INTRODUCTION

According to definition for the World Health Organization, mental health is composed of individual’s potential of success, and personal coping characteristics with stressful life events which are accepted as normal with social and emotional well-being state. Mental illness is defined as abnormal deviations in emotions, thoughts, and behaviors of individuals with presence of contradictions. In the contrary to common belief that population mental illnesses are encountered rarely, more than 25% of individuals experience a mental illness during their life-time period (1).

According to findings in the Turkish Mental Health Profile study, 18% of Turkish population developed a mental illness during their lives, and clinically problematic behaviors were determined in 11% of children. It was reported in the same study that treatment application rates were 4.7% in adults and 0.3% in children (2). Results indicated that very few people who required a professional mental healthcare service received this help. Labeling, namely stigmatism, is one of the most important causes of low rates of receiving psychological help, and treatment application. Stigmatism is defined as refusal by others; or shame, or perception as a black spot by others; or sign of disfavor by others; and negative beliefs, attitudes and behavioral results which cause prejudice and discrimination of the population about mental diseases (3-5).

Concept of attitude implies generally reaction tendency of an individual to a person or subject around him/her. In another definition, attitude may be defined as behavioral pattern of an individual against an event, condition or person (6).

Belief is unwritten laws composed of general established opinions on a certain issue ever since the beginning of human history. Elasticity or stiffness of attitudes are closely related to personal characteristics, values, beliefs, life experiences, education level, and sociocultural structure of the population that is lived in. They direct behavioral pattern of an individual with beliefs and attitudes of the person (5,6).

Critical life periods for formation of attitudes and beliefs is between 12 and 30 years of age; attitudes are formed during adolescence, and they become stiff during early adulthood period (7). Therefore, in addition to important roles of parents in behavioral developments of children and adolescents, beliefs and attitudes of teachers at the schools are also very important.

School counselors are mental health specialists who have improving and preventive roles in mental healthcare. Members of this occupation are interested in educational, social, and emotional problems of students, and help them solve those problems; they have face-to face psychological relationships helping in development and compliance of students. When required, they refer their students to child and adolescent psychiatrists and clinical psychologists (8,9). Due to these assignments, school counselling services have become centers where students seek solutions for their problems.

In the study of Karatas et al. (10), students defined school counselling service as a unit where they solved their problems, and they shared their worries, and they told that they wanted psychological help in the first line from their parents, in the second line from friends, and in the third line from counselling teachers. In another study, it was determined that 10% of adolescents applied to their counselling teachers when they had a problem (5). Therefore, favorable or unfavorable beliefs and attitudes of counselling teachers about mental diseases are very important in mental evaluation and benefitting from treatments of students.

In the present study, it was aimed to determine attitudes and beliefs of counselling teachers about mental diseases. The other aim of the study was to collect information about distribution of variables, such as program graduated from gender, age, seniority. In the second aim of the study, it was aimed to define reasons of referral of students to psychiatrists by counseling teachers who provided preventive mental health services at schools.

METHOD

The present study was designed both in qualitative and quantitative patterns. The study sample was composed of 350 counselling teachers working in the city of Malatya, and the sample size was composed of 118 teachers who were volunteered to participate in the study. Permissions were taken from Guidance and Research Center of the City of Malatya National Education Directorate.

Data Collection Tools

Data were collected by using Belief towards Mental Illness Scale (BMIS) form, sociodemographic data form prepared by investigators, and a form containing questions about attitudes about mental illnesses.

Sociodemographic and Clinical Data Form: This form prepared by investigators was composed of questions inquiring about sociodemographic characteristics, personal mental history, approaches to mental illnesses, and under which conditions they referred students to child and adolescent psychiatrists.

Belief towards Mental Illness Scale: BMIS was developed to determine favorable and unfavorable beliefs of individuals for mental illnesses from different cultural properties by Hirai and Clum (11). The Turkish validity and reliability study was performed by Bilge and Cam (12). BMIS is a 6-point Likert type scale with 21 items; 0=“I completely do not agree” and 5=“I completely agree”. The Turkish version of the scale was designed in three factors as dangerousness, incurability and poor social and interpersonal skills and shame. The scale is assessed with both total points and subscale points.

