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ScienceDirect Comprehensive Psychiatry 56 (2015) 198 – 205 www.elsevier.com/locate/comppsych

Psychometric properties of a Chinese version of the Stigma Scale: examining the complex experience of stigma and its relationship with self-esteem and depression among people living with mental illness in Hong Kong Andy H.Y. Ho a, b, c , Jordan S. Potash b, d, e , Ted C.T. Fong b , Vania F.L. Ho b , Eric Y.H. Chen f , Robert H.W. Lau g , Friendly S.W. Au Yeung h , Rainbow T.H. Ho b, d,⁎ a

Division of Psychology, School of Humanities and Social Sciences, Nanyang Technological University, Singapore b Centre on Behavioral Health, The University of Hong Kong, Hong Kong, China c Sau Po Centre on Ageing, The University of Hong Kong, Hong Kong, China d Department of Social Work and Social Administration, The University of Hong Kong, Hong Kong, China e Art Therapy Program, The George WA University, Washington, DC, USA f Department of Psychiatry, The University of Hong Kong, Hong Kong, China g Lok Hong Intergrated Community Centre for Mental Wellness, Tung Wah Group of Hospital, Hong Kong, China h The Providence Garden for Rehab, Hong Kong Sheng Kung Hui Welfare Council, Hong Kong, China

Abstract Background: Stigma of mental illness is a global public health concern, but there lacks a standardized and cross-culturally validated instrument for assessing the complex experience of stigma among people living with mental illness (PLMI) in the Chinese context. Aim: This study examines the psychometric properties of a Chinese version of the Stigma Scale (CSS), and explores the relationships between stigma, self-esteem and depression. Methods: A cross-sectional survey was conducted with a community sample of 114 Chinese PLMI in Hong Kong. Participants completed the CSS, the Chinese Self-Stigma of Mental Illness Scale, the Chinese Rosenberg Self-Esteem Scale, and the Chinese Patient Health Questionnaire-9. An exploratory factor analysis was conducted to identify the underlying factors of the CSS; concurrent validity assessment was performed via correlation analysis. Results: The original 28-item three-factor structure of the Stigma Scale was found to be a poor fit to the data, whereas a revised 14-item three-factor model provided a good fit with all 14 items loaded significantly onto the original factors: discrimination, disclosure and positive aspects of mental illness. The revised model also displayed moderate to good internal consistency and good construct validity. Further findings revealed that the total stigma scale score and all three of its subscale scores correlated negatively with self-esteem; but only total stigma, discrimination and disclosure correlated positively with depression. Conclusion: The CSS is a short and user-friendly self-administrated questionnaire that proves valuable for understanding the multifaceted stigma experiences among PLMI as well as their impact on psychiatric recovery and community integration in Chinese communities. © 2014 Elsevier Inc. All rights reserved.

1. Introduction Stigma of mental illness is a global public health concern. Repeated studies in both Western and Eastern societies have ⁎ Corresponding author at: Centre on Behavioral Health, The University of Hong Kong. 2/F, The HKJC Building for Interdisciplinary Research, 5 Sassoon Road, Pokfulam, Hong Kong, China. Tel.: +852 2831 5169; fax: +852 2816 6710. E-mail address: [email protected] (R.T.H. Ho). http://dx.doi.org/10.1016/j.comppsych.2014.09.016 0010-440X/© 2014 Elsevier Inc. All rights reserved.

found that people living with mental illness (PLMI), regardless of their ethnicity and race, are often robbed of valuable life opportunities such as stable employment, adequate housing, satisfactory healthcare, and civil engagement as a result of social stigma [1,2]. Undermined by prejudice and discrimination, it is also common for PLMI to internalize social stigma to become increasingly withdrawn and self-isolated, losing self-esteem and self-efficacy in the process [3]. Both social stigma and internalized stigma act as major barriers to medication adherence and psychiatric rehabilitation, which

