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How Chinese psychiatrists see and manage stigmatisation of psychiatric patients: a qualitative study in Hong Kong
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  1. Kai Sing Sun1,
  2. Tai Pong Lam1,
  3. Tak Lam Lo2,
  4. Dan Wu3
  1. 1 Department of Family Medicine and Primary Care, The University of Hong Kong, Hong Kong, China
  2. 2 Kwai Chung Hospital, Hong Kong, China
  3. 3 Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK
  1. Correspondence to Professor Tai Pong Lam; tplam{at}hku.hk

Abstract

Background Health professionals including psychiatrists were reported to have stigmatising opinions on psychiatric patients. Their views may be affected by clinical, social and cultural factors.

Objective This study explored the views of Chinese psychiatrists on stigmatisation of psychiatric patients.

Methods Focus group discussions with psychiatrists were conducted in Hong Kong. Their views towards stigmatisation of psychiatric patients and strategies to reduce stigmatisation were discussed.

Findings The psychiatrists perceived the clinical needs to classify the patients according to the diagnoses and they did not see it as stigmatisation. They believed that some mental illnesses are characterised with violence or deviance, and were not completely curable. Instead of trying to eliminate stigma, they managed in ways that took social expectations into consideration. They might offer a relative vague diagnostic label to save the ‘face’ of the patients and secure greater acceptance for the illness from the public. They tended to accept family members to make decisions on behalf of the patients. Reconciling public interest and patients’ autonomy, they encouraged stable psychotic patients to live in the community but agreed to institutionalise those patients with violent behaviours.

Conclusion While the psychiatrists argued that the diagnosis was not a form of stigma, they were sensitive enough and framed responses to patients in ways to minimise stigma. They tended to believe that stigma was inevitable given the nature of some psychotic disorders. Disguising the stigma appeared to be the common approach to deal with stigma in a Chinese context.

Clinical Implications The psychiatrists, especially those practicing in a Chinese context, may consider a wider perspective of community mental health rehabilitation which is not limited to social stability but also social life.

  • Chinese
  • Chinese, focus groups
  • mental illness
  • psychiatrists
  • stigmatization

https://doi.org/10.1136/ebmental-2018-300078

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    Introduction

    Stigmatisation towards people with mental illness is a worldwide phenomenon. It discourages them from seeking help and receiving treatment.1 2 Stigmatising opinions are held both by the general public and health professionals. Despite being the specialists to treat mental illnesses, psychiatrists were reported to have stigmatising opinions on psychiatric patients.3–6 They were shown in some Western studies to hold more negative views than other health professionals including general practitioners, mental health nurses, clinical psychologists and social workers.3 4 In comparison, the psychiatrists were least likely to believe that positive outcomes of recovery would result for patients with schizophrenia.3 Another survey found that psychiatrists and the public did not differ in their social distance to psychiatric patients, based on their willingness to interact with people suffering from psychiatric disorders in various social situations.7 Moreover, diagnostic labels used by psychiatrists, such as ‘schizophrenia’ and ‘personality disorder’, might give rise to negative stereotypes.6 8 Limited information is available in the literature regarding psychiatrists’ feedback to these concerns.

    Stigmatisation of psychiatric patients encompasses clinical, social and cultural aspects. Comparative surveys have shown that Chinese groups had higher stigma towards mental illnesses than the Western groups.9 10 Our previous qualitative study found that the general public tended to share very negative examples about the violent and annoying behaviours of patients with psychosis such as seeing them soliloquise, laugh aimlessly or denigrate others, and exaggerate these behaviours with examples like shooting or stabbing others.11 Yang et al 10 offered an explanation suggesting that Confucian traditions emphasised self-cultivation via moderate behaviour,12 and the stereotypes of dangerousness and unpredictability for psychiatric patients challenged these cultural norms. The mental illness labels might affect the societal roles of the patients and their families, leading to shame or ‘loss of face’.13 14 It is unclear whether these values also apply to Chinese psychiatrists who have undertaken professional training in Western medicine and psychiatry. This is especially the case in Hong Kong where the medical schools adopt a British curriculum. The perceptions of local practising psychiatrists are largely based on their medical knowledge on mental illnesses and clinical experience. Besides, utilitarianism, a popular Western ethical concept for public interest, as well as liberalism for human rights and individual freedom,15 are also at play to mould the psychiatrists’ views on managing psychiatric patients.

