The relationship between internalized stigma and quality of life among people with mental illness: are self-esteem and sense of coherence sequential mediators?
The relationship between internalized stigma and quality of life among people with mental illness: are self-esteem and sense of coherence sequential mediators?
Piotr S´ witaj 0 1
Paweł Grygiel 0 1
Anna Chrostek 0 1
Izabela Nowak 0 1
Jacek Wcio´rka 0 1
Marta Anczewska 0 1
0 Educational Research Institute , Go ́rczewska 8, 01-180 Warsaw , Poland
1 First Department of Psychiatry, Institute of Psychiatry and Neurology , Sobieskiego 9, 02-957 Warsaw , Poland
Purpose To elucidate the mechanism through which internalized stigma reduces the quality of life (QoL) of people with mental illness by exploring the mediating roles of self-esteem and sense of coherence (SOC). Methods A cross-sectional analysis of 229 patients diagnosed with schizophrenia or affective disorders was undertaken to test a sequential mediation model assuming that more severe internalized stigma is related to lower self-esteem, which is associated with weaker SOC, which in turn relates to worse QoL. Results The proposed model was supported by the data. A sequential indirect effect from internalized stigma to QoL via self-esteem and SOC turned out to be significant [beta = -0.06, SE = 0.02; 95% CI (-0.11, -0.03)]. Support was also found for simple mediation models with either self-esteem or SOC as single mediators between internalized stigma and QoL. Conclusions Self-esteem and SOC are personal resources that should be considered as potential targets of interventions aiming to prevent the harmful consequences of internalized stigma for the QoL of people receiving psychiatric treatment.
Internalized stigma esteem; Sense of coherence; Quality of life; Self-; Mental illness
People with mental illness are frequent targets of public
stigma, i.e., negative stereotypes, prejudice, and
discrimination . Many individuals turn these stigmatizing
societal attitudes against themselves, which may result in
internalized stigma (also referred to as self-stigma).
Internalized stigma can be defined as ‘‘a subjective process,
embedded within a socio-cultural context, which may be
characterized by negative feelings (about self),
maladaptive behaviour, identity transformation, or stereotype
endorsement resulting from an individual’s experiences,
perceptions, or anticipation of negative social reactions on
the basis of their mental illness’’ [2, p. 2151]. This
detrimental process may hamper the recovery of service users,
limit their life chances and substantially reduce their
quality of life (QoL) [1, 3].
However, although the negative impact of the
internalized stigma of mental illness on QoL is well
established [2, 4], the precise mechanism of this effect has not
been fully explained. Some previous research has
indicated that self-esteem may play a mediating role in this
relationship. More specifically, in a study including 179
people with serious mental illness, Mashiach-Eizenberg
et al.  found that self-esteem fully mediated the relation
between internalized stigma and hope, whereas hope
partially mediated the relationship between self-esteem
and QoL. In another study, based on data obtained from
403 persons with mental illness, Oliveira et al. 
demonstrated that self-esteem fully mediated the relation
between internalized stigma and the physical and the
social relationships domains of QoL, and partially
mediated the relationship between internalized stigma and
psychological, environment, and level of independence
Building and expanding on these findings, we propose a
model of the impact of internalized stigma on QoL
including sense of coherence (SOC) as another potential
mediating factor, in addition to self-esteem. SOC is the
term coined by Antonovsky, who defined it as ‘‘a global
orientation that expresses the extent to which one has a
pervasive, enduring though dynamic feeling of confidence
that (1) the stimuli deriving from one’s internal and
external environments in the course of living are structured,
predictable, and explicable; (2) the resources are available
to one to meet the demands posed by these stimuli; and (3)
these demands are challenges, worthy of investment and
engagement’’ [7, p. 19]. These three interrelated
components of SOC are called comprehensibility, manageability
and meaningfulness. The SOC construct is the core of
Antonovsky’s theory of salutogenesis, which seeks to
explain the origins of health. The theory posits that high
SOC reflects a greater capacity to cope with stressful
situations and predicts good health and QoL.
