Associative stigma experienced by mental health professionals in China and the United States

  • Xiaoming Lin
  • Robert Rosenheck
  • Bin Sun
  • Guojun Xie
  • Guhua Zhong
  • Changzan Tan
  • Zhupei Li
  • Min Yu
  • Hongbo HeEmail author
Original Paper



“Associative stigma” is the negative stereotyping of mental health service providers who treat people with serious mental illness. The Clinician Associative Stigma Scale (CASS) has been validated in a US sample but not in other nations, e.g., in China which has been found to have substantially higher levels of stigma towards people with mental illness than the US.


The 19-item CASS was translated into Chinese and administrated to 665 mental health professionals working in psychiatric hospitals in Southern China. Confirmatory factor analysis (CFA) was used to compare the factor structure with that found in the US sample. Socio-demographic correlates of CASS scores and comparison with US data were conducted using regression models and t test.


CFA showed a good model fit (GFI = 0.911 and RMSEA = 0.068) for the four factors found in the US study: (1) discomfort with disclosing about working with serious mental illness, (2) stereotypes about professionals’ own poor mental health, (3) stereotypes about unpleasantness of working with people with serious mental illness, and (4) stereotypes about lack of treatment effectiveness. Total CASS score and subscales concerning stereotypes about providers’ mental health and about unpleasantness of working with such patients were significantly lower in China than in the US (both P < 0.001), but stereotypes concerning professional ineffectiveness were higher in China.


Associative stigma was lower in China than in the US, possibly reflecting the cultural dominance of respect for educated professionals over stigma towards people with serious mental illness.


Associative stigma Mental illness Mental health Professionals Clinician Associative Stigma Scale 



Philip Yanos provided unpublished subscale scores from his study of the CASS. Dr. Jie Zhang gave important opinions in discussion.


This study was supported from funding to H H from the Guangzhou Municipal Psychiatric Diseases Clinical Transformation Laboratory (no: 201805010009), Key Laboratory for Innovation platform Plan, Science and Technology Program of Guangzhou, China and from the Guangzhou Municipal key discipline in psychiatry. The funding source had no role in the study design, analysis or interpretation of data or in the preparation of the report or decision to publish the results.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflicts of interest.


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Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  • Xiaoming Lin
    • 1
  • Robert Rosenheck
    • 2
  • Bin Sun
    • 1
  • Guojun Xie
    • 3
  • Guhua Zhong
    • 4
  • Changzan Tan
    • 5
  • Zhupei Li
    • 6
  • Min Yu
    • 1
  • Hongbo He
    • 1
    Email author
  1. 1.The Affiliated Brain Hospital of Guangzhou Medical University (Guangzhou Huiai Hospital)GuangzhouChina
  2. 2.Yale Medical SchoolNew HavenUSA
  3. 3.Foshan Third People’s HospitalFoshanChina
  4. 4.Jiangmen Third People’s HospitalJiangmenChina
  5. 5.Zhaoqing Third People’s HospitalZhaoqingChina
  6. 6.Dongguan Mental Health Center (Dongguan Xinchung Hospital)DongguanChina

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