research on stigma related to mental disorders in finland ... · research on stigma related to...

Stigma 89

Wahlbeck et al.Psychiatria Fennica 2011;42:87-109

Research on stigma related tomental disorders in Finland

Research on stigma related to mental disorders inFinland: a systematic literature review

Kristian Wahlbeck, Esa Aromaa

Abstract

A systematic literature review was performed to map Finnish research on stigma relatedto mental disorders. Searches of nine electronic databases resulted in a wide varietyof research, from psycho-historical studies to ongoing population surveys ofpopulation attitudes.

A set of studies have measured experience of stigma and discrimination among peoplewith mental disorders. Qualitative research among service users highlights theimportant role that mental health professionals and their classification systems havein creating identities, feelings of otherness and even self-stigmatisation amongservice users. Quantitative data indicate that more about one in three persons with amental disorder experience stigma due to their disorder, and international comparisonsindicate that personal stigma of people with schizophrenia is at least not less commonin Finland than in other developed countries. Fortunately, institutionaliseddiscrimination in public services seems to be uncommon in Finland.

Another extensive set of studies, ranging over more than 50 years, have measuredattitudes towards people with mental disorders among the general population. Attitudesof older people have been more negative than attitudes of younger people, which hasbeen interpreted as a generational effect. In earlier studies women had more negativeattitudes, but nowadays men have more negative attitudes. Education has consistentlybeen linked to more favourable attitudes. The overall picture given by a repeatedpopulation survey, implemented since 2005, indicates that in this short perspectivegeneral population attitudes in Finland are rather stable, but there are some signs ofa positive development. In the recent years, social acceptance seems to have increasedsomewhat, and more people tend to believe that you can live a full life despite havinga mental disorder. A European general population opinion poll and results from astudent survey indicate that attitudes in Finland may be less stigmatising than inmany other countries.

90 Stigma



A third line of research has analysed attitudes towards people with mental disordersamong special groups of interest, such as students or health care staff. A qualitativestudy of students’ attitudes indicates that it may be advisable to avoid clinicalcategories and language and, instead, to use descriptions in terms of concreteproblems and behaviours to describe mental disorders. Problems of mental health shouldbe portrayed as common, reversible and located within the variation of normality.Attitudes of medical students and health care staff have in general been found to bepositive, but a study shows rather surprisingly that access to psychiatricconsultation among general health care staff was associated with less favourableattitudes.

Taken together, research and opinion polls provide a multifaceted picture of mentalhealth stigma in the Finnish society. Stigmatising attitudes are prevalent, but thesituation may be better in Finland than in many of the other European countries.Younger generations tend to have more favourable attitudes. Interestingly, some of theresearch results point towards an aggravating role of mental health professionals.Diagnostic procedures and clinical language seem to increase stigma. There are groundsfor a critical and open discussion about the stigmatising effect of psychiatricdiagnoses, which are increasingly used also outside of psychiatric services.

Introduction

People with mental health problems have to cope with a double problem: first, thesymptoms of the mental health problem, and second, with the stigma of having a mentalhealth problem. (1) Stigma is a core concept in understanding the wider interactionbetween people and mental health services.

Stigma has an in-depth influence on the status of mental health services, theirresource allocation and attractiveness to work force. It constitutes a barrier thatgreatly contributes to low help-seeking among people with mental health problems, andaffects provision of services negatively. Mental health professionals seem to sharestigmatising attitudes with the rest of the population. (2)

Stigma and stereotypes form the public attitude towards people with mental healthproblems and psychiatry. Stigma related to mental health problems can be divided into1) perceived public stigma, i.e. stereotype awareness, and 2) personal stigma, i.e.

Stigma 91



stereotype agreement (people’s personal beliefs about mental illness) and 3)self-stigma (people’s view of their own mental health problem). (1) Discrimination ofpeople with mental disorders is a common manifestation of stigma. (3)

Reduction of stigma is a core aim of contemporary mental health policies, in Finland(4) as well as across Europe (5). It requires solid evidence on the occurrence,distribution, content and trends of stigma related to mental health problems, as wellevidence on effective interventions to reduce stigma. Stigma is contextual, and itsoccurrence and forms may vary between cultures. Findings from studies abroad are notnecessarily valid for Finland. We aimed at mapping Finnish research on stigma relatedto mental health problems, to describe the evidence base for developing culturallysensitive anti-stigma initiatives for Finland.

Method

Data sources

The authors searched nine relevant databases in March 2011. Three of the searcheddatabases contain publications from Finland only (ARTO, FENNICA, Medic) and fourdatabases have an international coverage but are probably biased towards publicationsin English (Cinahl, Medline, PsycInfo, SocIndex). In addition, two library collectiondatabases were searched (Linda, THLlib). For the international reader, the Finnishlanguage databases are described in detail:

ARTO is a reference database of Finnish articles, consisting of articles from approx.600 Finnish journals from 1990 onwards. ARTO contains journal article references andoccasionally references to articles in monographs.

FENNICA (the Finnish National Bibliography) contains information about monographs,serials, maps, audiovisual materials and electronic publications printed or producedin Finland. FENNICA also includes materials published outside of Finland that relateto Finland or are written by a Finnish author.

Medic is a Finnish health science database established in 1978. The database isproduced by Helsinki University Library, The Meilahti Campus Library Terkko. Mediccontains references to Finnish medical and health science literature: articles, books,dissertations and reports published in Finland and not included in internationaldatabases.

92 Stigma



Linda is a joint catalogue of Finnish university libraries, which contains the FinnishNational Bibliography as well as references to the books, journals, publicationseries, maps, visual materials, archives and electronic materials in the databases ofuniversity libraries, the Library of Parliament, the National Repository Library andthe Library of Statistics.

THLlib is the library catalogue of the National Institute for Health and Welfare,Finland

Search terms

The search terms were as follows:

Fennica: (mielenterv? OR psyyk? OR psyk? OR mental?)[in Word Search/Free text/Keyword] AND (syrji? OR eriarv? OR diskri? OR discri? OR stigma?)

Arto: (mielenterv? psyyk? psyk? mental?)[ in Any Word ]AND (syrji? ennakkoluul? eriarv?diskri? discri? stigma?)

