Schizophrenia Research 137 (2012) 185–189

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Schizophrenia Research

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Self-esteem as a mediator of the relationship between role functioning andsymptoms for individuals with severe mental illness: A prospective analysis ofModified Labeling theory

Lisa Davis ⁎, Seth Kurzban, John BrekkeUniversity of Southern California, School of Social Work, United States

⁎ Corresponding author.E-mail address: lisadavi@usc.edu (L. Davis).

0920-9964/$ – see front matter © 2012 Elsevier B.V. Alldoi:10.1016/j.schres.2012.02.003

a b s t r a c t

a r t i c l e i n f o

Article history:

Received 14 August 2011Received in revised form 1 February 2012Accepted 3 February 2012Available online 28 February 2012

Keywords:SchizophreniaSevere mental illnessSelf-esteemRole functioningPsychiatric symptoms

Background: Despite a growing body of evidence supporting the efficacy of psychosocial rehabilitation for in-dividuals with severe mental illness (SMI), a large proportion of these individuals remain unable to maintainbasic social roles such as employee, parent, or spouse. This study investigated whether changes in role func-tioning over time impact symptom severity indirectly through the mechanism of changes in self-esteem asposited by Modified Labeling theory.Methods: The study sample was composed of 148 individuals diagnosed with schizophrenia, schizoaffectivedisorder, bipolar disorder with psychotic features, and major depression with psychotic features who electedto participate in community-based psychosocial rehabilitation services. Measures of role functioning, self-esteem, and psychiatric symptoms were gathered at baseline and six months through a combination of struc-tured clinical interviews and self-report surveys.Results: SEM results at baseline provided support for a model in which self-esteem fully mediated the rela-

tionship between role functioning and psychiatric symptoms. The final model explained 20% of the variancein psychiatric symptoms. Analyses at six months post-baseline (time 2) indicate that changes in self-esteemfully mediated the relationship between changes in role functioning and changes in psychiatric symptoms.The final change model explained 23% of the variance in changes in psychiatric symptoms.Conclusion: Results provide empirical support for the principles underlying Modified Labeling theory. Impli-cations include the need for interventions that focus on social participation as a means of improving self-esteem, thereby decreasing symptom exacerbation and future relapse for people with SMI.

© 2012 Elsevier B.V. All rights reserved.

1. Introduction

Despite significant advances in psychosocial rehabilitation overthe past several decades (Kurzban et al., 2010), a large proportion ofindividuals with severe mental illness (SMI) remain socially margin-alized and perceive themselves as fundamentally lacking in self-worth (Link et al., 2001; Watson et al., 2007). Up to two-thirds of in-dividuals with SMI are unable to achieve or maintain basic social rolessuch as employee, spouse, parent and integrated member of the com-munity (Bellack et al., 2007). Furthermore, researchers have identi-fied that a lack of social participation and inability to fulfill socialroles is a significant contributor to low self-esteem for this population(Petryshen et al., 2001; Bracke et al., 2008). Modified Labeling theoryposits that the systematic devaluation and marginalization of personswith mental illness lead to internalized negative self-appraisals thatcan ultimately exacerbate symptoms and increase the likelihood ofrepeated episodes of illness (Link et al., 1989; Link and Phelan,

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2001). Although many studies have examined psychiatric symptomsfrom a biomedical perspective as determinants of role functioning(e.g. Perlick et al., 2008; Ventura et al., 2009), few studies have testedthe loss of socially valued roles as influencing symptoms through themechanism of self-esteem for people with SMI. The purpose of thisstudy is to examine whether changes in role functioning over timemay impact symptom severity indirectly through the mechanism ofchanges in self-esteem for people with SMI living in the community.

The processes by which individuals with mental illness may be la-beled as deviant and subject to social alienation, chronic economichardship, and psychological strain have been elucidated within Mod-ified Labeling theory (Link et al., 1989). First, individuals are social-ized to adopt negative conceptions and images regarding mentalillness. Once an official label of mental illness is conferred upon an in-dividual, a response to this stigmatizing status may consist of with-drawal from social participation or an attempt to keep this statushidden. This socially constructed process of stigmatization results insocial exclusion and lack of access to societal resources through struc-tural forms of discrimination (e.g. denial of employment and housingopportunities) as well as internalized devaluing beliefs that may di-minish self-esteem and solidify an identity of illness. Link et al.

Fig. 1. Hypothesized baseline path model. Paths where a positive association was pre-dicted are represented with a plus sign (+) and paths where a negative associationwas predicted are represented with a minus sign (−).

