心理疾病内隐污名的评估及其预测因素
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摘要
心理疾病污名是个体对心理疾病的负面认知、消极情感体验和歧视倾向所构成的负面态度。世界卫生组织指出心理疾病患者康复的最大阻碍是社会对他们的污名,它不仅会阻碍心理健康求助,降低治疗依从性,还会对心理疾病康复者带来持续的负面影响。不少国家和地区都在积极开展去污名干预,我国已实施的《精神卫生法》中也明确禁止对心理疾病患者的歧视、侮辱和虐待,力图实现全社会对心理疾病患者的尊重、理解和关爱。
对污名的确切了解是消除心理疾病污名及其负面影响的前提和基础。在传统的心理疾病污名研究中,外显测量易受社会赞许性影响,也往往忽略了人们对心理疾病患者的自动化反应,不能准确反映人们的真实态度。借鉴内隐社会认知的理论和方法,越来越多的研究者开始采用间接测量技术来了解心理疾病内隐污名,并对其构成内容、去污名评估及其与外显污名的关系等有了不少新发现。然而,这些研究都没有明确内隐污名的性质和结构成分,关于其表征概念的有效性也有待检验。同时,以往研究采用的测量方法也并不完全适用于心理疾病内隐污名的测评,也鲜有研究探讨内隐污名的影响因素。显然,这些问题都会影响对心理疾病内隐污名性质的认识。
在文献综述的基础上,本研究首先提出心理疾病内隐污名是个体对心理疾病的内隐负面态度,由个体对心理疾病难以内省的负面认知,自动化的负面情感反应和歧视倾向三个成分构成。基于此定义和构想,本研究设计了五个子研究,试图为内隐污名的准确测量奠定理论和方法基础。研究1通过文献回顾和开放式调查,整理和评定心理疾病内隐污名的评价词和概念标签,以此作为内隐污名表征的属性信息和范畴信息。研究2以自编材料为基础,采用三个独立的单一类型内隐联想测验(SC-IAT),考察内隐污名的性质,检验内隐污名的三成分构想,并分析内隐与外显污名的关系。研究3将采用SC-IAT和内隐联想测验(IAT)考察内隐污名的语义表征范畴及其典型性特点,检验以往研究使用的范畴标签的有效性。在前面三个子研究的基础上,研究4将采用代表性较高的评定词作为属性信息,选用典型更高的语义概念标签作为范畴信息,结合启动任务范式和事件相关电位技术(ERP),探讨心理疾病内隐污名的电生理学证据。研究5将在文献回顾的基础上,采用定量研究的方式初步分析内隐污名的有关预测因素。通过上述研究,得到了以下的研究结果：
1、自编的心理疾病内隐污名的认知评价、情感反应和行为倾向三类评定词以及相关的心理疾病标签,都具有较好的代表性,是研究和测评内隐污名的有效测量材料。基于此编制的内隐污名SC-IAT具有较好的信、效度,是评定内隐污名的可靠工具。
2、在认知评价、情感反应和行为倾向三个独立的SC-IATs中,相较于积极词,被试更倾向于将心理疾病词与消极词的联系在一起,内隐污名的三成分构想得到研究结果的支持。而心理疾病内隐污名与外显污名是彼此分离的,相关不显著。
3、概括化(如,心理问题)和具体疾病(如,抑郁症)的心理疾病标签与内隐污名表征的属性信息联结紧密度大于非属性信息,是内隐污名的语义表征范畴,且前者的范畴典型性更高。两类标签可作为范畴信息用于内隐污名测量,以往研究使用的此类概念标签是有效的。
4、行为和ERP结果发现,与人们心理疾病内隐态度一致的消极词更容易从记忆中提取出来,而与内隐态度冲突的积极词提取更困难,反应时更长,诱发的N400波幅更大。也就是说,体现语义冲突的N400反映了心理疾病内隐污名的激活,表明人们对心理疾病的负面态度是自动化的。
5、指向患者的病因认知(心理归因和人际归因)和负责任判断(个人负责任判断)与内隐污名有显著的相关关系,而心理健康素养和人际接触与内隐污名的相关不显著。回归分析发现,性别和个人负责任判断对内隐污名有显著的预测作用,且后者调节着人际归因对内隐污名的影响。
6、总体来看,大多数大学生对心理疾病的内隐态度是负面的。高校心理健康教育和心理咨询服务应重视心理疾病污名问题,积极开展去污名实践,提升心理健康服务的质量。
