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ATTITUDES OF MENTAL HEALTH PROFESSIONALS ABOUT MENTAL ILLNESS: A REVIEW OF THE RECENT LITERATURE Otto Wahl and Eli Aroesty-Cohen University of Hartford

A large body of research has documented public attitudes toward people with mental illness. The current attitudes of the people who provide services to those with psychiatric disorders are important to understand, as well. The authors review what studies over the past 5 years reveal about the attitudes of psychiatric professionals. Empirical studies of the attitudes of mental health professionals, published since 2004, were identified and reviewed. Only 19 such studies were found. Most of these studies revealed overall positive attitudes among mental health professionals. However, evidence of negative attitudes and expectations was also found, particularly with respect to social acceptance of people with mental illness. Results indicate a need for greater research attention to mental health professionals’ views and for improved attitudes among C 2009 Wiley Periodicals, Inc. caregivers. There is considerable literature documenting negative public attitudes and behavior toward persons with mental illness. Many studies have established that the general public perceives 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 to discrimination 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 serve are also very important (Chaplin, 2000). Mental health professionals serve as role models and opinion leaders with respect to mental health matters. They are also the people 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

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points and on whom they will rely for understanding and assistance. How people with mental illness are viewed by these caregivers can have significant impact on the treatment outcomes and quality of life experienced by those with mental illness. In addition, many mental health professionals are also educators whose attitudes and behaviors inform and influence future caregivers (Gray, 2002; Sartorius, 2002). Nevertheless, as pointed out by Schulze (2007), the attitudes of mental health caregivers have not been given the same attention that public attitudes have had. The assumption may be that the attitudes of such caregivers, who have dedicated themselves to 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 at several aspects of the relationship between stigma and mental health professionals, one aspect of which was the attitudes of mental health caregivers toward the people they serve. Based on 10 studies published between 1997 and 2006, Schulze (2007) concluded that these studies yielded an ‘‘inconsistent picture’’ of professional attitudes. Some studies indicated positive views whereas others found less positive, even negative, views. Schulze (2007) noted, in fact, that ‘‘nearly three quarters of the relevant publications report that beliefs of mental healthcare providers do not differ from those of the population, or are even more negative’’ (p. 142). In addition, the reports of people with psychiatric disorders and their families often include instances of disrespectful treatment and negative attitudes expressed by the mental health caregivers they encounter (Corrigan, 2005; Wahl, 1999a,b). Findings such as these have led researchers and advocates to suggest that the behavior and attitudes of mental health professionals may be strong contributors to the continuing discrimination and stigma with which people with mental illness are burdened (e.g., Sartorius, 2002). It is important, then, that we have an understanding of how mental health professionals view those with psychiatric disorders. In this review we attempt to build on Schulze’s (2007) report by focusing more exclusively on attitudes toward those with psychiatric disorders, adding studies not included in her review, and providing more detailed 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., since 2004). The reason for this restriction is that there has been increased attention to issues of stigma and discrimination within the past 5–10 years and this may have influenced or modified caregiver attitudes such that studies beyond 5 years will not accurately reflect current views of mental health professionals. We will also look at results for only the major mental health professions—psychiatrists, psychologists, and psychiatric nurses. It was decided to maintain a focus on current practitioners and to not include students in training, as students will not yet have completed their training or begun practice, and one might expect that their views are still being formed. We also do not include studies of the attitudes of general practitioners, and, again, focus on the views of those who have specifically chosen to work with those with psychiatric disorders. Finally, we will try to identify gaps in the current literature and establish a research agenda for furthering our understanding of caregiver attitudes.

