Psychiatry Research 225 (2015) 433–439

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Internalized stigma and its psychosocial correlates in Korean patients with serious mental illness Woo Jung Kim a, Youn Joo Song a, Hyun-Sook Ryu b, Vin Ryu c, Jae Min Kim a, Ra Yeon Ha a, Su Jin Lee b, Kee Namkoong a,b, Kyooseob Ha c,d, Hyun-Sang Cho a,b,n a

Department of Psychiatry, Yonsei University College of Medicine, Seoul, Republic of Korea Institute of Behavioral Science in Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea c Department of Psychiatry, Seoul National Hospital, Seoul, Republic of Korea d Department of Neuropsychiatry, Seoul National University Bundang Hospital, Gyeonggi-do, Republic of Korea b

art ic l e i nf o

a b s t r a c t

Article history: Received 22 December 2013 Received in revised form 25 November 2014 Accepted 28 November 2014 Available online 11 December 2014

We aimed to examine internalized stigma of patients with mental illness in Korea and identify the contributing factors to internalized stigma among socio-demographic, clinical, and psychosocial variables using a cross-sectional study design. A total of 160 patients were recruited from a university mental hospital. We collected socio-demographic data, clinical variables and administered self-report scales to measure internalized stigma and levels of self-esteem, hopelessness, social support, and social conflict. Internalized stigma was identified in 8.1% of patients in our sample. High internalized stigma was independently predicted by low self-esteem, high hopelessness, and high social conflict among the psychosocial variables. Our finding suggests that simple psychoeducation only for insight gaining cannot improve internalized stigma. To manage internalized stigma in mentally ill patients, it is needed to promote hope and self-esteem. We also suggest that a relevant psychosocial intervention, such as developing coping skills for social conflict with family, can help patients overcome their internalized stigma. & 2014 Elsevier Ireland Ltd. All rights reserved.

Keywords: Stereotyping Risk factors Self-concept Psychosocial factors Mental disorders Korea

1. Introduction Individuals with mental illness suffer from stigma associated with their disorder. Although stigma associated with mental illness is a universal phenomenon, its manifestation may differ by culture (Weiss et al., 2001; Angermeyer et al., 2004; Griffiths et al., 2006; Abdullah and Brown, 2011). Some studies further suggested that stigma in Asian culture is more severe than that in Western culture (Whaley, 1997; Lauber and Rössler, 2007), due to the group-centered nature which is common among Asian populations (Chong et al., 2007; Papadopoulos, 2009; Abdullah and Brown, 2011). In addition, the patterns of stigma vary throughout Asia (Yamamoto et al., 1996; Ng, 1997; Kurihara et al., 2000; Yamada et al., 2001; Chiu et al., 2005) and even between East Asian countries of similar cultures (Kumakura et al., 1992; Hanzawa et al., 2009). Internalized (or self) stigma refers to the inner subjective experience of stigma, which results from applying a socially negative stereotype to oneself (Link et al., 1989; Corrigan, 1998; Dickerson et al., 2002; Ritsher n Corresponding author at: Department of Psychiatry, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 120-752, Republic of Korea. Tel.: þ 82 2 2228 1620; fax: þ 82 2 313 0891. E-mail address: [email protected] (H.-S. Cho).

http://dx.doi.org/10.1016/j.psychres.2014.11.071 0165-1781/& 2014 Elsevier Ireland Ltd. All rights reserved.

et al., 2003; Dinos et al., 2004). According to a systematic review and meta-analysis of internalized stigma among mentally ill patients of diverse psychiatric diagnoses (Livingston and Boyd, 2010), high levels of internalized stigma were associated with various psychosocial (i.e., hopelessness, low self-esteem, low empowerment, reduced self-efficacy, and poor social support) and clinical factors, such as symptom severity, although not with socio-demographic factors. Moreover, previous studies revealed several effects of internalized stigma on individuals with mental illness, including reluctance to seek care (Corrigan, 2004), reduced trust in service providers (Verhaeghe and Bracke, 2011), poor adherence to psychosocial treatment (Fung et al., 2008) or medication (Tsang et al., 2009), increased hospitalizations (Rüsch et al., 2009), barrier to recovery (Ritsher and Phelan, 2004; Muñoz et al., 2011), less improvement in job functioning (Yanos et al., 2010), and poor quality of life (Vauth et al., 2007; Norman et al., 2011; Sibitz et al., 2011). Therefore, mental health professionals must come to understand the characteristics and correlates of internalized stigma to comprehend and manage their patients effectively. In Korea, the mental health service for patients with serious mental illness is mostly comprised of an inpatient system (Lee, 2011). This system may directly or indirectly affect internalized stigma of patients with mental illness. However, most available studies in Korea have been limited to public stigma towards the

