Stigma, Discrimination, and Mental Health in Israel: Stigma against People with Psychiatric Illnesses and against Mental Health Care Naomi Struch Yechiel Shereshevsky Alona Baidani-Auerbach Max Lachman Tali Zehavi Noga Sagiv The study was partially funded with the assistance of the National Institute for Health Services and Health Policy Research RR-478-07

Myers-JDC-Brookdale Institute

Center for Research on Disability and Special Populations

Ministry of Health Mental Health Services

Research Team Dr. Naomi Struch, Myers-JDC-Brookdale Institute Mr. Yechiel Shereshevsky, Mental Health Services, Ministry of Health, Jerusalem Ms. Alona Baidani-Auerbach, Mental Health Services, Ministry of Health, Jerusalem Dr. Max Lachman, Mental Health Services, Ministry of Health Ms. Tali Zehavi, Myers-JDC-Brookdale Institute Ms. Noga Sagiv, Myers-JDC-Brookdale Institute Consultants

Dr. Itzhak Levav, Mental Health Services, Ministry of Health, Jerusalem Ms. Denise Naon, Head, Disabilities and Special Populations Research Unit, Myers-JDC-

Brookdale Institute Steering Committee

Prof. Alian Al-Krenawi, School of Social Work, Ben-Gurion University of the Negev Ms. Shula Alperovitch, Benafshenu Ms. Irit Feldman, Director, Disability Pensions Division, National Insurance Institute Dr. Nurit Guttman, Department of Communication, Tel Aviv University Dr. Naomi Hadas-Lidor, Chair, National Council for Mental Health Rehabilitation Ms. Yael Harmel, Director of the Service for the Individual, Ministry of Social Affairs Dr. Julia Mirsky, School of Social Work, Ben-Gurion University of the Negev Ms. Denise Naon, Head, Disabilities and Special Populations Research Unit, Myers-JDC-

Brookdale Institute Dr. Bilha Noy, Director, Psychological Counseling Service, Ministry of Education Dr. Bruce Rosen, Head, Smokler Center for Health Policy Research, Myers-JDC-Brookdale

Institute Prof. Eli Shamir, Chair, Otzma: The National Forum of Families of the Mentally Ill Rabbi Shlomo Stern, Rabbi, Bene Beraq Israel Sykes, Myers-JDC-Brookdale Institute Prof. Shmuel Tiano, former Chair, National Council for Mental Health

Related Myers-JDC-Brookdale Institute Publications Struch, N.; Shereshevsky, Y.; Baidani-Auerbach, A.; Lachman, M.; Zehavi, T.; and Sagiv, N.

2007. Stigma: The Attitudes, Experiences, and Coping Mechanisms of People Attending Public Mental Health Clinics. Research Report (RR-492-07).

Struch, N.; Shereshevsky, Y.; Baidani-Auerbach, A.; Lachman, M.; Sagiv, N.; and Zehavi, T.

2007.Stigma in the Field of Mental Health: The Attitudes, Experiences, and Coping Mechanisms of Parents of People Who Cope with a Psychiatric Illness. Research Report (RR-468-07).

To order these publications, please contact the Myers-JDC-Brookdale Institute, P.O.B. 3886, Jerusalem, 91037; Tel: (02) 655-7400; Fax: (02)561-2391; E-mail: brook@jdc.org.il

i

Executive Summary Background In recent decades, there have been considerable developments in mental health care and the rehabilitation of people with psychiatric illnesses. However, the potential of these developments is not being fully realized due, inter alia, to the fact that people who could benefit from the various technologies may choose not to seek treatment because of the stigma associated with psychiatric help and mental health care. Stigma may have a destructive effect on the lives and functioning of people with psychiatric illnesses and on their rehabilitation and integration into society. Stigma is detrimental to quality of life and is expressed in discrimination in housing and employment, in alienation and social distance, and sometimes even in inadequate medical care. There are a range of intervention strategies to cope with stigma, from structural changes to personal contact. Structural changes, such as moving psychiatric services to a new location where they are less visible and more accessible, do not confront stigma itself but they can reduce its impact. Other interventions try to cope with the stigma itself, for example, by providing factual information about the rates of violence among people with psychiatric illnesses in order to counter a widespread stereotype of "mental illness," or by informing the public about the results of treatment and prognosis. Other programs offer contact with people with psychiatric illnesses. However, interventions of this kind do not necessarily reduce stigma. The current study is the first step toward the development of intervention programs to reduce stigma, which is being planned by the Ministry of Health in line with World Health Organization policy. The study is based on a representative sample of 1,583 people, who represent the adult population of Israel (age 22 and over). In addition, we took separate samples for the ultra-Orthodox sector and for Arab localities. Altogether, 2,100 telephone interviews were conducted. Note that this report presents the findings of one of three concurrent studies. Since stigma is not limited to people with psychiatric illnesses and also affects the lives of their families, we conducted another study in which we interviewed 52 parents of people with psychiatric illnesses. Furthermore, because stigma is liable to affect not only people with psychiatric illnesses but also the broader group of individuals receiving treatment at mental health clinics, we conducted a third study in which 167 persons undergoing treatment at these clinics were interviewed in order to examine their experience and perception of stigma. The findings of the additional two studies are the subject of separate reports. Study Goals 1. To examine stigma against "mental illness," against people with psychiatric problems, and

against mental health care and to improve the conceptualization (and assessment) of stigma, including an examination of its various facets:

ii

- The extent to which there are norms, beliefs, and expressions that reflect various types of stigma

- The essence of stigma with respect to its cognitive, emotional, and behavioral components (e.g., examining the role of fear as opposed to hostility or other emotions or examining the cognitive components of stigma, such as knowledge and beliefs) about "mental illness" and about the mental health services.

