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A survey of physiotherapy students' experiences and attitudes towards

treating individuals with mental illness

Article  in  International Journal of Therapy and Rehabilitation · June 2014

DOI: 10.12968/ijtr.2014.21.7.324

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 Research

A survey of physiotherapy
students’ experiences and
attitudes towards treating
individuals with mental illness
Tamara Dandridge, Brendon Stubbs, Carolyn Roskell, Andrew Soundy

Introduction: Very few research articles have considered the views and attitudes of student
physiotherapists towards treating individuals with a mental illness (MI). Therefore, this study’s objective was
to consider the experiences and attitudes of student physiotherapists towards treating individuals with MI.
Methods: A cross-sectional cohort design was used. One hundred and eighty one physiotherapy
undergraduate degree students at UK institutions participated in the survey. The survey had been
specifically designed for this study, and contained a mixture of open and closed questions.
Results: Seventy one per cent (123/173) of the students were exposed to less than 4 hours teaching
time about MI, and 76% (131/173) wanted further education on MI. Students were concerned about
limited knowledge of MI conditions and how to approach patients who have a MI. A summary of the
specific concerns of students is identified within the text.
Conclusions: Further education about MI is required to give students greater confidence in treating
patients who have an MI. Education would also likely benefit some students who identify negative
characteristics of patients with MI.

Key words: n Mental health n Education n Physiotherapy n Attitudes n Mental illness

Submitted 18 February 2014, sent back for revisions 3 April 2014; accepted for publication following double-blind peer
review 18 June 2014

P
hysiotherapists working in mental 2010). This includes stigmatised attitudes from
health are well equipped to provide health professionals (Thornicroft, 2009) and
interventions to benefit the physical students (Byrne, 2000; Wynaden et al, 2000;
and mental health (MH) of people who Happell and Gough, 2007). For people with a
have a mental illness (MI) (Chartered Society MI, this can mean being stereotyped as violent,
of Physiotherapy [CSP], 2008a; 2008b). unpredictable and less trustworthy than the aver-
Physiotherapeutic skills of benefit to patients age person (Dinos et al, 2004). Stigma affects
Tamara Dandridge
is a physiotherapy with MIs include: exercise prescription; deliv- a patient’s psychosocial wellbeing (Corrigan et
BSc graduate at ery of lifestyle and weight management pro- al, 2006; Watson et al, 2007) and help-seeking
the University of grammes; expertise in motivation and physical behaviour (Clement et al, 2014). This in turn can
Birmingham; healthcare; management of falls and mobility; impact on the long-term prognosis and recovery
Brendon Stubbs is
identification of non-pharmacological pain treat- for the individual (Watson et al, 2007), resulting
a PhD Student at the
University of Greenwich; ment; and consideration of the patient’s func- in a reduction of health service use (Dinos et al,
Carolyn Roskell tional abilities (Pope, 2009). Physiotherapists 2004; Teachman et al, 2006). Research is needed
is a Lecturer in also play a central role in reducing the physi- to explore the views and attitudes of health pro-
Physiotherapy, University cal health disparity in people with mental ill- fessionals towards individuals with MI, as this
of Birmingham;
ness (Stubbs et al, 2013; 2014a; 2014b) and naturally influences treatment and interactions
Andrew Soundy
is a Lecturer in in improving quality of life (Vancampfort et (Hansson et al, 2013).
Physiotherapy at al, 2012). However, outside of specialist men- Understanding the attitude of physiotherapy
the University of tal health services, physiotherapists’ knowledge students towards individuals with MI is impor-
© 2014 MA Healthcare Ltd

Birmingham, UK. about MH or MI is limited (Pope, 2009). tant as younger members of staff can often
Research has identified that individuals with express more negative beliefs about people with
Correspondence to:
Andrew Soundy MI experience high levels of stigma, face stere- mental illness (Hansson et al, 2013). Research
E-mail: a.a.soundy@ otypical views of their MI and, as a consequence, has shown that education is an effective method
bham.ac.uk can be rejected by others (Douglas and Sutton, of influencing student attitudes towards MH

