low self esteem essay pdf

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Article Contents

Introduction, identity development and the sources of negative self-esteem, outcomes of poor self-esteem, mechanisms linking self-esteem and health behavior, examples of school health promotion programs that foster self-esteem, self-esteem in a broad-spectrum approach for mental health promotion.

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Michal (Michelle) Mann, Clemens M. H. Hosman, Herman P. Schaalma, Nanne K. de Vries, Self-esteem in a broad-spectrum approach for mental health promotion, Health Education Research , Volume 19, Issue 4, August 2004, Pages 357–372, https://doi.org/10.1093/her/cyg041

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Self-evaluation is crucial to mental and social well-being. It influences aspirations, personal goals and interaction with others. This paper stresses the importance of self-esteem as a protective factor and a non-specific risk factor in physical and mental health. Evidence is presented illustrating that self-esteem can lead to better health and social behavior, and that poor self-esteem is associated with a broad range of mental disorders and social problems, both internalizing problems (e.g. depression, suicidal tendencies, eating disorders and anxiety) and externalizing problems (e.g. violence and substance abuse). We discuss the dynamics of self-esteem in these relations. It is argued that an understanding of the development of self-esteem, its outcomes, and its active protection and promotion are critical to the improvement of both mental and physical health. The consequences for theory development, program development and health education research are addressed. Focusing on self-esteem is considered a core element of mental health promotion and a fruitful basis for a broad-spectrum approach.

The most basic task for one's mental, emotional and social health, which begins in infancy and continues until one dies, is the construction of his/her positive self-esteem. [( Macdonald, 1994 ), p. 19]

Self-concept is defined as the sum of an individual's beliefs and knowledge about his/her personal attributes and qualities. It is classed as a cognitive schema that organizes abstract and concrete views about the self, and controls the processing of self-relevant information ( Markus, 1977 ; Kihlstrom and Cantor, 1983 ). Other concepts, such as self-image and self-perception, are equivalents to self-concept. Self-esteem is the evaluative and affective dimension of the self-concept, and is considered as equivalent to self-regard, self-estimation and self-worth ( Harter, 1999 ). It refers to a person's global appraisal of his/her positive or negative value, based on the scores a person gives him/herself in different roles and domains of life ( Rogers, 1981 ; Markus and Nurius, 1986 ). Positive self-esteem is not only seen as a basic feature of mental health, but also as a protective factor that contributes to better health and positive social behavior through its role as a buffer against the impact of negative influences. It is seen to actively promote healthy functioning as reflected in life aspects such as achievements, success, satisfaction, and the ability to cope with diseases like cancer and heart disease. Conversely, an unstable self-concept and poor self-esteem can play a critical role in the development of an array of mental disorders and social problems, such as depression, anorexia nervosa, bulimia, anxiety, violence, substance abuse and high-risk behaviors. These conditions not only result in a high degree of personal suffering, but also impose a considerable burden on society. As will be shown, prospective studies have highlighted low self-esteem as a risk factor and positive self-esteem as a protective factor. To summarize, self-esteem is considered as an influential factor both in physical and mental health, and therefore should be an important focus in health promotion; in particular, mental health promotion.

Health promotion refers to the process of enabling people to increase control over and improve their own health ( WHO, 1986 ). Subjective control as well as subjective health, each aspects of the self, are considered as significant elements of the health concept. Recognizing the existence of different views on the concept of mental health promotion, Sartorius (Sartorius, 1998), the former WHO Director of Mental Health, preferred to define it as a means by which individuals, groups or large populations can enhance their competence, self-esteem and sense of well-being. This view is supported by Tudor (Tudor, 1996) in his monograph on mental health promotion, where he presents self-concept and self-esteem as two of the core elements of mental health, and therefore as an important focus of mental health promotion.

This article aims to clarify how self-esteem is related to physical and mental health, both empirically and theoretically, and to offer arguments for enhancing self-esteem and self-concept as a major aspect of health promotion, mental health promotion and a ‘Broad-Spectrum Approach’ (BSA) in prevention.

The first section presents a review of the empirical evidence on the consequences of high and low self-esteem in the domains of mental health, health and social outcomes. The section also addresses the bi-directional nature of the relationship between self-esteem and mental health. The second section discusses the role of self-esteem in health promotion from a theoretical perspective. How are differentiations within the self-concept related to self-esteem and mental health? How does self-esteem relate to the currently prevailing theories in the field of health promotion and prevention? What are the mechanisms that link self-esteem to health and social outcomes? Several theories used in health promotion or prevention offer insight into such mechanisms. We discuss the role of positive self-esteem as a protective factor in the context of stressors, the developmental role of negative self-esteem in mental and social problems, and the role of self-esteem in models of health behavior. Finally, implications for designing a health-promotion strategy that could generate broad-spectrum outcomes through addressing common risk factors such as self-esteem are discussed. In this context, schools are considered an ideal setting for such broad-spectrum interventions. Some examples are offered of school programs that have successfully contributed to the enhancement of self-esteem, and the prevention of mental and social problems.

Self-esteem and mental well-being

Empirical studies over the last 15 years indicate that self-esteem is an important psychological factor contributing to health and quality of life ( Evans, 1997 ). Recently, several studies have shown that subjective well-being significantly correlates with high self-esteem, and that self-esteem shares significant variance in both mental well-being and happiness ( Zimmerman, 2000 ). Self-esteem has been found to be the most dominant and powerful predictor of happiness ( Furnham and Cheng, 2000 ). Indeed, while low self-esteem leads to maladjustment, positive self-esteem, internal standards and aspirations actively seem to contribute to ‘well-being’ ( Garmezy, 1984 ; Glick and Zigler, 1992 ). According to Tudor (Tudor, 1996), self-concept, identity and self-esteem are among the key elements of mental health.

Self-esteem, academic achievements and job satisfaction

The relationship between self-esteem and academic achievement is reported in a large number of studies ( Marsh and Yeung, 1997 ; Filozof et al. , 1998 ; Hay et al. , 1998 ). In the critical childhood years, positive feelings of self-esteem have been shown to increase children's confidence and success at school ( Coopersmith, 1967 ), with positive self-esteem being a predicting factor for academic success, e.g. reading ability ( Markus and Nurius, 1986 ). Results of a longitudinal study among elementary school children indicate that children with high self-esteem have higher cognitive aptitudes ( Adams, 1996 ). Furthermore, research has revealed that core self-evaluations measured in childhood and in early adulthood are linked to job satisfaction in middle age ( Judge et al. , 2000 ).

Self-esteem and coping with stress in combination with coping with physical disease

The protective nature of self-esteem is particularly evident in studies examining stress and/or physical disease in which self-esteem is shown to safeguard the individual from fear and uncertainty. This is reflected in observations of chronically ill individuals. It has been found that a greater feeling of mastery, efficacy and high self-esteem, in combination with having a partner and many close relationships, all have direct protective effects on the development of depressive symptoms in the chronically ill ( Penninx et al. , 1998 ). Self-esteem has also been shown to enhance an individual's ability to cope with disease and post-operative survival. Research on pre-transplant psychological variables and survival after bone marrow transplantation ( Broers et al. , 1998 ) indicates that high self-esteem prior to surgery is related to longer survival. Chang and Mackenzie ( Chang and Mackenzie, 1998 ) found that the level of self-esteem was a consistent factor in the prediction of the functional outcome of a patient after a stroke.

To conclude, positive self-esteem is associated with mental well-being, adjustment, happiness, success and satisfaction. It is also associated with recovery after severe diseases.

The evolving nature of self-esteem was conceptualized by Erikson ( Erikson, 1968 ) in his theory on the stages of psychosocial development in children, adolescents and adults. According to Erikson, individuals are occupied with their self-esteem and self-concept as long as the process of crystallization of identity continues. If this process is not negotiated successfully, the individual remains confused, not knowing who (s)he really is. Identity problems, such as unclear identity, diffused identity and foreclosure (an identity status based on whether or not adolescents made firm commitments in life. Persons classified as ‘foreclosed’ have made future commitments without ever experiencing the ‘crises’ of deciding what really suits them best), together with low self-esteem, can be the cause and the core of many mental and social problems ( Marcia et al. , 1993 ).

The development of self-esteem during childhood and adolescence depends on a wide variety of intra-individual and social factors. Approval and support, especially from parents and peers, and self-perceived competence in domains of importance are the main determinants of self-esteem [for a review, see ( Harter, 1999 )]. Attachment and unconditional parental support are critical during the phases of self-development. This is a reciprocal process, as individuals with positive self-esteem can better internalize the positive view of significant others. For instance, in their prospective study among young adolescents, Garber and Flynn ( Garber and Flynn, 2001 ) found that negative self-worth develops as an outcome of low maternal acceptance, a maternal history of depression and exposure to negative interpersonal contexts, such as negative parenting practices, early history of child maltreatment, negative feedback from significant others on one's competence, and family discord and disruption.

Other sources of negative self-esteem are discrepancies between competing aspects of the self, such as between the ideal and the real self, especially in domains of importance. The larger the discrepancy between the value a child assigns to a certain competence area and the perceived self-competence in that area, the lower the feeling of self-esteem ( Harter, 1999 ). Furthermore, discrepancies can exist between the self as seen by oneself and the self as seen by significant others. As implied by Harter ( Harter, 1999 ), this could refer to contrasts that might exist between self-perceived competencies and the lack of approval or support by parents or peers.

