Experienced stigma and self-stigma in Chinese patients with schizophrenia
Introduction
Many factors influence stigma in patients with mental disorders, and cultural context plays an essential role in its formation. Deeply held cultural and philosophical beliefs can promote stigma and act as a barrier to rehabilitation and recovery. In China, traditional cultural values, such as Confucianism, Taoism and Buddhism, strongly influence patients' and society's understanding and interpretation of mental illness and associated stigma. The core virtue in Confucianism, which has shaped Chinese culture for over 2000 years, is filial piety [1]. Filial piety encourages individuals to show respect for their elders and ancestors and to act in an ethical way, in harmony with the self, family, society and the universe. The extreme importance of social harmony and its maintenance take precedence over the expression of one's own opinions and values [2]. People are seen as living first and foremost in a strict network of social interaction (or guanxi). The maintenance of guanxi is dependent on the reciprocal returning of favors [3] which is itself directly related to the concept of “face” (or mianzi). Face is a crucial aspect of social identity and represents power and standing in Chinese social hierarchy. Thus, preserving face or mianzi is a part of daily life. Diagnosis of schizophrenia results in a “loss of face” for the individual [4], and suffering from mental illness is equated with extreme shame in Chinese society.
A review of the literature around the social and cultural history of medicine [5], [6] reveals that psychiatric stigma has existed in Europe since the times of Ancient Greece and the Middle Ages. Such stigma continues to be prevalent in Western countries [7]. Psychiatric stigma not only leads to negative stereotyping and to discriminatory behavior towards those affected by mental illness [8], [9], but causes feelings of shame in patients, both of which result in decreased life satisfaction and self-esteem [10]. Rehabilitation in schizophrenia patients is often hampered by stigma-related difficulties [11]. Stigma refers to the experience of discrimination by patients and the resulting limited social participation [12]. Self-stigma mainly refers to the internalization of public stigma. Corrigan [13] defines self-stigma as the internalizing of shame, blame, hopelessness, guilt and fear of discrimination associated with mental illness. It has also been described as a process, wherein the patient alters both what they expect of themselves and how they expect to be treated by society [14].
It is very common for those with mental illnesses to experience discrimination, as reported in findings in Hong Kong [15], [16], Mainland China [17], [18], as well as in the Western literature [[9], [19]]. However, the extent and nature of stigma and self-stigma in schizophrenia patients in China are still largely understudied. In particular, previous research has used nonstandardized questionnaires, making between-study comparisons difficult. For these reasons, our study measured stigma in a Chinese setting using two standardized questionnaires and describes the characteristics of stigma, self-stigma and other relevant factors. We discuss recommendations for policy around stigma prevention, especially related to patients' reintegration into society.
Section snippets
Participants
A nonprobabilistic sampling method was used to recruit participants. The participants were inpatients or outpatients with schizophrenia receiving treatment in the Second Xiangya Hospital between January and March 2011. For inclusion, the patients had to be (1) diagnosed with schizophrenia. Patient assessments were done by a psychiatrist using the DSM-IV criteria (American Psychiatric Association, 1994), and diagnoses were independently confirmed by a psychologist in a structured clinical
Participants' characteristics
An overview of the participants' sociodemographic and clinical characteristics is shown in Table 1.
Level of self-stigma
Mean scores on the ISMI were as follows: 2.29 for alienation (S.D.=0.49), 2.07 for stereotype endorsement (S.D.=0.44), 2.15 for discrimination experience (S.D.=0.45) and 2.19 for social withdrawal (S.D.=0.46) The mean overall score was 2.17 (S.D.=0.38).
The percentage of participants who rated themselves above the mid-point of 2.5 on the subscales and total scores of the ISMI (i.e., high level of
Discussion
Our study aimed to explore psychiatric stigma among Chinese patients with schizophrenia and factors influencing such stigma. In this study, nearly 70% of respondents reported mild or moderate self-stigma. Although this is comparable to findings in Spain [32] , a study including 14 European countries found higher levels of self-stigma, with 41.7% reporting moderate or high levels of self-stigma [33]. On the ISMI, over 60% of patients “agreed” or “strongly agreed” with “Living with a mental
References (47)
Psychiatric stigma in the classical and medieval period: a review of the literature
Compr Psychiatry
(1990)The culture and history of psychiatric stigma in early modern and modern Western societies: a review of literature
Compr Psychiatry
(1991)Stigma: what can psychiatrists do about it?
Lancet
(1998)The impact of stigma on severe mental illness
Cogn Behav Pract
(1999)- et al.
Quality of life and its determinants of hemodialysis patients in Taiwan measured with WHOQOL-BREF (TW)
Am J Kidney Dis
(2005) - et al.
Internalized stigma predicts erosion of morale among psychiatric outpatients
Psychiat Res
(2004) - et al.
Stigma, social function and symptoms in schizophrenia and schizoaffective disorder: associations across 6 months
Psychiat Res
(2007) - et al.
Self-stigma, empowerment and perceived discrimination among people with schizophrenia in 14 European countries: The GAMIAN-Europe study
Schizophr Res
(2010) - et al.
Correlates and consequences of internalized stigma for people living with mental illness: a systematic review and meta-analysis
Soc Sci Med
(2010) - et al.
Mental illness stigma: concepts, consequences, and initiatives to reduce stigma
Eur Psychiatry
(2005)
Chinese lay theory and mental illness stigma: implications for rehabilitation practices
J Rehabil
Mental health care in China: state policies, professional services and family responsibilities
Face, favor and families: the social course of mental health problems in China and American societies
Chin J Ment Health
Application of mental illness stigma theory to Chinese societies: synthesis and new direction
Singapore Med J
Experiences of stigma among outpatients with schizophrenia
Schizophr Bull
On stigma and its consequences: evidence from a longitudinal study of men with dual diagnoses of mental illness and substance abuse
J Health Soc Behav
Mental health consumers' experience of stigma
Schizophr Bull
Beyond good intentions. Making anti-discrimination strategies work
Disabil & Soc
The Participation Scale: measuring a key concept in public health
Disabil Rehabil
Internalized stigma: a barrier to employment for people with mental illness
Int J Ther Rehabil.
Stigmatizing attitudes towards individuals with mental illness in Hong Kong: implications for their recovery
J Community Psychol
Experience of social stigma by people with schizophrenia in Hong Kong
Br J Psychiatry
Stigma and expressed emotion: a study of people with schizophrenia and their family members in China
Br J Psychiatry
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