Utilizing Education to Change College Students'
Attitudes About Mental Illness
Chapter 1: Introduction to the Study
Introduction
The World Health Organization (WHO) reported an increase in disability rates in
developed countries primarily due to mental disorders (World Health Organization
[WHO], 2003). Patients with mental disorders present a challenge to worldwide health
care systems because they contribute to disability, death, and health care costs (Knapp,
2003; WHO, 2003). Despite the extensive research conducted on the stigma of mental
illness, negative attitudes still exist toward individuals afflicted with mental illness, which
can affect their daily lives and prevent them from seeking treatment (Health Service
Executive, 2012; National Disability Authority, 2012; National Suicide Research
Foundation, 2012).
Mental disorders are widespread in all countries, with tens of millions of people
suffering each year; however, only a fraction of those affected obtain treatment (National
Institute of Mental Health [NIMH], 2012). Almost half of all adults will develop at least
one mental illness in their lifetime, with the most common being anxiety and mood
disorders (Center for Disease Control [CDC], 2011). Even though mental illness is
pervasive in the population, the main problem is clustered among a much smaller
percentage (about 6 %) of people who suffer from a seriously debilitating mental illness
(CDC, 2011).
Stigmatization of those with mental illness has increased among the American
public (Torrey, 2011). Recent international surveys showed that the public frequently
holds negative views of people with mental illness and fails to understand the causes and
consequences of such illnesses (Scheffer, 2003). Researchers continue to find that
viewing people with mental illness as unsafe or delinquent is one of the most frequent
themes in accounts of mental illness (Elbogen & Johnson, 2009). Despite
deinstitutionalization and efforts to educate the general population about mental illness
concerns, stigmatizing attitudes continue to be widely held by the general population in
the United States and many Western European countries (Angermeyer & Matschinger,
2005; Arthur et al., 2010; Conner, Koeske, & Brown, 2010; Corrigan, Watson,
Warpinski, & Garcia, 2004; Gibson, Abel, White, & Hickling, 2008; Jorm & Griffiths,
2008; Samouilhan & Seabi, 2010).
The stigmatizing of mental illness may be more likely to persist in lower-income
nations such as Jamaica than in the United States and other Western countries (Gibson et
al., 2008). Jamaica has employed a system of deinstitutionalization since the 1960s, but
levels of stigma remain high among the general public and health professionals (Hickling,
Robertson-Hickling, & Paisley, 2011). Hutchinson (2012) stated that little is done to
address stigmatization in Trinidad and Tobago and other Caribbean Islands. The process
of community mental health care and reformation of the health system in Jamaica poses
particular concerns to the treatment of the mentally ill in Jamaica (Hickling et al., 2011).
Thus, in order to reduce negative attitudes toward those afflicted by mental illness, the
Jamaican government and public health officials should better educate the public.
Recent evidence in the United States showed that intervention services have not
reduced discrimination against people with serious mental illnesses or substance abuse
problems, and in some cases, discrimination may be getting worse (Pescosolido et al.,
2010). People afflicted with mental illness are viewed as being creators of their illnesses,
unpredictable, liable for their peculiar comportment, having weak willpower,
incompetent, and dangerous (Carter, Golant, & Cade, 2010). Additionally, these views
are not restricted to members of the general population; even professionals from mental
health fields contribute to stereotypes about mental illness (Angermeyer & Matschinger,
2005; Corrigan & Watson, 2002; Jorm & Griffiths, 2008; Mann & Himelein, 2004). The
rise in public mental health literacy combined with the endorsement of neurobiological
causation has little effect on public stigmatization, and in some cases even leads to an
unintended increase (Angermeyer & Matschinger, 2005; Jorm & Griffiths, 2008). Stigma
related to mental illness has also been found to vary depending on the mental illness in
question (Jorm & Griffiths, 2008). Stigmatization of schizophrenia is more common than
stigmatization of depression; additionally, treatable disorders have fewer stigmas attached
to them (Mann & Himelein, 2004).
The stigma of mental illness has been associated with reduced utilization of
services, causing a major barrier to treatment (Mann & Himelein, 2004). Connor et al.
(2010) noted how internalized stigma inhibits an individual from seeking mental health
support, particularly among older adults. Granello and Granello (2000) concluded that
stigma toward people with mental illness stems from a number of factors: (a) the belief
that individuals are responsible for their mental health problems; (b) the belief that
willpower is sufficient to overcome them; (c) a lack of knowledge regarding mental
illness; (d) the breadth of disorders that the term mental illness covers; and (e) not
knowing what different forms of mental illness entail for the sufferer, his or her family,
and society at large. Granello and Granello further suggested that educational programs
and campaigns could provide accurate information on all aspects of mental illness and
thus reduce stigmatization.
Background
The five factors Granello and Granello (2000) cited may function as important
components of mental health stigma reduction in nations where previous interventions
have failed and stigma towards mental illness remains high. Jamaica represents one of
these nations and is undergoing a transitional period of mental health service allocation
and organization (Hickling et al., 2011). The reorganization of mental health in Jamaica
included an update of the Jamaican Mental Health Policy that restructured the finances in
healthcare that had existed since 1997 and was considered outdated by the WHO (2009).
The need for reformed mental healthcare in Jamaica is perhaps more pressing than in
other Western nations given that there is no legislative, monetary endowment for persons
affected with mental disorders and only 1% of individuals with a mental infirmity obtain
social welfare benefits (WHO, 2009). There is a lack of consistent services available for
those suffering from mental illnesses. This indicates that Jamaica is a suitable case study
for analysis of the factors in mental health stigma and their reduction.
In 1962, Jamaica achieved independence from the United Kingdom and made
significant public policy modifications to its mental health services, including developing
a community mental health service, major deinstitutionalization of the single mental
hospital, and a profound reorganizing of the country’s mental health legislation (Hickling
et al., 2011; McKenzie, 2008; Whitley & Hickling, 2007). Concerted attempts to educate
the public about mental illness and its treatment have also been conducted through media.
Hence, significant changes have occurred in mental health care in the Caribbean, as
indicated by early reports (Hickling et al., 2011). However, in a national survey of
mental health, the majority of respondents stated that they did not feel comfortable with
people with mental illness and actively avoided contact with them (Gibson, Abel, White,
& Hickling, 2008). More recently, Hickling et al. (2011) examined whether
deinstitutionalization and the integration of mental health services had reduced stigma
attached to mental illness. They found that the Bellevue Mental Hospital in Jamaica was
a negative symbol of mental health care. This was due to the stigma of that hospital
being for patients with incurable mental illnesses.
A main factor of mental illness stigma in Jamaica is the dehumanization of those
with mental illness who live on the streets (Hickling et al., 2011). There was a
widespread prejudgment that the mentally ill are unpredictable and dangerous (Hickling
et al., 2011). However, there were positive accounts for community mental health care
services now in place and these appear to be transforming some of the negative stigma
associated with mental disorders and treatment. Gibson et al. (2008) revealed that despite
high levels of stigma attached to mental illness, people from families who have
experienced mental illness have a lesser tendency to stigmatize, suggesting a moderating
effect of exposure to mental illness and personalization of the problem. Therefore,
community integration may be one of the most powerful tools in reducing the stigma
associated with mental illness.
The director of mental health services in Jamaica’s Ministry of Health and
Environment has encouraged Jamaicans to ease stigma associated with mental illness as it
prevents people from accessing treatment. He further advised them to view mental illness
as a treatable chronic disorder (Francis, 2007). Arthur et al. (2010) found that stigma
could be subtle and interact in unique ways with Jamaican cultural norms and
idiosyncratic nuances in the meanings of madness and mental illness. Arthur et al. (2010)
established that people have various understandings of stigma, their conflicting views
leading to various emotional responses toward people living with mental illness.
Furthermore, McGoldrick et al. (2005) noted that many people in Jamaica are not aware
of all aspects of mental health problems. For example, they rarely use the word
depressed or anxious or see these issues as disorders needing therapy, but are more likely
to understand them as medical or spiritual disturbances. Other researchers found that
Jamaicans are less likely than those from other nations are to seek help with their mental
health problems (Yorke, 2007). Mental illness is a prevalent problem in Jamaica and
attitudes toward those with mental illness are often negative. This includes the
community at large and the individuals suffering from mental illness themselves,
indicating that cultural norms within Jamaica can affect communities and the mentally ill
in negative ways.
Jackson and Heatherington identified a need for more research on the attitudes of
Jamaicans toward mental illness, despite many decades since deinstitutionalization and
recent drives to improve the understanding of mental health through community
education and positive media representations. The few studies undertaken suggested that
stigma still exists, and continues in the younger population. Researchers have found that
adolescent Jamaicans prefer contact with individuals who do not have a history of mental
illness (Jackson & Heatherington, 2006). Hence, the goal of this study was to investigate
the gaps in literature regarding the understanding of mental illness of college students in
Jamaica and how it affects attitudes towards people with mental illness.
Jamaica has a young population with an average age of 24 years (World Fact
book, 2012); 33% of its population is below the age of 15 years and Jamaica spends 6%
of its total health budget on mental health (WHO, 2009). However, figures showed that
there is particular concern about mental health issues in the young Jamaican population.
For example, Moses (2011) examined stigma among 102 adolescents, and emphasized
that these issues are compounded by poverty and crime in particular areas within the
country. Furthermore, while stigma has been increasingly attached to mental illness, the
adolescent population is more likely to suffer from mental health issues. Smith and
Ashiabi (2007), as well as Lambert and Lyubansky (1999) reported that Jamaica has a
high rate of behavioral and emotional problems in adolescents between the ages of 11-18
years. It is unclear how many young people are aware of and utilize appropriate services
when suffering from mental illness. This is of particular concern, as only 9% of
outpatient services for mental illness in Jamaica are intended for young people and
adolescents (WHO, 2009).
Attitudes toward mentally ill people seeking help may also be negative. For
instance, in studies of Jamaican immigrants in Canada researchers have shown that they
tend to cope with depression by emotional resilience and not showing vulnerability
(Schreiber et al., 2000). As a result, there is a lack of help seeking and masking of
symptoms from friends and family (Schreiber et al., 2000). These coping mechanisms
are based on the negative stereotypes of others and are uniquely informed by Jamaican
culture, in contrast with the coping mechanisms native to other countries such as Canada.
Considering the high ratio of young people in Jamaica, the mental health issues prevalent
in this younger population, and the evidence that stigmatization of mental illness exists,
additional research was needed to consider the attitudes of younger Jamaicans toward
mental disorders. Furthermore, exploration of these attitudes and how to reduce stigma
was essential for future change and was lacking in the current literature.
Problem Statement
Since the early 1960s, people with mental illness have been deinstitutionalized in
Jamaica (Hickling, Robertson-Hickling, & Paisley, 2011). In spite of positive reporting
in the press, a generation of community care for mental illness and more favorable
attitudes toward mental illness than in other countries, stigmatization of mental illness
remains and is exacerbated by cultural attitudes and an internalization of stigma by
mentally ill people. This stigmatization leads to an attitude of fear and avoidance of
people with mental illnesses. Hence, there was a need to change the public perception of
mental illness.
Reducing this stigma could lead to increased provision of mental health treatment,
through mobilization of society and empowerment of those with mental illness in the
community. Education is an important means of achieving reduction of stigma attached
to mental illness. The method of delivering educational material might make a significant
difference. In this study, a didactic seminar was utilized to impact changes in attitudes
toward mental illness.
Purpose of the Study
The purpose of this current study was to close the gap regarding the understanding
of mental illness of college students in Jamaica and how a didactic seminar affects
attitudes towards people with mental disorders in Jamaica, West Indies. The study also
determined whether there were gender disparities in the attitudes towards mental illness
among college students in Jamaica.
Research Questions
The main research questions addressed in this study were:
RQ1. Does a didactic seminar change attitudes about mental health among
college students in Jamaica, West Indies, after controlling for 1st survey scores and age by
using them as covariates?
RQ2. Is there a difference between male and female in attitudes towards mental
illness among college students in Jamaica, after controlling for 1st survey scores and age
by using them as covariates?
Hypotheses
The following hypotheses addressed the research questions:
H1a: The didactic seminar positively affected Jamaican college student attitudes
toward mental illness, after controlling for 1st survey scores and age as covariates.
H10: The didactic seminar did not positively affect Jamaican college student
attitudes toward mental illness, after controlling for 1st survey scores and age as
covariates.
H2a: Gender positively affected Jamaican college student attitudes toward mental
illness, after controlling for 1st survey scores and age as covariates.
H20: Gender did not positively affect Jamaican college student attitudes toward
mental illness, after controlling for 1st survey scores and age as covariates.
The following hypotheses addressed interaction between the independent
variables:
H3a: There is a significant interaction between didactic seminar and gender on
Jamaican college student attitudes toward mental illness, after controlling for 1st survey
scores and age as covariates.
H30: There is no significant interaction between didactic seminar and gender on
Jamaican college student attitudes toward mental illness, after controlling for 1st survey
scores and age as covariates.
Theoretical Framework
The cognitive theories that form the basis of this research are cognitive
consistency and cognitive heuristics (Rydell, McConnell, Strain, Claypod, & Hugenberg,
2007; Simon, Snow, & Read, 2004; Wood, 2000). I chose these cognitive theories
because they contribute to the understanding of didactic intervention by the college in
changing attitudes of college students in Jamaica toward people with mental illness. I
utilized the cognitive consistency and cognitive heuristics theories in this study with two
main objectives in mind: one directed toward cognitive goals and the other related to the
students’ attitudes toward mental health. These theories focus on how people process,
deal with, and react to, information or stimuli.
In this study I drew on cognitive consistency theory to scrutinize the relationships
between students’ attitudes and beliefs toward people with mental illness (Rosenberg,
1956). The premise of cognitive consistency theory is that an unstable state may occur
when an individual’s attitude toward, and knowledge of, mental health are inconsistent.
Persuasive communications in the form of a didactic seminar attempted to change the
affective component of an attitude system by changing the cognitive component of an
attitude. The goal of the didactic seminar was to offer students new information
concerning mental health with the hope of changing the cognitive component of their
attitudes toward it.
Cognitive consistency theories hypothesize that, should contradictions develop
amongst perceptions, people are driven to reestablish agreement. Cognitive consistency
states that a person will attempt to ensure that his or her opinions, beliefs, and attitudes
are consistent with one another and with his or her own experiences, knowledge, and
behavior. This may be achieved by altering attitudes, but also by rejecting contradictory
evidence or altering how evidence is evaluated (Simon et al., 2004). At its very basic
level, cognitive consistency is a mechanism to ensure behavior consistent with
knowledge. People embrace particular attitudes because these attitudes help them attain
their key purposes (Walter & Langer, as cited in Crano & Prislin, 2010).
Cognitive consistency and cognitive heuristics theories suggested that offering a
didactic seminar would introduce students to new ways of thinking, which might
encourage the adoption of new attitudes toward mental health problems and the mentally
ill. Specifically, offering a didactic intervention by the college would aid in the
acceptance of a new opinion and hence attitude formation on students. Attitude
formation is dependent upon the incentives that are offered in communication; for
instance, the benefits of acceptance of the mentally ill to society (such as lowering the
cost if treated swiftly, etc.).
Nature of the Study
A quasi-experimental design study was used to determine the effect of a didactic
seminar (aimed at educating and informing participants) on attitudes amongst college
students toward individuals with mental illness in Jamaica, West Indies. In that, the
intention of this study was to support or refute the hypothesis that a didactic seminar is
effective in changing the attitudes toward people affected by mental illness. The overall
aim of the didactic seminar was to change the opinions of a sample of college students
regarding mental illness, thereby reducing the stigma associated with mentally ill
individuals, and thus decreasing the resistance of these students to interacting with such
individuals (Miller, 2002; York, 2007).
I conducted the research at a teachers' college in Jamaica, West Indies. The study
utilized a repeated measure quasi-experimental design, utilizing two groups of college
students: the experimental group (who attended the didactic seminar) and the
nonequivalent control group (who opted not to attend the didactic seminar). This study
utilized a nonequivalent group design, because random assignment to the control group
was used and I was restricted to selecting those students who opted out of attending the
didactic seminar to be included in the control group. However, I predetermined the
number of participants in the didactic seminar attendees group. The nonequivalent
control group was similar to the didactic seminar attendees group because both were
drawn from the same body of students.
The independent variables were attendance at the didactic seminar (yes, no) and
gender (male, female). First survey scores and age were the covariates. First survey
scores and age may have been related to the dependent variables; in addition, they may
have accounted for any differences between the two groups. Pretest is “usually the most
highly correlated with the posttest” (Trochim & Donnelly, 2008, p. 203). The dependent
variables were gender, a demographic item, and attitude toward mental illness, measured
as the total scores on the Help Seeking Attitude Scale (Fischer & Farina, 1995), Attitudes
to Mental Illness Questionnaire (Luty et al., 2006), and the Opinion About Mental Illness
Scale (Cohen & Struening, 1964), after accounting for 1st survey scores and age.
The study specifically measured pre- and postdidactic session scores on the Help
Seeking Attitude Scale (Fischer & Farina, 1995), Attitudes to Mental Illness
Questionnaire (Luty, Fekadu, Umoh, & Gallagher, 2006), and the Opinion About Mental
Illness Scale (Cohen & Struening, 1964). The use of these measures allowed
quantification of an individual’s level of stigmatization of (or overall perception of) the
mentally ill and assessed any changes caused by the didactic seminar. It also allowed
evaluation of gender differences in attitudes towards mental illness. I was thus able to
determine whether the didactic seminar affected the college students’ attitudes toward
mental illness in different ways. A significant correlation between the didactic seminar
and gender would indicate that changes in attitudes resulting from seminar attendance are
different between males and females.
This research study was based on the premise that didactic seminars were more
likely to change opinions than traditional types of classes, as the didactic seminar format
is more interactive, lively, and participatory, while delivering consistent and clear
information to all involved (Eiser & Ross, 1977; El-Sayeh et al., 2010; Simmons &
Brandon, 2007). The research questions were addressed with the use of a 2-way Analysis
of Covariance (ANCOVA). I also conducted descriptive statistical analyses to
characterize the samples gathered for the study.
Definition of Terms
The following terms were operationally defined for the purposes of the study:
Affective. Feelings or emotions that something evokes; for example, fear,
sympathy, hate (American Psychological Association [APA], 2006).
Behavioral. Includes all mental and bodily action in terms of reaction by glands
and muscles to exterior influences (motivations) or a bias to act in certain ways
(Dusenbery, 2009); for example, avoiding people with mental illness (Crano & Prislin,
2010).
Cognitive. Refers to our thoughts, beliefs, and ideas about something (The
American Heritage Dictionary, 2012). When a human being is the object of an attitude,
the cognitive component is frequently a stereotype. For example, people with mental
disorders are dangerous (Carter et al., 2010).
Mental health. “A state of well-being in which an individual realizes his or her
own abilities, can cope with the normal stresses of life, can work productively, and is able
to make a contribution to his or her community” (WHO, 2010, para. 2).
Mental illness. A clinically noteworthy behavioral or psychological syndrome
that occurs in an individual that is related to existing anguish which may be due to
cultural response to a specific incident, but may be due to an exhibition of a behavioral,
psychological, or biological dysfunction that is neither nonstandard behavior nor a
conflict that is principally between the individual and society (APA, 2000).
Stigma. A loss of status or discrimination (including labeling, stereotyping,
cognitive separation and/or emotional reactions) based on an often-objective attribute that
marks people as different, and is dependent on both relationship and context (Yang et al.,
2007).
Assumptions
I assumed the following in my research:
1. The participants would be representative of the population from which
they were drawn and they would engage actively with the didactic
seminars.
2. The participants would respond honestly and completely to the
assessments and would be available to complete the postintervention
assessments.
3. The participants would be given the opportunity to participate voluntarily
in this study and would not introduce any biases.
4. The experimental group and the nonequivalent group would be highly
comparable before the study (i.e., the study would not suffer from
selection threat or selection bias). If this was true, the single group threats
to internal validity would be ruled out and therefore could not explain
second survey group differences. This assumption was tested to some
extent by comparing the two groups across demographical information to
see whether there were similarities or differences that could affect the
analysis conducted. However, it was possible that there would be
differences on variables that I had not measured.
5. No historical event would occur between the first survey and second
survey to influence the second survey results of the two groups (i.e., the
second survey results would not suffer from selection history).
6. There would be no selection-testing threat (i.e., the experimental group
and the nonequivalent control group would not learn from the 1st survey
differently).
7. The study would not suffer from selection-regression (i.e. one group
would not score more extremely on the 1st survey than the other).
8. If some of the participants were not available to complete the
postintervention assessments, the assumption was that the selection-
mortality of both groups would be the same and there would be no
common factors between those who do and do not complete the post-
intervention assessments that may have biased the results.
9. The time allowed for any short-term effects of the didactic seminar to fade
would be sufficient for this purpose.
10. Validity and reliability of the assessment tools were generalizable to the
Jamaican population of college students.
11. The ANCOVA assumption of “randomization, linear relationship between
first survey and second survey scores and homogeneity of regression
slopes” (Dimitrov & Rumrill, Jr., 2003, p. 161) would not cause
significant problems in this nonrandomized design. With nonrandomized
designs, ANCOVA adjusts the second survey means for differences
among groups on the first survey because such differences were likely to
occur with intact groups (Dimitrov & Rumrill, Jr, 2003).
12. The first survey scores would be reliable. Unreliable first survey scores in
nonrandomized designs results in treatment effect that is seriously biased
(Dimitrov & Rumrill, Jr, 2003).
Scope and Limitations of this Study
This study did not attempt to understand population-level attitudes towards mental
health in Jamaica. The sample used for the research was based on college students, who
may have had different opinions and attitudes from those of the general population.
Furthermore, generalizability to other Caribbean nations may have been limited given the
specific population studied in this study.
Significance of the Study
As mentioned previously, there is little literature available on the attitudes of
Jamaicans toward mental illness; there is even less literature that examines the issue of
stigma associated with mental health in Jamaica. The literature that has been published
suggested that although understanding of mental illness has improved, stigma attaching to
severe mental illness is widespread, with two-thirds of Jamaicans actively avoiding
people with severe mental illness, and nearly three-quarters admitting that they feel
uncomfortable around them (Gibson et al., 2008). Therefore, in my research I aimed to
address the problems that stigma presents to mentally ill individuals in the context of
increasing deinstitutionalization of the mentally ill in Jamaica, which results in more
mentally ill people being treated in the community and more individuals coming into
contact with the mentally ill.
