Literature Review on Attitudes to Mental Health

Researching the literature on attitudes to mental health revealed interesting themes. Many papers focused on the historical views towards mental health or explained how stigma arises and affects those suffering from mental illness. Differences in attitudes towards those suffering from mental health issues were the focus among many more of these papers; including age, country, and religious differences. Finally, research has been carried out to assess the efforts of interventions that could be or have been made to reduce the stigma mental illness sufferers receive.

Historically, attitudes to mental illness were overwhelmingly poor. It was believed that mental illness was caused by evil spirits or an imbalance of humours in the body; these views lead to highly stigmatic beliefs, (Hinshaw & Stier, 2008). The process of stigmatic belief development involves identifying an individual with a mental disorder through cues, applying stereotypes based on those cues, and then acting in a prejudiced way, (Bulanda, Bruhn, Byro-Johnson, & Zentmyer, 2014). (Fein & Spencer, 1997) offer an explanation as to why this development occurs. From a social psychological standpoint, outgroup discrimination arises when an individual of one group (ingroup) distinguishes a member of another group (outgroup) as different from themselves. Thus a sufferer of mental illness may be viewed as ‘different’ and so belonging to an ‘outgroup’, encouraging prejudice. Additionally, discrimination towards an outgroup member has the potential for self-esteem enhancement of the observer, as they discern the stigmatised outgroup member (i.e. an individual with a mental health issue) as relatively lower in social status than themselves. (Hinshaw & Stier, 2008) also propose the evolutionary perspective, as it is suggested that isolating sufferers of a mental illness may give a survival advantage, as those with mental disorders may pose a threat to others.

In an effort to combat stigma, it had been proposed that the public should be educated on mental health matters. (Weiner, Perry, & Magnusson, 1988) explain ‘Attribution theory’, whereby when negative behaviours are attributed to an individual, blame and stigma follow, but when these behaviours are attributed to a non-controllable force (such as a medical condition) it results in less blame and more acceptance and empathy. However, this theory may be criticised for lack of application. Viewing issues this way doesn’t stop racism, as skin colour is a non-controllable factor yet still is criticised; it doesn’t reduce fear people may have surrounding mental disorders; it does not rule out incorrect accusations of causation such as demon possession or weak personality (uncontrollable factors); and it doesn’t stop people viewing those with mental disorders as inferior. (Brockington, Hall, Levings, & Murphy, 1993) highlight how viewing a mental illness as a ‘brain disorder’ indirectly fosters a “Benevolence Stigma”, in which individuals believe those with mental illnesses may never recover and will lead unproductive lives as a result, or views them patronisingly as innocent children that must be constantly looked after by a parental figure. This distinguishes those with mental illness as different, or ‘less human’ often provoking harsher prejudicial behaviour though reducing blame, (Mehta & Farina, 1997), and can exacerbate fear, (Read & Law, 1999). Even those associated with an individual with a mental disorder such as friends and family can experience rejection or distancing by a ‘Courtesy Stigma’, as well as mental health professionals due to their connection to “weak” or “blameworthy” patients, leading to a lack of funding and thus a lower wage, (Goffman, 2009).

The media depict mental illnesses negatively approximately 77% of the time over emphasising and over representing a minority of mental illness cases, promoting harmful stereotypes such as dangerousness and violence. It could be due to this over representation of rare cases of mental disorders that people generally delay professional help as they do not recognise that they may have a mental illness; they may normalise it by attribution to everyday stresses and believe they should deal with it on their own, as modern society has a higher tolerance of stress, (Jorm, 2012). This could explain the underutilisation of mental health services. Alternatively, stigma could be the reason for this lack of use, as the quantity of prescriptions for antidepressant medication have risen since the 1980’s, (Mackenzie, Erickson, Deane, & Wright, 2014) despite attitudes towards help-seeking have become increasingly negative. Self-enrolment in psychotherapy for depression has decreased by 28% in the last 20 years, potentially because most adults do not believe it is an effective treatment, (Jorm & Wright, 2007; Mackenzie et al., 2014). Due to public education enforcing that mental illness is biological, the desire for medicinal treatments has increased. It could be argued that because dependence on drugs is viewed negatively it contributes to the sigma surrounding mental health, as 1 in 4 Americans believe psychiatric mediations are harmful, (Jorm & Wright, 2007; Mackenzie et al., 2014).

