Attitudes toward psychiatric treatment among hospitalized patients: A review of quantitative research

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ATTITUDES TOWARD PSYCHIATRIC TREATMENT AMONG HOSPITALIZED PATIENTS: A REVIEW OF QUANTITATIVE RESEARCH RAYMOND M. WEINSTEIN* University

of South Carolina

Aiken, SC, U.S.A.

Abstract--Much of the data available in the literature dealing with psychiatric treatment from the point of view of hospitalized patients stem from qualitative research. Via observations, informal interviews, or masquerading as patients, social scientists have described hospital treatment and patients’ attitudes toward it largely in unfavorable terms. Relatively few scientists have taken representative samples of patients, questioned them formally about treatment with objective tests or validated scales, and displayed the findings in statistical format. The present report is a review of this body of quantitative research, with special consideration given to ascertaining patients’ degree of favorableness toward treatment. Results indicate that in 34 of the 44 different samples reviewed, or 779’,,, patients espoused favorable attitudes. Patients proved to be more favorable in their attitude toward treatment at psychiatric hospitals generally than the treatment they received at their own institution. Type of hospital and time of study had a negligible impact on patients’ views. Limited data suggest that attitudes improve, or at least do not worsen, as a consequence of hospitalization. Studies that compared patient and staff attitudes reported inconsistent findings. A content analysis of the attitude measures for treatment in general revealed that patients are positive toward the hospital’s therapeutic value, assistance with medical problems, restrictions, activities, and involvement of family members, negative toward its patient government and staff/patient relations, and ambivalent toward its patient freedoms and responsibilities. The content analysis of attitudes pertaining to specific therapies disclosed that indvidual, occupational, milieu, physical. recreational, and activity therapies are perceived positively by patients, group therapies negatively, and medication and ECT in an ambivalent manner. Social variables minimally affected the favorableness of patients’ responses, and the impact of psychiatric variables was somewhat greater. Interpretations of these results, particularly in regard to the discrepancy between qualitative and quantitative data, are offered

The treatment patients receive in psychiatric hospitals has been the object of intensive study by social scientists for some time. A number of studies have appeared since the 1950s dealing with those characteristics of the hospital&formal structure, informal relations, organizational functioning, staff behavior and ideology, ward environment-that impinge upon mental patients and affect the course of their illness. In general, what it is like to undergo psychiatric treatment in an institution has been inferred from qualiturire data, by scientists observing, interviewing, or masquerading as patients. Illustrations of such studies [l-9] are given in Table 1. By and large, scientists have criticized hospital treatment or charged that it has a deleterious effect on patients. Psychotherapies are pictured as unnecessary, emotionally threatening, and unsuccessful for many patients, while organic therapies are said to have a debilitating and fearinducing impact on patients; therapist-patient relationships are described as strained and impersonal. Hospitalized patients, it is concluded, have negative attitudes toward psychiatric treatment. Not surprisingly. these conclusions drawn by the qualitative researchers, mainly sociologists, coincide with the societal reaction or labeling theory approach to mental illness and hospitalization. According to this approach persons who have been committed to a * The author wishes to thank Andrew E. Skodol Scott Verinis for providing him with unpublished from their studies essential for this review.

psychiatric hospital have been publicly labeled as ‘mentally ill’ and become members of a deviant group [lo]. Precisely because of society’s adverse reaction to such persons’ abnormal behavior and commitment, they are likely to accept the deviant role imputed to them and develop an ignominous self-image. The societal reaction theorists contend that institutionalization, rather than curing persons of their psychopathology, only serves to create a population of relatively permanent deviants [ll]. It is assumed that hospital treatment is viewed negatively and actively avoided by patients and their relatives [12]. Indeed, in recent years ex-mental patients have joined the ranks of the politically active, demanding improvements in the quality of institutional care and freedom from forced medication and shock treatments [13]. Surprisingly, the traditional psychiatric perspective on illness and hospitalization (generally the polar opposite of labeling theory) supports the idea that many patients harbor unfavorable attitudes toward their therapists and treatment. Psychiatrists are wellaware that patients frequently do not benefit from treatment and are released from the hospital without being ‘cured’ [14]. Since treatment goals are generally scaled-down to limited resources, overburdened staff, and inadequate facilities patients may return to the community less than satisfied with the outcome of their hospitalization. Psychotherapy is exceedingly slow and time consuming, and presupposes on the part of the patient a willingness to introspect, tolerate frustration for extended periods, and locate the

and J. data

301

as pseudopatient

interactions

interactions,

Experiences

Observations,

Observations, interviews

12 different hospitals

State

Private

Private

Rosenhan

Scheff (1966)

Stanton and Schwartz (1954)

Strausset ul.

Observations. interviews

Observations of ward and therapy sessions, unstructured interviews

State

Pine and Levinson (1961)

(1964)

‘Natural history’ approach, longitudinal case studies

State

c’t ul.

Naboisek (1957)

(1973)

Observations, experiences pseudo-employee

State

(1961)

Goffman

unstructured

interactions, interviews

Observations, unstructured

State

Dunham and Weinberg (1960)

as pseudo-

Experiences patient

Method of determining patients’ views

hospital

Private

Type of hospital

1. Qualitative

Caudill er ul. (1952)

