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Attitudes toward mental illness among mental hospital personnel and patients
J. pychiaf. Res., 1970,Vol. 7, pp. 291-298. PergamonPress. Printed in Great Britain.
ATTITUDES
TOWARD
MENTAL
ILLNESS AMONG
MENTAL HOSPITAL PERSONNEL AND PATIENTS* CLARA
Department
MAYO
and
RONALD
G.
HAVELOCK~
of Psychology, Boston University, Boston, Massachusetts [Received
11 September
(Revised
1968)
31 July 1969)
A CONSISTENT theme of research into attitudes toward mental illness derives from the study of authoritarianism.1 It was, in fact, recognized in that study that authoritarianism had specific implications for attitudes toward mental illness among persons who were themselves mentally ill.2 Later, interest in the mental hospital environment itself led to the definition of ‘Custodial Mental Illness Ideology’” examined at various staff levels in the mental hospital. Custodial ideology (CMI) describes a cluster of beliefs related in manifest content to the care of mental patients and believed to be rooted in the personality dimension of authoritarianism. The authoritarian dimension in attitudes toward mental illness has been isolated repeatedly by factor analysis of a wide range of opinion statements among both mental hospital employees4 and patients.5 Despite this evidence for the pervasiveness of an authoritarian component in attitudes related to mental illness, some major studies have omitted this theme from their measures.e-8 The present study attempts an integration of previous conceptual and empirical strategies by (a) sampling related attitude domains in a single population of patients and staff, (b) supplementing questionnaire data with interview responses, and (c) including demographic data to clarify the specificity of factors obtained.
METHOD
Subjects The patient sample consisted of 89 non-psychotic males admitted to a Veterans Administration general hospital psychiatric service. The patients ranged in age from 20-65 years with a median age of 40 and in education from 5-18 years of schooling with a median level of 12 years. The staff sample consisted of 62 personnel who dealt with the patient group. Included were the professional staff comprising psychiatrists, psychologists, social workers, nurses * This study was supported by the Boston Veterans Administration Hospital. All statements are those of the authors and do not necessarily represent the opinion or policy of the Veterans Administration. t Center for the Research Utilization of Scientific Knowledge, University of Michigan, Ann Arbor, Michigan. 291
292
CLARA MAYO AND RONALD G. HAVELOCK
and aides, and trainees within these professions as well as the education, occupation and recreation specialists associated with the unit. As this was a teaching hospital giving shortterm treatment, the ratio of professional staff to aides was high. Measures A questionnaire was designed including items from the California /; scale,1 the CMI,s social distance measures,6 information content,8 and acquiescence tendencies.9 New items were written to sample attitudes especially relevant to life in the hospital. Subjects indicated their response to all items on a Likert-type scale of 7 levels of agreement centered around ‘neither agree nor disagree’. All subjects also responded to a 19-item Semantic Differential for the concepts of ‘myself’ and ‘mental patient’. For the staff sample, the questionnaires were filled out anonymously. Questionnaires were administered to the patient sample at or near the time of admission in individual interviews. At this time, patients also completed ten sentence stems directed to the dimension of social distance from mental patients and indicated their personal ideas about the nature, cause and treatment of their own illness.
RESULTS
AND
DISCUSSION
Product moment correlation matrices were computed for scores derived from questionnaires and interviews. Because of the large number of variables and diversity of content involved, factor analytic methods were applied to summarize these findings in an unrotated least squares solution for each matrix.* Common stafS-patient factor Among the staff, the most dominant factor, accounting for 12 per cent of the total variance, clearly reflected the dimension of authoritarianism, with loadings of -0.87 for the summed scores of the 12 California F Scale items, -0.71 for the CMI, and -0.68 for Nunnally’s ‘directiveness of therapist’ subset. This factor reflects a lack of social discrimination against mental patients with negative loadings on social distance items. Item loadings are presented in Table 1. The first factor extracted for the patient sample was remarkably similar in content to the first factor emerging from the staff sample. Also termed authoritarianism, it accounted for the same amount of the total variance (13 per cent) and had item loadings of strikingly similar magnitude and configuration but opposite direction from those found for the staff sample, as shown in Table 1. The Nunnally subset dealing with directiveness of therapist (O-75), the CM1 (0.70), and the California F Scale (0*58), all reflect an attitude of high authoritarianism combined with a rejection of mental patients (Cummings’ social distance item loading at 0.57 and a high discrepancy between ratings of self and mental patient * Factor loadings were also computed for a biquartimin simple structure solution. This produced an undesirable isolation of items from different response domains as exemplified in a ‘Semantic Differential factor and an ‘illness interview’ factor. The interrelations between different scales and the factors which cut across response modes (exemplified in Factor I in Table 1) were nullified. It is in demonstrating these relationships, however, that the authors feel this study makes a significant contribution.
