Fluent Essays

Use the attached document, Project 2-Articles, and the following articles to complete this project: Effects of Cognitive Behavioral Group Program for Mental Health Promotion of University Students, by Lee & Lee, from International Journal of Environmental Research and Public Health (2020). The Stigma Scale: A Canadian Perspective, by Meier et al., from Social Work Research (2015). PSY-380 Introduction to Probability and Statistics Benchmark - Project 2 For this assignment, you will review the two scholarly articles in the Topic 5 Project 2 assignment. Both articles are from psychology journals and utilize hypothesis testing. Review both articles then select one to respond to the following questions: 1. Provide the APA reference of the article you chose 2. Describe the study. What was the purpose of the study/or research question(s)? 3. Both articles use a quantitative method. Identify which test statistic was used. Did they use more than one test statistic? Explain. 4. Report the statistical results for all tests (using correct APA style formatting). 5. Interpret and explain the statistical results. Was the hypothesis supported? Explain. 6. Describe the limitations to the study and suggestions for future research. 7. How do results from this study contribute to research in behavioral health? 8. How will the results of this study impact practice in behavioral health? © 2021. Grand Canyon University. All Rights Reserved. International Journal of Environmental Research and Public Health Article Effects of Cognitive Behavioral Group Program for Mental Health Promotion of University Students Soojung Lee and Eunjoo Lee * Department of Nursing, Kyungnam University, 7 Gyeongnamdaehak-ro, Masanhappo-gu, Changwon-si, Gyeongnam 51767, Korea; [email protected] * Correspondence: [email protected] Received: 1 March 2020; Accepted: 13 May 2020; Published: 17 May 2020 ���������� ������� Abstract: This study aimed to explore the effects of a group cognitive behavioral program on depression, self-esteem, and interpersonal relations among undergraduate students. A non-equivalent control group pretest-posttest design was used. A convenient sample of 37 undergraduates (18 in the experimental group and 19 in the control group) at K university located in Changwon, South Korea was used. Data were collected from February 4, 2019 to June 18, 2019. The experimental group received eight sessions of the program, which were scheduled twice a week, with each session lasting 90 min. Collected data were analyzed using a chi-square test, Fisher’s exact test, independent t-test, and repeated measures ANOVA by SPSS/WIN 23.0 (SPSS, Inc., Chicago, IL, USA). The interaction of group and time was significant, indicating that the experimental group showed an improvement in depression, self-esteem, and personal relationship compared to the control group. A significant group by time interaction for depression, self-esteem, and personal relationship was also found between the two groups. The study results revealed that the group cognitive behavioral program was effective in reducing depression and improving self-esteem and interpersonal relation. Therefore, the group cognitive behavioral program can be used for promoting the mental health of students as well as for preventing depression in a university setting. Keywords: nursing; cognitive behavioral therapy; depression; self concepts; interpersonal relations 1. Introduction The suicide rates in Korea increased by 9.5\% year-on-year to 26.6 per 100,000 people as of 2018, the highest among the Organization for Economic Co-operation and Development (OECD) countries [1]. The causes of suicide may vary by age, but mental problems are common causes, with depression being an important factor directly related to suicide. Since recently, the number of university students suffering from depression has been increasing every year [2], and the nation’s incidence of major depressive disorder is the highest among those aged 20–29 years, which includes college students [3]. The post-adolescent college years are when students set their own goals with self-determination, and independence, and experience a significant shift in environment such as studying, personal relationships, employment, financial management, daily life management, and time management [4]. Adequate adaptations are required for the transition to college life, but some students face difficulties such as loneliness because of living alone, comparative consciousness with peers, academic and job stress, difficulties in interpersonal relationships, and economic independence [4]. Maladaptation may lead to negative symptoms and disorders such as amnesia, avoidance, stress, anxiety, and anger, whose likelihood of developing into an unsuitable aspect or serious depression in post-adult life, as well as into an impaired psychological and social development in college students, may increase [5]. Depression can get worse because college students have a high independence and autonomy and confide in peer groups first rather than seeking help from their parents and professors [6]. It is also Int. J. Environ. Res. Public Health 2020, 17, 3500; doi:10.3390/ijerph17103500 www.mdpi.com/journal/ijerph http://www.mdpi.com/journal/ijerph http://www.mdpi.com https://orcid.org/0000-0002-5752-7482 https://orcid.org/0000-0003-1387-7621 http://dx.doi.org/10.3390/ijerph17103500 http://www.mdpi.com/journal/ijerph https://www.mdpi.com/1660-4601/17/10/3500?type=check_update&version=2 Int. J. Environ. Res. Public Health 2020, 17, 3500 2 of 11 highly likely that the need for professional help is greater, but students are passive in seeking help, and tend to be negative about psychotherapy, counseling, and psychiatric therapy [6]. The incidence and prevalence of mental health problems among undergraduate students are high, and although prevention and treatment are essential before any serious mental illness develops due to the large spillover effect, there is a lack of prevention and treatment for depression among college students compared to other age groups [2]. In the United States, college counseling centers, organized by the American College Counseling Association, are operated to prevent depression in college students, and programs such as cognitive behavior therapy, interpersonal relationships, computer training, individual feedback by e-mail, exercise, and stress training are conducted [2]. In Korea, there are only a few counseling centers specializing in suicide cases, mental health centers, and suicide prevention activities. Though there are counseling centers in universities, they only encourage individual counseling or suggest visiting doctors. It is urgent to develop mental health care programs applicable to college students in the current situation where the level of depression and the crime rate of Korean undergraduate students is high and which can prevent them from developing negative emotions such as depression. In many studies and theories about depression, self-esteem serves as a risk factor for depression, and low self-esteem is known as a critical feature of depression [7]. The vulnerable model for depression also assumed that low self-esteem is a major factor causing depression [8]. Self-esteem