*2.3. Self-Concept Clarity*

As part of our biography, our identities form, evolve, and change in concert with our learning through experiences. These experiences are influenced by both internal and external factors: family, friends, geographic location, religious faith, culture, race, ethnicity, socioeconomic status, perceptions of stress and opportunity, and society. Being is the embodiment of our living existence. As such, it changes throughout our lives such that our biography, our being, is formed through learning acquired from the collective sum of our life's experiences [37]. Our biography is an "unfinished product constantly undergoing change and development—either through experiences that we self-initiate or else through experiences which are initiated by others" [37] (p. 25). Self-concept clarity reflects an individual's internal self-beliefs and is characterized by consistency and temporal stability [38]; however, it may also fluctuate contingent upon the influence of environmental factors [39]. Self-concept has been found to be correlated with psychological well-being and resiliency in adapting to stressors [40,41]. Furthermore, the evaluative self-analysis component of self-concept clarity is correlated with self-esteem, or individual discernment of value [42]. For those that experience IPV, there is a clear association with the self-doubt and loss of agency that negatively affects women's identities [43]. The "certainty about one's beliefs regarding his or her personal attributes" is knowledge integrant of self-esteem and can be influenced by individual perceptions of stress, psychological resiliency, and excogitative behaviors [42] (p. 486). Psychological stresses such as those associated with IPV elicit self-discontinuity or individual perceptions of past and present discontinuity, which necessarily compromise the clarity of self-views. Given that self-concept clarity was found to mediate the relationship between stress and perceptions of well-being, it is paramount that the effects of IPV on identity and concept of self be integral to addressing complex mental health issues [43,44]. This is especially critical given the previously discussed increased prevalence of comorbid mental health factors associated with women.

#### **3. Implications**

It has been suggested that women with poor self-esteem may be at greater risk for developing drug use disorders compared with men; however, research has shown mixed results related to self-esteem enhancing measures as they influence effective treatment outcomes. For example, Trucco et al.'s (2007) alcohol dependence research showed no correlation between self-esteem and the occurrence of relapse or successful treatment outcomes [45]. As such they suggested that while self-esteem may have a role in the development of substance use disorder, increased levels of self-esteem do not necessarily lead to treatment success [45]. Future research focused on "aspects of self-perception" rather than self-esteem as a general construct when looking to develop effective prevention and relapse measures may elucidate mitigation measures [45]. Prior research on selfconcept clarity has focused on distinctions within self-analysis, particularly between the two aspects of self-consciousness: private (attention to one's own thoughts and feelings) and public (awareness of oneself as a social object [46,47]. Women have an increased occurrence of self-reflection upon their own personality characteristics, suggesting higher private self-consciousness and validating prior hypotheses regarding gender differentiation of the self-consciousness trait [47]. Furthermore, women tend to be more open to the experiences of self and others through self-reflection, whereas "individuals higher in masculinity (agency) represented their own and others' emotions in less complex ways" [47] (p. 479). Yet, increased private self-consciousness or self-reflection may exacerbate potential negative self-perception in women. Rumination, the act of engaging in repetitive negative thoughts, "enhances the effects of depressed mood on thinking, impairs effective problem solving, interferes with instrumental behavior, and erodes social support", so that "the initial symptoms of depression among people who chronically ruminate are likely to become more severe and evolve into episodes of major depression" [48] (p. 367). Gender differentiation research in rumination found increased rates of rumination and reflection in women compared to men, with greater statistical significance for those in childhood and adolescence [48].

It is imperative that we gain a clearer understanding of women's lived experiences and values as they relate to the complex nature of mental health, including both IPV and SUD associated outcomes. Individualized interventions that recognize the role that gender, and intersecting identities have on women's experiences will help to potentially reduce stigma and treat trauma. Notably, research on mice has shown epigenetic inheritance of perpetuated trauma through the transformation of genomic changes found in subsequent generations [49] (p. 20). While there is a clear gap in the literature regarding human studies focused on the effect of traumatic stress on inheritance, several studies have shown increased inheritance susceptibility for PTSD [49,50]. Additional research on genetic epidemiology and environmental interactivity associated with SUD is also needed [51]. With the potential for inherited trauma and associated negative biological and psychological outcomes for future generations, we must acknowledge and address symptoms at inception.

The pervasive and expensive nature of complex mental health conditions has created a behavioral health crisis with exorbitant costs for organizations due to employee turnover, and reduced productivity and healthcare. However, companies that ensure that mental health resources and services are accessible improve employee outcomes, thereby increasing organizational performance. In a McKinsey study of more than 1000 employers, greater than 90% reported that the COVID-19 crisis has affected employee productivity and behavioral health [52]. Shortly before the pandemic spread across the globe and ensuing quarantine measures were implemented, published research illustrated the profound need for organizations to focus on mental health. At that time, 91% of respondents believed companies should be concerned about mental health, while 85% who were considering a new job were evaluating associated mental health benefits [53]. Estimates of behavioral health impacts of COVID-19 on the healthcare system in the U.S. alone may reach \$200 billion annually; this does not even factor in vulnerable or at-risk populations [52].
