The effects of self-stigma content and process on subjective quality of life in people with schizophrenia

1) Background: People with schizophrenia may endorse and internalize public stigma directed against them and at times experience self-stigma. Having self-stigmatizing thoughts per se does not necessarily lead to chronic psychological distress. Only when such thinking occurs frequently and automatically as a mental habit does this generate constant mental chaos, which may have deleterious effects on the subjective quality of life of individuals. The mental process of self-stigma should be distinguished from the mental content, assessed independently, and not be assumed to be homogeneous across all people with schizophrenia. The present study aims empirically to test whether habitual self-stigma contributes to decreased subjective quality of life after controlling self-stigmatizing cognitive content. 2) Methods: A community sample of 144 people with schizophrenia was recruited in Hong Kong. Subjective quality of life was measured with the Satisfaction With Life Scale (SWLS). Self-stigmatizing cognitive content was assessed with the Self-Stigma Scale-Short Form (SSS-S). We developed a self-reported measure of habitual self-stigma, that is, the Self-stigmatizing Thinking’s Automaticity and Repetition (STAR) scale. The STAR contains 15 items rated on a 5-point Likert scale from 1 (strongly disagree) to 5 (strongly agree) measuring the extent to which individuals experience frequent, automatic, and self-descriptive self-stigmatizing thinking. 3) Results: 47% of participants reported repetitive self-stigma, while 68% reported automatic self-stigma. Taken together, the prevalence of habitual self-stigma was 40%. More negative cognitive content of self-stigmatizing thinking (r=−0.246, p=0.003) and stronger self-stigmatizing thinking habit (r=−0.314, p<0.001) were correlated with decreased subjective quality of life. SWLS was regressed on SSS-S (Step 1) and STAR (Step 2) in a hierarchical multiple regression. Self-stigmatizing cognitive content yielded a significant relationship with subjective quality of life at Step 1 (p=0.003) which disappeared at Step 2 (p = 0.243) when STAR was added and found to be significant (p=0.008). 4) Discussion: The construct of self-stigmatizing thinking habit offers new perspectives on self-stigma’s theory, assessment, and intervention. Given that the deleterious effects of self-stigma on subjective quality of life are due to both the negative content and the habitual manifestation of self-stigmatizing thinking, the impact of self-stigma on people with schizophrenia may be underestimated if it is based solely on traditional content-oriented measures. Existing self-stigma interventions, which are cognitive content-oriented, should be improved by additionally targeting the automatic processes involved in the mental habit. In mitigating self-stigmatizing thinking habit, practitioners may apply mindfulness-based psychotherapies to enhance individuals’ awareness of automatic self-stigma process at the present moment. Interventions should also seek to help individuals with schizophrenia extend their self-definition beyond their minority status, thereby thinking about their stigmatized condition less.