[[Index for Spirituality]] #Spirituality - The main finding of the paper "Self-stigma and quality of life among people with psychosis: The protective role of religion" is that religiosity can moderate the relationship between self-stigma and psychological quality of life among individuals with psychosis. This suggests that strong religious beliefs and active participation in religious activities may help buffer the negative effects of self-stigma, thereby improving the quality of life for people living with psychosis. ---- # Self-stigma and quality of life among people with psychosis: The protective role of religion [Vanessa Seet](https://onlinelibrary.wiley.com/authored-by/Seet/Vanessa), [Ying Ying Lee](https://onlinelibrary.wiley.com/authored-by/Lee/Ying+Ying), [Yi Chian Chua](https://onlinelibrary.wiley.com/authored-by/Chua/Yi+Chian), [Swapna Kamal Verma](https://onlinelibrary.wiley.com/authored-by/Verma/Swapna+Kamal), [Mythily Subramaniam](https://onlinelibrary.wiley.com/authored-by/Subramaniam/Mythily) First published: 19 September 2023 [https://doi.org/10.1111/eip.13469](https://doi.org/10.1111/eip.13469) ## 1 INTRODUCTION The experience of psychosis is a debilitating one that encompasses major deterioration in cognition and functioning. The road to recovery is fraught with further hurdles, from difficulties with finding and sustaining employment (Ajnakina et al., [2021](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13469?campaign=woletoc#eip13469-bib-0004); Rinaldi et al., [2010](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13469?campaign=woletoc#eip13469-bib-0042)) to struggles with social relationships (Addington & Addington, [2008](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13469?campaign=woletoc#eip13469-bib-0002); Palumbo et al., [2015](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13469?campaign=woletoc#eip13469-bib-0038)). These difficulties, when added to the complexities of dealing with other aspects of psychosis such as symptom management and potential side effects of medications, contribute to a lower quality of life (Caron et al., [2005](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13469?campaign=woletoc#eip13469-bib-0010)). Studies have consistently demonstrated the compromised quality of life (QOL) among people with psychosis when compared to their non-psychiatric counterparts (Addington et al., [2003](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13469?campaign=woletoc#eip13469-bib-0003); Holubova et al., [2016](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13469?campaign=woletoc#eip13469-bib-0023); Neil et al., [2018](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13469?campaign=woletoc#eip13469-bib-0036); Saarni et al., [2010](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13469?campaign=woletoc#eip13469-bib-0045); Subramaniam et al., [2014](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13469?campaign=woletoc#eip13469-bib-0049)). In their study using the four-dimensional Assessment of Quality of Life (AQoL-4D), Neil et al. ([2018](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13469?campaign=woletoc#eip13469-bib-0036)) reported lower utility scores for QOL among those with psychosis, as opposed to the general population in Australia. Closer to home, Subramaniam et al. ([2014](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13469?campaign=woletoc#eip13469-bib-0049)) also found lower health-related QOL scores among 21- to 40-year-olds with first episode psychosis when compared to the general population in Singapore. Among the factors influencing QOL in persons with psychosis, self-stigma is one of the more insidious contributors to lower QOL. This is demonstrated by the strong, negative correlation found between self-stigma and QOL in a systematic review and meta-analysis by Sarraf et al. ([2022](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13469?campaign=woletoc#eip13469-bib-0046)). Self-stigma manifests when an individual with psychosis agrees with and internalizes the negative perceptions and prejudice that is perpetuated by the general public, and their self-esteem and self-efficacy decline in turn (Corrigan et al., [2006](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13469?campaign=woletoc#eip13469-bib-0013)). This creates a negative self-perception to the detriment of multiple domains of the individual's life, including looking for and sustaining employment (Link, [1982](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13469?campaign=woletoc#eip13469-bib-0032)), social inclusion (Berry & Greenwood, [2018](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13469?campaign=woletoc#eip13469-bib-0007)), and recovery beliefs (Boyd Ritsher et al., [2003](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13469?campaign=woletoc#eip13469-bib-0009)). Self-stigma is particularly prevalent in persons with psychosis. A study by Brohan et al. ([2010](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13469?campaign=woletoc#eip13469-bib-0508)) across 14 European