Stigma, Mental Ill, Hk

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Hector W.H. Tsang and Phidias K.C. Tam
The Hong Kong Polytechnic University

Fong Chan
University of Wisconsin–Madison

W.M. Cheung
University of Hong Kong

The literature suggests that stigmatizing attitudes in the community will affect lives and recovery of people with mental illness. This is particularly serious and obvious in Chinese societies where mental illness is often associated with shame and stigma. As Hong Kong and China have undergone rapid changes in terms of social and economic development, this study aimed at providing the most up-to-date empirical information regarding mental illness stigma and its impact on individuals with mental illness. A 31-item Questionnaire on Mental Illness was developed to measure public attitudes towards mental illness, with special reference to issues that affected the burden on family members of mental health consumers. The questionnaire together with the Level of Contact Sub-scale (Holmes et al., 1999) was distributed to primary and secondary students for their friends and relatives aged 16 or above to complete. A total of 1,007 validly completed questionnaires were returned constituting a response rate of 74%. An exploratory factor analysis identified eight factors which accounted for 50.6% of the total variance: hostility, aberrant, openness, resources, acceptance, rights, misgivings, and
I would like to thank Dr. P. W. Corrigan for his advice in revising the manuscript leading to successful publication in the Journal of Community Psychology. Correspondence to: Hector W.H. Tsang, Associate Professor, Department of Rehabilitation Sciences, the Hong Kong Polytechnic University, Hung Hom, Hong Kong; e-mail: [email protected]

JOURNAL OF COMMUNITY PSYCHOLOGY, Vol. 31, No. 4, 383–396 (2003) © 2003 Wiley Periodicals, Inc. Published online in Wiley InterScience ( DOI: 10.1002/jcop.10055


Journal of Community Psychology, July 2003

accommodation. The data showed that there were rather severe stigmatizing attitudes in the community, such as beliefs about parents causing the illness, strong opposition to setting up psychiatric community facilities near their residence, and limited employment opportunities for people with mental illness, which also increased both the subjective and objective burdens on clients’ relatives by denying them social and practical support. Correlations between previous contacts and attitudes are significant. Implications to further research and social policy are discussed. © 2003 Wiley Periodicals, Inc.

Mental health stigma and its implications to rehabilitation of individuals with mental illness have recently attracted attention from researchers and policy makers ~Corrigan, 2000; Garske & Stewart, 1999!. Miles ~1981! defined stigma as “a societal reaction which singles out certain attributes, evaluates them as undesirable and devalues the persons who possess them.” Thara and Srinivasan ~2000! similarly defined stigma as “social devaluation of a person because of personal attribute leading to an experience of sense of shame, disgrace and social isolation.” Goffman ~1964! considered physical deformity, abnormal behavior, and race the first causes of stigma, which were later extended to broader and more subtle characteristics. It is widely recognized that stigmatizing attitudes exist towards mental illness. Kelly and McKenna ~1997! pointed out that, although the more recent survey data such as those presented by Gould ~1992! and Brockington et al. ~1993! suggested positive attitudes in the community, the expressed attitudes were not mirrored by mental health consumers’ experience. The majority of consumers in Kelly and McKenna’s ~1997! study had experienced harassment or victimization. A study in Ireland ~Murphy, Black, & Duffy, 1993! found that 3% of the respondents would object to having ex-mental health consumers as neighbors, 18% would object to their closest of kin marrying a consumer, and 33% would object to having babysitters with a previous mental illness. As Gould ~1992! suggested, people would accept mental health consumers in the community only if they were kept at a social distance. Chou, Mak, Chung, and Ho ~1996! reported that in Hong Kong, 40% of the people were reluctant to have mental health consumers live in their neighborhood. Fifty-five percent of their respondents believed that people with mental illness should remain in psychiatric hospitals before they have recovered completely. The attribution model originated from social psychology had important implications on the formation and maintenance of mental illness stigma ~Corrigan, 2000!. Attribution is the process by which people infer causes of events and behaviors. Biased attribution of mishaps to the poor personal qualities of the victim is a common phenomenon. Mental illness stigma also represents a stereotype of mental health consumers, as people overgeneralize negative characteristics of some mental health consumers to all those who have mental illness ~Corrigan, 1998!. The mass media have been considered as the culprit in the formation and maintenance of stigmatizing attitudes towards mental health consumers. In his study of media influence, Philo ~1991! demonstrated that people’s memory of the miners strike in the UK in 1984 –1985 was more consistent with media accounts than with the actual situation. He pointed out that it was very difficult to challenge the accounts made by the dominant media as alternative sources of information were not readily

