Because mental health professionals are not immune to negative attitudes toward ... professionals as a tool to understand their attitudes toward mental illness.
Volume 37/N um ber I/Novem ber 2015/Pages 4 7 -6 2
A ttitudes o f Mental Health Professionals to w a rd Mental Illness: A D eeper Understanding A llison C ro w e Paige A v e r e tt
Because mental health professionals are not immune to negative attitudes toward adults with mental illness, researchers have questioned where these attitudes might originate, as well as what affects them. Although there have been quantitative studies that broadly explore attitudes toward mental illness, in-depth understanding o f factors that affect the attitudes o f mental health professionals will offer insight to practitioners and researchers alike. This qualitative study explored the impact o f educational programs and professional experience on the attitudes o f mental health professionals toward their clients. Based on the results, this article describes a continuum o f attitudes toward mental illness for counselors, educators, supervisors, and related professionals as a tool to understand their attitudes toward mental illness.
In the last decade, the counseling literature has begun to address the topic of mental illness stigma, or negative attitudes toward mental illness (Bathje & Pryor, 2011; Brown & Bradley, 2002; Crowe, 2013; Smith & Cashwell, 2010, 2011). Some authors have urged mental health professionals to investigate their own attitudes (Lauber, Anthony, Ajdacic-Gross, & Rossler, 2004; Nordt, Rossler, & Lauber, 2006), asserting that it would be simplistic to think that they are immune to stigma. Early researchers believed negative attitudes among mental health professionals might be a product of feelings of helplessness and futility (Cohen, 1990); feelings of resistance to providing services and to clients (Cohen, 1990; Minkoff, 1987); inadequate training and lack of preparedness to work with a given population and setting before starting in the mental health field (Hromco, Lyons, & Kikkel, 1995; Minkoff, 1987); or inadequate support and validation (Minkoff, 1987). More recent researchers (Lauber et al., 2004; Nordt et ah, 2006; Smith & Cashwell, 2010, 2011) continued to stress the importance of mental health professionals looking inward to reflect on their own attitudes toward mental illness, since it is well-documented that negative attitudes are damaging and have internal and external consequences for clients who experience them. Internal consequences include lowered self-esteem and heightened shame, fear, and avoidance (Byme, 2000; Corrigan, 2004; Link, Struening, Neese-Todd, Asmussen, & Phelan, 2001; Perlick et ah, 2001). External consequences include
Allison Crowe and Paige A ve re tt are a ffilia te d w ith East Carolina University. Correspondence about this a rticle should be addressed to Allison Crowe, ECU. 225, M a ilsto p 121, Ragsdale H all, Greenville, N C 27 858. Email: crowea@ edu.edu.
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Journal o f M en ta l H e a lth C ou n se lin g
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exclusion, discrimination, prejudice, stereotyping by others, and social distance (Byrne, 2000; Corrigan, 2004; Link, Yang, Phelan, & Collins, 2004). REVIEW OF THE LITERATURE
Smith & Cashwell (2010, 2011) surveyed mental health professionals and trainees to examine whether professional identity, among other factors, might contribute to their attitudes toward mental illness. Since these professionals are important figures in the lives of those diagnosed with mental illness, it is of paramount importance that research related to attitudes continue to assess what helps, hurts, or simply contributes to negative attitudes toward mental illness. The Substance Abuse and Mental Health Services Administration Center for Behavioral Health Statistics and Quality (SAMHSA, 2014) reported that the national rate of serious mental illness was 4%, affecting 9.3 million Americans. Therefore, the investigation of counselor attitudes and how they developed will help these professionals in their work with the many who are struggling with mental health concerns. Smith & Cashwell (2010) first explored the attitudes of counselors, social workers, psychologists, and non-mental-health professionals as well as trainees. Their results suggested that mental health trainees and professionals had less stigmatizing attitudes than did non-mental-health trainees and professionals. There were no differences in attitudes between trainees and professionals based on professional orientation. Finally, mental health professionals who were being supervised had more positive attitudes than those who were not, which suggests the efficacy of supervision in this area. In a similar study (Smith & Cashwell, 2011) on social distance—the proximity desired in various social situations— mental health professionals and trainees desired less social distance from adults with mental illness than did non-mental-health professionals and trainees, and women desired less social distance then men. Interestingly, counselors and psy chologists desired less social distance than social workers and non-mental-health professionals, suggesting that professional orientation might make a difference in the social distance context. Although these studies produced interesting findings, because they did not incorporate qualitative data about what might impact attitudes, further study is necessary to determine what and how certain variables might affect the atti tudes of mental health professionals toward those labeled mentally ill. Beyond the counseling literature, it has been suggested that both education (Bairan & Farnsworth, 1989; Penny, Kasar, & Sinay, 2001) and professional experience (Procter & Hafner, 1991; Wallach, 2004) impact attitudes. For example, a psy chiatric nursing course improved student attitudes about mental illness (Bairan & Farnsworth, 1989), suggesting that educational training can help improve attitudes. Penny et al. (2001) examined the impact of both coursework and field work on the attitudes of occupational therapy students toward those with mental illness. Attitudes changed in a significantly favorable way after coursework, and coursework was more effective than fieldwork in promoting favorable attitudes.
