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Shame among Forensic and Non-Forensic Patients and the Impact of the Social Determinants of Health: A Pilot Study
Abstract
Shame is associated with various mental health and social difficulties.
A broad range of social factors increase the risk of shame
among individuals. One group that experiences increased
shame due to their mental health diagnoses and criminal justice
involvement is forensic patients. The purpose of this pilot study
was to compare shame levels in forensic and non-forensic
patients with a diagnosis of schizophrenia or other psychotic
disorder, and to examine whether any social determinants of
health impacted the levels of shame among both groups. A selfreport
shame questionnaire and a measure of experiences with
various social determinants of health were completed by 43
patients with schizophrenia or other psychotic disorder (22
forensic and 21 non-forensic patients). Statistical analyses
revealed no significant differences in levels of shame between
the forensic and non-forensic patients. Early life experience as
well as employment and working conditions had the most
significant impact on shame levels for both forensic and nonforensic
patients. We also found a significant difference
between forensic and non-forensic scores in employment and
working conditions (p = .046), with forensic patients rating their
experiences with this factor as more positive than non-forensic
participants. Clinical implications are discussed.
INTRODUCTION: Internalized stigmatization indicates the internal acceptance of public stigmatization. Double stigma refers to stigmatization due to more than one personality characteristic. We aimed to investigate the levels of self-stigma and perceptions towards delinquents about both psychiatric disorders and forensic psychiatry hospitalization among male patients hospitalized in the high-security forensic psychiatry service in Turkiye.
METHODS: This cross-sectional study was conducted with 76 male participants. Sociodemographic, clinical, and offense-related variables were defined by interviewing patients and families and examining all records. Perceptions Towards Criminals Scale(PTCS), Self-Stigma Scale(SSS), and Violence Profile of Current Offense Scale were administered to the participants.
RESULTS: The participants' SSS total score was 37.73±16.4, the Internalized Devaluation subdimension score was 17.91±8.19, the Internalized Stereotypes score was 14.77±7.51 and the Social Withdrawal and Concealment Disorder score was 4.77±2.70. The total PTCS score was 32.30±10.38, the Perception of Moral and Personality Traits Subscale score was 21.16±7.23 and the Perceptions of Social Networks subscale score was 11.16±4.03. PTCS social network score was relatively more negative in the patients who received regular antipsychotic treatment before hospitalization compared to those who did not adhere to the treatment(p=0.043).
DISCUSSION AND CONCLUSION: The results of the study are important in terms of examining both internalized stigma and perceptions towards delinquency in male forensic patients diagnosed with schizophrenia. Another result is perceptions of the social networks of delinquency are more negative in the patient group receiving regular treatment. The results of the study do not support high self-stigma levels in the forensic psychiatry population, contrary to the double stigma theory and previous studies conducted in our country. The disparities between the results and the literature could be due to investigating the research with different cultural populations. It will be possible to prevent the effects of stigma on forensic patients and to develop appropriate strategies for the management of self-stigma with stigma studies.
Purpose
This study aimed to investigate the effects of media reporting of a homicide committed by a patient with schizophrenia on the knowledge about and stigma regarding psychosis among the general Hong Kong population. The effects of using the term ‘schizophrenia (jing-shen-fen-lei)’ in the news on the perceptions of the new Chinese term ‘psychosis (si-jue-shi-tiao)’ were explored.
Methods
Random telephone surveys of the general Hong Kong population were conducted in April 2009 (1 month before the incident) and June 2009 (1 week after the incident). Stigma was measured with the Link’s Perceived Discrimination-Devaluation Scale (LPDDS). Knowledge about the symptoms, treatment and belief of dangerousness of psychosis were assessed. The emotional reaction of the public to the news was explored, and its effects on knowledge and stigma were studied.
Results
Overall, 1016 and 506 participants completed the two surveys. More participants in the post-incident survey agreed that people with psychosis are dangerous to the public (χ² = 4.934, p = 0.026). However, no significant differences were observed in the LPDDS scores. Participants who reported a high level of distress related to the news were more likely to perceive people with psychosis as dangerous to the public (χ² = 6.738, p = 0.009). Women and older people reported greater distress.
Conclusions
These findings suggest that media reporting of violent incidents involving people with schizophrenia increases the public belief in the dangerousness of people with psychosis but not the overall stigma. Further studies of the differential effects of violence reporting on public perceptions about people with psychosis and schizophrenia are warranted.
Objectives To examine whether self-stigma mediates the relationship between perceived stigma and quality of life, self-esteem and general functioning among outpatients with depression, schizophrenia, anxiety and obsessive-compulsive disorder (OCD).
Design Cross-sectional survey.
Setting Outpatient clinics at a tertiary psychiatric hospital in Singapore.
Participants 280 outpatients with a primary clinical diagnosis of either schizophrenia, depression, anxiety or OCD.
Methods Data were collected in relation to self-stigma, perceived stigma, self-esteem, functioning and quality of life. In order to examine the mediating role of self-stigma on the relationship between perceived stigma and psychosocial outcomes, bootstrapping mediation analyses were used.
Results Mediation analyses revealed that the relationship between perceived stigma and psychosocial outcomes was subject to the effects of self-stigma among the overall sample. Separate mediation analyses were conducted by diagnoses and showed differences in the mediating effects of self-stigma. Among the whole sample and the subsample with OCD, self-stigma mediated the relationship between perceived stigma and all psychosocial outcomes. For those with anxiety, depression and schizophrenia, the mediating effects of self-stigma were present in all relationships except (1) perceived stigma with physical health in the anxiety sample, (2) perceived stigma with social relationships in the depression sample and (3) perceived stigma with physical health in the schizophrenia sample.
Conclusions The mediating effects of self-stigma on the relationship between perceived stigma and various psychosocial outcomes are evident and differ across diagnoses. Interventions to address and reduce the effects of self-stigma along with targeted treatments and psychoeducation to assist people with mental illness overcome or better manage self-stigma while providing them the skills to counteract public stigma are needed.
