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European Psychiatry 24 (2009) 307e316

Original article

Increasing self-esteem: Efficacy of a group intervention

for individuals with severe mental disorders
L. Borras a,*,1, M. Boucherie a,1, S. Mohr a,1, T. Lecomte b,2, N. Perroud a,1, Ph. Huguelet a,1
a

University Hospitals of Geneva, Department of Psychiatry, Division of Adult Psychiatry, Secteur 1 Eaux-Vives,
Rue du XXXI Decembre 36, 1207 Geneva, Switzerland
b
University of Montreal, Department of Psychology, Bur C-363, 90 rue Vincent dIndy, C.P. 6128, Succ. Centre-Ville, Montreal, QC H3C 3J7, Canada
Received 21 October 2008; accepted 18 January 2009
Available online 25 March 2009

Abstract
Background. e Individuals with psychosis are known to have a lower self-esteem compared to the general population, in part because of
social stigma, paternalistic care, long periods of institutionalization and negative family interactions. This study aimed at assessing the efficacy
of a self-esteem enhancement program for individuals with severe mental illness and at analyzing the results in their European context.
Method. e A randomized cross-over study including 54 outpatients with a diagnosis of schizophrenia from Geneva, Switzerland, was
conducted. Twenty-four were recruited from an outpatient facility receiving traditional psychiatric care whereas 30 came from an outpatient
facility with case-management care. Psychosocial, diagnostic and symptom measures were taken for all the subjects before treatment, after
treatment, and at 3-months follow-up.
Results. e Results indicated significant positive self-esteem module effects on self-esteem, self-assertion, active coping strategies and
symptom for the participants receiving case-management care. Results were not significant for those receiving traditional care. However, 71% of
all participants expressed satisfaction with the module.
Conclusion. e Individuals with schizophrenia appear to be benefit from the effects of the self-esteem module, particularly when they are
involved in a rehabilitation program and followed by a case manager who liaises with the other partners of the multidisciplinary team. This
encourages reconsidering the interventions format and setting in order to ensure lasting effects on the environment and in turn on coping, selfesteem and overall empowerment.
2009 Elsevier Masson SAS. All rights reserved.
Keywords: Schizophrenia; Self-esteem; Group; Psychosis; Cognitive; Therapy

Psychological recovery denotes the development of a fulfilling life and a positive sense of identity founded on hopefulness and self-determination [1]. Recovery has recently been
recognized as an organizing principle for the systems of care
for the mentally ill, therefore replacing the paternalistic,
illness-oriented services [28]. From this perspective, treatment
features should include a variety of services that support
consumer self-sufficiency. Self-esteem groups have been
developed in order to address this concern. Self-esteem results
* Corresponding author.
E-mail address: laurence.borras@hcuge.ch (L. Borras).
1
Tel.: 001 514 343 6274; fax: 1 514 343 2285.
2
Tel.: 41 22 305 47 60; fax: 41 22 305 47 59.
0924-9338/$ - see front matter 2009 Elsevier Masson SAS. All rights reserved.
doi:10.1016/j.eurpsy.2009.01.003

from the interaction between self-evaluation and social feedback [18]. From this perspective, social stigma, paternalistic
care, and negative family interactions can be detrimental to
self-esteem. Several studies have suggested that long periods
of institutionalization, with their load of stressors, can
contribute to significantly diminishing the self-esteem of
individuals with psychosis compare to that of the so-called
general population [10,27]. Others have found associations
between self-esteem and social functioning [24], self-esteem
and quality of life [32] and between low self-esteem and
paranoid delusion [3].
Research studies have shown that individuals with schizophrenia who show a low self-esteem also have marked
tendency towards depression [5], a loss of motivation

L. Borras et al. / European Psychiatry 24 (2009) 307e316

308

(often wrongly taken to be one of the negative symptoms of

schizophrenia), a tendency towards isolation as a defence
mechanism [33,35], an increase in the appearance of selfprotective psychotic symptoms [12], as well as difficulties in
adapting and in coping with stress or an increased apprehensiveness when confronting any new situation [17]. Studies
underscore the importance of motivation and self-esteem as
predictive factors for the acquisition and maintenance of
adaptative or coping strategies [4,20]. Other studies have
demonstrated that self-esteem predicts ones motivation to
performance [28,29,34,36].
This study follows Lecomtes work [19], who developed
a self-esteem module and tested it in a randomized clinical
trial including 95 subjects. Results had indicated module
effects on coping skills (active coping skills significantly
increased) and psychotic symptoms (positive symptoms
significantly decreased), demonstrating the efficacy of this
particular type of intervention. One of the limits of the original
study was that Dr. Lecomte had been the co-leader for all the
treatment groups, thus limiting the generalizability of the
results.
The goal of our study was therefore to evaluate the efficacy
of this self-esteem enhancement program in individuals with
schizophrenia treated in two different outpatients facilities in
Switzerland, in a randomized trial. In one facility, the participants benefited from routine care including psychosocial
treatments dispensed by a multidisciplinary team. In the other
facility, the participants benefited from the same treatment but
also had an active case manager. As compared with the original study of Lecomte et al. (1999), the evaluations were
conducted with specific scales, following recommendations
from Dr. Lecomte stemming from limitations she had
encountered. Also, the program was implemented directly,
involving clinicians in each site, thus making it possible to
assess programs real-world effectiveness. This study would

