Schizophrenia Bulletin vol. 33 no. 1 pp.
192–199, 2007
doi:10.1093/schbul/sbl016
Advance Access publication on August 7, 2006
Toward Understanding the Insight Paradox: Internalized Stigma Moderates the
Association Between Insight and Social Functioning, Hope, and Self-esteem
Among People with Schizophrenia Spectrum Disorders
Paul H. Lysaker1–3, David Roe4, and Philip T. Yanos5,6
2
Day Hospital 116H, 1481 West 10th Street, Roudebush VA
Medical Center, Indianapolis, IN 46202; 3Department of Psychi-
atry, Indiana University School of Medicine, Indianapolis, IN
46202; 4Department of Psychiatric Rehabilitation and Behavioral
Health Care, University of Medicine and Dentistry of New Jersey,
Scotch Plains, NJ; 5Department of Psychiatry, University of
Medicine and Dentistry of New Jersey, New Jersey Medical School,
Newark, NJ; 6Institute for Health, Health Care Policy, and Aging
Research, Rutgers University, New Brunswick, NJ
Research has paradoxically linked awareness of illness to
both better function outcomes and lesser hope and self-
esteem. One possible explanation for these findings is that
acceptance of having schizophrenia may impact outcomes
differently depending on the meanings the person attaches
to this acceptance, particularly whether he or she accepts
stigmatizing beliefs about mental illness. To explore this
possibility we performed a cluster analysis of 75 persons
with schizophrenia spectrum disorders based on single
measures of insight using the Positive and Negative Syn-
drome Scale, internalized stigma using the Internalized
Stigma of Mental Illness Scale, and compared groups on
concurrent assessments of hope and self-esteem. Three
groups were produced by the cluster analyses: low in sight/
mild stigma (n = 23), high insight/minimal stigma (n = 25),
and high insight/moderate stigma (n = 27). As predicted,
analysis of variance–comparing groups revealed that the
high insight/moderate stigma group had significantly the
lowest levels of hope on the Beck Hopelessness Scale and
self-esteem using the Multidimensional Self-esteem Inven-
tory. As predicted, the high insight/minimal stigma group
also had significantly less impaired social function than the
other groups. Implications for assisting persons to come to
cope with awareness of illness and stigma are discussed.
Key words: schizophrenia/stigma/quality of life/insight/
hope/social function/narrative
1
To whom correspondence should be addressed; e-mail:
plysaker@iupui.edu.
Ó The Author 2006. Published by Oxford University Press on behalf of the Maryland Psychiatric Research Center. All rights reserved.
For permissions, please email: journals.permissions@oxfordjournals.org.
192
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Relative to persons with other psychiatric disorders, per-
sons with schizophrenia spectrum disorders are often un-
aware or willfully contest that they have what others
think to be a mental illness.1,2 Taken as a whole, this phe-
nomenon, often referred to as ‘‘lack of awareness’’ or
‘‘poor insight,’’ has shown a pattern of apparently con-
tradictory associations with outcome. For instance, poor
insight has been linked to poorer treatment adherence,3,4
poorer clinical outcome,5 poorer social function,6–8 voca-
tional dysfunction,9 and difficulties developing working
relationships with mental health professionals.10 On the
other hand, greater insight has been associated with
higher levels of dysphoria,11–14 lowered self-esteem,15
and decreased well-being and quality of life.16–21
One possible explanation for the seemingly contradic-
tory findings is that the impact of the acceptance of
schizophrenia depends on the meanings persons attach
to schizophrenia.22 For example, if one believes the illness
means that he or she is not capable of achieving valued
social roles, then awareness could lead to hopelessness
and less motivation to persevere. However, if one does
not believe that this illness precludes chances for a satis-
fying life, then awareness of the illness may be a key part
of negotiating the challenges posed by the symptoms
and diagnostic label. Supporting this view is research
suggesting ‘‘role engulfment,’’ or the extent to which
a person adopts the identity of a ‘‘mental patient,’’23 is
associated with both better insight24 and poorer social
functioning.25 Internalized stigma,26 a related construct
reflecting the degree to which a person has internalized
societally endorsed stigmatizing beliefs about mental ill-
ness (eg, people with mental illness are violent and unable
to function independently), has been found to take on
personal relevance when a person is diagnosed with men-
tal illness27 and has been linked to depressed mood.26
Also consistent with this is a longitudinal qualitative
study that reported that the transformation of ‘‘sense
of self’’ from one of ‘‘patienthood’’ to ‘‘personhood’’ was
an important element in the process of improving func-
tioning in a group with severe mental illness.28
While these findings support the view that the mean-
ings a person attaches to having a mental illness can