Background: Stigma and discrimination may adversely affect the benefits of methadone maintenance treatment (MMT) for drug users, especially in disadvantaged settings. This study assessed stigma and discrimination against MMT patients in the mountainous and rural areas of Vietnam, and explored its associated factors to inform implementation strategies.
Methods: We interviewed 241 MMT patients in two clinics: Tuyen Quang Province’s inner city and Son Dong district, to assess stigma and discrimination that patients perceived and experienced. Socioeconomic status, health behaviors, health status and history of drug abuse were examined. Multivariate linear and logistic regression models were used to explore factors associated with stigma and discrimination.
Results: The majority of respondents reported experiencing stigma and discrimination including blame/judgment (95.1%) shame (95.1%), disclosure (71.4%), and the fear of Human immunodeficiency virus (HIV) transmission by others (74.1%). Unemployed patients were more likely to experience discrimination (Coef= -1.18, 95%CI= -1.87;-0.89). Those who were taking antiretroviral were more likely to disclose their health status (Coef= 2.27, 95%CI=0.6; 3.94). In addition, a higher likelihood of being blamed, judged was associated with those suffered from anxiety/ depression (Coef=1.59, 95%CI= 0.24; 2.93) and (Coef= 1.07, 95%CI=0.36; 1.79) respectively.
Conclusions: MMT patients in these mountainous areas perceived high levels of stigma and discrimination which were associated with mental health disorders, unemployment, and HIV infection. These findings highlighted the importance of reducing drug use and HIV related stigma against high-risk populations. Besides, psychosocial and familial supports, as well as job referrals also play crucial roles in terms of promoting quality of life among MMT patients
Objectives:
To conduct a preliminary study comparing different trauma and clinical populations on types of shame coping style and levels of state shame and guilt.
Methods:
A mixed independent groups/correlational design was employed. Participants were recruited by convenience sampling of 3 clinical populations-complex trauma (n = 65), dissociative identity disorder (DID; n = 20), and general mental health (n = 41)-and a control group of healthy volunteers (n = 125). All participants were given (a) the Compass of Shame Scale, which measures the four common shame coping behaviors/styles of "withdrawal," "attack self," "attack other," and "avoidance," and (b) the State Shame and Guilt Scale, which assesses state shame, guilt, and pride.
Results:
The DID group exhibited significantly higher levels of "attack self," "withdrawal," and "avoidance" relative to the other groups. The complex trauma and general mental health groups did not differ on any shame variable. All three clinical groups had significantly greater levels of the "withdrawal" coping style and significantly impaired shame/guilt/pride relative to the healthy volunteers. "Attack self" emerged as a significant predictor of increased state shame in the complex trauma, general mental health, and healthy volunteer groups, whereas "withdrawal" was the sole predictor of state shame in the DID group.
Conclusions:
DID emerged as having a different profile of shame processes compared to the other clinical groups, whereas the complex trauma and general mental health groups had comparable shame levels and variable relationships. These differential profiles of shame coping and state shame are discussed with reference to assessment and treatment. (PsycINFO Database Record
Within the past decade, empirical evidence has emerged supporting the use of Acceptance and Commitment Therapy (ACT) targeting shame and self-stigma. Little is known about the role of self-compassion in ACT, but evidence from other approaches indicates that self-compassion is a promising means of reducing shame and self-criticism. The ACT processes of defusion, acceptance, present moment, values, committed action, and self-as-context are to some degree inherently self-compassionate. However, it is not yet known whether the self-compassion inherent in the ACT approach explains ACT's effectiveness in reducing shame and stigma, and/or whether focused self-compassion work may improve ACT outcomes for highly self-critical, shame-prone people. We discuss how ACT for shame and stigma may be enhanced by existing approaches specifically targeting self-compassion.
Research has increasingly explored mental illness self-stigma: when people with mental illness believe that society's negative beliefs are true of them. Self-stigma predicts poorer functional and treatment outcomes. Stigma research has typically investigated the impact of a single stigma on people, without considering the potential effects of multiple stigmatizing labels. People with mental illness and a history of criminal conviction, however, may experience multiple stigmas related to mental illness and criminal history. This study investigated the impact of the combination of multiple stigmatized identities on self-esteem, depression, therapeutic alliance, and treatment adherence in a forensic psychiatric sample. It extended previous research on mental illness self-stigma to a forensic psychiatric sample.
Participants (N = 82) were people with mental illness and a history of criminal conviction recruited from their treatment sites. Participants completed self-report questionnaires focused on mental illness and criminality self-stigma, racial self- concept, self-esteem, depression, working alliance, and medication/psychosocial treatment adherence. Researchers confirmed demographics through a chart review and treatment adherence from participants' clinicians. Multiple regression analyses examined the relationship between self-stigma and outcome variables.
Mental illness self-stigma, racial self-concept, and to a lesser extent criminality self-stigma were associated with reduced self-esteem (p ≤ .05) and medication adherence (p ≤ .05). Criminality self-stigma also appeared to magnify the effects of racial and mental illness self-stigma on outcomes.
This study shows that self-stigma related to involvement in the criminal justice system may further contribute to the impact of mental illness self-stigma on important outcomes. Future research and interventions may tailor self-stigma interventions to a forensic psychiatric population. (PsycINFO Database Record
(c) 2015 APA, all rights reserved).
Mental illness remains a pervasive social issue that aff ects the well-being of millions of individuals globally. Despite the overall prevalence of mental illness, increasing numbers of individuals needing mental health treatment do not receive it. Mental Health Stigma (MHS) has been proposed as a signifi cant barrier to seeking/obtaining mental health treatment. Mounting evidence suggests that MHS is experienced in virtually all life domains and that it may signifi cantly influence multiple health outcomes, including treatment seeking behavior. The current review paper uniquely contributes to the literature on MHS in at least four ways. First, this paper provides a recent overview of the prevalence and social costs of mental illness in society. Second, this paper presents a current literature review of MHS and helps to elucidate the impact of MHS on a range of individual outcomes, including psychological and physical health. Third, this paper specifically reviews existing literature on understanding the relationship between MHS and treatment seeking behavior. This is the fi rst known review paper to focus specifi cally on the MHS-treatment seeking relationship. Finally, the paper presents implications for future research on MHS and treatment seeking which may lead to the development of theory-based interventions to address MHS in clinical practice.