also allow us to contextualise the main findings obtained by

Lecomte in Canada, and generalize the results to Europe.
1. Methods
1.1. Study design
Following screening and evaluation, individuals meeting
criteria were randomly assigned to one of the following two
treatment Samples: (A) a group that begun the 12-week
module directly and (B) a group that waited 12 weeks before
beginning the 12-week module. Participants were divided into
a total of 7 groups, with 4e9 subjects in each (Fig. 1).
Clinical ratings were administered for the first Sample (A) at
baseline (before treatment) (Evaluation 1), after the 12-week
treatment sessions (3 months) (Evaluation 2), and 3 months
after the last therapeutic session (Evaluation 3). The second
Sample (B) benefited from a first evaluation 12 weeks before the
beginning of the therapeutic sessions (Evaluation 1), a second
evaluation before beginning of treatment (Evaluation 2), after
the 12-week treatment sessions (Evaluation 3) and 3 months
after the last therapeutic session (Evaluation 4).
The aim of this approach was to unable us to progressively
include all the participants meeting criteria while conducting
a rigorous evaluation of the effects of the treatment.
During this protocol, participants received their usual care
and medications. Medication use was monitored for the
duration of the study.
1.2. Subjects
Fifty-four outpatients between 18 and 65 years of age
meeting the ICD-10 criteria for a diagnosis of schizophrenia or
other non-affective psychoses, all being followed in one of the
two participating Geneva psychiatric outpatient facilities, were

N=54

N=28
Sample A

N=8
Group1
Time 2 :
Drop-out
N=1

N=6
Group3
Time 2 :
Drop-out
N=1

N=7
Group1

N=5
Group5
Time 2 :
Drop-out
N=1

N=5
Group3

N=26
Sample B

N=9
Group7
Time 2 :
Drop-out
N=1

N=4
Group5

N=13
Group2
Time 2 :
Drop-out
N=4

N=8
Group7

N=7
Group4
Time 2 :
Drop-out
N=2

N=9
Group2

Fig. 1. Flow of participants through the study.

N=6
Group6
Time 1 :
Drop-out
N=1

N=5
Group4

N=5
Group6

L. Borras et al. / European Psychiatry 24 (2009) 307e316

included in the study. Twenty-four participants followed in the

first outpatient facility and receiving traditional psychiatric
care made up groups 3, 4, 5 and 6. Thirty participants followed
in the second outpatient facility, and receiving case-management care made up groups 1, 2 and 7 (Fig. 1). Group 2 counted
a larger number of participants (n 13) than the other groups.
Two therapeutic groups were scheduled at the beginning from
that group of patients. But following a large number of
dropout (n 4) before the groups started, all remaining
participants were grouped together (group 2). Diagnoses were
verified by chart reviews and with the MINI (Mini International Neuropsychiatric Interview) [26]. Individuals whose
clinical condition prevented them from participating in the
interviews were excluded. The study was approved by the
ethical committee of the University Hospital of Geneva.
Subjects participated only after receiving detailed information
about the study and signing a written consent document.
About one hundred patients were potentially eligible for this
study. Because of practical (feasibility) considerations, we had
only planned to recruit about 50 participants. Psychiatrists in
two outpatient clinics were provided with information about
the study. Each psychiatrist was asked to present the study to
their next five patients on their schedule in order to control for
selection bias, such as selection of patients according to their
low self-esteem or depressive or negative symptoms. One of
the authors (L.B.) then met the patients for the first interview.
Thirteen patients refused to participate, 6 in the outpatients
facility with case manager and 5 in the other facility. Patients
with mood disorders, current substance abuse (with the
exception of current cannabis misuse) or organic brain disorders were not considered for this study. Participants missing
more than three consecutive sessions or one out of four overall
sessions were excluded from the study, although they were not
excluded from attending the group.
1.3. Measures
The socio-demographic characteristics (age, gender, social
status, education, residence) were reported from the patients
medical file. Clinical characteristics (age of onset of illness,
main diagnosis and comorbidity, number and duration of
hospitalizations) were reported from the patients medical file
but also confirmed with a diagnostic interview (Mini International Neuropsychiatric Interview [26]).
Symptom measures included the Positive and Negative
Syndrome Scale (PANSS) [14] and the Clinical Global
Impression (CGI) [11]. Psychological measures included the
Self-Esteem Rating Scale [18], the Rathus Assertiveness
Schedule (RAS) [7], The Automatic Thoughts Questionnaire
(ATQ) [6], the Cybernetic Coping Scale (CCS) [8], and the
Medication Adherence Rating Scale (MARS) [31].
The SERS is a 20-item self-report assessment that yields
a positive and a negative self-esteem subscale e studies have
found it more sensitive to change than the Rosenberg SelfEsteem Scale [18]. The RAS is a self-report questionnaire that
evaluates self-affirmations with 30 items. Subjects must
determine how well each affirmation corresponds or not to

