12
Review article Acta Psychiatr Scand 1989:80:1-12 Key words: public opinion; attitude; mental illness. Attitudes towards mental illness A review of the literature D. Bhugra Maudsley Hospital, London, United Kingdom ABSTRACT - With the advent of community psychiatry, the pressure of care of the mentally ill will increasingly fall on the family and the community. In order for this transition to succeed, it is important to bear in mind the attitudes of the community and the caregivers. This article reviews the literature on public attitudes and sugges- tions are made for future research and lessons to be learnt from the experience in Northe America. Received November 26, 1988; accepted for publication December 22, 1988 Mental illness and the psychiatrist have been feared and made fun of for as long as mental illness has existed. Mentally ill people have been mistreated and loathed (1). The psychiatrists are seen as “modern day witch doctors, wise and powerful and capable of great good and great harm” (2). Throughout human history, mental illness and the treatment of mentally ill people have been emotional issues. The attitudes to the mentally ill have reflected the prevailing situation at the time. The associations of mental illness with (religious) possession, witchcraft, sorcery and later with mesmerism and hypnotism have aroused strong feelings among medical practi- tioners and among the lay public. Given the recent emphasis on the community care of the mentally ill, these attitudes have become important if this care is to succeed. As an editorial in Schizophrenia Bulletin (3) ob- served, . . . the increased presence of mental patients in the community is a reality. Thus like it or not, the general public is now more frequently confronted by formerly mental ill people in its day-to-day existence. It will be some time before public response to this new situation can be accurately assessed and very likely the response will vary from place to place . . . Despite the extremely fluid situation that exists, it is important to review and evaluate what we now know about attitudes toward mental disorder and the direction in which they seem to be moving . . . For community care to succeed, adequate financial and personnel resources are necessary. As Noble (4) points out, “All the watchdogs in the world, all the fine legal safeguards will not prove a substitute for the resources so often found wanting in this field.” Funding and recruitment are determined by the attitudes of people in charge. The stigma attached to the posts affects recruitment. Rabkin (5) points out that . . . [ a ] knowledge of such attitudes is not only germane to those concerned with the origins and the maintenance of disturbed behaviour, but critically important to workers involved in primary prevention programmes, early intervention and community treat- ment of psychiatric patients. The advent of social community psychiatry and the evolution of community mental health centres have introduced new areas of discussion. This distinct psychiatric subspeciality deals with I

Attitudes towards mental illness

Embed Size (px)

Citation preview

Page 1: Attitudes towards mental illness

Review article Acta Psychiatr Scand 1989:80:1-12

Key words: public opinion; attitude; mental illness.

Attitudes towards mental illness A review of the literature

D. Bhugra Maudsley Hospital, London, United Kingdom

ABSTRACT - With the advent of community psychiatry, the pressure of care of the mentally ill will increasingly fall on the family and the community. In order for this transition to succeed, it is important to bear in mind the attitudes of the community and the caregivers. This article reviews the literature on public attitudes and sugges- tions are made for future research and lessons to be learnt from the experience in Northe America.

Received November 26, 1988; accepted for publication December 22, 1988

Mental illness and the psychiatrist have been feared and made fun of for as long as mental illness has existed. Mentally ill people have been mistreated and loathed (1). The psychiatrists are seen as “modern day witch doctors, wise and powerful and capable of great good and great harm” (2). Throughout human history, mental illness and the treatment of mentally ill people have been emotional issues. The attitudes to the mentally ill have reflected the prevailing situation at the time. The associations of mental illness with (religious) possession, witchcraft, sorcery and later with mesmerism and hypnotism have aroused strong feelings among medical practi- tioners and among the lay public.

Given the recent emphasis on the community care of the mentally ill, these attitudes have become important if this care is to succeed. As an editorial in Schizophrenia Bulletin ( 3 ) ob- served,

. . . the increased presence of mental patients in the community is a reality. Thus like it or not, the general public is now more frequently confronted by formerly mental ill people in its day-to-day existence. It will be some time before public response to this new situation can be accurately assessed and very likely the response will vary from place to place . . . Despite the extremely

fluid situation that exists, it is important to review and evaluate what we now know about attitudes toward mental disorder and the direction in which they seem to be moving . . .

For community care to succeed, adequate financial and personnel resources are necessary. As Noble (4) points out, “All the watchdogs in the world, all the fine legal safeguards will not prove a substitute for the resources so often found wanting in this field.” Funding and recruitment are determined by the attitudes of people in charge. The stigma attached to the posts affects recruitment. Rabkin ( 5 ) points out that

. . . [ a ] knowledge of such attitudes is not only germane to those concerned with the origins and the maintenance of disturbed behaviour, but critically important to workers involved in primary prevention programmes, early intervention and community treat- ment of psychiatric patients.

The advent of social community psychiatry and the evolution of community mental health centres have introduced new areas of discussion. This distinct psychiatric subspeciality deals with

I

Page 2: Attitudes towards mental illness

2 D. BHUGRA

specific mental health issues, including aetiology and treatment within the community, rather than in psychiatric hospitals.

Few studies have looked at public attitudes towards mental illness in Western Europe. This article reviews literature available on the subject from North America, compares it with the stud- ies done in Western Europe, and make sugges- tions for applying the available research to fur- ther development of services in community care. This article does not deal with broader issues of community psychiatry - only with public atti- tudes and possible factors influencing these atti- tudes. A broad overview is taken, focusing on studies of attitudes towards mental illness, men- tally ill people and their treatment environs. Only the attitudes of the lay public are dealt with. A subsequent article will look at the attitudes of health care professionals. The views of mental illness, psychiatrists, as dealt with in cinema, literature and on television are not discussed.

