In this study, we assessed the impact of the renaming of the Japanese term for schizophrenia in clinical residents. We also assessed the change in attitudes toward schizophrenia before and after clinical training in psychiatry to elucidate the effect of having contact with schizophrenia patients.The result from before clinical training demonstrated that the old term “Seishin-Bunretsu-Byo” (Mind-Split Disease) was more congruent with criminal than the new term “Togo-Shitcho-Sho” (Integration Disorder), suggesting that the old term was strongly associated with “criminal” vs. “victims”, while the automatic association between the new term and criminal was not strong. This means that our results are consistent with the previous study
, which indicated that the name change led to reduced stigma, and even for clinical residents, not only for general students.Then, this automatic association between the old term “Seishin-Bunretsu-Byo” and criminal became diminished after clinical psychiatry training, even indicating that the old term had become unfamiliar after clinical training, as the use of the new term “Togo-Shitcho-Sho” in official documents became established in Japan.The most interesting finding from our study, however, was that the new term “Togo-Shitcho-Sho” actually became strongly associated with criminal after clinical psychiatry training. Some previous studies reported the negative and positive attitudes towards schizophrenia held by medical professionals
[34, 35], but little has been known about how contact with schizophrenia patients affects the formation of negative attitudes towards schizophrenia at implicit and explicit levels. Our result showed that contact with these patients, unexpectedly, changed the attitudes towards schizophrenia of clinical residents in a negative way, indicating that their implicit knowledge structure regarding schizophrenia changed to be strongly associated with criminal, as IAT indirectly measures the combined association strengths of two associative pairs contrasted with the strengths of two other associative pairs. This negative implicit knowledge structure towards schizophrenia does not mean prejudice and stigma. However, as it is detected by implicit measures that predict variation in behavior that is not accounted for by explicit measures such as in conditions where self-presentation concerns are high (i.e., prejudice and stereotyping domains)
[41, 42], the implicit knowledge structure towards schizophrenia strongly associated with criminal might actually induce discriminative attitudes and behaviors automatically.From an educational standpoint, with the expectation of reducing stigma, certain campaigns have been emphasizing biogenetic explanations of schizophrenia
. These kinds of campaigns disseminate the concept that "schizophrenia is an illness like any other" and bring about several effects, such as the causes of mental health problems being attributed to factors outside the self-control of individuals, like biological factors, and people’s attitudes will be less negative and patients and families will experience less blame
. On the other hand, it has been argued that biogenetic explanations might cause other complicating issues such as that patients with schizophrenia are viewed as individuals who are unpredictable and dangerous, which then is positively associated with fear
. A systematic review of biogenetic causal attributions of mental illness among the general public was conducted by Angermeyer et al. (2011)
, and it was indicated that increasing public knowledge of the biological and genetic basis was not associated with lesser rejection of people with mental illness, and in fact there seemed to be a danger that biogenetic illness concepts increased rather than decreased public stigma of mental illness. Our findings suggest that a general educational program emphasizing biogenetic explanations of schizophrenia for clinical residents is not sufficient. As pointed out by Corrigan et al. (2004)
, a popular strategy for combating mental illness may exacerbate other components of stigma, particularly the benevolence and dangerousness stigmas, and they proposed a balanced approach that combats the various myths about mental illness. Based on their findings, more appropriate programs that provide accurate information about violence and schizophrenia, and exposure not only to acute phase patients but also recovered patients who are active in the community would be both beneficial and necessary. Although there has been no established standard educational paradigm for reducing prejudice and stigma, our findings that the implicit knowledge structure regarding schizophrenia was influenced by contact with such patients indicate that appropriate educational programs such as to provide accurate information about violence and schizophrenia for clinical residents would be both beneficial and necessary in the early phase of their clinical training.
The attitudes towards schizophrenia of clinical residents could be influenced not only by contact with schizophrenia patients through their clinical training but also by the attitudes towards schizophrenia of the supervisors of their psychiatry care teams and co-medical staff including psychologists, social workers, and nurses in the psychiatric ward.
We could not find significant differences in Link's scale scores between the new and old terms, nor was there significant correlation between explicit scale and implicit scale for both the new and old terms. Although we do not have precise explanations, self-presentation is considered a cause. IAT is not actually a lie-detector nor does it reveal something that is more true
, and evidence for the factors moderating the predictive validity of implicit measures is still in its growth phase
. IAT is used to evaluate the severity of psychiatric symptoms of various mental illnesses
[48–51]. Taken together, IAT appears to be a useful tool for evaluating the attitudes towards mental illness.Our study has some limitations. First, the extent and type of exposure of the clinical residents in this study could not be fully integrated. We could not classify the type of contact they experienced and did not know their previous experience with mental illness, either academically or personally. Also, we assessed only a 1-month clinical training period, not a long-term follow-up, to determine whether changed attitudes towards schizophrenia caused by contact with schizophrenia patients remained thereafter. Thus, the findings may not pertain to other groups. Controlled previous experience and information of the assessment of contact with mental illness would be beneficial for future study. Secondly, mean age of the participants in this study (28.0 years, S.D. = 4.1 years) was older than that of the earlier study (21.5 years, S.D. = 1.4 years)
. The possibility of difference in the knowledge level of the old term “Seishin-Bunretsu-Byo” (Mind-Split Disease) cannot be ruled out, since the Japanese term for schizophrenia was changed in 2002. Information concerning prejudice and stigma about mental illness, usually gathered using questionnaires, is subject to response bias due to social desirability
[2, 23–25], and especially among medical professionals
. In order to minimize this bias, we used Link’s scale. However, it remains possible that we cannot directly access explicit attitudes toward schizophrenia using this scale.
Also, we investigated only the association between schizophrenia and criminal using hypertension as control illness by the task of IAT according to Takahashi et al. (2009)
. Additional IAT studies on the association between schizophrenia and other stereotypical attributes using different control illnesses are recommended, as also pointed out by Takahashi et al. (2009)