ATTITUDESTOWARD MENTAL ILLNESSAMONG MENTAL HOSPITALPERSONNEL AND
PATIENTS
293
(0.53)). This factor also includes the rejection of a psychological description of one’s own illness (0.57). Overall differences between the staff and patient samples were widespread and statistically significant. For example, on the 12 California F Scale items, a very large difference was obtained between staff and patient mean scores of 34.9 and 57-4 with S.D.s of 9-8 and 9.9 (p
FACTOR I : AUTHORITARIAN SUPPRESSION AND TOTALVAIUANCE:STAFF
11
REJECTION OF MENTALILLNESS(PER CENT .~;PATxENT 13.5)
OF
Factor loading Summary variables
Staff
Patient
California F scale (12 items)
-0.87
0.58
Custodial Mental Illness ideology (CMI)
-0.71
0.70
Nunnally I-directiveness of therapist
-0.68
0.75
-0.68
0.57
Cummings’ social distance from mental patients Psychological
description of own illness
N/A
-0.57
Discrepancy between ‘self’ and ‘mental patient’
0.07
0.53
Sentence completion
N/A
0.42
scored for ‘social distance from mental patients’
Psychiatric experience (amount of prior patient contact with psychiatry in any context)
N/A
-0.35
Item variables ‘There ishardly anything lower than a person who does not feel a great love, gratitude and respect for his parents’ (Cal. F)
-0.74
0.55
‘We should strongly discourage our children from marrying anyone who has been mentally ill.’ (Cummings)
-0.61
0.62
‘If a person concentrates on happy memories he will not be bothered by unpleasant things in the present.’ (Nunnally)
-0.56
0.65
‘It is important to know if a person has been in mental hospital before we make friends with him.’ (Mayo and Havelock)
-0.68
0.50
‘Psychiatrists try to teach mental patients to hold in their strong emotions.’ (Nunnally)
-0.60
0.55
‘Mental illness is usually caused by some disease of the nervous system.’ (CMI)
-0.64
0.47
‘The good psychiatrist acts like a father to his patients.’ (Nunnally)
- 0;42
0.63
-0.57
0.42
‘Obedience and respect for authority children should learn.’ (Cal. F)
are the most
important
virtues
‘When Steve found out that a mental hospital was under construction in his neighborhood, he decided to (completion scored for his social distance. .) (Mayo and Havelock) Discrepancy
between ‘self’ and ‘mental patient’ on ‘safe’
Was childhood
related to present illness? (interview question)
WA -0.24 N/A
0.52 0.42 PO.42
294
CLARA MAYO
AND RONALDG. HAVELQCK
greatest staff-patient differences and their respective loadings on Factor I. These differences are presented in Table 2. As might be expected, most of the items showing the greatest differences were drawn from the California F Scale which measures authoritarianism, the. dimension which best characterizes Factor I. This dimension has been identified repeatedly,in studies of attitudes toward mental illness. However, items drawn from such diverse sources as the Nunnally survey, the Gilbert and Levinson CM1 and the authors’ own measure of cause of disorder TABLE2.
ITEMSWITHGREATEST OVERALLSTAFF-PATIENT DIFFERENCES
Item
Factor I loading Staff Patient (n = 62) (n = 89)
Mean Difference
There is hardly anything lower than a person who does not feel a great love and respect for his parents. (Cal. F)
-0.74
0.55
3.07*
The main job of the psychiatrist is to explain to the patient the origin of his troubles. (Nunnally)
-0.56
0.45
2.71*
Obedience and respect for authority are the most important virtues children should learn. (Cal. F)
-0.57
0.42
2.69*
Every person should have complete faith in some supernatural ppwer whose decisions he obeys without question. (Cal. F)
-0.54
0.44
2.50*
When a person has a problem or worry, it is best for him not to think about it, but to keep busy with more cheerful things. (Cal. F)
-0.64
0.46
240*
Most mental disorders are caused by some sort of disease of the nerves in the body or the brain. (Mayo and Havelock)
-0.34
0.45
2.37*
Nowadays more and more people are prying into matters that should remain personal and private. (Cal. F)
-0.68
040
2.08*
Mental illness is usually caused by some disease of the nervous system. (CMI)
-0.64
0.47
2@4*
*p < 0~001. all have high loadings on Factor 1 and show significant differences between staff and patients (p t0.01). The most striking aspect of differences on this factor is the apparent rejection by patients of the views held most strongly by staff. These sharp differences in cognitive orientation erect barriers to communication which cannot but hinder psychotherapeutic relationships. Picture the cognitive reorganization required of a patient who enters into treatment with the belief that there is nothing lower than criticism of one’s parents, that personal problems are not to be thought about, that too many people are prying into personal matters and that submission to authority is a desirable solution to one’s problems. If he believes further that he has a physical ailment that a pill, medical procedure or operation will cure, he may be unwilling or unable to participate in the kind
ATTITUDESTOWARD MENTAL ILLNESSAMONG MENTAL HOSPITALPERSONNELAND PATIENTS
295
