How self-stigma dampens

personal and clinical recovery

among people in recovery of
mental illness?

Randolph C. H. Chan
Winnie W. S. Mak
Diversity and Well-being Lab
Department of Psychology
The Chinese University of Hong Kong
Presentation at the World Psychiatric Association Regional Congress, Hong Kong, December 14, 2014
 Self-stigma
• Self-stigma refers to the internalized stigma
that individuals may have toward
themselves due to their minority status
(Corrigan & Watson, 2002; Mak & Cheung, 2010)
– internalize negative stereotypes prescribed to
their social group
– perceive themselves as devalued
 • People with mental illness
who endorsed greater self-
stigma:

Impact of
– poorer self-esteem & self-
efficacy
(Corrigan & Watson, 2002)

Self-stigma – lower help-seeking intentions

(Barney et al., 2006)
– reduced service access &
participation
(Watson & Corrigan, 2001)
• Clinical recovery
– alleviation of psychiatric
symptoms and illnesses (Slade, 2009)
– medication adherence is
considered an important
indicator and route to clinical
recovery
• Personal recovery
– potential for attaining a self-
directing and fulfilling life despite
of the apparent limitations of the
mental illness (Anthony, 1993)
– live with distress and impairment
imposed by their illness and lead
a meaningful life with personal
dignity
(Corrigan et al., 2014)
– engagement in ones’ recovery is
an indicator of people taking
control of their illness and steering
towards a self-defined living
 Possible Mechanism between
Self-stigma and Recovery
• Direct impact of self-stigma on recovery:
– emotional discomfort symptoms (Lysaker et al., 2007)
– diminished well-being (Markowitz, 1998)
– poor life satisfaction (Rosenfield, 1997)
 Possible Mechanism between
Self-stigma and Recovery
Indirect impact of self-stigma on recovery:
1. Medication adherence:
– non-adherence to psychiatric medication is more prevalent
among people with high self-stigma (Livingston & Boyd, 2010)
– medication adherence affects symptom severity
(Fenton et al., 1997)
2. Service engagement:
– associated with severity of mental illness
(Bartels et al., 2004)
– recovery orientation of services as potential covariate of service
engagement and personal recovery (Kreyenbuhl et al., 2009)
 Aim of the Study
• To investigate whether and how the adverse effect
of self-stigma on personal and clinical recovery
would be mediated by mental health service
engagement and medication adherence, after
controlling for the recovery orientation of the
services
 Recovery
Mental health orientation
service of services
engagement

Personal
Self- recovery
Stigma

Medication Clinical
adherence recovery

Hypothesized Model
METHODS
 Study Participants
INCLUSION CRITERIA
1. Aged between 18 and 55 years
2. A ICD-10 diagnosis of schizophrenia, persistent delusional disorder,
schizoaffective disorder, other nonorganic psychotic disorders, or
unspecified nonorganic psychosis
3. A duration of illness, defined as the length of time since first
presentation to the hospital, less than 60 months
4. Ethnic Chinese
5. Speak Cantonese
6. Sufficient understanding and expressive capacity

EXCLUSION CRITERIA
1. Have organic brain disorder
2. Have a known history of intellectual disability
3. Diagnosed with drug-induced psychosis
 Study Participants
• 177 people in recovery of schizophrenia spectrum disorders
(57.6% female) were recruited from different psychiatric
outpatient clinics and community mental health centers
across various districts in Hong Kong
• Mean age = 31.67 years old (SD = 11.25)
• Mean illness duration = 2.54 years (SD = 2.44)
 Measures
• Self-stigma
– Self-Stigma Scale (SSS; Mak & Cheung, 2010) was used to assess
the extent to which the participants internalized prejudicial
attitudes of the public towards themselves
– Cronbach’s α = .91

• Recovery orientation of services

– The Recovery Self Assessment-Revised (RSA-R; O’Connell,
Tondora, Croog, Evans, & Davidson, 2005) was used to measure
perception on the extent to which the mental health
services received were recovery-oriented
– Cronbach’s α = .93
 Measures
• Mental health service engagement
– Service Engagement Scale (SES; Tait, Birchwood, & Trower, 2002)
was used to assess engagement with psychiatric treatment
and community mental health services
– Cronbach’s α = .79
• Medication Adherence
– Medication Adherence Rating Scale (MARS; Thompson,
Kulkarni, & Sergejew, 2000) was used to evaluate medication-
taking attitudes and behaviors over the past month
 Measures
• Personal recovery
– Recovery Assessment Scale (RAS; Giffort, Schmook, Woody,
Vollendorf, & Gervain, 1995) was used to evaluate the level of
personal recovery process
– Cronbach’s α = .93
• Clinical recovery
– positive and negative symptoms of psychosis were
assessed by trained research staff using:
• Scale for the Assessment of Positive Symptoms
(SAPS; Andreasen, 1984a), Cronbach’s α = .82
• Scale for the Assessment of Negative Symptoms
(SANS; Andreasen, 1984b), Cronbach’s α = .89
RESULTS
 Mean self-stigma score
(range: 1-6)

