Cognitive Behavioral Therapy Group for Reducing Self-Stigma for People With Mental Illness

Abstract

This research project aims to evaluate the effectiveness of a cognitive behavioral therapeutic (CBT) group in reducing self-stigma for people with mental illness in Chinese society. In this study, a quasi-experimental research method was adopted involving 71 people with mental illness receiving community-based mental health services. In total, 33 treatment group participants were assigned to a 10-session CBT group, while 38 control group participants received treatment as usual. Standardized assessment tools were used to collect data in the pre- and posttreatment periods by a research assistant. Analysis of covariance demonstrated that the CBT group was significantly more effective than the control group in terms of reducing self-stigma and depressive mood, with a moderate effect size, even after controlling for differences in various demographic variables between the treatment and control groups. This study provides evidence to support the efficacy and effectiveness of a CBT group for reducing self-stigma for people with mental illness.

Keywords

self-stigma mental illness cognitive behavioral therapy group Chinese culture

In Chinese society, it is fairly common for persons with mental illness to experience social stigma. For example, local surveys in Hong Kong reported that more than half of persons with mental illness felt that they had experienced social stigma and discrimination (Chung & Wong, 2004; Lee, Lee, Chiu, & Kleinman, 2005). Additionally, stigmatizing attitudes are found to be common among Chinese community residents (Tsang, Tam, Chan, & Cheung, 2003), employers (Tsang et al., 2007), family caregivers (Lee et al., 2005), and mental health professionals (Chien, Yeung, & Chan, 2014; Lee, Chiu, Tsang, Chui, & Kleinman, 2006), such that persons with mental illness are perceived as quick-tempered, unpredictable, dangerous, abnormal, weird, and introverted and are believed to have low self-esteem (Chien et al., 2014; Lee et al., 2005; Tsang et al., 2003, 2007). One consequence of social stigma is that persons with mental illness often internalize these stigmatizing beliefs and ultimately stigmatize themselves (Corrigan, Watson, & Barr, 2006).

The problem of self-stigma is common among people with mental illness. Recent studies have reported that 41.7% of mental health-care consumers in Europe (Brohan, Elgie, Sartorius, & Thornicroft, 2010), 36.1% of mental health-care consumers in the United States (West, Yanos, Smith, Roe, & Lysaker, 2011), and 38.8% of mental health-care consumers in Hong Kong have self-stigma (Young & Ng, 2015). Self-stigma is found to have a negative impact on the consumer’s life, such as reducing self-esteem and quality of life, while increasing depressive and psychiatric symptoms in Western (Boyd, Adler, Otilingam, & Peters, 2014; Corrigan et al., 2006; Gerlinger et al., 2013; Livingston & Boyd, 2010; Ritsher, Otilingam, & Grajiales, 2003) and Chinese societies (Fung, Tsang, Corrigan, Lam, & Cheng, 2007; Tang & Wu, 2012; Young, Ng, Pan, & Cheng, 2015).

As self-stigma has adverse effects on individuals’ lives, it is important to develop therapeutic interventions to reduce self-stigma in people with mental illness. Several pilot studies conducted in Western countries suggest that it is feasible to reduce self-stigma in people with mental illness through short-term therapeutic groups (Lucksted et al., 2011; Macinnes & Lewis, 2008). Cognitive behavioral therapy is recommended to help people with mental illness reduce self-stigma (Corrigan, Rao, & Tsang, 2011).

Cognitive Behavioral Therapeutic (CBT) Groups in Reducing Self-Stigma

A cognitive model of self-stigmatization has been proposed by Corrigan and colleagues (Corrigan et al., 2006, 2011; Corrigan & Sokol, 2012). The process of self-stigmatization involves four progressive stages of cognitive processes. At the first stage of awareness, a person with mental illness is aware of the public’s stigmatizing beliefs on mental illness (e.g., the public’s belief that people with mental illness are useless and become burdens on their family). At the second stage of agreement, he or she agrees that the public’s negative stigmatizing beliefs are true (e.g., I agree that people with mental illness are useless and become burdens on their family). At the third stage of self-concurrence, the person concurs that these stigmatizing beliefs apply to him or her (e.g., I am useless and have become a burden on my family). Subsequently, at the final stage of self-esteem decrement, the person suffers from a decrease in self-esteem and other harm. The degree of self-concurrence of these stigmatized beliefs varies among individuals; thus, individual differences exist in their self-stigmatized beliefs.

According to this cognitive model of self-stigma, self-stigmatized beliefs are regarded as irrational beliefs upheld by a person with mental illness, which lead to his or her decrease in self-esteem (Corrigan & Rao, 2012; Fung et al., 2007). Thus, cognitive behavioral therapy and related intervention techniques, such as cognitive restructuring, have been recommended to help a person with mental illness challenge these irrational self-stigmatizing beliefs and replace them with more rational and positive beliefs (e.g., I can take care of myself and perform household duties properly. Thus, I am neither useless nor a burden on my family; Fung, Tsang, & Cheung, 2011; Knight, Wykes, & Hayward, 2006; Lucksted et al., 2011; Macinnes & Lewis, 2008). Research evidence has supported the above cognitive model of self-stigma (Corrigan et al., 2006; Fung et al., 2007) and suggested that the reduction of self-stigmatizing beliefs is related to an increase in self-esteem (Macinnes & Lewis, 2008) and decrease in depressive mood (Shimotsu et al., 2014).

Several studies have been conducted to support the efficacy of CBT groups in reducing self-stigma in people with mental illness (Knight et al., 2006; Macinnes et al., 2008; Shimotsu et al., 2014). For example, a wait-list control study on a seven-session CBT group conducted with 21 outpatients with mental illness in South London, UK, reported that the CBT group was effective in increasing self-esteem and in reducing depressive mood in participants (Knight et al., 2006). Another study of a six-session CBT group conducted with 20 inpatients with mental illness in London, UK, reported that the CBT group was effective in reducing self-stigma in participants (Macinnes et al., 2008). Another study on a 10-session CBT group conducted with 46 outpatients with mood disorders in Miyazaki Prefecture, Japan, reported that the CBT group was effective in reducing self-stigma and depressive mood in participants (Shimotsu et al., 2014).

However, the generalizability of the research results is limited by the nonrandomized research designs, small sample sizes, and cultural differences. Additionally, the research findings on the effectiveness of CBT groups at reducing self-stigma in people with mental illness remain inconclusive (Griffiths et al., 2014). For example, a randomized control study on a 12-session CBT group with 34 Chinese people with mental illness failed to report the effectiveness of the CBT group in reducing self-stigma (Fung et al., 2011). Moreover, the long-term effects of CBT groups at reducing self-stigma have not been investigated. Thus, more studies are needed in this area.

