Go beyond the individual: an intersectional perspective on mental illness stigma in China

doi:10.21203/rs.3.rs-2851490/v1

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Go beyond the individual: an intersectional perspective on mental illness stigma in China

https://doi.org/10.21203/rs.3.rs-2851490/v1

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Background:

Stigma is a pervasive and severe issue for individuals with mental illness in China. It is a complex and multifaceted phenomenon that is influenced by social, cultural, and political factors. However, few concerned about mental illness stigma in China through intersectional perspective. This study aims to employ an intersectional lens to examine mental illness stigma in China and explore its heterogeneity and the disparities it creates among patients.

Methods:

The study is based on 16 months of ethnographic research conducted in a psychiatric hospital in 2019. The study sample includes 11 patients, 3 patients’ family members, and 23 medical workers from F hospital in Guangdong province. Data were collected through participant observation, interviews, and document analysis.

Results:

The research reveals that mental illness stigma is deeply ingrained in Chinese society, affecting individuals not only at a personal level but also within their families, healthcare facilities, and wider institutions. The study underscores that, social determinants, including education, rural-urban disparity, and economic circumstances, exacerbate the deleterious effects of stigma. In addition, the research reveals that medical professionals harbor unfavorable attitudes towards their patients or families, and that such attitudes are reflected through cultural symbols, such as the creation of a "mental illness hierarchy" within hospitals based on patients' socioeconomic status. Furthermore, the study highlights that mental illness stigma is not a monolithic construct and is characterized by individual differences, and that its effects may be mitigated by time and the resilience and self-efficacy of patients.

Conclusions:

This study contributes to the understanding of mental illness stigma in China and informs future anti-stigma efforts. It highlights the need to consider not only the stigma attached to mental illness but also the broader socio-cultural factors that exacerbate the experiences of disadvantaged individuals. To effectively address stigma, it is vital to recognize its heterogeneity and its intersection with social, cultural, and political factors. The findings of this study have implications for mental health policy and practice in China and beyond.

mental illness stigma

intersectionality

psychiatric hospital

China

As one of the most populated country, China now had 1.413 billion population by the end of 2021. The recent nationwide mental health epidemiological study showed that the weighted lifetime prevalence of any disorder (excluded dementia) is 16.6%, which is higher than the previous investigations on mental illness(Huang et al., 2019). The increasing problems caused by mental illness have brought the Chinese government attention and started to pull in resources to mental health, which once was with lower priority in political agenda. Recently, the pandemic with the strident policies worsened the mental health issue in China, particularly the older population (Yan et al., 2022). To solve this problem, a varieties of laws, policies and regulations have been implemented nationally and regionally; in 2019, the Healthy China Action Plan 2019–2030 was issued to specify the goals and strategies for the promotion of public mental health (Luo & Zhao, 2021).

However, previous studies found that stigma had become an obstacle for the Chinese to seek help(Hu et al., 2021; X. Xu et al., 2018; Yin et al., 2019), together with the unequal distribution of mental health resources between urban and countryside, as well as other social-cultural factors, creating barriers for the utilization of mental health resources(Li & Rose, 2017; Ran et al., 2018). Studies on mental illness stigma revealed that patients with mental illness experienced stigma in social-cultural contexts and that experiences varied(Ran et al., 2021). In a country such as China, “madness was seen as plural, rather than monolithic, and the responses it provoked reflected this perceived heterogeneity” (Baum, 2018, p.18). It is therefore crucial to untangle stigma from an intersectional perspective for those with mental illness. Targeting only mental illness and its associated types of stigmas separately could not help fully understand the mental illness stigma impacts from complicated socio-cultural and institutional apparats.

Despite the pressing need to investigate the stigma experienced by individuals with mental illness in China, there remains a dearth of scholarly literature that adopts an intersectional framework to comprehend how the stigma of mental illness is entangled with other social categorizations, such as gender, education, and birthplace, and how these intersections generate further inequalities for already marginalized individuals. The present study, therefore, endeavors to shed light on the phenomenon of mental illness stigma in China and provide medical health-related professionals with a more nuanced understanding of this complex issue.

1.1 Stigma on people with mental illness

According to Erving Goffman(1963), stigma is a powerful social phenomenon experienced by individuals who share a profoundly discrediting attribute. Stigma is socio-culturally constructed and leads to the unfair treatment of those individuals who are deviant from the majority, such as people with mental illness. Studies on stigma have been developing since Goffman and shifting from micro-level to macro-level to explore its social mechanisms (Clair, 2018). The stigma concept then is productively applied into a multiplicity of circumstances spanning from physical disparities to behavioral abnormalities to mental varieties. Stigma exists far beyond our consciousnesses, “when elements of labelling, stereotyping, separating, status loss, and discrimination co-occur in a power situation that allows these processes to unfold” (Link & Phelan, 2001), thereof restricting the well-being of the stigmatized individuals. A body of research has documented the multifaceted phenomenon of stigma and health-related stigma is one of such.