countries found moderate to high levels of self-stigma in 41.7% of service users diagnosed with schizophrenia or other psychotic disorders. In their systematic review, Dubreucq et al. reported a high prevalence of elevated self-stigma levels among people with mental health conditions across all regions, with the highest prevalence of self-stigma in people with schizophrenia (Dubreucq, Plasse, & Franck, [2021](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13469?campaign=woletoc#eip13469-bib-0016)). In turn, the high levels of stigma in people with psychosis hinder their ability to seek help, as found by Gronholm et al. ([2017](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13469?campaign=woletoc#eip13469-bib-0020)) who examined the impact of self-stigma on pathways to care among those with first-episode psychosis. Furthermore, when these internalizations are not addressed during treatment, they may be left to fester, and further compromise service users' psychological wellbeing. Vyas et al. ([2021](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13469?campaign=woletoc#eip13469-bib-0057)) found just this in their qualitative study on the stigma-related experiences of early intervention service users aged 19–39. The increased prevalence of high self-stigma, coupled with the strong association between self-stigma and QOL, warrants further insight into the mechanisms surrounding self-stigma, especially among persons with psychosis. Addressing these issues early in treatment is essential in improving functional outcomes and recovery. While the link between self-stigma and QOL has been consistently demonstrated, there has been less research about self-stigma correlates and how its effects may be propagated or buffered. Religion is one such potential correlate that warrants further study, due to the integral role it plays in the lives of the psychiatric population. Using Huguelet and Koenig's definition ([2009](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13469?campaign=woletoc#eip13469-bib-0025)), religion refers to ‘belief in a supernatural power or transcendent being, truth or ultimate reality, and the expression of such a belief in behaviour and rituals’. In general, a high prevalence of people with severe mental illness have been shown to ascribe great importance to religion in their lives. Tepper et al. ([2001](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13469?campaign=woletoc#eip13469-bib-0054)) found that among those who were diagnosed with a mental illness or seeking treatment at mental health facilities, over 80% reported that they coped with daily struggles through religion, which included the use of prayers. In the local setting, Roystonn et al. ([2021](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13469?campaign=woletoc#eip13469-bib-0044)) found religion to be important to over 65% of those with a psychosis-related disorder in Singapore. In addition, studies have shown religious coping to yield beneficial outcomes among people with psychosis. These include better insight and medication adherence (Kirov et al., [1998](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13469?campaign=woletoc#eip13469-bib-0027)), elevating QOL via improving emotional wellbeing, fostering a sense of purpose and identity, and providing a support community and togetherness in dealing with the trials of psychosis (Fallot, [2008](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13469?campaign=woletoc#eip13469-bib-0018); Koenig, [2009](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13469?campaign=woletoc#eip13469-bib-0028)). On the flip side, relying on religion may have negative consequences as well. In a qualitative study by Mohr et al. ([2006](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13469?campaign=woletoc#eip13469-bib-0035)), lower treatment adherence was reported by some respondents, who found that psychiatric care went against their religion. Moreover, religious communities may harbour stigma towards individuals with mental illness (Tabassum et al., [2000](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13469?campaign=woletoc#eip13469-bib-0051); Wesselmann & Graziano, [2010](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13469?campaign=woletoc#eip13469-bib-0059)). This may in turn corrode the quality of social interactions these individuals have with fellow believers and lower their QOL, or even strengthen their self-stigma as they internalize these stigmatic views. Despite this, the benefits of being in a supportive religious community should not be trivialized. Such benefits include increased availability and tendency to seek social support, the ability to make meaning of their experiences (Tabak & Weisman de Mamani, [2014](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13469?campaign=woletoc#eip13469-bib-0050)) and ultimately increased overall QOL. Given the multiple facets of religion and the different ways religion interplays with self-stigma and QOL, religion has an important part to play in one's psychosis recovery