Although psychiatric stigma in China is particularly pervasive and damaging, rates of high expressed emotion ("EE" or family members' emotional attitudes that predict relapse) are generally lower than rates found in Western countries. In light of this seemingly incongruous juxtaposition and because Chinese comprise approximately one-fifth of the world's mentally ill, we examine how one of the most widely held causal beliefs of schizophrenia--excessive thinking (xiang tai duo)--may powerfully shape how those exhibiting psychotic symptoms pass from "normal" status to stigmatized "other." Using a framework by which stigma threatens an actor's capacity to participate in core everyday engagements, we examine how expressions of excessive thinking intersect with psychotic symptoms and how this idiom reduces stigma by preserving essential moral standing. Four focus groups with family members (n = 34 total) of schizophrenia outpatients, who had participated in psychoeducation, were conducted in Beijing. Open coding was conducted by 2 bilingual coders achieving high interrater agreement. Common expressions of excessive thinking--taking things too hard that is perceived as a causal factor and unwarranted suspicion that is used to benignly interpret paranoid symptoms encapsulated disruptive behaviors that closely overlapped with psychotic symptoms. Because excessive thinking is understood to occur universally, this idiom encourages socially accommodating behavior that signifies acceptance of these individuals as full-status community members. In contrast, due to beliefs implying moral contamination, those labeled mentally ill are threatened with both subtle and outright social exclusion. We discuss implications of this idiom for EE and the detection of schizophrenia "prodrome" in China.
Purpose
As mental illness stigma contributes to poor outcomes for schizophrenia in China, locating strategies to reduce public stigma is imperative. It is currently unknown whether diagnostic labeling and contact with different help-seeking sources increase or decrease public stigma in China. Further, it remains unresolved whether prior personal contact acts to reduce stigma in this context. Advancing understanding of these processes may facilitate stigma-reduction strategies.
Methods
We administered an experimental vignette randomly assigning one of four labeling conditions to respondents to assess social distance towards a psychotic vignette individual in a sample of 160 Northern, urban Chinese community respondents.
Results
As expected, respondents given a “non-psychiatric, indigenous label” + “lay help-seeking” condition endorsed the least social distance. Unexpectedly, the labeling condition with a “psychiatric diagnostic label” + “lay help-seeking” condition elicited the greatest social distance. Unlike Western studies, personal contact did not independently decrease community stigma. However, prior contact reduced social distance to a greater extent in the labeling condition with a “non-psychiatric, indigenous label” + “lay help-seeking” condition when compared with all other labeling conditions.
Conclusion
The results indicate that cultural idioms do provide some protection from stigma, but only among respondents who are already familiar with what mental illness is. Our finding that the condition that depicted untreated psychosis elicited the greatest amount of stigma, while the “treated psychosis” condition was viewed relatively benignly in China, suggests that improved access to mental health services in urban China has the potential to decrease public stigma via labeling mechanisms.
In Chinese Americans with cancer pain, the DSES-C demonstrated acceptable psychometrics. Some participants experienced linguistic or cultural barriers preventing completion. Future investigations should provide additional validation in different Asian subgroups and those with varied medical conditions.
Encounters with Western psychiatric treatment and acculturation may influence causal beliefs of psychiatric illness endorsed by Chinese immigrant relatives, thus affecting help-seeking. We examined causal beliefs held by forty-six Chinese immigrant relatives and found that greater acculturation was associated with an increased number of causal beliefs. Further, as Western psychiatric treatment and acculturation increased, causal models expanded to incorporate biological/physical causes. However, frequency of Chinese immigrant relatives' endorsing spiritual beliefs did not appear to change with acculturation. Clinicians might thus account for spiritual beliefs in treatment even after acculturation increases and biological causal models proliferate.
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