186 L. Davis et al. / Schizophrenia Research 137 (2012) 185–189

(1989) describe the final outcome of this social alienation and stigma-tization as an induced state of vulnerability to the development of anew mental health disorder or the exacerbation of an existingdisorder.

In line with this theoretical orientation, Fig. 1 represents a pro-posed model of self-esteem as a mediator of the relationship betweenrole functioning and psychiatric symptoms. Fig. 2 depicts the self-esteem mediation model over time based on changes in the variablesof interest between baseline and 6 months post-baseline.

Several investigations provide empirical evidence related to theproposed model and the constructs underlying Modified Labelingtheory. For example, higher levels of social functioning are associatedwith a higher likelihood of symptom remission (Johnson et al., 2003)while employment status and tenure are negatively associated withsymptom severity for individuals with SMI (Mueser et al., 2001;Racenstein et al., 2002). Studies supporting the link between sociallyvalued roles and self-esteem have shown that poor global functioningpredicts self-devaluing beliefs (Lundberg et al., 2007) while socialparticipation predicts increases in self-esteem for people with schizo-phrenia (Petryshen et al., 2001). Several studies also suggest that so-cial exclusion and the acceptance of stigmatizing beliefs mutuallyreinforce one another and serve to undermine self-esteem for thispopulation (Link et al., 2001; Corrigan et al., 2006).

In further support of the proposedmodel, there is evidence to sup-port the link between low self-esteem and the manifestation of psy-chiatric symptoms for people with SMI (e.g. Link et al., 2001;Markowitz, 2001). Markowitz (2001) found that both higher levelsof psychosocial functioning and higher levels of self-esteemwere neg-atively associated with global symptom severity for people with men-tal illness. Other researchers have established that low self-esteem isassociated with positive psychotic symptoms (Barrowclough et al.,2003), paranoia (Thewissen et al., 2008), the onset of psychotic epi-sodes (Krabbendam et al., 2002), and anxiety and depression

Fig. 2. Proposed mediation model representing the mediation effect of change scoresbetween time 1 and time 2.

(Lysaker et al., 2008). Internalized stigma, a construct closely relatedto low self-esteem, has also been prospectively linkedwith depressivesymptoms (Ritsher and Phelan, 2004). Lastly, studies examining inter-ventions that specifically target self-esteem for individuals withschizophrenia have demonstrated post-treatment reductions in psy-chiatric symptoms along with increases in self-esteem (Lecomte etal., 1999; Borras et al., 2009).

Previous literature linking functioning and self-esteem (e.g.,Petryshen et al., 2001; Bracke et al., 2008) and self-esteem and symp-toms (e.g., Link et al., 2001; Markowitz, 2001), suggests that the rela-tionship between functioning and symptoms may be accounted forby self-esteem acting as a third variable that could mediate theirrelationship.

2. Methods and materials

2.1. Subjects

The present study used data from an investigation examiningbiopsychosocial variables that impact rates of functional improve-ment among people with SMI. The parent study employed a prospec-tive follow-along design of patients living in the community whoelected to participate in treatment at four community-based psycho-social rehabilitation programs in Los Angeles County. The baselinesample consists of 148 individuals diagnosed with schizophrenia(44%), schizoaffective disorder (16%), bipolar disorder with psychoticfeatures (23%), and major depression with psychotic features (17%).Out of the original sample, 115 individuals were measured at time 2(78% retention). Table 1 provides summary statistics of the demo-graphics. Analyses examining differences between the baseline sam-ple and those who were measured at time 2 suggest that there areno significant differences in the demographic profile of the samples.A combination of structured clinical interviews and self-report sur-veys was utilized to collect these data.

2.2. Psychiatric symptoms

Psychiatric symptoms were measured using the Brief PsychiatricRating Scale (BPRS; Ventura et al., 1993). The scale is based on a 24-item semi-structured interview that yields thinking disturbance (pos-itive symptom) and withdrawal/retardation (negative symptom)clusters with item responses ranging from 1(not present) to 7 (ex-tremely severe). Factor analyses of the BPRS have validated positivesymptom, negative symptom, and affect (depression, anxiety, andhostility) subscales (Long and Brekke, 1999). A summed score wasused for the present study. After receiving training on the BPRSusing a protocol described in Ventura et al. (1993), the reliability ofraters was excellent (median ICC=0.82; Brekke et al., 2009). TheCronbach's alpha for this sample is 0.81.

Table 1Demographic characteristics at baseline and time 2.

