ABSTRACT
Objectives: The study is aimed to compare the attitudes of medical
practitioners and allied medical professionals, other than mental health
workers, towards mental illness, mental health services and their patients in Jordan and to
recommend a strategy to reduce the stigma, which represents an additional
burden on patients with mental health problems and their families.
Methods: We collected views of 300 medical practitioners and
300 allied medical professionals, from different hospitals in the Jordanian
Royal Medical Services concerning stigma.
Results: One hundred seventy six medical practitioners compared
to one hundred fifty one allied medical professionals considered mental
illnesses to be a medical problem like diabetes or hypertension with a
statistically significant difference (p<0.001). A fair number of allied
medical professionals believed that mental illness is a type of madness (n=69)
or a possession by a demon (n=60), and that mentally ill patients are dangerous
and impulsive (n=140) compared to 29, 23, and 99 medical practitioners
respectively with statistically significant differences (p<0.0005, 0.00002,
0.002) in that order. One hundred forty five medical practitioners compared to 115
allied medical professionals thought that the public does not trust the
treatment provided by psychiatrists and other mental health workers with a
statistically significant difference (p<0.0007). Allied medical
professionals believed the media helped to reduce stigma of mental illness in
contrast to the medical professionals which thought that it did not. The
majority felt the need for an increase in public awareness of mental illness
and wish to participate in mental health campaigns to support mental health
development in Jordan.
Conclusion: Health care professionals at all levels are
still carrying negative attitude towards mental health services and their
patients in Jordan.
Key words: Mental illness, Negative perception, Stigma
JRMS
December 2012; 19(4): 60-65
Introduction
Stigma is a Greek word that in its
origins refers to a kind of tattoo mark that was cut or burned into the skin of
criminals, slaves, or traitors in order to visibly identify them as blemished
or morally polluted persons. These individuals were to be avoided or shunned,
particularly in public places.(1)
Social stigma is the severe disapproval of or
discontent with a person on the grounds of characteristics that distinguish
them from other members of a society. Almost all stigmata are based on a person
differing from social or cultural norms. Erving Goffman defined stigma as:
the process by which the reaction of others spoils normal identity.(2) The three forms of stigma recognized by Goffman
include: The experience of a mental illness (or the imposition of such a
diagnosis); a physical form of deformity or an undesired differentness, and an
association with a particular race, religion, belief, etc.(3)
The diagnosis of mental
illness comes with the additional burden of a negative label. Review of the
literature suggest that the community reacts adversely towards the mentally ill.(4-6)
Stigmatization affects employability(7-9) and social
acceptability.(10-12)
The stigma attached to mental illness, and to the
people who have it, is a major obstacle to better care and to the improvement
of the quality of their lives.(13) Because of the past and
recurring discrimination towards those with schizophrenia, the World
Psychiatric Association has initiated a program in order to prevent this social
stigmatization against mental diseases.(14) Twenty countries
are participating in the program, and others have expressed their interest in
joining.(15)
A study conducted
in Jordan in the year 2004, comparing views of medical professionals (other
than mental health workers) and lay people towards mental illness reported no
statistically significant difference between the two groups in their negative
attitude towards mental health workers ( n=4, 2% vs. n=6, 12%, p=0.08). Also
the same study found that 26% (n=13) of medical employees and 24% (n=12) of lay
people (p=0.4) believed that mental health services are still not satisfactory.(16)
Added to that, more studies reported that the public commonly perceives people
with schizophrenia, alcoholism and drug addiction as unpredictable and
dangerous.(17-19) Moreover, another study found that nursing
staff in medical/surgical care viewed people with schizophrenia as being more risky
and impulsive compared to the views of nursing staff in mental health. (20)
Psychiatrists
suffer from stigma too, and are more marginalized than other medical
professionals in public debate about their practice. Eventually, lack of public
credibility may produce a government unafraid to ignore psychiatrists’ views.(21)
Stigma against
mentally ill persons is so pervasive that it affects every aspect of their
lives. It even stops patients from getting the best treatment, or sometimes
from getting any treatment at all.(22) Doctors and medical
students tend to share the same negative attitude toward mentally ill people
just as the general public.(23)
Psychiatrists can
cause stigma too, the negative attitudes of members of the public towards
people with mental illness were mirrored by some psychiatrists.(24,25)
Lennox and Chaplin surveyed the attitudes of
Australian consultant psychiatrists in 1996. They found that 39% agreed with
the statement “personally I would prefer not to treat patients with learning
disability and mental illness”.(26)
As a part of our
mandate to support those with mental illness and offer leadership in strategies
to address mental illness in Jordan, we convened this study to discuss stigma hoping
that it would form the foundation for future scientific research that aimed to
facilitate the development of a scheme to deal with stigma and discrimination against
mentally ill patients and to improve mental health care in Jordan.