Stigmatizing Attitudes and Mental Illness


available. Indeed, dominant media are, by definition, what has the greatest influence on representations of people and events. When the public has little contact with mental health consumers, cinematic images of madness may remain unchallenged, which in turn, prevents future contact. As Corrigan and Penn ~1999! pointed out, contact with persons with mental illness is an effective way of dispelling psychiatric stigma; when stereotypes lead to contempt or fear that prevents contact, it is more difficult to change stigmatizing attitudes. In Chinese societies, there is more severe stigma against individuals and thus relatives of mental health consumers, as Chinese culture attaches more importance to the collective representation of families, and having a mentally ill relative is considered something one should feel ashamed of, for it can imply an inferior origin of the family, failure of the parents, or even sin committed by ancestors ~Hsu, 1995!. Hence, many Chinese families have concealed their relatives’ mental illness in order to avoid stigma. This results in social isolation, and limitation of emotional and practical resources important for dealing with the illness ~Tsang, Tam, & Chan, 2003!. This is further evidenced by the characteristic help-seeking behaviors of Chinese who often take the form of somatization and emphasis on medication ~Chin, 1998!. The reason is simply that shame and stigma are often associated with mental illness in Chinese societies. Findings from a survey conducted among mental health professionals in Beijing also highlighted the significance of stigma in China. Nearly 80% of the respondents rated social stigma as a major problem faced by people with mental illness returning to the community ~Tsang, Weng, & Tam, 2000!. In Hong Kong, the Health and Welfare Bureau estimated that there would be 96,005 people with mental illness requiring psychiatric services in 2002 ~Health and Welfare Bureau, 1999!. Functional psychoses and organic psychoses were expected to account for 25.7 and 40.2% of the cases respectively, and 15.8% of the cases were expected to be child and adolescent psychiatric disorders. Chen ~1995! estimated that the prevalence rate of mental illness in mainland China was approximately 11 per 1,000 people in the 1980s. This number translates into a total of over 10 million people. The World Health Organisation ~2000! estimated that in 1999, 106,845,000 life years were lost to unipolar major depression, bipolar disorder, psychoses, posttraumatic stress disorder, obsessive-compulsive disorder, and panic disorder in WHO regions. Apart from decreasing life expectancy, mental illness causes much suffering, and is very debilitating. People with mental illness frequently suffer impairments in cognitive functions such as reasoning and communication, and in daily activities such as working and friendship ~American Psychological Association, 1994!. Unfortunately, stigmatizing attitudes about persons with severe mental illnesses have a further negative impact on their rehabilitation and rehabilitation. This is evident in both the development of community-based rehabilitation facilities ~Helander, 1992! and lives of persons with these disorders ~Chan, Hedl, Parker, Lam, Can, & Yu, 1988; Murphy, 1998; Wang, Chan, Thomas, Lin, & Larson, 1997!. There may be protest against the setting up of community-based psychiatric rehabilitation facilities ~Cheung, 1988, 1990!. People with severe mental illness may experience discrimination when looking for a job ~Bordieri & Drehmer, 1986; Ip, Pearson, Ho, Lo, Tong, & Yip, 1995!, when leasing apartments ~Corrigan, 1998; Page, 1993!, and in the criminal justice system ~Steadman, 1981!. Stigma may add burden to families of those with mental illness ~Phelan, Bromet, & Bruce, 1998!. As a result, the study of attitudes toward disabilities including those suffering from mental illness has a long history in the field of rehabilitation.