324 International Journal of Therapy and Rehabilitation, July 2014, Vol 21, No 7
 (Wynaden et al, 2000; Happell and Gough, 2007; tice and specific MI conditions. Despite these
Probst and Peuskens, 2010; Gyllensten et al, findings, several aspects have been reported that
2011). may prevent effective teaching of MH to physio-
The attitudes of physiotherapy students therapists, including: a shorter duration of course
towards people with MI have been considered (2 and 3 years in the UK, compared with 4 years
in two studies; one of these studies was con- in most European institutions); the current scope
ducted in Belgium (Probst and Peuskens, 2010) of competencies demanded by the CSP learn-
and another in Sweden (Gyllensten et al, 2011). ing principles framework (CSP, 2008b); and the
Probst and Peuskens (2010) assessed the atti- requirement for a high number of clinical hours.
tudes of undergraduate physiotherapists by using Thus, it is unknown what current levels of teach-
the Attitudes Towards Psychiatry Questionnaire ing in the UK translate to physiotherapists’ expe-
(Burra et al, 1982). This research suggested riences of and attitudes towards MI.
that physiotherapists have ‘a moderately posi- In summary, research exploring attitudes of
tive’ attitude towards psychiatry, which compares UK physiotherapy students towards MH is lack-
favourably to other medically-related disciplines. ing, as is research that considers the provision of
In addition, the research identified the benefit of teaching for students. Previous research focuses
a specific training course on physiotherapists’ mainly on medical and nursing cohorts with the
attitudes. However, this scale was originally writ- aim of increasing numbers of students who spe-
ten for psychiatrists, with its questions orientated cialise in psychiatry. Two studies focus on physi-
towards this profession, e.g. question four on the otherapy cohorts, both of which use quantitative
scale states: ‘I would like to be a psychiatrist’ tools that are not designed for physiotherapy stu-
and question seven: states ‘psychiatrists seem dents. Indeed, Probst and Peuskens (2010) call
to talk about nothing but sex’. Given the need for a specific physiotherapy questionnaire to be
to rate such statements, it is clear that the focus designed. It has been demonstrated that attitudes
of the questions is aimed at understanding the can be affected by educational input. However, it
attitudes of the psychiatric profession rather than remains unclear exactly what volume of teaching
understanding health professionals’ attitudes is required to impact student attitudes and sense
more broadly. of preparedness for treating real-life patients.
Gyllensten et al (2011) examined how the Given the above points, the current study’s pur-
type and volume of teaching across six health pose was to describe the educational and personal
and social care degree programmes influenced experiences of physiotherapy students, and their
attitudes towards MH. This research identified attitudes towards working with people with a MI.
that duration of contact time, the examination
of case studies and provision of lectures about Methods
MH were the most influencing factors for reduc-
ing stigma in undergraduate students. Given this, A cross-sectional cohort design was used to
further research that considers UK cohorts is explore the views and attitudes of student physi-
required as there is currently very little consid- otherapists within the secure, online survey. All
eration towards the type, volume and experiences UK physiotherapy undergraduates undertaking
of MH or MI among UK physiotherapists as well an undergraduate physiotherapy course in the UK
as considering students’ attitudes towards MH. were invited to participate in this study (a provi-
Importantly, any further research must consider sional total accessible sample was 5 250). This
the influence of personal experience on students’ range across undergraduate cohorts was selected
attitudes as this has not yet been established to capture any changes in the courses over time.
(Probst and Peuskens, 2010). An online survey by the primary and corre-
In the UK, a brief scoping survey, conducted sponding author was designed. The survey was
for the higher education academy considered designed to be brief to maximise response rates
teaching in MH at 11 of the total 29 physio- (De Leeuw, 2005), and sub-domains and ques-
therapy teaching institutions (Spearing, 2012). tions were based on previous research (Happell
Findings were generated through email responses and Gough, 2007; Probst and Peuskens, 2010).
from physiotherapy programme leaders and illus- Following a pilot study of five final year physi-
trated that: in most cases, teaching about MH otherapy students from the primary author’s
© 2014 MA Healthcare Ltd

was provided on a generic module, rather than institution (full details obtainable from primary
through devoted MH or MI modules; delivery of author), no adjustments to the questionnaire were
MH teaching was similar across year groups; and made. The final questionnaire consisted of five
where teaching about MH did occur, it focussed sections (see Appendix A): section 1–4 was used
on the role of the physiotherapist, scope of prac- to identify an overview of the type and volume of

