ex-
perience stigma with their financial situation which, in turn, would
be related to their depression. However, SEM analyses showed that
this model did not fit the data as well as the hypothesized model,
χ
2
(20, N = 210) = 135.33, p < .001, CFI = .70, SRMR = .12, RMSEA =
.17 (CI = .14, .19). These results provide additional support for the
proposed mediational model; even so, these results should be inter-
preted with caution as longitudinal studies are needed to replicate
the directionality of the proposed model.
POVERTY AND DEPRESSION 923
DISCUSSION
The present analyses extend prior research on perceived stigma in
two important ways. First, the focus on perceived stigma of poverty
is a novel one. These analyses suggest that having a low income car-
ries with it the potential for strong feelings of stigma even though
many of these individuals’ network members are also low income.
Although other research has examined perceived stigma in the
context of welfare and utilization of means-tested government pro-
grams, the current study analyzes two primary components of per-
ceived stigma of poverty (internalized and experienced) and their
relations to interpersonal and intrapersonal factors. The second
major contribution of the present study is the examination of the
separate pathways by which internalized and experienced stigma
of poverty are related to depression. Prior research has discussed
these ideas, but no one, to date, has ever tested the dual-pathway
model. We discuss the implications of the present findings and di-
rections for future research below.
Overall, women reported feeling more internalized than experi-
enced stigma. In other words, women felt more ashamed of their
poverty than they felt others had treated them differently because
of their poverty. This result is in accordance with prior research
which suggests that actual experiences with stigma or discrimina-
tion by others are relatively infrequent (Scambler & Hopkins, 1986).
Furthermore, as predicted, internalized stigma was related to lower
levels of self-esteem, while experienced stigma was related to less
perceived support availability from network members; and, both
internalized and experienced stigma were related to a greater fear
of rejection of support requests. These results provide preliminary
evidence that the two components of perceived stigma while over-
lapping are also related to different facets of the individual.
The mediational model provides further evidence of the separate
pathways through which internalized and experienced stigma are
associated with depression. Structural equation modeling provided
partial support for our proposed mediational model; internalized
stigma and depression were partially mediated by self-esteem and
fear of rejection of support requests, while experienced stigma links
to depression through fear of rejection of support requests only. In
924 MICKELSON AND WILLIAMS
other words, perceived stigma is not a monolithic construct but
rather multidimensional. It is the combined effect of stereotype
awareness, self-identification, and perceived discrimination that
constitutes perceived stigma. In the context of poverty, even if poor
women rarely experience actual stigma events (such as exclusion,
ridicule, or discrimination), it is their belief that these events are
occurring, or are likely to occur in any given interaction, that color
their interactions with network members. Moreover, their accep-
tance of poverty stereotypes distorts both their general feelings of
self-worth and anticipated reactions from network members. Thus,
both interpersonal and intrapersonal processes are implicated, with
the two dimensions of perceived stigma activating separate and
similar mechanisms to influence depression.
Although fear of support request rejection was a significant in-
terpersonal mediator, perceived support availability was only di-
rectly related to experienced stigma in the multivariate structural
model. This result may be understood given past research which
shows that negative aspects of social support (in this model, fear of
support request rejection) can cancel or outweigh effects of positive
aspects of social support on distress (Newsom, Rook, Nishishiba,
Sorkin, & Mahan, 2005; Rook, 1998). Are other aspects of social sup-
port, not examined in the current study, more likely to act as me-
diators between experienced stigma and depression? One potential
aspect is indirect support seeking. Individuals may be less likely to
ask for support directly if they feel stigmatized. Instead, in an effort
to access the support network, these individuals may hint at their
problems or act sad or upset without disclosing the details of the
problem (Barbee & Cunningham, 1995). Indirect support seeking
strategies might allow the stigmatized to keep their situation par-
tially or fully hidden (Williams & Mickelson, 2007). Nondisclosure
of a stigmatized identity, or of problems related to the stigma, may
reduce the chance for others to think badly of the individual. Thus,
those who feel stigmatized may seek support in these more indirect
ways in order to avoid the feared rejection. However, Barbee and
her colleagues (Barbee et al., 1993; Barbee, Derlega, Sherburne, &
Grimshaw, 1998; Derlega, Winstead, Oldfield, & Barbee, 2003) have
postulated that while direct support seeking strategies are more
likely to be met with approach-related supportive behaviors (e.g.,
solace, problem-solving), indirect support seeking strategies may
more often result in avoidance behaviors by family and friends
POVERTY AND DEPRESSION 925
(e.g., dismissing the problem). As a result, indirect support seek-
ing may, in fact, be related to greater depression. Future research
should more fully examine social support processes to determine
which aspects are involved in the link between experienced stigma
and depression.