also has a causal effect on the development and maintenance of depression, particularly through interpersonal and interpersonal channels [7]. That is, low self-esteem causes social avoidance, which hinders social support, associated with depression, and which reduces attachment and satisfaction in close relationships due to people becoming more negative about the behavior of those around them [9]. Because of the nature of the developmental stage, college students are most affected by their friendships and become more vulnerable to depression [6] because they depend on interpersonal relationships, such as professors and family members. Therefore, depression among college students is closely related to self-esteem and interpersonal relationships, so this can be seen as an important factor for preventing depression. The cognitive behavioral program is a form of treatment that seeks to address behavioral and emotional problems by correcting negative cognition and that is based on the theory that in the course of cognitive, emotional, and behavioral interactions, individual behavior and emotions are determined by good cognitions [10]. This restructures one’s negative and dysfunctional cognition and that of other people to suit reality [11]; it changes emotions and behaviors, and has been shown to be effective in previous studies in reducing depression in university students [10,12,13]. Self-esteem and interpersonal relationships can also be described in relation to cognitive models. Low self-esteem causes interpersonal problems in relation to negative beliefs [14], and difficulties in interpersonal relationships in relation to key beliefs, assumptions, and negative automatic thinking [15], by recognizing information in a way that is biased toward one’s own distorted cognition [16]. Cognitive therapy helps to resolve interpersonal issues by deliberately reconstructing perceptions of these particular interpersonal styles [16]. Therefore, CBT can be expected not only to reduce depression but also to make positive changes or have positive effects on self-esteem and interpersonal relationships. Looking at previous studies applying the cognitive behavioral program to college students, we identified the effects of variables such as assessment-absorbing perfectionist college students [12], attention deficit disorder propensity [17], positive changes in the perception of life stress, social support, suicidal thoughts [13], perceived stress, physical symptoms, and negative automatic thinking [18]. Previous studies that designed cognitive behavior programs mostly focused on problem behavior or maladjustment among undergraduate students, but there was no approach at a preventive level for mental health promotion based on depression, self-esteem, and interpersonal relationships. On the other hand, a group cognitive behavioral program can compare one’s state with the state of others, and the more homogeneity one feels among one’s members, the more effectiveness one can Int. J. Environ. Res. Public Health 2020, 17, 3500 3 of 11 expect in a psychological intervention in a common experience [13]. The study also said that in terms of cost-effectiveness, there is a better effect than with individual CBT [5]. Therefore, in this study, we aimed to conduct a group cognitive behavioral program focusing on cognitive processes and behavioral changes to improve the mental health of undergraduate students to identify how the factors of depression, self-esteem, and interpersonal relationships are changed through a pre-test and post-test. This was expected to reveal the usefulness of a collective program of cognitive behavior for the mental health of undergraduate students and to serve as a basis for nursing interventions to prevent depression. 2. Materials and Methods 2.1. Setting and Sample This is a quasi-experimental trial to identify the effects of developing a group cognitive behavioral program for mental health promotion in undergraduate students. Participants were recruited into a convenience sample through a recruitment advertisement at K university located in Changwon, South Korea, between 4 February 2019 and 18 June 2019. Koreans are more culturally concerned about stigma related to mental illness than foreigners, so it was difficult to recruit participants with a risk of depression. Participants also had to adjust their time for the group program and be able to express their thoughts within the group. Because of these reasons, participants who easily agreed to engage in the group program were first assigned to the experimental group in view of the participation time and grade, and the rest were assigned to the control group. The sample size for the participants was calculated using the G*Power 3.1.2 program. The minimum sample size required for a t-test with α = 0.05, power β = 80\%, and effect siz 0.40, based on a previous study [18], was 36 subjects in both groups. Considering the dropout, we planned to recruit 20 participants in each group. Among them, two in the experimental group and one in the control group dropped out of the group. Overall, the study sample comprised 37 participants: 18 in the experimental group and 19 in the control group. All participants met the following inclusion criteria: (1) an undergraduate student; (2) having the ability to read, understand, and communicate; and (3) agreeing to participate voluntarily in this study. Exclusion criteria for the study were as follows: (1) serious medical illness; (2) severe depressive symptoms (hallucinations, delusions), and behavioral disorders. The study was approved by the institutional review board of the university (Approval no. 1040460-A-2018-064), and all students signed the informed consent form. 2.2. Procedure In this study, strengthening depression, self-esteem, and interpersonal relationships and having a positive self-image among undergraduate students was the main focus of attention in the group cognitive behavioral program. The contents of the program were based on the literature [19] applying the theory of cognitive therapy, and the analysis of previous studies applying the cognitive behavioral model. Depression focused on the content and process of negative thinking and cognitive vulnerability [20], and self-esteem focused on identifying self-concepts, experiences of praise and reward, and experiences of achievement [14]. Interpersonal relationships focused on issues such as identifying beliefs and assumptions about oneself and others in interpersonal situations, and intimacy, assertions, relationships, and maintenance issues [16]. The content validity and applicability of the program were received from a psychiatric nursing professor and a counseling professor at the student counseling center. The program was based on understanding the cognitive behavioral model, effective linkages between cognitive and therapeutic interventions, synchronizing program participation, and strengthening training. The elements of the theoretical framework and the interventions provided by the cognitive behavior group program are shown in Figure 1. Int. J. Environ. Res. Public Health 2020, 17, 3500 4 of 11 Int. J. Environ. Res. Public Health 2020, 17, x 4 of 11 Figure 1. Conceptual framework of the cognitive