METHOD Published articles related to the attitudes of mental health caregivers were identified through an electronic search of the following databases: PsychInfo, Proquest, and PubMed. Search terms used included the following: mental health professionals and Journal of Community Psychology DOI: 10.1002/jcop

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stigma, mental health professionals and beliefs, professionals and stigma, psychiatry and stigma, psychiatrists and stigma, mental health professionals and attitudes, mental illness and beliefs, mental health and professionals, mental illness and stigma, and stigma. In addition, reference lists from articles identified via these searches were used to find other relevant articles that may have been missed. We selected for review only articles that involved empirical assessments, not opinions or observations, and, as noted above, articles published in 2004 or later. In addition, we limited our consideration to studies of general attitudes and excluded ones that focused on opinions about specific aspects 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 HEALTH PROFESSIONALS Numerous studies provided evidence that mental health professionals have overall positive attitudes towards those with whom they work or, at least, attitudes that are more positive than those of the general population. Kingdon, Sharma, and Hart (2004), for example, asked psychiatrists in the United Kingdom their opinions about schizophrenia. The researchers mailed questionnaires to all 6,524 members of the Royal College of Psychiatrists and received responses from 2,813 of these. The questionnaire used items from the Community Attitudes to Mental Illness Scale (CAMI; Taylor & Dear, 1981) and from a survey used previously by the Office for National Statistics (ONS; Crisp et al., 2000). Overall, the respondents from the Royal College showed positive attitudes towards people with mental illness. The majority agreed that ‘‘people with mental illness are far less of a danger than most people suppose’’ (95%) and disagreed that ‘‘one of the main causes of mental illness is a lack of self-discipline and willpower’’ (98%). Moreover, when respondent results were compared with responses from a previous survey of the general public, they indicated that the Royal College respondents tended to be more positive on most items than were members of the public. For example, psychiatrists held the above views more strongly than did the public, only 66% of whom disagreed that mental illness was caused by lack of willpower and only 64% of whom agreed that people with mental illnesses are less of a danger than believed. In addition, psychiatrists were far less likely to think of someone with schizophrenia as being dangerous (5% compared to 66.3% of the public) or unpredictable (40% vs. 77% for the public). Kingdon et al. concluded that, in comparison with the public, psychiatrists hold nonstigmatizing views and feel more optimistic about people with schizophrenia. Lauber, Anthony, Ajdacic-Gross, and Rossler (2004) gathered information from 90 psychiatrists in office practice in the German-speaking part of Switzerland by means of computer-assisted telephone interviewing. Each participant was asked to respond to the Taylor and Dear (1981) Inventory of Community Mental Health Ideology (Taylor & Dear, 1981), which involves questions relating to the expected impact and acceptance of mental health facilities in residential neighborhoods. The survey items were also completed by a representative sample of 786 community residents in the same area. Both psychiatrists and the general public were found to have overall strongly positive attitudes toward the inclusion of mental health facilities in the community, but psychiatrists were more positive in their views. For example, psychiatrists disagreed more strongly with the statement that ‘‘mental health facilities Journal of Community Psychology DOI: 10.1002/jcop

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should be kept out of residential neighborhoods’’ and with the assertion that ‘‘locating mental health services in residential neighborhoods does endanger local residents.’’ Nordt, Rossler, and Lauber (2006) surveyed 1,073 mental health professionals from 29 inpatient and outpatient facilities in the same area of Switzerland and compared their responses to those of 1,737 members of the lay public. The professional sample included 204 psychiatrists, 67 psychologists, 684 nurses, and 118 other therapists. Data were collected via a computer-assisted telephone interview. Mental health professionals, including the psychiatrists, were less likely to favor social restrictions than the general public, with the exception of compulsory admission. Sixty-six percent of the lay respondents favored revocation of the driver’s licenses of people with severe mental illness, as opposed to only 29% of psychiatrist, 16% of psychologists, 34% of other therapists, and 46% of nurses. Twenty-nine percent of the public sample would recommend an abortion to a woman who had previously suffered from a severe mental illness, as opposed to only 5–10% of the mental health professionals. Only 1.5–5% of mental health professionals disapproved of the right to vote 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 