2. To assess the extent and prevalence of stigma in Israel: - The prevalence of various manifestations of stigma within the general population (overall

and in subgroups such as the ultra-Orthodox, Arabs, and various age cohorts); - The effect of stigma on the utilization of mental health services – to what extent does the

general population refrain from seeking mental health care due to the stigma and what are the public's preferences regarding the way it receives care?

3. To elucidate possible directions for intervention (with respect to goals, method, and target subgroups).

Findings I. Mental Health Care Knowledge about and Familiarity with Mental Health Care A lack of suitable treatment can lead to deterioration into a more serious condition and the need for more intensive treatment and care frameworks. One of the focuses of the current study is, therefore, to examine the public's willingness to seek mental health care, with an emphasis on the stigma associated with the care. As background, we examined the public's level of knowledge about mental health care. The public has some knowledge about mental health care. Many people are aware, for example, of the existence of antidepressants and tranquilizers although fewer know about medication for schizophrenia. With regard to the availability of services, it was found that about a third of the respondents do not know whether there is a mental health clinic in the vicinity. Attitudes to Mental Health Care and Willingness to Seek Care We found that only a small percentage of people (13%) would seek help from a mental-health professional if they were feeling tense or anxious or were in a bad mood. However, when the situation was specifically presented in terms of a psychiatric problem or mental difficulty, there appeared to be greater willingness to refer to the professionals (over two-thirds of respondents). Thus it appears that, on the whole, people are in principal open to the idea of seeking treatment. The openness to treatment and its perceived benefits are more positive among people who have been more exposed to treatment and to people receiving mental health treatment. We examined whether people would wish to conceal the fact that they had sought treatment. A third of the respondents said that if they were receiving treatment they would feel the need to hide the fact, even from people close to them. The negative attitude of people around them is

iii

considered by half of the respondents not only as a barrier that has to be overcome, but also as justification for not seeking treatment. No strong association was found between the extent to which people were acquainted with psychiatric treatment or had contact with people with psychiatric illnesses and their wish to hide seeking treatment. However, as expected, people who had actually considered seeking treatment showed more positive attitudes toward treatment and less desire to conceal the fact that they were seeking it. Preferences Regarding Ambulatory Care and Hospitalization In a hypothetical situation with identical costs for both private and public health care, people would prefer to be treated privately – and even more so in the case of mental health care. If under the reform of the health system, mental health care becomes the responsibility of the health plans, one of the issues that will have to be considered is the structural aspect of the provision of mental health care: Should it become incorporated into general medicine or should there be separate settings for mental health care? Given the argument sometimes put forward that general clinics are less stigmatic, it is interesting to note that not only did we find no preference for general clinics, but that we also found the Israeli public shows a preference for clinics dedicated solely to mental health care. Approximately 75% of the respondents who would prefer to receive treatment at a separate mental health clinic explained that their choice was based on the quality of care. The same reason was given by 18% of those who would prefer to receive treatment at a general clinic. The main consideration for respondents who preferred a general clinic was the possibility of consulting with additional physicians. Another consideration was confidentiality: over a fifth of the respondents who had a preference for either of the two types of clinic gave confidentiality and discretion as a reason for their preference. In the case of hospitalization, the picture is different – there is a clear preference for hospitalization in a psychiatric ward of a general hospital rather than in a psychiatric hospital. This preference is in line with the trend toward altering the ratio of psychiatric beds by reducing the proportion of beds in psychiatric hospitals and increasing the proportion of beds in general hospitals. When the respondent or member of his/her family is in need of a hostel, there is a clear preference for one in the immediate vicinity (72%). The most prominent reasons: the possibility of visiting and of monitoring the care. A minority (19%) prefer the hostel to be further away – apparently chiefly due to stigma.. Respondents in the ultra-Orthodox sector and in Arab localities showed some preference for having a hostel nearby, but their preference was not as strong. II. People with Psychiatric Illnesses Familiarity with People with Psychiatric Illnesses Knowing people with psychiatric illnesses is usually associated with a more positive attitude toward such people. To what extent is the Israeli public exposed to people with psychiatric illnesses? About one-fourth of the respondents reported having a "mentally ill" relative. When this figure is cross-tabulated with reports of respondents living with a "mentally ill" person (now or in the past), we find approximately 6%. We therefore estimate that up to 6% of the respondents have a close relative with a psychiatric illness. About one-fourth of the respondents said they had