Journal of Community Psychology, July 2003

In Hong Kong and Mainland China, there has been rapid growth in social, organizational, and economic aspects. Despite a number of previous studies ~e.g., Chou, Mak, Chung, & Ho, 1996; Lee & Chan, 1999; Tse, 1994! on this subject, this study aimed at providing the most up-to-date empirical findings of stigmatising attitudes towards individuals with mental illness and the impact on their lives and recovery in Chinese societies. METHOD Participants The respondents for the questionnaire survey were recruited through students of three primary and four secondary schools in Hong Kong. In order that the primary school students understood the instructions given by the researcher, only students at grade 4 or above were involved. This corresponded to an age range from 8 to 12. The age range of the students in secondary schools ranged from 12 to 19. At each school, two to four classes were drawn at random. In Hong Kong, class size ranged from 30 to 35. Each student was given a copy of the questionnaire and cover letter, and asked to invite a friend or relative aged 16 or above to complete the questionnaire. Questionnaires were collected in classrooms after 1 week. One thousand seven validly completed questionnaires were returned. The response rate was 74%. Table 1 presents the characteristics of the sample. Most of the respondents were the students’ parents, sisters and brothers.

Table 1. Sample Characteristics ( N 5 1007) Sex
Male Female Age 16 –25 26 –35 36 – 45 46 – 55 Over 55 Education Primary or below Secondary Postsecondary Tertiary Occupation Managers and administrators Professionals Associate professionals Clerical workers Service workers Craft workers Plant and machine operators Elementary occupations Students Homemakers 36.7% 58.0% 29.4% 5.2% 43.3% 12.0% 1.0% 16.1% 59.4% 8.5% 7.1% 3.6% 2.6% 3.7% 6.1% 3.3% 5.2% 3.7% 2.9% 29.1% 24.0% ~370! ~584! ~296! ~52! ~436! ~121! ~10! ~162! ~598! ~86! ~71! ~36! ~26! ~37! ~61! ~33! ~52! ~37! ~29! ~293! ~242!

Stigmatizing Attitudes and Mental Illness


Instruments There were altogether two measures used in this study. Questionnaire on Mental Illness was developed and used as the main scale to measure public attitudes. Level of Contact Subscale was used to control for the effect of previous contacts with mental health consumers. Questionnaire on Mental Illness. Although measures to assess public attitudes towards mental illness are numerous, almost all of them were developed overseas, which may not be relevant to Hong Kong. A questionnaire was therefore specially devised for this study to measure public attitudes towards mental illness with special reference to issues which affect the burden of client’ families. Items were gathered by a review of existing scales and the literature. Existing scales included the Opinions about Mental Illness Scale ~OMI; Cohen & Struening, 1962! and Attitude Toward Disabled Persons Scale ~ATDP; Yuker, Block, & Campbell, 1960!. Review of the literature on attitudes and family burden suggested additional items. In addition to the literature review, five rehabilitation health professionals ~including one psychologist, one social worker, one researcher, and two occupational therapists in different settings! and three people with mental illness were interviewed and invited to suggest new items. Items were selected based on their relevance to Hong Kong and Chinese culture. Repetitive items were then deleted from the list. The remaining items were translated ~English–Chinese for items originally in English, and vice versa for items originally in Chinese! and back-translated by another translator to verify that the Chinese and English versions of the items were equivalent. An expert panel of 10 mental health workers then examined the list of items. They were asked to comment on the relevance of each item when applied in Hong Kong. A pilot study was then conducted at a local secondary school. Eighty F.1 and F.4 students were asked to either complete the questionnaires themselves or ask a relative or acquaintance aged 16 or above to complete it. Responses were scored on a five-point Likert-type scale. Fifty-nine completed questionnaires were returned, constituting a response rate of 75%. Consistency checks of responses made to similar items showed that respondents had understood the questionnaire, and that the different wordings in the questionnaire had little effect on responses. Based on the results, items with very high correlations ~ .9! were either deleted or combined. The questionnaire items are shown in the Appendix. The new form was validated using a think-aloud procedure with two volunteers in two separate sessions. The items were interpreted as intended. Level of Contact Subscale. To control for the effect of previous contact with mental health consumers, the ordinal contact scale developed by Holmes et al. ~1999!, with which ordinal contact scores from 1 to 12 could be assigned to reflect respondents’ different levels of contact with mental health consumers, was translated and adapted. The 12 items in the original scale were translated, back-translated, and both the Chinese and English versions were examined by 11 mental health workers ~two psychiatrists, three social workers, four occupational therapists, one psychologist, and one researcher! for ranking and comments. Some items were considered repetitive ~“My job involves providing services0treatment for persons with a severe mental illness” and “My job includes providing services to persons with a severe mental illness.”! Some items were clear statements on their own, but unhelpful for differentiating between people who had frequent contact with mental health consumers and people


