During psychiatric clinical rotation at Karwan e Hayat, I came across a 29 years old female client who was admitted on March 04th, 2010, unmarried and since childhood was suffering from schizophrenia. She had premorbid personality of aggressive and attention seeking behavior. Her father has passed away a year ago since then she has a feeling of helplessness. She always verbalized that “I will not be cured and I have no worth”. Moreover, she also said that “my mother is very old, I feel myself burden on her because I can’t do anything for her”. Due to this feeling of worthlessness and low self-esteem, she shows aggression towards staff and other psychiatric patients to gain attention. I observed that she interferes in other’s work and tries to manipulate to achieve intentional goals. She acts childish behavior and remained dependent on others. Surprisingly, soon after the event, she also reflected herself of being aggressive. I also observed that staff used to label her as “Pagal” and make her responsible for anything bad happened. She always said to me that “staff beats me, tease me and blame me for anything happened or lost”. Even though, she also verbalized about the suicidal ideation that gives her the feeling of worthless.

Patient history and assessment reveal that patient has a feeling of low self esteem that exhibits in aggressive and irritating behavior. Moreover, staff attitude is also triggering anger and odd behavior in her. Labeling by staff and others may also cause low self-esteem. Individual with low self-esteem might blame others for their problems and it may be that individual with low self-esteem feel the need to act out or use attention seeking behavior as a way to increase their self-esteem and that was my patient’s case too.

There are two dimensions of self-esteem, high self-esteem and low self-esteem. High self-esteem includes enthusiasm, interest, excitement and confidence. However, shame, guilt and doubt are associated with low self-esteem. The concept which I will be focusing is “Low Self-esteem”. Low self-esteem refers to greater the disharmony between the needs of a person and support the person is getting from the environment, the poorer will be the adjustment and self-esteem. In Asian context, Zia (2006) stated in her article that a person with low self-esteem suffers from feeling of worthlessness and inferiority, is highly insecure, self centered and misinterprets others thoughts and actions and make himself/herself miserable for others. In my patient’s scenario, she wanted to be socially accepted to overcome obstacles but lack of awareness regarding her strengths and worth, generates the feeling of low self-esteem. Similarly, she was dependent on others, used to take help even for drinking water and said that “I can’t pour water myself please come with me else I won’t talk to you”. She was manipulating things also as she used to lie down on floor and cries a lot.

In Pakistan no efforts has been directed toward construct explication and development of a self-esteem measure so far. Bhugra & Desai (2002) highlighted in their study that “low self-esteem is one of the causes of suicide in South Asian women” (p 418). Similarly if I compare this with my patient she also verbalized about the suicidal ideation that gave her the feeling of worthless. Moreover, stressful life events and experiencing uncertainty in performing task are also the cause of developing low self-esteem. Aamir (2005) conducted a study in Rawalpindi, Pakistan and concluded that “people’s psychological and physical health is profoundly affected by the stressful life events which lead to develop the feelings of low self-esteem in one’s life” (p 65). Likewise, my patient always verbalized the love for her father that “I miss my father a lot, we are alone without him. Everyone tease me and hurts me because my father is not with me”. This reveals that client has a feeling of helplessness and low self-esteem.

In order to analyze the condition of my patient more critically in the light of literature, McManus, Waite & Shafran (2009) describe a cognitive model of low self-esteem. It talks about self appraisal. If it is excessively negative, the consequence is low self-esteem. The key concepts of this model talk about experiences, bottom line, rules of living, trigger situation, activation of bottom line and conformation of bottom line which leads to low self esteem (appendix A). I have integrated my patient in this model. She is suffering from lack of family support and loss of her father. This proceeds to bottom line where my patient felt herself worthless, and rejected which has very well discussed above. Then comes rules of living where person tries to identify coping strategies. If I relate my client on rules of living, then her coping is crying and aggression. This is a crucial stage where a person can overcome the situation and here the role of health care professional comes. If this stage is not been taken care properly, then person might end up in mental disorders and this would trigger bottom line component again. Similarly, this client has felt worthlessness, showed aggression and having suicidal thoughts because of lack of coping resources also (appendix B). There are some other factors which are also responsible for developing low self-esteem in my patient.

Family support & cohesion is the variable of one’s satisfaction and need of life. The greater the family support, cohesion and happiness, the greater will be the self-esteem. In my patient’s case, mother is the only one who used to visit her but other family members’ even neighbors ignored her due to mental illness and aggressive behavior. This was also one of the factors which trigger her for showing awful behavior. Moreover, due to lack of support system, she used to behave in childish way to gain attention from others as it was already discussed above.

Experiencing loss and loneliness is always difficult and challenging in one’s life. Similarly, loss of her father created a major impact on her life. She was much attached with her father and talked about him a lot. In addition she also verbalized about the suicidal ideation of being worthless. She said that “I lost my father, nobody is there to take care of me, and I just want to die because there is nothing left for me”. She was also having auditory and visual hallucination for suicidal ideation. She said that “black cat clings on me and tells me to die and white cat fights with it”. This reveals that loss of her father has created a major impact on her illness. This could trigger positive as well as negative symptoms such as anhedonia, affective changes and signs of depression in schizophrenic clients. Chaudhry, et al. (2005) conducted a study in Lahore that “there is significant association between depressed mood, loss of loved one, and suicidal behavior” (p. 401). The results are same in US also. Further they elaborated that “mental health professionals have to be careful when patient reports suicidal ideation after the death of loved one because patient feels inadequacy and extremely experiencing low self-esteem” (p. 401).

