Issues in Mental Health Nursing, 35:694–703, 2014 Copyright © 2014 Informa Healthcare USA, Inc. ISSN: 0161-2840 print / 1096-4673 online DOI: 10.3109/01612840.2014.892551
Predictors of Mental Illness Stigma and Attitudes among College Students: Using Vignettes from a Campus Common Reading Program Veronica D. Feeg, PhD, RN, FAAN, Laura S. Prager, MSN, RN, CDDN, QDCP, and Lois B. Moylan, PhD, RN, CNS PMH
Issues Ment Health Nurs Downloaded from informahealthcare.com by Oakland University on 05/02/15 For personal use only.
Molloy College, Division of Nursing, Rockville Centre, New York, USA
Kathleen Maurer Smith, PhD, and Meritta Cullinan, PhD Molloy College, Division of Social Sciences, Rockville Centre, New York, USA
Research has demonstrated that stigmatizing mentally ill individuals is prevalent and often results in lack of adherence to or avoidance of treatment. The present study sought to examine attitudes of college students regarding mental illness as part of a campus-wide “common readings” program. The book selected was a non-fiction account of a young girl with mental illness and the program was developed to initiate dialogue about young people with mental problems. Faculty from multiple disciplines collaborated on the project. A sample of 309 students completed a webbased survey after reading a vignette about an adolescent girl with mental illness. The vignette description was based on a character in the book selected in the program. The instruments measured attribution of stigma, social distance, and familiarity with people who have mental illness. Results demonstrated that younger students and those who are less familiar with mental illness were more likely to stigmatize and maintain social distance from those who are mentally ill. Awareness of the study findings can assist health professionals and mental health workers to identify interventions that can decrease stigma. Psychiatric mental health nurses are well positioned to lead the education effort aimed at reducing stigmatizing attitudes among the public.
INTRODUCTION Molloy College is an independent Catholic college situated in Long Island, New York. It has approximately 4,000 students divided among multiple Liberal Arts, Humanities and Professional programs. Nursing is the largest program, with approximately 2,000 students and it has the only doctoral program in the school. Several years ago, the college initiated a community reading program, where the entire college community, students, faculty, administrators and staff were encouraged to read a selected book. Titles selected relate to topics which address ethical Address correspondence to Veronica D. Feeg, Molloy College, Division of Nursing, 1000 Hempstead Avenue, Rockville Centre, New York 11571, USA. E-mail: [email protected]
issues or topics of social significance. At the end of the reading, campus activities are planned related to the content of the book, including discussion groups and a presentation by the author. Several years ago, the book Hurry Down Sunshine by Michael Greenberg (2008), describing a father’s attempt to understand and supportively deal with his daughter’s manicdepression was selected. The response generated led faculty to conduct a study related to mental illness stigma among the students. This became a multidisciplinary undertaking when members of the Sociology Department joined the project. This paper will discuss the phenomenon of stigma associated with mental illness and the study related to the characteristics of college students in conjunction with this project carried out at the college.
STIGMA AND MENTAL ILLNESS Stigma and discrimination affect all aspects of the lives of some patients with mental illness resulting in denial of their social, political, cultural, and civil rights. Many studies have described the problem of stigma for people with mental illness, which lead to patterns of discrimination and injustice in the workplace (Brohan & Thornicroft, 2010), in health care (Desai, Rosenheck, Druss, & Perlin, 2002) and written in public policies by legislators (Corrigan, Markowitz, Watson, Rowan, & Kubiak, 2003). In fact, the Surgeon General of the United States has identified stigma as a major impediment to the treatment of mental disorders (US Department of Health and Human Services, 1999). For these reasons, researchers have sought strategies to minimize the stigma that is associated with individuals who have had a mental illness. Mental illness stigma refers to the view that individuals with mental illness are marked, have undesirable characteristics, or deserve disdain. Stigma can be defined as “being socially discredited or perceived as flawed based on a personal characteristic” (Sanders, Thompson, Noel, & Campbell, 2004, p. 529). The
694
Issues Ment Health Nurs Downloaded from informahealthcare.com by Oakland University on 05/02/15 For personal use only.
PREDICTORS OF MENTAL ILLNESS STIGMA AND ATTITUDES AMONG COLLEGE STUDENTS
origins of the concept of stigma emerged from the theoretical classics of Bogardus (1925) and Goffman (1963), a concept suggesting that attributes of the mentally ill affected others’ discriminatory beliefs. From the ancient Greek word meaning “mark,” to contemporary derogatory labels, stigma has been the badge that differentiates some individuals from others in a socially derived “pecking order.” Unfortunately, mental illness stigma interferes with how patients are treated in health care and how they self-identify to seek help, which creates barriers to effective interventions (National Alliance for Mental Illness [NAMI], n.d.). Research is needed to recognize sources of stigma and ways to mediate how people are influenced by their reactions to people with mental illness. Nurses who work in mental health are key professionals to assist in changing the stigma that many non-professionals often associate with psychiatric disorders.