Health-related stigma is defined as “a social process or related personal experience characterized by exclusion, rejection, blame, or devaluation that results from experience or reasonable anticipation of an adverse social judgment about a person or group identified with a particular health problem” (Weiss & Ramakrishna, 2006). Mental illness stigma as a well-known health-related stigma(Weiss et al., 2001) and obstinate to tackle with, becomes a burden for those who suffered, affecting their self-efficacy, quality of life and stopping their help-seeking (Mannarini & Rossi, 2019; Parker et al., 2001; Z. Xu et al., 2017). Generally, patients with mental illness are confronted with three categories of stigma: the public stigma, the self-stigma, and the structural stigma(Van Brakel, 2006). The public stigma consisted of stereotype, prejudice and discrimination. The patients were described by the public as dangerous, aggressive, incompetent and contaminated (Ahmedani, 2011; Subu et al., 2021; X. Xu et al., 2018; Z. Xu et al., 2017; Z. Zhang et al., 2020). Self-stigma occurred when patients internalized the prejudiced public attitudes toward themselves. Structural stigma occurred through sociopolitical forces and exhibited through the policies that restrict the opportunities of patients, which may reflect in the context of health-care welfare system, medical-settings, and professional groups.

Mental illness stigma remains a pervasive issue in China (Xu et al. 2017). A review study showed that 80% of patients reported experiences of being stigmatized. 81.9% of the reports (from 1 May 2013 to 1 May 2017) from an official and widely-read newspaper depicted the psychiatric patients with negative attitudes(Zhang et al., 2020). Guo (2016) indicated that stigma of mental illness happened in the public (work unit, village), hospital and within family. Impacted by the stigma, the dominant Chinese culture takes family members diagnosed with mental illness as losing “face”. They attempted to hide the diagnosis and withdrew from the social networks (Wong et al., 2018; L. H. Yang et al., 2007; Z. Zhang et al., 2020), which worsened their desperate life situations. Patients also experienced internalized stigma (Ran et al., 2018; Wong et al., 2018). In China, community service was facilitated in 2004 and the national mental health legislation was passed in 2013, nevertheless, most of the mental health service heavily relied on psychiatric institutions, around 80% was hospital-based (Han et al., 2020; X. Xu et al., 2018). However, studies indicated that institutionalization itself may generate stigma for patients(X. Xu et al., 2018; L. H. Yang et al., 2007). The stigma in mental-health care settings vary in differing studies, some reported stronger discrimination nurses held toward patients, some showed that nurses working for psychiatric settings more tolerated than those in general hospital (Zhang et al., 2020). In sum, mental illness patients and their family members experienced stigma in differing forms. Apart from this, features of patients, such as gender, age, socio-economic class, and family backgrounds, might be the target of stigma and cast adverse effects on their access to services, however so far, received few attentions. My ethnographic data found factors that mediated the level of stigma patients experienced and new inequalities occurred in different contexts, which indicated that categories of stigma should not be treated separately, as other social identities may interact with mental illness to exacerbate the vulnerable individual with mental illness. A new approach was needed to unlock the myth of mental illness stigma.

1.2 Intersectional stigma as an approach

Intersectionality has become a key conceptual and theoretical framework to study social inequality nowadays. Knudsen (2006) states that intersectionality is a theory “to analyse how social and cultural categories intertwine” to create and intensify marginalization. While Collins (2000) and McCall (2005) highlight that intersectionality examines the relationships between gender, race, ethnicity, disability, sexuality, class and nationality along different structural axes. Power relations are central to this analytical approach to understand how individual experiences are shaped by broader structural and systemic inequalities(Crenshaw, 1989). According to Turan et al. (2019), “intersectional stigma’ is a concept that has emerged to characterize the convergence of multiple stigmatized identities within a person or group, and to address their joint effects on health and wellbeing.” The intersectionality approach has been used increasingly as an analytical tool in health-related research.