In this work I measured the extent of stigma within a subpopulation in Jamaica,
notably including a subpopulation (students in training to become teachers) in a position
to influence attitudes of children in schools. I also looked at whether a particular
educational intervention by the college (using didactic seminars) could help reduce this
stigma. This research will be published in a recognized peer-reviewed journal and I will
present the findings at relevant international conferences to make them available to the
research community. The importance of this research derived from the high incidence of
stigma placed upon the mentally ill worldwide.
In this research I aimed to achieve positive social change through exploration of a
specific educational intervention by the college in combatting stigmatization of mental
illness. Such interventions have an inconsistent basis of evidence and there is only a
small amount of data available for this specific population. Future educational methods
could be formulated based on the success or failure of this intervention. Additionally, I
aimed to show the positive effects of educational interventions, which suggest that
education could be effective as a primary tool in changing attitudes and opinions toward
the mentally ill. This would mean that such interventions have the potential to improve
the human and social conditions of the mentally ill who live in a community setting,
diminishing the stigma placed on them and encouraging people to be more likely to
interact with and help them. This would lead to advantageous attitudes or eagerness to
seek professional help, improvement in patient outcomes, a reduction in total health costs,
and greater social and health care benefits.
Summary
Mental illness continues to disturb the lives and well-being of millions of people
all over the world; it incurs considerable social and economic costs. The most destructive
aspect of mental illness is its devastating consequences for its victims and their families,
which include suicide, divorce, alcoholism and drug abuse, unemployment, child abuse,
damaged social relationships, and wasted lives. In these respects, mental illness can be
regarded as a terrible affliction for many people in Jamaica and elsewhere in the world.
In spite of optimistic reporting in the press and greater community care for mental illness
in Jamaica than in other countries, stigmatization of mental illness remains, and is
aggravated by cultural attitudes of the mentally ill people themselves. Hence, there was a
need to alter the public’s opinion of mental illness, and transform its attitudes and views
toward the mentally ill. Education is an important means of averting stigma from people
with mental illness and informs them of the importance of seeking treatments. Thus,
reduction in stigma would lead to an increased desire on the part of individuals with
mental disorders to seek out mental health treatments.
The aim of this study was for me to determine the effect of a didactic seminar,
which was intended at educating and informing participants on attitudes toward
individuals with mental illness, and specifically measured pre- and postdidactic session
scores on the Help Seeking Attitude Scale (Fischer & Farina, 1995), Attitudes to Mental
Illness Questionnaire (Luty, Fekadu, Umoh, & Gallagher, 2006), and the Opinion About
Mental Illness Scale (Cohen & Struening, 1964). This chapter provided an overview of
the study, presenting an introduction and context to the research, and a brief summary of
the literature as a background to the study. The chapter also included a statement of the
problem explored in the dissertation and an explanation of the purpose of the study. The
nature of the study was also outlined, along with the research questions, a formal
statement of the hypotheses, and the theoretical basis of the research. Terms used in the
course of the dissertation were defined, and the assumptions and limitations of the
research clearly indicated.
In Chapter 2 I present different studies conducted on the perception of mental
illness, to include empirical research conducted in Jamaica. A synthesis of all related
literature is provided. In Chapter 3 I discuss the research design and its appropriateness
for the study. The population and selected sampling, data collection, instrumentation, and
data analysis are discussed. Chapter 4 includes the results of the analyses and Chapter 5
includes the findings, recommendations, implications, conclusions, and summary.
Chapter 2: Literature Review
Introduction
In many Western industrialized countries there is a stigmatization of mental
illness (Borinstein, 1992; Pescosolido et al., 2010). The public may associate mental
illness with dangerousness and unpredictability (Elbogen & Johnson, 2009; Pescosolido
et al., 2010). Counterintuitively, some mental health professionals have been found to
hold negative attitudes about the mentally ill, and contribute to harmful stereotypes
(Angermeyer & Matschinger, 2005; Corrigan & Watson, 2002; Jorm & Griffiths, 2008;
Mann & Himelein, 2004). Hence, stigma remains a critical problem particularly in
efforts that intend to curb the rising global mental health disorders (WHO, 2003). Many
different factors influence prejudice towards people with mental illness. I proposed that,
to reduce intolerance to mental illness in a manner consistent with the philosophy of
mental health literacy, there is an urgent need for more educational programs and
campaigns that offer accurate information on all aspects of mental illness (Granello &
Granello, 2000).
Jamaica has made substantial public policy changes to its mental health services,
including development of a community mental health service, major deinstitutionalization
of the single mental hospital, and reorganization of mental health legislation (Hickling et
al, 2011; Hickling & Paisley, 2011). Substantial attempts to educate the general
population about mental illness and its treatment have also been employed through
popular media and other sources (Hickling et al. 2011). However, researchers have found
that stigmatization in Jamaica, although reduced, is still evident
(Gibson et al., 2008; Francis, 2007; Arthur et al. 2010; Hickling et al. 2011), and
continues even in the younger population (Jackson & Heatherington, 2006). Stigmatizing
attitudes are a factor that inhibit the utilization of mental health support (Arthur et al.
2010); there is also evidence suggesting that Jamaicans are less likely than other
populations to seek help for mental disorders (Yorke, 2007). These issues are particularly
relevant considering that Jamaica has a relatively young population, with an average age
of 24 years (World Factbook, 2012); and as figures show, that there is particular concern
regarding mental health issues in the young Jamaican population (Verhulst, as cited in
Smith & Ashiabi, 2007). These issues are compounded by other social and economic
problems such as poverty and crime in particular areas within the country.
In this chapter I summarized the current research literature on theoretical and
methodological issues relevant to the current study. To understand the social issues of
stigmatization in regards to mental illness, I addressed such topics as stereotypes,
stereotype formation, attitudes, attitude change, prejudice, and discrimination. The
research was relevant to theories of cognitive heuristics and cognitive consistency, which
were reviewed. The issue of mental illness and stigma in Jamaica is considered in more
detail. Finally, theories on attitudes and attitude change towards mental illness were also
summarized.
Literature Search Strategy
The following research databases were searched: Academic Search Premier,
PsycINFO, PsycArticles, and Google Scholar. The terms stereotypes, stereotype
formation, attitudes, attitude change, stigmatization, discrimination, cognitive heuristics,
cognitive consistency, cognitive dissonance, and didactic seminars were searched for,
together with spelling and tense variations and functional equivalents. Other publications
referenced in articles found in the initial searches were also examined for relevance.
Chapter 2 is organized by its examination of mental health and illness; public perceptions
of mental illness; stereotypes, prejudice and discrimination; stigma; mental illness and
stigma in Jamaica; and changing attitudes toward mental illness.
Mental Health and Mental Illness
Mental health and mental illness are associated with several interrelating social,
psychological, and biological factors. The WHO (2005) defined mental health as “a state
of well-being in which the individual realizes his or her own abilities, can cope with the
normal stresses of life, can work productively and fruitfully, and is able to make a
contribution to his or her community” (p. 2). At the heart of this progressive mental
health is an indication of the well-being of individuals, particularly because mental health
guides the daily operation in their community. In both industrialized and developing
nations, however, evidence indicates that poverty (related to low levels of education) is a
strong indicator of mental illness; and this seems to be worldwide, despite a country’s
level of development (WHO, 2005). The incidence of mental illness is higher among the
poor, homeless, unemployed, poorly educated, victims of violence, migrants and
refugees, indigenous populations, children and adolescents living in poverty, abused
women, and the neglected elderly (WHO, 2003).
Susceptibility to mental illness may occur when one experiences insecurity and
despair, threat of violence, and physical ill health (WHO, 2005). However, mental illness
and poverty act together in a destructive sequence. Mental illness inhibits the capacity of
an individual to learn and participate in their communities; however, poverty fosters the
chance of developing mental disorders, and reduces people’s ability to seek help from
health services (WHO, 2008). As such, while leader of poor countries should strive to
empower communities, the poverty condition continuously results in an increasing
number of mental illnesses among the people.
The various forms of mental disorders are diagnosed according to standard
classifications. The Diagnostic and Statistical Manual of Mental Disorders, 4th Edition
(DSM-IV) classified psychiatric diagnoses of mental illness. The five factors it evaluated
is published by the American Psychiatric Association and includes all mental health
disorders for both children and adults (WHO, 2005). The DSM-IV considered many
different aspects in diagnosis because many factors in a person's life frequently affect
their mental health. The five factors that the DSM-IV evaluated are as follows:
1. Axis I: Clinical Syndromes is considered the diagnosis for illnesses such as
depression, schizophrenia, social phobia, anorexia nervosa.
2. Axis II: Developmental Disorders and Personality Disorders. This includes
autism and mental retardation, which first become apparent in childhood.
Personality disorders are clinical conditions with longer lasting disorders and
include the individual's way of relating to the world. They include Paranoid,
Antisocial, and Borderline Personality Disorders.
3. Axis III: Physical Conditions affect the development, continuation, or
exacerbation of Axis I and II Disorders. For example, physical conditions
such as brain injury or HIV/AIDS that can result in symptoms of mental
illness are included on this axis.
4. Axis IV: Severity of Psychosocial Stressors are events in a person’s life, such
as death of a loved one, unemployment etc., which can influence the disorders
listed in Axes I and II.
5. Axis V: Highest Level of Functioning whereby the professional appraises the
person's level of functioning both in the present and for the previous year.
This helps identify how the above four axes relate to the person and what
fluctuations in behavior might be expected (DSM-IV).
Mental illness encompasses all diagnosable mental disorders and is indicated by
continuous, irregular shifts in thinking, mood, or behavior mixed with stress and a
diminished ability to function. Mental illness alone is a public health problem, but it is
often associated with other chronic diseases causing sickness and fatalities. According to
the WHO (2003), disability rates in developed countries are primarily due to mental
illness. The WHO (2003) estimated that 450 million people worldwide have a mental
health problem. Worldwide figures estimated that, to some degree, more than 150
million people experience depression; yearly close to 1 million commit suicide, roughly
25 million suffer from schizophrenia, 38 million suffer from epilepsy, and more than 90
million live with an alcohol- or drug-use disorder. The number of individuals with
disorders would likely increase significantly over the next 20 years (WHO, 2003).
Mental health problems also result in high costs to society through failure to treat
them early (CDC, 2011; WHO, 2003). Yet, mental illness and mental health issues have
been neglected topics for most governments and societies. Recent data demonstrated the
large gap that exists between the burden caused by mental health problems and the
resources available in countries to prevent and treat them (WHO, 2001). In contrast to
the overall health gains of the world’s populations in recent decades, the CDC (2011)
indicated that the burden of mental illness has increased requiring increasing efforts to
monitor mental illness and anxiety disorders.
Mental Illness in the United States
The National Institute of Mental Health (NIMH, 2012a) noted that psychiatric
epidemiology researchers have found that mental disorders are widespread in the United
States; with tens of millions of people suffering each year, only a fraction of those
affected obtain treatment. Around one quarter of adults are diagnosed with one or more
disorders in a given year. The NIMH (2012a) also noted that mental disorders are
common among children in the United States and just over 20% (or 1 in 5) children,
either presently or at some point during their life, deal with a debilitating mental disorder.
Almost 50% of adults will develop at least one mental illness in their life, with the
most common being anxiety and mood disorders (CDC, 2011). Even though mental
disorders are pervasive in the population, the main problem is clustered among a much
smaller percentage (about 6%) of people who suffer from a seriously debilitating mental
illness (CDC, 2011). The World Federation for Mental Health (WFMH, 2006) also
highlighted the link between mental illness (including substance abuse and dependence)
and the risk of suicide. In the WFMH report, the authors confirmed that while the
majority of individuals with a mental illness would not take their own lives, studies in
Europe and the United States have reported that up to 90% of individuals who died by
suicide are diagnosed with some type of mental disorder, including alcohol and drug
abuse.
In the 2007 report of the CDC, the authors showed an increase in suicide rates in
the United States from nearly 10.5% in 1999 to 11.3% (per 100,000 people). This could
be attributed to the rising number of individuals in the United States who experience
depression (Mark et al., 2007). Mark et al. (2007) compared depression levels and
suicide rates across the United States and found that mental health outcomes were more
favorable when access to mental health services and utilization of these services is
highest. There were also key significant associations found in socioeconomic status. The
more educated the population and the greater the percentage with health insurance, the
lower the suicide rate. In addition, there were fewer incidences of depression in the more
educated population (Mark et al., 2007).
The equitable distribution of health care services within a state resulted in a
greater number of people in the population obtaining mental health services (NIMHb,
2012). The US Department of Health and Human Services (DHHS) “National Survey on
Drug Use and Health” (2010) showed that mental illness and substance abuse in the
United States is on the increase. A five-year study found that in 2009, women aged 18 or
above were more likely than men aged 18 or older to have some mental illness (24% and
16 %, respectively) as well as serious mental illness (SMI) (6% and 3 % respectively).
Of the 45.1 million adults aged 18 or older with any mental illness in the past year, nearly
20% met conditions for substance dependence or abuse in that period compared with
6.5% among those who did not have mental illness in the past year. In the same period,
of the 11.0 million adults aged 18 or older with SMI, nearly 26% also had substance
dependence or abuse compared with 6.5% of adults who did not have mental illness.
Two million young people (aged 12 to 17) had major depressive episode (MDE) during
the past year. Among these, nearly 36% used illicit drugs in the past year compared with
18% who did not have past year MDE (DHHS, 2010). The most common reason for
substance abuse among youths who received mental health support was feeling depressed
(46%). Hence, it is important to appreciate the link between substance abuse and mental
illness when considering a population-wide intervention, in light of the strong association
between these two factors.
According to the National Alliance on Mental Illness (NAMI, 2003), the austere
mental disorders of 50% of individuals were exacerbated by substance abuse; 37% of
alcohol abusers and 53% of drug abusers also have at least one serious mental illness.
NAMI (2003) also mentioned that about 29% of the mentally ill individuals abuse either
alcohol or drugs, and that there is a need to cultivate proper cohesive treatments for the
mentally disabled. The report from DHHS (2010) also suggested that rising
unemployment rates have contributed to increasing mental health statistics. Most of the
mentally ill are unemployed, lose their health insurance and hence, and are unable to seek
treatment. The findings also verified that economic insecurity, shrinking social services,
and continued stigmatization of mental disorder all play a part in the mental health
dilemma in the United States (DHHS, 2010). The evidence indicates that the prevalence
of mental health illnesses continues to be of significant concern around the world, as well
as in the United States, and is likely to increase in forthcoming years. Together with
social and economic variations that affect mental illness, the issue of negative perceptions
of mental illness and its stigmatization is said to continue. The next section discussed
public perceptions of mental illness and how they could be related to stereotyping of
mental disorders.
Public Perceptions of People with Mental Illness
Mental illness is often considered separately from physical illness in the minds of
the public, representing a more mysterious and difficult to understand disease process.
Because of this lack of understanding and the association of mental illness with various
social taboos, such as substance abuse and unemployment, there is a high level of stigma
associated with mental illness throughout all societies (Scheffer, 2003). Stigmatization
could directly affect the well-being of the patient, leading to poorer health outcomes, but
it is also an important determinant of how policies providing access to and funding for
treatment are formulated (Scheffer, 2003). Therefore, understanding the public
perception of mental illness and identifying ways to modify such perceptions form an
important basis for policy creation and change in mental illness health care.
Historically, the study of public attitudes toward mental illness and persons with
mental illness had been conducted mainly in the field of psychology.
Deinstitutionalization and the employment of community-based mental health care
brought mental illness into the public domain (Hickling et al., 2011). Prior to the
introduction of deinstitutionalization process for persons with mental illness, mental
illness has been considered a private issue treatable by friends and families (Hickling et
al., 2011). The changes that concealed social problems became increasingly observable.
In recent years, worldwide surveys of public attitudes and beliefs concerning
persons with mental illness have shown that the general population frequently hold
negative and inflated views about their dangerousness, have adverse views of their
decision-making abilities, and lack knowledge of their disorders and their causes
(Borinstein, 1992). Bornstein (1992) found that Americans believed mental illness was
caused by either physical circumstances (e.g., chemical imbalances in the brain) or
societal influences (e.g., stress or alcoholism/drug abuse). While a number of Americans
did not perceive individuals with mental illness as extremely violent or specifically
dangerous, there was concern about the possibility of violent behavior (Borinstein, 1992).
Researchers have continued to find that viewing people with mental health issues
as unsafe or delinquents are the most frequent themes in the perception of mental illness
(Angermeyer & Matschinger, 2005; Anglin et al., 2006; Corrigan & Watson, 2002; Jorm
& Wright, 2008; Mann & Himelein, 2004; Pescosolido et al., 2010). However,
researchers proposed that it is more probable for mentally ill people to be victims than
perpetrators of violence; and further that mental illness alone is not a predictor of violent
behavior. Other elements, including substance abuse, history of violence, demographic
variables (e.g., sex, age), and the existence of stressors (e.g., unemployment) were found
to play a role (Elbogen & Johnson, 2009).
Wahl (2004) in a focus group study asked individuals (who in their occupations
could have an effect on people with mental health problems) what they thought about
people with mental illness. Nearly half of those polled mentioned instability as a primary
concern, fearing that individuals might be out of control and attack someone. In reality,
as Wahl (2004) noted, a substantial number of people with mental illness are ordinary
individuals who work and are members of the community. A British survey by the
Department of Health (2009) monitored public attitudes towards mental illness, and to
track changes over time (since 1994), found that levels of tolerance to people with mental
illness had increased over the period of the study. However, there was an increase from
previous years in those agreeing that one of the main causes of mental illness was a lack
of self-discipline and willpower. Further, when asked to signify what describes a person
who is mentally ill, the majority chose someone with schizophrenia.
Granello and Granello (2000) concluded that intolerance toward people with
mental illness stemmed from a number of factors: (a) the belief that individuals are
responsible for their mental health problems; (b) the belief that ‘willpower’ is sufficient
to overcome them; (c) a lack of knowledge regarding what mental illness is; (d) the
breadth of disorders that the term ‘mental illness’ covers; and (e) what different forms of
mental illness involve for the sufferer, family, and society at large. They advocated
educational programs and campaigns to provide accurate information about all aspects of
mental illness.
Beliefs about the etiology of mental disorders play a powerful role in attitudes
toward mental disorders (Corrigan et al., 2000; Goldstein & Rosselli, 2003; Granello &
Granello, 2000; van’t Veer, Kraan, Drosseart, & Modde, 2006). Specifically, the more
controllable a mental disorder is perceived to be, the more negative is the public attitude
(Granello & Granello, 2000). In the case of depression, many stigma reduction programs
are led by the medical model that describe this disorder as a medical illness, whereas
contextual models stress societal effects for which an individual should not be blamed
(Corrigan et al., 2000; Goldstein & Rosselli, 2003). Using an undergraduate sample,
Rusch et al. (2009) compared a medical, contextual, and control (talked about depression
stigma but did not examine the biomedical/contextual models of depression) stigma
reduction programs to one other, and to a no-program control. There was a significant
reduction in stigma in the contextual and control programs compared with the noprogram
control, whereas the biomedical program did not affect attitudes. The beliefs about
depression reduced the effect but only from a medical perspective. Therefore, based on
these studies, contextual and control programs seem to be effective in reducing stigma but
a biomedical model may be unwarranted to use with individuals who do not agree with
the representation.
In a meta-analysis, Read Haslam, Sayce, and Davies (2006) also reported that the
biogenetic approach was counterproductive and actually heightens prejudice, fear, and
desire for social distance. Studies from Hong Kong (Chou & Mak, 1998), New Zealand
(Read & Law, 1999), Australia (Haslam, Rothschild, & Ernst, 2002), Germany
(Angermeyer & Matschinger, 2005), Russia, Germany, and Mongolia (Dietrich et al.
2004), and the United States (Martin, Pescosolido, & Tuch, 2000; Phelan, Link, Stueve,
& Pescosolido, 2000) have documented these negative effects over time, augmenting the
international research conducted from as early as 1970 that had reported negative results.
Even without a specific psychiatric diagnosis, the early studies showed that the mere term
“mental illness” provoked negative reactions (Read et al., 2006). Manderscheid et al.
(2010) in a study of the general population of 35 states, the District of Columbia, and
Puerto Rico, reported that educated respondents were more likely to believe that mental
illness can be effectively treated. The majority (57.3%) expressed a belief that people in
general were caring and sympathetic towards individuals with mental illness. However,
only a quarter of the people who suffered from mental illness agreed with this
(Manderscheid et al., 2010).
Granello and Granello (2000) investigated college students’ beliefs regarding the
definition of mental illness and its relationship to their tolerance toward individuals with
mental disorders. They found that attitudes towards mentally ill people in the community
were predicted by a person’s definition of what mental illness is. For example, when
people embrace disorders such as bulimia nervosa and anxiety disorders into their
definition of mental illness, they are more compassionate, less authoritarian, and less
socially restrictive in their attitudes. Mental illness can affect an individual in a number
of ways (Jorm & Griffiths, 2008). First the damage caused by the disease itself, secondly
the social disapproval that is inflicted by people who are ignorant or afraid of what it
means, and finally the barriers that are raised by social stigma that prevent people who
desperately need help from seeking it (Corrigan, 2004).
People with mental illness suffer psychological distress and disabilities that
diminish the quality of their lives and deprive them of pleasure and goal fulfillment
(Knapp, 2003; Luty et al., 2006). In addition, negative attitudes and beliefs toward
mental illness can be threatening, leading to prejudice and discrimination that further
complicate living with mental illness and often prevent people with mental illness from
seeking appropriate help (Mann & Himelein, 2004; Moses, 2011). The next section
covers stereotyping, prejudice, and discrimination are considered in detail. Further, in
line with the theoretical underpinnings of this research, the cognitive processes linked to
these social psychological phenomena are assessed in order to evaluate the significance of
these processes in perpetuating the stigmatization of mental illness.
Stereotyping, Cognitive Heuristics, Prejudice, Discrimination, and Stigma
To appreciate stigmatization of a mental disorder, the concept of stigma must be
separated from the associated practices of stereotyping, prejudice, and discrimination
(Kanahara, 2006; Macrae, Milne, & Bodenhausen, 1994). Even though these phenomena
are often linked (Berndsen, Spears, van der Pligt, & McGarty, 2002; Johnson & Jacobs,
2003), it is potentially possible to have one without the others. Moreover, highlighting
their distinctiveness facilitates understanding.