STIGMA RESEARCH Research on the stigmatization of mental illness suggests that there are explicit, stereotyping attitudes, perhaps controllable, and implicit measures that are assumed to reflect more automatic beliefs (Greenwald & Banaji, 1995; Greenwald, Nosek, & Banaji, 2003). The relationship between these have been reported as significant but weak (Hoffman, Gawronski, Gschwendner, Le, & Schmitt, 2005) with implicit measures more predictive of behaviors (Asendorpf, Banse, & Mucke, 2002). Stigma derives from two major aspects: (1) a public one identifying reaction of the general public to people with mental illness, and (2) more private thinking of self-stigma, representing prejudice that people with mental illness tend to turn towards themselves (Goffman, 1963). How individuals internalize the social responses to themselves contribute to their self-perception of the mental illness and lack of willingness to self-disclose. Studies have found that in comparison, individuals self-perceive psychiatric disorders more negatively than physical disorders (Corrigan et al., 2000) and are less prone to disclose a personal history related to mental illness compared to hypertension or diabetes (Roeloffs, Sherbourne, Unutzer, Fink, Tang, & Wells, 2003). The social and health consequences associated with the stigma of mental illness labels can be costly. People with mental illness may hold the same beliefs as society at large and deny painful symptoms with their reluctance to seek care (Komiya, Good, & Sherrod, 2000). Negative health outcomes and health care costs associated with a mental illness label are significant and impede referrals (Cleary, Deacon, Jackson, Andrew, & Chan, 2012). In addition, adherence to treatment may be reduced due to stigma with those who have received a label of mental illness (Monteith & Pettit, 2011). According to Dew et al. (2007), fear of being labeled with mental illness may result in those experiencing psychological distress, to not seek necessary treatment. Numerous studies have documented the negative beliefs held by the public about persons with mental illness (Bathje & Pryor, 2011; Holmes, Corrigan, Williams, Canar, & Wozniak, 1999;
695
Roeloffs et al., 2003). According to SANE, a mental health charity to improve the quality of life for people affected by mental illness, 74% of people with a mental illness reported that they had experienced stigma in the last year; 16% reported stigma in the workplace; and 13% reported being affected from staff in the health service. Considering the serious impact of stigma, researchers and mental health workers have sought strategies to minimize the stigma that is associated with individuals who have mental illness and approach the diagnosis, treatment and policies with parity in all medical conditions. However, these strategies must be based on a sound understanding of pre-disposing characteristics of “stigmatizers” and the attributes they associate with these illnesses. Some studies have measured whether personal characteristics of individuals are determinants of their stigmatizing attitudes and behaviors. Personal experiences, such as familiarity with mental illness, have been predictive of the responses in groups of social distancing and negative attitudes (Holmes et al., 1999; Phelan & Basow, 2007). Some extrinsic behaviors such as stereotyping and overtly negative behaviors can be impacted by interventions, such as education and select experiences (Corrigan, Larson, Sells, Niessen, & Watson, 2007; Schulze, Richter-Werling, Matschinger, & Angermeyer, 2003; Stuart, 2006). Although internal characteristics, such as demographics and personal histories, cannot be changed, these still may be a focus for interventions which can modify the effects. Spagnolo, Murphy and Lue (2008) report multiple studies which demonstrate that attitudes and behaviors can be positively impacted by intervention. In their own study of 426 high-school students, a highly significant decrease in stigma attitudes was reported after the students received an intervention program which included education about mental illness and meeting mental health system care consumers who shared their stories. Recognizing the importance of the issue of stigma and the fact that the students at the college were about to engage in the reading project related to the experience of a family with a mentally ill adolescent, it was decided by faculty to conduct a study of the students’ attitudes toward mental illness.
CAMPUS “COMMON READING” PROGRAM STUDY The purpose of the first phase of this study was to describe the characteristics of the students before the implementation of the project. A follow-up was planned but is beyond the scope of this paper. The hypotheses for the study were: 1. Characteristics such as personal contact (i.e. “familiarity”) of college students with mental illness will affect students’: (a) “stigmatizing”/negative attitudes about individuals with mental illness, including: Factor 1 (Fear/Dangerousness); Factor 2 (Help/Interaction); Factor 3 (Responsibility); Factor 4 (Forcing Treatment); Factor 5 (Empathy); and Factor 6 (Negative Emotion).
Issues Ment Health Nurs Downloaded from informahealthcare.com by Oakland University on 05/02/15 For personal use only.
