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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Attitudes towards mental illness in medical students · B Green 167

Ó Blackwell Science Ltd MEDICAL EDUCATION 2000;34:166±167