داغ ننگ درونی سازی شده بیماری های روانی و بهزیستن ذهنی: نقش واسطه ای سلامت روانی
|کد مقاله||سال انتشار||تعداد صفحات مقاله انگلیسی||ترجمه فارسی|
|38040||2015||7 صفحه PDF||سفارش دهید|
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Publisher : Elsevier - Science Direct (الزویر - ساینس دایرکت)
Journal : Psychiatry Research, Volume 228, Issue 3, 30 August 2015, Pages 325–331
Abstract This study examines the relationships between internalized stigma, psychological well-being, and subjective well-being in a sample of people with mental illness. We conducted a cross-sectional study with 213 outpatients from the Spanish public social care network. The results showed that (a) internalized stigma was significantly negatively correlated with psychological well-being and subjective well-being (affect balance and life satisfaction) (all correlations are significant with at least p<0.05; most with p<0.001), (b) the two types of well-being were significantly positively correlated and regressions models were significant and (all correlations are at least p<0.01, and regression models are also significant), (c) the effect of internalized stigma on affect balance and life satisfaction was mediated by psychological well-being. The component of internalized stigma most consistently associated with both types of well-being was alienation (life satisfaction: B=−0.35, p=0.001; affect balance: B=−0.38, p=0.001). These findings should be confirmed in future longitudinal or experimental research. On the basis of these results we recommend that interventions to combat self-stigma aim to reduce feelings of alienation and improve self-acceptance and other aspects of positive psychological functioning.
. Introduction 1.1. The stigma of mental illness Social stigma is one of the most important difficulties faced by people with mental illness (PWMI) (European Commission Health & Consumer Protection Directorate-General, 2005, World Health Organization, 2005 and Muñoz et al., 2013). Stigma leads to exclusion and discrimination which affect access to housing, healthcare, employment and social activities for PWMI, adding to the problems that people with severe and persistent mental illness often have in these areas (Corrigan and Watson, 2002 and Magallares, 2011). Stigma also affects the well-being and behavior of PWMI. Stigmatizing experiences have been associated with lower psychological well-being, lower life satisfaction and a lower probability of seeking help from mental health services (Markowitz, 1998, Link et al., 2001 and Corrigan, 2004). Experiencing stigma can also lead to internalization of stigma. This is the process of endorsing negative stereotypes of PWMI and applying them to themselves, and the resulting psychological distress, social withdrawal, secrecy and reduction in sense of self-worth (Ritsher et al., 2003, Livingston and Boyd, 2010 and Bos et al., 2013). There is evidence that internalized stigma has numerous negative effects on the well-being of PWMI. It has been associated with low self-esteem and low self-efficacy (Ritsher et al., 2003, Ritsher and Phelan, 2004, Corrigan et al., 2006, Yanos et al., 2008 and Bos et al., 2009), depressive symptoms and negative symptoms (Ritsher and Phelan, 2004, Yanos et al., 2008 and Lysaker et al., 2009), lack of hope and greater use of avoidant coping strategies (Yanos et al., 2008), poor social functioning (Muñoz et al., 2011); and low scores on measures of empowerment and recovery orientation (Ritsher et al., 2003). 1.2. Subjective well-being and psychological well-being Since the emergence of positive psychology well-being has received increasing attention in psychological research (Sheldon and King, 2001). Ryan and Deci (2001) argued that there are two aspects to well-being: hedonic or subjective well-being and eudemonic or psychological well-being. Hedonic well-being relates primarily to happiness, which is based on a person's affective and cognitive evaluations of his or her own life (Diener et al., 2003). The affective evaluation is comprised by two measures: the presence of positive mood and absence of negative mood, which can be summarized as ‘affect balance’ (Bradburn, 1969). The cognitive evaluation represents what we call life satisfaction and can be measured as a global variable (Diener et al., 1985) or in terms of satisfaction with specific life domains (Baker and Intagliata, 1982). Eudemonic psychologists argue, however, that it does not follow that someone who claims to be happy – as most people do – is psychologically well (Ryff, 1989). The eudemonic approach to well-being emphasizes meaning and self-realization; defining well-being in terms of effective psychological functioning (Ryan and Deci, 2001). Ryff's multidimensional model of psychological well-being is one of the most integrative eudemonic models; it includes six aspects of psychological actualization: self-acceptance, relations with others, autonomy, environmental mastery, personal growth and purpose in life (Ryff, 1989 and Ryff and Keyes, 1995). The distinction between subjective well-being and psychological