696
V. D. FEEG ET AL.
(b) social distance desirability of the person with mental illness, including: (1) renting a room to; (2) working on the same job; (3) having a neighbor; (4) rooming with; (5) having children marry; (6) introducing to a friend; and (7) recommending for a job. 2. Demographic characteristics (age, marital status, having children, race/ethnicity) will affect students’: (a) “stigmatizing”/negative attitudes about individuals with mental illness, including: Factor 1 (Fear/Dangerousness); Factor 2 (Help/Interaction); Factor 3 (Responsibility); Factor 4 (Forcing Treatment); Factor 5 (Empathy); and Factor 6 (Negative Emotion). (b) social distance desirability of the person with a mental illness, including: (1) renting a room to; (2) working on the same job; (3) having a neighbor; (4) rooming with; (5) having children marry; (6) introducing to a friend; (7) recommending for a job. METHOD Sample The campus of approximately 4,000 students was the target population and all students in the community received the invitation and web-based survey via e-mail. The resulting convenience sample of participants in the beginning of the semester (n = 309) represented those who completed the survey and yielded a range of usable responses in the multiple analyses (n = 264–277). The demographics of the sample included: 186 White (67.9%); 27 Black/Non-Hispanic (9.9%); 32 Hispanic (11.7%); 17 Asian (6.2%); and 20 other (4.4%). Most respondents were undergraduate and under 25 years of age (72.8%). Marital status showed a majority of single, never married respondents (82.3%) and not surprisingly, without children (85.3%). These sample characteristics are similar to the campus community (Table 1). Procedures A cross-section, comparative descriptive design was used for the study. Molloy College is an independent Catholic college, which draws its students from suburban Long Island and the metropolitan area located 25 miles east of New York City. The ethnic diversity of the student population closely reflects the surrounding communities. Although a Catholic school, many religions are represented by the students. The study protocol was approved by the Institutional Review Board (IRB) in accordance with the guidelines for a web-based, anonymous survey. A modest incentive was offered to respondents who wished to participate in a raffle of $25 at the conclusion of the study. An invitation to participate was e-mailed to all students enrolled in full- and part-time classes, with a brief statement of informed consent and a vignette (description) of “Sally,” an adolescent with a mental illness who experiences a serious breakdown that requires hospitalization (Figure 1). The e-mail included information about informed consent, promise of
TABLE 1 Demographics – sample and campus comparison (undergraduate only) Sample (%) Race/ethnicity Black/non-Hispanic White/non-Hispanic Hispanic Asian Other∗ Age Under 18 18–21 22–35 36–45 46–55 Over 55 Marital status Single/never married Married Separated/divorced/widowed Children Without children With children
Campus (%)
9.9 67.9 11.7 6.2 4.4
14.5 63.7 11.8 7.1 0.8
4.4 52.3 30.8 7.3 3.7 1.5
3.4 48.3 37.9 6.1 3.5 0.8
82.4 14.4 3.2
90.1 9.3 0.1
85.3% 14.8%
Unknown Unknown
∗ Includes non-resident Alien, American Indian or Alaska Native, Native Hawaiian or Other Pacific Islander, Race/Ethnicity unknown, and two or more Races.
anonymity, a link to a web-based survey of attitudes toward mental illness, a demographic form, and information about whom to contact for questions about the study. Three reminders were sent to all students over the first month of the program. The survey was closed to new responses after 30 days. Study Materials – Vignette Research The study used a vignette approach to elicit deep attitudes from participants that may not surface in direct survey studies. The vignette allows the researcher to manipulate the variables of interest or stimulate the psychological responses of interest. In this study, the vignette about “Sally” was an abbreviated narrative, based on the book that would be part of the shared reading experiences across campus. It was clear that some students would read the full book and some would not, so the abbreviated description was used prior to the program and post-tested again to assess the impact of the program. Vignette research has been used extensively in research on stigma of mental illness (Link, Cullen, Frank, & Wozniak, 1987). A vignette portrays a character or brief scenario that prompts a response. It can be based on real events that have been developed with anonymity, or fictitious scenarios that are purely hypothetical. With the use of vignettes, participants read the vignette and respond to questions or participate in and
PREDICTORS OF MENTAL ILLNESS STIGMA AND ATTITUDES AMONG COLLEGE STUDENTS
697
Meet Sally
Issues Ment Health Nurs Downloaded from informahealthcare.com by Oakland University on 05/02/15 For personal use only.
Sally is a 15-year-old living with her father and his new wife in New York City. She is a student who spends an inordinate amount of time alone, reading, writing, and listening to music on her walkman. She goes through periods of not sleeping and not eating. Over the summer, her behavior changes and becomes erratic and out of control. The condition builds for a while, gathering strength, until it overwhelms her. She becomes delusional, has auditory hallucinations, with disjointed and fragmented thinking. The more she speaks, the more incoherent she becomes, uttering sounds that converge into a dialect that only she understands. Her body and mind, fueled with volts of what seem like electrifying energy, results in explosive periods of distorted, aggressive behavior. Because her problem is a combination of mood and thought disorders, it interferes with communication and her thinking is jumbled. She is ambivalent with her father from extreme adoration to extreme detestation of his presence. She has uncontrolled outbursts without boundaries of her own safety, and although she tries to control herself, she can’t. She is preoccupied with her own thinking and distracted from the alterations in her senses. She has flashes of insight but at other times, she has no idea of reality and responds to people inappropriately. Sally is hospitalized in a psychiatric facility and receives treatment with medication that controls her symptoms. When her behavior improves and her thinking is clear, she is discharged and goes home to live with her father and step-mother. She goes back to school and is able to accept the fact that she has a mental illness with appropriate insight into her condition. FIGURE 1. Vignette.