iv

worked with a "mental patient," and approximately one-fifth reported that the family had a friend with a "mental illness." Approximately one-fifth reported having a neighbor with a psychiatric illness. Identifying People with Psychiatric Illnesses and Perceptions about Them To what extent is the public capable of identifying people with psychiatric illnesses? What are the perceived characteristics of people with psychiatric illnesses? And to what extent are identification and perceptions associated with stigma? In order to facilitate evidence-based interventions, it is important to know what causes negative attitudes, emotions, and behaviors toward people with psychiatric illnesses. Are negative responses to an individual elicited by specific behaviors that cause him/her to be perceived as "mentally ill"? Or is it the concept/term "mental illness" that is perceived to be associated with certain characteristics and, when ascribed to a specific person, raises a negative orientation toward that person (regardless of his/her specific behaviors)? It is reasonable to assume that both the above paths are relevant to stigma in mental health. The first path, which involves identifying specific people, is meaningful because it concerns everyday situations in which people encounter stigma in response to their behavior. The public identifies some of the people with psychiatric illnesses and responds to them. Obviously, if a person with a psychiatric illness is not identified as such, s/he will be less susceptible to the stigma. The second path, which concerns perceptions of an abstract concept, is meaningful because it represents situations in which the public responds to the term "mentally ill" in a stigmatic way: they are, in fact, responding to the perceived characteristics of a "mental patient," without having a specific person in front of them. So, for example, when there are plans to build a hostel for people with psychiatric illnesses, neighbors will respond to the idea of "mental patients" as they perceive them to be. The two paths have different implications for interventions. Identifying Psychiatric Illnesses: We found a high prevalence of the perception that it is possible to identify people with psychiatric illnesses. Specifically, 41% thought they could identify patients by their appearance, 69% believed they could do so by the way they speak, and 78% thought they could recognize people with psychiatric illnesses by their behavior. When we presented the respondents with descriptions of people, we found that the public is capable of identifying depression – but that depression is not perceived as a psychiatric illness and that attitudes towards people suffering from depression are characterized, among other things, by feelings of anger. In contrast, when presented with a description of a person with schizophrenia, almost 90% of the respondents believed that the individual described was suffering from a "psychiatric problem." Interestingly, however, about a third did not think the individual had a psychiatric illness. When told that an individual showing no psychopathological symptoms had been hospitalized in the past as the result of a traumatic event (a car crash), respondents considered him to have psychiatric problems to a lesser extent than a person described in the same way without mention of the traumatic event (the accident). On the basis of this finding, we indicate a way in which it is possible, in certain cases, to reduce the stigma associated with

v

hospitalization: by emphasizing the external background as the reason for the hospitalization (thereby reducing the attribution of mental problems to the person). Perceived Image of a Person with a Psychiatric Illness: Alongside the issue of identification, there is the issue of the abstract concept of "mental illness." How clear is the distinction between "them" and "us"? We found that "mental illness" is clearly perceived as something that can happen to anyone, even to "us." The findings were not unequivocal with regard to the similarity/dissimilarity between "them" and "us": there is evidently great variance, not only among the respondents, but also in the perceptions of those same respondents themselves. This variance may be reflected in the perceived profiles of a "mentally ill" person and in the complexity of these perceptions. In some domains there is evidently a normative perception of people with psychiatric illnesses. Most of the public does not associate psychiatric illness with mental retardation and the "mentally ill" are perceived to have a similar level of education to that of the general population. Approximately 75% estimated, correctly, that only a small percentage are hospitalized. Using an open-ended question, we asked respondents to list three characteristics of a "mentally ill person". We did not suggest responses or answers. The most salient responses were abnormal/unusual outward behavior, violent behavior, and unexpected behavior. Unprompted, over half the respondents noted abnormal/unusual outward behavior as one of the characteristics of a "mentally ill person." They referred to talking loudly, strange facial expressions and dress, and tremors. About two-thirds of those who referred to abnormal/unusual behavior cited strangeness and, in particular, odd, inadequate, or irrational behavior. About a fifth of the respondents cited an imperfect grasp of reality (misinterpreting reality, hallucinating, speaking incoherently, etc.). Unprompted (i.e., without our suggesting any of the options), about a fifth of the respondents said that unpredictable behavior (including inconsistency and loss of control) was one of the characteristics of a person with "mental illness." When asked directly, 80% of the respondents concur that the "mentally ill" behave in an unpredictable manner. Unprompted (i.e., in response to the open question), about a fifth cited violence and aggression as three characteristics of the "mentally ill." When asked directly about violence, it was found that about a quarter of the respondents believed the "mentally ill" to be more violent than others. Moreover, violence is associated with unpredictable behavior – when asked, about a third of the respondents said that people with "mental illnesses" were violent for no reason. This perception of unexpected violence was mentioned whether the respondents believed patients to be either more violent or less violent than others or violent to the same degree as others. Approximately a fifth of the respondents (21%) described the mentally ill as depressive, weak, and unable to function. Approximately 14% of the respondents noted social problems (isolation, self-segregation, and withdrawal).