respondents with vignettes—of a person with depression, a person with schizophrenia, and a person without psychiatric symptoms—and asked them to complete a 7-item social distance rating. Nordt et al. reported that both professionals and the public tended to be accepting toward the person with depression, with mental health professionals rating the depressed person no differently than they did the person without symptoms. Magliano et al. (2004a) compared the beliefs of 465 mental health professionals, 709 relatives of people with schizophrenia, and 714 lay respondents in Italy. Mental health professionals came from 30 randomly selected mental health services in different areas of Italy and included psychiatrists, psychologists, nurses, sociologists, occupational therapists, social workers, and auxiliary and administrative personnel. The mental health professionals were asked to read a case vignette of a person with schizophrenia and complete a 34-item Questionnaire on the Opinions About Mental Illness–Professional Version (QO-P; Magliano et al., 1999). The self-report questionnaire contains statements related to causes of schizophrenia, effectiveness of available treatments, and the rights of individuals with schizophrenia. Members of the lay public were given the vignette and asked to fill out a similar questionnaire. Relatives were asked to fill out a family form of the questionnaire based on their experiences with their family member. Of particular 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 than family members. Eighty-nine percent of the mental health professionals indicated that the statement, ‘‘People can recover from this disorder,’’ was partly or completely true (as opposed to only 60% of relatives). Seventy-nine percent of mental health professionals indicated that it was completely or partly true that ‘‘patients with this disorder are as able to work as other people,’’ whereas only 56% of relatives indicated this. Mental health professionals were also more likely than relatives or the general public 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% of the public and 19% of relatives). In a separate article, Magliano et al. (2004b) looked separately at the beliefs of the psychiatrists (110) and the psychiatric nurses (190) in their sample. Both professional groups seemed to have greater optimism about recovery than did patient relatives. Journal of Community Psychology DOI: 10.1002/jcop


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Most mental health professionals (77% of nurses and 79% of psychiatrists) rated the statement, ‘‘Patients with this disorder are as able to work as other people,’’ as completely or partially true, as compared to only 56% of relatives. Most (71% of nurses and 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 as a babysitter,’’ whereas only 55% of relatives saw that as a possibility. Psychiatrists appeared to be more supportive of patient rights than either nurses or family members. Fifty-seven percent of psychiatrists disagreed that ‘‘patients with this disorder should not get married,’’ as opposed to only 37% of nurses and 29% of relatives. Similarly, 45% of psychiatrists believed it was not true that ‘‘patients with this disorder should not have children,’’ as contrasted with 29% of relatives or nurses who disagreed 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 relatives indicated 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-item Attitudes Toward Mental Illness Questionnaire (Weller & Grunes, 1988) to 409 nurses working in a psychiatric hospital in Singapore. They reported overall positive attitudes for these nurses, with the most positive attitudes shown by nurses with advanced diplomas or training and more years of experience. Responses to individual items were not reported. Munro and Baker (2007) administered the Attitudes Towards Acute Mental Health (ATAMH) Scale (Baker, Richards, & Campbell, 2005) to 140 nurses working in acute care mental health units in the United Kingdom. The ATAMH involves 25 Likert-scored questions (7-point scale) and eight semantic differential choices about ‘‘the mentally ill.’’ The authors reported generally high levels of positive attitudes. A large majority of nurses disagreed with statements such as, ‘‘Depression occurs in people with a weak personality’’ (90%); ‘‘Those with a psychiatric history should never be given a job with responsibility’’ (91%); ‘‘Psychiatric patients are difficult to like’’ (86%); and ‘‘Violence mostly results from mental illness’’ (85%). Ishige and Hayashi (2005) assessed the attitudes of psychiatric and public health nurses in Japan and compared them with the attitudes of those in other occupations—local welfare commissioners, probation officers, nonpsychiatric care workers, and noncare workers. On the basis of responses to 20 semantic differential items, the authors developed an evaluation scale to reflect the affective aspect of attitudes toward people with schizophrenia. Seven hundred eighty-six individuals completed the measure; 261 were psychiatric nurses and 83 public health nurses. Psychiatric nurses worked in inpatient psychiatric settings; public health nurses worked with psychiatric patients in community health centers. Ishige and Hayashi found that psychiatric