Some caveats about the present investigation are in order. In this
study, we used poverty, and specifically poverty in women, as the
stigmatizing condition. Thus, conclusions drawn from this study
may not generalize to men in poverty or to other potentially stig-
matizing conditions. The condition of poverty is unique in that it is
often a shared stigma with other network members. Thus, this type
of shared social stigma may have restricted perceptions of internal-
ized and experienced stigma, as well the association of these stigma
components with fear of rejection by and perceived support avail-
ability from family and friends. Future research also needs to de-
termine whether the dual-pathway model will replicate with other
stigmatizing conditions that vary along dimensions of visibility and
controllability. It is likely that the pathways linking internalized and
experienced stigma with depression will be even stronger in highly
visible and controllable stigmatizing conditions. Next, only one in-
trapersonal mechanism was examined—self-esteem. Others have
discussed the relation of internalized (or self) stigma on self-efficacy
(e.g., Corrigan, Watson, & Barr, 2006; Watson & River, 2005). This and
other intrapersonal mechanisms should be examined for their role
in internalized stigma and depression. Third, the alphas for internal-
ized stigma and fear of support request rejection were less than ideal
in the Women’s HOUR sample. Although there were methodologi-
cal reasons related to these alphas, and the Women’s HOUR study
sample was combined with the MOM study sample, it is possible
that the low alphas may have contributed to an attenuation of the
pathway coefficients in the model. Finally, the results reported here
are qualified by the cross-sectional nature of the design. As internal-
ized and experienced perceived stigma, social support, self-esteem,
and depression were all assessed at the same point in time, we cannot
confirm the temporal relations between variables. Longitudinal in-
vestigations would assist in explicating the causal relations of the me-
diational model. Despite the potential limitations, the current study
did find that internalized and experienced stigma of poverty influ-
ence depression through different pathways, providing the impetus
for future work on other stigmatizing conditions.
926 MICKELSON AND WILLIAMS
What are the applied implications for perceived stigma in the
lives of poor individuals? We have only explored the link between
perceived stigma of poverty and depression, but we suspect that in-
ternalized and experienced stigma perceptions may also impact in-
dividuals’ abilities to pull themselves out of poverty—as evidenced
by research on welfare stigmas and social service utilization (e.g.,
Horan & Austin, 1974; Jarrett, 1996; Kerbo, 1976; Stuber & Krone-
busch, 2004). Policy and interventions need to focus on the issue of
impaired self-esteem and fear of rejection by others in order to make
poor women feel more comfortable in getting assistance. Women
would benefit from interventions that de-emphasize blame and fo-
cus on active solutions. Future research should examine the process
by which internalized and experienced stigma impacts poor indi-
viduals’ educational and employment motivations, as well as their
attributions for their poverty. The present study also emphasizes
that an individual’s personal feelings of shame and their actual ex-
periences with societal stigma and discrimination are intertwined.
By examining both dimensions of perceived stigma, we can begin
to understand how internalized and experienced stigma work sepa-
rately and in concert with each other, which will allow us to ad-
vance stigma theory and research.
REFERENCES
Barbee, A. P., & Cunningham, M. R. (1995). An experimental approach to social sup-
port communications: Interactive coping in close relationships. In B. R. Bur-
leson (Ed.), Communication yearbooks/18 (pp. 381-413). Thousand Oaks, CA:
Sage.
Barbee, A. P., Cunningham, M. R., Winstead, B. A., Derlega, V. J., Gulley, M. R., Yan-
keelov, P. A., & Druen, P. B. (1993). The effects of gender role expectations on
the social support process. Journal of Social Issues, 49, 175-190.
