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Attitudes of Flemish physiotherapy students towards mental health and psychiatry
Physiotherapy 96 (2010) 44–51
Attitudes of Flemish physiotherapy students towards mental health and psychiatry Michel Probst ∗ , Jos Peuskens Department of Rehabilitation Sciences and Physiotherapy, Faculty of Kinesiology and Rehabilitation Sciences, K.U. Leuven and UPC-K.U. Leuven, Campus Kortenberg, Tervuursevest 101, 3001 Leuven, Belgium
Abstract Objectives In general, psychiatry is not very popular among healthcare providers, although no information is available concerning the attitudes of physiotherapy students towards mental heath. This study examined the attitudes of physiotherapy students towards psychiatry considering the subject’s gender, previous experience with psychiatry and the impact of a specific course. Method This experimental study compared the attitudes of physiotherapy students (n = 219) with those of students without a biomedical background (n = 112) towards psychiatry. All students were between 17 and 28 years of age, and completed an established international questionnaire entitled ‘Attitudes Towards Psychiatry’. Within the group of physiotherapy students, the effect of a 65-hour course on psychiatric rehabilitation on their attitudes was evaluated. Results Attitudes towards psychiatry were moderately positive [mean (SD) 103.3 (9.9)]. There was a small but significant difference between physiotherapy students and non-medical students (Cohen’s d = 0.31). Female students had a more positive attitude towards psychiatry than their male peers (Cohen’s d = 0.44). Prior experience with mental illness was associated with more positive attitudes (Cohen’s d = 0.68). Attitudes increased in positivity after completion of a psychiatry course (Cohen’s d = 0.72). Discussion and conclusion To ensure basic physiotherapeutic treatment for the mentally ill, physiotherapy education should aim to promote positive attitudes towards mental illness as well as psychiatry. High-quality courses and personal interaction with patients are the best strategies to achieve this goal. © 2009 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved. Keywords: Attitudes of health personnel; Psychiatry; Mental health; Physiotherapy education; Students
Introduction Psychiatric disorders and mental health problems are common sources of suffering and impairment, not only for the mentally ill themselves but also for close family and friends. According to the World Health Report [1], there are 450 million people suffering from mental illness worldwide. National and international campaigns aim to destigmatise mental illness. Stigma is defined as an identifying mark of disgrace or discredit that sets a person aside from others [2]. Stigmatisation is the process wherein one condition or aspect of an individual is attributively linked to some pervasive dimension of the target person’s identity [3]. It is a negative effect of a ∗
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label [4] or the process of establishing or accepting deviant identities [5]. According to Corrigan et al. [6,7], stigma is another term for prejudice based on negative stereotyping. The clear inference is that the ‘negative’ aspect reflects not only unfavourable stereotypes, but also the negative attitudes and adverse behaviour of the stigmatiser [8]. Stigma and unfavourable attitudes towards psychiatric patients and mental illness or psychiatry still exist among the general population and the medical professions at large [9]. People with mental illnesses are often wrongly accused of being violent, unpredictable, helpless, less competent and less trustworthy, and they are confronted with misrecognition, prejudice, confusion and fear [6]. These negative responses to people who have been identified as having a mental illness are seen as a major obstacle to recovery by limiting their opportunities and undermining their self-esteem [10].
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Psychiatry also receives frequent qualitative comments such as being a pseudo-science, ineffective, too theoretical, abstract and lacking positive results [11]. Furthermore, a career in this field is regarded as depressing and emotionally draining, since psychiatrists are required to deal with the mentally ill and put themselves at risk of personal harm [11]. This prejudice also influences the study and career choices made by young people. Mental health, especially psychiatry, is not an area favoured by healthcare providers, including physiotherapists. Research revealed that healthcare providers feel unprepared to support mental health needs [12]. Curricula in schools of physiotherapy differ, and not all healthcare workers show interest in this type of medical care. It might be expected that physiotherapists, since they are healthcare providers, may have developed a certain knowledge and expertise in this domain [12]. The research of van der Horst et al. [13] reveals that it is very plausible that physiotherapists, even those in primary care, are confronted with patients coping with complex mental problems. Some somatic disorders within the physiotherapy domain (e.g. chronic obstructive pulmonary disease, cerebrovascular or cardiovascular diseases) may involve psychiatric co-morbidity [14]. In contrast to medical students, no information is available regarding physiotherapy students’ attitudes towards mental health and psychiatry. This study examined the attitudes of Flemish physiotherapy students towards mental health and psychiatry. It sought to answer the following questions, based on previous research with medical students (Fig. 1): • Do physiotherapy students differ from students without a biomedical background in their attitudes towards mental health (A)? • Do first- and second-year physiotherapy students differ in their attitudes (B)? • Do female physiotherapy students have a more positive attitude towards mental health than male students (C1 and C2)? • Do physiotherapy students with experience in psychiatry (i.e. those with contact with mentally ill relatives or patients) have a more positive attitude towards psychiatry than students without previous experience (D)? • Do educational seminars of psychiatry (lectures and courses) have an impact on the attitudes of physiotherapy students (E)? • Do examination results following a psychiatry course reflect the attitudes of students towards psychiatry (F)? Based on findings in the medical literature [15–17], it was expected that physiotherapy students would have a more positive attitude towards psychiatry than students without a biomedical background. The cohort was compared with non-medical students in order to avoid bias. Women were expected to report a more positive attitude towards psychiatry than men. The contact hypothesis assumes that students who are more familiar with mental illness through previous
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psychiatric contact or personal history would have more positive attitudes about mental illness than students without previous exposure. It was also hypothesised that there would be a positive change in attitude towards psychiatry following educational seminars, and that the results of the examination would reflect students’ attitudes towards psychiatry. This last statement was inspired by the idea that subjects with a negative attitude will perform poorly in examinations and vice versa [18].