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mentally ill, whereas only a few studies have examined internalized stigma among patients with mental illness (Hwang et al., 2006; Ko et al., 2008; Kim and Jun, 2012). In this cross-sectional study, we aimed to 1) investigate internalized stigma among Korean patients with serious mental illness and 2) identify factors contributing to their internalized stigma among socio-demographic, clinical, and psychosocial variables.

2. Methods 2.1. Participants A total of 160 patients (102 patients with bipolar I disorder, 53 schizophrenia, and 5 schizoaffective disorder) were recruited in 2010 and 2011 from the bipolar and psychotic disorder clinic of a university mental hospital. All patients met the diagnostic criteria for their disorder based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (American Psychiatric Association, 2000). Each patient underwent an interview using the Mini-International Neuropsychiatric Interview (Sheehan et al., 1998) by two expert psychiatrists. We excluded any participants with a history of mental retardation or other significant neurological or medical diseases. All 124 inpatients (77.5% of the total patients) participated in the study immediately before their discharge. The other 36 patients (22.5%) were assessed upon visiting our outpatient clinic. There were no significant differences in diagnosis (bipolar vs. schizophrenia spectrum disorder) and socio-demographic data (gender ratio, employment status, education level, current marital status, and living arrangement) between in- and outpatients. The socio-demographic and clinical variables of our whole sample are described in Table 1. 2.2. Measures 2.2.1. Internalized stigma The Internalized Stigma of Mental Illness (ISMI) scale (Ritsher et al., 2003; Ritsher and Phelan, 2004) was developed to assess the subjective experience of stigma on a 29-item questionnaire that uses Likert scales ranging from 1 (strongly disagree) to 4 (strongly agree). The Korean version of the ISMI, which was used in this study, had been previously tested for reliability and validity (Hwang et al., 2006). The ISMI scale consists of 5 subscales: alienation, discrimination experience, stereotype endorsement, social withdrawal, and stigma resistance. Alienation refers to the subjective experience of being devalued as a member of society. Discrimination experience measures the respondent's perception of discrimination in dealing with others. Stereotype endorsement refers to the degree to which the respondent agrees with common stereotypes about mental illness. Social withdrawal measures the avoidance of social situations. Stigma resistance is a (reversescored) subscale that measures the ability to remain unaffected by internalized stigma. In agreement with previous studies (Lysaker et al., 2007; Brohan et al., 2010; Mashiach-Eizenberg et al., 2013; Boyd et al., 2014), better internal consistency on the ISMI was obtained in the current study when the stigma resistance subscale was removed. Therefore, we excluded the 5-item stigma resistance subscale and computed the ISMI total score from the remaining 24 items. In our Table 1 Demographic and clinical characteristics of subjects (n¼ 160). n

(%)

Female Employed Married Living with others More than 4 hospitalizations Involuntary hospitalizations

85 89 62 154 28 140

(53.1) (55.6) (38.8) (96.9) (17.5) (90.3)

Age (years) Education (years) Duration of illness (years) Duration of hospitalization(s)/duration of illness BPRS YMRSa MADRSa GAF

Mean 36.98 14.18 9.76 0.117 8.54 4.66 3.90 63.28

(S.D.) (9.93) (2.33) (8.32) (0.198) (7.77) (6.94) (4.68) (15.17)

BPRS, Brief Psychiatric Rating Scale; YMRS, Young Mania Rating Scale; MADRS, Montgomery–Åsberg Depression Rating Scale; GAF, Global Assessment of Functioning. a