Historical development of attitudes To examine the prevailing attitudes, it is helpful to look back at the development of these atti- tudes. Psychiatrically ill people are seen in all cultures and all societies, but the perceptions of lay people may not match those of psychiatrists in identifying “cases”. Horwitz (6) sees the use of labels such as madness, craziness or insanity as representing social control of mental illness. Community members usually recognize that someone is mentally ill first, not psychiatric pro- fessionals. It thus becomes important to look at the attitudes and perceptions of mental illness in the community to define and provide services. Horwitz (6) defines deviance as behaviour that violates social norms. Sometimes this deviance is equated with mental illness. Illness may be more acceptable than deviance. The latter only pro- duces feelings of incomprehensibility, scorn and hostility. It is certainly possible that the distinc- tion between illness and deviance is not always that clear cut and attitudes thus harden. As Rabkin (7) emphasizes, the construction of ill- ness as a burden, a handicap caused by the

invasion of a foreign agent, underlines the undesirable nature of the condition that most people would like to avoid. The difficulty is not in the negative evaluation of mental illness, but the accompanying rejective attitudes manifested towards mentally ill people, along with implica- tions for aetiological hypotheses, therapeutic approaches and preventive strategies. Johannsen (8) observed, “TO the average man, a person becomes a patient only when he enters a psychi- atric hospital.” The label thus once given sticks with the individual.

The descriptions of mental illness date back to the ancient Indian texts (9, lo). The methods of treatment were, however, physical. Whether these descriptions were a representation of met- aphysical entities has been discussed by Haldipur (10). In Europe, the concepts of mor- al treatment arose from the witch-hunts of the Middle Ages. In the United States, psychiatrists were fascinated by the idea that manipulation of the physical and social environment can be therapeutic intervention - a goal akin to that of modern community psychiatry (1 1). The develop- ment of mental hospitals reflected a progressive concern for mentally ill people and a desire to remove them from the intolerable conditions in jailhouses, workhouses or the community (12). Towards the latter part of the nineteenth cen- tury, the quality of care in these hospitals declined (13). The pendulum has swung now towards the ideals of community care and away from institutional care.

North America In the 1950s, several researchers looked at the attitudes of the lay public towards mental illness. Johannsen (8) and Rabkin (5,7) review the empiri- cal research of the era. A classic study of the period was that of Cumming & Cumming (14). They tested the residents of a small town in Cana- da before and 6 months after an educational cam- paign designed to educate them about mental ill- ness. In their films and discussions the researchers emphasized 3 propositions: the range of normal behaviour is wider than it is often regarded (they were actually more liberal in their interpretation than the psychiatrists); deviant behaviour is not

Page 3: Attitudes towards mental illness

ATTITUDES TOWARDS MENTAL ILLNESS 3

random, but has a cause and the behaviour can be understood and modified; and normal and abnor- mal behaviours are on a single continuum and qualitatively not distinct.

The third proposition was rejected outright, along with the entire educational programme. The third proposition meant that anyone in the com- munity could become mentally ill (insane) under certain situations and, therefore, was rejected (15). The first two propositions, which suggested a cause (a pathogen) and possible treatment (by the psychiatrist) of deviant behaviour, were compati- ble with the researchers’ outlook.

In a subsequent study Cumming & Cumming (16) proposed that the stigma associated with hos- pitalization for mental illness is (perceived as) a form of ego damage and suggested that this stigma is reversible. On interviewing 22 people after dis- charge, they inferred an outright expression of shame or inferiority that was linked with an expec- tation of discrimination or inferior treatment from others. Thus, the possible reasons for the stigma may be real or perceived. This perception is linked with several factors such as age, sex, race, educa- tional background and socioeconomic status. After replicating the Cumming’s earlier study (14), Brockman & D’Arcy (17) showed that a slight overall shift towards acceptance of mentally ill people had occurred. Education had no apprecia- ble impact on attitudes in their study, whereas age had negative influence only for those over 40 years old.

In a series of studies conducted in the late 1940s, Ramsey & Seiff (18, 19) asked a broadly represen- tative sample of 345 adults 6 questions on the aetiology and the treatment of mental illness. Sub- jects with higher educational and occupational status were less likely to view mental illness as a punishment for sin or the outcome of poor living conditions. They were also less pessimistic about recovery. These studies are remarkable in their broad representative sampling and looking at the aetiology and management of mental illness prior to the availability of modern drugs and aetiologi- cal advances.

Nunnally’s (20) 6-year survey of public know- ledge of mental health and illness was far more extensive. He sampled 400 adults with 180 opinion statements and concluded that “. . . mentally ill

(people) are regarded with fear, distrust and dis- like by the general public”. In this study old and young people, regardless of educational status, considered mentally ill people as relatively dan- gerous, dirty, unpredictable and worthless. Using the same scale 23 years later, Ahmed & Vish- wanathan (21) showed that the public is still uneducated about mental illness. The slight shift in the attitudes could be explained by the change in historical time context. They criticized the Nun- nally scale for its low inter-item consistency.

Whatley (22) went on to develop a social dis- tance scale measuring the distance people tend to keep between themselves and the mentally ill. The knowledge of such a distance is vital in terms of acceptance and providing social support. Admin- istering the scale to nearly 2000 respondents revealed that any tendencies to restrict social inter- action with formerly mentally ill people were most likely to arise in situations of closeness. Only 15% of the subjects were prepared to hire as a baby- sitter someone who had seen a psychiatrist. Subse- quently, the scale has been used to measure other deviant behaviour as well. Nevertheless, the study did not reflect all the factors in the social environ- ment to which recuperating people may be exposed. Whatley suggests that the liberalization of attitudes towards mental illness may be a reflection of liberalization in other areas.

In the 1960s the studies in the United States were either optimistic (showing improved attitudes and a greater acceptance of the mental hygiene move- ment’s concepts of mental illness) or pessimistic (in that little had changed) (5) . Twenty years on, the situation does not appear to have changed very much.

Star (23) used case vignettes to elicit attitudes towards mental illness and showed that the respondents tended to resist calling anyone men- tally ill and did so only as a last resort. The vignettes have been used in several studies.

