Findings from two path models provided support for the hypothesis that internalized stigma reduces a person’s hope and self-esteem, leading to negative outcomes related to recovery, including depressive symptoms, social avoidance, and a preference for using avoidant coping strategies. Simply put, findings supported the hypothesis that the process of accepting and internalizing social stigma changes the way people perceive and feel about themselves and their likelihood to plan and meet their life goals and consequently leads them to avoid others and experience depression.
Even though our original model analysis provided support for the view that social avoidance is linked to low self-esteem and diminished hope and that these together lead to increased severity of positive symptoms, the alternate model we tested provided evidence that positive symptoms may also plausibly be seen as a cause of social avoidance and avoidant coping. Notably, however, changing positive symptoms from an outcome to a predictor did not have a meaningful impact on the relationship between internalized stigma (as mediated by hope and self-esteem) and the other outcome variables.
Some aspects of our original model were not supported. Our analyses did not support the finding from our previous study (7
) that internalized stigma moderates the effects of awareness of mental illness on hope and self-esteem. The study reported here used a different method of assessing moderation (product-term analysis, as opposed to cluster analysis followed by a comparison of means), as well as a different measure of insight. It is possible that a restriction of range in insight, possibly related to how the SUMD measures awareness, may explain the failure to replicate the finding of moderation in these analyses.
In addition, although this study found evidence of a bivariate relationship between avoidant coping and social isolation, this relationship was not supported in the path analyses. Hope and self-esteem appeared to account for the observed relationship between these two variables. This finding may suggest that the links between coping and social isolation were largely a function of their mutual links with persons’ expectations of the future and their appraisals of their personal value. As with all unexpected findings, further research is needed to clarify this issue.
There were several limitations to the study that are important to consider. Given the cross-sectional nature of this study, we cannot draw definitive conclusions regarding causality, and alternative explanations of the findings cannot be ruled out. Notably, all participants were enrolled in vocational rehabilitation and had equivalent employment status, so we were unable to test the hypothesized impact of internalized stigma on employment status, an important construct in our original model. In addition, we did not have a variable representing suicidal ideation, so we used a depression item that may not have accurately represented this construct. Furthermore, participants were mostly men in their 40s, all of whom were involved in treatment. It may well be that a different relationship exists between the variables we measured among younger persons with schizophrenia, in a predominantly female sample, or in particular among persons who decline treatment. Thus more research is necessary and should involve the collection of data at multiple time points and with broader samples.