These measures were assessed in bipolar I disorder patients (n ¼102) only.

sample, the ISMI total score revealed a significant degree of internal consistency (Cronbach's α ¼ 0.89). 2.2.2. Self-esteem and hopelessness The Rosenberg Self-Esteem Scale (RSES) is a 10-item questionnaire that assesses general self-esteem (Rosenberg, 1965). We used the Korean version of the RSES, which uses a 4-point Likert scale for each item (Lee, 2009). A higher score on the RSES indicates higher self-esteem. The Beck Hopelessness Scale (BHS) consists of 20-items (yes or no questions) that measure negative and pessimistic thoughts about the future. A higher score suggests a higher level of hopelessness (Beck et al., 1974; Shin et al., 1990). Both the RSES and BHS were used in previous studies of internalized stigma (Ritsher et al., 2003; Ritsher and Phelan, 2004; Lysaker et al., 2007; Fung et al., 2008; Yanos et al., 2008, 2010, 2012; Norman et al., 2011; Mashiach-Eizenberg et al., 2013).

2.2.3. Social support and social conflict The Scale of Social Support (SSS) identifies the extent of social support to which an individual has access, and the Negative Social Interaction Scale (NSIS) identifies the degree of social conflict to which an individual has experienced. Both scales were cited from a Korean article about social adjustment in mental illness (Jung et al., 2008). The SSS is composed of questions that ask how the respondent perceives affection, concern, confidence, and help from family, friends, and health professionals. The SSS is a 6-item questionnaire that uses a 5-point Likert-type scale. A higher score on the SSS indicates a higher level of social support. The NSIS assesses the amount of hostility and conflict that the respondent experiences within their social network. The NSIS is an 8-item questionnaire that uses a 5-point Likert scale (modified form of the NSIS; Rauktis et al., 1995). A higher score on the NSIS indicates a greater perception of social conflict.

2.2.4. Insight, symptom severity, and function We examined patient insight using Item 1 (“Does the individual believe that he/she has a mental disorder?”) on the Scale to assess Unawareness of Mental Disorder (SUMD), which is scored from 1 to 5, with higher scores suggesting a lower level of insight (Amador et al., 1993; Song et al., 2006). To measure cognitive insight of current mental illness, we limited our analysis to “Current illness, Item 1” among 20 items of the SUMD (Lepage et al., 2008; Gilleen et al., 2011). Then, we assessed symptom severity using an 18-item version of the Brief Psychiatric Rating Scale (BPRS; range 0–108; Overall and Gorham, 1962), the Young Mania Rating Scale (YMRS; 11 items, range 0–60; Young et al., 1978), and the Montgomery– Åsberg Depression Rating Scale (MADRS; 10 items, range 0–60; Montgomery and Åsberg, 1979). The YMRS and MADRS were only assessed in relevant cases (Table 1). Psychological, social, and occupational functions were measured by the Global Assessment of Functioning (GAF) scale (American Psychiatric Association, 2000).

2.3. Data collection After obtaining informed consent, two expert psychiatrists and two psychiatric residents collected socio-demographic data of all patients. Through patients' medical records and psychiatric interview, the researchers assessed clinical variables related to patients' current symptom severity and hospitalization (e.g., the number of hospitalizations and whether hospitalization was voluntarily or involuntarily). Then, all patients completed self-report scales to measure the aforementioned psychosocial variables, including internalized stigma. This study was approved by the Institutional Review Board of the Severance Mental Health Hospital and was conducted in accordance with the Declaration of Helsinki.

