Zdrav Vestn 2008; 77: 481–5 481 Research article/Raziskovalni prispevek STIGMA OF MENTAL ILLNESS: COMPARISON OF PATIENTS’ AND STUDENTS’ ATTITUDES IN SLOVENIA STIGMA DUŠEVNE BOLEZNI: PRIMERJAVA STALIŠČ BOLNIKOV IN ŠTUDENTOV V SLOVENIJI Mateja Strbad1, Igor Švab2, Bojan Zalar1, Vesna Švab1 1 University Psychiatric Hospital Ljubljana, Studenec 48, 1260 Ljubljana Polje Department of Family Medicine, Medical Faculty Ljubljana, Poljanski nasip 58, 1000 Ljubljana Abstract Background Methods Results Conclusions Key words It is known that the consequences of stigmatization towards people with severe mental illness reflect themselves in a lack of self-esteem and consequently in low level of initiatives to improve one’s status in the community. The burden of stigma may cause denial of participation in the stigmatized group. So far, there were few studies to compare the mentally ill patients’ perception of the »other« mentally ill with the perception of future professionals in mental health services. We have compared stigmatizing attitudes of students with attitudes of patients with severe mental illness. The patients expressed higher stigmatization scores towards people with severe mental illness than the students. Negative attitudes of patients with severe mental illness towards their own group present a serious problem. Actions are needed to improve their identification and reduce the perceived need for exclusion from their group. mental illness; stigma; students; the »other« mentally ill; Slovenia Izvleček Izhodišča Ljudje z duševnimi boleznimi se sami diskriminirajo, zato ker se soočijo s svojimi manjšimi zmožnostmi in ker ponotranijo predsodke o duševnih bolnikih, kar prizadene njihovo samospoštovanje. Posledice se kažejo v upadu funkcioniranja, socialnem umiku, tesnobi in depresivnosti. Strah pred izključitvijo vodi v poskuse, da bi svojo bolezen prikrili. Stigmatiziranost in samostigmatizacija sta za duševne bolnike bolj obremenjujoča kot simptomi bolezni in posledična nezmožnost. Bolnikov ne ovirata le pri iskanju pomoči in sodelovanju v psihiatričnem zdravljenju, ampak tudi omejujeta njihove pobude za izboljšanje položaja v skupnosti. Stigmatizacija in samostigmatizacija sta pomembna razloga za zanikanje bolezni in s tem pripadnosti stigmatizirani skupini. Do zdaj je bilo opravljenih le malo študij, ki bi raziskovale odnos duševno bolnih do skupine ljudi s hudimi duševnimi motnjami, torej do njihove skupine. Raziskovanje tega področja je pomembno zato, da bi lahko zmanjšali predsodke prizadetih (bolnikov), ki so pomembni nosilci anti-diskriminacije in sodelavci v izobraževalnih antidiskriminacijskih programih, in zato da bi lahko vplivali na njihovo samospoštovanje. Corresponding author / Avtorica za dopisovanje: Doc. dr. Vesna Švab, Psihiatrična klinika Ljubljana, Studenec 48, 1260 Ljubljana, tel.: 041 913 766 482 Zdrav Vestn 2008; 77 Metode Pripravili smo anketo, s katero smo primerjali stereotipna in diskriminatorna prepričanja in socialno distanco do duševnih bolnikov pri odpuščenih psihiatričnih pacientih in študentih Univerze v Ljubljani. Anketo je reševalo 140 uporabnikov Slovenskega združenja za duševno zdravje ŠENT in 327 študentov šestih fakultet (medicine, psihologije, socialnega dela, delovne terapije, zdravstvene nege in socialne pedagogike), torej tistih bodočih strokovnjakov, ki bodo potencialno delali z ljudmi z duševnimi boleznimi. Anketo smo izvedli pri vseh študentih, ki so se udeležili pouka, in pri vseh pacientih, vključenih v dnevni center ŠENTA. Anketiranje je bilo anonimno in prostovoljno. Anketa je vsebovala štirinajst trditev o duševnih bolnikih: sedem pogostih stereotipov (da so nevarni, napadalni, nesposobni, da jih je mogoče prepoznati na prvi pogled, da so sami krivi za svojo bolezen, da se neprimerno vedejo in da so duševne bolezni nalezljive), šest trditev, ki kažejo na socialno distanco (strah živeti v sosedstvu z duševnim bolnikom; odselitev od sostanovalca, če bi zbolel za shizofrenijo; zapustitev partnerja, če bi zbolel za shizofrenijo; za družbo je bolje, če duševni bolniki nimajo otrok ter če ne opravljajo dela z otroki in najstniki; zagovarjanje dolge hospitalizacije), in izjavo o občutkih sramu, če bi se bolezen pojavila v družini. Uporabili smo petstopenjsko Likertovo lestvico (1 – absolutno/popolnoma se strinjam, 5 – nikakor se ne strinjam/sploh se ne strinjam). Veljavnost in konsistentnost vprašalnika smo potrdili s Cronbachovim alfa testom (0,83). Za ovrednotenje rezultatov smo uporabili multivariatno analizo. Rezultati Duševni bolniki imajo bolj stigmatizirajoč odnos do drugih duševnih bolnikov kot študenti (p=0,0059). Statistično značilne razlike med skupinama anketirancev so se pojavile pri trditvah, da je duševna bolezen nalezljiva (p = 0,0010), da se duševno bolni ne znajo ustrezno obnašati (p = 0,0006), da so sami krivi za svojo bolezen (p = 0,0000), da jih je mogoče prepoznati na prvi pogled (p = 0,0000) ter da bi jih bilo sram, če bi kdo izvedel, da je anketiranec v sorodu z bolnikom s shizofrenijo (p = 0,0000). Zaključki Rezultati so pokazali, da imajo duševni bolniki bolj stigmatizirajoč odnos do drugih ljudi z duševnimi boleznimi kot študenti. Bolniki se skušajo