Characteristic Baseline Time 2 t/χ2(n=148) (n=115)

% %

RaceAfrican-American 50.9% 53.9%White 25.8% 23.6%Latino 12.6% 12.7%Asian 4.4% 2.9%Other 6.3% 6.9%

Total Non-White 74.2% 76.4% χ2=3.66, p=0.13GenderMale 62.0% 67.7% χ2=4.17, p=0.29

Age 38.7 (sd=10.1) 38.1 (sd=9.8) t=−0.57, p=0.58Days on medication(last 6 months)

106.1 (sd=83.6) 112.75 (sd=85.3) t=0.17, p=0.86

187L. Davis et al. / Schizophrenia Research 137 (2012) 185–189

2.3. Role functioning

The Role Functioning Scale (RFS; Goodman et al., 1993) containsitems representing four domains of community functioning (work,independent living, family functioning, and social functioning) thatare rated based on a semi-structured interview. The items on theRFS are anchored with response categories ranging from 1 (severe im-pairment in functioning) to 7 (optimal functioning). Each of the fourfunctional domains was summed to calculate a composite score ofglobal functioning as has been suggested based on previous studiesdemonstrating item loadings on a single factor (Brekke et al., 2005).After interview training, the intra-class correlation (ICC) amongthree interviewers on the RFS scale was >0.80 (Brekke et al., 2009).The Cronbach's alpha for this sample is 0.54.

2.4. Self-esteem

The Index of Self-esteem (ISE) is a self-report measure that cap-tures the severity of self-esteem problems of the respondent(Hudson, 1982). This 25-item survey contains items ranging from 1to 5, with higher scores indicating more difficulties with self-esteem.For the present study, the scale was reverse scored so that higherscores reflect higher self-esteem. Based on previous research, the ISEhas demonstrated high reliability and good concurrent validity witha severely mentally ill population (Taylor, 2005). The Cronbach'salpha for this sample is 0.80.

2.5. Demographic covariates

The covariates for the present study were included based on re-search indicating that psychiatric symptoms are influenced by gender(Hafner, 2003) and ethnicity (Brekke and Barrio, 1997) for peoplewith SMI. Additionally, psychiatric medication adherence was includ-ed to control for the influence of this variable on symptoms. Theseitems were gathered as part of a self-reported demographic survey.Ethnicity was dichotomized into White and Non-White. The numberof days respondents were on psychiatric medication in the past6 months is a continuous variable.

2.6. Data analysis

Table 2 provides the mean changes in the variables of interestfrom baseline to time 2. To examine associations between the vari-ables of interest and evaluate the mediating role of self-esteem atbaseline and over a 6-month period, we performed a path analysisusing SEM with Mplus statistical software (Version 5.0; Muthén andMuthén, 1998-2007). The main benefit of this technique is its abilityto determine direct and indirect effects and the corresponding errorsof these estimates, along with measures of overall model fit. Full-information maximum likelihood estimation of parameters was con-ducted using raw data as input (less than 7% of values missing). Directand indirect effects and their standard errors were estimated, and the

Table 2Baseline, follow-up, and change in mean scores on symptoms, self esteem, and rolefunctioning.

Scale Baseline Time 2 Change

Mean/SD Mean/SD Mean/SD

Symptoms(BPRS)

43.73(sd=12.34) 37.98 (sd=11.59) 5.75⁎⁎(sd=12.82)

Self-esteem(ISE)

83.32 (sd=19.09) 87.56 (sd=16.97) 4.24⁎(sd=16.34)

Role functioning(RFS)

11.92 (sd=4.44) 12.83 (sd=5.08) 0.91⁎ (sd=4.60)

⁎ pb0.05.⁎⁎ pb0.01.

Sobel (1982) test was used to determine the significance of the indi-rect effect based on our directional hypotheses.

Model fit to the sample data was assessed to evaluate whether thedata collected fit the proposed theoretical models. A range of modelfit statistics (χ2, CFI, RMSEA) was used to determine adequatemodel fit. Indications of acceptable model fit are considered to be achi-square statistic that is non-significant (P>0.05), a CFI valueequal to or above 0.95, and an RMSEA value equal to or below 0.06(Kline, 2004; Ullman and Bentler, 2004). The 90% confidence intervalaround the RMSEA point estimate is considered to indicate an excel-lent fit to the data if it includes values less than 0.05 (Kline, 2004).