vi

In general, it appears that the perception of normativity – perceiving the "mentally ill" as people who can work and study like anyone else – coexists with the idea that they are odd, unpredictable, and, above all, violent. Perceived Etiology One significant dimension of the perception of patients and illnesses is the etiology. This is because the perceived etiology is liable to constitute the grounds for accusations and for blaming the person for his/her illness. (If, for example, persons with depression are perceived as simply being too easy on themselves and it is considered to be within their power to control their problems, there may be a tendency to blame them for their condition.) Concurrently, it may also be grounds for expecting the patient to recover and be able to function. (For example, if the illness is due to a chemical imbalance, then medication should redress the problem and enable him/her to function.) The prevalent perceived etiology is based both on physiological causes and on stress and traumatic events. About half the respondents indicated one or more physical causes for "mental illness": 42% noted genetic problems and about 14% mentioned chemical/organic problems in the brain. Approximately 73% of the respondents mentioned one or more causes that could be seen as psychosocial etiology – i.e., stress from external events including trauma (36%), unemployment, tension at work and in Israel (20%), domestic crises (34%), failures and disappointment, immigration difficulties, external troubles and complications, etc. However, along with the recognition of biochemical and psychosocial causes, we found a not inconsiderable measure of blame attributed to the patients for their illness, as reflected in the opinion of almost half the respondents (46%) that people would suffer less from mental illness if they stopped thinking negative/bad thoughts. Emotions: Fear and Anger The public fears violence from people with psychiatric illnesses especially unexpected violence. Their fear is exaggerated and does not fit reality. We also found it was not uncommon for the respondents to blame the patients for their behavior or condition, while at the same time recognizing the external or biological etiology. Apparently the image produced by the notion of "mentally ill" is closer to emphasizing aspects of schizophrenia than affective disorders, which is also reflected (as noted above) in the perceptions of strangeness and weirdness prevalent in the unprompted responses, in other words, in the responses we obtained to our open questions about three characteristics of "mental illness." A "mental patient" or a person with schizophrenia arouses more fear than a "normal" person (i.e., one whose description shows no signs of psychopathology) who has been hospitalized or a person with depression. The fear of someone with a psychiatric illness or schizophrenia is associated with the perception that the "mentally ill" have a relatively low ability to function like other people, to benefit from psychotherapy, or to be in control of their condition and change it. Despite the fear, people express more compassion and a greater willingness to help people with schizophrenia who have been hospitalized than "normal" people who have been hospitalized.

vii

Their willingness to help people with depression is somewhere between these two extremes and is not significantly different from either. In contrast, in the case of anger, it is interesting that a person with depression arouses more anger than a person with schizophrenia or a "normal" person who has been hospitalized. The anger directed at people with depression reflects a lack of empathy and an inability to understand their condition. Behavioral Intentions and Attitudes Beyond all the emotions, perceptions, and thoughts, the most meaningful aspect about the orientation toward people with psychiatric illnesses is the actual behavior towards them. We did not examine actual behavior, but we did try to examine several measures that could be considered a proxy for it. Most of the respondents said that they would be willing to support the establishment of a social club for people with "mental illnesses." There is a large disparity between the respondents' willingness to have a club in a remote neighborhood and their willingness to have one in their own (i.e., the "Not in My Backyard" phenomenon). This indicates that, even when there is – on the face of it – some openness, it diminishes when the matter impinges on the respondent himself. An interesting and informative finding is that the objections to the establishment of a club in a remote location – i.e., objections for which the respondent's personal interest is not clear – are linked to higher levels of anger toward patients. These findings could be significant for the planning of advance interventions as opposed to post-factum interventions regarding the establishment of hostels or employment units. To what extent does the public express willingness to have contact of various kinds with people with psychiatric illnesses? Willingness to have contact (i.e., the "social distance" scale) is accepted and prevalent in the literature as a proxy for actual behavior. The findings indicate a similar pattern of willingness for contact with someone "mentally ill" or a person with schizophrenia, as described to the respondents. Willingness for contact was greater in the case of a person with depression or a "normal" person who had been hospitalized. With regard to the findings about the "mentally ill," we found that 21% of the respondents would not be willing to sit on a bus next to a "mentally ill" person; 31% would not want such a person as a neighbor; 35% would not be prepared to work with one. In the case of hiring a "mentally ill" person, the figure rose to 52%, and 72% would not want such a person as their boss. Twenty-one percent of respondents would not want to befriend such a person; 34% would not want to continue to be a close friend and confidant of such a person. Finally, 88% would not be willing to have a "mentally ill" person drive their children to school. These percentages concern respondents who are unwilling to have the proposed forms of contact. The percentage of people who declared that they would be prepared to have contacts of these kinds should not be ignored. Nevertheless, the percentages of people unwilling to have the various forms of contact are not low and, furthermore, social desirability may be obscuring an even higher percentage. The figures are

viii

significant given the potentially devastating effect on the rehabilitation of people with psychiatric illnesses and their integration into society. As noted above, 31% of the respondents are not willing to have a person with a psychiatric illness as a neighbor. Responses were more extreme when we asked people what would happen if they had an apartment to rent. About 54% of the respondents would refuse to rent their apartment to a person with a "mental illness." We tried to focus where the problem lay – to what extent this reluctance could be reduced. We found that when the respondents were given a guarantee that the person would pay, the refusals dropped to 39%; if, in addition, there was someone who could be contacted if any problems arose, the percentage of respondents refusing to rent their apartment declined to 22%. In other words, it is possible that through intervention, a significant percentage of people would be willing to consider renting their apartment to a person with a psychiatric illness. A financial guarantee and the possibility of referring problems to a third party could provide a solution, or at least reduce the public's fears and apprehensions. This finding indicates the possibility of reducing the damage caused by stigma not only by changing attitudes but also through structural adaptations (introduction of a system of financial guarantees and a contact person). Relationship among Variables Different measures of orientations toward people with psychiatric illnesses – whether general attitudes, subtle discrimination, preferred social distance, or willingness to rent an apartment – tend to be related to age, education, actual contact with patients, and feelings of anger and fear. The strength of the relationship with the different measures and variables varies. Specifically, we found a more positive approach among people under (rather than over) age 60; those with more (rather than less) education; those with some kind of contact with the mentally ill (rather than those with none); and people who are less afraid of or less angry with mentally ill people. Gender differences are small. Beyond the attitudes and emotions, we examined two measures that are closer in essence to behavior. These examinations focused on social distance and subtle discrimination, which measure two types of discrimination – "regular" and "subtle." The former reflects the extent to whcih a person is willing to have various relationships with others (in the case of a "mentally ill" person). The latter is considered subtle because the discrimination appears to be justified – i.e., the discriminatory behavior is accompanied by justifications. People who behave in this way are unaware that they are being discriminatory. They do not think that their behavior is a response to a person's group affiliation (the "mentally ill"); rather, they believe they are responding to the individual's own characteristics, skills, etc. The importance of distinguishing between the two types of discrimination is not merely theoretical. It is also important with regard to interventions. In the case of subtle discrimination, it is possible to consider an intervention to clarify the problematic nature of these "justifications." Certain types of discrimination are characterized by "following the norm." As long as it is clear what constitutes appropriate behavior, the individual

