Revista Română de Bioetică, Vol. 13, Nr.

1, January - March 2015

THE ROLE OF SELF-ESTEEM AND

AUTONOMY IN IMPROVING SOCIAL
FUNCTIONING IN PATIENTS WITH
DEPRESSION: A MATTER OF DIGNITY

Maria Raluca Radu*, Roxana Chiriță**, Liana Rada Borza**,

George Florian Macarie***, Georgiana Nuc*,
Lucian Constantin Paziuc**
Abstract
The present study aims at highlighting the effects of introducing a supportive therapy
intervention to develop self-esteem. Thus, we analyzed a group of 142 patients with recurrent
depression who met the inclusion criteria and were randomly assigned into two study groups in
equal numbers, following two different therapeutic interventions, namely: group A of 71 patients
undergoing a 4-month social therapy program with a group session per week and a monthly
social meeting consisting of techniques to strengthen the ego, positive reinforcement and self-
valorization, and group B, which followed the support group psychotherapy. Patients in both
groups followed the specific psychiatric treatment. We used the Rosenberg self-esteem scales,
Hamilton Depression Rating Scale and SAS-SR for social adaptation. We found that the
therapeutic intervention based on the development of self-esteem would have better results with
respect to both self-esteem and social functioning dimensions than the intervention without this
component. Regarding the level of depression, the intervention based on self-esteem development
did not produce a statistically significant difference in comparison with the other group. Self-
esteem score represents the predictor of the level of social functioning. Furthermore, the age of
patients also has a predictive value on the response to therapy. In conclusion, self-esteem is a
parameter of mental health that is worth considering when thinking about the social functioning
of the patient, in relation to the level of depression and leading to the personal feeling of dignity.

Keywords: dignity, self-esteem, depression, social functioning

Corresponding author : Liana Borza: lianaborza20@gmail.com

* CSM Ghelerter Iasi, Romania

**Centre for Ethics and Health Policy, University of Medicine and Pharmacy "Gr.T.Popa" Iasi, Romania
*** Al.I.Cuza University, Iasi, Romania