behavioral group program. The experimental group engaged in a cognitive behavioral group program twice a week for one month. The time of intervention per session was 2 h, with the total duration of the intervention being 16 h. The experimental group consisted of three groups, and one group consisted of 6–7 people. Because the recruitment of the subjects was difficult, the experimental participants did not receive an intervention at the same time. Because the intervention was conducted as soon as the number of groups was recruited, the duration of the data collection was extended. The program consisted of eight sessions, and the details of each session are shown in Table 1. Participants assigned to the experimental group attended group sessions using a curriculum based on the new elements of the cognitive behavioral model to promote mental health. The contents of the group cognitive behavioral program included the following: (1) sharing their experiences that caused negative emotions and self-introduction, and setting goals to be achieved through this program; (2) distinguishing and understanding the process of cognitive–emotional behavior, which is the basic concept of cognitive behavior theory and describes an individual’s automatic thinking in the event or situation that caused the negative emotion; (3) learning the types of cognitive distortion, exploring their cognitive distortion through conversations with each other, and synchronizing to avoid this distortion; (4) cognitively reconstructing the individual’s automatic thinking in connection with the past session and talking about changes in emotion and behavior; (5) sharing their experiences in which cognitive distortion affected interpersonal relationships and activities, and planning new interpersonal relationships and activities; (6) talking about their experiences about the interpersonal relationship and activity strategies planned in the last session, and sharing with others experiences that influenced cognitive and emotional changes; (7) exploring their cognitive changes and sharing them with others; (8) sharing their experiences with changed thoughts and behaviors before and after participating in the program and the applicability in the future. The program allowed learners to participate through group activities, discussions, feedback, and assignments. In each session, education and various activities were conducted, and an active interaction within the group was achieved through discussions and feedback between group activities and participants. The task was to record the cognitive processes for events or situations that involved negative emotions during the week, and the researchers provided feedback on the cognitive and reconstruction processes described. Figure 1. Conceptual framework of the cognitive behavioral group program. The experimental group engaged in a cognitive behavioral group program twice a week for one month. The time of intervention per session was 2 h, with the total duration of the intervention being 16 h. The experimental group consisted of three groups, and one group consisted of 6–7 people. Because the recruitment of the subjects was difficult, the experimental participants did not receive an intervention at the same time. Because the intervention was conducted as soon as the number of groups was recruited, the duration of the data collection was extended. The program consisted of eight sessions, and the details of each session are shown in Table 1. Participants assigned to the experimental group attended group sessions using a curriculum based on the new elements of the cognitive behavioral model to promote mental health. The contents of the group cognitive behavioral program included the following: (1) sharing their experiences that caused negative emotions and self-introduction, and setting goals to be achieved through this program; (2) distinguishing and understanding the process of cognitive–emotional behavior, which is the basic concept of cognitive behavior theory and describes an individual’s automatic thinking in the event or situation that caused the negative emotion; (3) learning the types of cognitive distortion, exploring their cognitive distortion through conversations with each other, and synchronizing to avoid this distortion; (4) cognitively reconstructing the individual’s automatic thinking in connection with the past session and talking about changes in emotion and behavior; (5) sharing their experiences in which cognitive distortion affected interpersonal relationships and activities, and planning new interpersonal relationships and activities; (6) talking about their experiences about the interpersonal relationship and activity strategies planned in the last session, and sharing with others experiences that influenced cognitive and emotional changes; (7) exploring their cognitive changes and sharing them with others; (8) sharing their experiences with changed thoughts and behaviors before and after participating in the program and the applicability in the future. The program allowed learners to participate through group activities, discussions, feedback, and assignments. In each session, education and various activities were conducted, and an active interaction within the group was achieved through discussions and feedback between group activities and participants. The task was to record the cognitive processes for events or situations that involved negative emotions during the week, and the researchers provided feedback on the cognitive and reconstruction processes described. Int. J. Environ. Res. Public Health 2020, 17, 3500 5 of 11 Table 1. The Contents of Group Cognitive Behavioral Program. Session Topics Contents Activities 1 Understanding of experience and identifying individual characteristics Orientation of program and pre-test. Sharing personal experience causing negative emotions. small group individual exercise 2 Understanding the cognitive process Understanding the process of cognition, emotion, and behavior. Description of an individual’s automatic thinking in an event/situation where one felt negative emotions. Lecture small group individual exercise 3 Understanding the cognitive distortion Understanding the type of cognitive distortions and identifying the cognitive distortions of the individual. Lecture small group individual exercise 4 Reconstruction of cognitive process Reconstructing the cognitive process and identifying changes in emotion and behavior. Lecture small group individual exercise feedback 5 Planning of the interpersonal relationships and activities Sharing the experience that cognitive distortion affected interpersonal relationships and activities, and planning the new interpersonal relationships and activities. small group individual exercise feedback 6 Application of cognitive exercises Sharing experiences in interpersonal relationships and activities, and identifying the effect on cognition and emotion. small group individual exercise feedback 7 Identification of cognitive change Explaining the change in an individual’s cognitive process. small group individual exercise feedback sharing 8 Positive self-expression Positive self-assessment and explaining the future applicability. Post-test. small group feedback sharing The pre-survey was measured one week before the program in both the experimental and control groups, and included questionnaires about general characteristics, depression, self-esteem, and interpersonal relationships. The time to complete the questionnaires was about 15–20 min. The post-survey was conducted immediately after the eighth session. The survey was conducted in a quiet university classroom. The experimental participants were provided meals and were given vouchers during the pre- and post-intervention. The control participants were provided with vouchers for the pretreatment and one-month follow-up assessments. 