Finally, negative and positive feelings of self-worth could be the result of a cognitive, inferential process, in which children observe and evaluate their own behaviors and competencies in specific domains (self-efficacy). The poorer they evaluate their competencies, especially in comparison to those of their peers or to the standards of significant others, the more negative their self-esteem. Such self-monitoring processes can be negatively or positively biased by a learned tendency to negative or positive thinking ( Seligman et al. , 1995 ).

The outcomes of negative self-esteem can be manifold. Poor self-esteem can result in a cascade of diminishing self-appreciation, creating self-defeating attitudes, psychiatric vulnerability, social problems or risk behaviors. The empirical literature highlights the negative outcomes of low self-esteem. However, in several studies there is a lack of clarity regarding causal relations between self-esteem and problems or disorders ( Flay and Ordway, 2001 ). This is an important observation, as there is reason to believe that self-esteem should be examined not only as a cause, but also as a consequence of problem behavior. For example, on the one hand, children could have a negative view about themselves and that might lead to depressive feelings. On the other hand, depression or lack of efficient functioning could lead to feeling bad, which might decrease self-esteem. Although the directionality can work both ways, this article concentrates on the evidence for self-esteem as a potential risk factor for mental and social outcomes. Three clusters of outcomes can be differentiated. The first are mental disorders with internalizing characteristics, such as depression, eating disorders and anxiety. The second are poor social outcomes with externalizing characteristics including aggressive behavior, violence and educational exclusion. The third is risky health behavior such as drug abuse and not using condoms.

Self-esteem and internalizing mental disorders

Self-esteem plays a significant role in the development of a variety of mental disorders. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM IV), negative or unstable self-perceptions are a key component in the diagnostic criteria of major depressive disorders, manic and hypomanic episodes, dysthymic disorders, dissociative disorders, anorexia nervosa, bulimia nervosa, and in personality disorders, such as borderline, narcissistic and avoidant behavior. Negative self-esteem is also found to be a risk factor, leading to maladjustment and even escapism. Lacking trust in themselves, individuals become unable to handle daily problems which, in turn, reduces the ability to achieve maximum potential. This could lead to an alarming deterioration in physical and mental well-being. A decline in mental health could result in internalizing problem behavior such as depression, anxiety and eating disorders. The outcomes of low self-esteem for these disorders are elaborated below.

Depressed moods, depression and suicidal tendencies

The clinical literature suggests that low self-esteem is related to depressed moods ( Patterson and Capaldi, 1992 ), depressive disorders ( Rice et al. , 1998 ; Dori and Overholser, 1999 ), hopelessness, suicidal tendencies and attempted suicide ( Overholser et al. , 1995 ). Correlational studies have consistently shown a significant negative relationship between self-esteem and depression ( Beck et al. , 1990 ; Patton, 1991 ). Campbell et al. ( Campbell et al. , 1991 ) found individual appraisal of events to be clearly related to their self-esteem. Low self-esteem subjects rated their daily events as less positive and negative life events as being more personally important than high self-esteem subjects. Individuals with high self-esteem made more stable and global internal attributions for positive events than for negative events, leading to the reinforcement of their positive self-image. Subjects low in self-esteem, however, were more likely to associate negative events to stable and global internal attributions, and positive events to external factors and luck ( Campbell et al. , 1991 ). There is a growing body of evidence that individuals with low self-esteem more often report a depressed state, and that there is a link between dimensions of attributional style, self-esteem and depression ( Abramson et al. , 1989 ; Hammen and Goodman-Brown, 1990 ).

Some indications of the causal role of self-esteem result from prospective studies. In longitudinal studies, low self-esteem during childhood ( Reinherz et al. , 1993 ), adolescence ( Teri, 1982 ) and early adulthood ( Wilhelm et al. , 1999 ) was identified as a crucial predictor of depression later in life. Shin ( Shin, 1993 ) found that when cumulative stress, social support and self-esteem were introduced subsequently in regression analysis, of the latter two, only self-esteem accounted for significant additional variance in depression. In addition, Brown et al. ( Brown et al. , 1990 ) showed that positive self-esteem, although closely associated with inadequate social support, plays a role as a buffer factor. There appears to be a pathway from not living up to personal standards, to low self-esteem and to being depressed ( Harter, 1986 , 1990 ; Higgins, 1987 , 1989 ; Baumeister, 1990 ). Alternatively, another study indicated that when examining the role of life events and difficulties, it was found that total level of stress interacted with low self-esteem in predicting depression, whereas self-esteem alone made no direct contribution ( Miller et al. , 1989 ). To conclude, results of cross-sectional and longitudinal studies have shown that low self-esteem is predictive of depression.

The potentially detrimental impact of low self-esteem in depressive disorders stresses the significance of Seligman's recent work on ‘positive psychology’. His research indicates that teaching children to challenge their pessimistic thoughts whilst increasing positive subjective thinking (and bolstering self-esteem) can reduce the risk of pathologies such as depression ( Seligman, 1995 ; Seligman et al. , 1995 ; Seligman and Csikszentmihalyi, 2000 ).

Other internalizing disorders

Although low self-esteem is most frequently associated with depression, a relationship has also been found with other internalizing disorders, such as anxiety and eating disorders. Research results indicate that self-esteem is inversely correlated with anxiety and other signs of psychological and physical distress ( Beck et al. , 2001 ). For example, Ginsburg et al. ( Ginsburg et al. , 1998 ) observed a low level of self-esteem in highly socially anxious children. Self-esteem was shown to serve the fundamental psychological function of buffering anxiety, with the pursuit of self-esteem as a defensive avoidance tool against basic human fears. This mechanism of defense has become evident in research with primary ( Ginsburg et al. , 1998 ) and secondary school children ( Fickova, 1999 ). In addition, empirical studies have shown that bolstering self-esteem in adults reduces anxiety ( Solomon et al. , 2000 ).

The critical role of self-esteem during school years is clearly reflected in studies on eating disorders. At this stage in life, weight, body shape and dieting behavior become intertwined with identity. Researchers have reported low self-esteem as a risk factor in the development of eating disorders in female school children and adolescents ( Fisher et al. , 1994 ; Smolak et al. , 1996 ; Shisslak et al. , 1998 ), as did prospective studies ( Vohs et al. , 2001 ). Low self-esteem also seems predictive of the poor outcome of treatment in such disorders, as has been found in a recent 4-year prospective follow-up study among adolescent in-patients with bulimic characteristics ( van der Ham et al. , 1998 ). The significant influence of self-esteem on body image has led to programs in which the promotion of self-esteem is used as a main preventive tool in eating disorders ( St Jeor, 1993 ; Vickers, 1993 ; Scarano et al. , 1994 ).

To sum up, there is a systematic relation between self-esteem and internalizing problem behavior. Moreover, there is enough prospective evidence to suggest that poor self-esteem might contribute to deterioration of internalizing problem behavior while improvement of self-esteem could prevent such deterioration.

Self-esteem, externalizing problems and other poor social outcomes

For more than two decades, scientists have studied the relationship between self-esteem and externalizing problem behaviors, such as aggression, violence, youth delinquency and dropping out of school. The outcomes of self-esteem for these disorders are described below.

Violence and aggressive behavior

While the causes of such behaviors are multiple and complex, many researchers have identified self-esteem as a critical factor in crime prevention, rehabilitation and behavioral change ( Kressly, 1994 ; Gilbert, 1995 ). In a recent longitudinal questionnaire study among high-school adolescents, low self-esteem was one of the key risk factors for problem behavior ( Jessor et al. , 1998 ).

Recent studies confirm that high self-esteem is significantly associated with less violence ( Fleming et al. , 1999 ; Horowitz, 1999 ), while a lack of self-esteem significantly increases the risk of violence and gang membership ( Schoen, 1999 ). Results of a nationwide study of bullying behavior in Ireland show that children who were involved in bullying as either bullies, victims or both had significantly lower self-esteem than other children ( Schoen, 1999 ). Adolescents with low self-esteem were found to be more vulnerable to delinquent behavior. Interestingly, delinquency was positively associated with inflated self-esteem among these adolescents after performing delinquent behavior ( Schoen, 1999 ). According to Kaplan's self-derogation theory of delinquency (Kaplan, 1975), involvement in delinquent behavior with delinquent peers can increase children's self-esteem and sense of belonging. It was also found that individuals with extremely high levels of self-esteem and narcissism show high tendencies to express anger and aggression ( Baumeister et al. , 2000 ). To conclude, positive self-esteem is associated with less aggressive behavior. Although most studies in the field of aggressive behavior, violence and delinquency are correlational, there is some prospective evidence that low self-esteem is a risk factor in the development of problem behavior. Interestingly, low self-esteem as well as high and inflated self-esteem are both associated with the development of aggressive symptoms.

School dropout

Dropping out from the educational system could also reflect rebellion or antisocial behavior resulting from identity diffusion (an identity status based on whether or not adolescents made firm commitments in life. Adolescents classified as ‘diffuse’ have not yet thought about identity issues or, having thought about them, have failed to make any firm future oriented commitments). For instance, Muha ( Muha, 1991 ) has shown that while self-image and self-esteem contribute to competent functioning in childhood and adolescence, low self-esteem can lead to problems in social functioning and school dropout. The social consequences of such problem behaviors may be considerable for both the individual and the wider community. Several prevention programs have reduced the dropout rate of students at risk ( Alice, 1993 ; Andrews, 1999 ). All these programs emphasize self-esteem as a crucial element in dropout prevention.