309

themselves or to their behaviour. The ATQ is also a self-report

and assesses in 30 items the negative content of the inner
monologue of patients. It evaluates the frequency of automatic
thoughts which occurred the preceding week. The CCS is
a self-report questionnaire that evaluates in 20 items the
coping strategies of patients during stressful daily life situations. Five scores are generated, each evaluated by 4 items:
change the stressful situation, accommodation, minimisation,
avoidance and tension reduction. The subjects indicate the
frequency with which they use these tools in stressful situations. The MARS is a 10-item self-report questionnaire on
medication adherence, which has been used and validated with
individuals with schizophrenia. Participants were also asked to
evaluate their own self-esteem with the Visual Analogical
Scale, ranging from 0 to 10.
At Baseline (Evaluation 1) for each Sample (A and B), the
PANSS, CGI, RAS, ATQ, CCS, MARS, SERS, and the selfesteem Visual Analogue Scale were administered. A semistructured interview evaluating the participants expectations
towards the module was also conducted. Evaluation 2 for
Sample B (after a waiting 12 weeks and just before beginning
the self-esteem module) used the same scales and questionnaires as in Evaluation 1 in order to control for consistence
and stability of answers overtime.
For Evaluation 2 of Sample A and for Evaluation 3 of
Sample B (once the self-esteem module finished), the same
assessments were administered with the exception of the semistructured interview being one that asked about the participants likes or dislikes, as well as about what was retained
regarding the module and sessions. Furthermore, by means of
an analogical scale, participants were asked about the degree
of satisfaction with this module and they might wish to see
changed.
Evaluation 3 for Sample A and Evaluation 4 for Sample B
(three-month follow-up, i.e. conducted 12 weeks after the end
of the modules) used the same scales as for Evaluation 1.
Structured interview addressed on what new things the patient
had tried to do since the end of the module and what he
intended to do or continue doing in the near future. Each
evaluation took 60 min.
1.3.1. The self-esteem module e I am super!
This module, developed by Tania Lecomte et al. (1999),
aims at increasing self-esteem in individuals suffering from
psychosis. It is an adaptation of Reasoners module Building
Self-Esteem, [23] originally conceived for children and
adolescent in school contexts. It is one of the few existing
structured modules for the purpose of increasing self-esteem in
individuals with schizophrenia, and to our knowledge the only
one available in French and English.
The module is divided into five key building blocks: a sense
of security, a sense of identity, a sense of belonging, a sense of
purpose, and a sense of competence. A sense of security
implies feeling safe in ones environment, being able to trust
others, relying on past experience to predict or anticipate
events, and being aware of the environment rules and regulations. A sense of identity refers to self-perception, which