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in turn create a downward spiral of worsening illness, posing clear threats to individual and public health [4]. This is especially true in Chinese communities like Hong Kong where mental illness has long been a major taboo associated with matters of family failures. According to Government statistics, an estimated 14 to 24% of Hong Kong's 7.1 million residents are living with mental illness, and approximately 70,000 to 200,000 people suffer from a severe mental disorder [5]. Despite this astounding figure, only 1% is currently receiving psychiatric services [6]. The underlying reasons for such gross undertreatment are due not only to traditional taboos, but also the prominence of collective ideas in Chinese cultures. Having mental illness within the family is traditionally regarded as matters of inferior origins, failure of parents, and even retributions for the sins of past generations [2]. Hence, it is far too common for Chinese people to feel ashamed of their mental illness as they are often belittled and looked down upon, and perceived as dangerous, irresponsible and untrustworthy [7,8]. The degradation of social and self-stigma greatly limits the practical and emotional support they receive because they dare not to speak publicly about their needs or to seek help within the community for fear of losing face and disgracing the family name [9]. The burdens of stigma and isolation are exacerbated through conventional psychiatric services that are limited to in-patient care and hospital rehabilitation programs [10], resulting in more palpable difficulties in community reintegration among PLMI in the Chinese context. Thus, in order to develop adequate rehabilitation programs that facilitate both recovery and inclusion, it is imperative to attain an in-depth understanding on the experience of stigma among Chinese PLMI. While researchers have long studied public attitudes towards mental illness, less has been done on assessing the experience of stigma from the vantage point of PLMI, and particularly within the Chinese context [11]. This is due largely in part to the lack of a conceptual agreement over internalized stigma as well as the limited number of standardized instruments to measure it. Although recent literature has provided a more systematic definition of internalized stigma: ‘a subjective process, embedded within a socio-cultural context, which may be characterized by negative feelings (about self), maladaptive behavior, identity transformation, or stereotypes endorsement resulting from an individual experiences, perceptions or anticipation of notable social reactions on the basis of their mental illness' [12]; such a delineation is still considered by some to be overly negative and does not capture the full spectrum of experiences. According to Dinos et al. [13], experiences of stigma among PLMI are not universally negative, as some individuals may find that their mental illness enhances their experience of life and interpersonal relationships. Finlay et al. [14] and others [15,16] argued that stigma has the potential to arouse a positive construction of identity as PLMI employ various strategies to protect and bolster their self-esteem through inequality and adversity. Shih [17] further contended that

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individuals living successfully with stigma may adopt an empowering stance as opposed to a coping stance for overcoming prejudice and discrimination, gaining strength and learning valuable life lessons throughout the process; therefore, ‘in trying to understand how to ward off the negative consequences of stigma, investigators should also focus on…identify factors that allow them to achieve this successful outcome’. Unfortunately, most commonly used standardized instruments that evaluate stigma from the perspectives of PLMI focus predominately on negative aspects [18], to the extent that respondents often find them offensive and refuse to complete them [19]. One instrument recently developed by King et al. [20] consists of a dimension that taps into the potential positive aspects of mental illness, which allows for a more comprehensive assessment over the multifaceted experience of stigma. The Stigma Scale (SS) was originally developed from detailed qualitative interviews with 46 PLMI with regards to their feelings and experiences of prejudice and discriminations [13], and later validated via 193 service users in the UK. The initial scale composed of 42 items that were reduced to 28 items with a three-factor structure through exploratory factor analysis. The first factor of discrimination contains 13 statements that concern the perceived hostility by others or lost opportunity because of prejudice attitudes; the second factor of disclosure contains 10 statements that concern the need to conceal mental illness to avoid discrimination; and the third factor of positive aspects contains 5 statements that concern how people accept their illness and the potential to become a stronger, more understanding and accepting person. Each statement is rated on a 5-point Likert scale, with higher scores indicating higher levels of perceived stigma. The Stigma Scale has shown good reliability, internal consistency and concurrent validity; it is short, simple and can readily be incorporated into clinical practice and research. Despite its usefulness for measuring the wider experience spectrum of stigma among PLMI, the Stigma Scale has not been studied in non-Western population. As the experiences of stigma are culturally sensitive, its applicability cannot be assumed when used in a culture vastly different from its origin. Hence, the aims of this study are to explore the applicability of a Chinese version of the Stigma Scale (CSS) among PLMI in Hong Kong, examine its psychometric properties, and assess the relationships between different facets of stigma with self-esteem and depression. 2. Methods 2.1. Participants and procedures A cross-sectional survey with purposive sample was adopted. Ethics approval was obtained through the Human Research Ethics Committee of the authors' university. A total of 114 community-dwelling PLMI were recruited via two Integrated Community Centres for Mental Wellness (ICCMW)

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in Hong Kong. Respondents were service users of the two community-based out-patient centers, they were approached by members of staff or by the researchers, informed about the aim of the study and invited to participate. Those who could not read or understand Chinese were excluded from the study. Upon informed consent, they completed a self-administered questionnaire package.