Self-esteem and risk behavior

The impact of self-esteem is also evident in risk behavior and physical health. In a longitudinal study, Rouse ( Rouse, 1998 ) observed that resilient adolescents had higher self-esteem than their non-resilient peers and that they were less likely to initiate a variety of risk behaviors. Positive self-esteem is considered as a protective factor against substance abuse. Adolescents with more positive self-concepts are less likely to use alcohol or drugs ( Carvajal et al. , 1998 ), while those suffering with low self-esteem are at a higher risk for drug and alcohol abuse, and tobacco use ( Crump et al. , 1997 ; Jones and Heaven, 1998 ). Carvajal et al. ( Carvajal et al. , 1998 ) showed that optimism, hope and positive self-esteem are determinants of avoiding substance abuse by adolescents, mediated by attitudes, perceived norms and perceived behavioral control. Although many studies support the finding that improving self-esteem is an important component of substance abuse prevention ( Devlin, 1995 ; Rodney et al. , 1996 ), some studies found no support for the association between self-esteem and heavy alcohol use ( Poikolainen et al. , 2001 ).

Empirical evidence suggests that positive self-esteem can also lead to behavior which is protective against contracting AIDS, while low self-esteem contributes to vulnerability to HIV/AIDS ( Rolf and Johnson, 1992 ; Somali et al. , 2001 ). The risk level increases in cases where subjects have low self-esteem and where their behavior reflects efforts to be accepted by others or to gain attention, either positively or negatively ( Reston, 1991 ). Lower self-esteem was also related to sexual risk-taking and needle sharing among homeless ethnic-minority women recovering from drug addiction ( Nyamathi, 1991 ). Abel ( Abel, 1998 ) observed that single females whose partners did not use condoms had lower self-esteem than single females whose partners did use condoms. In a study of gay and/or bisexual men, low self-esteem proved to be one of the factors that made it difficult to reduce sexual risk behavior ( Paul et al. , 1993 ).

To summarize, the literature reveals a number of studies showing beneficial outcomes of positive self-esteem, and conversely, negative outcomes of poor self-esteem, especially in adolescents. Prospective studies and intervention studies have shown that self-esteem can be a causal factor in depression, anxiety, eating disorders, delinquency, school dropout, risk behavior, social functioning, academic success and satisfaction. However, the cross-sectional character of many other studies does not exclude that low self-esteem can also be considered as an important consequence of such disorders and behavioral problems.

To assess the implications of these findings for mental health promotion and preventive interventions, more insight is needed into the antecedents of poor self-esteem, and the mechanisms that link self-esteem to mental, physical and social outcomes.

What are the mechanisms that link self-esteem to health and social outcomes? Several theories used in health promotion or prevention offer insight into such mechanisms. In this section we discuss the role of positive self-esteem as a protective factor in the context of stressors, the developmental role of negative self-esteem in mental and social problems, and the role of self-esteem in models of health behavior.

Positive thinking about oneself as a protective factor in the context of stressors

People have a need to think positively about themselves, to defend and to improve their positive self-esteem, and even to overestimate themselves. Self-esteem represents a motivational force that influences perceptions and coping behavior. In the context of negative messages and stressors, positive self-esteem can have various protective functions.

Research on optimism confirms that a somewhat exaggerated sense of self-worth facilitates mastery, leading to better mental health ( Seligman, 1995 ). Evidence suggests that positive self-evaluations, exaggerated perception of control or mastery and unrealistic optimism are all characteristic of normal human thought, and that certain delusions may contribute to mental health and well-being ( Taylor and Brown, 1988 ). The mentally healthy person appears to have the capacity to distort reality in a direction that protects and enhances self-esteem. Conversely, individuals who are moderately depressed or low in self-esteem consistently display an absence of such enhancing delusions. Self-esteem could thus be said to serve as a defense mechanism that promotes well-being by protecting internal balance. Jahoda ( Jahoda, 1958 ) also included the ‘adequate perception of reality’ as a basic element of mental health. The degree of such a defense, however, has its limitations. The beneficial effect witnessed in reasonably well-balanced individuals becomes invalid in cases of extreme self-esteem and significant distortions of the self-concept. Seligman ( Seligman, 1995 ) claimed that optimism should not be based on unrealistic or heavily biased perceptions.

Viewing yourself positively can also be regarded as a very important psychological resource for coping. We include in this category those general and specific beliefs that serve as a basis for hope and that sustain coping efforts in the face of the most adverse condition… Hope can exist only when such beliefs make a positive outcome seem possible, if not probable. [( Lazarus and Folkman, 1984 ), p. 159]

Incidence = organic causes and stressors/competence, coping skills, self-esteem and social support

Identity, self-esteem, and the development of externalizing and internalizing problems

Erikson's ( Erikson, 1965 , 1968 ) theory on the stages of psychosocial development in children, adolescents, and adults and Herbert's flow chart ( Herbert, 1987 ) focus on the vicissitudes of identity and the development of unhealthy mental and social problems. According to these theories, when a person is enduringly confused about his/her own identity, he/she may possess an inherent lack of self-reassurance which results in either a low level of self-esteem or in unstable self-esteem and feelings of insecurity. However, low self-esteem—likewise inflated self-esteem—can also lead to identity problems. Under circumstances of insecurity and low self-esteem, the individual evolves in one of two ways: he/she takes the active escape route or the passive avoidance route ( Herbert, 1987 ). The escape route is associated with externalizing behaviors: aggressive behavior, violence and school dropout, the seeking of reassurance in others through high-risk behavior, premature relationships, cults or gangs. Reassurance and security may also be sought through drugs, alcohol or food. The passive avoidance route is associated with internalizing factors: feelings of despair and depression. Extreme avoidance may even result in suicidal behavior.

Whether identity and self-esteem problems express themselves following the externalizing active escape route or the internalizing passive avoidance route is dependent on personality characteristics and circumstances, life events and social antecedents (e.g. gender and parental support) ( Hebert, 1987 ). Recent studies consistently show gender differences regarding externalizing and internalizing behaviors among others in a context of low self-esteem ( Block and Gjerde, 1986 ; Rolf et al. , 1990 ; Harter, 1999 ; Benjet and Hernandez-Guzman, 2001 ). Girls are more likely to have internalizing symptoms than boys; boys are more likely to have externalizing symptoms. Moreover, according to Harter ( Harter, 1999 ), in recent studies girls appear to be better than boys in positive self-evaluation in the domain of behavioral conduct. Self-perceived behavioral conduct is assessed as the individual view on how well behaved he/she is and how he/she views his/her behavior in accordance with social expectations ( Harter, 1999 ). Negative self-perceived behavioral conduct is also found to be an important factor in mediating externalizing problems ( Reda-Norton, 1995 ; Hoffman, 1999 ).

The internalization of parental approval or disapproval is critical during childhood and adolescence. Studies have identified parents' and peers' supportive reactions (e.g. involvement, positive reinforcement, and acceptance) as crucial determinants of children's self-esteem and adjustment ( Shadmon, 1998 ). In contrast to secure, harmonious parent–child relationships, poor family relationships are associated with internalizing problems and depression ( Kashubeck and Christensen, 1993 ; Oliver and Paull, 1995 ).

Self-esteem in health behavior models

Self-esteem also plays a role in current cognitive models of health behavior. Health education research based on the Theory of Planned Behavior ( Ajzen, 1991 ) has confirmed the role of self-efficacy as a behavioral determinant ( Godin and Kok, 1996 ). Self-efficacy refers to the subjective evaluation of control over a specific behavior. While self-concepts and their evaluations could be related to specific behavioral domains, self-esteem is usually defined as a more generic attitude towards the self. One can have high self-efficacy for a specific task or behavior, while one has a negative evaluation of self-worth and vice versa. Nevertheless, both concepts are frequently intertwined since people often try to develop self-efficacy in activities that give them self-worth ( Strecher et al. , 1986 ). Self-efficacy and self-esteem are therefore not identical, but nevertheless related. The development of self-efficacy in behavioral domains of importance can contribute to positive self-esteem. On the other hand, the levels of self-esteem and self-confidence can influence self-efficacy, as is assumed in stress and coping theories.

The Attitude–Social influence–self-Efficacy (ASE) model ( De Vries and Mudde, 1998 ; De Vries et al. , 1988a ) and the Theory of Triadic Influence (TTI) ( Flay and Petraitis, 1994 ) are recent theories that provide a broad perspective on health behavior. These theories include distal factors that influence proximal behavioral determinants ( De Vries et al. , 1998b ) and specify more distal streams of influence for each of the three core determinants in the Planned Behavior Model ( Azjen, 1991 ) (attitudes, self-efficacy and social normative beliefs). Each of these behavioral determinants is assumed to be moderated by several distal factors, including self-esteem and mental disorders.

The TTI regards self-esteem in the same sense as the ASE, as a distal factor. According to this theory, self-efficacy is influenced by personality characteristics, especially the ‘sense of self’, which includes self-integration, self-image and self-esteem ( Flay and Petraitis, 1994 ).

The Precede–Proceed model of Green and Kreuter (Green and Kreuter, 1991) for the planning of health education and health promotion also recognizes the role of self-esteem. The model directs health educators to specify characteristics of health problems, and to take multiple determinants of health and health-related behavior into account. It integrates an epidemiological, behavioral and environmental approach. The staged Precede–Proceed framework supports health educators in identifying and influencing the multiple factors that shape health status, and evaluating the changes produced by interventions. Self-esteem plays a role in the first and fourth phase of the Precede–Proceed model, as an outcome variable and as a determinant. The initial phase of social diagnosis, analyses the quality of life of the target population. Green and Kreuter [(Green and Kreuter, 1991), p. 27] present self-esteem as one of the outcomes of health behavior and health status, and as a quality of life indicator. The fourth phase of the model, which concerns the educational and organizational diagnosis, describes three clusters of behavioral determinants: predisposing, enabling and reinforcing factors. Predisposing factors provide the rationale or motivation for behavior, such as knowledge, attitudes, beliefs, values, and perceived needs and abilities [(Green and Kreuter, 1991), p. 154]. Self-knowledge, general self-appraisal and self-efficacy are considered as predisposing factors.

