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ATTITUDES TOWARDS MENTAL PATIENTS

MARKKU OJANEN

SUMMARY A

study of attitudes towards mental patients was made using a questionnaire developed by Lehtinen and Väisänen. Five hundred and fourteen persons from different parts of Finland filled in the questionnaire. The attitudes were generally positive, although, as in other studies, the attitudes of those older and less educated were more negative compared with the other groups. This result was interpreted as a generational effect, which will vanish as the educational level of the population increases. The questionnaire also included questions about the attitudes and behaviour of ’other people’. The attitudes of ’other people’ were thought to be very negative compared with one’s own attitudes.

INTRODUCTION

study of public attitudes toward mental patients has been a very popular research topic. A Dialog reference search after 1974 produced 439 items. However, most of the listed studies are very narrow in scope. The samples tend not to be representative, because usually the object of study has been a group of students or professionals in psychology, psychiatry or psychiatric nursing. The results of this voluminous research can be interpreted variously. Some commentators perceive the situation of mental patients to be fairly good at present (see eg. Crocctti et at. 1974), whilst others find that they experience a lot of stigma (Farina, 1981). The reviews of Rabkin (1974, 1984) fall in between. The most pressing question in this field of research is the relationship between verbal statements and subjects’ actual behaviour. Few experimental studies of behaviour towards mental patients have been adequately realistic. Page (1977), Webbcr and Orcutt (1984) and Farina (1981) have done experiments which are fairly realistic. A patient or illness label in these studies seemed to lead to negative experiences more often than in The

control groups. The experiences of patients themselves are both positive and negative (Weinstein, 1983). Some have experienced negative attitudes and behaviour, but many have not. The reasons for the differences are not clear. The reasons for negative experiences may partly be in the patients themselves, and partly in those who interact with them. The seriousness of a patient’s mental illness and their deviant behaviour may have an effect on interaction as may the social statuses of both the patient and those who interact with them. In looking at attitudes towards mental patients, the most often studied variables are age and education. The results have been very consistent. The older and less schooled the subjects are, the more negative are their attitudes (Rabkin, 1974; 1984). There is a

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paradox, however. It is often those communities which are populated by well-educated, middle class people that oppose most strongly the opening of hostels for ex-patients within their boundaries (Segal et al. 1980). In this situation at least reported opinions appear not to relate to behaviour. The effect of age and education leads to another problem, which was pointed out in one of the earliest studies. Often an interviewed person stated that he had nothing against ’them’, only the others had (Cumming & Cumming, 1957). Do the well-educated know the tricks of questionnaires? Are their answers more strongly influenced by social

desirability? In Finland Lehtinen and Vaisanen (1977) carried out a large scale attitude survey in the late 1960s. They designed a 20-item Likert scale using five alternatives (from strongly agree to strongly disagree). The items included various opinions about mental illness and willingness to be in contact with mentally ill people. The total score varied from 20 (the most negative value) to 100 (maximum positive). On this attitude scale the total mean zit=941) was 73.6. Thus the general level of attitudes was clearly positive. The correlations with age and education were similar to those obtained in other studies. The present study had three aims. Firstly, the changes in attitudes over a 15 year period were evaluated. It was hypothesised that the changes would be positive for two reasons: the educational level has risen in Finland over the past 15 years; and the general knowledge of mental illness has increased through both formal schooling and mass media information. In Finland, as in other countries, mental health experts have emphasised the slogan ’mental illness is just as any other illness’. Secondly, the effects of age and education on attitudes were analysed thoroughly. If we assume that education is the primary factor, does it have a continuous linear effect, or is there a point after which the increase of education is no longer significant? The results of Lehtinen and Vaisanen (1977) suggested that the attitudes may not become any more positive after the completion of high school The concept of mental illness was also compared in different age and educational groups. It may be possible that there are differences in how mental illness is conceptualised in the different groups. Thirdly, there is the nagging question of how validly attitudes towards mental illness or mental patients can be measured. If we want to know something about the problems of the mentally ill in the community, we should use other methods. In the present study two other methods were used. They are not, strictly speaking, studies of attitudes, but their purpose is to collect more objective data about the response the mentally ill can expect from the community. We inquired about the opinions that other people held about the mentally ill and elicited general knowledge of mental illness related matters. It was hypothesised that these other methods would give a more pessimistic picture about the situation of the mentally ill than the measures of attitudes.