Stereotyping
A stereotype is a belief about a group of individuals. In social and psychological
research, “stereotype” usually pertains to a group of people, but the definition can equally
apply to any group of individual objects (Kanahara, 2006). The concept of a stereotype
was first applied to the social sciences by Lippmann (1922), who described it as a
definition that is applied based on what people already believe about something or
someone prior to the acquisition of any specific knowledge about that thing or person.
While there are several definitions available, all definitions however included a priori
belief that can be applied to members of a given group.
Stereotypes of people are based on social groupings (Scheffer, 2003; 2004). A
social group is cognitively constructed, and characteristics are attached to that group.
Some of these characteristics permit the identification of members of that group – dress,
physical appearance, age, location, language, pattern of speech, behavior, and so on
(Yorke, 2007). Other characteristics are informational and not immediately observed,
such as attitudes toward work or other personality characteristics (Stangor & Lange,
1993). People are not born with stereotypes (Scheffer, 2003; 2004). Moreover,
stereotypes, though their existence is universal, are culture-specific; the groups to which
stereotypes apply are themselves fluid (Cuddy et al., 2009).
The fact that stereotyping exists across cultures (Ota, Giles, & Gallois, 2002;
Sczesny, Bosak, Neff, & Schyns, 2004) and history (Schaller & Latané, 1996) would
suggest that it is a useful and positive adaptation, and that it provides more benefit than
harm. However, researchers found that stereotypes can be maladaptive. An illusory
correlation occurs when a person has merely indirect experience or knowledge of a social
group. Subsequently, more attention is focused on the infrequent behaviors of that group
than frequent behaviors, especially if the infrequent behaviors are negative (Berndsen,
Spears, van der Pligt, & McGarty, 2002; Johnson & Jacobs, 2003).
In Australia, the governing body on mental health found that certain social
influences encouraged the development and maintenance of stereotypical
misconstructions of people with a mental illness (Francis et al., 2004). For example,
legislation implied an association between mental illness and criminal behavior,
exaggerating the likelihood of those with mental illnesses participating in criminal
activities and encouraging a more reproachful handling of those suspected of such
behavior (Smith & Ashiabi, 2007). Further, there were no specifications for tackling
distortions in the media relating to mental illness (Schwarz & Gidron, 2002). Evidence
suggested that stereotyping of people who have a mental illness leads to stigmatization;
stigmatization then causes embarrassment to individuals with mental health disorders in
pursuing treatment and seeking employment and workplace support. Further,
stigmatization generates obstacles to mental health promotion (Senate Select Committee
on Mental Health, 2006).
Individuals’ instinctive tools for developing concepts of social groupings tend to
operate on any information that they have available to them, regardless of whether it is
accurate or based on direct experience (Scheffer, 2003, 2004). The easier it is to detect a
difference between them and another person, the more likely it is that the other person
would be labeled as part of an out-group (Linville, 1998). Inevitably, physical
appearance plays a significant role in the formation of our social group concepts, as does
language or physical location (Ensari & Miller, 2002). Social stereotypes can become
complex, contradictory, and misleading at this point, and incorrect assumptions can easily
be made about members of one’s own in-group (Kalmuss, Gurin, & Townsend, 1981).
Stereotypes are clearly social shortcuts (Linville, 1998 cited in Darley & Cooper). Like
any such heuristic, they can be incorrect. Stereotypes are not merely social heuristics;
they are also cognitive heuristics (Halberstadt & Catty, 2008). That is, they allow us to
reduce the amount of cognitive effort expended in interacting with others by allowing us
to assume certain things about them, and they permit us to move more quickly to more
useful specifics (Macrae, Milne, & Bodenhausen, 1994).
Cognitive Heuristics
One of the reasons that people reach inaccurate conclusions in social situations is
that they employ cognitive heuristics (Hayes & Allinson, 1998). Heuristics are mental
shortcuts that forego a degree of accuracy in return for cognitive economy. Heuristics
can be adjusted to different situations, permitting more cognitive tasks to be deduced
(Halberstadt & Catty, 2008). However, heuristics can be susceptible to errors of
judgment, especially when they are based on limited, skewed, or inaccurate experience or
information. Understanding heuristics is important in grasping how people form
prejudiced attitudes, inaccurate stereotypes, and how they can be altered (Hayes et al.,
2002). The availability cognitive heuristic operates when a person’s familiarity with a
subject, object, or event is used as the basis for judging its frequency, normality, or
popularity, rather than objective evidence (Halberstadt & Catty, 2008). More precisely,
the availability cognitive heuristic is the ease with which a person can recall information
or can associate one piece of information with another that is used as the basis for
determining whether something is frequent or normal (Schwarz & Gidron, 2002). The
availability cognitive heuristic is a mental shortcut that depends on instant examples that
come to memory.
Memory can be conceived as a network of interconnected ideas (Cohen &
Struening, 1962). Each idea has an association with another that is heavily connected
(Conner, Koeske, & Brown, 2010). The strength of that connection is based on a number
of factors including: (a) the frequency with which that connection is experienced; (b) the
frequency with which it is recalled, thought about, or considered; (c) the importance of
the connection; (d) the personal salience of the connection; (e) the emotional associations
of the connection; and (f) the number of other pieces of information that are also related
to the connection (Hayes et al., 2002). The availability heuristic assumes that the strength
of the connection, and therefore the ease of recall, is an indicator of the frequency or
normality of the information (Halberstadt & Catty, 2008). Since frequency is a
significant factor in how strongly integrated a piece of information is with the rest of our
memories, this can influence recall regardless of matters of personal importance or
emotional association (Schwarz & Vaughn, 2002). For example, media reporting of
mental illness among the prison population can often lead to such information being
highly accessible. The reporting that an individual is both a prisoner and mentally ill,
perhaps following escape, can link these issues strongly within the background of fear for
personal safety, thereby exaggerating the importance and emotional content of the
association (Conner, Koeske, & Brown, 2010). Repeated use of this association (often
not in real life, but in movies and other contexts) can reinforce these ideas on a regular
basis, strengthening the link between criminality and mental illness (Arthur et al., 2010).
A single or rare event or experience can become strongly connected with our other
memories if it is powerful or is repeatedly rehearsed through thinking or talking about it
(Arthur et al., 2010; Conner, Koeske, & Brown, 2010). Consequently, rare but impactful
events can be perceived to be considerably more common than they are because of the
effect that they have on us, and the degree to which they are spoken about (especially in
the media) or thought about (Schwarz et al., 1991). This kind of event can result in a
skewed and inaccurate perception of dangerousness of people with mental illness. Media
reporting of violence by people with mental disorders tends to be more frequent (i.e.,
multiple reports and follow-up reports, rather than just one) or more sensationalized than
violence committed by other people (Wahl, 2003).
The probability of a particular event occurring, or a behavior being expressed, or a
feature being true of an individual, is often estimated using the representativeness
heuristic (Halberstadt & Catty, 2008). This heuristic uses the degree to which an object
or person is representative of a class or group to estimate how likely it is that the object or
person share other, as yet un-assessed, features with that group (Kahneman & Tversky,
1972). Generally, the representativeness heuristic is based on the assumption that one’s
perception and understanding of the features of a group, a stereotype, are accurate. If
one’s understandings of the group is wrong or not knowledgeable in regards to mental
health, then the representativeness heuristic offer incorrect conclusions. The
representative heuristic should render immediately apparent how likely an object is able
to possess a certain feature based on other features, and to make adjustments in different
situations (Campbell, Sullivan, & Davidson, 1995). For example, when one encounters a
homeless individual, it is likely that one assumes they are mentally ill based on the
association between these two characteristics, despite the recognition that these two
groups are sociologically distinct. In light of the higher incidence of mental illness in this
group, it is possible that this heuristic would be reinforced should an individual be
considered mentally ill, depending on their behavior. However, application of such
assumptions to other groups (e.g., the unemployed) may lead to false conclusions and
would not be useful in this context.
An exemplar as a cognitive heuristic can be considered a sub-form of the
representativeness heuristic (Hutchinson & Alba, 1997). An exemplar is an individual in
a group who is viewed as embodying all the essential defining characteristics of that
group. In cases where a person has little experience with other members of a group, the
exemplar may be seen as a “perfect” representation of the group (Hutchinson & Lynch,
1990). Whatever features the exemplar displays may be assumed features of the group
rather than idiosyncratic features of the exemplar (Hutchinson & Lynch, 1990). For
example, encountering an individual with mental health issues who has marked
delusional beliefs can lead to the assumption that all forms of mental illness are
characterized in this way, regardless of any specific diagnosis or the underlying beliefs of
the exemplar. Associating these individualized characteristics with other individuals with
mental health problems distort perceptions and lead to false assumptions regarding the
beliefs and behavior of this group.
The commitment heuristic maintains that, once a person has become committed to
a certain course of action, or is personally invested in a particular belief, it is harder to
alter that person’s beliefs and dissuade him or her from either the action, or the reasoning
and evidence underlying it (Abelson, 1986). This heuristic overlaps somewhat with
cognitive dissonance, which also suggests that a person who has already expressed a
certain belief or engaged in a particular behavior would resist altering that belief or
contradicting that behavior to avoid cognitive dissonance. Kanodia, Bushman, and
Dickhaut (1989) suggested that people might factor in personal socical costs (e.g., loss of
face or reputation) into their decision-making, leading to decisions that would not be
logical based solely on the costs of the decision itself, but make sense when a wider
picture is examined. For instance, individuals with strong beliefs regarding the behavior
of those with mental illness would be less likely to change such attitudes when presented
with contradictory information, particularly if they champion this belief within a group
and do not wish to lose face over an opposing viewpoint or backtracking on previous
statements. A review of these studies suggests that the information may be credible,
persuasive, and can be overridden by the desire to remain in an authoritative position,
which weakens the desire to change.
Walton and Dawson (2002) argued that informal logic is often a logical and
reasonable approach to a complex scenario, particularly one in which a decision to
undertake a course of action is made before all the information is available. Thus, any
attempt to alter a person’s beliefs, or the actions they would take because of those beliefs,
needs to consider the subjective assumption that a person’s commitment to a certain path
is advantageous, even if it appears not to be. As Hinshaw (2007) noted, when stereotypes
become set in people’s minds, and especially when people ignore definite data about the
person or group in question, they have a tendency to develop a destructive, derogatory
attitude, and are prejudiced.
Further than stereotypes, which relate to a general portrayal of members of a
particular group, prejudice indicates a more sinister attitude loaded with negative
connotations. For example, people with mental illness may be stereotyped as substance
abusers; the stereotypes may be represented in a number of ways, including comically
and light-heartedly. However, when one converts this stereotype into prejudice, there
would be derogatory comments made to individuals with mental illness regarding drug
and alcohol abuse and only negative aspects of substance abuse recorded (Hinshaw,
2007). This development easily leads to victimization and discriminatory behavior
(Hinshaw, 2007; Walton & Dawson 2002), as previously described.
Prejudice
Even though social scientists often disagree in the exact way they define
prejudice, they generally agree that it encompasses a prejudgment, usually negative,
about a group or its members, exhibiting groundless attributions to individuals of a social
group (Fiske, & Haslam, 1997; Jones, 1997; Nelson, 2002, as cited in Plous, 2003). This
is in contrast to stereotyping, where standardized beliefs about one group are based on
some prior assumptions or observations. Prejudice is not merely a statement of opinion
or belief, but an attitude that includes feelings such as contempt, dislike, or loathing
(Hinshaw, 2007). Though multiple definitions of prejudice have been proposed,
explanations that are most applicable to this research include an assumption that the value
judgment that forms part of the prejudice is not based on accurate and reasonable
appraisal of factual evidence (Eagly, & Karau,2002). Hinshaw (2007) classified
prejudice as “an unreasoning, unjustifiable, overgeneralized, and negatively tinged
attitude towards others related to their group membership” (p. 22).
Research on prejudice began in the 1920s and was founded upon American and
European race theories that attempted to prove the superiority of White people (Duckitt,
& Sibley, (2007). As a result of changes in the 1930s and 1940s due to the civil rights
movement and challenges to imperialism, several theorists came to consider prejudice as
unreasonable; and they explored the prevalence of personality disorders in individuals
associated with racism, anti-Semitism, and other forms of prejudice. The researchers
concluded that prejudice was a part of an ”authoritarian personality;” rigid thinkers who
conformed to authority saw the world as black and white, and imposed obedience to
social rules and orders, and were more likely than others to hold prejudices against
lowstatus groups (Adrono, Frenke, Levinson, & Nevitt, 1950).
Allport (1954) investigated the connection between prejudice and categorical
thinking. He identified the emotional, social, economic, and historic dimensions of
prejudice, and proposed that prejudice is a product of normal human functioning. For
example, in the United States, at least 75% of African Americans have White ancestry,
and 1-5% of American Whites’ DNA is from African ancestors (Salazar Davis, 1991).
Biologically, Black and White ethnic individuals contain a range of genes rather than an
opposition. However, acceptance of the false purity of racial groups has permitted the
exploitation of Black people for centuries (Plous, 2003). By ignoring the factual basis of
genetic data and propagating the notion of racial purity, categorical thinking opposes two
distinct groups by highlighting difference rather than similarity (Allport, 1954; Plous,
2003).
Categorical thinking can misrepresent perceptions by minimizing differences
within groups (assimilation) and overstating differences between groups (contrast)
(Linville, Fischer, & Salovey, 1989). Linville, (1998) found that, closely related to
assimilation is the out-group homogeneity effect. He also found that in relation to
attitudes, principles, personality traits, and other features, more similarities are perceived
in out-group than in-group members. As a result, out-group members are at risk of being
seen as identical, and hence are more likely to be stereotyped. He further indicated that,
whether the out-group is that of another ethnic group, religion, or race; this judgment of
uniformity is confirmed.
Prejudice is also closely connected to the way that in-group and out-group
members justify another’s behavior (Brown, Jones, LaRusso, & Aber, 2010). For
example, if homelessness of people with mental health problems is often attributed to
idleness, lack of moral fiber or capability, prejudice toward such people is liable to
continue. Alternatively, if homelessness is thought of as being caused by redundancy or
domestic violence, prejudice may not be a factor or could decrease. Nevertheless,
individuals often assign harsh attributions to the behavior of out-group members (Brown,
Jones, LaRusso, & Aber, 2010). For over five decades, psychologists studied why some
people are more prejudiced than others are, highlighting two major lines of explanation
based on personality or social psychology. The personality account proposes that
prejudice is caused by personality traits (e.g., Adorno et al., 1950; Ekehammar & Akrami,
2003). The social psychology description suggests that prejudice is caused by situational
influences such as social group membership, social identity, social selfcategorization, and
social position (Ekehammar & Akrami, 2007).
Two theoretical frameworks explain individual differences in prejudice. One
approach originates from the authoritarian-personality theory (Adorno et al., 1950) and
was developed further by research on right-wing authoritarianism (Altemeyer, 1998).
The other is social dominance theory (Sidanius & Pratto, 1999), which states that
prejudice and discrimination are common human displays where groups are created on
the basis of powerful organizations in which participants of some groups have the wealth,
power and need to overpower others. The key individual difference variable is social
dominance orientation - a preference for inequalities (Altemeyer, 1998; Adorno et al.,
1950).
Conversely, more recent research suggested that right-wing authoritarianism
(RWA) and social dominance orientation (SDO) are not personality traits but measures of
social attitudes, social beliefs, or social evaluations (Kreindler & Lumsden, 2006; Saucier
& Goldberg, 2001) and should be situated in the field of social psychology. However,
Akrami and Ekehammar (2006) contended that RWA and SDO are linked by personality
and social psychology with underlying personality as a clear cause. It is important to note
that prejudice is a purely internal phenomenon and can be moderated by factors such as
social norms and learned behaviors to the extent that internally-held prejudice may be
suppressed entirely if social pressures are strong enough (Crandall, Eshleman, &
O’Brien, 2002).
Social forces, social norms, and learned behaviors affect the adoption of attitudes,
modification of them, and any subsequent modes of expression. Other factors also
moderate the expression of prejudiced attitudes. The expression of prejudice against
immigrants, for example, is moderated by both pragmatic (e.g., taking jobs) and symbolic
(e.g., threat to “national identity”) perceived threats (Pereira, Vala, & Costa-Lopes,
2010). Similarly, prejudice against the mentally ill can be moderated by the perceived
risk of violence or aggression (threat to self), a symbolic perceived threat, and a
perception of weakness on the part of the individual. Personal safety and fear of the
unpredictability of those suffering from mental illness are moderating factors directly
affecting prejudice. However, Hinshaw and Steir (2008) noted that although these
practices may take place due to people’s nature and environment, they are flexible and
can be changed through minding the situation of an individual, changing social policies to
encourage transformations in individuals’ attitudes and behavior. When stereotyping and
prejudice involve cognitive and affective components, discrimination is the resulting
behavior.
Discrimination
Discrimination is biased treatment of, or detrimental behavior toward, others
based on group membership (Corrigan et al., 2003). Discrimination can be prompted by
individuals, families, or communities, or by an entire society or country (Morrison &
Becker, 1975). Discrimination restricts the rights of people diagnosed with mental
illness; unfair practices may unofficially or officially be authorized by law or presiding
jurisdiction (Corrigan et al., 2003; Morrison & Becker, 1975). Stereotyping therefore
relates to the cognitive aspect of group segregation; prejudice concerns the responsive
and emotional component of such separation (Corrigan et al., 2004). Out-group members
are devalued and discrimination involves behavioral responses, above all acts that restrict
the rights of others or engage in blatant maltreatment of them (Hinshaw, 2007).
People with mental health issues are confronted by stereotypes and prejudice due
to the misunderstandings of mental illness (Pinfold, 2003). According to Corrigan and
Watson (2002), these people often face discrimination by being deprived of the
possibilities that make up a good life: a decent job, safe housing, reasonable health care,
and relationships with a variety of people. They further stated that comments or actions
can have a significant cumulative effect on individuals with mental health problems,
regardless of the perceived or intended innocuousness of each individual comment;
negative comments can be spread out over a long period of time and still have a
cumulative impact on the individual; ultimately, such comments destabilize and distress
the individual in question, through a process of mental attrition, characterizing the stigma
of society toward them.
The continual message that a person is different (not like you), or less (you are
better than them) is gradually learned and often internalized, which can result in
depression, anxiety, fear, hopelessness (Corrigan & Watson, 2002). The continued tacit
acceptance of treating a group or groups of people differently to “normal” people offers
support in principle for all discrimination (Pierce, 1995). Furthermore, though overt acts
of discrimination (e.g. refusing a promotion based on gender) are illegal, it is impossible
to legislate against overtly or covertly discriminatory behaviors. It is far more effective,
though perhaps harder, to address the underlying attitudes of prejudice and thereby
forestall discriminatory behaviors, than to attempt to police every behavior.
Prejudice is an individually held attitude of value judgment, and discrimination is
an individual expression of a prejudice (Murray, Holmes, & Griffin, 1996; Nelson, 2004).
According to (Gibson et al., 2008), bias is either positive or negative discrimination
against a particular group. They further indicated that, a prejudiced person may not act
on his or her attitude; someone can be prejudiced toward people with mental illness but
not discriminate against them (Gibson et al., 2008). Prejudice includes all three
components of an attitude (Murray, Holmes, & Griffin, 1996). The affective component
involves a person’s emotion, the behavioral component denotes the way in which one
may perform or behave, and the cognitive component involves a person’s belief or
knowledge about an attitude object (Nelson, 2004).
Discrimination involves behavior; it may be informal, but recognized and
accepted, like the ongoing pay discrepancies between single and married workers; or it
may be unrecognized and unquestioned, but widespread, as in the current and ongoing
bias against men working in child-care roles (Murray, Holmes, & Griffin, 1996; Nelson,
2004). In a research conducted in England, Pinfold (2003) asked service users of mental
health facilities about their experiences of stigma. The study revealed that the groups
most frequently cited in needing targeted educational sessions to reduce discrimination
were doctors, closely followed by school children, employers, and the police (as cited in
Thornicorft, Rose, & Kassam, 2007). Pinfold found that, a history of discrimination
hostile to a minority group can promote stereotyping and prejudice, even in people who
have never met a person from that group. These harmful attitudes can put biased
practices into effect by holding the sufferers responsible for their own predicament
(Nelson, 2004).
Today, people with mental health disorders are stigmatized (Moses, 2011). They
are being discriminated against on a daily basis, being deprived of access to goods, and
services, or, being treated based on false assumptions. Discrimination of people with
mental illness occurs across the world, regardless of culture (Angermeyer & Dietrich,
2006; Muller, Nordt, Lauber & Rossler, 2007). There is evidence that some individuals
who have mental illness avoid treatment due to the social stigma attached (Scheffer,
2003). For instance, many of these individuals are neglecting to take medications for
depression and other psychological disorders because they dread what would ensue if
other people learn of this. Individuals with mental disorders are most often distressed
that their friends and family would accuse them of being insane, absurd, or too
incompetent to solve their problems; there are some people who would not file insurance
claims for psychotherapy because they fear their employers would fire them (Schwartz,
2006).
Lauber, Nordt, Braunchweig, and Rossler (2006) found that there is little variation
between the attitudes of mental health professionals and those of the general population.
For example, people with personality disorders are often less well received for therapy by
psychiatric staff. Surprisingly, there has been little research into this possible stigma but
the evidence available implies that such staff has negative perceptions of people with
mental illness diagnosis; judgmental approaches from this segment of society can
significantly affect patient care (Social Exclusion Unit, 2004). Further, in a British study,
Corrigan, Watson, Byrne, & Davis (2005) evaluated how a past diagnosis of alcohol
dependence shaped consultant psychiatrists’ views about the treatment. The researchers
found that psychiatrists were more likely to assess patients with mental diagnosis as
problematic, difficult, and less in need of treatment than patients diagnosed with medical
conditions. Such valuations directly affect the way in which patients are treated; hence,
the extent of this problem within the health care system needs to be further explored.
Discrimination and oppression are also important determinants of mental health
outcomes (Krieger, 2001). In studies focused on racial discrimination, researchers
consistently found an association between higher rates of self-reported discrimination and
poorer mental health (Corrigan et al. 2003, Corrigan et al., 2004). Racial discrimination
is associated with a reduced sense of well-being, low self-esteem, and lack of influence,
psychological suffering, and other mental illnesses (Krieger, 2000). The relationship
between experiences of personal oppression in relationships and adverse mental health
outcomes is strong. For example, women who have experienced emotional and/or
physical violence in relationships have high rates of depression, anxiety, stress, pain
syndromes, phobias and chemical dependency as well as poor individual health (WHO,
2002). Researchers have also linked poor mental health with bullying. Disturbance from
bullying has been linked with depression, low self-esteem, weak self-concept, isolation,
and anxiety (NIMH, 2013).
