Isr J Psychiatry Relat Sci Vol 46 No. 3 (2009) 226–230
Stigma has been identified by professionals as a
key issue in mental illness. Stigmatizing attitudes
may inhibit help seeking among individuals with a
mental disorder, may provide barriers to their suc-
cessful reintegration into society, and may increase
their psychological distress (1).
Many stigma studies have focused on stigmatiz-
ing ideas and behaviors in the general population.
Nonetheless stigma against the mental health con-
sumers among mental health professionals is not a
rare issue (2). Professionals appear generally in line
with negative public views concerning the more
explicit components of the stigmatizing process.
These components, such as stereotyping and social
distance (3), which are key dimensions of social
stigma because avoidance is damaging, distressing,
and disruptive to people’s lives (4). The fact that
mental health professionals’ attitudes largely do
not differ from negative public opinions of mental
illness suggests a need to include mental health
profession as an important target group in anti-
stigma efforts (3).
Mental health professionals are specifically
trained to deal with, and obviously are in more
contact with persons with mental illnesses. It would
be natural to assume that, as a group, they would
have less stigmatizing attitudes towards persons
with mental illnesses as compared to the lay person,
non-medical professionals, and/or medical students
for that matter. However, this does not seem to be
the case, and as stated above their stereotyping atti-
tudes mirror those found in the general population.
Therefore, knowledge about the disorder and con-
stant contact do not seem to be enough in dealing
with the problem of stigmatization. To deal with the
problem of stigmatization by mental health profes-
sionals several strategies have been proposed. These
include improving professional education, assuring
the quality of professional contacts and prevent-
ing burn-out by relying on regular supervision (5).
However, none have been specifically tested so far.
Furthermore, there is a lack of knowledge as to the
Reducing Mental Illness Stigma in Mental Health
Professionals Using a Web-based Approach
Mahmut Reha Bayar, MD,1 Burç Ça˘grı Poyraz, MD,2 Cana Aksoy-Poyraz, MD,1 and Mehmet Kemal
Arıkan, MD 1
1 Department of Psychiatry, Cerrahpaşa Medical Faculty, Istanbul University, Aksaray, Istanbul, Turkey
2 Bakırköy Hospital of Mental and Nervous Diseases, Bakırköy, Istanbul, Turkey
Abstract: Objective: This study was designed to investigate the efficacy of a web-based mental disorder stigma educa-
tion program for mental health professionals. Methods: The sample consisted of 205 individuals who were either
residents or specialists in psychiatry. Participants were contacted through a national web-based e-mail group that
consisted of professionals in psychiatry, who were randomly assigned to experimental and control groups. The
experimental group received an informative e-mail which contained a general account of “stigma” before they were
asked to respond to an Internet-based questionnaire which was designed to predict their stigmatizing attitudes
towards individuals with mental disorders. Control subjects, on the other hand, were asked to respond to the
same Internet-based questionnaire without having been given the aforementioned informative e-mail. Results: The
experimental group, compared to the control group, demonstrated a lesser stigmatizing attitude towards individuals
with mental illness, as measured by the Internet-based survey which utilized the “social distance” concepts of stigma.
Conclusions: These data suggest that such “anti-stigma” campaigns using the potential of the Internet might be an
effective tool in the fight against the stigmatization of persons with mental illness.
Address for Correspondence: Dr. Kemal Arikan, Istanbul Universitesi, Cerrahpasa Tip Fakultesi, Psikiyatri Anabilim dali,
Istanbul, Turkey. E-mail: email@example.com
IJP 3 English 19 draft 17 balanced.indd 2269/2/2009 7:37:58 AM
Mahmut Reha Bayar et al.227
essential components that should be provided dur-
ing professional education which would help lessen
these stigmatizing attitudes.
Several studies describe the potential advan-
tages of web-based education for health-care pro-
fessionals (6). The Internet creates a cost-effective
environment which is readily accessible by the
targeted populations, and is expected to play an
important part in providing continuing education
for health-care professionals. However, research
regarding the application of Internet-based learn-
ing in providing education for health-care profes-
sionals is still in its infancy (7). On the other hand,
there is now evidence that Internet-based anti-
stigma programs directed towards lay people have
been successful in diminishing their stigmatizing
attitudes and stereotypes (8, 9).