ix

will try to conform to it. In such situations, it is better to focus on pointing to the discrimination itself and on the fact that it deviates from the desirable norm. As a step towards understanding the factors that affect people's preferred distance from people with psychiatric illnesses or lead to subtle discrimination, we examined models of prediction by employing different variables, such as demographic variables (e.g., age, gender, and education); perceived ability to recover and function; perceived visibility; perceived permeability of boundaries; actual contact with patients; general attitudes towards the "mentally ill"; and emotions of fear and anger. In examining the models, we made several assumptions about the possible order of the effect of these variables. Some variables were found to have a direct effect, some were found to be fully mediated, and some were found to have both a direct and mediated effect. In both the case of preferred social distance and that of subtle discrimination, we found the two main predictors to be fear of the mentally ill and general attitudes toward them. The perception that an ill person can recover and function, and actual contact with ill people, statistically predict the preferred social distance but do not contribute to the statistical prediction of subtle discrimination. In contrast, the degree of anger felt toward these patients is a significant predictor of the extent of subtle discrimination but is not a significant predictor of the preferred social distance after the fear and general attitudes are taken into account. These findings indicate that despite the strong relationship between subtle discrimination and the preferred social distance, these two measures also have different components. The general attitudes, which constitute a key factor in predicting the preferred social distance and subtle discrimination, are predicted by fear and anger, the perceived "visibility" of the person with a psychiatric illness, and the respondent's level of education. We tried to predict the extent of fear and anger by age, gender, education, and actual contact with a psychiatric patient. Both were found to be related to actual contact and anger was greater among men. However, the percentage of explained variance we found in both cases was negligible. The models we examined explained 44% of the variance in the preferred social distance, and 53% of the variance in subtle discrimination. III. Other Populations The Ultra-Orthodox We found less positive attitudes towards seeking mental health care in ultra-Orthodox society than among the non-ultra-Orthodox Jewish population. In particular, there was less willingness to seek treatment openly. The desire to conceal the request for treatment was stronger. A larger percentage of people knew people receiving care, but fewer had considered seeking treatment themselves. They were less familiar with mental-health professionals. Like the rest of the Jewish population, they expressed a preference for a clinic dedicated solely to mental health care rather than a general/integrated clinic and for a general hospital rather than a psychiatric institution. In

x

the case of a family member in need of a hostel, there was a tendency to prefer one located nearby, but this preference was weaker than in the non-ultra-Orthodox population. The ultra-Orthodox population also had a stronger preference than the non-ultra-Orthodox for private ambulatory care, but this applied to all medical treatment and not only mental health care. Regarding the approach to people with psychiatric illnesses, the ultra-Orthodox sample is characterized by a wish to maintain a greater social distance from people with psychiatric illnesses, i.e., they are less willing to have contact (as a neighbor, colleague, boss, etc.), but, as an exception to this trend, they expressed a greater willingness to befriend them. The ultra-Orthodox are no different from other Jews in their perception of the ability of people who have had a psychiatric illness and recovered from it, to marry. The perception that the "mentally ill" are violent is more prevalent in the ultra-Orthodox sample. They are fundamentally less willing to rent an apartment to a "mentally ill" person. However, there was a substantial change when a financial guarantee and contact person were provided, such that the percentage of ultra-Orthodox resolutely opposed to renting their apartment became similar to that of the rest of the Jewish population. Arab Localities In the sample taken in Arab localities, which we compared with respondents living elsewhere, we found a less positive perception of the benefits of mental health care. The respondents are also somewhat less informed about the existence of psychiatric medications. The respondents in Arab localities are less well acquainted with psychologists and more familiar with social workers and psychiatrists than respondents not living in Arab localities. Although we did not find clear differences as to the wish to conceal treatment, the preference for clinics dedicated solely to mental health care, which was also found in non-Arab localities, was stronger in the Arab localities. The preference for psychiatric hospitalization in a psychiatric ward in a general hospital rather than in a psychiatric hospital, was similar in Arab and non-Arab localities. Should a family member be in need of a hostel, we again found a preference for one nearby. However, we found that, as in the ultra-Orthodox sample, it was weaker than in the rest of the population. Willingness to have contact with a person with a psychiatric illness was greater in the case of certain forms of contact and smaller in others compared with responses in non-Arab localities. The perception of chances that a person who had had a psychiatric illness and recovered could marry was higher than in non-Arab localities. There was more evidence of subtle discrimination in Arab localities than elsewhere. Directions for Intervention The report presents recommended directions for interventions, based both on the findings and on the theoretical principles that underlie behavior and attitude-change interventions. These include adapting the intervention to the problematic dimension (i.e., emotional, cognitive, or behavioral); awareness of resistance to change and the difficulty in bringing about change; and adapting the intervention to the specific population, goals, and subject matter; different modes of intervention,