The United Kingdom and Western Europe In the United Kingdom and in part of Europe, the attitudes towards mental illness have arisen from the Athenian thinking on the psyche. Por-

I *

Page 4: Attitudes towards mental illness

4 D. BHUGRA

ter (24) admirably charts out the social history of madness. The growing importance of science and technology, among other things, was seen as influential in channelling the power of right- thinking people in imposing the social norms. The men of power and the church influenced pub- lic opinion, which then identified the attitudes and behaviour of marginal social elements that would then be called disturbed and, hence, alien. The apparent divide between those who set and met the norms and those who did not was linked with the expectations imposed by the central state or the market economy. Institutionalization created more “lunatics” who were then locked away and madness thus became infinitely more menacing. The expectations of cure were not fulfilled and asylums were forced to change their character. With the current winds of deinstitutionalization, the reversal of the asylum role has started, but without any alternative in the expectations in the cure and management of “madness”. Prins (25) and McDonald (26) have offered historical over- views of mental illness and law in early and mod- ern England respectively. Following the transmis- sion of a documentary on mental illness, the British Broadcasting Corporation audience re- search department (27) found that the public’s tolerance for people who were or had been men- tally ill varied depending upon the circumstances. More than 80% would be willing to mix with such people in areas of low personal involvement such as walking in the street, but with an increase in personal involvement, attitudes hardened consid- erably. Only 50% would work with someone who was or had been mentally ill and only 25 070 felt that such an individual should be in a position of responsibility over others. It is not clear whether the effects of the television documentary had con- tributed to such attitudes. McLean (28) had shown that for most people in her sample, television was the major source of education.

After 1960 in North America Star vignettes (23) were increasingly being used to look at the public attitudes and the public’s knowl- edge of mental illness. The psychiatrists were seen as distant, detached, expensive doctors who engendered more fear, anxiety and hostility (29).

Psychiatrists were usually criticized or lampooned in the media (30). Institutional (or public) psychia- try (in the United States) has been criticized for its lack of quality (31). This is only one of several factors associated with negative images of psychi- atrists. Noting a (chronic) shortage of psychiatrists in institutions, Shore (31) questioned whether the public associated psychiatrists with conditions in institutions despite their lack of involvement or because of it. Shore believes that the inadequate care provided in many public facilities is a result of a tacit social contract between the public and pri- vate sectors that enables private institutions to maintain their fiscal integrity and their quality of care by moving undesirable people to public institutions. Thus, in addition to increased expec- tations of cure and help, the psychiatrist is seen as failing to provide a basic network, which fuels the negative attitudes. Psychiatrists have been accused of having no special expertise in marriage counsel- ling, vocational guidance, juvenile delinquency and so on and yet posing as experts (32).

Bourne (33), tracing the reasons for negative attitudes to several factors dating from the mid- 1950s, suggests that psychiatrists were seen as peo- ple who promised too much and, in the final analy- sis, failed to deliver. Some of the factors outlined were: lack of any scientific basis; difficulties in proper measuring tools, especially for psycho- therapy; discounting of self-skills; and unrealistic expectations. Some factors have changed and are filtering through to the public consciousness. Ex- mental patients have been seen as potentially explo- sive, strange and mysterious, but also convincing. Fracchia et al. (34) argued that the slight improve- ment in acceptance of mentally ill people in their sample may be because mental illness is seen in a medical model. In a separate study (35) they sug- gested that reactions to any taboo group depend on:

the frequency of the actual or anticipated

place of the behaviour in the hierarchy of the

intensity of the behaviour; visibility in the open community; geographic location and distribution of the behaviour in the community; and the drama of circumstances surrounding the behaviour.

behavioural events;

taboos;

Page 5: Attitudes towards mental illness

ATTITUDES TOWARDS MENTAL ILLNESS 5

The small study sample was not able to dis- criminate between levels of severity of illness of the formerly mentally ill people, which the authors argued was because of the degree of depersonalization caused by mental illness. Lagos et al. (36) emphasize that community edu- cation programmes, which taught the public that there was no reason to fear mentally ill people, failed because of inaccurate teaching. Lagos et al. do not consider the problem to be fear, but the quality and the quantity of fear under the wrong circumstances and for the wrong reasons. They suggest that the public be told to what extent, under what circumstances or for what reasons formerly mentally ill people ought to be feared, and how one ought to respond when a person is frightening.

Some studies, notably those of Crocetti et al. (37-39), use case vignettes to show that virtually all the subjects in one of their samples agreed with the question, “DO you think people who are mentally ill require a doctor’s care as people who have any other sort of illness do?”. The sample of blue-collar workers may have been more aware of mental illness and its effects. Poor and uneducated people and these of low social class did not have negative attitudes. Dunham (40) criticized Crocetti et al. for equating attitudes with behaviour. Rabkin (7) cautions that atti- tudes are commonly viewed as precursors or determinants of overt behaviour and that the effect of situational variables and individual beliefs should not be underestimated.

Phillips (41) criticized Crocetti et al. for focus- ing on formerly mentally ill people and not on those who are currently ill. In another study, Phillips (42) interviewed 300 white females to examine rejection of the mentally ill as a con- sequence of seeking help for mental disorders. Using case vignettes, sources of help for these individuals and a social distance scale, Phillips found that the largest increase in rejection rates occurred when a person had been admitted to a mental hospital. These people may be rejected, not because they have a health problem or because they are unable to help themselves, but because contact with a psychiatrist or mental hospital (often) defines them as mentally ill or insane.

In a subsequent article, Phillips (43) concluded that rejection appears to be based on how visibly the behaviour deviates from customary role expectations. Men were rejected more often. Phillips cautioned that a distinction needs to be maintained between publicly defined mentally ill people and psychiatrically defined mentally ill people. Other reasons for rejection are that symptoms continue and visibility is high. Thus, if people are mentally ill, as long as they hide themselves, no overt rejection will occur. Two- thirds of lawyers surveyed endorsed ideas of secrecy about mental illness (44). Gurin et al. (45) found that 42% of subjects would seek out clergymen for support and only 18% a psychiatr- ist or a psychologist. Clergymen scored highest in recognizing the seriousness of mental illness (46). Therefore, it is not surprising that more people would choose friends, family physicians or cler- gymen before resorting to psychiatry (44). Scott et al. (47) showed that people accepted the build- ing where the help was sought rather than the mental illness.

Halpert (48) cautioned that a serious weakness of many mental hospitals is the lack of clear, unequivocal communication of agency goals and objectives. A big public mental hospital may not have personal implications, but a mental health centre may, and therefore aggressive and con- tinuing public education is necessary.