Barbee, A. P., Derlega, V. J., Sherburne, S. P., & Grimshaw, A. (1998). Helpful and un-
helpful forms of social support for HIV-positive individuals. In V. J. Derlega
& A. P. Barbee (Eds.), HIV and social interaction (pp. 83-105). Thousand Oaks,
CA: Sage.
Barusch, A. S. (1997). Self-concepts of low-income older women: Not old or poor,
but fortunate and blessed. International Journal of Aging and Human Develop-
ment, 44, 269-282.
Bassuk, E. L., Weinreb, L. F., Buckner, J. C., Browne, A., Salomon, A., & Bassuk, S. S.
(1996). The characteristics and needs of sheltered homeless and low-income
housed mothers. Journal of the American Medical Association, 278, 640-646.
Baxter, C. (1989). Investigating stigma as stress in social interactions of parents. Jour-
nal of Mental Deficiency Research, 33, 455-466.
POVERTY AND DEPRESSION 927
Bentler, P. M. (2006). EQS structural equations program manual. Encino, CA: Multivari-
ate Software, Inc.
Blascovich, J., & Tomaka, J. (1991). Measures of self-esteem. In J. Robinson, P. Shav-
er, & L. Wrightsman (Eds.), Measures of personality and psychological attitudes
(pp. 110-121). New York: Academic Press.
Camp, D. L., Finlay, W. M. L., & Lyons, E. (2002). Is low self-esteem an inevitable
consequence of stigma? An example from women with chronic mental health
problems. Social Science and Medicine, 55, 823-834.
Coffey, P., Leitenberg, H., Henning, K., Turner, T., & Bennett, R. T. (1996). Mediators
of the long-term impact of child sexual abuse: Perceived stigma, betrayal,
powerlessness, and self-blame. Child Abuse and Neglect, 20, 447-455.
Collins, S. B. (2005). An understanding of poverty from those who are poor. Action
Research, 3, 9-31.
Corrigan, P. W., & Calabrese, J. D. (2005). Strategies for assessing and diminishing
self-stigma. In P. W. Corrigan (Ed.), On the stigma of mental illness: Practical
strategies for research and social change (pp. 239-256). Washington, DC: Ameri-
can Psychological Association.
Corrigan, P. W., Watson, A. C., & Barr, L. (2006). The self-stigma of mental illness:
Implications for self-esteem and self-efficacy. Journal of Social and Clinical Psy-
chology, 25, 875-884.
Crandall, C. S. (1991). AIDS-related stigma and the lay sense of justice. Contemporary
Social Psychology, 15, 66-67.
Crandall, C.S., & Coleman, R. (1992). AIDS-related stigmatization and the disruption
of social relationships. Journal of Social and Personal Relationships, 9, 163-177.
Demi, A., Bakeman, R., Moneyham, L., Sowell, R., & Seals, B. (1997). Effects of re-
sources and stressors on burden and depression of family members who pro-
vide care to an HIV-infected woman. Journal of Family Psychology, 11, 35-48.
Derlega, V. J., Winstead, B. A., Oldfield, E. C., & Barbee, A. P. (2003). Close relation-
ships and social support in coping with HIV: A test of sensitive interaction
systems theory. AIDS & Behavior, 7, 119-129.
Derogatis, L. R. (1994). Symptom checklist-90-R: Administration, scoring, and procedures
manual. Minneapolis, MN: National Computer Systems.
Devins, G. M., Stam, H., & Koopmans, J. P. (1994). Psychological impact of laryn-
gectomy mediated by perceived stigma and illness intrusiveness. Canadian
Journal of Psychiatry, 39, 608-616.
Dunkel-Schetter, C., Feinstein, L., & Call, J. (1987). UCLA social support inventory. Los
Angeles: University of California.
Fife, B. L., & Wright, E. R. (2000). The dimensionality of stigma: A comparison of its
impact on the self of persons with HIV/AIDS and cancer. Journal of Health and
Social Behavior, 41, 50-67.
Gibbons, F. X. (1985). A social-psychological perspective on developmental disabili-
ties. Journal of Social and Clinical Psychology, 3, 391-404.