2.2.4. Chinese Patient Health Questionnaire-9 (CPHQ9) The Patient Health Questionnaire-9 is a screening instrument for depression [25]. Consisting of 9 items rated on a 4points Likert scale with higher scores indicating higher levels of depressive symptoms, the CPHQ-9 has shown strong reliability and predictive validity. It was included in this study to explore the relationship between stigma and depression [26].

2.2. Measures

2.3. Statistical analysis

Participants were asked to fill in a number of demographic items, followed by questions about the nature of their illness, years since diagnosis as well as the type of treatment received. Thereafter, they completed four standardized measures.

To explore the factor structure of the Chinese version of the Stigma Scale, Mplus 7 [27] was used to carry out exploratory factor analysis (EFA) on the original 28 items of the scale to identify underlying factors. The items were subject to maximum likelihood robust factor analysis with oblique Geomin rotation. Missing data were handled via the use of full-information maximum likelihood under the missing at random assumption [27]. The original 28-item three-factor EFA model was evaluated on the basis of the following cutoff criteria on the goodness of fit indices: insignificant χ 2 ( p N 0.05), comparative fit index (CFI) ≥ 0.95, Tucker–Lewis index (TLI) ≥ 0.95, root mean square error of approximation (RMSEA) ≤ 0.06, and standardized root mean square residual (SRMR) ≤ 0.08 [28]. In case of inadequate model fit, the scale items were screened on the basis of the following criteria: significant factor loadings on more than one factor, no significant loadings on any factors, and low item–total correlations. The identified problematic items were removed from the model in an iterative fashion until an adequate EFA model was obtained. Eigenvalues and proportions of explained variance were also taken into account in determining the underlying factor structure. Table 1 shows the original and the retained items of the Stigma Scale after the EFA. Our analysis generated two EFA models, one with a two-factor structure and one with a three-factor structure, these models were compared and contrasted, and the one with the strongest goodness of fit were retained. CSS total score and its subscale scores were obtained by adding together the corresponding item scores. Descriptive statistics were obtained by averaging the items and subscales scores on a 0–4 scoring range. Internal consistency was assessed using the criterion on Cronbach's alpha (α ≥ 0.70) [29]. Concurrent validity of the scale was evaluated by its bivariate correlation with participants' demographic characteristics such as age, gender, years since diagnosis, and validating scales including depression, self-esteem and selfstigma in relations to stereotype awareness, stereotype agreement, self-concurrence and self-esteem decrement. Significance level of this study was set at the .05 level.

2.2.1. Chinese Stigma Scale (CSS) The English Stigma Scale [20] was translated into Chinese by the fourth author who is fluently bilingual in Chinese and English. The translated Chinese version was then back-translated independently to English by the first author. Discrepancies in sematic meaning between the original English version and the back-translated Chinese version were identified by two postgraduate students with expertise in mental health research, and minor amendments were made for correcting mistranslated words and improving item presentation. This version was then examined by the first and fourth author again for linguistic accuracy before confirmation of the final text. 2.2.2. Chinese Self-stigma of Mental Illness Scale (CSSMIS) The Self-stigma of Mental Illness Scale assesses PLMI's sense of internalized stigma as a result of mental illness discrimination [21]. It consists of four subscales: (1) stereotype awareness, which represents perceived discrimination due to social stigma; (2) stereotype agreement, which represents the degree to which respondents agree with stigmatizing views; (3) self-concurrence, which represents the degree to which respondents apply stigmatizing views to themselves and other PLMI; and (4) self-esteem decrement, which represents the degree of harm to ones' self-esteem as a result of self-stigma. Composed of 40 items rated on a 9-point Likert scale with higher scores indicating higher levels of self-stigma, the CSSMIS has shown strong reliability and various forms of validity [22]. It was included in this study to examine the concurrent validity of the CSS. 2.2.3. Chinese Self-Esteem Scale (CSES) The Rosenberg Self-Esteem Scale consists of 10 items that measures psychological well-being and self-efficacy [23]. Rated on a 5-point Likert scale with higher scores indicating higher levels of self-esteem, the CSES has shown good strong reliability and concurrent validity [24]. It was included in this study for examining the concurrent validity of the CSS, as well as for exploring the relationship between stigma and self-esteem.

