Contemporary Beliefs About Mental UIness Among Medical Students: Implications for Education and Practice Mary-Keane, R.N., Dr. Ph. Forty-six medical students were administered the Opinion About Mental Illness (OMI) questionnaire and Derogatis' Symptom Checklist (SCL-90-R) before and after an eightweek academic and clinical course in psychiatry. Significant changes were found after the course on dimensions of Benevolence and Interpersonal Etiology, and mean scores on the community portion of the OMI scale revealed movement in a positive direction. Using multiple regression analysis the pre-test attitude scores accounted for most of the variance on post-test attitudes. Stereotyping, a very important dimension of the OMI scale, was not rejected on either the pre-course or post-course measures. The students' own psychological distress did not have an effect on attitude change.
A ttitudes are probably one of the most in hospitals who have serious psychiatric
~mportant forces in determining an
individual's response to treatment and rehabilitation (1,2). Humane attitudes among health profesSionals have been described in the literature as the most crucial ingredient of the helping relationships-patients improve significantly more with high-level empathy professionals than they do with those who function at a low level of empathy (3-7). Helping students develop desirable values and attitudes is viewed as an integral part of medical education. In the field of psychiatry, the attitudes of health professionals are of special concern because the professionals have intimate contact with the patient. Moreover, the nonpsychiatric physician is becoming more involved in the care of the mentally disabled due to the large numbers of medical patients Dr. Keane is assistant professor, City University of New York, City College-School of Nursing, West 137th Street and Convent Avenue, New York, NY 10031. Copyright e> 1990 Academic Psychiotry. );-::'
problems (8). In addition, a large proportion of the mentally ill, as well as their families, seek out the primary care physician in the community for recognition and treatment of their psychopathologic problems. Since mental patients are sensitive to and very much influenced by the attitudinal environment created by the members of the health team, holding positive attitudes should enable the medical practitioner to engage in more satisfactory and less stressful interactions. This study investigated the opinions and attitudes of a medical student population toward mental illness and placement of the mentally ill in the community before and after an eight-week academic and clinical course in psychiatry. Theorists have reported that direct experience with an attitude object has implications for change, even for deeply-rooted, long-standing attitudes based on misconceptions and inadequate information (9). On the other hand, Rabkin (10) reports \l11l \11 ) ~. '-.l
\1Il1·1~'.
I ,\11
I'NII
~ I \" I
that only some of the several components comprising attitudes are accessible to change through educational methods and direct exposure. Others feel that the presence of ego-defensive attitudes mitigates against change even with appropriate information and direct object contact because of their function in defending the self-image (11). A minor focus of the study was to measure the effect of psychological distress on attitude change. Stress is defined as a "response to stressful conditions consisting of a pattern of psychological and physiological reactions both immediate and delayed" (12). Several investigators have reported that high levels of stress in the education of medical students are an intense combination of academic requirements, clinical demands, and internal and external pressures (13,14). It was thought that symptoms of psychological stress might contribute to lack of change and/or negative change relative to mental illness attitudes. LITERATURE REVIEW Within the last several decades, several studies have examined the attitudes of medical students toward mental illness (15-18). These authors have reported significant and slight changes in a positive direction as well as lack of change or negative change on specific dimensions using the Opinions About Mental Illness questionnaire. However, more recent studies have concentrated less on measuring medical students' attitudes toward mental illness and more on their attitudes toward psychiatrists, the psychiatric clerkship, and the treatability of mentally ill patients (19,20). Four factors were added to the OMI questionnaire by Struening (Community Residence Program, Welcome Home, Stigma, and Stereotyping) (E. Struening, personal communication, 1978). This portion of the questionnaire has been used in various contexts, including populations of public health students and culturally diverse ,\l \!)I \ll( 1''-,\ ( III \ 11\1