Methods
A 26-item stigma
questionnaire was used to elicit the opinions on different forms of social
stigma against patients with mental illness and mental health services in Jordan.
This 26-item questionnaire is a modified version of a 30-item stigma
questionnaire which has been used previously in two different studies conducted
in Jordan
to evaluate views of medical workers vs. lay people and mental health vs.
non-mental health workers towards mentally ill people and mental health
services.(16,27)
Four items were omitted
upon discussion between the authors and mental health experts either because
the answer was apparent (‘Have you ever heard of mental illness?’ and ‘Do you think
that mental illness can affect anyone?’) or were addressed by other similar
questions in the questionnaire (‘Do you feel ashamed if one of your relatives
has mental illness?’ and a question regarding the influence of media on
reducing stigma).
The questionnaire
was distributed to 300 medical practitioners and 300 allied
medical professionals at different hospitals in the Jordanian Royal Medical
Services. The participants were chosen from different hospitals on convenience basis
and facility size, with ages ranging between 25 – 55 years; it included both
males and females. Each participant was given privacy and enough time to answer
the questionnaire. Moreover, nothing in the questionnaire can point in any way
to the respondent. The approval of the ethical committee of the Royal Medical
services was obtained in July 2011.
The Statistical
Package for Social Sciences version (SPSS) 11.2 was used to analyze the data.
Non parametric tests, χ2 test and frequencies were applied to analyze the data collected
by the questionnaire. Statistically significant results were those with p<
0.05.
Results
Table I
summarizes the answers given by both groups regarding the 26 items of the
questionnaire and their statistical significance. A total of 239 (79.6%) medical practitioners responded
to the stigma questionnaire compared to 253 (84.3%) allied medical
professionals.
More medical
practitioners considered mental illness to be an organic disease like diabetes
or arterial hypertension with a statistically significant difference (p<0.001)
compared to allied medical professionals (Question 1). More allied medical
professionals believed that mental illness is a form of madness (p<0.0005)
or a possession by an evil spirit (p<0.00002) compared to medical practitioners
(Questions 11, 12). Although, the
majority of both groups did not believe in the effectiveness of recipes
provided by native healers (Question 14), more medical practitioners stated
that the public do not trust treatment plans provided by psychiatrists and
other mental health workers (Question 15) with a statistically significant
difference (p< 0.0007).
Both groups would
not agree to rent a house to somebody who has a history of mental illness
(Question 20) neither to hire them for any kind of jobs (Question 21) with no
statistically significant difference. More allied medical professionals
believed that mentally ill patients are dangerous and impulsive with a
statistically significant difference (p<0.002) (Question 24). Both groups agreed that the number of
psychiatrists and mental health facilities in Jordan is not sufficient to meet
the needs (Questions 16, 17).
Significantly more
allied medical professionals than medical practitioners believed that the media
helped to reduce the stigma surrounding mental illness (Question 18) (p<0.00035), and were willing to participate in a march or
a festival to support mentally ill patients and protect them from the stigma
(Question 26) (p<0.0000029).
Discussion
The term stigma
refers to any persistent trait of an individual or group which evokes negative
or punitive responses. In his 1963 work titled ‘Stigma’, Goffman has made the
salient point that it is not the functional limitations of impairment which
constitute the greatest problems, but rather the perceptions of negative
difference (deviance) and their evocation of adverse social responses (stigma).
He argues that a person is not a deviant until his acts or attributes are
perceived as negatively different.(28)
Some people have theorized that stigma is
harmful to the self-esteem of persons who have mental illnesses. Others have
claimed that the stigma of mental illness is relatively inconsequential and
should therefore play only a very small role, if any, in shaping the
self-esteem of people with mental illnesses.(29) Furthermore,
people with mental illness face a double faced sword, and stigma leads to
discrimination.(30) Added to that, being stigmatized of
having mental illness prevents patients from seeking early help and treatment.(31) Therefore, it is time to change – tackling
stigma and prejudice against patients with mental health problems. The director
of Time to Change program in the UK gave accounts about sending
young people with mental health disorders to fitness centre to teach them new
ways to improve their self-esteem and mental health status. Moreover the
program aimed to create an environment of no stigma and for people with mental
health problems to get the same rights as other members of the public.(32) In our study we aimed to compare
the attitudes of medical practitioners and allied medical professionals towards
mental illness and patients with mental health disorders in Jordan.
