Attitudes of mental health professionals about mental illness: a review of the recent literature

A R T I C L E

ATTITUDES OF MENTAL HEALTHPROFESSIONALS ABOUT MENTALILLNESS: A REVIEW OF THERECENT LITERATURE

Otto Wahl and Eli Aroesty-CohenUniversity of Hartford

A large body of research has documented public attitudes toward peoplewith mental illness. The current attitudes of the people who provideservices to those with psychiatric disorders are important to understand,as well. The authors review what studies over the past 5 years revealabout the attitudes of psychiatric professionals. Empirical studies of theattitudes of mental health professionals, published since 2004, wereidentified and reviewed. Only 19 such studies were found. Most ofthese studies revealed overall positive attitudes among mental healthprofessionals. However, evidence of negative attitudes and expectationswas also found, particularly with respect to social acceptance of peoplewith mental illness. Results indicate a need for greater research attentionto mental health professionals’ views and for improved attitudes amongcaregivers. �C 2009 Wiley Periodicals, Inc.

There is considerable literature documenting negative public attitudes and behaviortoward persons with mental illness. Many studies have established that the general publicperceives such individuals as possessing undesirable traits (Corrigan, 2005; Crisp, Gelder,Rix, Meltzer, & Rowlands, 2000; Fink & Tasman, 1992; Rabkin, 1972). In particular,people with psychiatric disorders are viewed as dangerous and unpredictable (Corrigan,2005; Link, Phelan, Bresnahan, Stueve, & Pescosolido, 1999) and are subjected todiscrimination in jobs, education, housing, and other activities (Corrigan, 1998; Farina &Felner, 1973; Page, 1977; Thornicroft, 2006; Thornicroft et al., 2009; Wahl, 1999a, b).

The attitudes and behaviors of mental health professionals toward those they serveare also very important (Chaplin, 2000). Mental health professionals serve as rolemodels and opinion leaders with respect to mental health matters. They are also thepeople whom those with psychiatric disabilities will encounter at their most vulnerable

Correspondence to: Otto Wahl, Department of Psychology, University of Hartford, 200 Bloomfield Ave.,West Hartford, CT 06117. E-mail: [email protected]

JOURNAL OF COMMUNITY PSYCHOLOGY, Vol. 38, No. 1, 49–62 (2010)

Published online in Wiley InterScience (www.interscience.wiley.com).

& 2009 Wiley Periodicals, Inc. DOI: 10.1002/jcop.20351

points and on whom they will rely for understanding and assistance. How people withmental illness are viewed by these caregivers can have significant impact on thetreatment outcomes and quality of life experienced by those with mental illness.In addition, many mental health professionals are also educators whose attitudes andbehaviors inform and influence future caregivers (Gray, 2002; Sartorius, 2002).

Nevertheless, as pointed out by Schulze (2007), the attitudes of mental healthcaregivers have not been given the same attention that public attitudes have had. Theassumption may be that the attitudes of such caregivers, who have dedicated themselvesto the care of those with mental health problems, are positive and exemplary. However,this notion has not been consistently supported by research. Schulze (2007) looked atseveral aspects of the relationship between stigma and mental health professionals, oneaspect of which was the attitudes of mental health caregivers toward the people theyserve. Based on 10 studies published between 1997 and 2006, Schulze (2007) concludedthat these studies yielded an ‘‘inconsistent picture’’ of professional attitudes. Somestudies indicated positive views whereas others found less positive, even negative, views.Schulze (2007) noted, in fact, that ‘‘nearly three quarters of the relevant publicationsreport that beliefs of mental healthcare providers do not differ from those of thepopulation, or are even more negative’’ (p. 142). In addition, the reports of people withpsychiatric disorders and their families often include instances of disrespectfultreatment and negative attitudes expressed by the mental health caregivers theyencounter (Corrigan, 2005; Wahl, 1999a,b). Findings such as these have led researchersand advocates to suggest that the behavior and attitudes of mental health professionalsmay be strong contributors to the continuing discrimination and stigma with whichpeople with mental illness are burdened (e.g., Sartorius, 2002).

It is important, then, that we have an understanding of how mental healthprofessionals view those with psychiatric disorders. In this review we attempt to buildon Schulze’s (2007) report by focusing more exclusively on attitudes toward those withpsychiatric disorders, adding studies not included in her review, and providing moredetailed information about the findings and the methodologies used in the research.In addition, we will focus on work that has appeared within the past 5 years (i.e., since2004). The reason for this restriction is that there has been increased attention toissues of stigma and discrimination within the past 5–10 years and this may haveinfluenced or modified caregiver attitudes such that studies beyond 5 years will notaccurately reflect current views of mental health professionals. We will also look atresults for only the major mental health professions—psychiatrists, psychologists, andpsychiatric nurses. It was decided to maintain a focus on current practitioners and tonot include students in training, as students will not yet have completed their trainingor begun practice, and one might expect that their views are still being formed. Wealso do not include studies of the attitudes of general practitioners, and, again, focus onthe views of those who have specifically chosen to work with those with psychiatricdisorders. Finally, we will try to identify gaps in the current literature and establish aresearch agenda for furthering our understanding of caregiver attitudes.

METHOD

Published articles related to the attitudes of mental health caregivers were identifiedthrough an electronic search of the following databases: PsychInfo, Proquest, andPubMed. Search terms used included the following: mental health professionals and

50 � Journal of Community Psychology, January 2010

Journal of Community Psychology DOI: 10.1002/jcop

stigma, mental health professionals and beliefs, professionals and stigma, psychiatryand stigma, psychiatrists and stigma, mental health professionals and attitudes, mentalillness and beliefs, mental health and professionals, mental illness and stigma, andstigma. In addition, reference lists from articles identified via these searches were usedto find other relevant articles that may have been missed. We selected for review onlyarticles that involved empirical assessments, not opinions or observations, and, as notedabove, articles published in 2004 or later. In addition, we limited our consideration tostudies of general attitudes and excluded ones that focused on opinions about specificaspects of treatment, such as involuntary admission or use of antipsychotic medications.Altogether, 19 articles were identified that fit the above criteria.