However, traditional Chinese cultural values play a significant role in the stigmatization of mental illness and the development of self-stigma in people with mental illness (Fabrega, 1991; Lam et al., 2010; Young & Ng, 2015). Due to the stigmatization of mental illness by traditional Chinese cultural values, especially Confucianism, people with mental illness are perceived not to be competent members of society, failing to comply with the five cardinal relationships and duties proposed by Confucianism, and subsequently becoming a “disgrace” to the family and social systems (Lam et al., 2010; Young & Ng, 2015). In addition, the concept of “fate,” which reflects an individual’s acceptance of one’s role as unchangeable destiny determined by Transcendence, exacerbates the internalization of public stigma and development of self-stigma (Ng, Tsun, Su, & Young, 2013). Moreover, relatives of people with mental illness also experience disgrace within the community, which leads to their rejection and blame of people with mental illness (Mak & Cheung, 2012; Philips, Pearson, Li, Xu, & Yang, 2002). Under such cultural influences, people with mental illness are likely to endorse social stigma and to develop self-stigma. Thus, it is important for CBT groups to address these specific needs of Chinese persons with mental illness by helping them alter their self-stigmatizing beliefs, which are greatly influenced by Chinese culture.

Additionally, studies have suggested the following four essential therapeutic components of CBT groups related to their effectiveness at reducing self-stigma. First, it has been suggested that cognitive intervention skills, such as cognitive restructuring, can alter irrational stigmatized beliefs and replace them with more positive and rational beliefs in participants (Corrigan et al., 2006; Fung et al., 2011; Knight et al., 2006; Mittal, Sulivan, Chekuri, Allee, & Corrigan, 2012; Shimotsu et al., 2014). Second, it has been suggested that CBT groups can strengthen positive views of oneself (Lucksted et al., 2011). Replacing self-stigmatized beliefs with positive beliefs of oneself as well as recognizing one’s own strengths can enhance self-acceptance (Macinnes et al., 2008), self-concept (Fung et al., 2011), self-efficacy (Corrigan et al., 2006), and self-esteem (Knight et al., 2006). Third, it has been suggested that behavioral intervention skills, especially social skills training and practice assignments, can improve participants’ coping skills with social stigma (Fung et al., 2011; Lucksted et al., 2011; Mittal et al., 2012). These newly learned social skills can facilitate participants’ self-competency to address stigmatized social situations (Fung et al., 2011; Lucksted et al., 2011). Fourth, it has been suggested that CBT groups can improve social support among participants (Lucksted et al., 2011), which in turn can enhance a sense of belonging, sense of self-worth, sharing of resources and skills to respond to public stigma (Lucksted et al., 2011), and most importantly reduce self-stigma (Corrigan & Rao, 2012). Thus, it is important for CBT groups to include the above elements to help participants reduce self-stigma.

This research project thus aimed to develop a structured and short-term CBT group model for reducing self-stigma in Chinese persons with mental illness and to evaluate its effectiveness. The CBT group model involved in this study included the following group components, which were believed to be essential elements for reducing self-stigma in participants, including the following: (1) altering stigmatized beliefs, especially those self-stigmatizing beliefs that are greatly influenced by Chinese culture, by using cognitive restructuring techniques; (2) developing positive beliefs about oneself and recognizing one’s own strengths; (3) social skills training on responding to public stigmatizing situations; and (4) enhancing social support among participants (Corrigan et al., 2006; Corrigan & Rao, 2012; Fung et al., 2011; Knight et al., 2006; Lucksted et al., 2011; Mittal et al., 2012; Ng et al., 2013; Shimotsu et al., 2014; Young & Ng, 2015). Moreover, these elements of CBT groups can produce other positive effects for participants. In particular, replacing irrational, stigmatized beliefs with more positive and rational beliefs can reduce depressive mood (Shimotsu et al., 2014). Reducing self-stigmatized beliefs and replacing them with positive beliefs of oneself as well as recognizing one’s strengths can enhance self-esteem (Knight et al., 2006). Thus, it is hypothesized in this study that the CBT group model could help people with mental illness to reduce self-stigma, enhance self-esteem, and reduce depressive mood.

Research Design

In this study, a quasi-experimental design was adopted. Participants were recruited from community-based mental health services operated by nongovernmental organizations. Participants who provided their consent to participate in this research project were assigned to a treatment group or a control group. Standardized assessment tools were used for data collection at the pre- and posttreatment periods by a research assistant.

Subject Inclusion Criteria

In this study, the inclusion criteria were as follows: (a) they were aged 18 years or older, (b) they had received a diagnosis of any type of mental disorder according to the Diagnostic and Statistical Manual of Mental Disorders (Fifth edition; American Psychiatric Association, 2013), and (c) they were receiving services from an integrated community center for mental wellness, including community-based mental health services provided by a local nongovernmental organization. Those who reported having no and very low self-stigma (i.e., Internalized Stigma of Mental Illness [ISMI] score < 36) were excluded.

Treatment and Control Group

In addition to usual services provided by an integrated community center for mental wellness, the treatment group attended a 10-session CBT group that was held at multiple sites in Hong Kong. Each session was conducted once per week and lasted 90 min on average (please refer to Table 1 for an outline of the CBT group content). A standardized group manual was produced by the researcher for use in the group intervention. The social worker who led the treatment groups was given the manual and provided training by the researcher. Additionally, the researcher provided regular supervision to the social worker to ensure that the standardized manual was properly and fully implemented. Control group participants received treatment as usual, that is, received usual services provided by an integrated community center for mental wellness such as case management, educational workshops, and leisure activities.

Table 1.

Outline of CBT Group Content.

Session	Theme	CBT skills involved
1	Acknowledging each other; sharing the experience of social stigma	Building collaborating relationships
2	Introducing ABC model	ABC cognitive model relates antecedent, beliefs, feelings, and behavior
3	Disputing public stigmatizing beliefs	Using cognitive restructuring techniques (such as guided discovery) to dispute on public stigmatized beliefs
4	Mental illness is not my fault	Using cognitive restructuring techniques (such as “pie chart”) for depersonalizing the cause of mental illness
5	Having mental illness is not my fate	Using techniques of cognitive restructuring (such as “normalization”) and “behavioral experiment” to dispute against beliefs on fate and hopelessness
6	I am not a family burden	Using techniques of cognitive restructuring (such as “scaling questioning”) and behavioral experiment to dispute the beliefs on becoming family burden
7	I can make contributions	Using techniques of restructuring (such as guided discovery) and behavioral experiment to explore one’s potential, ability, and contribution
8	No fear on public stigma	Using “relaxation” techniques to break the cycle of worry
9	Self-protection strategies in practice	Learn to be assertive in face of social stigma through “social skill training”
10	Summary and review	Summarizing various CBT skills

Note. CBT = cognitive behavioral therapeutic.