Stigma harshly affects those suffering from mental illness, causing lowered self–esteem and reduced chances for social interaction, due to isolation, distancing and exclusion, (Bulanda et al., 2014). Sufferers of mental health issues may also experience fewer job opportunities, (Hansson, Jormfeldt, Svedberg, & Svensson, 2013), as evidenced by low levels of employment among those with mental illness; decreased life opportunities; loss of independence; and insurance disparities among those with mental illness and those with physical illness, leaving many unable to afford treatment, (Hinshaw & Stier, 2008). It has been noted that reduction in self-worth among those experiencing stigma is not inevitable, as many racial minorities continue to have positive self-esteems despite the racism they face, but it should be remembered that the symptoms of many mental health issues such as depression or eating disorders include pessimism, despair and low self-worth, resulting in the internalisation of the prejudicial messages they receive. Furthermore, mental illness sufferers may worry about monitoring their symptoms so as not to reveal they have a mental disorder due to the pressure in society to conform, causing more distress, (Hinshaw & Stier, 2008).

Cultural background has an effect on attitudes to mental health issues. Research in Japan revealed that mental illness is viewed as a weakness rather than a sickness, particularly for the mental disorder social phobia, while depression and schizophrenia were viewed as dangerous disorders (Ando, Yamaguchi, Aoki, & Thornicroft, 2013; Yoshioka, Reavley, MacKinnon, & Jorm, 2014). This data was compared against Australian attitudes, and while these opinions were present, were less prevalent. This could be because Australians are more exposed to mental illness as there is a high institutionalisation rate in Japan for those with mental disorders, reducing the chance for social interaction, (Ando et al., 2013), or rather that Japanese respondents were less likely to answer in a socially desirable way, (Yoshioka et al., 2014). In low income countries such as Senegal, the health system is more directed towards communicable diseases and so mental health is a low priority, (Monteiro, Ndiaye, Blanas, & Ba, 2014). Due to this, most Senegalese health care providers have no training on mental health issues, resulting in stigmatic beliefs among these health workers, such as describing those suffering from mental illness as “crazy”, or as having been influenced by sorcery, (Monteiro et al., 2014). Research carried out by (Coppens et al., 2013) in Europe, discovered schizophrenia to be the most negatively viewed mental disorder. Hungarian respondents were least willing to seek help for mental health issues and were least favourable towards depression, with 60% claiming you could “snap out of it”, and 76% viewing it as a weakness, as German respondents reported they would avoid people with depression so they do not become depressed themselves, and would not vote for a politican who suffers from depression. In contrast, Irish respondents were the most favourable towards depression and 19% viewed mental health services and professional help as valuable, as the Portuguese were the most willing to seek help. All four countries reported that if they had a mental disorder they would keep it a secret, and reported the perceived stigma of others as higher than their own personal stigma, with Germany reporting the highest perceived stigma. (Crisp, Gelder, Rix, Meltzer, & Rowlands, 2000)’s research in Great Britain showed prevalent negative opinions also, including an over generalisation of stereotypes, such as thinking those with depression are ‘dangerous’; potentially indicative of lack of knowledge of the disorder, and trivialising conditions such as eating disorders which were viewed as “self-inflicted” and could be quickly recovered from.

Age also plays a role in the changes of attitudes towards mental illness. Discrimination is highest among the youth which can be a barrier to seeking treatment because of embarrassment, despite the high prevalence of mental disorders in adolescents due to the onset of these illnesses during puberty, (Yoshioka et al., 2014). Stigmatic beliefs have been shown to decrease with age, including views of mental illnesses being weaknesses not sicknesses, however in Japan stigma increases with age, (Ando et al., 2013; Jorm & Wright, 2008; Tanaka, Inadomi, Kikuchi, & Ohta, 2004). Older men are among those at the highest risk of not getting treatment as they are most negative towards help seeking, (Coppens et al., 2013).