Importantly, according to Antonovsky the
development of a strong SOC requires the presence of so-called
generalized resistance resources (GRRs). These include
‘‘any characteristic of the person, the group, or the
environment that can facilitate effective tension
management’’ [8, p. 99]. In other words, within the
salutogenic framework, GRRs are biological, material, or
psychosocial factors that lead to life experiences which
contribute to seeing the world as more comprehensible,
manageable, and meaningful.
Self-esteem is regarded as one of the typical GRRs
promoting SOC . This view was supported empirically
by the studies performed on adolescent , adult , and
elderly  populations, which revealed that better
selfesteem predicted higher SOC. Hence, given that both
cross-sectional and longitudinal research  consistently
demonstrate a negative association of internalized stigma
of mental illness with self-esteem, it seems reasonable to
presume that self-esteem may mediate the relationship
between internalized stigma and SOC. Furthermore, since
there is a vast body of empirical evidence from studies on
various samples (mainly disease-specific groups of
patients) showing the positive influence of SOC on QOL
, one can expect that SOC may act as a mediator
between self-esteem and QoL.
Against this background, in the current study, we tested
a theoretical model which assumed that self-esteem and
SOC sequentially mediate the relationship between
internalized stigma and QoL among people with mental
illnesses. Specifically, we hypothesized that more severe
internalized stigma is related to lower self-esteem, which is
associated with weaker SOC, which in turn relates to worse
Study participants were recruited from various mental
health care facilities of the Institute of Psychiatry and
Neurology (IPN) in Warsaw (Poland). IPN is a large
scientific research and clinical center providing a broad
range of mental health services, mainly to the population
of Warsaw and its environs. The inclusion criteria were
as follows: (1) diagnosis of schizophrenia (F20) or
affective disorders (F30-F33) according to the
International Classification of Diseases, 10th Revision (ICD-10);
(2) age over 18 years; and (3) a stable mental condition,
according to the treating psychiatrist, sufficient to enable
the understanding and accurate answering of the
questions in the questionnaires. Individuals with active drug
or alcohol dependence, organic brain disease, severe
cognitive deficits, or documented mental retardation were
Of the 281 persons who were asked to participate in the
study, 229 (81.5%) agreed and formed the study sample.
Their socio-demographic and clinical characteristics are
shown in Table 1.
Internalized stigma was evaluated with the use of the
Stigma Experiences Scale (SES) from the Inventory of
Stigmatizing Experiences (ISE) . The SES is a complex
measure encompassing several related subdomains
(perceived stigma, experienced stigma, social withdrawal, and
impact of stigma) . This self-report questionnaire
comprises 10 items which use different response formats.
Following the procedure recommended by the instrument
developers , the responses were recoded into binary
variables: 0 = the absence of stigma and 1 = the presence
of stigma. The index was created by summing up scores
across all items. A higher total score indicates more severe
internalized stigma. In this study, Cronbach’s alpha
coefficient for the SES was 0.81.
QoL was measured with the extended version of the
Satisfaction with Life Domains Scale (SLDS) . This
instrument includes 20 items assessing the level of
satisfaction with various life areas and with life in general.
Responses are made on a scale from 1 (worst QoL) to 7
(best QoL). In order to reduce the number of missing
values, the overall score was calculated by summing up
individual item scores and dividing the total by the
number of valid answers. The higher the rating, the better
the QoL. Cronbach’s alpha for the SLDS turned out to be
Table 1 Socio-demographic and clinical characteristics of the
participants (n = 229)
Self-esteem was evaluated using the Rosenberg
SelfEsteem Scale (RSES) . This is a 10-item
self-administered questionnaire employing a four-point response scale
(1 = strongly agree; 4 = strongly disagree). All item
scores were summed up and divided by the number of valid
responses. A greater total score denotes higher self-esteem.
The RSES demonstrated good internal consistency in our
data (Cronbach’s alpha = 0.88).
SOC was assessed by means of the 29-item Sense of
Coherence Scale (SOC-29) [7, 18]. This tool contains 11
comprehensibility, 10 manageability, and 8 meaningfulness
items. Respondents are asked to select a response on a
sevenn (%) mean (SD)
point semantic differential scale with two anchoring phrases.