contribute to conversation. The primary role is to obtain information from participants about knowledge, attitudes, and perceptions in regard to a given described circumstance. With utilization of the research tool of vignettes, information can be gathered on difficult or sensitive topics (Hughes & Huby, 2002). They provide less intrusion, are less fatiguing and are a more efficient way of gathering preliminary data (Paddam, Barnes, & Langdon, 2010). The vignette approach provides researchers with a method and opportunity for complementing other analysis of data (Wareing, 2010). The character in this study vignette was based on the main character of the book. The vignette was developed by the researchers using content from the book to create a brief composite of the main character. Input into the creation of the vignette was sought from faculty of the sociology and nursing departments who had read the book. The final version of the vignette was submitted to four faculty judges who were nurses holding advanced psychiatric/mental health degrees and had also read the book. Used in conjunction with the established measures, the faculty judges made revisions to the vignette to yield acceptable readability for non-health students for content validity of the study. Attitude Measures The measures accompanied the vignette about Sally’s mental illness and were selected to measure college students’ attitudes and beliefs about individuals with mental illness, including aspects such as: (a) fear/dangerousness; (b) help/interaction; (c) responsibility; (d) forcing treatment; (e) empathy; and (f)
negative emotions; and to identify changes in the students’ desire for social distance and impact on mental illness stigma, as an outcome of the community dialogue. Sally’s psychiatric episode was depicted in the vignette and was followed by the Attribution Questionnaire (Brown, 2008); a Social Distance Scale – adapted (Link, Cullen, Frank, & Wozniak, 1987); and a familiarity scale-based level of contact (Holmes et al., 1999); as well as a set of demographic questions. The measures were selected from the literature based on their congruency with social attribution theory and with the research hypotheses. Based on the theoretical framework of social attribution theory, Corrigan and colleagues (2003, 2010) used a short description of “Harry,” a person with mental illness, and asked respondents 27 questions about how they perceived Harry. Brown (2008) further clarified the instrument by factor analysis to yield six attributes that were used as dependent variables in this study. The higher the score on each of these factors, the more negative the stigma ascribed to “Harry” in the respondent’s perception of him for that factor. Brown (2008) reported acceptable validity and reliability for use in research. These factors included: •
Factor 1. Fear/Dangerousness Factor 2. Help/Interaction Factor 3. Responsibility Factor 4. Forcing Treatment • Factor 5. Empathy • Factor 6. Negative Emotion. • • •
Issues Ment Health Nurs Downloaded from informahealthcare.com by Oakland University on 05/02/15 For personal use only.
698
V. D. FEEG ET AL.
Social distance (SD) is the willingness to be close to a person with mental illness in ways such as living near, working with, and dating, or allowing a loved one to date. Based on the theoretical discussions and feelings leading to discrediting and discrimination, Link and colleagues (1987) based their questions on a fictitious character “Jim” described with a mental illness. For this study, social distance variables were developed in the same format and included the total score and individual item measures for willingness to: (1) rent a room to someone like Sally; (2) work on the same job with someone like Sally; (3) have someone like Sally as a neighbor; (4) have Sally as a room-mate; (5) have your children marry someone like Sally; (6) introduce Sally with a young man you are friendly with; and (7) recommend someone like Sally for a job. The higher the score, the more social distance desired for each item. Familiarity or personal contact is a measure that established a metric to determine gradations of familiarity with a mentally ill person. The instrument designed by Holmes and colleagues (1999) is a 12-item checklist that produces a score that reflects the closeness or personal contact an individual has had with mental illness. The mean of rank order correlations summarizing interrater reliability is reported as 0.83. The higher the score on the 12 items, the more familiar or personal contact one has had with a person who has a mental illness. RESULTS For clarity, the data were analyzed according to each separate hypothesis, using the measures for each of the six attributes and total/individual social distance variables as the dependent variable. Preliminary descriptive statistics of intrinsic characteristics yielded a number of significant correlations to warrant hypothesis testing for predicting directional differences (Table 2). Demographic characteristics yielded statistically significant, albeit weak, correlations for age with the factors of fear or dangerousness (r = −0.138, p < 0.05); wanting to help or interact with Sally (r = 0.134, p < 0.05); forcing treatment (r = −0.210, p < 0.01); and negative emotion (r = −0.170, p < 0.01). Having
children was significantly related to wanting to help or interact with Sally (r = 0.123, p < 0.05); and to forcing treatment (r = −0.157, p < 0.01). Subsequent analyses were organized to test hypotheses according to predictors of the dependent variables of individual social distance items and aggregate factors. Differences among student majors were not analyzed at this phase of the study, although later, in the follow-up, findings did indicate differences between nurses, psychologists and other majors in the attribute of “Help/Interaction” (F = 3.77, p < 0.05). Predictors of Social Distance: Familiarity Familiarity was calculated from the checklist to yield scores that could be categorized as “high familiarity” and “low familiarity” in order to group findings to test mean scores of the individual and total scores on items for social distance (SD) (Table 3). Although the total scores for SD were non-significant, results indicated that students who have less familiarity with mental illness were significantly less willing to work with someone who is mentally ill than those who are more familiar with mental illness, t (264) = 2.95, p = 0.003. In addition, students who have less familiarity with mental illness were significantly less willing to have someone who is mentally ill as a neighbor than those who are more familiar with mental illness, t (263) = −2.36, p = 0.019. Predictors of Social Distance: Demographic Variables Several demographic variables were used to test total and individual items from the SD scale. Marital status (married, not married), age (≥25,
Predictors of Mental Illness Stigma and Attitudes among College Students: Using Vignettes from a Campus Common Reading Program Veronica D. Feeg, PhD, RN, FAAN, Laura S. Prager, MSN, RN, CDDN, QDCP, and Lois B. Moylan, PhD, RN, CNS PMH
Issues Ment Health Nurs Downloaded from informahealthcare.com by Oakland University on 05/02/15 For personal use only.