xi

including the drawbacks and potential of each; protest and legislation, education and information, and contact/exposure. With regard to seeking mental health care, we consider four directions: (1) Informing the public about mental health clinics and their location; (2) Changing the stigma about seeking treatment; (3) Increasing awareness of the arguments for and against the structural changes to the provision of services in the framework of the mental health reform; and (4) Interventions with family doctors. With regard to approaches toward people with psychiatric illnesses, we suggest several recommended contents for interventions based on the findings of the study: (1) Reducing the stigma associated with psychiatric hospitalization; (2) Decreasing the perception that people with psychiatric illnesses are violent and deflating the fear of them; (3) Reducing the extent to which people with psychiatric illnesses are blamed for their condition and the anger directed at them; (4) Specific interventions for schizophrenia, including informing the public about the existence of medications and their side effects; (5) Specific interventions for depression, particularly aimed at informing the public about the chemical basis of the illness and the treatments available; and (6) Bolstering empathy. Differential interventions are recommended for specific target groups including the ultra-Orthodox and residents of Arab localities. In order to address the above, a range of interventions including meetings/contact and the provision of information are required. We stress the importance of the way that people with psychiatric illnesses are presented: Alongside the emphasis on the normative aspects of the person, the aspects of the illness should not be ignored. Emphasizing the normative is essential if there is to be a process of change; however, over-emphasizing the normative without referring to the deviance/illness may lead to a situation in which the person in question is no longer perceived as representative of a stereotyped group and hence there will be no change in the stereotype. Contact or exposure should preferably not be with a single person, but with a group of people, so that the great variance among them can be recognized. We present a range of considerations about providing information on the illness and its etiology. Providing information about psychiatric illness helps to reduce stigma against people with psychiatric illnesses in general, but not against a specific person. Information can also refer to the etiology. In the case of some illnesses, such as depression, it is worthwhile considering reducing the perception of responsibility by stressing the physiological causes. This applies to problems and illnesses about which the perception that this is a condition over which the person has no control (as it is controlled by the biochemistry), may be difficult to understand but it does not arouse fear. In contrast, it is doubtful whether this approach is recommended when trying to change one's orientation to, for example, schizophrenia, concerning which the uncertainty is associated with perceived threat.

xii

We also discuss a range of aspects of exposure and contact. One of the most powerful interventions is direct encounter and contact. It is important to be judicious in the choice of conditions so as to prevent ineffective interventions or even harmful ones. Notwithstanding the positive effects of exposure on people with illnesses (such as empowerment), the possibility that exposure may harm them must also be considered. Contact is required with a diverse group of patients in order to reduce sub-typing. Diversity is required, inter alia, in the types of disorders/problems. One should strive for exposure and contact with people at different stages of their illness. In other words, on the one hand it is important for there to be contact with people who are getting better and are in remission. On the other hand, exposure to people only when they are in that condition could create a situation whereby the positive effect of the contact would not be generalized to include patients in more severe stages of the illness. The optimal solution could be exposure to the same person at different stages of his/her illness, i.e., to be exposed to the same patients both during good and less good periods. Finally, we raise some issues regarding interventions aimed at specific target groups such as current or potential neighbors, and potential employers and landlords.

Table of Contents 1. Introduction 1 2. Theoretical Background 2

2.1 Definitions and Implications 22.2 Measurement 32.3 Identification and Perceptions 42.4 Intervention 5

3. Study Goals 13 4. Method 13

4.1 Study Population and Sample 144.2 Study Design 174.3 Instruments: Questionnaires and Measures 18

5. Knowledge, Familiarity, Exposure, and Experience in Mental Health Care 20

5.1 Introduction 205.2 The Clinic 215.3 Payment 215.4 Medication 215.5 Exposure to Psychiatric Hospitalization and the Rehabilitation System 225.6 Indirect Exposure or Actual Experience of Mental Health Care 22

6. Attitudes and Preferences for Mental Health Care 22

6.1 Perceived Benefit of the Treatment 236.2 Willingness to Seek Treatment Openly 246.3 Behavioral Intentions to Seek Treatment 256.4 Attitudes toward Seeking Treatment – Relationship among Variables 27

7. Preference for Different Treatment Settings 32

7.1 Preference for Ambulatory Mental Health Care Settings 327.2 Preference for Hospitalization and Rehabilitation Settings 37

8. Schizophrenia, Depression, and Psychiatric Hospitalization: Identifying Psychiatric Illness, Attributions, and Perceptions

40

8.1 Introduction 408.2 Identification and Orientation 408.3 Depression 428.4 Schizophrenia 428.5 Response to Psychiatric Hospitalization 43

9. The Profile of a Person with a Psychiatric Illness as Perceived by Israeli Society 479.1 Perception of a Person with a Psychiatric Illness 489.2 Perceived Etiology: What Causes Mental Illness 54

10. Manifestations of Stigma in Various Dimensions 56

10.1 Contact with a Personal with a Psychiatric Illness 5610.2 Attributions, Emotions, and Attitudes towards People with Psychiatric Illnesses 5710.3 Behavioral Intentions 6010.4 Overt and Subtle Discrimination/Predjudice 65