2.3. Measurements 2.3.1. Depression Depression was measured using the Beck Depression Inventory (BDI), designed by Beck et al. [10]. The BDI consists of 21 items, and each item is rated on a 4-point Likert scale (0 = least; 3 = most). Higher total scores indicate greater depressive severity, with total scores ranging from 0 to 63. Cronbach’s α was 0.94 in the previous study [21] and 0.81 in this study. 2.3.2. Self-Esteem Self-esteem was measured using the Korean version of self-esteem, which was revised by Jon [22] based on the Self-esteem Scale developed by Rosenberg [23]. This 10 items tool, which uses a 4-point Likert scale, contains two dimensions: positive self (5 items) and negative self (5 items). Higher total Int. J. Environ. Res. Public Health 2020, 17, 3500 6 of 11 scores indicate a higher self-esteem, with total scores ranging from 10 to 40. Cronbach’s α was 0.92 in the previous study [23] and 0.88 in this study. 2.3.3. Interpersonal Relationships Interpersonal relationships were measured using the Relationship Chang Scale developed by Schlein [24], which was revised by Moon [25] and modified by Chun [26]. This 25-item tool, which uses a 5-points Likert scale, contains seven dimensions, including satisfaction, communication, trust, intimacy, sensitivity, openness, and understanding. Higher total scores indicate a higher interpersonal relationship, with total scores ranging from 25 to 125. Cronbach’s α was 0.88 in the previous study [24] and 0.79 in this study. 2.3.4. General Characteristics General characteristics included gender, religion, monthly allowance, smoking, drinking, and age. 2.4. Statistical Analyses Statistical analyses were conducted using the SPSS/WIN version 23.0 program. Descriptive statistics were used to analyze the general characteristics and variables, including depression, self-esteem, and interpersonal relationships. The Chi-square test, Fisher’s exact test, and t-test were used to examine the homogeneity in the variables between the experimental and control groups. In order to verify the effect of the group CBT program on mental health by time between the experimental group and control group, a repeated measures ANOVA was performed. Two-tailed tests and a 5\% significance level were used in all analyses. 3. Results 3.1. Homogeneity Test for General Characteristics and Dependent Variables between Experimental and Control Groups There were no differences between the two groups in terms of the general characteristics and study variables, including depression and self-esteem. However, there was a significant difference between the two groups in terms of interpersonal relationships (Table 2). Table 2. Homogeneity of the general characteristics and dependent variables between the experimental and control groups (N = 37). Characteristics Categories Exp. (n = 18) Cont. (n = 19) χ2 or t p M ± SD or n (\%) M ± SD or n (\%) Gender † Male 2(11.1) 5(26.3) 1.39 0.238 Female 16(88.9) 14(73.7) Religion † Christian 2(11.1) 4(21.1) 0.97 0.808 Catholics 2(11.1) 1(5.3) Buddhism 2(11.1) 2(10.5) None 12(66.7) 12(63.2) Monthly allowance † (10,000 won) 20≤ 2(11.1) 6(31.6) 3.26 0.353 21–30 6(33.3) 6(31.6) 31–40 5(27.8) 2(10.5) 41≥ 5(27.8) 5(26.3) Smoking † Yes 0(0.0) 3(15.8) 3.09 0.079 No 18(100.0) 16(84.2) Drinking † Never 6(33.3) 7(36.8) 3.60 0.165 Once a month 11(61.1) 7(36.8) More than once a week 1(5.6) 5(26.3) Age (yr) †† 22.44 ± 1.14 21.68 ± 1.56 1.67 0.103 Depression †† 16.16 ± 7.16 13.00 ± 6.53 1.40 0.168 Self-esteem †† 29.22 ± 5.87 32.84 ± 8.41 −1.50 0.140 Interpersonal relationship †† 76.50 ± 9.99 87.42 ± 10.85 −3.17 0.003 Exp. = Experimental group; Cont. = Control group; M = Mean; SD = Standard deviation; † Fisher’s exact test; †† Independent t-test. Int. J. Environ. Res. Public Health 2020, 17, 3500 7 of 11 3.2. Effects of the Cognitive Behavioral Group Program 3.2.1. Hypothesis 1 Depression has significant interactions between group and time (F = 12.48, p = 0.001) and time (F = 30.21, p < 0.001). When compared with the control, the depression in the experimental group showed a significant reduction (t = −6.48, p < 0.001) (Table 3). Table 3. Effects of the cognitive behavioral group program on the dependent variables between the experimental and control groups (N = 37). Variables Group Pre-Test Post-Test Source F p Post-Pre M ± SD M ± SD M ± SD t(p) Depression Exp. (n = 18) 16.16 ± 7.16 6.72 ± 4.67 G 0.78 0.781 −9.44 ± 6.17 −6.48(<0.001) Cont. (n = 19) 13.00 ± 6.53 10.94 ± 7.50 T 30.21 <0.001 −2.05 ± 6.52 −1.37(0.187) G × T 12.48 0.001 Self esteem Exp. (n = 18) 29.22 ± 5.87 3.44 ± 5.79 G 0.46 0.500 4.22 ± 4.83 3.70(0.002) Cont. (n = 19) 32.84 ± 8.41 33.00 ± 8.90 T 8.74 0.006 0.15 ± 4.16 0.16(0.871) G × T 7.53 0.010 Interpersonal Relation Exp. (n = 18) 76.50 ± 9.99 89.72 ± 10.65 G 2.28 0.139 13.22 ± 10.78 5.20(<0.001) Cont. (n = 19) 87.42 ± 10.85 89.10 ± 12.83 T 29.59 <0.001 1.68 ± 5.01 1.46(0.160) G × T 17.72 <0.001 Exp. = Experimental group; Cont. = Control group; M = Mean; SD = Standard deviation; G = Group; T=Time; G × T = Group × Time. 3.2.2. Hypothesis 2 Self-esteem has significant interactions between group and time (F = 7.53, p = 0.010) and time (F = 8.74, p = 0.006). When compared with the control, self-esteem in the experimental group showed a significant reduction (t = 3.70, p = 0.002) (Table 3). 3.2.3. Hypothesis 3 Personal relationship has significant interactions between group and time (F = 17.72, p < 0.001) and time (F = 29.59, p < 0.001). When compared with the control, personal relationship in the experimental group showed a significant reduction (t = 5.20, p < 0.001) (Table 3). 