Skip to main content

Advertisement

SpringerLink
Log in

An integrative model of internalized stigma and recovery-related outcomes among people diagnosed with schizophrenia in rural China

  • Original Paper
  • Published:
Social Psychiatry and Psychiatric Epidemiology Aims and scope Submit manuscript

Abstract

Purpose

Internalized stigma, an adverse psychological process, severely impedes the lives of people diagnosed with schizophrenia and restricts them from social integration and recovery. The aim of this study was to empirically evaluate an integrative model of relationship between internalized stigma and patients’ recovery-related outcomes among people diagnosed with schizophrenia in a rural Chinese community.

Method

A total of 232 people diagnosed with schizophrenia in Xinjin, Chengdu, participated in this study and completed measures of internalized stigma, social interaction, perceived social support, social functioning, and symptoms. The internalized stigma of mental illness scale (ISMI) was used to measure the internalized stigma. Path analysis was used to test the association between internalized stigma and recovery-related outcomes.

Results

There were no significant differences in mean scores of ISMI by gender, age (18–64 years and ≥ 65 years), education, marital status, or economic capacity. Internalized stigma was negatively associated with perceived social support and social interaction. Furthermore, higher level of internalized stigma was associated with impaired social functioning, and a lower level of social functioning was significantly associated with more severe symptoms.

Conclusion

Internalized stigma is associated with poor social interaction and weakened perceived social support in people diagnosed with schizophrenia, and is linked negatively to outcomes in their recovery. It is essential to tailor interventions related to reducing internalized stigma within a Chinese context and evaluate the effectiveness of anti-stigma intervention on recovery for people diagnosed with schizophrenia.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Corrigan PW, Watson AC (2002) The paradox of self-stigma and mental illness. Clin Psychol Sci Pract 9(1):35–53

    Article  Google Scholar 

  2. Corrigan PW, Watson AC, Barr L (2006) The self-stigma of mental illness: implications for self-esteem and self-efficacy. J Soc Clin Psychol 25(8):875–884

    Article  Google Scholar 

  3. Kim WJ, Song YJ, Ryu H-S, Ryu V, Kim JM, Ha RY, Lee SJ, Namkoong K, Ha K, Cho H-S (2015) Internalized stigma and its psychosocial correlates in Korean patients with serious mental illness. Psychiatry Res 225(3):433–439

    Article  PubMed  Google Scholar 

  4. Krajewski C, Burazeri G, Brand H (2013) Self-stigma, perceived discrimination and empowerment among people with a mental illness in six countries: Pan European stigma study. Psychiatry Res 210(3):1136–1146. https://doi.org/10.1016/j.psychres.2013.08.013

    Article  PubMed  Google Scholar 

  5. Ritsher JB, Phelan JC (2004) Internalized stigma predicts erosion of morale among psychiatric outpatients. Psychiatry Res 129(3):257–265

    Article  PubMed  Google Scholar 

  6. Brohan E, Gauci D, Sartorius N, Thornicroft G, Group GA-ES (2011) Self-stigma, empowerment and perceived discrimination among people with bipolar disorder or depression in 13 European countries: the GAMIAN-Europe study. J Affect Disord 129(1–3):56–63. https://doi.org/10.1016/j.jad.2010.09.001

    Article  PubMed  Google Scholar 

  7. Young DK-W, Ng PY-N (2015) The prevalence and predictors of self-stigma of individuals with mental health illness in two Chinese cities. Int J Soc Psychiatry 62(2):176–185

    Article  PubMed  Google Scholar 

  8. Berge M, Ranney M (2005) Self-esteem and stigma among persons with schizophrenia: implications for mental health. Care Manag J 6(3):139–144

    Article  PubMed  Google Scholar 

  9. Livingston JD, Boyd JE (2010) Correlates and consequences of internalized stigma for people living with mental illness: a systematic review and meta-analysis. Soc Sci Med 71(12):2150–2161. https://doi.org/10.1016/j.socscimed.2010.09.030

    Article  PubMed  Google Scholar 

  10. Kleim B, Vauth R, Adam G, Stieglitz R-D, Hayward P, Corrigan P (2008) Perceived stigma predicts low self-efficacy and poor coping in schizophrenia. J Mental Health 17(5):482–491