3. Results 3.1. Participants' characteristics All 114 participants were of Chinese ethnicity, 49.1% were male and 50.9% were female. The mean age of the

A.H.Y. Ho et al. / Comprehensive Psychiatry 56 (2015) 198–205 Table 1 Original and retained items of the Stigma Scale after EFA. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28.

I have been discriminated in education because of my MHP Sometimes I feel that I am being talked down to because of my MHP Having had MHP has made me a more understanding person I do not feel bad about having had MHP I worry about telling people I receive psychological treatment (R) Some people with MHP are dangerous People have been understanding of my MHP (R) I have been discriminated by police because of my MHP I have been discriminated by employers because of my MHP My MHP have made me more accepting of other people (R) Very often I feel alone because of my MHP I am scared of how others react if they find out about my MHP (R) I would have had better chances in life if I had not had MHP I do not mind people in my neighbourhood knowing I have had MHP I would say I have had MHP if I was applying for a job I worry about telling people that I take medicines/tablets for MHP (R) People's reactions to my MHP make me keep myself to myself I am angry with the way people have reacted to my MHP I have not had any trouble from people because of my MHP (R) I have been discriminated by health professionals due to my MHP (R) People have avoided me because of my MHP (R) People have insulted me because of my MHP (R) Having had MHP has made me a stronger person (R) I do not feel embarrassed because of my MHP (R) I avoid telling people about my mental health problems (R) Having had MHP makes me feel that life is unfair I feel the need to hide my MHP from my friends (R) I find it hard telling people I have MHP (R)

Italic items were removed after EFA. (R) = retained items. MHP = mental health problems.

sample was 51.2 with a range of 20 to 79 years (SD = 11.34). 73.9% of the respondents were single, 17.1% were separated or divorced and 9.0% were married. The majority had attained secondary education (62.2%), roughly one-third had only attained primary education (3.15%), and less than one-tenth had attained tertiary education (6.3%). Most respondents were diagnosed with schizophrenia (77.1%), others with depression (7.6%), early psychosis (3.8%), bipolar disorder (2.9%), and 8.6% suffered from comorbid mental illnesses. The mean years since diagnosis were 25.12 with a range of 1 to 55 years (SD = 11.14); 58.6% had undergone counseling and psychotherapy, while the remaining 41.4% had received mostly pharmacological treatments. 3.2. Factorial validity As shown in Table 2, the original 28-item three-factor EFA model showed a poor fit to the data with a highly significant χ 2 and both CFI and TLI well below 0.95. A total of 14 problematic items with double loadings or insignificant loadings were removed from the model iteratively. We then estimated a two-factor structure as well as a three-factor structure for the revised 14-item EFA model. Results show that the two-factor model displayed only a mediocre fit with a highly significant χ 2, CFI and TLI b0.95 and RMSEA N0.06. In contrast, the three-factor model displayed strong goodness-of-fit across all indices with an insignificant χ 2,