In accordance with the intention of Antonovsky, who
regarded the SOC-29 as a measure of a global orientation to
life and saw no basis for deriving distinguishable subscores
for comprehensibility, manageability, and meaningfulness
, only a total scale score was utilized in the analyses. To
calculate it, the responses for each item were summed and
divided by the number of valid answers. A higher total score
represents stronger SOC. In the current sample, the value of
Cronbach’s alpha for the SOC-29 was 0.91.
The severity of psychopathological symptoms was
measured with the standard version of the Brief Psychiatric
Rating Scale (BPRS) . This consists of 18 items scored
by a clinician on a scale ranging from 1 (symptom not
present) to 7 (symptom extremely severe). To create a
global score, the sum of the item scores was divided by the
number of valid items. The higher the score, the more
severe the individual’s psychopathology. Cronbach’s alpha
of the BPRS was found to be 0.91.
Ethical approval for the study was granted by the
Bioethical Committee at the IPN. All participants provided their
informed consent. The measures were administered by a
trained clinician; however, the patients could also fill in the
self-report questionnaires personally if they volunteered to
do so. At the beginning, the participants answered a set of
questions regarding their socio-demographic and clinical
characteristics (where necessary, the information was
supplemented or verified by reviewing their medical
records). Next, the self-report scales were completed in the
following order: the SES, SOC-29, RSES, and SLDS.
Finally, psychopathology was assessed by a clinician with
the use of the BPRS.
Means and standard deviations or percentages, as
appropriate, for all study variables, Cronbach’s alpha coefficients
for the instruments used, and Pearson product-moment
correlations between the key variables were computed by
means of IBM SPSS Statistics version 23 (SPSS Inc.,
In order to investigate whether self-esteem and SOC
sequentially mediate the relationship between internalized
stigma and QoL, we used a three-path sequential multiple
mediational model. In such a model, two mediators
intervene in a series between an independent and a dependent
variable , as depicted in Fig. 1. Apart from the
twomediator chain, we also examined two simple mediation
paths with either self-esteem or SOC as single mediators
between internalized stigma and QoL.
Fig. 1 Schematic representation of a sequential mediation path
model linking X to Y through M1 and M2. Y is the dependent
variable, X is the independent variable, and M1 and M2 are the two
mediators; a1 direct effect of X on M1, a2 direct effect of X on M2, b1
direct effect of M1 on Y, b2 direct effect of M2 on Y, d21 direct effect
of M1 on M2, c0 direct effect of X on Y, c total effect of X on Y
To estimate the model, three regression equations were
calculated: (1) regressing mediator 1 (self-esteem) on the
independent variable (internalized stigma), (2) regressing
mediator 2 (SOC) on mediator 1 (self-esteem) and the
independent variable (internalized stigma), and (3) regressing the
dependent variable (QoL) on mediator 1 (self-esteem),
mediator 2 (SOC) and the independent variable (internalized
stigma). In all three regression equations, the following
sociodemographic and clinical variables were included as
covariates: sex, age, education, marital status, living situation,
employment, illness duration, type of psychiatric setting,
diagnosis, and severity of psychopathological symptoms
(BPRS total score). The size of the three specific indirect
effects was compared using pairwise contrasts.
The hypothesized mediation model was analyzed by
means of the PROCESS macro for SPSS , based on
ordinary least-squares (OLS) regression (Model 6 as
described in PROCESS). Since the PROCESS macro
produces unstandardized coefficients, prior to analysis all
continuous variables were standardized to clarify the
interpretation and comparison of parameter estimates. The
bootstrapping procedure recommended by Preacher and
Hayes  was applied for testing the significance of the
indirect effects. Unlike traditional tests, such as the Sobel
test , bootstrapping does not require the assumption
that the sampling distribution of the indirect effect is
normal, which is difficult to meet for small research samples
especially. We used 20,000 bootstrap resamples to
calculate the bias-corrected 95% confidence interval (CI). If the
interval does not include zero, the effect is statistically
significant at p \ 0.05.
Descriptive statistics and intercorrelations of the measures
used in the study are presented in Table 2. Internalized
stigma, QoL, self-esteem, and SOC were all significantly
correlated in the expected direction, whereas psychiatric
symptoms showed significant (positive) association only
with internalized stigma.
The results of the mediation analysis are shown in Fig. 2
and in Tables 3 and 4.