International Journal of Therapy and Rehabilitation, July 2014, Vol 21, No 7 325
 Research

Table 1. Students’ education and exposure to mental health an identification number ensuring students could
Variable Outcome variable Result withdraw from the study. No identifiable data
(n) (%) was collected, ensuring anonymity for the insti-
tutions and students that participated. Ethical
Undertaken at least one Yes 12 7
mental health placement No 157 91 approval was obtained from the University of
Not identified 4 2 Birmingham (reference: ERN 11-1151).
Known someone with Yes 57 33
mental illness No 105 61 Analysis
Not identified 11 6 Descriptive statistics were undertaken on sec-
Has knowing someone Yes 38 73 tions 1–4 using SPSS (Version 19.0). Section  5
changed the way you view No 14 27 was analysed initially as a data-driven analysis
mental illness (n/52 valid (Gibbs, 2007). Due to the short nature of com-
responses)
ments provided by students, the authors used a
Hours teaching for all years <1 hours 37 21 quantitative content analysis (Pope et al, 2007).
1–4 hours 83 48
As part of this analysis the authors sorted
4–8 hours 20 12
8+ hours 16 9 responses by vocabulary repetition (Soundy
Not identified 17 8 et al, 2011). The grouped responses were used
Hours teaching for final year <1 hours 3 4 to provide thematic categories and subcatego-
students (n/79 response 1–4 hours 54 68 ries, which were grouped by the primary and
from year cohort) 4–8 hours 11 14 corresponding author. The analysis was con-
8+ hours 9 11 ducted in general for all responses and also split
Not identified 2 3
into six distinct groups to consider the interac-
Exposure (n/216 valid Stand-alone module 8 4 tion between time and personal exposure to MI
responses, as more than one Within broader module 73 34
(three groups on hours by two groups regarding
response per student could Within a lecture 88 41
be given) Within a seminar 28 13 exposure). The corresponding author acted as a
Within a tutorial 11 5 critical friend in order to ensure and check the
With a service user 8 4 quality of the analysis (Soundy et al, 2014). This
Wanting further education Yes 131 76 included checks for accuracy and representative-
No 30 17 ness, in order to ensure a rigorous approach to
Not identified 12 7 analysis. Further detailed comments are available
Type of further education Number giving correct details 55 32 from the corresponding author
(n/83 valid responses) Format of teaching
Lecture 27 33
Seminar 16 19
Results
Tutorial 6 7
Placements 19 23 One hundred and seventy three students
Delivery of teaching (138  female and 35  male) provided answers to
Clinical specialist 7 8 all the questions in the survey and were included
Service user involvement 7 8
in the analysis. This represented around 3.3%
Online 1 1
(173/5250) of the population of interest and a
response rate of 5.6% (173/3150). The mean age
teaching in MH. Section 5 was used to identify of individuals was 22.0  ±  5.0  years. Forty nine
the concerns students had towards MH. students were in their first year of study, 45 were
in their second year of study, and 79 were in their
Procedure final year of study.
All 35 universities running physiotherapy
undergraduate programmes in the UK were Descriptive statistics
approached to participate. The physiotherapy Only 7% (12/173) of students had undertaken
programme leader from each institution was sent a mental health placement. Nearly half of
a standardised letter, which included informa- the respondents were final year students. Over
tion regarding the study, information requesting a third (61/173, 35.3%) of respondents did not
student participation and a link to the survey. know someone with a MI. Seventy one percent
Programme leads who agreed to participate in (120/173) of all students and 72% (57/79) of final
© 2014 MA Healthcare Ltd

the research were asked to forward a cover email year students had undertaken less than 4 hours of
to participants (obtainable from first author) to training in mental health over their entire courses.
ensure privacy and confidentiality. Students were Ninety three per cent (161/173) of responses sug-
informed that consent was implied through par- gested exposure was contained within a broader
ticipation in the survey. Surveys were allotted module (for instance, a module that was not ded-