    Moreover, matching the Western trend of deinstitutionalisation of psychiatric patients,7 16 China has also planned to improve community-based care for patients with severe mental illness as a way to promote their human rights,16 alongside with the adoption of antistigmatisation strategies to change public perception on mental illnesses. The renaming of the Chinese translation for psychosis in Hong Kong is one such measure. It aims to replace the negative meaning of ‘mental split-mind disorder’ with a more objective description ‘dysregulation of thoughts and perception’.17 It is meaningful to understand the views of Chinese psychiatrists on these strategies.

    This study was part of a larger project investigating management of mental health problems in Hong Kong. The findings of some other themes of the project had been published elsewhere.18 19 This study aimed to explore qualitatively the views of Chinese psychiatrists on stigmatisation of psychiatric patients and strategies to reduce stigmatisation.

    Methods

    We conducted focus group discussions to explore in-depth the opinions of Chinese psychiatrists on the study topic. The focus groups placed participants in a natural and dynamic situation to share their ideas and past experiences with peers in a relaxing environment. Participants could interact with each other by responding to views shared in the discussion. The group interactions accentuated participants' similarities and differences; and gave information on a range of views.

    Sources of informants and methods of data collection

    We purposively recruited participants from both public and private settings with a wide range of characteristics and experience. We contacted the honorary teachers of a postgraduate psychological medicine course of The University of Hong Kong and asked them to recommend participants for the focus groups based on their professional network. Invitation letters were sent out to potential participants and followed by telephone contacts. We conducted two focus groups with one group consisting of seven psychiatrists and the other group of six psychiatrists. Among the 13 participants, 11 were male. The mean (SD) years after graduation from medical school was 22.7 (8.99) years. Their characteristics are summarised in table 1.

    View this table:
    Table 1

    Focus group participant characteristics

    Participants’ views on stigmatisation of psychiatric patients and strategies to reduce it were discussed in the focus groups. Prior written informed consent was obtained from the focus group participants. In a comfortable room environment, a chief facilitator led the 90 min discussion with a supporting facilitator who asked new or follow-up questions at times. Both facilitators were researchers experienced in qualitative and mental health studies, but were not practising medical doctors or therapists. They held a neutral stance and did not judge the views of the participants. Open-ended questions were asked and the participants were encouraged to share their opinions freely. A discussion guide was used to ensure relevant questions were covered. The discussions were audio-taped and then transcribed verbatim by a research assistant. The facilitator and one of the investigators of the study checked the accuracy of the transcriptions by listening to the audio records. Field notes were prepared by the supporting facilitator to record non-verbal responses during the discussions.

    Data analysis

    Using the conventional content analysis approach,20 coding categories were inductively derived from the text data of the transcripts. The text data were coded independently into main themes/subthemes by two investigators manually on the transcripts, with themes marked beside the coded sentences/paragraphs. The main themes/subthemes were organised in a tree structure. The coding consistency between the two sets was checked and the majority of the codes was consistent. Inconsistencies were resolved by discussion between the two investigators to reach an agreement for a common theme. Selected quotes were translated into English for the write-up of this paper.

    Results

    Various themes about the views on stigmatisation of psychiatric patients and antistigma strategies emerged from the content analysis. The themes regarding stigmatisation covered diagnostic label, clinical nature of psychotic disorders, typical and potential behaviours, perceived behavioural risk, institutionalisation and community care. The antistigma themes included wordings to express the diagnosis, renaming of psychosis and public education. These themes are illustrated below with quotes from the participants.