Medic: (mielenterv*, mental*, psyk*, psyyk*) AND (asenteet*, syrji*, stigma*, eriarv*,ennakkoluul*, leima*, prejudice*, diskrim*, discrim*)

Linda: (mielenterv? psyyk? psyk? mental?)[ in Any Word ]AND (syrji? ennakkoluul?eriarv? diskri? discri? stigma?)

THLlib: (mielenterv* tai psyk* tai psyyk* tai masen*) AND (syrji* tai leima taidiskrim* tai eriarvoi* tai ennakkoluul*)

Cinahl: (mental disorder* or mental illness* or psychiatric patients or depression ormental health services or mentally ill or mood disorders) AND (attitude to mentalillness or social worker attitudes or stigma* or stereotyping or discrimination) AND(Finland or Finnish or nordic)

Stigma 93



Medline:

1. Finland.mp. 2. (finland or finnish).ti,ab. 3. exp Mental Disorders/ 4. stereotyping/ or stereotyped behavior/ 5. exp "Discrimination (Psychology)"/ 6. Prejudice/ or stigma.mp. 7. exp Depressive Disorder, Major/ or exp Mentally Ill Persons/ 8. exp Mood Disorders/ 9. 1 or 210. 3 or 7 or 811. 4 or 5 or 612. 9 and 10 and 11

Psycinfo:

1. exp mental disorders/ 2. exp major depression/ 3. exp Adjustment Disorders/ 4. exp Stigma/ 5. stereotyped attitudes/ or discrimination/ or prejudice/ or social discrimination/ 6. Finland.mp. 7. (finland or finnish).ti,ab. 8. or/1-3 9. or/4-510. or/6-711. 8 and 9 and 10

Socindex: (mental disorder* or mental illness* or mentally ill* or depressi* orpychiatric disorder* or mental health problem* or psychiatric patients or mooddisorder*) AND (attitude to mental* or social worker attitudes or stigma* orstereotyp* or discrim* or prejud* or negative attitude* or exclusion) AND (Finland orfinnish or Nordic)

94 Stigma



Literature analysis

Psychohistorical studies

Finnish research on stigma and discrimination in relation to mental disorders includeshistorical overviews and analyses. The historian Jari Eilola has published widely onintolerance and discrimination in a historical context, focusing on beliefs ofwitchcraft and social stigmatisation in the 17th century. (6) Toivo Nygård has analysedthe situation of marginalised groups in Finland in the 19th and early 20th century. (7)He writes about the function of hospital institution for mentally ill and also aboutdifferent forms of remedies on those days.

Service users’ experience of stigma

a. Qualitative studies

One of the main research areas in Finland has been the subjective experience of stigmaand discrimination. The dissertation of Anna Kulmala is following the researchtradition of social constructivism and is based on life course narratives of peoplewith mental disorders. (8) The first data set consists of texts submitted to thewriting contest "When Wings Carry" organised by the Finnish Mental Health Association.The second data set consists of personal interviews with 14 men living in a shelterfor homeless people. The interviews show that the construction of own identity of theinterviewees was strongly permeated by professional definitions and conceptsconcerning the interviewees as service users. The concepts and definitions used byprofessional staff about their clients had been transposed to the self-images of therespondents. The interviewees conveyed a situation in which they were objects who hadbeen defined based on their problems, and this led them to narratives aboutmarginalisation, otherness and outsiderness. Stigmatisation by the professional staffled to a negative social identity, a sense of otherness and self-stigmatisation.Categorisation by staff was followed by self-classification by the clients. A mainconclusion of the study is the need to increase awareness of the impact ofclassification and categorisation of clients, especially as the categories anddiagnoses used in work with vulnerable often are negative and problem-oriented.Thinking of the persons categorised, the phenomenon of categorisation is particularlyhurtful if the categories are negative, like they tend to be in mental health care.The results of the research project by Anna Kulmala have been further explored in five

Stigma 95



articles. (9-13) This work highlights the important role that mental healthprofessionals and their classification systems have in creating identities, feelingsof otherness and even self-stigmatisation among service users.

b. Quantitative studies

The user-led Sateenkaaritalo (Rainbow House) in Vaasa, Finland, took part in theinternational INDIGO study on perceived stigma and discrimination in people withschizophrenia. (3) A structured interview using the Discrimination and Stigma Scale(DISC), which assesses experiences of being treated (dis)advantageously for severallive domains, was performed with people diagnosed with schizophrenia. The resultsconfirmed that people with severe mental disorders are confronted with stigmatisationand discrimination in several domains of life.

The major source of discrimination were personal relationships - two of threerespondents reported having been discriminated in making or keeping friends and almostone in two had experienced being treated differently by their family. In Finland,institutionalised discrimination was seldom observed. On the other hand, only a fewrespondents reported that having a mental disorder diagnosis had provided someadvantage to them.

Discrimination leads to self-discrimination, and a majority of the responders hadstopped themselves from applying for a job or education due to their diagnosis. Mostof the responders perceived a need to conceal or hide their mental illness diagnosisfrom other people.

International comparisons are bias-prone and should be interpreted with caution, butit should be noted that among people with schizophrenia, participants in only threecountries of the 27 countries participating in the INDIGO study, experienced morenegative discrimination than the respondents in Finland.

Compared to people with schizophrenia in other participating countries, peopleresiding in Finland had two times more often experienced threats to their personalsecurity. This can partly be explained by the socio-cultural context in Finland, whereviolence and violent crimes are more common than in many other countries.

Outside of the peer reviewed literature, the opinion poll "Mielenterveysbarometri"(Mental Health Barometer), initiated by the user organisation Finnish CentralAssociation for Mental Health, has since 2005 measured experience of stigma among a

96 Stigma



random sample of their membership. (14-19) The service user sample size has variedbetween 200 and 300 people. Over the years, about one in three of the responders havereported being subject to stigma due to their disorder.

Responders were also asked to estimate the position of people with mental disorders inthe Finnish society. On a scale from 1 (totally excluded) to 10 (full members ofsociety), the mean score in the years 2005-2010 has ranged between 5,60 and 5,99.