Study

Table

as

treatment

view

Meaning of psychiatric treatment for hospitalized patients

from the patient’s

Patients think that psychotherapy is ‘endless one-way talk’, are emotionally drained from repeating the same story over and over again, are apprehensive about the lack of specific therapeutic goals, are disturbed because few patients seem to get better or leave the hospital as ‘cured’. Patients overwhelmingly dislike electric shock therapy because of its unpleasant setting, compulsory character, adverse effect on memory, and tendency to cause sluggishness; patients resist psychotherapy because therapists try to change their ideas; patients’ anxieties and insecurities are heightened by almost all forms of therapy. Patients fight and hate psychiatrists in the course of psychotherapeutic relationships; group psychotherapy begins as a gripe session during which patients express demands and complaints rather permissively but ends with the therapist blaming the patient for his problems and attempting to change his thinking; patients must follow a ‘psychiatric line’ and support the occupational role of therapists in order to be judged as no longer in need of treatment. Patients enter the hospital with feelings of anxiety and resist standard treatment procedures; during hospitalization, patients have unresolved conflicts about their therapists and other staff workers; after release. patients fear rehospitalization and further treatment. Patients see psychotherapy as a ‘problem’; talking about life difficulties is threatening to patients and they must adapt to the requirements of therapists; hospital pressures to engage in psychotherapy come into sharp conflict with patients’ values. defenses, and character traits; patients believe that saying what is on one’s mind will lead to retaliations by staff. Patients feel depersonalized by hospital treatment due to the short time (average of 6.8 minutes daily) spent in individual and group psychotherapy, the few interpersonal contacts with doctoral staff, and the heavy reliance on psychotropic medication. Patients become extremely indignant and angry when they do not wish to be hospitalized but are forcibly treated; psychiatric treatment convinces patients that they are ‘sick’ and prolongs what may have otherwise been a transitory episode. Patients go to their regular psychotherapy ‘hour’ as simply the thing to do, without expressing the belief that they would be benefited or indicating an understanding of its purpose; the continual shortage of therapists makes it impossible for therapists to be matched to patients according to any planned procedure, causes patients to change therapists frequently, and interposes an impersonal barrier in the therapeutic relationship. Patients view the hospital’s therapeutic environment negatively-think occupational therapy is a ‘waste of time’, the administration of drugs is “doping them up so they won’t know what’s explain their going on,” and the doctors do not spend enough time with them or adequately treatment goals.

studies of psychiatric

2 3 9 4

$

;FI 2; 8 5

303

Attitudes toward psychiatric treatment primary sources of unhappiness within oneself. That many patients fail to qualify on one or more of these counts-or demand quick and painless answers to everyday problems-inevitably leads to their dissatisfaction with treatment [15]. A basic tenet in psychiatry is that the patient need not like the doctor or believe in therapy, and open expressions of hostility are welcomed [16, p. 4011. Therapists often are confronted with patients who manifest the ‘negative therapeutic reaction’, Freud’s formulation of a patient’s sense of guilt, need for punishment, and moral masochism [173. With this syndrome of negativism, patients vocalize defiant attitudes toward the therapist because any improvement or temporary suspension of symptoms produces an exacerbation of their mental illness. Some social scientists. however, have challenged the conclusions drawn from the qualitative studies in Table 1 and/or defended hospital treatment. Linn [18] contends that observational data give us a onesided and homogeneous conception of patienthood, and that a majority of patients in fact have positive attitudes because psychiatric hospitalization helps them cope with emotional and environmental problems. Wood et al. [19] claim that many discharged patients feel symptomatically improved and attribute this more to various aspects of the total hospital tr~dtment program than to the specific efforts of their therapists. In one survey [203 only a small number of former patients complained about the care they received while in the hospital. A sociologist-patientfamiliar with the sociological writings on ‘total institutions’ and the labeling theory of mental illnessconfesses that before being committed he had feared hospitalization* anticipated abuse by staff, and envisioned such evils as shock treatments. ice baths. and straight jackets [Zl]. After discharge, by contrast, he felt that hospital treatment had facilitated rather than retarded his recovery and believed the experience had been a pleasant one. The techniques employed in the qualitative studies have also been questioned. The descriptions of psychiatric treatment from the perspective of the hospitalized patient may be insightful and thought-provoking, but there are inherent limitations to the data collected. Renzikoff e’t ul. [22] point out that there is no ready method for appraising the accuracy of the observations upon which the data are based. The objectivity or reliability of the inferences and experiences reported is suspect since two or more observers with different backgrounds and training were not used. Moreover, subjective and experiential data, argue Reznikoff rf cl!., are almost impossible to quantify for individual or group comparisons and perforce have limited applicability. Linn [18] maintains that the patients interviewed or observed did not comprise representative samples. How typical the anecdotes and incidents cited were of the total hospital population remains a mystery. Linn is also critical of the qualitative researchers because they viewed patients as passive or powerless participants in the hospital system rather than as informants with useful opinions on the treatment process. Studies of the kind listed in Table 1 tend to eclipse the relatively few yuunrirufice reports in the literature dealing with hospitalized patients’ attitudes toward

psychiatric treatment. Social scientists have seldom taken representative samples of patients, questioned them directly about their experiences with different therapies, utilized objective tests or validated scales, and presented the findings in statistical format. Weinstein [23] believes this neglect or lack of interest in patients* views is due to a ‘bias’ among researchers, a tacit acceptance of the medical model of mental illness. Since the mentally ill (by definition) possess some kind of psychopathology and exhibit various symptomatology, their opinions of themselves or their situation are assumed to be unreliable or irrelevant and are not sought. Similarly, Sonn [24] claims that the ‘suspiciousness’ that is carefully bred into the training of psychiatrists helps account for the paucity of this kind of research. Patients’ statements are deemed to be unconscious distortions of reality, as food for the interpretive grind, and are not taken at face value. Psychiatry, according to Sonn, sees patients as objects of study rather than co-investigators in the treatment process, and discounts their views because of an incongruence with existing styles of therapy or research. The handful of quantitative works concerning hospitalized patients’ attitudes toward treatment do not comprise a unified body of knowledge. The few dozen studies are, for the most part, disjointed. Different scientists and investigative teams have largely focused on a specific patient attitude. and have not cited many of the other attitudinal studies in their bibliographies. Most team or individual researchers have not used the same or similar methodological techniques, but rather have developed and applied their own questions, tests, and scales. The purpose of this report, therefore, is to review these statistical studies, to draw together the diverse methodologies, findings, and conclusions. The degree of patients’ positiveness or favorableness to psychiatric treatment was the theoretical focus around which the quantitative data were organized. Of key importance is the overall level of favorableness, i.e. the number of studies in which hospitalized patients perceived treatment positively. Such a review, it is hoped, will complement the wealth of qualitative data already familiar to social scientists and shed light on the controversy between the critics and defenders of hospital treatment.