Methods Subjects The entire sample consisted of 331 students from various disciplines attending the Catholic University Leuven (K.U.L), Belgium (Flanders) during the 2006–2007 academic year. The experimental group consisted of 219 of the 285 officially registered first- and second-year students of rehabilitation sciences and physiotherapy. The mean (SD) age was 18.8 (1.1) years (range 17–24). Forty-four students did not attend the lecture (lectures are not mandatory) at the time of the first assessment. Twenty-two questionnaires were incomplete and thus excluded from the analyses. The comparison group was a convenience sample and consisted of 112 undergraduate students recruited from non-medical disciplines (social sciences, law, theology, communication sciences). The mean (SD) age of the control group was 20.2 (2.6) years (range 17–28). The experimental group was divided into two subgroups: first- (n = 126) and second-year students (n = 93). Of the 219 physiotherapy students, 155 students (74% of all first years and 67% of all second years) were retested after 20 weeks in order to assess any change in attitude and whether or not they had taken the psychiatry course. Not all of the students who completed the first assessment attended the course during the retest. The physiotherapy discipline at the K.U.L. is composed of 5 years (3 years as an undergraduate and 2 years as a graduate). Over the past two decades, the majority of physiotherapy students have been female. The study was approved by the ethical and research committee of the K.U.L. All participants gave their informed consent. The students were not paid for their participation. Instrument The Attitudes Towards Psychiatry (ATP-30) scale [19] is an ordinal scale developed in Canada for measuring medical students’ attitudes towards psychiatry. The scale measures attitudes towards: mental illness and treatment; psychiatric patients, psychiatric institutions and psychiatrists; and teaching, knowledge and career choice. It is a 30-item Likert-type scale. Briefly, respondents are asked to express their agreement or disagreement with each item in terms of
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M. Probst, J. Peuskens / Physiotherapy 96 (2010) 44–51
Fig. 1. Flow of participants through the study.
a five-point scale (1 = agree strongly, 5 = disagree strongly). Positive phrased items (Numbers 4, 5, 9–12, 14, 15, 18, 20, 23 and 27–29) are reversed by subtracting the score from 6. A total score is calculated by adding together all item scores. A high score on the scale (maximum 150) indicates a positive attitude towards psychiatry. A score of 90 is considered to represent the neutral point of the scale. The scale was chosen because it is used worldwide, and there is currently no specific tool to assess the attitudes of physiotherapy students towards psychiatry. The formulation of the items of the ATP-30 is general and not specifically dedicated to a specific group. The instrument is reliable and valid [15,19]. The ATP-30 scale was translated into Dutch by two research assistants and back-translated by an independent translator. In addition to the sociodemographic characteristics of the students, their experience with psychiatry (contact with men-
tally ill relatives or patients, or personal experience) was also documented. The psychometric characteristics of the instrument were assessed previously. Procedure The questionnaires were distributed during a non-medical course at the beginning of the academic year (time 1 = first week) and repeated after 20 weeks (time 2 = first week of the second semester). A non-medical course was selected to exclude a possible relationship between non-attendance of the course on psychiatry and attitude towards psychiatry. At the time of the first assessment, neither of the groups had completed a course in the mental health domain. Between the two assessments, the second-year students completed a 67-hour course entitled ‘Pathology and psychomotor rehabil-
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itation for patients with psychopathological illnesses’. This theoretical course consisted of 26 hours of psychopathology based on the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV R) [20], given by a psychiatrist, and 26 hours of psychomotor rehabilitation and 15 hours of practical relaxation exercises, given by experienced physiotherapists in the field of mental health and psychiatry. The psychomotor rehabilitation portion of the course consisted of specific interventions and strategies within a biopsychosocial frame related to different psychiatric disorders (somatic disorders, eating disorders, anxiety, depression, post-traumatic stress disorders, chronic fatigue syndrome and fibromyaligia, etc.) and methods dealing with different types of behaviour. Second-year students were retested after undergoing a written examination of the course. The information concerning the study was given to the students by an independent researcher. Participation in the study was voluntary and anonymous.
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for the item and the total score on the instrument, was significant for all items (P < 0.01) and ranged between 0.16 (Item 29) and 0.62 (Item 13). This result reflects how consistently an item is measuring the same concept as the instrument as a whole. Therefore, high values are desirable. The split half reliability for the ATP-30 was found to be high (r = 0.84; P < 0.01). The correlation between the first and second half of the questionnaire was 0.73 (P < 0.01). ATP-30: general results Examining the entire group of students, moderately favourable attitudes towards psychiatry and mental illness were found. The mean (SD) ATP score for all respondents was 104.5 (10.5) (range 58–138; median 105; interquartile range 99–111). Fifteen students scored below the neutral point of 90.
Statistical analyses Comparisons Since the data follow a normal distribution, parametric tests were used to assess the descriptive characteristics and differences. To enable comparison with other studies, the results are presented as means and standard deviations. For the psychometric characteristics of the questionnaire, reliability was determined by internal consistency (Cronbach’s alpha coefficient), and the average inter-item and item-total correlation. Student’s t-test was calculated to establish any differences between medical and non-medical students, firstand second-year students, males and females, students with and without experience of mental illness, and students with and without a positive examination result following the psychiatry course. Mean differences, 95% confidence intervals (CI) of differences of means and Cohen’s d were calculated using means and standard deviations. For Cohen’s d, the following guidelines were used: effects between 0.20 and 0.50 were considered small, between 0.50 and 0.80 were considered medium, and higher than 0.80 were considered large [21]. A repeated measures analysis of variance was used to analyse the difference in the groups between the two assessment points. Post-hoc contrast was conducted by the Scheffe method for complex contrast. P < 0.05 was considered to be significant. All data were coded and analysed using Statistica [22].
Results Psychometric characteristics of the ATP-30 Cronbach’s alpha of the ATP-30 for the total sample (n = 331) was 0.85, the average inter-item correlation was 0.19 and the item-total correlation, which is defined as the average correlation between the individual response scores
The non-medical students scored significantly higher than the physiotherapy students (t = 2.67, P < 0.01; mean difference 3.14, 95% CI 2.2 to 6.8; Cohen’s d = 0.31). The attitudes of first-year students did not differ from those of second-year students at the beginning of the academic year. Female students scored significantly higher than male students (t = 2.9, P < 0.01; mean difference 4.0, 95% CI 1.3 to 6.7; Cohen’s d = 0.44). Students with experience of psychiatry scored significantly higher than students without previous experience (t = 4.72, P < 0.001; mean difference 6.3, 95% CI 3.7 to 8.9; Cohen’s d = 0.68). Educational seminars of psychiatry and examination results Repeated measures analysis of variance showed an interaction time × group effect [F(153.2) = 45.67, P < 0.001], and post-hoc comparisons (Scheffe P < 0.05) showed significant differences between time 1 and time 2 for the second-year students (mean difference 5.9, 95% CI 3.3 to 8.3; Cohen’s d = 0.72). No significant differences were found for the firstyear students. As seen in Table 1, second-year students reported significantly better attitudes towards psychiatry after completing a psychiatry course compared with first-year students who did not complete the course. At time 1, neither the whole group (n = 219) nor the group with only one test score (n = 64) revealed significant differences in ATP-30 scores with the retest subgroup (i.e. the first- and second-year students; n = 155). Examination results at the end of the psychiatry course did not reflect students’ attitudes towards psychiatry. No significant correlations were found between the marks obtained and general attitude towards psychiatry.