journey, although whether for good or bad it remains to be conclusively proven. By shedding more light on the relationship between religion and self-stigma in psychosis, more can be gleaned on how best to u patients' religious beliefs and the implications of these beliefs during treatment. Hence, this study aims to address the gaps in the extant literature, and provide more insight about the mechanisms behind self-stigma and religion in influencing QOL. Specifically, we aim to investigate the potential effects of religiosity as a moderator of the relationship between self-stigma and QOL among persons with psychosis. We hypothesize that at high levels of religiosity, the effects of self-stigma on QOL are weaker than at low levels of religiosity. ## 2 METHODS ### 2.1 Sample The data analysed in this study was collected as part of a larger study on posttraumatic growth as experienced by patients with psychosis (Lee et al., [2022](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13469?campaign=woletoc#eip13469-bib-0030)). Participants (_n_ = 99) were recruited from the Early Psychosis Intervention Programme (EPIP) at the Institute of Mental Health, Singapore from April 2018 to May 2021. EPIP is a patient-centred program comprising a multi-disciplinary clinical team that provides services for those between 12 and 40 years old who have undergone first episode psychosis. EPIP clients were approached by the study team and recruited if they were: (1) EPIP clients for 10–14 months, (2) 21 years old and above, (3) English-literate, and (4) cognitively competent to give their informed consent to participate. Participants then completed a self-administered survey after giving their informed consent to take part in the study. Ethical approval was sought and received from the National Healthcare Group's Domain Specific Review Board (DSRB) (reference: 2018/01278). ## 3 MEASURES ### 3.1 Religious Commitment Inventory-10 (RCI-10) The 10-item RCI-10 was used to measure the level of participants' religious commitment, comprising the sub-domains of intrapersonal and interpersonal religious commitment (Worthington et al., [2003](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13469?campaign=woletoc#eip13469-bib-0060)). Items include ‘My religious beliefs lie behind my whole approach to life’. It is a 5-point Likert-type scale, with responses ranging from 1 – ‘Not at all true of me’ to 5 – ‘Totally true of me’. Total scores range from 10 to 50, with higher scores indicating greater overall religious commitment. The RCI-10 has generally been shown to have good reliability (Worthington et al., [2003](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13469?campaign=woletoc#eip13469-bib-0060)); in this study sample, it was shown to have a high internal consistency of Cronbach's _α_ = 0.96 (Lee et al., [2022](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13469?campaign=woletoc#eip13469-bib-0030)). For these analyses, RCI-10 total scores were used. ### 3.2 Internalized Stigma of Mental Illness (ISMI) The 29-item ISMI was used to measure participants' internalized stigma (Ritsher et al., [2003](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13469?campaign=woletoc#eip13469-bib-0009)). It comprises five sub-domains – alienation, stereotype endorsement, discrimination experience, social withdrawal and stigma resistance (these items are reverse-coded), which are then combined into a total score. Items include ‘I can't contribute anything to society because I have a mental illness’. Responses fall on a 4-point Likert scale from 1 (strongly disagree) to 4 (strongly agree); higher scores reflect greater internalized stigma experienced by the participant. The ISMI has been shown to have good reliability and validity (Ritsher et al., [2003](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13469?campaign=woletoc#eip13469-bib-0009)), and its robustness as a measure of internalized stigma has been demonstrated across various clinical and cultural settings (Boyd et al., [2014](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13469?campaign=woletoc#eip13469-bib-0008)). In this study sample, it has a high internal consistency of Cronbach's _α_ = 0.93; total ISMI scores were used in the analyses. ### 3.3 Abbreviated World Health Organization Quality of Life instrument (WHOQOL-BREF) The WHOQOL-BREF is the shortened version of the 100-item WHOQOL-100, with a total of 26 items measuring health-related QOL (The WHOQOL Group, [1998](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13469?campaign=woletoc#eip13469-bib-0055)). The WHOQOL-BREF also comprises four domains – physical health, psychological, social relationships and environment. Items include ‘To what extent do you feel your life to be meaningful?’ (psychological) and ‘How satisfied are you with your personal relationships?’ (social relationships). The four domain scores are computed separately from 24 items; the remaining two items are each a separate measure of overall QOL and general health. Each item is scored on a 5-point scale, with higher scores indicating better QOL. The WHOQOL-BREF's reliability and validity have been established across both the general and psychiatric populations (Berlim et al., [2005](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13469?campaign=woletoc#eip13469-bib-0006); Cheung et al., [2017](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13469?campaign=woletoc#eip13469-bib-0012); Hsiao et al., [2014](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13469?campaign=woletoc#eip13469-bib-0024); Trompenaars et al., [2005](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13469?campaign=woletoc#eip13469-bib-0056)). In this study sample, it has an acceptable internal consistency; Cronbach's _α_ ranged from 0.74 to 0.88 across the four domains. ### 3.4 Sociodemographic variables The information collected included the following variables (which were collapsed into the following sub-groups): sex (male and female), ethnicity (Chinese, Malay and Indian), marital status (married and unmarried/divorced/separated), highest education level (secondary, tertiary – including Polytechnic, Junior College, and vocational education, and university education), and employment status (employed and unemployed/economically inactive). ## 4 ANALYSIS Data was analysed using IBM SPSS Statistics for Windows, version 25 (IBM Corp, [2017](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13469?campaign=woletoc#eip13469-bib-0026)); statistical significance was indicated by _p_ < .05 for all analyses. After accounting for missing responses, 94 responses were analyzed. Mean QOL scores and their standard deviations (SDs) were computed by sex, ethnicity, marital status, highest education level and employment status. Score differences among sociodemographic groups were examined via independent _t_\-tests and one-way ANOVAs. Subsequently, sociodemographic variables were entered in preliminary regression models to examine the influence of these variables, ISMI and RCI on the four QOL domains. For the moderation analysis, the following predictor variables were entered simultaneously in the regression models: (1) RCI scores, (2) ISMI scores, (3) the interaction term between RCI and ISMI scores, and (4) sociodemographic variables with significant effects as found in the preliminary regression models. The WHOQOL-BREF domain scores were entered separately as dependent variables. In these models, a significant interaction between RCI and ISMI indicated the presence of moderating effects by RCI on the relationship between ISMI and QOL. At the preliminary and moderation stages, each QOL domain was analyzed separately, yielding four models at each step of the linear regression analysis. Hayes' PROCESS macro for SPSS was used for the moderation analysis (Guilford Press, [2022](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13469?campaign=woletoc#eip13469-bib-0021)). ## 5 RESULTS The means and SDs of respondents' WHOQOL-BREF scores are reported in Table [1](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13469?campaign=woletoc#eip13469-tbl-0001 "Link to table"). Univariate analyses revealed sex, marital status and education level differences in the QOL scores. Males had significantly lower QOL scores than their female counterparts in the physical health (_t_(92) = 2.29, _p_ = .02), psychological (_t_(92) = 2.55, _p_ = .01) and social relationships (_t_(92) = 2.37, _p_ = .02) domains. Significant differences in physical health QOL were also found with regards to marital status (_t_(92) = 2.1, _p_ = .04) and education level (_F_(2,91) = 4.53, _p_ = .01). TABLE 1. Respondents' WHOQOL-BREF scores. | | Physical health (domain 1) | Psychological (domain 2) | Social relationships (domain 3) | Environment (domain 4) | | --- | --- | --- | --- | --- | | Mean | SD | _t_/F | _p_ | Mean | SD | _t_/F | _p_ | Mean | SD | _t_/F | _p_ | Mean | SD | _t_/F | _p_ | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | Overall (_n_ = 94) | 3.62 | 0.60 | | | 3.33 | 0.67 | | | 3.41 | 0.78 | | | 3.66 | 0.69 | | | | Gender | | | 2.29 | .02 | | | 2.55 | .01 | | | 2.37 | .02 | | | 1.55 | .13 | | Female (_n_ = 50) | 3.75 | 0.61 | | | 3.49 | 0.61 | | | 3.59 | 0.78 | | | 3.76 | 0.69 | | | | Male (_n_ = 44) | 3.47 | 0.56 | | | 3.15 | 0.70 | | | 3.21 | 0.74 | | | 3.54 | 0.68 | | | | Ethnicity | | | 0.02 | .98 | | | 0.75 | .48 | | | 0.54 | .58 | | | 0.39 | .68 | | Chinese (_n_ = 68) | 3.62 | 0.61 | | | 3.28 | 0.69 | | | 3.42 | 0.78 | | | 3.69 | 0.69 | | | | Malay (_n_ = 16) | 3.61 | 0.55 | | | 3.39 | 0.62 | | | 3.27 | 0.60 | | | 3.53 | 0.61 | | | | Indian (_n_ = 10) | 3.59 | 0.69 | | | 3.55 | 0.57 | | | 3.60 | 1.06 | | | 3.60 | 0.83 | | | | Marital | | | 2.10 | .04 | | | 1.67 | .10 | | | 1.53 | .13 | | | 1.14 | .26 | | Married (_n_ = 13) | 3.93 | 0.60 | | | 3.62 | 0.53 | | | 3.72 | 0.80 | | | 3.86 | 0.53 | | | | Unmarried/divorced/separated (_n_ = 81) | 3.56 | 0.59 | | | 3.28 | 0.68 | | | 3.36 | 0.77 | | | 3.62 | 0.71 | | | | Education | | | 4.53 | .01 | | | 0.33 | .72 | | | 0.70 | .50 | | | 2.43 | .09 | | Secondary (_n_ = 15) | 3.21 | 