Bredström (2006) adopts an intersectional perspective to engage critically with feminist HIV/AIDS research, arguing for an effective sexual health policy, while Zhang (2022) explores those single mothers living with HIV in Thailand experience intersectional stigma based on their class, ethnicity, religious status and gender, which manifests at the different levels. In their study with 40 people affected by either of four stigmatizing health conditions (HIV, leprosy, schizophrenia, and diabetes) in Indonesia, Rai et al (2020) find the participants reported of experiencing intersectional oppression because of prevailing social norms, systems, and policies (macro-level), exclusion and discrimination from societal actors (meso-level), and self-shame and stigma (micro-level). Based on an extensive search of the literature on health-related stigma in China published between 1990 and 2021, Lin et al. (2022) finds little evidence of gender-affirming care and mental health interventions in China, and thus suggest integrating a multi-level intersectional intervention with education to reduce cultural stereotypes and transphobia in China. Within the context of intersectional stigma and psychosocial well-being, Yang et al. (2020) suggest that experiencing both HIV-related stigma and sexual and gender minority stigma may synergistically lead to poor psychosocial well-being among men who have sex with men in a more profound manner than experiencing only one type of stigma. An intersectional perspective thereof not only allows researchers and health professionals to think holistically about how multiple stigmatizations affect individuals’ behaviors and health outcomes, but also highlight how crucial to consider and incorporate all identity categories when making the policy to reduce health disparities and inequalities.

The analytic approach in this research builds on Weiss and Ramakrishna's (2006)definition of health-related stigma — the social process of the individual who is disqualified from a full social acceptance that results from a particular health problem — but also incorporates Crenshaw's (1989, 1991) intersectionality framework by highlighting how people live with mental illness suffers from the effects of multiple-subordination and experiences multi-layer stigma based on their gender, age, socio-economic class and family backgrounds in China. By developing the concept of “intersectional stigma” to study mental illness in China, this study tries to identify where the forms of stigma collide, interlock, and intersect, and thus contributes to theorizing the plurality of intersecting stigmatization in the Chinese context. This article argues that all people living with mental illness are intersectional subjects; in particular, their mental illness intersects with many other social categories will generate multiple disadvantages and social exclusions. Looking at people living with mental illness as a possible socio-culturally constructed category of multiple oppressions and marginalization will enable us to critically examine how stigmatizations interact at intrapersonal and interpersonal, hospital community, societal and state levels.

2.1 Statement of ethics

Prior to the commencement of the study, ethical review applications was approved by the Ethics Committee, F hospital. All the study participants were asked to give oral consent before joining the study; their participation is voluntary and participants have the right to change their minds at any moment and withdraw from this study without prejudice. To protect participants’ confidentiality and privacy, pseudonyms were used in place of their names.

2.2 Field site and participant recruitment

The data presented in this article originate from a fieldwork study conducted in 2019 focusing on mental illness stigma in China from an intersectional perspective. To meet patients, their family members and medical workers, I carried out ethnographic fieldwork at F hospital, in Guangdong province of China. F hospital was a city-level psychiatric hospital with 1,000 beds and 500 medical workers, established in the 1960s under the charge of Health Department. Originally it was designed to provide psychiatric treatment for patients with mental illness, the involvements of the Civil Affair Department and Public Security Department gradually made the hospital assumed some functions of civil assistance. The hospital itself became an intersecting social institution of culture, politics, and medicine.

Situated in the suburban area, the medical space in F hospital is constituted mainly by the Psychiatry Department buildings, which forms a closed area for patients admitted to this department. Nuances exist within the Psychiatry Department, which is made up of five wards (from second to the sixth ward); patients who are sent by family members are admitted to the second to the fifth ward, respectively situated in a four-floor building, I call them as “general wards”, with around 400 patients. Divided by gender, the first two are male wards and the fourth and fifth wards are female wards. Those homeless will live in the sixth ward, in another four-floor building. I mainly conducted the fieldwork at the general wards within the Psychiatry Department zone.

This paper presents a qualitative study investigating intersectional stigma on mental illness in China. Some of the study participants were recruited among those who had previously participated in a social work service project within hospital. Briefly, this service project was conducted in 2016. This qualitative study was performed in 2019 after the initial service project. Patients, their family members and medical workers were recruited through previous contacts and through referrals from the hospital. Upon my first encounter with the medical workers, I explained my personal background and research purposes. In the view of medical workers, I was a PhD student interested in psychiatric treatment and the history of a mental hospital; moreover, I has also been reminded not to reveal much of my other identities to the patients in order not to “stir up” their emotions. Nevertheless, I took the hospital’s concerns into consideration and was highly precautious about what I did within the ward, in order not to affect the ward environment. In conducting mental illness-related research, the recruitment process needs to be highly sensitive and to strictly abide by research ethics protocols. For those who initially volunteered to participate in this project, I answered all of their concerns before obtaining their consents.

