Volume 37/N um ber I/Novem ber 2015/Pages 4 7 -6 2

A ttitudes o f Mental Health

Professionals to w a rd Mental Illness:
A D eeper Understanding
A llison C ro w e
Paige A v e r e tt

Because mental health professionals are not immune to negative attitudes toward adults with
mental illness, researchers have questioned where these attitudes might originate, as well as
what affects them. Although there have been quantitative studies that broadly explore attitudes
toward mental illness, in-depth understanding o f factors that affect the attitudes o f mental
health professionals will offer insight to practitioners and researchers alike. This qualitative
study explored the impact o f educational programs and professional experience on the attitudes
o f mental health professionals toward their clients. Based on the results, this article describes a
continuum o f attitudes toward mental illness for counselors, educators, supervisors, and related
professionals as a tool to understand their attitudes toward mental illness.

In the last decade, the counseling literature has begun to address the topic
of mental illness stigma, or negative attitudes toward mental illness (Bathje &
Pryor, 2011; Brown & Bradley, 2002; Crowe, 2013; Smith & Cashwell, 2010,
2011). Some authors have urged mental health professionals to investigate their
own attitudes (Lauber, Anthony, Ajdacic-Gross, & Rossler, 2004; Nordt, Rossler,
& Lauber, 2006), asserting that it would be simplistic to think that they are
immune to stigma. Early researchers believed negative attitudes among mental
health professionals might be a product of feelings of helplessness and futility
(Cohen, 1990); feelings of resistance to providing services and to clients (Cohen,
1990; Minkoff, 1987); inadequate training and lack of preparedness to work with
a given population and setting before starting in the mental health field (Hromco,
Lyons, & Kikkel, 1995; Minkoff, 1987); or inadequate support and validation
(Minkoff, 1987). More recent researchers (Lauber et al., 2004; Nordt et ah, 2006;
Smith & Cashwell, 2010, 2011) continued to stress the importance of mental
health professionals looking inward to reflect on their own attitudes toward
mental illness, since it is well-documented that negative attitudes are damaging
and have internal and external consequences for clients who experience them.
Internal consequences include lowered self-esteem and heightened shame, fear,
and avoidance (Byme, 2000; Corrigan, 2004; Link, Struening, Neese-Todd,
Asmussen, & Phelan, 2001; Perlick et ah, 2001). External consequences include

Allison Crowe and Paige A ve re tt are a ffilia te d w ith East Carolina University. Correspondence about this
a rticle should be addressed to Allison Crowe, ECU. 225, M a ilsto p 121, Ragsdale H all, Greenville, N C
27 858. Email: crowea@ edu.edu.

Journal o f M en ta l H e a lth C ou n se lin g

47

exclusion, discrimination, prejudice, stereotyping by others, and social distance

(Byrne, 2000; Corrigan, 2004; Link, Yang, Phelan, & Collins, 2004).
REVIEW OF THE LITERATURE