Journal of Community Psychology, July 2003

who did not. For example, “I have a relative who has a severe mental illness” and “A friend of the family has a severe mental illness” gave no indication of the frequency of contact. These items were then rewritten. The revised scale was pilot-tested with a convenient sample of 20 lay respondents and five mental health workers, known to the researcher’s friends or colleagues. Respondents were aged between 22 and 58; seven of them were educated to secondary level and eighteen had postsecondary education. The respondents interpreted the items as the researcher had intended. Items were rearranged to minimize memory effect on a retest 2 weeks afterwards. Test-retest reliability was .95. The subscale was then incorporated into the main questionnaire. Procedure Both Questionnaire on Mental Illness and Level of Contact Subscale were self-administered. The questionnaires were accompanied by a cover letter that explained the purpose of the survey and stated that participation was voluntary and anonymous. Students were asked to bring completed questionnaires to school for collection after 1 week. Data Analyses The data were analyzed using SPSS version 10.0. Descriptive statistics were obtained for all variables. The categories “strongly agree” and “agree” were combined and so were the categories “strongly disagree” and “disagree,” due to the small percentages of endorsement for the extreme options. The percentages of positive, negative, and neutral responses were calculated for each item. An exploratory factor analysis ~EFA! was then conducted to identify major factors in respondents’ attitudes towards mental illness. Kendall’s tau_b coefficient was used to explore relationships between levels of previous contact and endorsement to the attitude factors identified. Questionnaires found to be incorrectly and inappropriately rated items were deleted for subsequent analyses. There were a few questionnaires where a small number of items were not rated and were found to be due to carelessness of the respondents. If these did not affect the validity of correctly rated items, the questionnaires were retained for analysis. The incomplete items were then treated as missing data. RESULTS Table 2 presents the results of the survey. Approximately 12% of the respondents ~n 123! believed that children’s mental illness were mostly caused by parents’ misbehavior ~Question 4!; another 21.2% of participants ~n 213! were undecided. A similar pattern of responses emerged for Question 11; 30.0% of the participants ~n 302! did not know that people might develop mental illness even if they had no family history of the illness. Regarding the provision of assistance to clients’ families, over 61.8% of respondents ~n 622! were in favor of allotting more resources to provide more support ~Question 8!. But only 46.2% of the respondents ~n 465! believed that elderly homes should accept senior citizens who had been mentally ill ~Question 1!. Forty-four point two percent of the respondents ~n 445! believed that parents’ mental illness should not affect the employment of their children in positions where guns might be used. Twenty-one point eight percent of respondents ~n 215! would screen out job applicants who had been mentally ill without interviewing them ~Question 28!.

Stigmatizing Attitudes and Mental Illness


Table 2. Attitudes Towards People with Mental Illness and Their Relatives ( N 5 1007) Item
Practical care 1. Elderly homes should not take in old people who have been mentally ill.a 8. I am in favor of allotting more resources to provide more support for family members of people with mental illness. 9. Property owners should not be blamed for refusal to lease properties to people with mental illness.a 18. Psychiatric rehabilitation facilities should be located away from people’s residence.a 24. If the government or other organizations propose to set up halfway houses near my home, I will oppose strongly.a Employment 22. Children of psychiatric patients should not be hired in positions where guns may be used, even if they have never had mental illness themselves.a 28. As an employer, I would screen out job applicants who have been mentally ill without interviewing them.a Emotional burden 2. Discrimination and alienation against psychiatric patients can affect their recovery. 4. The majority of psychiatric patients became ill because of their parents’ wrong approaches to bringing up children.a 11. If there has never been any case of mental illness in the family, no family member would become mentally ill in future.a 27. If the person sitting next to me on public transport keeps muttering to himself0herself, I will leave my seat.a

27.6% ~278! 61.8% ~622! 36.4% ~367! 19.3% ~194! 29.2% ~294! 18.8% ~189! 22.6% ~228! 83.8% ~844! 12.2% ~123! 10.0% ~101! 50.3% ~507!