2.3 Sampling

In total, 11 patients, 3 patients’ family members and 23 medical workers from F hospital participated in this qualitative research. A purposive sampling technique was adopted, and only study participants who met the following criteria were approached and recruited for this research: 1) For patients: experience of being admitted to Psychiatry Department; willing to communicate; living with mental illness at least one year; 2) For patients’ family members: at least one year’s caregiving experience; 3) For medical workers: at least one year’s working experience in F hospital. Socio-demographic information about the 37 study participants is presented in Table 1.

Table 1

Demographic information of participants
Gender
	male	13
	female	24
Age
	20- years	3
	20–30 years	8
	30–40 years	3
	40–50 years	10
	50–60 years	2
	60 + years	11
Edu
	high school or less	19
	college	18
	graduate	0
Employment status
	employed	17
	retired	9
	non-employed	8
Relationship status
	married	21
	single	10
	divorced	4
	remarried	1
	widow	1
Place of birth
	rural	26
	urban	11
Student status
	student	3
	non-student	34
Local/non-local
	local	26
	non-local	11

2.4 Data collection

A qualitative research methodology was chosen for this research to reveal the complexity of intersection stigma on mental illness. The aim of the research was to ascertain how social experience is constructed and what it means in practice by focusing on the nature of social reality (Denzin & Lincoln, 2008). As Liamputtong (2011) suggests, the qualitative method offers a holistic perspective for a researcher — in this case, one who seeks to examine the interpretations and meanings of mental illness stigma in China.

Unstructured and informal interviews, service records from the hospital and field notes were collected for this study. Although the hospital was sensitive about the patients’ contacts with the outsiders, my role of being a social worker reduced such concern and enable me to conduct the interview smoothly. The patients and their family members had the opportunity to share their experiences. Interviews with the medical workers adopted the semi-structured interviews and they were informed of the research and its purpose. Most of the interviews and records were conducted in 2019 and took place within the hospital, in addition, some interviews with the medical workers were conducted outside the hospital. The interviews lasted between half and one hour and were conducted in Mandarin Chinese mostly. For the patients, they would be asked for the reason why they were in the hospital firstly. Follow-up questions will be inquired in the first interview to explore their life experience with mental illness outside the hospital. Patients’ family members would also be asked about how they found out the patients’ “abnormal” behaviour and sent the patients to the hospital and how to cope with patients and their life when patients were discharged during the interview. For the interviews with medical workers, firstly, their motivation to become a mental health worker and the reason why they chose to work in a psychiatric hospital would be asked, then they were also given chances for them to share the experiences with patients and associated stigma they felt in their daily life.

Besides the interview, field notes gained from participant observation at F hospital are also essential data in this research. Participant observation becomes crucial for a researcher to delve into the local culture, not only the explicit culture but also its tacit aspects, to “gain a greater understanding of phenomena from the point of view of participants” (Musante & DeWalt, 2010). For the sensitivity and complexity of mental hospital issues in China, participant observation could open a door for the observation of how stigma is constructed and practised in the institutional daily practice. In this study, all the study participants were clearly informed that this observation was part of the research, I would not take any photos or videos, and their identities would be kept confidential. By participating in their daily activities at F hospital, I was able to record some essential details, such as participants’ emotions, the researcher’s thoughts and initial findings. The data related to the research are anonymized and securely stored in password-protected and encrypted computers and external hard disks.

2.5 Data analysis

The recorded interviews were transcribed in Chinese and English for data analysis after cross-checking. Transcripts were coded and analyzed. Based on the findings from interviews and participant observations, I attempted to identify the intersectional categories that could affect the way the participants perceived their life experiences as mental illness patients and what kinds of intersectional stigma and discrimination they have experienced in China. An initial coding scheme was developed in line with the intersectionality theory, topics outlined in the interview guide and the narratives obtained from the interviews.

The sample of study participants are 13 men and 24 women, ranged in age from 14 to 86 years, with a median age of 46. Both native-born in X province (N = 26) and non-native-born participants from other provinces (N = 11) participated in the study. Of the sample, 48.7% had a high school degree or higher. The majority of participants were married (N = 21), with an average of two children, and lived with their children at the time of the interview. 16 of participants reported that they were single, widow or were divorced. The majority of patients were diagnosed with mental illness over one years ago, mainly diagnosed as “schizophrenia”, with many having lived for more than one year in F hospital.

In this research, all study participants reported facing/experiencing negative views, attitudes and discriminations from other people and social groups regarding their mental illness status and other aspects of their multiple social identities and roles. In addition to mental illness-related stigma, participants also discussed the stigma related to their gender, age, socio-economic class and family backgrounds in the Chinese context and explained how intersectional stigma is interlinked and interconnected from self/familial to the broader community and then to societal and state levels in China.