QUANTITATIVE

STUDIES

The quantitative studies [25-721 of interest to us, covering a wide range of topics, are outlined in Table 2. Hospitalized patients’ opinions have been sought on psychiatric treatment in general as well as specific therapies, on treatment at psychiatric hospitals generally as well as their own institution. A variety of methodological techniques were utilized to measure these different attitudes. It is important to assess the validity and reliability of these measurements and the representativeness of the patient samples tested in the quantitative studies, since some researchers have criticized the qualitative studies largely on these grounds. Moreover, the means by which the favorableness of patients’ attitudes was determined needs to be explicated.

Gould and Glick (1976) Gove and Fain (1973) Gynther tr al. ( 1963) Hillard and Folger (1977)

Dowds and Fontana (1977) Freeman and Kendell (1980) Fryling and Fryling (1960) Goldstein rt ul. (1972)

Barton and Scheer (1975) Burke and Lafave (1963) Chastko et (II. (1971)

Allen and Barton (1976) Almond er LII. (1968)

Study

19

41

47

54

University

State

University

Veterans

of nurs

of rehabilitation

Perceptions Attributions

121 32 21

City

State State

treatment to electroconvulsive

of hospital

Helpfulness of 20 different treatment activities Evaluation of treatment outcome

therapy

and helpfulness therapy

Evaluation of meetings with doctors and total hospital program Benefits derived from treatment modalities or characteristics

Apprehension toward of electroconvulsive

Evaluation of I4 different treatment modalities

Helpfulness

Helpfulness

4-point rating scale for 8 items Rank-ordering of 20 items 1 multiple-choice question 4 multiple-choice questions 4 multiple-choice questions 7-point ratings on adjective dimensions in 3 contexts

3 open-ended questions

1 open-ended question 4-point rating scale for 1 statement 5-point rating scale for 14 items 13 multiple-choice questions

7-point agreement scale for 15 statements S-point agreement scale for 16 statements 1 open-ended question

Evaluation of the vjalue system of a therapeutic community Perceptions of an activity program

Techniques

treatment

3 open-ended questions

psychiatric

Usefulness of hospital treatment

429

44

University

toward

program

attitudes

measured

patients’

Attitudes

studies of hospitalized

State

346

48

University

State

66

llniversity

166

95

Patient sample

University

Type of hospital

Table 2. Quantitative --

10

I

12

1

Treatment in general

3

4

10

8

2

13

14

1

1

16

3

3

Specific therapies

Number of measures of favorableness for

Leonard (1973) Linn (1968)

Moos and Houts (1968) Moos and Houts (1970) Moos and Schwartz (1972) Moos et a\. (1973) Pierce et al. (1972) Verinis and Flaherty (1978) Kotin and Schur ( 1969) Lee (1979)

Klass et al. (1977) Moos (1974)

Keith-Spiegel et al. (1970) Kish (1971)

Kahn et cl/. (1979) Kahn and Weher (1972); Weber and Kahn (1973) Jones et ul. (1963)

Jones and Keener (1968) Kahn and Jones (1969)

Jansen (1973) Jones and Kahn (1964)

Same as above Same as above

292

111 17 27 55

76

Veterans

General

Veterans

State

Private

185

96

Same as above

186

University

Same as above

Same as above

Same as above

Same as above

1231 1687 391 365

State Veterans University 5 different hospitals State and Veterans Veterans

Same as above

Same as above

Same as above

Same as above

Same as above

431

Helpfulness of “talking with the doctors” Helpfulness of 5 types of treatment Evaluation of 12 different treatment modalities Preference for hospital over home treatment

Helpfulness of hospital treatment Perceptions of treatment program’s spontaneity, autonomy, practicality, organization and clarity

Conceptions of treatment

Preferences for 13 different treatment modalities Conception of the hospital as a place for physical treatment and therapeutic gain

State

169

54

University

Veterans

51

Veterans

360

42 43 55 56 50

State Veterans Military University City

Veterans

27

54

205

University

University

Stale

1 multiple-choice question 5 multiple-choice questions S-point rating scale for 12 items 1 open-ended question

4-point agreement scale for 12 statements 2 open-ended questions 5 subscales from the WAS?

13 multiple-choice questions Factors IV and V from the CPH* scale

5

x

2

12

5

I

2

4

13

64

50

II

7 142

30

154

50

93

State

Provincial

City Provincial Private

City

City

State

University

Pettit (1961)

Polak (1970)

Skodol et trl. (1980)

Small, Small and Gonzalez (1965); Small, Small and Hayden (1965) Spencer (1977)

Helpfulness treatment

of hospital

Fears and dislikes of electroconvulsive therapy

Motivation for hospital treatment and apperception of therapeutic situation

Perceptions of therapeutic community treatment

therapy

5-point rating scale for I item I9 multiple-choice questions I open-ended question

I open-ended question 2 multiple-choice questions 5-point ranking of 5 items 4-point rating scale for 2 items 7-point ratings on 12 adjective dimensions 2 open-ended questions Picture test 7 incomplete statements 4 multiple-choice questions 4-point agreement scale for 28 statements 5 open-ended questions

Techniques

5

28

1

2

Treatment in general

4

19

I

I

Specific therapies

Number of measures of favorableness for

-

* The Colorado Psychopathic Hospital (CPH) Scale, developed by Kahn ef ul. 1731, consists of 100 statements with a 4-point agreement scale. Via varimax rotation, five factors were extracted which account for 50.4”,, of the total variance. Two of these factors deal with mental patients’ attitudes toward hospital treatment. t The Ward Atmosphere Scale (WAS), a rational scale devised by Moos and Houts [SO], has 206 true-false statements arranged into 12 categories or subscales. Five subscales tap patients’ attitudes toward psychiatric treatment.