Outcome Assessment Tools

The ISMI Scale has been validated to assess self-stigma in people with mental illness (Ritsher et al., 2003) and has been widely used internationally (Boyd et al., 2014). In this study, the 24-item ISMI was used to measure changes in self-stigma. The construct validity of the Chinese version of the ISMI (24 items) was confirmed, in addition to its strong internal consistency (α = .93; Young et al., 2015). Item scores were averaged, with a higher score indicating greater self-stigma. As suggested by previous studies (Brohan et al., 2010; Ritsher et al., 2003), the cutoff point on the ISMI is 2.5, which was adopted in the present study.

The Self-Stigma of Mental Illness Scale (SSMIS) has been validated to assess self-stigma in people with mental illness, and it consists of four subscales such as Stereotype Awareness, Stereotype Agreement, Stereotype Self-Concurrence, and Self-Esteem Decrement (Corrigan et al., 2006). Each subscale contains 10 items, and each item is rated on a 9-point scale measuring level of agreement (9 = strongly agreed). The construct validity of the Chinese version of the SSMIS has been confirmed, with satisfactory internal consistency (α = .72–.91) and test–retest reliability (r = .68–.82; Fung et al., 2007). In this study, in view of the results of previous studies, the SSMIS Self-Concurrence (SSMIS-SC) subscale was used to measure the changes in self-stigma, while the SSMIS Self-Esteem Decrement (SSMIS-SED) subscale was used to measure the effect of self-stigma on self-esteem.

The Rosenberg Self-Esteem Scale (RSES) has been widely used in many countries and has been translated into many languages including Chinese. It consists of 10 items. Each item is rated on a 4-point scale with scores ranging from strongly agree to strongly disagree. The reliability and validity of the Chinese version of the RSES has been tested to be acceptable (α = .63; Leung & Wong, 2008).

The Beck Depression Inventory (BDI) is a widely used assessment scale to measure self-reported depression (Beck, Steer, & Brown, 1996). The reliability and validity of the BDI (Chinese version) has been tested to be good (α = .91; Byrne, Stewart, & Lee, 2004).

Data Analysis

Statistical analyses were performed using SPSS 22.0 (IBM Corp, 2013). The baseline demographic and clinical characteristics between the treatment and control groups were compared using χ² tests for categorical variables and analysis of variance (ANOVA) for continuous variables. Last observation carried forward analysis was used for missing data. A paired-sample t-test was used to analyze the significant changes in the pre- and posttreatment scores of self-stigma and other assessment scores for both treatment and control groups. Confidence intervals (CIs) of all statistically significant effects were reported. To investigate the magnitude of the treatment effect, the outcome measure was analyzed using the general linear model analysis of covariance (ANCOVA) for comparing the changes in self-stigma and other assessment scores between the treatment and control groups, controlling for group differences in most demographic variables such as age, sex, marital status, education, diagnosis, period of illness, and number of hospitalizations. The effect sizes were calculated using the partial η². For partial η², the values of 0.01, 0.06, and 0.14 indicated small, moderate, and large effects, respectively (Cohen, 1988). The identification of baseline variables relating to the improvement of self-stigma scores was conducted using a one-way ANOVA for the categorical variables and Spearman’s ρ correlation for the continuous variables due to the small sample size. For all analyses, two-tailed p values <.05 indicated statistical significance.

Ethical Considerations

The ethical considerations of this study were evaluated and approved by the Research Committee of the Hong Kong Baptist University (ref. no: HASC/15-16/0037). Written informed consent was obtained from all participants on the day of the pretreatment assessment.

Research Result

In total, 78 participants with mental illness were recruited from the local community-based mental health centers. Figure 1 illustrates the recruitment procedure. After excluding 7 participants whose ISMI score <36, 33 participants took part in the treatment group, while 38 were in the control group. Four treatment groups and four control groups were formed, respectively. Each treatment group consisted of 6–10 participants with mental illness. Four participants dropped out of the treatment group, while 29 participants completed the treatment group with an overall attendance rate of 87.8%. Two participants who completed the treatment group did not complete the posttreatment assessment, and one participant in the control group did not complete the posttreatment assessment.

Figure 1.

Flow of participants through each stage of the study.

Characteristics of Research Sample

The demographic and clinical characteristics of the studied participants are shown in Table 2. Analyses from the t-test and χ² test showed no significant differences between the treatment and control groups in all baseline demographic variables, except one. The treatment group had a mean age of 50.3 years (SD = 10.2), which was significantly older than the control group whose mean age was 45.3 years (SD = 10.3).

Table 2.

Demographic and Clinical Characteristics of Study Participants.

Characteristics	Valid Data	Treatment Group (n = 33)	Control Group (n = 38)	Total (n = 71)	χ²	p Value
Characteristics	Valid Data	n (%)	n (%)	n (%)	χ²	p Value
Gender^a	71				2.678	.10
Male		3 (9.1)	9 (23.7)	12 (16.9)
Female		30 (90.9)	29 (76.3)	59 (83.1)
Diagnosis^a	71				0.986	.91
Schizophrenia		8 (24.2)	11 (28.9)	19 (26.8)
Depression		15 (45.5)	18 (47.4)	33 (46.5)
Anxiety		3 (9.1)	4 (10.5)	7 (9.9)
Bipolar affective disorder		5 (15.2)	4 (10.5)	9 (12.7)
Others		2 (6.1)	1 (2.6)	3 (4.2)
Marital status^a	71				5.804	.06
Single		17 (51.5)	17 (44.7)	34 (47.9)
Married		13 (39.4)	9 (23.7)	22 (31.0)
Divorce, separated, widowed		3 (9.1)	12 (31.6)	15 (21.1)
Education level^a	71				0.541	.91
Postsecondary		8 (24.2)	9 (23.7)	17 (23.9)
Secondary		17 (51.5)	21 (55.3)	38 (53.5)
Primary		6 (18.2)	7 (18.4)	13 (18.3)
None		2 (6.1)	1 (2.6)	3 (4.2)
Occupational status^a	71				2.604	.27
OE (FT/PT)		7 (21.2)	3 (7.9)	10 (14.1)
SW/SE		2 (6.1)	3 (7.9)	5 (7.0)
Unemployed, housewife, retired		24 (72.7)	32 (84.2)	56 (78.9)
Place of residence^a	71				7.087	.07
Public housing		13 (39.4)	24 (63.2)	37 (52.1)
Private housing		19 (57.6)	11 (28.9)	30 (42.3)
Half-way house		0 (0.0)	2 (5.3)	2 (2.8)
Other		1 (3.0)	1 (2.6)	2 (2.8)
		Mean (SD)	Mean (SD)	Mean (SD)	t (p)	95% CI of the Difference
Age^b	71	50.27 (10.18)	45.26 (10.25)	47.59 (10.45)	2.060 (.04)*	[0.16, 9.86]
Period of illness^b	71	13.38 (10.30)	11.16 (9.73)	12.19 (9.99)	.917 (.36)	[−2.61, 7.03]
Number of hospitalizations^b	71	1.22 (2.18)	1.76 (2.55)	1.51 (2.39)	−.933 (.35)	[−1.69, .613]