Occurrence and measurement of stigmatisation

a. General population surveys

The first published study reporting attitudes towards mental illness of the generalpopulation is from 1973. (20) This study was performed in two rural communities inFinland, one of them mainly agricultural and the other industrialized. The sampleconsisted of 200 individuals, the response rate was 94 %, and personal interviews wereperformed using a Likert-type attitude scale created for the purpose. Each item wasscored from 1 to 5, positive attitudes were scored higher. The main hypothesis of thestudy, introduced on both sociological and epidemiological grounds, was that attitudesin the agricultural community would be more negative than in the industrializedcommunity, but the results failed to confirm the hypothesis. Men’s attitudes werefound to be more positive than those of women in both communities. A positiveassociation between attitudes and educational level was observed in both communities.

Publication of the abovementioned small scale study was followed by the breakthroughepidemiological UKKI study. The UKKI study was performed in a random population of1,000 subjects aged 15-64 living in southern Finland (Uusikaupunki) and in northernFinland (Kemijärvi) in the end of the 1960s. (21) The stratified sampling included 600people living in urban areas and 400 people living in rural areas. Attitudes weremeasured using a Likert-type attitude scale consisting of 20 items, identical to theinstrument used in the previous smaller study. (20) Altogether 941 people wereinterviewed in person (response rate 94 %).

In the UKKI study, attitudes were highly correlated with age, as older people had morenegative attitudes. Women expressed more negative attitudes towards mental disordersthan men. Education and socio-economic status group were distinctly correlated: thehigher the socio-economic status or the better education, the more positive theattitudes. In rural areas, attitudes tended to be more negative than among urbanresidents. In a multivariable analysis, age and educational level seemed to be themost important predictors of attitudes.

Stigma 97



Subjects suffering from psychological disturbances manifested at psychiatricinterviews and by other means, and who were assessed as being in need of psychiatrictreatment, displayed more negative attitudes towards mental illness than those whowere mentally healthy. Particularly negative attitudes were observed in subjectssuffering from neuroses. On the other hand it could be established that positiveattitudes towards mental illness correlated with subjective need of treatment andwillingness to utilize psychiatric treatment. (22)

A third study (23) of general population attitudes towards people with mental disorderswas made in the beginning of 1990s using the same instrument as in the previousstudies. 514 persons from different parts of Finland participated. The attitudes weregenerally positive, although, as in the previous studies, the attitudes of those olderand less educated were more negative compared with the other groups. This result wasinterpreted as a generational effect, which will vanish as the educational level ofthe population increases. The questionnaire also included questions about theattitudes and behaviour of ’other people’. The attitudes of ’other people’ werethought to be very negative compared with one’s own attitudes.

Recent methodological studies have analysed new Finnish instruments aiming atmeasuring public knowledge and attitudes as well as stigma. These studies originate inthe repeated general population survey which has been implemented in western Finlandsince 2005 to randomly selected samples of 10,000 persons aged 15-80 years. (24;25) Abasic explorative analysis showed that a clear majority (86%) of the Finnishpopulation believed that depression is a real disorder. (26) A majority (60%) ofrespondents shared the idea that depression can be considered as a shameful andstigmatizing disease and as many believed that depressed persons should pullthemselves together. A lot of negative consequences were connected with mental illnessin social relationships, health care system and working environment. It seemed to bedifficult for people to figure out the positive and adverse effects of medicine care.Many also believed that one may not get proper mental health services on primaryhealth care level.

A principal component analysis of the instrument identified four main attitudinalcomponents: (1) depression is a matter of will, (2) mental problems have negativeconsequences, (3) one should be careful with antidepressants and (4) you never recoverfrom mental problems. (27) Especially the first component which measures the personalbelief that people with depression are responsible for their illness and theirrecovery seemed to be valid enough to be used as a scale in future analysis.

98 Stigma



The same data were used to examine how well a combination of variables predictsstigmatizing attitudes and discrimination in a general population. (28) Attitudes weremeasured using a scale consisting of negative stereotypes about people with depressionand stereotypical beliefs connected with mental problems, while discrimination wasmeasured by a social distance scale. Predictors included demographic variables, mentalhealth resources, familiarity with mental problems and stereotypical beliefs. Socialdiscrimination was significantly associated with respondents’ age, gender, language,sense of mastery, depression, stereotypical beliefs and familiarity with mentalproblems. The results suggested that among men, older people and those withoutfamiliarity with mental problems the need for anti-stigma intervention is highest. Theconnection between sense of mastery and discrimination suggested that when planninginterventions to counter negative stereotypes, one potential target group could bethose with a low sense of life control and poor social networks.

A further study on the same data set analysed the links between attitudes andhelp-seeking among people with depression. (29) On the social discrimination scale,people with depression showed more tolerance towards people with mental problems. Theyalso carried more positive views about antidepressants. Among those with depression,users of mental health services, as compared to non-users, carried less desire forsocial distance to people with mental health problems and more positive views aboutthe effects of antidepressants. More severe depression predicted more active use ofservices. The authors conclude that although less favourable attitudes towards peoplewith mental health problems can reduce the use of mental health services, this doesnot necessarily prevent professional service use if depression is serious and viewsabout antidepressant medication are realistic.

Finland participated in the Special Eurobarometer wave 64.4 on mental wellbeing. (30)The Eurobarometer data was collected in December 2005 and January 2006 by telephoneinterviews of a general population sample. Participants had to be at least 15 years ofage. One section of the survey dealt with attitudes towards people with mentaldisorders. Participants were presented with a set of statements regarding "people withpsychological or emotional health problems". Overall, the survey found that Europeanshave a reasonable tolerant view of people with mental disorders. In general, opinionswere more positive among residents in the northern and western Europe, including theScandinavian countries, the Netherlands, UK, Ireland and Spain. An exception from thegeographical pattern was perceived dangerousness, where some of these countries(Sweden and UK) scored higher than the EU average. In the EU overall, men, elderly,and those with low education tended to have more negative attitudes. Europeans who hadreceived psychological treatment tended to have marginally less negative attitudes.