EVIDENCE OF POSITIVE ATTITUDES OF MENTAL HEALTHPROFESSIONALS

Numerous studies provided evidence that mental health professionals have overallpositive attitudes towards those with whom they work or, at least, attitudes that aremore positive than those of the general population. Kingdon, Sharma, and Hart(2004), for example, asked psychiatrists in the United Kingdom their opinions aboutschizophrenia. The researchers mailed questionnaires to all 6,524 members of theRoyal College of Psychiatrists and received responses from 2,813 of these. Thequestionnaire used items from the Community Attitudes to Mental Illness Scale(CAMI; Taylor & Dear, 1981) and from a survey used previously by the Office forNational Statistics (ONS; Crisp et al., 2000). Overall, the respondents from the RoyalCollege showed positive attitudes towards people with mental illness. The majorityagreed that ‘‘people with mental illness are far less of a danger than most peoplesuppose’’ (95%) and disagreed that ‘‘one of the main causes of mental illness is a lack ofself-discipline and willpower’’ (98%). Moreover, when respondent results werecompared with responses from a previous survey of the general public, they indicatedthat the Royal College respondents tended to be more positive on most items thanwere members of the public. For example, psychiatrists held the above views morestrongly than did the public, only 66% of whom disagreed that mental illness wascaused by lack of willpower and only 64% of whom agreed that people with mentalillnesses are less of a danger than believed. In addition, psychiatrists were far less likelyto think of someone with schizophrenia as being dangerous (5% compared to 66.3% ofthe public) or unpredictable (40% vs. 77% for the public). Kingdon et al. concludedthat, in comparison with the public, psychiatrists hold nonstigmatizing views and feelmore optimistic about people with schizophrenia.

Lauber, Anthony, Ajdacic-Gross, and Rossler (2004) gathered information from 90psychiatrists in office practice in the German-speaking part of Switzerland by means ofcomputer-assisted telephone interviewing. Each participant was asked to respond tothe Taylor and Dear (1981) Inventory of Community Mental Health Ideology (Taylor& Dear, 1981), which involves questions relating to the expected impact andacceptance of mental health facilities in residential neighborhoods. The survey itemswere also completed by a representative sample of 786 community residents in thesame area. Both psychiatrists and the general public were found to have overallstrongly positive attitudes toward the inclusion of mental health facilities in thecommunity, but psychiatrists were more positive in their views. For example,psychiatrists disagreed more strongly with the statement that ‘‘mental health facilities

Professionals’ Attitudes Toward Mental Illness � 51


should be kept out of residential neighborhoods’’ and with the assertion that ‘‘locatingmental health services in residential neighborhoods does endanger local residents.’’

Nordt, Rossler, and Lauber (2006) surveyed 1,073 mental health professionalsfrom 29 inpatient and outpatient facilities in the same area of Switzerland andcompared their responses to those of 1,737 members of the lay public. The professionalsample included 204 psychiatrists, 67 psychologists, 684 nurses, and 118 othertherapists. Data were collected via a computer-assisted telephone interview. Mentalhealth professionals, including the psychiatrists, were less likely to favor socialrestrictions than the general public, with the exception of compulsory admission.Sixty-six percent of the lay respondents favored revocation of the driver’s licenses ofpeople with severe mental illness, as opposed to only 29% of psychiatrist, 16% ofpsychologists, 34% of other therapists, and 46% of nurses. Twenty-nine percent of thepublic sample would recommend an abortion to a woman who had previously sufferedfrom a severe mental illness, as opposed to only 5–10% of the mental healthprofessionals. Only 1.5–5% of mental health professionals disapproved of the right tovote and run for office for someone who had experienced a serious mental illness,in contrast with 20% of the public. Nordt et al. (2006) also presented their respondentswith vignettes—of a person with depression, a person with schizophrenia, and a personwithout psychiatric symptoms—and asked them to complete a 7-item social distancerating. Nordt et al. reported that both professionals and the public tended to beaccepting toward the person with depression, with mental health professionals ratingthe depressed person no differently than they did the person without symptoms.

Magliano et al. (2004a) compared the beliefs of 465 mental health professionals, 709relatives of people with schizophrenia, and 714 lay respondents in Italy. Mental healthprofessionals came from 30 randomly selected mental health services in different areas ofItaly and included psychiatrists, psychologists, nurses, sociologists, occupationaltherapists, social workers, and auxiliary and administrative personnel. The mentalhealth professionals were asked to read a case vignette of a person with schizophreniaand complete a 34-item Questionnaire on the Opinions About Mental Illness–Profes-sional Version (QO-P; Magliano et al., 1999). The self-report questionnaire containsstatements related to causes of schizophrenia, effectiveness of available treatments, andthe rights of individuals with schizophrenia. Members of the lay public were given thevignette and asked to fill out a similar questionnaire. Relatives were asked to fill out afamily form of the questionnaire based on their experiences with their family member. Ofparticular interest for this review were the expressed beliefs about social functioning,recovery potential, and social and civil rights.