Stigma rejected + Illness accepted higher hope/self-esteem, better adaptation to illness
Stigma accepted + Illness accepted lower hope/self-esteem, better adaptation to illness
Stigma accepted + Illness rejected higher hope/self-esteem, poorer adaptation to illness
Fig. 1. The interactions of stigma and insight and their relationship to hope, self-esteem, and social function.
have important implications for how awareness impacts
outcomes, stigma’s impact on the effects of insight on
outcome in schizophrenia has yet to be explicitly studied.
To investigate this we have sought to determine whether
we could distinguish groups of persons with schizophre-
nia who varied according to level of insight and internal-
ized stigma and then to see whether these different groups
differed in hopefulness, self-esteem, and social function.
Social functioning includes a person’s capacity for social
relations and the breadth of social relations and is a major
outcome of interest for people with schizophrenia.29
Hopefulness has been found to predict problem-oriented
coping when accompanied by insight30 and is by matter
of definition an appraisal of the future and thus a context
in which persons make decisions about how to pursue life
goals. Self-esteem has been found to predict life satisfac-
tion and is related to positive outcome among people with
schizophrenia.31–33
Accordingly, we made 3 hypotheses. We first predicted
that clustering participants in a treatment sample by in-
sight and internalized stigma would result in 3 groups: (a)
those who held stigmatizing beliefs about mental illness
and believed they had a mental illness; (b) those who did
not endorse having internalized stigmatizing beliefs
about mental illness and believed they had a mental ill-
ness; and (c) those who endorsed stigmatizing beliefs
about mental illness but did not have insight or were
not aware of their mental illness. As illustrated in figure
1, we secondly predicted that the group that rejected
stigma but acknowledged their illness and the group
that accepted stigma but rejected their illness would
have more hope and self-esteem than the group that ac-
cepted stigma and acknowledged their illness. Third, as
also illustrated in figure 1, we predicted that the group
that rejected stigma and acknowledged their illness would
have the best social function of all 3 groups. Here we rea-
soned that the lesser hope and self-esteem of the group
that held stigmatizing beliefs about mental illness and be-
lieved they had a mental illness could erode social func-
tion just as the unawareness of illness in the third group
could erode social function by virtue of its limiting that
group’s adaptation to illness. We finally planned to com-
pare groups on symptom levels for exploratory purposes.
Methods
Participants
Sixty-four men and 11 women with Structured Clinical
Interview for Diagnostic and Statistical Manual of Mental
Toward Understanding the Insight Paradox
better social functioning
poorer social functioning
poorer social functioning
Disorders, Fourth Edition (DSM-IV) (SCID34)-confirmed
DSM-IV diagnoses of schizophrenia (n = 40) or schizo-
affective disorder (n = 35) were recruited from a compre-
hensive day hospital at a VA Medical Center (n = 55) and
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local Community Mental Health Center (CMHC; n = 20)
for a larger survey of the prevalence of anxiety symptoms
in schizophrenia. All participants were receiving ongoing
outpatient treatment and were in a postacute or stable
phase of their disorder, defined as no hospitalizations
or changes in medication or housing in the last month.
Participants with a history of mental retardation docu-
mented in a chart review were excluded. Participants
had a mean age of 48.25 years (SD = 7.01), a mean ed-
ucational level of 12.57 (SD = 2.05), and a mean of
8.73 (SD = 9.04) lifetime hospitalizations with the first
occurring on average at the age of 25.26 years (SD =
8.37). Thirty-six participants were Caucasian, 37 African
American, and 2 Latino.
Participants were recruited through contact with pri-
mary providers who informed patients whom they be-
lieved met study criteria. Of those 86 participants who
consented to participate, 11 completed only portions
of the assessments and failed to attend follow-up ap-
pointments to complete the assessments. It is estimated
that the total possible number of persons who could
have been recruited was approximately 450 (300 patients
in the VA and 150 in the CMHC).
Instruments
The Positive and Negative Syndrome Scale (PANSS35) is
a 30-item rating scale completed by clinically trained re-
search staff at the conclusion of chart review and a semi-
structured interview. For the purposes of this study, 2 of
the 5 PANSS factor analytically derived components36
were used: positive symptoms, which includes symptoms
such as hallucinations and delusions, and negative symp-
toms, which includes symptoms such as lack of affect. We
also included the PANSS insight and judgment item that
provides a rating of 1 to 7 which reflects global awareness
of symptoms, treatment need, and consequences of ill-
ness. Assessment of interrater reliability for this study
was found to be high to excellent with intraclass correla-
tions for blind raters observing the same interview rang-
ing from .84 to .93.
The Quality of Life Scale (QOLS37) is a 21-item scale
completed by clinically trained research staff following
a semistructured interview and chart review. For the pur-
poses of this study, we were interested in 2 of the 4 factor
scores of the QOLS that are most intimately tied to social
193
P. H. Lysaker et al.
function. The first, ‘‘interpersonal relations,’’ measures
the frequency of recent social contacts and includes sep-