    Views on stigmatisation of psychiatric patients

    The psychiatrists responded to the concerns on their stigmatisation towards psychiatric patients. They explained that there was a need to clinically classify the patients according to their diagnoses based on which the treatment plan was delineated.

    I think we first have to make it very clear what stigmatisation is. We have gone through training; and are able to assess the severity of illness and understand the needs of the patient. Therefore this is not stigmatisation. We work according to our knowledge and think of something that the patient may find helpful. Certainly, from the patients’ perspective they may think that we are labelling them. This is possibly our occupational habit. In fact psychiatrists have been severely stigmatised as well. It is essential for us to label the patients, because we are more familiar with (psychiatric diseases) and understand the patients’ illness. (Gp1, P3)

    Some psychiatrists thought that stigmatisation could never be completely eliminated because of the nature of certain types of mental illness, especially psychotic disorders. There were some typical symptoms and behaviours presented by the patients.

    For example let’s say that psychiatric patients are not violent. This is not entirely correct because some of the psychiatric patients are violent. As this is the real situation in some patients, zero stigmatisation is never going to happen. For example, leprosy. Although most of the leprosy patients will not infect other people, some will. This minority leads all leprosy patients to suffer from stigmatisation. It is the same with mental disorder. Some mental illnesses are characterised with violence, eccentricity, or deviance. These aberrant characteristics make people doubt if the illness is curable. (Gp2, P1)

    One of the psychiatrists expressed that a certain proportion of psychiatric patients could be very dangerous. They might exhibit aggressive behaviours threatening themselves and others.

    In fact, a large number of patients are dangerous. Although they are not murderous, they may have been harming their own health or posing risks to others. A discussion has been started on whether we should have patients, whose conditions are not yet that severe, on compulsory hospitalisation or forced medication. (Gp2, P4)

    The views on the potential risks of psychiatrist patients could affect policy making. The psychiatrists in the focus groups generally supported institutionalised psychiatric patients to return to the society after rehabilitation. They thought the benefits to these patients outweighed the risk to the community. The current approach is to discharge stable patients from hospitals.

    No doubt the public would oppose to the establishment of accommodation for psychiatric patients. We can’t guarantee that all patients are not going to present the (mental) symptoms as mentioned. However, for the sake of 99% of the patients returning to the community, we must handle it in such a way……. It is actually very easy to achieve zero accident: to have all the patients locked up. This is how it was done in the past. But now we should let the patients return (and live in) the community. There certainly is a process in place for selecting the less risky individuals, and the dangerous ones are incarcerated. (Gp2, P1)

    Moreover, the participants also commented about the inadequacy of community care which could lead to increase in incident rates of violent attacks. As a matter of fact, occasional adverse incidents did have impact on the public’s stigma of psychiatric patients, which cancelled out some of the positive effects from antistigma interventions.

    In the past when quality community care was offered, nothing too bad had happened even though there were lots of psychiatric patients; at least there wasn’t any case involving severe violence. Nowadays, stigmatisation is again getting worse; it could be due to inadequacy in community care, for example having patients discharged and settled in single-room accommodation by themselves. As a result, the number of incidents increased. What was achieved has then become a waste of effort. (Gp2, P6)

    Paradoxically, highly publicised adverse incidents had also triggered the government to allocate more resources to care for psychiatric patients.

    The quality of care usually depends on the trend. When there happens to be more adverse incidents, people pay more attention; when there isn’t any, people slacken and as a consequence, accidents repeatedly occur. (Gp2, P5)

    Although these incidents are bad, it indeed is a chance for us to advocate for more government resources. (Gp2, P1)

    Views on the strategies to reduce stigmatisation

    The psychiatrists also shared their experiences and views on reducing stigmatisation. Knowing that a psychiatric diagnosis might bring about stigmatisation, the psychiatrists were careful about the way they explain to the patients about their illnesses. They might use terms which sounded milder and with less stigma.