    Article  Google Scholar 

  11. Lien YJ, Kao YC, Liu YP, Chang HA, Tzeng NS, Lu CW, Loh CH (2015) Internalized stigma and stigma resistance among patients with mental illness in Han Chinese population. Psychiatr Q 86(2):181–197. https://doi.org/10.1007/s11126-014-9315-5

    Article  PubMed  Google Scholar 

  12. Mashiach-Eizenberg M, Hasson-Ohayon I, Yanos PT, Lysaker PH, Roe D (2013) Internalized stigma and quality of life among persons with severe mental illness: the mediating roles of self-esteem and hope. Psychiatry Res 208(1):15–20. https://doi.org/10.1016/j.psychres.2013.03.013

    Article  PubMed  PubMed Central  Google Scholar 

  13. Landeen J, Seeman M, Goering P, Streiner D (2007) Schizophrenia: effect of perceived stigma on two dimensions of recovery. Clin Schizophr Relat Psychos 1(1):64–68

    Article  Google Scholar 

  14. Vogel DL, Wade NG, Haake S (2006) Measuring the self-stigma associated with seeking psychological help. J Couns Psychol 53(3):325

    Article  Google Scholar 

  15. Vogel DL, Wade NG, Hackler AH (2007) Perceived public stigma and the willingness to seek counseling: the mediating roles of self-stigma and attitudes toward counseling. J Couns Psychol 54(1):40

    Article  Google Scholar 

  16. Tsang HW, Fung KM, Chung RC (2010) Self-stigma and stages of change as predictors of treatment adherence of individuals with schizophrenia. Psychiatry Res 180(1):10–15. https://doi.org/10.1016/j.psychres.2009.09.001

    Article  PubMed  Google Scholar 

  17. Yılmaz E, Okanlı A (2015) The effect of internalized stigma on the adherence to treatment in patients with schizophrenia. Arch Psychiatr Nurs 29(5):297–301

    Article  PubMed  Google Scholar 

  18. Karidi MV, Vassilopoulou D, Savvidou E, Vitoratou S, Maillis A, Rabavilas A, Stefanis CN (2015) Bipolar disorder and self-stigma: a comparison with schizophrenia. J Affect Disord 184:209–215. https://doi.org/10.1016/j.jad.2015.05.038

    Article  CAS  PubMed  Google Scholar 

  19. Werner P, Stein-Shvachman I, Heinik J (2009) Perceptions of self-stigma and its correlates among older adults with depression: a preliminary study. Int Psychogeriatr/IPA 21(6):1180–1189. https://doi.org/10.1017/S1041610209990470

    Article  Google Scholar 

  20. Lysaker PH, Roe D, Yanos PT (2007) Toward understanding the insight paradox: internalized stigma moderates the association between insight and social functioning, hope, and self-esteem among people with schizophrenia spectrum disorders. Schizophr Bull 33(1):192–199

    Article  PubMed  Google Scholar 

  21. Björkman T, Svensson B, Lundberg B (2007) Experiences of stigma among people with severe mental illness. Reliability, acceptability and construct validity of the Swedish versions of two stigma scales measuring devaluation/discrimination and rejection experiences. Nord J Psychiatry 61(5):332–338

    Article  PubMed  Google Scholar 

  22. Yanos PT, Roe D, Lysaker PH (2010) The impact of illness identity on recovery from severe mental illness. Am J Psychiatr Rehabil 13(2):73–93

    Article  PubMed  PubMed Central  Google Scholar 

  23. Lysaker PH, Roe D, Ringer J, Gilmore EM, Yanos PT (2012) Change in self-stigma among persons with schizophrenia enrolled in rehabilitation: associations with self-esteem and positive and emotional discomfort symptoms. Psychol Serv 9(3):240–247. https://doi.org/10.1037/a0027740

    Article  PubMed  Google Scholar 

  24. Yanos PT, Roe D, Markus K, Lysaker PH (2008) Pathways between internalized stigma and outcomes related to recovery in schizophrenia spectrum disorders. Psychiatr Serv 59(12):1437–1442