arate assessments, for example, of frequency of contacts
with friends and acquaintances. The second, ‘‘intrapsy-
chic foundations,’’ measures qualitative aspects of inter-
personal relationships and includes assessments, for
example, of empathy for others. High to excellent inter-
rater reliability was found for the 2 QOLS factor scores
for this study, with intraclass correlations for blind raters
observing the same interview ranging from .85 to .93. Al-
though originally created to assess negative symptoms in
schizophrenia, the QOLS has been widely used to study
social function in this population.7
The Internalized Stigma of Mental Illness Scale
(ISMIS26,38) is a 29-item paper and pencil questionnaire
designed to assess subjective experience of stigma. It
presents participants with first-person statements and
asks them to rate on a 4-point Likert scale regarding
whether they ‘‘Strongly disagree,’’ ‘‘Disagree,’’ ‘‘Agree,’’
or ‘‘Strongly agree’’ with statements related to having
a mental illness. Items are summed to provide 4 major
scale scores: alienation, which reflects feeling devalued
as a member of society; stereotype endorsement, which
reflects agreement with negative stereotypes of mental ill-
ness; discrimination experience, which reflects current
mistreatment attributed to the biases of others; and social
withdrawal, which reflects avoidance of others because of
mental illness. The fifth additional score, stigma resis-
tance, asks about participant’s perceived ability to deflect
stigma. All scales scores are calculated as averages with
higher scores suggesting graver experiences of stigma. Ev-
idence of acceptable internal consistency, test-retest reli-
ability, factorial, and convergent validity have been
reported, including links with morale and well-being.26,38
The instrument was presented to persons in its written
form with research assistants available to assist if partic-
ipants were confused about the meaning of any item.
Of note, items of ISMIS differ from the QOLS and
PANSS assessments of social function detailed above be-
cause they involve explicit attributions of abstract states
of impoverished function due to discrimination on the
basis of mental illness or acceptance that mental illness
renders persons to a lesser status. The QOLS, for in-
stance, asks how often a person socialized with a close
friend and the PANSS may involve asking a person about
the absence or presence of interest in others. The ISMIS,
on the other hand, asks if the person socializes less ‘‘be-
cause my mental illness might make me look or behave
weird’’ and whether they believe in general that ‘‘Men-
tally ill persons should not get married.’’ Items of the
ISMIS also differ from the PANSS assessments of diffi-
culties trusting people or accepting as true conspiracies
again them; the ISMIS asks whether the person feels dis-
criminated against ‘‘because I have a mental illness’’ or
whether they ‘‘feel out of place in the world because I
have a mental illness.’’
194
The Multidimensional Self-esteem Inventory (MSEI39)
is a 116-item self-report measure that assesses individuals’
self-perception of their overall social value. Respondents
rate items on a 5-point scale according to the degree or
frequency with which each item applies to them. The
MSEI offers t scores based on a community sample.
The t scores are normalized scores with a mean of 50
and a standard deviation of 10. The mean t score for
this sample was 44.56 with a standard deviation of
10.33. This suggests that participants’ reported level of
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self-esteem was approximately 0.5 standard deviations
lower than those of persons in a broad community sam-
ple. Because the MSEI has been largely used in samples of
persons without psychosis, internal consistency was ex-
amined in this sample. Examination of items comprising
the total score revealed a highly significant degree of in-
ternal consistency (coefficient a = .90).
The Beck Hopelessness Scale40 is a 20-item question-
naire that asks participants to endorse statements as
true or false as applied to them. Individual items are
then summed to provide an overall index of hope or
its absence. Examples of items include, respectively,
‘‘Things just won’t work out the way I want them to’’
and ‘‘I might as well give up because I can’t make things
better for myself.’’ This scale has been used successfully
with a wide range of psychiatric, medical, and community
populations.41
Procedures
All procedures were approved by the research review
committees of Indiana University and the Roudebush
VA Medical Center. Following informed consent, diag-
noses were determined using the SCID conducted by
a clinical psychologist. Following the SCID, participants
were administered the PANSS and QOLS interviews,
MSEI, and ISMIS. A research assistant was available
to assist participants if there were difficulties reading
or understanding the questionnaires. PANSS and
QOLS ratings were performed blind to responses to
the MSEI and ISMI. QOLS and PANSS interviews
were conducted by trained research assistants with a min-
imum of a BA degree in a field related to psychology.
Results
Means and standard deviations for all measures are pre-
sented in table 1. Analyses were conceived as the follow-
ing 4 steps: First, to determine whether the first 4
subscales of the ISMIS (alienation, stereotype endorse-
ment, discrimination experience, and social withdrawal)
could be combined into a total score for the purposes of
using it in a cluster analyses, internal consistency was de-
termined. This revealed a high degree of internal consis-
tency, coefficient a = .86, which was reduced to .80 if the
fifth score was included. Correlations among all 5 ISMIS
 Toward Understanding the Insight Paradox