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A ttitu d e s Toward M e n ta l Illness
In terms of contact as a way to improve attitudes, Proctor and Hafner (1991) reported that after a one-week placement at a psychiatric hospital, qualitative comments by nursing students about the experience revealed more positive attitudes (e.g., less fear and distrust of a person with mental illness, relaxed atmo sphere, “they are just normal people with an illness”) and suggested the efficacy of clinical placements for nursing students. Wallach (2004) surveyed psychology students on the impact of contact with those with mental illness and varied the degree of exposure. Results suggested that prolonged exposure had considerable impact on student attitudes and that limited exposure (e.g., a visit to a mental health institution) in addition to classroom instruction and classroom instruction alone were harmful. This study explores education and professional experience qualitatively in order to more fully understand what professionals report. Based on partici pant responses, we offer a conceptual model for understanding a continuum of attitudes affected by educational programs and as professional experience. Questions that framed this research were: RQ1: How did educational training influence attitudes toward mental ill ness in counselors, social workers, psychologists, and others? RQ2: How did professional experience with people diagnosed with a men tal illness influence the attitudes toward mental illness of counselors, social workers, psychologists, and others? RQ3: Aside from professional education and experience, what people or personal experiences influenced the attitudes toward mental illness of counselors, social workers, psychologists, and others?
METHOD Participants Participants in this study totaled 110. Seventy-six mental health profession als self-identified as counselor (n = 24), social worker (n = 20), or psychologist (n = 32) and had been employed as such for at least one year. O f these, 62.8% (n = 69) were female and 37.2% (n = 41) male. The majority described them selves as Caucasian (89.4%, n = 98); other participants identified as African American (4.2%, n = 6), Asian Pacific Islander (2.1%, n = 2), Hispanic (2.1%, n = 2), Multiracial (1.1%, n = 1), and other (1.1%, n = 1). Counselors ranged in age from 27 to 61 (M = 45.42, SD = 10.79), social workers from 28 to 64 (M = 53.30, SD = 9.45), and psychologists from 28 to 65 (M = 47.16, SD = 12.25). Mental health professionals had 1 to 20 years of experience (M = 14.32, SD = 6.25). Other professionals consisted of 34 participants who worked in business and other sectors in the southeast United States. They ranged in age from 25 to 64 (M = 43.76, SD = 10.62).