Molloy College, Division of Nursing, Rockville Centre, New York, USA
Kathleen Maurer Smith, PhD, and Meritta Cullinan, PhD Molloy College, Division of Social Sciences, Rockville Centre, New York, USA
Research has demonstrated that stigmatizing mentally ill individuals is prevalent and often results in lack of adherence to or avoidance of treatment. The present study sought to examine attitudes of college students regarding mental illness as part of a campus-wide “common readings” program. The book selected was a non-fiction account of a young girl with mental illness and the program was developed to initiate dialogue about young people with mental problems. Faculty from multiple disciplines collaborated on the project. A sample of 309 students completed a webbased survey after reading a vignette about an adolescent girl with mental illness. The vignette description was based on a character in the book selected in the program. The instruments measured attribution of stigma, social distance, and familiarity with people who have mental illness. Results demonstrated that younger students and those who are less familiar with mental illness were more likely to stigmatize and maintain social distance from those who are mentally ill. Awareness of the study findings can assist health professionals and mental health workers to identify interventions that can decrease stigma. Psychiatric mental health nurses are well positioned to lead the education effort aimed at reducing stigmatizing attitudes among the public.
INTRODUCTION Molloy College is an independent Catholic college situated in Long Island, New York. It has approximately 4,000 students divided among multiple Liberal Arts, Humanities and Professional programs. Nursing is the largest program, with approximately 2,000 students and it has the only doctoral program in the school. Several years ago, the college initiated a community reading program, where the entire college community, students, faculty, administrators and staff were encouraged to read a selected book. Titles selected relate to topics which address ethical Address correspondence to Veronica D. Feeg, Molloy College, Division of Nursing, 1000 Hempstead Avenue, Rockville Centre, New York 11571, USA. E-mail: [email protected]
issues or topics of social significance. At the end of the reading, campus activities are planned related to the content of the book, including discussion groups and a presentation by the author. Several years ago, the book Hurry Down Sunshine by Michael Greenberg (2008), describing a father’s attempt to understand and supportively deal with his daughter’s manicdepression was selected. The response generated led faculty to conduct a study related to mental illness stigma among the students. This became a multidisciplinary undertaking when members of the Sociology Department joined the project. This paper will discuss the phenomenon of stigma associated with mental illness and the study related to the characteristics of college students in conjunction with this project carried out at the college.
STIGMA AND MENTAL ILLNESS Stigma and discrimination affect all aspects of the lives of some patients with mental illness resulting in denial of their social, political, cultural, and civil rights. Many studies have described the problem of stigma for people with mental illness, which lead to patterns of discrimination and injustice in the workplace (Brohan & Thornicroft, 2010), in health care (Desai, Rosenheck, Druss, & Perlin, 2002) and written in public policies by legislators (Corrigan, Markowitz, Watson, Rowan, & Kubiak, 2003). In fact, the Surgeon General of the United States has identified stigma as a major impediment to the treatment of mental disorders (US Department of Health and Human Services, 1999). For these reasons, researchers have sought strategies to minimize the stigma that is associated with individuals who have had a mental illness. Mental illness stigma refers to the view that individuals with mental illness are marked, have undesirable characteristics, or deserve disdain. Stigma can be defined as “being socially discredited or perceived as flawed based on a personal characteristic” (Sanders, Thompson, Noel, & Campbell, 2004, p. 529). The
694
Issues Ment Health Nurs Downloaded from informahealthcare.com by Oakland University on 05/02/15 For personal use only.
PREDICTORS OF MENTAL ILLNESS STIGMA AND ATTITUDES AMONG COLLEGE STUDENTS
origins of the concept of stigma emerged from the theoretical classics of Bogardus (1925) and Goffman (1963), a concept suggesting that attributes of the mentally ill affected others’ discriminatory beliefs. From the ancient Greek word meaning “mark,” to contemporary derogatory labels, stigma has been the badge that differentiates some individuals from others in a socially derived “pecking order.” Unfortunately, mental illness stigma interferes with how patients are treated in health care and how they self-identify to seek help, which creates barriers to effective interventions (National Alliance for Mental Illness [NAMI], n.d.). Research is needed to recognize sources of stigma and ways to mediate how people are influenced by their reactions to people with mental illness. Nurses who work in mental health are key professionals to assist in changing the stigma that many non-professionals often associate with psychiatric disorders.