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CFI and TLI N0.95, and RMSEA and SRMR b0.04. Thus, the three-factor model was retained as the final model. 3.3. Internal consistency Table 3 shows the descriptive statistics and rotated factor matrix for the revised 14-item three-factor EFA model. As shown, the eigenvalue of the three factors was 4.54, 1.87, and 1.23 for discrimination (4 items), disclosure (5 items) and positive aspects (5 items), respectively; together accounting for 54.6% of the total variance. In the model, all 14 items loaded significantly onto their respective factors. The Cronbach's alpha for discrimination, disclosure and positive aspects were 0.84, 0.81, and 0.58, respectively; and the Cronbach's alpha for the composite score of all 14 items was 0.83. While discrimination was significantly and strongly associated with disclosure (r = 0.65, p b 0.01), positive aspects was significantly but weakly associated with other factors (r = 0.19–0.23, p b 0.05). Mean scores were as follows: Chinese Stigma Scale 34.03 (SD = 9.19), discrimination subscale 10.65 (SD = 4.91), disclosure subscale 15.35 (SD = 5.58) and positive aspects subscale = 7.88 (SD = 4.22). 3.4. Concurrent validity Table 4 shows the bivariate correlation between the Chinese Stigma Scale, respondents' demographics, levels of depressive symptoms as assessed by the CPHQ-9 and the two validating scales of CSES and CSSMI. As shown, the total stigma scale score and the discrimination subscale score (high score indicates high perceived discrimination) were negatively correlated with age (r = −0.34 and −0.27, respectively) and men (r = −0.26 and −0.20, respectively). The disclosure subscale score (high score indicates less likely to disclose mental illness) was also negatively correlated with the male gender (r = 0.25) but not with age, while the positive aspects subscale score (high score indicates less positive outlook on mental illness) was positively correlated with age only (r = −0.20). Although the CSS and none of its subscales correlated with education level, years since diagnosis and types of treatment; total stigma score associated positively with depression (r = 0.42), as with the discrimination subscale (r = 0.32) and the disclosure subscale (r = 0.30). Moreover, total stigma, discrimination, disclosure and positive aspects all correlated negatively with self-esteem (r = −0.57, −0.42, −0.30 and –0.37, respectively), and positively with the selfstigma dimension of stereotype agreement (r = 0.32, 0.32, 0.41 and 0.22, respectively). Finally, apart from positive aspects, total stigma as well as discrimination and discourse were positively correlated with the three self-stigma dimensions of stereotype awareness (r = 0.51, 0.41 and 0.56, respectively), self-concurrence (r = 0.42, 0.31 and 0.46, respectively) and self-esteem decrement (r = 0.47, 0.34 and 0.48, respectively).

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Table 2 Goodness of fit indices of the EFA models on the Stigma Scale. Model description

χ2

df

CFI

TLI

RMSEA (90% CI)

SRMR

1. Original 28-item, 3-factor 2. Revised 14-item, 2-factor 3. Revised 14-item, 3-factor

453.89⁎⁎

297

.807

.754

.068 (.055-.080)

.062

105.95⁎⁎

64

.869

.814

.076 (.049-.101)

.068

54.93

52

.991

.984

.022 (.000-.065)

.039

χ 2: chi-square from maximum likelihood robust estimation; df: degree of freedom; CFI: Comparative fit index; TLI: Tucker–Lewis index; RMSEA (90% CI): Root mean square error of approximation (90% confidence interval); SRMR: standardized root mean square residual. ⁎⁎ p b 0.01.

4. Discussion The goals of this study were to examine the applicability, reliability and validity of a Chinese version of the Stigma Scale for clinical and research proposes, as well as to explore the relationships between different facets of stigma with selfesteem and depression in the Chinese context. To this end, we have successfully translated the Stigma Scale into Chinese and examined its psychometric properties with a representative community sample of PLMI in Hong Kong. Our findings supported the applicability of the CSS, as there were no reports of difficulties for completing the instrument and all participants understood the instructions as well as the

meaning of each individual item. Some participants expressed an appreciation for the positive tone used in the CSS as opposed to the harsh voice found in CSSMIS [22]. Moreover, the completion time of approximately 5–10 minutes for the shorten 14-item CSS can promote wider use in the community and serve as an ideal screening tool for most clinical and social care settings. With reduced assessment burden, it can easily be adopted for large scale empirical research to advance our understanding on mental health stigma among PLMI of different Chinese communities. 4.1. Reliability, validity and clinical implications Although the original 28-item three-factor model was a poor fit to our data, the revised 14-item three-factor structure was found to be a good fit with all 14 items loaded significantly onto the original factors of discrimination, disclosure and positive aspects. Reliability data supported the internal consistencies of the 14-item CSS, with moderate to good homogeneity on the total stigma scale and its three subscales. The alpha levels and inter-correlations of subscales found in this study were also similar to those reported by King et al. [20]. Specifically, the strong association between the discrimination subscale and the disclosure subscale suggests that Chinese PMLI who felt discriminated through social stigma are more likely to avoid disclosure for fear of stereotyping and labeling. Yip [30] reported comparable findings in his Hong Kong study as he commented that public labeling had prevented mental health service users from disclosing their illness to others, thus seriously hindering their community integration leading to

