During clinical rotation of Mental health nursing in Karwan-e- Hayyat, I interviewed a 34 years old male patient who is diagnosed with schizophrenia. He wants to become a doctor but due to low grades he was not selected for premedical later he did his graduation and unable to complete his studies from university. He is unmarried living with his parents and brother who is mentally retarded. He is suffering from this disease since 1998; along with he has obsessive-compulsive disorder (OCD). In compulsive behaviors he repetitive perform hand washings, spend more time in washroom. He has history of aggressive behavior, destroyed household chores. He has auditory hallucination and distorted thinking. He is not initiating any activity; he always says “I can’t do it”; “it is very difficult task”, “I have no strength”, I cant doing any thing for my parent. He used to spend his by watching television; eating and sleeping. He used to live alone, he has no friends, and he did not prefer to go outside. He needs encouragement and motivation in order to build confidence and self esteem.
According to Brekke et al cited by Seo, J.M et al. (2007), “A patient with chronic mental illnesses often have low self-esteem, delay effective interpersonal relations, and negatively affects their abilities to cope with stress and problems”(p.317). Self-esteem is very important element to prevent the reoccurrence of illness and help the person to effectively utilize their coping mechanism in a positive manner.
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Introduction of the concept:
Self-love and self-confidence are the essences of self-esteem. According to Coopersmith et al cited by Lyubomirsky et al (2006), “Self esteem has been defined as a global feeling of self-worth or adequacy as a person, or generalized feelings of self-acceptance, goodness, and self-respect”(p.366). Self-esteem has two elements competence and worth. Competence means a person view himself as an efficient and capable whereas worth give sense of value. According to Erickson theory, individual is occupied with his self-esteem and self-concept, which continues as long as the process of crystallization of person’s identity continues. If this process is not negotiated effectively, the person remains puzzled, not knowing about self. It means that self-identity is important for a person to know his important in life.
Factors contributing to low self-esteem:
Family background: If parents have negative behaviors and makes classification or labels the child that he is bad, losers or wrong on continuous basis as a result child protect his ego by suppressing his labels in the subconscious mind, which contribute to the way the child perceives himself and influences his self-esteem.
Hadley and Staudacher cited by Van Zyl et al. (2006):
It is quite common among most parents, and apparently it does not have a huge negative impact on the psychological development of the child. If constant parental judgment is involved in the upbringing of the child however, it will lead to problems within the child’s self-esteem. (p. 184)
When the child is not under pressure he or she manages to suppress these negative labels but when child is under severe pressure these negative labels come to the surface and the child becomes aware of it in the form of fear of failure, loss of emotional stamina, poor self-confidence, and low self-esteem.
Mental illness and stigma related to illness is major factor of low self-esteem. Mental illness effects their daily functioning that hinders them to adjust themselves in the society. People with mental illness are often perceived as less competent and violent. According to Hayward and bright (2002), “It seems that person having a serious mental illness would likely to damage one’s sense of self esteem if they exposed to any stigma or discrimination” (p.62). This factor may be cause of low self worth in my patient. Because his family does not understand his OCD symptoms and gives punishment verbally and physically because of his repetitive hand washings.
Self-efficacy: According to Francis et al. (2007), “Self-efficacy is people’s beliefs in their capacity to perform and behave in a way that influence events affecting their life” (p.23). If I compare my patient he always doubt in his abilities and verbalized that, I can’t do this task, I am not prepared for this task because he assumes every task as a difficult. Even he verbalized that OCD is not treatable, he is not taking initiating to change himself. Moreover, he said my brothers are well settle in USA and they are happy but I am not.
Significance in Pakistani context:
In Pakistan I didn’t find direct study on self esteem and its interventions but few studies indicate that there are certain factors, which result in low self-esteem. According to Khurshid & Rehman (2006), “Juveniles having the history of child abuse, reported more problems with their self-esteem, and peers problems compared to those juveniles who have no history of child abuse” (p.78).
Recent research indicates the manner in which the family interaction goes with their children it will impact on developmental outcomes. If interaction is not healthy results in low self esteem and conduct disorders. According to Shafi cited by Agha et al. (2008), “Psychosocial risk factors of heroine abuse in Pakistan and found that heroine users tended to perceive low positive parental relations, high psychosocial stress, low self esteem, high sensation seeking behaviors and high need for affiliation as compared to non users” (p.121). It shows that in Pakistan child abuse, negative parenting and stressors of life are major factors for decrease self esteem.
According to Rehman and Hussain (2009), “Shows that patients suffering from obsessive compulsive disorder suffer significant degree of lowered self-esteem”. My patient is also suffering from OCD since five years. He used to live alone, don’t visit his friends and relatives after having this problem. He thinks that they are not good and they don’t understand me.
Another factor is explained in literature is resilience. Resilience is the act of rebounding or springing back after being stretched or recovering strength, spirit, and good humor. In clinical terms “resilience” is reserved for unpredicted or markedly successful adaptations to negative life events, trauma, stress, and other forms of risk.”(Unaiza Niaz 2006 p.205). It means that people with poor resilience are unable to cope with stressful events as result person can adopt maladaptive behaviors.
