Public Attitudes to Mental Illness Research Paper

1. Definitions

Mental illness is a broad generic term which includes major mental illnesses such as schizophrenia, bipolar affective disorders, common mental disorders such as anxiety and depression, personality disorders, and various other conditions sometimes named after etiology (for example, post-traumatic stress disorder), or after abnormal behavior (for example, episodic dyscontrol syndrome). Therefore, when discussing attitudes towards mental illness, it is important that individual categories are accepted rather than broad generic terms.

1.1 Attitudes

Attitudes form a key point of an individual’s thinking, especially toward things that matter to the individual. Attitudes have several components—some a function of the dimensions of personality traits, whereas others are a function of access. By assessing attitudes, one can measure beliefs, but it is not always likely that these beliefs can be turned into behavior. Thus, both cognitive and affective components of these attitudes must be assessed, separately and together. These attitudes do not always remain static and are influenced markedly by a number of factors such as media, education, and societal conditions.

1.2 Stigma

Stigma is the expectation of stereotypical and discrediting judgment of oneself by others in a particular context. The term originates from Goffman’s (1963) definition of stigma, which states that stigma originates when an individual, because of some attributes, is disqualified from full social acceptance. Stigma, like the attributes, is deeply embedded in the sociocultural milieu in which it originates and is thus negotiable.

The Greeks in ancient times used the word stigma to refer to bodily signs that exposed something unusual and negative about the signifier. Further conceptualization of stigma has included a mark that sets an individual apart (by virtue of mental illness in this case), that links that individual to some undesirable characteristic (perceived or real in cases of mental illness using violence, fear, and aggression) and rejection, isolation, or discrimination against the individual (e.g., at the workplace by virtue of the sick role and mental illness). Stigma thus includes cognitive and behavioral components and can be applied to age, race, sexual orientation, criminal behavior, and substance misuse, as well as to mental illness. Stigmatizing reactions are always negative and related to negative stereotypes. Stigma allows the society to extend the label of being outside the society to all those who have negative stereotypes. Such an exclusion may be seen as necessary for bifurcation of society, and will take the same role as scapegoating. The definitions of sickness and sick roles will change with the society, and stigma will also influence how distress is expressed, what idioms are used, and how help is sought.

Stigma and negative attitudes to mental illness are by and large universal. These are briefly discussed below to highlight similarities prior to discussing various factors responsible for these attitudes.

2. Attitudes in Europe

The attitudes of public and professionals alike across different countries of Europe have been shown to vary enormously. In this section some of the key studies and the findings are reported.

2.1 Historical

In ancient Greece, stigma and shame were interlinked and these can be studied using theories of causation and the balance within the culture between exclusion of mentally ill individuals and the ritual means of cleansing and re-inclusion. The interwoven theories of shame, stigma, pollution, and the erratic unpredictability of the behavior of severely mentally ill individuals suggest that, in spite of scientific and religious explanations, attitudes were generally negative. Simon (1992) suggests that the ambivalence of the ancient Greeks can explain their attitudes toward mental illness. The diseases of the mind were seen in parallel with those of the body, and even the doctors were part and parcel of the same cultural ambience of competition, shame, and fear of failure. During the Medieval and Renaissance periods, mental illness was perceived as a result of imbalance of various humors of the body, and related concepts of shame contributed to this. As Christianity encouraged a God-fearing attitude to the world, mental illness was seen as a sign that God was displeased and punishing the individual, thereby making negative attitudes more likely and more acceptable.

In the seventeenth and eighteenth centuries attitudes shifted, but overall remained negative and in turn provided entertainment to the visitors to Bedlam asylum where individual visitors paid a penny to see the inmates.

2.2 Current Recent

In the nineteenth century, with the establishment of various psychiatric asylums in the UK and the USA, there was generally a growing perception among the lay public and physicians alike that the mind is a function of the brain, thereby influencing a shift toward more humane treatments—although these were still called moral therapy, thereby giving it a moral religious tinge. The Athenian thinking on psyche has influenced these attitudes. Porter (1987) proposed that the growing importance of science and technology (among other things) was influential in channeling the power of right thinking people in imposing the social norms. The men of the church (also men of power) influenced public opinion, and informed attitudes and behavior toward marginal social elements that would then become disturbed and alien. Central state or market economy influenced the expectations which then divided those who set and met the norms from those who did not.