Table 1. Mean and Standard Deviations K-Means cluster analysis is a nonhierarchical form of
cluster analysis appropriate when hypotheses exist re-
Standard garding the number of clusters contained in a sample.
Instrument Score Mean Deviation It produces the number of clusters as initially called
ISMIS Alienation 2.31 0.65
for, minimizing variability within clusters and maximiz-
ing variability between clusters. We chose this procedure
ISMIS Stereotype endorsement 1.99 0.54
rather than rationally defining groups in order to deter-
ISMIS Discrimination experience 2.42 0.69 mine, in an exploratory and statistical manner, whether
ISMIS Social withdrawal 2.30 0.66 we could detect participants who demonstrated patterns
ISMIS Stigma resistance 2.17 0.52 of these scores as hypothesized rather than as we had arti-

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PANSS Positive component 15.93 5.65
PANSS Negative component 17.36 5.24
PANSS Insight and judgment item 3.29 1.39
QOL Interpersonal relations 19.92 7.39
QOL Intrapsychic foundations 22.57 5.20
BHS Total 14.16 5.45
MSEI Total 30.28 7.05
Note: ISMI, Internalized Stigma of Mental Illness Scale;
PANSS, Positive and Negative Syndrome Scale; QOL, Quality
of Life; BHS, Beck Hopelessness Scale; MSEI,
Multidimensional Self-esteem Inventory.
scores revealed that the first 4 scores were all significantly
related to one another (P < .05), while the fifth, stigma
resistance, was significantly correlated only with stereo-
type endorsement. These findings were taken as support
to not include the fifth score in the summary score.
In the second phase of analyses, insight and stigma
scores were separately correlated with symptoms, social
function, hope, and self-esteem. These revealed that inter-
nalized stigma was significantly related (P < .05) to pos-
itive (r = .36) and negative (r = .26) symptoms, as well as
hope (r = ÿ.45), self-esteem (r = .54), and QOLS interper-
sonal relations (r = ÿ.34). Insight was related to positive
(r = .24) and negative (r = .29) symptoms, as well as self-
esteem (r = .26).
In the third phase, ISMIS and PANSS insight and
judgment items were standardized into z scores and
a K-Means cluster analysis was performed to identify
3 homogenous participant groups based on these scores.
Cluster analysis is a method of classifying people into ty-
pologies by determining clusters of participants that dis-
play small within-cluster variation relative to the
between-cluster variation.42–44 In cluster analysis, each
participant is assigned to a cluster and participants are
moved from one cluster to another until terminating con-
ditions are met. In essence, a cluster analysis is similar in
some respects to both factor analysis and discriminant
function analysis. It differs primarily from factor analysis
in that its end is the determination of orthogonal groups
of participants rather than orthogonal groups of varia-
bles, and it differs from a discriminant function analysis
in that determining group assignment is the goal and not
known ahead of time.
ficially defined them ahead of time. To give the groups
contextual meaning, however, we assigned labels with
reference to the meaning of the insight and stigma scores.
First, we chose to categorize groups as ‘‘low insight’’ if
the PANSS insight item was equal or greater than 4 of
7 and scores of less then 4 as good insight. This catego-
rization has been used elsewhere30 and reflects the differ-
ence between general vs minimal awareness that
something is wrong. To describe a group’s stigma level,
we decided that groups with scores of 2 or less would be
labeled as ‘‘minimal stigma’’ because such scores indicate
general disagreement with items. Scores of greater than 2
but less than 2.5 were chosen to be labeled as ‘‘mild
stigma,’’ as these scores reflect agreement of roughly
less than half of the ISMIS items. Scores of greater than
2.5 but less than 3 were chosen to be labeled as ‘‘moderate
stigma’’ because these scores reflect either agreement of
more than half of ISMIS items or strong agreement on sev-
eral. Scores of greater than 3 were chosen to be labeled as
‘‘severe stigma’’ as these scores reflect either agreement
with all ISMIS items or strong agreement on many items.
The cluster analysis produced 3 groups which, based
on insight and stigma levels, we have labeled low in-
sight/mild stigma (n = 23), high insight/minimal stigma
(n = 25), and high insight/moderate stigma (n = 27). As
revealed in table 2, these groups did not differ signifi-
cantly in age, education, or hospitalization history.
Chi-square analyses additionally found that groups did
not differ in proportion of participants with schizoaffec-
tive disorder or schizophrenia or in proportion of partic-
ipants from the VA medical center or the CMHC.
Analysis of variance also found no significant differences
in raw stigma or insight score for participants from the
VA medical center compared with the participants
from the CMHC. Examination of symptoms, however,
found that the high insight/minimal stigma group had
significantly lower levels of positive and negative symp-
toms on the PANSS.
In the third phase of analyses we compared hope, self-
esteem, and social function between groups. As revealed
in table 3, the high insight/minimal stigma group had sig-
nificantly better interpersonal function on the QOLS
than either of the other 2 groups. The high insight/mod-
erate stigma group, by contrast, reported significantly
poorer self-esteem and lesser hope than either of the other
2 groups. Given that the groups differed significantly on
195
P. H. Lysaker et al.