Note. CI = confidence Interval; OE (FT/PT) = open employment (full time/part time); SW/SE = sheltered workshop/supported employment; government fin. Support = government financial support.

^aPearson χ². ^bIndependent sample t-test.

*p = < .05.

Considering all participants, most of the participants were female (83.1%), had attained a secondary school level of education (53.5%), and had a mean age of 47.6 years (SD = 10.5). Nearly half (47.9%) were single, and one third were married (31.0%), while the remaining participants were divorced, widowed, or separated (21.1%). Half of them were living in public housing (52.1%), and two fifths were living in a privately owned flat (42.3%), while only a few (2.8%) were living in psychiatric halfway houses. The majority of participants (78.9%) were unemployed, housewives, or retired, and only one seventh (14.1%) were engaged in full-time or part-time employment. Nearly half of the participants were diagnosed with depression (46.5%), followed by schizophrenia (26.8%), bipolar (12.7%), and anxiety disorders (9.9%). The majority of participants (85.5%) had suffered from a mental illness for 3 years or more, with a mean of 12.2 years (SD = 10.0). Most participants (71.0%) had been hospitalized for their mental illness 1 or more times, with a mean of 1.5 times (SD = 2.4).

Baseline Self-Stigma and Other Assessment Scores

The baseline outcome measures of the participants are shown in Table 3. The t-test and 95% CI showed no significant differences between the treatment and control groups in all baseline outcome assessment scores, including ISMI, SSMIS-SC, SSMIS-SED, RSES, and BDI. Additionally, participants who dropped out of the treatment group did not show any significant differences in any of the baseline demographic variables and outcome assessment scores compared to the participants who did not drop out of the treatment group.

Table 3.

Baseline Self-Stigma and Other Assessment Scores of the Cognitive Behavioral Therapeutic Versus Control Groups.

Baseline variables	Valid Data	Treatment Group (n = 33)	Control Group (n = 38)	Total (n = 71)	t (p)	95% CI of the Difference
Baseline variables	Valid Data	Mean (SD)	Mean (SD)	Mean (SD)	t (p)	95% CI of the Difference
ISMI^b	71	2.62 (0.51)	2.52 (0.46)	2.57 (0.48)	0.816 (.42)	[−0.14, 0.32]
Shame^b	71	2.89 (0.62)	2.74 (0.65)	2.81 (0.63)	0.980 (.33)	[−0.15, 0.45]
Stereotype endorsement^b	71	2.27 (0.49)	2.30 (0.46)	2.28 (0.47)	−0.255 (.80)	[−0.25, 0.19]
Perceived discrimination^b	71	2.62 (0.68)	2.54 (0.61)	2.57 (0.64)	0.532 (.60)	[−0.22, 0.39]
Social withdrawal^b	71	2.75 (0.69)	2.56 (0.59)	2.65 (0.64)	1.278 (.21)	[−0.11, 0.50]
SSMIS-SC^b	71	38.97 (13.55)	41.84 (16.03)	40.51 (14.89)	−0.809 (.42)	[−9.96, 4.21]
SSMIS-SED^b	71	37.80 (15.60)	40.34 (19.29)	39.16 (17.58)	−0.605 (.55)	[−10.93, 5.84]
RSES^b	71	24.30 (2.44)	24.11 (1.83)	24.20 (2.12)	0.389 (.70)	[−0.82, 1.21]
BDI^b	71	24.58 (15.09)	26.52 (16.11)	25.62 (15.56)	0.831 (.41)	[−1.80, 4.36]
		n (%)	n (%)	n (%)	χ² (p)
Having depression (BDI ≥ 14)^a	71	24 (72.7)	30 (78.9)	54 (76.1)	.375 (.54)
BDI < 14		9 (27.3)	8 (21.1)	17 (23.9)
BDI: 14–19		5 (15.2)	5 (13.2)	10 (14.1)
BDI: 20–28		8 (24.2)	12 (31.6)	20 (28.2)
BDI ≥ 29		11 (33.3)	13 (34.2)	24 (33.8)
Having self-stigma (ISMI ≥ 2.5)^a	71	20 (60.6)	20 (52.6)	40 (56.3)	.457 (.50)

Note. CI = confidence interval; ISMI= Internalized Stigma of Mental Illness Scale Self-Stigma subscale; RSES= Rosenberg Self-Esteem Scale; BDI = Beck Depression Inventory; SSMIS-SC: Self-Stigma of Mental Illness Scale Self-Concurrence subscale; SSMIS-SED = Self-Stigma of Mental Illness Scale Self-Esteem Decrement subscale.

^aPearson χ². ^bIndependent sample t-test.

*Significant at p < .05.

Considering all participants, nearly half (56.3%) of the participants reported self-stigma as assessed by the ISMI (i.e., ISMI ≥ 2.5). Among the four subscales of the ISMI, participants ranked shame/alienation the highest (M = 2.81, SD = 0.63), followed by social withdrawal (M = 2.65, SD = 0.64) and perceived discrimination (M = 2.57, SD = 0.64), while stereotype endorsement was ranked the lowest (M = 2.28, SD = 0.47). Additionally, participants reported a moderate level of self-concurrence, as assessed by the SSMIS-SC (M = 40.51, SD = 14.89), and subsequently manifested a moderate level of self-esteem decrement on the SSMIS-SED (M = 39.16, SD = 17.58). Additionally, three quarters (76.1%) of participants were found to have depressive mood, as assessed by the BDI (i.e., BDI score ≥ 14).