结合已有研究和以上结果,本研究认为心理疾病内隐污名是个体对心理疾病难以内省的负面态度,它并不等同于贴标签、刻板印象或歧视,且与外显污名是相互分离的。从结构成分或表征的属性信息看,内隐污名包括个体对心理疾病的难以觉察的负面认知,自动化的负面情感反应和歧视倾向三种成分。从表征范畴看,概括化和具体疾病标签都属于内隐污名的语义表征范畴,均可用作测量内隐污名的范畴信息。而ERP结果表明,反映语义冲突的N400可能是内隐污名激活的电生理学证据。影响内隐和外显污名的因素之间有重叠,也有差异,其中性别、指向患者的病因认知和负责任判断对内隐污名有预测作用。
与以往研究相比,本研究的创新主要表现在以下五个方面：
第一,明确界定了心理疾病内隐污名的操作性定义,将其与相近概念进行了区分,从理论和实证上确定了心理疾病内隐污名的性质是人们对心理疾病自动化的负面态度。
第二,提出并验证了心理疾病内隐污名的三成分构想,检查了内隐污名测量中两类常用的语义范畴的有效性及其典型性特点,为内隐污名的准确测量奠定了理论基础。
第三,编制了适用于中国被试的有效的心理疾病内隐污名的评定材料,并对材料中可能影响测量准确性的语义信息进行了较好地控制。基于这些材料开发的心理疾病内隐污名SC-IAT也具有较好的信、效度；
第四,将ERP用于探测心理疾病内隐污名的激活,并发现了N400可能是内隐污名激活的电生理学证据,丰富了内隐污名的测量方法和指标体系。
第五,初步考察了影响心理疾病内隐污名的潜在因素,为内隐污名的评估和干预提供了重要参考。
虽然本研究对内隐污名的评估进行了一系列探讨,但仍有不少值得未来研究予以关注的问题。第一,本研究对内隐污名评定词的语义信息进行了平衡,在避免这些信息干扰污名测量的同时,也丢失了大量关于人们评价心理疾病的属性信息,这是进一步研究应当突破的地方。第二,本研究提出并验证了心理疾病内隐污名的三成分构想,但这并不等同于内隐污名的内在结构或维度,未来研究可采用其他测量技术探讨内隐污名成分的结构或关系。第三,本研究仅分析了内隐污名的语义表征范畴,后续研究应对具体形象范畴及其与语义范畴的关系进行更为系统的探讨,以便更全面好地认识内隐污名的表征范畴及其特点。
Mental illness stigma is negative attitudes toward people with mental illness, concluding negative cognition, passive emotion and discrimination tendency. WHO pointed out that stigmatization of mental illness was the biggest impediment to the rehabilitation of patients with mental illness. Many studies have shown that it is a significant barrier to the seeking of mental health service, successful treatment and rehabilitation. More and more contryies have taken various interventions to reduce mental illness stigma. In China, Mental Health Act going into effect in May this year also clearly defined prohibiting discrimination, insults and abuse agsinst persons with mental illness, in attempt to achieve respect, understanding and care toward people with mental illness in our society.