In a survey, the British Broadcasting Corporation (BBC 1957) reported that the public’s tolerance of mentally ill individuals depended upon the circumstances in which contact was made. More than three quarters of those surveyed were willing to mix with mentally ill individuals in areas where low personal involvement occurred; only half were willing to work with people with mental illness, whereas only a quarter were agreeable to such an individual being in authority over them. Attitudes toward mental illness and mentally ill individuals is influenced by a number of external factors such as legal conditions, expectations of treatment, etc.

In Turkey, for example, Eker (1989) reported that paranoid schizophrenia was identified easily among various groups. These attitudes influenced family perceptions, helpseeking, and caring for the individual who is mentally ill, and are influenced by educational status, gender, age, social class, and knowledge. Brandli (1999) observed that in Switzerland stigma was more common in older nonurban males with low education, and poorly informed. There were differences in public knowledge about Alzheimer’s disease, depression, and other psychiatric conditions. The findings also suggested that the general public was more accepting of seeking help from their primary care physician rather than a psychiatrist. In Greece, a study revealed that the younger, more educated, and higher social class individuals saw mental illness as a psychosocial problem, whereas older people saw it as a disorder of the nervous system (Lyketsos et al. 1985). Follow-up studies showed an improvement in people’s attitudes. Religion has been shown to play a role in forming these attitudes, but a sample from Israel (Shurka 1983) demonstrated that attitudes were more likely to be mixed and inconsistent. From the UK, the role of gender (Bhugra and Scott 1989) and ethnicity (Wolf et al. 1999) have been shown to influence attitudes to mentally ill individuals. The attitudes of other medical and nonmedical professions are also important, but are beyond the scope of this research paper.

3. Attitudes in America

Most of the studies from North America have been carried out by social scientists and have illustrated a range of attitudes to a number of conditions. Here only some of the important studies will be discussed.

3.1 Historical

In America from the seventeenth century onward, the traditional belief prevailed among Christians that madness is often a punishment visited by God on the sinner, and this influenced subsequent views and attitudes. Although both physical and mental illnesses were seen as punishments, it was only in the latter that moral components were seen, especially in the context of teachings from the Bible. A lack of faith and persistence of sinful and lewd thoughts, were seen as key causation factors in the development of insanity. In the early 1940s, Cumming and Cumming (1957), in their classic study of lay public perceptions of the mentally ill, demonstrated that, when asked to agree with the proposition that anyone in the community could become mentally ill, as normal and abnormal occur on a continuum, the whole educational package was rejected. An explanation was that expression of shame and inferiority was seen as important.

In the 1940s, Ramsey and Seipp (1948) demonstrated that subjects who had higher socioeconomic and educational levels were less likely to view mental illness as a punishment for sins and or poor living conditions. Yet they were less pessimistic about recovery. In the 1960s, studies from the USA were seen as either optimistic or pessimistic depending upon whether the researcher saw changes in attitudes toward the mentally ill as positive accepting, or negative rejecting. It is often difficult to ascertain whether stigma or deviant behavior causes the rejection.

3.2 Recent Studies

Star vignettes have been used in determining public knowledge of mental illness, and public attitudes to mental illness and mentally ill people (Rabkin 1974). Crocetti and Lemkau (1963) used vignettes to demonstrate that virtually all the subjects in their sample agreed with the question, ‘Do you think that people who are mentally ill require a doctor’s care as people who have any other sort of illness do?’ In this sample, low social class and low educational levels did not predict negative attitudes. In another study using case vignettes, it was shown that the largest increase in rejection rates occurred when a person had been admitted to a mental hospital and this was seen as due not to the fact that they were unable to help themselves, but that a psychiatrist or mental health professional had confirmed their status as mentally ill (Phillips 1963). The rejection appeared to be based on how visibly the behavior deviates from the customary role expectations. Continuance of symptoms, and public visibility of these symptoms, and behavior, influences attitudes and makes them more negative. Social distance is the distance between mentally ill individuals and the lay public on a number of parameters, especially in social interactions. It may also show how individuals will employ mentally ill persons at different levels of responsibility, thereby denoting acceptance or rejection. People may feel reasonably comfortable with mentally ill individuals if they do not have to mix with them on a regular basis. Meyer (1964) reported that three quarters of the subjects in his sample were willing to work with mentally ill people, but only 44 percent would imagine falling in love with such a person. There is no doubt that some illnesses are more stigmatizing than others, as is the severity of the illness, presence of a diagnostic label, and availability of alternative roles. In addition, attitudes can be influenced by the type of treatment and the patient’s response to it. Dovidio et al. (1985) reported that people are ambivalent in their attitude toward persons with psychological problems. In an undergraduate class of 94 males and 81 females, the students were asked to give their first impressions of mentally ill applicants in the process of college applications. The results showed that individuals with mental illness were seen favorably in terms of character and competence, but negatively in the context of security and sociability.