The significance of prejudicial viewpoints is that they can become transformed
into discriminatory behavior with mental disorders (especially certain diagnoses)
continuing to be trademarked as unacceptable, reprehensible, and shameful (Corrigan et
al., 2004). Whether this behavior is present in the general population or the health care
profession, discrimination poses a risk to the well-being of those with mental illness and
obstructs the process of equitable care for this group (NIMH, 2013). In the next section, I
address the concept of stigma, its relation to mental illness, and how the stigmatization of
mental illness has progressed to the present.
Stigma
According to Hinshaw (2007), the term “stigma” comes from the act of branding
members of disapproved groups so they displayed an observable sign of shame for all
members of society to see. The researcher noted that stigma is a worldwide depreciation
of certain individuals due to their having a particular trait or belonging to a group that is
disapproved, devalued, or shamed by general society. Stigmatization is inherently
selfreinforcing (Gibson et al., 2008). Once an impression is formed, whether through
direct experience or though impressions offered by others, it is hard to alter (Hayward
&Bright, 1997). The saying “first impressions last” received research support, for very
realistic reasons (Denrell, 2005).
According to Denrell (2005), individuals form first impressions; people are
inevitably going to evaluate anyone they meet; if the first impression is positive, then
further interaction is likely; the first impression is reinforced and “proven” through
experience; if the first impression is negative, then further interaction is less likely, as the
negatively evaluated person is more likely to be avoided; the initial negative impression
is then left unchallenged. Denrell further stated that, it is only in situations where further
interaction occurs in spite of a negative first impression (such as in a work or school
scenario where interaction is required regardless of personal preferences) that an initial
negative impression is challenged, and then only to the extent that the mandated
interaction requires; if, however, there is sufficient interaction, the negative first
impression is usually altered, and becomes a positive impression.
Stigma characterizes individuals as imperfect and degraded; it generates
discrimination in employment, housing, medical care, and social relationships
(Rosenfield, 1997). Having a record of psychiatric treatment and institutionalization can
have a negative effect on how the character of that person is perceived by others. Most
people with mental illnesses are stigmatized and often suffer antagonistic consequences
such as increased social segregation, lack of opportunities to work, and the inability to
access treatment (Rosenfeld, 1997). There are low employment rates among people with
mental health issues (Hayward & Bright, 1997). Conversely, some people with mental
health diagnoses can have problems that affect their working life. In schizophrenia, for
example, poor concentration can be a particular problem (Hickling et al., 2011).
Nonetheless, rates of employment among people with this disorder vary greatly between
countries, so mental illness alone cannot explain low work rates (Thornicroft, 2012).
Those people with mental illness may be exposed to prejudice and discrimination
from others (received stigma), as well as adopting feelings of devaluation (self-stigma)
(Jackson & Heatherington, 2006). In society, stigma has been associated with low access
to services, and insufficient funding for mental health research and treatment of
institutional stigma (Jorm & Griffiths, 2010). Public stigma exposes a social and cultural
background with undesirable community attitudes that affect every day, professional, and
official reactions (Kitchener & Jorm, 2002). Recent evidence in the United States
showed that researchers found no progress in discrimination toward people with serious
mental health conditions or substance abuse problems, and in some cases discrimination
may even be getting worse (Pescosolido et al., 2010).
Public Stigmatization of Mental Illness
In relation to mental illness, Jones et al. (1984) noted that stigma occurs when a
sign links a person through attributional processes to unattractive features that shame
them. There are six measures of stigma:
1. Conceal-ability: How observable a characteristic is to others.
2. Course: Is the difference for life or changeable?
3. Disruptiveness: The effect of the difference on social interactions and
relationships.
4. Aesthetics: Does the difference produce aversion or is it seen as unpleasant?
5. Origin: Is the individual seen as responsible for this difference?
6. Peril: Does the difference produce feelings of risk in others? (Pescosolido et
al., 2010, pp. 214-218)
From these six categories, stigma takes place when the mark links the identified person
through attributional processes to unwanted characteristics that may damage his or her
reputation.
Evidence suggests that stigmatizing attitudes about people with mental illness are
widely held by the general population in the Western world, with studies supporting these
findings in the United States and many Western European countries. Additionally, these
views are not restricted to members of the general population; even professionals from
mental health fields contribute to stereotypes about mental illness (Corrigan & Watson,
2002). In the United States, the DHHS Surgeon General’s report (1999) highlighted the
fact that a very low rate of people with mental illness accessed services, along with a
shortage of resources, and continuing high rates of prejudice and discrimination toward
individuals with mental health conditions. The report saw scientific research as a
possible deterrent against stigma in that if evidence presented mental illnesses as
brainbased disorders, it would liberate people from misconceptions. Some commercial
advertisements ensued, relating mental illness to brain-based etiologies with this very
goal.
Pescosolido et al. (2010) studied public attitudes of schizophrenia, major
depression, and alcohol dependence between 1996 and 2006. They found that despite the
advances in public knowledge, there were no significant decreases in public instances of
stigmatization, with little change in attitudes toward stigma (Pescosolido et al., 2010). A
majority of the public continued to voice reluctance to work or socialize with a person
with schizophrenia or alcohol dependence or to have a person with these problems marry
into their family (Pescosolido et al., 2010). The findings also showed that significantly
more respondents in 2006 than 1996 reported an aversion to having someone with
schizophrenia as a neighbor or to having someone with alcohol dependence marry into
their family. Additionally, a majority of the sample associated violence with
schizophrenia and alcohol dependence. While stigmatizing reactions did not significantly
decrease for attitudes toward depression, levels were lower to some degree (Pescosolido
et al., 2010).
Angermeyer and Matschinger (2005) found similar results in the German
population. Regardless of increases in public mental health literacy and the endorsement
of neurobiological causation, there was neither change nor growth in public
stigmatization of mental illness. The appreciation and recognition of neurobiological
factors in causing mental illness was also associated with maintaining a social distance
(i.e., a lack of befriending). Jorm and Griffiths’ (2008) research in Austria also replicated
the finding that neurobiological causation literacy has little effect on public stigmatization
of mental illness, although it had no influence on social distance. Mann and Himelein
(2004) surveyed undergraduate students to examine the effect of diagnosis, attitudes
about treatment, and psychiatric language on stigma connected with mental illness. They
found stigmatization of schizophrenia was significantly higher than stigmatization of
depression; in addition, fewer stigmas were attached to disorders that could be treated.
Further, some studies encompassed a much wider spectrum of mental health disorders
including eating disorders, social phobia, posttraumatic stress disorder, and anxiety
disorders, revealing variations not only among how different disorders are perceived but
also in terms of the different dimensions of stigma (e.g. Granello &
Granello, 2000; Jorm & Wright, 2008; Samouilhan & Seabi, 2010).
Anglin et al. (2006) examined the stigma of mental illness within ethnic minority
groups. They found that Black individuals were more likely to believe that people living
with a mental illness are dangerous and more likely than Caucasians to believe that
individuals with schizophrenia or major depression could become violent toward others.
They also found that Black individuals were less likely than Caucasians to believe that
people with mental illness should be blamed or punished for violent behaviors; these
perceptions of ethnic differences were not due to socio-demographic factors. Their
results, however, showed that stigma is a complex process and that any interventions
aimed at educating the public regarding mental health should consider cultural
differences in the perceptions of mental health and the level of stigma imposed upon
people with mental health problems.
The motives of individuals with mental illness are often considered mysterious or
strange by the general population, which serves to increase speculation regarding the
determinants of mental illness behavior patterns, resulting in assumptions (Kessler et al.,
2003; Wahl, 2003). It seems to matter little that far more people will suffer from mental
health problems during their lives than due to clinically significant chronic physical
disorders (Kessler et al., 2005). It does not seem to matter that the motivations of people
with mental health issues are only very rarely different from those of anyone else (Wahl,
2003). The aforementioned media images help to support, perpetuate, and reinforce the
stigma associated with mental health problems, and interfere with people both
acknowledging that they may need help and then accepting the risk of “discovery” that
comes with seeking help. Ironically, sensational media reports may be perpetuating the
very events that they report and decry (Corrigan et al., 2004).
Some media organizations appear to be altering their coverage of mental health
issues. Reporting in Australia, for example, is notable for an increase in factual styles of
presentation and a minimization of sensationalist views that might encourage a negative
perception of those with mental illness (Francis et al., 2004). Gary (2005) proposed that
ethnic minority groups, which already face issues of prejudice and discrimination due to
their minority status, face a double stigma when it comes to mental health problems. The
burden of this double stigma may prevent mentally ill Black people from seeking
treatment and help when it is needed. Gary argued that the stigma of mental illness,
combined with racial discrimination, could be a virtually impenetrable barrier to mentally
ill people receiving help.
In the United States, Conner et al. (2010) investigated the effects of stigma on
people’s access to mental health treatment with the hypothesis that stigma mediates the
relationship between attitudes towards mental health treatment and race in older Blacks
and White adults. They found that Black individuals were more likely to have negative
attitudes toward mental health treatment than Caucasian individuals were, with the
relationship between attitudes toward mental health treatment being partially mediated by
internalized stigma; this suggests that internalized stigma may cause Black adults to
develop negative attitudes about mental health treatment. As they stated, this finding of
ethnic differences in the implications of stigma for accessing mental health treatment
should be addressed at the level of social work and community psychology.
Researchers also showed that while attitudes toward mental illness fluctuate
among non-Western cultures, the stigma of mental illness may not be as acute as in
Western cultures (Corrigan & Watson, 2002). Fabrega (1991) suggested that an
important consideration is the modest segregation between psychiatric and nonpsychiatric
illness in the major non-Western medical traditions; and if stigmatization occurs in these
cultures, it is mostly connected to more enduring forms of illness that are difficult to treat.
The research highlighted the virtual absence of stigma in Islamic societies. De Toledo
Piza Peluso and Blay (2004) conducted a research review of public perceptions of mental
disorder in Latin America and the Caribbean. Overall, they found no significant
differences between the perceptions of mental illness in Caribbean and
Latin American countries compared to developed countries. They also found that for the
20-year period they reviewed there is a general international trend toward more positive
attitudes regarding mental disorders, especially among more educated and affluent
classes.
Mental Illness in Jamaica
There have been substantial attempts to educate the public in Jamaica about
mental illness and its treatment through popular media (Hickling et al., 2011). However,
researchers found that stigma in Jamaica, although improving, is still evident (Arthur et
al., 2010; Gibson et al., 2008; Hickling et al., 2011; Francis, 2007); stigma continues even
in the younger population (Jackson & Heatherington, 2006). Stigmatizing attitudes
inhibit the utilization of mental health support (Arthur et al. 2010); in addition to
evidence suggesting that Jamaicans are less likely than other populations to seek help for
mental disorders (Yorke, 2007). The issue of stigmatization attitudes is particularly
relevant considering that Jamaica has a considerably young population, with an average
age of 24 years (World Factbook, 2012). Researchers point out results that indicate great
concern about mental illness in the young Jamaican population (Verhulst et al., 2003 as
cited in Smith & Ashiabi, 2007). The issues of mental illnesses are compounded by other
social and economic problems such as poverty and crime in particular areas within the
country. Because Jamaica represents a Western nation at the lower end of personal
income, issues surrounding mental health attitudes and perceptions have been explored
over recent decades in detail. The following section describes the mental health system
and its processes in Jamaica.
Since achieving independence from the United Kingdom in 1962, Jamaica made
substantial public policy changes to its mental health services, including developing a
community mental health service, major deinstitutionalization of the single mental
hospital, and profound reorganizing of the country’s mental health legislation (Kukoyi et
al., 2010; McKenzie, 2008). Substantial attempts to educate the public about mental
illness and its treatment have also been employed through popular media. Hence,
significant changes have occurred in mental health care in the Caribbean since early
reports (Hickling et al. 2011). However, very few studies have examined whether
substantial changes in regulations, along with significant efforts to inform and educate the
Jamaican population about mental illness, have reduced stigma. The next section focuses
on the prevalence of mental illness in Jamaica and discusses attitudes, the existence of
stigma in the Jamaican public, and evaluates whether mental health education affected the
social acceptability of mental illness.
Jamaica is a small island nation in the Caribbean, with a population of 2.9 million
(Miller, 2002). It has had a stable democracy since it attained independence from Britain
in 1962 (Reid, 2011). The World Bank classifies the country's economy as Lower Middle
Income (McKenzie, 2008). The age structure of the population stands at 30% between 0-
14 years, 62% between 15-64 years, and 8% aged 65 or over (Smith & Ashiabi, 2007).
Overall, there is a relatively young population with an average age of 24 years (World
Factbook, 2012). However, the island scores low on many social indicators. There is
widespread poverty and a widening social gap between the rich and poor, as evidenced by
concentrations of extreme wealth, a shrinking middle class, and a stagnant economy.
Unemployment rates in those aged 15 – 24 years is particularly high at 27%. The
incidence of AIDS/HIV was estimated at 1.7% in 2009 and is concentrated among the
poor (World Factbook, 2012). The adolescent birth rate is high, with 85% of Jamaican
babies born to unmarried mothers and 50% without a registered father (World
Factbook, 2012).
In Jamaica, epidemiological studies showed that the most prevalent mental
disorder is Major Depressive Disorder (MDD) (Whitley & Hickling, 2007). However,
schizophrenia is the most prevalent disorder that is diagnosed and treated; patients
admitted to the mental health hospital are diagnosed primarily with schizophrenia (79%)
and Mood Affective Disorder (10%). Thirty-seven percent of the patients treated at the
mental hospital were female (WHO, 2009). Whitley and Hickling indicated that in the
Mental health outpatient facilities, the majority of users were women (45%) and 19% of
outpatients were children and adolescents. In these facilities, individuals were primarily
diagnosed with schizophrenia (51%) and Mood Affective Disorder (36%) (WHO, 2009).
There are two community-based psychiatric inpatient units in Jamaica, in which 41% of
admissions are female. Those admitted to community-based psychiatric inpatient units
for 2007 were mainly from the diagnostic categories of neurotic, stress-related and
somatoform disorders (32%), and schizophrenia (46%) (WHO, 2009).
UNICEF (2006) estimated that 37,000 Jamaican children were living with at least
one of several types of disability, including mental retardation and learning disability.
Furthermore, the paper highlighted the stigma and harshness that such children encounter.
In a 2005 study, Strohchein found that many parents supposed the birth of a disabled
child had paranormal influences. Researchers showed a continual link between economic
deprivation and children’s socio-emotional well-being. Poor youth display higher rates of
aggressive behaviors and mental health issues (e.g., social withdrawal, mood problems,
and depression) than more wealthy peers do (Smith & Ashiabi, 2007).
Some authors maintained that the poor were more liable to be defined as mentally ill
when they had the same symptoms as their more prosperous colleagues, and found
associations between hardship and mental illness. Strohschein (2005) used data from an
American survey and examined the psychosocial position of more than 7,000 children.
The researcher found that long-lasting poverty is connected with higher degrees of
psychiatric difficulties and antisocial behaviors; as family earnings increase, children's
mental health, and behavioral problems decline.
Smith and Ashiabi (2007) found that in Jamaica, between 1996 and 1998, the
frequency of suicide among adolescents increased twofold and in 1998, 31% of all
reported suicides were adolescents. A cross-cultural study of seven countries rating
selfreported behavioral and emotional problems in adolescents (11-18 years) found that
Jamaica was one of the countries where young people displayed the highest rates of
emotional and behavioral problems (Smith & Ashiabi, 2007). Females described more
internalizing behavior difficulties, while males stated more externalizing behavior
problems (Verhulst et al., as cited in Smith & Ashiabi, 2007).
More recently, Kukoyi et al. (2010) examined risk factors associated with the
presence of suicidal ideation and suicide attempts in Jamaican adolescents. They found
that by undertaking a cross-sectional study of 342 adolescents (10-19 years) from 19
schools in Jamaica, there was a high rate (58.7%) of mental health problems among
adolescents; with 24.7% reporting a suicide attempt. They further indicated that causal
factors for attempted suicide included a history of family violence, a history of sexual
abuse, and a history of depression. They concluded that there were powerful contributory
factors to mental illness among adolescents in Jamaica, including sexual abuse, poor
education, and lack of social contact.
McGoldrick et al. (2005) noted that many Jamaicans did not like to address mental
health problems, rarely use the term “depressed” or “anxious,” or see these issues as
disorders needing therapy; Jamaicans are more likely to understand them as medical or
spiritual disturbances. According to Millwood (2011), most Jamaicans view
psychospiritual illness as a numinous etiology treated by seeking folk remedies, which
consist of a spiritual basis to counter evil forces. McDermott (2002) pointed out that for
many years, Jamaicans utilized folk healing as a treatment for mental or physical
disturbances. The next section considers attitudes to mental health and whether these
have improved because of the attempts to reduce stigmatization.
Stigmatization of Mental Illness in Jamaica
The Jamaican government deinstitutionalized its mental health care system with
advocacy groups set up to educate the public regarding mental health issues (WHO,
2009), and to have education as a fundamental part of overcoming the stigma attached to
mental illness (Corrigan et al., 2002). Overcoming stigma in this manner in the context
of legislation by the Jamaican Government is problematic, in that the legislation classifies
mental illness as an impairment of the individual’s capacity to be socially responsible
(Arthur et al., 2010).
The Jamaican government explicitly limits the definition of mental illness to
severe diagnoses that can be linked to aggressiveness, unruly conduct, and crime (Arthur
et al., 2010). As in the United States, deinstitutionalization, together with the expansion
of mental health facilities in the community, brought a major increase in the number of
mentally ill persons becoming homeless in Jamaica. This was primarily due to a lack of
services and accommodations for new patients in need of care. This made a once hidden
social problem evident to the public, increasing their contact with mentally ill persons
(Hickling et al., 2011). In a national survey on mental health, 66.4% of respondents
admitted to actively avoiding people with mental illness, and 74.7% of respondents stated
that they did not feel comfortable with people who had mental illness (Gibson et al.,
2008). More than 7% of respondents to the same survey admitted targeting people with
mental illness for both verbal and physical attacks (Gibson et al., 2008). In fact, the
prevalence of severe mental illnesses that may result in aggressive behavior is low in
Jamaica, with people more likely to assault a person with mental illness than be assaulted
by one.
Gibson et al. (2008) argued that the culture of stigma that is associated with
mental illness was intense when people who are victims of stigma act negatively toward
others who are stigmatized. They examined the internalization and consequent
stigmatization of others by people who are themselves victims of stigma. In the study,
they used data from a national survey undertaken in 2006 on mental health, analyzing
demographic variables, the presence or absence of mental health in respondents, and the
attitudes of all respondents to mental health. They found that family members of people
with mental illness were less likely to stigmatize others, whereas people who themselves
were mentally ill were just as likely to exhibit stigmatizing attitudes and behaviors as the
population in general. The researchers concluded that interaction with people with
mental illness reduces stigma, offering a more accurate alternative viewpoint than the
attitude of fear toward the mentally ill found in the rest of the population. Hinshaw
(2007)also indicated that when an individual’s self-esteem declines, he or she has a
higher tendency to express prejudice; also for some people, prejudice is a way of
upholding their self-confidence. According to Hinshaw, it may be possible to reduce
prejudice by merely enhancing a person’s self-esteem (Hinshaw, 2007).
Arthur et al. (2010) explored the stigma of mental health in Jamaica and its
relationship with the utilization of mental health care services. The researchers found that
stigma could be subtle and can interact in unique ways with Jamaican cultural norms, and
even with local and idiosyncratic nuances in the meaning of common terms like madness
and mental illness. The researchers established that different people have differing
understandings of the term stigma, leading to different emotional responses toward
people living with mental illness. They indicated that different understandings of mental
health dictate the behavioral approaches people take towards the mentally ill and fall
along a spectrum that includes fear, avoidance, approaching with caution, or feeling pity,
among others. These varying definitions and understandings of words and concepts
undoubtedly influenced the perceptions of, and beliefs about, mental illness in Jamaica.
A qualitative study by Hickling et al. (2011) examined whether
deinstitutionalization and the integration of mental health services reduced stigma
associated with mental illness. In the participants’ accounts, the researchers identified a
number of issues. Firstly, the researchers found that Bellevue Mental Hospital was a
negative symbol of mental health care, where to a great extent stigma originated with
associations of irreversible mental illness. They also found that despite the legislative
changes to mental care, these connections seemed to be well established and attached to
any person receiving treatment in secure care however, participants distinguished levels
of mental illness depending on whether treatment was received in secure care or at a
walk-in clinic.
Secondly, Hickling et al. (2011) indicated that a main factor which influenced
stigma was the dehumanization of persons with mental illness who were living on the
streets; homelessness seemed connected to mental illness and stigma was generated by
the connotation of homelessness with dirtiness, prompting reactions of disgust and
avoidance; together with this was a widespread prejudgment that the mentally ill are
unpredictable and dangerous. They found that even though participants recognized these
views as unfair and biased, the stigma was evident; one aspect of stigma that was present
in the attitudes of relatives was the belief that people with mental illness are prone to
violence. The survey did not ask the respondents the nature of their family member’s
mental disorder but simply whether they had a relative with a mental disorder (Hickling
et al., 2011). Gibson et al. (2008) speculated that the respondents might have reserved
the label “mental illness” for “relatives, who exhibited the most disruptive, and therefore
potentially dangerous, behavior,” which would explain why they viewed individuals with
mental illness as threatening (p. 31). The researchers also acknowledged that mental
illness would have been underreported, perhaps because of perceived social stigma. In
addition to viewing the person as dangerous, the only other negative attitudes expressed
by the respondents were disgust (43.1%) and anger (36.9%). Despite these negative
emotions, the relatives endorsed few stigmatizing beliefs, causing the researchers to
recommend contact with individuals with mental illness as a strategy for reducing social
stigma.
Jackson and Heatherington (2006) observed that a factor analysis showed the
students’ responses to be especially negative if they viewed mentally ill people in
Jamaica as lazy or irresponsible. During the debriefing session, the students described
mentally ill individuals as “dirty,” “smelly,” “half-naked men” who wore “torn-up
clothes,” and in some instances were “throwing stones at you” and “eating out of garbage
cans” as well as talking to themselves or to invisible companions (p. 573). These
descriptions reflect what some observers have seen as the negative side of
deinstitutionalization, the aberrant behaviors that were traditionally hidden and now
exposed, reinforcing social stereotypes about mental illness (Gibson et al., 2008).