well-being is empirical as well as theoretical. Keyes et al. (2002) found that, although both types of well-being were highly correlated, their constituent components loaded on two different factors. This finding was later replicated in China (Biaobin et al., 2004), and in the UK (Linley et al., 2009). Some authors have suggested that subjective well-being might be a consequence of living well (Ryan et al., 2006 and Sanjuán, 2011). Sanjuán (2011) suggested that experiencing autonomy and personal growth and having positive relationships with others and a purpose in life could increase positive feelings and improve satisfaction with life. As stated above there is evidence that internalized stigma is related to various measures of psychological well-being. Ritsher and Phelan (2004) found that in a sample of psychiatric outpatients internalized stigma score predicted depressive symptoms at a four-year follow-up and that alienation also negatively predicted self-esteem. Associations between internalized stigma and depressive symptoms and low self-esteem were also found in a cross-sectional study which also found a negative association between internalized stigmas and self-efficacy (Corrigan et al., 2006). A meta-analysis found that internalized stigma was associated with a low life satisfaction, low perceived social support and low scores on measures of empowerment and hope (Livingston and Boyd, 2010). Although the relationship of positive and negative moods with internalized stigma has not previously been tested, affect balance was shown to be negatively associated with social experience of stigma and perceived discrimination (Kahng and Mowbray, 2004; Magallares et al., 2013; Pérez-Garin et al., in press). In short, internalized stigma has been shown to have a generally detrimental effect on well-being, and psychological well-being appears to be causally related to subjective well-being (affect balance and life satisfaction). On this basis we hypothesized that psychological well-being mediated the relationship between the internalization of stigma and subjective well-being. Drawing on previous empirical findings on well-being and internalized stigma we propose a pathway in which internalized stigma has a negative impact on psychological well-being which, in turn, has a negative impact on affect balance and life satisfaction. We formulated the following specific hypotheses, Hypothesis 1: the various components of internalized stigma are negatively associated with subjective well-being (affect balance and life satisfaction); Hypothesis 2: internalized stigma is negatively associated with psychological well-being; Hypothesis 3: psychological well-being is positively associated with subjective well-being and Hypothesis 4: psychological well-being mediates the relationship between internalized stigma and subjective well-being. A longitudinal study demonstrated that the various aspects of stigma have different effects on depressive symptoms and self-esteem (Ritsher and Phelan, 2004). In this study the more ‘internal’ components of self-stigma (particularly alienation) were the strongest predictors of self-esteem and depressive symptoms, whereas discrimination experiences were not predictors of either. The authors argued that this was consistent with the notion that internalization is the most psychologically harmful aspect of stigma (Ritsher and Phelan, 2004). We expected to find similar relationships between the components of self-stigma and psychological well-being and subjective well-being. In order to provide more information and guide future interventions to combat stigma we decided to analyze the various facets of internalized stigma and psychological well-being separately. On the basis of Ritsher and Phelan's (2004) results, we predicted negative associations between both psychological and subjective well-being and alienation (Hypothesis 5), stereotype endorsement (Hypothesis 6), and social withdrawal (Hypothesis 7). Feeling inferior, different and thus set apart from others seems to play an important role in the stigmatization process. The finding that alienation reduces self-esteem and increases depressive symptoms hints at the existence of a vicious cycle involving alienation and psychological distress (Ritsher and Phelan, 2004). Ritsher and Phelan (2004) found that the factor most consistently associated with negative psychological outcomes was alienation so we expected that alienation would be strongly negatively associated with both types of well-being.
نتیجه گیری انگلیسی