Schizophrenia is a serious mental illness that is highly complex and not fully understood. Individuals with serious mental illnesses like schizophrenia experience difficulty trying to access mental health services. Few have the opportunity to receive the most optimal evidence-based treatment and only half of those who do actually adhere to the recommended treatment. Understanding what it is like to have this illness would help in our approaches to treatment.
In-depth interviews were conducted on nine Turkish patients with schizophrenia in order to explore the illness from the perspective of patients in remission.
Five themes emerged from the patients' descriptions of schizophrenia: schizophrenia is a complicated illness, a mystery, a lost life, a dynamic journey towards recovery, and a developmental process of recovery.
This study has identified areas of concern about reflecting the patients' perspectives on their experiences thoroughly, which should help improve healthcare provision and guide future research.
Copyright © 2014 Elsevier Inc. All rights reserved.
Given the theoretical and empirical associations among posttraumatic stress, shame, and interpersonal aggression, this study examined whether trait shame accounts for the associations between posttraumatic stress and aggressive behavior in a sample of 103 men with a history of interpersonal trauma. Results indicated that trait shame accounted for the associations of posttraumatic stress with the variety of both physically and psychologically aggressive behavior, as well as with the frequency of physical aggression. This study also examined trait guilt, given its conceptual relationship to both shame and posttraumatic stress; unlike trait shame, trait guilt did not account for the association between posttraumatic stress and the variety of physically aggressive acts. Additionally, although trait guilt reduced the association between posttraumatic stress and the frequency of physical aggression, the indirect path including guilt was nonsignificant. Taken together, the present study supports existing theories suggesting that shame, but not guilt, may contribute to aggressive behavior, especially among individuals with histories of traumatic exposure. (PsycINFO Database Record
(c) 2015 APA, all rights reserved).
Studies have shown that the experiences and consequences of unemployment can affect people differently depending on, for example, age and gender. The purpose of the present study was to describe young Finnish men's experiences of being unemployed as well as how their experiences of health emerged. Fifteen young unemployed Finnish men in the age range 18 to 27 years were interviewed face to face. Purposive sampling was used to increase the variation among informants. The interview texts were analyzed using both manifest and latent qualitative content analysis. The present results showed that the young men were strongly negatively affected by being unemployed. They described how they had slowly lost their foothold. They also described feelings of shame and guilt as well as a flight from reality. The present results show that even young men who have only experienced shorter periods of unemployment, in this study periods between 2 and 6 months, are negatively affected, for example, with regard to their identity and emotional life. Further research is needed to describe and elucidate in more detail the effects of unemployment on men of different ages and living in different contexts.
Psychological research using mostly cross-sectional methods calls into question the presumed function of shame as an inhibitor of immoral or illegal behavior. In a longitudinal study of 476 jail inmates, we assessed shame proneness, guilt proneness, and externalization of blame shortly after incarceration. We interviewed participants (N = 332) 1 year after release into the community, and we accessed official arrest records (N = 446). Guilt proneness negatively and directly predicted reoffense in the 1st year after release; shame proneness did not. Further mediational modeling showed that shame proneness positively predicted recidivism via its robust link to externalization of blame. There remained a direct effect of shame on recidivism: Unimpeded by defensive externalization of blame, shame inhibited recidivism. Items assessing a motivation to hide were primarily responsible for this pattern. Overall, our results suggest that the pain of shame may have two faces-one with destructive potential and the other with constructive potential.
Drawing on the self-injury and self-conscious emotion literatures, this study examined the functions of and motivations for self-injury in 67 women, 25 of whom had a history of nonsuicidal self-injury (NSSI). Specifically, the present study tested whether women with a history of NSSI engaged in such behavior in order to reduce shame, in particular, and whether shame-related constructs represent important motivational factors for NSSI. To do so, participants completed (a) self-reports of NSSI functions and relevant personality dimensions (e.g., shame-proneness; shame aversion); and (b) a pain-inducing laboratory task with assessments of state emotions pre- and post-task. Elevations in aversion to general negative affect were associated with presence (vs. absence) of an NSSI history. However, consistent with a role for shame in NSSI, among women with an NSSI history, endorsement of shame regulation functions was positively associated with the frequency of NSSI. Moreover, elevations in shame-proneness were associated with more frequent NSSI, even after taking relevant, broader personality dimensions (e.g., proneness to general negative affect) into account. Finally, following the laboratory task, women with and without an NSSI history experienced reductions in state shame. Future directions for and clinical implications of the present research are discussed. (PsycINFO Database Record (c) 2013 APA, all rights reserved).
Focussing on the psychosocial dimensions of poverty, the contention that shame lies at the ‘irreducible absolutist core’ of the idea of poverty is examined through qualitative research with adults and children experiencing poverty in diverse settings in seven countries: rural Uganda and India; urban China; Pakistan; South Korea and United Kingdom; and small town and urban Norway. Accounts of the lived experience of poverty were found to be very similar, despite massive disparities in material circumstances associated with locally defined poverty lines, suggesting that relative notions of poverty are an appropriate basis for international comparisons. Though socially and culturally nuanced, shame was found to be associated with poverty in each location, variably leading to pretence, withdrawal, self-loathing, ‘othering’, despair, depression, thoughts of suicide and generally to reductions in personal efficacy. While internally felt, poverty-related shame was equally imposed by the attitudes and behaviour of those not in poverty, framed by public discourse and influenced by the objectives and implementation of anti-poverty policy. The evidence appears to confirm the negative consequences of shame, implicates it as a factor in increasing the persistence of poverty and suggests important implications for the framing, design and delivery of anti-poverty policies.