distancirati od drugih duševnih bolnikov na način, da izražajo visok odpor do svoje skupine. Pripadnost stigmatizirani skupini duševno bolnih ponuja malo možnosti za socialno integracijo, zaposlitev in onemogoča dostop do drugih bolj privilegiranih družbenih skupin. Rezultati govorijo v prid terapevtskim postopkom in družbenim dejavnostim, ki krepijo moč skupine ter izboljšujejo njen družbeni in ekonomski položaj. bolniki; študentje; Slovenija Ključne besede duševna bolezen; stigma; duševni Introduction The importance of self-discrimination among patients with severe mental illness is well known. The psychological basis for self-discrimination is internalization of prejudices, damaged self-esteem1 and well-being.2 The process of self-discrimination starts with the in-ternalization of negative stereotypes and development of stigmatised identity, which leads to deterioration of functioning, lower academic performance,3 anxiety, social avoidance, depression and disability in general.4 Because of anticipated stigma,5 the patients withdraw from social relations and develop low self-esteem. They also harbor feelings of »otherness«, of not being like other patients. Denial and fear from exclusion have a strong effect on perceptions of self and serve to heighten their fears about mental illness. Stigma also entails a low public esteem that leads to the perception of hopelessness and to a shift in identity towards second-class category of psychiatric case. Many patients with severe mental illness try to conceal the illness. The ones who decide to reveal it, risk major obstacles to their lives and performance.6, 7 A patient can resist stigmatization by exclusion from the discriminated group8 and by attempting to enter the privileged social groups by denying any relationship with it. The group of women with chronic mental health problems for example did not accept society’s unfavourable representations of mental illness as valid and therefore rejected them as applicable to the self.9–12 So far little has been known about the perception of mentally ill people by the patients themselves. This perception may be important because it would reflect their possibility to identify themselves with their group. It is known that the acceptance of disability and identification with the group of patients with mental illness enables them to develop coping strategies learned through education and self-help. It can establish or enhance their self-concept, giving them better control over their illness and, consequently, lessen the stigma of perceived mental disability.13 If patients stigmatize their peers, their ability to be supportive to others such as themselves may also be difficult.14 We have tried to measure stereotypes and social distance to assess stigmatization of the mentally ill among Strbad M, Švab I, Zalar B, Švab V. Stigma of mental illness: comparison of patients’ and students’ attitudes in Slovenia 483 psychiatric patients, discharged from psychiatric hospital and to compare it with the stereotypes of university students of medicine, psychology, nursing, occupational therapy, social work and social pedagogy. The hypothesis was that the two groups would differ in their attitudes and that the level of stigmatization among the mentally ill would be lower because of their past experience. No similar study on stigmatization of people with severe mental illness was performed in Slovenia by now. Methods Subjects Participants The questionnaire was distributed to 140 patients involved in rehabilitation services and to 327 students from six faculties (medicine, psychology, social pedagogy, social work, occupational therapy and nursing) in the beginning of the academic year 2003. 19 patients and 25 students did not complete the questionnaire. Participation in the study was voluntary and anonymous for both groups. Patients were attending day centres of a Slovenian non-government association that provides services for persons with severe mental illness. They were aged from 21 to 54 years. This was a group of patients with severe mental illness characterised by high social exclusion and poverty.15 The average age of students was 22.3 years (female 22.1, male 22.5) at the beginning of their mental health curricula. Measures Assessment instrument A questionnaire with 14 statements characterizing common stereotypes and social distance to people with mental illness was developed. We have selected items that describe common prejudices about people with mental illness, used in World Psychiatric Association stigma assessment schedules and from the Schulze et al. questionnaire16 for assessing stigma among secondary students. The statements expressing discriminatory attitudes were chosen regarding the Slovenian cultural background and perceived common stereotypes among university students: that they are dangerous, disabled, incapable of work, guilty for their disease, that they would better not have any children, they are disturbing as neighbours or partners, not fit to deal with children and adolescents, that they can be recognised by sight, that they should stay hospitalised as long as possible, that mental illness is contagious and a statement