The stigma of mental health professionals towards users with a mental disorder

Abstract

INTRODUCTION

Individuals with mental disorders are labeled in such a way that it leads to stigmatization. This generates a disadvantage as regards to the rest of the members of the society, limiting their participation as active members within it and at the same time being deleterious to their way of life. Mental health professionals are not safe from internalizing these stereotypes and prejudices assumed from their environment, thereby showing stigmatizing attitudes and behaviors towards the users in the different mental health resources.

METHODOLOGY

The design used in this study to determine the stigma of mental health professionals is a quantitative study, which was used to analyze the level of stigma presented by professionals using the Attribution Questionnaire-27 (AQ- 27). The sample consisted of 59 professionals.

RESULTS

The results obtained showed the existence of stigmatizing attitudes and behaviors by the professionals analyzed. Within the sociodemographic data of the sample, it should be noted that the higher level of education of the professionals decreased the attitudes and behaviors associated to stigma.

CONCLUSIONS

It was possible to confirm the existence of different stigma factors such as helping, coercion, pity and avoidance that affect mental health professionals.

INTRODUCTION

A stigma can be considered a mark or attribute that associates a person with undesirable characteristics. Many theoretical approaches on the stigma associated to mental health have been developed, among which we find social cognitive models that grant importance to stereotypes (negative beliefs about a group), prejudice (agreement with stereotype beliefs, or the negative emotional reactions such as fear, anger, or both), and discrimination (behavioral consequence from prejudices, such as exclusion from social and economic opportunities).

In general, the development of stigma associated to mental health comes from one's perception towards these individuals as being strange, to be feared, unpredictable, aggressive, and lacking self-control. The role played by communication media also has a negative influence on the development of stigma towards these individuals. In this context, health professionals are influenced by the ideas and cultures of the health system in which they work. According to Kassam et al., (2012), health professionals are expected to promote positive, compassionate, and supportive attitudes towards individuals with mental illness. However, some health professionals often transmit perceptions that are less supportive associated to the probability of success and recovery of people with mental illnesses.

Within the stigma associated to mental illness, three levels that interact between each other have been identified: structural, social, and internalized (2).

The structural or institutional stigma refers to the existing discriminations at the structural level, found in laws and institutions.

The social or public stigma refers to the general population stigma with respect to different groups or characteristics of the individuals. It is related with ideas or judgements created by oneself towards a context or sector of the population. In the case of individuals who suffer from mental disorders, aside from the pre-conceived ideas of the disorder, the conditioning factor is added that many of them have or have had addiction problems, increasing the stereotypes created and making difficult their access to the most adequate treatments,. From the perspective of social stigma, the effects have been studied in different groups and situations, such as the family surroundings of people with mental illness, mental health professionals, the work environment, the communication media, or the general population.

Lastly, we find the internalized stigma, which refers to the stigma that every person assumes; self-stigma., Within it, negative thoughts are created, which at the same time reduce one's self-efficacy, resulting in self-discriminatory behavior.,

The professionals who treat people with mental disorders also manifest stigmatizing attitudes and behaviors that can affect their interventions, becoming an obstacle in the search and adherence to the treatment and recovery of their patients. Situations have also been found in which illnesses or physical complaints of this profile of user are considered as psychiatric symptoms, ignoring the organic cause that could be provoking it.

Despite the existence of a greater awareness of the medical nature about psychiatric illnesses, a great number of health professionals still perceive psychiatric patients as being inferior to the others, and even violent or unpredictable, and also considering psychiatric reclusion as a type of punishment, even reaching the point in which they no longer question the emotional well-being of the patient. In a systematic review which analyzed the stigma of health professionals in Spain and at the international level, the discriminatory attitudes varied as a function of the conditions and the pathology of the patients, without their opinion differing much from the general population. Also, the authors indicated the need to delve into the stigma of health professionals towards mental illness.

Given the above, the objective of the present study was to discover if stigma exists towards individuals with mental disorders, in the professionals who serve them.