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Procedure After approval from the Institutional Review Board, potential participants were invited to respond to the survey via electronic email. Email addresses of mental health professionals were obtained from comprehensive statewide lists. Other professionals were reached through an alumni listserv obtained from a non-mental-health training program. Participants were told that the survey was designed to investigate attitudes toward adults with mental illness. Included in the email was a link to the survey, which was housed at a commercial online site for electronic survey research. The survey incorporated both open-ended and Likert-type questions. Due to the expansive dataset, only results of the openended questions are analyzed here; scholars interested in quantitative responses are encouraged to consult Smith and Cashwell (2011). Analysis For purposes of this paper, the responses to three open-ended questions were analyzed. There were 51 responses to question 1 dealing with educa tional training, 51 to question 2 dealing with professional experiences, and 13 to question 3 dealing with personal experiences. According to Patton (2002), content analysis “attempts to identify core consistencies and meanings” (p. 453). Conventional content analysis is used when the theory or literature on a topic is limited and pre-existing categories do not exist (Hsieh & Shannon, 2005). Although there have been some studies of the current topic, it is limited and not theoretical. Thus, conventional content analysis was chosen. Initially the responses were reviewed by the second author to gain a gen eral sense of the content and identify initial patterns (Hsieh & Shannon, 2005; Patton, 2002). Emergent themes were noted, and the data were sorted and re-sorted via codes or themes. The emergent themes were then reconsidered to seek consistency and continually re-sorted and re-themed as needed. As part of the content sorting process, numerous themes were then collapsed into a smaller number. From the themes a final model emerged that suggested a continuum of cognitive, affective, and behavioral responses, a result supported in previous anal ysis of attitudinal data (Haddock & Zanna, 1998). Additionally, as is consistent with content sorting, the connections and relationships between themes (Hsieh & Shannon, 2005) lend themselves to a continuum model. The resulting themes are discussed below. RESULTS
Influence o f Educational Programs on Attitudes Question 1 asked participants to consider how training in their educational programs (e.g., counseling, psychology, social work) influenced their attitudes toward mental illness. The continuum of responses (table 1) ranged from the belief that the educational program had not influenced their attitudes at all to various levels of integration of knowledge into practice behaviors, to attaining a critical deconstructionist approach to mental illness.
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A ttitu d e s Toward M e n ta l Illness
Table I . Continuum of the Influence of Education on Attitudes No Influence
Increased
Problems &
Empathy
Person-
Strengths-
Critical
Knowledge
Needs
&To!erance
Centered
Based
Deconstruction
“ N o influence
“ 1learned
“ 1 have a b e tte r
“ 1am m o re
“ 1 learned to
“ T h e m o re
fro m pro g ra m ”
m o re than 1
understanding
to le ra n t: 1
th in k about
education you
is actually a
had previously
o f th e needs
don’t judge as
h o w a client's
receive th e
som etim es
harshly.”
kn o w n about
and lack o f
th e scientific
su p p o rt fo r
‘"M e n ta l illness'
m ental illness
m o re y o u r
arb itra ry
m ight affect her
m ind is open to
classification.”
basis o f m ental
those w ith
“ M o re
o r him ra ther
th e gifts th a t all
“ 1am n o t sure
illness, but
m ental illness."
em pathetic and
than label o r
types o f people
"S om e o f the
th a t it d id ”
o n ly generally
understanding.”
describe w h o
have to offer.”
things th a t
speaking.”
has really”
“ It has
he/she is as a
w e classify as
given m e an
“ 1feel 1
"O n ly th a t it
appreciation fo r
becam e m o re
gave m e th e
th e problem s
em pathetic
appreciate
result o f cultural
foundation fo r
th a t individuals
to those w ith
th e strengths
differences."
w o rk in g w ith
w ith m ental
diagnosable
o f those w h o
people w ith
illness face."
m ental illness.”
have m ental
“ 1d o n 't th in k it
person.”
m ental health
“ 1 have learned
illnesses may
to id e n tify and
in fact be the
illnesses.”
p ro b le m s."