310

L. Borras et al. / European Psychiatry 24 (2009) 307e316

includes knowledge of ones strengths, weaknesses and

desires, and awareness of how one appears to others. A sense
of belonging stems from feeling socially accepted and being
part of a group sharing certain attributes, as well as the ability
to reach self-determined goals, overcome obstacles, and take
appropriate risks. A sense of competence is obtained by
challenges to achieve goals and experience success. It is
important to emphasize that ones sense of competence
depends not only on possessing specific skills but also on
believing that one can use them effectively and that one is
worthy of happiness and fulfilment [23]. The module was used
and applied as defined by Lecomte et al. (1999) elsewhere.
The present study followed the same protocol, i.e. offering
participants 24 one-hour sessions over a period of 12 weeks.
The main aspects of self-esteem, namely the sense of
security, identity, belonging, purpose and competence
described above, as well as retroactive environmental and
relational mechanisms which contribute towards developing
and maintaining self-esteem, are worked on progressively.
At the first session, each participant received a manual in
which all the aspects of the 24 sessions are described. For
example, the first session targets ones sense of security and
begins with a group exchange on the importance of feeling
secure and comfortable in ones environment. In order to
encourage dialogue among participants, open-ended questions
are asked on what they like, dislike or would wish to change in
their environment and how. Participants take time to write
their answers in their manual and to share them with others. At
the end of the session, the main points raised by the participants are briefly recapitulated with each one in turn expressing
what they have learned and wish to remember. The module
suggests various interaction modes during the sessions, such as
open questions, multiple choice questions, role playing, or
writing in the manual or on the board. Each group consisted of
5e13 participants, with two therapists (a psychiatrist and
a psychologist).
1.4. Statistics
Baseline characteristics were compared using chi-square or
t-test for categorical and continuous variables respectively.
Predictors of time to dropout were assessed by Cox proportional hazard regression. KolmogornoveSmirnov test was
used to test whether outcome measure distributions were
normally distributed. To approach normality and homogeneity
in the data the scales describing the PANSS as well as ATQ
total score were logarithmically transformed whereas the total
score of coping by tension reduction was squared. All variables were then standardized in z-scores.
To use all available data and provide unbiased estimates in
the presence of missing values, outcomes were analyzed using
mixed models with individual random intercepts and slopes,
and fitted with full maximum likelihood estimation. Age,
gender, and treatment group were included as fixed covariates.
The mixed effect models allow the use of all available data and
provide unbiased estimates without the need for imputation of
missing values. Analyses were first performed separately for

both samples (3 time points for Sample A and 4 time points for
Sample B) and then together in the pooled sample (Sample A
and B, including all time points). In the latter analysis,
randomized sample was assigned as fixed covariate as well.
All analyses were conducted with Stata 10.
2. Results
2.1. Demographic and clinical characteristics
Table 1 describes the clinical and socio-demographic
characteristics of the 54 outpatients. These characteristics are
representative of those patients followed in outpatient settings.
Eleven subjects dropped out during follow-up. There were
significantly fewer single Sample B than in the Sample A (17
(65.4%) vs 26 (92.9%), p 0.041). There was no significant
difference on any other baseline measured variable between
Table 1
Demographic and clinical characteristics.
Geneva
N

Gender
Male
Female

38
16

70.0
30.0

Ethnicity
White European
Arab
African
Asian
Latino

41
4
5
2
2

76.0
7.4
9.2
3.7
3.7

Marital status
Single
Married
Separated or divorced
Without remunerated work

43
4
7
49

80.0
7.0
13.0
91.0

Living
Alone
In a halfway house
With family

25
20
9

46.0
37.4
16.6

Diagnosis
Paranoid schizophrenia
Hebephrenic schizophrenia
Undifferentiated schizophrenia
Schizoaffective disorder
Psychotic disorder not otherwise specified

32
0
5
13
4

59.2
0.0
9.2
24.1
7.3

Current comorbidity
Substance abuse

10

18.5

Clinical Global Impression scale

Slightly ill
Moderately ill
Severely ill

38
39
38

33.0
34.0
33.0

Hospitalizations
Median number
Median duration (months)

5
5

Age (years)
Mean (sd)

41 (9)

Duration of illness (years)

Mean (sd)

18.9 (9.96)

L. Borras et al. / European Psychiatry 24 (2009) 307e316

subjects randomly assigned to either Sample A, Sample B or

to any of the therapeutic groups.
2.2. Attrition
Of the 54 participants who started the study, 43 (79.63%)
completed the three periods of time. The rate of dropout
tended to be highest among participants randomly allocated to
Sample B (hazard ratio 1.81, 95%CI 0.87e1.02, p 0.12)
(Fig. 2). None of the other baseline characteristics were related
to attrition.
3. Mixed effect models
Results of the full mixed models including fixed effects of age,
gender, type of treatment and randomization status are presented
in Tables 2 and 3. We noted a stability of results for all the scales
in Sample B during the initial waiting period (12 weeks).
3.1. PANSS
For the whole sample, over the three time periods, an
average subject was estimated to have improved from 14.3 to
12.4 on the scale measuring positive symptoms (b 0.28;
p < 0.0001; 95%CI 0.41/0.19), 37.9e33.5 on general
symptoms (b 0.3; p <0.0001; 95%CI 0.38/0.18),
and 74.9e67 on total symptoms (b 0.34; p < 0.001;
95%CI 0.44/0.24).
These improvements were also observed when analyzing
both samples (Sample A and Sample B) separately (Table 3).
When looking at the different therapeutic groups, subjects in
therapeutic groups 1, 2 and 7 displayed an improvement in
positive symptoms, whereas subjects following the treatment
groups 3, 4, 5 and 6 did not show any significant change
(0.24; p 0.199; 95%CI 0.61/0.12, b 0.09; p 0.581;
95%CI 0.43/0.24, b 0.5; 95%CI 1.12/0.11; p 0.108
and b 0.3; 95%CI 0.7/0.09; p 0.134) (Table 3). There
was also no significant improvement in general and total
symptoms for those following the therapeutic group 2
Kaplan-Meier survival estimates
1.00