2.4. Statistical analyses We first performed descriptive statistics on all variables collected from our sample. We also analyzed the correlation between the ISMI, continuous demographic, clinical, and psychosocial variables. To determine which categorical variables were associated with the ISMI, we analyzed the differences of means of the ISMI for each categorical variable using Student's t-tests. Variables that were significantly associated with the ISMI were added to hierarchical multiple regression analyses to determine the cross-sectional predictors of internalized stigma. The demographic, clinical, and psychosocial variables were respectively put into the regression analyses sequentially. The ISMI total score was set as the dependent variable. Multicollinearity was not observed among the independent predictors that were included in the multiple regression models. A statistical power analysis was performed, which was expected to require a power of 0.8 based on α o 0.05 for medium effect size (effect size f2 ¼0.15) using Gnpower 3 (Faul et al., 2007). The needed sample size was 123–157 when the number of predictors was 11–20; this result of power analysis showed that our sample size (160 subjects) was statistically relevant. The other analyses were conducted using the Statistical Package for the Social Science version 20 (SPSS Inc., Chicago, IL, USA), and the criterion for significance was set at P o 0.05.

13 12 15

(8.1) (7.5) (9.4)

12.40 (2.33)

6–24

15

(9.4)

(2.29) 5–17 5–20 (4.80) 12–40 10–40 (3.65) 0–18 0–20 (3.58) 14–30 6–30 (5.33) 8–31 8–40

33

(20.6)

10.76 29.13 3.71 23.45 18.11

6–18

ISMI, Internalized Stigma of Mental Illness; RSES, Rosenberg Self-Esteem Scale; BHS, Beck Hopelessness Scale; SSS, Scale of Social Support; NSIS, Negative Social Interaction Scale.

Po 0.05. Po 0.01.

49.40 (8.68) 24–75 24–96 13.59 (3.03) 7–23 7–28 12.64 (2.23) 6–19 6–24

nn

(%)

n

n

1  0.216** 0.209** 1  0.700** 0.249**  0.249** 1 0.147  0.072  0.023 0.076 1 0.391** 0.106  0.165* 0.122  0.162* 1  0.431**  0.318**  0.051 0.073  0.002 0.031 1 0.105  0.124  0.296** 0.222**  0.100  0.005 0.020 1  0.335* 0.086 0.026 0.096  0.200* 0.111  0.055  0.022 1 0.072  0.100  0.046 0.012  0.063  0.059  0.090 0.147  0.125 1 0.077 0.512**  0.265** 0.074 0.086 0.119  0.203** 0.061  0.117  0.112 1 0.197* 0.188* 0.174*  0.168*  0.335** 0.039 0.183*  0.462** 0.392**  0.212** 0.228**

(5) (4) (3)

Stigma (þ )

ISMI, Internalized Stigma of Mental Illness; AL, Alienation; DE, Discrimination experience; SE, Stereotype endorsement; SW, Social withdrawal; Duration of H/I, Duration of Hospitalization(s)/Duration of Illness; BPRS, Brief Psychiatric Rating Scale; GAF, Global Assessment of Functioning; RSES, Rosenberg Self-Esteem Scale; BHS, Beck Hopelessness Scale; SSS, Scale of Social Support; NSIS, Negative Social Interaction Scale.

ISMI Total Alienation Discrimination experience Stereotype endorsement Social withdrawal RSES BHS SSS NSIS

Range Possible range

(2)

Mean (S.D.)

(1)

Table 2 Internalized stigma and psychosocial variables (n¼ 160).

Table 3 Correlations among variables including internalized stigma (ISMI total and ISMI subscales).

To identify what kind of factors predict internalized stigma, we designed a hierarchical model including the factors significantly associated with the ISMI in each step, in the following order: 1) demographic variables, 2) demographic and clinical variables, and 3) demographic, clinical, and psychosocial variables (Table 4). The final regression model showed that greater internalized stigma was independently predicted by higher education level, greater than 4 for hospitalizations, higher insight, lower self-esteem, increased

(6)

3.3. Predictive factors for the ISMI total score

1 0.704** 0.140 0.096 0.261**  0.198*  0.055  0.052 0.215**  0.541** 0.467**  0.250** 0.394**

(7)

(8)

(9)

(10)

Table 3 lists the Pearson's correlation coefficients that were observed between the ISMI and other continuous variables. We found that the ISMI total score was positively associated with age, education, the duration of illness, and a patient's level of insight (reversed score of Item 1 of the SUMD), hopelessness (BHS), and social conflict (NSIS), and negatively associated with the ratio of the duration of hospitalization to the duration of illness, a patient's level of self-esteem (RSES), and a patient's perception of social support (SSS). Student's t-tests revealed significant differences in the ISMI total score by gender (male, 47.687 9.07 vs. female, 50.92 78.08; t¼ 2.388, P¼ 0.018), employment status (employed, 47.66 77.88 vs. unemployed, 51.58 79.19; t¼ 2.898, P ¼0.004), and the number of hospitalizations ( r4 times, 48.68 78.62 vs.4 4 times, 52.797 8.32; t¼2.302, P¼ 0.023).