Religion also can dramatically change attitudes to mental health issues. Many health care professionals undervalue the importance of religion, although people are more likely to seek help for mental distress from their religious leaders than any health care professional, (Bergin, 1983; Chalfant et al., 1990). However, when professionals do see significance in religion, it is viewed negatively. This could be due to the knowledge of negative encounters experienced by those who sought aid from religious leaders. (Stanford, 2007) studied American Christians and discovered that 30% of adults seeking help from their church for mental health issues experienced negative relations, as often the clergy viewed mental illness as the work of demons, sin or lack of faith, and would exclude members with mental disorders from the church. Women in particular are more likely to have their mental disorders dismissed and told not to take prescription medication (Mansfield, Mitchell, & King, 2002; Stanford, 2007). (Cinnirella & Loewenthal, 1999) carried out research among other religions in Britain, including Pakistani Muslim, Indian Hindu, Orthodox Jew and Afro Caribbean Christian. All respondents from these religious groups testified to a fear of being misunderstood by outgroup health professionals or potential racism. Among all religious groups, depression is seen as impossible in the truly religious individual, and a devout person should not consult professionals without prior confirmation from their religious leaders as it may lead to immoral practices. However, it should be noted that stigmatic beliefs though prevalent among the extrinsically motivated religious individuals, are not found among the intrinsically motivated, (Allport & Ross, 1967).

Multiple studies have demonstrated efforts to reduce stigma. (Ando et al., 2013) highlights how contact with those who suffer from mental disorders can reduce stigma, however only in adults, as when adolescents meet an individual with mental illness who presents typical behaviour it can reinforce negative stereotypes. The World Psychiatric Association ran a global program for the last 10 years with over 200 interventions in 20 countries to battle the stigma surrounding schizophrenia, (Sartorius & Schulze, 2005; Stuart, 2008), however only 19 intervention results have been published. In order for an effective change in attitudes to mental health, a real commitment must be made to follow through with results in the long term. A single mental illness was chosen to combat stigma in order to have a clear focus, however all sufferers of all mental disorders live with negative attitudes and thus it should be a goal to reduce stigma for all mental health issues. (Jorm & Wright, 2008)’s campaign to raise awareness in Australian youths and their parents proved to be effective in reducing the belief that a person with mental illness is weak not sick. They advise that in order to influence a change in attitudes of young people, parents should be a potential target to educate. A social media intervention in Canada 2012 carried out by (Livingston, Cianfrone, Korf-Uzan, & Coniglio, 2014) proved to be effective in raising awareness of mental health issues, but it did not improve attitudes, and appeared to have no lasting effect. These researchers highlighted that of 22 interventions they researched, the longest follow up period was 9 months, and so they sought to ensure a long term effect of reduction in stigma by repeating this study with a follow up period of 1 year. Stigma did reduce, as exposure and awareness increased. An extensive review of all the research on intervention is needed in order to assess which are successful mechanisms of change and can affect long term attitudes, (Heijnders & Van Der Meij, 2006). As previously mentioned, biological facts alone can encourage stigma, and so (Morrison, 1980) encourages the psychosocial explanation which focuses on environmental stresses and trauma, which can make mental illness more relatable as everyone can understand these life events, (Read & Law, 1999). Thus a multidimensional approach appears to be most effective.

In conclusion, attitudes to mental health persist to be negative across many cultures, religions and age brackets. Focusing on specific countries, cultural backgrounds, or religions, and tailoring interventions could prove to be useful in reducing stigmatic beliefs. Furthermore, it is clear more support is needed for those with mental health issues, and so future research could focus on the effectiveness of fundraising activities to support mental health research and mental health workers, as well as the willingness for those suffering from mental illness to receive support and help in light of the stigma they encounter. It would be interesting to discover if a reduction in stigma would encourage those facing mental health issues to seek help when they otherwise would not.