To erase mental illness stigma and its negative impact, first of all have accurate measurements, which is the prerequisite and foundation. Previous studies indicated that explicit measures were likely to underestimate the true levels of mental illness stigma because they are subject to social desirability biases, and that also ignored the atuomaitically-activated stigma aspects. Referring the theories and methods of implicit social cognition, stigma researchers have placed more interest on automatic attitudes toward people with mental illness to better understand mental illness stigma, and have found many new knowledges about mental illness stigma by implicit measurements. However, very little has been done to explore the property and components implicit stigma toward mental illness, and to discover what category was in implicit stigma mental representation. In addition, there were some shortcomings in the measurement methods used in previous studies, and almost no studies have examined the factors impacting implicit stigma. Obviously, these problems or deficiencies affect the accurate measurement of implicit stigma toward mental illness.
On the basis of past studies, and combining the ABCs of Attitudes, the present study considered that the implicit stigma toward was the introspectively (or inaccurately) unidentified traces about mental illness, which unconsciously regulate the individual's belief and reaction of people with mental illness; these traces include three automatically activated aspects that are negatively cognitive evaluations, affective reactions and discriminatory tendencies. At the top of this definition and conceptions, the current research designed five sub-studies takeing the evaluation of implicit stigma as the centre. Study1collated and assessed the evaluative and concept words of implicit stigma toward mental illness by literature-reviewing and open-ended questions, as the attribute and category of stigma' mental representation. Study2examined the property and component of implicit stigma and its relationship with explicit stigma, using self-designed materials and Single Category Implicit Association Test (SC-IAT). Study3exmined the semantic categories of stigma representation and the validity of the categories of mental representation in previous implicit stigma research by IAT. Study4used the attribute and category information of stigma representation exmined by study2and3to explore the electrophysiology evidence of implicit stigma by piming task and event-related potentials (ERP). Study5preliminary explore the predictive factors of implicit stigma on the basis of the literature review. The findings of these studies were as follows:
1, self-designed materials, reflecting the attribute and category information of stigma representation, was reliable and valid. Prepared implicit stigma SC-IAT also had good reliability, validity, and was a reliable tool for implicit stigma assessment.
2, the three-component model of implicit stigma (negative cognition, negative affect, and discriminatory tendencies) was supported by measurements of response times using three independent SC-IATs. Explicit and implicit measures of stigma toward mental illness were unrelated.
3, the associated labels (e. g. psychological problems) and specific labels of mental illness had closer automatic association with negative words relative to positive words and were the representing categories of implicit stigma. Both categorical labels could be used as representing categories for implicit stigma measurement, and the sort of mental illness labels used in previous research was valid.
4, behavior and ERP results found the negative words consistent with the implicit attitude toward mantal illness more easily were extracted from the memory after mental illness words were presented, and the positive words conflict with the implicit attitude were extracted more difficult, taking longer reaction time and activating N400amplitude greater relative negative words. This indicated that the N400reflecting the semantic conflicts can be regard as the electrophysiological evidence of the activation of implicit stigma toward mental illness.
5, the cause of mental illness (mental attribution and interpersonal attribution) and responsibility judgment (individuals responsible judgment) attributed to people with metanl illnes were significantly associated with implicit stigma, but the relationships between mental health literacy, interpersonal contact and implicit stigma were unrelated. Gender and individuals responsible judgment were predictive factors of implicit stigma.
6, most college students had negative implicit attitudes toward people with mental illness. College mental health education and psychological counseling services should pay attention to theis issue, and improve stigma intervention in order to enhance the quality and utilization of mental health services.
This present research had some innovations and implications in the thory, relative to the previous studies. First, this study clearly defined implicit stigma toward mental illness, determined its property basing on the theoretical and empirical evidence. Second, we systematically examined the semantic categories of stigma representation and the validity of the categories of mental representation in previous research. Third, the study primarly explored the predictive factors of implicit stigma. There were also some innovation or breakthrough in the method. First, this study designed valid materials assessing imiplicit stigma toward mental illness. Second, implicit stigma SC-IAT programmed by this study also had good reliability, validity, and was a reliable tool for implicit stigma assessment. Third, we primarly used ERP to examine implicit stigma activation, enriching the implicit stigma measurement methods.