and public health nurses were significantly more favorable in their affective (semantic differential) appraisals than were workers in other occupations. No breakdown was provided for specific items, however. Chin and Balon (2006) compared the attitudes toward depression and schizophrenia of 38 psychiatry residents at a U.S. School of Medicine with those of 29 residents in other specialties, using the Attribution Questionnaire-Short Form (AQ-SF; Corrigan et al., 2000). This questionnaire asks questions about nine kinds of reactions to mental illness—blame, anger, pity, help, dangerousness, fear, avoidance, segregation, and coercion. Chin and Balon reported that the psychiatry residents had a significantly lower AQ-SF score than did the other residents for both schizophrenia and depression, indicating more accepting attitudes toward psychiatric disorders. The Journal of Community Psychology DOI: 10.1002/jcop

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authors, however, did not provide mean scores or descriptions of responses to specific items. Grausgruber, Meise, Katschnig, Schony, and Fleischhacker (2007) received responses from a mailed questionnaire from 460 nonphysician staff members from mental healthcare institutions in Austria. These staff members included psychiatric nurses, social workers, psychologists, physiotherapists, and occupational therapists. Respondents were given case vignettes of persons with schizophrenia and asked questions about perceived dangerousness, expected success of treatment, and preferences 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 of persons with mental illnesses. Staff members were found to have more optimistic views of schizophrenia treatment than the lay population, agreeing that schizophrenia is a treatable condition nearly twice as often (69% vs. 37%). Mental health staff members were also much less likely than the public to see people with schizophrenia as ‘‘more dangerous than healthy people’’ (28.4% vs. 55%) and more willing to accept a person with 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 between those of the lay and staff groups. Peris, Teachman, and Nosek (2008) used measures of explicit and implicit stigma to compare several groups of study participants—undergraduate students (n 5 204), the general public (112), health/social services workers (541), and a ‘‘mental health’’ group consisting of both professional clinicians (407) and clinical psychology graduate students (275). The explicit stigma measure involved semantic differential ratings of a person with mental 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 positive or negative descriptors with items related to a key concept, in this case people with mental illness. Peris et al. reported that the mental health group was more positive than the general public and other health service providers for both the good–bad and helpless–competent items, but there were no group differences on the blameworthy–innocent item. They also found that explicit stigma did not differ as a function of specific professional role (psychologist, counselor, social worker) or with indicators of experience (e.g., student vs. professional, licensed or not). Specific scores on the three semantic differential items were not provided, however. Peris et al. also found that the mental health group had more implicit positive attitudes toward people with mental illnesses than did any of the other groups. Within the mental health group, graduate students reportedly had more positive associations with mental illness than did professionals. Within the professional group, clinical psychologists were found to be more positive than were counselors, social workers, or other mental health professionals. Des Courtis, Lauber, Costa, and Cattapan–Ludewig (2008) distributed a questionnaire to ward staff at a public hospital in southern Brazil. Approximately one fourth of the 99 participants (28.3%) were psychiatrists and psychologists; the rest (71.7%) were nurses or other therapists. The questionnaire included items about community placement of people with mental illnesses and willingness to interact in social situations with a person (with depression) described in an accompanying vignette. The mental health professionals showed positive opinions about the placement of people with mental illness in the community, disagreeing with suggestions that residential facilities downgrade the neighborhood or endanger local residents. Brazilian health care professionals were very willing to move next door to a Journal of Community Psychology DOI: 10.1002/jcop