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Table 1 Difference in attitudes towards psychiatry between groups: mean (standard deviation). Experimental group (A)b
Comparison group
(D)
Physiotherapy students (n = 219) 103.9 (8.9) First-year physiotherapy students (n = 126) 103.4 (8.9) Female physiotherapy students (n = 154) 105.1 (8.3) Female non-medical students (n = 69) 109.4 (10.3) Physiotherapy students with experience of mental illness (n = 63)
ATP-30 (E) ATP-30 First year ATP-30 Second year (F)
108.5 (10.8) Time 1: beginning of academic year 103.2 (8.1) (n = 93) 102.8 (8.1) (n = 62) Second-year physiotherapy student: failed examination (n = 15)
ATP-30
102.3 (9.1)
ATP-30 (B) ATP-30 (C1) ATP-30 (C2)
P-value (n = 112)a
Non-medical students 107.1 (11.5) Second-year physiotherapy students (n = 93)a 104.7 (9.2) Male physiotherapy students (n = 65)a 101.1 (9.9) Male non-medical students (n = 43)a 103.4 (12.3) Physiotherapy students without experience of mental illness (n = 146)a 102.2 (7.4) Time 2c : after 20 weeks 101.3 (8.3) (n = 93) 108.7 (8.4)d (n = 62) Second-year physiotherapy student: passed examinationd (n = 47)a 103.0 (7.9)
<0.01 ns <0.01 <0.01
<0.01 ns <0.01
ns
ns, not significant. a Student’s t-test, *P < 0.01. b (A), (B), (C), etc. refers to the flow chart diagram (Fig. 1). c Repeated measures analysis of variance, post-hoc Scheffe. d After psychiatry course.
Discussion The unpopularity of psychiatry as a field of specialisation has been a source of international concern [17,23–26], leading to studies throughout the world on attitudes towards psychiatry. In contrast to studies concerning the general attitudes of psychology students [27] and the attitudes of nursing students [28] towards psychiatry [9,15,19,26], no comparable study is available regarding the attitude of physiotherapy students towards mental health and psychiatry. The current study assessed the attitudes of physiotherapy students towards psychiatry. In general, physiotherapy students and students without a biomedical background showed a moderately positive attitude towards psychiatry, and non-medical students scored higher than physiotherapy students. This could be explained by the response style. Non-medical students scored more items as neutral/no opinion (score 3), while physiotherapy students scored in a differentiated way (scores 1–5). Table 2 shows the results from previous studies of students’ attitudes using the same questionnaire (ATP-30) in widely diverse cultures. In general, the scores from the present study compare favourably with those reported by different authors. The variation in the results can be explained by social characteristics, regional bias, varying (medical) school admission requirements, regional differences between universities, varying educational concepts (different teaching methods and course content, amount of feedback, intensity of training, patient sample, personal responsibility, problembased learning vs lectures, and whether or not there is direct contact with patients), employment perspectives [15], cultural background [29], personality and clinical competency [30].
The data from the current study reveal substantial differences between male and female students. Female students had more positive and empathetic attitudes towards those with emotional and mental problems, and more positive attitudes towards psychiatry as a whole. Many other studies [15,23,31–35], but not all [26–38], have also reported a gender difference. Prior experience with mental illness was associated with more positive attitudes towards psychiatry, as found in other studies [15,26,35,37,39,40]. However, this was not found in the study by Creed and Goldberg [32]. Further research needs to evaluate the need for a specific questionnaire for physiotherapy students, and to elaborate on the definition, type and duration of prior experience. The following questions should be considered: was the experience acquired through a campaign of public education or direct personal contact with mental illness, or interpersonal skills developed through training or through indirect contact by lectures, seminars, courses and films? What type of contact was it: prolonged (working with mental health patients) or brief (visiting a psychiatric hospital), voluntary or involuntary (such as knowing a person who has been hospitalised)? A specific course in psychiatry and psychiatric rehabilitation had a positive influence on the attitudes of second-year physiotherapy students. As shown previously [9,18,32,34,36,38,41–43], a course and psychiatry practice seem to have a positive influence on students’ attitudes, although some studies did not find a measurable change [9,15,33]. Stigma can be challenged by social psychology through strategies of protest (to suppress stigmatisation thoughts), education and contact [6,7,35]. Courses and practice are two important possible strategies to help overcome stigma. Nev-
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Table 2 A summary of published ATP-30 scores: mean (standard deviation). Authors
Subjects
Burra 1982 [19]
Medical students (n = 189) Students of psychiatry, Queens (n = 18) Students of psychiatry, Canada (n = 144) Students of occupational therapy (n = 63)
103.8 (10.9) 116.3 (9.6) 116.0 (11.9) 111.7 (9.9)
Alexander 1986 [23]
Medical students, Scotland (n = 79)
104.3 (10.9)
Creed 1987 [32]
Medical students, England (n = 261) Before practice in psychiatry After practice in psychiatry
98.1 (9.7) 108.1 (11.3)
Medical students, Dublin (n = 110) Pre-clerkship Post-clerkship
98.4 (3.5) 107.3 (2.3)
Medical students, Nottingham (n = 110) Before practice in psychiatry After practice in psychiatry
109.1 (8.8) 114.8 (9.1)
Sloan 1996 [18]
Singh 1998 [36]
ATP-30 [mean (SD) score]
Strebel 2000 [37]
Medical students, Ludenscheid, Germany (n = 105)
Baxter 2001 [24]
Medical students, Nottingham (n = 100) Pre-attachment Post-attachment Follow-up (1 year)
104.6 (13.4) 112.6 (8.7) 115.3 (7.5) 82.1 (7.9)
Al Ansari 2002 [31]
Medical students, Arabian Gulf (n = 122)
105.8 (13.3)
Maidment 2003 [16]
Prospective medical students (n = 837)
110.0 (12.8)
McParland 2003 [17]
Medical students (n = 378)
107.7 (11.9)
Reddy 2005 [34]
Medical students, Malaysia (n = 122) Pre-clinical posting in psychiatry Post-clinical posting in psychiatry
108.3 (8.1) 110.4 (10.9)
Medical students, Germany (n = 508)
106.8 (12.9)
Kuhnigk 2007 [15]
ertheless, education can both aggravate and reduce stigma [44]. The knowledge achieved through lectures and written sources may serve as a mode of decreasing stigma but, at the same time, students’ lack of appropriate skills for managing severe patients in the hospital or in private practice may increase stigma [44]. Direct experience is probably a more important agent of change than course material to build and modify attitudes [45]. Examination results following the psychiatry course did not reflect students’ attitudes towards psychiatry. This is in agreement with other studies [32,43], and in disagreement with the study by Sloan et al. [18]. A positive attitude is not a guarantee for an enduring attitude, but it can influence the ability of future physiotherapists to treat patients with emotional problems. Lack of practical acquaintance with mental health problems is often associated with prejudiced attitudes about mental illness [40]. There is no consensus between existing studies about whether a positive attitude acquired by contact is lasting. Wilkinson et al. suggested that changes in general attitudes towards psychiatry remain stable for at least 1 year [43], Burra et al. [19] and Creed and Goldberg [32] found that changes were temporary, Fabrega [33] did not find any changes over time, and Sivukumar et al. [42] and Baxter et al. [24] found that positive attitudes declined over time.