To sum up the Pakistani literature it indicates that child abuse, negative parenting and stressors of life leads, maladaptive behaviors are major factors of decrease self esteem.
Analysis:
A cognitive model of low self-esteem, given by McManus (2009 p.271). In this model I have integrated my patient’s scenario. First component tells us early experience and circumstance in life that is my patient faced academic problems, due to which he selected that field in which he was not interested. Furthermore verbal and physical abuse by parents. As a result person experience global negative attitudes about himself. In my patient he always said I can’t do this task, it is very difficult and in this world everyone is running for competition. Next step leads to conditional/dysfunctional assumptions. In this stage my patient adopts these coping strategies that are aggressive behaviors, very limited socialization and not ready for task. All above situations triggers the person and at final stage there are two pathways, if person not met the standard leads to self-criticism and hopelessness. Second way is maladaptive behaviors as an outcome if standards could not be met. (See Appendix A).
Effects:
According to literature, that low self-esteem is the basis for several problematic behaviors that is feeling inadequacy, inferiority, and shame by externalizing blame for their problems and failures, which leads to aggression and violence toward others. (Ostrowsky 2010 p.70)
Studies have noted the impact of low self-esteem on the vulnerability of adolescents to risky behaviors. For example initiate sexual intercourse with out precaution. (Biro,F.M 2006).
Interventions/Strategies:
At individual level:
Assessment is basic step to apply any interventions. Assessment of self-esteem, which I collected from patient and file, is mentioned in scenario. The Rosenberg Self-Esteem Scale (RSES), which is the most frequently used self report self-esteem instrument in the literature. There are 10 items of the RSES were designed to measure a core namely global self-esteem. (Lecomte,T et al. 2006 p.100). I was able to apply this scale on patient which shows that he feels useless and don’t have positive attitude about self. For implementation I found Caring theory for mentally ill patient to improved self-esteem given by Suie, K & Sue, K. (2007). The domain of interpersonal caring theory effects on person’s motivation, self-esteem and self worth. The domains are noticing, active listening, complimenting, hoping, participating, sharing, companioning, comforting, forgiving and accepting. By working on these domains nurse will able to help patient to feels good and worthy. Acknowledging the strength and potential and expressing gratitude for it. I was able to apply some of the domains on Patient. I motivated my patient to write his strengths on a piece of paper. Furthermore I gave teaching on OCD and allowed him to read a story which summarize that life ‘s problems are like this if you hold them for few minutes they seem OK but if you hold for longer period it give ache and paralyze you. In addition, individual counseling session was done by psychologist, in which she encouraged him to take part in occupational therapy and as well she motivated him to utilize your time effectively by teaching computer skills and English language to other patients.
He also participated in-group activity, he colored picture and presented in front of others and sweets were given as a reward to all patients. Moreover, I help patient to make friends with his colleagues and play games with others. The purpose of these activities was to realize him the importance of positive peer support.
.Through cognitive group therapy, patients often express negative thoughts about themselves and situations. It teaches patients to distinguish among events and thoughts, as well as to find their negative automatic thoughts. This helps patients to find out the cause, which affect their emotions and organize their cognitive pattern. (Chen, T.H et al 2006 p.8)
At family level:
It is my limitation to work with family members and community but as a nurse I could give teaching to family members to avoid labeling person that you are nut, you always do wrong, and you are stupid. These types of words can hurt the feelings of a person and has negative consequences for the self-concept. Positive parenting should emphasize during parenting counseling. Media is also play important to give awareness about mental health and illness.
At institutional level:
Our group members gave teaching to staff on effective communication with patients. I encouraged staffs to involve my patient in small task. Create environment where family get psycho education. I felt that institution should encourage inpatients to involve in therapies according to their needs.
Own thinking/ prejudices and learning from paper:
Initially I felt that by writing a scholarly paper would not give any benefits to patient but when I took concept of self-esteem and started reading on it. I was able to apply some of the interventions that motivated the client to think positive about self. Firstly, I learned about the concept of self-esteem and its effects on the physical as well as psychosocial wellbeing. Self-esteem seems to be major contributing factor of mental illness. Health care team works with patients, so they feel motivated towards positive attitude about health. I also learned that role of family and group support is very important for patient’ well-being. So, as a nurse we should make implementations in a way, where family get motivated and take part in patient’s care.
The important aspect of this paper is, I am able to analyze the concept of self esteem in Pakistani context so it gives me sense that what are the implementations are applicable in real setting and will benefits to patient. Furthermore I feel that if I have more days during clinical so I would able to implement more interventions on patient.
To sum up, self-esteem has been conceptualized as an outcome, motive, and act as psychological buffer system for body. We some time easily forget that like other organs, brain is also vulnerable to disease and people with mental illness can show many types of behaviors which alarming us they need help, but instead of supporting we stigmatize and discriminate them. Social skill, group therapy, cognitive behavioral therapy and family support have significant role in enhancing self worth of patient by motivating to decrease the negative thoughts about themselves. By working on self-esteem, individual feels confidence and able to socialize with others and take interest in activity. Through this we can promote mental health and decrease the incidence of mental illness by implementing the necessary interventions.