Despite its implications, select limitations of the current study must be acknowledged. First, self-designed materials assessing implicit stigma had some limitations because of balanceing their semantic information. This issue may lead to these matrials could not completely reflecting implicit stigma. Second, the components of implicit stigma were not the same as the structure of implicit stigma, and could not reflect its main dimensions. Third, this study only discussed the semantic categories of stigma representation, and did not explore other categories.
对污名的确切了解是消除心理疾病污名及其负面影响的前提和基础。在传统的心理疾病污名研究中,外显测量易受社会赞许性影响,也往往忽略了人们对心理疾病患者的自动化反应,不能准确反映人们的真实态度。借鉴内隐社会认知的理论和方法,越来越多的研究者开始采用间接测量技术来了解心理疾病内隐污名,并对其构成内容、去污名评估及其与外显污名的关系等有了不少新发现。然而,这些研究都没有明确内隐污名的性质和结构成分,关于其表征概念的有效性也有待检验。同时,以往研究采用的测量方法也并不完全适用于心理疾病内隐污名的测评,也鲜有研究探讨内隐污名的影响因素。显然,这些问题都会影响对心理疾病内隐污名性质的认识。
在文献综述的基础上,本研究首先提出心理疾病内隐污名是个体对心理疾病的内隐负面态度,由个体对心理疾病难以内省的负面认知,自动化的负面情感反应和歧视倾向三个成分构成。基于此定义和构想,本研究设计了五个子研究,试图为内隐污名的准确测量奠定理论和方法基础。研究1通过文献回顾和开放式调查,整理和评定心理疾病内隐污名的评价词和概念标签,以此作为内隐污名表征的属性信息和范畴信息。研究2以自编材料为基础,采用三个独立的单一类型内隐联想测验(SC-IAT),考察内隐污名的性质,检验内隐污名的三成分构想,并分析内隐与外显污名的关系。研究3将采用SC-IAT和内隐联想测验(IAT)考察内隐污名的语义表征范畴及其典型性特点,检验以往研究使用的范畴标签的有效性。在前面三个子研究的基础上,研究4将采用代表性较高的评定词作为属性信息,选用典型更高的语义概念标签作为范畴信息,结合启动任务范式和事件相关电位技术(ERP),探讨心理疾病内隐污名的电生理学证据。研究5将在文献回顾的基础上,采用定量研究的方式初步分析内隐污名的有关预测因素。通过上述研究,得到了以下的研究结果：
1、自编的心理疾病内隐污名的认知评价、情感反应和行为倾向三类评定词以及相关的心理疾病标签,都具有较好的代表性,是研究和测评内隐污名的有效测量材料。基于此编制的内隐污名SC-IAT具有较好的信、效度,是评定内隐污名的可靠工具。
2、在认知评价、情感反应和行为倾向三个独立的SC-IATs中,相较于积极词,被试更倾向于将心理疾病词与消极词的联系在一起,内隐污名的三成分构想得到研究结果的支持。而心理疾病内隐污名与外显污名是彼此分离的,相关不显著。
3、概括化(如,心理问题)和具体疾病(如,抑郁症)的心理疾病标签与内隐污名表征的属性信息联结紧密度大于非属性信息,是内隐污名的语义表征范畴,且前者的范畴典型性更高。两类标签可作为范畴信息用于内隐污名测量,以往研究使用的此类概念标签是有效的。
4、行为和ERP结果发现,与人们心理疾病内隐态度一致的消极词更容易从记忆中提取出来,而与内隐态度冲突的积极词提取更困难,反应时更长,诱发的N400波幅更大。也就是说,体现语义冲突的N400反映了心理疾病内隐污名的激活,表明人们对心理疾病的负面态度是自动化的。
5、指向患者的病因认知(心理归因和人际归因)和负责任判断(个人负责任判断)与内隐污名有显著的相关关系,而心理健康素养和人际接触与内隐污名的相关不显著。回归分析发现,性别和个人负责任判断对内隐污名有显著的预测作用,且后者调节着人际归因对内隐污名的影响。
6、总体来看,大多数大学生对心理疾病的内隐态度是负面的。高校心理健康教育和心理咨询服务应重视心理疾病污名问题,积极开展去污名实践,提升心理健康服务的质量。
结合已有研究和以上结果,本研究认为心理疾病内隐污名是个体对心理疾病难以内省的负面态度,它并不等同于贴标签、刻板印象或歧视,且与外显污名是相互分离的。从结构成分或表征的属性信息看,内隐污名包括个体对心理疾病的难以觉察的负面认知,自动化的负面情感反应和歧视倾向三种成分。从表征范畴看,概括化和具体疾病标签都属于内隐污名的语义表征范畴,均可用作测量内隐污名的范畴信息。而ERP结果表明,反映语义冲突的N400可能是内隐污名激活的电生理学证据。影响内隐和外显污名的因素之间有重叠,也有差异,其中性别、指向患者的病因认知和负责任判断对内隐污名有预测作用。
与以往研究相比,本研究的创新主要表现在以下五个方面：
第一,明确界定了心理疾病内隐污名的操作性定义,将其与相近概念进行了区分,从理论和实证上确定了心理疾病内隐污名的性质是人们对心理疾病自动化的负面态度。
第二,提出并验证了心理疾病内隐污名的三成分构想,检查了内隐污名测量中两类常用的语义范畴的有效性及其典型性特点,为内隐污名的准确测量奠定了理论基础。