0.75

311

(b 0.071; p 0.516; 95%CI 0.29/0.15 and b 0.16;

p 0.103; 95%CI 0.35/0.03 respectively) and no improvement in total symptoms for those following the therapeutic
group 5 (b 0.33; p 0.077; 95%CI 0.69/0.03).
For negative symptoms, only sample 1 displayed a significant improvement over time (24.1e20.9, b 0.22,
p < 0.0001; 95%CI 0.31/0.12). This improvement was
mainly explained by the subjects assigned to the treatment
group1 and group7 (b 0.24; p 0.027; 95%CI 0.45/
0.03 and b 0.33; p < 0.0001; 95%CI 0.45/0.21
respectively) and group3 (b 0.21; p 0.019; 95%CI
0.38/0.03) and was not significant for those assigned to the
therapeutic group5 (b 0.04; p 0.598; 95%CI 0.12/0.21).
Moreover in the Sample B, those assigned to treatment group2
displayed a significant worsening of negative symptoms (from
24 to 38; b 0.37; p 0.03; 95%CI 0.036/0.71) (Table 3).
3.2. Coping
A global improvement for coping over time was observed
with an improvement from 3.6 to 4.4 for changing the stressful
situation (b 0.16; p 0.009, 95%CI 0.04/0.28), from 2.8 to
3.7 for accommodation (b 0.29, p < 0.0001; 95%CI 0.19/
0.4), from 2.6 to 3.6 for minimisation (b 0.31 p < 0.0001;
95%CI 0.19/0.43), from 3 to 3.8 for avoidance (b 0.29
p < 0.0001; 95%CI 0.17/0.41) and from 3.6 to 4.3 for tension
reduction (b 0.18, p 0.0003; 95%CI 0.08/0.27).
For both changing the situation and tension reduction, the
significant results were found only in Sample A (Table 3).
Moreover, in Sample A, there was no significant improvement
in changing the situation for those following the therapeutic
group5 (b 0.03; p 0.909; 95%CI 0.58/0.65 and b 0.12;
p 0.403; 95%CI 0.16/0.41). Most of the coping measures
improved over time among subjects following the therapeutic
group1, group2 and group7 (b 0.47; 95%CI 0.10/0.83;
p 0.012, b 0.47; 95%CI 0.28/0.66; p < 0.0001 and
b 0.54; 95%CI 0.26/0.81; p < 0.0001 for accommodation;
b 0.55; 95%CI 0.21/0.89; p 0.002, b 0.45; 95%CI 0.28/
0.62; p < 0.0001 and b 0.51; 95%CI 0.15/0.86; p 0.005
for minimisation; b 0.66; 95%CI 0.26/1.07; p 0.001,
b 0.29; 95%CI 0.14/0.44; p < 0.0001 and b 0.51; 95%CI
0.23/0.78; p 0.0003 for avoidance: b 0.43; 95%CI 0.13/
0.72; p 0.005, b 0.22; 95%CI 0.07/0.37; p 0.004 and
b 0.51; 95%CI 0.31/0.71; p < 0.0001 for tension reduction)
but not among those following other therapeutic groups.
3.3. Self-esteem

0.50

0.25

0.00
0

analysis time
sample1

sample2

Fig. 2. Retention of participants in the study (survival graph). Scale on the left
indicates proportion of participants retained in the study.

We observed, in the whole sample, a significant increase

from 36.6 to 38.4 for the positive self-esteem subscale
(b 0.15, p 0.016, 95%CI 0.03/0.28). The significant
improvement was found only in Sample A and within Sample
A by the subjects following therapeutic group1 (b 0.47;
95%CI 0.08/0.86; p 0.019) and group3 (b 0.3; 95%CI
0.06/0.54; p 0.014) (Table 3).
For the negative self-esteem subscale a significant
improvement was observed only in Sample A with a decrease

L. Borras et al. / European Psychiatry 24 (2009) 307e316

312

Table 2
Means, standard deviations and number of observed values for all scales at times 1, 2, 3 and 4.
T

Sample1
Mean

PANSS

Coping

Positive symptoms
1
2
17.3
3
13.6
4
12.7
Negative symptoms
1
2
24.1
3
21.5
4
20.9
General symptoms
1
2
40.5
3
33.9
4
32.9
Total symptoms
1
2
81.8
3
68.9
4
66.5