Smith & Cashwell (2010, 2011) surveyed mental health professionals and
trainees to examine whether professional identity, among other factors, might
contribute to their attitudes toward mental illness. Since these professionals
are important figures in the lives of those diagnosed with mental illness, it is of
paramount importance that research related to attitudes continue to assess what
helps, hurts, or simply contributes to negative attitudes toward mental illness.
The Substance Abuse and Mental Health Services Administration Center for
Behavioral Health Statistics and Quality (SAMHSA, 2014) reported that the
national rate of serious mental illness was 4%, affecting 9.3 million Americans.
Therefore, the investigation of counselor attitudes and how they developed will
help these professionals in their work with the many who are struggling with
mental health concerns.
Smith & Cashwell (2010) first explored the attitudes of counselors, social
workers, psychologists, and non-mental-health professionals as well as trainees.
Their results suggested that mental health trainees and professionals had less
stigmatizing attitudes than did non-mental-health trainees and professionals.
There were no differences in attitudes between trainees and professionals based
on professional orientation. Finally, mental health professionals who were being
supervised had more positive attitudes than those who were not, which suggests
the efficacy of supervision in this area. In a similar study (Smith & Cashwell,
2011) on social distancethe proximity desired in various social situations
mental health professionals and trainees desired less social distance from adults
with mental illness than did non-mental-health professionals and trainees, and
women desired less social distance then men. Interestingly, counselors and psy
chologists desired less social distance than social workers and non-mental-health
professionals, suggesting that professional orientation might make a difference in
the social distance context.
Although these studies produced interesting findings, because they did not
incorporate qualitative data about what might impact attitudes, further study
is necessary to determine what and how certain variables might affect the atti
tudes of mental health professionals toward those labeled mentally ill. Beyond
the counseling literature, it has been suggested that both education (Bairan &
Farnsworth, 1989; Penny, Kasar, & Sinay, 2001) and professional experience
(Procter & Hafner, 1991; Wallach, 2004) impact attitudes. For example, a psy
chiatric nursing course improved student attitudes about mental illness (Bairan
& Farnsworth, 1989), suggesting that educational training can help improve
attitudes. Penny et al. (2001) examined the impact of both coursework and field
work on the attitudes of occupational therapy students toward those with mental
illness. Attitudes changed in a significantly favorable way after coursework, and
coursework was more effective than fieldwork in promoting favorable attitudes.

48

A ttitu d e s Toward M e n ta l Illness

In terms of contact as a way to improve attitudes, Proctor and Hafner (1991)

reported that after a one-week placement at a psychiatric hospital, qualitative
comments by nursing students about the experience revealed more positive
attitudes (e.g., less fear and distrust of a person with mental illness, relaxed atmo
sphere, they are just normal people with an illness) and suggested the efficacy
of clinical placements for nursing students. Wallach (2004) surveyed psychology
students on the impact of contact with those with mental illness and varied the
degree of exposure. Results suggested that prolonged exposure had considerable
impact on student attitudes and that limited exposure (e.g., a visit to a mental
health institution) in addition to classroom instruction and classroom instruction
alone were harmful.
This study explores education and professional experience qualitatively
in order to more fully understand what professionals report. Based on partici
pant responses, we offer a conceptual model for understanding a continuum
of attitudes affected by educational programs and as professional experience.
Questions that framed this research were:
RQ1: How did educational training influence attitudes toward mental ill
ness in counselors, social workers, psychologists, and others?
RQ2: How did professional experience with people diagnosed with a men
tal illness influence the attitudes toward mental illness of counselors, social
workers, psychologists, and others?
RQ3: Aside from professional education and experience, what people or
personal experiences influenced the attitudes toward mental illness of
counselors, social workers, psychologists, and others?

METHOD
Participants
Participants in this study totaled 110. Seventy-six mental health profession
als self-identified as counselor (n = 24), social worker (n = 20), or psychologist
(n = 32) and had been employed as such for at least one year. O f these, 62.8%
(n = 69) were female and 37.2% (n = 41) male. The majority described them
selves as Caucasian (89.4%, n = 98); other participants identified as African
American (4.2%, n = 6), Asian Pacific Islander (2.1%, n = 2), Hispanic (2.1%, n
= 2), Multiracial (1.1%, n = 1), and other (1.1%, n = 1). Counselors ranged in
age from 27 to 61 (M = 45.42, SD = 10.79), social workers from 28 to 64 (M =
53.30, SD = 9.45), and psychologists from 28 to 65 (M = 47.16, SD = 12.25).
Mental health professionals had 1 to 20 years of experience (M = 14.32, SD =
6.25). Other professionals consisted of 34 participants who worked in business
and other sectors in the southeast United States. They ranged in age from 25 to
64 (M = 43.76, SD = 10.62).