326 International Journal of Therapy and Rehabilitation, July 2014, Vol 21, No 7
 Table 2. Participants’ comments regarding the concerns of treating individuals with mental illness organised into categorical groups
Hour groupings Interacting with Understanding Safety *** The provision of Patient Total concerns
(known patients * of condition ** treatment **** characteristics
someone with a *****
mental illness)
<1 (yes) 7 (41%) 4 (24%) 3 (18%) 2 (12%) 1 (6%) 17
<1 (no) 7 (23%) 3 (10%) 7 (23%) 9 (29%) 3 (10%) 29
1–4 (yes) 16 (38%) 11 (26%) 4 (10%) 11 (26%) 0 (0%) 42
1–4 (no) 12 (22%) 13 (24%) 7 (13%) 9 (16%) 12 (22%) 53
4+ (yes) 3 (21%) 3 (21%) 4 (29%) 1 (7%) 2 (14%) 13
4+ (no) 6 (29%) 5 (24%) 0 (0%) 4 (19%) 0 (0%) 15
Total 51 (30%) 39 (23%) 25 (14%) 36 (20%) 18 (10%) 169
Notes: Percentages are given per row; *=being able to engage with patients in a clinical setting within the role of a student physiotherapist; **=the students’ generic
understanding of the range of mental illnesses and disorders; ***=students’ concerns regarding their own safety during treatment; ****=knowing what treatment
individuals would be required to provide for patients with MI; *****= negative characteristic that a patient with MI may have, e.g. being dangerous

icated solely to MI) or within a lecture. Three conditions. Fifteen (15/144, 10.4%) students
quarters (131/173, 75.7%) of students wanted fur- highlighted the problem of not knowing what to
ther education in the area, with more lectures, do for patients in the rehabilitation setting when
placements and seminars most consistently called providing patients care. This included concerns
for. Table 1 provides the full breakdown of the over the aim and scope of treatment, capabili-
demographics for the sample. ties of patients and their responses and reac-
tions to treatment. Two (2/144, 1.4%) students
Comments considering students’ wanted to know about users’ attitudes towards
concerns in treating patients with MI treatment and one student just stated that help
Students were asked if they had concerns regard- was required.
ing treating patients with a MI. One hundred
and seventy eight comments were made by 144 The provision of treatment
students. These comments fell into five catego- Nineteen comments (19/144, 13%) identified
ries: interaction with patients; understanding of not knowing how best to treat patients with MIs,
condition; the provision of treatment; patient what is appropriate for treatment or how physi-
characteristics; and safety. Table 2 provides a otherapy influences treatment, because of a lack
summary of these concerns. Finally, some stu- of knowledge. Nine (9/144, 6%) comments sug-
dents reported no concerns or identified that they gested students were unsure of the benefits of
didn’t know what concerns they had. treatment, concerned that a patient would not
respond, or even that treatment could harm a
Interacting with patients patient. Four (4/144, 3%) comments mentioned
Nineteen participants (19/144, 13%) identified a concern about the skills needed during treat-
concerns around not knowing how to approach ment, such as the need to provide goals, or what
the patient, how to act, or saying the wrong thing to do if a patient is self-harming, and knowing
and having a negative impact on the patient. the side effects of medication. Four (4/144, 3%)
Eight participants (8/144, 6%) just stated the comments suggested a worry about the patient’s
word ‘communication’. Eight (8/144, 6%) com- ability to consent or comply with treatment if
ments identified a lack of knowledge about how they had an MI. Two (2/144, 1%) comments sug-
to communicate effectively or how to adjust gested that the patient’s understanding of physio-
communication to meet the patient’s needs. Ten therapy would be limited if they had an MI. One
(10/144, 7%) comments identified barriers to (1/144, 1%) comment considered the clinical his-
communication, with three identifying that there tory of patients a potential problem.
may be an uncertain reaction from the patient.
Three participants (3/144, 2%) identified a con- Patient characteristics
cern for not knowing how to deal with or manage Seven (7/144, 5%) comments expressed con-
© 2014 MA Healthcare Ltd

challenging situations. cern about anger, aggression or violence. Eight

(8/144, 6%) comments were concerned about
Understanding of MH conditions unpredictable behaviour or mood swings
Twenty one (21/144, 14.6%) students high- or behavioural issues among people with MI.
lighted a concern about their knowledge of MH Finally, one comment suggested that stereotypes

