The Prevalence of Low SelfEsteem in a LearningDisabled Forensic Population

1
The Prevalence of Low Self-Esteem in a
Learning-Disabled Forensic Population

• Paula A. Johnson, Clinical Nurse Specialist
• Calderstones NHS Trust
• Research - 2007

2
Introduction to Research

• Anecdotal clinical issues of low self-esteem
• Low self-esteem evident in learning disabled
  (Dagnan Waring, 2004) and prison populations
  (Jacques Chason, 1977)
• Look at prevalence in forensic learning disabled
  population with consideration of
• Differences in low and medium secure service
• Influence of offence types
• Effects of disrupted childhood attachments

3
Definition of learning disabled forensic
population

• IQ 70 or below impaired social functioning
• Mild LD 50-69, borderline 70-80
• Unique group all LD, most committed offences
  against property or people, only some prosecuted
  through Criminal Justice system
• Some dual diagnosis LD and Mental illness
• Prevalence 1-8 ( Barron et al, 2002 ) 0.4-5
  (Johnston, 2005)
• Low medium secure parts to service revolving
  door phenomenon

4
Definition of Self-Esteem

• A fundamental human motive (Rosenberg et al,
  1989).
• Three key principles
• Reflected appraisals
• Social comparison
• Self attribution
• An evaluation, either positive or negative, of
  ones own self-worth or value

5
Self-esteem measures

• Rosenberg Self-Esteem Scale
• Global measure of self-esteem, reflects feelings
  of self acceptance, self respect and generally
  positive self evaluation
• The Evaluative Core Beliefs Scale (Chadwick,
  Trower Dagnan, 1999)
• Assesses negative evaluations of people beliefs
  about themselves, how others see them, how they
  see others
• Encompasses the principle of social comparison

6
Cognitive model of self-esteem

• Fennell (1997) a schema a global image of
  self as a whole person
• Based on Becks (1976) generic cognitive model of
  emotional disorder
• From experience people form beliefs or
  assumptions about themselves, others and the
  world
• Negative beliefs about self-worth

7
Literature review stigmatisation and loneliness
in minority groups

• Prisoners people in MH institutions lower
  self-esteem (Jacques Chason 1977)
• Students with LD able to make social comparisons
  between themselves and others, use of downward
  comparison (Szivos-Bach 1993)
• The experience of feeling different is linked to
  a persons core negative evaluative beliefs
  (Dagnan Waring 2004)
• People with LD perceive stigma and make negative
  self evaluations. LD less peer acceptance,
  lower self-esteem, lonelier (ValAs 1999)

8
Literature review offender behaviour and
self-esteem

• Prisoners and psychiatric patients lower self
  esteem than all other groups (Jacques Chason,
  1977)
• Offenders with LD sex offending and
  fire-setting most prevalent offences (Barron et
  al., 2002)
• As the IQ of the offender increases so does the
  probability of violence in the sex offence
  (Murrey et al., 1992)
• Rapists showed an increase in self-esteem post
  CBT treatment (Valliant Antonowicz, 1992)

9
Literature review attachment self-esteem

• Anxious resistant and anxious avoidant
  attachments may lead to personalities of anxiety
  and depression and, by implication, lower
  self-esteem (Bowlby, 1988)
• LD sex offenders came from dysfunctional homes
  (Corbett, 1996)
• Perception of poor parent-child connectedness
  among teenagers depression low self-esteem
  (Ackard, 2006)
• Disrupted parental attachments low self-esteem
  (Fennell, 1997)

10
Literature review depression and self-esteem

• Depression one of the first emotional disorders
  to be treated with CBT (Beck, 1976), CBT
  beneficial for associated problems such as low
  self-esteem (Fennell, 1997)
• CBT more effective than just medication, also
  helps self-esteem (Scott et al., 2000)
• People with LD with high depression had low
  self-concept (Benson Ivins, 1992)
• Depression in people with LD is significantly
  negatively correlated with positive self-esteem
  and social comparison (Dagnan Sandhu, 1999)