nursing students, but it has not been used to measure medical student reponses to placement of the mentally ill in the community. None of the studies to date have measured medical student responses to placement of the mentally ill in the community using Struening's OMI questionnaire. Periodic surveys of opinions about mental illness provide the psychiatric educator with information regarding the kind of impact education and practice have on attitude change. Furthermore, this information can help identify gaps in knowledge about mental illness and develop more effective educational strategies to assist practitioners to meet the needs of the acute and chronic mentally disabled regardless of the setting. METHODOLOGY Sample Medical students were solicited for their participation in the study by an announcement in small groups of about 20 or less and through assistance from faculty in some classes. Appointments for data collection began in June 1984 and extended through September 1985. A total of 80 questionnaires (OMI, Derogatis Symptom Checklist-90 [SCL-90-RJ, and a demographic data form) were distributed in class prior to the psychiatric clerkship. Only 65 medical students completed all the information. When the OMI was administered again at the completion of the course there were 46 sets of completed pre- and post-test responses. Medical students were matched on preand post-tests via demographics, particularly date of birth. This was done in order to preserve anonymity and to facilitate a reporting of the respondents' true attitudes and psychological distress profiles. Instruments The OMI questionnaire is composed of 100 Likert-type opinion items with provisI ~,
1,11111 '"'
\I~l
II 1 \11"; \: III '-I ,",'
ions for subjects to indicate their responses to each item by checking one of six choices on a strongly agree-strongly disagree continuum. Subjected to factor analytic techniques, the OMI yields nine significant attitude dimensions (factors) underlying opinions about mental illness and the mentally ill. The items in the questionnaire refer to the causes, descriptions, treatment measures, prognoses, and responses to placement of the mentally ill in the community. Reliabilities and validities have already been established for the original five dimensions of the OMI scale (1). Reliability coefficients for the more recent community factors ranged from .83 to .86 using a population of psychology students, lay people, and religious community groups (B. Link, personal communication). The final tOO-item OMI scale provides nine separate scores for each respondent, one for each factor. The six possible response choices for each of the items on the scales were assigned numeric values ranging from one for a strongly agree to six for a strongly disagree, regardless of the direction (positive or negative) of the content. There are eight attitude
dimensions (factors) comprising the OMI scale for this study. (Factor C, Mental Hygiene Ideology, was omitted). The eight factors are defined in the appendix. The Derogatis Symptom Checklist, or SCL-90-R, is a measure of current psychological distress involving nine dimensions (including anxiety, depresSion, hostility, and somatic concerns) which have evolved through clinical and empirical procedures. Internal consistency and test-retest reliability measures have been carried out by Derogatis and reported in his SCL-90-R administration, scoring, and procedures manual (21). Comparisons of the nine primary symptom dimensions of the SCL-90-R with the various Minnesota Multiphasic Personality Inventory scales established very high convergent validity for the SCL-90 (22). RESULTS Cronbach's alpha coefficient was used to determine the estimated reliability of the OMI in the measurement of attitudes in this study. The reliability coefficients for the eight OMI factors (attitude dimensions in-
TABLEt. Change analysis on eight factors (attitude dimensions) of OMI scale (N=46) Pre-Test OMIChange Factors
Mean
Factor A, 18.5 Authoritarianism 45.9 FactorB, Benevolence FactorD, 18.5 Social Restrictiveness FactorE, 20.2 Interpersonal Etiology 28.2 FactorF, Community Residence Program FactorG, 34.6 Welcome Home FactorH, 26.8 Stigma 31.4 Factor I, Stereotyping inion about mental illness
Post-Test
S.D.
Mean
S.D.
Diff.
5.3
18.5
5.0
.065
0.10
.919
5.4
46.5
4.6
1.67
2.54
.013"
4.5
18.2
5.8
.32
.42
.679
3.9
21.4
4.0
1.21
1.94
.059"
7.9
27.5
7.5
.76
.83
.413
5.3
35.5
4.6
.91
1.33
.190
5.2
26.4
5.1
.39
.68
.490
5.2
30.4
5.0
.95
1.36
.179
estionnaire.