Goffman, E. (1963). Stigma: Notes on the management of spoiled identity. Englewood
Cliffs, NJ: Prentice.
Hermann, B. P., Whitman, S., Wyler, A. R., Anton, M. T., & Vanderzwagg, R. (1990).
Psychosocial predictors of psychopathology in epilepsy. British Journal of Psy-
chiatry, 156, 98-105.
Horan, P. M., & Austin, P. L. (1974). The social bases of welfare stigma. Social Prob-
lems, 21, 648-657.
928 MICKELSON AND WILLIAMS
Hoyle, R. H. (1995). Structural equation modeling: Concepts, issues, and applications.
Thousand Oaks, CA: Sage Publications.
Jackson, D. L. (2003). Revisiting sample size and number of parameter estimates:
Some support for the N:q hypothesis. Structural Equation Modeling, 10,
128-141.
Jacoby, A. (1994). Felt versus enacted stigma: A concept revisited: Evidence from
a study of people with epilepsy in remission. Social Science and Medicine, 38,
269-274.
Jarrett, R. L. (1996). Welfare stigma among low-income, African American single
mothers. Family Relations, 45, 368-374.
Jones, E. E., Farina, A., Hastorf, A. H., Markus, H., Miller, D. T., & Scott, R. A. (1984).
Social stigma: The psychology of marked relationships. New York: Freeman.
Kahng, S. K., & Mowbray, C. T. (2005). What affects self-esteem of persons with
psychiatric disabilities: The role of causal attributions of mental illnesses. Psy-
chiatric Rehabilitation Journal, 28, 354-361.
Kent, G. (1999). Correlates of perceived stigma in vitiligo. Psychology and Health, 14,
241-251.
Kerbo, H. R. (1976). The stigma of welfare and a passive poor. Sociology and Social
Research, 60, 173-187.
Kline, R. B. (2005). Principles and practice of structural equation modeling (2
nd
ed.; pp.
63-66). New York: Guilford Press.
Levinson, R. M., & Starling, D. M. (1981). Retardation and the burden of stigma.
Deviant Behavior, 2, 371-390.
Link, B. G., Cullen, F. T., Struening, E. L., Shrout, P. E., & Dohrenwend, B. (1989). A
modified labeling theory approach to mental disorders: An empirical assess-
ment. American Sociological Review, 54, 400-423.
Link, B. G., & Phelan, J. C. (2001). Conceptualizing stigma. Annual Review of Sociol-
ogy, 27, 363-385.
Link, B. G., Struening, E. L., Neese-Todd, S., Asmussen, S., & Phelan, J. C. (2001).
Stigma as a barrier to recovery: The consequences of stigma for self-esteem of
people with mental illnesses. Psychiatric Services, 52, 1621-1626.
Link, B. G., Struening, E. L., Rahav, M., Phelan, J. C., & Nuttbrock, L. (1997). On stig-
ma and its consequences: Evidence from a longitudinal study of substance
abuse. Journal of Health and Social Behavior, 38, 177-190.
Lott, B. (2002). Cognitive and behavioral distancing from the poor. American Psy-
chologist, 57, 100-110.
MacDonald, L. D., & Anderson, H. R. (1984). Stigma in patients with rectal cancer: A
community study. Journal of Epidemiology and Community Health, 38, 284-290.
Major, B., Quinton, W. J., & McCoy, S. K. (2002). Antecedents and consequences of
attributions to discrimination: Theoretical and empirical advances. Advances
in Experimental Social Psychology, 34, 251-330.
Mansouri, L., & Dowell, D. A. (1989). Perceptions of stigma among the long-term
mentally ill. Psychosocial Rehabilitation Journal, 13, 79-91.
Markowitz, F. E. (1998). The effects of stigma on the psychological well-being and
life satisfaction of persons with mental illness. Journal of Health and Social Be-
havior, 39, 335-347.
McDowell, I. (2006). Measuring health: A guide to rating scales and questionnaires (pp.
350-358). New York: Oxford Press.
POVERTY AND DEPRESSION 929
McMullin, J. A., & Cairney, J. (2004). Self-esteem and the intersection of age, class,
and gender. Journal of Aging Studies, 18, 75-90.