Link et al. (1992) suggest that patients’ perceptions of how others see them are extremely important. A mental illness label gives personal relevance to an individual’s beliefs about how most people respond to mental patients. The degree to which the individual with mental illness expects to be rejected is associated with demoralization, income loss, and unemployment in individuals labeled mentally ill, but not in those without mental illness. Thus it appears that labeling activates beliefs that lead to negative consequences. Patients may use such strategies to protect themselves or their networks.

Such stigmatized attitudes are also reflected in relationships with other outsider groups, such as the homeless, and influence portrayals of negative spoken and visual media (see Fink and Tasman 1992).

4. Attitudes Elsewhere in the World

Attitudes to the mentally ill from other societies and cultural settings are also influenced by a number of factors. Studies on the topic vary tremendously in their methods and data access. The beliefs about mentally ill people and toward mental illness are likely to be related to types of illness prevalent in that group.

4.1 Historical

In ancient Ayurvedic texts, the description of mental illness also suggested physical forms of treatment. In addition, diet and seasons were reported as playing key roles in the genesis of such conditions. This approach allowed the locus of control to be shifted to some degree away from the individual, thereby making that individual less responsible and less likely to be stigmatized.

4.2 Current

Ilechukwu (1988), in a survey of 50 male and 50 female psychiatric outpatients in Lagos, was able to demonstrate that some patients did believe in supernatural causes of neuroses and disorders, but psychosocial causes were cited most commonly. The attitudes and beliefs of patients are important, but beyond the scope of this research paper.

Wig et al. (1980), in a three-site study from India, Sudan, and the Philippines, found that, when asked to comment on case vignettes, community leaders were able to identify mental retardation (in all sites), alcohol and drug-related problems (in the Sudanese and Philippines areas), and acute psychosis (in India). Thus it appears that there are cultural differences in the identification of different clinical conditions. They also reported that attitudes toward mentally ill people were more negative in India compared with the other two sites. Thus the studies can be used to establish the needs of the general public and will allow planners to develop appropriate services.

Verghese and Beig (1974), in a survey from South India, reported that over 40 percent of Muslim and Christian respondents reported that marriage can help mental illness, although only 20 percent of Hindus shared this belief. Virtually no respondents reported believing in evil spirits. The most commonly recognized causes mentioned were emotional factors, including excessive thinking. In respondents over the age of 40, one fifth saw mental illness as God’s punishment. Christians were again more likely than Hindus to fear mentally ill people (although this fear disappeared with education), and yet the Christians believed strongly in the possibility of a complete cure. Nearly three-quarters of Hindus believed that the moon influences mental illness. These are interesting findings in that they address religious differences in public attitudes.

5. Reasons for Negati e Attitudes

Reactions to any taboo or outsider group depend upon a number of factors. These include the frequency of the actual or anticipated behavioral events, intensity and visibility of such behavior, and circumstances and location of such behavior on the one hand, and personal factors on the other. In this section we focus on the latter.

5.1 Age

Several studies have shown that older people tend to have more negative attitudes toward mentally ill people. The reasons for this are many. Older people, in spite of their life experiences, are generally more conservative and equally rejecting of behavior which is seen as odd and alien. The role of age is likely to be mediated by other factors such as education, social and economic class, etc.

5.2 Types of Illness

Attitudes towards people with schizophrenia are likely to differ from those reported toward people with depression or personality disorder. This may reflect the stereotypic images of the condition or fear related to the condition. It may also be due to previous knowledge about the illness. The perceived causative etiological factors also play a role in attitudes.

5.3 Gender

Males tend to have more negative attitudes and, as noted above, are also more likely to be rejected when they suffer mental illness. Females may be more sympathetic, for a number of reasons. Other studies of attitudes toward other alien groups also demonstrate that females are more positive. They are also more likely to be carers, and may be the first to contact psychiatric services on behalf of individuals. For women, change in role after mental illness is likely to produce more stigma. Yet they are more likely to be admitted with more ‘masculine’ illnesses such as personality disorder and drug abuse. The gender roles in the context of illness may well play a role in generating negative attitudes.