METHODOLOGY

A quantitative, observational and descriptive study was designed for the present study. The study population was composed by mental health professionals from the different healthcare resources at the Roman Alberca Psychiatric Hospital in Murcia, and the objective was to discover their attitudes and thoughts towards individuals with mental disorders. The health resources where these individuals were employed were: the General Hospital, the Long-term Stay Unit (ULE), the Medium-term Stay Regional Unit (URME), the Short-term Stay Unit (UCE), and the Mental Health Rehabilitation Centers (CRSM), the Community Assertive Treatment (TAC), and Day Hospital (HD), and the Therapeutic Apartments Program (PPT)

Before the start of the research study, the management team of the Roman Alberca Psychiatric Hospital of Murcia was contacted, and an explanation was provided about the content and objectives of the study. They were ensured from the start about the confidentiality of the data provided by the participants. The documents to the completed by the participants were provided in person, and the collection of the documents was done through a box, in order to not breach anonymity.

All the study participants signed an informed consent form. The study was approved by the Ethics Committee of Clinical Research at the Clinical University Virgen de la Arrixaca Hospital (Murcia).

The inclusion criteria for the study were: being a health professional with at least one year of work experience in mental health who wanted to participate in the study. Non-health professionals from the different healthcare resources, who were part of the Roman Alberca Psychiatric Hospital staff, were excluded from the study, such as ward staff, administrative personnel, cleaning personnel, kitchen staff, etc.

Sample

From the 118 mental health professionals who were part of the staff at the different centers, 80 wanted to be part of the study. All of them were mental health professionals, in different job categories, who were part of the healthcare resources integrated within the Roman Alberca Psychiatric Hospital of Murcia. They were provided with a short informative paragraph, a sociodemographic data sheet, and the Attribution Questionnaire-27 (AQ-27). Ultimately, 62 documents were collected. Of these, 3 were considered invalid, for a final sample number of 59 subjects.

Variables and measurement instruments of the study

To obtain the study variables, as previously mentioned, the participants were provided with the sociodemographic data sheet and the Attribution Questionnaire-27 (AQ-27) from Corrigan, Markowitz, Watson, Rowan and Kubiak (2003). In the scientific literature, the stigma associated to mental illness has been analyzed with different strategies and evaluation instruments. One of these instruments is the Attribution Questionnaire-27 (AQ-27), designed for measuring the stigmatizing attitude and beliefs towards people with mental illness, through the evaluation of constructs that explain stereotypes, beliefs, and behaviors when dealing with these patients. This instrument has been validated and widely utilized at the international level,. The populations it has been utilized with are varied. Among them, we find family members of individuals diagnosed with schizophrenia, police officers, students, and medical professionals. In Spain, it was validated by Muñoz et al., (2015), in a sample of the general population comprised of 439 individuals. Also, it has been utilized in a study with professionals who work in mental health in Spain, Portugal, and Italy, where positive and negative attitudes were observed in these professionals towards mental illnesses. The factors (Table 1) of this questionnaire constitute the dependent variables of the study. The situations posed included various possibilities: neutral or without danger, danger, danger without controllability of cause, and danger with controllability of cause. It is composed of 27 items which were answered using a Likert-type scale ranging from 1 to 9. The total stigma score oscillated between 27 and 243 points.

Table 1.

Attribution factors (AQ27)

STIGMA FACTORS	DESCRIPTION
Responsibility on mental illness	Consider the patient at fault of his/ her situation
Pity	Having pity, compassion, excessive worrying, consider that they understand him/her
Anger	Feeling angry, violent, irritated.
Dangerousness	Consider the person with a mental disorder as dangerous and unpredictable, feeling unsafe and threatened.
Fear	Feeling terrified, scared.
Helping	Wanting to help in excess, consider oneself as unable, facilitate the tasks, over-protection, paternalism.
Coercion	Force a person with a mental disorder to follow a treatment.
Segregation	Consider that the most adequate treatment is to banish him from society through confinement in a psychiatric hospital.
Avoidance	Not wanting to experience normal situations with people with mental disorders, such as having a drink, sharing a car, work together.