Zaslove et (11.(1966)

Renznikoff et rrl. (1960); Toomey et ul. (1961)

220

State

Expectations of hospital treatment Perceptions of the therapy situation, hospital treatment, and the outcome of treatment

Helpfulness of hospital treatment Evaluation of 5 treatment modalities Evaluation of hospital activities and patient care Apprehension toward electroshock

183

City

of treatment

measured

Expectations

Attitudes

I00

Patient sample

Private

Type of hospital

conrinrtrtl

Lowenkopf and Greenstein (1972) Luft er trl. (1978) Mayer and Ronseblatt (1974) Morrow (1973)

Study

Table 2.

307

Attitudes toward psychiatric treatment

Rating scales, rank orderings, agreement-disagreement scales, and multiple-choice questions all have ‘face validity”, i.e. are measures based directly on the attitude in question and do not purport to measure any other attitude [74, p. 1781. Five of the 20 studies [33,36.45,63,66] using these methods checked reliability via the stability of patients’ responses, either for a control group or the total sample, and reported satisfactory test-retest levels; in the other studies [26, 27, 29, 30, 34, 35, 37, 38, 5658, 61, 62, 68, 711 tests of reliability were either not conducted or not reported. The unstructured methods also have face validity, except the indirect techniques (picture and sentence compietion tests) which sacrifice precise measurements in the interest of breadth and depth [74, p. 3651. Here 6 of the 11 researchers [29, 32, 59, 65, 66, 691 ascertained the reliability of their categorization procedures by nbtaining high consistency of independent judges’ interpretation of patients’ remarks; the others (25,28,46,60,72f either did not seek consensus in the classification of data or failed to report it. With the semantic differential [37,64] the validity and reliability did nut have to be tested, as this was demonstrated by the developers of the measure. On the factor analytic scale [39-44] and rational scale [47-551 the issue of construct validity is paramount, as these scales purport to measure various abstractions, attitudes presumed to be reflected in the test scores but not depicted on the face of the questionnaire statements [74, p. 1731. Validational data were gathered for the CPH and WAS with correlations of variables known to be related to the constructs. Acceptable reliability data, via the stability of test scores, are also available for both scales. Thus, for almost all methods of measurement used by Table 2 researchers, validity was either demonstrated or presumed. The fact that reliability was not ascertained in a number of cases is not a major source of weakness in the group of studies under review. If a test instrument is valid then to a considerable extent it is also reliable [74, p. lS1]O Moreover, attitudes normally fluetuate and are expected to show variation at different testings [74, p. 1863.

In the vast majority of quantitative studies, the means by which patients were selected for testing were appropriate for the different research purposes. Probability sampling plans were largely employed. Some researchers selected all admissions over several weeks or months [25,26, 30, 36,44 4244, 59--61, 66. 67, 69, 701, others selected all discharges during a given time frame [29, 3f35,43,44, 46.48, 36, 58, X2]. In some studies a cross-section of a hospital’s population was obtained through a simple random sample of patients or wards [37, 39, 41, 45, 47, 49955, 57, 62, 64, 65, 681, in others the entire hospital population was tested [28,38]. Patients were also interviewed at home one year after experiencing a partic&r therapy at a given time [31]. Attitudes toward psychiatric treatment at various points in the patient and postpatient career were therefore represented. Nonprobability samples were taken in two studies [63, 713 to represent patients in specific treatment programs. In

two cases reported.

127,323

sampling

criteria

were

not

Determination of fauorabkness For each measure of patients’ attitudes in each Table 2 study it was necessary to determine if the treatment was viewed either favorably or unfavorably. This posed no problem for some of the studies, as their own criteria were simply taken. Researchers utilizing open-ended questions categorized the unstructured replies not only by content but purposefully to reflect a positive, neutral, or negative attitude [25, 28, 29, 32, 46, 59, 60, 65, 66, 69, 71]. Researchers using multiple~cho~~ questions gave patients choices that signified the degree of which they preferred or were helped by various treatments [31, 35-i-38, 56, 57, 61, 66, 711, while those picking rating scales or ranking procedures had the quality of favorableness built in to the different points [29, 30, 33, 34, 58, 62, 63, 711. In the majority of studies, however, patients’ attitudes were got analyzed in terms of favorableness and the data had to be interpreted in this context. Thus, on the agreement-disagreement scales the statements were dichotomized in terms of positive or negative descriptions of psychiatric treatment [26, 27, 45, 681. With the semantic differential technique, the adjectives rated suggested positions of approval or disapproval [X,64]. Un the factor analytic scale [39#] and rational scale [47-551 favorableness was determined by the difference between the midpoint of the subscales and patients’ mean scores. Subscale scores indicate the degree of endorsement of particular attitudes, the content of which denotes a favorable or unfavorable view. The ranges, midpoints, and other information pertaining to the factor analytic and rational scales are described by Weinstein [753. Severat studies in the literature that tested hospitalized patients’ attitudes toward psychiatric treatment were not included in Table 2 because the measures and data content were not interpretable aiong a favorable-u~avorable continuum [76-79). The quantitative works under review here are not the consumer satisfaction studies in mental health program evaluation [80]. These studies-as well as studies of satisfaction with medical care [81]-have uniformly reported that patients were quite satisfied with the hospital or c&tic treatment received and complimented the staff. The findings, however, are biased due to a variety of methodological weaknesses. All too often questionnaires were put together hastiiy, validity and reliability af measurements not ascertained, probability sampling techniques ignored, and data collected by non-research personnel. In these program evaluation studies. patients’ responses are highly suspect. The Table 2 studies, by contrast, primarily were concerned with the effects of patient attitudes on treatment, did not focus directly on the issue of satisfaction or favorableness, and are methodologically much more sound.