Although many incarcerated offenders suffer from major mental disorders, little is known about their criminality. The present study addressed two hypotheses: (a) mentally disordered inmates, as compared to nondisordered inmates, would have a history of more convictions and more convictions for violent offenses; (b) among the mentally disordered, those with co-occurring antisocial personality disorder (APD) would have more total convictions and more convictions for violent offenses. A representative sample of male inmates of the penitentiaries situated in Quebec were examined. Mental health was assessed using the Diagnostic Interview Schedule. Comparisons were made between the 107 inmates who had suffered at least one episode of a major mental disorder and the other 349 inmates. The first hypothesis was not supported, as it was found that the criminal careers of mentally disordered and nondisordered inmates differed little. However, the hypothesis that APD combined with major mental disorder increases the risk of crime was supported; the risk of violent crime, however, was not increased. The results argue for the existence of two distinct groups of mentally disordered inmates.
Recent mental illness stigma research has almost exclusively studied community and family responses to the stigmas of mental illness. Too little has been done to understand the current subjective experience of psychiatric patients. Our study explores the influence of self-stigma on the quality of life of mentally disabled people. Participating in the survey were 100 people diagnosed with schizophrenia. Using Ritsher's Internalized Stigma of Mental Illness Scale, which incorporates alienation, stereotype endorsement, discrimination experience, social withdrawal, and social resistance subscales, along with the standard SF-12, helped us evaluate the subjective experience of mental illness stigma. According to our survey data, self-stigma correlates negatively with all of the quality of life measures except the Internalized Stigma of Mental Illness subscale's 'stigma resistance', which did not correlate significantly. Improved stigma resistance requires an understanding of one's sociocultural background and a strong social network to provide the sense of comfort and security that enables a fulfilling life.
Social wariness and anxiety can take different forms. Paranoid anxiety focuses on the malevolence of others, whereas social anxiety focuses on the inadequacies in the self in competing for social position and social acceptance. This study investigates whether shame and shame memories are differently associated with paranoid and social anxieties.
Shame, traumatic impact of shame memory, centrality of shame memory, paranoia and social anxiety were assessed using self-report questionnaires in 328 participants recruited from the general population.
Results from path analyses show that external shame is specifically associated with paranoid anxiety. In contrast, internal shame is specifically associated with social anxiety. In addition, shame memories, which function like traumatic memories, or that are a central reference point to the individual's self-identity and life story, are significantly associated with paranoid anxiety, even when current external and internal shame are considered at the same time. Thus, traumatic impact of shame memory and centrality of shame memory predict paranoia (but not social anxiety) even when considering for current feelings of shame.
Our study supports the evolutionary model suggesting there are two different types of ‘conspecific’ anxiety, with different evolutionary histories, functions and psychological processes. Paranoia, but less so social anxiety, is associated with traumatic impact and the centrality of shame memories. Researchers and clinicians should distinguish between types of shame memory, particularly those where the self might have felt vulnerable and subordinate and perceived others as threatening and hostile, holding malevolent intentions towards the self. Copyright
This article examines the extent of stigma and discrimination as reported by people with a diagnosis of schizophrenia. The hypothesis is that when people express in their own words the discrimination they experience such discrimination will be found to be widespread.
Seventy-five people with a diagnosis of schizophrenia from 15 different countries were interviewed with a mixed methods instrument to assess reported discrimination. The data were analysed for frequency counts and then a thematic analysis was performed. A conceptual map is provided.
The study was a cross-cultural one but, contrary to expectations, few transnational differences were found. The main hypothesis was supported. Conversely, we found that when participants reported 'positive discrimination', this could as easily be conceptualised as being treated similarly to how others in society would expect to be treated.
Negative discrimination is ubiquitous and sometimes connotatively very strong, with reports of humiliation and abuse. 'Positive discrimination' conversely indicates that people with a mental illness diagnosis expect discrimination and are grateful when it does not occur. The literature on self-stigma is discussed and found wanting. Similarly, the theory that contact with mentally ill people reduces stigma and discrimination is not fully supported by our results.
The authors examined age differences in shame, guilt, and 2 forms of pride (authentic and hubristic) from age 13 years to age 89 years, using cross-sectional data from 2,611 individuals. Shame decreased from adolescence into middle adulthood, reaching a nadir around age 50 years, and then increased in old age. Guilt increased from adolescence into old age, reaching a plateau at about age 70 years. Authentic pride increased from adolescence into old age, whereas hubristic pride decreased from adolescence into middle adulthood, reaching a minimum around age 65 years, and then increased in old age. On average, women reported experiencing more shame and guilt; Blacks reported experiencing less shame and Asians more hubristic pride than other ethnicities. Across the life span, shame and hubristic pride tended to be negatively related to psychological well-being, and shame-free guilt and authentic pride showed positive relations with well-being. Overall, the findings support the maturity principle of personality development and suggest that as people age they become more prone to experiencing psychologically adaptive self-conscious emotions, such as guilt and authentic pride, and less prone to experiencing psychologically maladaptive ones, such as shame and hubristic pride.
Many people with schizophrenia experience stigma caused by other people's knowledge, attitudes, and behaviour; this can lead to impoverishment, social marginalisation, and low quality of life. We aimed to describe the nature, direction, and severity of anticipated and experienced discrimination reported by people with schizophrenia.
We did a cross-sectional survey in 27 countries, in centres affiliated to the INDIGO Research Network, by use of face-to-face interviews with 732 participants with schizophrenia. Discrimination was measured with the newly validated discrimination and stigma scale (DISC), which produces three subscores: positive experienced discrimination; negative experienced discrimination; and anticipated discrimination.