Sample2
N

Mean

5.8
4.8
5.1

26
23
20

14.3
14.2
12.5
12.1

8
5.8
5.1

26
23
20

9.1
7.1
8.5

16.8
13.2
16

Mean

5.8
5.6
4
3.6

22
21
16
16

15.9
13.1
12.4

5.9
4.4
4.4

47
39
36

22.6
23.2
29.8
27.9

7.4
7.6
15.2
15.9

22
21
16
16

23.7
24.9
24

7.8
11.3
11.6

47
39
36

26
23
20

37.9
36.8
35.2
34.3

11.5
11.8
8.5
8.9

22
21
16
16

38.8
34.4
33.5

10.5
7.6
8.6

47
39
36

26
23
20

74.9
75.5
69.9
67.6

21.4
20.9
15.7
16.3

22
21
16
16

74.9
79
69.3
67

18.8
14.1
15.9

47
39
36

1.5
1.3
1.3

28
24
21

3.6
3.9
4.2
3.5

1.6
1.6
1.3
1.1

26
24
18
19

3.9
4.8
4.4

1.5
1.4
1.5

52
42
40

1.1
1.2
1.3

28
24
21

2.8
3
4
3.4

1.5
1.6
0.9
0.9

26
24
18
19

3
4.1
3.7

1.3
1.1
1.1

52
42
40

1.4
1.3
1.5

28
24
21

2.6
2.7
3.8
3.3

1.5
1.6
1.4
1

26
24
18
19

2.7
3.8
3.6

1.4
1.3
1.3

52
42
40

1.1
1.4
1.4

28
24
21

3
3.18
3.86
3.64

1.4
1.3
1.4
0.8

26
24
18
19

2.9
3.9
3.8

1.2
1.4
1.2

52
42
40

1.3
1
1.1

28
24
21

3.6
3.8
4
3.9

1.6
1.5
1.3
1.1

26
24
18
19

3.9
4.4
4.3

1.4
1.2
1.2

52
42
40

28
24
21

69.3
69.6
63.7
60.1

23.9
23
22
22.5

26
24
18
19

70.6
63.4
64.2

23.8
23.6
27.7

52
42
40

28
24
21

116.4
118.6
99.6
103.9

20.6
21
19.9
21.6

26
24
18
19

116.1
101.6
105.5

20.9
21.3
22.1

52
42
40

28
24
21

5
4.8
5.7
5.2

2.3
2.1
1.4
1.5

26
24
18
19

4.4
5.9
5.3

2.2
1.7
1.7

52
42
40

SD

Change the situation

1
2
3.9
3
5.2
4
5.2
Accommodation
1
2
3
3
4.1
4
3.9
Minimisation
1
2
2.7
3
3.8
4
3.9
Avoidance
1
2
2.75
3
3.99
4
3.94
Tension reduction
1
2
3.9
3
4.7
4
4.7

Total

Automatic thoughts (ATQ)

1
2
71.5
24.9
3
63.2
25
4
67.9
31.7
Assertiveness (RAS)
1
2
113.9
21.1
22.5
103.2
3
4
107
23
Self-esteem (VAS)
1
2
4.1
2.3
3
6.1
1.9
4
5.4
1.9

SD

SD

p (S1 S2)

p (S1)

<0.0001

<0.0001

0.008

0.226

<0.0001

0.516

<0.0001

<0.0001

0.009

<0.0001

<0.0001

<0.0024

0.009

<0.0001

0.688

<0.0001

<0.0001

<0.0003

<0.0001

<0.0001

<0.001

<0.0003

<0.0001

<0.008

<0.0003

<0.0001

0.165

0.002

0.023

0.042

<0.0001

0.021

<0.0005

0.007

0.002

0.309

p (S2)

L. Borras et al. / European Psychiatry 24 (2009) 307e316

313

Table 2 (continued )
T

Sample1
Mean

Self-esteem

Sample2
SD

Positive self-esteem subscale

1
2
31.7
13.5
3
40.9
10.3
4
38.9
11.4
Negative self-esteem subscale
1
2
39.9
11.9
3
30.1
9.6
4
33.6
11.2

p (S1 S2)

Total

Mean

SD

Mean

SD

28
24
21

36.6
32.7
37.6
37.7

9.5
10.2
7.6
8.3

25
24
18
19

32.2
39.5
38.4

12
9.3
9.9

52
42
40

28
24
21

31.6
40.8
44.8
34.6

18.6
10.4
45.6
10.4

25
24
18
19

40.3
36.4
34

11.1
31.1
10.7

52
42
40

of negative self-esteem from 39.9 to 33.6 (b 0.18;