No influence. At one end of the continuum is the belief that their educa tional experience had no effect on participants or their attitudes toward mental illness. Typical responses were: “Didn’t impact them at all.” “I am not sure that it did.” “I don’t think it has really.” Unfortunately, there was no explanation for such responses. Increased knowledge. At the next point on the continuum is the notion that education increased the knowledge of participants about mental health and illnesses. The implication was that though they knew more about mental illness, that did not necessarily translate into specific changes in attitudes. Sample responses: “I learned more than I had previously known about the scientific basis of mental illness, but only generally speaking.” “Yes, if only to be aware of types of mental illness.” “Only that it gave me the foundation for working with people with mental health problems.” It seems evident that while these participants felt they had increased their general knowledge about mental illness, they did not connect this to their attitudes or
51
changes in attitudes. They had moved an incremental step beyond those who felt their education had not affected their attitudes at all. More aware of problems and needs. The next group of participants felt they had gained specific awareness of the problems a person with mental illness has to face and the needs they have as a result, stating, for example: “I have a better understanding of the needs and lack of support for those with mental illness.” “It has given me an appreciation for the problems that individuals with mental illness face (as do there [sic] families).” “Made me more aware of the needs of people who suffer from mental illness.” Though these participants had moved beyond basic knowledge into viewing mental illness as a social issue, their attitudes did not necessarily demonstrate a deeper understanding or connection to the issue. This suggests another incre mental increase in understanding, where respondents felt that they gained more from their education than merely academic knowledge of diagnosis and other foundational knowledge. These participants seemed to understand how mental illness translates into everyday struggles and issues. This place on the continuum suggests an initial level of understanding and awareness of the problems and needs associated with mental illness. Increased empathy and tolerance. Further along the continuum were those who believed they had increased in either empathy toward or tolerance of individuals with mental illness, as a result of their educational program: “My degree program teaches us to be tolerant of all people and to be aware of the needs of all people, with no discrimination.” “I feel I became more empathic to those with diagnosable mental illness.” “I am more tolerant; I don’t judge as harshly.” These respondents demonstrated movement beyond recognizing mental illness as a social issue to also having an inner response that incorporated empathy and tolerance. More than knowing or recognizing, participants identified a shift in themselves as a result of what they had gleaned from their education. In the first quote we see the idea of being aware of needs (the last level on the continuum) in addition to an increase in tolerance. This combination of ideas demonstrates that movement along the continuum from one level to the next is possible. Person-centered. Next on the attitudes continuum was the notion that edu cational programs may help participants to focus on the person rather than the diagnosis. This theme resonates in the following responses: “The emphasis was on wellness and developmental conceptualization of clients. ... I learned to think about how a client’s mental illness might affect her or him rather than label or describe who he /she is as a person.”
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A ttitu d e s Toward M e n ta l Illness
“Seeing people as people with a disorder/difficulties rather than a label.” These respondents demonstrated a greater shift in attitudes. Their responses communicated their beliefs that their programs not only increased their knowl edge, awareness, and empathy, but also transformed how they see and work with the individual rather than the illness. Responses in this category demonstrated a shift toward seeing the person first and the label or diagnosis second. Strengths-based. These participants not only saw the individual but also had become able to consider client strengths and abilities in addition to the challenges mental illness caused: “I learned to identify and appreciate the strengths of those who have mental illnesses.” “The more education you receive, the more your mind is open to the gifts that all types of people have to offer.” “Very intelligent people often have mental ‘quirks.’ I am hesitant to call them illnesses when the individual is highly functional and successful.” These responses demonstrated awareness that went beyond seeing clients as more than a label to taking into account their strengths and abilities. The last quote also seems to demonstrate movement toward the next step on the continuum: thinking critically about the very idea of mental illness. Critical deconstruction. At the last point on the continuum participants spoke of an ability to critically deconstruct the idea of mental illness and examine the social powers that classify behaviors: “By showing that what we term ‘mental illness’ is actually a sometimes arbitrary classification that only describes a grouping of symptoms, not the person.” “It has taught me that some of the things we classify as illnesses may in fact be the result of cultural differences.” “They are still individuals with some common characteristics that make it hard for them to function ‘normally.’” Through their educational programs, these respondents learned to engage in some level of deconstruction and to question the classification system and cul tural constructs of what is “normal vs. “pathological.” They were able to question the legitimacy of deeming some individuals as beyond what is acceptable. Mental health professionals thus reported that educational experiences affected their attitudes along a continuum from having no influence, to increas ing basic knowledge, to awareness of the problems, to developing greater toler ance and empathy, to focusing more on the person and less on the label, to seeing the strengths and abilities, and finally to being able to question the entire concept of mental illness. Within the various sample responses are combinations of ideas (e.g., needs and tolerance) that demonstrate respondents moving from one level on the continuum to the next. This gives support for the idea of a continuum
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model of attitudes to mental illness that includes movement from one level to the next as well as the capacity of respondents to fall between two levels rather than a stage-model conceptualization of how attitudes toward mental illness develop. Influence o f Professional Experience on Attitudes Question 2 asked participants to consider how professional experience with people diagnosed with mental illness influenced their attitudes toward mental illness. This continuum of responses (table 2) ranged from the belief that their experience had a negative influence to levels very similar to those defined for the responses to question 1, but there were also noteworthy differences. Table 2. Continuum of the Influence of Professional Experience on Attitudes Negative
Increased
Problems &
Empathy &
Person-
Strengths-
Influence
Understanding
Needs
Tolerance
Centered
Based
“ 1am m o re critical
“ 1 acquired
“ 1 have co m e to
“ Increased
“ 1see th e m as
“ Initially in career
o f people w h o
a greater
see m ental illness
em pathy.”
hum an beings. It
focused m o re on
p ro p o rt (sic) to have
understanding
as a real problem ,
is d iffe re n t w hen
pathology, b u t ove r
m ental illness.”
o f people w ith
afflicting real
“ I’ve learned to be
yo u p u t a face and
th e years have
a m ental illness.
people, w ith real
patient w ith them .
em otions w ith a
refocused m o re on
N e v e r associated
consequences and
T h e re are a lo t o f
disorder, instead
peo p le ’s strengths.”
1did n o t w a n t to
m e ntally ill people
difficulties.”
w o r k exclusively
w ith a stigm a."
“ It taught m e th a t
w ith a m entally ill population.”
people o u t th e re
o f talking about
w ith m ental illness
h o w one m ight be
“ It has helped m e
“ H ave becom e
and th e y generally
according to th e
to develop a g re a te r
b o o k ."
“ It has helped m e
m o re aw are o f
can’t help th e ir
to understand
th e need fo r m o re
behavior even
it b e tte r in its
com prehensive
w h e n it’s
“ By p u ttin g a
m ental illnesses can
entirety. N o t just
m ental health
fru stra tin g o r
human face on it
in te ra ct w ith and
regarding w h a t 1
tre a tm e n t
insulting."
1n o w th in k o f a
co n trib u te to society
assumed."
facilities."
person instead o f
as a w h o le .”
understanding o f h o w people w ith
an illness.”
Negative influence. Several respondents stated clearly that they believed their professional interactions with people with mental illnesses had had a nega tive influence on their attitudes. For example: “I am more critical of people who proport [sic] to have mental illness.” “My experiences with the mental ill usually make me want to avoid conflict or prolonged contact with them.” “It taught me that I did not want to work exclusively with a mentally ill population.” “As a professional in child protective services it often makes me nervous regarding their ability to make sound choices for their children. Though overall my attitude is that with treatment and help most [can] function on a daily basis.”