Physiotherapy courses are not identical in all countries. Some curricula show little interest in domains such as mental health and psychiatry, so physiotherapists are not given the opportunities to develop the necessary skills. Little interest in this area also implies that in mental health care, physiotherapy remains an unknown domain with few effective therapeutic interventions. Lack of interest for this domain by physiotherapists means that a plausible market is created and then filled in by other ‘alternative’ help providers. These providers use a number of physiotherapeutic techniques without any quality control or scientific base. Therefore, to reduce the stigma, physiotherapy training should equip students with appropriate attitudes as well as knowledge and skills. It is important that students develop positive attitudes towards patients with psychiatric disorders as they will encounter them in different fields of physiotherapy, and also because this will have an influence on their later actions as practising physiotherapists. This is not only valid specifically in the context of mental health care, but also in the general practice of physiotherapy where patients often show (undiagnosed) psychological and psychosomatic problems. Problems that still need to be addressed include the use of paper and pencil investigations or self-report research where subjects are asked to state their opinions about different aspects of mental health and mental illness. The ATP-30
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questionnaire was not specifically developed for physiotherapists, and its items refer not only to attitudes but also to facts and values. In addition, the students may feel obligated to give the desired responses [39]. Students may doubt the anonymity of questionnaires, and adjust their responses or offer the expected response after the seminars [18]. Unfortunately, at the time of assessment, it was not possible to study the differences in characteristics between second-year students who did attend the course compared with those who did not. Comparison of the present results with other studies must be undertaken with caution due to differences in students’ educational levels in different countries. This study is limited to the attitudes of physiotherapy students towards mental health and psychiatry as a specialisation. Further investigations must pay particular attention to the attitudes of physiotherapists in the field, the durability of these positive results over time and attitudes towards the person suffering from mental illness. Physiotherapy in mental health and psychiatry is still in its early stage of development but is gaining more attention [46–48]. The term ‘development’ is not only related to having the skills to treat physical issues and problems in the psychiatric population, but also to developing specific physiotherapy strategies or techniques. Specific physiotherapy techniques for somatoform disorders [49–51], eating disorders [52–56] and depression [57,58], as well as specific approaches such as basic body awareness therapy in the Scandinavian countries [59,60] and psychomotor therapy in Belgium [61], are being developed. In order to ensure adequate basic physiotherapeutic care for people with mental illnesses, it should be a fundamental aim of physiotherapy training/education to promote positive attitudes towards people with mental illnesses and towards psychiatry through high-quality courses and personal patient contact or practice. From the authors’ point of view, psychiatric skills are essential in the general practice of physiotherapy.
Acknowledgement This study was conducted with the aid of Evy Vanhoutte and Vicky Docx. The authors would like to thank them for data collection and entry. Ethical approval: Ethical Commission of Biomedical Sciences, K.U. Leuven, Belgium. Conflict of interest: None declared.
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M. Probst, J. Peuskens / Physiotherapy 96 (2010) 44–51 [29] Soufi HE, Raoof AM. Attitude of medical students towards psychiatry. Med Educ 1992;26:38–41. [30] Mowbray RM, Davies BM, Biddle N. Psychiatry as a career choice. Aust NZ J Psychiatr 1990;24:57–64. [31] Al Ansari A, Alsadadi A. Attitude of Arabian Gulf university medical students towards psychiatry. Educ Health (Abingdon) 2002;15:180–8. [32] Creed F, Goldberg D. Students’ attitudes towards psychiatry. Med Educ 1987;21:227–34. [33] Fabrega Jr H. Does a clerkship affect students’ views of psychiatric patients? J Nerv Ment Dis 1995;183:736–42. [34] Reddy JP, Tan SM, Azmi MT, Shaharom MH, Rosdinom R, Maniam T, et al. The effect of a clinical posting in psychiatry on the attitudes of medical students towards psychiatry and mental illness in a Malaysian medical school. Ann Acad Med Singapore 2005;34:505–10. [35] Watson A, Miller FE, Lyons JS. Adolescent attitudes toward serious mental illness. J Nerv Ment Disease 2005;193:769–72. [36] Singh SP, Baxter H, Standen P, Duggan C. Changing the attitudes of ‘tomorrow’s doctors’ towards mental illness and psychiatry: a comparison of two teaching methods. Med Educ 1998;32:115–20. [37] Strebel B, Obladen M, Lehmann E, Gaebel W. Attitude of medical students to psychiatry. A study with the German translated, expanded version of the ATP-30. Nervenarzt 2000;71:205–12. [38] Wilkinson DG, Greer S, Toone BK. Medical students’ attitudes to psychiatry. Psychol Med 1983;13:185–92. [39] Addison SJ, Thorpe SJ. Factors involved in the formation of attitudes towards those who are mentally ill. Soc Psychiatry Psychiatr Epidemiol 2004;39:228–34. [40] Penn DL, Guynan K, Daily T, Spaulding WD, Garbin CP, Sullivan M. Dispelling the stigma of schizophrenia: what sort of information is best? Schizophr Bull 1994;20:567–78. [41] Mino Y, Yasuda N, Kanazawa S, Inoue S. Effects of medical education on attitudes towards mental illness among medical students: a five-year follow-up study. Acta Med Okayama 2000;54:127–32. [42] Sivakumar K, Wilkinson G, Toone BK, Greer S. Attitudes to psychiatry in doctors at the end of their first post-graduate year: two-year follow-up of a cohort of medical students. Psychol Med 1986;16: 457–60. [43] Wilkinson DG, Toone BK, Greer S. Medical students’ attitudes to psychiatry at the end of the clinical curriculum. Psychol Med 1983;13:655–8. [44] Ay P, Save D, Fidanoglu O. Does stigma concerning mental disorders differ through medical education? A survey among medical students in Istanbul. Soc Psychiatry Psychiatr Epidemiol 2006;41:63–7. [45] Wallach HS. Changes in attitudes towards mental illness following exposure. Community Ment Health J 2004;40:235–48. [46] Everett T, Donaghy M, Feaver S. Interventions for mental health. An evidence based approach for physiotherapists and occupational therapists. Edinburgh: Butterworth Heinemann; 2003.