The overall favorableness of patients’ attitudes was determined by counting the number of different hospital samples, for which data were available and tabulated separately, that had findings ‘in a favorable di-

308

RAYMOND M. WEINSTEIN

rection’. This was defined as either (a) more than half the patients viewing psychiatric treatment positively or the total sample receiving a mean score on the better side of the midpoint, if a single scoring technique was adopted, or (b) a majority of positive responses or mean scores on the better side of the midpoint if multiple questions, tests, or subscales were used. These criteria appear to be the best means of assessing the issue of attitudinal favorableness across the various studies, given the fact that multiple measures were often used and patients sometimes tested at different institutions. In each sample, findings in a favorable direction imply that the patients exhibit a tendency, and not a unanimity, to view psychiatric treatment positively. The number of different samples from Table 2 studies that could be counted is 44. This includes one sample each from 33 studies [25527.29-36,38,42. 45-48.54-64,67-69,71.72-J. 2 samples each from 2 studies [37.65], and 3 and 4 samples, respectively, from different groups of studies [49,41]. One study [ZS] was not counted because the data for the total sample were not reported and could not be calculated. Certain Table 2 studies [39.40,43,44,5@ 53. 66,701 did not have to be counted because data for the total sample were available in other publications [41.49,67,69]. Thus, patients tended to espouse favorable attitudes in 34 of the 44 samples (77”J. Of those studies utilizing a single score, 4 samples met the criteria C35.36, 56.641 and 3 did not 159.651. Of those studies with multiple responses or scores. patients were favorable to psychiatric treatment on ev’ery question. test. or subscale in 11 samples [29,41, 42.46.58.60.61.631, were favorable in a majority of attrtude measures in 19 c26.27.30 34.37.45,4749, 55.62.67.68.711. were unfavorable in 6 [37.38,54. 57,69. 721. and ambivalent in 1 1251. The data indicate that the frequency of favorable results varied considerably according to the type of attitude measured. Patients view treatment at psychiatric hospitals generally in a positive light much more often than the treatment they received at their own institution. Of those studies dealing with ‘any’ hospital, all 13 samples [26, 30. 36.41,42,45,62, 64.67,68] met the criteria for favorableness (lOO(‘,,). On the other hand, of those patient samples tested for their hospital experiences, 21 C27.29. 31L35,37,4649,55, 57,58.60.61.63,71] perceived treatment favorably while 10 [25. 37. 38. 54, 57, 59.65, 69. 721 did not (68” .). Results did not vary according to type of hospital sampled. Two different but complementary methods of data analysis both revealed few differences among patients at various psychiatric facilities in their tendencies to express positive views. First, for all studies the frequency of favorable attitudes across institutional types can be compared. Here scores in a favorable direction were counted for 73”,, of the patient samples taken from state (or public) facilities; all 6 samples from veterans hospitals and 82”” from university hospitals met one of the two criteria for positiveness. Second. data from two individual studies that compared the three types of hospitals [41,49] essentially support these findings. In each study. the subscale or factor scores of patients at different institutions did not differ significantly.

Time of study likewise had a negligible effect on patients’ attitudes toward psychiatric treatment. All three studies conducted (not published) in the 1950s. 73’::, in the 1960s. and 79:; in the 1970s found that patients looked at treatment favorably. It was anticipated that patients’ test scores over the past quarter century would reflect an increasing degree of favorableness, owing to the changes in hospital administration that have occurred, but the data do not bear this out. Methodologically, the best way to determine if time of study had affected patients’ attitudes would be to compare the test scores of different samples, by type of hospital, on the same measure over a long period. Such comparisons were not possible, however, since researchers during the past 25 years have mainly developed their own measures and applied them in various institutional settings. An important issue is whether or not patients’ attitudes toward psychiatric treatment change during the course of their hospital stay. Unfortunately, not many researchers tested patients at two or more time periods and this issue cannot be given the attention it deserves. Nevertheless, the data do suggest that patients’ attitudes improve, and generally do not worsen, as a result of hospitalization, Patients’ proved to be more favorable toward treatment after two months [36.66]. four months [66], and six months intervals [54.55,66]. and between admission and discharge [25]. In 3 studies patients’ attitudes did not change significantly between admission and discharge 130.43.691. Follow-up interviews 3- 18 months after discharge revealed that patients either register a positive change [70] or a negative one [25]. A number of researchers compared patients’ test or scale responses with those of hospital personnel. The findings, however, do not disclose any clear-cut patterns. Patients were significantly more favorable toward psychiatric treatment than different staff groups or staff in general in 7 studies [30.33,54, 55, 58.68, 721 and also less favorable in 6 C47749.52, 62,651. There were no significant differences between patients’ and staffs responses in 4 studies [34,42. 43,671. These inconsistencies in staff-patient attitudes occurred in all types of hospitals and thus cannot be explained by the different treatment settings in which the studies were conducted. Each of the 44 hospital studies from Table 2 with data for the total sample contains one or more measures of attitudinal favorableness for either psychiatric treatment in general or for specific therapies. These measures may be examined individually in terms of conrunr to determine the particular characteristics or modalities of treatment that patients perceive positively or negatively. The 44 samples had 122 such questions, subscales, or factors for treatment in general and 156 for specific therapies. Each of these measures was thus content analyzed and placed into different categories. The favorableness of these measures, by category, was then tabulated for all study samples combined (Table 3). The data in Table 3 reveal that patients claim different psychiatric therapies helped them (or help patients generally) just as much as treatment in general; 67”” of the attitude measures dealing with individual, group, milieu, physical, and other therapies were placed in a favorable context as against 68”,‘, of

Attitudes

toward

psychiatric

the measures relating to such facets of hospitalization as therapeutic value, patient freedoms, staff/patient relations, or ward restrictions. It is clear that not all hospital characteristics or treatment modalities are viewed equally favorably by patients. Patients are rather positive in their orientations toward the psychiatric hospital’s therapeutic value, assistance with medical problems, restrictions, activities, and involvement of family members, are somewhat less positive about its patient freedoms and responsibilities, and are negative toward its patient government and staff/ patient relations. Individual, milieu, physical, and recreational therapies are perceived quite positively by patients, while occupational. medication, activity, and Table

