Mental health of Irish students: Self-criticism as a complete mediator in mental health attitudes and caregiver identity

Mental health is a concern in the Republic of Ireland, and in particular the mental health of higher education students is challenging. Further, their poor mental health may be negatively impacted by their negative mental health attitudes and caregiver identity, which can yield high self-criticism and low self-reassurance. Accordingly, this study aimed to (i) elucidate the relationships among these five constructs, and (ii) assess the impact of self-criticism and self-reassurance in the relationship between (a) mental health attitudes and mental health, and (b) between caregiver identity and mental health. One-hundred and twenty-nine Irish undergraduate students completed self-report measures regarding these constructs. Correlation and path analyses were conducted. Overall, all variables were related to each other, and in particular family-related shame subscales were strongly related to mental health problems. In path analysis, self-criticism completely mediated the relationship between mental health attitudes and mental health, while self-reassurance did not. Likewise, self-criticism also completely mediated the relationship between caregiver identity and mental health, while self-reassurance did not. The findings suggest the importance of self-criticism to students’ mental health. While current literature highlights the importance of mental health attitudes such as stigma and caregiver identity (a strong sense of identity as someone who offers care), our results indicated that it was their self-criticism that predicted poor mental health. As such, their mental health may be more effectively improved by targeting self-criticism. Compassion training, peer-support groups, and reframing were recommended to counter self-criticism. Our findings will help educators and researchers identify alternative and more effective means of improving mental health in Irish students.


Introduction
Mental health is one of the global challenges we face today.In Europe, one in six people had some type of mental health problem in 2016, amounting to 84 million Europeans, and deaths caused by mental health problems (including suicide) totaled over 84,000 in 2015 (Organization for Economic Cooperation and Development/European Union [OECD/EU], 2018).Costs of mental health problems exceed 4% of Gross Domestic Product on average, totaling €600 billion across Europe (OECD/EU, 2018).Ireland was reported to have the most challenging mental health status in Europe: about 20% of the Irish suffered from a mental health problem, including anxiety, bipolar disorder, schizophrenia, depression, or substance abuse, costing its economy €8.2 billion annually (OECD/EU, 2018).In particular, Irish higher education students suffer from poor mental health: more than half of Irish students felt their mental health problems negatively impacted their academic performance (Kerrigan, 2018).Approximately 40% had mild to very severe depression or anxiety; 50% had suicidal ideation; and 20% had engaged in self-harm (Dooley & Fitzgerald, 2012).These figures delineate poor mental health of Irish students.Further, considering that (i) 70% of health problems (including fatal ones) in the young are derived from mental health difficulties (McGorry, 2005), and (ii) 75% of life-long mental health difficulties start to develop between the ages of 15 and 25 (Hickie, 2004;Kessler et al., 2005;Kim-Cohen et al., 2003), it is worthwhile to explore the mental health of students in Irish higher education.
One student group that suffers from poor mental health is social care students, who aspire to work with the most vulnerable populations in society.Professional practitioners offer psychosocial care, protection, and advocacy for vulnerable individuals and groups (Social Care Workers Registration Board, 2019).While the importance of this profession has been more recognized recently (Golightley & Holloway, 2019), it is still in its infancy regarding researching the mental health conditions of social care students.Social care education programs can be mentally challenging to many students (Kotera, Green, & Sheffield, 2019).More than a third of social care students reported serious depressive symptoms (Horton et al., 2009).40% of students in this subject have suicidal thoughts in their lives, and 4% reported they had them recently (Horton et al., 2009).Partly because they are trained to be attuned to service users' suffering, they can be influenced by others' suffering: after a natural disaster, half of them had clinical levels of depression, one-fifth used substances, and a quarter felt the disaster triggered their past traumas (Lemieux et al., 2010).Despite these findings for social care students, mental health of Irish social care students has not been intentionally investigated to date.