To summarize, self-esteem can function both as a determinant and as an outcome of healthy behavior within health behavior models. Poor self-esteem can trigger poor coping behavior or risk behavior that subsequently increases the likelihood of certain diseases among which are mental disorders. On the other hand, the presence of poor coping behavior and ill-health can generate or reinforce a negative self-image.

Self-esteem in a BSA to mental health promotion and prevention in schools

Given the evidence supporting the role of self-esteem as a core element in physical and mental health, it is recommended that its potential in future health promotion and prevention programs be reconsidered.

The design of future policies for mental health promotion and the prevention of mental disorders is currently an area of active debate ( Hosman, 2000 ). A key question in the discussion is which is more effective: a preventive approach focusing on specific disorders or a more generic preventive approach?

Based on the evidence supporting the role of self-esteem as a non-specific risk factor and protective factor in the development of mental disorders and social problems, we advocate a generic preventive approach built around the ‘self’. In general, changing common risk and protective factors (e.g. self-esteem, coping skills, social support) and adopting a generic preventive approach can reduce the risk of the development of a range of mental disorders and promote individual well-being even before the onset of a specific problem has presented itself. Given its multi-outcome perspective, we have termed this strategy the ‘BSA’ in prevention and promotion.

Self-esteem is considered one of the important elements of the BSA. By fostering self-esteem, and hence treating a common risk factor, it is possible to contribute to the prevention of an array of physical diseases, mental disorders and social problems challenging society today. This may also, at a later date, imply the prevention of a shift to other problem behaviors or symptoms which might occur when only problem-specific risk factors are addressed. For example, an eating disorder could be replaced by another type of symptom, such as alcohol abuse, smoking, social anxiety or depression, when only the eating behavior itself is addressed and not more basic causes, such as poor self-esteem, high stress levels and lack of social support. Although there is, as yet, no published research on such a shift phenomenon, the high level of co-morbidity between such problems might reflect the likelihood of its existence. Numerous studies support the idea of co-morbidity and showed that many mental disorders have overlapping associated risk factors such as self-esteem. There is a significant degree of co-morbidity between and within internalizing and externalizing problem behaviors such as depression, anxiety, substance disorders and delinquency ( Harrington et al. , 1996 ; Angold et al. , 1999 ; Swendsen and Merikangas, 2000 ). By considering the individual as a whole, within the BSA, the risk of such an eventuality could be reduced.

The BSA could have practical implications. Schools are an ideal setting for implementing BSA programs, thereby aiming at preventing an array of problems, since they cover the entire population. They have the means and responsibility for the promotion of healthy behavior for such a common risk and protective factor, since school children are in their formative stage. A mental health promotion curriculum oriented towards emotional and social learning could include a focus on enhancing self-esteem. Weare ( Weare, 2000 ) stressed that schools need to aim at helping children develop a healthy sense of self-esteem as part of the development of their ‘intra-personal intelligence’. According to Gardner (Gardner, 1993) ‘intra-personal intelligence’ is the ability to form an accurate model of oneself and the ability to use it to operate effectively in life. Self-esteem, then, is an important component of this ability. Serious thought should be given to the practical implementation of these ideas.

It is important to clearly define the nature of a BSA program designed to foster self-esteem within the school setting. In our opinion, such a program should include important determinants of self-esteem, i.e. competence and social support.

Harter ( Harter, 1999 ) stated that competence and social support, together provide a powerful explanation of the level of self-esteem. According to Harter's research on self-perceived competence, every child experiences some discrepancy between what he/she would like to be, the ‘ideal self’, and his/her actual perception of him/herself, ‘the real self’. When this discrepancy is large and it deals with a personally relevant domain, this will result in lower self-esteem. Moreover, the overall sense of support of significant others (especially parents, peers and teachers) is also influential for the development of self-esteem. Children who feel that others accept them, and are unconditionally loved and respected, will report a higher sense of self-esteem ( Bee, 2000 ). Thus, children with a high discrepancy and a low sense of social support reported the lowest sense of self-esteem. These results suggest that efforts to improve self-esteem in children require both supportive social surroundings and the formation and acceptance of realistic personal goals in the personally relevant domains ( Harter, 1999 ).

In addition to determinants such as competence and social support, we need to translate the theoretical knowledge on coping with inner self-processes (e.g. inconsistencies between the real and ideal self) into practice, in order to perform a systematic intervention regarding the self. Harter's work offers an important foundation for this. Based on her own and others' research on the development of the self, she suggests the following principles to prevent the development of negative self-esteem and to enhance self-worth ( Harter, 1999 ):

Reduction of the discrepancy between the real self and the ideal self.

Encouragement of relatively realistic self-perceptions.

Encouraging the belief that positive self-evaluations can be achieved.

Appreciation for the individual's views about their self-esteem and individual perceptions on causes and consequences of self-worth.

Increasing awareness of the origins of negative self-perceptions.

Providing a more integrated personal construct while improving understanding of self-contradictions.

Encouraging the individual and his/her significant others to promote the social support they give and receive.

Fostering internalization of positive opinions of others.

Haney and Durlak ( Haney and Durlak, 1998 ) wrote a meta-analytical review of 116 intervention studies for children and adolescents. Most studies indicated significant improvement in children's and adolescents' self-esteem and self-concept, and as a result of this change, significant changes in behavioral, personality, and academic functioning. Haney and Durlak reported on the possible impact improved self-esteem had on the onset of social problems. However, their study did not offer an insight into the potential effect of enhanced self-esteem on mental disorders.

Several mental health-promoting school programs that have addressed self-esteem and the determinants of self-esteem in practice, were effective in the prevention of eating disorders ( O'Dea and Abraham, 2000 ), problem behavior ( Flay and Ordway, 2001 ), and the reduction of substance abuse, antisocial behavior and anxiety ( Short, 1998 ). We shall focus on the first two programs because these are universal programs, which focused on ‘mainstream’ school children. The prevention of eating disorders program ‘Everybody's Different’ ( O'Dea and Abraham, 2000 ) is aimed at female adolescents aged 11–14 years old. It was developed in response to the poor efficacy of conventional body-image education in improving body image and eating behavior. ‘Everybody's Different’ has adopted an alternative methodology built on an interactive, school-based, self-esteem approach and is designed to prevent the development of eating disorders by improving self-esteem. The program has significantly changed aspects of self-esteem, body satisfaction, social acceptance and physical appearance. Female students targeted by the intervention rated their physical appearance, as perceived by others, significantly higher than control-group students, and allowed their body weight to increase appropriately by refraining from weight-loss behavior seen in the control group. These findings were still evident after 12 months. This is one of the first controlled educational interventions that had successfully improved body image and produced long-term changes in the attitudes and self-image of young adolescents.

The ‘Positive Action Program’ ( Flay and Ordway, 2001 ) serves as a unique example of some BSA principles in practice. The program addresses the challenge of increasing self-esteem, reducing problem behavior and improving school performance. The types of problem behavior in question were delinquent behavior, ‘misdemeanors’ and objection to school rules ( Flay and Ordway, 2001 ). This program concentrates on self-concept and self-esteem, but also includes other risk and protective factors, such as positive actions, self-control, social skills and social support that could be considered as determinants of self-esteem. Other important determinants of self-esteem, such as coping with internal self-processes, are not addressed. At present, the literature does not provide many examples of BSA studies that produce general preventive effects among adolescents who do not (yet) display behavioral problems ( Greenberg et al. , 2000 ).

To conclude, research results show beneficial outcomes of positive self-esteem, which is seen to be associated with mental well-being, happiness, adjustment, success, academic achievements and satisfaction. It is also associated with better recovery after severe diseases. However, the evolving nature of self-esteem could also result in negative outcomes. For example, low self-esteem can be a causal factor in depression, anxiety, eating disorders, poor social functioning, school dropout and risk behavior. Interestingly, the cross-sectional characteristic of many studies does not exclude the possibility that low self-esteem can also be considered as an important consequence of such disorders and behavioral problems.

Self-esteem is an important risk and protective factor linked to a diversity of health and social outcomes. Therefore, self-esteem enhancement can serve as a key component in a BSA approach in prevention and health promotion. The design and implementation of mental health programs with self-esteem as one of the core variables is an important and promising development in health promotion.

The authors are grateful to Dr Alastair McElroy for his constructive comments on this paper. The authors wish to thank Rianne Kasander (MA) and Chantal Van Ree (MA) for their assistance in the literature search. Financing for this study was generously provided by the Dutch Health Research and Development Council (Zorg Onderzoek Nederland, ZON/MW).

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Author notes

1Department of Health Education and Promotion, Maastricht University, Maastricht and 2Prevention Research Center on Program Development and Effect Management, The Netherlands

• mental health
• self esteem

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The impact of low self-esteem on academic achievement and the behaviors related to it among medical students in Saudi Arabia

Saleh a. alghamdi.