3.1 Self-stigma and stigma from family

All the study participants perceived that they were stigmatized by others because of their mental illness status. Qiong, now a fifty-year-old outpatient with Bipolar, recalled her suffering experience as bellow:

“For others, I am a sopou [the local idiom to describe women with mental illness, silly woman] …I thought I was a poor girl without schooling, without ability of analysing… In the beginning, after my first discharge, due to a variety of reasons, I thought of suicide. I tried to release all my joy and sorrow with different strategies. I asked myself why this happened to me. I didn’t find a job during this period… Indeed, I don’t have a place in the village….they treat me as a dead person”. (Qiong, fifty-year-old outpatient, with Bipolar)

In Cantonese context, patient with mental illness was depicted as “so⁴”, a local idiom indicated a sense of despises. The onset of mental illness thereof stopped Qiong to interact as before and she was isolated by other villagers. They ignored her and treated her like a “dead person”. She lost her position as a member of the community. Like what Corrigan and Rao (2012) argued, people who live with conditions such as schizophrenia are also vulnerable to endorsing stereotypes about themselves. Qiong adopted the villagers’ eyes to view herself as a “pollution” to the community. The illness affected Qiong’s feeling of herself, and she was shame to interact with others. She thought herself as “a poor girl” and incompetent. Attempts of suicide occurred to her several times.

In contrast to Qiong, forty-eight-year-old Min, who also originated from a village, with schizophrenia and a college education background, demonstrated a more positive perception of herself. When reflecting on her experience with mental illness, Min characterized her symptoms as "crazy" but not "poor," and she emphasized her recovery from the disease. Despite her family's abandonment during hospitalization, Min remained committed to her recovery and physical fitness through exercise. Additionally, she actively pursued strategies for discharge. Her educational background endowed her with the ability to explore and cultivate stronger self-efficacy, which mitigated self-stigma. Nonetheless, in comparison to a female inpatient from F city, Min expressed concerns regarding resource deficits despite living in the same ward.

The study found that many participants, including Qiong and Min, reported experiencing stigma at the familial level. The presence of strong son preference was observed, which influenced the roles played by patients within their families. Psychiatrist Cen, an experienced doctor at F hospital, reported that family members would attempt to find partners for male patients to continue their family line, even if they suffered from mental illness. In contrast, female patients lost their rights to pursue romantic relationships. Luan, a 45-year-old individual with schizophrenia, shared that she was forced to break up with her boyfriend by her family members. Similarly, Qiong, a woman living with mental illness, experienced stigmatization from her brother who believed that she brought shame to the family. Her family arranged for her to marry a disabled man, whose family also viewed her with contempt.

Ah Yuan, a 32-year-old patient diagnosed with schizophrenia, reported experiencing discrimination from her brother due to her social role as a daughter and sister. Her brother viewed her as "lazy" in fulfilling her household responsibilities, while her family members deemed her morally improper due to an illusionary symptom of being sexually harassed by her own father. These findings illustrate how self and familial stigmatization intersect with patients' multiple identities, such as birthplace, gender, education, and their role in the family, which in turn, impact their experiences with mental illness.

3.2 Stigmatization within hospital community

According to the ethnographic data, the psychiatric hospital was commonly referred to as " so⁴ lou² jyun^6 − 2," meaning "a place for fools," and its workers were labeled " so⁴ lou² ji¹ sang¹," or "doctors for the fools." This derogatory term reflects the societal prejudices against the mental health facility, its patients, and staff. Medical professionals who were interviewed also shared their experiences of being discriminated against and often concealed their workplace when interacting with outsiders. While psychiatric workers may face discrimination due to their association with patients, they may also hold biases against those they serve. Z, a nurse who has worked at the hospital for nearly 30 years, manages the occupational rehabilitation program. When discussing her experience working at the hospital, she recounted:

“I have been assaulted by the patients before, several times. They are dangerous. You should know how to keep distance from them and stand in your safe zone, like you should not stand in front of a patient or surrounded too closely by patients. At least a distance that your hand could be stretched out. This distance would be better.” (Service record,2016/03/16)

Dr. L, who frequently collaborated with community physicians to visit outpatients, expressed similar apprehension when discussing his attitude towards patients:

"I don't fear these patients when they are within the hospital, but I am hesitant to maintain close contact with them in the community. (The interviewer inquired about his reasoning.) Within the hospital, I have other colleagues, so if a patient became violent, we could work together to restrain them. However, in the community, it is too risky as we lack adequate support." (Fieldnote, 2019/03/08)