Shame for Mental Health Problems
Despite the serious nature of mental health problems, Irish students' attitudes towards mental health problems are negative.Three-quarters of Irish students reported fear of having mental health problems (Union of Students in Ireland, 2017).A study analyzing focus group sessions attended by 33 Irish students highlighted shame and stigma about mental health problems (Karwig, Chambers & Murphy, 2015).Negative attitudes towards mental health problems can leave symptoms untreated, leading to poor clinical outcomes.Shame and stigma were a major reason for help avoidance (Byrne, 2000;Corrigan et al., 2003;Eisenberg et al., 2007;Gonzalez et al., 2005;Nordt et al., 2006;Ting, 2011), which was related to depression in 700 professional social workers in America (Siebert, 2004).Stigmatized attitudes perceive mental health sufferers as weak, incompetent, and unable to take care of themselves, which could lead to discriminatory behaviours such as social isolation (Corrigan, Edwards, Green, Diwan, & Penn, 2001;Link, Yang, Phelan, & Collins, 2004).At the same time, negative mental health stigma can be internalized, causing feelings of shame (Antonak & Livneh, 2000;Byrne, 2000).Particularly, social care students are afraid to seek help, as they aspire to help other people with mental health problems.Their strong caregiver identity was associated with poor mental health and high mental health shame (Kotera, Green & Sheffield, 2019;Kotera, Green, & Van Gordon, 2018;Ting, 2011).Despite these relationships, mental health attitudes and caregiver identity of Irish social care students have not been explored in-depth to date.
The present study focused on shame instead of stigma, because shame is strongly related to professional identity and the mental health of healthcare students (Kotera, Green & Sheffield, 2019).Shame relates to a sense of inadequacy, compared with some internal or external standard (Tangney, 1990), whereas stigma is an undesirable social mark causing isolation (Lewis, 1999).Therefore, stigma can lead to a sense of shame, and shame can have other sources than stigma (Corrigan, Duss, & Perlick, 2014).In a previous study by Golberstein, Eisenberg and Gollust (2009), there was no significant relationship between stigma and help-seeking, suggesting that the participating students were aware of stigma yet still received help; some students were not worried if they would become isolated from their close friends by receiving mental health help because they did not feel any shame.Shame is a potent emotion of inadequacy, and particularly relevant to practitioners and trainees in the caring profession (Frost, 2016).Shame can lead to self-doubt, causing one to hide, escape, and repair one's self-image (de Hooge, Zeelenberg, & Breugelmans, 2010).Shame is a form of pervasive self-devaluations (Benetti-McQuoid & Bursik, 2005), involving fear of others' judgement (Agrawal & Duhachek, 2010), and self-criticism for one's own identity (Lewis, 1971;Tangney & Dearing, 2002).This feeling of shame is salient in social care work (as seen in the words 'social worker shame' noted by Gibson, 2014, p.417), and thus worthwhile to explore in Irish social care students.

Caregiver Identity in Social Care Students
Because shame is related to one's identity, this study explored the caregiver identity of Irish social care students: how they perceive themselves as a caregiver.A strong sense of caregiver identity, to be seen as someone who offers care for those in need, was related to poor mental health and a negative mental health attitude, which is essentially high shame, in UK social care students (Kotera, Green & Sheffield, 2019).These significant relationships may suggest that social care students are constantly compared with their professional standard to be a social care worker.This reinforces a notion that they must care for others, making it more difficult for them to seek help, leading to poor mental health.Indeed, creating a professional identity that focuses on helping others is important, however asking for help does not mean they have failed as a caregiver.Skilled caring practitioners have high self-awareness and implement self-care effectively.Self-care is essential for social care workers, which is enabled by creating a sound professional identity (Dalphon, 2019).In general, students in healthcare subjects are intrinsically motivated to help others (Kotera, Green, & Van Gordon, 2018), however it can cause burnout if those students feel that they must care for others all the time (Dalphon, 2019).As reported in work-life balance research, having balanced identities in one's life is crucial to one's mental health (Kotera, Green & Sheffield, 2019).Caregiver identity of Irish social care work students has not been explored in depth to date, suggesting a need for research.

Self-Criticism and Self-Reassurance
Lastly, self-criticism and self-reassurance were evaluated in this study, as these internal constructs have been significantly related to mental health and mental health attitudes (Gilbert & Procter, 2006;Kotera, Gilbert, Asano, Ishimura, & Sheffield, 2018).As described before, shame is a potent affect that activates our self-criticism, leading to poor mental health.Although we have developed self-criticism for self-correction (to be accepted by parental figures and society), prolonged self-criticism could harm our mental health, and ironically disable the reception of acceptance and love from others (Gilbert, 2010).On the other hand, self-reassurance -equally being supportive of and caring for oneself -can reduce shame and improve mental health (Kotera et al., 2018).Social care students tend to be self-critical as they must meet the professional standards, which leads them to constantly compare themselves with these standards (Kotera, Green & Sheffield, 2019).While self-criticism and self-reassurance are important to the mental health of social care students, these constructs have not been appraised in Irish social care students.
Given the internal nature of self-criticism and selfreassurance, this study aimed to test two hypotheses: self-criticism and self-reassurance would mediate the relationship between (i) mental health attitudes and mental health (Figure 1), and (ii) between caregiver identity and mental health (Figure 2).