In a study that had methodological problems, Meyer (49) found that 75% of his sample would work with the mentally ill, but only 44% could imagine falling in love with such a person. Nev- ertheless, these subjects were able to identify the features and were less worried about dangerous- ness. Clark & Martire (50) also showed that psychiatrists were viewed positively but not hos- pitals. Thus, it may seem that the stigma is placed on the institution rather than the mental health professional, but this is not always clear.

Various authors have argued that the label of mental illness is stigmatizing (51, 52). The usage of terms such as clients instead of patients has been criticized by some (53), because it turns psychistrists (and doctors) into businesspeople. Sarbin & Mancuso (54) found that the public tends to be more tolerant of deviant conduct when it is not described using mental illness

Page 6: Attitudes towards mental illness

6 D. BHUGRA

labels. The person in the street needs to collabor- ate in setting rules for deviant or perplexing conduct. It could be argued that women who care for the mentally ill are also more likely to be seen as mentally ill and their cooperation is needed to change public attitudes.

When male schizophrenics live with their mothers or wives, they are more prone to relapse than when they live with more distant relatives ( 5 5 ) . This has obvious implications for manage- ment; expressed emotion is focused on this (56- 58). No data are currently available on the rela- tionships between opinions towards mental ill- ness and expressed emotion.

Johannsen (8) suggested that the effects of society’s attitudes produce effects on family and job after discharge. Socioeconomic factors in themselves can hamper discharge. Cumming & Cumming (16) showed that some illnesses pro- duce more stigma than others, and certainly for women, the role they take up after returning from mental hospitals is important in reversing the loss of reputation caused by hospitalization. Stigma, secrecy, withdrawal and concealment are some of the responses of families. People with knowledge of mentally ill people, not sur- prisingly, are knowledgeable (59). The issue becomes complicated further because men are more likely to be admitted with “feminine” ill- nesses, such as neuroses, and women with more “masculine” illnesses, such as personality disor- ders and drug abuse (60). The issues of diag- nosis, education and support are interrelated and extremely complex. Kreisman & Joy (61) provide literature that looks at family responses to men- tal illness in relatives.

Johnson & Beditz (62) showed that attitudes towards mental illness were becoming more posi- tive among the young. In addition to age, the set-up of the care system and the distance to facilities are linked to the perception of the avail- ability of health services (63).

The effects of education on attitudes towards mental illness are mixed. Yamamoto & Dizney (64) did not find any effect, whereas Wright & Klein (65) and Clark & Binks (66) did. Pupils at a secondary medical school reflected the attitudes held by lay people in one study (67), whereas psychologists showed textbook knowledge only.

Compared with these two groups, the mentally ill people had much more realistic attitudes, per- haps because they were based on their own expe- riences.

Interestingly, Dovidio et al. (68) concluded that people are ambivalent in their attitudes towards persons with psychological problems. In an undergraduate college class, 94 males and 81 females were asked to participate in a study of first impressions and the college application pro- cess. Individuals described in these applications as having psychological problems were perceived by others in relatively negative ways in terms of security and sociability, but relatively favourably in terms of character and competence. Educated people had stereotype images. The study did not specify the type of illness, which, in itself, could have produced different results. Social status has always been associated with social attitudes and it is not different for attitudes towards mental illness (69, 70). Hollingshead & Redlich (70) fur- ther demonstrated that people of lower social class almost never actively sought psychiatric help for themselves or their relatives. Dohren- wand & Chin-Shong (71) suggest that the defini- tions of mental illness vary according to social status. People of lower socioeconomic status hold a narrower definition of mental illness. Freeman (72) reports similar findings; social class variables, independent of education, were not associated with attitudes towards mental illness. Hollingshead & Redlich (70) showed that rela- tives of mentally ill people in higher socioeconomic classes expressed feelings of shame and guilt, whereas relatives with low social status showed fear and resentment.

Other factors that have been suggested to pro- mote negative attitudes include the severity of ill- ness, presence of a diagnostic iabel and the avail- ability of alternative roles (73). Attitudes can also vary according to other factors such as the degree that symptoms can be controlled with drugs and the degree that people respond to encouragement from others. Attitudes may be more favourable if people are eager to be treated than when they are apathetic and withdrawn. The public rejects psychotics more than neurotics.

Attitudes towards community-based services vary. Kirk & Therrien (75) point out that there is a

Page 7: Attitudes towards mental illness

ATTITUDES TOWARDS MENTAL ILLNESS 7

well-established, although slowly changing, pat- tern of public fear, anxiety and revulsion in response to mentally ill people. Thus, placing peo- ple who have spent long periods in hospital back in the community (without adequately preparing the person and the community) often risks subjecting people to negative attitudes. Not only are these people unwelcome in the community, but formal and informa1 attempts are quite often made to exclude them from the community by using city ordinances, zoning codes and police arrests (76).

Morrison (77) suggested using “demythologiz- ing” seminars to look at the changes in attitudes towards mental illness. Morrison suggested that an educational programme using the Client Atti- tude Questionnaire is a vital component that may help to demythologize primary prevention; thus, the community can be prepared and people can avoid excessive dependence on professionals. Preparing the community for people means that direct and indirect approaches need to be employed. Key community leaders and neigh- bourhood groups need to be contacted (78). The media may not play a constructive role (79). Specific programmes may leave great doubt in the minds of all who may need help (80).

Stern&Minkoff (81) suggest that the community needs to be confronted by models of community health ideology. The clinicians’ sources of self- esteem and professional ability and their views of chronicity inhibited effective programming. The lack of trust in a psychiatrist’s ability to maintain confidentiality is another factor quoted as hinder- ing people from obtaining psychiatric care (82). Block (83) found a need for in-service education, workshops and sensitivity training to help bridge the gaps in attitudes among various staff levels, disciplines and service units. Legislation may achieve some things, but not acceptance (78). This was further highlighted in 1986. After changes in admission laws in Washington State, Pierce et al. (84) found that, despite no change in the population needing help, one hospital responded by imposing a cap on admissions and the other by phasing out voluntary admissions at a rate roughly equal to the increase in commitments. Pierce et al. suggest that public events and administrative interventions may have significant causal links with legal interven- tions.