    Article  PubMed  PubMed Central  Google Scholar 

  25. Link BG, Cullen FT, Struening E, Shrout PE, Dohrenwend BP (1989) A modified labeling theory approach to mental disorders: An empirical assessment. Am Sociol Rev 54:400–423

    Article  Google Scholar 

  26. Chronister J, Chou C-C, Liao H-Y (2013) The role of stigma coping and social support in mediating the effect of societal stigma on internalized stigma, mental health recovery, and quality of life among people with serious mental illness. J Community Psychol 41(5):582–600. https://doi.org/10.1002/jcop.21558

    Article  Google Scholar 

  27. Muñoz M, Sanz M, Pérez-Santos E, de los Ángeles Quiroga M (2011) Proposal of a socio–cognitive–behavioral structural equation model of internalized stigma in people with severe and persistent mental illness. Psychiatry Res 186(2):402–408

    Article  PubMed  Google Scholar 

  28. Drapalski AL, Lucksted A, Perrin PB, Aakre JM, Brown CH, DeForge BR, Boyd JE (2013) A model of internalized stigma and its effects on people with mental illness. Psychiatr Serv 64(3):264–269. https://doi.org/10.1176/appi.ps.001322012

    Article  PubMed  Google Scholar 

  29. Lv Y, Wolf A, Wang X (2013) Experienced stigma and self-stigma in Chinese patients with schizophrenia. Gen Hosp Psychiatry 35(1):83–88. https://doi.org/10.1016/j.genhosppsych.2012.07.007

    Article  PubMed  Google Scholar 

  30. Chen F-p, Lai GY-C, Yang L (2013) Mental illness disclosure in Chinese immigrant communities. J Couns Psychol 60(3):379

    Article  PubMed  PubMed Central  Google Scholar 

  31. Ran M-S, Chui CH, Wong IY-L, Mao W-J, Lin F-R, Liu B, Chan CL-W (2016) Family caregivers and outcome of people with schizophrenia in rural China: 14-year follow-up study. Soc Psychiatry Psychiatr Epidemiol 51(4):513–520

    Article  PubMed  Google Scholar 

  32. Ran M-S, Weng X, Chan CL-W, Chen EY-H, Tang C-P, Lin F-R, Mao W-J, Hu S-H, Huang Y-Q, Xiang M-Z (2015) Different outcomes of never-treated and treated patients with schizophrenia: 14-year follow-up study in rural China. Br J Psychiatry 207(6):495–500

    Article  PubMed  PubMed Central  Google Scholar 

  33. Ran M-S, Weng X, Liu Y-J, Zhang T-M, Thornicroft G, Davidson L, Chui CH, Hu S-H, Yang X, Lin F-R (2017) Severe mental disorders in rural China: a longitudinal survey. Lancet 390:S37

    Article  Google Scholar 

  34. Ran MS, Chen EY, Conwell Y, Chan CL, Yip PS, Xiang MZ, Caine ED (2007) Mortality in people with schizophrenia in rural China: 10-year cohort study. Br J Psychiatry 190:237–242. https://doi.org/10.1192/bjp.bp.106.025155

    Article  PubMed  Google Scholar 

  35. Ran M, Xiang M, Huang M, Shan Y (2001) Natural course of schizophrenia: 2-year follow-up study in a rural Chinese community. Br J Psychiatry 178(2):154–158

    Article  CAS  PubMed  Google Scholar 

  36. Boyd Ritsher J, Otilingam PG, Grajales M (2003) Internalized stigma of mental illness: psychometric properties of a new measure. Psychiatry Res 121(1):31–49. https://doi.org/10.1016/j.psychres.2003.08.008

    Article  Google Scholar 

  37. Boyd JE, Adler EP, Otilingam PG, Peters T (2014) Internalized stigma of mental illness (ISMI) scale: a multinational review. Compr Psychiatry 55(1):221–231. https://doi.org/10.1016/j.comppsych.2013.06.005

    Article  PubMed  Google Scholar 

  38. Brohan E, Elgie R, Sartorius N, Thornicroft G, Group G-ES (2010) Self-stigma, empowerment and perceived discrimination among people with schizophrenia in 14 European countries: the GAMIAN-Europe study. Schizophr Res 122(1):232–238

