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The Link between different kinds of Knowledge about Mental Illness and their Stigma Henrik Ho & Jacqueline Jaconelli

Örebro University

Psychology III Spring 2019

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Abstract

The purpose of this study was to examine if people's knowledge about mental illness is related to their stigma against mental illness. We examined four types of knowledge a) knowledge treatment, b) knowledge of non-traditional diagnoses, c) knowledge of traditional , diagnoses, and d) personal knowledge of people with mental illness (called associations). Based on prior research, we hypothesized that the relation between high knowledge about mental health problems and treatment effectiveness would be curvilinearly related to stigma - with the higher and lower levels associated with more stigmatic cognitions, but moderate levels associated with holding fewer stigma. We also hypothesized that knowing others would be negatively related to stigma. We collected self-report survey data from 256 participants, using convenience sampling via social media forms. The results revealed that people's ability to identify traditional forms mental illness diagnoses was related to their stigmatic cognitions. In terms of associations the result revealed two subsets, including the groups we expected, but revealing more complexity. The results point to several issues that need to be addressed by future research.

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Abstrakt

Syftet med denna studie var att undersöka om människors kunskap om psykiska sjukdomar är relaterat till deras stigma mot psykisk sjukdom. Vi undersökte fyra typer av kunskaper a) kunskap om behandling, b) kunskap om icke-traditionella diagnoser, c) kunskap om traditionella diagnoser, c), och d) personlig kunskap om personer med psykisk sjukdom (kallade associationer). Baserat på tidigare forskning hypotiserade vi att förhållandet mellan hög kunskap om psykiska problem och behandlingseffektivitet skulle vara kurvlinjärt relaterad till stigma - med högre och lägre nivåer associerat med mer stigmatiserande kognitioner men måttliga nivåer associerade med mindre stigma. Vi hypotiserade också att känna andra skulle vara negativt relaterat till stigma. Vi samlade självrapporterings data från 256 deltagare, med hjälp av bekvämlighetsurval via sociala medier. Resultaten visade att människors förmåga att identifiera psykiska sjukdomsdiagnoser var signifikanta för deras stigmatiska kognitioner. Vidare visade resultatet i samband med associationer två delgrupper. De lägsta nivåerna av stigmatiska kognitioner hittades i den förväntade gruppen, men det fanns andra grupper som inte var signifikant olika. Nyckelord: associationer, attityd, kunskap, psykisk ohälsa, stigma.

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The Link between different kinds of Knowledge about Mental Illness and their Stigma Mental health isone of the biggest growth challenges we face around the world according to the World health organization [WHO] (2016). In 1990, 416 million people suffered from anxiety and depression, by 2013 it increased to 615 million people (WHO, 2016). In 2010 nearly 2.5 trillion American dollars was spent on mental illness making it one of the biggest issues in people’s health worldwide. That number is projected to rise to 6 trillion American dollars by 2030, but even that is not enough money compared to what is needed to combat mental illness in the world (Insel, 2011; Thronicroft, Rose & Kassam, 2007). One of the reasons that the health care of mental illness does not get the funding it needs is because of stigma, and the negative attitudes that society and those people responsible for providing the health care have towards people with mental health issues (Nordt, Rössler & Lauber, 2006). A report written by the U.S. Surgeon General (1999) announced that the severity of stigma and its impact on mental health is one of the biggest obstacles toward mental health care. The report highlighted barriers towards addressing mental health issues, proposing that one of the most effective weapons towards stigma is through research, building more knowledge, and more effective treatment (U.S. Department of Health and Human Service, 1999).

Knowledge about mental illness is theorized to be a mainstay of the stigma issue that exists in today's society (Henderson, Evans-Laco & Thornocroft, 2013). Research however, has not confirmed this idea, showing contradictory results when examining the associations between knowledge and stigma. Results may be contradictory because researchers have focused on linear associations (i.e., higher values on the one variable covarying with higher or lower values on another variable). As some have suggested that the association could be strongly positive or negative (Corrigan, Morris, Michaels, Rafacz & Rüsch, 2012; Nationell samverkan för psykisk hälsa [NSPH], 2014), we concluded that curvilinear associations should be examined.

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Another reason for the contradictory results may be an oversimplification of what stigmas entail. The concept of stigma is complex and there is a difference of opinion among researchers as to how stigma is defined (Canfield & Cunningham, 2018; Thornicroft, Rose & Kassam, 2007). Originally, the word stigma stems from the Greek word stigmata, that is a mark, brand or some sort of sign on a person's body. The term was used to signify bodily abnormalities or derogatory characteristics in a person’s moral status (Brunt & Hansson, 2005). The notion of stigma became a social construct, mark of disgrace, and devalued identity (Sorel, 2013). In today's research, stigma is defined by the person holding the stigma and identified the target of the stigma. Thus, perceived-stigma, are the attitude and

behaviours a targeted person experiences from others. Self-stigma, are the negative attitude individuals hold about themselves. Disease-specific stigma isnegative attitudes towards people with a specific mental illness (Christensen, Griffiths & Jorm, 2008; Corrigan, 1998; Goffman, 1963; Link & Phelan, 2001;Thornicroft, Leff, Warner, Sartorius & Schulze, 2006). Hence, stigma is operationalized differently depending on who stigmatizes and who is

stigmatized. In this study, we are interested in the last type of stigma - beliefs and intentions directed at individuals with mental illness.

Stigmatization is very common against people with different mental health problems (Whiteman, 2019). The first interaction with someone is enough for us to stigmatize peoples' characteristics into compartments following different kinds of stigma (Goffman, 1963). Among the first researchers in stigma, Erving Goffman (1963) says that we judge peoples' personalities if they are not labelled as “normal”. This type of stigma is most connected with mental illness and can be observed through behaviour that is outside the frames of social acceptance such as alcoholism, incarceration, unemployment, and suicide attempts. Since Erving Goffman (1963) there are researchers conducting studies on stigma and how we stigmatize. For example, Link and Phelan (2001) adopted and further developed Goffman’s (1963) definition of stigmatization. More specifically, they propose a social cognition

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perspective including components of how we categorize different kinds of attributes (Link & Phelan, 2001). The first component is distinguishing and labelling differences in individuals. Most attributes between people like the colour of their houses or different preferences are ignored and irrelevant in several social situations. These differences are therefore not a basis for classification of people. However, characteristics such as skin colour and gender are considered highly important in our society and are frequently used for labelling people. The second component of stigma involves stereotypes and negative attributes. Labels that were produced in the first component are now linked to stereotypes. These stereotypes together with negative attributes create a negative stereotype. This process usually occurs implicitly without any voluntary control (Link & Phelan, 2001). The third component involves labelling self and others, categorizing people in groups in terms of” us” and ”them”. For example, people speak about a person with a mental disorder as if they were possessed of an illness rather than having it and that they are considered responsible for causing their disabilities (Link & Phelan, 2001). By comparison, a person suffering from cancer may still be considered “us” rather than “them” if “them” refers to people with mental illness. People seem to disapprove of mental illness more than physical illness, which may be why mental illnesses have more stigma than do physical illness (Corrigan et al., 2000; Link & Phelan, 2001; Weiner, Magnusson & Perry, 1988). Because of these labels that people create, both the stigmatized and those who stigmatize react emotionally to the labels which affect the interactions between these two groups of “us” and “them” (Link & Phelan, 2001). These processes, according to Goffman (1963) and Link and Phelan are to stigmatize.