Mental health professionals were significantly more optimistic about recovery thanfamily members. Eighty-nine percent of the mental health professionals indicated thatthe statement, ‘‘People can recover from this disorder,’’ was partly or completely true(as opposed to only 60% of relatives). Seventy-nine percent of mental healthprofessionals indicated that it was completely or partly true that ‘‘patients with thisdisorder are as able to work as other people,’’ whereas only 56% of relatives indicatedthis. Mental health professionals were also more likely than relatives or the generalpublic to rate as ‘‘not true’’ the statement, ‘‘There is little to be done for these patients,apart from helping them to live in a peaceful environment’’ (60%, in contrast to 31% ofthe public and 19% of relatives).

In a separate article, Magliano et al. (2004b) looked separately at the beliefs of thepsychiatrists (110) and the psychiatric nurses (190) in their sample. Both professionalgroups seemed to have greater optimism about recovery than did patient relatives.



Most mental health professionals (77% of nurses and 79% of psychiatrists) rated thestatement, ‘‘Patients with this disorder are as able to work as other people,’’ ascompletely or partially true, as compared to only 56% of relatives. Most (71% of nursesand 83% of psychiatrists) indicated that it was completely or partially true that‘‘a woman who previously suffered from this disorder and has recovered could work asa babysitter,’’ whereas only 55% of relatives saw that as a possibility. Psychiatristsappeared to be more supportive of patient rights than either nurses or familymembers. Fifty-seven percent of psychiatrists disagreed that ‘‘patients with thisdisorder should not get married,’’ as opposed to only 37% of nurses and 29% ofrelatives. Similarly, 45% of psychiatrists believed it was not true that ‘‘patients with thisdisorder should not have children,’’ as contrasted with 29% of relatives or nurses whodisagreed with this. Eighty-three percent of psychiatrists indicated it was untrue that‘‘people with this disorder should not vote’’; 66% of nurses and 68% of relativesindicated disagreement with that idea.

A number of other studies have found positive attitudes among psychiatric nurses.Tay, Pariyasami, Ravindran, Ali, and Rowsudeen (2004) administered the 24-itemAttitudes Toward Mental Illness Questionnaire (Weller & Grunes, 1988) to 409 nursesworking in a psychiatric hospital in Singapore. They reported overall positive attitudesfor these nurses, with the most positive attitudes shown by nurses with advanceddiplomas or training and more years of experience. Responses to individual itemswere not reported. Munro and Baker (2007) administered the Attitudes TowardsAcute Mental Health (ATAMH) Scale (Baker, Richards, & Campbell, 2005) to 140nurses working in acute care mental health units in the United Kingdom. The ATAMHinvolves 25 Likert-scored questions (7-point scale) and eight semantic differentialchoices about ‘‘the mentally ill.’’ The authors reported generally high levels of positiveattitudes. A large majority of nurses disagreed with statements such as, ‘‘Depressionoccurs in people with a weak personality’’ (90%); ‘‘Those with a psychiatric historyshould never be given a job with responsibility’’ (91%); ‘‘Psychiatric patients aredifficult to like’’ (86%); and ‘‘Violence mostly results from mental illness’’ (85%). Ishigeand Hayashi (2005) assessed the attitudes of psychiatric and public health nurses inJapan and compared them with the attitudes of those in other occupations—localwelfare commissioners, probation officers, nonpsychiatric care workers, and noncareworkers. On the basis of responses to 20 semantic differential items, the authorsdeveloped an evaluation scale to reflect the affective aspect of attitudes toward peoplewith schizophrenia. Seven hundred eighty-six individuals completed the measure; 261were psychiatric nurses and 83 public health nurses. Psychiatric nurses worked ininpatient psychiatric settings; public health nurses worked with psychiatric patients incommunity health centers. Ishige and Hayashi found that psychiatric and publichealth nurses were significantly more favorable in their affective (semantic differential)appraisals than were workers in other occupations. No breakdown was provided forspecific items, however.

Chin and Balon (2006) compared the attitudes toward depression andschizophrenia of 38 psychiatry residents at a U.S. School of Medicine with thoseof 29 residents in other specialties, using the Attribution Questionnaire-Short Form(AQ-SF; Corrigan et al., 2000). This questionnaire asks questions about nine kinds ofreactions to mental illness—blame, anger, pity, help, dangerousness, fear, avoidance,segregation, and coercion. Chin and Balon reported that the psychiatry residents hada significantly lower AQ-SF score than did the other residents for both schizophreniaand depression, indicating more accepting attitudes toward psychiatric disorders. The



authors, however, did not provide mean scores or descriptions of responses to specificitems.

Grausgruber, Meise, Katschnig, Schony, and Fleischhacker (2007) receivedresponses from a mailed questionnaire from 460 nonphysician staff members frommental healthcare institutions in Austria. These staff members included psychiatricnurses, social workers, psychologists, physiotherapists, and occupational therapists.Respondents were given case vignettes of persons with schizophrenia and askedquestions about perceived dangerousness, expected success of treatment, andpreferences for social distance. The responses of staff were compared with responses,obtained by interviews, from 1,042 members of the general public and 137 relatives ofpersons with mental illnesses. Staff members were found to have more optimistic viewsof schizophrenia treatment than the lay population, agreeing that schizophrenia is atreatable condition nearly twice as often (69% vs. 37%). Mental health staff memberswere also much less likely than the public to see people with schizophrenia as ‘‘moredangerous than healthy people’’ (28.4% vs. 55%) and more willing to accept a personwith schizophrenia as an employee (52.6% vs. 35%), as a family member (45% vs. 32%),and as a superior (30% vs. 20%). The opinions of relatives tended to fall in betweenthose of the lay and staff groups.