Community leaders have an important role to play. They can influence the community by example and innovation. Bentz & Edgerton (85) found that their leader groups were more likely to reserve judgement on a given issue and also less able to be categorical than the general pub- lic. The general public, in their sample, believed that mental illness is caused by deficits in moral strength or heredity. In the private sector, the ability to pay was seen as of primary importance in getting treatment from psychiatrists. In a sam- ple of suburban residents, Mannheimer et al. (86) found that 40% of respondents believed that one of the main causes of mental illness was lack of moral strength or will. The belief in certain aetiological factors is bound to affect seeking help, as well as the provision of support.

The information to the public needs to target specific populations, bearing in mind their age, educational attainments, social status, etc.

After the 1960s in the United Kingdom and Western Europe Norton (87) asserted that even though the num- bers of schizophrenic people may fall and mental hospitals may be reduced in size, the community can only carry a certain number of mentally abnormal people. This is also true for mentally ill people. In a survey of former inpatients, more than half of 788 respondents would go back to the same hospital (88). Paramedical and non- medical staff were rated highly in their attitudes towards the staff. Klein (88) states: “By defini- tion, patients are experts at knowing what it feels like to be a patient and their views thus carry unique authority.” Only a few mentally ill peopie are vociferous enough to express their needs, and voluntary agencies such as the National Schizo- phrenia Fellowship and MIND in the United Kingdom must be developed. Their roles and influences will be discussed in a subsequent arti- cle. As Shadish et al. (89) warn, there is no guarantee that the preferences of voluntary bodies represent real needs. It is therefore impor- tant to also look at other factors when evaluating needs. Southwood (90) warned that public rela- tion exercises would not help the public and

Page 8: Attitudes towards mental illness

8 D. BHUGRA

emphasized teaching psychological medicine to medical students and general practitioners.

In the late 1960s, two surveys in North- amptonshire and Nottinghamshire showed peo- ple expressing considerable reservation about mentally ill people. Attitudes became less liberal as more personal contact was involved (91, 92). In the Northamptonshire survey, there was no measurable indication that knowledge in the community had changed in the desired direction, even after an extensive and enthusiastic educa- tional campaign. As the British Medical Journal (93) warned, “. . . a prerequisite for an effective community care services is a community that cares”. A World Health Organization technical report stressed that “. . . if society is to reap the full benefit of the advances of modern psychia- try, it must learn to collaborate in the prevention of mental disorder and in the therapy and rehabilitation of the mentally ill” (94). The British Medical Journal (95) pointed out that managing change in personal habits or in public attitudes required understanding the forces motivating individuals and groups in the com- munity. The emphasis on the success of care in the community depends on positive attitudes, among other factors (96). The success or failure of the plans was seen to be dependent upon finances and lack of doctors (97).

Graves et al. (98), using Star case vignettes, showed that even though their subjects recog- nized the need to help schizophrenic people and alcoholic people, they did not recognize either as a mental illness. The anxious neurotic was less likely to be seen as mentally ill. More highly educated people were less likely to permit close contact with simple schizophrenic people. Bliz- zard (99) appeared to be more optimistic in his belief that folk beliefs about the causation of mental illness were giving way to “scientific” forms of explanation.

Lyketsos et a]. (100) showed that fear of men- tally ill people had been reduced in Greece. This study, however, looked at a very selected sample of visitors attending a concert at a psychiatric hospital. The younger age group, well educated people and those in social classes I and I1 saw mental illness as a psychosocial problem, where- as older people saw it as a disorder of the nerv-

ous system. Thus, the former groups are capable of taking into account various factors and man- age to look at the psychosocial areas, whereas the latter see it as an organic illness. In a subse- quent study Aritzi et al. (101) showed that rural Greeks were more likely to accept a mentally ill person as a neighbour or workmate. Using the same questionnaire 2 years on, Malliori et al. (102) found that there was little change in nega- tive views of people attending a concert at the largest psychiatric hospital in the same area.

The attitudes of a group of clinicians and students in Turkey showed broadly similar results to their counterparts in the United States (103). Mexican-Americans show “old-fashioned” views if they are not acculturated (104). Parra & So (105) showed that the Chicano generation perceives mental illness, not only differently from, but more narrowly than the Anglo and the older Mexican-American.

Sue et al. (105) examined the conceptions of mental illness of Asian and Caucasian students in the United States, Asian-Americans were more likely to believe that mentally ill people look and act differently, that willpower is the basis of personal adjustment, that women are more prone to mental disorder than men, that avoiding mor- bid thoughts enhances mental health and that mental disorder is induced by organic factors. After controlling for age and socioeconomic sta- tus, only the last 2 factors remained significant. Thus, the notion of self-control and organic causality reflect Asian-Americans’ subcultural constructs.

A study of Arabs in Israel (107) showed that Christian and highly educated respondents ex- pressed less negative attitudes. Cohen & Strue- ning’s Opinions on Mental Illness Scale was used to show that people in Israel held dual, inconsis- tent opinions on mental illness, although they were affected by education, religiosity and age (108). Thus, cross-cultural comparisons across cultures and within the same culture (between different ethnic groups) are important in plan- ning service needs, education and financing.

In a recently completed study of people attending a general practice surgery (109), males were more likely to object to the opening of a hostel for mentally ill people in their street and

Page 9: Attitudes towards mental illness

ATTITUDES TOWARDS MENTAL ILLNESS 9

also less liberal in their attitudes towards men- tal illness.

Ingham (1 10) also suggests that prolonged treatment leading to slow improvement is impor- tant in promoting negative attitudes. Studies in the Federal Republic of Germany (1 1 1 ) and Pol- and (67) also suggest that attitudes are affected by a multitude of factors. The attitudes of employers towards fomerly mentally ill people have been studied in the United States (1 12), but no similar studies could be traced in the literature in Europe. The increased emphasis on communi- ty care and the paucity of studies of the attitudes of the community will lead to a discrepancy in supply and demand and, once again, psychiatrists will fail people after raising high expectations. Johannsen (8) cautions that “one major block to the dissemination of information about mental illness is that the subject in itself is anxiety- arousing and predisposes the recipient of the information to reject it . . .”. This needs to be remembered. The perception of (existent and nonexistent) barriers is also a major factor in seeking help (1 13).