131
 Context
Preserving dignity in the context of
care/case management of people with
mental disorders becomes more and
more an issue of primary interest in
health policies. This pathological
category is part of a wider framework
of persons who need specialized
assistance, framework for which a
practical guide to promote dignity in
the units for health and social care [1]
already exists. However, the specialty
literature fails to provide a clear and
consensual definition of dignity. For
professionals working with vulnerable
persons, defining what it means to
promote dignity in practice has been a
challenge. Some studies suggest that
the medical personnel would take the
concept of human dignity as a term
that is understood a priori based on
their own experience and educational
context [2], which leaves room for a
large bias in this area. In other words,
dignity means different things to
different people [3, 4]. There is no
general agreement on what the concept
of dignity actually means.
Although it is essential that a
standardized and common vision
would cover the obscure areas of the
definition and evaluation of human
dignity, in order to promote both a
common language for research and
principles of good practice [5], the
question that emerges is whether
dignity itself does not contain a touch
of subjectivity and a proper, intimate
sense, so that its cancellation would
only be a Procrustean bed altering the
very core of this concept.
Moreover, for people with mental
disorders, where one can speak most of
the time (except for dementia) only
about functional impairment, dignity
should be understood at its complex
dimension. Dignity has been analyzed
132
from multiple angles, some researchers
reducing it to the possession of some
skills or to autonomy [6]. But for
people with mental disorders, both
concepts are elements with subtle
ramifications in the patient's subjective
reality. Moreover, for this category of
patients, there can be an acute sense of
lack of dignity even in the absence of a
disability per se or in spite of
preserving autonomy. Defining dignity
simply by having certain abilities thus
raises a few problems. This suggests
that some people, such as those with
severe intellectual disabilities or
advanced dementia, may not have
dignity, a statement with which few
would agree. Due to the lack of
inclusion in these definitions, it was
suggested that dignity must be
separated from autonomy and that it is
risky to assume that people who do not
have the capacity for autonomous
choice lack human dignity [7][8].
Dignity, Self-esteem and
Depression
There are a variety of factors that
may make an individual vulnerable [9]
with regard to self-perception. Even so,
the concepts of dignity, autonomy,
social skills, and adaptation form a
complex area and seem to be of great
importance in the evaluation of
patients with mental disorders. Thus,
dignity and self-esteem influence the
patient’s image of his/her ability to
integrate into society, as well as the
quality and quantity of the social
approaches that he/she initiates.
Although most of the research on
autonomy, social functioning and
dignity has been performed with regard
to pathological conditions of profound
destructuring, such as dementia or
terminal illnesses, severe depression is
also often associated with the loss of
social involvement and of the capacity
to adapt to certain conditions, with
feelings of guilt, helplessness and with
the subjective lack of dignity.
Therefore, one might conclude that
the loss of dignity is not an inevitable
consequence of dependence, and this is
due to the fact that dignity can be
maintained by providing opportunities
for control and choice. Here again we
will find a weak link for the depressed
patient who, rather than the lack of
skills, feels the frailty of the control
over his own life and is overly affected
by negative projections.
Depression, through its
manifestations related to egophobia
and self-deprecation, outlines a new
space in which we can evaluate the
concept of human dignity. There are
significant differences regarding what
the patient considers to be unworthy in
relation to a mental disorder. In the
context, specific to depression is the
tendency to exaggerate the negative
aspects of emotional, physical or
material dependence, deepening shame
and feelings of being a burden or of
lack of value. These last elements align
in a flexible manner in the conceptual
framework of self-esteem, which is
easier to evaluate than the ineffable
sphere of dignity [10].
Thus, we can better understand
why, in the case of depressive disorder,
the feeling of lack of dignity associates
mostly with blanketing self-
consciousness that refers to control and
choice, rather than to a certain level of
competence [11].
But self-esteem is actually a
dynamic process that evolves over a
relational context. Besides its intrinsic
component, self-esteem also depends
on the interactive framework of the
social support network [12]. This
133
suggests that individuals experience a
positive feeling of personal value if
they are seen or treated positively by
others. Therefore, self-esteem is high
when others look at us with respect and
treat us with dignity, whereas it is
reduced if we are disregarded and
treated without dignity. In this
equation, the great advantage is that
the externally controlled dimension of
self-esteem can be influenced by
therapeutic and/or social intervention
[13].
Objective and hypotheses
Through this study, we sought to
highlight the effects of introducing a
supportive therapy intervention that
seeks supporting/developing self-
esteem.
This article aims to evaluate the
role of self-esteem in the social
spectrum of the depressed patient and
if improved self-esteem could
influence the social functioning of the
depressed patient.
A first hypothesis that we
formulate is that therapeutic
intervention based on the development
of self-esteem will have better results
with respect to self-esteem, social
functioning and depression level
dimensions than the intervention
without this component.
A second hypothesis of the study
refers to the assumption that self-
esteem score represents the predictor
for the degree of social functioning.
Finally, we believe that older
patients will benefit to a greater extent
than younger patients from the therapy
based on self-esteem.
Materials and Methods
We analyzed a group of 142
patients diagnosed with recurrent
depression, who meet the inclusion
criteria and who were randomly
assigned into two study groups in
equal numbers, following two different
therapeutic interventions, namely:
Intervention Groups:
 Group A of 71 patients
undergoing a social therapy