Additionally, the ISMI score was found to be significantly positively related to the SSMIS-SC score (Spearman’s ρ = .637, p < .001), SSMIS-SED score (ρ = .602, p < .001), and BDI score (ρ = .565, p < .001), as well as negatively related to the RSES score (ρ = −.277, p < .05). The SSMIS-SC score was significantly positively related to the SSMIS-SED score (ρ = .518, p < .001) and BDI score (ρ = .512, p < .001) and was negatively related to the RSES score (ρ = −.264, p < .05).

Treatment Outcomes

Table 4 summarizes the changes in ISMI scores and outcome measures of both treatment and control groups. The results of the paired t-test and 95% CI demonstrated that after completing the CBT group intervention, the treatment group showed significant improvement on all outcome assessments, including ISMI, SSMIS-SC, SSMIS-SED, BDI, and RSES, while the control group did not show any significant changes in any of the outcome assessments. In particular, the ISMI score of the treatment group decreased from 2.62 (SD = 0.51) to 2.30 (SD = 0.56), which was significant (t = −3.69, p < .01), and the mean decrease in ISMI score was −.32 (95% CI [−0.50, −0.14]). The SSMIS-SC score of the treatment group decreased from 38.97 (SD = 13.55) to 32.78 (SD = 13.56), which was significant (t = −3.41, p < .01), and the mean decrease in SSMIS-SC score was −6.19 (95% CI [−9.98, −2.49]). The SSMIS-SED score of the treatment group decreased from 37.80 (SD = 15.58) to 31.83 (SD = 16.95), which was significant (t = −2.55, p < .05), and the mean decrease in SSMIS-SED score was −5.97 (95% CI [−10.73, −1.21]). The BDI score of the treatment group decreased from 24.58 (SD = 15.09) to 17.74 (SD = 15.83), which was significant (t = −3.60, p < .01), and the mean decrease in BDI score was −6.84 (95% CI [−10.72, −2.97]). The RSES score of the treatment group increased from 24.30 (SD = 2.44) to 25.58 (SD = 3.16), which was significant (t = 2.50, p < .05), and the mean increase in RSES score was 1.27 (95% CI [0.23, 0.231]).

Table 4.

Pretest, Posttest, and Comparison of Change Score on Self-Stigma and Other Assessment Scores Between Treatment and Control Group.

	Treatment Group (n = 33)	t (p)	Control Group (n = 38)	t (p)	F (p)	Partial η²
	Mean (SD)	t (p)	Mean (SD)	t (p)	F (p)	Partial η²
ISMI
Pretest	2.62 (0.51)	−3.690 (.001)**	2.52 (0.46)	0.004 (.997)	5.552 (.022)*	.086
Posttest	2.30 (0.56)		2.52 (0.48)
Change score	−0.32 (0.50)		0.00 (0.40)
95% CI of the change score	[−.50, −.14]		[−0.13, 0.13]
ISMI-Sh
Pretest	2.89 (0.62)	−3.810 (.001)**	2.74 (0.65)	0.786 (.437)	8.911 (.004)**	.131
Posttest	2.52 (0.71)		2.81 (0.59)
Change score	−0.37 (0.55)		0.07 (0.55)
95% CI of the change score	[−0.56, −0.17]		[−0.11, 0.25]
ISMI-SE
Pretest	2.27 (0.49)	−3.354 (.002)**	2.30 (0.46)	−0.889 (.380)	1.593 (.212)	.026
Posttest	2.04 (0.52)		2.23 (0.55)
Change score	−0.22 (0.38)		−0.068 (0.47)
95% CI of the change score	[−0.36, −0.09]		[−0.22, 0.09]
ISMI-PD
Pretest	2.62 (0.68)	−2.196 (.035)*	2.54 (0.61)	−0.012 (.990)	3.475 (.067)	.056
Posttest	2.33 (0.69)		2.54 (0.55)
Change score	−0.28 (0.75)		−0.00 (0.65)
95% CI of the change score	[−0.55, −0.02]		[−0.22, 0.21]
ISMI-SW
Pretest	2.75 (0.69)	−3.337 (.002)**	2.56 (0.59)	0.132 (.895)	2.832 (.098)	.046
Posttest	2.34 (0.76)		2.57 (0.57)
Change score	−0.29 (0.75)		0.011 (0.53)
95% CI of the change score	[−0.67, −0.16]		[−0.16, 0.19]
SSMIS-SC
Pretest	38.97 (13.55)	−3.407 (.002)*	41.84 (16.03)	−0.479 (.635)	4.414 (.040)*	.070
Posttest	32.78 (13.56)		41.05 (15.76)
Change score	−6.19 (10.44)		−0.79 (10.16)
95% CI of the change score	[−9.89, −2.49]		[−4.13, 2.55]
SSMIS-SED
Pretest	37.80 (15.58)	−2.554 (.016)*	40.59 (16.87)	0.099 (.922)	4.855 (.031)*	.076
Posttest	31.83 (16.95)		40.34 (19.29)
Change score	−5.97 (13.43)		0.24 (15.12)
95% CI of the change score	[−10.73, −1.21]		[−4.73, 5.21]
BDI
Pretest	24.58 (15.09)	−3.601 (.001)**	26.52 (16.11)	−1.834 (.075)	4.078 (.048)*	.065
Posttest	17.74 (15.83)		24.36 (16.04)
Change score	−6.84 (10.92)		−2.16 (7.25)
95% CI of the change score	[−10.72, −2.97]		[−4.54, 0.23]
RSES
Pretest	24.30 (2.44)	2.496 (.018)*	24.84 (2.79)	1.527 (.135)	1.760 (.190)	.029
Posttest	25.58 (3.16)		24.11 (1.83)
Change score	1.27 (2.93)		0.74 (2.98)
95% CI of the change score	[0.23, 2.31]		[−0.24, 1.72]

Note. CI = confidence interval; t = paired-sample t-test; F = analysis of covariance controlling for age, sex, marital status, education, diagnosis, period of illness, number of hospitalization, and baseline score; ISMI = Internalized Stigma of Mental Illness Scale self-stigma subscale; ISMI-Sh= Shame subscale of ISMI; ISMI-SE= Stereotype Endorsement subscale of ISMI; ISMI-PD= Perceived Discrimination subscale of ISMI; ISMI-SW= Social Withdrawal subscale of ISMI; RSES= Rosenberg Self-Esteem Scale; BDI: Beck Depression Inventory; SSMIS-SC: Self-Stigma of Mental Illness Scale Self-Concurrence subscale; SSMIS-SED: Self-Stigma of Mental Illness Scale Self-Esteem Decrement subscale; p = p value.