49

Procedure
After approval from the Institutional Review Board, potential participants
were invited to respond to the survey via electronic email. Email addresses of
mental health professionals were obtained from comprehensive statewide lists.
Other professionals were reached through an alumni listserv obtained from a
non-mental-health training program. Participants were told that the survey was
designed to investigate attitudes toward adults with mental illness. Included in
the email was a link to the survey, which was housed at a commercial online
site for electronic survey research. The survey incorporated both open-ended
and Likert-type questions. Due to the expansive dataset, only results of the openended questions are analyzed here; scholars interested in quantitative responses
are encouraged to consult Smith and Cashwell (2011).
Analysis
For purposes of this paper, the responses to three open-ended questions
were analyzed. There were 51 responses to question 1 dealing with educa
tional training, 51 to question 2 dealing with professional experiences, and 13
to question 3 dealing with personal experiences. According to Patton (2002),
content analysis attempts to identify core consistencies and meanings (p. 453).
Conventional content analysis is used when the theory or literature on a topic
is limited and pre-existing categories do not exist (Hsieh & Shannon, 2005).
Although there have been some studies of the current topic, it is limited and not
theoretical. Thus, conventional content analysis was chosen.
Initially the responses were reviewed by the second author to gain a gen
eral sense of the content and identify initial patterns (Hsieh & Shannon, 2005;
Patton, 2002). Emergent themes were noted, and the data were sorted and
re-sorted via codes or themes. The emergent themes were then reconsidered to
seek consistency and continually re-sorted and re-themed as needed. As part of
the content sorting process, numerous themes were then collapsed into a smaller
number. From the themes a final model emerged that suggested a continuum of
cognitive, affective, and behavioral responses, a result supported in previous anal
ysis of attitudinal data (Haddock & Zanna, 1998). Additionally, as is consistent
with content sorting, the connections and relationships between themes (Hsieh
& Shannon, 2005) lend themselves to a continuum model. The resulting themes
are discussed below.
RESULTS

Influence o f Educational Programs on Attitudes

Question 1 asked participants to consider how training in their educational
programs (e.g., counseling, psychology, social work) influenced their attitudes
toward mental illness. The continuum of responses (table 1) ranged from the
belief that the educational program had not influenced their attitudes at all to
various levels of integration of knowledge into practice behaviors, to attaining a
critical deconstructionist approach to mental illness.

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A ttitu d e s Toward M e n ta l Illness

Table I . Continuum of the Influence of Education on Attitudes

No Influence

Increased

Problems &

Empathy

Person-

Strengths-

Critical

Knowledge

Needs

&To!erance

Centered

Based

Deconstruction

N o influence

1learned

1 have a b e tte r

1am m o re

1 learned to

T h e m o re

fro m pro g ra m

m o re than 1

understanding

to le ra n t: 1

th in k about

education you

is actually a

had previously

o f th e needs

dont judge as

h o w a client's

receive th e

som etim es

harshly.

kn o w n about

and lack o f

th e scientific

su p p o rt fo r

"M e n ta l illness'

m ental illness

m o re y o u r

arb itra ry

m ight affect her

m ind is open to

classification.

basis o f m ental

those w ith

M o re

o r him ra ther

th e gifts th a t all

1am n o t sure

illness, but

m ental illness."

em pathetic and

than label o r

types o f people

"S om e o f the

th a t it d id

o n ly generally

understanding.

describe w h o

have to offer.

things th a t

speaking.

has really

It has

he/she is as a

w e classify as

given m e an

1feel 1

"O n ly th a t it

appreciation fo r

becam e m o re

gave m e th e

th e problem s

em pathetic

appreciate

result o f cultural

foundation fo r

th a t individuals

to those w ith

th e strengths

differences."

w o rk in g w ith

w ith m ental

diagnosable

o f those w h o

people w ith

illness face."

m ental illness.

have m ental

1d o n 't th in k it

person.

m ental health

1 have learned

illnesses may

to id e n tify and

in fact be the

illnesses.

p ro b le m s."