Dangerousness Subscale (DSS): It is composed of eight items which indicate that mental illnesses and patients are dangerous, and the point range collected from this subscale is 0-40.

Incurability and Poor Social and Interpersonal Skills Subscale (IPSISS): It is composed of 11 items implying how mental illnesses affect interpersonal relationships and related feeling of incurability.

It implies restrains in interpersonal relationships in mentally ill individuals, and feeling of incurability about it. The score range which can be obtained from this subscale is 0-55 points.

Shame Subscale (SSS): It is composed of two items implying that mental illness is a condition to be ashamed of, and the score range of this subscale is 0-10 points.

The total points which can be obtained from the scale is 0-105 points; DSS score ranges 0-40 points, IPSISS ranges 0-55 points, and SSS ranges 0-10 points. High scores show unfavorable beliefs. Cronbach’s alpha coefficients for validity and reliability study were 0.82 for total scale, 0.80 for incurability and poor social and interpersonal skills subscale, 0.71 for dangerousness subscale, and 0.69 for shame subscale (12).

Statistical Analysis

Statistical analysis of data was performed by using SPSS 17.0 (Statistical Package for the Social Sciences) package program. Firstly, it was assessed whether data were normally distributed, and two extreme values were omitted. As central tendency values were close to each other, they were used as a measurement of normal distribution, it was observed that these values were very close to each other (The central tendency of total point; mean=80.4, median=81.5, mod=78.0). For paired groups, independent t test, for triple groups one way ANOVA, for categorical variables Chi-square tests were used. Mann Whitney U test was used only in one item (the question about approval for drug use of his/her student. Yes=108, and No=10), because number of subscale elements was few. Simple linear regression analysis was performed also for age and seniority variables. In affiliation worked at variable, guidance and research center (GRC) category (n=6) was added up to other categories and included in the analysis. In all analyses, 95% possibility with level of significance at p<0.05 was based on. Qualitative findings were obtained by evaluation of participant answers to open ended questions in line with content analysis methods (13).

RESULTS

Of participants, 42.4% (n=50) were female, and 57.6% (n=68) were male teachers. The age range was 23-55 years with the mean age of 35.5±6.59 years. The mean seniority duration was 10.1±5.93 years with the range of 1-24 years. Of teachers, 79.7% (n=94) were married. Of counselling teachers, 73.7% (n=87) were graduated from psychological counselling and guidance (PCG) program, and 55.9% (n=66) were working at primary schools, 39% are working at secondary schools (including high schools), and 5.1% (n=6) were working at guidance and research center (GRC).

When personal mental illness histories and attitudes towards mental illnesses were evaluated, 15.3% (n=18) of participants applied for a psychiatrist due to a mental problem; 10 out of 18 received drug treatment, 3 had regular interviews, and 5 did not have any treatment. Of counselling teachers, 16.9% (n=20) declared that they applied to a psychologist, and 5.9% (n=7) declared that they applied both to a psychiatrist and a psychologist. While 32.2% (n=38) of teachers applied to a child and adolescent psychiatrist because of a mental problem in his/her child, 52.5% (n=62) applied to a psychologist. Medical treatment was started in 15 children of 38 teachers who brought their children to a psychiatrist, 2 receive psychotherapy, and 21 of them had just one interview.

It was observed that 89.8% (n=106) of teachers directed their students to a child and adolescent psychiatrist because of mental problems. When approval of teachers for medication use was examined, the rates were 81.4% (n=96) for themselves, 88.1% (n=104) for their own children, and 91.5% (n=108) for their students.

When the mean scores of counselling teachers that they gained from beliefs towards for mental illnesses scale were examined, we observed that they obtained scores near to the highest scores. The scores of participants were the total score of 80.41±9.32 points from BMIS, 43.83±4.93 points from IPSISS, 28.82±5.35 points from DSS, and 7.76±1.81 points from SSS.