Mental Health Attitudes Mental Health
Self-Criticism In summary, we aimed to address 1) how mental health would be related to mental health attitudes, self-criticism/-reassurance, and caregiver identity, 2) whether self-criticism/-reassurance would mediate the relationship between mental health attitudes and mental health, and 3) whether self-criticism/reassurance would mediate the relationship between caregiver identity and mental health in Irish social care students.Findings from these aims could indicate relevant constructs to their mental health, and help identify effective solutions for challenging mental health in these students.

Participants
Participants had to be aged 18 years or older and studying in a social care program at an Irish higher education institute (HEI).In total, 140 students were approached across two campuses, of which 129 undergraduate students (109 females, 16 males, 4 did not specify; Mage=25.12,SDage=7.68,RNGage=18-47 years old) agreed to participate and completed selfreport measures about mental health, mental health attitudes, caregiver identity, self-criticism, and selfreassurance.The gender balance and age in our sample was almost identical to the general social care student demography (86% female, 28 years old on average combining both undergraduates and postgraduates; Skills for Care, 2016).

Instruments
Mental health was evaluated using the Depression Anxiety Stress Scale (DASS-21), a shortened version of the original DASS-42 (Lovibond & Lovibond, 1995).The 21 items in the DASS-21 are categorized into three subscales: depression (e.g.'I couldn't seem to experience any positive feeling at all'), anxiety (e.g.'I was worried about situations in which I might panic and make a fool of myself'), and stress (e.g.'I tended to over-react to situations').The subscales of the DASS-21 have good internal consistency (α=.94 for depression, α=.87 for anxiety, and α=.91 for stress; Antony et al., 1998).
Attitudes Towards Mental Health Problems (ATMHP) was used to measure participants' mental health attitudes.ATMHP consists of 35 items divided into four sections: i) community and family attitudes, ii) community and family external shame, iii) internal shame, and iv) family and self-reflected shame.The first section evaluated how their community and family perceive mental health problems (community and family attitudes).The second section considered their perception of how their community and family would see them if they had a mental health problem, respectively (community and family external shame).Internal shame was appraised in the third section: how they would perceive themselves if they had a mental health problem.Finally, the fourth section evaluated how their family would be perceived if they had a mental health problem (family reflected shame), and how worried they would be if their close relative had a mental health problem (self-reflected shame).All of the subscales had good internal consistency (α=.85 to .97;Gilbert et al., 2007).
Caregiver identity was assessed using the Role Identity Scale (RIS), an eight-item self-report measure considering how they see themselves as a caregiver, and how they recognize others' view of them as a caregiver (Siebert & Siebert, 2005, 2007).Participants rate how much they agree or disagree to each item (e.g.'Friends frequently turn to me when they have problems or concerns') on a five-point Likert scale.A higher total score means a stronger caregiving identity.The internal consistency for this measure is high (α=.78;Siebert & Siebert, 2005).
Lastly, the Forms of Self-Criticizing/Attacking & Self-Reassuring Scale (FSCSR; Gilbert et al., 2004) was used to assess self-criticism and self-reassurance, namely how participants treat themselves internally in difficult times.The 22 five-point Likert scale items evaluate two types of self-criticism (inadequate-self and hated-self) and self-reassurance (reassured-self).

Caregiver Identity Mental Health
Self-Criticism

Self-Reassurance
Nine items consider inadequate-self, which is a sense of personal inadequacy (e.g.'I find it difficult to control my anger and frustration at myself').Five items concern hated-self, namely a desire to hurt or persecute the self (e.g.'I have a sense of disgust with myself').The rest of the eight items are related to reassured-self, meaning a sense of self-support or compassion for the self (e.g.'I can still feel lovable and acceptable').FSCSR subscales had good internal consistency (α=.90 for inadequate-self, α=.86 for hated-self, and α=.86 for reassured-self).

Procedure
Once they consented to take part in the study, the participants received links to the online scales.The debrief was sent to them, after completion of the scales.The study materials were given to students by their lecturers (not the researchers) to eliminate their response biases.Should students experience distress from responding to the scales, available mental health services were informed (both inside and outside the HEI, to consider their mental health shame).The HEI research ethics committee approved this study.
First, the collected data were screened for outliers and assumptions of parametric tests.Second, correlation analysis was conducted to appraise relationships among these variables.Third, path analyses were conducted to examine whether self-criticism and selfreassurance would mediate the relationship between (i) mental health attitudes and mental health, and (ii) between caregiver identity and mental health.Analyses were conducted using IBM SPSS version 24 and Process macro version 3.1 (Hayes, 2017).