3. Favorableness

electroconvulsive therapies are looked at less positively. Patients are equally divided in their beliefs about the beneficial effects of group therapy. Sociul und psychiatric

of patient sample responses or mean scores tions, subscales, and factors-by content

of attitudes

Treutnmr in qmrrul Therapeutic value” Medical assistance” Patient freedoms’ Patient responsibilities“ Patient government’ Staff/Patient relations’ Ward restrictions” Ward activities” Family involvement’ Total Sprcifc rhrrupies Individual’ Groupk Occupational’ Milieu” Physical” Recreational Medication Activity ECT Total

vuriables

Attitudinal differences between groups of patients within particular hospital samples were examined in a number of Table 2 studies, either by correlational, chi-quare, or analysis of variance statistical techniques. Data are presented here for the social and psychiatric characteristics of patients or hospitalization that researchers delineated. Our criteria for determining the effect of such variables on attitudes consist of counting (a) the number of times statistically signifi-

Questions, Content

309

treatment

subscales,

to attitude

clues-

and factors Unfavorable

Favorable 0,’

N 21 5 7 13 I 3 10 20 3

7: 100 54 62 I4 33 91 83 75

83

68

12 I 10 17 5 3 6 15 29

15 50 59 89 100 100 60 65 59

4 8 20

40 35 41

104

67

52

33

46 38 86 67 9 17 25 39

32

25 50 41 11

*Treatment is helpful, patients get well as a result of hospitalization. ‘Hospital provides treatment for physical disorders, helps with hearing aids and false teeth. ‘Treatment encourages patients to wear own clothing, have own money, express themselves, act spontaneously. “Treatment encourages patients to help care for other patients, seek out activities, cope with personal problems, become autonomous. ’ Hospital permits patients to help make decisions about rules, misbehavior, priviledges, group meetings, or other patients. ’ Staff explain treatment to patients, act on patients’ suggestions, communicate freely with patients, are friendly, are sociable. r Hospital pressures patients to conform, fails to discharge them on time. does not make ward rules known, has unclear program goals. h Hospital provides work programs, recreational activities, small group meetings, contacts with community agencies, order and organization on the ward, practical assistance to patients, ’ Hospital permits family members freedom of expression, encourages them to participate in therapy. j Psychotherapy, psychological counseling, ‘talking with doctors’. ’ Group therapy, family therapy, psychodrama. ’ Occupational therapy, vocational counseling, job training. m Hospital environment, rest and relaxation, retreat from society, eating regularly. ” Medical treatment, nursing care, physical therapy.

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cant group differences appeared in specific patient populations, if a single score for favorableness was given, or (b) the number of times half or more of the questions, tests, or subscales of each study yielded significant group differences. if multiple measures of favorableness were employed. These criteria parallel those drawn to ascertain whether a total sample of patients expresses positive or negative opinions of psychiatric treatment. A review of data for five social variables revealed that, for each one, studies that did not find signficant differences between groups outnumbered those that did. The age of the patient proved to be unrelated to his/her attitude in 8 of the IO samples in which it was taken into account [28,34,37.39,50,51.58,69]. Gynther et 01.1361 observed that older patients were more favorable toward psychiatric treatment than younger patients, but the reverse finding was reported by Jansen [38]. Out of IO studies, 8 noted that srx differences were negligible 125. 34,36.39,50,51,58, 691. Females interviewed by Jansen [38] and males by Pettit [64] were more favorable. Both investigations considering rcrce 136,691 discovered that blacks and whites were largely similar in attitude. With respect to education one study learned that more educated patients perceived treatment more favorably [38], but 3 found no significant group differences at all [39, 43,691. In 5 studies out of 6 muritul Starus was not an important variable [25.37,39,53.69]. Only Gynther et NI. [36] found that married patients’ views were more positive than either the single or formerly married. While social variables had very little effect upon patients’ attitudes toward treatment, the impact of psychiatric variables was somewhat greater. The data indicated that, for 4 psychiatric variables, the number of studies that observed statistically significant group differences in terms of the criteria adopted was equal to or exceeded those that did not. Of the 3 studies that looked at history of preckws hospitukurion, readmitted patients espoused both a more favorable [36] and less favorable opinion [69] than those committed for the first time; no such differences occurred in Jones and Kahn’s [39] sample. Time in therap! proved to be crucial in 2 of the 4 studies [33,40], with both yielding a direct relationship to degree of favorableness. Burke [28] and Kahn and Weber [43] found that patients with longer and shorter periods of therapy were not differentiated in attitude. Differences between patients, based on the type of ward they were on. reached statistical significance in 3 of the 5 samples tested. In these cases, patients on ‘better’ wards (wards that were unlocked, had high release rates, lower dropout rates) had more positive attitudes toward psychiatric treatment than those on ‘poorer’ wards [50,52.53]. The other two studies [39, 581 failed to observe these milieu differences. Studies that considered ECT treulment were divided; one noted that patients receiving electroconvulsive therapy were more favorable toward that type of treatment [37], the other found no differences between ECT and non-ECT patients [64]. For three psychiatric variables, however, studies that reported significant group differences were outnumbered by those that did not. The patient’s diugnosis was found to be relevant for 2 of the 6 samples

in which it was considered. In one case neurotics were more favorable in attitude [25], in another psychotics were more favorable [33], and in 4 diagnostic differences were not significant [34,37,39,53]. The /en@ of hospikdizution of patients in only 2 out of the 1 I samples affected the favorableness of their views; patients with shorter stays were more favorable toward treatment in both cases [38,43]. For the most part, researchers found length of time in the institution to be unrelated to attitudes [28,34,37,39,40, 50,51,53,58]. Of the 3 studies that looked at in-hospitul change (therapists’ ratings of patients’ mental functioning or success in therapy), 1 found that ‘improved’ patients were more positive in attitude than the ‘unimproved’ [40], and 2 did not [28,44]. DISCUSSION