4. Discussion This study attempted to examine the effect of a group program for mental health promotion on depression, self-esteem, and interpersonal relationships among undergraduate students. The BDI is an inventory measuring the attitudes and symptoms of depression and is divided into four alternative statements. The standard cutoffs are scores of 0–9 for the normal range, 10–15 for mild depression, 16–23 for moderate depression, and 24–63 for severe depression [10]. The mean score of the BDI before intervention in the study was 16.16 in the experimental group and 13.00 in the control group, which indicates more than mild depression in both groups. Participants may have been interested in depression because they saw the advertisement and applied it to the study. On the other hand, the mean score of depression in previous studies [5,12,27] applying cognitive behavioral therapy to undergraduate students was relatively higher than that in this study, ranging from 21.63 to 23.16. This is because the cutoffs were set to 21 [5], 18 [12], and 10 and more [27], respectively, and students who agreed to participate in the experiment by the therapist’s recommendation were included. The mean score of self-esteem before the intervention was 29.22 in the experimental group and 32.84 in the control group. In Park and Son’s study [28], the self-esteem score of female college students with a negative physical image was 24.50 in the experimental group and 25.13 in the control group, which was relatively lower than that in this study. Since female college students have a high correlation between physical satisfaction and self-esteem [28], self-esteem may be lower in female college students with a negative physical image. The mean score of interpersonal relationships before the intervention was 76.50 in the experimental group and 87.42 in the control group, which was significantly higher Int. J. Environ. Res. Public Health 2020, 17, 3500 8 of 11 in the control group. Homogeneity between the two groups was not met because those with more willingness to treat depression were assigned to the experimental group. In other words, people with more problems in their personal relationships may feel more depressed and want some treatments. Hwang et al. [29] showed that the mean score of interpersonal relationships in undergraduate … The Stigma Scale: A Canadian Perspective Amanda Meier, Rick Csiernik, Laura Warner, and Cheryl Forchuk Stigma is a devastating psychosocial issue for many individuals with mental illness. This study examined the mental illness stigma experiences of 380 individuals with a self-reported psy- chiatric diagnosis in London, Ontario, Canada, using the Stigma Scale, a tool recently de- veloped in the United Kingdom (UK). Data for the Canadian sample were examined and compared with those from the UK pilot group. Results indicated that both samples experi- enced mental illness stigma, with Canadian participants reporting fewer stigma experiences on close to half of the scale items. In general, the results suggested that antistigma efforts have achieved some successes, particularly for targeted recipient groups; however, the need remains for continued and varied methods of stigma reduction to eliminate stigma within society. KEY WORDS: mental health; mental illness; psychiatric survivors; stigma; Stigma Scale It is estimated that 20\% of Canadians live with mental illness, with close to 500,000 missing work each week for psychiatric reasons ( Mental Health Commission of Canada, 2014b). Moreover, the Men- tal Health Commission of Canada (2014b) reported that 60\% of people with mental health issues do not seek help for fear of being labeled. Stigma toward those who are perceived as different has existed for centuries, with mental illness stigma being a par- ticularly prominent and detrimental issue in society today ( Arboleda-Florez & Stuart, 2012). Expanded understanding of stigma and its associated conse- quences for individuals with mental illness is neces- sary to counteract its oppressing impact within society. MENTAL ILLNESS STIGMA Stigma has been defined as “a feeling of being nega- tively differentiated owing to a particular condition, group membership or state in life” ( Arboleda-Florez & Stuart, 2012, p. 458). There are two main forms of mental illness stigma discussed in literature. Public stigma, also referred to as societal stigma, denotes prejudicial attitudes held by the public toward people with mental illness ( Arboleda-Florez & Stuart, 2012; Corrigan, Markowitz, Watson, Rowan, & Kubiak, 2003). Self-stigma, also known as internalized stigma, refers to personal shame, withdrawal, and loss of self- esteem experienced by some people with mental ill- ness. Self-stigma is often triggered by applying to ones elf the negative stereotypes held by the public ( Chronister, Chou, & Liao, 2013; Corrigan et al., 2003). There is no single cause of stigma; instead it has multiple interconnecting sources, though misguided perceptions about mental illness and those who are living with mental illness are believed to be one of the most prominent sources. Previous research has demonstrated that members of the public lack know- ledge of mental illnesses and hold a number of mis- informed beliefs about individuals with mental illnesses. Crisp, Gelder, Rix, Meltzer, and Rowlands (2000) surveyed 1,737 British adults in an effort to determine public opinions about individuals with mental illness. Their findings demonstrated that ap- proximately 70\% of respondents believed people with schizophrenia, alcoholism, or drug addiction were dangerous, which has been an ongoing issue with this population ( Csiernik, Forchuk, Speechley, & Ward-Griffin, 2007). Wang and Lai (2008) surveyed 3,047 adults in Canada to obtain attitudes concern- ing depression and found that 45\% of participants considered people with depression to be unpredict- able, with over 20\% considering them dangerous. Stuart (2003) conducted a review of mental health and violence literature and concluded that the gen- eral public exaggerates the strength of relationship between mental illness and violence and also exag- gerates their own personal risk of being harmed by individuals with mental illness. Some researchers have traced the connection between mental illness and violence to the often unrealistic portrayals of individuals with mental illness in the media ( Blood, Putnis, & Pirkis, 2002; Byrne, 2000; Leff & Warner, 2006). Another common misguided belief about individuals with mental illness is that their illnesses 213doi: 10.1093/swr/svv028 © 2015 National Association of Social Workers are self-inflicted, making them blameworthy for their situation ( Corrigan et al., 2003; Corrigan & Watson, 2007; Crisp et al., 2000). Unfortunately, stigmatizing attitudes are not limited to the general public but often occur within individuals’ social circles as well. For example, Moses (2010) interviewed adolescents with mental illness and found that 46\% reported stigmatization from their family members and 62\% experienced stigmatization from peers. In Crisp et al.’s (2000) study, 50\% of respondents reported knowing someone with a mental illness; however, between 70\% and 80\% of them also reported generalized negative views about individuals with mental illness. Experiencing stigmatizing attitudes from the pub- lic and within social circles can lead to numerous detrimental effects on an individual’s health and well- being. Livingston and Boyd (2010) conducted a sys- tematic review of 45 stigma and mental health articles and found that the social effects of stigmatization include exclusion, diminished social support, low subjective quality of life, and poor self-esteem. Fur- ther, self-stigma was found to be positively associated with symptom severity and negatively associated with adherence to treatment ( Livingston & Boyd, 2010; Perlick et al., 2001). Wright, Gronfein, and Owens (2000) surveyed 88 individuals with mental illness recently discharged from hospitals and found that stigmatization was associated with increased stress and a weakened sense of mastery among participants. Common consequences of experiencing stigmatiza- tion include shame, secrecy, isolation, social exclu- sion, and feeling like an outsider