The hypothesized structural model at baseline was computed withall paths freely estimated, and an indirect effect estimate and its stan-dard error were computed (from role functioning to symptoms viaself-esteem). Next, a path model using change scores between time1 and time 2 was modeled. Change scores were obtained by calculat-ing the difference between scores from time 1 to time 2. Examiningthe way in which changes in role functioning and self-esteem relateto changes in symptoms provides an understanding of the dynamicinterrelations of the constructs under study. This analysis linkschanges in the independent variables to changes in the dependentvariable, allowing us to answer the question of whether reducingthe severity of psychiatric symptoms may be motivated by alterationsin an individual's role functioning and self-esteem, rather than simplyestablishing whether initial levels of role functioning and self-esteempredict changes in symptoms at a later point (e.g., Strazdins et al.,2011; Thomas and Zumbo, 2011).

3. Results

3.1. Mediation model at baseline

The hypothesized mediation model at baseline displayed an excel-lent fit to the data (χ2=5.51, df=6, p=0.48, RMSEA=0.000 withCI: 0.000–0.102, CFI=0.999). The model explained 21% of the vari-ance in psychiatric symptoms for this sample. As hypothesized, rolefunctioning was positively associated with self-esteem (β=0.929,t=2.37, p=0.02), indicating that individuals with higher levels offunctioning have higher self-esteem. As was also predicted, self-esteem was negatively associated with psychiatric symptom severity(β=−0.268, t=−5.25, pb0.001). Those individuals with higherself-esteem displayed less psychiatric symptoms when controllingfor the influence of medication adherence. Additionally, the statisticalsignificance of the indirect effect based on Sobel's (1982) method in-dicates that the relationship between role functioning and symptomswas mediated by self-esteem (Indirect effect estimate=−0.221,p=0.02). Lastly, we also tested a ‘reverse’ mediation model as sug-gested by Baron and Kenny (1986). A model that tested self-esteemas a potential mediator with symptoms predicting role functioningshowed that self-esteem was not a significant mediator (p=ns).

3.2. Mediation model with change scores

The sample demonstrated significant increases in functioning andself-esteem over time while concurrently demonstrating significantdecreases in symptom severity (see Table 2).

The change score model also yielded excellent fit statistics(χ2=5.46, df=8, p=0.71, RMSEA=.000 with CI: .000–.092,CFI=1.0). This model explained 23% of the variance in changes inpsychiatric symptoms. As hypothesized, changes in role functioningwere positively associated with changes in self-esteem (β=0.721,t=2.15, p=0.03), indicating that the more individuals change inrole functioning, the more they will display concurrent changes inself-esteem. Additionally, the change in self-esteem was negativelyassociated with changes in symptoms (β=−0.225, t=−2.74,pb0.01) as hypothesized. In other words, increases in self-esteem

188 L. Davis et al. / Schizophrenia Research 137 (2012) 185–189

over time will be associated with decreases in symptoms while de-creases in self-esteem will be associated with increases in symptoms.

Importantly, these findings are robust to the inclusion of the de-mographic covariates, the number of days of medication in the lastsix months, and symptom levels at time 1. In addition, the statisticalsignificance of the indirect effect indicates that the relationship be-tween changes in role functioning and changes in symptoms was me-diated by changes in self-esteem based on a one-tailed test of ourdirectional hypotheses (Indirect effect estimate=−0.064, p=0.04).Given the direction and significance of mean changes in the variablesof interest for the sample, these results suggest that as participants'functioning increased over time, their symptoms concurrently de-creased and that this relationship was accounted for by increases inself-esteem. Once again, to further support the hypothesized se-quence of variables in the model, we tested a ‘reverse’ mediationmodel (Baron and Kenny, 1986). A model testing changes in self-esteem as a potential mediator with changes in symptoms predictingchanges in role functioning indicated that changes in self-esteem wasnot a significant mediator (p=ns).

4. Discussion

In contrast to the majority of studies examining psychiatric symp-toms as major determinants of role functioning impairment (e.g.Velligan and Gonzalez, 2007; Ventura et al., 2009), this study is oneof the few to provide support for the notion that role functioningmay indirectly influence psychiatric symptoms through the mecha-nism of self-esteem. Specifically, results suggest that improvementsin functioning over time led to a reduction in symptom severity andthat this change can be explained by increases in self-esteem for par-ticipants. The temporal dimension of these findings provides supportfor the causal processes posited by Modified Labeling theory whichsuggest that social inclusion leads to positive self-appraisals thatmay ultimately reduce vulnerability to the development of symptomsand future psychiatric relapse for people with SMI.