The findings presented in this report lead us to conclude that the picture of psychiatric treatment drawn by patients is quite different from the one sketched by the critics of hospitals. Social scientists who have gathered qualitative data-by observing or interviewing patients informally or assuming the role of pseudopatient-have chiefly argued that patients are unfavorable in attitude because of fears and anxieties about certain treatments, poor relationships with therapists, problems in adjusting to institutional life. the social stigma attached to hospitalization, and the lack of apparent ‘cures’ for patients at the time of discharge. However, patients responding to formal interviews and questionnaires repeatedly stress the positive, not the negative, side to hospital treatment. This review of quantitative data for numerous samples representative of different types of hospital populations has revealed that a rather large majority of patients voice favorable attitudes toward treatment in general as well as specific therapies. Patients often claim that psychiatric hospitalization has therapeutic value, helped them with medical problems, is not very restrictive, and provides them with meaningful activities; patients also assert that they benefited from the individual, recreational, milieu, and physical therapies they received while in the hospital. The defenders of hospital treatment, it appears, have more accurately portrayed the views of patients than the critics. That Table 1 researchers’ descriptions of the meaning of psychiatric treatment for patients deviate so markedly from the meanings patients themselves ascribe to their hospital experiences is due, in part, to certain methodological biases inherent in such qualitative studies. The role of observer in the hospital, for example, can lead researchers to misinterpret the patient’s point of view. Linn [lS] notes that when he observed patients on the ward he wondered how they could tolerate such ‘deplorable conditions’, but when he later formally interviewed these same patients he began to understand their social situation; patients’ favorableness toward the hospital seemed justified in light of the poverty, isolation, and disability from which many had come. The role of pseudopatient is not a satisfactory method of data collection either. Since the researchers are not mentally ill and are therefore notin a position to benefit from treatment, they cannot possibly perceive their experiences in the same manner as do bona fide patients. Caudill et trl.

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[l] openly state that the use of pseudopatients involves a subjectivity bias and discuss some of the disadvantages of this procedure. Similarly, Rosenhan [6] admits that he and the other pseudopatients had distinctly ‘negative reactions’ and do not pretend to describe the experiences of true patients. A third problem with the qualitative data on psychiatric treatment is the lack of representativeness. Informal interviews do not test attitudes in a systematic way, but instead are usually limited to topics that patients mention spontaneously, those most problematic to them at the time [24]. Such unstructured data tend to be collected via a nonprobability sampling of patients and not interpreted within the context of a total hospital experience. Qualitative researchers’ theoretical biases also help to explain why the negative aspects of psychiatric treatment have been exaggerated in their reports. It is clear that these scientists were not neutral toward patients or completely objective in their orientations. Goffman [3, p. x] concedes that his view of the psychiatric hospital “is probably too much that of a middle-class male”, that perhaps he “suffered vicariously about conditions that lower-class patients handled with little pain”, and that unlike some patients he “came to the hospital with no great respect for the discipline of psychiatry”. Qualitative researchers tended to identify with the disadvantaged patients, were deeply concerned with their welfare although they had no direct responsibility toward them. These scientists were ‘outsiders’ whose central aim was to analyze the mental hospital as a life setting for patients, as Levinson and Gallagher [82, p. 91 put it, “with emphasis upon its pathogenic. ego-wounding, corrosive qualities”. Another fault of the qualitative studies, according to Linn [18], is the conceptual error of assuming that patients in psychiatric institutions have a homogeneous definition of their situation, i.e. all view their hospitalization with embitterment, distrust, and hostility. He believes that in any hospital there are at least as many patients with favorable as unfavorable orientations, who eye treatment as a retreat from poor environmental conditions and a chance to begin a new life. Findings from hospital studies other than those reviewed in Table 2 offer clues as to why it is that patients are so favorably disposed toward psychiatric treatment. The data strongly suggest that hospitalization for a psychiatric disorder provides for patients’ needs and is helpful to them. Hudgens [83], for example, explored the goals patients had at the time of admission; to be protected or cared for permissively, to escape from the pressures of everyday life, to improve interpersonal relationships, and to establish control over feelings and behavior were found to be key motivations for entering treatment. Martin et ul. [78] observed that a very small minority of patients viewed their recovery as beyond their control and remained passive in treatment; most adopted an active role and endeavored to better their adjustment to treatment. A survey of over 9500 patients [84] disclosed that they were not merely using state hospitals as convenient living accommodations; most needed staff attention for support in the skills of daily living or control for disruptive behavior. Gove and Fain [85] contend that there is nothing intrinsic in the

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commitment process that is seriously debilitating; a follow-up study of commited and voluntary patients indicated that the situation and behavior (via employment, marriage, or relationships) of both groups improved after discharge. Studies of recidivism show that most patients return to the hospital voluntarilybecause of poverty, deprivation, inactivity, or the lack of alternatives open to them [86]. The assumptions of the labeling theory approach to mental illness and hospitalization uis-&is the attitudes of patients seem to apply to only a small proportion of them. We observed that a minority of patients in three-fourths of the quantitative studies reviewed, and a majority in one-fourth, expressed negative or ambivalent opinions of the characteristics of psychiatric treatment in general or the therapies they received. These patients were especially critical of patient government and staff/patient relations in the hospital but equally divided between favorable and unfavorable views of group therapies. These results underscore the fact that a good many patients still sense the coerciveness and ineffectiveness of psychiatric inpatient settings, exactly as the qualitative researchers of the 1950s and 1960s so aptly described. Affirmative changes in hospital administration and growth of milieu therapy during the past two decades have apparently not completely assuaged a negative impression of psychiatric treatment. Since the attitudes of the vast majority of patients in the Table 2 samples were positive, our observations are thus consistent with a growing number of studies in recent years that have found labeling theory to be a less than adequate framework for interpreting psychiatric phenomena. Schwartz et al. [87] report that the stigma of mental hospitalization is not a major problem for the ex-patient, Quadagno and Antonio [SS] note that patients resist labeling by employing nonstigmatized categories to explain their commitment, and Greenley [89] found that expectations of patient improvement were not related to ex-patients’ psychiatric symptomatology. The traditional psychiatric perspective likewise does not adequately account for the attitudes toward treatment of the majority of hospitalized patients. There is reason to presume that many patients would harbor negative feelings, since mental illness involves psychic pain, distress, and anxiety and patients are sufficiently distraught by the time they reach the hospital. However, this potential for negativism is never realized for most patients. It may be that unfavorable attitudes are only characteristic of higher class patients or those from environments that are more attractive than the hospital, a small percentage of the total psychiatric population at any given moment. Or, perhaps the bulk of patients in institutions, regardless of class status or social situation, are favorably disposed to treatment because it offers them the opportunity to relieve symptoms, learn to cope with life difficulties, overcome personal inadequacies, or correct behavioral problems. Whatever the reason, it seems that psychiatrists and other mental health professionals have misjudged how patients might feel about their illness or hospitalization. Data from other investigations substantiate this conclusion. Zaslove ef al. [72] found that in fewer than half the cases the therapist had accurate insight into that treatment