within one’s family ( Byrne, 2000). Yanos, Roe, and Lysaker (2010) fur- ther found that self-stigma is associated with poorer vocational outcomes. In recent years, policymakers have begun to acknowledge the detrimental effects of stigmatization and programs have been developed to counteract misinformation about mental illnesses among the public. However, individuals continue to experience mental illness stigma within their com- munities and social circles. Stigma has been described as potentially more detrimental than mental illnesses themselves and is considered to be one of the great- est obstacles remaining in the treatment of mental illness ( Cechnicki, Matthias, & Angermeyer, 2011; Chronister et al., 2013). THE STIGMA SCALE The Stigma Scale was developed by King et al. (2007) as a standardized measure of the stigma of mental illness. Items for the scale were developed on the basis of results from an earlier study by Dinos, Stevens, Serfaty, Weich, and King (2004). In the initial study, 46 patients from community and day mental health services in North London, United Kingdom (UK), participated in qualitative one-on-one interviews concerning their feelings and experiences with men- tal illness. King et al. (2007) reviewed the results and developed a 42-item scale using participant phrases regarding stigma experiences; the process of item development involved adapting participant phrases to make them more general and applicable to other people’s experiences. The scale was pilot-tested with 193 mental health services users, 93 of whom were asked to complete the scale once at baseline and again two weeks later. Items with low test–retest reliability were dropped, resulting in a final scale with 28 items. The final version contains three subscales determined by factor analysis of the pilot results: discrimination, disclosure, and potential positive aspects of mental ill- ness ( King et al., 2007). We conducted an extensive search of literature by reviewing all articles that have cited King et al. (2007) and searching the PsycINFO, CINAHL, and Social Sciences Abstracts databases for the key words “Stigma Scale.” Through this review we found that the Stigma Scale has been used in a small number of studies, but mostly in modified or adapted form. Schwenk, Davis, and Wimsatt (2010) conducted a cross- sectional Web- based survey study with 769 medical students at the University of Michigan to evaluate their levels of de- pression, stigma, and suicidal ideation; some state- ments for the survey were drawn from the Stigma Scale but were adapted to reflect the population of medical students and specific depression experiences. Sanders (2012) ran a mixed methodology study to investigate how women with drug addiction use mu- tual support to counteract stigma in Maryland. She distributed surveys to women attending Narcotics Anonymous meetings that included items adapted from the Stigma Scale to reflect the specific issue of drug addiction. Further, the Stigma Scale has been used in three graduate theses from U.S. universities: Conrad-Garrisi (2011) administered the full Stigma Scale during a correlation study examining the rela- tionship between a number of variables and mental health recovery with 143 members of psychiatric re- habilitation “clubhouses”; Hall (2012) adapted the Stigma Scale during a vignette-based survey study examining intimate partner violence with 250 male and female undergraduate student participants; and Walston (2012) used the positive aspects of mental Social Work Research Volume 39, Number 4 December 2015214 illness subscale from the Stigma Scale to investigate illness acceptance as a mediator to schizophrenia re- covery in 100 participants diagnosed with schizophre- nia receiving outpatient mental health treatment. PURPOSE OF STUDY To date, the Stigma Scale or sections of it have been used in a small number of studies and theses within the United States and the UK. The purpose of our study was to examine stigma experiences for indi- viduals living with mental illness in London, Ontario, Canada, and provide a direct comparison between a Canadian sample and the King et al. (2007) results. To our knowledge, this study is the first one to use the Stigma Scale in a Canadian context. METHOD Design The findings from this study are part of a five-year Community-University Research Alliance (CURA) program funded by the Social Sciences and Human- ities Research Council of Canada on the topics of poverty and social inclusion for psychiatric survivors (that is, individuals with lived experience of mental illness). The CURA used a participatory-action re- search approach to longitudinally collect quantitative and qualitative data on the issues of concern. This study used a cross-sectional descriptive comparative research design. Data from the first year of the CURA were obtained and analyzed to describe stigma experiences for the sample as well as compared with those from the Stigma Scale pilot sample. Re- search ethics approval was obtained from the research ethics board at Western University, London, Ontario. Setting and Sample This study was conducted in London, Ontario, Canada, a midsize city with a population of approxi- mately 365,000 ( Statistics Canada, 2012). Although specific rates of mental illness for London are un- available, it is estimated that 20\% of Canadians ex- perience a mental health problem or illness in any given year; however, only one in three people ex- periencing mental health problems or illnesses re- port seeking and receiving services and treatment ( Mental Health Commission of Canada, 2012). A total of 380 psychiatric survivors participated in the study. Individuals were recruited to participate if they had been diagnosed with a mental illness for a minimum of one year prior to participation (self- reported), were between the ages of 18 and 75, spoke and understood English, and provided informed consent. Quota sampling was used to ensure equal representation by gender (male and female) and housing status (homeless, residing in a group living setting, unemployed housed, and employed housed). Sample sites included homeless shelters, group living settings for psychiatric survivors, community men- tal health agencies, public housing, and hospitals. The study was advertised using a variety of methods, including posters, newspaper advertisements, word of mouth, social media, and identification of inter- ested participants by mental health workers con- nected to the CURA program. Participants were recruited over a six-month period in the summer and fall of 2011. Interviews took place at locations chosen by participants. Instrument The Stigma Scale contains 28 items rated on a five- point Likert scale ranging from 1 = strongly disagree to 5 = strongly agree. Item wording alternates between positive and negative statements to avoid response set bias, with negative statements undergoing reverse scoring during analysis ( King et al., 2007). Thirteen items on the scale pertain to discrimination experi- ences (that is, “perceived hostility by others or lost opportunities because of prejudiced attitudes”), 10 items evaluate a person’s willingness to disclose men- tal health information to others, and five items con- cern a