46.2% ~465! 7.5% ~76! 32.0% ~322! 40.1% ~404! 69.8% ~703! 44.2% ~445! 76.1% ~766! 5.5% ~55! 66.6% ~671! 70.0% ~705! 48.8% ~491!

26.2% ~264! 30.6% ~308! 31.6% ~318! 39.4% ~397! N0A

36.8% ~371! N0A

10.7% ~108! 21.2% ~213! 20.0% ~201! N0A

Items marked with


are statements to which people with better knowledge0more positive attitudes should disagree.

Only 40.1% of the participants ~n 404! agreed that psychiatric rehabilitation facilities did not need to be far away from residential areas ~Question 18!. If the government proposed to set up halfway houses in the neighborhood, 28.8% of the respondents ~n 285! opposed strongly ~Question 24!. Fifty-one percent of the respondents ~n 504! reported that they would change seats on public transport if the passenger beside them muttered to oneself ~Question 27!. Overall, respondents seemed to be aware that many difficulties confronted people with mental illness and their relatives, but possessed only limited knowledge about mental illness. Although they would welcome the provision of more comprehensive services to these people by public bodies, at the personal level they were suspicious that people who had been mentally ill are dangerous, and thus preferred to stay aloof from individuals who have had a mental illness. Support for People with Mental Illness and Their Relatives The majority of respondents ~n 884, 83.8%! recognized that alienation and discrimination would adversely affect the recovery from mental illness ~Question 2!. However, while 80% of the respondents were aware that alienation of people with mental illness would affect their recovery, only 60% considered alienation of these people unacceptable. Hence, at least 20% of all respondents accept or tolerate discrimination even


Journal of Community Psychology, July 2003

though they know that such behavior has negative consequences for people with mental illness. By the same light, only one-forth of the respondents indicated that they would help a new colleague who had been mentally ill adapt to the workplace; if put into the position of the employer, 20% of all respondents would not even allow job applicants who had been mentally ill to participate in interviews. Therefore, although there is a general awareness that people with mental illness should be given support, the amount of support they actually get is bound to be limited. Knowledge and Perceptions of Mental Illness Misbeliefs about mental illness persisted in the respondents. People who had been mentally ill were most commonly described by respondents as quick-tempered ~n 469, 46.6%!, unpredictable ~n 390, 38.7%!, introverted ~n 515, 51.1%!, and having low self-esteem ~n 470, 46.7%!. The majority believed that autism ~n 556, 55.2%! and depression ~n 687, 68.2%! are psychiatric conditions, while anorexia nervosa ~n 167, 16.6%!, ADHD ~n 308, 30.6%! and Parkinson’s disease ~n 125, 12.4%! are not. This reflected the perception that people with psychiatric conditions are “weird” or “crazy,” and fundamentally different from “normal” people; those disorders that appear to be deviance in degree not in kind, for example, the elderly whose senses deteriorate faster than others’, the girl who refuses to eat for a longer period than other girls on diet, and the child who displays less patience than other children, do not seem “crazy” enough to be categorized as psychiatric conditions. Congruent with such perceptions was the belief that people with mental illness are dangerous and remain so for a lifetime, as the abnormality that lies deep in the person can only be suppressed, not eradicated. In this survey, 28.9% ~n 291! of the respondents thought that “people who had been mentally ill are dangerous no matter what” ~Question 17!. Furthermore, only 39.4% ~n 397! of the respondents considered it appropriate to have psychiatric rehabilitation facilities located near residential areas; 30% of all respondents would strongly oppose to setting up halfway houses near their homes. Exploratory Factor Analysis An exploratory factor analysis was conducted and eight factors with eigenvalues over 1.0 were extracted. Items belonging to each factor were identified using Varimax rotation with Kaiser normalization. The factors identified accounted for 50.6% of the total variance ~see Table 3!. The factors are: hostility, aberrant, openness, resources, acceptance, rights, misgivings, and accommodation. Correlations Between Contact and Attitudes Each respondent was assigned a contact score based on the highest level of contact he0she indicated. Table 4 presents the frequencies of this score and the number of people indicating different levels of previous contacts with mental health consumers. Table 5 shows the correlations between levels of previous contacts and endorsement to the attitude factors identified, using Kendall’s tau_b coefficient. Higher levels of contact were associated with more openness towards mental illness, more support for increasing resources and services for consumers and families, more acceptance of consumers in the community, more concern about the rights of consumers, and higher

