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Canadian Journal of Community Mental Health 16 (1): 23-38 (1997)

The role of self-esteem in psychosocial adaptation of persons with schizophrenia

T Lecomte , M Cyr , AD Lesage
Research on the efficacy of rehabilitation programs for people with schizophrenia have shown that gains often are not kept over long periods of time and many behaviours do not generalize to other situations. Most psychosocial rehabilitation programs suppose that the acquisition of skills creates a sense of competence and improves overall self-esteem, which in turn helps to generalize and maintain the acquired skills over time. We propose that self-esteem is a basic variable in the rehabilitation of people suffering from schizophrenia and not simply the possible result of life-skills programs. Self-esteem has been defined as being 'the experience of being capable of managing life's challenges and feeling worthy of happiness' and is built on the consolidation of five components: a sense of security, identity, belonging, purpose, and competence (Reasoner, 1992). A sense of security is defined as the feeling of being protected, of being able to trust others, to predict or anticipate events based on past experience, and of knowing one's limits and how to act in one's environment. A sense of identity refers to self-perception, to the capacity to self-observe and to know oneself. A sense of belonging consists of feeling similar to others in certain ways and feeling a part of a group of unique individuals who have shared some common experiences. A sense of purpose is defined as the capacity to set goals based on personal aspirations and to adequately solve problems. A sense of competence comes from the belief that one is capable of reaching goals, of overcoming problems, and of succeeding in personal ventures. This implies the ability to identify options, to make wise choices, to use problem-solving techniques, and to actively make use of available resources. Different studies have demonstrated that pecple suffering from schizophrenia have significantly lower self-esteem than the general population. All five components of self-esteem are affected by the deficits, handicaps, stigma, and institutionalization associated with schizophrenia. For example, a sense of security is damaged when an individual is taken away from his or her normal environment, often by family members. The social stigma and the ambivalent attitude and fear of the population toward mental illness also affects the sense of security. The sense of identity is troubled with the first psychotic episode and the diagnosis of schizophrenia. During acute psychotic episodes, the person goes through a de-identification of the self with a lack of differentiation between self and others, thoughts and emotions, etc. Schizophrenia is an illness of the 'I am' which redefines the identity of the person and where chronicity is perceived as a loss of the self. With the establishment of the illness, there is also a modification of the sense of belonging marked by the loss of valued roles such as work or studies and a certain withdrawal from family and friends. The role that remains is that of the 'ill', which increases a sense of learned helplessness and dependency on others. Institutionalization has been particularly harmful for individuals' self-esteem. For example, a sense of purpose is affected by the way the institution 'takes charge' of the patient, imposing routines, tasks, and orders to be followed. Institutional neurosis is characterized by a lack of initiative and motivation, apathy, and a general lack of interest. Many individuals suffering from schizophrenia who have been hospitalized for more than 10 years suffer from institutional neurosis. Though institutional ways have changed in the past years, they remain protected, ritualized, and structured environments which don't always encourage motivation and initiative. The symptoms and manifestations associated with schizophrenia alter the sense of competence and therefore the person's self-esteem. In fact, many cognitive deficits come with the illness: attention deficits, memory problems, and difficulties in integrating and processing information or transposing the information to other situations. Deficits in social skills and independent living skills often follow schizophrenia. Many individuals suffering from schizophrenia are aware of these handicaps and feel even more diminished and incompetent.
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