of therapeutic alliance offered by a psychodynamically oriented staff. At best, this conflict will prolong his treatment and at worst, it may lead him to leave the hospital against advice or to retreat into illness so as to be judged by staff as an ‘unreachable’ or ‘chronic’ case. A recent report on the evaluation of a therapeutic community treatment program noted that the interaction of patient and staff characteristics may be one of the major factors in patient improvement.iO Other staf attitudes The second staff factor, accounting for 9 per cent of total variance, deals with the selfcritical image of the therapist. The highest loadings occur on the Semantic Differential ratings of ‘myself’ with summed ratings at -0.83, the negative direction of the loadings indicating that among paired adjectives, the self is seen as relatively ‘insincere’ (-0.68), ‘twisted’ (-0*67), ‘dirty’ (-O-65), ‘bad’ (-0.65), ‘dangerous’ (-0*61), ‘worthless’ (-0.57) and ‘unpredictable’ (-0.57). The factor is further characterized by a low discrepancy between ratings of ‘self’ and ‘mental patient’. With respect to demographic variables, this factor is salient for those with upper professional status (0*52), specifically residents (0.47) having contact in therapy with patients (0.59). The third staff factor reflects the attitude of the highly educated (O-58) professional (0.53) with training in human behavior (0.61) who engaged in therapy (0.52). The self is rated as more ‘safe’ (0.49) and ‘valuable’ (0.43) than not, while the mental patient is seen as ‘passive’ (-0.45) and highly discrepant from the self in intelligence (0.49). This factor might be described as the self-assurance of the senior staff in contrast to those in a training status. The factor includes the beliefs that childhood security and happiness preclude mental illness, that psychiatrists need a sense of humor to treat patients, and that it is possible to love and feel close to mental patients. Similar content has recently been identified with the more distant personnel relationships with patients.11 The fourth additional factor extracted for the staff sample is characterized by a quality of toughmindedness exemplified by disagreement with the belief that use of force by police is bad and disagreement also with the belief that punishment is a poor way to treat children. As might be expected, the factor includes concomitantly low overall evaluation of the mental patient (-0.53). It appears to be associated with administrative responsibility for patients. In general, the staff factors appear to mirror different aspects of the professional role of those who make decisions about patients, the not-always-consonant roles of therapist, theorist and warden. Staff Factor 2 highlights the complex interaction of self and other, inherent in the therapeutic relationship. The complexity of such relationships is reflected in the difference between staff Factors 2 and 3. The low discrepancy between the self and mental patients associated in staff Factor 2 with relative inexperience but high patient contact is reversed in Factor 3 whose content is linked to greater experience and formal training in psychotherapy. In Factor 3, greater self-confidence is shown with self-ratings of ‘safe’ and ‘valuable’ and with a rated discrepancy in intelligence between self and mental patient. Greater experience and training not only lead to greater confidence but apparently also give rise to the view that a sense of humor is helpful in treating psychiatric patients. The fourth staff factor, of which psychiatric residency status is the strongest component, best expressed the warden role in patient care. The presence of this factor, stressing the use of
296
CLARA MAYOAND
RONALD G.HAVELOCK
control and punishment, suggests that psychiatric residency may be marked by inherent role conflicts. The novice therapist who is responsible for making administrative decisions with respect to patient care, may come to feel that the use of constraints is the safest course of action. The emergence of different factors for different staff groups documents the attitudinal differences whose manifestations in intra-staff conflict have been noted in many hospital studies and experienced by most hospital personnel. In particular, the divergent content of staff Factors 2 and 4, associated with resident status and of staff Factor 3 characteristic of those who train residents suggests that attitude change as well as the traditional learning is involved in residency training. Patient factors
In addition to patient Factor 1 (authoritarianism), three other factors were extracted for the patient sample. Factor 2 among patients (accounting for 7 per cent of the total variance) is marked primarily by negative ratings of ‘self’ on the Semantic Differential, particularly with the view of ‘self’ as ‘twisted’ (-0.63). In contrast to the first patient factor, this factor involves rejection of physical description of one’s own illness. Apparently those patients who do hold a psychological view of their illness consonant with that of the staff are burdened with an excessively negative view of themselves, as reflected in patient Factor 2 where they see themselves and mental patients generally as bad. This self-devaluation has been linked by GOFFMAN~~ to the therapy dictum which requires the patient to accept the fact of his illness in order to benefit from treatment. Goffman suggests that the patient injects a moral meaning of personal transgression into his understanding of the therapy contract with a concomitant loss of self-esteem. This loss of self-esteem is often reinforced by the patient’s appraisal of the objective loss of rights and community status associated with mental patienthood. The third patient factor reflects an acceptance of mental illness based more on social desirability than on understanding. Positive ratings of ‘mental patient’ (0.67) on the Semantic Differential combined with a low discrepancy between ratings of ‘self’ and ‘mental patient’ (-0.52). However, a close examination of these generally positive ratings disclosed that they centered around a view of the mental patient as ‘clean’ (0.59), ‘safe’ (0.58), ‘warm’ (0.55), and ‘good’ (0*52), and that the low discrepancy seen between the self and the patient is on the dimensions of ‘safe’ (0.54) and ‘clean’ (O-52). Combined with a relatively high over-all California F Scale loading of 0.49, this factor would seem to indicate an attitude toward mental illness based on evaluative adjectives interpreted in a socially desirable way. The desire to do and say the ‘right and proper’ thing about mental illness seems to be the underlying theme. There was a slight loading for religion-Catholic (0.27) on the factor and no appreciable loadings with respect to illness descriptions. Demographic