p 0.001; 95%CI 0.28/0.07). This observation was made
only for the subjects following the therapeutic group1 and
group7 (b 0.17; p 0.023; 95%CI 0.31/0.02 and
b 0.37; p 0.003; 95%CI 0.61/0.12 respectively).
For the subjective measure of self-esteem, an improvement
from 5 to 5.3 (b 0.16, p 0.007, 95%CI 0.04/0.28) was
observed. As for the positive self-esteem subscale, the
significant improvement was found only in Sample A and
within Sample A by the subjects following therapeutic group3
and group7 (b 0.47; 95%CI 0.02/0.93; p 0.041 and
b 0.36; 95%CI 0.05/0.69; p 0.029 respectively) (Table 3).
3.4. Automatic thoughts
In the whole sample, the following changes were observed
over the three periods of time for automatic thoughts (69.3e
64.2, b 0.15, p 0.005, 95%CI 0.26/0.05). Although
the results were significant in the Sample A, they were not
confirmed in the second sample. In Sample A, although for each
treatment group the same trend was observed, the significant
change was mainly found by the subjects following therapeutic
group7 (b 0.28; p 0.002; 95%CI 0.47/0.10).
3.5. Assertiveness
In the whole sample, the following changes were observed
over the three periods of time for assertiveness 116.4e105.5
(b 0.24, p < 0.0001, 95%CI 0.35/0.13). Only the
subjects following therapeutic groups 2 and 7 displayed
a significant change over time (b 0.45; p 0.0001; 95%CI
0.65/0.24 and b 0.34; p 0.005; 95%CI 0.58/0.10
and) whereas those following groups 1 and 3e6 did not.
There were no modifications of the Medication Adherence
Rating scale over the three time periods (table not shown).
Overall, 71% of patients expressed satisfaction with the
module. What they had liked during the sessions was: the good
ambiance within the group (14%), rediscovering their own
qualities by themselves and/or thanks to others (14%), meeting
and exchanging with others (12%) and the intellectual stimulation (12%). What they had not liked about the encounters
was: the back to school aspect with having to use a manual
to keep a record of sessions (16%), some of the questions were

p (S1)

p (S2)

0.016

0.01

0.403

0.891

0.001

0.436

perceived as being too personal (8%), some other members of

the group who were not making an effort to participate (8%),
that some members were too symptomatic (10%), and that it
was demanding for some participants to get up in the morning
to come to the group (8%).
What the group did give them was: moments to meet
together and exchange (15%), learning to know themselves
and their qualities better, thanks to the exercises and feedback from others (15%), learning to be more objective
regarding their problems and confront them differently
(11%), realizing that they were not the only ones who had
such problems, talking more easily and learning to pay
attention to others (8%), becoming aware that they enjoyed
discussing (6%), asserting themselves and expressing an
opinion (6%). They felt motivated by the group to start
engaging in the immediate future in activities that were
important for them (13%), to approach and communicate
with others (22%), to continue to stimulate their memory by
continuing to learn things (through books, TV, radio) (13%),
to gain renewed self-confidence in dealing with problems by
realizing that they were not alone having them (13%). When
seen again at the three-month follow-up and asked about
what they had been able to achieve since then, they
answered that: they seemed able to engage a conversation
more easily (22%). For example, a 35-year-old person with
paranoid schizophrenia said: Learning to speak first rather
than second in the group has encouraged me to initiate
conversations more easily. Another said: I dont like
speaking, I feel as if I loose something when I talk, but I
learnt from the group that speaking is important, you cant
stay alone and thats by speaking that we can be with
others (a 42-year-old woman with paranoid schizophrenia).
They also said they felt more inclined to do an activity when
someone proposes one (19%), and that they had more selfconfidence when they were with other people (19%). A 53year-old person with paranoid schizophrenia said: I am
more present in my life than before. I have learned to feel
present with you and with the group. What does being
present mean for you? (asked the evaluator). Feeling more
alive as if I really exist, more confident in myself. Others
were now engaged in some kind of activity (6%), and others
still said they felt more motivated to go out, not just stay at
home (6%).

L. Borras et al. / European Psychiatry 24 (2009) 307e316

Total

Improvement; 0 steady state;  worsening.

0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0

0
0

0
0

0
0
0
0
0
0

0


0
0
B

1
3
5
7

2
4
6

0
0

0
0
0
0
0

0
0
0

0
0
0

0
0

0
0

0
0

0
0

0
0

Negative
Positive

ATQ
thoughts
Negative
Positive
Change

4. Discussion

TTT

PANSS
Sample

Table 3
Status over time of the different scales.