Peris, Teachman, and Nosek (2008) used measures of explicit and implicit stigma tocompare several groups of study participants—undergraduate students (n 5 204), thegeneral public (112), health/social services workers (541), and a ‘‘mental health’’ groupconsisting of both professional clinicians (407) and clinical psychology graduate students(275). The explicit stigma measure involved semantic differential ratings of a person withmental illness for the paired adjectives bad/good, helpless/competent, and blameworthy/innocent. The measure of implicit stigma was the Implicit Association Test (Greenwald,McGhee, & Schwartz, 1998), which looks at how easily respondents can associate positiveor negative descriptors with items related to a key concept, in this case people withmental illness. Peris et al. reported that the mental health group was more positive thanthe general public and other health service providers for both the good–bad andhelpless–competent items, but there were no group differences on the blameworthy–in-nocent item. They also found that explicit stigma did not differ as a function of specificprofessional role (psychologist, counselor, social worker) or with indicators of experience(e.g., student vs. professional, licensed or not). Specific scores on the three semanticdifferential items were not provided, however. Peris et al. also found that the mentalhealth group had more implicit positive attitudes toward people with mental illnessesthan did any of the other groups. Within the mental health group, graduate studentsreportedly had more positive associations with mental illness than did professionals.Within the professional group, clinical psychologists were found to be more positive thanwere counselors, social workers, or other mental health professionals.

Des Courtis, Lauber, Costa, and Cattapan–Ludewig (2008) distributed aquestionnaire to ward staff at a public hospital in southern Brazil. Approximatelyone fourth of the 99 participants (28.3%) were psychiatrists and psychologists; the rest(71.7%) were nurses or other therapists. The questionnaire included items aboutcommunity placement of people with mental illnesses and willingness to interact insocial situations with a person (with depression) described in an accompanyingvignette. The mental health professionals showed positive opinions about theplacement of people with mental illness in the community, disagreeing withsuggestions that residential facilities downgrade the neighborhood or endanger localresidents. Brazilian health care professionals were very willing to move next door to a



person like the one in the vignette (M 5 4.59 on a 5-point scale). They were also willingto work with the person (3.84), make friends with (3.96), and rent a room to (3.35)such a person , but they tended to express unwillingness (2.93) to recommend theperson for a job. Results from the questionnaire were compared with results fromsimilar questions asked in Switzerland in previous studies (Lauber, Nordt,Braunscheig, & Rossler, 2006; Nordt, Rossler, & Lauber, 2006). Brazilian mentalhealth professionals were found to have more positive attitudes than Swiss caregiversabout community treatment and to show less need for social distance.

Bjorkman, Angelman, and Jonsson (2008) conducted a questionnaire study ofattitudes toward people with mental illness among nurses at a university hospital inSweden. Using the Attitudes to Persons with Mental Illness Questionnaire, theycompared the attitudes of nurses in a psychiatric clinic (51) with those at a somaticclinic (69) about seven different forms of mental illness. Nursing staff in psychiatriccare units were found to have more positive attitudes than those providing somaticcare, with most of the differences between the groups found in their reactions topatients with schizophrenia or drug addiction. Psychiatric care nurses, for example,were less likely to see individuals with schizophrenia or drug addiction as dangerous,unpredictable, and hard to talk to than were somatic care nurses. Moreover, negativecorrelations were reported between amount of professional experience and percep-tions of people with schizophrenia as dangerous and unpredictable.

Vibha, Saddichha, and Kumar (2008) administered the Community AttitudesToward Mental Illness Scale (CAMI) to 100 attendants on a psychiatric ward in EasternIndia. Attendant responses were compared with those of 100 guardians of patientsadmitted to the psychiatric institution. Both groups tended to express overall positiveviews, but psychiatric ward attendants had more positive attitudes than did theguardians. In particular, the ward attendants expressed less support for socialrestrictions and more support for community care than did home carers. With respectto specific items, more attendants (93%) than guardians (77%) endorsed the statement,‘‘Residents have nothing to fear from people coming into their neighborhoods toobtain mental health services.’’ Similarly, more attendants (95%) than guardians (64%)disagreed with the statement, ‘‘It is best to avoid anyone who has a mental problem.’’

EVIDENCE OF NEGATIVE ATTITUDES OF MENTAL HEALTHPROFESSIONALS

Several studies found less favorable, or even negative, attitudes among mental healthprofessionals. Lauber et al. (2006) asked their sample of 1,073 Swiss mental healthprofessionals to rate on a 5-point Likert scale, how much people with mental illnessdiffer from the general public with respect to a list of positive and negative traits (e.g.,unreliable, clever, stupid, creative). Overall, mental health professionals rated allnegative descriptors (except ‘‘stupid’’) as more characteristic of people with mentalillness. Among the negative descriptors seen as applicable to persons with mentalillness were unpredictable, bedraggled, weird, threatening, and dangerous. Mentalhealth professionals also rated all positive descriptors (except ‘‘creative’’ and ‘‘highlyskilled’’) as less characteristic of people with psychiatric disorders. Lauber et al.reported further that psychiatrists showed more negative attitudes than otherprofessionals, rating persons with mental illness as more dangerous, less skilled, andmore socially disturbing than did psychologists, nurses, or other therapists.



Deans and Meocivic (2006) asked 65 registered psychiatric nurses in Australia tocomplete a 50-item questionnaire concerning their reactions to people diagnosed withborderline personality disorder (BPD). A majority of the respondents indicated thatthey considered BPD patients to be manipulative (88%) and engaging in ‘‘emotionalblackmail’’ (51%). More than one in three (38%) saw them as ‘‘nuisances,’’ with 32%indicating that BPD patients made them angry. Relatively few nurses felt that patientswith BPD were fascinating (21%), charming (13%), or fun to work with (11%). A studyof 65 psychiatric nurses in Ireland by James and Cowman (2007) produced similarresults. Three quarters (75%) agreed that they found clients with BPD very ormoderately difficult to look after and 80% agreed that BPD clients are more difficultthan other clients. On the other hand, the nurses tended to believe that BPD clientscould be treated successfully and that nurses had an appropriate role in that treatment.