Findings from this study support a view of self-esteem as both aproduct of socially constructed experiences and a factor that shapesindividual indices of distress (Markowitz, 2001). As Modified Labelingtheory predicts, individuals evaluate their social circumstances andinfer feelings of self-worth based on socially shared cognitive repre-sentations of normative social roles (Link et al., 2001). Those whoare better able to maintain employment, social relationships, and in-dependent living situations within the community are likely to gener-ate positive self-evaluations and higher self-esteem. The degree towhich individuals with SMI view themselves with positive regardmay directly impact symptoms as well as impacting behaviors thatin turn affect symptoms. For example, higher self-esteem may in-crease motivation to engage in self-care behaviors that ultimately re-duce symptoms or may directly improve mood, thereby reducingsymptoms.

This study has important implications for psychosocial rehabilita-tion and emerging views of recovery from SMI. Recent emphasis onreclaiming a positive sense of self as a key feature of recovery high-lights the importance of subjective experience and its influence onthe course and outcome of SMI (Ridgway, 2001; Bellack, 2006). Thisstudy supports the need for wide-spread access to cognitive interven-tions targeting the modification of self-devaluing beliefs that havebeen linked with low self-esteem and are prevalent among this pop-ulation (Lecomte et al., 1999; Link et al., 2001; Borras et al., 2009). Ev-idence related to psychosocial treatments targeting self-esteemamong individuals with schizophrenia indicates a reduction in symp-toms and enhanced coping skills associated with participation(Lecomte et al., 1999; Borras et al., 2009). Additionally, programsthat facilitate social participation as a starting point for treatmentmay improve self-concept and in turn reduce symptoms, leading toa positively reinforcing cycle of symptom and functional

improvement. Research has shown that for people with SMI, workprovides an avenue for generating a sense of accomplishment, socialbelonging, and self-esteem that fosters a diminishing of symptomsand further reinforces competent functioning (Roe, 2001). Programssuch as Supported Employment (Becker et al., 2005) and HousingFirst (Gulcur et al., 2003) that rapidly place individuals in non-sheltered settings may facilitate such opportunities.

Previous findings indicating that the relationship between rolefunctioning and self-esteem is moderated by level of neurocognitivefunctioning for people with schizophrenia suggest further clinical im-plications (Brekke et al., 2001). Based on a negative relationship be-tween functioning and self-esteem for mentally ill individuals withintact neurocognitive functioning, Brekke et al. (2001) concludedthat individuals with greater neurocognitive capacities may be atrisk for low self-esteem based on their ability to compare themselvesto their non-mentally ill counterparts. In contrast, individuals withlower neurocognitive capacities may experience increases in self-esteem as their role functioning improves because of deficits in suchcomparative-referencing abilities. Therefore, interventions targetingincreased role functioning as means of promoting self-esteem shouldincorporate an assessment and understanding of consumers' levels ofneurocognitive functioning and the way this may impact self-appraisals related to functioning and self-esteem.

Despite the clinical and theoretical utility of the present findings,this study has several limitations. The model presented indicatesthat self-esteem accounts for the relationship between role function-ing and symptoms. However, it is possible that self-esteem may inturn lead to other behaviors or attitudes that impact symptom se-verity. For example, low self-esteem and fear of further stigmatiza-tion based on receiving mental health services may interfere withhelp-seeking behaviors and treatment compliance (Corrigan, 2004;Fung et al., 2008), thereby exacerbating symptoms. Alternatively, in-creased levels of self-esteem may increase behaviors related to self-care that may in turn reduce symptom severity. Thus, future studiescan provide a more detailed understanding of various avenues bywhich self-esteem may impact symptom severity. Additionally, aconvenience sample based on consumers who had elected to partic-ipate in treatment may limit the degree to which these findings canbe generalized. Lastly, though a strength of the present study is itsprospective design, observations extending beyond a 6-month peri-od would provide a greater understanding of the causal processessuggested here.

Role of funding sourceSupport for this study has been provided by NIMH grant R01 MH 53282 awarded

to Dr. John Brekke. The NIMH had no further role in study design, analysis and inter-pretation of the data, the writing of the report, or the decision to submit the manu-script for publication.

ContributorsJohn Brekke designed and oversaw the implementation of the parent study, wrote

the protocol, and worked on the preparation of the final version of the manuscript. LisaDavis designed the study, conducted the literature review and statistical analyses, andwrote the manuscript. Seth Kurzban contributed to the interpretation of the resultsand final version of the manuscript. All authors have contributed to and have approvedthe final manuscript.

Conflict of interestThe authors report no competing interests.

AcknowledgmentsThe authors would like to thank Mr. Mark Morales and Mr. Bob Aisley who kindly

assisted in the collection of these data.

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