variables
The relative weakness of the demographic variables deserves special comment. While it is generally found that age and education contribute significantly to many attitude domains, in this patient group, in no instance did the factor loadings on any demographic variable exceed 0.27, the loading for age on Factor 1. For patient Factors 2, 3 and 4, the loadings
ATTITUDESTOWARD MENTAL ILLNESSAMONGMENTAL HOSPITAL PERSONNEL AND
PATIENTS 297
for age were -0.14,0.22 and 0.02 respectively and the loadings for years of schooling were of similar magnitude. It may be that for attitudes toward mental illness, the social impact of experiencing the illness itself overrides the influence of the demographic variables. Age and education contribute more significantly to staff factors, although not to the extent that might be anticipated from the literature linking authoritarianism to social class. While staff-patient class differences are an obvious aspect of the present study, they do not account for all the attitude differences found. Indeed, the same strong component of authoritarianism was identified by LEVINSON and GALLAGHER~in a patient sample of higher class standing. In any case, the attribution of attitudinal differences to group membership differences does not materially advance an understanding of their effects. It may be that the staff-patient differences found here reflect substantive differences in outlook, causally tied to the nature of mental illness. For instance, the patients’ tendency to blame their illness on others, to deny personal responsibility and to resist change may be either precursors or byproducts of mental illness rather than general attributes of lower social class standing. As seen here, mental patients present a constellation of anti-intraceptive, self-devaluative, passively compliant attitudes toward mental illness that actively restrict and reduce the effectiveness of any treatment decisions based only on attitudes held by the staff. While staff and patients might naturally be expected to differ in attitudes based on differences in experience and training, the consequences of bringing these divergent belief systems into direct confrontation in the treatment context are usually overlooked. The likelihood of communication between therapist and patient is low and it is the latter who is likely to break the contact. Treatment institutions expect the patient to make the requisite change and yet few take into account the relatively impervious cognitive structure patients bring to the hospital. Indeed, hospital policies in their own rigidities may be inadvertently reinforcing the patient’s view of himself as a passive, worthless physically-ill ‘case’ thereby fixing him all the more in his initial attitudes. The present study has dealt with the assessment and description of attitude differences, Research is now underway to explore the cognitive changes and treatment outcomes of patients depending on the particular system of beliefs they bring into the interaction with hospital treatment personnel. SUMMARY Attitudes relevant to mental illness were sampled among 62 psychiatric ward staff members and 89 hospitalized psychoneurotic patients. Content dealing with authoritarianism, social distance, information about mental illness, evaluations of ‘self’ and ‘mental patient’, patient description of own illness and demographic variables was factor analyzed. The main attitudinal component identified in both samples is termed general authoritarianism and yields factors loadings for patients and staff strikingly similar in magnitude and configuration and opposite in direction. Other staff factors describe different aspects of professional roles. Patient factors show the predominance of low self-esteem, passive compliance and a physical orientation toward the patient’s own mental illness. Implications of staffpatient differences for therapeutic interaction are discussed. Acknowledgements-Appreciation is expressed to ARTHUR S. COUCH and RONALD L. NUTTALL for assistance in computer analyses and to DIANE LEAR SIMPSONand LUCIANA NOYMER for help in data collection.
295
CLARA MAYO AND RONALD G. HAVELOCK
REFERENCES
1. 2.
3. 4. 5. 6. 7. 8. 9. 10. 11.
12.
ADORNO, T. W., FRENKEL-BRUNSWIK, E., LEVINSON, D. J. and SANFORD, R. N. The Authoritariun Personality. Harper, New York, 1950. LEVINSON, H. Psychological ill health in relation to potential Fascism: A study of psychiatric clinic patients, in ADORNO, T. W., FRENKEL-BRUNSWIK, E., LEVINSON, D. J. and SANFORD, R. N. The Authoritarian Personality. Harper, New York, 1950. GILBERT, C. and LEVINSON, D. J. Ideology, personality and institutional policy in the mental hospital. J. abnorm. sot. Psychol. 60, 151, 1960. COHEN, J. and STRUENING, E. L. Opinions about mental illness in the personnel of two large mental hospitals. J. abnorm. sot. Psychol. 64, 349, 1962. LEVINSON,D. J. and GALLAGHER, E. B. Patienthood in the Mental Hospital. Houghton-Mifflin, Boston, 1964. CUMMING, E. and GUMMING, J. Closed Ranks. Harvard University Press, Cambridge, 1957. GURIN, G., VEROFF, J. and FELD, S. Americans View Their Mental Health. Basic Books, New York, 1960. NUNNALLY, J. C. Popular Conceptions of Mental Health. Holt, Rinehart and Winston, New York, 1961. COUCH, A. and KENISTON, K. Yeasayers and naysayers: Agreeing response set as a personality variable. J. abnorm. sot. Psychol. 60, 151, 1960. BINNER, P. R. Studies of the Fort Logan program: in Evaluating the Efictiveness of Community Mental Health Services. GRUENBERG, E. M. (Ed.), Milbank Memorial Fund. New York. 1966. SPIEGEL, D. E., KEITH-SPIEGEL, P. and GRAYSON, Hl’M. Behavior of the typical mental patient as seen by eight groups of hospital personnel. J. psychiat. Res. 5, 317, 1967. GOFFMAN, E. Asylums. Doubleday Anchor, New York, 1961.