Thornicroft, Brohan, Kassam, and Lewis-Holmes (2008) described three other components interacting when stigma towards people with mental illness occur: attitudes (prejudice), behaviour (discrimination), and knowledge (ignorance). For stigmatizing to occurs, negative attitudes and beliefs are formed and represented in some kind of behaviour. That is, people can not only lack knowledge, but their knowledge can also be incorrect or

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misleading, creating the opportunity for stigma formation (Corrigan & Watson, 2002a). Research also shows that improving either knowledge, attitude or behaviour alone does not mean that stigmatization will stop occurring. The interaction between all of the three components is what determines the amount of stigma (Thornicroft, Rose, Kassam & Sartorius, 2007).

Researchers have measured separate kinds of stigma in their studies, but they all fall under the same concept of general stigma (Griffiths et al., 2008; Pescosolido, 2015). When stigma is present, it varies between different conditions. For example, Ebner and Latner (2013) measured the stigma toward obesity, eating disorders, and major depressive. The results revealed that eating disorders, especially obesity, held more stigma than did major depressive disorder. It would seem that stigmatizing attitudes vary across mental illness and results fluctuate when measuring stigma against a specific illness (Ebner & Latner, 2013). Problems that occur when asking the general public about certain mental disorders is the fact that most people have a preconception of most commonly known mental illnesses. Some have a set of stereotypes but that does not imply that they agree with them (Corrigan & Watson, 2002b). Furthermore, there are several themes such as forms of media that represent misconceptions about a specific mental illness and its corresponding stigmatizing attitudes (Gabbard, Hyler & Schneider, 1991). Most research conducted on stigma focuses on a specific group of people or diagnosis. There are a few studies about the stigma that look into people'sknowledge about mental illnesses and its relation to stigma in the general population (Evans-Lacko, Little, Meltzer, Rose, Rhydderch, Henderson & Thornicroft, 2010;

Thornicroft, Rose & Kasam, 2007). To examine knowledge about mental illness in

stigmatizing behaviour and intentions, future research needs to investigate the importance of different types of knowledge, including attitudes, fears, and intentions towardsmental illness (Evans-Lacko et al., 2010).

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Knowledge about mental illness is most commonly measured in terms of educational knowledge about mental illness and the association people have to others with mental illness (Evans-Lacko et al., 2010; Open the doors, 2019; Ramon, 1978; Thornicroft et al., 2006). According to Goffman (1963) knowledge is based on associations to people with some kind of mental illness. Hence, people with more association with mental illness holds less

stigmatized attitudes. It could, for example, be people who have a relative, family member or friend, who suffers from a mental illness and is a victim of stigma. In this instance, Goffman (1963) uses the term "the wise” for people with these kinds of associations and knowledge. Another group of people that perceive less stigma are those who are victims of the same sort of stigma, for example, a person who has a disability feels more comfortable among others with the same disability because they share the same stigma. People who have the same stigma will share experiences that lead these persons to feel” normal” in their own group (Goffman, 1963). Longitudinal studies have found that people with some kind of association to others with mental illnesses have the lowest amount of stigma (Mehta, Kassam, Leese, Butler & Thornicroft, 2009; NSPH, 2014; Taylor Nelson Sofres [TNS], 2014). Whilst people with no association to others with mental illness has shown to have the highest amount of stigmatizing attitudes (Ramon, 1978). Both results support the notion that associations to people with mental illness have an important part regarding the amount of stigma that is present. Individuals with more association with people with mental illness seem to show fewer stigmatizing attitudes.

Knowledge about mental illness is a mainstay of the stigma issues that exist in today's society (Henderson, Evans-Laco & Thornocroft, 2013; NSPH, 2014). It is known through research that knowledge about mental illness and stigma are correlated to each other, however, the correlation between knowledge and stigma has shown different results in the past (Goffman, 1963; Link & Phelan, 2001; Thornicroft et al., 2008; TNS, 2014). Low knowledge about mental illness has a correlation to high stigma (Goffman, 1963; Griffiths et

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al., 2008; Wang et al., 2005). For example, Pierce (2012) talks about the importance of knowledge about mental illness when reducing stigmatizing attitudes towards people with mental illness. She found in her study that stigmatizing attitudes correlated with a lack of knowledge about mental illness. Participants in the study that reported more stigmatized attitudes also reported that they had less overall knowledge about mental illness. In addition, participants that reported more knowledge in the field of mental illness showed results of less negative attitudes. These findings suggest that knowledge about mental illness is correlated with less stigmatizing attitudes. However, this study was conducted solely on undergraduates from one university, which would result in lack of age diversity as well as the spread of geographic location, which would result in similar result among the participants (Pierce, 2012).

Likewise, a meta-analytic study analysed the effects of anti-stigma programs. They found in their conclusion that education and contact, specifically association, have some positive value in stigma change, namely, knowledge about mental illness and associations reduce stigmatizing attitudes (Corrigan et al., 2012). Further, in 1978 Ramon tested social and personal involvement with people with mental illness. In the study, mental health care professionals showed the least amount of stigma. Whilst people that were not involved with people with mental illness had the most stigma. Patients and family members were in the middle. This result indicates that the group with most associations to people with mental illness has the least amount of stigma (Ramon,1978). These findings concur with Goffman´s (1963) suggestion that associations to mental illness are an alternative form of knowledge in the context of stigma.