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A ttitu d e s Toward M e n ta l Illness
These quotes make it clear that interactions and professional exposure led some respondents to think more negatively about individuals with mental illness, even to the point of intentionally choosing to avoid contact. The last quote, for example, demonstrates a negative view of someone with a mental illness (causing inability to parent); however, the respondent seemed to have some hope in the abilities of clients, given the proper treatment. Increased understanding. Here, again, the next level on the continuum was increased understanding: “I acquired a greater understanding of people with a mental illness. Never associated mental [sic] ill people with a stigma.” “It has helped me to understand it better in its entirety. Not just regarding what I assumed.” “I understand them better and am able to work well with them.” “Much more understanding of persons with mental illness.” Professional exposure made these respondents more understanding, which seemed to lend itself to more emotional integration than basic knowledge but had some aspects of being foundational. The first quote suggests that the partici pant understood those with mental illness but did not necessarily recognize that the person might feel stigmatized or have other difficulties as a result of a mental illness. More aware of problems and needs. As on the education and attitudes continuum, the next step on the professional experiences continuum is beyond mere understanding to a realization of the problems and struggles that those with mental illnesses face. For example: “I am more aware of their problems.” “I have come to see mental illness as a real problem, afflicting real people, with real consequences and difficulties.” “It has made me aware of how it can affect daily life and functioning in society, as well as how positive medication can be when used properly.” “I understand the need for community services to the mentally ill.” These participants felt that their professional exposure had made them aware of the problems people with mental illness can face. Some of the quotes speak to specific services needed (e.g., medications and community services); yet this group of respondents had not necessarily integrated their experiences to the point of changes in their affect and response. Increased empathy and tolerance. The respondents on the next point of the continuum demonstrated integration and a changed response due to professional experience with persons with mental illness. They felt that their professional exposure had increased their empathy and tolerance. For instance:
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“I’ve learned to be patient with them. There are a lot of people out there with mental illness and they generally can’t help their behavior, even when it’s frustrating or insulting.” “More open and less judgemental [sic].” “I have worked with some pretty severe clinical diagnoses and feel great empathy for these clients.” “Increased empathy.” “I believe that it has increased my compassion toward people diagnosed with mental illness.” While these respondents spoke of tolerance and empathy, there also is a sense of struggle in the statements, as demonstrated in the first two quotes, which both show hesitancy or inconsistency in their acceptance and attitudes. For example, the second quote describes becoming more open and less judgmental, which suggests recognition that the respondent is still not completely open or free of judgments. Many of these respondents seemed to focus more on empathy and less on the need for tolerance than those at the same point on the education continuum, who spoke more of tolerance and less of empathy. Person-centered. The next group of participants demonstrated a per son-centered approach to their professional work: “Pay attention to what is observed and experienced—not just to diagnosis provided before contact.” “To humanize mental health problems.” “I see them as human beings. It is different when you put a face and emo tions with a disorder, instead of talking about how one might be according to the book.” “By putting a human face on it I now think of a person instead of an illness.” “Puts a face to a diagnosis and challenges the stereotypes and myths.” These quotes demonstrate a movement away from merely understanding and being more tolerant to acceptance and a person-first mentality. For these respon dents their professional experiences had encouraged them to focus on the indi vidual, not just the diagnosis. Strengths-based. At the end of the professional experience continuum was a focus on seeing the strengths and abilities of a person with a mental illness: “It has provided me with the opportunity to develop an awareness of the strengths of people who have to live with the burden of mental illness and compassion for their struggle to live in dignity in spite of the stigma associ ated with their illness.” “Initially in career focused more on pathology, but over the years have refo cused more on people’s strengths.”
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A ttitu d e s Toward M e n ta l Illness
“It has helped me to develop a greater understanding of how people with mental illnesses can interact with and contribute to society as a whole.” “Awareness of the impact of professionals and non-professionals attitudes toward mental illness on those clients.” These participants spoke of the importance of finding worth, having dignity, and focusing on strengths. As a result of their professional experiences, they seemed to move away from a pathological orientation. The last quote also demonstrated recognition of how the attitude of professionals can affect clients. The continuum of the influence of professional experience on attitudes of participants demonstrated a variety of ways they were affected. While some respondents seemed clearly to be at a certain point on the continua other quotes suggested movement from one level to the next. Professionals reported their experience in the field as having a negative influence, to a basic increase in understanding, to an awareness of the problems, to developing greater empathy and tolerance, to focusing more on the person and less on the label, to seeing the strengths and abilities of their clients. While there were overlaps between the two continua, there were also note worthy differences. The first level of the educational experience continuum sug gests that education has no influence; the first level of the professional experience demonstrates a negative influence. On the education continuum, respondents who spoke of tolerance and empathy put more emphasis on tolerance; on the professional continuum respondents who spoke of empathy and tolerance put more emphasis on empathy. In addition, the educational experience continuum has one more level —those who engaged in a critical deconstruction of mental illness—while the experience continuum stops at the strengths-based point.