Servais and Saunders (2007) mailed questionnaires to 1,000 randomly selectedclinical psychologists from the Directory of the American Psychological Association andreceived usable responses from 306 of these psychologists. Respondents were asked torate specific categories of people on 7-point semantic differential scales with respect tosix bipolar characteristics (e.g., safe–dangerous). The categories included ‘‘yourself,’’a member of the public, and three clinical targets (a person with moderate depression,a person with borderline features, and a person with schizophrenia). Persons withschizophrenia and persons with borderline features fared least well in psychologists’ratings. Both groups were rated as ineffective, undesirable (to be with), and dissimilarto the rater. Both were rated significantly lower on these categories than a member ofthe general public. Persons with schizophrenia were rated as the most ineffective, with60% of respondents giving a 6 or 7 (on the 7-point scale). Those with schizophreniawere also rated as the most dissimilar to the rater, with extreme scores given by 69% ofthe respondents. In addition, persons with schizophrenia were given the most extremeratings as ‘‘undesirable’’ by 34% of respondents and as ‘‘dangerous’’ by 12%. Personswith borderline features received the highest ratings on dangerousness, with 22% ofrespondents giving them a 6 or 7, and on undesirability, with extreme scores from 42%of the psychologists. Findings were mixed with respect to a person with moderatedepression. The person with depression was rated as less desirable than a member ofthe public, but more understandable and safer.

Negative appraisals of the ability of individuals with schizophrenia to participate ina collaborative therapeutic relationship were implicit in findings by Ucok, Polat,Sartorius, Erkoc, and Atakli (2004). Ucok et al. obtained responses from 60psychiatrists who were members of the schizophrenia section of the PsychiatricAssociation of Turkey to a mail survey concerning attitudes and practices related topatients with schizophrenia. The survey contained 12 simple questions, one of whichwas, ‘‘Do you inform your patients of their diagnoses?’’ Nearly half (42.7%) of thepsychiatrists indicated that they never informed patients of their schizophreniadiagnosis. Another 41.7% reported that they inform patients only on a case-by-casebasis. Together, these data indicate that the vast majority of psychiatrists participatingin the study—over 80%—do not routinely share their diagnoses with theirschizophrenia patients. In contrast, almost all (85%) indicated they would informpatients of their diagnosis of depression. The most common reason given for thepractice of not revealing diagnosis was the belief that people with schizophrenia wouldnot understand the meaning of the diagnostic label (32.6%).

Ucok et al. also asked questions related to encounters with people withschizophrenia outside the treatment setting. According to the researchers, 43% of



the psychiatrists reported that they would not visit a patient with schizophrenia at hisor her home and 55.2% indicated they would feel discomfort if they ran into one oftheir schizophrenia patients at a social event. It is unclear, however, whether theselatter results represent feelings about interactions with people with schizophrenia orfeelings about maintaining professional boundaries with someone who is one’s patient.

In addition, many of the studies revealing overall positive attitudes neverthelessfound evidence of negative views among substantial numbers of the participatingmental health professionals. For example, despite overall positive attitudes, only aboutone quarter of the Royal College participants (26%) indicated a belief that a personwith schizophrenia could recover fully (Kingdon et al., 2004). One in 8 did not agreethat ‘‘residents need not fear people receiving mental health services in theirneighborhoods’’ and one in 10 agreed that ‘‘there is something about people withmental illness that makes it easy to tell them from normal people.’’ Within the generalpositive attitudes of U.K. acute care nurses in Munro and Baker’s (2007) study was asemantic differential rating indicating pessimism about recovery. Psychiatric nurses inSweden (Bjorkman et al., 2008) had more favorable attitudes than somatic care nurses,but still tended to rate people with schizophrenia as unpredictable (3.5 on a 5-pointscale), hard to talk to (3.1), unusual (4.5), and unlikely to recover (3.2). Mental healthcaregivers in Grausgurber et al.’s (2007) Austrian study were significantly morepositive than the general public in their views about schizophrenia. However, 31% ofthe staff sample expressed doubts about the success of treatment for individuals withschizophrenia and almost a third (28%) indicated such individuals were dangerous.Ward attendants in Vibha et al.’s study in India had mostly favorable attitudes, but theyalso strongly endorsed (90%) the disempowering statement, ‘‘Mental patients need thesame kind of control and discipline as a young child.’’

Despite many favorable attitudes in Magliano et al.’s (2004a) sample of Italianmental health professionals, there was support for a variety of social restrictions forpeople with schizophrenia. The majority of professionals (54%) agreed that ‘‘peoplewith this disorder should not get married.’’ Sixty-four percent agreed that ‘‘peoplewith this disorder should not have children.’’ More than one in four (27%) felt that‘‘patients with this disorder should not vote.’’ Forty-three percent of psychiatrists and63% of nurses believed that schizophrenia patients should not get married, and themajority of both nurses (72%) and psychiatrists (55%) agreed that such patients shouldnot have children. One in five nurses (21%) and psychiatrists (23%) rated as ‘‘not true’’the statement asserting that people with schizophrenia are as able to work as others.Twenty-nine percent of nurses and 16% of psychiatrists felt it was ‘‘not true’’ that awoman with schizophrenia could recover sufficiently to be trusted as a babysitter.

Despite Nordt et al.’s (2006) findings of less restrictive attitudes of Swiss mentalhealth professionals compared to the lay public, negative attitudes were also revealed.Nordt et al. asked questions about specific traits respondents associated with mentalillnesses and combined the responses to form a negative stereotype scale. They thencompared the results across five groups—psychiatrists, psychologists, nurses, othertherapists, and the general population. All groups fell on the negative side of themidpoint on the stereotype scale, with psychiatrists showing significantly morenegative stereotypes than any of the other groups.