In this study we investigated whether an Inter-
net-based anti-stigma campaign, targeting mental
health professionals, and designed to focus on key
issues of stigmatization and discrimination would
be useful in reducing the stigma towards mentally
ill persons among mental health professionals (e.g.,
psychiatrists and psychiatric residents).
Materials and Method
Subjects and setting
The study was conducted in Turkey by recruit-
ing participants over the Internet. A national
web-based e-mail group totaling 918 medical
professionals in psychiatry (e.g., psychiatrists and
residents in psychiatry) were solicited to partici-
pate in the study via an e-mail notification. Of the
918 professionals contacted 713 of them either
refused to participate or did not respond to the
e-mail notification. Two hundred and five (205)
individuals were enrolled in the study (22% of the
Participants were randomly assigned to ex-
perimental and control groups. The experimental
group (N=100) received an informative e-mail
which contained a general account of “stigma”
before they were asked to respond to an Internet-
based questionnaire which aimed at predicting
their stigmatizing attitudes towards individuals
with mental disorders. Control subjects (N=105),
on the other hand, were asked to respond to the
same Internet-based questionnaire without having
received the informative e-mail.
An instructive e-mail was sent to the experimental
group that presented a general account of stigmati-
zation and consisted of the following propositions:
1. Stigma is based on beliefs, and discrimination
occurs when actions are taken (or not taken) on
the basis of a stigmatizing belief.
2. Stigma and discrimination occur in many set-
tings, including the family, local community,
school and health-care facilities.
3. There are many negative effects of stigma and
Table 1. Questionnaire statements
1. If an individual with mental illness resided in my neighborhood, I
would not let my children go to movies unattended.
2. If an individual with a previous mental illness was accepted for a
job where I work, I would insist that he/she be fired.
3. The important thing with the mentally ill is that you cannot know
what they will be doing from one minute to the next.
4. If I learned that someone I know had a mental illness, the likelihood that
I could depend on him/her would significantly decrease.
5. The main purpose of mental hospitals is to protect society from the mentally ill.
6. No matter how fine they might seem, one should not forget for a moment that they are mentally ill.
7. They should pass a legislation that prohibits giving hunting licenses to the mentally ill.
8. My having heard that a person has a mental illness is sufficient proof that he/she is mentally ill.
9. One’s describing oneself as mentally ill is sufficient proof that he/she is mentally ill.
IJP 3 English 19 draft 17 balanced.indd 2279/2/2009 7:37:58 AM
228Reducing Mental Illness Stigma in Mental Health Professionals
4. There are many actions which can be taken
by individuals and organizations to overcome
stigma and discrimination. Psychiatrists as role-
models and opinion-leaders have a lot more to
do to diminish this widespread phenomenon
and they should be aware of similar attitudes
they might also hold.
The Internet-based questionnaire consisted of 9
statements each of which represented a popular
stigmatizing opinion towards individuals with
mental illness (see Table 1). Each statement was
chosen from surveys used in earlier studies de-
signed to examine population-wide stigmatizing
tendencies in the domain of social distance. Mea-
sures of social distance try to assess a respondent’s
eagerness to interact with a target person in dif-
ferent types of relationships. Subjects were asked
to rate their agreements with each statement on a
7-point Likert scale (1-Totally agrees and 7-Totally
disagrees). Possible responses to the survey state-
ments were ordered so that a higher score would
indicate a lesser stigmatizing attitude. The ques-
tionnaires minimum and maximum scores were
9 and 63 respectively. A Cronbach’s alpha of the
social distance scale in our study was 0.664, which
resembled that obtained in previous studies (10).
For the statistical analysis, we used the overall score
that was obtained by adding the responses for each
of the 9 items. Since these data were not normally
distributed, we applied the Mann-Whitney U test.
A chi-square test was used to compare the propor-
tions involved. Where appropriate, the Student’s t
test was utilized. All statistical tests were two-tailed
and differences were considered as significant
when p < 0.05.
The mean age and male-to-female ratio in the
sample were 41.4±9.4 and 2.0, respectively. Resi-
dent and specialist ratios roughly matched each
other (102 vs. 103). The control and experimental
groups did not differ with respect to age and sex
distribution. The two groups were also comparable
with respect to the ratio of psychiatric residents to
We found that subjects from the experimental
group had significantly higher overall question-
naire scores (i.e., less stigmatizing attitudes) (me-
dian = 55, range = 39–63) than subjects from the
control group (median = 50, range = 15–63) (p=
0.0001), hence subjects from the experimental
group had lesser stigmatizing attitudes.