Other Influences on Attitudes Respondents were asked in a third open-ended question to share any other influences on attitudes toward mental illness. Because the responses were very brief, without much detail or explanation, they were not rich enough to require analysis. It is interesting, however, to note the variety of responses, such as none, religion, the media, family (both in terms of having a family member who was mentally ill or the impact of family attitudes toward mental illness), and personal interactions, such as friends and volunteer work. DISCUSSION When asked about how education affected attitudes toward mental illness, the responses of mental health professionals varied from no influence at all to critically deconstructing the notion of mental illness. Other influences were increased knowledge, more tolerance and empathy, looking at the person first, and considering client strengths. These findings appear to be similar to those of earlier studies (Bairan & Farnsworth, 1989; Penny et ah, 2001), indicating that education and training influence the attitudes of those preparing to go into the fields of counseling and mental health, but exactly how each impacts attitudes
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will vary with the individual. Regarding the influence of professional experience on attitudes toward mental illness, the continuum looked different from the influence of education on attitudes. At one end was a negative influence (com pared to no influence at the end of the education continuum). Participants in this category indicated that being in the mental health field made them more critical of those with mental illness or that they did not want to work exclusively with this population. This seems to suggest that professional experience might impact attitudes differently than education, since this category was only found when asking about experience. The other categories related to professional experience were similar to those found when asking about education—increased understanding, problems and needs, tolerance and empathy, person- centered, and strengths-based. Interestingly, the continuum for professional experience influences ended with strengths-based, whereas with education it was critical deconstruction. Perhaps the educational component challenges mental health professionals to think critically about the concept of mental illness altogether. Courses that provide information about psychopathology, diagnosis, or various marginalized populations may be influential as students learn about serious mental illness and think critically about the concept. Earlier authors discussed whether professional experience (Procter & Hafner, 1991; Wallach, 2004) or training and education (Bairan & Farnsworth, 1989; Penny et al., 2001) impacted attitudes, suggesting the efficacy of both. Through this research, it seems both might have an impact, although in our sample, how each impacted professionals varied. The similarities of the continua appear to outweigh the differences. This might be a product of research design, given that we asked both questions of the same participants, who by nature will answer consistently (Haddock & Zanna, 1998). Research on attitudes of mental health professionals in recent studies found mixed results. In a sample of counselors, social workers, and psychologists (Smith & Cashwell, 2010), mental health professionals had less negative attitudes than those not engaged in mental health care; however, there were differences in preference for social distance in mental health professionals according to pro fessional identity (Smith & Cashwell, 2011). The current study did not separate professionals by discipline but looked at mental health professionals as a group, and in general we did not uncover many negative attitudes, which is promising. The third research question, which explored other influences on attitudes toward mental illness, did not yield much data. Participants mentioned the following sources as impactful on attitudes: none, religion, the media, having a family member with a mental illness, family attitudes toward mental illness, and personal interactions such as friends and volunteer work. This suggests that these sources, while worth mentioning, might not have affected our participants as much as education and professional experience. Since this question was one of three, perhaps the lack of data was a result of survey fatigue; future research with a sole focus on this question might garner more responses. Educators and supervisors of mental health counselors may be interested in using the attitudes continuum in a classroom or supervision setting with trainees. Many counseling students will work with clients in severe distress (SAMHSA,
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A t t it u d e s T o w a rd M e n t a l Illn e s s
2014), so it is important to assess their attitudes toward mental illness. Just as counseling students reflect on stereotypes, attitudes, and biases with various types of clients in a course related to multiculturalism and diversity, reflecting on atti tudes toward clients with mental illness could help students to work with a wide variety of clients in a variety of settings. Uncovering negative attitudes, biases, and stereotypes toward mental illness could thus promote more positive attitudes toward adults with mental illness. As early authors (Cohen, 1990; Hromco et ah, 1995; Minkoff, 1987) suggested, there are many reasons why negative attitudes might develop; perhaps identifying these during a counselor training program would help to buffer against negativity. FUTURE DIRECTIONS AND LIMITATIONS