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person like the one in the vignette (M 5 4.59 on a 5-point scale). They were also willing to 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 the person for a job. Results from the questionnaire were compared with results from similar questions asked in Switzerland in previous studies (Lauber, Nordt, Braunscheig, & Rossler, 2006; Nordt, Rossler, & Lauber, 2006). Brazilian mental health professionals were found to have more positive attitudes than Swiss caregivers about community treatment and to show less need for social distance. Bjorkman, Angelman, and Jonsson (2008) conducted a questionnaire study of attitudes toward people with mental illness among nurses at a university hospital in Sweden. Using the Attitudes to Persons with Mental Illness Questionnaire, they compared the attitudes of nurses in a psychiatric clinic (51) with those at a somatic clinic (69) about seven different forms of mental illness. Nursing staff in psychiatric care units were found to have more positive attitudes than those providing somatic care, with most of the differences between the groups found in their reactions to patients 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, negative correlations were reported between amount of professional experience and perceptions of people with schizophrenia as dangerous and unpredictable. Vibha, Saddichha, and Kumar (2008) administered the Community Attitudes Toward Mental Illness Scale (CAMI) to 100 attendants on a psychiatric ward in Eastern India. Attendant responses were compared with those of 100 guardians of patients admitted to the psychiatric institution. Both groups tended to express overall positive views, but psychiatric ward attendants had more positive attitudes than did the guardians. In particular, the ward attendants expressed less support for social restrictions and more support for community care than did home carers. With respect to specific items, more attendants (93%) than guardians (77%) endorsed the statement, ‘‘Residents have nothing to fear from people coming into their neighborhoods to obtain 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 HEALTH PROFESSIONALS Several studies found less favorable, or even negative, attitudes among mental health professionals. Lauber et al. (2006) asked their sample of 1,073 Swiss mental health professionals to rate on a 5-point Likert scale, how much people with mental illness differ 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 all negative descriptors (except ‘‘stupid’’) as more characteristic of people with mental illness. Among the negative descriptors seen as applicable to persons with mental illness were unpredictable, bedraggled, weird, threatening, and dangerous. Mental health professionals also rated all positive descriptors (except ‘‘creative’’ and ‘‘highly skilled’’) as less characteristic of people with psychiatric disorders. Lauber et al. reported further that psychiatrists showed more negative attitudes than other professionals, rating persons with mental illness as more dangerous, less skilled, and more socially disturbing than did psychologists, nurses, or other therapists. Journal of Community Psychology DOI: 10.1002/jcop

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Deans and Meocivic (2006) asked 65 registered psychiatric nurses in Australia to complete a 50-item questionnaire concerning their reactions to people diagnosed with borderline personality disorder (BPD). A majority of the respondents indicated that they considered BPD patients to be manipulative (88%) and engaging in ‘‘emotional blackmail’’ (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 patients with BPD were fascinating (21%), charming (13%), or fun to work with (11%). A study of 65 psychiatric nurses in Ireland by James and Cowman (2007) produced similar results. Three quarters (75%) agreed that they found clients with BPD very or moderately difficult to look after and 80% agreed that BPD clients are more difficult than other clients. On the other hand, the nurses tended to believe that BPD clients could be treated successfully and that nurses had an appropriate role in that treatment. Servais and Saunders (2007) mailed questionnaires to 1,000 randomly selected clinical psychologists from the Directory of the American Psychological Association and received usable responses from 306 of these psychologists. Respondents were asked to rate specific categories of people on 7-point semantic differential scales with respect to six 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 with schizophrenia and persons with borderline features fared least well in psychologists’ ratings. Both groups were rated as ineffective, undesirable (to be with), and dissimilar to the rater. Both were rated significantly lower on these categories than a member of the general public. Persons with schizophrenia were rated as the most ineffective, with 60% of respondents giving a 6 or 7 (on the 7-point scale). Those with schizophrenia were also rated as the most dissimilar to the rater, with extreme scores given by 69% of the respondents. In addition, persons with schizophrenia were given the most extreme ratings as ‘‘undesirable’’ by 34% of respondents and as ‘‘dangerous’’ by 12%. Persons with borderline features received the highest ratings on dangerousness, with 22% of respondents 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 moderate depression. The person with depression was rated as less desirable than a member of the public, but more understandable and safer. Negative appraisals of the ability of individuals with schizophrenia to participate in a collaborative therapeutic relationship were implicit in findings by Ucok, Polat, Sartorius, Erkoc, and Atakli (2004). Ucok et al. obtained responses from 60 psychiatrists who were members of the schizophrenia section of the Psychiatric Association of Turkey to a mail survey concerning attitudes and practices related to patients with schizophrenia. The survey contained 12 simple questions, one of which was, ‘‘Do you inform your patients of their diagnoses?’’ Nearly half (42.7%) of the psychiatrists indicated that they never informed patients of their schizophrenia diagnosis. Another 41.7% reported that they inform patients only on a case-by-case basis. Together, these data indicate that the vast majority of psychiatrists participating in the study—over 80%—do not routinely share their diagnoses with their schizophrenia patients. In contrast, almost all (85%) indicated they would inform patients of their diagnosis of depression. The most common reason given for the practice of not revealing diagnosis was the belief that people with schizophrenia would not understand the meaning of the diagnostic label (32.6%). Ucok et al. also asked questions related to encounters with people with schizophrenia outside the treatment setting. According to the researchers, 43% of Journal of Community Psychology DOI: 10.1002/jcop


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the psychiatrists reported that they would not visit a patient with schizophrenia at his or her home and 55.2% indicated they would feel discomfort if they ran into one of their schizophrenia patients at a social event. It is unclear, however, whether these latter results represent feelings about interactions with people with schizophrenia or feelings about maintaining professional boundaries with someone who is one’s patient. In addition, many of the studies revealing overall positive attitudes nevertheless found evidence of negative views among substantial numbers of the participating mental health professionals. For example, despite overall positive attitudes, only about one quarter of the Royal College participants (26%) indicated a belief that a person with schizophrenia could recover fully (Kingdon et al., 2004). One in 8 did not agree that ‘‘residents need not fear people receiving mental health services in their neighborhoods’’ and one in 10 agreed that ‘‘there is something about people with mental illness that makes it easy to tell them from normal people.’’ Within the general positive attitudes of U.K. acute care nurses in Munro and Baker’s (2007) study was a semantic differential rating indicating pessimism about recovery. Psychiatric nurses in Sweden (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-point scale), hard to talk to (3.1), unusual (4.5), and unlikely to recover (3.2). Mental health caregivers in Grausgurber et al.’s (2007) Austrian study were significantly more positive than the general public in their views about schizophrenia. However, 31% of the staff sample expressed doubts about the success of treatment for individuals with schizophrenia 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 they also strongly endorsed (90%) the disempowering statement, ‘‘Mental patients need the same kind of control and discipline as a young child.’’ Despite many favorable attitudes in Magliano et al.’s (2004a) sample of Italian mental health professionals, there was support for a variety of social restrictions for people with schizophrenia. The majority of professionals (54%) agreed that ‘‘people with this disorder should not get married.’’ Sixty-four percent agreed that ‘‘people with 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 and 63% of nurses believed that schizophrenia patients should not get married, and the majority of both nurses (72%) and psychiatrists (55%) agreed that such patients should not 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 a woman with schizophrenia could recover sufficiently to be trusted as a babysitter. Despite Nordt et al.’s (2006) findings of less restrictive attitudes of Swiss mental health professionals compared to the lay public, negative attitudes were also revealed. Nordt et al. asked questions about specific traits respondents associated with mental illnesses and combined the responses to form a negative stereotype scale. They then compared the results across five groups—psychiatrists, psychologists, nurses, other therapists, and the general population. All groups fell on the negative side of the midpoint on the stereotype scale, with psychiatrists showing significantly more negative stereotypes than any of the other groups. Negative attitudes were particularly apparent in measures of social distance, even when other attitudes were positive. Social distance measures ask respondents to indicate their willingness to interact with the person from the vignette in a variety of social situations. Lauber et al. (2004) asked the psychiatrists in their study to read a Journal of Community Psychology DOI: 10.1002/jcop