Results Table 1 displays descriptive statistics for the variables used in the analyses, as well as the correlations between them. All four internalized stigma subscales were negatively correlated with the six psychological well-being scales. All the components of internalized stigma and psychological well-being were also correlated with life satisfaction and affect balance. Table 1. Means, standard deviations and correlations for the main variables in this study. M SD Self-acceptance Positive relations Autonomy Environmental mastery Personal growth Purpose in life Life satisfaction Affect balance M SD M SD M SD M SD M SD M SD M SD M SD 3.23 1.00 3.20 0.76 3.14 0.73 3.13 0.69 3.59 0.80 3.26 0.93 3.40 0.71 0.74 1.27 Alienationa 2.81 0.92 −0.48⁎⁎⁎ −0.49⁎⁎⁎ −0.40⁎⁎⁎ −0.39⁎⁎⁎ −0.30⁎⁎⁎ −0.38⁎⁎⁎ −0.42⁎⁎⁎ −0.47⁎⁎⁎ Stereotype endorsementa 2.20 0.69 −0.24⁎⁎⁎ −0.30⁎⁎⁎ −0.25⁎⁎⁎ −0.30⁎⁎⁎ −0.24⁎⁎⁎ −0.26⁎⁎⁎ −0.27⁎⁎⁎ −0.30⁎⁎⁎ Discrimination experiencea 2.75 0.97 −0.29⁎⁎⁎ −0.41⁎⁎⁎ −0.28⁎⁎⁎ −0.42⁎⁎⁎ −0.15⁎ −0.19⁎⁎ −0.28⁎⁎⁎ −0.29⁎⁎⁎ Social withdrawala 2.59 0.94 −0.34⁎⁎⁎ −0.51⁎⁎⁎ −0.35⁎⁎⁎ −0.36⁎⁎⁎ −0.28⁎⁎⁎ −0.28⁎⁎⁎ −0.36⁎⁎⁎ −0.42⁎⁎⁎ Life satisfactiona 3.40 0.71 0.60⁎⁎⁎ 0.43⁎⁎⁎ 0.22⁎⁎ 0.46⁎⁎⁎ 0.41⁎⁎⁎ 0.53⁎⁎⁎ – 0.57⁎⁎⁎ Affect balanceb 0.74 1.27 0.62⁎⁎⁎ 0.40⁎⁎⁎ 0.42⁎⁎⁎ 0.46⁎⁎⁎ 0.54⁎⁎⁎ 0.61⁎⁎⁎ 0.57⁎⁎⁎ – a Rated on scale of 1 to 5 with higher scores indicating greater agreement. b Rated on a scale of −4 to 4 with higher scores indicating predominance of positive affect. ⁎ p<0.05. ⁎⁎ p<0.01. ⁎⁎⁎ p<0.001. Table options Table 2 shows the results of multiple regression analyses with life satisfaction or affect balance as outcome variables; these were used totest for the possible mediation of the components of psychological well-being. Table 2. Multiple regression analyses. Life satisfaction Affect balance Model 1 Model 2 Model 1 Model 2 Alienation −0.35⁎⁎⁎ −0.09 −0.38⁎⁎⁎ −0.11 Stereotype endorsement −0.01 −0.03 0.00 0.03 Discrimination experience 0.03 0.06 0.07 0.04 Social withdrawal −0.14 −0.02 −0.21⁎ −0.11 Self-acceptance – 0.40⁎⁎⁎ – 0.16 Positive relations – 0.23⁎⁎ – 0.07 Autonomy – −0.17⁎⁎ – 0.09 Environmental mastery – 0.15⁎ – 0.08 Personal growth – 0.04 – 0.21⁎⁎ Purpose in life – 0.07 – 0.21⁎ R2 (Adjusted) 0.18 0.44 0.23 0.50 F change 12.03 16.97 16.69 19.37 df (4.203) (6.197) (4.203) (6.197) Note Table reports standardized regression coefficients for each variable. ⁎ p<0.05. ⁎⁎ p<0.01. ⁎⁎⁎ p<0.001. Table options Alienation was the only aspect of internalized stigma which predicted life satisfaction. When psychological well-being scores were added to the model the effect of alienation became non-significant, and self-acceptance, positive relations with others, autonomy and environmental mastery all predicted life satisfaction. This second model explained 44% of the variance in life satisfaction. Alienation and social withdrawal both predicted affect balance, but once again they lost their predictive significance when psychological well-being scores were added to the model. The only psychological well-being factors which predicted affect balance were personal growth and purpose in life. The second model explained 50% of the variance in affect balance. We ran mediation analyses to confirm that our data were consistent with the hypothesis that the relationship between internalized stigma and both indices of subjective well-being (affect balance; life satisfaction) was mediated by psychological well-being. We used Hayes's (2013) PROCESS macro for SPSS, which uses bootstrapping to generate confidence intervals for the total and indirect effects of one variable on another through one or more mediator variables. We generated 10,000 resamples, twice the minimum recommended by Preacher and Hayes (2008) for final reporting. Because alienation was the only aspect of internalized stigma that predicted subjective well-being in our regression analyses, we only report mediation analyses with alienation as a predictor variable. The relationship between alienation and life satisfaction (Fig. 1) appeared to be mediated by self-acceptance, relations with others, autonomy and environmental mastery; the mediation model had R2=0.47. The results met the criteria for full mediation; the total effect of alienation on life satisfaction (c path) was significant, but the direct effect (c′) was not. It should be noted, however, that experts have recently argued against the use of terms such as ‘full’ or ‘partial’ mediation as, paradoxically, these criteria are easier to meet with a smaller sample size and a smaller initial direct effect ( Preacher and Kelley, 2011 and Rucker et al., 2011). Mediation model for life satisfaction (constructed using the method described by ... Fig. 1. Mediation model for life satisfaction (constructed using the method described by Preacher and Hayes (2008)). Data are standardized regression coefficients. Total effect (c path) is given in parentheses. †p<0.10; *p<0.05; **p<0.01; ***p<0.001. Figure options The relationship between alienation and affect balance (Fig. 2) appeared to be mediated instead by personal growth and purpose in life. The results were consistent with partial mediation; the direct effect of alienation on affect balance was significant (p<0.05) after the effect of the mediators was taken into account. The model had R2=0.46. Mediation model for affect balance (constructed using the method described by ... Fig. 2. Mediation model for affect balance (constructed using the method described by Preacher and Hayes (2008)). Data are standardized regression coefficients. Total effect (c path) is given in parentheses. †p<0.10; *p<0.05; **p<0.01; ***p<0.001.