P
cluding recent additional items to the OMI scale) were internally consistent (.51 to .79). A major focus of this study was the emphasis on attitudes and how they changed before and after a psychiatric clerkship. Correlated t's were performed to test whether attitudes had changed in medical students before and after the course. The OMI scale revealed significant changes in a positive direction on Benevolence (Factor B, p
A ttitudes are probably one of the most in hospitals who have serious psychiatric
~mportant forces in determining an
individual's response to treatment and rehabilitation (1,2). Humane attitudes among health profesSionals have been described in the literature as the most crucial ingredient of the helping relationships-patients improve significantly more with high-level empathy professionals than they do with those who function at a low level of empathy (3-7). Helping students develop desirable values and attitudes is viewed as an integral part of medical education. In the field of psychiatry, the attitudes of health professionals are of special concern because the professionals have intimate contact with the patient. Moreover, the nonpsychiatric physician is becoming more involved in the care of the mentally disabled due to the large numbers of medical patients Dr. Keane is assistant professor, City University of New York, City College-School of Nursing, West 137th Street and Convent Avenue, New York, NY 10031. Copyright e> 1990 Academic Psychiotry. );-::'
problems (8). In addition, a large proportion of the mentally ill, as well as their families, seek out the primary care physician in the community for recognition and treatment of their psychopathologic problems. Since mental patients are sensitive to and very much influenced by the attitudinal environment created by the members of the health team, holding positive attitudes should enable the medical practitioner to engage in more satisfactory and less stressful interactions. This study investigated the opinions and attitudes of a medical student population toward mental illness and placement of the mentally ill in the community before and after an eight-week academic and clinical course in psychiatry. Theorists have reported that direct experience with an attitude object has implications for change, even for deeply-rooted, long-standing attitudes based on misconceptions and inadequate information (9). On the other hand, Rabkin (10) reports \l11l \11 ) ~. '-.l
\1Il1·1~'.
I ,\11
I'NII
~ I \" I
that only some of the several components comprising attitudes are accessible to change through educational methods and direct exposure. Others feel that the presence of ego-defensive attitudes mitigates against change even with appropriate information and direct object contact because of their function in defending the self-image (11). A minor focus of the study was to measure the effect of psychological distress on attitude change. Stress is defined as a "response to stressful conditions consisting of a pattern of psychological and physiological reactions both immediate and delayed" (12). Several investigators have reported that high levels of stress in the education of medical students are an intense combination of academic requirements, clinical demands, and internal and external pressures (13,14). It was thought that symptoms of psychological stress might contribute to lack of change and/or negative change relative to mental illness attitudes. LITERATURE REVIEW Within the last several decades, several studies have examined the attitudes of medical students toward mental illness (15-18). These authors have reported significant and slight changes in a positive direction as well as lack of change or negative change on specific dimensions using the Opinions About Mental Illness questionnaire. However, more recent studies have concentrated less on measuring medical students' attitudes toward mental illness and more on their attitudes toward psychiatrists, the psychiatric clerkship, and the treatability of mentally ill patients (19,20). Four factors were added to the OMI questionnaire by Struening (Community Residence Program, Welcome Home, Stigma, and Stereotyping) (E. Struening, personal communication, 1978). This portion of the questionnaire has been used in various contexts, including populations of public health students and culturally diverse ,\l \!)I \ll( 1''-,\ ( III \ 11\1