Table 3. Rotated Component Matrix for Items 1 to 28 Factor Hostility Aberrant Openness Resources Acceptance 6 7 8


Stigmatizing Attitudes and Mental Illness

24 25 18 28 17 13 27 6 5 11 16 4 22 23 26 15 7 8 19 21 3 2 10 20 14 12 1 9

Oppose strongly to halfway house near home If new neighbor had MI, would avoid the family Rehab facilities far away from residences Screen out job applicant without interview Ex-consumers dangerous Don’t want to work with ex-consumer Leave seat if fellow passenger act strangely Counseling only for severe mental problems Medications only for severely deranged Kin will not have MI if none occurred in family Helping physical handicap more important Most MI due to faulty child-rearing Consumers’ children not serve in armed forces Suggest counseling if relative depressed Would help newcomer to workplace May lead normal life given appropriate help More funding for psychiatric rehabilitation In favor of more support for families Alienation unacceptable Some ex-consumers successful at work Modern drugs can control Discrimination can affect recovery Treated unfairly in Hong Kong Government not enough attention Newspaper portrayals exaggerated Don’t know how to get along with Elderly homes should not take in Property owners’ rejection acceptable

.642 .623 .615 .607 .548 .528 .484 .001 .057 .113 .371 .083 .257 .113 .233 .107 .082 .157 .099 .181 .040 .066 .011 .051 .132 .054 .047 .254

.134 .048 .056 .120 .008 .054 .007 .792 .756 .461 .433 .381 .334 .093 .090 .026 .047 .010 .110 .026 .068 .249 .028 .043 .073 .009 .059 .005

.033 .139 .242 .040 .064 .198 .189 .022 .048 .353 .109 .312 .059 .692 .586 .420 .162 .112 .033 .459 .055 .091 .040 .212 .015 .065 .077 .138

.077 .019 .103 .015 .145 .016 .049 .024 .022 .093 .050 .010 .106 .145 .076 .168 .795 .744 .002 .096 .461 .222 .002 .214 .141 .099 .025 .003

.004 .285 .173 .300 .145 .180 .033 .083 .025 .111 .229 .061 .066 .046 .105 .416 .080 .054 .618 .504 .478 .371 .014 .101 .268 .034 .101 .026

.072 .027 .113 .045 .022 .009 .091 .075 .047 .078 .019 .299 .119 .115 .091 .042 .122 .250 .261 .104 .188 .283 .787 .575 .458 .037 .023 .088

.086 .045 .257 .065 .312 .423 .237 .032 .023 .184 .158 .193 .118 .173 .112 .227 .116 .053 .101 .021 .272 .277 .000 .009 .109 .697 .057 .295

.077 .082 .116 .039 .178 .078 .359 .038 .031 .107 .177 .161 .095 .060 .093 .138 .094 .021 .065 .104 .078 .073 .041 .030 .075 .132 .796 .550


Extraction method: Principal component analysis. Rotation method: Varimax with Kaiser normalization. Rotation converged in 22 iterations.