    I reckon patients do care about what disorders they are having. They want to know their (psychiatric) diagnoses. The problem is, when we are telling them, should we use the name that is associated with greater stigma or one that’s less so?(Gp2, P4)

    Although the psychiatrists might use a relative vague diagnostic label, what they told the patients were still based on the facts.

    No matter what you say, there has to be some supporting evidence to back you up instead of just babbling a random name. Another principle is no deception. You can express in whatever way you want; as long as you, when the patient asks about it again in the future, can keep it justified and consistent without false information. (Gp2, P1)

    Regarding the question whether renaming a mental disorder would reduce stigma, some participants tended to support the renaming of the official Chinese name for psychosis, while some others were uncertain about the effects:

    My view is that a person sees the need to rename a disorder because that person has stigmatising opinions towards it. The action of renaming itself implies stigmatising attitude towards the mental problem. (Gp2, P4)

    When the Castle Peak Hospital (a well-known local psychiatric hospital) was under reconstruction, there were considerations to rename the Hospital. The name was retained at the end, because renaming it would not ameliorate the stigma. What it has as its essence is of higher importance. (Gp2, P1)

    Apart from the diagnostic labels, the need for seeing a psychiatrist was already in itself a stigma under the Chinese context. The patient’s visit to the psychiatrist gave rise to a subjective feeling of being stigmatised. As revealed by the participants, in order to persuade the patient to visit the psychiatrist, sometimes the patient’s family might request the psychiatrists not to mention their specialty, in order to lessen or prevent the patient’s fear from being stigmatised. The consultation was coined as a visit to treat the patient’s physical problems. It was also observed that family members often assumed a significant role in the help-seeking process and made decisions on behalf of the patients.

    There are cases where the family members bring an elder patient or a child (to my clinic) for consultation. They ask me not to mention to the patients that I am a psychiatrist or what their (psychiatric) problems are, but just tell the patients that the consultation is only for physical assessment; if it is a case of anorexia nervosa, I would tell the patient that I am here to help her to gain some weight. (Gp2, P4)

    Last but not the least, public education to reduce stigmatisation was fully supported by the psychiatrists. They believed case sharing by patients or their family members would be helpful to let the public know about the positive side of the patients. Besides, personal experience and interaction with psychiatric patients could also neutralise the negative impression from extreme cases reported by the mass media.

    I once went to a primary school to give a talk. I gave every student a pen and a piece of paper and asked them to draw the psychiatric patient in their mind. At that time there was a recent murder committed by a psychiatric patient. As a result, among the psychiatric patients the children drew, many were holding knives. But a few children drew a psychiatric patient who was holding them in his arms. One child put down that some psychiatric patients were cute. I asked why. They replied that their mothers suffered from depression and yet they brought the children up; another child said that he knew a female who lived next door suffering from bipolar disorder, and yet she acted normally once she took her medication. (Gp2, P5)

    Discussions

    As expressed in the focus groups, the Chinese psychiatrists did not see the diagnostic labels on their patients as a form of stigmatisation. They perceived the necessity to classify the patients according to the diagnoses. While most participants emphasised throughout the discussions that only a small proportion of patients had aggressive behaviours, some still perceived that quite a large number of patients might be dangerous. In fact, in the bulk of surveys on stigmatisation, the questions in the questionnaire seldom distinguished whether the respondents’ perceptions were on a small or large proportion of psychiatric patients.4 5 7 Some of our participants mentioned that they could not say the psychiatric patients were not violent because some mental illnesses were characterised with violence or deviance. But holding these views could be regarded as evidence for stigmatisation in survey studies,4 5 7 21 especially when the survey questions were based on either one patient or every patient, for example: ‘should somebody be admitted to a psychiatric hospital even against his/her will?', ‘how likely is the person in the given vignette does something violent towards other people?’ and ‘would you trust this patient to take care of your child?'. Besides, in our focus groups, the patients discussed by the psychiatrists were usually severe cases. It might not be accurate to compare the attitudes between psychiatrists and other health professionals as their patient profiles could be very different.