STIGMA RESEARCH Research on the stigmatization of mental illness suggests that there are explicit, stereotyping attitudes, perhaps controllable, and implicit measures that are assumed to reflect more automatic beliefs (Greenwald & Banaji, 1995; Greenwald, Nosek, & Banaji, 2003). The relationship between these have been reported as significant but weak (Hoffman, Gawronski, Gschwendner, Le, & Schmitt, 2005) with implicit measures more predictive of behaviors (Asendorpf, Banse, & Mucke, 2002). Stigma derives from two major aspects: (1) a public one identifying reaction of the general public to people with mental illness, and (2) more private thinking of self-stigma, representing prejudice that people with mental illness tend to turn towards themselves (Goffman, 1963). How individuals internalize the social responses to themselves contribute to their self-perception of the mental illness and lack of willingness to self-disclose. Studies have found that in comparison, individuals self-perceive psychiatric disorders more negatively than physical disorders (Corrigan et al., 2000) and are less prone to disclose a personal history related to mental illness compared to hypertension or diabetes (Roeloffs, Sherbourne, Unutzer, Fink, Tang, & Wells, 2003). The social and health consequences associated with the stigma of mental illness labels can be costly. People with mental illness may hold the same beliefs as society at large and deny painful symptoms with their reluctance to seek care (Komiya, Good, & Sherrod, 2000). Negative health outcomes and health care costs associated with a mental illness label are significant and impede referrals (Cleary, Deacon, Jackson, Andrew, & Chan, 2012). In addition, adherence to treatment may be reduced due to stigma with those who have received a label of mental illness (Monteith & Pettit, 2011). According to Dew et al. (2007), fear of being labeled with mental illness may result in those experiencing psychological distress, to not seek necessary treatment. Numerous studies have documented the negative beliefs held by the public about persons with mental illness (Bathje & Pryor, 2011; Holmes, Corrigan, Williams, Canar, & Wozniak, 1999;
695
Roeloffs et al., 2003). According to SANE, a mental health charity to improve the quality of life for people affected by mental illness, 74% of people with a mental illness reported that they had experienced stigma in the last year; 16% reported stigma in the workplace; and 13% reported being affected from staff in the health service. Considering the serious impact of stigma, researchers and mental health workers have sought strategies to minimize the stigma that is associated with individuals who have mental illness and approach the diagnosis, treatment and policies with parity in all medical conditions. However, these strategies must be based on a sound understanding of pre-disposing characteristics of “stigmatizers” and the attributes they associate with these illnesses. Some studies have measured whether personal characteristics of individuals are determinants of their stigmatizing attitudes and behaviors. Personal experiences, such as familiarity with mental illness, have been predictive of the responses in groups of social distancing and negative attitudes (Holmes et al., 1999; Phelan & Basow, 2007). Some extrinsic behaviors such as stereotyping and overtly negative behaviors can be impacted by interventions, such as education and select experiences (Corrigan, Larson, Sells, Niessen, & Watson, 2007; Schulze, Richter-Werling, Matschinger, & Angermeyer, 2003; Stuart, 2006). Although internal characteristics, such as demographics and personal histories, cannot be changed, these still may be a focus for interventions which can modify the effects. Spagnolo, Murphy and Lue (2008) report multiple studies which demonstrate that attitudes and behaviors can be positively impacted by intervention. In their own study of 426 high-school students, a highly significant decrease in stigma attitudes was reported after the students received an intervention program which included education about mental illness and meeting mental health system care consumers who shared their stories. Recognizing the importance of the issue of stigma and the fact that the students at the college were about to engage in the reading project related to the experience of a family with a mentally ill adolescent, it was decided by faculty to conduct a study of the students’ attitudes toward mental illness.
CAMPUS “COMMON READING” PROGRAM STUDY The purpose of the first phase of this study was to describe the characteristics of the students before the implementation of the project. A follow-up was planned but is beyond the scope of this paper. The hypotheses for the study were: 1. Characteristics such as personal contact (i.e. “familiarity”) of college students with mental illness will affect students’: (a) “stigmatizing”/negative attitudes about individuals with mental illness, including: Factor 1 (Fear/Dangerousness); Factor 2 (Help/Interaction); Factor 3 (Responsibility); Factor 4 (Forcing Treatment); Factor 5 (Empathy); and Factor 6 (Negative Emotion).
Issues Ment Health Nurs Downloaded from informahealthcare.com by Oakland University on 05/02/15 For personal use only.