Table 2. Background and Symptoms Among Groups

Group 1, Low Group 2, High Group 3, High

Insight/Mild Stigma Insight/Minimal Insight/F = Moderate Group Comparisons,
(n = 23) Stigma (n = 25) Stigma (n = 27) ANOVA P < .05

Age 48.00 (7.65) 49.60 (6.40) 47.22 (7.04) 0.76 NS

Education 12.00 (1.47) 13.04 (2.25) 12.63 (2.23) 1.56 NS
Lifetime 10.35 (9.63) 7.84 (7.22) 9.33 (10.27) 0.19 NS
hospitalizations

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Age of first 23.30 (5.44) 25.20 (7.03) 26.78 (10.89) 0.99 NS
hospitalization
Stigma score 2.19 (0.30) 1.80 (0.40) 2.75 (0.54) 5.93** 3>1>2
PANSS insight and 4.83 (0.87) 2.40 (0.76) 2.81 (1.11) 40.08** 1 > 2, 3
judgment
PANSS positive 17.70 (5.01) 12.92 (4.31) 17.22 (6.25) 6.11* 2 < 1, 3
PANSS negative 19.22 (5.35) 14.80 (3.89) 18.15 (5.47) 5.28* 2 < 1, 3

Note: ANOVA, analysis of variance; PANSS, Positive and Negative Syndrome Scale; NS, not significant.
*P < .01; **P < .001.