Table I: Attitudes of Medical Practitioners and Allied Medical
Professionals towards Mental Illness and Patients with Mental Health Disorders
in Jordan
|
|
Medical
Practitioners
|
Allied
Medical Professionals
|
p
|
OR
|
CI
|
|
Questions
|
yes
|
no
|
yes
|
no
|
|
|
|
|
1. Do you consider mental illness as an
organic disease such as diabetes and arterial hypertension?
|
176
74%
|
63
26%
|
151
59.6%
|
102
40.4%
|
0.001
|
1.89
|
1.27-2.82
|
|
2. Will you try to hide the presence of a
mental illness in a relative of yours from your friends or colleagues at
work?
|
121
50.6%
|
118 49.4%
|
106
41.8%
|
147
48.2%
|
0.052
|
1.42
|
0.98-2.06
|
|
3. Do you feel ashamed or embarrassed if
you had a mental illness?
|
135
56.4%
|
104
43.6%
|
153
60.4%
|
100
39.6%
|
0.36
|
0.85
|
0.58-1.23
|
|
4. Do you feel ashamed or embarrassed if
you visited a psychiatrist?
|
89
37.2%
|
150
62.8%
|
105
41.5%
|
148
48.5%
|
0.33
|
|
|
|
5. Do you feel ashamed or embarrassed if
you were found by accident in the psychiatric clinic?
|
90
37.6%
|
149
62.4%
|
76
30%
|
177
70%
|
0.07
|
|
|
|
6. If you visit a psychiatrist, do you try
to hide that from your friends and colleagues?
|
138
57.7%
|
101
42.3%
|
146
57.7%
|
107
42.3%
|
0.99
|
|
|
|
7. Do you consult a psychiatrist or a
psychotherapist if you have had any kind of mental illness?
|
175
73.2%
|
64
26.8%
|
196
77.4%
|
57
22.6%
|
0.27
|
|
|
|
8. Does it affect your decision to marry a
particular person, if his/ her relative(s) suffer from a mental illness?
|
105
43.9%
|
134
56.1%
|
110
43.4%
|
143
56.6%
|
0.91
|
|
|
|
9. Do you feel embarrassed or ashamed when
you visit a friend or a relative in a psychiatric hospital?
|
45
18.8%
|
194
81.2%
|
58
22.9%
|
194
77.1%
|
0.22
|
|
|
|
10. Have you ever visited the department
of psychiatry?
|
123
51.4%
|
116
48.6%
|
135
53.3%
|
118
46.7%
|
0.67
|
|
|
|
11. Do you think that mental illness is a
kind of madness?
|
29
12.1%
|
210
87.9%
|
69
27.2%
|
184
72,8%
|
0.0005
|
2.72
|
1.64-4.50
|
|
12. Do you think that mental illness is a
possession by the devil?
|
23
9.6%
|
216
90.4%
|
60
23.7%
|
193
76.3%
|
0.00002
|
2.92
|
1.69-5.07
|
|
13. Do you urge your relative or friend to
continue the treatment if he/she was diagnosed to have a mental illness?
|
209
87.4%
|
30
12.6%
|
217
85.7%
|
36
14.3%
|
0.58
|
|
|
|
14. Do you think that the treatment with
sorcery is better than the medical treatment with drugs and behavioral
psychotherapy?
|
20
8.3%
|
219
91.7%
|
28
11%
|
225
89%
|
0.31
|
|
|
|
15. Do you think that people trust the
treatment prescribed by psychiatrists and psychotherapists?
|
94
39.3%
|
145
60.7%
|
138
54.5%
|
115
45.5%
|
0.0007
|
1.85
|
1.27-2.69
|
|
16. Do you think that the numbers of
psychiatrists and psychotherapists are more than that required for the needs
of the country?
|
30
12.5%
|
209
87.5%
|
40
15.8%
|
213
84.2%
|
0.3
|
|
|
|
17. Do you think that mental health
services are sufficient in Jordan?