11
Research hypotheses

• Self-esteem will be categorised as low in a
  learning disabled forensic population
• A large number of the population will have
  committed sexual offences and fire-setting
  offences and there will be a high prevalence of
  low self-esteem associated with these offences

12
Research hypotheses

• People in this population who have evidence of
  disrupted attachments (evidenced by time spent in
  care or boarding school) will have lower
  self-esteem than those who have not experienced
  disrupted attachments
• In this population, there will be no difference
  in self-esteem between the low and medium secure
  services due to the revolving door phenomenon

13
Methodology - participants

• 44 clients 20 low, 24 medium secure
• All male age range 18-61yrs, mean35.6yrs
• Medium secure service mean age31.25yrs
• Low secure service mean age40.9yrs
• IQ range 6077 mild/borderline LD
• 43 on criminal section of MHA (1983)
• 1 detained under CPA (1991) part 1
• 41 Caucasian, 3 Asian all English speaking

14
Methodology - participants

• Offence categories
• Sexual offences (against either adults or
  children) (N19)
• Arson (N9)
• Violent offences (N16)
• Parental separation almost 2/3 (N25)
• Sample size 44 out of possible 55 80,
  suggests prevalence rate reliable

15
Methodology - measures

• Rosenberg Self-Esteem Scale (RSES) 6-item
• Global measure, reflects feelings of
  self-acceptance, self-respect and generally
  positive self-evaluation (Rosenberg et al., 1989)
• High reliability. Four point Likert scale.
• Adapted for use with people with LD by Dagnan
  Sandhu (1999) simplified wording, five point
  scale (scores 0-4)

16
Methodology - measures

• The Evaluative Beliefs Scale (EBS) (Chadwick et
  al., 1999)
• Developed as an assessment of negative evaluative
  beliefs of people, either oneself or others
• 6 evaluative themes sense of worthlessness,
  vulnerability, weakness, badness, failure and
  inferiority
• 18 items, 3 subscales (self-self, other-self,
  self-other) of 6 items each
• 5 point Likert scale
• Good internal reliability and face validity
  reported
• Adapted for use with LD population by Dagnan
  Waring (2004)

17
Methodology - design

• Quantitative study aimed primarily at measuring
  the prevalence of low self-esteem in LD forensic
  population
• Repeated measures design with independent
  variables
• Age range, date of admission, low or medium
  secure service, index offence, disrupted
  childhood attachments
• Dependent variables were the adapted Rosenberg
  Self-Esteem Scale (6-item) the adapted
  Evaluative Beliefs Scale

18
Methodology - procedure

• COREC, University and Hospital ethics committees
• Hospital managers ward managers briefed
• Client interviews client research and
  information sheet, informed consent for
  interview to complete measures and then for
  access to personal notes on hospital records
• Collection of independent variables

19
Results

• Age of clients between services
• Younger group in medium secure service
• Statistically significant
• Length of stay between services
• Low SS 62.3 months (5yrs 2months)
• Medium SS 49.8 months (4yrs 2 months)
• Not statistically significant
• Reflective of revolving door phenomenon

20
Results

• Self-esteem between services
• RSES mean score for self-esteem slightly higher
  in low secure service not statistically
  significant
• EBS same slight trend of higher self-esteem in
  low secure service not statistically significant
• No statistical difference between services
  therefore sample groups were collapsed from this
  point and treated as one set of data
• Majority of clients scored as having moderate or
  high self-esteem on both RSES and EBS

21
Results

• Self-esteem and offence categories
• 64 of population studied had committed either
  sexual offences or fire-setting offences
• With both RSES and EBS those who committed
  violent offences had lowest self-esteem no
  statistical significance found between 3 groups
  of the offences with either measure

22
Results

• Disrupted childhood attachments
• Of sample group, 56.8 (N25) had spent time in
  care or at boarding school
• Of these 25, 17 were in medium secure service 8
  in low secure service the difference was
  statistically significant
• On both RSES EBS slightly higher self-esteem
  noted for those who had experienced disrupted
  attachments but not statistically significant
• Correlations between measures - there is a
  statistically significant positive correlation
  between the RSES the EBS