5.4 Religious Beliefs

Some studies have demonstrated that Christians tend to have more negative attitudes toward mental illness, but again this is not a consistent finding. The individual subject’s level of religiosity and depth of religious values must be studied rather than simple religious ascription.

5.5 Educational Status

The effects of education on attitudes are mixed (Bhugra 1989). Some studies have related negative attitudes clearly with low educational status, whereas others have failed to show such association, or showed that highly educated subjects held more negative attitudes, including those studying professionally.

5.6 Professions

Medical students may hold more negative and stereotypical attitudes, and other branches of medicine too have been shown to have negative attitudes to mentally ill people (e.g., schizophrenics), those with odd behavior (e.g., deliberate self-harm), and psychiatry as a profession. The psychiatrist is often lampooned and seen as a ‘head shrinker’ or a modern-day witchdoctor. There are individuals who are well educated and belong to a high socioeconomic class and yet hold negative attitudes.

5.7 Others

Some ethnic groups such as African-Caribbeans in the UK, and Hispanics, Asian-Americans, and Mexican-Americans in the USA have been found to have more negative attitudes toward mentally ill individuals or be far more restrictive in their description of etiology of mental illness compared to the white majority population. Nonacculturated individuals appeared to have more old-fashioned attitudes (i.e., negative stereotypes).

These are some of the complex set of factors that influence attitudes and stereotypes.

6. Educational Interventions

Educational interventions in order to reduce stigma toward mentally ill individuals and foster positive attitudes towards mental illness and those who are mentally ill are based on several levels of education. One-off educational programs and fact sheets on any illness are not likely to produce long-term changes. There is considerable evidence in the literature to suggest that education, if given at an appropriate and stable level, and repeated as required, will produce changes that can be sustained. In addition, educational interventions must target specific populations, bearing in mind their age, gender, ethnic composition, primary language, educational attainments, social class, etc.

Wolff et al. (1999) reported on the results of followup of neighbors, where two group homes for people with mental illness had been set up and one set of neighbors had received extensive education. They found that although the public education intervention may have had at best only a modest effect on knowledge, behavior toward the mentally ill residents changed. There was a decrease in fear and exclusion, and increased levels of social contact in the experimental area. They observed that educational intervention per se did not in itself lead directly to a reduction in fearful attitudes, whereas contact with patients did. Thus, any campaign which encourages subjects to increase contact with mentally ill individuals may prove to be more successful. The educational programs must be paced slowly and in a sustainable manner. The patients and their carers must be involved in planning these interventions without turning the whole exercise into a circus.

Any educational intervention must target the intervention either at the group most at risk of negative attitudes or at those already having negative attitudes. Repeated packages and adequate time for consultation and discussion will influence attitudes. Using small groups with experiential teaching is more likely to be successful compared with seminars or lectures with large groups. Any educational campaign must be sustained and momentum maintained. The effect on attitudes following several interventions is more sustained, and greater than the sum of the individual effects. Using a number of strategies, involving participation on the part of the public, carers, and patients, can influence attitudes.

The educational packages and interventions aimed at improving attitudes will, in the long run, influence resource allocation into mental health, improve recruitment, and move toward acceptance of community care. Such interventions can reduce fear, make expectations more realistic, and prevent attitudes from hardening. However, these interventions must be clear, focused, and appropriate, based upon the needs of the group that is being educated rather than on perceptions of need by the professionals. These packages must deal with alienation experienced by patients at different levels and in different settings, such as housing, employment, and social settings.

7. Conclusions

The attitudes of the public toward mentally ill individuals reflect prevalent social norms and mores. Expectations from psychiatric services, response to treatment, type of treatment, type of mental illness, and inaccessibility to treatment are external factors that will influence public attitudes. Age, gender, personality traits, and social and economic class are some of the personal factors that will influence these attitudes. These attitudes will not always translate into behavior, but one will be influenced by the other. Labeling of mental illness and the perception of mentally ill individuals as dangerous along with associated fear will all influence attitude formation. Any educational intervention must include some or all of these factors. Negative attitudes will influence helpseeking as well as compliance. These attitudes may well be linked to illness, but also to stereotypes of the illness, and to associated or perceived impairment as a result of that illness. These negative attitudes will also influence rejection of any preventative strategies the psychiatric profession may wish to advocate.

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