11. Orientation to People with Psychiatric Illnesses by Background Variables and Perception Variables

66

11.1 People with Psychiatric Illnesses by Gender, Age, Education and Previous Relationship

67

11.2 Orientation to People with Psychiatric Illnesses by Perceived Permeability of Boundaries and Visibility

76

11.3 Relationship among Variables 79 12. Findings in the Ultra-Orthodox Sector 90

12.1 Attitudes toward Mental Health Care 9012.2 Preference for Ambulatory Treatment Settings 9612.3 Preference for Hospitalization and Rehabilitation 9812.4 Familiarity with People with Psychiatric Illnesses and the Profile of the "Mentally Ill" in Ultra-Orthodox Society

101

12.5 Manifestations of the Stigma in Different Dimensions 103 13. Findings in Arab Localities 108

13.1 Attitudes toward Mental Health Care 10813.2 Preference for Ambulatory Treatment Settings 11313.3 Preference for Hospitalization and Rehabilitation 11513.4 Familiarity with People with Psychiatric Illnesses and the Profile of the "Mentally Ill" in Arab Localities

117

13.5 Manifestations of the Stigma in Different Dimensions 119 14. Directions for Interventions 124

14.1 Orientation to People with Psychiatric Illnesses 12414.2 Seeking Mental Health Care 134

Bibliography 137 Appendices 148

List of Tables Table 1: Recognition of the Benefit of the Treatment 23 24Table 2: Willingness to Seek Treatment Openly Table 3: Where and from Whom Would People Seek Help if They Were in a Very Bad Mood or Felt Very Troubled by Tension or Anxiety 25 Table 4: Attitudes toward Mental Health Care 26 Table 5: Preferences for Professionals when the Family Doctor Determines that the Respondent's Condition Requires Psychiatric Help 27 Table 6: Attitudes toward Treatment by Gender 27 Table 7: Attitudes toward Treatment by Exposure to and Familiarity with Treatment and People Receiving Treatment 30 Table 8: Multivariate Regression for Predicting Perceived Lack of Benefit/Futility of Treatment 31 Table 9: Multivariate Regression for Predicting the Perception of Lack of Benefit of Treatment when Adding as a Second Step Variables of Attitudes to People with Psychiatric Illnesses 32 Table 10: Preferences for Private Treatment versus Treatment through the Health Plans – Concerning Mental Health Care and General Medical Care 33 Table 11: Reasons for Preferring Private Treatment or Treatment through the Health Plans for Mental Health Care and General Medical Treatment 34 Table 12: Distribution of Preferring Mental Health Treatment at a General Clinic versus a Mental Health Clinic 36 Table 13: Reasons for Preferring Mental Health Treatment at a Mental Health Clinic versus a General Clinic 36 Table 14: Distribution of Preferences for Hospitalization in a Psychiatric Hospital versus a Psychiatric Ward at a General Hospital 38

Table 15: Reasons for Preferring to be Admitted to a Psychiatric Ward in a General Hospital versus a Psychiatric Hospital 38 Table 16: Reasons for Preferring a Hostel or Sheltered Accommodation, Near Home versus One that is Further Away 39 Table 17: Perception of a Vignette Describing a Person with Depression 42 Table 18: Perception of a Vignette Describing a Person with Schizophrenia 43 Table 19: Perception of a Vignette Describing a Person with Schizophrenia who is Hospitalized 43 Table 20: Perception of a Vignette Describing a "Normal" Person who has been Hospitalized as a Result of a Traumatic Event 45 Table 21: Perception of a Vignette Describing a "Normal" Person who has been Hospitalized 45 Table 22: Identifying Vignettes and Attributing Characteristics 46 Table 23: Perceived Characteristics of a "Mentally Ill" Person 50 Table 24: Perceived Violence among "People with Mental Illnesses" Compared with the General Population and Attributed Reasons 53 Table 25: Perceived Violence of "People with Mental Illnesses" by Attributed Reasons 54 Table 26: Perceived Etiology of Psychiatric Illnesses 55 Table 27: Contact and Familiarity with "Mentally Ill" People 57 Table 28: Fear, Anger, Perceived Ability to Recover and Function, and Willingness to Help by Vignette: Analysis of Variance, Means, and Number of Cases 58 Table 29: Preferred Social Distance: Unwillingness to have Contact in Response to the "Mentally Ill" or to Vignettes 61 Table 30: Preferred Social Distance from the "Mentally Ill": People Unwilling to have Various Types of Contact by Description Provided 62 Table 31: Subtle Discrimination: Agreement/Disagreement among Respondents who were not Provided with a Vignette 66 Table 32: Key Measures by Gender 68 Table 33: Willingness to Rent One's Apartment to a "Mentally Ill" Person by Gender 68