Negative discrimination was experienced by 344 (47%) of 729 participants in making or keeping friends, by 315 (43%) of 728 from family members, by 209 (29%) of 724 in finding a job, 215 (29%) of 730 in keeping a job, and by 196 (27%) of 724 in intimate or sexual relationships. Positive experienced discrimination was rare. Anticipated discrimination affected 469 (64%) in applying for work, training, or education and 402 (55%) looking for a close relationship; 526 (72%) felt the need to conceal their diagnosis. Over a third of participants anticipated discrimination for job seeking and close personal relationships when no discrimination was experienced.
Rates of both anticipated and experienced discrimination are consistently high across countries among people with mental illness. Measures such as disability discrimination laws might, therefore, not be effective without interventions to improve self-esteem of people with mental illness.
Background: The literature about perceived stigmatization of forensic patients with schizophrenia is sparse.
Aims: To examine relations between the perceived stigmatization of forensic patients with schizophrenia and the intensity of the symptoms, age, regular home visiting, kind of offence, perceived family support and duration of hospitalization.
Method: Sixty-two male forensic patients with schizophrenia were included. Perceived stigmatization was measured by the modified questions from the World Health Organization Disability Assessment Schedule II. Symptomatology was assessed with the Positive and Negative Syndrome Scale. Perception of family support was assessed with a visual-analogue scale. Due to different characteristics of offences and possibilities for home visiting, patients were divided into groups of those who had committed violent and non-violent offences, and those with and without the possibility of regular home visiting.
Results: Symptoms have an impact on the perception of stigma. The kind of offence committed does not have a significant role in the perception of discrimination. Age was negatively correlated with the perception of stigma.
Conclusion: Results might have significance for a better understanding of social relations between forensic patients and their environment and provide us with information about institutionalized forms of stigma. Results might have implications for the treatment and the quality of life of these patients.
Treatment non-adherence has frequently been noticed among people with schizophrenia. Self-stigma towards one's mental illness is believed to be a contributing factor undermining adherence. This study aimed at obtaining empirical support regarding the relationship between psychosocial treatment adherence and self-stigma. Other significant predictors of adherence to psychosocial interventions were to be identified.
Eighty-six people with DSM IV diagnoses of schizophrenia were recruited from psychiatric hospitals and community settings in Hong Kong. Their level of stigma, self-esteem, self-efficacy, insight, psychosocial treatment adherence and demographic data were collected. Multiple regression was used to investigate the adjusted relationship between psychosocial treatment adherence and the selected independent variables.
Higher level of self-stigma, poorer current insight on the social consequences of having mental illness, and living with others were found to be significant predictors of poor psychosocial treatment attendance. Better self-esteem and current insight about the negative social consequences were significant predictors of better psychosocial treatment participation. Self-stigma and self-esteem exhibited the strongest contributions to psychosocial treatment adherence.
Self-stigmatization is associated with the level of treatment adherence among people with schizophrenia, and its negative effect was found to intensify along the self-stigmatization process. Further studies to enhance understanding of self-stigma and improve treatment adherence are suggested.
More than 15 years ago, findings from the Epidemiological Catchment Area Study indicated that antisocial personality disorder (APD) is more prevalent among persons with schizophrenia than in the general population. The present study analyzed data from a multisite investigation to examine the correlates of APD among 232 men with schizophrenic disorders, three-quarters of whom had committed at least one crime. Comparisons of the men with and without APD revealed no differences in the course or symptomatology of schizophrenia. By contrast, multivariate models confirmed strong associations of comorbid APD with substance abuse, attention/concentration problems, and poor academic performance in childhood; and in adulthood with alcohol abuse or dependence and deficient affective experience (a personality style indexed by lack of remorse or guilt, shallow affect, lack of empathy, and failure to accept responsibility for one's own actions). At first admission, men with schizophrenia and APD presented a long history of antisocial behavior that included nonviolent offending and substance misuse, and an emotional dysfunction that is thought to increase the risk of violence toward others. Specific treatments and management strategies are indicated.
Previous research has demonstrated that shame-proneness (the tendency to feel bad about the self) relates to a variety of life problems, whereas guilt-proneness (the tendency to feel bad about a specific behavior) is more likely to be adaptive. The current analyses sought to clarify the relations of shame-proneness and guilt-proneness to substance use problems in three samples with differing levels of alcohol and drug problem severity: college undergraduates (Study 1 N=235, Study 2 N=249) and jail inmates (Study 3 N=332). Across samples, shame-proneness was generally positively correlated with substance use problems, whereas guilt-proneness was inversely related (or unrelated) to substance use problems. Results suggest that shame and guilt should be considered separately in the prevention and treatment of substance misuse.
Shame plays a central role in social and self-development, particularly throughout childhood and adolescence. Nonetheless, shame can also be harmful if it involves unbearable and persistent feelings of being inferior, inadequate, and worthless. Gender differences in endorsing either internalizing/externalizing symptoms may reflect different ways of coping with shame rather than differences in the experience of shame per se. Using a community adolescent sample (n = 368; 65.8% female), this study investigated the role of external shame and shame coping strategies in the endorsement of externalizing and internalizing symptoms, looking at the moderator role of gender. Although gender differences were found in the endorsement of shame coping strategies and psychological symptoms, results indicated that gender had no impact on the pathways linking external shame and shame coping strategies to psychological symptoms. By clarifying the routes linking external shame to psychological symptoms, current findings may contribute to better define appropriate interventions for adolescents.
Background
Social experiences have a significant impact on cognitive functioning and appraisals of social interactions. Specifically, recalls of antipathy from parents, submissiveness, and bullying during childhood can have a significant influence on paranoid ideation later in life.
Method
Multiple hierarchical regression analysis was performed on a sample of 91 patients diagnosed with paranoid schizophrenia in remission and active phase, their first‐degree relatives (n = 32) and unaffected controls (n = 64).
Objectives
Exploring the impact of distal (events from childhood) and proximal factors (current cognitive, emotional, and behavioural aspects of social functioning) in the frequency, degree of conviction, and distress resulting from paranoid ideation in the participants from 4 samples.