nursing students, but it has not been used to measure medical student reponses to placement of the mentally ill in the community. None of the studies to date have measured medical student responses to placement of the mentally ill in the community using Struening's OMI questionnaire. Periodic surveys of opinions about mental illness provide the psychiatric educator with information regarding the kind of impact education and practice have on attitude change. Furthermore, this information can help identify gaps in knowledge about mental illness and develop more effective educational strategies to assist practitioners to meet the needs of the acute and chronic mentally disabled regardless of the setting. METHODOLOGY Sample Medical students were solicited for their participation in the study by an announcement in small groups of about 20 or less and through assistance from faculty in some classes. Appointments for data collection began in June 1984 and extended through September 1985. A total of 80 questionnaires (OMI, Derogatis Symptom Checklist-90 [SCL-90-RJ, and a demographic data form) were distributed in class prior to the psychiatric clerkship. Only 65 medical students completed all the information. When the OMI was administered again at the completion of the course there were 46 sets of completed pre- and post-test responses. Medical students were matched on preand post-tests via demographics, particularly date of birth. This was done in order to preserve anonymity and to facilitate a reporting of the respondents' true attitudes and psychological distress profiles. Instruments The OMI questionnaire is composed of 100 Likert-type opinion items with provisI ~,
1,11111 '"'
\I~l
II 1 \11"; \: III '-I ,",'
ions for subjects to indicate their responses to each item by checking one of six choices on a strongly agree-strongly disagree continuum. Subjected to factor analytic techniques, the OMI yields nine significant attitude dimensions (factors) underlying opinions about mental illness and the mentally ill. The items in the questionnaire refer to the causes, descriptions, treatment measures, prognoses, and responses to placement of the mentally ill in the community. Reliabilities and validities have already been established for the original five dimensions of the OMI scale (1). Reliability coefficients for the more recent community factors ranged from .83 to .86 using a population of psychology students, lay people, and religious community groups (B. Link, personal communication). The final tOO-item OMI scale provides nine separate scores for each respondent, one for each factor. The six possible response choices for each of the items on the scales were assigned numeric values ranging from one for a strongly agree to six for a strongly disagree, regardless of the direction (positive or negative) of the content. There are eight attitude
dimensions (factors) comprising the OMI scale for this study. (Factor C, Mental Hygiene Ideology, was omitted). The eight factors are defined in the appendix. The Derogatis Symptom Checklist, or SCL-90-R, is a measure of current psychological distress involving nine dimensions (including anxiety, depresSion, hostility, and somatic concerns) which have evolved through clinical and empirical procedures. Internal consistency and test-retest reliability measures have been carried out by Derogatis and reported in his SCL-90-R administration, scoring, and procedures manual (21). Comparisons of the nine primary symptom dimensions of the SCL-90-R with the various Minnesota Multiphasic Personality Inventory scales established very high convergent validity for the SCL-90 (22). RESULTS Cronbach's alpha coefficient was used to determine the estimated reliability of the OMI in the measurement of attitudes in this study. The reliability coefficients for the eight OMI factors (attitude dimensions in-
TABLEt. Change analysis on eight factors (attitude dimensions) of OMI scale (N=46) Pre-Test OMIChange Factors
Mean
Factor A, 18.5 Authoritarianism 45.9 FactorB, Benevolence FactorD, 18.5 Social Restrictiveness FactorE, 20.2 Interpersonal Etiology 28.2 FactorF, Community Residence Program FactorG, 34.6 Welcome Home FactorH, 26.8 Stigma 31.4 Factor I, Stereotyping inion about mental illness
Post-Test
S.D.
Mean
S.D.
Diff.
5.3
18.5
5.0
.065
0.10
.919
5.4
46.5
4.6
1.67
2.54
.013"
4.5
18.2
5.8
.32
.42
.679
3.9
21.4
4.0
1.21
1.94
.059"
7.9
27.5
7.5
.76
.83
.413
5.3
35.5
4.6
.91
1.33
.190
5.2
26.4
5.1
.39
.68
.490
5.2
30.4
5.0
.95
1.36
.179
estionnaire.
P
cluding recent additional items to the OMI scale) were internally consistent (.51 to .79). A major focus of this study was the emphasis on attitudes and how they changed before and after a psychiatric clerkship. Correlated t's were performed to test whether attitudes had changed in medical students before and after the course. The OMI scale revealed significant changes in a positive direction on Benevolence (Factor B, p