According to Jackson and Heatherington (2006), of the socio-demographic
characteristics, socio-economic status (SES) had a broad and powerful impact on the
students’ attitudes toward mental illness. They found that students from lower SES
backgrounds were less predisposed to endorse socially restrictive attitudes or relate
mental illness to lack of willpower. They attributed this to greater awareness of the
impact of stressors such as poverty and violence on psychological health, and perhaps
placing less emphasis on independence and personal accountability, which are more
reflective of middle and upper class values. In addition, Jackson and Heatherington
(2006) stated that youth in economically disadvantaged neighborhoods are more likely to
see homeless mentally ill people on the street. The researchers noted that students from
rural communities, who may be least likely to encounter mentally ill individuals,
exhibited less benevolent attitudes. The pattern offered some evidence for the positive
effect of social contact on attitudes toward mentally ill individuals (Corrigan et al., 2001),
but also showed that contact exposes the public to “homeless, sometimes threatening
mentally ill street people,” whose appearance and demeanor may reinforce stereotypes
and stigma, particularly related to dangerousness.
Jamaican students’ attitudes, including the pattern for SES, parallel the findings
reported in other countries. Jackson and Heatherington (2006) advocated the
implementation of anti-stigma programs for Jamaican youth. Santor, Poulin, LeBlanc,
and Kusumakar (2007) described an effective program for middle school students that
could easily be adapted to different age groups and educational settings. Finally, a
notable finding of the study was caring and thoughtful demonstrations toward people with
mental illness by many participants due to experiences in communities with those who
have problems. Interestingly, one participant revealed the contradictory change in
community members’ views of mental illness when she provided a homeless man with
clothes. The authors noted that these positive statements and comments in relation to
mental illness have important implications for ongoing public education (Santor et al.,
2007).
Whitley and Hickling (2007) examined media representations of mental illness
and psychiatric deinstitutionalization in Jamaica; they concluded that the media provides
a non-stigmatizing viewpoint that opposes the government’s own definition that
emphasizes severe mental illness, aggression, and psychosis. They also established in
their analysis of all Jamaican print media for a 26-month period that the stories regarding
psychiatric deinstitutionalization in Jamaica were positive. In the articles the researchers
analyzed, newspaper reporters prioritized the views of experts and translated relevant and
positive research findings into lay language so that readers could interpret and understand
the findings. As the researchers stated, it may be somewhat surprising that negative
attitudes toward mental illness remain in Jamaica, given the media’s openness and
positive attitude toward these issues.
In summary of this section, review of the researches would indicate that
stigmatization of people with mental health issues in Jamaica remains; however, there
seemed to be a reduction of stigma due to legislative changes and educational drives
through community-based projects and local media (Arthur et al., 2010; Hickling et al.,
2011). Where stigma remained, there was a link to homelessness, danger, and custodial
care (Santor et al., 2007). Degrees of stigma were dependent on the type of treatment a
person receives, the definition of stigma, visual representations, and how much the
disorder was attributed to the person’s own deficiencies (Corrigan, Rafacz, & Rüsch,
2011). The proportion of mental health issues in the younger population and the
continuing stigma of mental illness are of particular concern in regards to this younger
cohort (Gibson et al., 2008). In the next section, I explore the issue of changing attitudes
and the role of education.
Changing Attitudes toward Mental Illness
As considered earlier, stigma refers to an attitude toward mental illness that can
result in prejudice and discrimination against individuals suffering with mental disorders.
In this section, I discuss the theories of attitude and cognitive functions in relation to
behavioral changes. I consider the germane studies in the context of providing a
grounded theoretical framework in understanding the changes of the mental state of an
individual.
Attitudinal and Cognitive Theories
An attitude is a favorable or unfavorable evaluative reaction exhibited in beliefs,
feelings, or intended behavior (Breckler & Wiggins, 1989). According to Crano and
Prislin (2010), it is a social orientation – an underlying inclination to respond to
something either favorably or unfavorably. Attitudes consist of three components: (a)
cognitive – our thoughts, beliefs, and ideas about something. When a human being is the
object of an attitude, the cognitive component is frequently a stereotype e.g., people with
mental disorders are dangerous; (b) affective – feelings or emotions that something
evokes e.g., fear, sympathy, hate; (c) behavioral – a bias to act in certain ways e.g., to
avoid people with mental illnesses (Crano & Prislin, 2010). In the context of stereotypes,
the concept of attitude is defined as “mental and neural representation, organized through
experience, exerting a directive or dynamic influence on behavior” (Breckler & Wiggins,
1989, p. 409).
Whereas stereotypes are collections of characteristics associated with members of
a group, attitudes are the mental representations of those characteristics, the
understanding of what those characteristics mean, how they need to be responded to, and
how one feels about them (Fazio & Zanna, 1978). Attitudes are the existing mental
representations of characteristics that can comprise a stereotype, and these characteristics
may be positive or negative or may prompt specific behaviors, including discriminatory
behaviors (Wojnowicz, Ferguson, Dale, & Spivey, 2009). For instance, an individual
diagnosed with mental illness received stereotyping perceptions (e.g., unreliable and
lazy), which discriminates them to participate in social activities.
People are not born with particular attitudes; they develop attitudes through
experience. One can develop attitudes based on descriptions of others’ experiences,
stories, or an association with other things (Fazio & Zanna, 1978). It would be
reasonable to believe that stereotypes, prejudices, and discrimination are connected.
Stereotypes lead to detrimental attitudes that consequently end in discriminatory practices
(Wojnowicz et al., 2009). In reality, the links between attitudes, association, and
behavior reflect complicated processes (Hinshaw, 2007). It is possible for someone to
express stereotyped beliefs (e.g., people with mental illnesses are unpredictable) or
prejudicial attitudes (e.g., people with mental illnesses have themselves to blame) while
having contact with a representative of this denigrated group (e.g., a friend at college with
a mental illness; Wojnowicz, Ferguson, Dale, & Spivey, 2009). People’s attitudes about
the groups as a whole may not apply to individual members of that group
(Hinshaw, 2007).
Katz (1960) recommended a functionalist theory of attitudes, stating that attitudes
are controlled by how they operate and work for us. People embrace particular attitudes
because these attitudes help them attain their key purposes (Crano & Prislin, 2010).
According to Katz (1960), learning theory (which describes attitude formation) suggests
that attitudes can be learned in several ways. The theorist further states that one way in
which attitudes are developed is under the pressure of social norm; people learn how to
behave within a particular society by observing the behaviors of others and learning the
social norms. Some social norms are universal and are clearly functional whereas others
are culture-bound and seemingly arbitrary (Fehr & Fischbacher, 2004).
According to Simon et al. (2004), consistency theories hypothesize that, should
contradictions develop among perceptions, people are driven to reestablish agreement;
cognitive consistency states that a person attempts to ensure that his or her opinions,
beliefs, and attitudes are consistent with one another and with his or her own experiences,
knowledge, and behavior. The researchers concluded that is may be achieved by altering
attitudes, but may also be achieved by rejecting contradictory evidence or altering how
evidence is evaluated. At its very basic level, cognitive consistency is a mechanism to
ensure that people behave in a manner consistent with what they know. Thus, attitudes
can be sustained despite convincing evidence to the contrary.
Cognitive dissonance forms a part of cognitive consistency theory and describes
the mental discomfort that occurs in trying to hold two contradictory viewpoints
simultaneously (Festinger, 1957; Simon et al., 2004). Fetinger originally outlined that
cognitive dissonance theory implies that an individual holds two incompatible thoughts.
The simultaneous presence of these two thoughts causes dissonance, a distressing mental
sensation, resulting in a drive to reduce the dissonance. The individual then applies
techniques to reduce the dissonance, which can include changing attitudes and beliefs.
More recent research showed that dissonance can be induced not only by an individual’s
contradictory behaviors or statements, but also by witnessing such behaviors in others
(Norton et al., 2003). Trivialization is a simple method of reducing dissonance. If the
cognitive inconsistency is perceived to be unimportant, then the dissonance is reduced
(Simon, Greenberg, & Brehm, 1995).
Cognitive dissonance is also impacted by the attitudes and support, or lack of
these, received from a group (Norton et al., 2003). Finding that a group disagrees with
one’s own viewpoint can result in dissonance-reducing responses, such as altering one’s
own views, seeking to persuade others, or simply finding a more supportive group (Matz
& Wood, 2005). Individuals with mental health problems may be perceived as
unpredictable in their behavior by an observer, though interacting with an individual with
mental health problems may in fact challenge this belief (Simon et al., 1995). The
individual is likely to underestimate the extent of mental illness to maintain the idea that
unpredictability is strongly associated with mental illness in general (Matz & Wood,
2005).
Fischer, Jonas, Frey, & Kastenmüller (2008) reported that there are tendencies to
ignore, reject, or negatively evaluate information that contradicts our currently held
beliefs results in confirmation bias. People restrict their intake of information to that
which reinforces what they already hold to be true. They stated that overcoming
confirmation bias by presenting contradictory information in a non-threatening or
nonjudgmental manner is one of the challenges of altering attitudes and changing beliefs;
in the context of mental health, this is a difficult process to achieve. The researchers
further stated that a reduction in negative perceptions of mental illness in the media is one
way in which this process has been facilitated. According to Wood (2000), attitudes do
not, in general, spontaneously change; it is possible for a person to evaluate his or her
own attitudes and choose to alter them, but even then it is likely that a person would be
prompted by an external impetus to begin such a reevaluation. Willingness and ability to
change one’s attitudes are related to a number of individual factors. Openness to
experience is correlated with a greater willingness to challenge and change one’s
stereotyped views (Flynn, 2005). People who hold attitudes that are more prejudiced
spend more mental effort trying to reason and understand when confronted with
information that challenges their attitudes than people whose attitudes are less prejudiced
(Wood, 2000). This cognitive effort may be due to attempts to explain the challenging
information and defend the prejudice without having to alter it (Sherman, Stroessner,
Conrey, & Azam, 2005). Individuals who volunteer to work with those suffering from
mental health problems often have fewer prejudices and are more open to change their
attitudes toward the mentally ill because of the close contact and challenge to their
stereotyped views (Flynn, 2005; Wood, 2000).
Attitude Change
People understand information that they receive in the context of what they
already know – this is one of the fundamental mechanisms of learning (Matz & Wood,
2005). Anything new that people learn is incorporated into their current understanding
and knowledge of the world (Flynn, 2005; Gawronski & Bodenhausen, 2006; Matz &
Wood, 2005). Consequently, they interpret information they are given in relation to what
they already know and believe (Sarnoff & Katz, 1954). In spite of factors that serve to
resist attitude change, it would be maladaptive if there were no cognitive mechanisms to
allow attitudes to be changed (Rogers & Mewborn, 1976; Sarnoff & Katz, 1954).
Researchers indicated that multiple factors influence how received information is
evaluated; these factors vary between people and vary at different times and in different
contexts for the same person (e.g., Gawronski & Strack, 2004; Edwards, 1990; Flynn,
2005; Gawronski & Bodenhausen, 2006; Matz & Wood, 2005; McGregor, 2003; Rogers
& Mewborn, 1976; Sarnoff & Katz, 1954; Stone, 2003; Stone & Cooper, 2001).
Facts can be persuasive for some people, but this does not mean that facts alone
are sufficient, or even necessary, for persuasion (Sarnoff & Katz, 1954). The simple fact
that there are people who believe things in spite of the absence of evidence, the existence
of conflicting evidence, or even the presence of overwhelming disproof, should make it
apparent that the routes to persuasion are multiple, complex, and often not rational
(Flynn, 2005; Gawronski & Bodenhausen, 2006). Sarnoff and Katz stated that, for a
broadly effective method of attitude change, straightforward facts should comprise part of
the process; for instance, contextualizing the incidence of substance abuse among those
with mental illness can help minimize stigma and challenge attitudes. They further stated
that, statistics need to be presented in a factual manner, but with an emphasis on other
risk factors involved in order to provide a more complete analysis of the problem.
Learning Context and Attitude Change
Different people evaluate the same evidence in differing ways, and the same
person might evaluate the same evidence in differing ways depending on the context in
which it is presented (Stone & Cooper, 2003). The two primary routes through which
evidence is evaluated are deep and shallow processing (Graham & Golan, 1991; Saegert
& Young, 1981). Shallow processing involves a cursory evaluation of presented facts,
and relies more on affective cues (e.g., cheerful music, bright colors, and happy
expressions) than on the information itself. Social and associative cues are also
significant in shallow processing (Graham & Golan, 1991). If the information is implied
to elicit positive social responses, or is associated with something that the individual finds
pleasing or desirable, this can be more persuasive (Nordhielm, 2002). Hence, in
attempting to address public perceptions about mental illness, information needs to be
presented in an informative and pleasing way in order to maximize the persuasiveness of
the message.
Deep processing entails a thoughtful analysis of the information presented and the
arguments advanced (Saegert & Young, 1981). Emotional cues are less significant in
deep processing, as are social associations (Nordhielm, 2002). According to Graham and
Golan (1991), deep processing is also less personal and more logical; the more personally
involved or invested a person is in the subject being discussed, the less likely he or she is
to use deep processing. Shallow processing is much faster and attitude change occurs
much more quickly, but it is less profound. Deep processing takes more time – both to
present the information and for the individual to process and consider it – and attitude
change occurs more slowly (Saegert & Young, 1981). However, once the attitude change
has occurred, it is longer lasting, less impacted by later emotional states, and less likely to
be altered by non-factual information (e.g., celebrity endorsements). Direct interaction
with individuals suffering from mental illness can increase the personal nature of attitude
change (Stone & Cooper, 2003). In addition, an emphasis on case studies and true stories
can help humanize and personalize the relevant issues, increasing the impact of the
message in mental health settings (Graham & Golan, 1991; Saegert & Young, 1981).
Persuasion and attitude change are not only a matter of reasoning. The individual
emotional impact of the information presented and how it is presented can be just as
powerful as the factual content (Saegert & Young, 1981). Emotionally charged charity
television advertisements are an obvious example of this. People in general want to feel
happy, and want to avoid feeling painful emotions such as sadness, guilt, or fear (Stone &
Cooper 2003). An argument that elicits and manipulates such emotions, whether
intentionally or not, can be considerably more persuasive in altering attitudes and altering
behaviors than one that does not (Gawronski & Bodenhausen, 2006). The impact of
mental illness and associated perceptions on a patient, presented in an advertisement, can
induce an emotional response, again suggesting that a personalized approach can lead to
more persuasive reasoning.
Attitude Change toward Mental Illness
In a Serbian study, researchers examined the effect of an education program on
the attitudes of students toward mental health (Pejović-Milovancević, Lecić-Tosevski,
Tenjović, Popović-Deusić & Draganić-Gajić, 2009). After six months, the authors found
that discrimination and the trend toward social control were reduced while awareness of
mental health-related problems increased among young people (Pejović-Milovancević et
al., 2009). In the United Kingdom, Naylor, Cowie, Walters, Talamelli, and Dawkins
(2009) evaluated the influence of a mental health teaching program on adolescent pupils’
perceptions. The researchers found that teaching 14- and 15-year-olds about mental
health problems helped reduce stigma by adding knowledge and encouraging positive
attitudes.
Stuart, Koller, Christie, and Pietrus (2011) evaluated results of a contact-based
educational intervention carried out as part of the youth scheme to reduce stigma among
journalism students in Canada. The intervention was a half-day seminar that brought
students into contact with three presenters who had personal experience with mental
illness. The results showed a statistically significant reduction in stigma, noting an
improvement concerning attributions of danger and unpredictability (Stuart et al., 2011).
A large proportion of students testified that the seminar had changed their opinions of
people with a mental disorder. Although the authors noted that this was an uncontrolled
study, it would appear that this contact-based intervention had an effect on students'
opinions of people with a mental illness. This process of change highlights the
importance of a personalized approach to mental health attitude change through deep
processing and a high emotional impact. According to the researchers, factual
dissemination in this context allows for a strong basis on which to formulate new
attitudes and beliefs, while the group work encourages social acceptance of such attitudes
and the dissolution of negative perceptions. Hence, such interventions use a variety of
techniques to encourage attitude change and highlight the need to address multiple
aspects to achieve a satisfactory result.
Jorm et al. (1997) pioneered the use of vignettes describing mental illness
symptoms to identify gaps in the mental health knowledge of the general population and
target specific points on which the public and mental health professionals diverge.
Mental health literacy is based on the philosophy that the public needs knowledge and
understanding of the causes of mental disorders, self-help strategies, available
professional treatment options with emphasis on dispelling misconceptions about
treatments, and knowledge of how to seek mental health information (Jorm, 2000). This
means that a broad range of interventions and techniques is required for effective attitude
change in reality and case studies/vignettes may be a useful tool in this regard, covering
factual and personal aspects of mental illness simultaneously.
Attitudes and stigmatization and their role in seeking treatment for, and interacting
with, individuals with mental disorders are essential aspects of mental health literacy.
Barney et al. (2006) found that it is not only stigma associated with mental illness that
can prevent people from seeking help, but also the stigma that people with mental illness
themselves perceive – even if that perception of stigma is incorrect. According to Jorm,
Korten, Jacomb, Rodgers, and Pollitt (1997), mental health professionals need to be
particularly aware of the issue of mental health literacy, as the understanding of mental
illness in the general population is very different from that of mental health professionals.
The researchers indicated that even people who suffer from mental disorders generally
possess an understanding of mental illness much closer to that of the general population
than that of professionals.
Corrigan et al. (2001) investigated the effects of three popular strategies for
altering stigmatizing attitudes toward mental illness: education, contact, and protest. The
educational programs were designed to dispel myths about mental illness by challenging
them with accurate information, challenging misconceptions in such areas as the
relationship between psychotic disorders and violence, homelessness, and independence.
The researchers noted that most marked effect of the educational program was on
stability attributions; after completing the class the participants were more inclined to
agree that individuals with mental disorders could recover with appropriate treatment. A
particularly notable finding was the relationship between changes in the participants’
attitudes and their perceptions of the group leader. The participants who described the
leader as more interesting, credible, and likeable showed the greatest changes in attitudes.
This is consistent with Hogan’s (2002) emphasis on the behavior of the facilitator in
engaging group members and promoting active discussion, and suggests that simply
presenting factual information is not an optimal strategy for encouraging attitude change:
personal engagement and investment are key ingredients for increasing effectiveness.
Personal engagement and deep processing requirements are vital for attitude change and
therefore interventions need to be well constructed and managed in a strong way
(Corrigan et al., 2001; Jorm et al., 1997). Strong leadership can encourage the promotion
of new social norms and assists in the transition of attitudes; hence, it must be
emphasized in such interventions (Corrigan et al., 2001; Hogan, 2002).
Summary
Mental illness is a significant and widespread problem, with the majority of
people experiencing a mental illness at some point in their lives – and many others living
close to someone who suffers or has suffered from a mental illness. In summation, most
of the literature review revealed that stigma associated with mental illness is common and
based on stereotypes of people with mental illness that are founded on ignorance or false
information. Such stigma can be a significant barrier to those with mental health
problems seeking help, which can further exacerbate their suffering.
In this chapter, I provided evidence indicating the global prevalence of people
with mental health who were stigmatized. In many developed Western countries, the
process of deinstitutionalization and attempts in recent years to educate the public in
mental health matters have not been successful in significantly reducing stigmatizing
attitudes; recent research indicates that this trend may be rising. There is a pervasive
misunderstanding, or lack of understanding, regarding what comprises a mental health
problem, what its impact is, and what might be expected of someone who has mental
health issues. Mental health problems and mental health care overall remain subjects of
ignorance and fear. These factors may be amplified because of conflicting cultural
ideologies and influences along with certain socioeconomic backgrounds. For instance,
in Jamaica and other lower-income countries where public resources for the education of
the population are fewer, there are likely to be greater negative feelings toward mental
illness.
I also presented a summary of research into the development of stereotypes and
attitudes – how they are formed, maintained, and changed. Both are developed through
experience, observation, and social learning. Based on these studies, social reinforcement
and social norms were identified as significant ways in which individual with mental
illness could learn the attitudes within the social norms. It is therefore not surprising that
social acceptance is a significant process through which attitudes can be altered.
Interestingly, it is not necessary for an opinion or attitude to be disapproved of or to lead
in reality to social rejection; it is sufficient for a person to believe that this is the case. In
other words, it can be sufficient to give the impression that “everyone else is doing it”
without this actually being true (Wood, 2000).
Within the mental health context, it is vital that social norms are challenged and
modified to encourage a broad change in society. Campaigns that promote employment
of those with mental illness are important in this regard, as they encourage employers to
reject previous attitudes to this group by demonstrating the employability of individuals
with mental health in a variety of contexts. Based on these studies, it was assumed that
the attitudes against the individual diagnosed with mental illness could be changed.
In Chapter 3, I explain the methodology for the study, taking into account a
quantifiable data inquiry. I then present the research design and its appropriateness for the
study; discuss population and selected sampling; and present the procedures involved in
data collection, instrumentation, and data analysis. In Chapter 4, I confer the data
analysis, data collection, preliminary analysis, comments on didactic seminar treatment,
inferential analysis of each dependent variable, and a summary of findings. In Chapter 5,
I discuss the research findings, limitations of the study, and offers recommendation,
implication, and conclusion of the study.
Chapter 3: Research Method
Introduction
This chapter includes a description of the design of this study, sample,
instrumentation, data analysis, and ethical considerations. An overview of the study’s
design includes a rationale behind the selection of this particular research design. I
present the sample characteristics and size as well as a description of the instrumentation.
The data collection process and analysis are also discussed. The purpose of this study
was to examine the effect of a didactic seminar on attitudes of Jamaican college students
in Jamaica, West Indies toward mental illness. This study would either support or refute
the hypothesis that a didactic seminar was effective in changing the attitudes toward
people affected by mental illness.
Research Design and Approach
I aimed to examine the effectiveness of a targeted intervention by the college of a
didactic seminar on mental illness on a student population in Jamaica in reducing stigma
and perceived support available for mental health problems. The objective of employing
a didactic seminar was to reduce mental health stigma through effective education.
Similar research had not been conducted in Jamaica.