ATTITUDES
TOWARD
MENTAL
ILLNESS AMONG
MENTAL HOSPITAL PERSONNEL AND PATIENTS* CLARA
Department
MAYO
and
RONALD
G.
HAVELOCK~
of Psychology, Boston University, Boston, Massachusetts [Received
11 September
(Revised
1968)
31 July 1969)
A CONSISTENT theme of research into attitudes toward mental illness derives from the study of authoritarianism.1 It was, in fact, recognized in that study that authoritarianism had specific implications for attitudes toward mental illness among persons who were themselves mentally ill.2 Later, interest in the mental hospital environment itself led to the definition of ‘Custodial Mental Illness Ideology’” examined at various staff levels in the mental hospital. Custodial ideology (CMI) describes a cluster of beliefs related in manifest content to the care of mental patients and believed to be rooted in the personality dimension of authoritarianism. The authoritarian dimension in attitudes toward mental illness has been isolated repeatedly by factor analysis of a wide range of opinion statements among both mental hospital employees4 and patients.5 Despite this evidence for the pervasiveness of an authoritarian component in attitudes related to mental illness, some major studies have omitted this theme from their measures.e-8 The present study attempts an integration of previous conceptual and empirical strategies by (a) sampling related attitude domains in a single population of patients and staff, (b) supplementing questionnaire data with interview responses, and (c) including demographic data to clarify the specificity of factors obtained.
METHOD
Subjects The patient sample consisted of 89 non-psychotic males admitted to a Veterans Administration general hospital psychiatric service. The patients ranged in age from 20-65 years with a median age of 40 and in education from 5-18 years of schooling with a median level of 12 years. The staff sample consisted of 62 personnel who dealt with the patient group. Included were the professional staff comprising psychiatrists, psychologists, social workers, nurses * This study was supported by the Boston Veterans Administration Hospital. All statements are those of the authors and do not necessarily represent the opinion or policy of the Veterans Administration. t Center for the Research Utilization of Scientific Knowledge, University of Michigan, Ann Arbor, Michigan. 291
292
CLARA MAYO AND RONALD G. HAVELOCK
and aides, and trainees within these professions as well as the education, occupation and recreation specialists associated with the unit. As this was a teaching hospital giving shortterm treatment, the ratio of professional staff to aides was high. Measures A questionnaire was designed including items from the California /; scale,1 the CMI,s social distance measures,6 information content,8 and acquiescence tendencies.9 New items were written to sample attitudes especially relevant to life in the hospital. Subjects indicated their response to all items on a Likert-type scale of 7 levels of agreement centered around ‘neither agree nor disagree’. All subjects also responded to a 19-item Semantic Differential for the concepts of ‘myself’ and ‘mental patient’. For the staff sample, the questionnaires were filled out anonymously. Questionnaires were administered to the patient sample at or near the time of admission in individual interviews. At this time, patients also completed ten sentence stems directed to the dimension of social distance from mental patients and indicated their personal ideas about the nature, cause and treatment of their own illness.
RESULTS
AND
DISCUSSION
Product moment correlation matrices were computed for scores derived from questionnaires and interviews. Because of the large number of variables and diversity of content involved, factor analytic methods were applied to summarize these findings in an unrotated least squares solution for each matrix.* Common stafS-patient factor Among the staff, the most dominant factor, accounting for 12 per cent of the total variance, clearly reflected the dimension of authoritarianism, with loadings of -0.87 for the summed scores of the 12 California F Scale items, -0.71 for the CMI, and -0.68 for Nunnally’s ‘directiveness of therapist’ subset. This factor reflects a lack of social discrimination against mental patients with negative loadings on social distance items. Item loadings are presented in Table 1. The first factor extracted for the patient sample was remarkably similar in content to the first factor emerging from the staff sample. Also termed authoritarianism, it accounted for the same amount of the total variance (13 per cent) and had item loadings of strikingly similar magnitude and configuration but opposite direction from those found for the staff sample, as shown in Table 1. The Nunnally subset dealing with directiveness of therapist (O-75), the CM1 (0.70), and the California F Scale (0*58), all reflect an attitude of high authoritarianism combined with a rejection of mental patients (Cummings’ social distance item loading at 0.57 and a high discrepancy between ratings of self and mental patient * Factor loadings were also computed for a biquartimin simple structure solution. This produced an undesirable isolation of items from different response domains as exemplified in a ‘Semantic Differential factor and an ‘illness interview’ factor. The interrelations between different scales and the factors which cut across response modes (exemplified in Factor I in Table 1) were nullified. It is in demonstrating these relationships, however, that the authors feel this study makes a significant contribution.