Perhaps the main outcomes from this study are the two informal continua of attitudes toward mental illness, which demonstrate promise for use with coun seling trainees in a degree program or for supervisors who work with counselors in the field. Assessing attitudes about mental illness is particularly important to ensure that negative attitudes, compassion fatigue, and burnout are not affect ing clinicians. This tool could be used to assess such attitudes. Since previous research (Smith & Cashwell, 2011) suggested the efficacy of clinical supervision on attitudes toward mental illness in those working in mental health fields, supervisors and clinicians might use a continuum to locate where they perceive themselves to be at any given point in their careers. While there is still much to learn about how counselors and other mental health professionals acquire negative attitudes, with this research we now know a bit more about how two variables of interest—education and professional expe rience-affect attitudes toward individuals with mental illness. Future research might explore the relationships between specific educational and professional experiences and whether mental health professionals see people with mental illness in a negative, neutral, or positive light. To the best of our knowledge, there has been no previous qualitative study exploring the impact of education and experience on attitudes toward mental illness in mental health professionals. Continued research exploring particular negative attitudes and their origins will add to the knowledge base. Future longitudinal research might also assess attitudes of counseling stu dents pre- and post-degree in order to see whether attitudes change at all as a result of education. It is possible that those who decide to enter mental health fields already have more positive attitudes toward mental illness than non-mental-health trainees or professionals. The first author made a similar suggestion (Smith & Cashwell, 2011) to assess attitudes to determine if training does in fact matter, or if personal qualities have more impact on attitudes toward men tal illness. Finally, studying various types of professionals through a qualitative research design will offer the field more information about how professional identity and orientation might affect development of attitudes toward mental illness. This study did not separate mental health professionals by discipline, so future inquiries into that might uncover interesting results. Other studies might
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focus solely on mental health trainees rather than professionals and trainees in order to increase within-group sample sizes. As with all research, tire current study has limitations that both contextu alize the findings and provide direction for future research. One limitation of this study was the participants who identified as in the other professional cate gory. Since the survey was electronic and had the capacity to reach unintended audiences, participants who identified as other could have been from a variety of professions. The question forced participants to choose between the four professions rather than allowing the participant to write in a particular profession if it was outside of counseling, psychology, or social work. It is also of note that one participant reported in a later open-ended question as having had both a psychology and a social work background, while another who self-classified as other also noted in response to an open-ended question a background in coun seling psychology. Thus participants who chose the “other” response could have been mental health professionals who were merely unsure how to respond or who responded in error. Similarly, for those who indicated that education had “no impact” on attitudes toward mental illness, the wording of the question did not allow for explanation of why respondents did not believe themselves to be affected. Future researchers might consider adding followup questions such as, “if yes, how so?” and “if no, why not?” to capture these perceptions. Finally, only the member of the research team who had knowledge of qualitative analysis analyzed and themed the data, which gave no opportunity for triangulation through multiple analysts (Patton, 2002). The researcher who con ducted the qualitative analysis has a background in human services with degrees in family science, social work, and human development, which may have affected interpretation of the data and design of the continua. While qualitative research typically does not attempt to exclude bias, there is a need for transparency so that the reader can better interpret the findings (Lincoln & Guba, 1985). In addition, because data were collected electronically, we were unable to conduct member checks. While according to Lincoln and Guba (1985) both of these factors limit the credibility of the analysis, the team did engage in other forms of credibili ty-enhancing measures, such as peer scrutiny of the project through colleague feedback, examination of previous research findings, and inclusion of a qualified and experienced investigator (Shenton, 2004). CONCLUSION
It is worth noting that the attitudes toward mental illness of mental health trainees and professionals can be understood as falling on a continuum. Although education and professional experience had similar impacts on partici pants, noteworthy differences in attitudes were associated with each. Clearly, the investigation of attitudes of mental health professionals toward mental illness is far from complete.
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A t t it u d e s T o w a rd M e n t a l Illn e s s
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