Results
Proximal and distal factors (shame, submissive behaviour, negative social comparison, antipathy from father) predicted several aspects of paranoid ideation. Those variables had a differential impact in affected patients and healthy controls.
Discussion
Finding suggests different variables being involved in paranoid ideation, and the specificities of patients with paranoid schizophrenia should be considered in the development of more effective psychotherapeutic interventions.
Internalised shame and self-esteem have both been proposed to play an integral role in the relationship between stigma and its negative psychological sequalae in people who experience psychosis, but there has been little quantitative exploration to examine their roles further. The aim of this study was to examine the relationship of stigma (experienced and perceived) with emotional distress and recovery in psychosis, and to examine internalised shame and self-esteem as potential mediators. A total of 79 participants were included for the purposes of this study. Participants were administered a battery of assessment measures examining experienced and perceived stigma, internalised shame, self-esteem, depression, hopelessness, and personal recovery. Results illustrated that stigma (experienced and perceived) was significantly associated with internalised shame, low self-esteem, depression, hopelessness and poor personal recovery. Stigma (experienced and perceived) and its relationship with depression, hopelessness and personal recovery was mediated by both internalised shame and low self-esteem. In conclusion, stigma can have significant negative emotional consequences and impede recovery in people with psychosis. This may indicate that stigma needs to be addressed therapeutically for people with psychosis with a particular emphasis on addressing internalised shame and low self-esteem.
Objective:
People with mental illness struggle with symptoms and with public stigma. Some accept common prejudices and lose self-esteem, resulting in shame and self-stigma, which may affect their interactions with mental health professionals. This study explored whether self-stigma and shame are associated with consumers' preferences for participation in medical decision making and their behavior in psychiatric consultations.
Methods:
In a cross-sectional study conducted in Germany, 329 individuals with a diagnosis of a schizophrenia spectrum disorder or an affective disorder and their psychiatrists provided sociodemographic and illness-related information. Self-stigma, shame, locus of control, and views about clinical decision making were assessed by self-report. Psychiatrists rated their impression of the decision-making behavior of consumers. Regression analyses and structural equation modeling were used to determine the association of self-stigma and shame with clinical decision making.
Results:
Self-stigma was not related to consumers' participation preferences, but it was associated with some aspects of communicative behavior. Active and critical behavior (for example, expressing views, daring to challenge the doctor's opinion, and openly speaking out about disagreements with the doctor) was associated with less shame, less self-stigma, more self-responsibility, less attribution of external control to powerful others, and more years of education.
Conclusions:
Self-stigma and shame were associated with less participative and critical behavior, which probably leads to clinical encounters that involve less shared decision making and more paternalistic decision making. Paternalistic decision making may reinforce self-stigma and lead to poorer health outcomes. Therefore, interventions that reduce self-stigma and increase consumers' critical and participative communication may improve health outcomes.
There is an increasing interest in psychological research on shame
experiences and their associations with other aspects of psychological
functioning and well-being, as well as with possible maladaptive
outcomes. In an attempt to confirm and extend previous knowledge on
this topic, we investigated the nomological network of shame
experiences in a large community sample (N D 380; 66.1% females),
adopting a multidimensional conceptualization of shame. Females
reported higher levels of shame (in particular, bodily and behavioral
shame), guilt, psychological distress, emotional reappraisal, and
hostility. Males had higher levels of self-esteem, emotional suppression,
and physical aggression. Shame feelings were associated with low selfesteem,
hostility, and psychological distress in a consistent way across
gender. Associations between characterological shame and emotional
suppression, as well as between bodily shame and anger occurred only
among females. Moreover, characterological and bodily shame added
to the prediction of low self-esteem, hostility, and psychological distress
above and beyond the influence of trait shame. Finally, among females,
emotional suppression mediated the influence of characterological
shame on hostility and psychological distress. These findings extend
current knowledge on the nomological net surrounding shame
experiences in everyday life, supporting the added value of a
multidimensional conceptualization of shame feelings.
High levels of stigma and discrimination are reported by individuals with mental health problems. Aim: To assess self-reported levels of stigma and discrimination in forensic psychiatric patients, with psychotic illness, compared with general adult psychiatric patients with psychosis. Hypothesis: Individuals with a history of violent offending, as well as severe mental illness, report more stigma and discrimination, than non offender patients, as a result of them being perceived as dangerous and unpredictable. Method: Experiences of stigma and discrimination were compared in 32 forensic and 32 non-forensic general psychiatric patients, with schizophrenia or schizoaffective disorder, using the Stigma and Discrimination Scale (DISC). Results: Stigma and discrimination were widely reported by all patients, particularly affecting relationships with family, intimate relationships and friendships. No significant difference emerged between the forensic and non-forensic patients, in experienced or anticipated stigma. Conclusions: We suggest that the lower level of psycho pathology, longer inpatient stays and intensive rehabilitation for forensic patients may reduce the extent to which these patients experience stigma and discrimination.
Young unemployed people in six local communities in Sweden were interviewed to test the assumption that variations in the social and healtn effects of unemployment could be seen as a function of financial hardship and of experiences of shame. The results indicate that there seems to be a link between the health and social effects of unemployment, on the one hand, and the degree of financial hardship and the number of shaming experiences on the other. The group of unemployed people who suffered a greater degree of financial hardship and also experienced a greater number of shaming experiences seemed to exhibit the poorest health, reported deteriorated health to a greater degree than other groups, experienced negative changes in their lifestyle, did less in their free time, and had lower self-confidence than other unemployed persons. The opposite applied for those who experienced less financial hardship and less pressure in terms of experiences of shaming. Against this background, we have formulated a theoretical model based on financial circumstances and social bonds; a model that could have a wider value in explaining social and health problems.