    Although the psychiatrists argued that the diagnosis itself was not a form of stigma, they framed feedback to patients and their family in ways that might reduce stigma. They tended to use relatively vague terms to describe the problems. This was a way to save the ‘face’ of the patients and help others to be more tolerant towards the patients. This indicated that the psychiatrists were in fact sensitive to the impact of a psychiatric diagnosis on stigma, and they made efforts to minimise it. Following this approach, the professional diagnostic term for psychosis has been renamed to defuse stigmatising impact.22 Despite that, the psychiatrists tended to believe that stigma was inevitable given the nature of some psychotic disorders. Instead of fighting to eliminate stigma, they managed in ways that took social expectations into consideration. A good example was that the patient’s family asked the psychiatrist to claim that he was treating the patient’s physical problems only. In most Western countries, giving informed consent to the patient is a standard procedure.23 However, family making decision on behalf of an individual is not uncommon in collectivist societies and it has been argued that the autonomous unit is the family rather than the individual.24 25 Our findings suggested that this concept was shared by both the general public and the psychiatrists under a Chinese context. In addition, disguising the stigma appeared to be the common approach to deal with stigma considering the cultural context. It is debatable whether disguising or facing the stigma directly is a better approach locally. Future research is needed to explore this.

    Similar to our previous study findings on the general public,11 our psychiatrists had stronger emphasis than their Western counterparts on the risk of psychiatric patients to community, and raised fewer concerns on their ability to work and social relationships.26 When the psychiatrists were trying to decide whether the patients should return to the community, apart from medical perspectives, they also considered the matter from the angles of public interest and patients’ rights for autonomy.15 27 To reconcile competing perspectives, their approach was to discharge stable individuals and institutionalise those who were potentially violent. A review study reported that patients with schizophrenia were significantly more likely to be violent than the average person, and occasional violent incidents did happen in the community.28 Despite that, the review also indicated that the proportion of violent crime in society attributable to schizophrenia was consistently under 10%. Presently, the level of risk exhibited by psychiatric patients is assessed according to the kind of illnesses they suffer and their medical history. Since psychiatrists are more likely to see patients with severe symptoms in their daily clinical practice, it would be interesting to ask if the psychiatrists have overestimated the risk. The answers to this might provide further insights into the query of stigmatisation.

    This study has two limitations. First, we conducted two focus groups on the psychiatrists with a range of personal and practice characteristics. Although repetitive views were found on the major themes, it was unsure whether we had reached data saturation point. Second, the participants tended to express their general views on stigmatisation by focusing on severe mental disorders with psychotic conditions, their perceptions on other mild mental conditions might be different.

    Conclusions

    While the psychiatrists argued that the diagnosis itself was not a form of stigma, they were sensitive to it and framed responses to patients and their family in ways that might minimise stigma. They tended to believe that stigma was inevitable given the nature of some psychotic disorders. These findings suggest that disguising the stigma appears to be the common approach to deal with stigma in a Chinese context. It is worth exploring the pros and cons of these strategies to reduce stigma in future studies.

    Acknowledgments

    The authors thank Magdalene Tang for English editing of the final manuscript.

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    Footnotes

    • Contributors TPL, KSS and TLL wrote the study protocol. TPL and TLL coordinated the study. KSS and TPL undertook the analysis. KSS, TPL and DW wrote the first draft of manuscript. All authors participated in the drafting of the final version of the manuscript.

    • Funding This study was funded by the Committeeon Research and Conference Grants of The University of HongKong [ grantnumber 10401224 ] .

    • Competing interests None declared.

    • Ethics approval Ethics approval was obtained from the local Institutional Review Board of The University of Hong Kong/Hospital Authority Hong Kong West Cluster (UW 09-326).

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Patient consent for publication Not required.