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[47] Hare M. Physiotherapy in psychiatry. London: Heinemann Medical Books; 1986. [48] Hüter-Becker A, Dölken M. Physiotherapie in der Psychiatrie [Physiotherapy in psychiatry]. Stuttgart: Thieme; 2008. [49] Calvert P, Palmer C. Application of the cognitive therapy model to initial crisis assessment. Int J Ment Health Nurs 2003;12: 30–8. [50] Van Synghel M, Van Coppenolle H. The conversion syndrome: an indication for physiotherapy. In: Vermeer A, Bosscher R, Broadhead G, editors. Movement therapy across the lifespan. Amsterdam: VU University Press; 1997. [51] Dragesund T, Raheim M. Norwegian psychomotor physiotherapy and patients with chronic pain: patient’s perspective and body awareness. Physiother Theory Pract 2008;24:243–54. [52] Davison K. Physiotherapy in the treatment of anorexia nervosa. Physiotherapy 2007;74:62–4. [53] Nilsen M, Danielsen M, Gronlund G. Fysiotherapi of spisefastyrrelser [Physiotherapy in eating disorders]. Bergen: University of Bergen; 2006. [54] Probst M, Van Coppenolle H, Vandereycken W. Body experience in anorexia nervosa patients: an overview of therapeutic approaches. Eat Dis J Treat Prev 1995;3:186–98. [55] Probst M. In: Van Wilgen C, Geraets J, Marinus J, Nieuwboer A, Nijs J, editors. Kinesitherapie bij patiënten met eetstoornissen [Physiotherapy for patients with eating disorders]. Houten: Bohn Stafleu van Loghum; 2007. p. 62–73. [56] Catalan Matamoros DJ. Physiotherapy in mental health. A physiotherapeutic intervention in patients with eating disorders. Malaga: University of Malaga; 2007. [57] Knapen J, Van de Vliet P, Van Coppenolle H, David A, Peuskens J, Knapen K, et al. The effectiveness of two psychomotor therapy programmes on physical fitness and physical self-concept in nonpsychotic psychiatric patients: a randomized controlled trial. Clin Rehabil 2003;17:637–47. [58] Van de Vliet P. The physical self in clinically depressed patients. Leuven: K.U. Leuven; 2002. [59] Lundvik Gyllensten A. Basic body awareness therapy, assessment, treatment and interaction. Lund: Physiotherapy Lund; 2001. [60] Skjaerven LH, Kristoffersen K, Gard G. An eye for movement quality: a phenomenological study of movement quality reflecting a group of physiotherapists’ understanding of the phenomenon. Physiother Theory Pract 2008;24:13–27. [61] Probst M, Van de Vliet P. La thérapie psychomotrice appliquée aux patients psychiatriques adultes dans une perspective flamande [Psychomotor therapy with patients with psychiatric disorders in Flanders]. Eur Bull Adapt Phys Activ 2003;3:1–24. Available at http://www.eufapa.upol.cz/www/images/stories/files/Journals/ Compl Art vol2 iss1.pdf (last accessed 13/10/2009).
Available online at www.sciencedirect.com
Attitudes of Flemish physiotherapy students towards mental health and psychiatry Michel Probst ∗ , Jos Peuskens Department of Rehabilitation Sciences and Physiotherapy, Faculty of Kinesiology and Rehabilitation Sciences, K.U. Leuven and UPC-K.U. Leuven, Campus Kortenberg, Tervuursevest 101, 3001 Leuven, Belgium
Abstract Objectives In general, psychiatry is not very popular among healthcare providers, although no information is available concerning the attitudes of physiotherapy students towards mental heath. This study examined the attitudes of physiotherapy students towards psychiatry considering the subject’s gender, previous experience with psychiatry and the impact of a specific course. Method This experimental study compared the attitudes of physiotherapy students (n = 219) with those of students without a biomedical background (n = 112) towards psychiatry. All students were between 17 and 28 years of age, and completed an established international questionnaire entitled ‘Attitudes Towards Psychiatry’. Within the group of physiotherapy students, the effect of a 65-hour course on psychiatric rehabilitation on their attitudes was evaluated. Results Attitudes towards psychiatry were moderately positive [mean (SD) 103.3 (9.9)]. There was a small but significant difference between physiotherapy students and non-medical students (Cohen’s d = 0.31). Female students had a more positive attitude towards psychiatry than their male peers (Cohen’s d = 0.44). Prior experience with mental illness was associated with more positive attitudes (Cohen’s d = 0.68). Attitudes increased in positivity after completion of a psychiatry course (Cohen’s d = 0.72). Discussion and conclusion To ensure basic physiotherapeutic treatment for the mentally ill, physiotherapy education should aim to promote positive attitudes towards mental illness as well as psychiatry. High-quality courses and personal interaction with patients are the best strategies to achieve this goal. © 2009 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved. Keywords: Attitudes of health personnel; Psychiatry; Mental health; Physiotherapy education; Students
Introduction Psychiatric disorders and mental health problems are common sources of suffering and impairment, not only for the mentally ill themselves but also for close family and friends. According to the World Health Report [1], there are 450 million people suffering from mental illness worldwide. National and international campaigns aim to destigmatise mental illness. Stigma is defined as an identifying mark of disgrace or discredit that sets a person aside from others [2]. Stigmatisation is the process wherein one condition or aspect of an individual is attributively linked to some pervasive dimension of the target person’s identity [3]. It is a negative effect of a ∗
Corresponding author. Tel.: +32 2 7580578; fax: +32 2 7589878. E-mail address: [email protected] (M. Probst).
label [4] or the process of establishing or accepting deviant identities [5]. According to Corrigan et al. [6,7], stigma is another term for prejudice based on negative stereotyping. The clear inference is that the ‘negative’ aspect reflects not only unfavourable stereotypes, but also the negative attitudes and adverse behaviour of the stigmatiser [8]. Stigma and unfavourable attitudes towards psychiatric patients and mental illness or psychiatry still exist among the general population and the medical professions at large [9]. People with mental illnesses are often wrongly accused of being violent, unpredictable, helpless, less competent and less trustworthy, and they are confronted with misrecognition, prejudice, confusion and fear [6]. These negative responses to people who have been identified as having a mental illness are seen as a major obstacle to recovery by limiting their opportunities and undermining their self-esteem [10].