Stigma involves negative beliefs and devaluations of people in socially identified groups, which some people internalize. Research has increasingly explored mental illness self-stigma, when people with mental illness believe society's negative beliefs are true of them (e.g., they are hopeless due to mental illness). Self-stigma predicts poorer functional and treatment outcomes. Forensic psychiatric patients experience multiple stigmas, yet no research has explored how stigmas due to mental illness, race, and criminal history influence each other. This review discusses relevant stigma research, which suggests that self-stigma in forensic psychiatric populations likely interferes with rehabilitation and avoiding re-arrest. Forensic psychiatric stigma is particularly relevant given increasing social attention on violence, incarceration, mental illness, and race. Conclusions discuss targets for future research.
Although shame is one of the most primitive and universal of human emotions, it is often still considered a taboo topic among researchers, practitioners, and clients. This paper presents the empirical foundation for shame resilience theory--a new theory for understanding shame and its impact on women. Using grounded theory methodology, 215 women were interviewed to determine why and how women experience shame and to identify the various processes and strategies women use to develop shame resilience. The article describes the major theoretical categories, including acknowledged vulnerability, critical awareness, and mutually empathic relationships, and introduces the concept of "speaking shame." Practice implications are explored, including the importance of psychoeducational group work in building shame resilience. (PsycINFO Database Record (c) 2012 APA, all rights reserved)(journal abstract)
The current study examined shame in a clinical sample recovering from a first episode of psychosis by focusing on the contribution of different types of shame to post-psychotic trauma while controlling for current affective symptoms.
The study used a cross-sectional correlational design.
Fifty individuals who met the criteria for a psychotic disorder whose acute psychotic symptoms were in remission completed measures of internal and external shame associated with psychosis, general shame, post-psychotic trauma, and depression.
Post-psychotic trauma symptoms were correlated with internal and external shame associated with psychosis and general shame. However, the relation between post-psychotic trauma and external shame associated with psychosis remained after controlling for general shame and current affective symptoms. In addition, internal shame had a stronger association with depression. Thus, internal and external shame due to psychosis had different associations with different types of post-psychotic emotional dysfunction.
The results support the importance of assessing shame as a multi-faceted construct and suggest that assessing shame directly associated with mental illness is a worthwhile endeavour.
Assessing different types of shame following psychosis can inform assessments, formulations, and interventions with post-psychotic trauma. Our results support the application of Compassionate Mind Therapy to psychosis. However, we did not assess self-criticism or self-reassurance. We also did not investigate the relation between specific psychotic symptoms and different types of shame.
The ‘Recovery Approach’ is widely regarded as the guiding principle for mental health service delivery in the UK. However, it is not clear whether this approach has any relevance, or is applicable to mentally disordered offender patients, who are almost invariably detained against their will and whose capacity to exert choice and control over their treatment must therefore be severely restricted. This study set out to explore definitions, experiences, and perceptions of recovery in patients with severe mental illness, currently detained in medium secure psychiatric provision. Most patients defined recovery as getting rid of symptoms and feeling better about themselves. Medication and psychological work, relationships with staff and patients and being in a secure setting were all cited as being important in bringing about recovery. The stigma associated with being an offender, as well as having a serious mental illness, was perceived as a factor holding back recovery, particularly in relation to discharge and independent living in the community. Core recovery concepts of hope, self-acceptance, and autonomy are more problematic and appear to be less meaningful to individuals, who are detained for serious and violent offences. The recovery approach may need to be modified for use in forensic psychiatric services.
A systematic electronic PubMed, Medline and Web of Science database search was conducted regarding the prevalence, correlates, and effects of personal stigma (i.e., perceived and experienced stigmatization and self-stigma) in patients with schizophrenia spectrum disorders. Of 54 studies (n=5,871), published from 1994 to 2011, 23 (42.6%) reported on prevalence rates, and 44 (81.5%) reported on correlates and/or consequences of perceived or experienced stigmatization or self-stigma. Only two specific personal stigma intervention studies were found. On average, 64.5% (range: 45.0-80.0%) of patients perceived stigma, 55.9% (range: 22.5-96.0%) actually experienced stigma, and 49.2% (range: 27.9-77.0%) reported alienation (shame) as the most common aspect of self-stigma. While socio-demographic variables were only marginally associated with stigma, psychosocial variables, especially lower quality of life, showed overall significant correlations, and illness-related factors showed heterogeneous associations, except for social anxiety that was unequivocally associated with personal stigma. The prevalence and impact of personal stigma on individual outcomes among schizophrenia spectrum disorder patients are well characterized, yet measures and methods differ significantly. By contrast, research regarding the evolution of personal stigma through the illness course and, particularly, specific intervention studies, which should be conducted utilizing standardized methods and outcomes, are sorely lacking.
Social science research on stigma has grown dramatically over the past two decades, particularly in social psychology, where researchers have elucidated the ways in which people construct cognitive categories and link those categories to stereotyped beliefs. In the midst of this growth, the stigma concept has been criticized as being too vaguely defined and individually focused. In response to these criticisms, we define stigma as the co-occurrence of its components–labeling, stereotyping, separation, status loss, and discrimination–and further indicate that for stigmatization to occur, power must be exercised. The stigma concept we construct has implications for understanding several core issues in stigma research, ranging from the definition of the concept to the reasons stigma sometimes represents a very persistent predicament in the lives of persons affected by it. Finally, because there are so many stigmatized circumstances and because stigmatizing processes can affect multiple domains of people's li...
When designing a clinical trial an appropriate justification for the sample size should be provided in the protocol. However, there are a number of settings when undertaking a pilot trial when there is no prior information to base a sample size on. For such pilot studies the recommendation is a sample size of 12 per group. The justifications for this sample size are based on rationale about feasibility; precision about the mean and variance; and regulatory considerations. The context of the justifications are that future studies will use the information from the pilot in their design. Copyright © 2005 John Wiley & Sons, Ltd.