program for 4 months with a
group session per week and a
monthly social meeting consisting
of techniques to strengthen the
ego, positive reinforcement and
self-valorization;
 Group B that follow support group
psychotherapy, also including 71
patients.
Patients in both groups followed
the specific psychiatric treatment.
Informed consent was signed by all
patients before entering the study; 13
patients left the study.
Inclusion criteria:
1. Major depression with current
HAM-D of at least 20
2. Declarative adherence to treatment
3. Age between 18 and 80 years
4. No major psychiatric
comorbidities
5. Availability and ability to
complete the 6 month study
Procedure / therapeutic
intervention:
Each of the subjects randomly
assigned to the two study groups
participated in therapeutic groups
composed of 8-10 participants,
relatively homogeneous in age,
considering young the participants
under 45 and the elderly over 45. The
average age of the young group was 31
years and of the elderly was 62 years.
These groups received one of the two
134
versions of psychotherapy: support
group psychotherapy and
psychotherapy focused on self-esteem.
Supportive psychotherapy implied
the application of techniques to address
the following issues: universalisation
of the problem, validation and
legitimization of the problem,
communication and acceptance/giving
feedback, stimulating the therapeutic
relationship and strengthening the
relationships within the group,
providing and accepting support,
creating the premises for change,
socialization, building trust within the
group.
Psychotherapy focused on self-
esteem was based on supportive
psychotherapy by using group
bounding and strengthening the
therapeutic relationships, but it mainly
used methods and techniques aimed at
ego strengthening, self-affirmation,
rebuilding self-image, building self-
confidence, validation and self-
validation, self-acceptance,
constructive feedback and forgiveness
of self and others, optimizing reality
testing and personal exigencies,
gratification and self-reward.
Instruments used:
Rosenberg scale was originally
developed to measure the overall
feeling of personal value and self-
acceptance. The scale includes 10
items with four response options from
strongly disagree (1 point) and totally
agree (4 points). The scores may be
between 10 and 40; high scores
indicate low self-esteem. Cronbach
coefficient = 0.89, reported by the
author, indicates a good internal
consistency, and test – retest reliability
is included in the author's studies
between 0.85 (one week interval) and
0.88 (two week interval) [13].
Hamilton Depression Rating Scale
is the "golden standard" for the
depression scales, having no rival in
general psychiatry. It is the most used
scale to describe the degree of severity
and the evolution under treatment, as
well as a reference for other
instruments. Hamilton describes his
depression scale as a tool for the
assessment of the symptoms in patients
diagnosed with depression and not as a
diagnostic tool. The version we used
has 21 items, with scores between 0
representing the absence of depressive
symptoms and 62 for major depression
symptoms [15].
Social Adjustment Scale SAS-SR
[16] provides an understanding of the
individual level of satisfaction towards
personal social status. The scale is
frequently used to assess the response
to treatment, emphasizing the effect
that the intervention has on the
respondent. This scale is used in
mental health clinical research by
psychiatrists, psychologists, social
workers etc. In the present study we
used the short version with 21 items
that assess areas of 6 different social
roles from two perspectives –
instrumental (activity per se) and
expressive (relational). These roles are:
work, social and leisure activities,
relationships with extended family,
marital role as a partner, parental role
and the role within the family unit
including the perception of economic
functioning. This version is
Table 1. Summary for a mixed two-way ANCOVA
Interactions* Sum of squares DF Mean square
Self esteem 1933.38 1 1933.38
Depression 8.45 8.45
Social functioning 4268.31 1 4268.1
*Factor and intervention
135
recommended when the contact time
with the respondent is limited and it
may be used in monitoring the
progress under treatment.
The subjects were evaluated at the
beginning and at the end of the therapy
sessions.
Results
Evaluation of self-esteem and
social functioning before and after
therapeutic intervention:
After verifying the conditions for
performing the test (the Shapiro-Wilks
W test for checking the normal
distribution of scores, homogeneity of
variances, error variance similarity),
we used the mixed analysis of variance
2-way ANOVA.
After calculations, we found that
the interaction between the two
conditions and the changes that
occurred over time were statistically
significant in terms of self-esteem (F
(1,140) = 564.91) and social
functioning (F (1,140) = 631.83, p <
0.001), but not with respect to the level
of depression reported on the Hamilton
scale (F (1,140) = 0.736, p = 0.392).
Therefore, regarding factors 1 and 3,
there are differences between cells that
cannot be explained by the pre-existing
differences between the groups of
participants or by the changes in all
conditions, but this is not true for the
changes in the level of depression as
assessed with HADMR (for details, see
Table 1).
F-ratio
564.91
0.74
631.83
 Using independent T-test, we found
that, before the intervention, the means
of the scores of the subjects who were
randomly assigned into the two
intervention groups were not
significantly different in terms of self-
esteem (t = 0.83, df = 140, two tailed p
= 0.40), depression (t = 0.63, df = 140,
p = 0.53) and social functioning (t =
0.22, df = 140, p = 0.83).
After the therapeutic interventions,
we could notice the following: the
means after self-esteem (M = 25.99,
SD = 2.74) and social functioning (M
= 52.72, SD = 3.64) intervention were
significantly higher (calculated using
independent t-test) in the group of
subjects under the therapy based on
self-esteem (t = 25.58, df = 140, p <
0.001) in the case of Rosenberg scale
and in the case of SAS-SR (t = 25.70,
df = 140, p < 0.001); the difference
remained not significant with regard to
the depression scores (t = -0.3, df =
140, p = 0.76).
Changes in the scores registered
between the initial assessment and the
one after intervention, evaluated using
the paired t-test, are statistically
significant regarding all three
indicators, in terms of increase (self-
esteem and social functioning) or
decrease (the level of depression),
regardless of the therapy followed (see
Table 2).