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Psychiatry also receives frequent qualitative comments such as being a pseudo-science, ineffective, too theoretical, abstract and lacking positive results [11]. Furthermore, a career in this field is regarded as depressing and emotionally draining, since psychiatrists are required to deal with the mentally ill and put themselves at risk of personal harm [11]. This prejudice also influences the study and career choices made by young people. Mental health, especially psychiatry, is not an area favoured by healthcare providers, including physiotherapists. Research revealed that healthcare providers feel unprepared to support mental health needs [12]. Curricula in schools of physiotherapy differ, and not all healthcare workers show interest in this type of medical care. It might be expected that physiotherapists, since they are healthcare providers, may have developed a certain knowledge and expertise in this domain [12]. The research of van der Horst et al. [13] reveals that it is very plausible that physiotherapists, even those in primary care, are confronted with patients coping with complex mental problems. Some somatic disorders within the physiotherapy domain (e.g. chronic obstructive pulmonary disease, cerebrovascular or cardiovascular diseases) may involve psychiatric co-morbidity [14]. In contrast to medical students, no information is available regarding physiotherapy students’ attitudes towards mental health and psychiatry. This study examined the attitudes of Flemish physiotherapy students towards mental health and psychiatry. It sought to answer the following questions, based on previous research with medical students (Fig. 1): • Do physiotherapy students differ from students without a biomedical background in their attitudes towards mental health (A)? • Do first- and second-year physiotherapy students differ in their attitudes (B)? • Do female physiotherapy students have a more positive attitude towards mental health than male students (C1 and C2)? • Do physiotherapy students with experience in psychiatry (i.e. those with contact with mentally ill relatives or patients) have a more positive attitude towards psychiatry than students without previous experience (D)? • Do educational seminars of psychiatry (lectures and courses) have an impact on the attitudes of physiotherapy students (E)? • Do examination results following a psychiatry course reflect the attitudes of students towards psychiatry (F)? Based on findings in the medical literature [15–17], it was expected that physiotherapy students would have a more positive attitude towards psychiatry than students without a biomedical background. The cohort was compared with non-medical students in order to avoid bias. Women were expected to report a more positive attitude towards psychiatry than men. The contact hypothesis assumes that students who are more familiar with mental illness through previous
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psychiatric contact or personal history would have more positive attitudes about mental illness than students without previous exposure. It was also hypothesised that there would be a positive change in attitude towards psychiatry following educational seminars, and that the results of the examination would reflect students’ attitudes towards psychiatry. This last statement was inspired by the idea that subjects with a negative attitude will perform poorly in examinations and vice versa [18].
Methods Subjects The entire sample consisted of 331 students from various disciplines attending the Catholic University Leuven (K.U.L), Belgium (Flanders) during the 2006–2007 academic year. The experimental group consisted of 219 of the 285 officially registered first- and second-year students of rehabilitation sciences and physiotherapy. The mean (SD) age was 18.8 (1.1) years (range 17–24). Forty-four students did not attend the lecture (lectures are not mandatory) at the time of the first assessment. Twenty-two questionnaires were incomplete and thus excluded from the analyses. The comparison group was a convenience sample and consisted of 112 undergraduate students recruited from non-medical disciplines (social sciences, law, theology, communication sciences). The mean (SD) age of the control group was 20.2 (2.6) years (range 17–28). The experimental group was divided into two subgroups: first- (n = 126) and second-year students (n = 93). Of the 219 physiotherapy students, 155 students (74% of all first years and 67% of all second years) were retested after 20 weeks in order to assess any change in attitude and whether or not they had taken the psychiatry course. Not all of the students who completed the first assessment attended the course during the retest. The physiotherapy discipline at the K.U.L. is composed of 5 years (3 years as an undergraduate and 2 years as a graduate). Over the past two decades, the majority of physiotherapy students have been female. The study was approved by the ethical and research committee of the K.U.L. All participants gave their informed consent. The students were not paid for their participation. Instrument The Attitudes Towards Psychiatry (ATP-30) scale [19] is an ordinal scale developed in Canada for measuring medical students’ attitudes towards psychiatry. The scale measures attitudes towards: mental illness and treatment; psychiatric patients, psychiatric institutions and psychiatrists; and teaching, knowledge and career choice. It is a 30-item Likert-type scale. Briefly, respondents are asked to express their agreement or disagreement with each item in terms of
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M. Probst, J. Peuskens / Physiotherapy 96 (2010) 44–51
Fig. 1. Flow of participants through the study.
a five-point scale (1 = agree strongly, 5 = disagree strongly). Positive phrased items (Numbers 4, 5, 9–12, 14, 15, 18, 20, 23 and 27–29) are reversed by subtracting the score from 6. A total score is calculated by adding together all item scores. A high score on the scale (maximum 150) indicates a positive attitude towards psychiatry. A score of 90 is considered to represent the neutral point of the scale. The scale was chosen because it is used worldwide, and there is currently no specific tool to assess the attitudes of physiotherapy students towards psychiatry. The formulation of the items of the ATP-30 is general and not specifically dedicated to a specific group. The instrument is reliable and valid [15,19]. The ATP-30 scale was translated into Dutch by two research assistants and back-translated by an independent translator. In addition to the sociodemographic characteristics of the students, their experience with psychiatry (contact with men-
tally ill relatives or patients, or personal experience) was also documented. The psychometric characteristics of the instrument were assessed previously. Procedure The questionnaires were distributed during a non-medical course at the beginning of the academic year (time 1 = first week) and repeated after 20 weeks (time 2 = first week of the second semester). A non-medical course was selected to exclude a possible relationship between non-attendance of the course on psychiatry and attitude towards psychiatry. At the time of the first assessment, neither of the groups had completed a course in the mental health domain. Between the two assessments, the second-year students completed a 67-hour course entitled ‘Pathology and psychomotor rehabil-
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itation for patients with psychopathological illnesses’. This theoretical course consisted of 26 hours of psychopathology based on the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV R) [20], given by a psychiatrist, and 26 hours of psychomotor rehabilitation and 15 hours of practical relaxation exercises, given by experienced physiotherapists in the field of mental health and psychiatry. The psychomotor rehabilitation portion of the course consisted of specific interventions and strategies within a biopsychosocial frame related to different psychiatric disorders (somatic disorders, eating disorders, anxiety, depression, post-traumatic stress disorders, chronic fatigue syndrome and fibromyaligia, etc.) and methods dealing with different types of behaviour. Second-year students were retested after undergoing a written examination of the course. The information concerning the study was given to the students by an independent researcher. Participation in the study was voluntary and anonymous.