describing feeling of shame because of mental illness in the family. A five point Likert-type scale was used, ranging from 1 (I completely agree) to 5 (I completely disagree). The magnitude of the Cronbach’s ? of the questionnaire was 0.83, and can be therefore regarded as high reliability instrument for a sum scale of only 14 items. Analysis The standardized variables and the variables evaluated according to Likert-type were used in multivariate analysis (MANOVA). Students and users represented independent grouping variables, while the rest were dependent variables. Our sample was large enough to allow for a normal sample distribution and to justify the use of the parametrical statistical method. The samples were comparable, and the possibility of Type 1 error was excluded by using the Box M test of homogenity of variances (Box M = 310.65, p = 0.00). Results The results of the MANOVA between students and patients are given in Table 1. Overall, the stigmatization score, based on the scale, was higher with the patients (p = 0.0059). Statistically important differences between both groups appear regarding statements that people with severe mental illness can infect another person, that they can not behave, that they are to be blamed for their disease, that they are easily recognizable, that one would be ashamed to have a family member with schizophrenia. In all these items patients tend to agree more with discriminatory statements than students (Table 1): Table 1. Comparison of attitudes among university students and users of rehabilitation services (Wilks Lambda [15.378] = .0768). Razpr. 1. Primerjava stališč med študenti Univerze v Ljubljani in uporabniki (Wilks Lambda [15.378] = .0768). Students Študentje Users Uporabniki Item Stališče Mean SD Mean SD F [1.392] p Povprečna Standardni Povprečna Standardni vrednost odklon vrednost odklon People with mental illness are more dangerous than other people. Ljudje z duševnimi boleznimi so bolj nevarni od drugih ljudi. People with mental illness might attack somebody. Mentalno prizadeti ljudje lahko koga napadejo. Mental illness is contagious. Duševna bolezen je nalezljiva. 3.44 3.44 4.72 1.21 1.19 0.70 3.39 3.27 4.29 1.48 1.41 1.21 1.310 0.8821 0.022 0.8622 0.030 0.0010* 484 Zdrav Vestn 2008; 77 Item Stališče Students Študentje Users Psihiatrični pacienti Mean Povprečna vrednost SD Standardni odklon Mean Povprečna vrednost SD Standardni odklon F [1.392] p 3.95 1.08 3.15 1.37 10.996 0.0006* 3.63 mi. 1.15 3.28 1.53 12.182 0.1168 4.72 0.73 4.15 1.19 2.473 0.0000* 4.06 1.15 3.75 1.47 27.155 0.4932 3.81 1.14 3.65 1.40 0.471 0.7745 3.71 1.15 3.58 1.39 0.082 0.8301 3.44 1.13 3.19 1.39 0.046 0.1502 2.71 1.07 2.93 1.40 2.081 0.3031 4.13 1.04 3.41 1.44 1.064 0.0000* 4.14 0.89 3.98 1.29 17.540 0.2339 People with mental illness do not know to behave themselves. Ljudje z duševnimi boleznimi se ne znajo obnašati. People with mental illness are less capable than other people. Ljudje z duševnimi boleznimi so manj sposobni v primerjavi z drugimi ljudmi. People with mental illness are responsible for their disorder. Ljudje z duševnimi boleznimi so sami krivi za svojo bolezen. I am afraid to live in a neighbourhood with a person with schizophrenia. Bojim se živeti v sosedstvu z osebo, ki ima shizofrenijo. If my room-mate had schizophrenia I should move. Če bi imel/a moj/a sostanoval/ec/ka shizofrenijo, bi se odselil/a. If my boy/girlfriend had schizophrenia I should brake the relationship. Če bi imel/o moj/e fant/dekle shizofrenijo, bi prekinila/prekinil razmerje. It is better for society that people with schizophrenia do not have children. Za družbo je bolje, da osebe s shizofrenijo nimajo otrok. It is better for society that people with schizophrenia do not work with children and adolescents. Za družbo je bolje, da ljudje s shizofrenijo ne delajo z otroki in adolescenti. I can recognise a person with mental illness by sight. Ljudi z duševnimi boleznimi lahko prepoznam že na prvi pogled. If I could decide, people with schizophrenia should stay in hospitals. Če bi lahko odločal/a, bi osebe s shizofrenijo čim dlje obdržal v psihiatrični bolnišnici. I should feel ashamed if my friends found out that somebody in my family had schizophrenia. Počutil/a bi se osramočen/o, če bi moji prijatelji ugotovili, da ima kdo v moji družini shizofrenijo. 4.09 1.12 3.35 1.42 1.423 0.0000* Overall score Skupni rezultat 3.85 1.07 3.51 1.38 7.66 0.0059* The differences among different groups of students were not statistically important. Discussion The aim of the study was to assess stigmatization of people with severe mental illness by their own group and to compare it with the attitudes of future mental health professionals. The hypothesis was that the mentally ill people would stigmatise this group to a lesser degree because they are very familiar with the illness, they have personal and direct experience with it and they have more contacts with other mentally ill. All of these characteristics should reduce stigmatiza-tion. Results proved that our hypothesis was wrong, because the patients were more negatively discriminative towards their own group than the students. The possibility that the patients would