Mickelson, K. D. (2001). Perceived stigma, social support, and depression. Personal-
ity and Social Psychology Bulletin, 27, 1046-1056.
Mirowsky, J. &, Ross, C. E. (1986). Social patterns of distress. Annual Review of Sociol-
ogy, 12, 23-45.
Newsom, J. T., Rook, K. S., Nishishiba, M., Sorkin, D. H., & Mahan, T. L. (2005).
Understanding the relative importance of positive and negative social ex-
changes: Examining specific domains and appraisals. Journals of Gerontology:
Series B: Psychological Sciences and Social Sciences, 60B, 304-312.
Nolen-Hoeksema, S. (2001). Gender differences in depression. Current Directions in
Psychological Science, 10, 173-176.
Ostrove, J. M., & Adler, N. E. (1998). The relationship between socio-economic sta-
tus, labor force participation, and health among men and women. Journal of
Health Psychology, 3, 451-463.
Radloff, L. S. (1977). The CES-D scale: A self-report depression scale for research in
the general population. Applied Psychological Measurement, 1, 385-401.
Rook, K. S. (1998). Investigating the positive and negative sides of personal relation-
ships: Through a lens darkly? In B. H. Spitzberg & W. R. Cupach (Eds.), The
dark side of close relationships (pp. 369-393). Mahwah, NJ: Lawrence Erlbaum
Associates.
Rosenberg, M. (1965). Society and the adolescent self-image. Princeton, NJ: Princeton
University Press.
Rosenfield, S. (1997). Labeling mental illness: The effects of received services and per-
ceived stigma on life satisfaction. American Sociological Review, 62, 660-672.
Rybarczyk, B. D., Nyenhuis, D. L., Nicholas, J. J., Cash, S. M., & Kaiser, J. (1995).
Body image, perceived social stigma, and the prediction of psychosocial ad-
justment to leg amputation. Rehabilitation Psychology, 40, 95-110.
Scambler, G., & Hopkins, A. (1986). Being epileptic: Coming to terms with stigma.
Sociology and Health and Illness, 8, 26-43.
Stuber, J., & Kronebusch, K. (2004). Stigma and other determinants of participa-
tion in TANF and Medicaid. Journal of Policy Analysis and Management, 23,
509-530.
Stuber, J., & Schlesinger, M. (2006). Sources of stigma for means-tested government
programs. Social Science & Medicine, 63, 933-945.
Swendeman, D., Rotheram-Borus, M. J., Comulada, S., Weiss, R., & Ramos, M. E.
(2006). Predictors of HIV-related stigma among young people living with
HIV. Health Psychology, 25, 501-509.
U.S. Bureau of the Census (2006). Poverty in the United States: 2005 (Rep. No. Current
Population Reports, Series P60-231). Authored by DeNavas-Walt, C., Proctor,
B.D., & Lee, C. H.; Washington, DC: US Government Printing Office.
Vogel, D. L., Wade, N. G., & Hackler, A. H. (2007). Perceived public stigma and the
willingness to seek counseling: The mediating roles of self-stigma and atti-
tudes toward counseling. Journal of Counseling Psychology, 54, 40-50.
Watson, A. C., & River, L. P. (2005). A social-cognitive model of personal responses
to stigma. In P. W. Corrigan (Ed.), On the stigma of mental illness: Practical strat-
egies for research and social change (pp. 145-164). Washington, DC: American
Psychological Association.
930 MICKELSON AND WILLIAMS
Waxman, C. I. (1983). The stigma of poverty: A critique of poverty theories and policies.
New York: Pergamon Press.
Westbrook, L. E., Bauman, L. J., & Shinnar, S. (1992). Applying stigma theory to
epilepsy: A test of a conceptual model. Journal of Pediatric Psychology, 17,
633-649.
Williams, S. L., & Mickelson, K. D. (2007). A paradox of support seeking and rejection
among the stigmatized. Personal Relationships.
Wills, T. A., & Shinar, O. (2000). Measuring perceived and received social support.
In S. Cohen, L. G. Underwood, & B. H. Gottlieb (Eds.), Social support measure-
ment and intervention (pp.86-135). New York: Oxford University Press.