Aggressing is another contributing factor which is equally responsible for expressing and developing low self-esteem. There is no such data available which shows the relationship between aggression and low self-esteem in Pakistani and Regional context. However, Ostrowsky (2009) conducted a study in U.S regarding aggressive people are likely to have low self-esteem. He stated that “low self-esteem leads to numerous antisocial behaviors including violent behavior” (p. 70). I observed that my patient used to interfere in other’s matters, irritate and misbehaves with them. Soon after the event, she reflected while crying that “I know, I have done very bad but they also misbehave with me, they never give me anything and blame me for everything”.

Literature indicates that in Pakistan, not only ordinary public stigmatize mentally ill clients’ instead health care professionals also have negative attitudes towards psychiatric patients. Naeem et al. (2006) conducted a research survey from medical students and doctors in Lahore, Pakistan. The outcomes indicated that over half of the respondents held negative attitudes towards people with schizophrenia, depression, drug and alcohol disorders. To support this idea, WHO European Ministerial Conference on Mental Health (2005) addressed that “stigma is one of the most important problems encountered by people with severe psychiatric disorders. It lowers their self-esteem, contributes to disrupted family relationships and adversely affects their ability to socialize, obtain housing and become employed” (p.1). Similarly, I also saw one of the staff threatening my patient that “I will beat you if you will come to counter again”.

Based on the assessment, first of all building trust relationship is very important so that patient can share as much as information. Similarly, I had established and followed therapeutic principles of dealing with my client and built trust relationship. Next, teaching coping strategies is essential to minimize stressful or triggering situation that can be managed on time hence worsening of mental illness can be achieved. Then, Involving patient in activity actually diverts the mind and making them socially active. It helps patients to share concerns and emotions in a group. I gave coloring and pasting pulses activity to my patient and she performed very well. Giving activity only is not enough, praising and encouragement make patient motivated to build on further. This was the right time where I had praised and encouraged her to make her feel that she is worthy and has potentials to do task hence strengthening self-esteem. Strengthening individual or increasing resilience through interventions to promote self-esteem, are the best strategy for promoting mental health. I made a teaching plan on strengthening self-esteem and covered anger management. I also made a daily activity plan card and client had to mark her feelings for each day that expressed her emotions. It was an achievement for me that at least my patient enjoyed that particular day. After the completion of activity, she made happy face on the card. As I had already discussed that aggression is likely the cause of low self-esteem, so by controlling aggression, my client was able to reflect and identified ways of managing anger in evaluation. Another intervention was to develop self-esteem by making her independent in self care activities. She always used to tell me to seek attention that “I can’t pour water for myself, comb my hair and take me to the shower room etc”. Initially it was very difficult for me to make her independent and set limits for her. But throughout clinical I was focused in setting limits and helped her in doing self care activities independently. Hence this gave her the message that she has an ability to do things by herself which ultimately enhancing self-esteem and promoting mental health.

Strengthening communities, group and family, not only provide awareness regarding mental illness, but also enhance caring attitude in them. Moreover, working collaboratively helps us in reducing stigmatization and discrimination also. By increasing social inclusion and participation, improving neighborhood environment foster mental health. Initially it was in my planning that family education needs to be done but unfortunately, I was unable to talk to her family because patient’s mother used to visit her in evening timings. I had observed that whenever her mother visited her, she remained happy throughout the day; it gave her strength and courage to live. Educating family regarding mental illness is very important because lack of family support can cause relapse of disease. Marshall, Solomn, Steber & Mannion (2003) in their study found out that:

Family environments, poor family communication, behavior of family members, family criticism, and hostility and over involvement are the major factors of relapse and rehospitalization. Family education and psycho education has been shown to be successful by educating families about mental illness and introducing more effective coping strategies. (p. 230).

At institutional level based on our observation, planning was to educate staff regarding therapeutic communication skills and principles of dealing with client. Susie Kim & Sue Kim (2007) said that “therapeutic and collaborative nurse patient relationship based on mutual trust, connection, and respect for the patients. The nurse in the relationship does not exercise power over or dominate, but rather helps” (p. 12). Moreover, we also assessed that staff is also responsible in stigmatizing patients which is one of the cause of low self-esteem and they have lack of awareness about how to deal with mentally ill clients. Therefore, we made teaching plan. We had also included role of a nurse as therapist, care giver and medication nurse. They participated well during teaching and shared their experiences. We faced lots of problems in delivering teaching because there were some timing issues and availability of staff. Unfortunately, evaluation was not done because of time constraint and availability of staff due to rounds and their other obligations. We could have taught health care professionals to develop social support groups for mentally ill clients but we were not able to make support groups due to some limitations, and we didn’t want to impose our practices on them. But at least we had tried to deliver message to them.

My own thinking and feeling regarding my patient is that I was not able to spent lot of time with her and interact with family but I tried to do every possible effort to strengthen her self-esteem. I felt helpless whenever she verbalized about her father and family. I observed that staff usually scolds her even though if she has not done anything which made me very upset. On termination day, when my faculty told me to stay away from her as she is getting dependent on me, this was very upsetting situation. I have learned after studying this concept that low self-esteem creates a great impact on person’s life. We as a nurse sometimes unintentionally stigmatized these patients but never realize that this could worsen anyone’s situation and leads to the feeling of low self-esteem. We always take prompt action for physical illness but forget to take action in promoting mental health. Therefore, if I will get chance to care as mental health nurse, I will work collaboratively and plan as much as intervention for them to promote mental health.

Low self esteem is associated with many mental health problems including schizophrenia and other psychotic disorders in which it is often common and pervasive. Self-esteem results from the interaction between self evaluation and social feedback but from the perspective of social stigma, loss of loved one, negative self and family interaction can be unfavorable to self-esteem. Studies also emphasize the importance of motivation and self esteem as predictive factors for achievement, maintenance of adaptive coping strategies and promoting mental health.