From the Department of Clinical Neurosciences (Alghamdi), College of Medicine, from the College of Medicine (Alahmari,. Alasiri, Alkahtani, Alhudayris, Alhusaini), Imam Mohammad Ibn Saud Islamic University, and from Department of Psychiatry (Aljaffer), College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia.

Mohammed A. Aljaffer

Faisal s. alahmari, ahmed b. alasiri, abdullah h. alkahtani, fadhah s. alhudayris, bassam a. alhusaini, objectives:.

To measure the prevalence of low self-esteem among medical students in Saudi Arabia and determine its impact on their behaviors and academic achievement.

We hypothesized that the level of self-esteem reflected on the student’s academic performance and linked to some of their behaviors. A cross-sectional study was carried out among students of the medical colleges in Saudi Arabia. A self-administered questionnaire was distributed electronically using social media platforms, socio-demographic data, Rosenberg’s self-esteem scale, and a questionnaire about self-esteem-related behaviors.

Of 1099 participants (55.9% females and 50% males), 24.1% showed low self-esteem. Independent significant predictors of low self-esteem were female gender and diagnosis with mental illness. Increasing GPA was associated with better self-esteem. Participating in students’ study groups and attending self-development programs were estimated to be the protective factors against low self-esteem.

Conclusion:

One-quarter of medical students are assumed to have low self-esteem. Improved GPA ratings positively influence self-esteem, while attending students’ study groups and self-development programs were identified as protective factors for low self-esteem. Further studies are needed to shed more light on this important topic.

S elf-esteem is an individual’s sense of satisfaction with oneself and reflects the relationship between personal self-image and ideal self-image. 1 Self-esteem is a measure of self-assessment because it is considered the most important psychological formula. 2 Self-esteem has 2 types, specific and global. Global self-esteem is more relevant to the psychological aspect, while specific self-esteem (academic) is more relevant to behavior and is a tool for evaluating academic achievements. 3

Behaviors are defined as external changes or activities of living organisms that are functionally mediated by other external phenomena in the present moment. 4 Behaviors must be considered because people might have specific behaviors toward an object as a whole and toward specific facets of that object. Behaviors have both directions (such as positive or negative orientation) and intensity, as shown by the fact that behaviors are affected. 3

High self-esteem is the belief that one is worthy of privilege and admiration by others for being unique and special and possessing fantasies of brilliance and beauty. It is considered a heterogeneous category. High self-esteem is not entirely responsible for academic successes and achievements but rather is a result of these or a partial reason for those successes and helps to facilitate perseverance and diligence after failure. 5

Low self-esteem is the contradiction between the competitive aspects of the self, such as between the real and ideal selves. Also, between the self as seen by oneself and as seen by significant others, a person monitors and evaluates one’s behaviors and competencies to determine self-efficacy. This condition leads to psychosocial weakness and lack of self-confidence, creating problems and risky behaviors. 6 Low self-esteem is considered one of the risk factors for depression and anxiety, eating disorders, violence and educational exclusion, and drug abuse. 7 , 6

A student’s academic performance is measured by grade point average (GPA), high school graduation rate, annual standardized tests, and college entrance exams. A person’s achievement in school, college, or university indicates how well they performed in activities meant to help them achieve certain goals. School systems mostly define cognitive goals across multiple subject areas (such as critical thinking) or include the acquisition of knowledge and understanding in a specific intellectual domain (such as: numeracy, literacy, science, and history). 8

Many studies have shown the association between self-esteem and students’ academic achievement and how self-esteem is affected. One factor that can negatively impact self-esteem is the experience of imposter syndrome, characterized by feelings of inadequacy and a persistent fear of being exposed as a fraud, despite evidence of competence. 9 Locally, a study was carried out at King Saud University (KSU) to determine the prevalence of self-esteem and imposter syndrome among KSU medical students. 9 The study revealed prevalent low self-esteem and positive imposter syndrome in 23.6% and 42.1% of participants, respectively. 9 These findings suggest that imposter syndrome may be a significant barrier to academic success for a significant proportion of medical students at KSU, highlighting the importance of addressing this issue in educational settings. 9

A recent cross-sectional study carried out at Princess Nourah bint Abdulrahman University (PNU) in 2019 found that there is a weak relationship between self-esteem and academic achievement. 10 Another cross-sectional study carried out at Taif University and King Abdulaziz University determined that self-esteem showed a low but significant correlation with academic performance. 11

Globally, a study at Jimma University, Ethiopia, assessed the prevalence and associated factors of low self-esteem (LSE) and mental distress among medical students and showed that students with poor academic achievement were also more likely to have LSE. 12 Moreover, students’ self-esteem, self-efficacy, and academic performance were also assessed among students in the United Arab Emirates (UAE), 13 and found that academic achievement was associated with high academic self-efficacy. Another study in Pakistan in 2015 showed a significant relationship between self-esteem and academic performance. 13 , 14

A cross-sectional study was conducted from March 2022 to December 2022 among Saudi and non-Saudi medical students in 5 regions (North, South, East, West, and Central) of Saudi Arabia. Medical students who attended a government and private medical college in Saudi Arabia were recruited. Inclusion criteria included any current medical student, male or female, who studies in Saudi Arabia. At the same time, participants who were non-medical or medical students not studying in Saudi Arabia were excluded.

The sample size was estimated using the sample size formula, assuming that 50% would be the response distribution, 95% confidence level, and 5% margin of error, resulting in a sample size of 379. A convenience sampling technique was used. A self-administered questionnaire (online survey) including Rosenberg’s self-esteem scale questionnaires and behavior related to low self-esteem questionnaire was distributed electronically using social media platforms. Participation in this study was voluntary; each participant was notified to consent and was invited to participate. Participants did not earn a material income due to their participation as it would adhere to the tenets of the Declaration of Helsinki, 2013.

The questionnaire was divided into 3 categories. The first part inquired regarding the participant’s demographic data, the second part of information on academic performance (GPA) and self-esteem, and the last part of the questionnaire was regarding the participant’s behaviors dealing with low self-esteem. The self-esteem of the medical students and their related behaviors was assessed by using Rosenberg’s self-esteem scale 15 (10 items) and behavior related to low self-esteem questionnaire (26 items). Rosenberg’s self-esteem scale questionnaire contains a 4-point Likert scale ranging from “strongly disagree” coded as 0 to “strongly agree” coded as 3, while the behavior questionnaire has a category ranging from “strongly disagree” coded with 1 to “strongly agree” coded with 4.

A pilot study was carried out among 39 participants to determine the internal consistency of the study questionnaires. The Rosenberg’s self-esteem scale with ten items has a reliability result of 0.777 Cronbach Alpha (77.7%), indicating a generally good internal consistency. Compared with the behavior towards low self-esteem with 26 items, the reliability result was 0.905 Cronbach Alpha (90.5%), indicating excellent internal consistency. The overall reliability test was 0.841 Cronbach Alpha (84.1%), suggesting good internal consistency. Thus, the questionnaires were valid to be used in this study.

The study was approved by the Institutional Review Board approval at the Medical Research Unit, Faculty of Medicine, Al-Imam Mohammad ibn Saud Islamic University, Riyadh, Saudi Arabia. Participation in this study is completely voluntary; each participant is notified to consent and is invited to participate. Participants do not earn a material income due to their participation. Review Board at Al-Imam Mohammad ibn Saud Islamic University (Research Project No. 201/2022). All ethical considerations were taken into account. Informed consent was obtained.

Statistical analysis

The data were gathered, entered, and analyzed by the Statistical Packages for Software Sciences version 26 (IBMCorp, Armonk, NY, USA). Descriptive statistics were calculated and summarized as numbers, percentages, mean, and standard deviation. The differences in the level of self-esteem and behavior were analyzed using an independent sample t-test. A Chi-square test was also used to determine the relationship between the level of self-esteem and the socio-demographic characteristics of the medical students. Significant results were then tested in a multivariate regression model to determine the significant factor associated with low self-esteem with a corresponding odds ratio and a 95% confidence interval. A p -value of <0.05 (2-sided) was used to indicate statistical significance.

In total, 1,099 medical students were recruited. Half of them (50%) were aged between 21 to 23 years. Around 55.9% were females and mostly single (92.2%). Nearly all (89.4%) were studying in a government medical institution. Further, 33.4% were living in the Central region. Approximately 23.6% were in the 5th year of their studies, with 28.5% having GPA ratings between 4 to 4.49. The majority (73.2%) had a personal monthly income of 1,000 to 2,000 SAR. Participants who were living with family constituted 84.2%. The prevalence of smoking participants was 20.3%, while those with associated chronic diseases were 12.3%. In addition, the proportion of medical students who had been diagnosed with mental illness was 18.2%, and of them, the most commonly known mental illness was depression (46.5%) ( Table 1 ).

- Socio-demographic characteristics of the medical students (N=1099).

In the assessment of Rosenberg’s self-esteem scale, it was observed that the rating was higher in the statement “I feel that I have a number of good qualities” (mean score: 2.27), followed by “I am able to do things as well as most other people” (mean score: 2.20) and “I feel that I’m a person of worth” (mean score: 2.03). The total mean score for self-esteem was 17.9 (SD 5.38), with 67.2% classified as having normal self-esteem, 8.7% having high, and 24.1% having low self-esteem ( Table 2 ).

- Assessment of Rosenberg’s self-esteem scale questionnaire (n=1099).

Response has a range from “strongly disagree” coded with 0 to “strongly agree” coded with 3. † Score was reverse coded.