Table 3 Descriptive statistics and rotated factor matrix for the revised 14-item Stigma Scale. Item Factor 1: Discrimination (Cronbach's alpha = .84) I worry about telling people that I take medicines/tablets for MHP I have been discriminated by health professionals due to my MHP People have avoided me because of my MHP People have insulted me because of my MHP Factor 2: Disclosure (Cronbach's alpha = .81) I worry about telling people I receive psychological treatment I am scared of how others react if they find out about my MHP I avoid telling people about my MHP I feel the need to hide my MHP from my friends I find it hard telling people I have MHP Factor 3: Positive aspects (Cronbach's alpha = .58) People have been understanding of my MHP My MHP have made me more accepting of other people I have not had any trouble from people because of my MHP Having had MHP has made me a stronger person I do not feel embarrassed because of my MHP Total factor scores (SD) Average factor mean (SD) Eigenvalue Proportion of explained variance

Mean (SD) 1.92 (1.48) 1.53 (1.45) 1.69 (1.52) 1.63 (1.41)

Factor 1

Factor 2

Factor 3

.70 .61 .79 .75

2.14 (1.45) 2.04 (1.48) 1.95 (1.46) 1.86 (1.47) 2.17 (1.48)

.52 .50 .65 .97 .62

1.66 (1.39) 1.28 (1.35) 1.84 (1.60) 1.25 (1.27) 1.84 (1.47) 10.65 (4.91) 1.66 (1.23) 4.54 32.5%

15.35 (5.58) 2.08 (1.12) 1.87 13.4%

.40 .36 .63 .62 .33 7.88 (4.22) 1.58 (0.84) 1.23 8.8%

Maximum likelihood robust estimation with Geomin rotation. Factor loadings less than .2 are suppressed. All shown factor loadings are significant at .05 level. MHP = mental health problems. Each item/factor is scored on a 0–4 scale.

A.H.Y. Ho et al. / Comprehensive Psychiatry 56 (2015) 198–205 Table 4 Correlations between Stigma Scale, demographics, and validating scales (N = 114).

Age Gender (male) Education level Years since diagnosis Types of treatment (medication) Depression (CPHQ-9) Self-esteem (CSES) Self-stigma (CSSMI) Stereotype awareness Stereotype agreement Self-concurrence Self-esteem decrement

Total stigma

Discrimination Disclosure Positive aspects

−.34⁎⁎ −.26⁎⁎ .49 −.15 −.24

−.27⁎⁎ −.20⁎ .84 −.11 −.26

.42⁎⁎ .32⁎⁎ −.57⁎⁎ −.42⁎⁎ .51⁎⁎ .32⁎⁎ .42⁎⁎ .47⁎⁎

.41⁎⁎ .32⁎⁎ .31⁎⁎ .34⁎⁎

−.19 −.25⁎ .47 −.08 −.13

.20⁎ .04 −.30 .08 .16

.30⁎⁎ −.30⁎⁎

.19 −.37⁎⁎

.56⁎⁎ .41⁎⁎ .46⁎⁎ .48⁎⁎

.14 .22⁎ .02 −.01

⁎ p b 0.05. ⁎⁎ p b 0.01.

social exclusion. Conversely, the weaker associations between the positive aspects subscale with the discrimination and disclosure subscales may reflect that Chinese PLMI who were more accepting of their mental illness were more open to making positive changes, and hence were less affected by stigma. These results underline that PLMI would benefit from interventions that facilitate both introspection and expression of their experiences with mental illness so as to derive at greater levels of self-understanding and selfacceptance. Moreover, anti-stigma campaigns that foster community dialogues between PLMI and the public can cultivate social understanding and authentic empathy, leading to the alleviation of prejudice and discrimination. Recent research has highlighted the robust potential of art therapy for nurturing self-appreciation, social dialogues and empowering partnerships to promote positive changes in mental health inclusion [31,32]. Clearly, art therapy can be competently adopted in psychiatric rehabilitation for promoting growth and transformation, while the role of art in the eradication of social stigma and discrimination warrants future investigations. It is important to note that the items that were removed from the original scale tend to be context specific and emotion focused (i.e. I am angry with the way people have reacted to my mental health problems; I have been discriminated by the police/by employers because of my mental health problems), and this may point towards a cultural discrepancy in how Western and Chinese individuals react to authorities and situations that disrupt social harmony. In fact, Phillips et al. [33] reported that the damaging effects of stigma on Chinese PLMI are significantly greater for those with higher levels of negatively expressed emotions within the family system, as criticism and hostility formed anxious and destructive interaction

