Understanding the attitudes towards mental illness among graduate students at a small midwestern religious college


 Objective: To describe college students’, specifically health care professionals in-training, attitudes towards individuals diagnosed with mental illness. Participants: Graduate students (n=214) at a small midwestern college. Sixty-two percent enrolled in community psychology; 38% in nursing; and 30% from other graduate programs. Almost all were female (97%) and white (70%).Methods: A cross-sectional electronic survey designResults: Community psychology students had significantly more empathy towards individuals with mental illness then other graduate students (p<0.05). Other graduate students (p=0.04) and nursing students (p=0.010) had significantly more acceptance toward deinstitutionalization as compared to community psychology students. Those who indicated higher levels of individual knowledge and personal experience with mental illness had less stigma and pessimistic attitudes (p<0.05). Conclusions: Health care professionals in-training have underlying stigma regarding individuals diagnosed with mental illness. It is imperative for our institutions of higher learning to provide educational opportunities to help decrease this stigma.


Introduction
Nationwide there is an epidemic of discrimination and stigma associated with identifying and treating people with mental illness 1 . When looking at stigma and mental health there is a "sense of shame," and with it also "a sign of weakness" 2 . Mental health stigma has become a trigger for adversity for many individuals seeking treatment 2 . Stigma has been de ned as, "a product of disgrace that sets a person apart from others" 3 . Unfortunately, stigmatizing views about mental illness are not limited to members of the general public; even well-trained professionals from most mental health disciplines subscribe to stereotypes about mental illness 4,5 .
Due to the stigma associated with individuals with a diagnosis of mental health many researchers in the eld of psychology have created and examined possible ways to reduce or avoid mental health stigmas.
One of the most promising solutions for decreasing stigma is training health care professionals by creating multicultural courses or imbedding materials within college-level courses aimed at increasing awareness and skills when treating individuals diagnosed with mental illness 6,7 . Boysen and Vogel speci cally focused on assessing the multicultural competencies and implicit bias of counselor trainees.
Their study found signi cant implicit bias among a sample of counselor trainees suggesting that the trainees had the presence of implicit bias when working with their diverse clients 6 .
Moreover, individuals who are living with a mental health diagnosis may internalize their negative attitude towards mental illness which may lead them not to seek treatment 2 . Due to the stigma around mental health from the general population, this has caused individuals within the population to have some sort of bias toward mental illness 8 . One study showed that individuals who had mental health training compared to those who did not, "showed more positive implicit and explicit evaluations of people with mental illness" 8 .
One of the primary objectives of graduate programs in Community Psychology at the Midwest institution where this study was conducted was to "emphasize health and community involvement in prevention, intervention and treatment of mental health issues". The program believes that it is imperative to be able to train students to identify mental illness and overcome any personal stigma they might have. The purpose of this study was to evaluate the attitudes towards mental illness among graduate students at a small Midwestern University. More speci cally to see if there were differences among students enrolled in the Community Psychology Counseling program that is focused on education to overcome some of the stigma associated with mental illness as compared to their graduate student counterparts.

Materials And Methods
We utilized a cross-sectional survey design for this study. We administered an electronic survey in the Spring of 2018 to all graduate students in the departments of community psychology, education, business, and nursing from a small, Midwestern University. We gained permission to use students email from the program deans. We contacted the students up to three times to remind them to complete the survey. The survey included basic demographic questions and a modi ed version of the valid and reliable Community Attitudes Toward the Mentally Ill (CAMI) questionnaire about personal attitudes towards mental illness 9 . The CAMI is a valid and reliable tool that is "freely granted to use for research, educational, academic and professional purposes". The CAMI uses four subscales (Authoritarian, Social restrictiveness, Benevolence, and Community Mental Health Ideology) measured on a 5-point Likert scale ranging from 1-strongly disagree to 5-strongly agree to assess attitudes toward individuals diagnosed with mental illness 9 .
Statistical analysis was completed in SPSS 10 . We used descriptive statistics to summarize the data. Chisquare analysis was used for dichotomous variables and t-test/ANOVAs was used for continuous variables. A p-value of less than or equal to 0.05 was considered signi cant. IRB approval was obtained for this study.

Results
A total of 214 out of 600 graduate students completed the electronic survey; a 36% response rate. Sixty two percent of respondents were from the community psychology program; 38% from the graduate nursing program; and 30% from 'other' graduate programs (education, nursing, and business). Almost all the respondents were female (97%) and white (70%). When comparing community psychology student with only nursing students; community psychology students had signi cantly more Benevolence (MD=0.17; p<0.05) and less stigma on Social Restrictiveness (MD=0.11; p=0.006) as compared to their graduate nursing student counterparts. On the other hand, the nursing graduate students had signi cantly less stigma than community psychology students around Community Mental Health Ideology (MD= 0.13; p=0.010). There was no difference in Authoritarian between these two groups. Additionally, we looked at the difference between community psychology students just entering the program (<30 credits completed) and those leaving the program (>30 credits completed) and we found no signi cant difference in any of the four subscales.
We also explored how individual knowledge and personal experience with mental illness impacts students' attitudes. Overall, respondents who indicated that they were 'very knowledgeable about mental illness' indicated signi cantly less pessimistic attitudes (Authoritarian) than those that indicated they were 'not very knowledgeable' (MD=0.05, p<0.05) Those who indicated that they had 'ever, had a family member or friend diagnosed with a mental illness' (M=2.72) showed signi cantly less pessimistic attitudes (Authoritarian) and a greater level of acceptance toward deinstitutionalization (Community Mental Health Ideology) than those who indicated that they 'never, knew someone diagnosed with a mental illness' (Authoritarian; MD=0.07; p<0.05; Community Mental Health Ideology; MD=0.08).

Discussion
Overall, our data suggests that stigma towards individuals with mental illness exists, even among health care professionals in training, such as community psychologists and nurses that are on the front lines caring for these individuals. Our ndings are similar to others who have looked a stigma in nurses and counselors 6,12 .
Community psychology students seem to have a high level of empathy and compassion for individuals with mental illnesses, even more so than their nursing counterparts. These are promising results given that the community psychology graduate programs goal is to encourage the exploration of individual stigma associated with individuals diagnosed with mental illness.
Interestingly when comparing other' graduate students, nursing students and community psychology student the community psychology students had more stigma around deinstitutionalization of those with mental illness and having mental health facilities in the community (Community Mental Health Ideology). This is an interesting and perplexing nding. It would be interesting to explore further but it could be hypothesized that since students in community psychology are often employed in these types of institutions, they see the need for these types of institutions throughout the community.
Additionally, knowing someone with a diagnosis of a mental illness or even a perceived greater knowledge of mental illness seemed to signi cantly decrease students' pessimistic attitudes and increase their acceptance of people with mental illness in the community. Research has suggested that more education and knowledge of persons diagnosed with mental illness will lead to an overall better understanding of mental illness are less likely to have stigma and can decrease negative stereotypes 13,14 .
Several studies have shown that participation in education programs speci c to mental illness can lead to decreased stigma as well 5,13−17 . This study had several limitations that diminishes the generalizability of the results such as a small sample of graduate students from a small, local university. We also were only able to receive responses from 36% of the graduate students. Even with these limitations, we were able to further add to the literature around stigma of people diagnosed with mental health disorders within health care professionals in-training, speci cally community psychologist. It is our hope that we can use these data to help inform future standalone professional development, internship opportunities or by embedding curriculum into existing classes.