*Significant at p < .05. **Significant at p <. 01.

The results of the ANOVA indicated that after controlling for differences between the treatment and control groups in demographic variables such as age, sex, marital status, education, diagnosis, number of hospitalizations, and period of illness as well as baseline outcome assessment scores, the treatment group was significantly more effective than the control group in the following: reducing ISMI total scores (F = 5.55, p < .05) with a moderate effect size (partial η² =.09), reducing SSMIS-SC scores (F = 4.41, p < .05) with a moderate effect size (partial η² =.07), reducing SSMIS-SED scores (F = 4.86, p < .05) with a moderate effect size (partial η² =.08), and reducing BDI scores (F = 4.08, p < .05) with a moderate effect size (partial η² =.07). However, the treatment group was not significantly more effective than the control group in improving the RSES score (F = 1.76, p > .05).

Moreover, after completing the CBT group, the percentage of participants reporting self-stigma (i.e., ISMI score ≥ 2.5) decreased from 60.6% (n = 20) to 33.3% (n = 11), which was significant (nonparametric McNemar test <.01); additionally, the percentage of participants having depression, as assessed by the BDI (i.e., BDI score ≥14), decreased from 72.7% (n = 24) to 42.4% (n = 14), which was significant (nonparametric McNemar’s test <.01). No significant changes were found in the percentage of control group participants reporting self-stigma and depression.

Baseline Variables Related to the Improvement of Self-Stigma Scores

Table 5 indicates the baseline variables related to improvements in ISMI and SSMIS-SC scores. The results indicated that improvements in ISMI and SSMIS-SC scores were unrelated to any of the demographic variables, including sex, age, marital status, education, occupational status, residential location, diagnosis, number of hospitalizations, and period of illness, as well as baseline BDI scores. Rather, improvements in ISMI scores were found to be related to baseline ISMI scores (ρ = −.395, p = <.05), while improvements in SSMIS-SC scores were related to baseline SSMIS-SC (ρ = −.359, p = <.05) and ISMI (ρ = −.456, p = <.01) scores. In particular, improvements in ISMI and SSMIS-SC scores were significantly related to baseline perceived discrimination and social withdrawal scores on the ISMI (ρ ranged from −.42 to −.48, p < .05).

Table 5.

Variables Related to the Improvement of Self-Stigma Scores for Treatment Group Participants.

	Valid Data	Imp ISMI		Imp SSMIS-SC
	Valid Data	F	p Value	F	p Value
Sex^a	33	0.912	.346	0.748	.393
Diagnosis^a	33	0.581	.679	0.375	.825
Marital status^a	33	0.800	.459	1.842	.176
Education level^a	33	1.186	.332	0.317	.813
Place of residence^a	33	0.869	.430	0.806	.456
Occupational status^a	33	0.468	.631	0.981	.387
		ρ	p Value	ρ	p Value
Age^b	33	−.185	.303	−.306	.083
Period of illness^b	33	−.067	.715	.110	.549
Number of hospitalization^b	33	−.207	.256	.007	.968
ISMI^b	33	−.395	.023*	−.456	.008**
Shame^b	33	−.246	.168	−.304	.086
Stereotype endorsement^b	33	−.207	.247	−.301	.089
Perceived discrimination^b	33	−.466	.006**	−.475	.005**
Social withdrawal^b	33	−.453	.008**	−.419*	.015**
SSMIS-SC^b	33	.011	.952	−.359*	.040**
SSMIS-SED^b	33	−.026	.887	−.218	.223
RSES^b	33	.043	.811	.267	.133
BDI^b	33	−.019	.914	−.271	.127

Note. ρ = Spearman’s rho; ISMI-SS= Internalized Stigma of Mental Illness Scale self-stigma; RSES= Rosenberg Self-Esteem Scale; BDI= Beck Depression Inventory; SSMIS-SC= Self-Stigma of Mental Illness Scale Self-Concurrence subscale; SSMIS-SED= Self-Stigma of Mental Illness Scale Self-Esteem Decrement subscale; Imp ISMI = Improvement score of ISMI; Imp SSMIS-SC= Improvement score of SSMIS-SC.

^aANOVA. ^bSpearman correlation.

*Significant at p < .05. **Significant at p <. 01.

Discussion and Application to Social Work Practice

In this study, 56.3% of participants reported having self-stigma, as assessed by the ISMI, which was higher than the 41.7% reported in Europe (Brohan et al., 2010), 36.1% reported in the United States (West et al., 2011), and 38.3% in an earlier study in Hong Kong (Young & Ng, 2015). This was because individuals reporting no or very low self-stigma were excluded in this research project.

Consistent with previous research findings, participants in this study ranked shame/alienation the highest, followed by social withdrawal and perceived discrimination, while stereotype endorsement was ranked the lowest (Brohan et al., 2010; Young & Ng, 2015). Additionally, self-stigma was found to be positively related to depressive mood and negatively related to self-esteem, supporting the notion that self-stigma negatively impacts individuals’ lives by reducing self-esteem and by increasing depressive symptoms (Boyd et al., 2014; Corrigan et al., 2006; Fung et al., 2007; Gerlinger et al., 2013; Young et al., 2015)

Consistent with this study’s hypothesis, this present study showed that CBT groups can significantly reduce self-stigma in participants with mental illness, supporting the feasibility and effectiveness of CBT groups in Chinese society. In particular, the ANCOVA demonstrated that the CBT group was significantly more effective than the control group at improving self-stigma assessment scores with moderate effect sizes after controlling for differences between the treatment and control groups in most demographic variables and baseline self-stigma scores. Moreover, consistent with this study’s hypothesis, this present study showed that the CBT group was significantly more effective than the control group at reducing depressive mood after controlling for differences in most demographic variables and baseline BDI scores. For self-esteem, the ANCOVA indicated that the CBT group had a nonsignificant increase in self-esteem score compared with that of the control group.

Previous studies have reported that self-stigma is unrelated to most demographic variables (Gerlinger et al., 2013; Livingston & Boyd, 2010; Young & Ng, 2015). Thus, it was not surprising to find in this study that improvements in self-stigma scores were unrelated to demographic variables, including sex, age, marital status, occupational status, residential location, diagnosis, number of hospitalizations, and period of illness. In this study, improvements in self-stigma scores were found to be significantly related to baseline self-stigma scores, suggesting that the more participants stigmatized themselves, the greater they could reduce self-stigmatization through the CBT group.