After accounting for socio-demographic and clinical
factors, all individual paths between the key variables in
the model turned out to be significant, with the exception of
the direct effect of internalized stigma on QoL when
controlling for the effects of the mediators (i.e., self-esteem
and SOC). There was a significant sequential indirect effect
of internalized stigma on QoL through self-esteem and
SOC [path a1d21b2: beta = –0.06, SE = 0.02; 95% CI
(-0.11, -0.03)]. Also significant were simple mediation
paths from internalized stigma to QoL via self-esteem [path
a1b1: beta = –0.11, SE = 0.03; 95% CI (-0.18, –0.05)]
and from internalized stigma to QoL through SOC [path
a2b2: beta = -0.06, SE = 0.03; 95% CI (-0.12, -0.02)].
Examination of the pairwise contrasts of the indirect effects
(see Table 4) revealed that the three indirect effects cannot
be distinguished in terms of magnitude (zero is contained
in the interval).
In this study, we found evidence for a theoretical model
proposing that self-esteem and SOC sequentially mediate
the relationship between internalized stigma and QoL
among people with mental illness. Our findings are in
keeping with previous research which has already
convincingly demonstrated a robust association of self-stigma
with diminished self-esteem [2, 4] and documented the role
of self-esteem in mediating the negative effect of
selfstigma on QoL [5, 6]. However, the study results also make
an additional contribution to the existing literature by
identifying SOC as another important element in the chain
of self-stigma consequences and speaking in favor of the
idea that self-esteem is a potential GRR for SOC.
It should be emphasized that apart from the
two-mediator path, two simple mediation paths with either
self-esteem or SOC as single mediators between internalized
stigma and QoL were also found to be significant and the
three indirect effects did not differ in terms of magnitude.
This further corroborates the importance of both of these
self-related variables for the QoL and highlights the
complexity of the ways in which self-stigma acts on people
with mental illness.
Contrary to self-esteem, SOC is a construct that has not
been thus far extensively studied in the context of
internalized mental health stigma and the harms it causes. This
may be somewhat surprising given the well-described role
of SOC in coping with stressors or enhancing health and
1. Stigma Experiences Scale (SES)
2. Satisfaction with Life Domains Scale (SLDS)
3. Rosenberg Self-Esteem Scale (RSES)
4. Sense of Coherence Scale (SOC-29)
5. Brief Psychiatric Rating Scale (BPRS) Mean (SD) 3.58 (2.85) 4.46 (1.05)
Fig. 2 Sequential mediation path model with self-esteem and SOC as
mediators in the relationship between internalized stigma and QoL
(n = 229). In parenthesis: total effect of internalized stigma on QoL;
before parenthesis: direct effect of internalized stigma on QoL.
Covariate paths were estimated, but are not reported in the figure.
*p \ 0.05, **p \ 0.01
QoL [13, 24, 25] as well as its clear relevance for mental
health treatment and rehabilitation [26–28]. Identifying the
mediating effects of SOC is noteworthy as it indicates that
the mechanism through which self-stigma affects the QoL
of people with mental illness involves the restriction of
their capacity to manage stress. Thus, for service users,
self-stigma not only is a stressor itself, but also a factor
diminishing their ability to mobilize the GRRs and to adapt
to stressful situations. Given the harmful effects of stress
on the course and outcome of mental disorders  and the
accumulated evidence that stronger SOC is associated with
better health (especially mental health) , it can be
recommended that future studies investigate whether SOC
acts as a mediator in the relationship of internalized stigma
not only with QoL, but also with various indicators of
health and disability in people receiving psychiatric
treatment. This could shed more light on the routes through
which self-stigma hinders recovery from mental illness.