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for the item and the total score on the instrument, was significant for all items (P < 0.01) and ranged between 0.16 (Item 29) and 0.62 (Item 13). This result reflects how consistently an item is measuring the same concept as the instrument as a whole. Therefore, high values are desirable. The split half reliability for the ATP-30 was found to be high (r = 0.84; P < 0.01). The correlation between the first and second half of the questionnaire was 0.73 (P < 0.01). ATP-30: general results Examining the entire group of students, moderately favourable attitudes towards psychiatry and mental illness were found. The mean (SD) ATP score for all respondents was 104.5 (10.5) (range 58–138; median 105; interquartile range 99–111). Fifteen students scored below the neutral point of 90.
Statistical analyses Comparisons Since the data follow a normal distribution, parametric tests were used to assess the descriptive characteristics and differences. To enable comparison with other studies, the results are presented as means and standard deviations. For the psychometric characteristics of the questionnaire, reliability was determined by internal consistency (Cronbach’s alpha coefficient), and the average inter-item and item-total correlation. Student’s t-test was calculated to establish any differences between medical and non-medical students, firstand second-year students, males and females, students with and without experience of mental illness, and students with and without a positive examination result following the psychiatry course. Mean differences, 95% confidence intervals (CI) of differences of means and Cohen’s d were calculated using means and standard deviations. For Cohen’s d, the following guidelines were used: effects between 0.20 and 0.50 were considered small, between 0.50 and 0.80 were considered medium, and higher than 0.80 were considered large [21]. A repeated measures analysis of variance was used to analyse the difference in the groups between the two assessment points. Post-hoc contrast was conducted by the Scheffe method for complex contrast. P < 0.05 was considered to be significant. All data were coded and analysed using Statistica [22].
Results Psychometric characteristics of the ATP-30 Cronbach’s alpha of the ATP-30 for the total sample (n = 331) was 0.85, the average inter-item correlation was 0.19 and the item-total correlation, which is defined as the average correlation between the individual response scores
The non-medical students scored significantly higher than the physiotherapy students (t = 2.67, P < 0.01; mean difference 3.14, 95% CI 2.2 to 6.8; Cohen’s d = 0.31). The attitudes of first-year students did not differ from those of second-year students at the beginning of the academic year. Female students scored significantly higher than male students (t = 2.9, P < 0.01; mean difference 4.0, 95% CI 1.3 to 6.7; Cohen’s d = 0.44). Students with experience of psychiatry scored significantly higher than students without previous experience (t = 4.72, P < 0.001; mean difference 6.3, 95% CI 3.7 to 8.9; Cohen’s d = 0.68). Educational seminars of psychiatry and examination results Repeated measures analysis of variance showed an interaction time × group effect [F(153.2) = 45.67, P < 0.001], and post-hoc comparisons (Scheffe P < 0.05) showed significant differences between time 1 and time 2 for the second-year students (mean difference 5.9, 95% CI 3.3 to 8.3; Cohen’s d = 0.72). No significant differences were found for the firstyear students. As seen in Table 1, second-year students reported significantly better attitudes towards psychiatry after completing a psychiatry course compared with first-year students who did not complete the course. At time 1, neither the whole group (n = 219) nor the group with only one test score (n = 64) revealed significant differences in ATP-30 scores with the retest subgroup (i.e. the first- and second-year students; n = 155). Examination results at the end of the psychiatry course did not reflect students’ attitudes towards psychiatry. No significant correlations were found between the marks obtained and general attitude towards psychiatry.
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Table 1 Difference in attitudes towards psychiatry between groups: mean (standard deviation). Experimental group (A)b
Comparison group
(D)
Physiotherapy students (n = 219) 103.9 (8.9) First-year physiotherapy students (n = 126) 103.4 (8.9) Female physiotherapy students (n = 154) 105.1 (8.3) Female non-medical students (n = 69) 109.4 (10.3) Physiotherapy students with experience of mental illness (n = 63)
ATP-30 (E) ATP-30 First year ATP-30 Second year (F)
108.5 (10.8) Time 1: beginning of academic year 103.2 (8.1) (n = 93) 102.8 (8.1) (n = 62) Second-year physiotherapy student: failed examination (n = 15)
ATP-30
102.3 (9.1)
ATP-30 (B) ATP-30 (C1) ATP-30 (C2)
P-value (n = 112)a
Non-medical students 107.1 (11.5) Second-year physiotherapy students (n = 93)a 104.7 (9.2) Male physiotherapy students (n = 65)a 101.1 (9.9) Male non-medical students (n = 43)a 103.4 (12.3) Physiotherapy students without experience of mental illness (n = 146)a 102.2 (7.4) Time 2c : after 20 weeks 101.3 (8.3) (n = 93) 108.7 (8.4)d (n = 62) Second-year physiotherapy student: passed examinationd (n = 47)a 103.0 (7.9)
<0.01 ns <0.01 <0.01
<0.01 ns <0.01
ns
ns, not significant. a Student’s t-test, *P < 0.01. b (A), (B), (C), etc. refers to the flow chart diagram (Fig. 1). c Repeated measures analysis of variance, post-hoc Scheffe. d After psychiatry course.
Discussion The unpopularity of psychiatry as a field of specialisation has been a source of international concern [17,23–26], leading to studies throughout the world on attitudes towards psychiatry. In contrast to studies concerning the general attitudes of psychology students [27] and the attitudes of nursing students [28] towards psychiatry [9,15,19,26], no comparable study is available regarding the attitude of physiotherapy students towards mental health and psychiatry. The current study assessed the attitudes of physiotherapy students towards psychiatry. In general, physiotherapy students and students without a biomedical background showed a moderately positive attitude towards psychiatry, and non-medical students scored higher than physiotherapy students. This could be explained by the response style. Non-medical students scored more items as neutral/no opinion (score 3), while physiotherapy students scored in a differentiated way (scores 1–5). Table 2 shows the results from previous studies of students’ attitudes using the same questionnaire (ATP-30) in widely diverse cultures. In general, the scores from the present study compare favourably with those reported by different authors. The variation in the results can be explained by social characteristics, regional bias, varying (medical) school admission requirements, regional differences between universities, varying educational concepts (different teaching methods and course content, amount of feedback, intensity of training, patient sample, personal responsibility, problembased learning vs lectures, and whether or not there is direct contact with patients), employment perspectives [15], cultural background [29], personality and clinical competency [30].