Table 2. Measures of pre- and post intervention

Intervention Pre- Post- P (paired t-
Dimension
group test test test)*

M SD M SD t
Self-esteem 7.21 1.520 25.99 2.74 -54.66
Rosenberg self-
esteem Standard 7.00 1.493 15.34 2.19 -30.48
Self-esteem 35.82 4.685 23.00 3.39 20.86
Hamilton
depression Standard 35.31 4.898 23.18 3.79 23.37
Social Self-esteem 25.04 3.096 52.72 3.64 -59.16
functioning Standard 24.93 3.039 37.10 3.60 -30.26
*Df = 70, P < 0.001

Predictors of social functioning: of the individual.

As each of the studied dimensions
– increasing self-esteem and lowering
the level of depression – are targets of
the therapeutic intervention (in both
cases), we will see to what extent they
can be considered predictors of social
functioning, measure that supposedly
indicates the direct impact of the
intervention on the social relationships
A multiple regression was run to
predict social functioning from self-
esteem, level of depression and also
age group of the participants, both
before and after intervention. The
assumptions of linearity, independence
of errors, homogeneity of variance,
unusual points and normality of
residuals were met.

136
 Before therapy, self-esteem and the
group age proved to predict a
statistically significant social
functioning, F (2, 139) = 27.52, p <
.001, adj. R2 = .27. In terms of
statistics, both variables have
significantly contributed to the
prediction, p < .01, while self-esteem
alone explains 24.3% from the social
functioning variance.
After the intervention, self-esteem
and the group age were statistically
significant to predict the social
functioning, F (2, 139) = 225.24, p <
.001, adj. R2 = .76. Again, self-esteem
taken as a single predictor explains
71.3% from the social functioning
variance.
Regression coefficients and
standard errors can be found in Table 3
(below).

Table 3. Summary of Multiple Regression Analysis

Evaluation B SE Beta
Intercept 19.37 1.198
First Self-esteem 1.05 .15 .52*
Age group -1.20 .44 -.20*
Second (after intervention) Intercept 24.39 1.61
Self-esteem 1.28 .06 .87*
Age group -3.83 .71 -.22*

Note: * P < .05; B – unstandardized regression coefficient;

SEB = Standard error of the coefficient; Beta - standardized coefficient.

Taking into account the finding that
there is some variation due to the
group age, we wanted to check if there
are significant differences between the
means obtained for the studied
dimensions within the two age groups.
Using the t test for independent
samples, we note that, with respect to
the groups that followed standard
psychotherapy, the mean of the scores
reported by the elderly group after self-
esteem intervention (M = 16.16, SD =
2.29) was slightly higher than for the
youth group (M = 14.44, SD = 1.91),
the difference being statistically
significant (t = -3.57, df = 69, p <
0.001). Another difference found is
that related to the social functioning (t
= 4.33, df = 69, p < 0.001), where the
average scores are higher in the youth
group (M = 38.82, SD = 3.55) in
comparison to the elderly group (M =
35.51, SD = 2.87); the difference is not
significant with regard to the
depression scores (t = 1.57, df = 69, p
= 1.22).
It's worth mentioning that there are
no significant differences between the
means of the scores of the two age
groups regarding the therapy groups
based on self-esteem.
With respect to the hypotheses of
the study, the obtained results indicate
us the following:
 The therapeutic intervention based
on the development of self-esteem
will have better results on self-
esteem and social functioning
dimensions than the intervention
without this component
(Hypothesis 1). Regarding the
level of depression, the
intervention based on developing
self-esteem does not produce a