0.62 | | | 3.21 | 0.83 | | | 3.20 | 0.89 | | | 3.31 | 0.78 | | | | Tertiary (_n_ = 44) | 3.72 | 0.56 | | | 3.38 | 0.70 | | | 3.48 | 0.76 | | | 3.75 | 0.67 | | | | University (_n_ = 35) | 3.65 | 0.59 | | | 3.32 | 0.56 | | | 3.42 | 0.78 | | | 3.69 | 0.64 | | | | Employment | | | −0.35 | .72 | | | −0.61 | .54 | | | 0.23 | .82 | | | −1.03 | .31 | | Employed (_n_ = 32) | 3.58 | 0.56 | | | 3.27 | 0.63 | | | 3.44 | 0.66 | | | 3.55 | 0.65 | | | | Unemployed/economically inactive (_n_ = 62) | 3.63 | 0.62 | | | 3.36 | 0.69 | | | 3.40 | 0.85 | | | 3.71 | 0.70 | | | - Abbreviations: WHOQOL-BREF, abbreviated World Health Organization Quality of Life instrument. These sociodemographic variables were subsequently entered into preliminary regression models, as shown in Table [2](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13469?campaign=woletoc#eip13469-tbl-0002 "Link to table"). Sex was significantly associated with psychological QOL, while its association with QOL in social relationships almost reached significance. As expected, increased ISMI scores were significantly associated with a deterioration in all four QOL domains. Hence, for the final regression models testing for the interaction effect of internalized stigma and religious commitment on QOL, sex was entered as a covariate in the models with psychological and social relationships QOL as the outcomes. TABLE 2. Results of preliminary regression models. | | Physical health (domain 1) | Psychological (domain 2) | Social relationships (domain 3) | Environment (domain 4) | | --- | --- | --- | --- | --- | | _B_ | 95.0% CI | _p_ | _B_ | 95.0% CI | _p_ | _B_ | 95.0% CI | _p_ | _B_ | 95.0% CI | _p_ | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | Gender | | Male (reference) | | Female | 0.11 | −0.09 | 0.35 | .25 | 0.21 | 0.05 | 0.52 | .02 | 0.22 | 0.00 | 0.69 | .05 | 0.06 | −0.21 | 0.37 | .58 | | Marital status | | Unmarried (reference) | | Married | 0.13 | −0.07 | 0.51 | .14 | 0.10 | −0.11 | 0.50 | .21 | 0.11 | −0.21 | 0.70 | .28 | 0.05 | −0.28 | 0.47 | .62 | | Highest education level | | Secondary (reference) | | Tertiary | 0.20 | −0.09 | 0.56 | .15 | 0.07 | −0.24 | 0.43 | .58 | 0.07 | −0.38 | 0.61 | .64 | 0.18 | −0.17 | 0.66 | .24 | | University | 0.08 | −0.25 | 0.45 | .58 | −0.05 | −0.44 | 0.30 | .72 | −0.05 | −0.63 | 0.46 | .77 | 0.11 | −0.30 | 0.61 | .51 | | ISMI score | −0.52 | −0.84 | −0.41 | <.001 | −0.40 | −0.77 | −0.32 | <.001 | −0.22 | −0.68 | −0.01 | .04 | −0.40 | −0.83 | −0.28 | <.001 | | RCI-10 score | 0.12 | 0.00 | 0.02 | .16 | 0.47 | 0.02 | 0.04 | <.001 | 0.17 | 0.00 | 0.03 | .12 | 0.16 | 0.00 | 0.02 | .12 | - Abbreviations: ISMI, Internalized Stigma of Mental Illness; RCI-10, Religious Commitment Inventory-10; WHOQOL-BREF, abbreviated World Health Organization Quality of Life instrument. For the psychological QOL model, after adjusting for sex, the interaction between internalized stigma and religious commitment was significant (_b_ = 0.016, SE = 0.008, _t_ = 2.07, _p_ < .05). This indicated religious commitment significantly moderated the relationship between internalized stigma and psychological QOL. At higher levels of religious commitment, the negative association between internalized stigma and psychological QOL was weak (_b_ = −0.41, SE = 0.13, _t_ = −3.081, _p_ < .01). At lower religiosity levels, this negative association was stronger (_b_ = −0.77, SE = 1.43, _t_ = −5.37, _p_ < .001). The differing effects of internalized stigma on psychological QOL at the different levels of religious commitment (±1 SD) are presented in Figure [1](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13469?campaign=woletoc#eip13469-fig-0001). [](https://onlinelibrary.wiley.com/cms/asset/c15bd45f-6d42-4090-a23c-95069b0e9495/eip13469-fig-0001-m.jpg) Effects of self-stigma on WHO-QOL BREF psychological domain QOL scores at varying levels of religious commitment. WHOQOL-BREF, abbreviated World Health Organization Quality of Life instrument. ## 6 DISCUSSION To the best of our knowledge, this is the first study to examine the relationships among self-stigma, religious commitment and quality of life among people living with psychosis. In our preliminary regression analyses, QOL was found to differ by sex; males had lower scores in the psychological and social relationships domains than their female counterparts. While these findings seem to be in direct contradiction with studies demonstrating the opposite pattern (Dubreucq, Plasse, Gabayet, et al., [2021](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13469?campaign=woletoc#eip13469-bib-0017); Teh et al., [2008](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13469?campaign=woletoc#eip13469-bib-0053)), or no pattern at all (Rotstein et al., [2022](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13469?campaign=woletoc#eip13469-bib-0043); Shafie et al., [2021](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13469?campaign=woletoc#eip13469-bib-0047)), a plausible explanation for this discrepancy is one that takes sex differences in premorbid functioning into