第三,编制了适用于中国被试的有效的心理疾病内隐污名的评定材料,并对材料中可能影响测量准确性的语义信息进行了较好地控制。基于这些材料开发的心理疾病内隐污名SC-IAT也具有较好的信、效度；
第四,将ERP用于探测心理疾病内隐污名的激活,并发现了N400可能是内隐污名激活的电生理学证据,丰富了内隐污名的测量方法和指标体系。
第五,初步考察了影响心理疾病内隐污名的潜在因素,为内隐污名的评估和干预提供了重要参考。
虽然本研究对内隐污名的评估进行了一系列探讨,但仍有不少值得未来研究予以关注的问题。第一,本研究对内隐污名评定词的语义信息进行了平衡,在避免这些信息干扰污名测量的同时,也丢失了大量关于人们评价心理疾病的属性信息,这是进一步研究应当突破的地方。第二,本研究提出并验证了心理疾病内隐污名的三成分构想,但这并不等同于内隐污名的内在结构或维度,未来研究可采用其他测量技术探讨内隐污名成分的结构或关系。第三,本研究仅分析了内隐污名的语义表征范畴,后续研究应对具体形象范畴及其与语义范畴的关系进行更为系统的探讨,以便更全面好地认识内隐污名的表征范畴及其特点。
Mental illness stigma is negative attitudes toward people with mental illness, concluding negative cognition, passive emotion and discrimination tendency. WHO pointed out that stigmatization of mental illness was the biggest impediment to the rehabilitation of patients with mental illness. Many studies have shown that it is a significant barrier to the seeking of mental health service, successful treatment and rehabilitation. More and more contryies have taken various interventions to reduce mental illness stigma. In China, Mental Health Act going into effect in May this year also clearly defined prohibiting discrimination, insults and abuse agsinst persons with mental illness, in attempt to achieve respect, understanding and care toward people with mental illness in our society.
To erase mental illness stigma and its negative impact, first of all have accurate measurements, which is the prerequisite and foundation. Previous studies indicated that explicit measures were likely to underestimate the true levels of mental illness stigma because they are subject to social desirability biases, and that also ignored the atuomaitically-activated stigma aspects. Referring the theories and methods of implicit social cognition, stigma researchers have placed more interest on automatic attitudes toward people with mental illness to better understand mental illness stigma, and have found many new knowledges about mental illness stigma by implicit measurements. However, very little has been done to explore the property and components implicit stigma toward mental illness, and to discover what category was in implicit stigma mental representation. In addition, there were some shortcomings in the measurement methods used in previous studies, and almost no studies have examined the factors impacting implicit stigma. Obviously, these problems or deficiencies affect the accurate measurement of implicit stigma toward mental illness.