Conclusions The issues of attitudes, provision of help and most important, acceptance of help are all com- plex. The following issues need to be given due consideration if caregivers are to succeed in providing care to those who need it.

Expectations Expectations of the community, and the family and friends of mentally ill people should be realistic. In the past, psychiatry (and the psy- chiatrist) have promised, but failed to deliver. Adequate, sensible information delivered in a practical format in simple language, accom- panied by written information (booklets or pamphlets) should help to change attitudes and expectations.

Public psychiatry The issue of private vs. public psychiatry is not

currently important in the United Kingdom, but is likely to become so. The psychiatrist needs to be seen to be approachable by both public and private patients and fellow professionals.

Time for filter It takes more than one generation for any change to filter through. It is important to keep pressing on with information, rather than providing it once and forgetting about it.

Failure to educate There has been a failure to educate not only the relatives and friends of mentally ill people, but also other health professionals. Kartun ( 1 14) indicated that

. . . when it comes to psychiatry, we found ourselves taking liberties we would never dream of taking when talking of, say, oncology or even dental hygiene. The merest trace of a sneer - a knowing wink, perhaps, or one of the smarter psychiatrist jokes - all this seems to be in order.

Catching medical students and general practi- tioners earlier in their careers will certainly add to the acceptance and early referral of cases.

Specific illnesses The attitudes towards specific illnesses are likely to vary. This may reflect previous knowledge of the illness or the fear of abnormal behaviour. The aetiological factors for different illnesses need to be explained to the caregivers. Placing a variety of patients in the same hostel may create some prob- lems in attitudes, while solving some others.

Confidentiality The fears about broken confidence need to be allayed. The psychiatrist should not be perceived as an agent of the police or the law, but a profes- sional in his own right, capable of offering care.

Research needs to focus on the discrepancy

Page 10: Attitudes towards mental illness

10 D. BHUGRA

between public education on mental health and contemporary psychiatric thinking. Epidemiolo- gical studies identifying people that suffer from mental illness in the community may give us a more realistic framework within which to work for education and care. Frameworks of psycho- social aetiology need to be emphasized and explained, in addition to biological or genetic explanations.

Attitudes have several components - some a function of enduring personality traits and others a function of the dimension of access. Increased knowledge may lower the affective component, even if the cognitive component remains unaffec- ted. The knowledge, affect and behavioural com- ponents of attitudes need to be assessed and dealt with separately. Multivariate factors and criteria need to be taken into account while designing studies that measure the availability and the accessibility of services during both acute and chronic phases. Gibson (115) warns that the result of losing the leadership of mental health professionals would be catastrophic:

. . . the essence o f professionalism is control over bo th the performance of professional tasks and t h e setting and conditions under which such tasks are performed. Individually and collectively we mus t demonstrate through responsible act ion that psychiatry is a profes- sion worthy of public trust .

Acknowledgements The author would like to thank Dr C.M.B. Pare and Professor J .P. Leff for their comments on earlier drafts of this paper. Mrs M. Legge has been invaluable in the literature search -

grateful thanks to her - and also to Mrs S . Wagstaff for secretarial help.

References I . Dain N. Concepts of insanity in the United States 1789-

1865. New Brunswick, NJ: Rutgers University Press, 1964. 2. Jones K. Society looks at the psychiatrist. Br J Psychiatry

1978:132:321-332. 3. Anon. Editorial. Schizophr Bull 1974:10:6-8. 4. Noble P. Mental health services and legislation - an histor-

ical review. Med Sci Law 1981:21:16-26. 5. Rabkin J. Public attitudes toward mental illness: a review

of the literature. Schizophr Bull 1974:10:9-23. 6. Horwitz A. The reaction to mental illness In: Horwitz A,

ed. The social control of mental illness. New York: John Wiley, 1982:85-120.

7. Rabkin J . Opinions about mental illness: a review of the literature. Psychol Bull 1972:77:153-171.

8. Johannsen WJ. Attitudes towards mental patients: a review of empirical research. Ment Hygiene 1969:53:218- 228.

9. Bhugra D. Psychopathology in ancient India. Submitted. 10. Haldipur CV. Madness in ancient India, concept of

insanity in Charaka Samhita. Compr Psychiatry 1984: 25:335-344.

11. Caplan R. Psychiatry and the community in 19th century America. New York: Basic Books, 1969.

12. Wing JK. Services for the mentally ill. In: Wing JK, ed. Reasoning about madness. Oxford: Oxford University Press, 1978: 194-244.

13. Bockhoven JS. Moral treatment in American psychiatry. New York: Springer, 1963.

14. Cumming E, Cumming J. Closed ranks: an experiment in mental health. Cambridge, MA: Harvard University Press, 1957.

15. Susser M, Watson W. Sociology in medicine. London: Oxlord Univesity Press, 1962.

16. Cumming J , Cumming E. On the stigma of mental illness. Community Ment Health J 1965:1:135-143.

17. Brockman J , D’Arcy C. Correlates of attitudinal social distance toward the mentally ill: a review and resurvey. SOC Psychiatry 1978: 13:69-77.

18. Ramsey G, Seipp M. Attitudes and opinions concerning mental illness. Psychiatr Q 1948:22:428-444.

19. Ramsey G, Seipp M. Public opinions and information concerning mental health. J Clin Psychol 1948:4:397-406.

20. Nunnally J . Popular conceptions of mental health: their development and change. New York: Holt, Rinehart and Winston, 1961.

21. Ahmed S, Vishwanathan P. Factor-analytical study of Nunnally’s scale of popular concepts of mental health. Psychol Rep 1984:54:455-461.

22. Whatley C. Social attitudes towards discharged patients. SOC Problems 1958-1959:6:313-320.

23. Star S. Cited in (5). 24. Porter R. Mind forg’d manacles. London: Athlone, 1987. 25. Prins HA. Attitudes towards the mentally disordered. Med

26. McDonald M. Insanity in early modern England. Psychol

27. British Broadcasting Corporation. The hurt mind: an

28. Mclean U. Community attitudes to mental illness in Edin-

29. Felix RH. The image of the psychiatrist - past, present and

30. Myers JM. The image of the psychiatrist. Am J Psychiatry

31. Shore MF. Public psychiatry: the public’s view. Hosp

32. Davidson HA. The image of the psychistrist. Am J Psychi-

33. Bourne P. The psychiatrist’s responsibility and the public

Sci Law 1984:24: 18 1 - 19 1.