Research Design
This was a nonequivalent control group quasi-experimental design. The design is
similar to experimental design but lacks random assignment. The nonequivalent form of
quasi-experimental design is a common design (Trochim & Donnelly, 2008). It requires
a first survey and second survey for a didactic seminar attendees group and a
nonequivalent control group.
Like other research designs, nonequivalent control quasi-experimental design has
limitations (Trochim & Donnelly, 2008). Nonrandom assignment and nonequivalent
groups present challenges in statistical analysis. In this study, I drew both the didactic
seminar attendees and control groups from the same college, which made them similar in
socioeconomic status (SES). They were all student teachers, mostly drawn from rural
Jamaica; they lived either on the college campus or in communities close to the college. I
used the first survey to determine whether the groups were comparable before the
didactic seminar intervention by the college.
Threats to Validity
The validity of this research was based on an assumption that the didactic seminar
attendees group and the nonequivalent group were comparable before the study.
Therefore, second survey group differences could be explained by the didactic seminar
intervention by the college. However, that assumption might not have been valid. To test
it, I compared the groups using age and gender. Any differences in these variables would
be accounted for by including them in the analysis. However, it was possible that there
would be group differences on variables measured in this study.
Research Approach
A number of research approaches could be selected. I did not choose a two-group
experimental design approach because randomized sampling of participants was not
done. Instead, I considered the following pre-experimental and quasi-experimental
research approaches: single-group interrupted time-series design, in which measures are
taken for a single group before and after treatment; one-group pre-test-post design, in
which pre-test measures followed by treatment then post-test for a single group; static
group comparison or post-test-only with nonequivalent groups, in which after treatment,
comparison group and didactic seminar attendees group are given post-test; post-test-only
with nonequivalent groups design, in which different treatment are given and after
treatment, comparison group and didactic seminar attendees group are given post-test;
control-group interrupted time-series, in which measures are taken for two groups before
and after treatment and only one group gets the treatment; nonequivalent (pre-test and
post-test) control-group design, in which the didactic seminar attendees group and the
control group are selected without random assignment and both groups take pre-test and
post-test, but only the didactic seminar attendees group receives treatment (Creswell,
2009).
I chose a multiple-group approach with the second group being a control group to
rule out the single-group threats to internal validity because those threats would be
common to both groups and cannot explain why second survey group differences would
occur. According to Trochim and Donnelly (2008), the condition of the groups being
comparable was assumed; and this assumption could not be fully tested. Hence, I used a
nonequivalent control group quasi-experimental design in this study to help determine
whether the changes in attitudes between the pre- and posttests were related to the
didactic seminar (see Figure 1).
Non-randomly assigned
experimental group
Non-randomly assigned
control group 1st survey
2nd survey 1st survey
2nd survey
Didactic
Seminar
Figure 1. Pre-post design with control group.
The independent variables were attendance at the didactic seminar (yes, no) and
gender (male, female); I used first survey scores and age as covariates. First survey is
“usually the most highly correlated with the second survey” (Trochim & Donnelly, 2008,
p. 203). The use of it as a covariate controlled the variability that occurred because
different people had different scores on the first survey. I included age because it may
have been related to the dependent variable; in addition, it helped to account for any
differences between the two groups. Also, I measured age and gender with questions on
the demographic questionnaire. The dependent variables were attitude toward mental
illness – measured as the total scores on the Help Seeking Attitude Scale (Fischer &
Farina, 1995), Attitudes to Mental Illness Questionnaire (Luty et al., 2006), and the
Opinion About Mental Illness Scale (Cohen & Struening, 1964). The didactic seminar
was treated as a between-subjects variable. Since repeated measures were obtained from
the sample participants (pre-seminar, post seminar), variables were correlated samples
(within-subjects) variables.
I conducted the postassessments four weeks after the preassessment to ensure that
the didactic seminar had more than a short-term effect. I used a nonequivalent control
group design to determine whether the change in attitudes between the pre- and posttest
were related to the didactic seminar rather than the passage of time. Only the didactic
seminar attendees group participated in the didactic session four weeks prior to the
second survey for both groups. The nonequivalent control group included those who
participated in the first and second survey but chose not to participate in the didactic
seminar. The didactic seminar attendees group included participants who completed the
first survey, the didactic seminar, and the second survey.
Methodology
I used a quantitative methodology in this research. All test questionnaires were in
the form of surveys. These surveys provided a quantitative description of trends,
attitudes, and opinions of the population of college students in Jamaica. Additionally, a
first survey followed by didactic seminar and then followed by a second survey approach
allowed me to evaluate if a didactic seminar on mental health affected the attitudes of the
college students towards mental illness. The first and second surveys utilized the same
questionnaires. However, the second survey was given four weeks after the didactic
seminar.
Setting and Sample
The research population was a convenience sample drawn from a college in
Jamaica. The students at this college were from all parts of Jamaica (see Appendix B for
the recruitment flyer). I recruited two hundred college students, which was more than
needed and not all of them returned for the second survey. The first survey consisted of
all student volunteers. The college presented the didactic seminar, which was open to all
students at the college who found time to attend. Volunteer students who chose not to
participate in the didactic seminar were allowed to take the second survey and were
placed in the nonequivalent control group. Those who chose to participate in the didactic
seminar were allowed to take the second survey and were placed in the didactic seminar
attendees group.
I obtained permission to conduct this research on the college campus from the
Principal of the college (see Appendix C). A Principal in a Jamaican college is
equivalent to President of a college or university in the United States of America. I also
obtained permission to conduct this research from the Walden Institution Review Board
(IRB) before the study began. Subsequently, I launched a campaign at the college to
solicit participants for the study. In this research, I selected pparticipants for the
following reasons: (a) accessibility, (b) being of age to provide informed consent, and (c)
educational level, which would provide them with the necessary reading comprehension
skills to complete the questionnaires. The inclusion criteria were: (a) students must be
registered at the college and (b) students must be at least 18 years of age or older.
Sampling and Sampling Procedure
I conducted sampling of college students to recruit participants for this research.
There are different methods of sampling, of these sampling methods, I applied
convenience and nonprobability sampling for this study because it was not feasible or
practical to use random sampling (Trochim & Donnelly, 2008). I was able conveniently
to gain access to college students by consent of the college administration and faculty.
Also, the research was nonprobabilistic because it did not involve random sampling.
There was no evidence that the sample would be representative of the population
(Trochim & Donnelly, 2008).
The results of Lipsey and Wilson’s (1993) meta-analysis of treatment research
showed that for “Cognitive therapy, modification of covert self-statements of adult
patients; all outcomes,” (p. 1183) an effect size of 0.66 with n = 69 is achievable. In this
research, I utilized a didactic seminar as a cognitive tool to modify the self-assessed
attitudes of students. Based on the forgoing effect size outcome, I utilized a minimum
effect size of 0.37 in this research. Using this effect size, I conducted a power analysis to
determine the number of participants needed in this study (Cohen, 1988) using G*Power
3.1. I examined the hypotheses using ANCOVA. The independent variables were
participation in the didactic seminar (yes, no), gender (male, female), and the interaction
between these two. I examined first, survey scores and age as covariates. The dependent
variables were attitude towards mental illness – measured as scores on the Help Seeking
Attitude Scale (Fischer & Farina, 1995), Attitudes to Mental Illness Questionnaire (Luty
et al., 2006), and the Opinion About Mental Illness Scale (Cohen & Struening, 1964),
after accounting for first survey scores and age.
The α for the ANCOVA model was set at .05. To achieve power of .80 and a
medium effect size (f =.37), a total sample size of 128 was required to detect the critical
F-value (F [4, 127] = 1.90). A minimum of 64 participants in the control group and 64
participants in the didactic seminar attendees group would be acquired. I sent informed
consent and written information (see Appendix C and D) about the study to the principal
of the college for distribution to individual teachers who provided them to students.
Procedures for Recruitment, Participation, and Data Collection
A volunteer at the selected college conducted recruitment for this research by
means of research flyers distributed at the selected college in Jamaica. The flyer
explained the nature of the study, the criteria for participating in the study, and gave my
contact information. In addition to research flyers, a teacher read the information on the
flyers to the entire student body during devotion, or normal assembly. I presented the
Informed Consent during devotion, or normal assembly. Devotion is a time where it is
mandatory for all faculties and students to meet to offer devotion and listen to special
announcements on a weekly basis. Normal assembly is a time for general announcement
to staff and student body on Tuesdays to Fridays. It usually lasts for half an hour.
Students’ participation in the study was voluntary in all aspects. The first and
second survey participation was from students who chose to collect the consent form and
surveys from me while I was alone in the secretary’s office. The participants returned the
surveys to me within one to two days at the same location. This prevented the
interruption, or displacement of any planned educational activities. The college offered
the didactic seminar to students after the first survey was taken. Students could attend the
didactic seminar without participating in the first survey. The second survey took place
four to six weeks after the didactic seminar. Only students who took the first survey were
allowed to take the second survey. Both first and second surveys utilized the same
questionnaires.
Potential participants of the research were notified of the first survey date, time,
and test location during assembly and by flyers posted at the college. I used the same
method of notification to announce dates, times, and locations for the second survey. In
addition, I sent e-mails to students who volunteered in the first survey to remind them to
volunteer for the second survey. Student volunteers met with me at the secretary’s office
to collect informed consent forms and survey, as well as to return the completed surveys
at their convenience, within one to two days. This allowed for privacy of the volunteers.
Participants were given the questionnaires on paper after I verified their consent and
understanding of the test instructions. Later, I transferred the first and second survey data
to the statistical analysis software, SPSS. I coded the data from each test instrument as
described in the instrumentation section.
The informed consent form included a brief background of the study, the
procedures for participation, a discussion of confidentiality, the voluntary nature of the
study, ethical matters, and request for consent for the second survey portion of the study.
I provided a phone number, mailing address, and e-mail address for participants with
additional questions regarding their participation in the study to direct them to me. This
provided teachers and participants with multiple ways of contacting me.
Didactic Seminar
As part of the research procedure, the didactic seminar included handouts on the
definition, causes, types, diagnoses, risk factors, treatment, stigma, etc., of mental illness.
The didactic seminar presenter facilitated discussions about mental illness, as outlined in
the handouts, and participants were given the opportunity to read and discuss vignettes on
mental illness. Didactic seminar attendance was used to determine which group
participants were placed in – the didactic seminar attendees group or the nonequivalent
control group. I drew the nonequivalent control group from those who opted not to be
present at the didactic seminar, whereas I drew the didactic seminar attendees group from
participants in the didactic seminar.
The college in Jamaica, West Indies where this research was performed, presented
the didactic seminar for one session. The college implemented and oversaw the didactic
seminar activity on mental health according to its policies and procedures. The college
allowed me to invite students who attended the seminar to complete surveys for the
research. The didactic seminar was a customized module of “The Science of Mental
Illness” teaching module, produced by Biological Sciences Curriculum Study (BSCS) for
the National Institutes of Health and the National Institute of Mental Health (Resch,
2005). I was granted permission for it to be used as an intervention in this research, as
customized (see Appendix L). The objective I had for the didactic seminar was to
educate participants on major concepts in mental illness, such as its center of control,
symptoms, causes, risk factors, treatment, consequences of no treatment, and stigma. The
main goal I had for the seminar was to aid the participants in becoming more
knowledgeable in regards to the effect of mental illness when one is stigmatized by it;
and to identify the role that one could play in society to aid those that are suffering from
mental illness. I intended that the seminar impart coping skills to combat mental illness
and to facilitate discussions of participants’ understanding of mental illness and scenarios
of mental illness in the form of vignettes, based on real-life stories of people diagnosed
with the illness. Being knowledgeable about mental illness could dissipate
misconceptions and positively affect the way individuals understand mental illness
(Resch, 2005).
In this seminar, I also aimed at enhancing students’ appreciation of the role their
own attitudes and value-systems play as they engaged with others having mental health
issues. They could achieve a better understanding of the pervasiveness of diverse mental
health disorders among people in Jamaica and the need for decreased stigmatization in
their communities. A qualified professional with a Doctorate in Ministry (focus on
marriage and family) and a Master of Science in Psychology conducted the seminar.
Instruments
I employed a number of measures to assess whether didactic seminars would
change the attitudes of college students in Jamaica towards mental illness and their
willingness to seek help for their mental health. These included the Attitudes to Mental
Illness Scale (Luty et al., 2006; see Appendix G), the Opinion about Mental Illness Scale
(Cohen & Struening, 1964; Luty et al., 2006; see Appendix H), and the Help Seeking
Attitudes Scale (Fischer & Farina, 1995; see Appendix I). I used these scales to assess
Hypotheses 1 to 3.
I utilized a demographic questionnaire (see Appendix F) consisting of two
questions to collect basic information regarding the participants’ age and gender. I used
age as a covariate in assessing attitudes toward mental illness; gender as an independent
variable in assessing attitudes toward mental illness (see Appendix G); and the
demographic questionnaire to assess Hypotheses 1 to 3.
Attitudes to Mental Illness Questionnaire
The AMIQ (Luty et al., 2006) is a 5-item self-administered Likert scale (from -2
to +2, indicating “strongly agree” to “strongly disagree”). It measures components of
stigmatized attitudes toward mental illness. The questionnaire presented a vignette
describing a stigmatized individual (schizophrenic). An example item was, “I would be
comfortable if Michael was my colleague at work.” Individual questions were scored on
a 5-point Likert scale (maximum +2, minimum -2), with the options “neutral” and “don’t
know” scored as 0. For three items on the scale, the points for negative items were
“strongly agree” = -2, “agree” = -1, “neutral” = 0, “disagree” = +1, “strongly disagree” =
+2, “don’t know” = 0. The scores were reversed for positive items. For the two negative
items on the scale, the points were “very likely” = -2, “quite likely” = -1, “neutral” = 0,
“unlikely” = +1, “very unlikely” = +2, “don’t know” = 0. The range for the total score
for each vignette was -10 to +10. Lower scores indicated more negative attitudes towards
mental illness.
The scale was developed to provide a brief snapshot of people’s attitudes toward
mental illness, and could be quickly adapted to allow responses to specific vignettes or
instances of mental illness. The AMIQ could be used to assess attitudes towards specific
mental illnesses, possibly separating attitudes toward psychotic illnesses such as
schizophrenia from attitudes toward potentially less-stigmatized disorders such as
complex grief. Luty et al. (2006) found test-retest reliability in a sample of 256
participants to be .70; correlation between the AMIQ and an alternate version was high (r
= .70, p < .01) demonstrating alternate-form reliability (Luty et al., 2006). They and
other researchers found that the AMIQ had convergent validity with the OMI and with
other measures of stigmatization of mental illness (Corrigan, Markowitz, Watson, Rowan,
& Kubiak, 2003).
Though the AMIQ appeared simply to replicate the OMI, it was significant in
being a much shorter scale. Although the AMIQ is a smaller scale, it is uni-dimensional
(Luty et al., 2006). Thus, the OMI allowed for a more nuanced analysis of the impacts of
various attitudes toward mental illness and people with mental illness, while the AMIQ
permitted a succinct snapshot of a participant’s overall attitude to mentally ill people in
general (positive or negative), without seeking to tap in to the practicalities of the
authoritarianism or social restrictiveness subscales, or the value judgments of the
benevolence or mental health hygiene subscales on the OMI.
Opinions about Mental Illness Scale
The OMI Scale (Cohen & Struening, 1962, 1964) is a self-response scale
comprising 51 items scored on a Likert scale (from 1 to 6 , indicating “strongly disagree”
to “strongly agree” for positive items; 6 to 1, indicating “strongly agree” to “strongly
disagree” for negative items). An example item is, “There is something about mental
patients that makes it easy to tell them from normal people.”
The scale is divided into five subscales that measure attitudes and opinions
regarding people with mental illness: authoritarianism, benevolence, mental health
hygiene ideology, social restrictiveness, and interpersonal etiology (Dielman, Stiefel, &
Cattell, 1973). Authoritarianism represents people’s beliefs about how people with
mental illnesses are different from or inferior to people without mental illness. In this
context, authoritarianism described an attitude about how people with mental illnesses
should be treated. It contained items assessing belief in a need for restraint, security, and
involuntary commitment to in-patient facilities. It also included a belief that thinking or
talking about one’s problems is unhelpful and should be avoided. An example item was,
“A heart patient has just one thing wrong with him, while a mentally ill person is
completely different from other patients.” Benevolence represented a moral kindliness
toward people with mental illness, but one that could be patronizing and distant.
Mental health hygiene ideology also represented a kind, constructive attitude, but
one based on notions of treatment and treatability of mental illness, and a belief that
people with mental illness are themselves decent, moral individuals. An example item
was, “More tax money should be spent on the care and treatment of people with severe
mental illness.” Social restrictiveness described a belief that people with mental illness
should be controlled or restricted in society. Social restrictiveness included removal of
parental rights, restrictions on employment, and even forced sterilization. Interpersonal
ideology encompassed beliefs about the causes of mental illness, including the idea that
mental illness was caused by parental abuse or avoiding one’s own problems.
For each subscale, the points on the scale for positive items were “strongly
disagree” = 1, “disagree” = 2, “partly disagree” = 3, “partly agree” = 4, “agree” = 5,
“strongly agree” = 6. The scores were reversed for negative items. On each subscale,
lower scores indicated more negative opinions about mental illness, while higher scores
indicated more positive opinions. The range of the total score on the subscales were: 17
to 102 for authoritarianism, 8 to 48 for benevolence, 9 to 54 for mental hygiene ideology,
10 to 60 for social restrictiveness, and 7 to 42 for interpersonal etiology, giving an overall
OMI score range of 51 to 306. The internal-consistency reliability of the subscales, range
from .82 (authoritarianism) to .59 (interpersonal ideology) with a main scale reliability
of .75. The scale had convergent validity with the Leary Interpersonal Checklist and
Edwards Personal Preference Schedule (Lawton, 1964) and convergent validity with a
measure of willingness to seek help with mental illness (Leong & Zachar, 1999).
Analysis was conducted on the overall OMI score since scoring on the questionnaire was
reversed, where necessary, to maintain consistency so that higher scores means more
positive opinions about mental illness.
Help Seeking Attitudes Scale
Fischer and Farina (1995) designed the HSAS is a 10-item scale. They developed
it to measure attitudes toward seeking psychological help and it is a one-dimensional
version of Fischer and Turner’s 29-item scale. Some items on the 10-item scale were
slightly modified. However, their psychometrics appeared to match those of the original
version with correlated scores of .87. The 10-item attitude toward seeking professional
psychological help scale was standardized with samples of university students, similar to
the original version.
The 10-item HSAS scale consisted of statements on a 4-point Likert scale. The
points on the scale for negative items were “agree” = 0, “partly agree” = 1, “partly
disagree” = 2, “disagree” = 3. The scores were reversed for positive items. The range for
the total score of the scale was 0 to 30. Lower scores indicated less willingness to seek
professional psychological help, while higher scores indicated more willingness. An
example item was, “If I believed I was having a mental breakdown, my first inclination
would be to get professional attention.” The internal consistency of the 10 items was .84
(Cronbach’s alpha), comparable to what Fischer and Turner (1970) obtained for their full
scale (that is, .83 and .86, in two samples).
In validating the 10-item HSAS scale, Fischer and Farina (1995) found that “of
the total respondents, 154 indicated they had previously experienced a serious emotional
or personal problem and briefly described it” (p. 370). Those who sought professional
help for problems were 32 (37%) females and 10 (15%) male. “The point of biserial
correlation between having sought help or not and the person’s scale score was .39 (p
< .0001) overall, .24 (p < .03) for women and .49 (p < .0001) for men” (p. 370). The
biserial correlation between gender and attitude score was .30 (p< .0001). For women,
the mean was 19.08 (SD = 5.45; n = 214); for men the mean was 15.46 (SD = 6.00, n =
175).
The 10-item HSAS scale had a test-retest correlation of .80 (n = 32) with a
1month interval between tests (Fischer & Farina, 1995). The correlation between the old
version of the scale and the new 10-item scale was .87 (n = 62). According to Fischer
and Turner (1970), a factor analysis of the longer scale suggested four dimensions,
namely recognition of need for help, tolerance of stigma, interpersonal openness, and
confidence in mental health professionals. These four dimensions were collapsed into
one in the shorter scale.
Operationalization of Variables
In this research, the dependent variable was attitudes toward mental illness and the
independent variables were didactic seminar attendance and gender. I operationalized
attitude toward mental illness as how well a participant did on tests regarding thoughts
about psychological help and mental illness (Cohen & Struening, 1964; Fischer & Farina,
1995; Luty et al., 2006). I also operationalized didactic seminar attendance as a “yes” or
“no” value that indicated attendance at didactic seminar on mental illness and age as the
number of years since the individual’s birthday (Bowen & Atwood, 2004); and gender as
the response to the gender (Male, Female) demographic questions (Haig, 2004).
Data Analysis Plan
In this study, I employed an ANCOVA. The research questions and associated
hypotheses that follow were answered with the results of a 2x2 factorial ANCOVA on
assessment scales that measured various mental health attitudes and opinion, after
accounting for first survey scores and age.
Research Questions and Hypotheses
The research questions I addressed in this study and corresponding hypotheses
were:
RQ1. Does a didactic seminar change attitudes about mental health among
college students in Jamaica, West Indies, after controlling for 1st survey scores and age
by using them as covariates?
H1a: The didactic seminar positively affected Jamaican college student attitudes
toward mental illness, after controlling for 1st survey scores and age as covariates.
H10: The didactic seminar did not positively affect Jamaican college student
attitudes toward mental illness, after controlling for 1st survey scores and age as
covariates.
RQ2. Is there a difference between male and female in attitudes towards mental
illness among college students in Jamaica, after controlling for 1st survey scores and age
by using them as covariates?
H2a: Gender positively affected Jamaican college student attitudes toward mental
illness, after controlling for 1st survey scores and age as covariates.
H20: Gender did not positively affect Jamaican college student attitudes toward
mental illness, after controlling for 1st survey scores and age as covariates.
The following hypotheses addressed interaction between the independent
variables:
H3a: There is a significant interaction between didactic seminar and gender on
Jamaican college student attitudes toward mental illness, after controlling for 1st survey
scores and age as covariates.
H30: There is no significant interaction between didactic seminar and gender on
Jamaican college student attitudes toward mental illness, after controlling for 1st survey
scores and age as covariates.
The independent and dependent variables are described in Table 1.