1 0.738** 0.582** 0.058 0.187* 0.206**  0.199*  0.129  0.045 0.176*  0.383** 0.307**  0.253** 0.344**

3.2. Relationships between ISMI and other variables

1 0.669** 0.759** 0.701** 0.192* 0.133 0.201*  0.212** 0.009  0.096 0.217**  0.555** 0.434**  0.206** 0.441**

(11)

(12)

(13)

(14)

The results for all psychosocial variables, including the ISMI, are presented in Table 2, together with the observed and possible ranges for each scale. Based on a previous study in which a midpoint cut-off of 2.5 was determined for the ISMI (Ritsher and Phelan, 2004), 8.1% of our sample reported a high level of internalized stigma. The mean value of Item 1 on the SUMD in our sample was 1.91 (S.D., 1.15). There was no difference of the ISMI by diagnosis (the ISMI total score (mean7S.D.), 49.5179.32 in bipolar disorder vs. 49.2177.51 in schizophrenia spectrum disorder; t¼0.211, P¼0.833). Between in- and outpatients, the ISMI total scores were not different significantly (inpatients, 46.9779.47 vs. outpatients, 50.1078.35; t¼  1.793, P¼0.079).

1 0.909** 0.842** 0.908** 0.846** 0.171* 0.170* 0.239**  0.222**  0.034  0.075 0.227**  0.559** 0.459**  0.260** 0.409**

3.1. ISMI and psychosocial variables

(1) ISMI total (2) ISMI AL (3) ISMI DE (4) ISMI SE (5) ISMI SW (6) Age (7) Education (8) Duration of illness (9) Duration of H/I (10) BPRS (11) GAF (12) Insight (13) RSES (14) BHS (15) SSS (16) NSIS

(15)

3. Results

435

1  0.338**

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W.J. Kim et al. / Psychiatry Research 225 (2015) 433–439

Table 4 Predictive factors for internalized stigma (ISMI total). Model 1

Female Age Employed Education More than 4 for hospitalizations Duration of H/I Insight RSES BHS SSS NSIS

Model 2

Model 3

Adjusted R2

ΔR2

Stand. β

Adjusted R2

ΔR2

Stand. β

Adjusted R2

ΔR2

Stand. β

0.100

0.000

0.174n 0.140 0.145 0.148

0.170

0.084

0.165n 0.067 0.165n 0.129 0.147n  0.128 0.194n

0.548

0.373

0.108 0.096 0.063 0.199nn 0.145 n  0.044 0.174nn  0.266nn 0.212 nn  0.062 0.322 nn

ISMI, Internalized Stigma of Mental Illness; ΔR2, change in R2; Stand. β, standardized β; Duration of H/I, Duration of Hospitalization(s)/Duration of Illness; RSES, Rosenberg Self-Esteem Scale; BHS, Beck Hopelessness Scale; SSS, Scale of Social Support; NSIS, Negative Social Interaction Scale. n

Po 0.05. Po 0.01.

nn

hopelessness, and severer social conflict. In this model, the adjusted R2 increased substantially with the inclusion of the psychosocial variables, compared with demographic or clinical variables (Table 4).