Med 1981:11:11-25.

audience research report. London: BBC, 1957.

burgh. Br J Prev SOC Med 1969:23:45-52.

future. Psychiatry 1964:121:318-322.

1964: 121 :323-328.

Community Psychiatry 1979:30:768-771.

atry 1964:121:329-334.

trust. Am J Psychiatry 1978:135:174-177.

Page 11: Attitudes towards mental illness

ATTITUDES TOWARDS MENTAL ILLNESS 11

34. Fracchia J, Sheppard C, Canale D et al. Community perception of serverity of illness levels of former mental patients. Compr Psychiatry 1976:17:775-778.

35. Fracchia J , Canale D, Cambria E et al. Public views of ex- mental patients: a note on perceived dangerousness and unpredictability. Psychol Rep 1976:38:495-498.

36. Lagos J, Perlmutter K, Saexinger H. Fear of the mentally ill: empirical support for the common man’s response. Am J Psychiatry 1977:134:1134-1137.

37. Crocetti G, Lemkau P. Public opinion of psychiatric home care in an urban area. Am J Public Health 1963:53:409- 417.

38. Crocetti G, Spiro H, Lemkau P et al. Multiple models and mental illness: a rejoinder to “Failure of a moral enter- prise: attitudes of the public toward mental illness’’ by T. Sarbin and J. Mancuo. J Consult Clin Psychol 1972: 391-5.

39. Crocetti G, Spiro H, Siassi I . Are the ranks closed? Attitudinal social distance and mental illness. Am J Psy- chiatry 1971:127: 1121-1 127.

40. Dunham H. Discussion of Crocetti and Lemkau’s study. Am J Public Health 1963:53:415-417.

41. Phillips D. Rejection of the mentally ill: the influence of behaviour and sex. Am Sociol Rev 1964:29679-687.

42. Phillips D. Rejection: a possible consequence for seeking help for mental disorders. Am Sociol Rev 1963:28:963- 972.

43. Phillips D. Public identification and acceptance of the mentally ill. Am J Public Health 196656755-763.

44. Woodward JL. Changing ideas on mental illness and its treatment. Am Sociol Rev 1951:16443-454.

45. Gurin G, Verof J , Field S . Americans view their mental health. New York: Basic Books, 1960.

46. Dohrenwand B, Bernard V, Kolb L. The orientations of leaders in an urban area toward problems of mental illness. Am J Psychiatry 1961:118:683-691.

47. Scott R, Blach P, Flynn T. A comparison of community attitudes toward CMHC services and clients with those of mental hospitals. Am J Community Psychol 1983:11:741- 749.

48. Halpert HP. Public relations in mental health pro- grammes. Public Health Rep 196520: 195-200.

49. Meyer JK. Attitudes towards mental illness in a Maryland community. Public Health Rep 1964:79769-772.

50. Clark R, Martire G. Public attitudes towards psychiatry. Cited in (31).

51. Farina A, Ring K. The influence of perceived mental illness on interpersonal relationships. J Abnorm Psychol 1965:70:47-51.

52. Farina A, Holland C, Ring K. Role of stigma and set in interpersonal reaction. J Abnorm Psychol 1971: 76:421- 429.

53. Weinberg J . Response to the Presidential Address. Am J Psychiatry 1977:134:729-730.

54. Sarbin T, Mancuso J. Failure of a moral enterprise: atti- tudes of the public towards mental illness. J Consult Clin

55. Brown G, Carstairs GM, Topping G. Post hospital adjust- ment of chronic mental patients. Lancet 1958:i1’:685-689.

56. Brown G, Birley JL, Wing JK. Influence of family life in

Psycho1 1970:35: 159-173.

the course of schizophrenic disorders: a replication. Br J Psychiatry 1972:121:241-258.

57. Vaughn C, Leff JP. The influence of family and social factors on the course of psychiatric illness. Br J Psychiatry 1976:129:125-137.

58. Leff JP, Kuipers L, Berkowitz R et al. A controlled trial of intervention in the families of schizophrenic patients. Br J Psychiatry 1982:141: 121 -134.

59. Halpert HP. Public acceptance of the mentally ill. Public Health Rep 1969:84:59-64.

60. Rosenfield S. Sex roles and societal reactions to mental illness: the labelling of “deviant” deviance. J Health SOC Behav 1982:23:18-24.

61. Kreisman D, Joy V. Family response to the mental illness of a relative: a review of the literature. Schizophr Bull 1974:1034-57.

62. Johnson P, Beditz J . Community support systems: scaling community acceptance. Community Ment Health J 1981:17153-160.

63. Thouez JP, Munan L. Attitudes and opinions on mental health care - a care study of the rural population of the Eastern townships/Quebec/. Geogr Med 1982:12:7-25.

64. Yamamoto K, Dizney H. Rejection of the mentally ill: a study of the attitudes of student teachers. J Counsel Psy- chol 1967:14:264-268.

65. Wright F, Klein R. Attitudes of hospital personnel and the community regarding mental illness. J Consult Psychol 1966:13:106-107.

66. Clark A, Binks N. Relation of age and education to attitudes towards mental illness. Psychol Rep 1966:19:649- 650.

67. Hese R, Kret K . Opinions of the patients of the psychiatric department, medical students and students of psychology on mental diseases. Psychiatr Pol 1980:4:383-388.

68. Dovidio JF, Fishbane R, Sibicky M. Perceptions of people with psychological problems: effects of seeking counsel- ling. Psychol Rep 1985:57:1263-1270.

69. Myers J, Bean L. A decade later: a follow-up of social class and mental illness. New York: Wiley, 1968.

70. Hollingshead A, Redlich F. Social class and mental illness. New York: John Wiley & Sons, 1958.

71. Dohrenwand 9 , Chin-Shong T. Social status and attitudes toward psychological disorders: the problem of tolerance of deviance. Am Sociol Rev 1967:32:417-433.