Results
There were no outliers.All the variables demonstrated good internal consistency (α≧.77).All the variables except for inadequate-self and reassured-self were not normally distributed (Shapiro-Wilk p<.05), and so were square-root transformed.Pearson's correlations were used to evaluate the relationships between these variables.Overall, mental health attitudes, mental health, selfcriticism, and self-reassurance were related to each other (Aim 1).Particularly, family-related subscales in the mental health attitudes scale (family attitudes, family external shame, and two types of reflected shame) were strongly related to mental health problems.Self-criticism was more strongly associated with mental health shame and mental health problems than self-reassurance.Caregiver identity was related to mental health problems and self-criticism, but not with mental health attitudes and self-reassurance.

Path Analyses
To evaluate whether self-criticism and selfreassurance would mediate the relationship between mental health attitudes and mental health (Figure 1), path analyses were conducted, using model 4 in the manual (parallel mediation model; Hayes, 2017).Mental health attitudes were calculated by totaling the subscale scores of the ATMHP scale (Gilbert et al., 2007); the total score of DASS-21 was used to indicate their mental health (Lovibond & Lovibond, 1995); and self-criticism was calculated by combining the scores in inadequate-self and hated-self (Kotera et al., 2018).
While there was no significant indirect effect through self-reassurance (b=.01,BCa CI [-.01, .04]),there was a significant indirect effect of mental health attitudes on mental health through self-criticism (b=.35,BCa CI [.21,.50]), which explained 42% of the variance in mental health and accounted for 78% of the total effect, indicating a large effect.The total effect of mental health attitudes on mental health, including self-criticism and self-reassurance, was significant (b=.45, t(129)=4.52,p<.001).The direct effect of mental health attitudes on mental health, controlling for self-criticism and self-reassurance, was not significant (b=.09, t(127)=1.06,p=.29), implying that mental health attitudes did not directly predict the variance in mental health.Self-criticism completely mediated the relationship between mental health attitudes and mental health (Figure 3; Aim 2).Next, the model illustrated in Figure 2 was tested, to determine whether self-criticism and self-reassurance would mediate the relationship between caregiver identity and mental health.
As with the mental health attitudes, there was no significant indirect effect of caregiver identity on mental health through self-reassurance (b=1.02,BCa CI [-.13, .08]).There was a significant indirect effect of caregiver identity on mental health through selfcriticism (b=.76,BCa CI [.38, 1.28]), which explained 39% of the variance in mental health and accounted for 73% of the total effect, indicating a large effect.The total effect of caregiver identity on mental health, including self-criticism and self-reassurance, was significant (b=.92, t(129)=3.26,p=.0014).The direct effect of caregiver identity on mental health, controlling for self-criticism and self-reassurance, was not significant (b=.18, t(127)=.80,p=.42), implying that caregiver identity did not directly predict the variance in mental health.Self-criticism again completely mediated the relationship between caregiver identity and mental health (Figure 4; Aim 3).