Total scores of counselling teachers in BMIS are shown as a graph in Figure 1. It is observed in the figure that majority of the group (54.23%) received higher scores in total scores (X=80.41). According to this result, 64 out of 118 teachers received higher points than the mean score in BMIS.

As there was no statistically significant correlation in none of Chi-square results of demographical variables (p>0.05), Chi-square tables are not given. Similarly, as regression analysis results for age and seniority did not indicate that these two variables were not predictors of BMIS, so their tables are not given.

BMIS scores of counselling teachers according to sociodemographic characteristics, t test and one way variation analysis results are given in Table 1. It is observed that there is no difference in BMIS of the sample size in the aspect of sociodemographic variables.

BMIS scores and t test results obtained from answers that counselling teachers have given to close ended questions are shown in Table 2. It was observed that the difference in total DSS score was significantly different between counselling teachers who brought their children to psychiatrists and who did not (p>0.05). According to this result, it may be claimed that beliefs towards mental illnesses of participants answering as “Yes” had significantly unfavorable approaches when compared with participants answering as “No”. Again, it was observed that the difference was statistically significant in total SSS between counselling teachers approving and non-approving drug use of their students (p<0.05). This result indicated that beliefs towards mental illnesses of counselling teachers who did not approve drug use were more unfavorable than the ones who approved of drug use. No statistically significant difference was determined in other variables (p>0.05).

Reasons why counselling teachers referred their students to psychiatrists were collected under the same category according to teachers’ statements and are shown in Table 3. Counselling teachers referred students to a child and adolescent psychiatrist most commonly with the following reasons: behavioral disorders (31.10%), attention deficit (16.10%), depressive mood (14.72%) and hyperactivity (12.20%).

DISCUSSION

In the present study performed to determine beliefs, attitudes, and reasons of referral of their students to a child and adolescent psychiatrist, it was determined that counselling teachers had unfavorable beliefs for mental illnesses. It was determined that teachers were shamed of these patients and illnesses; they considered mental illnesses and patients with them as dangerous; these diseases caused poor social and interpersonal skills, and incurability.

It is observed that beliefs about mental illnesses and patients with these diseases are unfavorable around the world (14). Unfavorable beliefs were reported in American military personnel by Greene-Shortridge et al. (15), as well as they were reported in some national studies such as negative beliefs for patients with mental illnesses in the western part of Turkey (16), individuals with mental illnesses were dangerous and it was not easy to build up a relationship with them (16), and adolescents perceived patients with mental illnesses as dangerous, and they intended to keep a social distance with them (17). It was observed that our results were consistent with the literature.

It was shown in the studies that in the population, individuals, especially families, were ashamed of the person with mental illness; they believed that these individuals were dangerous and stigmatized them; they tried to keep more distance when personal closeness was required; and they believed that drugs used in treatments caused addiction (18-21).

In the present study, it was determined that higher percentage of teachers who took their children to a child and adolescent psychiatrist considered these patients and illnesses more dangerous, and teachers who did not approve drug use in their children and students felt more ashamed.

In the present study, it was determined that counselling teachers applied more frequently to a specialist for mental problems of themselves, and their children when compared with the society (2), and additionally teachers referred their students to a child and adolescent psychiatrist at higher rates, opposite to other studies, they approve drug use at higher rates for themselves, their children and students (19-22).

Under the light of these findings, we may say that similar to previous study results performed with different occupations, attitudes of counselling teachers were favorable for mental illnesses and patients with mental illnesses (23,24), but their beliefs were unfavorable (16,17).

Beliefs and attitudes about mental illnesses and patients with them are related to factors such as age, gender, marital status, education level, socioeconomic level, and contradictory results have been reported in the literature in which way these sociodemographic characteristics affect attitudes and beliefs about mental illnesses (16-34).

In general, it was observed that people from high social classes, young, and well-educated were more tolerant about individuals with mental illnesses (27,28). In another study, although attitudes of these people to mental illnesses were more favorable, it was proposed that this might be because people desired to be admired more (25).