person’s acknowledgment of the positive aspects of their mental illness ( King et al., 2007, p. 250). The scale can be analyzed to yield one total score and three subscale scores. A total stigma score can be determined by adding all responses; the lowest possible total score is 0 and the highest possible total score is 112, with higher scores indicating more mental illness stigma. A dis- crimination subscale score can be determined by add- ing responses to the 13 discrimination items; the lowest possible discrimination score is 0 and the high- est possible discrimination score is 48, with higher scores indicating more discrimination experiences due to mental illness. A disclosure subscale score can be obtained by adding responses to the 10 disclosure items; the lowest possible disclosure score is 0 and the highest possible disclosure score is 44, with a higher disclosure score indicating a lower likelihood of dis- closing mental illness information. A positive aspects subscale score can be determined by adding responses to the five positive aspects items; the lowest possible positive aspects score is 0 and the highest possible Meier, Csiernik, Warner, and Forchuk / The Stigma Scale: A Canadian Perspective 215 positive aspects score is 20, with higher scores indicat- ing a lower likelihood of seeing the positive aspects of mental illness. Previous analyses have shown the Stigma Scale to have good reliability. In the original study by King et al. (2007), Cronbach’s alpha was determined to be .87 for the total score, with alphas for the sub- scales being .87 (discrimination), .85 (disclosure), and .64 (positive aspects). The overall Stigma Scale was also shown to be negatively correlated with the Self-Esteem Scale, demonstrating its concurrent validity ( King et al., 2007). Data Collection Each of the 380 participants completed one-on-one interviews with trained research assistants. Research assistants read all items of the Stigma Scale out loud to participants, and participants rated their responses verbally or by pointing at the instrument. Responses were recorded using paper-and-pencil methods and entered into electronic databases after the interview. An honorarium of $20 was given at the end of each interview to compensate for time and travel. Data Analysis Frequencies and percentages of sample characteristics were calculated. Responses to items in the Stigma Scale were scored according to the guidelines set out by King et al. (2007). These were then used to de- termine the scores for each of the three subscales and an overall total scale score. Reliability of the Stigma Scale was assessed through a Cronbach’s alpha for the final scale and each of the subscales. This was also assessed for the individual items, examining the Cronbach’s alpha with each item removed. Measures of central tendency were calculated for each item, and t tests were used to determine if significant differences existed between the measures calculated for the current sample and those reported by King et al. (2007). Measures of central tendency were also calculated for the subscales and compared with those found in the King et al. (2007) article through t-test analyses. As the original King et al. (2007) article did not contain sample sizes for the subscales, these were estimated by summing the number of missing responses from each of the indi- vidual items. Using this conservative method, sample sizes were calculated to be 150 (discrimination sub- scale), 164 (disclosure subscale), 172 (positive aspects subscale), and 100 (total score). Mean differences for the subscales were then standardized using the pooled standard deviation. All mean differences (individual items and subscales) were calculated so that a positive value indicated higher stigma in the Canadian sample. A Bonferroni correction was ap- plied to account for the multiple testing, lowering the threshold from p < .05 to p < .0016. RESULTS Description of Sample Characteristics for both the UK and Canadian samples are presented in Table 1. There was little difference in age (42.9 years for UK sample, 40.7 years for Canadian sample), though the UK sample had a slightly greater percentage of men (57.1\% versus 50.0\%), and a slightly lower proportion of individuals currently employed (17.0\% versus 24.7\%). Ethnicity could not be directly compared due to differences in data collection, though it did appear that the UK sample contained a slightly higher percentage of Caucasians (87.4\% versus 75.5\%). Table 1: Comparison of Demographics in the UK and Canadian Samples UK Sample (n = 193) Canadian Sample (n = 380) Demographic Characteristic M (SD) n (\%) M (SD) n (\%) Age (years) 42.9 (12.4) 40.7 (14.0) Gender Male 109 (57.1) 190 (50.0) Female 82 (42.9) 190 (50.0) Ethnicity Caucasian 159 (87.4) 287 (75.5) African American 11 (6.0) 4 (1.1) Indian/Bangladeshi 18 (9.0) NR Native American NR 45 (11.8) Other 25 (13.7) 44 (11.6) Currently employed 34 (17.0) 94 (24.7) Note: NR = not relevant. Social Work Research Volume 39, Number 4 December 2015216 In addition, psychiatric diagnoses were classified slightly differently, although in both samples each in- dividual could report more than one dia gnosis. Both samples reported similar rates of mood and anxiety disorders, and the UK sample reported slightly higher rates of schizophrenia and personality disorders. Reliability of the Stigma Scale Table 2 highlights the results of the reliability testing in the Canadian sample and the comparison data from King et al. (2007). Cronbach’s alpha for the total scale score in the Canadian sample was .86, which was similar to .87 in the UK sample. When examining how this changed with item deletion, the alphas ranged from .86 to .87 in the Canadian sample. The alphas for the subscales were all calculated to be lower in the Canadian sample than in the UK sample. TOTAL STIGMA SCORES Total stigma scores for the Canadian sample ranged from 9 to 99 (possible range was 0 to 112). In com- parison with the UK sample, the Canadian sample scored lower on both the total stigma score (56.0 ver- sus 62.6, p < .0016) and the discrimination subscale (25.0 versus 29.1, p < .0016) (see Table 3). Although this trend was repeated for the disclosure subscale (22.9 versus 24.7) and positive aspects subscale (8.0 versus 8.8), neither of these differences were found to be statistically significant. These results indicate that the UK sample was experiencing a higher level of dis- crimination and stigma in general than the Canadian sample. ISSUES IN THE UK UK participants experienced more stigma on 12 items of the Stigma Scale (see Table 4 for the full list of items). Significantly more UK participants re- ported feeling bad about having mental health prob- lems (mean difference –0.69, p < .0016), feeling alone because of their mental health problems (mean difference –0.53, p < .0016), and feeling embar- rassed because of their mental health problems (mean difference –0.51, p < .0016). UK participants indicated that they worried about telling people they received psychological treatment (mean differ- ence –0.51, p < .0016) and that they took medicine/ tablets for mental health problems (mean difference –0.67, p < .0016) significantly more than Canadian participants. In terms