Journal of Community Psychology, July 2003

Table 4. Frequencies of the Contact Scores Score
8 7 6 5 4 3 2 1 0

I have had a mental illness. I have lived with someone with a mental illness. I have frequent contact with a friend or relative who has a mental illness. It is my main duty to provide service to people with mental illness. I often encounter people with mental illness ~at least twice a month!. I encounter people with mental illness occasionally. I have observed, in passing, someone who might have a mental illness. I have seen realistic portrayals of people with mental illness in newspapers, magazines, films, or TV programs. None of the above is true.

19 32 81 17 29 231 192 271 108

~1.9%! ~3.2%! ~8.0%! ~1.7%! ~2.9%! ~22.9%! ~19.1%! ~26.9%! ~10.7%!

likelihood to regard consumers as respectable and competent members of society. However, greater amount of contact was also associated with the impression of mental health consumers as weak personalities. Different levels of contact made no difference to hostility towards consumers, the impression of consumers as aberrant, misgivings over interaction with consumers, rejection of consumers from “normal” accommodations, and the impression of consumers being inferior and dangerous. DISCUSSION The results show that there are rather severe stigmatizing attitudes in the community that affect the lives of people who have mental illness. As nearly 30% of the respondents were against the acceptance of senior citizens who had been mentally ill into elderly homes, and another one-fourth had reservations about accepting them, elderly homes are pressured by residents and families not to take in people who have0had a mental illness. In Hong Kong, the majority of aged homes are run by the private and nongovernment organizations, of which the operations are largely uncontrolled by the government. Together with the shortage of residential places, aged homes can easily
Table 5. Correlations Between Level of Contact and Attitude Components Using Kendall’s tau_b Correlation Coefficient Component
Hostility and segregation Consumers as aberrant Openness towards metal illness More resources and services Acceptance in community Rights of consumers Misgiving over interaction Rejection from accommodations Respectable Inferior Weak Dangerous Competent

Correlation Coefficient
.015 .005 .064 .102 .150 .125 .016 .006 .082 .031 .080 .044 .065

.587 .849 .025 .000 .000 .000 .577 .843 .004 .272 .005 .125 .023

Stigmatizing Attitudes and Mental Illness


be led to choose residents. The burden of care on families will increase when they are unable to find a place for their elderly relative who had been mentally ill. Similarly, 20% of respondents were against and 40% were hesitant about the setting up of psychiatric rehabilitation facilities in the community ~Question 18!; close to 30% would “oppose strongly” if the government or other organizations proposed to set up halfway houses near their homes. The “Not in My Backyard” phenomenon is evident. This fully explains why there was strong resistance regarding the setting up of community-based rehabilitation facilities for people with mental illness ~Cheung, 1988, 1990; Tse, 1994!. Similarly, the results indicate that employment opportunities for people who had been mentally ill are limited by negative attitudes. This finding is consistent with the low employment rate ~around 30%! of individuals with mental illness in Hong Kong as reported by the Equal Opportunities Commission ~1997! and the survey in the Chinese Mainland that social stigma is one of the reasons leading to unemployment of people with psychiatric disabilities in China ~Tsang et al., 2000!. Obviously, unemployment bears important implications on the burden on clients’ relatives. Unemployment brings not only financial burden but also hindrance to clients’ recovery. As previous research has repeatedly shown, employment offers opportunities for social interaction, builds self-esteem and identity, and is the best predictor of recovery and social integration ~Dawis, 1987; Mowbray, Bybee, Harris, & McCrohan, 1995; Osipow, 1968!. When clients are deprived of employment opportunities, disappointment and negative self-attributions would add stress to the home. In cases where recovery is affected, relatives face not only an emotional burden but also difficulties in practical care. The results showed that misbeliefs about the family being inferior existed in the community. The large number of people who would change seats on public transport when another passenger appeared to be abnormal implied that relatives of clients might be embarrassed when going out with the clients. These results point to the effects of stigma in increasing the emotional burden of relatives. Over 60% of participants were in favor of allotting more resources to help clients’ relatives, indicating an awareness of the difficulties faced by these families. However, when viewed together with the unwillingness to accept them in the community and in the workplace, this support for more resources from the government also reflects the reluctance to help mental health consumers at the individual level, and the reliance on the government to help consumers’ families. Yet the allocation of social resources are greatly influenced by the society’s values and priorities ~Mechanic, 1989!. When the problems faced by clients’ relatives are not the concern of the public, their chance of winning the keen competition for resources is slim. The authors reviewed various types of documents of the Legislative and District Councils in Hong Kong, including the questions raised by legislators at Council meetings and Committee meeting minutes between October 2000 and March 2001, and the minutes of meetings of the Eastern District Council and its Committees from December 1999 to December 2000. Hundreds of questions had been raised at Legislative Council meetings during the specified period, and a wide range of issues had been discussed at the Councils and Committees, but no question about the welfare of mental health consumers had been raised. Over 90% of the consumers on psychiatric medication for schizophrenia and bipolar disorder today are still using drugs developed in the 1950s and 1960s, which bring serious side effects. But due to cost considerations, new antipsychotics are supplied to only a small proportion of consumers at public hospitals and clinics.