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patterns that could lead to the internalization of negative selfimage. Hence, given the cultural tendency to reserve emotions for avoiding conflicts, more general items, which enquire about situations but without the potential shame of naming specific individuals or groups, seem more appropriate for assessing stigma among Chinese PLMI. Accordingly, the CSS can competently and adequately identify those who are at greater risks for emotional disturbances due to discrimination, fear of discourse and a negative outlook on mental illness. Our data supported the validity of the CSS. Specifically, the total stigma scale and its three subscales of discrimination, disclosure and positive aspects were inversely and significantly related to self-esteem. Significant positive associations were also found between total stigma, discrimination and disclosure with stereotype awareness, stereotype agreement, self-concurrence and self-esteem decrement. These relationships demonstrate the concurrent validity of the instrument and its subscales. Interestingly, while total stigma, discrimination and disclosure were significantly associated with depression, positive aspects was not; this finding provides further evidence that Chinese PLMI who were able to accept their illness and construct a more positive self-identity as well as outlook on life were less likely to be affected by depression as a result of stigma [14–17]. These findings once again accentuate the vast potential of art therapy for enhancing psychiatric rehabilitation and mental health intervention and promotion. Finally, our data suggest that older PLMI were more likely to feel discriminated against and less likely to find positive aspects through their experiences, while female PLMI were less likely to disclose their illness due to discrimination and thus limiting their opportunity for support. Preventive measures should target these specific population groups who are at greater risk of the adverse effect of social and self-stigma. 4.2. Strengths, limitations and future directions This is the first study that successfully translated the Stigma Scale and examined its psychometric properties among a representative community sample of Chinese PLMI. While the clinical and research utility of the CSS for assessing the multifaceted nature of mental illness stigma is supported by our findings, there are several limitations. First, although the sample size of 114 was adequate for factor analysis with 28 variables and 3 factors [34], this number of participants could only provide a general impression but not a comprehensive picture of the experience of mental illness stigma among Chinese PLMI in Hong Kong. In order to gain a more in-depth understanding of the severity and impact of stigma, a much larger sample that includes both communitydwelling and institutionalized PLMI is needed. Second, this study was based on cross-sectional data and did not include a stability assessment of the CSS, thus, future research should include a test–retest reliability evaluation with longitudinal data. Third, the clinical implications derived from our study

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should not be fully generalized to all Chinese PLMI in other countries due to the potential differences in societal attitudes towards mental illness, and future research should be carried out with other Chinese groups in different parts of the world. Despite these limitations, our study supported the applicability and validity of the CSS in all Chinese speaking contexts. Instruments that can competently measure the diverse experience and impact of stigma on PLMI with low assessment burden are pivotal for informing and evaluating clinical interventions and mental health promotion programs that gear towards recovery, community integration and stigma alleviation. Given the devastating impact of mental illness stigma on individual and public health as well as the need for greater mental health inclusion worldwide, the CSS will play an important role in establishing an evidence-based foundation for stigma changing practices in Hong Kong and other Chinese communities around the globe.

Declaration of Interest No Conflict of Interest.