Negative attitudes were particularly apparent in measures of social distance, evenwhen other attitudes were positive. Social distance measures ask respondents toindicate their willingness to interact with the person from the vignette in a variety ofsocial situations. Lauber et al. (2004) asked the psychiatrists in their study to read a



vignette depicting a person with schizophrenia and then complete a social distancequestionnaire. Swiss psychiatrists did not differ from the general public in their desirefor social distance from the person with schizophrenia. In both groups, the level ofsocial distance increased as the intimacy of the social situation increased, with bothpsychiatrists and community residents indicating reluctance to recommend the personin the vignette for a job, rent a room to him, or have that person marry their child.

Ishige and Hayashi (2005) also had their participants fill out a social distancequestionnaire indicating their preferences for social interaction with people withschizophrenia. Public health nurses showed lower preference for social distance thanother groups, but psychiatric nurses did not differ from the other groups, all of whichtended to have scores indicating rejection of social contact with a person withschizophrenia. Although Nordt et al. (2006) reported accepting attitudes for a personwith depression, they also found that all groups of mental health professionals, similarto the public, indicated a greater desire for social distance from a person withschizophrenia than from a person with depression or with no symptoms. WithinGrausgruber et al.’s (2007) Austrian sample, barely half (53%) expressed willingness toengage an individual with schizophrenia as an employee. A large majority of staffindicated reluctance to accept a person with schizophrenia as a superior (70%) or in acaretaking role with their children (81%). Approximately one in five (19%) RoyalCollege psychiatrists either agreed or were uncertain that they ‘‘would not want to livenext door to someone who has been mentally ill’’ (Kingdon et al., 2004).

OVERVIEW AND IMPLICATIONS

There is some support from the above studies for the existence of positive attitudestoward mental illnesses among psychiatric professionals. Fourteen of the 19 studiesreviewed found the overall attitudes of mental health professionals to be both positivein an absolute sense and more positive in comparison to public views, whereas only fiveshowed predominantly negative attitudes. However, as noted, negative attitudes werepresent even in those studies with overall positive results. Many mental healthprofessionals appeared to share the public belief that people with serious mentalillnesses are dangerous. Many doubted the possibility of recovery and espoused viewsthat people with serious mental illness should not marry or have children. Negativeattitudes were particularly apparent for social distance measures. Even when mentalhealth professionals made statements indicating optimistic and understanding views ofmental illnesses, they tended to be similar to the public in being reluctant to acceptthose with psychiatric disorders within their social and occupational circles.

It may be more appropriate, then, to conclude that results are mixed with respectto the nature of professional attitudes toward people with mental illnesses. This is thesame conclusion reached by Schulze in her 2007 review. Given that there is significantoverlap in the studies included in this review and the earlier one (8 of the 19 studies),this similar conclusion is not surprising. It is noteworthy, however, that the pattern ofmixed results is also apparent in the 11 studies not included in Schulze’s review.A mixture of positive and negative views continues to be found for mental healthprofessionals.

The failure to find consistent positive results for the attitudes of mental healthprofessionals and the substantial number of mental health professionals expressingnegative views is troubling and challenges assumptions that mental health profes-



sionals are models of positive attitudes. It also underscores concerns about thepotential impact of professional attitudes on patient care. It is easy to see how thenegative views expressed by many professionals may perpetuate stigma and interferewith practitioners’ ability to respond helpfully to their patients’ needs or to establishsuccessful therapeutic relationships. It is easy to see how those negative attitudes mayprovide models for continued public negativity related to mental illness. The findingsof this review point to the need for mental health professionals to pay increasedattention to their own attitudes and behaviors with respect to the people they serve.The persistence of inconsistent or negative attitudes among mental health profes-sionals also seems to call for greater attention to the training mental health caregiversreceive. We may need to take a careful look at possible ways the current training offuture mental health professionals may create or reinforce negative attitudes and atstrategies within training that might help to generate greater acceptance andunderstanding. At the very least, we may need to include more discussion of attitudesabout mental illnesses within our training programs.

Implications for Future Research

One of the first things that may be apparent from this review is the relatively smallnumber of studies exploring the attitudes of mental health professionals. Only 19published studies were found that empirically assessed the attitudes of mental healthprofessionals between 2004 and the present. For a topic as important to the treatmentand recovery of people with psychiatric disorders, this is a very small number. Theattitude of mental health professionals toward those they treat remains a neglectedtopic. Increased research in this area is important not only to help understand—andimprove—the attitudes faced by people with mental disorders within the mental healthsystem, but it is also important as a response to criticism that mental healthprofessionals have not yet demonstrated a willingness to look critically at their ownprofessions and their own potential contributions to stigma and discrimination.

The available studies come from 13 different countries. It is likely that differentcountries have different philosophies, different cultural beliefs, and different types oftraining that may influence attitudes toward psychiatric disorders. The limited cross-country comparison in the reviewed studies gives support to the idea that suchdifferences exist (Des Courtis, Lauber, Costa, & Cattapan-Ludewig, 2008). Moreover,the variety of countries and settings in which the research has been conducted may bea contributor to the mixed results obtained. Conclusions about prevailing attitudes inany one country will need a greater number of studies from each country thancurrently exist. For example, the three studies that employed U.S. samples are hardlysufficient to draw firm conclusions about the attitudes of U.S. practitioners.