696
V. D. FEEG ET AL.
(b) social distance desirability of the person with mental illness, including: (1) renting a room to; (2) working on the same job; (3) having a neighbor; (4) rooming with; (5) having children marry; (6) introducing to a friend; and (7) recommending for a job. 2. Demographic characteristics (age, marital status, having children, race/ethnicity) will affect students’: (a) “stigmatizing”/negative attitudes about individuals with mental illness, including: Factor 1 (Fear/Dangerousness); Factor 2 (Help/Interaction); Factor 3 (Responsibility); Factor 4 (Forcing Treatment); Factor 5 (Empathy); and Factor 6 (Negative Emotion). (b) social distance desirability of the person with a mental illness, including: (1) renting a room to; (2) working on the same job; (3) having a neighbor; (4) rooming with; (5) having children marry; (6) introducing to a friend; (7) recommending for a job. METHOD Sample The campus of approximately 4,000 students was the target population and all students in the community received the invitation and web-based survey via e-mail. The resulting convenience sample of participants in the beginning of the semester (n = 309) represented those who completed the survey and yielded a range of usable responses in the multiple analyses (n = 264–277). The demographics of the sample included: 186 White (67.9%); 27 Black/Non-Hispanic (9.9%); 32 Hispanic (11.7%); 17 Asian (6.2%); and 20 other (4.4%). Most respondents were undergraduate and under 25 years of age (72.8%). Marital status showed a majority of single, never married respondents (82.3%) and not surprisingly, without children (85.3%). These sample characteristics are similar to the campus community (Table 1). Procedures A cross-section, comparative descriptive design was used for the study. Molloy College is an independent Catholic college, which draws its students from suburban Long Island and the metropolitan area located 25 miles east of New York City. The ethnic diversity of the student population closely reflects the surrounding communities. Although a Catholic school, many religions are represented by the students. The study protocol was approved by the Institutional Review Board (IRB) in accordance with the guidelines for a web-based, anonymous survey. A modest incentive was offered to respondents who wished to participate in a raffle of $25 at the conclusion of the study. An invitation to participate was e-mailed to all students enrolled in full- and part-time classes, with a brief statement of informed consent and a vignette (description) of “Sally,” an adolescent with a mental illness who experiences a serious breakdown that requires hospitalization (Figure 1). The e-mail included information about informed consent, promise of
TABLE 1 Demographics – sample and campus comparison (undergraduate only) Sample (%) Race/ethnicity Black/non-Hispanic White/non-Hispanic Hispanic Asian Other∗ Age Under 18 18–21 22–35 36–45 46–55 Over 55 Marital status Single/never married Married Separated/divorced/widowed Children Without children With children
Campus (%)
9.9 67.9 11.7 6.2 4.4
14.5 63.7 11.8 7.1 0.8
4.4 52.3 30.8 7.3 3.7 1.5
3.4 48.3 37.9 6.1 3.5 0.8
82.4 14.4 3.2
90.1 9.3 0.1
85.3% 14.8%
Unknown Unknown
∗ Includes non-resident Alien, American Indian or Alaska Native, Native Hawaiian or Other Pacific Islander, Race/Ethnicity unknown, and two or more Races.
anonymity, a link to a web-based survey of attitudes toward mental illness, a demographic form, and information about whom to contact for questions about the study. Three reminders were sent to all students over the first month of the program. The survey was closed to new responses after 30 days. Study Materials – Vignette Research The study used a vignette approach to elicit deep attitudes from participants that may not surface in direct survey studies. The vignette allows the researcher to manipulate the variables of interest or stimulate the psychological responses of interest. In this study, the vignette about “Sally” was an abbreviated narrative, based on the book that would be part of the shared reading experiences across campus. It was clear that some students would read the full book and some would not, so the abbreviated description was used prior to the program and post-tested again to assess the impact of the program. Vignette research has been used extensively in research on stigma of mental illness (Link, Cullen, Frank, & Wozniak, 1987). A vignette portrays a character or brief scenario that prompts a response. It can be based on real events that have been developed with anonymity, or fictitious scenarios that are purely hypothetical. With the use of vignettes, participants read the vignette and respond to questions or participate in and
PREDICTORS OF MENTAL ILLNESS STIGMA AND ATTITUDES AMONG COLLEGE STUDENTS
697
Meet Sally
Issues Ment Health Nurs Downloaded from informahealthcare.com by Oakland University on 05/02/15 For personal use only.
Sally is a 15-year-old living with her father and his new wife in New York City. She is a student who spends an inordinate amount of time alone, reading, writing, and listening to music on her walkman. She goes through periods of not sleeping and not eating. Over the summer, her behavior changes and becomes erratic and out of control. The condition builds for a while, gathering strength, until it overwhelms her. She becomes delusional, has auditory hallucinations, with disjointed and fragmented thinking. The more she speaks, the more incoherent she becomes, uttering sounds that converge into a dialect that only she understands. Her body and mind, fueled with volts of what seem like electrifying energy, results in explosive periods of distorted, aggressive behavior. Because her problem is a combination of mood and thought disorders, it interferes with communication and her thinking is jumbled. She is ambivalent with her father from extreme adoration to extreme detestation of his presence. She has uncontrolled outbursts without boundaries of her own safety, and although she tries to control herself, she can’t. She is preoccupied with her own thinking and distracted from the alterations in her senses. She has flashes of insight but at other times, she has no idea of reality and responds to people inappropriately. Sally is hospitalized in a psychiatric facility and receives treatment with medication that controls her symptoms. When her behavior improves and her thinking is clear, she is discharged and goes home to live with her father and step-mother. She goes back to school and is able to accept the fact that she has a mental illness with appropriate insight into her condition. FIGURE 1. Vignette.