    Article  PubMed  Google Scholar 

  39. Young DKW, Ng PYN, Pang J, Cheng D (2015) Validity and reliability of internalized stigma of mental illness (Cantonese). Res Soc Work Pract. 27(1):103–110. https://doi.org/10.1177/1049731515576209

    Article  Google Scholar 

  40. Ran M-S, Zhang T-M, Wong IY-L, Yang X, Liu C-C, Liu B, Luo W, Kuang W-H, Thornicroft G, Chan CL-W (2018) Internalized stigma in people with severe mental illness in rural China. Int J Soc Psychiatry 64(1):9–16

    Article  PubMed  Google Scholar 

  41. Koenig HG, Westlund RE, George LK, Hughes DC, Blazer DG, Hybels C (1993) Abbreviating the Duke Social Support Index for use in chronically ill elderly individuals. Psychosomatics 34(1):61–69

    Article  CAS  PubMed  Google Scholar 

  42. Jia C, Zhang J (2012) Psychometric characteristics of the Duke Social Support Index in a young rural Chinese population. Death Stud 36(9):858–869

    Article  PubMed  PubMed Central  Google Scholar 

  43. Startup M, Jackson MC, Bendix S (2002) The concurrent validity of the Global Assessment of Functioning (GAF). Br J Clin Psychol 41(4):417–422

    Article  PubMed  Google Scholar 

  44. Kay S, Flszbein A, Opfer L (1987) Positive and negative scale for schizophrenia. Schizophr Bull 13(2):463–468

    Article  Google Scholar 

  45. Kay SR, Opler LA, Lindenmayer J-P (1989) The positive and negative syndrome scale (PANSS): rationale and standardisation. Br J Psychiatry 155(S7):59–65

    Article  Google Scholar 

  46. Ran M-S, Mao W-J, Chan CL-W, Chen EY-H, Conwell Y (2015) Gender differences in outcomes in people with schizophrenia in rural China: 14-year follow-up study. Br J Psychiatry 206(4):283–288

    Article  PubMed  PubMed Central  Google Scholar 

  47. Werner P, Aviv A, Barak Y (2008) Self-stigma, self-esteem and age in persons with schizophrenia. Int Psychogeriatr 20(01):174–187

    Article  PubMed  Google Scholar 

  48. Evans-Lacko S, Brohan E, Mojtabai R, Thornicroft G (2012) Association between public views of mental illness and self-stigma among individuals with mental illness in 14 European countries. Psychol Med 42(8):1741–1752. https://doi.org/10.1017/S0033291711002558

    Article  CAS  PubMed  Google Scholar 

  49. Yen C-F, Chen C-C, Lee Y, Tang T-C, Yen J-Y, Ko C-H (2005) Self-stigma and its correlates among outpatients with depressive disorders. Psychiatr Serv 56(5):599–601

    Article  PubMed  Google Scholar 

  50. Mueller B, Nordt C, Lauber C, Rueesch P, Meyer PC, Roessler W (2006) Social support modifies perceived stigmatization in the first years of mental illness: a longitudinal approach. Soc Sci Med 62(1):39–49

    Article  PubMed  Google Scholar 

  51. Corrigan PW, Rao D (2012) On the self-stigma of mental illness: Stages, disclosure, and strategies for change. Can J Psychiatry 57(8):464–469

    Article  PubMed  Google Scholar 

  52. Kleinman A, Kleinman J (1993) Face, favor and families: the social course of mental health problems in Chinese and American societies. Chin J Mental Health 6(1):37–47

    Google Scholar 

  53. Mak WW, Ho CY, Wong VU, Law RW, Chan RC (2015) Cultural model of self-stigma among Chinese with substance use problems. Drug Alcohol Depend 155:83–89. https://doi.org/10.1016/j.drugalcdep.2015.08.011

    Article  PubMed  Google Scholar 

  54. Yang LH, Kleinman A (2008) ‘Face’ and the embodiment of stigma in China: the cases of schizophrenia and AIDS. Soc Sci Med 67(3):398–408. https://doi.org/10.1016/j.socscimed.2008.03.011