General

Total

Coping

Accommodation

Minimisation

Avoidance

Reduction

Self-esteem

Subjective

Others

(RAS)
assert
iveness

MARS

314

In this study, we implemented and evaluated a self-esteem

module developed in Quebec, Canada, that aims at empowering individuals suffering from chronic schizophrenia. Our
principal objective was to assess how this program worked in
terms of effectiveness in real-world clinical settings not
influenced by research training. We also wished to contextualise the module to a European setting, in order to
determine if the results could be generalized.
The study supported the efficacy of this therapeutic
approach, as we observed an increased self-esteem, increased
self-assertion, decreased negative automatic thoughts,
improved coping strategies and decreased psychotic symptoms. This module was used easily, without training in the two
sites. In addition, the drop-out rate (20, 37%) was weak as
compared with other naturalistic studies [22], though this may
be due to the small size of the groups. Furthermore, the degree
of satisfaction with the module was high (71%).
Concerning the self-esteem dimension, a significant
improvement was highlighted through the SERS and confirmed
by the analogical scale, as was predicted by Lecomte (1999),
who had recommended this scale over the Rosenberg SelfEsteem Scale [25]. As mentioned earlier, the SERS [18] is more
specific to change over time than the Rosenberg, which
measures stable and global self-esteem.
In agreement with previous findings [15,19,30], our study
also showed an increase in the use of active coping strategies,
an improvement of self-assertions and a significant decrease in
positive, general and total symptoms. Several explanations
could be given for the effect of the groups. Firstly, according
to qualitative results, these types of groups seemed to help
patients to develop alternative explanations for their experiences by stressing the contradictions underlying their ideas.
Socratic questioning by the therapists and reality testing used
during group sessions probably allowed them an access to
more functional alternatives [2]. Secondarily, participants
were shown to tackle psychotic symptoms in a normalizing
perspective, placing them on a continuum with normal experiences and explaining psychotic themes and reactions to these
in more accessible terms, linked to real-life experiences [16].
Thirdly, the group helped participants master the therapeutic
process of questioning their delusional ideas [22]. Finally, as
highlighted by Lecomte et al. (1999), the decrease in positive
symptoms stemmed from the groups empowering effect,
which apparently somewhat buffered psychotic manifestations. In this perspective, the module offered a secure,
understanding, and structured environment that appeared to
decrease stress and allow an increase in the ability to cope
with symptoms.
As was found in the study of Lecomte et al. (1999), the
positive effects of the module diminished once the treatment
ended. This could be because the environment did not provide
opportunities for the changes and growth which had occurred,
which may be common in institutional settings. This loss of
efficacy could be bypassed by the introduction of booster
sessions every 2 or 3 weeks as suggested by Lecomte in her

L. Borras et al. / European Psychiatry 24 (2009) 307e316

study or by the pursuit of an individual cognitive-behavioural

therapy aiming at specific aspects needing to be reinforced.
The results obtained also varied from one group to another.
This could be related to the way the treatment was administered, or by the environment in which participants were
treated. Concerning the latter, those showing significant
parametric improvement had the advantage of beneficiating
from a case management in addition to usual psychiatric care;
in comparison to the groups who did not significantly improve.
Thus, our result suggested that the module and group setting,
particularly the ongoing support in the treatment environment,
can have an impact on outcomes. This encourages reconsideration of the interventions format and setting. For individuals
with psychosis to truly benefit from its effects, the module
should be offering within a rehabilitation program in which
patients are involved and for which they receive continuous
support from a case manager working in a multidisciplinary
team.
We can also note that in the outpatient facility without
case management, few of the mental health staff were
responsive and some offered resistance to the implementation
of this module (for e.g., some clinicians said they did not see
the real use of this group which they saw as being imposed
on them, since different dimensions of self-esteem could be
treated in individual sessions, that the coordination of the
group would take too much time and that the pace of the
sessions was too intensive for patients, etc). Thus, we not
only need to concentrate more of our energy in empowering
individuals with schizophrenia who have suffered from years
of institutionalization but we also need to educate and
empower institutionalized mental health staff in order for
patients to benefit from this type of approach. Often, mental
health staff working with individuals with severe mental
illness becomes disillusioned about treatments, and develops
stigmatizing views regarding the individuals they treat. A
change in thinking is required if the recovery of people with
severe mental illness is to become the leading philosophy of
care.
The study has some limitations, namely the absence of
a control group and the selection of the sample size based on
practicality factors, rather than a power analysis. However,
Lecomte [19] had conducted a randomized controlled trial and
we obtained similar results. The results obtained could not be
attributed solely to the intensiveness of the group-work;
indeed, the results differed from one facility to another
whereas frequency of treatment was identical.
The frequency of residual psychotic symptoms in individuals
treated with antipsychotic drugs [21], the lack of trained
personnel and the difficulties in engaging some patients in
treatment [9,13] call for the development of new approaches.
This self-esteem module studied here seems to be effective in
improving self-esteem, self-assertion, coping strategies and
symptoms in individuals with psychosis, particularly for individuals treated in a supportive rehabilitation setting. The
intervention could most likely be used for most patients with
psychotic symptoms, with the exception of those with severe
conceptual disorganisation.

315

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