Stigma 99



The results from Finland indicated less stigmatizing attitudes as compared to theaverage general opinion among Europeans. 55% of Finns agreed that people withpsychological or emotional health problems are unpredictable. Among the EU population,the corresponding figure was 63%. 31% of Finns agreed that people with psychologicalor emotional health problems constitute a danger to others, and only 10% agreed thatpeople with psychological or emotional health problems never recover. Thecorresponding EU-wide figures were 37% and 21%, respectively.

b. University students

Hannu Räty has aimed at an qualitative-descriptive analysis of beliefs concerningmental illness and their attitudinal organization (31). His study was based oninterviews of a group of 30 university students, mostly female, average age 21,supposed to represent people with liberal and educated stands towards variousminorities.

Pessimistic beliefs could be grouped into three assumptions, which portrayed mentalillness as a basically unknown, incurable and dangerous condition. Mental illness wasseen as a category of sinister behaviour obeying some unknown and irresistible laws.In contrast a positive approach based on the "criticism of civilization" also existed:mental illness has a symbolic role in representing the victims of society and itsdisharmony. There was a general tendency to avoid explicit psychiatric attributionsbecause their use was regarded as "negative labelling". Two clusters of orientationcould be extracted. The first one - a notion of object responsibility - was typical ofthe pessimistic attitude. The second cluster - a notion of co-responsibility - wastypical of the optimistic attitude. Attitude-related differences were also seen in thejudgment of deviant behaviour: a subject with a pessimistic attitude attributed morepathology to behaviour descriptions and evaluated them more negatively than one withan optimistic attitude.

There appeared to be two quite independent determinants of the mental illnessattitude: one’s behavioural history and one’s values. A subject’s own behaviouralhistory - or more precisely, her retrospective account of it - correlated stronglywith her attitude: the more negative the experience concerning the mentally ill, themore rejective the attitude. Expressed values also correlated with attitudes: a personwith an optimistic view emphasized democracy, morality and "soft values" such as ahumane, anti-bureaucratic and ecologically-sound society. Based on a detailed analysis

100 Stigma



of accounts the following features appeared typical of a consistently positiveattitude: (a) a tendency to minimize and counter-balance the negative characteristicsof mental illness, (b) a questioning of taken-for-granted thinking, (c) a tendency toconsider mental illness rather a social problem than a form of pathology, and (d)symbolic "we-categorization", i.e. the mentally ill person is a victim of unjustconditions and deserves our sympathy.

In his discussion author claims that there is no easy way of changing people’sconception of mental illness; it is neither simple "like any other illness" nor "justa myth". He also optimistically claims that there is probably no any activediscrimination against mental patients. It seems likely that people are willing tobehave in more a positive way if they know how. It seems advisable to avoid clinicalcategories and language and, instead, to use descriptions in terms of concreteproblems and behaviours. Problems of mental health should be portrayed as common,reversible and located within the variation of normality. The finding that thepessimistic view is tied to the value of self-reliance is problematic, since it mayprevent a person from seeking help for his difficulties.

c. Mental health nurses

A international questionnaire survey analysed attitudes of 810 registered nursesworking in 72 inpatient wards and units and five community facilities in Finland,Lithuania, Ireland, Italy and Portugal. (32) The data were collected using TheCommunity Attitudes towards the Mentally Ill (CAMI) scale, which is a 40-itemself-report questionnaire. (33)

Nurses’ attitudes were mainly positive. Attitudes differed across countries, withPortuguese nurses’ attitudes being significantly more positive and Lithuanian nurses’attitudes being significantly more negative than others’. Positive attitudes wereassociated with being female and having a senior position.

d. Emergency room staff

A series of studies examined attitudes of the emergency room (ER) staff towardssuicide attempters. The first study explained the attitudes of a general hospitalemergency personnel (N=184) towards patients who had attempted suicide by comparingthe attitudes of the staff in the emergency room (N=64), emergency ward (N=47) andintensive care unit (N=73). (34) The attitudes were most negative among emergency roomstaff, where all attempters are first treated. The intensive care staff, who treatsthe most serious cases, evidenced the most positive attitudes.

Stigma 101



In another study the aim was to compare the attitudes towards patients who haveattempted suicide of emergency room staff between two general hospitals, one withpsychiatric consultation available and the other without. The Understanding SuicidalPatients (USP) Questionnaire was given to all the staff in the emergency rooms ofthese two hospitals (N=115). Female gender, older age and working in hospital withoutroutine psychiatric consultation were associated with more positive attitudes.Surprisingly, working in hospital with routine psychiatric consultation was associatedwith more negative attitudes (35).

Next study examined the association between emergency room staff members’psychological distress and the attitudes towards suicide attempters. The USPquestionnaire and the 12-item version of General Health Questionnaire (GHQ-12) weregiven to all staff in the emergency rooms of a general hospital and a psychiatrichospital (N=151). There was a general tendency among emergency room staff to viewattempted suicide patients positively and sympathetically. However, there were cleardifferences in staff attitudes between the two hospitals: those working in the generalhospital expressed more negative attitudes than those in the psychiatric hospital. Noevidence emerged of association between staff members’ own psychological distress andnegative attitudes towards suicide attempters (36).

In the fourth study the aim was to compare the attitudes of emergency room staff in ageneral hospital towards suicide attempters before and after establishment of apsychiatric consultation service. Attitudes were measured with the USP questionnaire(N=100). The result was that general understanding and willingness to nurse patientswho attempted suicide did not increase during the first year of the consultationimplementation, but in general, the emergency room staff was content with theopportunity for psychiatric consultation (37).

Taken together, the studies indicate that possibilities for psychiatric consultationsdo not alter attitudes of ER staff favourably.

e. Pharmacy students

A recent international comparison study analysed mental health stigma and itsdeterminants among pharmacy students in Finland, Australia, Belgium, Estonia, Indiaand Latvia. (38) In this study, data were collected as part of the InternationalPharmacy Students Health Survey, a census survey of third-year pharmacy students

102 Stigma



studying at eight universities in six countries. Response rates varied by countrybetween 70 and 98 %. Respondents (N=642) indicated how strongly they endorsed sixstigmatising statements about patients with schizophrenia and severe depression andcompleted a seven-item social distance scale.