actually stigmatize themselves should probably be ruled out, since it does not seem likely that patients would consider themselves being contagious. There are probably other, more logical explanations. It is more likely that the patients tried to distance themselves from their peers, exhibiting the excessive levels of stigmatization they have encountered as patients. They did not want to identify themselves with the group and wanted to make it clear that they are different. This distance may also be influenced by the social and psychological deprivation of this group, that tries to improve its chances for social integration, social position and access to the privileged groups of society through denial of its disease.17 Besides lessening their coping abilities and compliance it reflects their resentment to participate in improving public attitudes with competent and self assured presentation of their improved functioning after psychiatric treatment and rehabilitation programs. These preliminary results may have some important implications for the work of professionals within rehabilitation and medical services and suggest that professionals should do more to empower their patients. Globally the results present also the need to take action to improve the social position of people with severe mental illness. The efforts should go beyond purely professional attitude, patients’ involvement in decision making and beyond persuasions of individual’s competences. Lobbying for better employment and economic possibilities for the whole group may be a better strategy to improve their identification. We believe that the research we have conducted should be followed up by additional comparative analyses of self-discrimination that would take into account other sociodemographic variables that may influence the attitudes towards psychiatric patients. Limitations The instrument we have developed has proven to be valid and feasible. We have encountered no major problems in adminstering it. All the students and patients have responded within 20 minutes. The high reliability coefficient allows us to use the questionnaire in future research of this kind. Nevertheless, it does not include all the important components of stigma. It includes relevant stereotypes and attitudes per- Strbad M, Švab I, Zalar B, Švab V. Stigma of mental illness: comparison of patients’ and students’ attitudes in Slovenia 485 ceived through the study process and in the Slovenian cultural environment. It is possible that the different levels of education might have played a role, since university students have higher education than the patients15 regardless the fact that students were just entering mental health education programs. We were not able to determine the amount of this bias. The study was conducted in a selected sample of students, who will most likely deal with these patients as professionals. This selection is a source of bias, since the students in this group are labelling mentally ill people less than students of other faculties, because they enter study programs that also deal with mental health. The comparison therefore does not reflect the attitudes of the general public. There is no study that would compare the discriminatory attitudes of students of different schools, which would help us in estimating this bias. The other source of bias may be the influence of specific education. Since we have sampled students from early stages of their university education (none of them had any formal teaching of mental health problems before the questionnaire was conducted), we believe that this bias could be ignored. The selection of patients from only one service may be a source of bias, as they cannot be representative of all the patients with psychiatric illness. The rehabilitation service where the study was conducted gathers people with severe mental illness, discharged and referred from psychiatric hospitals because of disability and need for support. The group actually represents the most disadvantaged group, characterised by low family support and low income,15 therefore their experience of discrimination may be more pronounced as well as their need to be excluded from this group. Acknowledgements This work was supported by ŠENT – Slovenian Association for Mental Health and by University Psychiatric Hospital Ljubljana. References 1. Link BG, Struening EL, Neese-Todd S, Asmussen S, Phelan JC. The consequences of stigma for the self-esteem of people with mental illnesses. Psychiatr Serv 2001; 52: 1621–6. 2. Link BG, Struening EL, Rahav M, Phelan JC, Nuttbrock L. On stigma and its consequences: evidence from a longitudinal study of men with dual diagnoses of mental illness and substance abuse. J Health Soc Behav 1997; 38: 177–90. 3. Quinn DM, Kahng SK, Crocker J. Discreditable: stigma effects of revealing a mental illness history on test performance. Pers Soc Psychol Bull 2004; 30: 803–15. 4. Ertugrul A, Ulug B. 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Soc Sci Med 2003; 56: 299–312. 17. Oakes PJ, Haslam JC, Turner JC. Stereotyping and social reality. Oxford: Blackwell Publishers; 1994. pp. 186–213. Arrived 2008-05-11, accepted 2008-07-11