The CBT group involved in this study included the following group components: (1) altering stigmatized beliefs, especially those self-stigmatizing beliefs that are greatly influenced by Chinese culture, using cognitive restructuring techniques; (2) developing positive beliefs about oneself and recognizing one’s own strengths; (3) social skills training on responding to public stigmatizing situations; and (4) enhancing social support among participants. It seemed that these group components were related to its effectiveness, which warrants further discussion.

Due to the stigmatization of mental illness in traditional Chinese cultural values, especially Confucianism, people with mental illness are likely to endorse public stigma, self-stigmatize, and subsequently experience “shame,” “loss of face,” “devaluation,” and “being a burden to others” in their families and communities (Lam et al., 2010; Young et al., 2015). The CBT group involved in this study addressed the special needs of Chinese persons with mental illness by helping them alter those self-stigmatizing beliefs that were greatly influenced by Chinese culture using CBT techniques such as cognitive restructuring. For example, a negative self-stigmatized belief, “Having mental illness is my fate (hopelessness), and I can do nothing about it (helplessness)” was challenged using techniques of cognitive restructuring and was replaced by a positive belief, “I can live with mental illness and achieve my own goals.” Additionally, by using techniques of homework assignments, participants were encouraged to devise concrete, specific, and achievable short-term plans and complete them outside the group session, such as performing physical exercise. Previous research has also suggested that cognitive intervention skills, such as cognitive restructuring, can alter irrational self-stigmatized beliefs (Corrigan et al., 2006; Fung et al., 2011; Knight et al., 2006; Mittal et al., 2012; Shimotsu et al., 2014). This study demonstrated the feasibility and effectiveness of helping participants challenge those self-stigmatizing beliefs that are greatly influenced by Chinese culture. As shown in this study, participants in the CBT group had a significant reduction in shame, which is a typical self-stigmatized belief influenced by traditional Chinese cultural values. Nevertheless, other self-stigmatized beliefs such as fate and “being a burden” which are influenced by Chinese traditional values were not properly assessed by the SSMIS-SC and ISMI, and thus, more research is needed in this area.

According to Eastern philosophy, especially the Yin-Yang theory, strengths and weaknesses coexist within individuals even when they are suffering from a chronic mental illness (Ng et al., 2013). Therefore, in addition to challenging self-stigmatized beliefs, this CBT group emphasized helping participants recognize their own strengths and develop positive beliefs about themselves. For example, a negative self-stigmatizing belief, “I am a burden on my family” was challenged and replaced with a positive belief, “I can contribute to my family and even my community” by using cognitive restructuring techniques such as scaling questions. Additionally, by using behavioral experiments and homework assignments, participants learned to recognize their strengths and started to contribute to their family by doing activities such as specific household duties and/or serving the community-based mental health center through short-term and simple volunteer service. However, as shown in this study, the CBT group participants only showed nonsignificant increases in self-esteem compared with the control group, suggesting that more efforts were needed to help participants develop positive beliefs about themselves.

In view of the success of previous studies (Fung et al., 2011; Lucksted et al., 2011; Mittal et al., 2012), this CBT group also provided social skills training to participants to address their stigmatized social situations, and it facilitated emotional support among participants. Participants shared their current specific and individualized stigmatized social situations during the first two sessions, and then they learned to address these situations through social skills training and role-play in-group sessions as well as by practicing these newly learned skills in their real-life situations. However, by sharing similar difficulties that were encountered in social stigma, participants learned to “normalize” their experiences of social stigma. Nonetheless, by receiving emotional support and sharing resources and skills with other group members to respond to social stigma, participants were able to reduce their feelings of loneliness, helplessness, and hopelessness and enhance their self-efficacy to face social stigma.

Several methodological limitations of this study required attention. First, the generalizability of the study’s results was limited by the nonrandomized research design and small sample size. Second, the following group components were believed to be essential elements of this CBT group: (1) altering stigmatized beliefs, especially those self-stigmatizing beliefs that are greatly influenced by Chinese culture, using cognitive restructuring techniques; (2) developing positive beliefs about oneself and recognizing one’s own strengths; (3) social skills training on responding to public stigmatizing situations; and (4) enhancing social support among participants. However, these components were not properly assessed by standardized assessment tools in this study, and whether or not these components contributed to the effectiveness of the CBT group remains unanswered. In the future, it would be better to conduct a larger scale randomized controlled study to further validate the effectiveness and essential components of the CBT group model in reducing self-stigma in persons with mental illness.

This present study provides evidence to support the efficacy and effectiveness of structured and time-limited CBT groups at reducing self-stigma in persons with mental illness in Chinese society. In particular, ANCOVA demonstrated that the CBT group was significantly more effective than the control group in improving assessment scores for self-stigma and depressive mood, even when controlling for differences in various demographic variables between the treatment and control groups.

Footnotes

Declaration of Conflicting Interests

The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author received no financial support for the research, authorship, and/or publication of this article.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Beck

A. T.

Steer

R. A.

Brown

G. K.

(1996). Manual for the beck depression inventory-II. San Antonio, TX: Psychological Corporation.

Boyd

J. E.

Adler

E. P.

Otilingam

P. G.

Peters

(2014). Internalized Stigma of Mental Illness (ISMI) Scale: A multinational review. Comprehensive Psychiatry, 55, 221–231.

Brohan

Elgie

Sartorius

Thornicroft

(2010). Self-stigma, empowerment and perceived discrimination among people with schizophrenia in 14 European countries: The GAMIAN-Europe study. Schizophrenia Research, 122, 232–238.

Byrne

B. M.

Stewart

Lee

P. W. H.

(2004). Validating the beck depression inventory-II for Hong Kong community adolescents. International Journal of Testing, 4, 199–216.

Chien

W. T.

Yeung

F. K. K.

Chan

A. H. L.

(2014). Perceived stigma of patients with severe mental illness in Hong Kong: Relationships with patients’ psychosocial conditions and attitudes of family caregivers and health professionals. Administration and Policy in Mental Health and Mental Health Services Research, 41, 237–251.

Chung

K. F.

Wong

M. C.

(2004). Experience of stigma among Chinese mental health patients in Hong Kong. Psychiatric Bulletin, 28, 451–454.

Cohen

(1988). Statistical power analysis for the behavioral sciences (2nd ed.). Hillsdale, NJ: Lawrence Erlbaum.