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modality which the patient considered most helpful. And Kahn et nl. [42] discovered that staff think patients are ‘quite negative’ toward different facets of mental health but patients’ actual attitudes were not nearly as extreme as staff considered them to be. Various findings noted in this review make it obvious that institutionalization for a psychiatric disorder does not cause patients to lower their opinions of such treatment. In 9 of the 11 studies that examined length of hospitalization, patients with longer stays were not more unfavorable than those with shorter. ln 9 of the 10 studies that measured attitudinal changes, patients were either more or just as favorable toward treatment from one time period to the next. None of the 4 studies that looked at time in therapy showed patients with greater amounts of therapy to be less favorable. The character of the hospital milieu is also an important determinant of patients’ attitudes. Results for type of ward indicated that patients on better wards were generally more, but never less. favorable than those on poorer. An interesting question is whether patients are more or less positive toward treatments they have personally received in relation to treatment at psychiatric institutions generally. Unfortunately. our observation that treatment at hospitals in general were evaluated favorably by patients more often than treatment at their own institution only indirectly addressed this issue, since none of the research studies reviewed here specifically compared both types of patient attitudes. What is needed from future investigators is a simultaneous measurement of general and personal attitudes in a given population with a similarly worded questionnaire, and then a comparison of the two mean scores or response frequencies. Such a test could determine if patients have general expectations of treatment which are either attenuated or augmented by their actual hospital experiences. Analysis of the data dealing with the content of patients’ attitudes toward psychiatric treatment in general and specific therapies suggest two different but complementary interpretations. First, patients tend to place in a favorable context those therapies or characteristics of treatment that are ‘self-directed’, attentive to their individual needs. Hospital services such as medical treatment, vocational training, psychological counseling, regular meals, recreational activities. etc. received high ratings by patients. Indeed. help with physical, occupational, and personal problems are the very reasons why most patients come to the hospital. Second, patients tend to cast in an unfavorable or ambivalent light those aspects of treatment that are ‘other-directed’. concern reIationships with staff and patients in the hospital. Low or lower ratings were assigned by patients to patient meetings, interactions with staff, group therapy, and spontaneous behavior. Patients’ interpersonal difficulties, the keynote of mental illness, are thus evident from the treatment characteristics and therapies they do not view favorably. It appears that, as Petttit [64] has stated, eiectroconvulsive therapy is “not the ‘shocker’ we think”. ECT patients were either more or just as favorable toward that treatment than non-ECT patients. When the content of ECT questionnaire items was analysed,

patients were fairly positive in attitude. The four studies reviewed here with dealing ECT [31,37,64,71] all conclude that the exaggerated impression of shock treatment is unfounded. Images of heavjly-muscled attendants holding down screaming patients, of unscrupulous administrators meting out ECT as punishment to troublemakers, of patients walking around in a stupor after an ECT session. of therapists placing a cloth in the patient’s mouth and turning up the voltage, etc. are more a part of the world of cinema and journalism than the reality of contemporary psychiatric hospitals. ECT is generally administered with short-acting barbiturates to relax patients. Most patients who have received ECT claim that they do not mind or even like the treatment, that it helped them, and that they did not suffer undesirable side effects. And psychiatrists tend to agree that ECT ‘works,‘ i.e. it is an effective means of reducing a patient’s level of symptomatology. although they may disagree as to why or how it works. Our finding that social variables do not substantially affect the attitudes of patients is consistent with data from other reports in the literature. Fitzgibbons et rtl. [76], for example, correlated three background variables with 7 factors of patients’ self-perceived treatment needs and observed minimal relationships in each case. Friedman et ol. [PO] correlated 6 characteristics of patients with 14 factors of perceptions of the mental hospital milieu and came up with only a handful of statistically significant coefficients. It is often argued by mental health researchers that patients’ age, sex, race, ethnic origin, marital status. education, occupation. place of residence, etc. are meaningful frameworks from which they interpret their psychological difficulties and illness-related phenomena. The evidence, however. casts doubt on this argument. The key observation of this study, that patients in 77”,, of the hospital samples reviewed espoused favorable attitudes toward psychiatric treatment. was frankly quite surprising to us. We had anticipated that patients in perhaps 20-30”” of the Table 2 studies would register positive views, as we too pictured the mental hospital as a ‘total institution’ with all the concomitant detriments the term implies. We can thus join ranks with other mental health researchers who have recently reported results that run counter to popular beliefs. Frank et rri. [91] found virtually no basis for the widely-held notion that social class affects expectations for psychiatric treatment. At a walk-in clinic, lower-class patients scored high on presumed middle-class requests (for insight therapy and clarification of problems) while middle-class patients often endorsed typical lower-class requests (for therapist control and medical help). Pearlin and Schooler [92] state that their work involved the overcoming of stubbornly held mythologies and preconceptions. They were surprised to find that help-seeking for marital and parental problems is associated with more, rather than less, psychological distress, and question the idea that so-called ‘social supports’ actually provide support. In this review, the facts concerning hospitalized patients’ degree of favorableness toward psychiatric treatment do not coincide with the myth about patients’ attitudes.

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