4. Discussion In this cross-sectional study, we examined internalized stigma and its correlates in Korean patients with serious mental illness. The scores and percentages of patients with internalized stigma among our sample were distinct from the results of other studies. We showed that internalized stigma was independently predicted by education level, the number of hospitalizations, and the levels of insight, self-esteem, hopelessness, and social conflict. Although an understanding of internalized stigma is important for the comprehensive management of patients with mental illness, there is a paucity of studies to examine internalized stigma in Korea. 4.1. Expression of internalized stigma and its comparison with other studies The mean ISMI score per item was relatively low (2.06 points, which was 49.40 points divided by 24 items) in our sample compared with other studies (Brohan et al., 2010; Margetić et al., 2010; Adewuya et al., 2011; Lucksted et al., 2011; Cerit et al., 2012; Mashiach-Eizenberg et al., 2013; Sarısoy et al., 2013; Sibitz et al., 2013). The percentage of patients who reported a high level of internalized stigma (above the midpoint of the ISMI; Ritsher and Phelan, 2004) was also lower in our study (8.1%) than in others (20– 40%) (Gerlinger et al., 2013; Boyd et al., 2014). The results of previous Korean studies (Hwang et al., 2006; Ko et al., 2008; Kim and Jun, 2012) were consistent with those of studies in other countries. The differences between our results and others' might be caused by the composition of the subjects or the location of data collection. Our sample included a large percentage of patients with bipolar disorder (63.8%), unlike other studies which included patients with schizophrenia mostly. However, we discovered no significant differences in internalized stigma among different diagnostic groups, as did an earlier study (Sarısoy et al., 2013). Moreover, even though most previous studies, including those conducted in Korea, recruited individuals from outpatient clinics or community settings, we mainly collected inpatients. In the inpatient setting, patients are separated from the majority of social situations for the duration of their hospitalization and therefore may be less aware of their internalized stigma. On the other hand, outpatients are likely to encounter social

situations that may result in social conflict that sensitizes the individuals to their internalized stigma. Nevertheless, we found no significant differences between in- and outpatients, though outpatients tended to exhibit a higher ISMI. Here, note that we should consider an unremarked point of our data collection. In the present study, the data collection was performed by clinical staff members who were charged of the management of each patient. Patients, therefore, might have felt that they should present a more positive impression during and after, at which they responded to the ISMI, the interview with their doctor. This point derived from our method might contribute somewhat to the low expression of internalized stigma among our subjects. While a direct comparison was not possible, different trends in the ISMI subscales were observed in this study compared with previous studies. Several earlier studies, which had reported a higher mean ISMI than ours, showed higher scores for most of the ISMI subscales (Lysaker et al., 2007; Adewuya et al., 2011; MashiachEizenberg et al., 2013; Sarısoy et al., 2013; Sibitz et al., 2013). Notwithstanding, stereotype endorsement subscale was higher in our study than in others and was similar to the score observed in a previous Korean study (Hwang et al., 2006). Stereotype endorsement refers to the “agreement with negative ideas about themselves” and may represent the construct of internalized stigma (Yanos et al., 2010). Therefore, we cannot infer from our results that internalized stigma is low among mentally ill patients in Korea. 4.2. Factors associated with and predictive of internalized stigma The variables shown to be correlated with the ISMI included age, education level, the duration of illness, ratio of the duration of hospitalization to the duration of illness, insight, self-esteem, hopelessness, social support, and social conflict. Some previous studies reported that education level is negatively associated with internalized stigma (Brohan et al., 2010; Cerit et al., 2012), in contrast with the current study. It should be taken into account, however, that our patients had high education levels (i.e., beyond high school). In addition, although a positive relationship between internalized stigma and symptom severity was common among previous studies (Livingston and Boyd, 2010), the symptom severity (i.e., BPRS and GAF) in this sample did not correlate with internalized stigma. The low overall symptom severity may have contributed to this result. It should also be considered that psychiatric symptom severity may influence internalized stigma via other certain factors such as insight or psychosocial variables (Mak and Wu, 2006; Yanos et al., 2008; Lindon, 2011).