Different professional groups likewise may have different training, differentexperiences, and different philosophies of treatment that affect their attitudes. Again,several of the studies reviewed support the existence of differences betweenpsychologists, psychiatrists, psychiatric nurses, and other caregivers (Magliano et al.,2004b; Nordt et al., 2006; Peris et al., 2008). Some studies also found differencesrelated to different levels of training or experience within the same fields (Ishige &Hayashi, 2005; Tay et al., 2004). Generalizations about the attitudes of mental healthprofessionals as a group may be as elusive and inaccurate as generalizations about anyvaried group. More studies of specific professional groups and/or ones that breakdown results from mental health professionals into specific professional groups



are needed. With respect to knowledge about specific professional groups, nursesseem to be relatively well-represented among the studies reviewed; psychiatrists andpsychologists are more rarely included. This is an important limitation in that theselatter two sets of professionals are likely to be in positions to make important executivedecisions about people with mental illnesses and to act as authoritative role models forpublic opinion.

The majority of research inquiries into mental health professional attitudes havefocused on severe mental illnesses, schizophrenia, in particular. This is understandablein that such disorders are known to receive the least public acceptance and to be themost challenging for mental health professionals. However, as is apparent in thestudies that have included other disorders (e.g., Bjorkman et al., 2008; Nordt et al.,2006; Servais & Saunders, 2007), there are very likely differences in attitudes towarddifferent disorders. Attitudes about schizophrenia and borderline personality disorderwould appear to be considerably less accepting than those toward depression, forexample. It would be of benefit to inquire about specific disorders and to begin togenerate a more differentiated understanding of attitudes toward those specificpsychiatric disorders, among both mental health professionals and the general public.In addition, some common disorders (e.g., anxiety disorders, bipolar disorder) areabsent altogether from the studies reviewed. More specific inquiry about professionalattitudes toward these disorders is needed.

It is apparent also that the reviewed studies involve a wide variety of methods andinstruments. Data collection involved Likert-format questionnaires, semantic differ-ential ratings, interviews, response to vignettes, social distance ratings, and experi-mental measures of implicit attitudes. On the one hand, this variety of measures andmethods is valuable in that it approaches the complex question of attitudes from manyvantage points. On the other hand, it limits direct comparison of results and probablyalso contributes to the mixed results obtained. The lack of an accepted, widely used,instrument—a gold standard of sorts—is common in research on attitudes, as noted byLink, Yang, Phelan, and Collins (2004) in their review of stigma measures. The closestto such a standard may be the Social Distance Measure. This measure was not only themost frequently used instrument in the studies above (in six of the studies), but it alsoseemed capable of revealing negative attitudes even when other self-report measuresdid not.

Finally, there were numerous types of related studies that were not considered inthis review, but are nevertheless important to consider. Physicians and nurses ingeneral practice were not included. Yet these are professionals who come into frequentcontact with and provide services for people with psychiatric disorders. Theirattitudes, particularly those of general practice physicians who may be the first contactfor many people with psychiatric disorders, are important to understand as well. Theidentification of research for the current review revealed numerous studies that lookedat the views of general practice physicians and nurses, and those warrant review andsummary also. In addition, there are many studies that have looked at the views ofstudents in training for psychiatric work and at the impact of training on attitudes. Asnoted above, it is important to understand what is being done in training and howattitudes are being shaped among future practitioners. Studies of students before andafter training may provide insight into how different aspects of training lead to theattitudes—positive and negative—that were found in the current review. Moreimportant, they may give us ideas of how training may be improved to generate amore consistently positive attitude among mental health care professionals.



REFERENCES

Baker, J.A., Richards, D., & Campbell, M. (2005). Nursing attitudes towards acute mental healthcare: Development of a measurement tool. Journal of Advanced Nursing, 49, 522–529.

Bjorkman, T., Angelman, T., & Jonsson, M. (2008). Attitudes towards people with mental illness:a cross-sectional study among nursing staff in psychiatric and somatic care. ScandinavianJournal of Caring Science, 22, 170–177.

Chaplin, R. (2000). Psychiatrists can cause stigma too. British Journal of Psychiatry, 177, 467.

Chin, S.H., & Balon, R. (2006). Attitudes and perceptions toward depression and schizophreniaamong residents in different medical specialties. Academic Psychiatry, 30, 262–263.

Corrigan, P. (1998). The impact of stigma on severe mental illness. Cognitive and BehavioralPractice, 5, 201–222.

Corrigan, P.W. (Ed.). (2005). On the stigma of mental illness. Washington, DC: AmericanPsychological Association.

Corrigan, P.W., River, L.P., Lundin, R.K., et al., (2000). Stigmatizing attributions about mentalillness. Journal of Community Psychology, 28, 91–102.

Crisp, A.H., Gelder, M.G., Rix, S., Meltzer, H.I., & Rowlands, O.J. (2000). Stigmatisation ofpeople with mental illness. British Journal of Psychiatry, 177, 4–7.

Deans, C., & Meocivic, E. (2006). Attitudes of registered psychiatric nurses towards patientsdiagnosed with borderline personality disorder. Contemporary Nurse, 21, 43–49.

Des Courtis, N., Lauber, C., Costa, C.T., & Cattapan-Ludewig, K. (2008). Beliefs about thementally ill: A comparative study between healthcare professionals in Brazil and inSwitzerland. International Review of Psychiatry, 20, 503–509.

Farina, A., & Felner, R.D. (1973). Employment interviewer reactions to former mental patients.Journal of Abnormal Psychology; 82, 268–272.

Fink, P.J., & Tasman, A. (1992). Stigma and mental illness. Washington, DC: AmericanPsychiatric Press.

Grausgruber, A., Meise, U., Katschnig, H., Schony, W., & Fleischhacker, W.W. (2007). Patterns ofsocial distance towards people suffering from schizophrenia in Austria: A comparisonbetween the general public, relatives, and mental health staff. Acta Psychiatrica Scandinavia,115, 310–319.