A low self-esteem level was more associated with a higher score in behaviors related to low self-esteem, such as self-injury behaviors ( p <0.001), suicidal behaviors ( p <0.001), procrastination ( p <0.001), avoiding certain situations or people ( p <0.001), quitting tasks partially ( p <0.001), rushing through work ( p <0.001), displaying an “I do not care” attitude ( p <0.001), trying to please others all the time ( p <0.001), acting angrily if mistakes are made ( p <0.001), being unable to say no ( p <0.001), frequently putting oneself down while speaking ( p <0.001), and attending self-development programs ( p <0.001) ( Table 3 ).

- Low self-esteem’s related behaviors (N=1099).

Response has a range from “strongly disagree” coded with 1 to “strongly agree” coded with 4. * P -value has been calculated using an independent sample t-test. **Significant at p <0.05 level.

When measuring the relationship between the level of self-esteem and the socio-demographic characteristics of the medical students, it was found that the prevalence of low self-esteem was significantly more common among the female gender ( p <0.001), GPA ratings of 4 to 4.49 ( p =0.039) and diagnosed with mental illness ( p <0.001) ( Table 4 ).

- Association between the level of self-esteem and the socio-demographic characteristics of the medical students (N=1099).

§ P -value has been calculated using Chi-square test, **significant at p <0.05 level.

In a multivariate regression model, it was observed that compared to males, the chance of having low self-esteem among females was predicted to increase by at least 1.8 times higher (AOR=1.851; 95% CI=1.365 – 2.511; p <0.001). Also, compared to medical students without the diagnosis of mental illness, the chance of having low self-esteem among those diagnosed with mental illness was predicted to increase by at least 1.9 fold higher (AOR=1.971; 95% CI=1.408–2.759; p <0.001). Further, compared to medical students with the lowest GPA ratings (GPA 2.99 or less), the chance of low esteem among students with GPA ratings between 3 to 3.99 was estimated to decrease by at least 70% (AOR=0.308; 95% CI=0.155 – 0.612; p =0.001), and by almost 40% in GPA ratings of 4 to 4.99 (AOR=0.574; 95% CI=0.365 – 0.894; p =0.014), but it did not reach statistical significance in GPA ratings between 4.75 to 5 ( p =0.173) ( Table 5 ).

- Multivariate regression analysis to determine the independent significant factor associated with low self-esteem (N=1099).

AOR:adjusted odds ratio, CI: confidence interval. **Significant at p <0.05 level.

This study evaluated the self-esteem of medical students, the behaviors related to it, and how academic performance affects self-esteem. The findings of this study revealed that nearly one-fourth (24.1%) of the medical students demonstrated low self-esteem, 67.2% were normal, and only 8.7% had high self-esteem; this was consistent with the study of Alsaleem et al. 9 According to their report, low self-esteem was found in 23.6% of the medical students, and this has been experienced mainly by students who were in the early years of the academic year levels, specifically females; this has been concurred by Gidi et al 12 wherein 19% of the medical students exhibited low self-esteem and 19.7% were distressed. Self-esteem would have been affected by medical students’ mental health conditions, which could lead to Low self-esteem. Thus, early intervention is imperative for those showing signs of low self-esteem. Coping strategies to boost student morale could be one of the most essential steps to improving learners’ self-esteem. Another study showed that students are at the edge of self-criticism and low self-esteem, to the extent that they do not even feel themselves capable of undertaking tasks within their abilities. 16 Furthermore, another study highlighted those medical students had high levels of distress for multiple reasons, and they exhibited low self-esteem. It was also found that nearly one out of 2 medical students suffered from burnout issues. 17 Another study carried out in China included 30,817 Chinese medical students and found that these medical students had a relatively low prevalence of eating disorders but a high prevalence of depression, anxiety, and suicidal ideation. 18

Female medical students who had been diagnosed with mental illness were the significant recipients who suffered from low self-esteem. Consistent with the present findings, a study carried out among health science students in Riyadh 10 reported that any students with an underlying disease were predicted to exhibit signs of low self-esteem and had more negative feelings than normal students. Another study carried out in Pakistan 14 revealed a significant difference in self-esteem scores between males and females, suggesting that male university students demonstrated higher self-esteem scores than female university students. In contrast, a study on Chinese medical students does not show significant differences among the genders. 18

A different study found that students who perform well academically may not necessarily have high subjective well-being levels. In fact, the study suggests that there may even be cases where high-achieving students have low levels of subjective well-being. 19 More investigations are warranted to establish the level of self-esteem in males and females with underlying diseases.

Several papers concluded that low self-esteem correlated to poor academic performance. For instance, Alyami et al 11 documented that there was a weak but significant correlation between self-esteem and academic performance along with self-efficacy. Studies conducted by Afari et al 13 and Correlating 20 found a positive association between global self-esteem and academic self-efficacy, while academic achievement might positively influence academic self-efficacy. Another study published by Hyseni Duraku and Hoxha 21 noted that a higher level of self-esteem was influenced by a student’s success. This is also true for the current study, as it was found that medical students’ increased academic GPA ratings were correlated with better self-esteem. However, a study published by Baumeister et al 5 clarified that the moderate links between school performance and self-esteem do not suggest that high self-esteem was due to good performance at school; instead, it is just partly the result of good school performance. Further, it was indicated that attempts to lift students’ self-esteem did not indicate increasing academic performance and might sometimes be the opposite. Similarly, another study revealed that increased academic performance was moderately and significantly associated with student engagement. 22

When measuring the possible behaviors related to self-esteem, it was also discovered that students who frequently attended a study group and self-development programs might have better self-esteem than the other students. In a study published by Mete, 24 among secondary-level science students, it was observed that positive coping and projective coping strategies were seen among students, while students shown to have non-coping strategies were predicted to impact self-efficacy negatively. However, the fear of losing one’s self-esteem negatively affected self-efficacy. In a review article published by Baumeister et al 5 they discovered that people with high self-esteem asserted themselves as more likable, more attractive, could have better relationships, and had a higher impression on others. However, objective measures contradicted these beliefs. Another study by Li J et al 24 showed that self-esteem is mediated by social support and improves emotional exhaustion and academic achievement.

Students in medical schools might be prone to adversities that affect their mental condition. Therefore, issues that affect their mental health should be discussed and addressed. Strategies to improve students’ self-esteem are vital in educational systems. Hence, the role of mental health services is imperative.

Although our study addresses an important topic that needs to be adequately studied in Saudi Arabia, it has certain limitations. The researchers developed the behavioral questionnaire; hence, it was not a well-established, standardized questionnaire. Additionally, the online questionnaire distribution usually bears a higher degree of selection bias. Moreover, generalizability was limited because the findings based on a survey included medical students residing exclusively in Saudi Arabia. In addition, the study tried to reveal the behaviors linked to low self-esteem among medical students without addressing the explanation of that behaviors. To overcome the following limitations, we recommend generating a standardized questionnaire that can be generalized to any country or center. Moreover, if additional studies are to be conducted regarding this topic, reporting the explanation of that behaviors can be beneficial to build more research on it.

In conclusion, one out of 4 medical students was assumed to have low self-esteem. Female medical students who had been diagnosed with mental illness were found to demonstrate low self-esteem more than others. Further, the improved GPA ratings positively influenced self-esteem, while positive behavior towards attending students’ study groups and self-developmental programs were identified as protective factors for low self-esteem. Low self-esteem is negatively affected by the mental condition of medical students. Hence, improved behavior among this group of students is vital to boost self-esteem in addition to periodic counseling. More research is needed to shed more light on the self-esteem of medical students, their behavior on it, and how it correlates to academic performance.

Acknowledgment

We would like to thank Claire Black; ( moc.liamg@kcalbennaerialc ) and Sofia fields ( https://www.sofiafields.com ) for the English language editing.

Disclosure. Authors have no conflict of interests, and the work was not supported or funded by any drug company.

Low Self-Esteem: The Uphill Struggle for Self-Integrity

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• Steven J. Spencer 3 ,
• Robert A. Josephs 4 &
• Claude M. Steele 5  

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Like Steinbeck, we have wondered why some people are more resilient to the vicissitudes of life than others, that is, why their sense of worth and the psychological states that vary with it (e.g., defensiveness, efficacy, positive affect) are less affected by particular threats to their self- image. They have “thicker skins.” Clearly all of us fluctuate in this respect; sometimes and in some settings, we are more resilient than at other times or in other settings. But personal experience suggests there are reliable individual differences in this capacity. For example, one of the authors was presented with an option to buy a particularly risky stock by his brother. Like most such stocks, there was a good chance of a high payoff, coupled with, a good chance of a big loss. The author’s brother, thick of skin, was eager to buy. If the stock failed, he may have calculated, he had lots of esteem cushioning, a happy family, a good career as a lawyer, and so on. But the author, who had a thinner skin (perhaps because he was a poor graduate student at the time), was wary of the gamble. He focused on the possibility that the stock might lose value, and how foolish he would feel if he gambled away his tenuous financial security.

I have wondered why it is that some people are less affected and torn by the verities of life and death than others. Una’s death cut the earth from under Samuels’s feet and opened his defended keep and let in old age. On the other hand Liza, who surely loved her family as deeply as did her husband, was not destroyed or warped. Her life continued evenly. She felt sorrow but she survived it. (Steinbeck, 1952, p. 258)

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Spencer, S.J., Josephs, R.A., Steele, C.M. (1993). Low Self-Esteem: The Uphill Struggle for Self-Integrity. In: Baumeister, R.F. (eds) Self-Esteem. The Plenum Series in Social / Clinical Psychology. Springer, Boston, MA. https://doi.org/10.1007/978-1-4684-8956-9_2

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Low Self Esteem: What Does it Mean to Lack Self-Esteem?