W.J. Kim et al. / Psychiatry Research 225 (2015) 433–439

In the current study, a higher level of insight not only was associated with higher internalized stigma but also predicted internalized stigma. Insight enables individuals with mental illness to be aware of their illness; therefore, greater insight may induce greater levels of internalized stigma (Mak and Wu, 2006). In terms of the management of the mentally ill, simple strategies such as psychoeducation that only focus on increasing the insight level cannot alleviate feelings of internalized stigma. Among the psychosocial variables associated with internalized stigma, lower self-esteem, higher hopelessness, and higher social conflict independently predicted a higher level of internalized stigma. In our regression model for internalized stigma, the prediction power substantially increased when the psychosocial variables were included in the model. This result appears to be similar with the results of a meta-analysis that reported consistent relationships between internalized stigma and several psychosocial variables (e.g., self-esteem, hope, and social support, etc.) yet not demographic variables and only a few clinical variables (Livingston and Boyd, 2010). These results should be interpreted with caution, however, as there was a possibility of some conceptual overlap among the measurement of the psychosocial variables and internalized stigma (Rauktis et al., 1995; Link and Phelan, 2001; Mueller et al., 2006; Livingston and Boyd, 2010). Our findings, together with the results of previous studies, suggest that factors related to personal agency, such as hopelessness and self-esteem, are important targets of clinical intervention for helping patients with mental illness overcome internalized stigma, in addition to increasing levels of insight. Another important aspect of internalized stigma is its association with social conflict. There is a general consensus that social support is associated with internalized stigma (Rüsch et al., 2005; Livingston and Boyd, 2010; Gerlinger et al., 2013). As social conflict is not always contrary to social support, social conflict and social support should be addressed separately in this kind of research (Schuster et al., 1990). Thus far, only a few studies have attempted to examine the relationship of internalized stigma and social conflict (or negative social interaction) itself (Yanos et al., 2001). To lessen internalized stigma, it would be necessary to help mentally ill patients develop coping skills for managing familial conflict. Indeed, as seen from our sample, in which most patients (95%) were living with family members, management of conflicts with family members is an important part of treating internalized stigma of mentally ill patients in Korea. These associations between internalized stigma and psychosocial variables, especially social conflict, bring up grounds to establish psychosocial rehabilitation services and intervention programs of social conflict for patients with serious mental illness. As well as intervention for patients, programs for a patient's family members are also needed to help settle conflicts so that they can live in harmony with each other (Link et al., 1989; Yanos et al., 2001; Shibre et al., 2003; Coker, 2005; Mueller et al., 2006; Lundberg et al., 2008; Boyd et al., 2010; Lindon, 2011). Additionally, further studies are needed to explore the effect of psychosocial rehabilitation for improving internalized stigma, such as previous research on self-stigma reduction programs (Fung et al., 2011; Yanos et al., 2012). The current study has some limitations. First, our study was not free from the bias of using self-report methods. We also could not confirm the causal relationship between internalized stigma and the correlates that emerged from our analyses due to the crosssectional design. Longitudinal studies are needed to clarify the relationships observed in this study. Next, although the size of our sample was relatively moderate, our sample size was not smaller than those of other related studies. Furthermore, our sample size was enough to develop statistically significant regression models, which was beyond the minimum required size calculated by the statistical program. Third, although we intended to examine internalized stigma in patients with serious mental illness, we were unable to recruit patients with major depressive disorder due to

437

our clinical setting. Moreover, our sample was confined to a university mental hospital, which does not represent all Korean patients with serious mental illness. Hereafter, the more broad approaches to this topic will be needed, which include diverse diagnostic groups and various clinical settings in Korea. Lastly, our measurement of insight was limited to one item. Future studies should investigate the relationship of internalized stigma with multiple dimensions of insight. In conclusion, although the total expression of internalized stigma was relatively low, the stereotype endorsement of internalized stigma was high in our sample of Korean patients with serious mental illness compared with other studies. The independent predictors of internalized stigma that emerged from our cross-sectional design included education level, the number of hospitalizations, and the levels of insight, self-esteem, hopelessness, and social conflict. This study provides evidence of the necessity for programs that promote personal agency such as hope and self-esteem among patients with mental illness who suffer from internalized stigma. Our findings also suggest that an active psychosocial intervention that builds coping skills for social conflict may help mentally ill patients to overcome internalized stigma. The results of the present study, which investigated internalized stigma in a group-centered culture that has high rates of institutionalization, may be useful to clinicians and researchers who wish to understand the characteristics of internalized stigma in an international context.

Declaration of conflicting interests The authors declare that there are no conflicts of interest.

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