ATTITUDESTOWARD MENTAL ILLNESSAMONG MENTAL HOSPITALPERSONNEL AND
PATIENTS
293
(0.53)). This factor also includes the rejection of a psychological description of one’s own illness (0.57). Overall differences between the staff and patient samples were widespread and statistically significant. For example, on the 12 California F Scale items, a very large difference was obtained between staff and patient mean scores of 34.9 and 57-4 with S.D.s of 9-8 and 9.9 (p
FACTOR I : AUTHORITARIAN SUPPRESSION AND TOTALVAIUANCE:STAFF
11
REJECTION OF MENTALILLNESS(PER CENT .~;PATxENT 13.5)
OF
Factor loading Summary variables
Staff
Patient
California F scale (12 items)
-0.87
0.58
Custodial Mental Illness ideology (CMI)
-0.71
0.70
Nunnally I-directiveness of therapist
-0.68
0.75
-0.68
0.57
Cummings’ social distance from mental patients Psychological
description of own illness
N/A
-0.57
Discrepancy between ‘self’ and ‘mental patient’
0.07
0.53
Sentence completion
N/A
0.42
scored for ‘social distance from mental patients’
Psychiatric experience (amount of prior patient contact with psychiatry in any context)
N/A
-0.35
Item variables ‘There ishardly anything lower than a person who does not feel a great love, gratitude and respect for his parents’ (Cal. F)
-0.74
0.55
‘We should strongly discourage our children from marrying anyone who has been mentally ill.’ (Cummings)
-0.61
0.62
‘If a person concentrates on happy memories he will not be bothered by unpleasant things in the present.’ (Nunnally)
-0.56
0.65
‘It is important to know if a person has been in mental hospital before we make friends with him.’ (Mayo and Havelock)
-0.68
0.50
‘Psychiatrists try to teach mental patients to hold in their strong emotions.’ (Nunnally)
-0.60
0.55
‘Mental illness is usually caused by some disease of the nervous system.’ (CMI)
-0.64
0.47
‘The good psychiatrist acts like a father to his patients.’ (Nunnally)
- 0;42
0.63
-0.57
0.42
‘Obedience and respect for authority children should learn.’ (Cal. F)
are the most
important
virtues
‘When Steve found out that a mental hospital was under construction in his neighborhood, he decided to (completion scored for his social distance. .) (Mayo and Havelock) Discrepancy
between ‘self’ and ‘mental patient’ on ‘safe’
Was childhood
related to present illness? (interview question)
WA -0.24 N/A
0.52 0.42 PO.42
294
CLARA MAYO
AND RONALDG. HAVELQCK
greatest staff-patient differences and their respective loadings on Factor I. These differences are presented in Table 2. As might be expected, most of the items showing the greatest differences were drawn from the California F Scale which measures authoritarianism, the. dimension which best characterizes Factor I. This dimension has been identified repeatedly,in studies of attitudes toward mental illness. However, items drawn from such diverse sources as the Nunnally survey, the Gilbert and Levinson CM1 and the authors’ own measure of cause of disorder TABLE2.
ITEMSWITHGREATEST OVERALLSTAFF-PATIENT DIFFERENCES
Item
Factor I loading Staff Patient (n = 62) (n = 89)
Mean Difference
There is hardly anything lower than a person who does not feel a great love and respect for his parents. (Cal. F)
-0.74
0.55
3.07*
The main job of the psychiatrist is to explain to the patient the origin of his troubles. (Nunnally)
-0.56
0.45
2.71*
Obedience and respect for authority are the most important virtues children should learn. (Cal. F)
-0.57
0.42
2.69*
Every person should have complete faith in some supernatural ppwer whose decisions he obeys without question. (Cal. F)
-0.54
0.44
2.50*
When a person has a problem or worry, it is best for him not to think about it, but to keep busy with more cheerful things. (Cal. F)
-0.64
0.46
240*
Most mental disorders are caused by some sort of disease of the nerves in the body or the brain. (Mayo and Havelock)
-0.34
0.45
2.37*
Nowadays more and more people are prying into matters that should remain personal and private. (Cal. F)
-0.68
040
2.08*
Mental illness is usually caused by some disease of the nervous system. (CMI)
-0.64
0.47
2@4*
*p < 0~001. all have high loadings on Factor 1 and show significant differences between staff and patients (p t0.01). The most striking aspect of differences on this factor is the apparent rejection by patients of the views held most strongly by staff. These sharp differences in cognitive orientation erect barriers to communication which cannot but hinder psychotherapeutic relationships. Picture the cognitive reorganization required of a patient who enters into treatment with the belief that there is nothing lower than criticism of one’s parents, that personal problems are not to be thought about, that too many people are prying into personal matters and that submission to authority is a desirable solution to one’s problems. If he believes further that he has a physical ailment that a pill, medical procedure or operation will cure, he may be unwilling or unable to participate in the kind
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295
