Self-Esteem as a Mediator of the Relationship Between Role Functioning and Symptoms Among Individuals with Severe Mental Illness

Purpose: Up to two-thirds of individuals with severe mental illness (SMI) are unable to achieve or maintain basic social roles such as employee, spouse, or parent. Furthermore, lack of social participation and inability to fulfill social roles is a significant contributor to low self-esteem for this population. Modified labeling theory posits that the marginalization of persons with SMI leads to internalized negative self-appraisals that can ultimately exacerbate symptoms and increase the likelihood of repeated episodes of illness. Few studies have tested modified labeling theory and the loss of socially valued roles as influencing symptoms through the mechanism of eroded self-esteem. It is hypothesized that global role functioning will be positively related to self-esteem which will in turn be negatively related to symptom severity. It is also hypothesized that self-esteem will mediate the relationship between role functioning and symptom severity.

Methods: This study, consisting of 138 individuals diagnosed with severe mental illness from an NIMH funded investigation of community-based services, examined the role of self-esteem as a mediator in the relationship between role functioning and psychiatric symptoms. The Role Functioning Scale measures four domains of family, independent living, social and work functioning. The Brief Psychiatric Rating Scale is a 24-item scale measuring psychiatric symptoms. The Index of Self-esteem is a 25-item self-report measure capturing the self-esteem of the respondent. Regression analysis was used to test the meditation model.

Results: Results indicated that self-esteem fully mediated the relationship between role functioning and psychiatric symptoms. Bivariate analyses reveal that role functioning was negatively correlated with psychiatric symptoms (r = -.231, p< 0.05), role functioning had a positive correlation with self-esteem (r = .180, p< 0.05), and self-esteem had a negative correlation with psychiatric symptoms (r = -.459, p< 0.005). Results suggest that role functioning is a significant negative predictor of psychiatric symptoms after controlling for the effects of ethnicity, gender, and number of days on medication (β = -.540, t = -2.042, p = .044), role functioning was a significant predictor of self-esteem after controlling for the covariates (β = .980, t = 2.006, p = .048), and self-esteem was a significant predictor of psychiatric symptoms (β = -.303, t = -5.874, p = .000). Lastly, with role functioning and self-esteem in the regression model, role functioning was rendered statistically insignificant and self-esteem remained a significant predictor of symptoms (β = -.301, t = -5.709, p = .000), indicating a full mediation effect. In addition, self-esteem did not mediate the relationship between symptoms and role functioning (the model in reverse order), thereby affirming the robustness of the model which supports the labeling theory under study.

Implications: This study provided support for modified labeling theory as an explanation for why self-esteem mediates the relationship between role functioning and psychiatric symptoms. Specifically, reductions in self esteem due to the loss of role functioning result in higher symptom levels for individuals with severe mental illness. Recovery-oriented services for persons with SMI should focus on social participation as a means of improving self-esteem and ultimately reducing symptomatology.