Other studies conducted contradict these conclusions, suggesting that people with high levels of knowledge in fields of psychology and mental health care neverthrless show signs of stigma (Chambers et al., 2010; Gray, 2002; Horsfall, Cleary & Hunt, 2010; Jonsson & von Schuppler, 2012; Nordt et al., 2006; Sun et al., 2014). For instance, Thornicroft, Rose

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and Kasam (2007) conducted research on people in health care and their discrimination towards people with mental illnesses. In this study, patients described encountering stigma towards them from people working in health care about their prognosis. They reported that the negative attitudes were part of something called: “physicians bias”, this means that doctors will tend to lean on their previous experiences when advising patients, which appeared relatively often in the general health care settings. Of these participants, 13% received care as adequate (Thornicrof, Rose & Kasam, 2007). However, how “adequate” treatment is measured is not specified. It could be subjective to the patient to be perceived as adequate or is it adequate to the guidelines of treatment within psychiatry.

Another example is a study from Australia where they conducted a survey comparing the general population with mental health professionals. Their results suggest that mental health professionals have more negative and discriminating attitudes compared to the general public. In this study, the researchers theorized that these negative attitudes are realistic due to the fact that they have a greater knowledge of mental illnesses, as a result of education and previous contact with patients with mental illnesses (Jorm, Korten, Jacomb, Christensen & Henderson, 1999). As they declare in the study, they use questions that are subjectively influenced by social desirability, which skews the answers towards the option that is more socially acceptable. This could be an explanation for the findings in this study. These

contradictory results indicate that even people who have high knowledge about mental illness nevertheless have stigmatizing attitudes.

The conclusion is that knowledge is a part of measuring stigma, but it is complex. Different levels of knowledge, high or low, appear to be related to stigmatizing attitudes (Corrigan & Penn, 1999; Ramon, 1978). Corrigan et al., (2012) gathered over 8,000 documents on stigma studies. Out of all documents, less than 1% were found usable for a meta-analysis. This shows how complicated stigma research is and that there needs to be common ground in how stigma is measured to exclude differences in findings (Corrigan et

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al., 2012). Furthermore, Evans-Lacko et al., (2010) talked about the limitation of only measuring knowledge about mental illness as an assessment of the amount of stigma. They say in their studies that knowledge scales alone are not enough for assessing changes in stigma (Evans-Lacko et al., 2010). Therefore, an attitude and behaviour related measurement should be used, together with a knowledge scale, so that it can better understand the relation between these components: attitudes, behaviour, and knowledge (Evans-Lacko et al., 2010). In summary, knowledge about mental illness is highly relevant to the stigma issues in today's society. Stigma is one of the biggest obstacles to mental health problems. Research on stigma remains inconclusive, thus, results are easily contradicted by studies. Therefore, we wanted to further examine the link between knowledge about mental illness and stigma with a new proposal on what direction it would take. The relevance could be positive or negatively related to each other, that is, higher amounts of knowledge could show higher or lower amounts of stigma (NSPH, 2014). The present study focused on the three different

components described by Thornicroft et al., (2008) of knowledge, attitude, and behaviour. Furthermore, even though research has agreed that there is a correlation between these three components, we followed the principles of Link and Phelan (2001) that for there to be stigma present there needs to be action reflecting negative beliefs. Thus, we set a condition that in order for the stigma to be valid there must be a correlation between behavioural intentions and attitudes. As mentioned above, previous research has focused on specific stigma towards certain mental illness. It would seem that stigmatizing attitudes vary across mental illness (Ebner & Latner, 2013). Hence, the following study measured general stigma and not any specific stigma towards any mental illness to avoid misleading preconceptions.

Our research question on this matter was: What is the relation between people’s knowledge about mental illness and the stigmas they hold. Due to what previous research has advocated, we hypothesized that the relation between knowledge about mental health

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and lower levels associated with more stigmatic cognitions, but moderate levels associated with holding fewer stigma.

Goffman (1963) presented a notion that knowledge in the context of stigma is based on associations to other people exposed to stigma. Various researches have shown results of how people that are associated with mental illness have lower amounts of stigma, thus, this has been explained as an alternative kind of knowledge about mental illness.

Based on these findings our second research question was: Do people with more associations to mental illness show fewer stigmatic cognitions? We hypothesized that people who have more associations would have fewer stigmatic cognitions.

Method Participants

The study contains 256 participants, compiled through convenience sampling since the study was directed towards people living in Sweden. Participants were selected through different social media forms such as student groups and personal pages on Facebook, E-mail groups from our survey homepage and personal Twitter. Participants ranged in age from 15 to 69 years (M = 31.92, SD = 12.01). Attrition was 14 people, which lead to the conclusion in 242 valid participants were 60.9% were females and 36.7% were males and 2.3% stated others. The majority of the participants, 233 people (91.7%), reported they had an association to mental illness, this means that they know someone with a mental illness or that the

respondent themselves have a mental illness. Participants that reported no association was 21 people (8.3%).

Pre-Pilot

We performed a pilot test in 2017 on a selected sample of ten people who have experience in academics and statistics. The pilot test was conducted to clarify any

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test agreed that the face validity was acceptable. The changes made in the scales was pointed out by the majority of the participants (see Appendix 1, 2, and 3).

Measures

Knowledge about mental illness. To assess participants knowledge of mental illnesses, we used a revised version of the Mental Health Knowledge Schedule (MAKS, Evans-Lacko et al., 2010). The original measure taps knowledge about mental illness and is comprised of two parts, each consisting of six items. Part A involves statements related to mental health knowledge areas such as: “Medication is an effective treatment for people with mental health problems”. Part B involves identifying various conditions in mental illness such as: “Stress is a type of mental illness” (Evans-Lacko et al., 2010). Response possibilities ranged from 1 (Strongly agree) to 5 (strongly disagree) (Evans-Lacko et al., 2010; NSPH, 2014), where participants indicated how much they agreed or disagreed with each statement. Evans-Lacko et al., (2010) stated that the mental health knowledge schedule instruments were not developed to function as a scale alone and should be used in conjunction with other measures. The feedback during our pilot test indicated that some questions in the MAKS scale were unclear therefore we rephrased these items. The pilot test also showed that there was confusion about the difference in the response set. CAMI-S and FABI already had the same response alternative so we changed MAKS response options to match the other scales (see Appendix 1).