Journal of Community Psychology, July 2003

In Hong Kong, families of mental health consumers are a minority that is largely socially isolated due to their fear of stigma. They are unable to organize mass action or bring large numbers of votes to politicians, and thus they have little influence in social policy making. To alleviate their burden, traditional efforts center around the provision of psychiatric rehabilitation program in hospitals, day hospitals, and community facilities to the clients and family psychoeducation to the families. For instance, skills training ~Tsang, 2001! is provided to clients to increase their chance of getting and sustaining competitive employment and goal attainment program ~Ng & Tsang, 2000! is provided to help people with severe mental illness to formulate their life goals. Nevertheless, this study indicates that public education against stigmatization and marginalization of these families are necessary but currently neglected in Hong Kong. In particular, myths about causes of mental illness and the “danger” of clients and relatives must be dispelled. Education and empowerment programs are also important in helping families not to be intimidated from seeking help but stand up for their own welfare. Research effort to develop and evaluate the effect of these education and empowerment programs are urgently needed. Previous research has shown that contact with persons with mental illness diminishes negative attitudes towards them ~Angermeyer & Matschinger, 1997; Chou & Mak, 1998!. In the present study, higher levels of contact were associated with more openness towards mental illness as treatable conditions, more support for increasing resources and services for consumers and families, more acceptance of consumers in the community, more concern about the rights and welfare of consumers, and higher likelihood to regard consumers as respectable and competent members of society. However, greater amount of contact was also associated with the impression of mental health consumers as weak personalities, being timid, and having low self-esteem. Also, different levels of contact made no difference to hostility towards consumers, the impression of consumers as aberrant, misgivings over interaction with consumers, rejection of consumers from “normal” accommodations, and the impression of consumers being inferior and dangerous. In other words, increased contact might encourage benevolence towards people with mental illness, but at the same time reinforce the impression that they are pitiful, possibly because people learn more about consumers’ weaknesses ~e.g., low selfesteem! through the contact. The suspicion that mental health consumers may become irrational and violent without signs is the most resistant to change, and people still want to keep away from these persons. The author speculates that this is because the absence of danger can never be proven, and the myth about the potentially violent consumer cannot be logically refuted. This implies that providing opportunities for the public to have more contacts with individuals with mental illness may be an effective measure to reduce stigma. Further studies are needed in this aspect. CONCLUSION This study provides further and most up-to-date empirical evidence as to the severe mental illness stigma in Hong Kong, which has a population of 7.2 million. As an economically and commercially developed city in Chinese mainland, there is reason to speculate that similar problems exist in other developed Chinese cities such as Shanghai and Beijing and Chinese communities in America. The social stigma has tremendous impacts on the recovery of individuals with mental illness in terms of employment, social resources, and availability of community-based facilities. To counter such stigma, further research needs to be conducted to better understand the mechanism

Stigmatizing Attitudes and Mental Illness


leading to the stigmatisation. With this knowledge, appropriate social policies and actions can be taken to reduce this barrier as to the recovery of individuals with mental illness. REFERENCES
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Journal of Community Psychology, July 2003

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