Mental Health Attitudes Mental Health
Self-Criticism

Discussion
This study explored the relationship between mental health attitudes, mental health, caregiver identity, self-criticism, and self-reassurance among Irish social care work students.Overall, all the variables were related with each other, and self-criticism completely mediated the relationship between mental health attitudes and mental health, as well as between caregiver identity and mental health.
In our correlation analysis, family-related subscales (family attitudes, family external shame, and two types of reflected shame) were more strongly related with mental health problems than the other subscales.How their family perceives and treats mental health was important to students' own mental health.This suggests that enhancing mental health awareness in their family may be an alternative approach for improving their mental health.Indeed, the medical students' family environment was significantly related to their mental health (Yu et al., 2015).This may also mean that a good understanding of mental health problems can help, as mental health problems are not all genetic.For example, heritability of depression is just about 35% (Matsumoto, Kunimoto, & Ozaki, 2013), and aetiology of mental health problems include a wide range of potential causesnot only familial factors, but also other environmental or psychological factors.A good understanding of mental health can help students reduce their negative attitudes and shame about mental health problems.
One of the primary contributions of this study is that, as revealed in our path analyses, self-criticism played an important role in their mental health.While mental health attitudes and caregiver identity were significantly related to mental health, it was selfcriticism that completely mediated the relationships (as indicated by non-significant direct effects from mental health attitudes to mental health in Figure 3, and from caregiver identity to mental health in Figure 4).Contrarily, self-reassurance did not mediate these relationships.Our results suggest that negative mental health attitudes and a strong caregiver identity activate self-criticism, which exacerbates mental health.Irish social care students may feel strong shame about having a mental health problem, which can stimulate their self-criticism.Likewise, their strong identity as a caregiver can enhance their selfcriticism: for instance, students may believe that 'I should give care to others, not receive it'.Heightened self-criticism can negatively impact their mental health (Gilbert, 2010).Reducing self-criticism may be an alternative and effective approach for the mental health of Irish social care students, especially considering their negative attitudes towards mental health problems (therefore students may not engage with mental health training).Cultivating a compassionate mind has been reported to be effective in reducing self-criticism (Toole & Craighead, 2016).By practicing compassionate thoughts, students can activate a soothing mind that is related to the parasympathetic system, reducing their self-criticism (Gilbert, 2010).Also, experiencing compassion can enhance self-compassion -being kind and understanding towards oneself in difficult times (Neff, 2003).Self-compassion has been identified as a key predictor of good mental health in students within various disciplines, including social care (Kotera, Conway, & Van Gordon, 2019;Kotera, Green & Sheffield, 2019;Kotera, Green, & Van Gordon, 2018).Compassion-based training can enhance students' self-compassion and reduce their self-criticism.Furthermore, our findings highlighting the great impacts of self-criticism on mental health were in line with a current emphasis in the social care field.While compassion has been increasingly recognized within healthcare in general, more acknowledgement is needed in social care (Stickle, 2016).Irish social care educators can protect their students' mental health by embedding compassion training in their curriculum.For example, discussing self-compassion in their student orientation may be effective, so that students would be more prepared to cultivate their own compassionate mind, which can counter selfcriticism.Mandatory personal development lectures targeting self-criticism and self-care may be also useful (Maughan, 2016).Future research should explore how compassion training can tone down their self-criticism and help their mental health.
Alternatively, creating peer-support groups may be useful as well, because students in this subject tend to find it easier to offer care for others than to themselves (Kotera, Green, & Van Gordon, 2018).When students become critical of themselves, supportive peers can help reduce their self-criticism by listening to them emphatically (Kuo, Turton, Lee-Hsieh, Tseng, & Hsu, 2007).Further, reframingchanging a seemingly negative quality or situation into a positive onewould also be useful in a peer group or personal development group (Kotera & Van Gordon, 2019).In the first author's teaching experience, a student reported that she did not like her rigidness about regulations.Peers at her table reframed that quality (rigidness) as a sign of responsibility, which is an essential quality in social care.The student noted that she was able to have a different perspective towards this quality, thereby reducing self-criticism.Likewise, in the second author's personal development module, students helped each other to re-examine experiences and thoughts that emerged in their placement.The effects of relatively straightforward techniques such as reframing should be examined for self-criticism and mental health.
Though this study offers useful insights, several limitations need to be noted.First, though it satisfied the required size (n=84; Faul, Erdfelder, Buchner, & Lang, 2009), the sample size could be larger to attain higher generalizability.Relatedly, we could not explore gender differences, as the sample size for male students was small.Second, our sample was recruited through convenient sampling from one subject area at one institution and from two campuses, hence the risk of subject bias and institution bias.Third, social desirability bias might have been present, as self-report measures were used (Latkin, Edwards, Davey-Rothwell, & Tobin, 2017).Lastly, the causal directions of these relationships were not explored.In the future, longitudinal data would help appraise the temporal patterning of these identified relationships.

Conclusion
Among the challenging mental health climate in Ireland, higher education students are one population group which particularly suffers from poor mental health.Their mental health was related to negative mental health attitudes, caregiver identity, selfcriticism, and self-reassurance.Self-criticism completely mediated the relationship between i) mental health attitudes and mental health problems, and ii) between caregiver identity and mental health problems.The results indicated self-criticism as a key player in their mental health.Compassion training, supportive peer groups, and reframing were suggested to reduce self-criticism of Irish students, leading to better mental health.Our findings can help educators and researchers identify alternative and effective means to improve the challenging mental health of Irish students.

Figure 1 .
Figure 1.Self-criticism and self-reassurance mediating the relationship between mental health attitudes and mental health.

Figure 2 .
Figure 2. Self-criticism and self-reassurance mediating the relationship between caregiver identity and mental health.

Figure 3 .
Figure 3. Parallel mediation model: Self-criticism fully mediated the relationship between mental health attitudes and mental health.***p<.001.The confidence interval for the indirect effect is a BCa bootstrapped CI based on 5000 samples.

Figure 4 .
Figure 4. Parallel mediation model: Self-criticism fully mediated the relationship between mental health attitudes and mental health.*** p<.001, ** p<.01.The confidence interval for the indirect effect is a BCa bootstrapped CI based on 5000 samples.

Table 1 .
Descriptive statistics and correlations between mental health attitudes, mental health, self-criticism, self-reassurance, and caregiver identity among 129 Irish social care students.