After collecting the data for this study, we analysed the reliability and validity of our revised measure. Initial results suggested that the structure of the measure we created was not the same as the original. Internal consistency was low (α = .23), arguing for examining the factor structure. Examining the scree plot from a principal component analysis with varimax rotation suggested that there were three dimensions, explaining 50.63 % of the variance. We removed two items, one because it did not load on any factor and one because it loaded on two factors. As seen in Table 1, we labelled these dimensions as follows: 1) knowledge of

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treatment, 2) knowledge of non-traditional diagnoses, and 3) knowledge of traditional diagnoses. Further, we conducted reliability analysis on all three dimensions and found that only two of the dimensions had acceptable alphas: knowledge of non-traditional diagnoses (α = .64) and knowledge of traditional diagnoses (α = .71). For knowledge of treatment, the alpha was not acceptable (α = .41), and there was no indication that removal of an item would improve the reliability. Thus, we dropped this scale from further analysis.

Table 1.

Component loadings of the Mental Health Knowledge Schedule (MAKS)

Knowledge component Scale item Non-traditional diagnoses Traditional diagnoses Treatment 1. Most people with mental health problems wants

to have paid employment.a .42 - -

2. If a friend had mental health. problem, I'd know

how to advise. him/her to get professional help. - - .58 3. Medication is an effective treatment for people

with mental health problems. - - .65

4. People with severe mental health problems can

fully recover.b - - -

5. Most people with mental health problems

consult a healthcare professional to get help. - -

.60 6. Psychotherapy (e.g. taking therapy or

counselling) is an effective treatment for people

with mental health problems. - - .53

7. Depression is a type of mental illness. .58 .52 -

8. Stress is a type of mental illness. - .79 - 9. Schizophrenia is a type of mental illness. .88 - - 10. Bipolar is a type of mental illness. .87 - - 11. Drug addiction is a type of mental illness. - .57 -

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12. Grief is a type of mental illness. - .75 -

aItem removed due to low factor loading. bItem removed due to double loading.

Knowledge through personal associations. To assess how many people our participants knew with mental illnesses, we created a measure where participants checked whether themselves had a mental illness or someone they knew, including family members, friends, and work or school associates. We assigned the following values to these

possibilities:” Myself” = 2, “a family member” = 4, “a friend” = 7, “a work/school associate” = 10, “None” = 0. We then created 15 possible categories (see Appendix 4) by summing the values associated with those participants checked. The resulting categories are mutually exclusive.

Stigmaticattitudes. We used a Swedish version of the Community Attitudes

Towards Mental Illness scale (CAMI-S), a translated version of Taylor and Dear’s (1981) 40-item questionnaire used to assess stigmatic attitudes about mental illness, with four subscales. The version we used was adjusted from 40 items to 20 items to better fit the Swedish culture. Example of question is: “The mentally ill are not as dangerous as most people suppose they are”. Answer options ranged from 1 (strongly agree) to 5 (strongly disagree), where higher score meant more negative attitude towards mentally ill (Högberg, Magnusson, Ewertzon & Lützen, 2008).

Our pilot test indicated that the three scales together contained too many items. The pilot testers also reported that the language for some questions was too confusing, making them hard to understand. We used 15 items that were relevant for our purposes and were not difficult to understand (see Table 2), rephrasing to make them clear and easy to understand (see Appendix 2).

We conducted a principal component analysis to examine the structural validity of our version. The 15-item version of the CAMI-S scale loaded on to one component, accounting for 34.02% of the variance. Loadings ranged between .02 and .51. We removed the item that had the

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lowest loading, keeping items with loadings greater than .30 (see Table 2). The inter-item reliability of the remaining items, assessed with Cronbach’s alpha, was .82.

Table 2

Component loadings of the Swedish version of the Community Attitude Towards Mental illness (CAMI-S)

Scale item Loading

1. Most persons who were once patients in a mental hospital can be trusted as a babysitter.

.41

2. Mental illness is an illness like any other illness. .33

3. We need to adopt a far more tolerant attitude towards the mentally ill in our society.

.64

4. The mentally ill are not as dangerous as most people suppose they are. .57 5.The best therapy for many mental patients is to be part of a normal community. .43 6.The mentally ill should not be treated as outcasts of society. .43 7.No one has the right to exclude the mentally ill from their neighbourhood. .69 8. Mental health facilities should be kept out of residential neighbourhood. .62 9. Having mental patients living in residential neighbourhoods exposes risk of danger

to the residents.

.68

10. It is best to avoid anyone who has mental problems. .68

11. I would not want to live next door to someone who has been diagnosed with an mental illness.

.70

12. The best way to handle the mentally ill is to keep them behind locked doors. .71 13. Less emphasis should be placed to protect the public from the mentally ill. .70 14. It is frightening to think of people with mental problems living in residential

neighborhoods.a

-

15. The mentally ill should be isolated from the rest of the community. .61 aItem removed due to low factor loading.

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Stigmatic fears and intentions. We used the measure Fear of and Behavioral Intentions toward the mentally ill (FABI), constructed by Wolff, Pathare, Craig and Leff (1996) to measure stigmatic fears and intentions. The FABI measures fears and expected behaviour in different kinds of situations or interactions with people with mental illness (Wolff et al., 1996). The measurements are divided into three parts; fear and exclusion, social control, and goodwill. Questions are structured in the form of a statement, such as: “I am willing to work with someone with a mental illness”. Participants indicated agreement using a 5-point Likert scale ranging from 1 (strongly agree) to 5 (strongly disagree) (Wolff et al., 1996).

Our pilot test underscored that three of the statements was very similar to each other and participants of the pilot study did not relate to the situation suggested in two of these three questions. Therefore, we removed two out of these three questions. We reverse coded and took the mean value of the items, so that higher score on the FABI scale indicated more negative beliefs and intended behaviours towards people with mental illnesses (see Appendix 3).

The results from the factor analysis on the 8 items scale FABI showed that the items loaded in one factor (see Table 3), accounting for 51.46% of the variance in the measure. Loadings ranged between .66 and .79, indicating that all items should be retained. Cronbach´s alpha was .89.

Table 3

Component loadings of the Fear of and Behaviour Intentions towards the mentally ill (FABI)

Scale item Loading

1. I am afraid of people with mental illness. .69

2. I object to having mentally ill people living in my neighbourhood. .79

3. I would avoid conversations with neighbours who have suffered from mental illness.

.69

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5.I would invite those who suffer from a mental illness in to my home. .70

6. I would not like to have a friend who has been a former psychiatric patient. .66

7. I would not visit a former psychiatric patient that comes to live next door to me. .74

8. It would bother me if a mentally ill person attends my school. .76

Combined stigma (stigmatic cognition). Pearson’s correlations indicated that attitudes, fears, and intentions (as measured by the CAMI-S and FABI) were significantly correlated, r = .78, p < .001. We, therefore, created a single score indicating more stigmatic cognitions by averaging the two scales.