On the basis of past studies, and combining the ABCs of Attitudes, the present study considered that the implicit stigma toward was the introspectively (or inaccurately) unidentified traces about mental illness, which unconsciously regulate the individual's belief and reaction of people with mental illness; these traces include three automatically activated aspects that are negatively cognitive evaluations, affective reactions and discriminatory tendencies. At the top of this definition and conceptions, the current research designed five sub-studies takeing the evaluation of implicit stigma as the centre. Study1collated and assessed the evaluative and concept words of implicit stigma toward mental illness by literature-reviewing and open-ended questions, as the attribute and category of stigma' mental representation. Study2examined the property and component of implicit stigma and its relationship with explicit stigma, using self-designed materials and Single Category Implicit Association Test (SC-IAT). Study3exmined the semantic categories of stigma representation and the validity of the categories of mental representation in previous implicit stigma research by IAT. Study4used the attribute and category information of stigma representation exmined by study2and3to explore the electrophysiology evidence of implicit stigma by piming task and event-related potentials (ERP). Study5preliminary explore the predictive factors of implicit stigma on the basis of the literature review. The findings of these studies were as follows:
1, self-designed materials, reflecting the attribute and category information of stigma representation, was reliable and valid. Prepared implicit stigma SC-IAT also had good reliability, validity, and was a reliable tool for implicit stigma assessment.
2, the three-component model of implicit stigma (negative cognition, negative affect, and discriminatory tendencies) was supported by measurements of response times using three independent SC-IATs. Explicit and implicit measures of stigma toward mental illness were unrelated.
3, the associated labels (e. g. psychological problems) and specific labels of mental illness had closer automatic association with negative words relative to positive words and were the representing categories of implicit stigma. Both categorical labels could be used as representing categories for implicit stigma measurement, and the sort of mental illness labels used in previous research was valid.
4, behavior and ERP results found the negative words consistent with the implicit attitude toward mantal illness more easily were extracted from the memory after mental illness words were presented, and the positive words conflict with the implicit attitude were extracted more difficult, taking longer reaction time and activating N400amplitude greater relative negative words. This indicated that the N400reflecting the semantic conflicts can be regard as the electrophysiological evidence of the activation of implicit stigma toward mental illness.
5, the cause of mental illness (mental attribution and interpersonal attribution) and responsibility judgment (individuals responsible judgment) attributed to people with metanl illnes were significantly associated with implicit stigma, but the relationships between mental health literacy, interpersonal contact and implicit stigma were unrelated. Gender and individuals responsible judgment were predictive factors of implicit stigma.
6, most college students had negative implicit attitudes toward people with mental illness. College mental health education and psychological counseling services should pay attention to theis issue, and improve stigma intervention in order to enhance the quality and utilization of mental health services.
This present research had some innovations and implications in the thory, relative to the previous studies. First, this study clearly defined implicit stigma toward mental illness, determined its property basing on the theoretical and empirical evidence. Second, we systematically examined the semantic categories of stigma representation and the validity of the categories of mental representation in previous research. Third, the study primarly explored the predictive factors of implicit stigma. There were also some innovation or breakthrough in the method. First, this study designed valid materials assessing imiplicit stigma toward mental illness. Second, implicit stigma SC-IAT programmed by this study also had good reliability, validity, and was a reliable tool for implicit stigma assessment. Third, we primarly used ERP to examine implicit stigma activation, enriching the implicit stigma measurement methods.
Despite its implications, select limitations of the current study must be acknowledged. First, self-designed materials assessing implicit stigma had some limitations because of balanceing their semantic information. This issue may lead to these matrials could not completely reflecting implicit stigma. Second, the components of implicit stigma were not the same as the structure of implicit stigma, and could not reflect its main dimensions. Third, this study only discussed the semantic categories of stigma representation, and did not explore other categories.
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