Our findings suggest that anti-stigma campaigns
delivered to psychiatrists and psychiatric residents
via the Internet might be effective in reducing
stigma against individuals with mental disorders,
among this particular subset of health-care profes-
sionals. The study also showed that well planned
and delivered information may have some effect
on stigmatizing attitudes, at least on the measure of
social distance investigated in this study. The social
distance scale of the experimental group, which
was made aware of the existence of the problem,
was higher at a statistical significance (i.e., less
Table 2. Age and gender distribution, ratio of psychiatric residents to specialists and overall questionnaire scores in
control and experimental groups
Variable All respondents
Age (years)41.4±9.4 41.1±9.741.7±9.2 p*=0.6
Gender (male/female) 137/68 71/3466/34 p=0.8
52.5; 15–63 50; 15–63 55; 39–63p=0.0001
IJP 3 English 19 draft 17 balanced.indd 2289/2/2009 7:37:58 AM
Mahmut Reha Bayar et al.229
stigmatizing attitudes) than that of the control
group. Finally, the study also indicates that the
Internet may be a powerful outreach tool in dis-
seminating anti-stigmatization information since,
this study, by relying solely on the Internet, was
able to show some efficacy.
Although we were able to show some efficacy,
there are several limitations of our study. This
study was a cross-sectional survey and relied on
self-reporting. In any study obtaining data using
an Internet-based survey, selection bias can limit
the generalizability of the results. It is also possible
that professionals who responded to our e-mail and
completed the survey (22% of the subjects consti-
tuting the e-mail group) were specifically interested
in the subject and therefore may have been more
prone to “social desirability” bias than a general
sample of specialists and residents in psychiatry.
Not wanting to appear as heartless professionals,
subjects might have denied social distancing re-
sponses in order to appear enlightened and caring.
Also, people in the sample were highly educated
and were experienced users of computers and the
Internet. Mental health professionals without In-
ternet access or computer and Internet experience
would certainly be out of the reach of a web-based
However, our study provides the first evidence
for a feasible and effective strategy to combat stigma-
tization among health professionals. Unfortunately,
a well-known limitation arises when one tries to
determine real-life behaviors from reported inten-
tions using self-administered surveys. Although
behavioral intentions like social distance items are
often good predictors of behavior, other factors
such as situational circumstances can intervene so
as to make the association far from perfect (10).
Several factors have been suggested as being re-
sponsible for a high stigmatizing tendency among
mental health professionals. Clinicians who have
contact with people who are unwell, and who se-
lectively stop seeing people who have recovered,
may therefore develop a pessimistic view of the
outlook for people with mental illnesses. An ex-
treme version of this process has been described for
forensic psychiatrists whose working life consists of
assessing and treating mentally ill offenders. As a
consequence, such psychiatrists are inclined to be
even more cautious and pessimistic about disease
outcomes than general psychiatrists (11). A burn-
out phenomenon attached to the above-mentioned
“physician bias” might also contribute to the pro-
cess. Therefore, future research is needed to assess
effectiveness of such strategies like regular supervi-
sion to prevent burn-out and educational programs
supporting recovery notions of mental illness.
Based on our findings, future research is required
to build a more sophisticated and systematic model
which might be repeatedly delivered to mental health
professionals. As stated above a single intervention
showed some efficacy. It would be useful to investi-
gate how repeated information delivery effects the
variables measured in this study especially does
each repeated administration have a corresponding
effect, and is there an upper limit to the effect that
this type of intervention can have (of course taking
into account test-retest bias). Also the efficacy of
Internet-based education might be assessed with
some implicit and behavioral measurements since
in this study a one-time intervention over the In-
ternet was able to provide some results. A second
line of outcome assessments might be derived from
observations of health-care consumers’ self-stigma
(12) and their general ideas about the mental health
professionals (13), in order to acquire a real-life ac-
count of stigma that emerges during utilization of
psychiatric services. These findings might also be
used as baseline for more systematic models to be
developed in the future, and effectiveness of such
models could be assessed by comparing outcome
measures between our model and newer models.
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Reducing Mental Illness Stigma in Mental Health Professionals
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