The results (Table 1) indicate that among young people, some stigmatising beliefs areless common in Finland than in the comparison countries. In Finland 8% (95% CI 3-12%)of pharmacy students agreed that a patient with severe depression is a danger toothers, in the other participating countries the corresponding percentage ranged from13% in Australia to 39% in India. Of the Finnish students 24% agreed that people withsevere depression are unpredictable. In the other countries, the share of agreeingstudents varied from 36% in Australia to 61% in India. On the other hand, the largestshare (44%) of students in Finland agreed that people with severe depression havethemselves to blame, indicating differing views on the determinants of depressionacross countries.

Table 1. Percentage of respondents who strongly agreed or agreed in relation to a patient with severe depression (95% CI)(38).

Estonia & India Belgium Australia Finland Latvia (N=106) (N=102) (N=241) (N=130) (N=70)

A danger to others 37.7 39.0 23.8 13.3 7.7 (26.3-49.1) (29.7-48.3) (15.5-32.1) (9-17.6) (3.1-12.3)

Are unpredictable 57.1 60.6 59.8 36.4 23.8 (45.5-68.7) (51.2-70.0) (50.3-69.3) (30.3-42.5) (16.5-31.1)

Are difficult 72.9 45.2 42.2 36.4 37.7 to talk to (62.5-83.3) (35.7-54.7) (32.6-51.8) (30.3-42.5) (29.4-46.0)

Have themselves to 26.1 31.1 9.8 11.7 43.8 blame (15.7-36.5) (22.3-39.9) (4.0-15.6) (7.6-15.8) (35.3-52.3)

Not improve without 72.9 55.8 58.4 39.2 86.7 treatment (62.5-83.3) (46.3-65.3) (48.8-68.0) (33-45.4) (80.8-92.6)

Will never recover 21.4 2.8 10.8 5.0 14.6 (11.8-31.0) (0.0-6.0) (4.8-16.8) (2.2-7.8) (8.5-20.7)

Stigma 103



A further analysis of the survey indicated that there were no significant differencesin social distance to people with mental disorders as expressed by the students in theparticipating countries. (39) In Finland, social distance among pharmacy students waslinked to perceived dangerousness.

Much contemporary research has indicated that women tend to have more favourableattitudes towards people with mental disorders, and thus comparability of results ishampered by differing gender distributions in the student samples. The Finnish samplehad the highest share of female students, and no standardisation for sex was performedby the authors. Any conclusions are thus preliminary, but this study hints thatstigmatising beliefs regarding depression may be more common in low and middle incomecountries than in high income countries like Finland.

Stigmatising attitudes towards people with schizophrenia and severe depression werecommon among pharmacy students in all countries. The authors conclude that new modelsof pharmacy education are required to address the attitudes and misconceptions amongpharmacy students.

f. Medical students

In this prospective study of attitudes of medical students data were collected twiceduring their studies and once after graduation. (40) Respondents’ own explicitattitudes and their perception of others’ attitudes towards psychiatric patients,disorders and health care were evaluated by a questionnaire. Throughout the follow-upperiod the medical students and new doctors had positive attitudes towards psychiatricissues. There were, however, significant negative and positive attitude changes inmany individual statements, mainly after the fourth year of study. Most of the changescould be explained with the increase of knowledge and the experience of real patients,but some negative changes indicated increasing cynicism. The ratings of other people’ssupposed attitudes changed significantly in a positive direction, mostly between thefirst and fourth year of study. Interpreting respondents’ perception of others’attitudes as a projection of respondents’ own attitudes, this study suggests that theeducation had changed unconscious attitudes of medical students in a positivedirection.

104 Stigma



Non peer-reviewed literature

One sign of the heightened interest is an increasing number of master theses on thesubject; many of them dealing with stigma of people with schizophrenia (41-43) or theself-concept of stigma (44-46). Other have explored attitudes of nurses (47) orexperiences of non-psychotic patients with depression during their firsthospitalisation for a depressive disorder (48).

Of special interest is the yearly opinion poll and attitude measurement"Mielenterveysbarometri" [Mental Health Barometer] initiated by the user organisationFinnish Central Association for Mental Health. The poll has been performed every yearsince 2005. (14-19) The responder sample has consisted of general population (aged15-70 years), mental health service users and their families, and since 2006 alsopsychiatrists and psychologists.

In 2005, a population sample of 639 persons were surveyed. Results indicated that 8%of the population agreed that a person with mental health problems should blamehimself. 65% believed that full recovery is possible after a mental disorder. Almostone in three (30 %) would not like a person with a mental disorder as a neighbour.According to the survey, only drug addicts, alcoholics and criminals were less popularas potential neighbours than people with mental disorders. On the other hand, 52% saidthat more social and health care resources should be devoted to people with mentaldisorders. On a scale from 0 to 10 (0 designates total exclusion and 10 designatesfull inclusion), the position of people with mental disorders in the Finnish societywas estimated to be on average 5.47.

In 2006, the general population sample was almost 1300 people. The attitudes of thegeneral population were similar to the previous year: 32% would not like to have aperson with a mental disorder as a neighbour, 9% thought that people with mentaldisorders have to blame themselves, and 58% would like to invest more in health andsocial services for people with mental disorders. The position of people with mentaldisorders in the Finnish society was estimated to be on average 5.42.

In 2007, the general population sample consisted of almost 1300 people. Comparing withthe two previous surveys, a trend towards slight improvement in attitudes begins toappear: 29 % would not like to have a person with a mental disorder as a neighbour and9 % thought that people with mental disorders have to blame themselves. On a scalefrom 0 to 10, the position of people with mental disorders in the Finnish society wasestimated to be on average 5.24.

Stigma 105



In 2008, the general population sample consisted of 628 respondents. The positivetrend was maintained, and 28 % of respondents reported that they would not like tohave a person with a mental disorder as a neighbour and 8% thought that people withmental disorders have to blame themselves. 61 % would like to invest more in healthand social services for people with mental disorders. The position of people withmental disorders in the Finnish society was estimated to be on average 5.24.

In 2009, the representative population sample was 611 respondents. The positive trendwas strengthened. 27 % of respondents reported that they would not like to have aperson with a mental disorder as a neighbour and 8% thought that people with mentaldisorders have to blame themselves. 56 % would like to invest more in health andsocial services for people with mental disorders. The position of people with mentaldisorders in the Finnish society was estimated to be on average 5.24.