The data from the current study reveal substantial differences between male and female students. Female students had more positive and empathetic attitudes towards those with emotional and mental problems, and more positive attitudes towards psychiatry as a whole. Many other studies [15,23,31–35], but not all [26–38], have also reported a gender difference. Prior experience with mental illness was associated with more positive attitudes towards psychiatry, as found in other studies [15,26,35,37,39,40]. However, this was not found in the study by Creed and Goldberg [32]. Further research needs to evaluate the need for a specific questionnaire for physiotherapy students, and to elaborate on the definition, type and duration of prior experience. The following questions should be considered: was the experience acquired through a campaign of public education or direct personal contact with mental illness, or interpersonal skills developed through training or through indirect contact by lectures, seminars, courses and films? What type of contact was it: prolonged (working with mental health patients) or brief (visiting a psychiatric hospital), voluntary or involuntary (such as knowing a person who has been hospitalised)? A specific course in psychiatry and psychiatric rehabilitation had a positive influence on the attitudes of second-year physiotherapy students. As shown previously [9,18,32,34,36,38,41–43], a course and psychiatry practice seem to have a positive influence on students’ attitudes, although some studies did not find a measurable change [9,15,33]. Stigma can be challenged by social psychology through strategies of protest (to suppress stigmatisation thoughts), education and contact [6,7,35]. Courses and practice are two important possible strategies to help overcome stigma. Nev-
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Table 2 A summary of published ATP-30 scores: mean (standard deviation). Authors
Subjects
Burra 1982 [19]
Medical students (n = 189) Students of psychiatry, Queens (n = 18) Students of psychiatry, Canada (n = 144) Students of occupational therapy (n = 63)
103.8 (10.9) 116.3 (9.6) 116.0 (11.9) 111.7 (9.9)
Alexander 1986 [23]
Medical students, Scotland (n = 79)
104.3 (10.9)
Creed 1987 [32]
Medical students, England (n = 261) Before practice in psychiatry After practice in psychiatry
98.1 (9.7) 108.1 (11.3)
Medical students, Dublin (n = 110) Pre-clerkship Post-clerkship
98.4 (3.5) 107.3 (2.3)
Medical students, Nottingham (n = 110) Before practice in psychiatry After practice in psychiatry
109.1 (8.8) 114.8 (9.1)
Sloan 1996 [18]
Singh 1998 [36]
ATP-30 [mean (SD) score]
Strebel 2000 [37]
Medical students, Ludenscheid, Germany (n = 105)
Baxter 2001 [24]
Medical students, Nottingham (n = 100) Pre-attachment Post-attachment Follow-up (1 year)
104.6 (13.4) 112.6 (8.7) 115.3 (7.5) 82.1 (7.9)
Al Ansari 2002 [31]
Medical students, Arabian Gulf (n = 122)
105.8 (13.3)
Maidment 2003 [16]
Prospective medical students (n = 837)
110.0 (12.8)
McParland 2003 [17]
Medical students (n = 378)
107.7 (11.9)
Reddy 2005 [34]
Medical students, Malaysia (n = 122) Pre-clinical posting in psychiatry Post-clinical posting in psychiatry
108.3 (8.1) 110.4 (10.9)
Medical students, Germany (n = 508)
106.8 (12.9)
Kuhnigk 2007 [15]
ertheless, education can both aggravate and reduce stigma [44]. The knowledge achieved through lectures and written sources may serve as a mode of decreasing stigma but, at the same time, students’ lack of appropriate skills for managing severe patients in the hospital or in private practice may increase stigma [44]. Direct experience is probably a more important agent of change than course material to build and modify attitudes [45]. Examination results following the psychiatry course did not reflect students’ attitudes towards psychiatry. This is in agreement with other studies [32,43], and in disagreement with the study by Sloan et al. [18]. A positive attitude is not a guarantee for an enduring attitude, but it can influence the ability of future physiotherapists to treat patients with emotional problems. Lack of practical acquaintance with mental health problems is often associated with prejudiced attitudes about mental illness [40]. There is no consensus between existing studies about whether a positive attitude acquired by contact is lasting. Wilkinson et al. suggested that changes in general attitudes towards psychiatry remain stable for at least 1 year [43], Burra et al. [19] and Creed and Goldberg [32] found that changes were temporary, Fabrega [33] did not find any changes over time, and Sivukumar et al. [42] and Baxter et al. [24] found that positive attitudes declined over time.
Physiotherapy courses are not identical in all countries. Some curricula show little interest in domains such as mental health and psychiatry, so physiotherapists are not given the opportunities to develop the necessary skills. Little interest in this area also implies that in mental health care, physiotherapy remains an unknown domain with few effective therapeutic interventions. Lack of interest for this domain by physiotherapists means that a plausible market is created and then filled in by other ‘alternative’ help providers. These providers use a number of physiotherapeutic techniques without any quality control or scientific base. Therefore, to reduce the stigma, physiotherapy training should equip students with appropriate attitudes as well as knowledge and skills. It is important that students develop positive attitudes towards patients with psychiatric disorders as they will encounter them in different fields of physiotherapy, and also because this will have an influence on their later actions as practising physiotherapists. This is not only valid specifically in the context of mental health care, but also in the general practice of physiotherapy where patients often show (undiagnosed) psychological and psychosomatic problems. Problems that still need to be addressed include the use of paper and pencil investigations or self-report research where subjects are asked to state their opinions about different aspects of mental health and mental illness. The ATP-30
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questionnaire was not specifically developed for physiotherapists, and its items refer not only to attitudes but also to facts and values. In addition, the students may feel obligated to give the desired responses [39]. Students may doubt the anonymity of questionnaires, and adjust their responses or offer the expected response after the seminars [18]. Unfortunately, at the time of assessment, it was not possible to study the differences in characteristics between second-year students who did attend the course compared with those who did not. Comparison of the present results with other studies must be undertaken with caution due to differences in students’ educational levels in different countries. This study is limited to the attitudes of physiotherapy students towards mental health and psychiatry as a specialisation. Further investigations must pay particular attention to the attitudes of physiotherapists in the field, the durability of these positive results over time and attitudes towards the person suffering from mental illness. Physiotherapy in mental health and psychiatry is still in its early stage of development but is gaining more attention [46–48]. The term ‘development’ is not only related to having the skills to treat physical issues and problems in the psychiatric population, but also to developing specific physiotherapy strategies or techniques. Specific physiotherapy techniques for somatoform disorders [49–51], eating disorders [52–56] and depression [57,58], as well as specific approaches such as basic body awareness therapy in the Scandinavian countries [59,60] and psychomotor therapy in Belgium [61], are being developed. In order to ensure adequate basic physiotherapeutic care for people with mental illnesses, it should be a fundamental aim of physiotherapy training/education to promote positive attitudes towards people with mental illnesses and towards psychiatry through high-quality courses and personal patient contact or practice. From the authors’ point of view, psychiatric skills are essential in the general practice of physiotherapy.
Acknowledgement This study was conducted with the aid of Evy Vanhoutte and Vicky Docx. The authors would like to thank them for data collection and entry. Ethical approval: Ethical Commission of Biomedical Sciences, K.U. Leuven, Belgium. Conflict of interest: None declared.
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