15%,
Minimal self-stigma (< 2.5)
n = 27 30%,
n = 53
Low self-stigma (2.5-3.5)
25%,
n = 43 Moderate self-stigma (3.5-4.5)

High self-stigma (> 4.5)

30%,
n = 53
Demographics and Self-stigma
• Contrary to previous findings (Corrigan & Watson, 2007), this
study showed that:
– No difference of self-stigma endorsement in gender and
employment status
– No significant correlation of self-stigma with age, illness
duration, education level, and monthly income level
 1 2 3 4 5 6 7

1. Self-stigma -

2. Recovery orientation of the services -.03 -

3. Mental health service engagement -.11 .20** -

4. Medication adherence -.14 -.04 .06 -

5. Personal Recovery -.29*** .51*** .37*** .09 -

6. Positive symptoms of psychosis .16* -.01 -.07 -.17* -.10 -

7. Negative symptoms of psychosis .29*** -.04 -.16* -.08 -.36*** .10 -

Range of scale 1-6 1-5 1-4 0-10 1-5 0-175 0-120

Mean 3.26 3.60 3.27 6.33 3.58 11.82 28.42

Standard deviation 1.16 .52 .44 1.99 .57 12.28 18.44

Note: * p < 0.05, ** p < 0.01, *** p < 0.001; n = 166

Descriptive statistics & intercorrelation of variables

Measurement model fit: χ2(215) = 390.11, p < .001, CFI = .90, RMSEA = .07, SRMR = .08
Structural model fit: χ2(219) = 401.08, p < .001, CFI = .90, RMSEA = .07, SRMR = .08
Note: * p < 0.05, ** p < 0.01, *** p < 0.001

Structural Equation Modeling

 Summary of findings

• Self-stigma was negatively associated with personal

and clinical recovery
• Self-stigma has an effect on medication adherence
but not mental health services engagement
• Only the mediating effect of medication
adherence between the relationship of self-stigma
and clinical recovery was significant
 • Self-stigma can have a direct
as well as indirect impact on
symptom severity through the
mediation of adherence to
psychiatric medication
– directly affect personal recovery
and impede the development of
a self-directed and fulfilling life

DISCUSSION
 • Hypothesized relationships among
the variables were tested based on
cross-sectional data
– Conducting follow-up assessment
with those participants at 6-month
and 12-month

Limitations • Data collection mainly relied upon

self-report instruments, which might
potentially limit the reliability of the
information reported
– Collecting and analyzing the service
engagement rating from service
providers to reduce the potential bias
of self-report data
 • Provide empirical evidence for
the detrimental impact of self-
stigma on personal and clinical
recovery
Implications • Anti-self-stigma initiatives should
be introduced to reduce the
endorsement and internalization
of negative societal attitudes
towards mental illness
 Acknowledgments
Acknowledgments
 This study (Project no.: 449312) is funded by the General Research
Fund of the Hong Kong Research Grants Council
 Thanks for the following parties in giving permission and assistance in
data collection in their respective psychiatric outpatient clinics and
community mental health centers:
 Prof. Eric Y.H. Chen, Dr. Sherry K.W. Chan (Department of Psychiatry, Queen Mary
Hospital)
 Dr. Roger M.K. Ng, Dr. Alfert W.K. Tsang (Department of Psychiatry, Kowloon Hospital)
 Dr. W.S. Yeung (Department of Psychiatry, Pamela Youde Nethersole Eastern Hospital)
 Dr. T.L. Lo, Dr. Catherine S.Y. Chong, Mr. K.K. Kwan (Department of Psychiatry, Kwai
Chung Hospital)
 Dr. P.F. Pang (Department of Psychiatry, United Christian Hospital)
 Ms. Sania S.W. Yau, Ms. Candy Y.M. Ling (New Life Psychiatric Rehabilitation Association)
 Mr. Dan K.S. Yu (The Mental Health Association of Hong Kong)
 Ms. Christine Cheuk, Ms. Peony Lai (Caritas Wellness Link - North District)
 Ms. Dora Tam (Stewards)
 Dr. Keith Wong (Richmond Fellowship of Hong Kong)
 Ms. S.K. Chan (Baptist Oi Kwan Social Service)
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