In 2010, the population sample was 532 respondents. The attitudes seem to remainstable: 27 % would not like to have a person with a mental disorder as neighbour and 9% thought that people with mental disorders have to blame themselves. Fewer thanbefore, i.e. 51 %, would increase investments in health and social care for peoplewith mental disorders, which may reflect an overall movement away from egalitarianattitudes in Finland. The awareness of the social exclusion of people with mentaldisorders in the Finnish society seems to continue to increase. In 2010, the averagescore given was 5.17.

The overall picture given by the repeated surveys indicates that in Finland generalpopulation attitudes have been rather stable, but there are some signs of a positivedevelopment since 2005. The social acceptance seems to have increased somewhat. Italso seems that respondents are more aware of the stigmatisation of people with mentaldisorders, as the estimate of the social position of people with mental disordersseems to have deteriorated over time. Across the years since 2005, men have evidencedless positive attitudes towards people with mental disorders than Finnish women.

106 Stigma



Discussion

Our review highlights that in Finland there is a long tradition in measuring attitudestowards mental illness and patients in a general population. The literature reviewindicates that stigma of mental disorders occurred as an issue in the late 1960s, whenquestions about attitudes towards mental disorders were included in the UKKIepidemiological study. The issue was further raised in the 1970s in a report from thenational Social Security Institution (49). In those early works the researchersdeveloped their own attitude scale and interpreted results to show quite positiveattitudes (20;49). They also optimistically thought that new generations with bettereducation and knowledge about mental problems will carry more positive attitudes. Afollow-up study showed that the direction of change was although only slightlypositive between 1970-1985. (23) It is interesting to note that already on those daysthere was an interest about the effects of attitudes on utilization of psychiatrictreatment. (22) The researchers were also well aware of the problems connected withattitude surveys and critically reminded that attitudes do not predict behaviourwell. (23)

Although the history of stigma research is 50 years old in Finland it has started toflourish so late as in the late 1990s and in the 20th century. There seems to havebeen little research activities in this field in the 1980s and 1990s. Scarcity ofresearch is indicated by a Finnish review on stigma and diseases, published in 2001,which did not include a single reference to stigma research conducted in Finland. (50)However, international activities such as the Zero stigma project led by EuropeanFederation of Associations of Families of People with Mental Illness (EUFAMI) (51), ledto an increase in interest and awareness about stigma related to mental disorders andmay have contributed to the recent revisits of Finnish researchers to the field ofmental health stigma research. In addition to the scientific literature reviewedabove, many opinion papers and papers targeting the general audience have beenpublished on the topic of mental health stigma during the last ten years (e.g.(52;53)).

Lately, the Mental Health Barometer Surveys have highlighted discriminatory attitudesin the general population and stigma perceived by the users (14-19). The overallpicture indicates that in this short time perspective general population attitudes inFinland are rather stable, but there are some signs of a positive development. In therecent years, social acceptance seems to have increased somewhat, and more people tendto believe that you can live a full life despite having a mental disorder.

Stigma 107



Attitudes of older people have been more negative than attitudes of younger people,which has been interpreted as a generational effect. In earlier studies women had morenegative attitudes, but nowadays men have more negative attitudes. Education hasconsistently been linked to more favourable attitudes.

The voice of service users was at first time listened as late as 1996 in the Finnishresearch, in the form of a thesis on experiences of first-time hospitalised patientsfrom a psychiatric ward (46). After that, in the 21th century a series of importantqualitative research highlights the important role that mental health professionalsand their classification systems have in creating identities, feelings of othernessand even self-stigmatization among service users (8;12;13). Quantitative data fromIndigo study showed that people with serious mental disorders confronted a lot ofstigma and discrimination especially in relationships with friends and relatives butvery little on institutional level (3).

The studies concentrated on stigma among special student and professional groups inhealth care have been a third line in the Finnish stigma research. Attitudes ofmedical students and health care staff have in general been found to be positive, butone study shows rather surprisingly that access to psychiatric consultation amonggeneral health care staff was associated with less favourable attitudes (37). Onepossible explanation may come from another qualitative study of university students’attitudes where the author advices to avoid clinical categories and language and,instead, to use descriptions in terms of concrete problems and behaviours to describemental disorders (31). It might be that mental health professionals with bestintentions use stigmatizing language in consultation.

One important body of research is missing in Finnish stigma research; namelyexperimental research, i.e. evaluations of anti-stigma interventions. We found notrial reports. Some researchers have made suggestions about possible target groups forinterventions, such as people with no familiarity with mental disorders or those withlow sense of control and poor social networks (28), but actual intervention research islacking. This may be due to early researchers’ disbelief in simple educationinterventions. More extensive information is recommended to be given in a formenabling its gradual integration with the personality and so that also unconsciousfactors are taken into consideration (20;21). However, it has also been concluded fromqualitative research that it seems likely that young people are willing to behave inmore a positive way if they would know how (31).

108 Stigma



Taken together, research and opinion polls provide a multifaceted picture of mentalhealth stigma in the Finnish society. Stigma is prevalent, but the situation may bebetter in Finland than in many of the other European countries. Interestingly, some ofthe research results point towards an aggravating role of mental health professionals.Diagnostic procedures and clinical language seem to increase stigma, as pointed out bythe qualitative studies (8;31) and corroborated by a study of the effect of access topsychiatric consultations on general health care staff (37). There are grounds for acritical and open discussion about the stigmatising effect of psychiatric diagnoses,which are increasingly used also outside of psychiatric services.

Acknowledgements

Information specialist Pia Pörtfors, THL, is aknowledged for helpful assistance indefining search strategies and performing searches. This review was undertaken as apart of the Anti-Stigma Programme: European Network (ASPEN) Project and was co-funded by the European Commission.