No influence. At one end of the continuum is the belief that their educa
tional experience had no effect on participants or their attitudes toward mental
illness. Typical responses were:
Didnt impact them at all.
I am not sure that it did.
I dont think it has really.
Unfortunately, there was no explanation for such responses.
Increased knowledge. At the next point on the continuum is the notion
that education increased the knowledge of participants about mental health
and illnesses. The implication was that though they knew more about mental
illness, that did not necessarily translate into specific changes in attitudes. Sample
responses:
I learned more than I had previously known about the scientific basis of
mental illness, but only generally speaking.
Yes, if only to be aware of types of mental illness.
Only that it gave me the foundation for working with people with mental
health problems.
It seems evident that while these participants felt they had increased their general
knowledge about mental illness, they did not connect this to their attitudes or

51

changes in attitudes. They had moved an incremental step beyond those who
felt their education had not affected their attitudes at all.
More aware of problems and needs. The next group of participants felt
they had gained specific awareness of the problems a person with mental illness
has to face and the needs they have as a result, stating, for example:
I have a better understanding of the needs and lack of support for those
with mental illness.
It has given me an appreciation for the problems that individuals with
mental illness face (as do there [sic] families).
Made me more aware of the needs of people who suffer from mental
illness.
Though these participants had moved beyond basic knowledge into viewing
mental illness as a social issue, their attitudes did not necessarily demonstrate a
deeper understanding or connection to the issue. This suggests another incre
mental increase in understanding, where respondents felt that they gained more
from their education than merely academic knowledge of diagnosis and other
foundational knowledge. These participants seemed to understand how mental
illness translates into everyday struggles and issues. This place on the continuum
suggests an initial level of understanding and awareness of the problems and
needs associated with mental illness.
Increased empathy and tolerance. Further along the continuum were
those who believed they had increased in either empathy toward or tolerance of
individuals with mental illness, as a result of their educational program:
My degree program teaches us to be tolerant of all people and to be aware
of the needs of all people, with no discrimination.
I feel I became more empathic to those with diagnosable mental illness.
I am more tolerant; I dont judge as harshly.
These respondents demonstrated movement beyond recognizing mental illness
as a social issue to also having an inner response that incorporated empathy and
tolerance. More than knowing or recognizing, participants identified a shift in
themselves as a result of what they had gleaned from their education. In the first
quote we see the idea of being aware of needs (the last level on the continuum)
in addition to an increase in tolerance. This combination of ideas demonstrates
that movement along the continuum from one level to the next is possible.
Person-centered. Next on the attitudes continuum was the notion that edu
cational programs may help participants to focus on the person rather than the
diagnosis. This theme resonates in the following responses:
The emphasis was on wellness and developmental conceptualization of
clients. ... I learned to think about how a clients mental illness might affect
her or him rather than label or describe who he /she is as a person.

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A ttitu d e s Toward M e n ta l Illness

Seeing people as people with a disorder/difficulties rather than a label.

These respondents demonstrated a greater shift in attitudes. Their responses
communicated their beliefs that their programs not only increased their knowl
edge, awareness, and empathy, but also transformed how they see and work with
the individual rather than the illness. Responses in this category demonstrated a
shift toward seeing the person first and the label or diagnosis second.
Strengths-based. These participants not only saw the individual but also
had become able to consider client strengths and abilities in addition to the
challenges mental illness caused:
I learned to identify and appreciate the strengths of those who have mental
illnesses.
The more education you receive, the more your mind is open to the gifts
that all types of people have to offer.
Very intelligent people often have mental quirks. I am hesitant to call
them illnesses when the individual is highly functional and successful.
These responses demonstrated awareness that went beyond seeing clients as more
than a label to taking into account their strengths and abilities. The last quote
also seems to demonstrate movement toward the next step on the continuum:
thinking critically about the very idea of mental illness.
Critical deconstruction. At the last point on the continuum participants
spoke of an ability to critically deconstruct the idea of mental illness and examine
the social powers that classify behaviors:
By showing that what we term mental illness is actually a sometimes
arbitrary classification that only describes a grouping of symptoms, not the
person.
It has taught me that some of the things we classify as illnesses may in fact
be the result of cultural differences.
They are still individuals with some common characteristics that make it
hard for them to function normally.
Through their educational programs, these respondents learned to engage in
some level of deconstruction and to question the classification system and cul
tural constructs of what is normal vs. pathological. They were able to question
the legitimacy of deeming some individuals as beyond what is acceptable.
Mental health professionals thus reported that educational experiences
affected their attitudes along a continuum from having no influence, to increas
ing basic knowledge, to awareness of the problems, to developing greater toler
ance and empathy, to focusing more on the person and less on the label, to seeing
the strengths and abilities, and finally to being able to question the entire concept
of mental illness. Within the various sample responses are combinations of ideas
(e.g., needs and tolerance) that demonstrate respondents moving from one level
on the continuum to the next. This gives support for the idea of a continuum