Corrigan

P. W.

Rao

D. P.

(2012). The impact of self-stigma and mutual help program on quality of life of people with serious mental illness. Community Mental Health Journal, 49, 1–6.

10.

Corrigan

P. W.

Roe

Tsang

W. H.

(2011). Challenging the stigma of mental illness: Lessons for therapists and advocates. West Sussex, England: Wiley-Blackwell.

11.

Corrigan

P. W.

Sokol

K. A.

(2012). On the self-stigma of mental illness: Stage, disclosure, and strategies for change. Canadian Journal of Psychiatry, 57, 464–469.

12.

Corrigan

P. W.

Watson

A. C.

Barr

(2006). The self-stigma of mental illness: Implications for self-esteem and self-efficacy. Journal of Social and Clinical, 25, 875–884.

13.

Fabrega

(1991). Psychiatric stigma in non-Western societies. Comprehensive Psychiatry, 32, 534–551.

14.

Fung

K. M. T.

Tsang

H. W. H.

Cheung

W. M.

(2011). Randomized controlled trial of the self-stigma reduction program among individuals with schizophrenia. Psychiatric Research, 189, 208–214.

15.

Fung

K. M. T.

Tsang

W. H.

Corrigan

P. W.

Lam

C. S.

Cheng

W. M.

(2007). Measuring self-stigma of mental illness in China and its implications for recovery. International Journal of Social Psychiatry, 53, 408–418.

16.

Gerlinger

Hauser

De Hert

Lacluyse

Wampers

Correll

C. U.

(2013). Personal stigma in schizophrenia spectrum disorders: A systematic review of prevalence rates, correlates, impact and interventions. World Psychiatry, 12, 155–164.

17.

Griffiths

K. W.

Carron-Arthur

Parson

Reid

(2014). Effectiveness of programs for reducing the stigma associated with mental disorders. A meta-analysis of randomized controlled trials. World Psychiatry, 13, 161–175.

18.

IBM Corp. (2013). IBM SPSS Statistics for Windows (Version 22.0). Armonk, NY: Author.

19.

Knight

T. D.

Wykes

Hayward

(2006). Group treatment of perceived stigma and self-esteem in schizophrenia: A waiting list trial of efficacy. Behavioural and Cognitive Psychotherapy, 34, 305–318.

20.

Lam

C. S.

Tsang

H. W. H.

Corrigan

P. W.

Lee

Y. T.

Angell

Shi

… Larson

J. E.

(2010). Chinese lay theory and mental illness stigma: Implications for research and practices. Journal of Rehabilitation, 76, 35–40.

21.

Lee

Chiu

M. Y. L.

Tsang

Chui

Kleinman

(2006). Stigmatizing experience and structural discrimination associated with the treatment of schizophrenia in Hong Kong. Social Science & Medicine, 62, 1685–1696.

22.

Lee

M. T. Y.

Chiu

Kleinman

(2005). Experience of social stigma by people with schizophrenia in Hong Kong. British Journal of Psychiatry, 186, 153–157.

23.

Leung

S. O.

Wong

P. M.

(2008). Validity and reliability of Chinese Rosenberg Self-Esteem Scale. New Horizons in Education, 56, 62–69.

24.

Livingston

J. D.

Boyd

J. E.

(2010). Correlates and consequences of internalized stigma for people living with mental illness: A systematic review and meta-analysis. Social Science and Medicine, 71, 2150–2161.

25.

Lucksted

Drapalski

Calmes

Forbes

DeForge

Boyd

(2011). Ending self-stigma: Pilot evaluation of a new intervention to reduce internalized stigma among people with mental illness. Psychiatric Rehabilitation Journal, 35, 51–54.

26.

Macinnes

D. L.

Lewis

(2008). The evaluation of a short group programme to reduce self-stigma in people with serious and enduring mental health problems. Journal of Psychiatric and Mental Health Nursing, 15, 59–65.

27.

Mak

W. W. S.

Cheung

R. Y. M.

(2012). Psychological distress and subjective burden of caregivers of people with mental illness: The role of affiliate stigma and face concern. Community Mental Health Journal, 48, 270–274.

28.

Mittal

Sulivan

Chekuri

Allee

Corrigan

P. W.

(2012). Empirical studies of self-stigma reduction strategies: A critical review of literature. Psychiatric Services, 63, 974–981.

29.

Tsun

Young

K. W.

(2013). Cognitive behavioural therapy in the Chinese cultural context: A case report. Asia-Pacific Psychiatry, 5, 205–211.

30.

Philips

M. R.

Pearson

Yang

(2002). Stigma and expressed emotion: A study of people with schizophrenia and their family members in China. British Journal of Psychiatry, 181, 488–493.

31.

Ritsher

J. B.

Otilingam

P. G.

Grajiales

(2003). Internalized stigma of mental illness: Psychometric properties of a new measure. Psychiatry Research, 121, 31–49.

32.

Shimotsu

Horikwa

Emura

Ishikawa

S. I.

Nagao

Ogata

… Hosomi

(2014). Effectiveness of group cognitive behavioural therapy in reducing self-stigma in Japanese psychiatric patients. Asian Journal of Psychiatry, 10, 39–44.

33.

Tang

I. C.

H. C.

(2012). Quality of life and self-stigma in individuals with schizophrenia. Psychiatric Quarterly, 83, 497–507.

34.

Tsang

H. W. H.

Angell

Corrigan

P. W.

Lee

Y. T.

Shi

Lam

C. S.

… Fung

K. M. T.

(2007). A cross sectional study of employers’ concerns about hiring people with psychiatric disorder: Implications for recovery. Social Psychiatry and Psychiatric Epidemiology, 42, 723–733.

35.

Tsang

W. H.

Tam

K. C.

Chan

Cheung

W. M.

(2003). Stigmatizing attitudes towards individuals with mental illness in Hong Kong: Implication for their recovery. Journal of Community Psychology, 31, 383–396.

36.

West

M. L.

Yanos

P. T.

Smith

S. M.

Roe

Lysaker

P. H.

(2011). Prevalence of internalized stigma among persons with severe mental illness. Stigma Research Action, 1, 3–10. doi:10.5463/sra.v1i1.9

37.

Young

K. W.

(2015). The prevalence and predictors of self-stigma of individuals with mental health illness in two Chinese cities. International Journal of Social Psychiatry, 62, 176–185. doi:10.1177/0020764015614596

38.

Young

K. W.

Pan

J. Y.

Cheng

(2015). Validity and reliability of Internalized Stigma of Mental Illness (Cantonese). Research on Social Work Practice. doi:10.1177/1049731515576209