Procedures

This study was conducted using a cross-sectional design. The questionnaire was sent out through different social media platforms using Facebook™, e-mail groups, and Twitter™. The survey was constructed on the Örebro university survey service and then linked to the participants who responded to the survey online. The estimated time for completion of the survey was under 10 minutes. The survey started with a small presentation explaining the purpose of the study and the ethical principles such as the participants' rights of dropping out at any time they want, that their information will not be used for any other purpose than this study and that they will remain anonymous (see appendix 5). The questions in the

questionnaire are not meant to harm anyone or offend political or religious opinions. Data were collected for 9 days.

Statistical Analyses

To test the research question of this study the data were treated and analysed in the Statistical Package for Social Science version 25 (SPSS-25, 2017). To test our first

hypothesisthat the relation between high knowledge about mental illness and treatment effectiveness would be curvilinearly related to stigma - with the higher and lower levels associated with more stigmatic cognitions, but moderate levels associated with holding fewer stigma, we examined twobivariate scatterplots and conducted curve estimations analysis on

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two different knowledge subscales. To test our second hypothesis that knowing others would

be negatively related to stigma we conducted a one-way ANOVA, using R-E-G-W-Q (

Ryan-Einot-Gabriel-Welsch and Quiot) for post-hoc comparisons, as it corrects for Type I errors,

with adjustment to avoid Type II errors, and handles unequal group sizes and unequal variance.

Result Knowledge and stigmatic cognitions

To test the hypothesis: What shape do the relations between different types of knowledge and stigmatic cognitions have?, we created two bivariate scatterplots to see the relations and conducted curve estimations.

Knowledge of non-traditional diagnoses. The first curve estimation was conducted to see the relation between knowledge of Non-traditional diagnoses and stigmatic cognitions (see Figure 1). The linear shape resulted in non-significant parameter estimate, F (1, 240) = 1.18, p > .28, R2 = .01, accounting for only 1% of the variance in stigmatic cognition -. The quadratic model showed significant results, F (2, 239) = 4.49, p <.01. This model accounted for an additional 4% (R2 = .04). Thus, knowledge of non-traditional forms of mental illnesses had a negative quadratic association with stigmatic cognitions: The people who had the least amounts of stigmatic cognitions were those who could identify the fewest and most forms of non-traditional diagnoses. Our expectation that the relation would be a positive U-shaped function was not supported.

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Figure.1 Curve estimate of stigma levels on knowledge dimension Non-traditional diagnoses.

Knowledge of traditional diagnoses

The second curve estimation was conducted on knowledge of traditional diagnoses and stigmatic cognition (see Figure 2), attempting to fit both the linear and quadratic shapes. The linear model, F (1, 239) = 56.71, p < .001, R2 = .19, accounted for 19% of the variance in stigmatic cognition. The quadratic model was also significant, F (2, 238) = 28.42, p < .001, R2 = .19. The additional variance accounted for by the quadratic shape was not significant. Thus, the association was linear and negative: the more forms of diagnoses people could identify, the fewer stigma they held. Our expectation for a U-shaped function was not supported here, either.

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Figure 2. Curve estimation of stigma levels on knowledge dimension Forms of traditional diagnoses.

Knowledge through association and stigmatic cognition

The one-way ANOVA result showed that there was a significant overall difference across the 15 different groups of association combinations on the amount of stigmatic

cognition they house (see Table 4), F (14,227) = 4.24, p < .001. The post-hoc test, using R-E-G-W-Q, showed that those who indicated they had only “Work/school” or “no” association had significantly more stigmatic cognitions than all other combinations. Those with the most associations, those combining self and others, and the combination of having at least on friend and one family member who had mental illnesses held the fewest stigmatic cognitions. Although the highest and lowest levels of stigmatic cognitions were found in these groups as expected, there were other groups that were not significantly different. Thus, our hypothesis was only partially supported.

Table 4

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21 KNOWLEDGE PART IN STIGMA

Subset for alpha = 0.05

Association N 1 2

1. Myself + Family + Friend + Work/School 28 3.15

2. Myself + Friend 8 3.15

3. Myself + Family + Friend 16 3.16

4. Family + Work/School 5 3.37

5. Myself 9 3.44

6. Myself + Family + Work/School 2 3.53 7. Myself + Friend + Work/School 12 3.54

8. Myself + Family 5 3.57

9. Family + Friend 18 3.62

10. Family + Friend + Work/School 12 3.72 3.72

11. Friend 30 3.90 3.90 12. Family 51 3.90 3.90 13. Friend + Work/School 15 3.92 3.92 14. None 18 4.74 15. Work/School 13 4.86 Sig. .20 .13 DISCUSSION

Our study was conducted to expand how different dimensions of knowledge and associations are related to stigmatic cognitions against mental illness. We expected

curvilinear associations between the dimensions of knowledge and stigmatic cognitions, were having the least or most knowledge would be related to holding fewer stigmatic attitudes, fears, and intentions.

Our hypotheses for basic types of knowledge—including knowledge of treatments and diagnoses, however, were not supported. Recognizing non-traditional forms of diagnoses was negatively quadratic related to stigmatic cognition. That is, people who could identify

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22 KNOWLEDGE PART IN STIGMA

more non-traditional forms of diagnoses had fewer stigmatic cognitions. Those who

identified the fewest non-traditional forms of diagnoses also had fewer stigmatic cognitions, but not as few as those with the highest levels of identifying non-traditional forms of

diagnoses. Moderate knowledge was associated with more stigmatic cognitions. Further, knowledge of traditional diagnoses was only linearly related. That is, people with better knowledge of traditional mental illnesses, such as depression and schizophrenia, held fewer stigmatic cognitions. We also expected that knowing others would be negatively related to stigmatic cognitions which was only partially supported by our findings, as it showed two subsets of groups, some of who were not different than those with the most or fewest associations.

These unexpected findings bear consideration. First, we found dimensions that others have not. Knowledge of traditional diagnoses fits the patterns found in some studies, but knowledge of non-traditional diagnoses did not. Further, we tapped associations, which has also not been examined in most of the research. Here, our findings were similar to patterns found in other research, but more illuminating. Thus, we believe we met our overall aim--to explore the contradictory results in previous literature. Our results suggest two ways the research and theory should be adjusted.