References

1. Rüsch N, Angermeyer MC, Corrigan PW. Mental illness stigma: concepts, consequences, and initiatives toreduce stigma. Eur.Psychiatry 2005;20:529-39. 2. Lauber C, Anthony M, Ajdacic-Gross V, Rössler W. What about psychiatrists’ attitude to mentally ill people?Eur.Psychiatry 2004;19:423-7. 3. Thornicroft G, Brohan E, Rose D, Sartorius N, Leese M. Global pattern of experienced and anticipateddiscrimination against people with schizophrenia: a cross-sectional survey. Lancet 2009;373:408-15. 4. Ministry of Social Affairs and Health (2010). Plan for mental health and substance abuse work. Proposals ofthe Mieli 2009 working group to develop mental health and substance abuse work until 2015. Reports 2010:5.Helsinki: Ministry of Social Affairs and Health. Available:http://www.stm.fi/c/document_library/get_file?folderId=1082856&name=DLFE-12329.pdf 5. World Health Organization Regional Office for Europe. Mental health: facing the challenges, buildingsolutions: Report from the WHO European Ministerial Conference. Copenhagen: World Health OrganizationRegional Office for Europe, 2005. 6. Eilola, J (2003). Rajapinnoilla. Sallitun ja kielletyn määritteleminen 1600-luvun jälkipuoliskon noituus jataikuustapauksissa. Helsinki: Suomalaisen Kirjallisuuden Seura. Bibliotheca Historica 81. 7. Nygård T. Erilaisten historia: Marginaaliryhmät Suomessa 1800-luvulla ja 1900-luvun alussa. Jyväskylä:Atena Kustannus Oy, 1998.

Stigma 109



8. Kulmala A. Kerrottuja kokemuksia leimatusta identiteetistä ja toiseudesta . Tampere: Tampere UniversityPress, 2006. 9. Kulmala A. Ulkopuolisuuden paikat - metaforat kokemusten kerronnan välineinä omaelämäkerrallisissakirjoituksissa. JANUS 2003;11:319-33. 10. Kulmala A, Valokivi H, Vanhala A. Sosiaalityön kohtaamisia asiakkaiden kertomana. In Satka M, Pohjola A,Rajavaara M, eds. Sosiaalityö ja vaikuttaminen, pp 125-46. Jyväskylä: SoPhi, 2003. 11. Kulmala A, Vanhala A. Vanhemmuus marginaalissa: kulttuurinen mallitarina osana henkilökohtaistavanhemmuutta. In Jokinen A, Huttunen L, Kulmala A, eds. Puhua vastaan ja vaieta. Neuvottelu kulttuurisistamarginaaleista., pp 98-114. Tampere: Gaudeamus, 2004. 12. Kulmala A. Toiset identiteettiä rakentamassa. Yhteiskuntapolitiikka 2004;69:231-41. 13. Kulmala A. Kertomus mielenterveysongelmaiseksi määrittymisestä - saatu diagnoosi osana itseymmärrystä.Sosiaalilääketieteellinen aikakauslehti 2005;42:281-93. 14. Finnish Central Association for Mental Health (2005). Mielenterveysbarometri 2005 [Mental Health Barometer2005]. Helsinki: Finnish Central Association for Mental Health. Available:http://www.mtkl.fi/@Bin/11132/Mielenterveysbarometri_2005.pdf 15. Finnish Central Association for Mental Health (2006). Mielenterveysbarometri 2006 [Mental Health Barometer2006]. Helsinki: Finnish Central Association for Mental Health. Available:http://www.mtkl.fi/@Bin/11162/Mielenterveysbarometri_2006.pdf 16. Finnish Central Association for Mental Health (2007). Mielenterveysbarometri 2007 [Mental Health Barometer2007]. Helsinki: Finnish Central Association for Mental Health. Available:http://www.mtkl.fi/@Bin/66301/Mielenterveysbarometri+2007.pdf 17. Finnish Central Association for Mental Health (2008). Mielenterveysbarometri 2008 [Mental Health Barometer2008]. Helsinki: Finnish Central Association for Mental Health. Available:http://www.mtkl.fi/@Bin/661761/Mielenterveysbarometri+2008+%5bYhteensopivuustila%5d.pdf 18. Finnish Central Association for Mental Health (2009). Mielenterveysbarometri 2009 [Mental Health Barometer2009]. Helsinki: Finnish Central Association for Mental Health. Available:http://www.mtkl.fi/@Bin/661776/Mielenterveysbarometri+2009+%5bYhteensopivuustila%5d.pdf 19. Finnish Central Association for Mental Health (2010). Mielenterveysbarometri 2010 [Mental Health Barometer2010]. Helsinki: Finnish Central Association for Mental Health. Available:http://www.mtkl.fi/@Bin/872766/Yhteenveto%20Mielenterveysbarometri%202010.pdf 20. Laine A, Lehtinen V. Attitudes toward mental illnes and their relationship to social structure and mentalhospital bed utilization in two finnish rural communities. Social Psychiatry and Psychiatric Epidemiology1973;8:117-23. 21. Lehtinen V, Väisänen E. Social-demographic aspects in the attitudes towards mental illness in a Finnishpopulation. Acta Psychiatr.Scand. 1977;55:287-98. 22. Lehtinen V, Väisänen E. Attitudes towards mental illness and utilization of psychiatric treatment.Soc.Psychiatry 1978;13:63-8. 23. Ojanen M. Attitudes towards mental patients. Int.J.Soc.Psychiatry 1992;38:120-30. 24. Herberts K, Wahlbeck K, Aromaa E, Tuulari J. Enkät om mental hälsa 2005. Metodbeskrivning.Diskussionsunderlag 13/2006. Helsinki: STAKES, 2006.