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vignette depicting a person with schizophrenia and then complete a social distance questionnaire. Swiss psychiatrists did not differ from the general public in their desire for social distance from the person with schizophrenia. In both groups, the level of social distance increased as the intimacy of the social situation increased, with both psychiatrists and community residents indicating reluctance to recommend the person in 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 distance questionnaire indicating their preferences for social interaction with people with schizophrenia. Public health nurses showed lower preference for social distance than other groups, but psychiatric nurses did not differ from the other groups, all of which tended to have scores indicating rejection of social contact with a person with schizophrenia. Although Nordt et al. (2006) reported accepting attitudes for a person with depression, they also found that all groups of mental health professionals, similar to the public, indicated a greater desire for social distance from a person with schizophrenia than from a person with depression or with no symptoms. Within Grausgruber et al.’s (2007) Austrian sample, barely half (53%) expressed willingness to engage an individual with schizophrenia as an employee. A large majority of staff indicated reluctance to accept a person with schizophrenia as a superior (70%) or in a caretaking role with their children (81%). Approximately one in five (19%) Royal College psychiatrists either agreed or were uncertain that they ‘‘would not want to live next 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 attitudes toward mental illnesses among psychiatric professionals. Fourteen of the 19 studies reviewed found the overall attitudes of mental health professionals to be both positive in an absolute sense and more positive in comparison to public views, whereas only five showed predominantly negative attitudes. However, as noted, negative attitudes were present even in those studies with overall positive results. Many mental health professionals appeared to share the public belief that people with serious mental illnesses are dangerous. Many doubted the possibility of recovery and espoused views that people with serious mental illness should not marry or have children. Negative attitudes were particularly apparent for social distance measures. Even when mental health professionals made statements indicating optimistic and understanding views of mental illnesses, they tended to be similar to the public in being reluctant to accept those with psychiatric disorders within their social and occupational circles. It may be more appropriate, then, to conclude that results are mixed with respect to the nature of professional attitudes toward people with mental illnesses. This is the same conclusion reached by Schulze in her 2007 review. Given that there is significant overlap 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 of mixed 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 health professionals. The failure to find consistent positive results for the attitudes of mental health professionals and the substantial number of mental health professionals expressing negative views is troubling and challenges assumptions that mental health profesJournal of Community Psychology DOI: 10.1002/jcop


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sionals are models of positive attitudes. It also underscores concerns about the potential impact of professional attitudes on patient care. It is easy to see how the negative views expressed by many professionals may perpetuate stigma and interfere with practitioners’ ability to respond helpfully to their patients’ needs or to establish successful therapeutic relationships. It is easy to see how those negative attitudes may provide models for continued public negativity related to mental illness. The findings of this review point to the need for mental health professionals to pay increased attention to their own attitudes and behaviors with respect to the people they serve. The persistence of inconsistent or negative attitudes among mental health professionals also seems to call for greater attention to the training mental health caregivers receive. We may need to take a careful look at possible ways the current training of future mental health professionals may create or reinforce negative attitudes and at strategies within training that might help to generate greater acceptance and understanding. At the very least, we may need to include more discussion of attitudes about 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 small number of studies exploring the attitudes of mental health professionals. Only 19 published studies were found that empirically assessed the attitudes of mental health professionals between 2004 and the present. For a topic as important to the treatment and recovery of people with psychiatric disorders, this is a very small number. The attitude of mental health professionals toward those they treat remains a neglected topic. Increased research in this area is important not only to help understand—and improve—the attitudes faced by people with mental disorders within the mental health system, but it is also important as a response to criticism that mental health professionals have not yet demonstrated a willingness to look critically at their own professions and their own potential contributions to stigma and discrimination. The available studies come from 13 different countries. It is likely that different countries have different philosophies, different cultural beliefs, and different types of training that may influence attitudes toward psychiatric disorders. The limited crosscountry comparison in the reviewed studies gives support to the idea that such differences exist (Des