First, researchers should attend to multiple dimensions of knowledge, even beyond what we measured. Dividing the types of diagnoses revealed different associations with cognitions. One fit with previous research, where having more knowledge of traditional diagnoses was related to less stigmatic beliefs. We suspect, but cannot confirm, that

knowledge of treatment might look similar. This was because our measurement did not work out. As for knowledge of non-traditional diagnoses (e.g., mental illness including stress and grief), we can only speculate why the association was a negative quadratic curve. Some might have disagreed with the non-traditional diagnoses, but not stigmatize either. They would look like they did not know these diagnoses, explaining the negative curve. Thus, we suggest

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23 KNOWLEDGE PART IN STIGMA

probing these types of knowledge more. For example, researchers might develop measures asking what people know about these illnesses, rather than simply asking if they are or aren’t mental illnesses.

Second, we found an interesting pattern for associations that suggests further probing is needed. Participants with the most stigmatic beliefs either knew no one or only knew work/school associates. Work/school associations are not necessarily always chosen

associations. Nor are they necessarily close, intimate relationships, where people have more understanding, trust, and empathy. This may be why having work/school associates who have mental illnesses was associated with holding as many stigmatic beliefs as knowing no one. By comparison, having many associations, and associations including self and others, or close personal relationships (i.e., friends and family) was related to holding fewer stigmatic cognitions. We argue that this finding suggests that it is difficult to hold stigmas while having close personal relationships with others who are mentally ill, probably because of such relationships involve understanding others. However, we recognize that this idea, too needs more probing. We recommend studying not only what types of associations people have, but whether these quality and temporal stability of the relationships.

A third need is for studies that can speak to direction of associations and causality. Our data were cross-sectional, so we cannot know if the associations mean that knowledge leads to stigma or holding stigmas leads to avoiding personal contact and knowledge of people with mental illnesses. Both are possible.

Our study was not without limitations. Our sample size was neither large nor random. Almost half of the people that opened the survey closed it without answering any questions. This likely introduced a selection effect—where only people who were relatively open to answering questions about mental illnesses or felt a personal investment in our research continued. It could also be that our survey was too long or those who chose not to continue were not comfortable answering question in English. The latter is very possible, given we

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24 KNOWLEDGE PART IN STIGMA

focused on the Swedish population. We acknowledge, then, that we should not over-generalize our results.

As we stated above, our measures of knowledge presented substantial problems, and that the results for our measure of treatment was not reliable. We made substantial changes to the measures, which could have affected their psychometric properties. We highly

recommend that researchers focus attention on measurement.

Nonetheless, our study also had some strengths. It was conducted online, which allowed respondents to choose the time and environment for answering. We believe this eliminates some of the artificiality that could arise in lab environments or interviews. Another strength is that we conducted a pilot study to try to eliminate problems with our measures. Due to the feedback from the pilot, we made quite a few changes to the scales (look at Appendix 1,2, and 3). Although this may have made the measures easier to understand and shorter to complete, it may have also introduced measurement error. However, we measured several cognitive components of stigma, with the hope of broadening the scope of the research.

Future research could examine these components and what people actually do, in terms of their intentions and stigmatizing behaviours. The three components of Thornicroft et al., (2008) have validity in their claims, but we believe that these components need to be strengthened with associations. Different types and combinations of associations can affect stigma, both in more and less. The findings in this study when comparing different kinds of associations to stigmatic cognition was that the type of association made a difference. This could be considered in future research, to use measurement to look into the type of

association and the quality or intimacy of that relationship. Also, as mentioned previously more knowledge do not simply mean fewer stigmatic cognition or that less knowledge means more stigmatic cognition. What we concluded is that there are multiple dimensions of

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25 KNOWLEDGE PART IN STIGMA

further research should investigate the different dimensions of knowledge when measuring stigma.

In conclusion, association and different dimensions of knowledge have a relation to peoples' stigmatic cognitions. Moving forward to understanding the complexity of these associations may provide avenues for reducing stigmas in the future.

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26 KNOWLEDGE PART IN STIGMA

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Chambers, M., Guise, V., Välimäki, M., Botelho, A., Scott, A., Staniuliene, V., & Zanotti, R. (2010) Nurses’ attitudes to mental illness: A comparison of a sample of nurses from five European countries. International Journal of Nursing Studies.47,350-362. doi: https://doi.org/10.1016/j.ijnurstu.2009.08.008

Corrigan, P. W. (1998). The impact of stigma on severe mental illness. Cognitive and Behavioral Practice, 5(1), 201-222. doi: 10.1016/S1077-7229(98)80006-0.

Corrigan, P., Morris, S., Michaels, P., Rafacz, J., & Rüsch, N. (2012). Challenging the Public Stigma of Mental Illness: A Meta-Analysis of Outcome Studies. Psychiatric Services, 63(10), 963-973. doi: 10.1176/appi.ps.201100529

Corrigan, P. W., & Penn, D. L. (1999). Lessons from social psychology on discrediting psychiatric stigma. American Psychologist, 54(9), 765-776.

Corrigan, P. W., River, L., Lundin, R. K., Uphoff Wasowski, K., Campion, J., Mathisen, J.,Goldstein H., Bergman M., Gagnon C., & Kubiak, M. A. (2000). Stigmatizing attributions about mental illness. Journal of Community Psychology, 28, 91–102. Corrigan, P. W., & Watson, A. C. (2002a). Understanding the impact of stigma on people

with mental illness. World psychiatry : official journal of the World Psychiatric Association (WPA), 1(1), 16–20.

Corrigan, P. W., & Watson, A. C. (2002b). The paradox of self‐stigma and mental illness. Clinical Psychology: Science and Practice, 9(1), 35-53.

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Ebner, S. D., & Latner, D., J. (2013). Stigmatizing attitudes differ across mental health dissorders: A comparison of stigma across eating disorders, obesity and major depressive disorder. Journal of Nervous & Mental Disease. 201:281-285. doi:10.1097/NMD.0b013e318288e23f

Evans-Lacko, S., Little, K., Meltzer, H., Rose, D., Rhydderch, D., Henderson, C., &

Thornicroft, G. .(2010) Development and psychometric properties of the Mental Health Knowledge Schedule. Can J Psychiatry.55(7): 440-8.doi:10.1177/07074371005500707 Gabbard G.,O., Hyler S.,E., Schneider I. (1991) Homicidal maniacs and narcissistic parasites.

Stigmatization of mentally ill persons in the movies. Hosp Commun Psychiatry. 1991;42:1044–1048.

Goffman, E. (1963). Stigma:Den avvikandes roll och identitet. Stockholm, Sverige: Norstedts förlag.