of disclosure, UK participants indicated that they were significantly more scared of how people would react if they found out about their mental health problems (mean difference –0.57, p < .0016), avoided telling people about their mental health problems (mean difference –0.39, p < .0016), minded if people in their neighborhood knew about their mental health problems (mean difference –0.45, p < .0016), felt the need to hide their mental health problems from their friends (mean difference –0.42, p < .0016), and generally found it hard to tell others about their mental health problems (mean difference –0.60, p < .0016). Finally, significantly fewer UK participants agreed with the notion that having a mental illness made them a stronger person (mean difference –0.43, p < .0016), and significantly more UK participants felt that having mental health problems made them feel like life was unfair (mean difference –0.47, p < .0016). The results demon- strate that individuals in the UK feel more negatively about their mental illnesses and are more hesitant to disclose mental illness information to friends and Table 2: Summary of Reliability Analysis Results for the UK and Canadian Samples UK Sample Canadian Sample Cronbach’s Alpha Cronbach’s Alpha Range of Alphas When Items Removed Disclosure .85 .79 .76–.81 Discrimination .87 .83 .81–.83 Positive aspects .64 .46 .26–.60 Total .87 .86 .86–.87 Table 3: Summary of Stigma Scale Scores for the UK and Canadian Samples Subscale UK Sample Canadian Sample M Difference Standardized DifferenceResponse (n) M (SD) Response (n) M (SD) Discrimination 150 29.1 (9.5) 371 25.0 (9.0) –4.1 –0.49* Disclosure 164 24.7 (8.0) 367 22.9 (7.6) –1.8 –0.23 Positive aspect 172 8.8 (2.8) 375 8.0 (3.1) –0.8 –0.27 Total score 100 62.6 (15.4) 362 56.0 (15.8) –6.6 –0.42* *p < .0016. Meier, Csiernik, Warner, and Forchuk / The Stigma Scale: A Canadian Perspective 217 Ta b le  4 : R e sp o n se s to t h e S ti g m a S ca le I te m s fo r th e U K a n d C a n a d ia n S a m p le s It e m N u m b e r S ta te m e n t S tr o n g ly A g re e S tr o n g ly D is a g re e U K S a m p le C a n a d ia n S a m p le M D if fe re n ce R e sp o n se (n ) M ( S D ) M e d ia n R e sp o n se (n ) M ( S D ) M e d ia n 1 I ha ve b ee n di sc ri m in at ed a ga in st in e du ca tio n be ca us e of m y m en ta l h ea lth p ro bl em s (D c) 4 0 18 8 1. 59 (1 .0 3) 1 .5 37 9 1. 91 (1 .3 6) 2 .0 0. 32 2 So m et im es I fe el th at I a m b ei ng ta lk ed d ow n to b ec au se o f m y m en ta l h ea lth p ro bl em s (D c) 4 0 18 9 2. 40 (1 .2 4) 3 .0 37 9 2. 42 (1 .2 6) 3 .0 0. 02 3 H av in g ha d m en ta l h ea lth p ro bl em s ha s m ad e m e a m or e un de rs ta nd in g pe rs on (P ) 0 4 19 0 1. 08 (0 .8 9) 1 .0 37 9 1. 22 (1 .1 1) 1 .0 0. 14 4 I do n ot fe el b ad a bo ut h av in g ha d m en ta l h ea lth p ro bl em s (D ) 0 4 18 8 2. 32 (1 .2 6) 3 .0 37 8 1. 63 (1 .2 7) 1 .0 –0 .6 9a 5 I w or ry a bo ut te lli ng p eo pl e I re ce iv e ps yc ho lo gi ca l t re at m en t ( D ) 4 0 18 9 2. 71 (1 .1 8) 3 .0 37 4 2. 20 (1 .2 6) 2 .0 –0 .5 1a 6 So m e pe op le w ith m en ta l h ea lth p ro bl em s ar e da ng er ou s (P ) 4 0 19 0 2. 82 (0 .9 5) 3 .0 37 8 2. 67 (1 .1 3) 3 .0 –0 .1 5 7 Pe op le h av e be en u nd er st an di ng o f m y m en ta l h ea lth p ro bl em s (P ) 0 4 18 5 1. 84 (1 .0 6) 2 .0 37 8 1. 61 (1 .0 8) 1 .0 –0 .2 3 8 I ha ve b ee n di sc ri m in at ed a ga in st b y po lic e be ca us e of m y m en ta l he al th p ro bl em s (D c) 4 0 18 8 1. 72 (1 .2 1) 2 .0 37 5 1. 79 (1 .4 0) 1 .0  0 .0 7 9 I ha ve b ee n di sc ri m in at ed a ga in st b y em pl oy er s be ca us e of m y m en ta l h ea lth p ro bl em s (D c) 4 0 18 7 2. 08 (1 .1 6) 2 .0 37 8 1. 88 (1 .3 4) 2 .0 –0 .2 0 10 M y m en ta l h ea lth p ro bl em s ha ve m ad e m e m or e ac ce pt in g of ot he r pe op le (P ) 0 4 19 1 1. 19 (1 .0 1) 1 .0 37 8 1. 18 (0 .9 9) 1 .0 –0 .0 1 11 V er y of te n I fe el a lo ne b ec au se o f m y m en ta l h ea lth p ro bl em s (D c) 4 0 19 0 2. 85 (1 .1 4) 3 .0 37 7 2. 32 (1 .3 0) 3 .0 –0 .5 3a 12 I am s ca re d of h ow o th er p eo pl e w ill re ac t i f t he y fin d ou t a bo ut m y m en ta l h ea lth p ro bl em s (D ) 4 0 19 2 2. 65 (1 .1 3) 3 .0 37 8 2. 08 (1 .3 0) 2 .0 –0 .5 7a 13 I w ou ld h av e ha d be tt er c ha nc es in li fe if I h ad n ot h ad m en ta l he al th p ro bl em s (D c) 4 0 19 1 2. 89 (1 .1 5) 3 .0 37 8 2. 76 (1 .2 0) 3 .0 –0 .1 3 14 I do n ot m in d pe op le in m y ne ig hb or ho od k no w in g I ha ve h ad m en ta l h ea lth p ro bl em s (D ) 0 4 19 2 2. 58 (1 .3 4) 3 .0 37 7 2. 13 (1 .2 4) 2 .0 –0 .4 5a 15 I w ou ld s ay I h av e ha d m en ta l h ea lth p ro bl em s if I w as a pp ly in g fo r a jo b (D ) 0 4 18 9 2. 16 (1 .3 1) 2 .0 37 8 2. 44 (1 .3 7) 3 .0  0 .2 8 16 I w or ry a bo ut te lli ng p eo pl e th at I ta ke m ed ic in es /t ab le ts fo r m en ta l h ea lth p ro bl em s (D ) 4 0 19 1 2. 58 (1 .1 8) 3 .0 37 1 1. 91 (1 .1 9) 2 .0 –0 .6 7a 17 Pe op le ’s re ac tio ns to m y m en ta l h ea lth p ro bl em s m ak e m e ke ep m ys el f t o m ys el f ( D c) 4 0 18 8 2. 40 (1 .1 9) 3 .0 37 7 2. 23 (1 .2 4) 2 .0 –0 .1 7 18 I am a ng ry w ith th e w ay p eo pl e ha ve r ea ct ed to m y m en ta l h ea lth pr ob le m s (D c) 4 0 19 0 2. 23 (1 .1 8) 2 .0 37 7 2. 11 (1 .2 6) 2 .0 –0 .1 2 19 I ha ve n ot h ad a ny tr ou bl e fr om p eo pl e be ca us e of m y m en ta l he al th p ro bl em s (D c) 0 4 19 2 2. 24 (1 .1 4) 2 .0 37 8 2. 28 (1 .2 2) 3 .0 0. 04 (c on tin ue d) Social Work Research Volume 39, Number 4 December 2015218 acquaintances when compared with Canadian par- ticipants. Common Issues There were 16 items on the Stigma Scale that elicited similar results between Canadian and UK partici- pants. Both Canadian and UK participants reported that they somewhat agreed they had been talked down to because of their mental health problems and that they had some trouble from other people be- cause of their mental health problems. Neither set of participants agreed or disagreed as to whether they had been insulted because of their mental health problems, whether the reactions of others made them keep their mental illness information to them- selves, or whether they were angry with the way others have reacted to their mental health problems. In terms of specific discrimination, participants re- ported similar rates of discrimination from police, employers, the education system, and health care providers, with results indicating that participants somewhat disagreed to experiencing discrimination from all sources. Both Canadian and UK participants agreed with the notion that some people with men- tal health problems are dangerous. Both sets of par- ticipants agreed that having mental health problems made them more understanding people and more accepting of others. However, both sets of partici- pants also agreed with the statement that they would have had better chances in life if they did not have mental health problems. Canadian participants did not report significantly more stigma than UK par- ticipants on any of the scale items. DISCUSSION This study was the first in Canada to use the full Stigma Scale ( King et al., 2007) as a measure of men- tal illness stigma. Whereas other studies throughout North America have used excerpts of the scale or …