Besides, it was reported in studies that having low educational levels and being older were related to be more tolerant (29-31), and sociodemographic characteristics had no effect on attitudes and beliefs (16-34). Similarly, the present study showed that sociodemographic variables such as age, gender, marital status, graduated program, duration of working period, and affiliation worked at had no effects on attitudes and BMIS scores.

The firmer the beliefs, the firmer the attitudes which have arisen from them, but attitude is not an unchangeable condition. During establishment of attitudes, learned knowledge and emotions are always interacting with beliefs. Attitudes function as a protective mechanism; namely individuals try to develop attitudes which will ease themselves and protect their own egos (7). In the present study, while counselling teachers considered mental illnesses and patients with them as subjects of shame and, dangerous, and poorly successful in interpersonal relationships, their education, occupation of being a mental health counselor, their social class might cause masking of their personal unfavorable beliefs, as it was the expected favorable attitude them from (25-36).

Attitudes and beliefs of guiding teachers who work as “counselors” at schools are important factors which prevent required support and treatment for students with mental problems. Counselling teachers are individuals who can help stigmatism feeling of children and families, may give mental health support at the first stage, can refer cases which should be evaluated by psychiatrists, follow-up treatment compliance, and also who can inform other teachers and establish a collaboration bridge with other teachers, so that beliefs and attitudes towards students with mental diseases develop favorably (37-39).

In the present study, referral reasons of counselling teachers about their students to a child and adolescents psychiatrist were also evaluated, and the reasons were determined as behavioral disorders, attention deficit, depressive mood, and hyperactivity. The reasons were transferred as they were noted by teachers.

In previous studies it was reported that most common diagnoses among cases which applied to a child and adolescent psychiatrist outpatient clinic were extraversion disorders such as attention deficit and hyperactivity disorder, behavioral disorder, which were followed by introversion disorders such as depression and anxiety disorder (46-48).

As it was observed in study results, the most common application reasons to a child and adolescent psychiatry outpatient clinic were similar to referral reasons of teachers. This result indicates that interactions of units working for child and adolescent mental health and sharing information about students are important.

When the related literature is reviewed, it may be claimed that the present study is the first one which has evaluated beliefs, attitudes of counselling teachers about mental illnesses, and referral reasons of teachers to a child and adolescent psychiatrist.

Counselling teachers have an important role in establishment of healthy attitudes about mental illnesses, because our culture has proverbs such as “People who have a dead person cry one day, but ones with mental patients cry every day” and “Mentally ill person is not ashamed, but their relatives are” which indicate social point of view in mental illnesses and individuals who are relatives of these patients (40,41). When studies were evaluated, it was determined that trainings about mental illnesses improved community knowledge about these diseases; decreased stigmatism of individuals with mental illnesses; and were effective to develop more favorable attitudes (5,42,43). Therefore, it may be proposed to the Ministry of Education that mental health lectures are implanted in the educational program; these lectures should be given by counseling teachers with community mental health nurses; and all branch teachers will be included in this training so as to increase healthy mental development, and to contribute to favorable beliefs and attitudes starting at the childhood (5,44,45). Again, lectures which will prevent from stigmatization in mental health and illnesses in their university education program to all teacher candidates may have positive effects on beliefs and attitudes of this profession group. Counselling teachers may give seminars in healthy mental development and prevention of stigmatization to other branch teachers and families. The Ministries of Health and Education may produce collaborative school-based projects.

The most important limitation of the study is that it has involves teachers only in one city, and difficulties in assessment of subjective concepts such as beliefs, attitudes by measuring tools. Therefore, this study results cannot be generalized for all counselling teachers. Similar studies should be performed in multiple centers both with counselling teachers and other branch teachers to determine beliefs and attitudes about mental illnesses. Further similar studies with larger scale should be performed to obtain more general study results.

Conflict of Interest: Authors declared no conflict of interest.

Financial Disclosure: Authors declared no financial support.

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