Table 34: Key Measures by Respondents' Age (Above and Below the Age of 60) 69 Table 35: Willingness to Have a Social Club Established for the "Mentally Ill" and to Rent One's Apartment to a Mentally Ill Person by Age of Respondent 70 Table 36: Key Measures by Education: Analysis of Variance, Means, and Number of Respondents 71 Table 37: Key Measures by Level of Contact with People with Psychiatric Illnesses (3 levels): Analysis of Variance, Means, and Number of Respondents 74 Table 38: Willingness to Have a Social Club Established for the "Mentally Ill" and to Rent One's Apartment to a Mentally Ill Person by Level of Contact 75 Table 39: Key Measures by Perceived Visibility 76 Table 40: Key Measures by Perceived Permeability of Boundaries 77 Table 41: Willingness to Have a Social Club Established for the "Mentally Ill" and to Rent One's Apartment to a Mentally Ill Person by Perceived Visibility 78 Table 42: Willingness to Have a Social Club Established for the "Mentally Ill" and to Rent One's Apartment to a Mentally Ill Person by Perceived Permeability of Boundaries 79 Table 43: Pearson Coefficients of Correlation 80 Table 44: Spearman Coefficients of Correlation 81 Table 45: Multiple Regression for Predicting Social Distance 83 Table 46: Multiple Regression for Predicting Subtle Discrimination/Predjudice 84 Table 47: Multiple Regression for Predicting General Attitudes 85 Table 48: Multiple Regression for Predicting Fear of People with Psychiatric Illnesses 85 Table 49: Multiple Regression for Predicting Anger toward People with Psychiatric Illnesses 85 Table 50: Exposure to and Familiarity with Mental Health Care in the Ultra-Orthodox and the Comparison Samples 91

Table 51: Knowledge about the Existence of Psychiatric Medications in the Ultra-Orthodox and the Comparison Samples 92 Table 52: Attitudes and Emotions toward Mental Health Care in the Ultra-Orthodox and the Comparison Samples 93 Table 53: Where and from Whom Would People in the Ultra-Orthodox and Comparison Samples Seek Help if They Were in a Very Bad Mood or Felt Troubled by Tension or Anxiety 94 Table 54: Preferences of the Ultra-Orthodox and the Comparison Samples for Professionals when the Family Doctor Determines that the Respondent's Condition Requires Psychiatric Help 95 Table 55: Preferences of the Ultra-Orthodox and the Comparison Samples for Private Treatment versus Treatment through the Health Plans 96 Table 56: Distribution of Preferences of the Ultra-Orthodox and the Comparison Samples for a General Clinic versus a Clinic Dedicated to Mental Health Care 98 Table 57: Distribution of Preferences of the Ultra-Orthodox and the Comparison Samples for Admission to a Psychiatric Ward in a General Hospital vs. Admission to a Psychiatric Hospital 99 Table 58: Distribution of Preferences of the Ultra-Orthodox and the Comparison Samples for a Hostel near Home versus Further Away 100 Table 59: Exposure to and Familiarity with People with Psychiatric Illnesses among the Ultra-Orthodox and the Comparison Samples 101 Table 60: Perception of Violence among the "Mentally Ill" in the Ultra-Orthodox and the Comparison Samples 102 Table 61: Perceived Etiology of "Mental Illness" in the Ultra-Orthodox and the Comparison Samples 103 Table 62: Social Distance: Willingness of the Ultra-Orthodox and the Comparison Samples to Have Contact with People with Psychiatric Illnesses 104 Table 63: Willingness of the Ultra-Orthodox and the Comparison Samples to Rent an Apartment to People with Psychiatric Illnesses 105

Table 64: Subtle Discrimination in the Ultra-Orthodox and the Comparison Samples 107 Table 65: Exposure and Experience with Mental Health Care in Arab and non-Arab Localities 108 Table 66: Knowledge about the Existence of Psychiatric Medications in Arab and non-Arab Localities 109 Table 67: Attitudes and Emotions about Mental Health Care in Arab and non-Arab Localities 110 Table 68: Where and from Whom Would People in Arab and non-Arab Localities Seek Help if They Were in a Very Bad Mood or Felt Very Troubled by Tension or Anxiety 111 Table 69: Preferences in Arab and non-Arab Localities for Professionals when the Family Doctor Determines that the Respondent's Condition Requires Psychiatric Help 112 Table 70: Preferences in Arab and non-Arab Localities for Private Treatment versus Treatment through the Health Plans 113 Table 71: Distribution of Preferences in Arab and non-Arab Localities for a General Clinic Versus a Clinic Dedicated to Mental Health Care 114 Table 72: Distribution of Preferences in Arab and non-Arab Localities for Admission to a Psychiatric Ward in a General Hospital vs. Admission to a Psychiatric Hospital 115 Table 73: Distribution of Preferences in Arab and non-Arab Localities for a Hostel near Home versus One that is Further Away 116 Table 74: Exposure to and Familiarity with People with Psychiatric Illnesses in Arab and non-Arab Localities 117 Table 75: Arab and non-Arab Localities: Respondents' Perception of the Number of Hospitalized Patients 118 Table 76: Perception of Violence among the "Mentally Ill" in Arab and non-Arab Localities 118 Table 77: Perceived Etiology of "Mental Illness" in Arab and non-Arab Localities 119 Table 78: Social Distance: Willingness in Arab and non-Arab Localities to Have Contact with People with Psychiatric Illnesses 120

Table 79: Willingness in Arab and non-Arab Localities to Rent an Apartment to People with Psychiatric Illnesses 121 Table 80: Subtle Discrimination in Arab and non-Arab Localities 122 Table 81: Perception in Arab and non-Arab Localities of the Possibility of Marriage for a Person who has Recovered after Psychiatric Hospitalization 123 List of Figures Figure 1: Path Analysis for Predicting Preferred Social Distance from People with

Psychiatric Illnesses 88

Figure 2: Path Analysis for Predicting Subtle Discrimination against People with

Psychiatric Illnesses 89