Gray, A. J. (2002). Stigma in psychiatry. Journal of the Royal Society of Medicine, 95(2), 72– 76.

Griffiths, K. M., Christensen, H., & Jorm, A. F. (2008). Predictors of depression stigma. BMC Psychiatry, 8, 25.doi:http://doi.org/10.1186/1471-244X-8-25

Henderson, C., Evans-Lacko, S., & Thornicroft, G. (2013). Mental Illness Stigma, Help Seeking, and Public Health Programs. American Journal Of Public Health, 103(5), 777-780. doi: 10.2105/ajph.2012.301056

Horsfall, J., Cleary, M., & Hunt, E. G. (2010). Stigma in mental health: clients and professionals. Taylor & Francis, 31, 450-455. doi: http://dx.doi.org/10.3109/01612840903537167 Högberg, T., Magnusson, A., Ewertzon, M., & Lützen, K. (2008). Attitudes towards mental

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https://www.nimh.nih.gov/about/directors/thomas-insel/blog/2011/the-global-cost-of-mental-illness.shtml

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APPENDIX Appendix 1. Mental Health Knowledge Schedule (MAKS) (Strongly agree 1 – Slightly agree 5)

Note: Response range changed to Strongly agree 1 – Strongly Disagree 5

1. Most people with mental health problems want to have paid employment (true) 2. If a friend had a mental health problem, I know what advice to give them to get

professional help (true)

3. Medication can be an effective treatment for people with mental health problems (true)

4. Psychotherapy (e.g. talking therapy or counselling) can be an effective treatment for people with mental health problems (true)

5. People with severe mental health problems can fully recover (true)

6. Most people with mental health problems go to a healthcare professional to get help (false)

Note: Question 2 was changed to: “If a friend had mental health problem, I’d know how to advise him/her to get professional help”. This question was, according to the pilot test, hard because you might know how to advise someone but not what kind of advise. Question 5 was changed to: “Most people with mental health problems consult a healthcare professional to get help”. This question was rephrased to make it more specific.

The following items report agreement as to whether each condition is a type of mental illness: Depression (true)

Stress (false)

Schizophrenia (true)

Bipolar disorder (manic depression) (true) Drug addiction (true)

Grief (false)

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statement is a mental illness or not. Therefore, we changed all descriptions to statements adding is a type of mental illness after every word.

Appendix 2. Community attitudes towards the mentally ill – Swedish version (CAMI-S) CAMI-S

1. Residents should accept the location of mental health facilities in their neighbourhood to serve the needs of the local community.

2. Most persons who were once patients in a mental hospital can be trusted as baby sitters.

3. Locating mental health services in residential neighbourhoods does not endanger local residents.

4. Mental health facilities should be kept out of residential neighbourhoods.

5. Having mental patients living within residential neighbourhoods might be a good therapy, but the risks to the residents are too great.

6. Local residents have good reason to resist the location of mental health services in their neighbourhood.

7. Mental illness is an illness like any other.

8. We need to adopt a far more tolerant attitude towards the mentally ill in our society. 9. The mentally ill are far less of a danger than most people suppose.

10. It is best to avoid anyone who has mental problems.

11. I would not want to live next door to someone who has been mentally ill. 12. It is frightening to think of people with mental problems living in residential

neighbourhoods

13. The best way to handle the mentally ill is to keep them behind locked doors.

14. Residents have nothing to fear from people coming into their neighbourhood to obtain mental health services.

15. Less emphasis should be placed on protecting the public from the mentally ill. 16. The best therapy for many mental patients is to be part of a normal community 17. The mentally ill should not be treated as outcasts of society

18. As far as possible, mental health services should be provided through community-based facilities.

19. No one has the right to exclude the mentally ill from their neighbourhood. 20. The mentally ill should be isolated from the rest of the community.

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Note: Question 1 “Residence should except the location of mental health living in facilities in their neighborhood to serve the need of the local community”. This question was removed from the scale due to the pilot test showed this question hard to relate to.

Question 3 “Locating mental health service in residential neighborhoods does not endanger local residence”. This question was removed due to the pilot test suggested that also this question was hard to relate to.

Question 5 “Having mental patient living within residential neighborhoods might be a good therapy but the risk of the residence are too great”. This question was rephrased into:” Having mental patients living in residential neighborhoods exposes risk of danger to the residents”. The pilot test participants were unclear to what the phrase:” risk to the residents” referred to.

Question 6 “Local residence have good reason to resist the location of mental health service in their neighborhoods.” This question was removed due to the pilot test indicated it was too similar to question one that also was hard to relate on.

Question 7 “Mental illness is an illness like any other.” This question was rephrased into:” Mental illness is an illness like any other illness” to make it clearer.

Question 9 “The mentally ill are far less of a danger than most people suppose”. -This question was rephrased, to make it clearer, into:” The mentally ill are not as dangerous as most people suppose there are”.

Question 11 “I would not want to live next door to someone who has been mentally ill. ” This question was rephrased into: ”I would not want to live next door to someone who has been diagnosed with an mentally illness” to make it more clear.

Question 14 “Residents have nothing to fear from people coming into their neighborhood to obtain mental helat services”. This was removed because the pilot test pointed out that when seeking mental health services one is anonymous.

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34 KNOWLEDGE PART IN STIGMA

Question 18 “As far as possible mental health service should be provided through community-based facilities.” This question was removed because the pilot test said that the question was too uncertain.

Appendix 3. Fear of and behavioural intentions towards the mentally ill scale (FABI) 1. I am afraid of people with mental illness

2. Would you object to having mentally ill people living in your neighbourhood? 3. Would you avoid conversations with neighbours who had suffered from mental

illness?

4. Would you be willing to work with somebody with a mental illness?

5. Would you invite somebody into your home if you knew they suffered from mental illness?

6. Would you be worried about visiting somebody with a mental illness?

7. If somebody had been a former psychiatric patient, would you have them as a friend? 8. If somebody who had been a former psychiatric patient came to live next door to you,

would you greet them occasionally?

9. Would you have casual conversations with neighbours who had suffered from mental illness?

10. If somebody who had been a former psychiatric patient came to live next door to you, would you visit them?

Note: Question 2 changed to: “I object to having mentally ill people people living in my neighbourhood”.

Question 3: Changed to:” I would avoid conversations with neighbors who has suffered from mental illness”.

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35 KNOWLEDGE PART IN STIGMA

Question 5: Changed to: “I would invite those who suffered from a mental illness to my home.”

Question 6: Changed to: “I would not like to have friend who has been a former psychiatric patient.”

