Impact Of Family On Stigma Internalization Among People With Severe Mental Illness

BackgroundThe internalization of stigma leads to an array of negative consequences among people with mental illness.The impact of related factors and the mechanism of internalized stigma are important for developing targeted interventions.Family is one of the main areas to be explored for a better understanding of the internalization of stigma in people with mental illness.However,limited studies have paid attention to the impact of family on patients' internalized stigma,especially in Chinese culture.Objectives(1)To explore the impact of family on stigma internalization among people with mental illness in the context of Chinese culture and to construct a theoretical model of the mechanism.(2)To test the theoretical model of the impact of family on stigma internalization among people with mental illness.Methods(1)Part 1 was a qualitative study based on grounded theory method.From March 2018 to April 2019,semi-structured interviews were carried out with a sample of 20 people with severe mental illness and 10 family members of them,through purpose sampling and theoretical sampling,from Beijing Anding Hospital and Tiancun community health care center.Each participant was interviewed for one to six times accordingly.We also visited five of the recruited families to implement informal participatory observation for one to four half days each.Materials about family members'conceptions and attitudes toward mental illness,and daily interactions among patient and family members were collected.All the interviews were transcribed verbatim in texts and field notes were taken while conducting family observation.Data analysis followed 3 steps of coding(open coding,axial coding and selective coding),using constant comparative method and memo writing,to identify the main categories and their relations,and then to ultimately form the theoretical model of the impact of family on stigma internalization among patients with mental illness.(2)Part 2 was a cross-sectional survey.243 patients diagnosed with severe mental illness were recruited in Beijing Anding Hospital and three community health care centers in Beijing,from August 2019 to February 2020 by convenience sampling.Self-Stigma Scale-Short Form,stereotype agreement subscale in Self-Stigma of Mental Illness Scale,Family Attitudes About Mental Illness Associated Stigma Scale,the Level of Expressed Emotion Scale,family associated stigma and stigma coping questionare,family support subscale in Perceived Social Support Scale,and Family APGAR Index were used.Structural equation modeling was applied to confirm pathways from family factors to stereotype endorsement and internalized stigma in the hypothesized theoretical model,which was developed in part 1.Results(1)Based on the qualitative study,a theoretical model was developed to present the potential effects of the identified family factors in stigma internalization.Our findings revealed that family could both facilitate and impede the process of stigma internalization in people with mental illness,via daily interactions within family.Three major family factors influencing patients' internalized stigma were identified,including the "biased beliefs of family members" at the individual level,the "negative responses within the family" at the intra-familial level,and the "differentiated family environment" at the level of the whole family system,in which "biased beliefs of family members" could bring about the "negative responses within the family".In addition,"patient's individualized response" and "stereotype endorsement" were important mediating factors in the process from family factors to patient's internalized stigma.(2)The average score of internalized stigma of 243 participants in our survey was(2.21±0.72).Overall,35.40%of the subjects had moderate-to-high scores(?2.5)of internalized stigma.Multiple regression analysis indicated that internalized stigma among people with severe mental illness was associated with stigma coping of family members and stigma attitude of family members towards patient's recovery and outcomes(R2=0.398,P<0.001),the standardized regression coefficients were 0.548 and 0.193,respectively.Path analysis showed that the direct coefficient of patient's stereotype endorsement on patient's internalized stigma was 0.42;the direct coefficient of family stigma coping on patient's internalized stigma was 0.42,the indirect coefficient of family stigma coping on patient's internalized stigma by patient's stereotype endorsement was 0.11;the indirect coefficient of family associated stigma on patient's internalized stigma by family stigma coping was 0.37;the total indirect coefficient of family stigma attitude on patient's internalized stigma by family stigma coping and patient's stereotype endorsement was 0.22;the direct coefficient of family expressed emotion on patient's internalized stigma and the indirect coefficient through patient's stereotype endorsement were not statistically significant(P>0.05).Indices of model fitting were:?2/df=1.148,RMSEA=0.025,GFI=0.991,AGFI=0.968,NFI=0.989.ConclusionFamily could both strengthen and weaken internalized stigma among people with mental illness,via negative or positive daily interactions within family.Family-based interventions should be developed directed at beliefs of family members,responses within the family,and the family environment,with particular attention to the family stigma coping,family associated stigma,and the family stigma attitude towards mental illness,to impede the process of stigma internalization of patient.