53

model of attitudes to mental illness that includes movement from one level to the
next as well as the capacity of respondents to fall between two levels rather than
a stage-model conceptualization of how attitudes toward mental illness develop.
Influence o f Professional Experience on Attitudes
Question 2 asked participants to consider how professional experience with
people diagnosed with mental illness influenced their attitudes toward mental
illness. This continuum of responses (table 2) ranged from the belief that their
experience had a negative influence to levels very similar to those defined for the
responses to question 1, but there were also noteworthy differences.
Table 2. Continuum of the Influence of Professional Experience on Attitudes
Negative

Increased

Problems &

Empathy &

Person-

Strengths-

Influence

Understanding

Needs

Tolerance

Centered

Based

1am m o re critical

1 acquired

1 have co m e to

Increased

1see th e m as

Initially in career

o f people w h o

a greater

see m ental illness

em pathy.

hum an beings. It

focused m o re on

p ro p o rt (sic) to have

understanding

as a real problem ,

is d iffe re n t w hen

pathology, b u t ove r

m ental illness.

o f people w ith

afflicting real

Ive learned to be

yo u p u t a face and

th e years have

a m ental illness.

people, w ith real

patient w ith them .

em otions w ith a

refocused m o re on

N e v e r associated

consequences and

T h e re are a lo t o f

disorder, instead

peo p le s strengths.

1did n o t w a n t to

m e ntally ill people

difficulties.

w o r k exclusively

w ith a stigm a."

It taught m e th a t

w ith a m entally ill

population.

people o u t th e re

o f talking about

w ith m ental illness

h o w one m ight be

It has helped m e

H ave becom e

and th e y generally

according to th e

to develop a g re a te r

b o o k ."

It has helped m e

m o re aw are o f

cant help th e ir

to understand

th e need fo r m o re

behavior even

it b e tte r in its

com prehensive

w h e n its

By p u ttin g a

m ental illnesses can

entirety. N o t just

m ental health

fru stra tin g o r

human face on it

in te ra ct w ith and

regarding w h a t 1

tre a tm e n t

insulting."

1n o w th in k o f a

co n trib u te to society

assumed."

facilities."

person instead o f

as a w h o le .

understanding o f
h o w people w ith

an illness.

Negative influence. Several respondents stated clearly that they believed

their professional interactions with people with mental illnesses had had a nega
tive influence on their attitudes. For example:
I am more critical of people who proport [sic] to have mental illness.
My experiences with the mental ill usually make me want to avoid conflict
or prolonged contact with them.
It taught me that I did not want to work exclusively with a mentally ill
population.
As a professional in child protective services it often makes me nervous
regarding their ability to make sound choices for their children. Though
overall my attitude is that with treatment and help most [can] function on
a daily basis.

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A ttitu d e s Toward M e n ta l Illness

These quotes make it clear that interactions and professional exposure led some
respondents to think more negatively about individuals with mental illness,
even to the point of intentionally choosing to avoid contact. The last quote, for
example, demonstrates a negative view of someone with a mental illness (causing
inability to parent); however, the respondent seemed to have some hope in the
abilities of clients, given the proper treatment.
Increased understanding. Here, again, the next level on the continuum
was increased understanding:
I acquired a greater understanding of people with a mental illness. Never
associated mental [sic] ill people with a stigma.
It has helped me to understand it better in its entirety. Not just regarding
what I assumed.
I understand them better and am able to work well with them.
Much more understanding of persons with mental illness.
Professional exposure made these respondents more understanding, which
seemed to lend itself to more emotional integration than basic knowledge but
had some aspects of being foundational. The first quote suggests that the partici
pant understood those with mental illness but did not necessarily recognize that
the person might feel stigmatized or have other difficulties as a result of a mental
illness.
More aware of problems and needs. As on the education and attitudes
continuum, the next step on the professional experiences continuum is beyond
mere understanding to a realization of the problems and struggles that those with
mental illnesses face. For example:
I am more aware of their problems.
I have come to see mental illness as a real problem, afflicting real people,
with real consequences and difficulties.
It has made me aware of how it can affect daily life and functioning in
society, as well as how positive medication can be when used properly.
I understand the need for community services to the mentally ill.
These participants felt that their professional exposure had made them aware
of the problems people with mental illness can face. Some of the quotes speak
to specific services needed (e.g., medications and community services); yet this
group of respondents had not necessarily integrated their experiences to the point
of changes in their affect and response.
Increased empathy and tolerance. The respondents on the next point
of the continuum demonstrated integration and a changed response due to
professional experience with persons with mental illness. They felt that their
professional exposure had increased their empathy and tolerance. For instance:

55

Ive learned to be patient with them. There are a lot of people out there
with mental illness and they generally cant help their behavior, even when
its frustrating or insulting.
More open and less judgemental [sic].
I have worked with some pretty severe clinical diagnoses and feel great
empathy for these clients.
Increased empathy.
I believe that it has increased my compassion toward people diagnosed
with mental illness.
While these respondents spoke of tolerance and empathy, there also is a sense of
struggle in the statements, as demonstrated in the first two quotes, which both
show hesitancy or inconsistency in their acceptance and attitudes. For example,
the second quote describes becoming more open and less judgmental, which
suggests recognition that the respondent is still not completely open or free of
judgments. Many of these respondents seemed to focus more on empathy and
less on the need for tolerance than those at the same point on the education
continuum, who spoke more of tolerance and less of empathy.
Person-centered. The next group of participants demonstrated a per
son-centered approach to their professional work:
Pay attention to what is observed and experiencednot just to diagnosis
provided before contact.
To humanize mental health problems.
I see them as human beings. It is different when you put a face and emo
tions with a disorder, instead of talking about how one might be according
to the book.
By putting a human face on it I now think of a person instead of an illness.
Puts a face to a diagnosis and challenges the stereotypes and myths.
These quotes demonstrate a movement away from merely understanding and
being more tolerant to acceptance and a person-first mentality. For these respon
dents their professional experiences had encouraged them to focus on the indi
vidual, not just the diagnosis.
Strengths-based. At the end of the professional experience continuum was
a focus on seeing the strengths and abilities of a person with a mental illness:
It has provided me with the opportunity to develop an awareness of the
strengths of people who have to live with the burden of mental illness and
compassion for their struggle to live in dignity in spite of the stigma associ
ated with their illness.
Initially in career focused more on pathology, but over the years have refo
cused more on peoples strengths.

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A ttitu d e s Toward M e n ta l Illness

It has helped me to develop a greater understanding of how people with

mental illnesses can interact with and contribute to society as a whole.
Awareness of the impact of professionals and non-professionals attitudes
toward mental illness on those clients.
These participants spoke of the importance of finding worth, having dignity, and
focusing on strengths. As a result of their professional experiences, they seemed
to move away from a pathological orientation. The last quote also demonstrated
recognition of how the attitude of professionals can affect clients.
The continuum of the influence of professional experience on attitudes
of participants demonstrated a variety of ways they were affected. While some
respondents seemed clearly to be at a certain point on the continua other quotes
suggested movement from one level to the next. Professionals reported their
experience in the field as having a negative influence, to a basic increase in
understanding, to an awareness of the problems, to developing greater empathy
and tolerance, to focusing more on the person and less on the label, to seeing the
strengths and abilities of their clients.
While there were overlaps between the two continua, there were also note
worthy differences. The first level of the educational experience continuum sug
gests that education has no influence; the first level of the professional experience
demonstrates a negative influence. On the education continuum, respondents
who spoke of tolerance and empathy put more emphasis on tolerance; on the
professional continuum respondents who spoke of empathy and tolerance put
more emphasis on empathy. In addition, the educational experience continuum
has one more level those who engaged in a critical deconstruction of mental
illnesswhile the experience continuum stops at the strengths-based point.