Data analysis

The analysis of the data obtained was performed with the statistical program SPSS v.21.0 (SPSS, Inc., Chicago, IL, USA). The categorical variables are presented as frequencies and percentages. The continuous variables are presented as mean ± standard deviation (SD), with all the factors from the AQ-27 analyzed (Table 1).

RESULTS

Table 2 describes the sociodemographic data of the professionals studied in the present work.

Table 2.

Sociodemographic Data of the Health Professionals

Gender	18 men (30.5%) 41 women (69.5%)
Age	between 24 and 63 years old mean of 43 ± 11.3 years
Profession	2 social workers (3.4%) 4 psychologists (6.8%) 4 occupational therapists (6.8%) 5 psychiatrists (8.5%) 16 nurses (27.1%) 28 nursing assistants (47,5%)
Length of time working in mental health	between 1 year and 36 years mean of 12 ± 9.1 years
Type of healthcare resource where they work	- Hospital resources 46 subjects (78%) Composed by 3 psychiatrists, 3 psychologists, 1 social worker, 2 occupational therapists, 10 nurses and 27 nursing assistants. - Community resources 13 subjects (22%) Composed by 2 psychiatrists, 1 psychologist, 1 social worker, 2 occupational therapists, 6 nurses and 1 nursing assistant.

Next, after the analysis of the AQ-27 provided to the professionals, the results obtained are described. The mean level of stigma of the entire sample was 105.03±24.81, which corresponds to a low-medium level, with the helping factor obtaining the greatest score, with a mean of 22.88±4.38, considered a high score (Figure 1).

Figure 1.

Stigma factors among the health professionals

This is followed by the factors pity, with a mean of 16.74±4.45, coercion with a mean of 16.67±4.45, and avoidance with a mean of 12.05±6.78, which obtained medium scores. The factors of responsibility, with a mean of 9.63 ± 3.4, and segregation, with a mean of 8.08±5.1, obtained low scores. The factors with the lowest scores were anger, with a mean of 5.33±3.42, followed by fear, with a mean of 6±4.26, which were considered very low scores (Figure 1).

When analyzing the questionnaire according to item, a higher mean score was obtained by the items belonging to the factor helping: AQ20 (probability of helping), with a mean of 7.83±1.49; AQ8 (willingness to talk about his/her problem), with a mean of 7.76±1.99, and AQ21 (certainty with which one believes he/she would help), with a mean of 7.29±1.63. On the contrary, the items with the lowest scores were AQ3 (I would be frightened), with a mean of 1.44±1.18; AQ10 (his current situation is his own fault), with a mean of 1.47±1.05, and AQ4 (I would be angry), with a mean of 1.51 ± 1.26.

After analyzing the data, and using gender as the variable (Figure 2), the level of general stigma was slightly higher in women, with a mean of 108.14±26.19 as compared to the men, with a mean of 97.94±20.22. This difference was also observed in the factors of stigma, with the factors compassion obtaining a mean of 17.78±4.15 for women, and 14.38±4.29 for men, an ddangerousness obtaining a mean of 8.31±4.52for women, and 5.88±2.44 for men, with the greatest difference observed in these factors. In the responsibility and avoidance factors, the values were inverted, with the men obtaining the greatest scores: 10.88±3.37 for men, and 9.14±3.32 for women, and 12.50±8.76 for men and 11.85±5.82 for women respectively.

Figure 2.