The portrayal of patients as "dangerous" in institutional narratives contributes to a general sense of fear within the facility. Nevertheless, this perception could be influenced by patients' age and gender. During field observations, I witnessed instances of intimate physical contact between female nurses and young female patients, such as assisting a young girl with her hair. Conversely, young male patients were frequently deemed violent, as evidenced by Hui's case. Hui, a 25-year-old man from a rural area with limited education, was labeled as "violent" and "dangerous." Medical staff not only expressed fear of patients, but also regarded them as a source of contamination. For instance, one nurse cautioned a social worker against allowing a patient to sit in her chair, citing concerns about the patient's cleanliness. Similarly, some staff members rejected a rehabilitation plan that involved donations of shoes from medical staff, as they were uncomfortable with the idea of patients wearing items that had belonged to them. As a result, not only physical distance but also item distance was deemed necessary. These negative attitudes and emotions from medical staff were reflected in daily institutional life and intersected with other factors, such as patients' socio-economic status, resulting in the classification of mental illness into buildings with distinct designs.

At F hospital, medical staff tended to associate mental illness with specific departments, such as psychiatry for brain-related issues, neurology for neurasthenia, and clinical psychology for heart-related concerns. Such categorization was utilized to facilitate communication with external parties. During an interaction with a medical staff member regarding a meeting between patients and physicians, the staff member made the following statement:

“There is no use in talking to those idiots (sha zi). (She stopped for a few seconds). No, those living in the Neurology Department are not idiots, neither are those admitted to the Clinical Psychology Department. They are poor people with some problems in their hearts, like anxiety or depression. But those live in the Psychiatry Department are idiots”. (Fieldnote, 2019/06/25)

The use of the term "idiot" to describe individuals residing in the Psychiatry Department suggests the presence of physical distance and social stigma. In contrast, the Clinical Psychology Department, with superior resources and medical staff, garnered a reputation as the most lucrative department within the hospital, offering superior treatment in comparison to the Psychiatry Department. This led to feelings of envy amongst patients in the latter department. In a physician interview, the reasons for such sentiments were identified:

“The Clinical Psychology Department had a good reputation; indeed it was the same with the Psychiatry Department. But patients and their family members would accept it if mental illness was called a psychological problem. The expenditure was different: the inpatient fee for one day was 500 yuan in the Clinical Psychological Department (10,000 yuan/month), but only 150 yuan in the Psychiatry Department”. 1 (Fieldnote, 2018/01/26)

“Those with desirable status, demanded for a better condition of inpatient living environment, calling for an independent space and freedom on the ward”. (Fieldnote, 2019/11/05)

According to physician narratives, individuals of higher economic status required differentiation from those residing in the Psychiatry Department, who were often labelled as "idiotic" or "mad". Consequently, a new department was established to cater to these patients. Buildings within the facility came to symbolize patients' status, with patient flow between different wards or buildings indicating differences in treatment and revealing a hierarchy of mental illness. Mental illness stigma was not solely reflected in medical staff attitudes towards patients but also interacted with patients' socio-economic status to crystallize into cultural symbols, such as buildings, thereby creating new forms of inequality within the hospital.

3.3 Institutional and structural stigma from the state

To comprehend the role of the state in perpetuating the stigma experienced by patients with mental illness, it is essential to examine the impact of mental health policies. Prior to 2005, the Chinese government had made little headway in the field of mental health, with knowledge about mental illness and its management remaining largely theoretical. However, a tragic incident at Peking University Hospital in August 2004, involving a patient with schizophrenia who committed a crime, triggered significant national awareness about mental illness. The incident resulted in increased reporting of violent incidents attributed to patients with mental illness, reinforcing the stigma associated with mental illness and branding patients as "dangerous" (Ma, 2020). Subsequently, a series of policies aimed at reducing harm caused by patients with mental illness were implemented in local societies.

One example of such policies is the comprehensive governance of patients with severe mental disorders in F City. This policy mandated that individuals with severe mental illness be reported to the Comprehensive Governance Office (CGO) upon discharge, which would then establish a community guardianship team comprising community psychiatric doctors, community neighbourhood cadre, community security cadre, and family members (the guardian) (Government Notice, 2016). However, patients and their families were unaware of this reporting system. For instance, a teenage girl with schizophrenia who was treated and discharged from the Psychiatry Department was diagnosed with "adolescent affective disorder" instead of "schizophrenia" at her mother's request to avoid stigma. Although the mother negotiated with the doctor, she was unaware that her daughter's risk level had been rated as "3"2 in the reporting system. As a result, upon returning to her community, the girl was unexpectedly visited by numerous individuals, which alarmed her family members. The girl's mental illness was subsequently disclosed to the community and her school, leading to the hope that her mother would keep her at home. Additionally, the diagnosis of "adolescent affective disorder" was not covered by medical insurance, and the family had to bear the cost of medication, which amounted to approximately 1000 RMB per month. Had the diagnosis been "schizophrenia," however, the cost of medication would have been covered by medical insurance. Moreover, the migrant worker status of the girl's mother made it challenging for her to access support systems. However, a native patient with adequate knowledge and understanding was able to effectively engage with the local government, advocating for their rights and ultimately securing significant compensation for the violation of their privacy.