Table 1
Study Variables
Variable How Measured Type
Help seeking attitude
(2nd survey)
2nd survey scores on the HSAS (Fischer & Farina, 1995) DV
Attitude to mental
illness (2nd survey)
2nd survey scores on the AMIQ (Luty et al., 2006) DV
Opinion about
mental illness (2nd
survey)
2nd survey scores on the OMI (Cohen & Struening,
1964)
DV
Gender Item on the demographic questionnaire for
sociodemographic variables
IV
Didactic seminar
attendance
Yes or no value that indicates whether or not they
attended the didactic seminar
IV
Data Analysis
The nonequivalent control group quasi-experimental design employed a first
survey variable, second survey variable, and a dummy variable to identify the group to
which each participant belonged. In this researcher, I was interested in estimating the
difference between the didactic seminar attendees group and nonequivalent control group
after adjusting for differences in the first survey. This was the ANCOVA analysis model.
However, this model gave a biased estimate of the treatment effect due to first survey
measurement error and the nonequivalence nature of the groups (Trochim & Donnelly,
2008). I tested each hypothesis using 2x2 factorial ANCOVA.
I conducted all analyses on SPSS 19.0. Prior to analysis, I examined all data for
outliers, skewness, and kurtosis. I removed any outliers prior to analysis; i.e., scores that
were far lower or higher than other scores by plotting the data. I examined the
assumptions of all statistical tests before analysis (e.g., homoscedasticity, normal
distribution). Also, I ran descriptive statistics on the questionnaires to give a
demographic overview of the sample in relation to age and gender; measures of central
tendency and dispersion (such as mean and standard deviation) to show descriptive
statistics for scale responses of the total sample pre- and posttest.
For testing hypotheses 1 to 3, I used 2x2 factorial ANCOVAs with the OMI,
AMIQ, and HSAS scales to compare the didactic seminar attendees and the control
group’s scores. The two ANCOVA factors were didactic seminar and gender, each with
two levels. The level for didactic seminar was (yes, no) while the level for gender was
(male, female).
Protection of Participants
Before conducting this research, I sought approval from the IRB of Walden
University to comply with the university's ethical standards as well as US federal
regulations; and approvals from the Medical Officer of Health in St. Elizabeth, Jamaica,
West Indies and the principal of the college where the research was conducted. I only
solicited adult participants to obviate the need for parental approval for participation. I
did not involve deception in this study and participants were notified that they were free
to withdraw from participation at any time, without needing a reason.
I gathered identifying information before the first survey to allow first survey and
second survey scores to be paired appropriately. The identifying information included a
list containing each participant’s name and e-mail address, assigned code, first survey
packet number, and second survey packet number (see Participant List, Appendix K). I
did not expected that participation in the didactic seminar or completion of the first or
second survey assessments would pose any danger beyond what might normally be
encountered in the participants’ day-to-day life. However, should participants have felt
any distress because of participating in the study or because of considering the
implications of mental illness stereotypes and stigma, I made provision for counseling by
a mental health professional (see Appendix M for a list of potential therapists).
I obtained information about participants on paper for both first and second survey
assessments. I assigned each set of questionnaires in a packet the same number and each
packet to a unique number. For security, I kept the list containing participants’
information in a locked cabinet with access only to me. Once the second survey was
complete, I removed the participants’ names and e-mail addresses from the list. I did this
to protect the participants’ confidential information and I informed them of this process at
the time of informed consent discussion (see American Psychological Association,
Standard 4.01, Standard 4.02b, Standard 6.02b, 2012).
Ethical Procedures
I conducted this research internationally in the country of Jamaica, West Indies.
Therefore, I obtained the “Guidelines for Conducting Research at the Ministry of
Education” from Jamaica’s Ministry of Education regarding regulation for conducting
research on education (see Appendix P). I took all relevant regulations regarding human
research in Jamaica into consideration to maintain compliance with the country’s
regulations.
The Jamaica’s Ministry of Education approved the study (see Appendix R) and
they sent the college where the research would be conducted the approval on my behalf.
The names and addresses of all the investigators and collaborators are listed in Appendix
W. I included a short summary of the study in Appendix X and a declaration of
conformity with guidelines in Appendix Y. I collected first and second survey data. I
completed the human subject protection online training by Family Health International
(FHI), in English. Copy of the certification is contained in Appendix T.
In this research, I did not assume dual roles. A teacher announced the
forthcoming research during normal assembly (non-academic time); I asked another
teacher to post research flyers on billboards throughout the college; I did informed
consent, first and second survey at the participant’s convenience; and the college
implemented and oversaw the didactic seminar presentation according to its policies and
procedures. Students could attend the didactic seminar without participating in the study.
The college allowed me to invite students who attended the didactic seminar to complete
surveys for the research.
Although I am a Jamaican by birth, I am not originally from the community where
the research was conducted. Essentially, my role was to recruit participants, perform
analyses, and present the findings.
I conducted written informed consent and its verbal explanation in English, which
is the official language of Jamaica. I am a Jamaican who grew up in Jamaica and
attended college in Jamaica. I was therefore aware of local norms of privacy,
confidentiality, and advocacy. However, in case there were breaches in confidentiality, I
would consult with qualified experts (Mensana – a mental health support group in
Jamaica, nearby hospital, a clinic, and the Guidance Counselor of the college) to
determine appropriate action plans.
I had been in contact with the Ministry of Health in Kingston, Jamaica, West
Indies and Mensana – a local mental health advocacy in Jamaica, West Indies, in case
help was needed to deal with adverse events. This local mental health advocacy group
had experience in conducting community forums on issues of mental health, influencing
Jamaica’s mental health policies, and in dealing with the local press. At the end of the
research, I made a general description of a college in Jamaica where the research was
conducted. For example, “I conducted research at a college in Jamaica, West Indies to
determine if a didactic seminar on mental illness is effective in positively changing the
attitudes of college students in Jamaica toward mental illness.” In this research, I utilized
non-academic time (normal assembly) for data collection to minimize disruption of
learning time. This research was beneficial to student teachers, enabling them to
recognize and address their students’ mental health problems, as well as to refer those
young people affected by mental health complications to health professionals for
treatment. In doing this, these future instructors had an exceptional opportunity to
participate in an important imperative in the health and well-being of Jamaican youth. It
prepared them with useful implements and awareness required to recognize and intervene
aptly in situations where mental illness may be a concern.
For this research, I first collected test data on paper. After collection of the data, I
immediately stored them in a locked briefcase until I was able to transfer them to a filing
cabinet. I am the only one who could access the briefcase and filing cabinet. Later, I
transferred the data to electronic format on a password-protected computer with access
only to me. I stored the same data on a password-protected flash drive that was kept in a
locked cabinet with access only to me; consent forms separately from this data and from
the completed questionnaires; and all three data files in separate secured locations with
access only to me.
I entered data from the first and second surveys into SPSS and verified them for
accuracy of entry. I used the SPSS statistical program to conduct data analyses. The
research design is available for replication and raw data (without participants’ identifying
information) for reanalysis only by other competent members of the scientific community
(see American Psychological Association, Standard 6.01(2), Standard 8.14, and Standard
9.04, 2012). Once the data retention period is over, I will shred all data on paper;
electronic data stored on USB and hard drives will be overwritten using Secure Erase
(Secure Data Deletion, 2012).
Summary
In Chapter 3, I described the research methodology for the current study. In this
research, I sought to enhance and understand the effect of a didactic seminar on attitudes
of college students in Jamaica toward mental illness. I used a sample of 184 participants
and a 2X2 mixed factorial ANCOVA design to determine the impact of pre- and
postdidactic sessions on attitudes about mental illness. In this study, I used participants’
first survey scores and age as controls when measuring the effects of a didactic seminar
and gender on attitudes toward mental illness. All the measures utilized in this experiment
were self-administered and participants were presented with a paper-and-pencil battery
comprising all the scales to be completed. I included in the chapter, material pertaining
to protection of human subjects and informed consent from participants.
In Chapter 4, I present data analysis, data collection, preliminary analysis,
comments on didactic seminar treatment, inferential analysis of each dependent variable,
and a summary of findings. In Chapter 5, I discuss the research findings, limitations of
the study, and provide the recommendation, implication, and conclusion of the study.
Chapter 4: Data Analysis
Introduction
The purpose of this study was to close the gap regarding the understanding of
mental illness of college students in Jamaica, as well as to determine how a didactic
seminar affected attitudes towards people with mental disorders in Jamaica, West Indies.
The purpose of the study also included determining whether there were gender disparities
in the attitudes towards mental illness among college students in Jamaica. I posed two
research questions in Chapter 1:
RQ1. Does a didactic seminar change attitudes about mental health among
college students in Jamaica, West Indies, after controlling for 1st survey scores and age
by using them as covariates?
H1a: The didactic seminar positively affected Jamaican college student attitudes
toward mental illness, after controlling for 1st survey scores and age as covariates.
H10: The didactic seminar did not positively affect Jamaican college student
attitudes toward mental illness, after controlling for 1st survey scores and age as
covariates.
RQ2. Is there a difference between male and female in attitudes towards mental
illness among college students in Jamaica, after controlling for 1st survey scores and age
by using them as covariates?
H2a: Gender positively affected Jamaican college student attitudes toward mental
illness, after controlling for 1st survey scores and age as covariates.
H20: Gender did not positively affect Jamaican college student attitudes toward
mental illness, after controlling for 1st survey scores and age as covariates.
The following hypotheses addressed interaction between the independent variables:
H3a: There is a significant interaction between didactic seminar and gender on
Jamaican college student attitudes toward mental illness, after controlling for 1st survey
scores and age as covariates.
H30: There is no significant interaction between didactic seminar and gender on
Jamaican college student attitudes toward mental illness, after controlling for 1st survey
scores and age as covariates.
In the current chapter, I presented the results from the analyses performed to test
the three null hypotheses of this study. Initially, I presented the results from preliminary
analyses, including how the data were collected, descriptive statistics for all study
variables, and the results from the testing of the assumptions required for the ANCOVA
analysis. Then, I presented the results from the inferential analyses performed to test the
three null hypotheses, and the chapter ends with a summary.
Data Collection
The research population was a convenience sample drawn from a college in
Jamaica, West Indies. Two hundred college students volunteered and participated in the
first survey. Prior to the first survey, I explained to the participants that participating in
the study was voluntary and that their names or the college would not be mentioned in the
study. In addition, I gave information about the study, explained the risk of participating
in the study; and told participants that they could withdraw at any time, that they must be
18 years or older, and that they must be registered at the college to participate. Each
participant had to sign the informed consent to participate in the study.
I collected data for the first survey over a period of two days on the campus of the
college in a private office. There were 200 student participants. After the first survey was
completed, the college presented the didactic seminar and was open to all students at the
college who found the time to attend. Some students were absent from the college at the
time of the didactic seminar due to required teaching internships off campus. The second
survey was completed four weeks after the didactic seminar was given. Again, I collected
data over a period of two days on the campus of the college, in a private office. I asked
participants at the completion of the second survey to check “yes” or “no” if they
attended the didactic seminar given by the college. Only 184 of the 200 participants
returned for the second survey. I conducted all analyses using SPSS.
Preliminary Analyses
Descriptive Statistics
A total of 184 individuals participated in this study. Only 16 of the 200
participants did not return for the second survey. Thus, these participants were not
considered in the study. I determined that about 8% of the participants that participated
in the first survey did not return for the second survey. Tables 2 and 3 contain descriptive
statistics for the group, gender, and age of the participants in this study. The majority of
the participants (64.1%) attended the didactic seminar. Most of the participants (85.9%)
were female, and the average age was 22.75 years old (SD = 5.00 years).
Table 2
Descriptive Statistics for Sample Demographic and Group Characteristics
Variable N %
Group
Didn’t attend the seminar
66
35.9
Attended the seminar 118 64.1
Gender Male
26
14.1
Female 158 85.9
For all three dependent variables, I generated histograms to determine whether
there were outliers. For the purpose of this study, outliers were defined as data points
outside the normal range. Points outside the normal range are observed based on the
normal curve in the histogram. These are data points that lie outside the bell curve.
Based on the histograms in Appendix T (Figures 2 to 7), I determined that there are no
outliers for the dependent variables scores are within normal range and there were no
observed data points lying outside the norm. I presented the means, standard deviations,
and range of values for the dependent variables in Table 3. Higher scores for the
dependent variables are indicative of more positive attitudes. I examined histograms for
each of the three dependent variables (see Appendix T) at the first survey and second
survey and showed approximate.
I presented descriptive statistics for the dependent variables in Table 3. Scores on
the AMIQ ranged from -10 to 4 with a mean of -3.35 (SD = 3.28) at the first survey and
from -10 to 8 with a mean of -1.93 (SD = 4.02) at the second survey. In the normative
sample, the mean AMIQ score was -1.86 (Luty et al., 2006), indicating that the current
sample had more negative views of mental illness at the first survey, but scores
comparable to the normative sample at the second survey. For the OMI, scores ranged
from 114 to 262 with a mean of 198.02 (SD = 25.70) at the first survey and from 121 to
283 with a mean of 207.01 (SD = 33.04) at the second survey. There were no normative
data for the OMI. For the HSAS, scores ranged from 3 to 30 with a mean of 19.38 (SD =
5.09) at the first survey and from 1 to 30 with a mean of 20.18 (SD = 5.15) at the second
survey. In the normative sample, scores on the HSAS averaged 17.45 (Fischer & Farina,
1995), indicating that the scores in the current sample were somewhat higher than the
normative sample at both the first survey and the second survey.
Table 3
Descriptive Statistics of Dependent Variables
Variable M SD Min. Max
AMIQ first survey -3.35 3.28 -10 4
AMIQ second survey -1.93 4.02 -10 8
OMI first survey 198.02 25.7 114 262
OMI second survey 207.01 33.04 121 283
HSAS first survey 19.38 5.09 3 30
HSAS second survey 20.18 5.15 1 30
I presented descriptive statistics for the three dependent variables done separately
for each group in Table 4. I examined these scores in more detail in the inferential
section of this chapter, but two trends are visible. First, for the OMI, the difference
between the first and second survey scores was more substantial for those who attend the
seminar than for those who did not attend the seminar. Second, for the AMIQ and HSAS,
there was little change between the first and second survey scores for the two groups.
Table 4
Descriptive Statistics for Dependent Variables as a Function of Group
Did not Attend (n
= 66)
Did Attend
(n = 118)
95% CI of the
Difference
Variable M SD M SD Lower Upper
AMIQ first survey -3.24 3.51 -3.42 3.16 -0.82 1.17
AMIQ second survey -2.20 3.46 -1.79 4.31 -1.63 0.81
OMI first survey 204.29 21.33 194.52 27.31 2.09 17.45
OMI second survey 198.35 23.33 211.85 36.59 -22.23 -4.76
HSAS first survey 19.09 5.49 19.53 4.86 -1.99 1.10
HSAS second survey 18.41 5.44 21.17 4.72 -4.27 -1.25
Assumption Checking
To determine whether age would be used as a covariate, it was important to
determine whether age was related to the dependent variables. I computed Pearson
correlations between age and scores on the three dependent variables at the first survey.
These correlations were not statistically significant for AMIQ first survey scores, r = .07,
OMI first survey scores, r = .10, or HSAS first survey scores, r = .12. To determine
whether male and female participants differed in terms of their scores on the three
dependent variables at the first survey, I performed three independent sample t-tests.
The tests were not statistically significant for the difference between males’ and females’
AMIQ first survey scores, t(182) = 1.96, OMI first survey scores, t(182) = .78, or HSAS first
survey scores, t(182) = -1.32. Based on the analyses of age and gender in relation to the
three first survey dependent variable scores, I concluded that age and gender were not
significantly related to the dependent variables at baseline. However, some of the p
values for these correlations and t-tests were close to the .05 level of statistical
significance (indicating a trend toward significance for the HSAS and age and for the
AMIQ and gender), and therefore I included both age (as a covariate) and gender (as an
independent variable) in the ANCOVA analyses.
The ANCOVA analyses require the assumptions of normality for the distributions
of the dependent variables and homoscedasticity. I examined histograms for second
survey scores and showed approximate normality (see Figures 2 through 7 in Appendix
T). I also computed the skew statistic and kurtosis values. For AMIQ second survey
scores, the skew statistic was .18, whereas the kurtosis was -.58. For OMI second survey
scores, the skew statistic was .51, whereas the kurtosis was .10. For the HSAS second
survey scores, the skew statistic was -.60, whereas the kurtosis was .07. None of these
values exceeded 1.00 in absolute value, indicating approximate normality for the
dependent variables in this study.
I examined homoscedasticity using Levene’s (1960) test of the equality of
variances. These tests were not statistically significant for the AMIQ test, F(3, 180) = 1.60,
or the HSAS, F(3, 180) = .58. However, Levene’s (1960) test was statistically significant for
the analysis of OMI scores, F(3, 180) = 6.95, p < .001, indicating that the assumption of
homoscedasticity was not met. Therefore, I used ANCOVA for AMIQ and HSAS scores,
whereas I used a generalized linear model to analyze the OMI scores.
Inferential Analyses
In this section, I presented the results from the three ANCOVAs performed to
answer the two research questions and test the three null hypotheses of this study. In this
section, I presented the results from each of the three ANCOVA. In the summary of
findings section at the end of the chapter, I interpreted the results in light of the research
questions and hypotheses of this study.
Analysis of AMIQ Scores
Table 5 shows the results from the ANCOVA with AMIQ second survey scores as the
dependent variable. The independent variables were gender and group (attended or did
not attend didactic seminar) and the covariates were AMIQ first survey scores and age.
The only statistically significant effect was for the covariate of AMIQ first survey scores,
F(1, 178) = 6.63, p = .01, Partial eta squared = .036. This effect indicated that AMIQ first
survey scores were associated with AMIQ second survey scores. The effects for the
covariate of age, F(1, 178) = .23; p = .663, Partial eta squared= .001, the main effect of
gender, F(1, 178) = .77; p = .382, Partial eta squared = .004, the main effect of group, F(1,
178) = 2.37; p =.126, Partial eta squared = .013, and the gender by group interaction, F(1,
178) = 2.34; p = .382, Partial eta squared = .013, were not statistically significant. Based
on this analysis, there was no statistically significant difference between AMIQ second
survey scores between those who did not attend the seminar versus those who attended
when controlling for age, gender, and first survey scores.
Table 5
Results from ANCOVA with AMIQ second Survey Scores as the Dependent Variable (N =
184)
Source of Variance Sum of
Squares Df Mean
Squares F P Partial eta
squared
Covariate: AMIQ
first survey scores 104.70 1 104.70 6.63 .011 .036
Covariate: Age 3.62 1 3.62 .23 .633 .001
Gender 12.14 1 12.14 .77 .382 .004
Group 37.38 1 37.38 2.37 .126 .013
Gender * Group 36.89 1 36.89 2.34 .128 .013
Error 2809.63 178 15.78
Analysis of OMI Scores
The results from the generalized linear model with OMI second survey scores as
the dependent variable are shown in Table 6. The generalized linear model is used to
analyze the effect of independent variables on the dependent variable without following
normality and homogeneity assumptions of parametric tests such as ANCOVA. In that,
the OMI scores do not have equal variances, a generalized linear model is more
appropriate to analyze relationships between variables as opposed to an ANCOVA. As
expected, the effect of the OMI first survey scores was statistically significant, X2 (1, 178) =
42.015, p < .001, indicating that OMI first survey scores were associated with OMI
second survey scores. The effects for age, X2(1, 178) = .066, p = .797, and gender, X2(1, 178) =
3.066; p = .080, were not statistically significant. However, the effect of group (those
who did not attend the seminar versus those who attended the seminar) was statistically
significant, X2(1, 178) = 14.31, p < .01.
Table 6
Results from the Generalized Linear Model with OMI second Survey Scores as the
Dependent Variable (N = 184)
Parameter
B
Std. Error
95% Wald CI
Lower Upper
Wald X2
df
Sig.
(Intercept) 91.398 19.6479 52.888 129.907 21.639 1 0.000
OMI First
Survey 0.55 0.0848 0.384 0.716 42.015 1 0.000
Age 0.111 0.4321 -0.736 0.958 0.066 1 0.797
Gender 11.211 6.4026 -1.338 23.76 3.066 1 0.080
[Group=N]
* gender -18.587 4.9136 -28.218 -8.957 14.31 1 0.000
[Group=Y]
* gender 0
(Scale) 845.863 88.1874 689.535 1037.634
Analysis of HSAS Scores
Table 7 contains the results from the ANCOVA with HSAS second survey scores
as the dependent variable. The HSAS first survey scores were statistically significant in
this model, F(1, 178) = 13.12, p < .001, Partial eta squared = .069, indicating that first
survey and second survey scores on the HSAS were associated, as expected. The effects
for age, F(1, 178) = .07; p = .789, Partial eta squared < .001, and gender, F(1, 178) = 1.05; p
= .308, Partial eta squared = .006, were not statistically significant. However, the effect
of group was statistically significant, F(1, 178) = 9.25, p = .003, Partial eta squared = .049.
The estimated marginal means for the two groups (controlling for age, gender, and first
survey HSAS scores) indicated that those who had attended the didactic seminar had
higher second survey HSAS scores (estimated marginal mean = 21.04, SE = .69) than
those who had not attended the didactic seminar (estimated marginal mean = 17.88, SE
= .78; F(1,178) = 9.25, p =.003). This indicated that when controlling for age, gender, and
first survey scores, those who had attended the didactic seminar tended to have more
positive views about seeking mental health help than those who had not attended the
didactic seminar. The interaction between gender and group was not statistically
significant, F(1, 178) = .62; p = .431, indicating that the difference between those who did
and did not receive the didactic seminar was the same for male and female participants.
Table 7
Results from ANCOVA with HSAS second Survey Scores as the Dependent Variable (N =
184)
Source of Variance Sum of
Squares df Mean
Squares F P
Partial
eta
squared
HSAS first survey scores 306.58 1 306.58 13.12 < .001 .069
Age 1.68 1 1.68 .07 .789 .000
Gender 24.48 1 24.48 1.05 .308 .006
Group (Did or did not attend
seminar) 216.17 1 216.17 9.25 .003 .049
Gender * Group (Did or did
not attend seminar) 14.56 1 14.56 .62 .431 .003
Error 4160.81 178 23.38
Summary of Findings
This chapter contains the results from the preliminary analyses and the
ANCOVAs and generalized linear model analysis performed to determine the effect of
the didactic seminar on attitudes about mental health among college students in Jamaica.
The analyses provided answers to the research questions on: (a) Will a didactic seminar
change attitudes about mental health among college students in Jamaica, West Indies,
after controlling for first survey scores and age by using them as covariates, and (b) is
there a significant difference between male and female in attitudes towards mental illness
among college students?