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On This Page:

Self-esteem should be viewed as a continuum and can be high, medium, or low, and it is often quantified as a number in empirical research.

When considering self-esteem, it is important to note that both high and low levels can be emotionally and socially harmful to the individual. Indeed it is thought an optimum level of self-esteem lies in the middle of the continuum. Individuals operating within this range are thought to be more socially dominant within relationships.

Empirical Research

Research has shown key differences between individuals with high and low self-esteem. For example, people with high self-esteem focus on growth and improvement, whereas people with low self-esteem focus on not making mistakes in life.

Low self-esteem has been shown to be correlated with several negative outcomes, such as depression (Silverstone & Salsali, 2003).

Rosenberg and Owen (2001) offer the following description of low self-esteem people based on empirical research. People with low self-esteem are more troubled by failure and tend to exaggerate events as being negative.

For example, they often interpret non critical comments as critical. They are more likely to experience social anxiety and low levels of interpersonal confidence.

This in turn makes social interaction with others difficult as they feel awkward, shy, conspicuous, and unable to adequately express themselves when interacting with others (p. 409). Furthermore, low self-esteem individuals tend to be pessimistic towards people and groups within society.

Research has also shown that low self-esteem has to linked to an increased risk of teenage pregnancy.

Guindon (2002) asked school counsellors to list five characteristics that best describe students with low self-esteem. Over 1000 words were used and the most common are listed below:

• Withdrawn/shy/quiet
• Underachieving
• Negative (attitude)
• Socially inept
• Angry/hostile
• Unmotivated
• Dependent/follower
• Poor self-image
• Non-risk-taker
• Lacks self-confidence
• Poor communication

Low Self-Esteem in Children

It should be noted that, on average, self-esteem during childhood is found to be relatively high. However, there are individual differences, and some children are unfortunate to experience feelings of low self-esteem.

Low self-esteem in children tends to be related to physical punishment and the withholding of love and affection by parents. Carl Rogers would describe this as conditional positive regard, whereby individuals only receive positive attention from significant others (such as parents) when they act in a certain way. This reinforces to the child that they are only a person of value when they act a certain way (e.g., achieving A grades on a test).

Children with low self-esteem rely on coping strategies that are counterproductive such as bullying, quitting, cheating, avoiding, etc. Although all children will display some of these behaviors at times, low self-esteem is strongly indicated when these behaviors appear with regularity.

Socially children with low self-esteem can be withdrawn or shy and find it difficult to have fun. Although they may have a wide circle of friends, they are more likely to yield to group pressure and more vulnerable to bullying. At school, they avoid trying new things (for fear of failure) and will give up easily.

Low Self-Esteem in Teenagers

Self-esteem continues to decline during adolescence (particularly for girls). Researchers have explained this decline to body image and other problems associated with puberty.

Although boys and girls report similar levels of self-esteem during childhood, a gender gap emerges by adolescence in that adolescent boys have higher self-esteem than adolescent girls (Robins et al., 2002).

Girls with low self-esteem appear to be more vulnerable to perceptions of the ideal body image perpetuated in western media (through methods such as airbrushing models on magazine covers).

Abraham, T. (1988). Toward a Self-Evaluation Maintenance Model of Social behavior. In L. Berkowitz (Ed), Advances in Experimental Social Psychology (pp. 181–227).Academic Press.

Coopersmith, S. (1967). The Antecedents of Self-esteem . Freeman.

Harter, S. 1993. Causes and Consequences of Low Self-esteem in Children and Adolescents. In Baumeister, R.F. (Ed.) Self-Esteem: The Puzzle of Low Self-regard (pp. 87-116).

Mruk, C. (1995). Self-Esteem: Research, Theory, and Practice . Springer.

Guindon, M. H. (2002). Toward Accountability in the Use of the Self‐Esteem Construct. Journal of Counseling & Development, 80(2) , 204-214.

Robins, R.W., Trzesniewski, K.H., Tracy, J.L., Gosling, S.D., & Potter, J. (2002). Global self-esteem across the lifespan. Psychology and Aging , 17, 423-434.

Rosenberg, M. (1976). Beyond Self-Esteem: The Neglected Issues in Self-concept Research . Paper presented at the annual meetings of the ASA.

Rosenberg, M. (1979). Conceiving the Self . Basic Books.

Rosenberg, M., & Owens, T.J. (2001). Low self-esteem people: A collective portrait. In T.J. Owens. S. Stryker, & N. Goodmanm (Eds.), Extending self-esteem theory and research (pp. 400-436). New York: Cambridge University Press.

Silverstone, P. H., & Salsali, M. (2003). Low self-esteem and psychiatric patients: Part I–The relationship between low self-esteem and psychiatric diagnosis. Annals of General Psychiatry, 2(1) , 2.

Viktor, G. (1982). The Self-Concept. Annual Review of Sociology , 8:1–33.

Viktor, G., & Schwalbe, M.L. (1983). Beyond the Looking-glass Self: Social Structure and Efficacy-Based Self-Esteem. Social Psychology Quarterly , 46:77–88.

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Guest Essay

The Happiness Gap Between Left and Right Isn’t Closing

By Thomas B. Edsall

Mr. Edsall contributes a weekly column from Washington, D.C., on politics, demographics and inequality.

Why is it that a substantial body of social science research finds that conservatives are happier than liberals?

A partial answer: Those on the right are less likely to be angered or upset by social and economic inequities, believing that the system rewards those who work hard, that hierarchies are part of the natural order of things and that market outcomes are fundamentally fair.

Those on the left stand in opposition to each of these assessments of the social order, prompting frustration and discontent with the world around them.

The happiness gap has been with us for at least 50 years, and most research seeking to explain it has focused on conservatives. More recently, however, psychologists and other social scientists have begun to dig deeper into the underpinnings of liberal discontent — not only unhappiness but also depression and other measures of dissatisfaction.

One of the findings emerging from this research is that the decline in happiness and in a sense of agency is concentrated among those on the left who stress matters of identity, social justice and the oppression of marginalized groups.

There is, in addition, a parallel phenomenon taking place on the right as Donald Trump and his MAGA loyalists angrily complain of oppression by liberals who engage in a relentless vendetta to keep Trump out of the White House.

There is a difference in the way the left and right react to frustration and grievance. Instead of despair, the contemporary right has responded with mounting anger, rejecting democratic institutions and norms.

In a 2021 Vox article, “ Trump and the Republican Revolt Against Democracy ,” Zack Beauchamp described in detail the emergence of destructive and aggressive discontent among conservatives.

Citing a wide range of polling data and academic studies, Beauchamp found:

More than twice as many Republicans (39 percent) as Democrats (17 percent) believed that “if elected leaders won’t protect America, the people must act — even if that means violence.”

Fifty-seven percent of Republicans considered Democrats to be “enemies,” compared with 41 percent of Democrats who viewed Republicans as “enemies.”

Among Republicans, support for “the use of force to defend our way of life,” as well as for the belief that “strong leaders bend rules” and that “sometimes you have to take the law in your own hands,” grows stronger in direct correlation with racial and ethnic hostility.

Trump has repeatedly warned of the potential for political violence. In January he predicted bedlam if the criminal charges filed in federal and state courts against him damaged his presidential campaign:

I think they feel this is the way they’re going to try and win, and that’s not the way it goes. It’ll be bedlam in the country. It’s a very bad thing. It’s a very bad precedent. As we said, it’s the opening of a Pandora’s box.

Before he was indicted in New York, Trump claimed there would be “potential death and destruction” if he was charged.

At an Ohio campaign rally in March, Trump declared, “If I don’t get elected, it’s going to be a blood bath for the whole country.”

In other words, Trump and his allies respond to adversity and what they see as attacks from the left with threats and anger, while a segment of the left often but not always responds to adversity and social inequity with dejection and sorrow.

There are significant consequences for this internalization.

Jamin Halberstadt , a professor of psychology at the University of Otago in New Zealand and a co-author of “ Outgroup Threat and the Emergence of Cohesive Groups : A Cross-Cultural Examination,” argued in his emailed reply to my inquiry that because “a focus on injustice and victimhood is, by definition, disempowering (isn’t that why we talk of ‘survivors’ rather than ‘victims’?), loss of control is not good for self-esteem or happiness.”

But, he pointed out:

this focus, while no doubt a part of the most visible and influential side of progressive ideology, is still just a part. Liberalism is a big construct, and I’m reluctant to reduce it to a focus on social justice issues. Some liberals have this view, but I suspect their influence is outsized because (a) they have the social media megaphone and (b) we are in a climate in which freedom of expression and, in particular, challenges to the worldview you characterize have been curtailed.

Expanding on this line of argument, Halberstadt wrote:

I’m sure some self-described liberals have views that are counterproductive to their own happiness. One sub-ideology associated with liberalism is, as you describe, a sense of victimhood and grievance. But there is more than one way to respond to structural barriers. Within that group of the aggrieved, some probably see systemic problems that cannot be overcome, and that’s naturally demoralizing and depressing. But others see systemic problems as a challenge to overcome.

Taking Halberstadt’s assessment of the effects of grievance and victimhood a step farther, Timothy A. Judge , the chairman of the department of management and human resources at Notre Dame, wrote in a 2009 paper, “ Core Self-Evaluations and Work Success ”:

Core self-evaluations (C.S.E.) is a broad, integrative trait indicated by self-esteem, locus of control, generalized self-efficacy and (low) neuroticism (high emotional stability). Individuals with high levels of C.S.E. perform better on their jobs, are more successful in their careers, are more satisfied with their jobs and lives, report lower levels of stress and conflict, cope more effectively with setbacks and better capitalize on advantages and opportunities.