3.4 Changes in stigma experiences over time

The ethnographic data also revealed that several factors influence the impact of stigma over time. One of these factors is the resilience and self-empowerment of patients. Qiong, a community-dwelling patient with bipolar disorder, exemplifies this phenomenon. Despite initially internalizing negative perceptions about herself from outsiders, she gradually empowered herself and raised her two children. She expressed confidence in her ability to control her mood and medication, and boldly expressed her identity as a patient without shame to outsiders. Qiong's experience provides valuable insights into how married female patients with children cope with mental illness and can inform future research in this area. Age also appears to play a significant role in shifting perceptions and attitudes towards patients with mental illness. Qiong noted that only older individuals in her village approached her and showed concern for her well-being. Another mediating factor is the establishment of an interpersonal network between patients and medical workers over time. Qiong's relationship with her doctors exemplifies this, as does Kuan's case with medical workers, who was hospitalized for nearly twenty years and knew how to manage his relationships with the medical staff to gain their support.

[1] I heard from doctors that fee in Psychiatry Department one day for medical insurance raised up to nearly 200 yuan nowadays. So, the expenditures charged by the Psychiatry Department could be covered by medical insurance.

[2] Risk evaluation was initiated to gain the knowledge of the occurrences of violence conducted by those with severe mental illness. It was a short form with 6 levels: 0 - without any behavior listed on 1 to 5 levels; 1- Verbal threats, shouting, but no smashing behavior; 2 - Smashing behavior, limited to the home, for items. Accept persuasion. 3 - Obvious smashing behavior, regardless of the occasion, for items. Can't be persuaded. 4 - Continuous smashing behavior, regardless of the occasion, for property or people, can’t accept persuasion and stop. 5 - Behaviors included violence, arson, explosion, etc. against people with controlled dangerous weapons. Whether at home or in public. According to the document aforementioned, a risk evaluation higher than “3” should be reported to the CGO, community neighborhood and public security department.

The results of this study highlight the pervasive nature of stigma experienced by individuals with mental illness in China and this article through intersectional lens, goes further a step to uncover how stigma acts as a barrier to accessing mental health resources. In doing so, it not only brings to light the types of mental illness stigma, such as self-stigma, the public stigma, professional stigma, and institutional stigma, which support the previous studies (Guo, 2016; Subu et al., 2021; Van Brakel, 2006), but also sheds light on the role of healthcare providers, including hospitals and medical staff, as well as national policy designers, as producers of stigma (X. Xu et al., 2018; L. H. Yang et al., 2007). By creating an environment that stigmatizes mental illness, these actors inadvertently prevent individuals and families from seeking the help they need. Furthermore, the intersectionality of stigma with various social categorizes, including gender, education, birthplace, and family background, demonstrates that the stigma surrounding mental illness in China is not a homogenous phenomenon but rather one marked by individual differences. The stigma associated with mental illness thereof cannot be solely examined in terms of typologies but must also consider the secondary stigma engendered by its intersection with social factors. This finding raises the followings issues that need to concern.

Consistent with prior studies, the present investigation sheds light on the pervasive sense of shame experienced by many patients with mental illness, which often arises from external stigma and discrimination (Parker et al., 2001; Xu et al., 2017;Mannarini & Rossi, 2019, etc) Having grown up in a society where perception of mental illness rooted in traditional Chinese culture of ghost and ancestral worship (Kleinman, 1980), patients are regarded as “abnormal” and with the help of psychiatry, they became the objectified “risk” for governance (Ma, 2020; Zhu et al., 2018). Such kind of phenomenon exacerbated patients’ self-stigma (or internalized stigma), encompassing “negative beliefs about the self, which are largely based on shame, the acceptance of mental illness stereotypes, a sense of alienation from others, and consequent low mood” (Henderson et al., 2014, p.468) .

