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Attitudes towards mental illness in medical students
There is no conclusive evidence in this specialized area
concerning attitudes and the paper by Roth et al.1 is
therefore a unique piece in a jigsaw that will help our
understanding of our professional attitudes towards the
mentally ill. Perhaps this work will also shed light on
how we deal with mental illness in our peers. It is im-
portant to recognize that the literature is very much an
incomplete jigsaw. Indeed a search of the literature
regarding attitudes towards mental illness raises more
questions about the subject than de®nitive answers.
The literature is also a complex area, sometimes
focussing on the attitudes of the general public and
sometimes on the attitudes of health professionals. It is
dif®cult to tease out consistent themes from the re-
search done to date. The element of the Roth paper
that is particularly interesting concerns the students'
prior experience with mental illness and this is a par-
ticular twist not much seen in other work. Where this
element is discussed elsewhere this has been called the
`contact hypothesis'. For instance Callaghan et al.
looked at this contact hypothesis amongst Chinese
student nurses.2 Although their group of nurses with
previous contact expressed generally more positive at-
titudes towards the mentally ill, when presented with
speci®c issues that might impinge on their daily lives
their attitudes were less positive.
Generally negative attitudes towards the mentally ill
and the whole issue of stigma are, of course, well-docu-
mented.3,4 Half of those patients surveyed by Read and
Baker4 had been abused or harassed in public and a
third had been dismissed or forced to resign from work.
Such stigmatization of the mentally ill has led to gross
crimes against humanity such as nationwide steriliza-
tion and euthanasia programmes. Indeed the attitudes
of professionals and the general public towards the
mentally ill can be seen to oscillate between acceptance
and rejection throughout history.
Lawrie et al.5,6 used vignettes to look at the attitudes
of general practitioners. General practitioners were less
happy to have patients with severe mental disorder on
their lists than people with diabetes or overall good
health, suggesting that medical practitioners also dis-
criminate against the mentally ill.
Paradoxical attitudes towards mental illness also
occur in the general population. In a survey of 103
members of the general population Lawrie found that
globally attitudes to illness did not vary much between
physical and psychiatric illness.7 He concluded that
discrimination against those with a mental illness might
be limited to a relatively small sector of society or may
only be manifest as a result of close contact with the
individuals with mental illness. Health professionals
tend to be more pessimistic about the outcome of
mental illness than the general public in some studies.8
Jorm et al.7 suggested that professionals' attitudes
might actually be biased by greater contact with
patients with chronic or recurrent disorders.
Experience of personal mental illness is not unusual
in the medical profession. Indeed, the processes of self-
selection and the high demands of the job raise mor-
bidity levels above those seen in the general population,
as ably demonstrated by the research of Jenny Firth
Cozens and others.
As a student I was impressed by a book entitled
The Wound and the Doctor by Glin Bennett, a psy-
chiatrist from the University of Bristol, UK.9 The
book advanced the notion that most doctors have
been directly or indirectly wounded in some way and
through their practice seek to resolve issues sur-
rounding that wound. Bennett seemed to be saying
that acknowledging that wound could make doctors
better healers. It would make their own motives clear
and enable them to disentangle their needs from
those of the patient. Denying their own wounds
might make them confuse their own needs for healing
with those of the patient.
The direct or indirect experience of mental illness
could well make one more sympathetic or maybe illness
could be feared and therefore denied as a personal
attribute which could make the individual less than
sympathetic or even hostile towards mentally ill
`others'.
This only partially explains the paradox. There could
be many other reasons. For instance, an experience of
illness might lead to better understanding of how
mental illness affects thought and behaviour. It might
encourage the sufferer to be more cautious about
practising medicine themselves (perhaps leading them
to build defensive strategies such as regular supervision
of their own practice) or being cautious in allowing
other people with such illness to practise.
Correspondence: Dr Ben Green, Consultant Psychiatrist, Halton
Hospital and Honorary Senior Lecturer in Psychiatry, University of
Liverpool, Liverpool, UK
Commentaries
166 Ó Blackwell Science Ltd MEDICAL EDUCATION 2000;34:166±167
The paper by Roth et al.1 concludes with comments
about looking at how illness affects the performance of
medical students. The position in the UK is that the
General Medical Council (GMC) can promote good
performance, and regulate and protect the general
public from mentally ill doctors who are lacking in in-
sight. Universities generally see the medical course as
one of many courses of study offered by them. The
students themselves are not encouraged to work when
ill, and are not excluded from further study once they
have returned to health. Thus students with severe
mental illness could be studying and working in hos-
pitals when perhaps they might not be if they were
doctors. This potential dif®culty is managed with tact
and care by undergraduate deans and their academic
staff, but the potential reckoning is sometimes delayed
until after graduation when the pre-registration house
of®cer is subject to the General Medical Council.
Should there be a change in this? Should medical stu-
dents be subject to the same rigorous scrutiny that
practising doctors are? Since most student doctors go
on to practise medicine, there is perhaps a case, but
without further research like Roth et al.'s1 it will be
dif®cult to know whether such actions are motivated by
logic and good sense or the inherent prejudices of
medical educators and politicians.
Undergraduate and postgraduate medical education
seeks to promote the `correct' attitudes, whatever these
might be. The question arises `How can medical stu-
dent attitudes towards the mentally ill be improved and
ethical decisions and treatment promoted?' Singh et al.
have reported on the bene®ts of interactive, student-
centred and problem-oriented teaching producing im-
provements in attitudes as measured using the Attitude
to Psychiatry Questionnaire.9 Green et al. have found
that interactive workshops on ethics in psychiatry in-
volving work on group ethos, using historic accounts
and video sequences produced improvements in ethical
sensitivity amongst students.10
Roth et al.'s1 paper should stimulate further re-
search into this complex and multifaceted area. There
needs to be a clear focus however, and any research
hypotheses need to tease out whether the study is of
the attitudes of the general public to the mentally ill,
or the attitudes of students and professionals, and
whether personal illness or experience affects these
attitudes. More importantly still, further research
could look at how these attitudes affect educational
and medical practice.
Ben Green
Liverpool
References
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2 Callaghan P, Shan CS, Yu LS et al. Attitudes towards
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3 Goffman E. Stigma: Notes on the Management of Spoiled Iden-
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4 Read J, Baker S. Not just sticks and stones. London: MIND,
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5 Lawrie SM, Parsons C, Patrick J et al. A controlled trial of
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9 Bennett G. The Wound and the Doctor. London: Secker &
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10 Singh SP, Baxter H, Standen P, Duggan C. Changing the
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11 Green BH, Miller P, Routh C. Teaching ethics in psychiatry:
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Attitudes towards mental illness in medical students · B Green 167
Ó Blackwell Science Ltd MEDICAL EDUCATION 2000;34:166±167
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