    Article  PubMed  PubMed Central  Google Scholar 

  55. Read J, Haslam N, Sayce L, Davies E (2006) Prejudice and schizophrenia: a review of the ‘mental illness is an illness like any other’ approach. Acta Psychiatr Scand 114(5):303–318. https://doi.org/10.1111/j.1600-0447.2006.00824.x

    Article  CAS  PubMed  Google Scholar 

Download references

Acknowledgements

The authors thank all the collaborative institutes (e.g., Peking University, Sichuan College of Traditional Chinese Medicine, Xinjin Mental Hospital, Chengdu Mental Health Center, Sichuan Veterans Hospital, Jingzhou Mental Health Center, Guangyuan Mental Health Center, Southwest Medical University, Chongqing Medical University, Chengdu Mental Hospital, Panzhihua Mental Health Center, Santai Mental Health Center) and CMHP Study group for collaboration, support and data collection.

Funding

The mental health survey in 2015 was supported in part by Seed Funding Programme for Basic Research (HKU, 2014–2016, PI: Ran), Seed Funding Programme for Applied Research (HKU, 2014–2016, PI: Ran), Strategic Research Theme: Contemporary China Seed Funding (HKU, 2014–2016, PI: Ran), Small Project Funding (HKU, 2014–2016, PI: Chan), and Mental Health Research in Chengdu, China (Dept. Matching Fund, 2015–2017, PI: Ran).

Author information

Authors and Affiliations

  1. Department of Social Work and Social Administration, The University of Hong Kong, Hong Kong, China

    Tian-Ming Zhang, Yue-Hui Yu, Cecilia Lai-Wan Chan & Mao-Sheng Ran

  2. School of Social Policy and Practice, University of Pennsylvania, Philadelphia, PA, USA

    Irene Yin-Ling Wong

  3. Graduate School at Shenzhen, Tsinghua University, Shenzhen, China

    Shi-Guang Ni

  4. School of Society and Public Administration, East China University of Science and Technology, Shanghai, China

    Xue-Song He

  5. Social Sciences Research Centre, Faculty of Social Sciences, The University of Hong Kong, Hong Kong, China

    John Bacon-Shone

  6. Department of Psychiatry, Southwest Medical University, Sichuan, China

    Ke Gong & Chao-Hua Huang

  7. Sichuan Veterans Hospital, Sichuan, China

    Yan Hu & Ming-Min Tang

  8. Chongqing Medical University, Chongqing, China

    Wan Cao

Authors
  1. Tian-Ming Zhang
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Irene Yin-Ling Wong
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Yue-Hui Yu
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Shi-Guang Ni
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Xue-Song He
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. John Bacon-Shone
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Ke Gong
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Chao-Hua Huang
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Yan Hu
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Ming-Min Tang
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. Wan Cao
    View author publications

    You can also search for this author in PubMed Google Scholar

  12. Cecilia Lai-Wan Chan
    View author publications

    You can also search for this author in PubMed Google Scholar

  13. Mao-Sheng Ran
    View author publications

    You can also search for this author in PubMed Google Scholar

Consortia

CMHP Study Group

Contributions

Dr. Ran designed the study and Miss. Zhang wrote the first draft. The draft was modified by Dr. Wong, Dr. Ran, Mrs. Yu, Dr. Ni, Prof. He, Prof. Chan. and Prof. Bacon-Shone. In addition, Dr. Gong, Dr. Huang, Ms. Hu, Ms. Tang, and Dr. Cao made contribution to the data collection. The data were derived from Dr. Ran’s Chengdu Mental Health Project (CMHP). All authors made a significant intellectual contribution to the paper.

Corresponding author

Correspondence to Mao-Sheng Ran.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Zhang, TM., Wong, I.YL., Yu, YH. et al. An integrative model of internalized stigma and recovery-related outcomes among people diagnosed with schizophrenia in rural China. Soc Psychiatry Psychiatr Epidemiol 54, 911–918 (2019). https://doi.org/10.1007/s00127-018-1646-3

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00127-018-1646-3

Keywords

Search

Navigation