However, level of this shame may vary depending on social categories. In Chinese society, education, rural-urban division, economic status and gender are the common factors to categorize people (Nieuwenhuis & Shen, 2023; Whyte, 2010; D. Xu & Wu, 2022), an impoverished rural woman with lower schooling may suffer more than those with a better social-economic status. Individuals with higher education, such as Min, may exhibit a different understanding and perception of their illness compared to those with lower education, like Qiong, who is often described as an uneducated crazy woman and feels that her lack of education exacerbates her difficulties. Therefore, patients with lower education may be in a more disadvantaged position regarding the stigma of mental illness, which contradicts previous research indicating that individuals with higher levels of education exhibit higher levels of self-stigma (Ren et al., 2016). Apartment from education, urban-rural disparity and economic conditions also helped created prejudices. These social determinants as the risk factors, thereof not only may associate with the cause of mental illness (Compton & Shim, 2015), but also moderated the stigma patients felt. Yet, hospitals often do not have corresponding policies to address this issue. In the pursuit of profits, patients might be classified based on their social-economic status, exacerbating the stigma effect for those residing in psychiatric departments.

However, within hospital settings, the medical staff, may affected by the local culture (Subu et al., 2021) and cast prejudice on patients in terms of some social factors, but this perception may be varied for those outside hospital. For example, while Chinese society may exhibit a son preference as the son could continue the genealogy and the daughter was viewed as useless (Murphy et al., 2011), male patients may face more stigma due to being viewed as violent perpetrators by nurses in hospital settings. Therefore, the effect of stigma related to social categories may vary depending on the location and requires further investigation. An ethnographic inquiry of the psychiatric hospital thereof could not only reveal the patients’ experience of mental illness stigma, but shed light on how stigma was produced within the hospital.

In present study, medical staffs were not only found to have negative feelings and attitude toward their own patients or families (Heim et al., 2020; X. Xu et al., 2018; Guo, 2016), but also such kind of subjective beliefs were crystalized and manifested through cultural symbols: by associating with patient’s socioeconomic status, the hospital categorized patients into different buildings to create “mental illness hierarchy” within hospital. Dominated by biomedical treatment, patients with mental illness were objectified and their illness narratives were neglected (Ma, 2020; Zhu et al, 2018). What’s worse, in light of the conflict between morality and self-interest, even if doctors may express sympathy towards patients who experience discrimination in the community due to policies, confronting with strong state power, doctors may choose to protect themselves (Yao, 2016), leaving patients in a vulnerable and isolated position.

This article also finds that the effect of stigma may also be mediated by time as observed by Sangaramoorthy (2017) who found that those with HIV gradually accepted the disease. In the case of Qiong, she finally expressed her identity as a patient without shame to the outsider. Despite initially internalizing negative perceptions about herself from outsiders, Qiong was able to raise her two children, and express confidence in her ability to control her mood and medication after receiving help from a hospital social worker. Qiong's experience of resilience and self-empowerment provides valuable insights into how married female patients with children live with mental illness and can inform future research on this topic.

The main limitation of this study is that the findings cannot be generalized to understand mental illness stigma in other countries, given the small number of study participants. However, the ethnographic methodologies used for this study facilitate the interpretive conceptualization of intersectional stigma in the context of complex social, political and cultural processes.

In conclusion, the study highlights the pervasive nature of stigma experienced by individuals with mental illness in China and the role of various actors, including healthcare providers and national policy designers, in producing stigma. The intersectionality of stigma with various social categories demonstrates that the stigma surrounding mental illness in China is not a homogenous phenomenon. The impact of stigma may vary depending on social categories, and patients with disadvantaged social status may face unique challenges in terms of stigma. The findings suggest the need for interventions to address the stigma associated with mental illness and the secondary stigma engendered by its intersection with social determinants. Practical implications include the need for hospitals to respond to patients' experiences of stigma and for healthcare professionals to be aware of the stigma that occurs within the hospital.

Ethical Approval

This study was approved by the Ethics Committee of the Third Hospital of Foshan City. This article has gained consent for publication.

Competing interests

No applicable.

Authors' contributions

No applicable.

Funding

During the ethnography, this study received 2019 Guangzhou Concord Medical Humanities Research and Education Research Fund.

Availability of data and materials

The data are not publicly available due to ethical, legal, or other concerns.

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Go beyond the individual: an intersectional perspective on mental illness stigma in China

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Abstract

1. Background

1.1 Stigma on people with mental illness

1.2 Intersectional stigma as an approach

2. Methods

2.1 Statement of ethics

2.2 Field site and participant recruitment

2.3 Sampling

2.4 Data collection

2.5 Data analysis

3. Results

3.1 Self-stigma and stigma from family

3.2 Stigmatization within hospital community

3.3 Institutional and structural stigma from the state

3.4 Changes in stigma experiences over time

4. Discussions

5. Conclusions

Declarations

References

Additional Declarations

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