Regarding implications for clinical practice, with
replication this study may support the need for targeting
selfesteem and SOC in therapeutic programs aiming to prevent
the harmful impact of internalized stigma on people with
mental illness. There is some empirical evidence indicating
that these personal resources are modifiable by means of
specific group interventions. An example of a method of
improving self-esteem may be the ‘‘self-esteem module’’
designed by Lecomte et al. . This is a 12-week
structured group intervention, consisting of 24 1-h sessions and
divided into five blocks addressing the following key
aspects of self-esteem: a sense of security, a sense of
identity, a sense of belonging, a sense of purpose, and a
sense of competence. A randomized cross-over study by
Borras et al.  has confirmed the effectiveness of this
approach among individuals with severe mental disorders,
in particular those receiving case-management care. In
turn, an example of a promising intervention promoting
SOC is a talk-therapy group program developed by
Langeland et al. [27, 32]. It consists of 16 weekly group
meetings and homework, with mental health professionals
acting as group leaders. Its main purpose is to raise
participants’ awareness of their potential, their internal and
external resistance resources (such as personal qualities,
coping abilities and social support), and their ability to use
them, and thus to improve their SOC, coping, and level of
mental health. In a randomized controlled trial, this
intervention was demonstrated to have a significant positive
influence on the SOC of people with mental health
problems . In the light of the findings obtained, these types
of interventions may have the potential to break the chain
of negative effects triggered by self-stigma and leading to
the impairment of QoL and may be a useful addition to the
interventions directly targeting self-stigmatizing beliefs
and attitudes, e.g., through psychoeducation or cognitive
behavioral therapy (CBT) techniques [33, 34].
Some limitations of the study are to be mentioned. Most
importantly, the cross-sectional design does not allow us to
draw any definite conclusions about causality. While there
is considerable evidence for the detrimental effect of
selfstigma on self-esteem , it has also been suggested that
enhancing self-esteem may lead to the reduction of
selfstigma . Similarly, although it seems reasonable to
hypothesize that stigma may weaken SOC, alternative
models have also been proposed in which SOC is a
predictor of stigma [35, 36]. Clearly, longitudinal studies are
needed to further disentangle the complex relationships
Table 3 Results of the
regression analyses testing the
sequential mediation effect of
self-esteem and SOC in the
internalized stigma and QoL
(n = 229)
Table 4 Bootstrapped point
estimates with standard errors
and 95% confidence intervals
for all indirect effects and the
pairwise contrasts of the indirect
effects between internalized
stigma and QoL
Psychiatric settingf Diagnosisg
Direct effect (SE)
Total effect (SE)
Standardized regression coefficients (beta) with standard errors (SEs) in parentheses are presented
a 0 = female, 1 = male
b Secondary = reference category
c 0 = non-married (including separated/divorced, widowed and never married), 1 = married (including by
d 0 = living with someone, 1 = living alone
e 0 = unemployed, 1 = employed
f 0 = inpatient ward, 1 = other (including day ward, outpatient clinic and community mental health
g 0 = schizophrenia, 1 = affective disorders
* p \ 0.05, ** p \ 0.01
Bootstrapping 95% CI
SE standard error, CI confidence interval
If the CI does not include zero, the effect is statistically significant at p \ 0.05
between internalized stigma, self-esteem, SOC, and QoL.
Next, the generalizability of the findings may be restricted
by the fact that our participants were a convenience sample
recruited from just one psychiatric institution. Furthermore,
we cannot rule out the possibility that some unmeasured
factors account for the relationships observed in this study.
It needs to be noted as well that the stigma instrument
utilized in the analyses (the SES) is not a pure measure of
internalized stigma. In this respect, however, it is similar to
the Internalized Stigma of Mental Illness (ISMI) scale ,
the instrument extensively used for assessing internalized
stigma among people with mental illness, which is also a
multidimensional, complex measure covering several
stigma domains (including, e.g., experienced
discrimination). Finally, the validation of the SES against other, more
fully tested psychometrically internalized stigma
instruments is yet to be performed in order to confirm its
Despite these limitations, this research provides further
evidence for the significance of internalized stigma as a
barrier to recovery from mental illness and extends the
understanding of the mechanism of its impact on service
users by showing how it may compromise their QoL
through undermining their personal resources (such as
selfesteem and SOC).
Compliance with ethical standards
Ethical approval All procedures performed in studies involving
human participants were in accordance with the ethical standards of
the institutional and/or national research committee and with the 1964
Helsinki declaration and its later amendments or comparable ethical
Informed consent Informed consent was obtained from all
individual participants included in the study.
Open Access This article is distributed under the terms of the
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appropriate credit to the original author(s) and the source, provide a
link to the Creative Commons license, and indicate if changes were
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