Funding This study was funded by the Public Policy Research Scheme, Research Grant Council, Hong Kong SAR Government (Ref. No.: HKU 7006-PPR-11). Acknowledgment We would like to express our gratitude to all participants and staffs of the Providence Garden for Rehab, Hong Kong Sheng Kung Hui Welfare Council, and those from the Lok Hong Integrated Community Centre for Mental Wellness, Tung Wah Group of Hospitals, for their kindest contributions and assistances to this study. References [1] Holmes EP, River LP. Individual strategies for coping with the stigma of severe mental illness. Cogn Behav Pract 1998;5:231-9. [2] Tsang HWH, Tam PKC, Chan F, Cheung WM. Stigmatizing attitudes towards individuals with mental illness in Hong Kong: implications for their recovery. J Community Psychol 2003;31:383-96. [3] Corrigan PW, Watson AC. The paradox of self-stigma and mental illness. Clin Psychol Sci Pract 2002;9:35-53. [4] Wright SC, Taylor DM, Moghaddam FM. Responding to membership in a disadvantaged group: from acceptance to collective protest. J Pers Soc Psychol 1990;58:994-1003. [5] Hong Kong Hospital Authority. Hospital Authority Mental Health Service Plan for Adult 2010–2015. Hong Kong Hospital Authority; 2011. [6] Health Check. Hong Kong conducts first mental health survey. BBC News [newspaper online]; 2011. [cited 2013 Jan 15. Available from: BBC News. http://www.bbc.co.uk/news/health-13687793].

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A.H.Y. Ho et al. / Comprehensive Psychiatry 56 (2015) 198–205 [32] Potash J, Ho RTH. Drawing involves caring: foster relationship building through art therapy for social change. Art Ther 2011;28:74-81. [33] Phillips MR, Person V, Li F, Xu M, Yang L. Stigma and expressed emotion: a study of people with schizophrenia and their family members in China. Br J Psychiatry 2002;181:488-93. [34] Arrindell WA, van der Ende J. An empirical test of the utility of the observations-to-variables ratio in factor and components analysis. Appl Psychol Meas 1985;9:165-78. Andy, H.Y. Ho, PhD, MFT, FT – Assistant Professor, Division of Psychology, School of Humanities and Social Sciences, Nangyang Technological University, Singapore; Honorary Research Fellow, Centre on Behavioral Health, and Sau Po Centre on Ageing, The University of Hong Kong, Hong Kong. HSS-04, 14 Nanyang Drive, Singapore 637332. Tel: (852) 6012–1886; Email: [email protected]

Jordan S. Potash, PhD, ATR-BC, REAT, LCAT – Visiting Assistant Professor, Art Therapy Program, The George Washington University, USA; Honorary Assistant Professor, Centre on Behavioral Health, and Department of Social Work & Social Administration, The University of Hong Kong. 1925 Ballenger Avenue, Suite 250, Alexandria, VA 22314. Tel: (703) 299– 4148 Email: [email protected]

Ted C. T. Fong, MPhil – Senior Research Assistant, Centre on Behavioral Health, The University of Hong Kong. 2/F, The HKJC Building for Interdisciplinary Research, 5 Sassoon Road, Pokfulam, Hong Kong. Tel: (852) 2831–5174; Email: [email protected]

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Vania F. L. Ho, BA – Research Coordinator, Centre on Behavioral Health, The University of Hong Kong. 2/F, The HKJC Building for Interdisciplinary Research, 5 Sassoon Road, Pokfulam, Hong Kong. Tel: (852) 2831–5202; Email: [email protected]

Eric Y. H. Chen, MD, FRCPsyc – Professor, Department of Psychiatry, The University of Hong Kong. Queen Mary Hospital, 102 Pokfulam Road, Hong Kong. Tel: (852) 2255–3063; Email: [email protected]

Robert H. W. Lau, MSocSc – Team Leader, Lok Hong Integrated Community Centre for Mental Wellness, Tung Wah Group of Hospital. TWGHs Wong Chuk Hang Complex 2 Wong Chuk Hang Path, Wong Chuk Hang, Hong Kong. Tel: (852) 2816–2837; Email: [email protected]

Friendly S. W. Au Yeung, MSocSc – Chief Manager, The Providence Garden for Rehab, Hong Kong Sheng Kung Hui Welfare Council. 82 Tsun Wen Road, Tuen Mun, N.T. Hong Kong. Tel: (852) 3511–0951; Email: [email protected]

Rainbow, T. H. Ho, PhD, BC-DMT, CMA – Director, Centre on Behavioral Health; Associate Professor, Department of Social Work and Social Administration, The University of Hong Kong; 2/F, The HKJC Building for Interdisciplinary Research, 5 Sassoon Road, Pokfulam, Hong Kong; Tel: (852) 2831–5169; Email: [email protected]