positive and negative symptoms, analyses comparing so-
cial function, hope, and self-esteem were repeated with
positive and negative symptom scores included as cova-
riates. In these analyses the groups continued to differ on
hope and self-esteem (F2,68 = 4.72, P < .05; F2,68 = 9.35,
P < .001), with the high insight/moderate stigma group
again in post hoc comparisons having significantly poor-
er hope and self-esteem. When symptoms were statisti-
cally controlled for, however, no significant differences
were found between groups on the QOLS interpersonal
relations scores (F2,62 = 0.53, P = NS).
Discussion
In the current study we examined the hypothesis that the
effects of awareness of illness in schizophrenia on self-
esteem, hope, and functioning would be affected by the
degree to which persons internalize stigmatizing views
about mental illness. As predicted, a cluster analysis of
persons in a stable phase of illness revealed 2 groups
of persons relatively aware of having a mental illness:
one group that did and another that did not endorse hav-
ing self-stigmatizing beliefs about their condition. Also,
as predicted, persons with high insight who endorsed
self-stigmatizing beliefs had lower levels of self-esteem
and hope and fewer interpersonal relationships than
those with high insight who rejected stigmatizing beliefs.
Finally, as predicted, the cluster analyses produced a third
group that demonstrated low awareness and also en-
dorsed stigmatizing beliefs, though to a lesser degree
than did the high insight/moderate stigma group. This
group also had more self-esteem and hope than the group
with high insight and moderate stigma but did not differ
from them in social functioning. This last finding may

Table 3. Hope, Self-esteem, Symptoms, and Social Function Among Groups

Group 2, High Group 3, High

Group 1, Low Insight/Minimal Insight/F = Moderate Group Comparisons,
Insight/Mild Stigma Stigma Stigma ANOVA P < .05

Beck Hopelessness 14.80 (4.46) (n = 20) 16.33 (4.10) (n = 24) 11.65 (6.38) (n = 26) 5.39** 3 < 1, 2
Scale
MSEI self-esteem 32.95 (7.92) (n = 21) 32.92 (4.41) (n = 24) 25.69 (6.07) (n = 26) 11.20*** 3 < 1, 2
total
QOLS interpersonal 18.06 (6.18) (n = 17) 23.29 (8.08) (n = 21) 18.36 (6.79) (n = 25) 3.54* 2 > 1, 3
relations
QOLS intrapsychic 21.65 (4.21) (n = 17) 24.33 (5.00) (n = 21) 21.72 (5.20) 1.86 NS
foundations (n = 25)

Note: ANOVA, analysis of variance; MSEI, Multidimensional Self-esteem Inventory; QOLS, Quality of Life Scale.
*P < .05; **P < .01; ***P < .001; NS, not significant.