Gray, A.J. (2002). Stigma in psychiatry. Journal of the Royal Society of Medicine, 95, 72–76.

Greenwald, A.G., McGhee, D.E., & Schwartz, J.L.K. (1998). Measuring individual differences inimplicit cognition: The implicit association test. Journal of Personality and Social Psychology,74, 1463–1480.

Ishige, N., & Hayashi, N. (2005). Occupation and social experience: Factors influencing attitudetowards people with schizophrenia. Psychiatry and Clinical Neurosciences, 59, 89–95.

James, P.D., & Cowman, S. (2007). Psychiatric nurses’ knowledge, experience, and attitudestowards clients with borderline personality disorder. Journal of Psychiatric and MentalHealth Nursing, 14, 670–678.

Kingdon, D., Sharma, T., & Hart, D. (2004). What attitudes do psychiatrists hold towards peoplewith mental illness? Psychiatric Bulletin, 28, 401–406.

Lauber, C., Anthony, M., Ajdacic-Gross, V., & Rossler, W. (2004). What about psychiatrists’attitude to mentally ill people? European Psychiatry, 19, 423–427.

Lauber, C., Nordt, C., Braunscheig, C., & Rossler, W. (2006). Do mental health professionalsstigmatize their patients? Acta Psychiatrica Scandanavia, 113, 51–59.

Link, B.G., Phelan, J.C., Bresnahan, J.C., Stueve, A., & Pescosolido, B.A. (1999). Publicconceptions of mental illness: Labels, causes, dangerousness, and social distance. AmericanJournal of Public Health, 89, 1328–1333.



Link, B.G., Yang, L.H., Phelan, J.C., & Collins, P.Y. (2004). Measuring mental illness stigma.Schizophrenia Bulletin, 30, 511–541.

Magliano, L., Fiorillo, A., De Rosa, C., Malangone, C., & Maj, M. (2004a). Beliefs aboutschizophrenia in Italy: A comparative nationwide survey of the general public,mental health professionals, and patients’ relatives. Canadian Journal of Psychiatry, 49,322–330.

Magliano, L., De Rosa, C., Fiorillo, A., Malangone, C., Guarneri, M., Marasco, C., et al. (2004b).Beliefs of psychiatric nurses about schizophrenia: A comparison with patients’ relatives andpsychiatrists. International Journal of Social Psychiatry, 50, 319–330.

Magliano, L., Marasco, C., Guarneri, M., Malangone, C., Lacrimini, G., Zanus, P., et al. (1999). Anew questionnaire assessing the opinions of the relatives of patients with schizophrenia onthe causes and social consequences of the disorder: Reliability and validity. EuropeanPsychiatry, 41, 71–75.

Munro, S., & Baker, J.A. (2007). Surveying the attitudes of acute mental health nurses. Journalof Psychiatric and Mental Health Nursing, 14, 196–202.

Nordt, C., Rossler, W., & Lauber, C. (2006). Attitudes of mental health professionals towardpeople with schizophrenia and major depression. Schizophrenia Bulletin, 32, 709–714.

Page, S. (1977). Effects of the mental illness label in attempts to obtain accommodation.Canadian Journal of Behavioral Sciences, 9, 85–90.

Peris, T.S., Teachman, B.A., & Nosek, B.A. (2008). Implicit and explicit stigma of mental illness.Journal of Nervous and Mental Disease, 196, 752–760.

Rabkin, J.G. (1972). Opinions about mental illness. Psychological Bulletin, 77, 153–171.

Sartorius, N. (2002). Iatrogenic stigma of mental illness. British Medical Journal, 324,1470–1471.

Schulze, B. (2007). Stigma and mental health professionals: A review of the literature.International Review of Psychiatry, 19, 137–155.

Servais, L.M., & Saunders, S.M. (2007). Clinical psychologists’ perceptions of persons withmental illness. Professional Psychology: Research and Practice, 38, 214–219.

Taylor, S.M., & Dear, M.J. (1981). Scaling community attitudes to the mentally ill. SchizophreniaBulletin, 7, 225–240.

Tay, S.C., Pariyasami, S., Ravindran, K., Ali, M.I.A., & Rowsudeen, M.T. (2004). Nurses’ attitudestoward people with mental illnesses in a psychiatric hospital in Singapore. Journal ofPsychosocial Nursing & Mental Health Services, 42, 40–47.

Thornicroft, G. (2006). Shunned: Discrimination against people with mental illness. Oxford:Oxford University Press.

Thornicroft, G., Brohan, E., Rose, D., Sartorius, N., Leese, M., & the INDIGO Study Group.(2009). Global pattern of experienced and anticipated discrimination against people withschizophrenia: a cross-sectional survey. Lancet, 373, 408–415.

Ucok, A., Polat, A., Sartorius, N., Erkoc, S., & Atakli, C. (2004). Attitudes of psychiatrists towardpatients with schizophrenia. Psychiatry and Clinical Neurosciences, 58, 89–91.

Vibha, P., Saddichha, S., & Kumar, R. (2008). Attitudes of ward attendants towards mentalillness: Comparisons and predictors. International Journal of Social Psychiatry, 54, 469–478.

Wahl, O.F. (1999a). Mental health consumers’ experience of stigma. Schizophrenia Bulletin, 25,467–478.

Wahl, O.F. (1999b). Telling is risky business: Mental health consumers confront stigma. NewBrunswick, NJ: Rutgers University Press.

Weller, L., & Grunes, S. (1988). Does contact with the mentally ill affect nurses’ attitudes to amental illness. British Journal of Medicine, 61, 277–284.



Attitudes of mental health professionals about mental illness: a review of the recent literature

Documents

Transcript of Attitudes of mental health professionals about mental illness: a review of the recent literature