Analyses of the AMIQ indicated that there was no statistically significant
difference between the attitudes toward mental illness as measured through the AMIQ
second survey scores between those who did not attend the seminar and those who did
attend the seminar when controlling for age, gender, and first survey AMIQ scores. The
analysis for second survey OMI scores (controlling for age, gender, and first survey OMI
scores) indicated that those who received the didactic seminar had more positive views of
mental illness than those who did not receive the didactic seminar. There was no
interaction between gender and group, indicating that the difference between those who
did not attend the didactic seminar and those who did attend the didactic seminar was the
same for males and females.
The estimated marginal means for the two groups (controlling for age, gender, and
first survey HSAS scores) indicated that those who had received the didactic seminar had
higher second survey HSAS scores than those who had not received the didactic seminar.
This indicated that when controlling for age, gender, and first survey scores, those who
had received the didactic seminar tended to have more positive views about seeking
mental health help than those who had not received the didactic seminar. The interaction
between gender and group was not statistically significant, indicating that the difference
between those who did and did not receive the didactic seminar was the same for male
and female participants.
For all three dependent variables in this study, the interactions between gender
and taking the didactic seminar were not statistically significant. This indicated that the
lack of a difference in AMIQ scores and the statistically significant differences for OMI
and HSAS scores did not depend on the gender of the participants. In the next chapter, I
discussed these results in the context of past research and I offered recommendations for
mental health education and future research in this area.
Chapter 5: Discussion
Introduction
Public stigma, negative thoughts, and discrimination have pernicious effects on
the lives of people and individuals with serious mental illnesses. I focused this study on
determining whether a didactic seminar on mental health issues could change the attitudes
of students towards mental illness. I discussed the results of this study in this chapter.
There have been campaigns to alleviate the condition and eliminate discrimination among
individuals with mental illness. I considered three questionnaires to measure the
perceptions on mental illness. These measures included the OMI, HSAS, and AMIQ
scores. I focused the OMI and the HSAS scores on measuring the perceptions on mental
illness, whereas I focused the AMIQ score on measuring how the participants reacted
given a situation with mentally ill patients. Based on the analyses in this study,
participants who received the didactic seminar had more positive views about mental
health than those who did not receive the didactic seminar, as evidenced using the OMI
and the HSAS measures. However, I found no significant difference in AMIQ scores
between those who attended the didactic seminar and those who did not attend the
didactic seminar.
There are four sections in this chapter. The first section presents an interpretation
of the results in the context of past research in this area, as well as the conclusions in the
context of the theoretical framework for this study. The second section is a discussion of
the limitations of the study. In the third section, I provided recommendations for future
research in this area. Finally, I presented the conclusions and implications of the findings
from this study.
Despite more favorable attitudes toward mental illness in Jamaica than in other
countries, the stigma of mental illness remains. This stigma is exacerbated by cultural
attitudes and an internalization of stigma by mentally ill people (Health Service
Executive, 2012; National Suicide Research Foundation, 2012). Therefore, I focused this
study on closing the gap in literature, which lacks studies regarding the attitudes and
beliefs of mental illness and the mentally ill among college students in Jamaica, through
analyzing whether a didactic seminar would be effective in changing the perspectives on
mental illness. The teachers' college in Jamaica, West Indies where I did the research,
conducted a didactic seminar, aimed at educating and informing participants regarding
mental illness.
I conducted this study to determine whether there were gender differences in
attitudes towards mental illness among college students in Jamaica. I investigated gender
disparities to determine whether gender played a role in attitudes toward mental health.
In analyzing whether gender was related to differences in attitude towards mental health,
programs focused on improving perceptions towards mental illness could be directed
towards a particular gender group. The results also showed that the didactic seminar had
a positive effect on the attitudes toward mental illness and help-seeking behavior, and that
these effects were the same for male and female participants. However, positive benefits
were only found on two of the three dependent variables (the OMI and HSAS, but not the
AIMQ).
Interpretation of the Findings
In this study, I used a convenience sample of 184 students attending a college in
Jamaica.. The students at this college are from all sections of Jamaica. The college
presented the didactic seminar and it was open to all students at the college who found
time to attend. I asked students who chose and chose not to participate (nonequivalent
control group) in the didactic seminar to take a second survey.
This study is important because in general, not only is there a high prevalence of
mental illnesses in Jamaica, there is also a stigma attached to having a mental illness.
Mental illnesses contribute to disability, death, and health care costs (Knapp, 2003;
WHO, 2003) and the stigma of having a mental illness or receiving treatment for a mental
illness adversely affects the daily lives of these individuals (National Disability
Authority, 2012). The stigma attached to having a mental illness can also decrease the
likelihood of an individual seeking treatment (Health Service Executive, 2012; National
Suicide Research Foundation, 2012). Seminars such as the one evaluated in this study
can be used to improve attitudes towards people with mental illness. The results of the
changed attitudes can be better care for the patients.
Based on the results of the analyses I presented in Chapter 4, I drew the following
conclusions:
1. Although not statistically significant, those who attended the seminar had
more positive attitude scores towards mental illness after the seminar than
those who did not attend.
2. Those who attended the didactic seminar had more positive views about
mental illness than those who did not, based on the OMI and the HSAS
scores. However, there was no change in AMIQ scores of the study, despite
the appropriate use of the scales.
3. There were no gender differences in the attitudes of mental illness after the
seminar.
The results from the current study are consistent with the results from past studies
conducted in Jamaica (Arthur et al., 2010; Gibson et al., 2008; Hickling et al., 2011;
Francis, 2007), in that I observed positive effects of educational programs on attitudes
toward mental illness. However, this study was the first to focus on a specific didactic
seminar in terms of its effects on attitudes toward mental illness. The use of the didactic
seminar allowed the participants to visualize the benefits of changing their attitudes
toward mental illness. On the other hand, other programs are focused on the existence of
mental illness and the implications to the patients.
According to Pescosolido et al. (2010), changing negative attitudes toward mental
illness is difficult, and attitudes have not changed substantially in recent years. This is
somewhat inconsistent with the results from the current study, which indicated that it
might be possible to change negative attitudes toward mental illness through
interventions such as the didactic seminar used in this study. Pescosolido et al. had
examined changes in attitudes towards mental illness over time. However, they did not
consider a specific intervention. Attitudes may not change by themselves over time.
It can be very difficult to change attitudes because individuals are resistant to
change (Prochaska, 2013). The levels of change for attitudes vary based on the stage of
change that occurs with a person. A change in attitude requires a deeper level of change
than perceptions, in that people must be convinced that change in their behavior would
only occur if they willingly changed their attitude in regards to how they think. Thus,
actions must be taken to implement the change and prevent resistance. Although
Pescosolido et al. (2010) did not evaluate the effectiveness of a specific intervention such
as a didactic seminar and other conferences designed to change the attitudes of different
individuals, the generally negative conclusion they offered is inconsistent with the results
from the current study, in which I observed positive changes.
Based on the findings of this study, there are factors that can influence people to
change their attitudes. Attitudes towards mental illness have remained the same over
time, despite the general trend in changes of the attitudes of individuals towards other
phenomena such as physical and emotional conditions (Carter et al., 2010). Most people
in society had negative perceptions towards the families, relatives, and persons with
mental conditions. These negative perceptions included the idea that people with mental
illness are incompetent, unpredictable, and dangerousness, resulting in their resistance to
seeking medications and psychological help (Angermeyer & Matschinger, 2005; Carter et
al., 2010; Corrigan & Watson, 2002; Jorm & Griffiths, 2008; Mann & Himelein, 2004).
For instance, the 1999 Surgeon General’s Report on Mental Health acknowledged stigma
as one of humanity’s leading hindrances to enhanced mental health care and stigma
contributing to decreased self-respect of people and hinderance to involvement in society.
Conversely, Granello and Granello (2000) suggested that educational programs
and campaigns have the potential to provide accurate information on all aspects of mental
illness, and thus reduce stigmatization. This is consistent with the results from this study
(and with cognitive consistency theory as described later in this section). The educational
program I examined in the current study (the didactic seminar) appeared to have
positively affected attitudes toward those with mental illnesses, just as Granello and
Granello predicted.
Hickling et al. (2011) indicated that in Jamaica, prior efforts have been made to
educate people regarding mental illness to reduce the stigma associated with mental
illness and help-seeking behaviors. They also pointed out that a main factor of mental
illness stigma in Jamaica was the dehumanization of those with mental illness who lived
on the streets. The stigma causes negative impacts not just to the individuals who have
mental illness, but also to their families. Hickling et al. further indicated that there is a
widespread prejudgment that the mentally ill are unpredictable and dangerous. The
perception of danger associated with mental illness increases as the stigma against
individuals with mental illness increases. People with mental illness have been viewed as
having a negative impact on society and as being incapable of benefiting society.
However, community mental health care services are now in place and these appear to be
transforming some of the negative stigma associated with mental disorders and treatment.
In general, the stigma towards health seeking is attributed to the fact that those
who seek help for psychological conditions are already prejudged by society to engage in
certain behaviors that can be detrimental to the society and to other people (Hickling et
al., 2011). While health programs conducted in Jamaica have been effective in raising
people’s awareness of mental illnesses, the effects have been small (Arthur et al., 2010;
Gibson et al., 2008; Hickling et al., 2011; Francis, 2007). The didactic seminar
considered in this study included educating and providing information on mental
illnesses, its symptoms, and ways in which individuals could help and support people
with mental illnesses. Although existing health programs have tried to increase
awareness of mental illness, these programs did not provide detailed discussions on
experiences with mentally ill individuals and ways in which these people could be
supported. The didactic seminar focused on sharing experiences through two-way
communication to learn from these experiences, raise individuals’ awareness of how
people with mental illness should be treated, and how they could be supported.
Whereas changes to attitudes may occur over time, there have been no studies
conducted to evaluate interventions that could result in positive changes in attitudes
toward mental illness, specifically in Jamaica. Because mental illnesses have been
prevalent in Jamaica, it is important to consider whether attitudes of Jamaicans on mental
illness could positively change. As previous studies have focused on whether attitudes
change naturally over time, the current study represented an extension of past research
because a specific and targeted intervention was examined (Arthur et al., 2010; Hickling
et al., 2011).
The conceptual framework for this study was based on the theories of cognitive
consistency and cognitive heuristics (Rydell et al., 2007; Simon et al., 2004; Wood,
2000). These theories explain how people process, deal with, and react to information.
According to cognitive consistency theory, an individual’s attitude toward mental health
could be inconsistent with information on mental health. These cognitive theories were
chosen, as they contribute to the understanding that attitudes can change over time and as
a result of an intervention such as the didactic seminar. According to Cvencek, Meltzoff,
and Kapur (2014), these theories focus on how people process, deal with, and react to
information or stimuli; cognitive consistency may be culturally universal and a key
mechanism for developmental change in social cognition; both cultural universals and
cultural variations matter in developing social cognition. According to cognitive
consistency theory, the inconsistency between the attitude and the factual state of health
can be attributed to the importance of the social and the cultural aspects of cognitive
development. Social and cultural backgrounds of individuals affect their attitudes toward
mental illness. This suggests that it is important to consider the change in attitudes
towards mental illness, considering the specific social cultural background of Jamaicans.
Therefore, my goal of this study was to determine whether a person’s attitude could be
brought into consistency with factual information.
According to the results from this study, this approach was effective. For two of
the three dependent variables in this study (attitudes toward mental illness and attitudes
towards help seeking), the participants who attended the didactic seminar had more
positive attitudes after the seminar than those who did not attend. The OMI and HSAS
measures indicated significant difference in the attitude towards mental illness between
those who attended the seminar and those who did not. However, there were no
significant differences in AMIQ scores. The insignificant difference may be because of
the nature of the items in the three questionnaires. The OMI and the HSAS are more
focused on the perceptions on mental illness, whereas the AMIQ is focused on how a
person will react given a situation with people with mental illness. This implies that the
respondents may have changed their perceptions, but they have yet to apply this on how
they treat mentally ill people. A more positive view may be present in respondents who
have participated in the didactic seminar. However, the didactic seminar did not affect
the way in which the respondents reacted to people with mental illnesses. These results
are consistent with cognitive consistency theory. As the participants rejected
contradictory evidence (what they learned in the seminar versus their own opinion or
what they had learned from others) or altered how evidence was evaluated, their attitudes
were changed (Simon et al., 2004).
The didactic seminar allowed participants to understand the benefits and the
importance of seeking medications and professional help for mental illness. Seminar
participants were able to learn about the nature as well as the difficulties of having mental
illness. However, the way they act with mentally ill people has not changed. Therefore,
this implies that continuous efforts are necessary to change the behavior of people
towards mentally ill people. The overall effect size was determined to be small, less
than .05, which indicates that firm generalization of conclusions cannot be achieved. The
small effect size could be attributed to the unequal number of participants for those who
attended and did not attend the seminar, or it could be attributed to the small effect of the
intervention considered in this study.
Limitations of the Study
The limitations of the study included the factors inherent to the type of study and
the variables available to the researcher. In this study I did not attempt to understand
population-level attitudes towards mental health in Jamaica. I recruited the participants
in this study from students at a particular college, who may have different opinions and
attitudes from those of the general population. However, the participants were future
teachers able to initiate change through their students, which may have an impact in terms
of the direction of change within this field. Furthermore, generalizability to other
Caribbean nations may be limited given the specific population studied in this study. This
was not a true experimental study, as the participants were free to choose whether to
attend the seminar. This resulted in the use of a quasi-experimental research design in
which the participants selected the group in which they would be. This had the potential
to bias the results, as individuals with more positive attitudes toward mental illness could
have chosen to participate in the seminars, whereas while those with more negative
attitudes could have chosen not to participate (and consequently place themselves into the
control group). However, there were no differences between the groups on the measures
before the presentation of the seminar. Thus, even though a limitation of this study was
that a true experimental study was not performed, it is likely that the obtained results
from this study are valid because pre-existing group differences were controlled through
the selection of the appropriate statistical tests and control variables.
Another limitation of this study was that the results might not generalize beyond
the type of individuals who participated in this study. The samples were limited to
students at one particular college in Jamaica who completed both the first and the second
surveys. Moreover, participants were not equally distributed in the two groups
considered in this study. Gender as well as age differences were not very diverse in the
sample, which may have affected the results of the study. This might be an explanation
for why no gender differences were observed. Dell'Osso, Carmassi, and Massimetti
(2011) found that there were gender differences in the attitudes to mass trauma
considering PTSD. They also found gender differences in attitudes about PTSD after
trauma; it is possible that there are gender differences in attitudes towards mental illness
in general. However, the authors had inconclusive findings regarding the significance of
gender on the attitudes towards mental illness. Future researchers could address the
generalizability of the findings from this study by exploring the effectiveness of didactic
seminars designed to change attitudes toward mental illness in other countries and among
individuals with different demographic characteristics, including age and personal
experience with the mentally ill.
In total, 184 individuals participated in this study. Sixteen of the 200 initial
participants did not return for the second survey. Thus, these participants were not
considered in the study. Sixty-two percent (n = 10) of the 16 participants who did not
complete the second survey attended the didactic seminar during the first survey. Thus,
more participants who attended the seminar completed the second survey as opposed to
participants who did not attend the seminar. A limitation is that more students
participated in the didactic seminar, which resulted in an unequal number of participants
in each group (attended seminar and did not attend seminar).
Another limitation is that the participants were not followed for a longer period.
Responses of participants may change over time (Cozby, 2009). For example, responding
to the survey a week after the didactic seminar could provide different responses as
opposed to completing the survey immediately after the didactic seminar. Moreover,
responses of participants a month or a year after the seminar could also be different.
Recommendations
Based on results and limitations of this study, I developed several recommendations
for future research. First, I noted above that a true experiment was not conducted in this
study because the participants selected their own group by either participating in the
didactic seminar or not participating in the didactic seminar (resulting in the use of a
quasi-experimental research design). Thus, firm causal conclusions cannot be drawn
from this study. Despite controlling for pre-existing group differences such as gender and
age, the participants were not randomly assigned to identify causal relationships between
variables of attending the didactic seminar and the attitudes toward mental illness.
Therefore, it is possible that the didactic seminar itself was not responsible for the
observed results. Future researchers should examine the effectiveness of didactic
seminars such as the one examined in this study in situations in which true experiments
could be performed. However, considering the difficulty of random sampling and
random assignment in a true experiment, a stronger quasi-experimental model can also be
used. Students should be encouraged to attend the didactic seminar through including
such seminars in the curriculum.
Different kinds of seminars should also be compared because seminars other than
didactic seminars might have strikingly different results. Thus, another recommendation
for this study is to enhance the didactic seminar or to examine other types of seminars
that could help in positively changing attitudes toward mental illness. The experience of
conducting the didactic seminar could provide insights as to how the seminar could be
improved for succeeding sessions. The content of the seminar could also be improved
through focusing on possible differences in the attitudes of the participants towards
mental illness. Participants of the seminar could have been given information on the
consequences of negative attitudes toward mental illness and stigma, in that one’s
attitudes and beliefs about mental illness are shaped by personal knowledge about mental
illness and cultural stereotypes about mental illness (Corrigan et al., 2004; Wahl, 2003).
For instance, once such attitudes and views are communicated confidently, they can end
in compassionate and wide-ranging comportments (e.g., readiness to seek psychological
assistance or talking about their mental illness). Conversely, if such attitudes and opinions
are uttered negatively, they may result in averting and refusing to participate in daily
activities.
Another limitation of this study was that the sample was relatively homogenous in
terms of their ethnicity and age group, consisting of individuals in college in Jamaica.
The participants were also not equally represented in terms of gender, which may have
affected the results of this study. Therefore, another recommendation for future research
is that researchers should explore the generalizability of the results from this study to
other geographic areas and with individuals of varying demographic backgrounds. It is
also recommended that future researcher focus on following up on the participants over a
longer period, as attitudes may change.
Implications for Social Change
According to cognitive consistency theory, a successful effort to change the
attitudes of the participants toward mental illness could result in changes in behavior
(Crano & Prislin, 2010; Simon et al., 2004). Negative stigma associated with mental
illness may change to positive attitudes through understanding the circumstances of
individuals suffering from mental illnesses. The change in attitudes may lead to changes
in behavior, which could motivate people to help improve the situations of those who
suffer from mental illnesses. Although the results of this study did not show significant
changes in behavior towards mental illness, the results showed that perceptions towards
mental illness have changed. Through educating people regarding mental illness, they
develop perceptions that may later lead to a change in behavior. Moreover, the
perceptions on mental illness gained from the seminar could be used to educate other
people. Given the high prevalence of mental illness, the negative effects of the stigma of
having a mental illness, and the reduced likelihood of seeking help for mental illnesses
due to the associated stigma (Health Service Executive, 2012; National Suicide Research
Foundation, 2012), those individuals suffering from mental illness as well as their
families and friends might benefit from changes in attitudes towards mental illness by
others as a result of the didactic seminars, through sharing their own understanding of
mental illness. Although not proven significant, the changes in behavior may have been
initiated through the seminar conducted. With more knowledge, people have better
understanding of mentally ill people.
If didactic seminars such as the one examined in this study are implemented on a
broader scale, attitudes towards the mentally ill may positively change. This could
reduce the stigma associated with mental illnesses and consequently improve the lives of
those who suffer by increasing the likelihood of obtaining the help they need. The
families of those who suffer from mental illnesses could also benefit, as a member of the
family could receive the help that he or she needs.
Community awareness in Jamaica and other countries can be raised so that
individuals with mental illness, as well as their families, can seek out and receive help to
change their attitudes. Moreover, the results of the study benefit communities and
countries in raising community awareness by having more seminars in the community.
Conducting community seminars provide more in-depth understanding of the situations
and predicaments of the individuals with mental illness, as well as their families.
Community leaders also have a means to help mentally ill individuals through hosting
didactic seminars to inform community members on how to support such individuals.
However, it should be noted that none of these benefits would materialize unless attitudes
are changed through programs such as the didactic seminar examined in the current
study.
Conclusions
The purpose of this study was for me to evaluate a didactic seminar aimed at
increasing understanding of mental illness in Jamaica. An additional research question
was whether there were gender disparities in the attitudes towards mental illness among
college students in Jamaica. The results showed that for two of the three dependent
variables (the OMI and HSAS, but not the AMIQ), the didactic seminar had a positive
effect on attitudes toward mental illness and help-seeking behavior, and that these effects
were the same for male and female participants. The results were insignificant for the
AMIQ scores of participants. A reason for this is that the nature of the items in the
questionnaire also warrants social and cultural beliefs specific to Jamaicans, rather than
only the perceptions on mental illness. The AMIQ scores are focused on the situations
instead of directly capturing the perception of people on mental illness.
The insignificant change after the didactic seminar may be due to preconceived
ideas on how to react, given the situation, or may be due to habits developed early on and
can be changed slowly over time. The difference in measured constructs may have
resulted in the insignificant change after the didactic seminar. Because the AMIQ
focused on what people would do in a given situation, the perceptions towards mental
illness may have changed due to the didactic seminar but not on how they would act
when interacting with mentally ill individuals. The didactic seminar seems to have
created a positive impact on attitudes towards mental health and health-seeking behavior.
Further, the effects of the didactic seminar resulted in more positive perceptions of
individuals with mental illness, their families, and to society in general.
Based on these results and on the limitations and design of this study, I developed
two recommendations for future research:
1. Future researchers should examine the effectiveness of didactic seminars, such
as the one examined in this study, in situations in which true experiments
could be performed.
2. Future researchers should explore the generalizability of the results from this
study to other geographic areas and with individuals of varying demographic
backgrounds.
Based on the positive results of this study, didactic seminars are effective in improving
attitudes towards mental illness when implemented on a broader scale. Different kinds of
seminars should also be compared because seminars other than didactic seminars might
have strikingly different results.
This research may be the beginning of many efforts to follow by advocate for the
changing of attitude toward people with mental illness, utilizing didactic seminars as
intervention strategies. Positively changing society’s attitudes toward the mentally ill will
lead people toward being more caring and sympathetic. I hope that understanding
attitudes toward mental illness can help identify and inform primacies that award the
efforts of mental health public interventions, benefactors, legislators, educators, and
others to diminish stigma. Most of all, it should offer prized awareness of people living
with mental illness. I also hope that this data can help form initiatives to actively decrease
stigma and eradicate blockades for those pursuing or getting treatment for mental illness.