72. Freeman H. Attitudes toward mental illness among rela- tives of former mental patients. Am Sociol Rev 1961: 2659-66.

73. Nierdazik K, Cochrane R. Public attitudes towards mental illness - the effects of behaviour, role and psychiatric labels. Int J SOC Psychiatry 1985:31:23-33.

74. Bord RJ. Rejection of the mentally ill: continuities and further developments. SOC Problems 1971 :18:496-509.

75. Kirk S, Therrien M. Community mental health myths and the fate of former hospitalised patients. Psychiatry 1975:38:209-217.

76. Aviram U, Segal S . Exclusion of the mentally ill. Arch Gen Psychiatry 1973:29 126-131.

77. Morrison J. The public’s current beliefs about mental illness: serious obstacle to effective community psychol- ogy. Am J Community Psychol 1980:8:697-707.

Page 12: Attitudes towards mental illness

12 D. BHUGRA

78. Bowen WT, Twemlow SW, Boquet RE. Assessing com- munity attitudes toward mental illness. Hosp Community Psychiatry 1978:29:2S 1-253.

79. Linter JM. Refelctions on the media and the mental patient. Hosp Community Psychiatry 1979:30:415-416.

80. Torch EM. An unfair portrayal of psychiatry. Am J Psychiatry 1977:134: 1045.

81. Stern R, Minkoff K. Paradoxes in programming for chronic patients in a community clinic. Hosp Community Psychiatry 1979:306 13-61 7.

82. Lindenthal J J , Thomas CS. Psychiatrists, the public and confidentiality. J Nerv Ment Dis 1982:170:319-323.

83. Block WE. The study of attitudes about mental health in the CMHC. Community Ment Health J 1974:10:216-220.

84. Pierce GL, Durham ML, Fisher WH. The impact of public policy and publicity on admissions to state mental health hospitals. J Health Polit Policy Law 1986:11:41- 66.

85. Bentz W, Edgerton J. Consensus on attitudes towards mental illness. Arch Gen Psychiatry 1970:22:468-473.

86. Mannheimer D, Davison S , Baker M et al. Popular attitudes and beliefs about tranquillisers. Am J Psychiatry 1973 : 130 1246- 1253.

87. Norton A. Mental hospitals ins and outs. Br Med J 1961 :i:528-536.

88. Klein R . Public opinion and the NHS. Br Med J 1979:;: 1296-1 297.

89. Shadish WR, Thomas S , Bootzin RR. Criteria for success in deinstitutionalisation: perceptions of nursing homes by different interest groups. Am J Community Psychol 1982:10:553-564.

90. Southwood H. The psychiatrist and the public. Med J Aust 1961:48:771-776.

91. Gatherer A, Reid JJA. Public attitudes and mental health education: Northampton mental health project 1963. Northampton: Northampton County Council, 1967.

92. Willcocks A. Cited in (95). 93. Anon. Does the community care? Br Med J 1966:ii:655-

656. 94. World Health Organization. Technical Report Services.

Geneva: WHO, 1959 (Report No. 17). 95. Anon. Public attitudes to mental health education. Br

Med J 1968:i:69-70. 96. Altman B. Studies of attitudes towards the handicapped:

the need for a new direction. SOC Problems 1981:28:321- 337.

97. Anon. Ten year hospital plan. Br Med J 1962:i:238-239. 98. Graves GD, Krupinski J , Stoller A et al. A survey of

community attitudes towards mental illness. Aust NZ J Psychiatry 1971:5:18-28.

99. Blizzard PJ. Public images of the mentally ill in New Zealand. NZ Med J 1968:68:297-303.

100. Lyketsos G, Mouyas A, Malliori M et al. Opinion of public and patients about mental illness and psychiatric care in Greece. Br J Clin SOC Psychiatry 1985:3:59-66.

101. Aritzi S . Richardson C, Lyketsos C et ai. Opinions con- cerning mental illness and psychiatric care in a remote rural area in Greece. Br J Clin SOC Psychiatry 1987:5:19-21.

102. Malliori M, Kyriakakis V, Papadatos Y. Public opinion and psychiatric care in Greece. Br J Clin SOC Psychiatry 1987:5:78-83.

103. Eker D. Attitudes of Turkish and American clinicians and Turkish psychology students toward mental patients. Int J Psychiatry 1985:31:223-229.

104. Edgerton R, Karno M. Mexican-American bilingualism and the perception of the mental illness. Arch Gen Psy- chiatry 1971:24:286-290.

105. Parra F, So AY-C. The changing perceptions of mental illness in a Mexican-American community. Int J SOC Psychiatry 1983:2995-100.

106. Sue S , Wagner N, Davis JA et al. Conceptions of mental illness among Asian and Caucasian-American students. Psycho1 Rep 1976:38:703-708.

107. Shurka E. Attitudes of Israeli Arabs towards the mentally ill. Int J SOC Psychiatry 1983:29108.

108. Rahav M, Struening E, Andrews H. Opinions on mental illness in Israel. SOC Sci Med 1984:191151-1158.

109. Bhugra D, Scott J . Public image of psychiatry - a pilot study. Psychol Bull (in press).

110. lngham J . The public image of psychiatry. SOC Psychiatry l985:2O: 107-108.

1 1 1 . Christiansen U. The mentally ill and their psychiatric care - opinions and experience of the inhabitants of Dussel- dorf, Essen and Cologne. Psychiatr Prax 1976:3:3-15.

112. Long E, Runck B. Combating stigma through work for the mentally restored. Hosp Community Psychiatry 1983:34: 19-20.

113. Leaf P , Bruce M, Tischler G. The differential effect of attitudes on the use of mental health services. SOC Psychi- atry 1986:2f: 187-192.

114. Kartun D. Psychiatry in anguish. World Med 1983:22:46. 115. Gibson RW. A profession worthy of the public trust. Am

J Psychiatry 1977:134:723-728,

Address Dr. Dinesh Bhugra, MBBS., MRCPsych. Senior Registrar The Maudsley Hospital Denmark Hill London SE5 6AZ United Kingdom