Other Influences on Attitudes

Respondents were asked in a third open-ended question to share any other
influences on attitudes toward mental illness. Because the responses were very
brief, without much detail or explanation, they were not rich enough to require
analysis. It is interesting, however, to note the variety of responses, such as none,
religion, the media, family (both in terms of having a family member who was
mentally ill or the impact of family attitudes toward mental illness), and personal
interactions, such as friends and volunteer work.
DISCUSSION
When asked about how education affected attitudes toward mental illness,
the responses of mental health professionals varied from no influence at all to
critically deconstructing the notion of mental illness. Other influences were
increased knowledge, more tolerance and empathy, looking at the person first,
and considering client strengths. These findings appear to be similar to those of
earlier studies (Bairan & Farnsworth, 1989; Penny et ah, 2001), indicating that
education and training influence the attitudes of those preparing to go into the
fields of counseling and mental health, but exactly how each impacts attitudes

57

will vary with the individual. Regarding the influence of professional experience
on attitudes toward mental illness, the continuum looked different from the
influence of education on attitudes. At one end was a negative influence (com
pared to no influence at the end of the education continuum). Participants in
this category indicated that being in the mental health field made them more
critical of those with mental illness or that they did not want to work exclusively
with this population. This seems to suggest that professional experience might
impact attitudes differently than education, since this category was only found
when asking about experience. The other categories related to professional
experience were similar to those found when asking about educationincreased
understanding, problems and needs, tolerance and empathy, person- centered,
and strengths-based. Interestingly, the continuum for professional experience
influences ended with strengths-based, whereas with education it was critical
deconstruction. Perhaps the educational component challenges mental health
professionals to think critically about the concept of mental illness altogether.
Courses that provide information about psychopathology, diagnosis, or various
marginalized populations may be influential as students learn about serious
mental illness and think critically about the concept.
Earlier authors discussed whether professional experience (Procter &
Hafner, 1991; Wallach, 2004) or training and education (Bairan & Farnsworth,
1989; Penny et al., 2001) impacted attitudes, suggesting the efficacy of both.
Through this research, it seems both might have an impact, although in our
sample, how each impacted professionals varied. The similarities of the continua
appear to outweigh the differences. This might be a product of research design,
given that we asked both questions of the same participants, who by nature will
answer consistently (Haddock & Zanna, 1998).
Research on attitudes of mental health professionals in recent studies found
mixed results. In a sample of counselors, social workers, and psychologists (Smith
& Cashwell, 2010), mental health professionals had less negative attitudes than
those not engaged in mental health care; however, there were differences in
preference for social distance in mental health professionals according to pro
fessional identity (Smith & Cashwell, 2011). The current study did not separate
professionals by discipline but looked at mental health professionals as a group,
and in general we did not uncover many negative attitudes, which is promising.
The third research question, which explored other influences on attitudes
toward mental illness, did not yield much data. Participants mentioned the
following sources as impactful on attitudes: none, religion, the media, having a
family member with a mental illness, family attitudes toward mental illness, and
personal interactions such as friends and volunteer work. This suggests that these
sources, while worth mentioning, might not have affected our participants as
much as education and professional experience. Since this question was one of
three, perhaps the lack of data was a result of survey fatigue; future research with
a sole focus on this question might garner more responses.
Educators and supervisors of mental health counselors may be interested in
using the attitudes continuum in a classroom or supervision setting with trainees.
Many counseling students will work with clients in severe distress (SAMHSA,

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2014), so it is important to assess their attitudes toward mental illness. Just as

counseling students reflect on stereotypes, attitudes, and biases with various types
of clients in a course related to multiculturalism and diversity, reflecting on atti
tudes toward clients with mental illness could help students to work with a wide
variety of clients in a variety of settings. Uncovering negative attitudes, biases,
and stereotypes toward mental illness could thus promote more positive attitudes
toward adults with mental illness. As early authors (Cohen, 1990; Hromco et ah,
1995; Minkoff, 1987) suggested, there are many reasons why negative attitudes
might develop; perhaps identifying these during a counselor training program
would help to buffer against negativity.
FUTURE DIRECTIONS AND LIMITATIONS