International Journal of Therapy and Rehabilitation, July 2014, Vol 21, No 7 327
 Research

may overshadow and impact their treatment, MI. The majority of students (71%) reported
while one comment (1/144, 1%) identified a need receiving less than 4  hours of training in MH,
to guard against stereotypes. often within a broader module or within a sin-
gle lecture. A similar number would have liked
Safety more training on their course. The main con-
The most frequently-reported concern partici- cerns of students included limited knowledge
pants raised was for their own safety or other of MH conditions, not knowing how to provide
physiotherapists’ safety (14/144,10%); this was treatment or how to interact with patients and,
followed by seven (7/144, 5%) comments having additionally, many had safety concerns. There
a concern for the safety of other patients. Four were fewer concerns among students who per-
comments (4/144, 3%) suggested a concern for sonally knew someone with a MI. For those
patients with MIs’ own safety. One (1/144, 1%) who did not know someone with MI personally
mentioned a concern for the safety of treatment. and had less training (comparing more than 4
hours of training to up to 1  hour of training),
No concerns there were greater concerns about interacting
Seven comments in total reported no concerns. with these patients, and a greater need for more
This included five participants who had received understanding about MI. This may suggest that
4  hours or more of training and two who had when students do not have personal experience
received up to 1  hour of training. Two (2/144, of someone with a MI, the volume of teaching
1%) comments stated that students had no con- can provide an awareness of MI but can also
cerns specifically as they had undertaken a raise concerns about their lack of knowledge
placement in a MH setting. One (1/144, 1%) and ability to interact with patients.
stated that treatment would be the same as a nor- Over 70% of all respondents had less than
mal patient. 4  hours of training around MH. This may
explain why, outside of specialist MH serv-
Don’t know ices, the knowledge of physiotherapists towards
Two (2/144, 1%) comments suggested they MH or MI is limited (Pope, 2009). Further,
didn’t know what concerns they had. these current results fall below the volume of
teaching reported in previous studies of physi-
The value of knowing someone otherapy students (Probst and Peuskens, 2010;
personally and number of hours of Gyllensten et al, 2011) and go against find-
teaching received ings reported regarding the volume of teaching
Table 2 provides a breakdown of the number of reported by programme leads (Spearing, 2012).
comments by hours and themes. This table high- Although previous studies have reported posi-
lights that, in general, the most frequent concerns tive attitude changes following a MH teaching
made by all students related to interaction with programme (Probst and Peuskens, 2010), it is
patients (51/169, 30%), understanding of condi- not possible to generalise these findings to UK
tions (39/169, 23%) and the provision of treat- populations. One reason for this is because of
ment (36/169, 21%). In general, individuals who the variation between the MH teaching input
knew someone with MI personally had fewer reported in these studies.
concerns (72/169, 43%) than individuals who Lectures and seminars were reported to be the
did not know someone with a MI (99/169, 59%). most common modality of MH teaching in this
Over 20% of students who had at least 1 hour of study, supporting previous research (Spearing,
training expressed a concern about their under- 2012). However, despite the amount of MH
standing of a MI. Of the individuals who did teaching students had received, the majority of
not know someone with a MI, those with more respondents wanted further education on MI.
than 4 hours of training had more concerns about Despite some institutions providing teach-
interacting with patients and regarding their ing that considers knowledge of specific MH
understanding of the MI than those with less than conditions and the role of the physiotherapist
1 hour of training. (Spearing, 2012), a greater number of lectures
and teaching methods are required. Previous
Discussion research has identified two factors that posi-
© 2014 MA Healthcare Ltd

tively influence attitudes towards mental health,

To the best of the author’s knowledge, this including length of time devoted to teaching
study represents the first attempt at conduct- MH (Gyllensten et al, 2011), and modules
ing a national survey of physiotherapy stu- devoted to MH (Probst and Peuskens, 2010).
dents’ attitudes toward treating individuals with The current results support these statements,