137
 statistically significant difference
in comparison with the other
group.
 The self-esteem score represents
the predictor of the social
functioning level (Hypothesis 2).
Moreover, the age of the
participants explains part of the
variation with regard to the
response to therapy.
 The hypothesis that the elderly
patients will benefit, to a greater
extent than the younger patients,
from the therapy based on self-
esteem (Hypothesis 3) is not
confirmed. A significant
difference occurs only in the
elderly group on supportive
therapy for the self-esteem
dimension, but not for social
functioning.
Discussion and Conclusions
During the management of the
therapy groups, we noticed that people
with a seriously damaged self-image
tend to withdraw from the social
structures to which they happily
adhered before the onset of the
pathology. This tendency appears to be
progressive and extensive, and
contributes to closing a vicious circle
of depression, the individual having
access to a decreasing number of
support resources.
On the other hand, we observed
that after treatment, people who have
improved their self-image returned
more rapidly to a proper social
functioning in comparison to those
who have only improved their state of
depression, without making important
progresses in the field of self-esteem
and still struggling with both disbelief
and the sense of personal inadequacy.
The results confirm that the group
138
psychotherapy interventions bring
benefits in terms of self-esteem, social
adaptation and improvement of
depression. However, there are
differences between the two types of
intervention, as well as between age
groups.
According to our results,
supportive therapy seems to be more
useful to the elderly than to the young
people with regard to increasing self-
esteem, but not for social functioning,
where young people seem to report
better results. An explanation would be
that this does not have the same major
effect as for young people in re-
establishing the social functioning.
Social functioning is based on several
dimensions. In the elderly, where
emotional needs were related to the
relational component and to combating
loneliness and sense of worthlessness,
the intervention managed to
successfully fill in the gaps. On the
other hand, when the primary need was
related to the economic aspects and to
the absence of the productive social
roles, the interventions were less
effective. In this case, due to the lack
of irreversible somatic conditions,
young people have had better results.
Regarding the therapy focused on
self-esteem, it seems to be equally
effective in both age groups in terms of
improving self-esteem and social
functioning. The explanation consists
in the fact that, working on self-
esteem, we will get improvements in
the subjective vision on patients own
abilities, as well as reduction of
subjective discomfort given by the
presence of somatic distress. Patients
come to redefine themselves, going all
the way from identifying with their
inability to building a positive and self-
valued image.
As a limit of our study, we note
that within the two types of
intervention it was not possible to
create a total segregation between the
results of therapy, improvements of
self-esteem and techniques to act
collaterally and on its behalf, this
limitation being inevitable in the
clinical context. As a result, in our
support therapy group we also had
interventions which improved the self-
esteem of subjects, although not so
sustainable as it was in the second
group.
Social functioning is also
influenced by other factors besides
self-esteem. Satisfaction of some basic
needs within the group also leads to
improved results in the direction of
social functionality, and such factors
are difficult to isolate, the therapy
process being complex and
multimodal. This explains why the
answer of elderly group was different
from the one of the young groups. The
need of belonging to a community, of
validation and escaping from
loneliness were the dominant issues in
these groups, which therapy has
improved significantly. On the other
hand, the therapeutic approach was
conducted harder when the problems
were mostly related to the poor
economic status and the lack of social
perspectives.
In order to make service providers
and caregivers prioritize both self-
esteem and dignity, it may be
important for them to be aware of the
devastating impact that the loss of
these two can have.
Studies on dignity in healthcare
units have given some indication with
respect to the types of emotional
139
reactions that people experience when
their dignity is compromised, including
anger, anxiety, humiliation and
embarrassment [17]. Our results
support these findings, showing the
strong correlation between self-esteem
and social functioning.
The extent to which a person is
treated with dignity may thus not only
give rise to an immediate emotional
response, but can also have a more
profound and lasting effect. This
means that the subjective experience of
dignity includes how the person is
determined to feel at present and also
how he/she is determined to feel on a
longer term, with a positive or negative
impact on the degree of his/her social
functioning.
We found that the groups that were
encouraged towards social interactions
consolidated in a positive way and
going through ego reinforcement
techniques experienced the most of
progress in terms of self-esteem. This
attitude has a therapeutic dimension,
but also a humane one, being available
for every caregiver willing to take this
attitude. Maintaining dignity is not a
science, but it is based on
understanding, empathy and
compassion. Adding personal
valorization and/or social valorization
techniques to the standard treatment
can make a big difference, as shown by
the results.
Sometimes, certain aspects of
dignity could be compromised due to a
need to provide emergency or
necessary care. There may also be a
conflict of opinion between the self-
view and the view of others regarding
dignity.
 Acknowledgement
This paper has been supported within the Project entitled: “Excellence Programme
in Multidisciplinary Doctoral and Postdoctoral Research in Chronic Diseases” ID
POSDRU/159/1.5/S/133377, beneficiary “Gr. T. Popa” University of Medicine and
Pharmacy, co-funded by the European Social Fund through the Sectoral Operational
Programme – Human Resources Development 2007-2013.” This paper does not
represent the official view of the Romanian Government or European Union.

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