110 Stigma



25. Forsman, A, Herberts, K., Aromaa, E., Tuulari, J., Wahlbeck, K. (2009). Kohti pohjalaista hyvinvointia:Mielenterveyttä koskeva kyselytutkimus 2008. Menetelmäraportti. Helsinki: THL. Avauksia 3/2009. Available:http://www.thl.fi/thl-client/pdfs/ce70fb36-a84d-4d85-af09-4cf8bbb6589a 26. Aromaa E, Tuulari J, Herberts K, Wahlbeck K. Pohjalaisen väestön suhtautuminen masennukseen ja mielenhoitamiseen. Suomen Lääkärilehti 2007;62:788-9. 27. Aromaa E, Tolvanen A, Tuulari J, Wahlbeck K. Attitudes towards people with mental disorders: thepsychometric characteristics of a Finnish questionnaire. Soc.Psychiatry Psychiatr.Epidemiol. 2010;45:265-73. 28. Aromaa E, Tolvanen A, Tuulari J, Wahlbeck K. Predictors of stigmatizing attitudes towards people withmental disorders in a general population in Finland. Nordic Journal of Psychiatry 2011;65:125-32. 29. Aromaa E, Tolvanen A, Tuulari J, Wahlbeck K. Personal stigma and use of mental health services amongpeople with depression in a general population in Finland. BMC.Psychiatry 2011;11:52. 30. European Commission (2006). Mental well-being. Brussels: European Commission, Directorate GeneralCommunication. Special Eurobarometer 248/Wave 64.4. Available:http://ec.europa.eu/health/ph_information/documents/ebs_248_en.pdf 31. Räty, H (1987). Uhka vai uhri: tutkimus mielisairauteen asennoitumisesta [Threat or victim: a study onattitudes to mental illness]. University of Joensuu. 32. Chambers M, Guise V, Välimäki M, Botelho MA, Scott A, Staniuliene V et al. Nurses’ attitudes to mentalillness: a comparison of a sample of nurses from five European countries. Int.J.Nurs.Stud. 2010;47:350-62. 33. Guise V, Chambers M, Välimäki M, Makkonen P. A mixed-mode approach to data collection: combining web andpaper questionnaires to examine nurses’ attitudes to mental illness. J.Adv.Nurs. 2010. 34. Suokas J, Lönnqvist J. Work stress has negative effects on the attitudes of emergency personnel towardspatients who attempt suicide. Acta Psychiatr.Scand. 1989;79:474-80. 35. Suominen K, Suokas J, Lönnqvist J. Attitudes of general hospital emergency room personnel towardsattempted suicide patients. Nord.J.Psychiatry 2007;61:387-92. 36. Suokas J, Suominen K, Lönnqvist J. Psychological distress and attitudes of emergency personnel towardssuicide attempters. Nord.J.Psychiatry 2008;62:144-6. 37. Suokas J, Suominen K, Lönnqvist J. The attitudes of emergency staff toward attempted suicide patients: acomparative study before and after establishment of a psychiatric consultation service. Crisis 2009;30:161-5. 38. Bell JS, Aaltonen SE, Bronstein E, Desplenter FA, Foulon V, Vitola A et al. Attitudes of pharmacy studentstoward people with mental disorders, a six country study. Pharm.World Sci. 2008;30:595-9. 39. Bell JS, Aaltonen SE, Airaksinen MS, Volmer D, Gharat MS, Muceniece R et al. Determinants of mental healthstigma among pharmacy students in Australia, Belgium, Estonia, Finland, India and Latvia. Int.J.Soc.Psychiatry2010;56:3-14. 40. Virtala A, Salmelin R, Tamminen T, Anttinen E. Change of attitudes towards psychiatric issues duringmedical education. Med.Teach. 1998;20:356-63. 41. Turunen, M (2010). Mental health rehabilitators’ experiences of stigmatization. Diaconia University ofApplied Sciences. 42. Nyström, C (2009). Faktorer som påverkar stigmatisering av personer som lider av schizofreni. Åbo Akademi,Humanistiska fakulteten.

Stigma 111



43. Mykkänen, S (2007). Skitsofreniaa sairastavien leimautuminen. University of Helsinki, Department ofPsychology. 44. Heikkilä, P (2005). Leimatut puhuvat - Akateemisesti koulutettujen mielenterveyskuntoutujien leimautumistakoskevan puheen diskurssianalyyttinen tulkinta. University of Jyväskylä, Department of social sciences andphilosophy. Available:https://jyx.jyu.fi/dspace/bitstream/handle/123456789/11635/URN_NBN_fi_jyu-2005131.pdf?sequence=1 45. Mielonen, M-L (1997). Mielenterveysasiakkaiden hoitoon hakeutuminen. Oulun yliopisto, Hoitotieteen laitos. 46. Kokko, S (1996). Mahdollisuus moneen. Ensimmäistä kertaa psykiatrisessa sairaalahoidossa olevan potilaankokemuksia hoidostaan. Oulun yliopisto, Hoitotieteen laitos. 47. Ranne, P (2007). Hoitajien asenteet mielisairautta ja mielenterveyspotilaita kohtaan [Nurses’ attitudestoward mental illness and mental patients]. Turku: University of Turku, Department of nursing science. 48. Inkilä J, Paavilainen E, Halme N. Psykiatriseen hoitoon liittyvästä häpeän pelosta ei kerrota [Fears ofshame and stigmatisation related to psychiatric care and not shared with other people]. Sairaanhoitajalehti2007;80:34-6. 49. Lehtinen, V (1975). Psykiatrisen hoidon ja kuntoutuksen tarve sekä mielisairauteen kohdistuvat asenteet[Need of psychiatric treatment and rehabilitation; attitudes toward mental illness]. Turku: Kansaneläkelaitos/ Social Security Institution. Kansaneläkelaitoksen julkaisusarja AL3. 50. Kaltiala-Heino R, Poutanen O, Välimäki M. Sairauden häpeällinen leima [Illnesses and stigmatization].Duodecim 2001;117:563-70. 51. Salonen, K (2005). Näe ihminen - älä leimaa. Mielenterveys 44(2), 16-18. 52. Salonen, K (2000). Kun mielisairaus mainitaan, ihmiset kääntävät minulle selkänsä [When mymental disorder is mentioned, people turn their backs to me]. Mielenterveys 38(3), 16-19. 53. Salonen, K (2003). Kun mieli sairastaa: millainen on sairas mieli. Miksi tauti leimaa koko ihmisen?Mielenterveys 42(4), 6-11.

Kristian Wahlbeck, MD, DMedScNational Institute for Health and Welfare, Deptartment of Mental Health and Substance Abuse Services,Vaasa, Finland

Esa Aromaa, MScNational Institute for Health and Welfare, Deptartment of Mental Health and Substance Abuse Services,Vaasa, Finland

Correspondence: [email protected]

research on stigma related to mental disorders in finland ... · research on stigma related to...

Documents