328 International Journal of Therapy and Rehabilitation, July 2014, Vol 21, No 7
 suggesting that a greater number of MH place- less teaching. Also, this study could not identify
ments, and a greater use of MH service users the variability in teaching between institutions.
within the curriculum may also benefit students’ The term MI was not defined by authors for
confidence and attitudes around MH. the students in order to capture a wide range
Previous studies of nursing students have of open responses and to avoid limiting the
shown a link between levels of anxiety towards responses or attitudes from students. However, a
MH and lack of knowledge around MH lack of definition may impact on the generalisa-
(Happell and Gough, 2007; Thornicroft, 2009). bility of the findings; in this study, the thematic
Phrases such as ‘unpredictable behaviour’ and analysis was designed to collect similar find-
‘risk of violence’ were common within the ings so this may be less problematic, since any
current results. This supports the theory that generalisations are specific to responses made.
negative stereotyping may exist amongst some Different outcome measures have been used in
students (Byrne, 2000; Dinos et al, 2004; past studies, making direct and specific com-
Thornicroft, 2009) and that it could be stereo- parisons with other countries more difficult.
types that are fostering students’ anxiety or con-
cerns within the treatment setting. Removing Conclusion
such concerns could be easily achieved through
additional training. The findings of this study suggest that many
Personal exposure of MH has been shown to UK physiotherapy undergraduates feel their
have a positive effect on attitudes towards MH skills and knowledge around MH are lacking.
in other health professions, including student Qualitative information regarding students’
nurses and medical students (Dixon et al, 2008; feelings about treating patients with a known
Markström et al, 2009; Schafer et al, 2011). MI revealed concerns regarding the ability to
One study of medical students revealed that stu- communicate with patients effectively, a lack
dents who knew someone with MI expressed of knowledge and skills, and a lack of under-
increased empathy towards patients with MH standing of a patient’s cognition and behav-
problems (Dixon et al, 2008). The current study iours. Future studies need to use more rigorous
would support a need to encourage and include exploratory research and investigate associa-
more training and education in MH. Training tions between the hours taught, clinical expo-
should include teaching from service users, sure and personal exposure. IJTR
more placements in MH or alternative types of Ethical approval: Ethical approval was gained following
experiences, e.g. students gaining clinical expe- ethical review from the University of Birmingham (Protocol
rience from volunteering (Soundy et al, 2013). reference number: ERN 11-1151).

Funding: The study was funded by authors.

Limitations Conflict of Interest: There are no conflicts of interest.
This study has a number of limitations. A very
Burra P, Kalin R, Leichner P, Waldron JJ, Handforth JR,
low response rate to the survey was obtained Jarrett FJ et al (1982) The ATP 30 a scale for measuring
from the population of interest and the psycho- medical students’ attitudes to psychiatry. Med Educ 16(1):
31–8
metric properties of the survey had not been Byrne P (2000) Stigma of mental illness and ways of dimin-
established. Asking for ‘concerns’ invites a neg- ishing it. Adv Psychiatr Treat 6: 65–72
Chartered Soceity of Physiotherapy (2008a) Commissioning
ative view point to be expressed by students Mental Health Services: The contribution of physi-
and this was not balanced by questions probing otherapy to integrated services for health and wellbeing.
for positive attitudes. This suggests a degree of
question bias may have been introduced into Key points
this study.
Without examining the programme docu-
ments for each course, it is difficult to say for n Low levels of specific training in mental health (MH) were reported in UK
certain how limited the teaching is. The knowl- undergraduate physiotherapy programmes.
edge of students in years one and two regard-
ing the course and module content is partially n Training alone was insufficient to allay student concerns when treating
dependent on whether they have read their people with a mental illness (MI).
course handbooks. Thus, conclusions regarding
© 2014 MA Healthcare Ltd

n Experience of knowing someone with a MI reduced student concerns.

the optimal hours of teaching must be viewed
with some caution. Caution is required when n Learning strategies should be adopted which increase students’ knowledge
considering the number of contact hours relat- and exposure to people with MI.
ing to MH reported by students as students may
have reported fewer hours if they had attended

International Journal of Therapy and Rehabilitation, July 2014, Vol 21, No 7 329
 Research

Douglas KM, Sutton RM (2010) Constructive or cruel?

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Section 1 tive and negative stereotypes of the mentally ill. Br J
Psychol 102(1): 97–107
Age Gibbs G (2007) Analysing Qualitative Data. Sage, London
Gyllensten A, Svensson B, Björkman T, Hansson L,
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Healthcare Students Towards Mental Illness – a Pre and
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Current year of course: Allied Health Sci Prac 9(3): 1–7
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