Perhaps the main outcomes from this study are the two informal continua
of attitudes toward mental illness, which demonstrate promise for use with coun
seling trainees in a degree program or for supervisors who work with counselors
in the field. Assessing attitudes about mental illness is particularly important to
ensure that negative attitudes, compassion fatigue, and burnout are not affect
ing clinicians. This tool could be used to assess such attitudes. Since previous
research (Smith & Cashwell, 2011) suggested the efficacy of clinical supervision
on attitudes toward mental illness in those working in mental health fields,
supervisors and clinicians might use a continuum to locate where they perceive
themselves to be at any given point in their careers.
While there is still much to learn about how counselors and other mental
health professionals acquire negative attitudes, with this research we now know a
bit more about how two variables of interesteducation and professional expe
rience-affect attitudes toward individuals with mental illness. Future research
might explore the relationships between specific educational and professional
experiences and whether mental health professionals see people with mental
illness in a negative, neutral, or positive light. To the best of our knowledge,
there has been no previous qualitative study exploring the impact of education
and experience on attitudes toward mental illness in mental health professionals.
Continued research exploring particular negative attitudes and their origins will
add to the knowledge base.
Future longitudinal research might also assess attitudes of counseling stu
dents pre- and post-degree in order to see whether attitudes change at all as a
result of education. It is possible that those who decide to enter mental health
fields already have more positive attitudes toward mental illness than non-mental-health trainees or professionals. The first author made a similar suggestion
(Smith & Cashwell, 2011) to assess attitudes to determine if training does in
fact matter, or if personal qualities have more impact on attitudes toward men
tal illness. Finally, studying various types of professionals through a qualitative
research design will offer the field more information about how professional
identity and orientation might affect development of attitudes toward mental
illness. This study did not separate mental health professionals by discipline, so
future inquiries into that might uncover interesting results. Other studies might

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focus solely on mental health trainees rather than professionals and trainees in
order to increase within-group sample sizes.
As with all research, tire current study has limitations that both contextu
alize the findings and provide direction for future research. One limitation of
this study was the participants who identified as in the other professional cate
gory. Since the survey was electronic and had the capacity to reach unintended
audiences, participants who identified as other could have been from a variety
of professions. The question forced participants to choose between the four
professions rather than allowing the participant to write in a particular profession
if it was outside of counseling, psychology, or social work. It is also of note that
one participant reported in a later open-ended question as having had both a
psychology and a social work background, while another who self-classified as
other also noted in response to an open-ended question a background in coun
seling psychology. Thus participants who chose the other response could have
been mental health professionals who were merely unsure how to respond or
who responded in error. Similarly, for those who indicated that education had
no impact on attitudes toward mental illness, the wording of the question did
not allow for explanation of why respondents did not believe themselves to be
affected. Future researchers might consider adding followup questions such as,
if yes, how so? and if no, why not? to capture these perceptions.
Finally, only the member of the research team who had knowledge of
qualitative analysis analyzed and themed the data, which gave no opportunity for
triangulation through multiple analysts (Patton, 2002). The researcher who con
ducted the qualitative analysis has a background in human services with degrees
in family science, social work, and human development, which may have affected
interpretation of the data and design of the continua. While qualitative research
typically does not attempt to exclude bias, there is a need for transparency so that
the reader can better interpret the findings (Lincoln & Guba, 1985). In addition,
because data were collected electronically, we were unable to conduct member
checks. While according to Lincoln and Guba (1985) both of these factors limit
the credibility of the analysis, the team did engage in other forms of credibili
ty-enhancing measures, such as peer scrutiny of the project through colleague
feedback, examination of previous research findings, and inclusion of a qualified
and experienced investigator (Shenton, 2004).
CONCLUSION

It is worth noting that the attitudes toward mental illness of mental

health trainees and professionals can be understood as falling on a continuum.
Although education and professional experience had similar impacts on partici
pants, noteworthy differences in attitudes were associated with each. Clearly, the
investigation of attitudes of mental health professionals toward mental illness is
far from complete.

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