|
51
21.3%
|
188
87.7%
|
67
26.4%
|
186
73.6%
|
0.18
|
|
|
|
18. Do you think that the media had
reduced the stigma of mental illness?
|
91
38%
|
148
62%
|
137
54.1%
|
116
45.9%
|
0.00035
|
1.92
|
1.32-2.80
|
|
19. Have you ever thought of becoming a
psychotherapist or a psychiatrist?
|
80
33.4%
|
159
66.6%
|
90
35.5%
|
163
64.5%
|
0.62
|
|
|
|
20. Do you agree to rent your house to a
person with mental illness?
|
72
30.1%
|
167
69.9%
|
59
23.3%
|
194
76.7%
|
0.087
|
|
|
|
21. Do you agree to hire/ employ a person
with a mental illness?
|
62
25.9%
|
177
74.1%
|
53
20.9%
|
200
79.1%
|
0.19
|
|
|
|
22. Do you think that children may develop
a mental illness?
|
210
87.8%
|
29
12.2%
|
225
94.1%
|
28
5.9%
|
0.71
|
|
|
|
23. Do you think that mental illnesses are
curable diseases just like any other diseases?
|
179
74.8%
|
60
25.2%
|
189
74.7%
|
64
25.3%
|
0.96
|
|
|
|
24. Do you think that a person with mental
illness is dangerous and reckless?
|
99
41.4%
|
140
58.6%
|
140
58.5%
|
113
41.5%
|
0.002
|
1.75
|
1.2-2.55
|
|
25. Do you take the work done by
psychotherapists and psychiatrists seriously?
|
41
17.1%
|
298
82.9%
|
44
17.3%
|
209
82.7%
|
0.06
|
|
|
|
26. Are you willing to participate in a
march or a festival to support mentally ill patients and protect them from
the stigma?
|
146
61%
|
93
39%
|
203
80.2%
|
50
19.8%
|
0.0000029
|
2.59
|
1.69-3.96
|
Compared to
another study conducted in Jordan in the year 2005, this study showed that
health care workers other than mental health professionals are still carrying a
belief that mentally ill patient are
dangerous and unpredictable.(27)
Added to that, another study was conducted in Jordan in the
year 2004 and it was found that there was no statistically significant
difference between medical employees and lay people regarding the belief that
mentally ill patient are dangerous and reckless.(16)
Furthermore, health care workers other than mental health professionals
believed that mental illness is madness and a possession by evil.(27)
Moreover, no statistically significant
difference was found between medical employees and lay people believes that mental illness is a form of madness and
a possession by demon.(16)
The small sample
size is a limitation in this study, so we hope and recommend carrying out a
larger sample sized study or conduct a wider research or survey in this field
in the future to reduce the chance of type two errors (False negative results).
Added to that, the responses to the questionnaire were indicated by yes/no.
This might well be an issue that influence the sensitivity and increase the
possibility of more false negative responses.
In addition to
the formerly mentioned limitation, we considered this rarely used instrument to
be another limitation despite the considerable and significant face value and
test re-test reliability. However, questions on stigma are highly influenced by
cultural issues; therefore such a questionnaire may not suit other cultures,
for example in Europe. We hope that
researchers in our country may share with us their interests, notes and
possible improvements or modifications concerning the use of the above
questionnaire.
One should put in
mind the impact of stigma and negative attitudes on early detection,
management, and follow up of patients and probably cost, (Question 7) indicated
more tendencies to refer or consult mental health workers in case of need for
help in the medical worker group, such attitude may have its own impact and disposition
on early referral to psychiatric care, probably similar results were found by Adeyemi
et al., 2002.(33)
Conclusion
The diagnostic
label of mental illness can pose a threat to self-esteem, relationships and job
opportunities of psychiatric patients and may render them vulnerable to
stigmatization, even by health care providers, which forms an additional burden
to their lives.
The study results
showed that the practitioners’ and allied medical professionals shared negative
views towards mental illness and their patients in Jordan. Such an issue necessitates
the need to promote psychiatry. Health authorities should support mental health
workers and alert the public to the importance of such services. Workshops
targeting pre- and post-graduates can help to create a positive attitude
towards people with mental health illness, as well as towards people working in
this field. Furthermore there is a need to encourage newly medical graduates to
join psychiatry-training programs.
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