Stigma factors according to gender

Next, the independent variable age was analyzed (Figure 3), with the 60-63 years-old interval obtaining a mean of 118±49.49, 51-60 years-old with a mean of 113.84±28.5 obtaining the highest scores, and the interval 24-30 years-old, with a mean of 92.50±13.54, the one with the lowest level of stigma, followed by the age intervals 41-50 years-old with a mean of 99.70±19.63, and the 31-40 years-old with a mean of 107.68±26.7 (Figure 3). Most of the stigma factors obtained higher values in the older-age intervals, with the greatest difference observed in the factor coercion, with values of 21.5±3.53 in the 61-63 years-old interval, and 20.3±7 in the 51-60 years-old interval, as compared with 11.62±4.43 in the 24-30 years-old interval. Flowever, the factor of responsibility obtained a lower value in the 51-60 years-old interval, with a mean of 7.84±3.43.

Figure 3.

Stigma factors according to age

According to profeoion (Figure 4), the differences in the levels of general stigma were very evident, with the nursing assistants having a level that was clearly superior than the rest, with a mean of 121.53±24.23 as compared to the levels of the other groups, such as psychologists, with a mean of 98.75±16.52, and the social workers, with a mean of 98.5±10.6. The lower levels of stigma were found in the occupational therapists, with a mean of 83.75±13.09, followed by psychiatrists with a mean of 87.8±17.36, and nurses, with a mean of 89.25±11.68 (Figure 4). According to the factors, the highest scores were obtained by the nurses in the factor of helping, with a mean of 25.25±2.01, the nursing assistants in the factor coercion, with a mean of 20.5±5.13, the psychologists with the compassion factor with a mean of 18.25±1.70, the social workers with the factor avoidance, with a mean of 17.5±9.19, the assistants with the segregation factor, with a mean of 11.85±4.8, and the psychiatrists in the responsibility factor with a mean of 11.8±2.58. The maximum values of coercion and segregation belonging to the group of assistants were the furthest away from the second-highest values of these factors: 20.5±5.13 and 11.85±4.81 as compared to 15.50±6.36 in social workers, and 6±2.58 in occupational therapist, respectively.

Figure 4.

Stigma factors according to professional category

The results found considering the length of time at their current employment in mental health (Figure 5) showed that the higher levels of stigma were obtained by the interval 31-36 years of work, with a mean of 131.33±41.94, followed by 16 to 20 years, with a mean of 110±13.94, and 21 to 25 years, with a mean of 109.5±43.24. The lowest values of stigma corresponded to the intervals 11 to 15 years, with a mean of 96.88±19.69, followed by 1 to 5 years, with a mean of 100.33±23.71 (Figure 5).

Figure 5.

Stigma factors according to length of time worked

According to factors, the 31 to 36 years of work also obtained the greatest scores in most of the stigma factors: responsibility, with a mean of 12±1, pity, with a mean of 17.66±5.77, danger, with a mean of 11±7, fear, 12.33±8.14, helping, 26±1, coercion 22.66±3.21, segregation 12±8.18, and avoidance 14.66±10.4. The factor of anger obtained the highest value in the 16 to 20 years of work interval, with a mean of 6.8±4.38 (Figure 5).

The type of healthcare resource (Figure 6) where they participants worked was differentiated between hospital (Medium-term and Short-term Stay Regional Units), and community (Day Hospital, Community Assertive Treatment, and Therapeutic Apartments). The stigma was higher in the professionals from hospital resources, with a mean of 111.36±23.69, as compared to the mean of 82.61±13.13 obtained by the community resources. In the stigma factors, the hospital resource professionals obtained the highest scores, except for the factor of helping, in which the scores were higher for the professionals from community resources.

Figure 6.

Stigma factors according to resources

DISCUSSION

Due to the care offered by a hospital institution, the ratio of hospital personnel clearly leans towards less-qualified professionals (nursing assistants), who are mainly destined to provide basic care to the users. As the proportion of the other professional categories was unequal, a decision was made to compare the nursing assistant personnel with the rest of the professionals. From the data obtained, the greater level of general stigma in the nursing assistant group was verified, and as they were greater in number as compared to the rest of the professionals, they tended to sway the level of the total sample towards a low-medium range, although the rest of the participants had a lower level of stigma.