of therapeutic alliance offered by a psychodynamically oriented staff. At best, this conflict will prolong his treatment and at worst, it may lead him to leave the hospital against advice or to retreat into illness so as to be judged by staff as an ‘unreachable’ or ‘chronic’ case. A recent report on the evaluation of a therapeutic community treatment program noted that the interaction of patient and staff characteristics may be one of the major factors in patient improvement.iO Other staf attitudes The second staff factor, accounting for 9 per cent of total variance, deals with the selfcritical image of the therapist. The highest loadings occur on the Semantic Differential ratings of ‘myself’ with summed ratings at -0.83, the negative direction of the loadings indicating that among paired adjectives, the self is seen as relatively ‘insincere’ (-0.68), ‘twisted’ (-0*67), ‘dirty’ (-O-65), ‘bad’ (-0.65), ‘dangerous’ (-0*61), ‘worthless’ (-0.57) and ‘unpredictable’ (-0.57). The factor is further characterized by a low discrepancy between ratings of ‘self’ and ‘mental patient’. With respect to demographic variables, this factor is salient for those with upper professional status (0*52), specifically residents (0.47) having contact in therapy with patients (0.59). The third staff factor reflects the attitude of the highly educated (O-58) professional (0.53) with training in human behavior (0.61) who engaged in therapy (0.52). The self is rated as more ‘safe’ (0.49) and ‘valuable’ (0.43) than not, while the mental patient is seen as ‘passive’ (-0.45) and highly discrepant from the self in intelligence (0.49). This factor might be described as the self-assurance of the senior staff in contrast to those in a training status. The factor includes the beliefs that childhood security and happiness preclude mental illness, that psychiatrists need a sense of humor to treat patients, and that it is possible to love and feel close to mental patients. Similar content has recently been identified with the more distant personnel relationships with patients.11 The fourth additional factor extracted for the staff sample is characterized by a quality of toughmindedness exemplified by disagreement with the belief that use of force by police is bad and disagreement also with the belief that punishment is a poor way to treat children. As might be expected, the factor includes concomitantly low overall evaluation of the mental patient (-0.53). It appears to be associated with administrative responsibility for patients. In general, the staff factors appear to mirror different aspects of the professional role of those who make decisions about patients, the not-always-consonant roles of therapist, theorist and warden. Staff Factor 2 highlights the complex interaction of self and other, inherent in the therapeutic relationship. The complexity of such relationships is reflected in the difference between staff Factors 2 and 3. The low discrepancy between the self and mental patients associated in staff Factor 2 with relative inexperience but high patient contact is reversed in Factor 3 whose content is linked to greater experience and formal training in psychotherapy. In Factor 3, greater self-confidence is shown with self-ratings of ‘safe’ and ‘valuable’ and with a rated discrepancy in intelligence between self and mental patient. Greater experience and training not only lead to greater confidence but apparently also give rise to the view that a sense of humor is helpful in treating psychiatric patients. The fourth staff factor, of which psychiatric residency status is the strongest component, best expressed the warden role in patient care. The presence of this factor, stressing the use of
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control and punishment, suggests that psychiatric residency may be marked by inherent role conflicts. The novice therapist who is responsible for making administrative decisions with respect to patient care, may come to feel that the use of constraints is the safest course of action. The emergence of different factors for different staff groups documents the attitudinal differences whose manifestations in intra-staff conflict have been noted in many hospital studies and experienced by most hospital personnel. In particular, the divergent content of staff Factors 2 and 4, associated with resident status and of staff Factor 3 characteristic of those who train residents suggests that attitude change as well as the traditional learning is involved in residency training. Patient factors
In addition to patient Factor 1 (authoritarianism), three other factors were extracted for the patient sample. Factor 2 among patients (accounting for 7 per cent of the total variance) is marked primarily by negative ratings of ‘self’ on the Semantic Differential, particularly with the view of ‘self’ as ‘twisted’ (-0.63). In contrast to the first patient factor, this factor involves rejection of physical description of one’s own illness. Apparently those patients who do hold a psychological view of their illness consonant with that of the staff are burdened with an excessively negative view of themselves, as reflected in patient Factor 2 where they see themselves and mental patients generally as bad. This self-devaluation has been linked by GOFFMAN~~ to the therapy dictum which requires the patient to accept the fact of his illness in order to benefit from treatment. Goffman suggests that the patient injects a moral meaning of personal transgression into his understanding of the therapy contract with a concomitant loss of self-esteem. This loss of self-esteem is often reinforced by the patient’s appraisal of the objective loss of rights and community status associated with mental patienthood. The third patient factor reflects an acceptance of mental illness based more on social desirability than on understanding. Positive ratings of ‘mental patient’ (0.67) on the Semantic Differential combined with a low discrepancy between ratings of ‘self’ and ‘mental patient’ (-0.52). However, a close examination of these generally positive ratings disclosed that they centered around a view of the mental patient as ‘clean’ (0.59), ‘safe’ (0.58), ‘warm’ (0.55), and ‘good’ (0*52), and that the low discrepancy seen between the self and the patient is on the dimensions of ‘safe’ (0.54) and ‘clean’ (O-52). Combined with a relatively high over-all California F Scale loading of 0.49, this factor would seem to indicate an attitude toward mental illness based on evaluative adjectives interpreted in a socially desirable way. The desire to do and say the ‘right and proper’ thing about mental illness seems to be the underlying theme. There was a slight loading for religion-Catholic (0.27) on the factor and no appreciable loadings with respect to illness descriptions. Demographic