23
Discussion - Hypothesis 1 Self-esteem would be
low

• Majority of clients had moderate or high
  self-esteem
• Population removed from non-LD peer group, into
  safe supported environment
• Culture of unconditional positive regard
• Principle of normalisation in social role
  valorisation
• Overarching clinical approach of non-punitive
  behavioural approaches
• ? Self-esteem rises during detention (Greve
  Enzman, 2003)
• Differences between low and medium secure parts
  of service progress, activities, resettlement

24
Discussion - Hypothesis 1 Self-esteem would be
low

• Population studied tend to compare themselves to
  their peer group, not to staff, when considering
  their self-esteem
• Dimension of downward comparison (Szivos-Bach,
  1993)
• This counteracts stigmatisation (Finlay Lyons,
  2000)
• Difference between using a once-only measurement
  of self esteem outside of a therapeutic
  relationship, and discovering low self-esteem
  issues during the course of therapy
• Clients wanted to be seen in a positive light?

25
Discussion - Hypothesis 2mostly sexual and
fire-setting offences with associated low
self-esteem

• 64 sexual offences or fire-setting, concurred
  with literature
• However self-esteem was moderate or high
• Self-esteem lower for aggressive offenders but
  still mostly moderate or high overall
• Narcissism linked to people who display a high
  but unstable self-esteem aggression may
  therefore occur when a persons grandiose
  self-image is questioned (Baumeister et al., 2000)

26
Discussion - Hypothesis 3Those with disrupted
childhood attachment would have low self-esteem

• Majority of population studied had moderate of
  high self-esteem
• Do people with a learning disability, in care or
  boarding school, develop protective behavioural
  mechanisms with which to cushion themselves and
  boost their own self-esteem against the
  psychological trauma caused by disrupted
  attachments?
• Or is this reflective of the desire to project
  oneself in a positive light for an once only
  measure?

27
Discussion - Hypothesis 4No difference in
self-esteem between medium and low secure service

• Revolving door phenomenon
• People in low secure service had slightly longer
  stay than in medium secure but 8/24 people in
  medium secure had been there 7yrs or more
• Admission to medium secure progress to low
  secure stressful situation behavioural
  problems transfer back to medium secure
• Occurs in prison and mental health settings
  (Denkla Berman, 2001)

28
Clinical implications

• No significant difference in length of stay
  between medium and low secure but significant
  difference in ages with younger people in medium
  secure changing client group
• Self-esteem is a complex personal concept which
  is possibly not accurately measured in a one-off
  interview outside of a trusting therapeutic
  relationship
• In CBT scores may appear higher at start of
  therapy than becomes apparent later when core
  beliefs are explored may need specific help

29
Clinical implications

• Statistically significant positive correlation
  between adapted RSES (Dagnan Sandhu, 1999) and
  adapted EBS (Dagnan Waring, 2004) both scales
  appropriate to LD forensic population
• RSES is shorter may be beneficial for those
  with short attention span
• Subscales in EBS useful in CBT when measuring
  personal self-esteem and perceptions of others
  views of oneself to help conceptualisation of
  negative core beliefs

30
Methodological limitations

• Key researcher had met 70 of population before
  this study
• Revolving door phenomenon may have skewed some
  results
• No attempt made to control ages of clients so no
  real comparison between ages of clients in
  different parts of service possible

31
Further research

• Further analysis of offending history of sexual
  offenders to compare with research by Murrey et
  al. (1992)
• Study of the environment and ethos of care in LD
  forensic service compared with prison service
• Study of those convicted of violent offences to
  explore theory of threatened egotism (Baumeister
  et al., 2000)

32
Conclusion

• Not low self-esteem as predicted
• Self-esteem is a complex personal concept
• Not easily recognised or realistically measured
  outside of a trusting therapeutic relationship
• Offence types concurred with previous research
• Positive correlation between RSES and EBS adds
  validity to adapted scales with this population
• Clinical work needs to be published to add to
  knowledge of prevalence and efficacy of CBT in
  raising self-esteem