In the present study, the presence of stigmatizing attitudes and behaviors towards people with mental disorders was evident in the health professionals who are dedicated to their care and treatment. It was observed that the more relevant factors of the stigma, and therefore the attitudes that more frequently appeared in these professionals, were helping, coercion, pity, and avoidance. To be able to change these attitudes and behaviors (5)_, a tool that can be used is the direct contact with the users, facilitating interaction in community surroundings outside the institution. Within the data analyzed, we found that the professional category which showed the lowest levels of stigma was Occupational Therapy, who tended to conduct interventions outside the hospital context, by maintaining a direct contact with the user during the development of the different everyday activities, thus allowing for a closer and normalized behavior.

As for the sociodemographic data, differences were found in the attitudes and behaviors of the health professionals according to their profession and training, highlighting the greater abundance of stigmatizing attitudes among the professionals with less training.

According to our results, as well results from other studies (24), the level of stigma decreases as the training of the professionals increases, so that we can attribute the differences in the results obtained to this difference in training in both samples. The level of stigma is inversely correlated with the training of the professionals: the greater the training, the lower the stigma. Thus, Tay et al. (2004) manifested that the professional qualification and experience in the area of psychiatry favored attitudes that were significantly more positive.

The nursing assistants obtained higher scores that the rest of the professionals with university degrees,. However, the attitudes of coercion results were reiterated, in regard to the taking of medication or the referral to resources by the professionals with more training, with paternalistic behaviors observed among the psychiatrists, who tended to be overprotective (11).

Therefore, without being aware, the health professionals also had negative beliefs and behaviors towards persons with mental illness. With respect to gender, age, employment in mental health, or the type of resource, taking account our results and those obtained in other studies (21), we cannot affirm that there was a significant relationship with respect to the stigmatizing attitudes of the professionals.

The health professionals in the area of mental health showed stigmatizing behaviors towards persons with mental disorders, with them perceiving that these attitudes tended to appear more frequently when they went to general hospitals and were treated by professionals who were not specialists in mental health. In the work conducted by the Royal College of Psychiatrists of London, we found that doctors, without training or experience in mental health, tended to believe that people with mental illness were dangerous or unpredictable.

Without being aware, the stigma suffered by persons with a mental disorder makes more difficult their recovery, as it has a series of negative connotations which impede them from having the same opportunities than the rest of the people. The characteristics of the pathology itself should be taken into account, and we should also add the prejudices and erroneous ideas that exist towards this type of patient profile.

All of these negative connotations that appeared throughout the study will have repercussions on the quality of life of persons with mental disorders. The health professionals must promote the empowerment of the patient to improve the health care they receive and to reduce stigma.

According to Lien et al. (2019), it is necessary and fundamental to determine the changes in the attitudes towards mental illnesses among the health professionals. In this sense, and from this perspective, the results of the present study show the stigma of the workers at different healthcare resources at the Roman Alberca Psychiatric Hospital of Murcia towards mental patients. Ultimately, the results provide evidence that could be used by the institutions for the implementation of programs and actions against stigmatization, which could be focused on the improvement of the attitudes of health professionals towards mental health. This could have positive repercussions on their recovery and could help improve the health care provided, among other aspects.

A limitation of this study is that is addressed the perspective of the health professionals, although delving into the perspective of the patients is also necessary. As a future line of research, we propose the need to develop a complementary qualitative study to the present one, with a sufficiently large population and from the perspective of the mental health services user that could allow delving into the subject of study. In this manner, the clinical situations and the multiple factors that could be involved could be better understood.

CONCLUSION

Throughout the study, we verified the existence of different stigma factors such as helping, coercion, pity, and avoidance, which affect mental health professionals. Among the tools that could be used to mitigate these factors, we find training and the interaction with these users in everyday situations outside the institution, which could allow the breaking of the barrier which has a negative effect on the improvement of the intervention.