Question 7: This question was removed due to the pilot test indicated that it was hard to put it into reality.

Question 8: This question was removed because the pilot test said that if you don´t greet a neighbour you would probably not have an conversation with them.

Question 9: Changed to: “ I would not visit a former psychiatric patient that comes to live next door to me.”

Question 10: Changed to: “It would bother me if a mentally ill person attends my school”.

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Appendix 4. Association Code.

Association Coded Group Nr

1. None 0 0 2. Myself 2 2 3. Family 4 4 4. Friend 7 7 5. Work/School 10 10 6. Myself + Family - 6 7. Myself + Friend - 9 8. Myself + Work/School - 12

9. Myself + Family + Work/School - 16

10. Myself + Friend + Work/School - 19

11. Myself+Family+Friend - 13 12. Myself+Family+Friend+Work/School - 23 13. Family+Friend - 11 14. Family+Work/school - 14 15. Family+Friend+Work/school - 21 16. Friend+Work/School - 17

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37 KNOWLEDGE PART IN STIGMA

Appendix 5. Survey. Thank you for your interest!

We are two psychology students from Örebro University that are writing a thesis for our bachelor degree. This questionnaire will ask your opinion and takes less than 10 minutes to complete. The questionnaire is based on statements such as: " People with mental illness can take care of themselves " followed by multiple answers. For each statement respond with the answer you most agree with.

The study follows the ethical principle of research which means that the results from this data collected will only be used in research purpose for this study. Your answers will be

anonymous and confidential. It is voluntary to participate and you have the rights to drop out whenever you want.

If you have any questions, don´t hesitate to contact us: Henrik Ho & Jacqueline Jaconelli

Contactorebrosurvey@gmail.com

How to fill in the paper survey

Below you can see how you mark an answer option in the check boxes, and how you change a selection.

The answer option has been marked correctly

The answer option has been marked incorrectly, the cross must be in the middle of the box

The answer option has been marked incorrectly, the cross is too strong Changed selection, the answer option will not be counted as being marked

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1 EXEMPEL TITEL Gender Male Female Other Age

Do you have an education? No

Yes Ongoing

In which category is your education? Technology

Economi

Health care, Medicine Journalism, Communication Law and Legal Studies Art, Design, Media Natural science Religion Education

Social work, Welfare Social Science, Psychology Other

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2 EXEMPEL TITEL

How many semesters have you studied? 1 2 3 4 5 6 7 8 9 10 11+

What semester are you on? 1 2 3 4 5 6 7 8 9 10 11+

I know a person with/who had a mental illness which is... Myself

A family member A friend

A work/School Associate None

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3 EXEMPEL TITEL

I work with mental health as a... Scientist

Psychologist/Therapist Doctor

Teacher Other

I dont work in mental health care

For each statements please select the answer that you most agree with ranging between 1(Strongly agree) to 5(Strongly disagree)

1. Most persons who were once patients in a mental hospital can be trusted as a babysitter Strongly agree Agree Neutral Disagree Strongly disagree

2. Mental health facilities should be kept out of residential neighbourhoods Strongly agree

Agree Neutral Disagree

Strongly disagree

3. Having mental patients living in residential neighbourhoods exposes risk of danger to the residents Strongly agree Agree Neutral Disagree Strongly disagree

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4 EXEMPEL TITEL

4. Mental illness is an illness like any other illness Strongly agree

Agree Neutral Disagree

Strongly disagree

5. We need to adopt a far more tolerant attitude towards the mentally ill in our society Strongly agree

Agree Neutral Disagree

Strongly disagree

6. The mentally ill are not as dangerous as most people suppose they are Strongly agree

Agree Neutral Disagree

Strongly disagree

7. It is best to avoid anyone who has mental problems Strongly agree

Agree Neutral Disagree

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5 EXEMPEL TITEL

8. I would not want to live next door to someone who has been diagnosed with an mental illness Strongly agree Agree Neutral Disagree Strongly disagree

9. It is frightening to think of people with mental problems living in residential neighbourhoods Strongly agree Agree Neutral Disagree Strongly disagree

10. The best way to handle the mentally ill is to keep them behind locked doors Strongly agree

Agree Neutral Disagree

Strongly disagree

11. Less emphasis should be placed to protect the public from the mentally ill Strongly agree

Agree Neutral Disagree

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6 EXEMPEL TITEL

12. The best therapy for many mental patients is to be part of a normal community Strongly agree

Agree Neutral Disagree

Strongly disagree

13. The mentally ill should not be treated as outcasts of society Strongly agree

Agree Neutral Disagree

Strongly disagree

14. No one has the right to exclude the mentally ill from their neighbourhood Strongly agree

Agree Neutral Disagree

Strongly disagree

15. The mentally ill should be isolated from the rest of the community Strongly agree

Agree Neutral Disagree

Strongly disagree

For each statement please select the answer that you think is correct, ranging between 1(Strongly agree) to 5(Strongly disagree).

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7 EXEMPEL TITEL

16. Most people with mental health problems wants to have paid employment Strongly agree

Agree Neutral Disagree

Strongly disagree

17. If a friend had mental health problem, I'd know how to advise him/her to get professional help Strongly agree Agree Neutral Disagree Strongly disagree

18. Medication is an effective treatment for people with mental health problems Strongly agree

Agree Neutral Disagree

Strongly disagree

19. People with severe mental health problems can fully recover Strongly agree

Agree Neutral Disagree

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8 EXEMPEL TITEL

20. Most people with mental health problems consult a healthcare professional to get help Strongly agree Agree Neutral Disagree Strongly disagree

21. Psychotherapy (e.g. taking therapy or counselling) is an effective treatment for people with mental health problems

Strongly agree Agree

Neutral Disagree

Strongly disagree

22. Depression is a type of mental illness Strongly agree

Agree Neutral Disagree

Strongly disagree

23. Stress is a type of mental illness Strongly agree

Agree Neutral Disagree

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9 EXEMPEL TITEL

24. Schizophrenia is a type of mental illness Strongly agree

Agree Neutral Disagree

Strongly disagree

25. Bipolar is a type of mental illness Strongly agree

Agree Neutral Disagree

Strongly disagree

26. Drug addiction is a type of mental illness Strongly agree

Agree Neutral Disagree

Strongly disagree

27. Grief is a type of mental illness Strongly agree

Agree Neutral Disagree

References

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Pedagogen är mycket målmedveten och tycks ha en röd tråd genom hela samlingen som sedan ska leda fram till ett bestämt mål, något som hon också berättar för barnen redan i