I asked Judge and other scholars a question: Have liberal pessimists fostered an outlook that spawns unhappiness as its adherents believe they face seemingly insurmountable structural barriers?

Judge replied by email:

I do share the perspective that a focus on status, hierarchies and institutions that reinforce privilege contributes to an external locus of control. And the reason is fairly straightforward. We can only change these things through collective and, often, policy initiatives — which tend to be complex, slow, often conflictual and outside our individual control. On the other hand, if I view “life’s chances” (Virginia Woolf’s term) to be mostly dependent on my own agency, this reflects an internal focus, which will often depend on enacting initiatives largely within my control.

Judge elaborated on his argument:

If our predominant focus in how we view the world is social inequities, status hierarchies, societal unfairness conferred by privilege, then everyone would agree that these things are not easy to fix, which means, in a sense, we must accept some unhappy premises: Life isn’t fair; outcomes are outside my control, often at the hands of bad, powerful actors; social change depends on collective action that may be conflictual; an individual may have limited power to control their own destiny, etc. These are not happy thoughts because they cause me to view the world as inherently unfair, oppressive, conflictual, etc. It may or may not be right, but I would argue that these are in fact viewpoints of how we view the world, and our place in it, that would undermine our happiness.

Last year, George Yancey , a professor of sociology at Baylor University, published “ Identity Politics, Political Ideology, and Well-Being : Is Identity Politics Good for Our Well-Being?”

Yancey argued that recent events “suggest that identity politics may correlate to a decrease in well-being, particularly among young progressives, and offer an explanation tied to internal elements within political progressiveness.”

By focusing on “political progressives, rather than political conservatives,” Yancey wrote, “a nuanced approach to understanding the relationship between political ideology and well-being begins to emerge.”

Identity politics, he continued, focuses “on external institutional forces that one cannot immediately alleviate.” It results in what scholars call the externalization of one’s locus of control, or viewing the inequities of society as a result of powerful if not insurmountable outside forces, including structural racism, patriarchy and capitalism, as opposed to believing that individuals can overcome such obstacles through hard work and collective effort.

As a result, Yancey wrote, “identity politics may be an important mechanism by which progressive political ideology can lead to lower levels of well-being.”

Conversely, Yancey pointed out, “a class-based progressive cognitive emphasis may focus less on the group identity, generating less of a need to rely on emotional narratives and dichotomous thinking and may be less likely to be detrimental to the well-being of a political progressive.”

Yancey tested this theory using data collected in the 2021 Baylor Religion Survey of 1,232 respondents.

“Certain types of political progressive ideology can have contrasting effects on well-being,” Yancey wrote. “It is plausible that identity politics may explain the recent increase well-being gap between conservatives and progressives.”

Oskari Lahtinen , a senior researcher in psychology at the University of Turku in Finland, published a study in March, “ Construction and Validation of a Scale for Assessing Critical Social Justice Attitudes ,” that reinforces Yancey’s argument.

Lahtinen conducted two surveys of a total of 5,878 men and women to determine the share of Finnish citizens who held “critical social justice attitudes” and how those who held such views differed from those who did not.

Critical social justice proponents, on Lahtinen’s scale,

point out varieties of oppression that cause privileged people (e.g., male, white, heterosexual, cisgender) to benefit over marginalized people (e.g., woman, Black, gay, transgender). In critical race theory, some of the core tenets include that (1) white supremacy and racism are omnipresent and colorblind policies are not enough to tackle them, (2) people of color have their own unique standpoint and (3) races are social constructs.

What did Lahtinen find?

The critical social justice propositions encountered

strong rejection from men. Women expressed more than twice as much support for the propositions. In both studies, critical social justice was correlated modestly with depression, anxiety, and (lack of) happiness, but not more so than being on the political left was.

In an email responding to my inquiries about his paper, Lahtinen wrote that one of the key findings in his research was that “there were large differences between genders in critical social justice advocacy: Three out of five women but only one out of seven men expressed support for the critical social justice claims.”

In addition, he pointed out, “there was one variable in the study that closely corresponded to external locus of control: ‘Other people or structures are more responsible for my well-being than I myself am.’”

The correlation between agreement with this statement and unhappiness was among the strongest in the survey:

People on the left endorsed this item (around 2 on a scale of 0 to 4) far more than people on the right (around 0.5). Endorsing the belief was determined by political party preference much more than by gender, for instance.

Such measures as locus of control, self-esteem, a belief in personal agency and optimism all play major roles in daily life.

In a December 2022 paper, “ The Politics of Depression : Diverging Trends in Internalizing Symptoms Among U.S. Adolescents by Political Beliefs,” Catherine Gimbrone , Lisa M. Bates , Seth Prins and Katherine M. Keyes , all at Columbia’s Mailman School of Public Health, noted that “trends in adolescent internalizing symptoms diverged by political beliefs, sex and parental education over time, with female liberal adolescents experiencing the largest increases in depressive symptoms, especially in the context of demographic risk factors, including parental education.”

“These findings,” they added, “indicate a growing mental health disparity between adolescents who identify with certain political beliefs. It is therefore possible that the ideological lenses through which adolescents view the political climate differentially affect their mental well-being.”

Gimbrone and her co-authors based their work on studies of 85,000 teenagers from 2005 to 2018. They found that

while internalizing symptom scores worsened over time for all adolescents, they deteriorated most quickly for female liberal adolescents. Beginning in approximately 2010 and continuing through 2018, female liberal adolescents reported the largest changes in depressive affect, self-esteem, self-derogation and loneliness.

In conclusion, the authors wrote, “socially underprivileged liberals reported the worst internalizing symptom scores over time, likely indicating that the experiences and beliefs that inform a liberal political identity are ultimately less protective against poor mental health than those that inform a conservative political identity.”

From another vantage point, Nick Haslam , a professor of psychology at the University of Melbourne, argued in his 2020 paper “ Harm Inflation: Making Sense of Concept Creep ” that recent years have seen “a rising sensitivity to harm within at least some Western cultures, such that previously innocuous or unremarked phenomena were increasingly identified as harmful and that this rising sensitivity reflected a politically liberal moral agenda.”

As examples, Haslam wrote that the definition of “trauma” has been

progressively broadened to include adverse life events of decreasing severity and those experienced vicariously rather than directly. “Mental disorder” came to include a wider range of conditions, so that new forms of psychopathology were added in each revision of diagnostic manuals and the threshold for diagnosing some existing forms was lowered. “Abuse” extended from physical acts to verbal and emotional slights and incorporated forms of passive neglect in addition to active aggression.

Haslam described this process as concept creep and argued that “some examples of concept creep are surely the work of deliberate actors who might be called expansion entrepreneurs.”

Concept expansion, Haslam wrote, “can be used as a tactic to amplify the perceived seriousness of a movement’s chosen social problem.” In addition, “such expansion can be effective means of enhancing the perceived seriousness of a social problem or threat by increasing the perceived prevalence of both ‘victims’ and ‘perpetrators.’”

Haslam cited studies showing that strong “correlates of holding expansive concepts of harm were compassion-related trait values, left-liberal political attitudes and forms of morality associated with both.” Holding expansive concepts of harm was also “associated with affective and cognitive empathy orientation and most strongly of all with endorsement of harm- and fairness-based morality.” Many of these characteristics are associated with the political left.

“The expansion of harm-related concepts has implications for acceptable self-expression and free speech,” Haslam wrote. “Creeping concepts enlarge the range of expressions judged to be unacceptably harmful, thereby increasing calls for speech restrictions. Expansion of the harm-related concepts of hate and hate speech exemplifies this possibility.”

While much of the commentary on the progressive left has been critical, Haslam takes a more ambivalent position: “Sometimes concept creep is presented in an exclusively negative frame,” he wrote, but that fails to address the “positive implications. To that end, we offer three positive consequences of the phenomenon.”

The first is that expansionary definitions of harm “can be useful in drawing attention to harms previously overlooked. Consider the vertical expansion of abuse to include emotional abuse.”

Second, “concept creep can prevent harmful practices by modifying social norms.” For example, “changing definitions of bullying that include social exclusion and antagonistic acts expressed horizontally rather than only downward in organizational hierarchies may also entrench norms against the commission of destructive behavior.”

And finally:

The expansion of psychology’s negative concepts can motivate interventions aimed at preventing or reducing the harms associated with the newly categorized behaviors. For instance, the conceptual expansion of addiction to include behavioral addictions (e.g., gambling and internet addictions) has prompted a flurry of research into treatment options, which has found that a range of psychosocial treatments can be successfully used to treat gambling, internet and sexual addictions.

Judge suggested an approach to this line of inquiry that he believed might offer a way for liberalism to regain its footing:

I would like to think that there is a version of modern progressivism that accepts many of the premises of the problem and causes of inequality but does so in a way that also celebrates the power of individualism, of consensus and of common cause. I know this is perhaps naïve. But if we give in to cynicism (that consensus can’t be found), that’s self-reinforcing, isn’t it? I think about the progress on how society now views sexual orientation and the success stories. The change was too slow, painful for many, but was there any other way?

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Thomas B. Edsall has been a contributor to the Times Opinion section since 2011. His column on strategic and demographic trends in American politics appears every Wednesday. He previously covered politics for The Washington Post. @ edsall