Courtis, Lauber, Costa, & Cattapan-Ludewig, 2008). Moreover, the variety of countries and settings in which the research has been conducted may be a contributor to the mixed results obtained. Conclusions about prevailing attitudes in any one country will need a greater number of studies from each country than currently exist. For example, the three studies that employed U.S. samples are hardly sufficient to draw firm conclusions about the attitudes of U.S. practitioners. Different professional groups likewise may have different training, different experiences, and different philosophies of treatment that affect their attitudes. Again, several of the studies reviewed support the existence of differences between psychologists, psychiatrists, psychiatric nurses, and other caregivers (Magliano et al., 2004b; Nordt et al., 2006; Peris et al., 2008). Some studies also found differences related to different levels of training or experience within the same fields (Ishige & Hayashi, 2005; Tay et al., 2004). Generalizations about the attitudes of mental health professionals as a group may be as elusive and inaccurate as generalizations about any varied group. More studies of specific professional groups and/or ones that break down results from mental health professionals into specific professional groups Journal of Community Psychology DOI: 10.1002/jcop

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are needed. With respect to knowledge about specific professional groups, nurses seem to be relatively well-represented among the studies reviewed; psychiatrists and psychologists are more rarely included. This is an important limitation in that these latter two sets of professionals are likely to be in positions to make important executive decisions about people with mental illnesses and to act as authoritative role models for public opinion. The majority of research inquiries into mental health professional attitudes have focused on severe mental illnesses, schizophrenia, in particular. This is understandable in that such disorders are known to receive the least public acceptance and to be the most challenging for mental health professionals. However, as is apparent in the studies 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 toward different disorders. Attitudes about schizophrenia and borderline personality disorder would appear to be considerably less accepting than those toward depression, for example. It would be of benefit to inquire about specific disorders and to begin to generate a more differentiated understanding of attitudes toward those specific psychiatric disorders, among both mental health professionals and the general public. In addition, some common disorders (e.g., anxiety disorders, bipolar disorder) are absent altogether from the studies reviewed. More specific inquiry about professional attitudes toward these disorders is needed. It is apparent also that the reviewed studies involve a wide variety of methods and instruments. Data collection involved Likert-format questionnaires, semantic differential ratings, interviews, response to vignettes, social distance ratings, and experimental measures of implicit attitudes. On the one hand, this variety of measures and methods is valuable in that it approaches the complex question of attitudes from many vantage points. On the other hand, it limits direct comparison of results and probably also 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 by Link, Yang, Phelan, and Collins (2004) in their review of stigma measures. The closest to such a standard may be the Social Distance Measure. This measure was not only the most frequently used instrument in the studies above (in six of the studies), but it also seemed capable of revealing negative attitudes even when other self-report measures did not. Finally, there were numerous types of related studies that were not considered in this review, but are nevertheless important to consider. Physicians and nurses in general practice were not included. Yet these are professionals who come into frequent contact with and provide services for people with psychiatric disorders. Their attitudes, particularly those of general practice physicians who may be the first contact for many people with psychiatric disorders, are important to understand as well. The identification of research for the current review revealed numerous studies that looked at the views of general practice physicians and nurses, and those warrant review and summary also. In addition, there are many studies that have looked at the views of students in training for psychiatric work and at the impact of training on attitudes. As noted above, it is important to understand what is being done in training and how attitudes are being shaped among future practitioners. Studies of students before and after training may provide insight into how different aspects of training lead to the attitudes—positive and negative—that were found in the current review. More important, they may give us ideas of how training may be improved to generate a more consistently positive attitude among mental health care professionals. Journal of Community Psychology DOI: 10.1002/jcop


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Journal of Community Psychology DOI: 10.1002/jcop