variables
The relative weakness of the demographic variables deserves special comment. While it is generally found that age and education contribute significantly to many attitude domains, in this patient group, in no instance did the factor loadings on any demographic variable exceed 0.27, the loading for age on Factor 1. For patient Factors 2, 3 and 4, the loadings
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for age were -0.14,0.22 and 0.02 respectively and the loadings for years of schooling were of similar magnitude. It may be that for attitudes toward mental illness, the social impact of experiencing the illness itself overrides the influence of the demographic variables. Age and education contribute more significantly to staff factors, although not to the extent that might be anticipated from the literature linking authoritarianism to social class. While staff-patient class differences are an obvious aspect of the present study, they do not account for all the attitude differences found. Indeed, the same strong component of authoritarianism was identified by LEVINSON and GALLAGHER~in a patient sample of higher class standing. In any case, the attribution of attitudinal differences to group membership differences does not materially advance an understanding of their effects. It may be that the staff-patient differences found here reflect substantive differences in outlook, causally tied to the nature of mental illness. For instance, the patients’ tendency to blame their illness on others, to deny personal responsibility and to resist change may be either precursors or byproducts of mental illness rather than general attributes of lower social class standing. As seen here, mental patients present a constellation of anti-intraceptive, self-devaluative, passively compliant attitudes toward mental illness that actively restrict and reduce the effectiveness of any treatment decisions based only on attitudes held by the staff. While staff and patients might naturally be expected to differ in attitudes based on differences in experience and training, the consequences of bringing these divergent belief systems into direct confrontation in the treatment context are usually overlooked. The likelihood of communication between therapist and patient is low and it is the latter who is likely to break the contact. Treatment institutions expect the patient to make the requisite change and yet few take into account the relatively impervious cognitive structure patients bring to the hospital. Indeed, hospital policies in their own rigidities may be inadvertently reinforcing the patient’s view of himself as a passive, worthless physically-ill ‘case’ thereby fixing him all the more in his initial attitudes. The present study has dealt with the assessment and description of attitude differences, Research is now underway to explore the cognitive changes and treatment outcomes of patients depending on the particular system of beliefs they bring into the interaction with hospital treatment personnel. SUMMARY Attitudes relevant to mental illness were sampled among 62 psychiatric ward staff members and 89 hospitalized psychoneurotic patients. Content dealing with authoritarianism, social distance, information about mental illness, evaluations of ‘self’ and ‘mental patient’, patient description of own illness and demographic variables was factor analyzed. The main attitudinal component identified in both samples is termed general authoritarianism and yields factors loadings for patients and staff strikingly similar in magnitude and configuration and opposite in direction. Other staff factors describe different aspects of professional roles. Patient factors show the predominance of low self-esteem, passive compliance and a physical orientation toward the patient’s own mental illness. Implications of staffpatient differences for therapeutic interaction are discussed. Acknowledgements-Appreciation is expressed to ARTHUR S. COUCH and RONALD L. NUTTALL for assistance in computer analyses and to DIANE LEAR SIMPSONand LUCIANA NOYMER for help in data collection.
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ADORNO, T. W., FRENKEL-BRUNSWIK, E., LEVINSON, D. J. and SANFORD, R. N. The Authoritariun Personality. Harper, New York, 1950. LEVINSON, H. Psychological ill health in relation to potential Fascism: A study of psychiatric clinic patients, in ADORNO, T. W., FRENKEL-BRUNSWIK, E., LEVINSON, D. J. and SANFORD, R. N. The Authoritarian Personality. Harper, New York, 1950. GILBERT, C. and LEVINSON, D. J. Ideology, personality and institutional policy in the mental hospital. J. abnorm. sot. Psychol. 60, 151, 1960. COHEN, J. and STRUENING, E. L. Opinions about mental illness in the personnel of two large mental hospitals. J. abnorm. sot. Psychol. 64, 349, 1962. LEVINSON,D. J. and GALLAGHER, E. B. Patienthood in the Mental Hospital. Houghton-Mifflin, Boston, 1964. CUMMING, E. and GUMMING, J. Closed Ranks. Harvard University Press, Cambridge, 1957. GURIN, G., VEROFF, J. and FELD, S. Americans View Their Mental Health. Basic Books, New York, 1960. NUNNALLY, J. C. Popular Conceptions of Mental Health. Holt, Rinehart and Winston, New York, 1961. COUCH, A. and KENISTON, K. Yeasayers and naysayers: Agreeing response set as a personality variable. J. abnorm. sot. Psychol. 60, 151, 1960. BINNER, P. R. Studies of the Fort Logan program: in Evaluating the Efictiveness of Community Mental Health Services. GRUENBERG, E. M. (Ed.), Milbank Memorial Fund. New York. 1966. SPIEGEL, D. E., KEITH-SPIEGEL, P. and GRAYSON, Hl’M. Behavior of the typical mental patient as seen by eight groups of hospital personnel. J. psychiat. Res. 5, 317, 1967. GOFFMAN, E. Asylums. Doubleday Anchor, New York, 1961.