196

suggest that both the acceptance of stigma or unaware-
ness of illness may lead to social isolation. However, it is
also possible that an underlying risk factor for both poor
insight and social isolation, such as neurocognitive im-
pairment,9 may explain these relationships.
Exploratory comparisons of symptom levels between
the groups revealed that groups with higher insight
and minimal stigma had significantly lower levels of pos-
itive and negative symptoms than either of the 2 other
groups. This suggests several possible interpretations.
First, it is possible that having more symptoms makes
one the target of more stigma and therefore makes it
more difficult to reject these beliefs. Second, it is possible
that with more symptoms it becomes harder to formulate
positive beliefs about oneself and, therefore, to reject so-
cietal beliefs about schizophrenia. It is also possible that
having less internalized stigma allows one to manage
symptoms more effectively, thereby reducing their sever-
ity. Regardless of which interpretation is valid, when
symptoms were controlled for, groups continued to
differ on self-esteem and hope, although notably group
differences in interpersonal relatedness were no longer
significant once initial differences in symptoms were
accounted for.
While the cross-sectional nature of this study precludes
reaching any conclusions regarding causality, results do
suggest hypotheses and directions for future research.
First, consistent with the initial hypotheses of this study
it appears that persons who both accept that they have
a mental illness and who accept stigmatizing beliefs about
mental illness are at risk for having low self-esteem and
expecting less of their futures. These persons, regardless
of whether they adhere to treatment, may show little
‘‘motivation’’ to pursue personal or rehabilitation
goals,45 having little hope that they can find a satisfying
life. This group, substantial in size (roughly a third of our
sample), may pose a great challenge to mental health pro-
viders, who struggle to encourage these clients to pursue
vocational and other goals, when they, the clients them-
selves, lack hope for the future.
Our findings, consistent with others,16–18 also poten-
tially raise a challenge to the view that insight, as tradi-
tionally defined, is always desirable for people with
schizophrenia. In fact, some with stigmatizing beliefs
about mental illness may find accepting their illness bur-
densome in some ways. This is consistent with the find-
ings suggesting that benefit from psychiatric treatment is
related to the meanings persons assign to both their ill-
ness and the treatment itself.46–48 It is also consistent
with observations that well-being for persons who suffer
from a wide range of chronic medical illnesses is a func-
tion of the degree to which they experience a balance
among bodily concerns or symptoms, the sense of co-
herence of their personal narrative or biography, and
conceptions they have formed about the nature of
their identity.49–51
Toward Understanding the Insight Paradox
With replication, our findings may have several clinical
implications. First, it may be useful to consider interven-
tions that decrease internalized stigma. Warner,52 for in-
stance, has suggested that it is just as important for
interventions to assist in developing a sense of mastery
as it is to help enhance insight. This is consistent with a re-
cent intensive case study that suggested that as a person
with schizophrenia recovered, he first evolved a greater
sense of personal agency before developing a more com-
plex grasp of his illness .53 It is also consistent with a study
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using a different sample that suggested that hope was
more closely tied to sense of agency than illness aware-
ness.54 Perhaps, if dysfunctional beliefs stemming from
social stigma impact life in such an enduring manner, tai-
lored interventions could be devised to help persons com-
bat these self-stigmatizing beliefs. Future interventions
and research could be directed to help persons with
schizophrenia overcome their negative beliefs and find
newer and more adaptive ways to think of themselves
and their futures, thus allowing for the acceptance of
mental illness to have fewer devastating effects. One pos-
sibility is for research to study ways to facilitate the
efforts of persons with schizophrenia to replace self-
stigmatizing beliefs and transform their narratives and
experience themselves as active protagonists in their
own lives with realistic appraisals of their strengths and
deficits.55,56
Of note there may be additional parallels here with
earlier studies of differing styles of framing past experi-
ence of mental illness as persons recover. Specifically,
McGlashan and colleagues57–59 have suggested the exis-
tence of a continuum of recovery styles. On one end of
their continuum lies ‘‘integration,’’ which is characterized
by patients showing interest in their psychotic experien-
ces, appearing eager to discuss and learn more about
them and to gain a perspective of them. On the other
end of the continuum is ‘‘sealing over,’’ characterized
by patients’ denial of the existence and/or severity of their
illnesses, expectations to return rapidly to normal func-
tioning, and poor ability to recall or describe the phase of
acute psychosis. Perhaps these findings coupled with the
results of this study point to the reality that, for some,
forgetting or recasting the past in such a way as to
deny previous difficulties may be adaptive. As a corollary,
it may also be that forcing or urging persons who have
sealed over to do otherwise may not be helpful, and re-
search that more fully explores what meets their needs is
needed.
Importantly, there are several limitations to the study.
Given its cross-sectional nature, no conclusions can be
drawn regarding causality and alternative explanations
of the findings cannot be ruled out. For instance, it is
possible that having less hope and self-esteem makes per-
sons more vulnerable to stigma or that acceptance of
stigma and low self-esteem is the product of other bio-
logical or sociocultural variables not measured here.
197
P. H. Lysaker et al.
Generalization of findings is also limited by sample com-
position. Participants were mostly men in their 40s, all of
whom were involved in treatment. It may well be that
a different relationship exists among insight, internalized
stigma, hope, and self-esteem among younger persons
with schizophrenia, in a predominantly female sample,
or among persons who decline treatment. Thus, more re-
search that involves collecting data at multiple time
points with broader samples is necessary. We also did
not assess the nature of stigmatizing experiences. More
‘‘fine-grained’’ assessments of stigma including apprais-
als of the nature of stigmatizing experiences are necessary
to replicate and confirm the importance of the findings
noted here.
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