contribute to conversation. The primary role is to obtain information from participants about knowledge, attitudes, and perceptions in regard to a given described circumstance. With utilization of the research tool of vignettes, information can be gathered on difficult or sensitive topics (Hughes & Huby, 2002). They provide less intrusion, are less fatiguing and are a more efficient way of gathering preliminary data (Paddam, Barnes, & Langdon, 2010). The vignette approach provides researchers with a method and opportunity for complementing other analysis of data (Wareing, 2010). The character in this study vignette was based on the main character of the book. The vignette was developed by the researchers using content from the book to create a brief composite of the main character. Input into the creation of the vignette was sought from faculty of the sociology and nursing departments who had read the book. The final version of the vignette was submitted to four faculty judges who were nurses holding advanced psychiatric/mental health degrees and had also read the book. Used in conjunction with the established measures, the faculty judges made revisions to the vignette to yield acceptable readability for non-health students for content validity of the study. Attitude Measures The measures accompanied the vignette about Sally’s mental illness and were selected to measure college students’ attitudes and beliefs about individuals with mental illness, including aspects such as: (a) fear/dangerousness; (b) help/interaction; (c) responsibility; (d) forcing treatment; (e) empathy; and (f)
negative emotions; and to identify changes in the students’ desire for social distance and impact on mental illness stigma, as an outcome of the community dialogue. Sally’s psychiatric episode was depicted in the vignette and was followed by the Attribution Questionnaire (Brown, 2008); a Social Distance Scale – adapted (Link, Cullen, Frank, & Wozniak, 1987); and a familiarity scale-based level of contact (Holmes et al., 1999); as well as a set of demographic questions. The measures were selected from the literature based on their congruency with social attribution theory and with the research hypotheses. Based on the theoretical framework of social attribution theory, Corrigan and colleagues (2003, 2010) used a short description of “Harry,” a person with mental illness, and asked respondents 27 questions about how they perceived Harry. Brown (2008) further clarified the instrument by factor analysis to yield six attributes that were used as dependent variables in this study. The higher the score on each of these factors, the more negative the stigma ascribed to “Harry” in the respondent’s perception of him for that factor. Brown (2008) reported acceptable validity and reliability for use in research. These factors included: •
Factor 1. Fear/Dangerousness Factor 2. Help/Interaction Factor 3. Responsibility Factor 4. Forcing Treatment • Factor 5. Empathy • Factor 6. Negative Emotion. • • •
Issues Ment Health Nurs Downloaded from informahealthcare.com by Oakland University on 05/02/15 For personal use only.
698
V. D. FEEG ET AL.
Social distance (SD) is the willingness to be close to a person with mental illness in ways such as living near, working with, and dating, or allowing a loved one to date. Based on the theoretical discussions and feelings leading to discrediting and discrimination, Link and colleagues (1987) based their questions on a fictitious character “Jim” described with a mental illness. For this study, social distance variables were developed in the same format and included the total score and individual item measures for willingness to: (1) rent a room to someone like Sally; (2) work on the same job with someone like Sally; (3) have someone like Sally as a neighbor; (4) have Sally as a room-mate; (5) have your children marry someone like Sally; (6) introduce Sally with a young man you are friendly with; and (7) recommend someone like Sally for a job. The higher the score, the more social distance desired for each item. Familiarity or personal contact is a measure that established a metric to determine gradations of familiarity with a mentally ill person. The instrument designed by Holmes and colleagues (1999) is a 12-item checklist that produces a score that reflects the closeness or personal contact an individual has had with mental illness. The mean of rank order correlations summarizing interrater reliability is reported as 0.83. The higher the score on the 12 items, the more familiar or personal contact one has had with a person who has a mental illness. RESULTS For clarity, the data were analyzed according to each separate hypothesis, using the measures for each of the six attributes and total/individual social distance variables as the dependent variable. Preliminary descriptive statistics of intrinsic characteristics yielded a number of significant correlations to warrant hypothesis testing for predicting directional differences (Table 2). Demographic characteristics yielded statistically significant, albeit weak, correlations for age with the factors of fear or dangerousness (r = −0.138, p < 0.05); wanting to help or interact with Sally (r = 0.134, p < 0.05); forcing treatment (r = −0.210, p < 0.01); and negative emotion (r = −0.170, p < 0.01). Having
children was significantly related to wanting to help or interact with Sally (r = 0.123, p < 0.05); and to forcing treatment (r = −0.157, p < 0.01). Subsequent analyses were organized to test hypotheses according to predictors of the dependent variables of individual social distance items and aggregate factors. Differences among student majors were not analyzed at this phase of the study, although later, in the follow-up, findings did indicate differences between nurses, psychologists and other majors in the attribute of “Help/Interaction” (F = 3.77, p < 0.05). Predictors of Social Distance: Familiarity Familiarity was calculated from the checklist to yield scores that could be categorized as “high familiarity” and “low familiarity” in order to group findings to test mean scores of the individual and total scores on items for social distance (SD) (Table 3). Although the total scores for SD were non-significant, results indicated that students who have less familiarity with mental illness were significantly less willing to work with someone who is mentally ill than those who are more familiar with mental illness, t (264) = 2.95, p = 0.003. In addition, students who have less familiarity with mental illness were significantly less willing to have someone who is mentally ill as a neighbor than those who are more familiar with mental illness, t (263) = −2.36, p = 0.019. Predictors of Social Distance: Demographic Variables Several demographic variables were used to test total and individual items from the SD scale. Marital status (married, not married), age (≥25,