The first episode of schizophrenia, usually considered the first five years of the illness brings with it a challenging period of acceptance and adaptation for patients and their families. As part of this process, feelings of shame and guilt about having schizophrenia are common and need to be treated by clinicians in ways that are sensitive to patients deep-rooted feelings that now they are stigmatized. This article examines the intra- and inter-psychic phenomena that contribute to feelings of shame and guilt and offers suggestions with clinical examples of how to work towards losing the stigma. The treatment descriptions and examples are taken from work with 71 patients in the first episode of schizophrenia, many of whom experienced intense feelings of unworthiness, expressed in their words and behavior as guilt and shame.
BACKGROUND: Social anxiety disorder (SAD) is surprisingly prevalent among people with psychosis and exerts significant impact on social disability. The processes that underlie its development remain unclear. The aim of this study was to investigate the relationship between shame cognitions arising from a stigmatizing psychosis illness and perceived loss of social status in co-morbid SAD in psychosis.Method
This was a cross-sectional study. A sample of individuals with SAD (with or without psychosis) was compared with a sample with psychosis only and healthy controls on shame proneness, shame cognitions linked to psychosis and perceived social status. RESULTS: Shame proneness (p<0.01) and loss of social status (p<0.01) were significantly elevated in those with SAD (with or without psychosis) compared to those with psychosis only and healthy controls. Individuals with psychosis and social anxiety expressed significantly greater levels of shame (p<0.05), rejection (p<0.01) and appraisals of entrapment (p<0.01) linked to their diagnosis and associated stigma, compared to those without social anxiety. CONCLUSIONS: These findings suggest that shame cognitions arising from a stigmatizing illness play a significant role in social anxiety in psychosis. Psychological interventions could be enhanced by taking into consideration these idiosyncratic shame appraisals when addressing symptoms of social anxiety and associated distress in psychosis. Further investigation into the content of shame cognitions and their role in motivating concealment of the stigmatized identity of being 'ill' is needed.
A number of accounts of shame and guilt emphasise an association between shame and anger difficulties, and it has been suggested that shame and rage may promote one another. The shame–anger relationship may be particularly relevant to the study of forensic populations, as the fact of having committed a criminal offence has the potential to be a highly shame-provoking experience. The current study investigates the prediction that shame and guilt reactions to an offence are differentially related to the propensity to experience and ability to control anger. A measure of offence-related shame and guilt and a measure of anger experience and control was completed by 60 men detained in forensic psychiatric units. The results supported the prediction that offence-related shame is associated with elevated levels of anger difficulties, whilst offence-related guilt is associated with ability to control anger. The findings of the current study are consistent with those of previous investigations of shame, guilt and anger. Specific implications for the understanding and prevention of violent offending are discussed.
The primary aim of this study was to examine the prospective association of shame with self-inflicted injury (SII), including suicide attempts and nonsuicidal self-injury, among women with borderline personality disorder (BPD) who were enrolled in a clinical trial (N = 77). A multi-method approach was used to assess self-reported shame, nonverbal shame behaviors, and assessor ratings of shame during an interview regarding antecedents for a recent episode of SII. Higher levels of nonverbal shame behaviors predicted a higher likelihood of subsequent SII, and shorter time to SII, after controlling for past SII as well as other emotions associated with SII. Self-reported state shame and assessor ratings of shame were associated with prospective SII, but not after controlling for other emotions. These findings underscore the important role of shame in SII, particularly shame in the presence of contextual prompts for events that surround episodes of SII.
The self-esteem of some people with serious psychiatric disorders may be hurt by internalizing stereotypes about mental illness. A progressive model of self-stigma yields four stages leading to diminished self-esteem and hope: being aware of associated stereotypes, agreeing with them, applying the stereotypes to one's self, and suffering lower self-esteem. We expect to find associations between proximal stages - awareness and agreement - to be greater than between more distal stages: awareness and harm. The model was tested on 85 people with schizophrenia or other serious mental illnesses who completed measures representing the four stages of self-stigma, another independently-developed instrument representing self-stigma, proxies of harm (lowered self-esteem and hopelessness), and depression. These measures were also repeated at 6-month follow-up. Results were mixed but some evidence supported the progressive nature of self-stigma. Most importantly, separate stages of the progressive model were significantly associated with lowered self-esteem and hope. Implications of the model for stigma change are discussed.
Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.
We develop the idea of using data from the first 'few' patients entered in a clinical trial to estimate the final trial size needed to have specified power for rejecting H0 in favour of H1 if a real difference exists. When comparing means derived from Normally distributed data, there is no important effect on test size, power or expected trial size, provided that a minimum of about 20 degrees of freedom are used to estimate residual variance. Relative advantages and disadvantages of using larger internal pilot studies are presented. These revolve around crude expectations of the final study size, recruitment rate, duration of follow-up and practical constraints on the ability to prevent the circulation of unblinded randomization codes to investigators and those involved in editing and checking data.
To compute the sample size needed to achieve the planned power for a t-test, one needs an estimate of the population standard deviation sigma. If one uses the sample standard deviation from a small pilot study as an estimate of sigma, it is quite likely that the actual power for the planned study will be less than the planned power. Monte Carlo simulations indicate that using a 100(1-gamma) per cent upper one-sided confidence limit on sigma will provide a sample size sufficient to achieve the planned power in at least 100(1-gamma) per cent of such trials.
To examine the extent to which the public's desire for social distance from people with schizophrenia is influenced by beliefs about the disorder and stereotypes about those suffering from it.
In spring 2001, we carried out a representative survey of individuals of German nationality aged 18 years and over (n = 5025). Each subject was given a fully structured interview that began with the presentation of a vignette.
Both labelling and beliefs about the disorder's causes and prognosis, as well as the perception that those suffering from it are unpredictable and dangerous, had an impact on the public's desire for social distance. However, the latter proved to be more important. As expected, respondents who identified the disorder depicted in the vignette as mental illness, those who blamed the individual for its development, and those who anticipated a poor prognosis expressed a stronger desire for social distance. Endorsing biological factors as a cause was also associated with increased social distance.
Our findings have important implications for interventions aimed at reducing stigma and discrimination related to schizophrenia. Targeting the stereotype of unpredictability and dangerousness appears to be particularly important.