account. Compared to females, males have been shown to have lower levels of premorbid functioning (Rabinowitz et al., [2002](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13469?campaign=woletoc#eip13469-bib-0040)), which is defined as ‘social, interpersonal, school and work functioning in the period before the onset of psychosis’ (Addington & Addington, [2005](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13469?campaign=woletoc#eip13469-bib-0001)), and adjustment (Preston et al., [2002](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13469?campaign=woletoc#eip13469-bib-0039)). This poorer adjustment has been linked to deteriorations in later functioning and health-related quality of life (MacBeth & Gumley, [2008](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13469?campaign=woletoc#eip13469-bib-0033); Preston et al., [2002](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13469?campaign=woletoc#eip13469-bib-0039)). Additionally, males have been shown to experience more psychological barriers, and thus greater reluctance in seeking help for psychosis in the early phase when compared to females – such barriers include problems articulating their symptoms and the male-oriented stereotype of seeking help as a sign of weakness (Ferrari et al., [2018](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13469?campaign=woletoc#eip13469-bib-0019)). These internalized perceptions may also impact their social support, and in turn their perceived quality of social relationships as they may feel that they have no one to turn to, or be disinclined to approach people for support. Finally, in terms of treatment engagement and adherence, males have been found to exhibit lower medication adherence (Tan et al., [2019](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13469?campaign=woletoc#eip13469-bib-0052)) and general treatment compliance (Rao et al., [2017](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13469?campaign=woletoc#eip13469-bib-0041)), and to have a higher tendency of disengaging from treatment (O'Brien et al., [2008](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13469?campaign=woletoc#eip13469-bib-0037)), all of which compromise functional outcomes and adversely affect QOL and recovery. Given the psychosocial differences between the two sexes, it may be prudent to address these issues differently in interventions. Greater focus can be placed on social support interventions for males in order to build a support network they can turn to in times of need during their recovery journey. Ultimately, taking these differences into account can help tailor more targeted treatment in order to improve psychosocial outcomes in males. In our main set of analyses, religion was found to buffer the association between self-stigma and psychological QOL, thus supporting our hypothesis. At higher levels of religious commitment, the debilitating effects of self-stigma on psychological QOL were significantly weaker. The role of religion as a coping strategy during times of crisis has been demonstrated across different life situations, including medical and mental illness and their accompanying problems (Koenig et al., [2001](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13469?campaign=woletoc#eip13469-bib-0029); Tepper et al., [2001](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13469?campaign=woletoc#eip13469-bib-0054)). Among people with psychosis, turning to religion has been shown to instil hope, comfort, and self-confidence, and allowed them to reframe their experiences more positively (Mohr et al., [2006](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13469?campaign=woletoc#eip13469-bib-0035)). Religion also allows people with psychosis an avenue to make meaning of their experiences and empowers them as they work towards reconciling their psychotic experiences with their religious beliefs and connection with their faith (Marriott et al., [2019](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13469?campaign=woletoc#eip13469-bib-0034); Smith & Suto, [2012](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13469?campaign=woletoc#eip13469-bib-0048)). This may in turn lend some resistance to the negative effects of self-stigma. In our sample, the protective effects conferred by religion among those who were more devout may have helped lessen the negative psychological effects of self-stigma on their QOL. Moreover, self-stigma is especially pervasive in people with psychosis, as they internalize the more negative beliefs held by the general public (when compared with public stigma on those with nonpsychotic disorders) (Dubreucq, Plasse, & Franck, [2021](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13469?campaign=woletoc#eip13469-bib-0016); Hasan & Musleh, [2018](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13469?campaign=woletoc#eip13469-bib-0022)). One of the more effective ways of combating the negative self-perceptions and QOL experienced by people with higher levels of self-stigma has been social support (Couture & Penn, [2003](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13469?campaign=woletoc#eip13469-bib-0014); Denenny et al., [2015](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13469?campaign=woletoc#eip13469-bib-0015); Li et al., [2021](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13469?campaign=woletoc#eip13469-bib-0031)). Religion is a multidimensional avenue through which people create and bolster social support networks in addition to the psychological benefits of engaging in individual religious practices. In turn, positive religious social support has been linked to improved recovery from serious mental illness (Webb et al., [2011](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13469?campaign=woletoc#eip13469-bib-0058)), and lower psychological distress (Chatters et al., [2015](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13469?campaign=woletoc#eip13469-bib-0011)). Allport et al.'s ([1954](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13469?campaign=woletoc#eip13469-bib-0005)) contact hypothesis also provides a complementary mechanism through which religion works – theoretically, increased contact under conducive conditions, namely in the presence of common ideals and ‘institutional supports’ such as local custom and practice, helps to reduce prejudice between groups. In the current context, religion is the platform through which contact is established and maintained. Through the pursuit of spiritual betterment, as people engage together in prayer and other religious practices, both people with and without psychosis interact and foster relationships. This increased contact from higher religious commitment allows both groups to gain a better understanding of each other and helps to turn around the negative stereotypes and stigma people without psychosis may have towards people living with it. The self-stigma experienced by people with psychosis in turn decreases as they face less of the public stigma which contributes to their negative self-perceptions. Ultimately, our results corroborate the findings of studies pertaining to the positive psychological effects of turning to religion as an important part of one's life, and expands on the contact hypothesis, by demonstrating the attenuating effects of religious commitment on self-stigma and psychological QOL. Among people with psychosis, the benefits from the increased social support via religion is especially crucial in alleviating the negative self-perceptions that may hinder their recovery and reduce their psychological QOL. Hence, it will be useful for early intervention services and clinicians to assess the level of religiosity and nature of religious beliefs held by those with psychosis at the start of treatment. These assessments can then be incorporated into the treatment process, and help service users navigate and make meaning of their experiences, or even provide alternative avenues of informal support to bolster their help-seeking resources. Integrating religion in the context of treatment can also help tackle and alleviate internalized stigma, which can improve psychological QOL among those with psychosis. Our findings should be considered within the context of several limitations. Firstly, due to the small sample size, the statistical power of our moderation analysis is weakened. Secondly, the narrow age range of our sample (21–40 years) limits the generalizability of our findings to the younger age groups. Future studies could look at age as a potential covariate in the relationship among self-stigma, religion and QOL, and investigate the influence of age (younger adults versus their middle-aged and elderly counterparts) on this three-way relationship. Despite these limitations, this study provides preliminary insight into the effects of self-stigma on QOL, and demonstrates the role of religion as a buffer against these negative effects. ## 7 CONCLUSION This study examined the role of religiosity in the relationship between self-stigma and QOL among people with psychosis. Our results revealed religiosity as a moderator between the two variables, with higher levels of religiosity attenuating the negative effects of self-stigma on psychological QOL. The findings from this study suggest that addressing religion and incorporating it in treatment programs may yield substantial benefits for people with psychosis, especially those who are committed to their religion. With their faith and the support of like-minded people guiding them, the negative perceptions they may harbour about themselves will have less room to fester and comprom. Hence, taking steps to address and incorporate religion during interventions will facilitate better outcomes, and improve their QOL as they continue on their recovery journey. ## ACKNOWLEDGMENTS The authors would like to thank the participants for their help in this study. ## CONFLICT OF INTEREST STATEMENT The authors declare no conflicts of interest. ## [Open Research](https://onlinelibrary.wiley.com/doi/full/10.1111/eip.13469?campaign=woletoc#) ## REFERENCES