METHOD

Sample study was carried out in five Finnish towns (South: Helsinki, West: Seinäjoki, East: Joensuu, North: Pieksamaki, and Central: Tampere). Only the northernmost districts of The

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the country were not represented. In Joensuu a random sample was collected which included rural areas. In the other towns the questionnaires were distributed to four or five socioeconomically different areas. The overall response rate was 69%, varying from 50% (Pieksamaki) to 80% (Tampere). The area samples were made because the study also included area comparisons within the largest towns. The results were subsequently used in planning informational programmes in some of these areas. Altogether 514 people returned the questionnaire. The mean age of the sample was 44 years, and 43% were women. Fifty three percent had completed secondary school (9 years). Compared with general Finnish statistics, the sample represents well the Finnish population, except in education, which is higher in the sample than in the whole country. This was as predicted, because the sample was town-centered and thus represented well the urban population. In the Joensuu area the questionnaires were sent by post, but in the other areas they were distributed by a research assistant, who also retrieved them. Measures Three methods of measuring attitudes were employed. Firstly, a scale by Lehtinen and Viisinen (1977, 1978) was used. This consists of 20 Likert-type questions. The questions are similar to those used in previous studies, eg. &dquo;I could be a close friend with a former mental patient&dquo; and &dquo;Most mental patients are dangerous.&dquo; The scale is described in Laine and Lehtinen (1973). Short descriptions of the questions are given in Table 1. Reliability (Cronbach’s Alpha) of the full scale was .87. Together with this scale, 24 other statements concerning mental patients and their treatment were used. Secondly, all the items in Lehtinen and V51sdnen’s scale were rewritten in order to describe the respondent’s perception of other people’s opinions and behaviour. Thus the above items became &dquo;Other people could be close friends with a former mental patient just as with anybody else&dquo; and &dquo;People regard most mental patients as dangerous.&dquo; The subjects were asked to use their own experiences and rate the behaviour and attitudes of other people accordingly. The translation to the ’other people’ version was necessarily a little clumsy at times, but the principle seemed to be clear for the subjects. The reliability of the scale was .88. Thirdly, the subjects were given a Mental Health Knowledge Questionnaire. This included 33 questions about mental patients, mental hospitals and the psychiatric professions. This questionnaire was described as a test of knowledge, but 15 of the questions were heavily loaded by attitudes eg. &dquo;There are dangerous patients in mental hospitals as follows: 1. most of them; 2. about half; 3. somewhat less than half; 4. a clear minority; 5. no-one.&dquo; Similar questions were asked about the criminality and stigma of the mental patients. These items did not produce a clear common factor. The reliability of the 15 items was only .59 (Cronbach’s alpha). Data on background demographic variables were collected. These included age, sex, basic and vocational education and family structure. [The latter two variables were recorded as follows: Basic education: 1== primacy school only, 2 = less than primary school, 3 = secondary school, 4 = senior secondary school (full high school). Vocational education: 1= nothing, 2 = vocational courses, 3 = trade school, 4 = techraical school, 5 = college, 6 = univcrsity (I~A-level). Family status: 1= living alone, 2 = living with spouse

or

opposite-sex partner,

or

children.]

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The degree of closeness to mental illness or mentally ill people through personal relations or work was elicited by six questions where simply &dquo;yes&dquo; or &dquo;no&dquo; alternatives were provided. These were: 1. Have you known closely a person who has been in a mental hospital? 2. Has there been mental illness in your family? 3. Have you yourself experienced mental problems (many examples provided)°? 4. Have you used experts for the problems mentioned above? 5. Do you work in an administrative position (examples given)? 6. Do you work in health-related professions?

RESULTS Attitudes toward mental patients The reported attitudes of the sample were generally positive (see also Table 1). The percentage of two positive alternatives (completely agree, partly agree) for selected items were as follows: I could hire an ex-patient to work for me 75% I could be a close friend with an ex-patient ... 89% I could accept an ex-patient as a co-worker ...92% 1 could give my child for care to an ex-patient ...40% I could fall in love with an ex-patient 40% ...

...

The statement that &dquo;Most mental patients are dangerous&dquo; was agreed by only 15% of sample. The knowledge test gave similar results, although it was expected that social desirability would not have as great an effect here as it had on traditional attitude measurement. Thus the public at large stated that a minority was dangerous and only a small minority were criminal cases. Attitudes appeared to be less positive regarding close relationships with mental patients (eg. falling in love, give my child into care) than more distant relationships (eg. hire an ex-patient to work for me). the

Changes in attitudes 1970-1985 Because Lehtinen and Vaisanen (1977) used the same questionnaire 15 years earlier, it was possible to compare the results. Both samples represent Finnish citizens fairly well. Lehtinen and Vaisanen’s average (min. 20, max. 100) was 73.6 and that of this study 77. i . If the over-representation of well-educated in this sample is corrected to be representative of the current general population, the mean score is 76.1. If the educational distribution of Lehtinen and Vdisdnen is used, the average of this study is 75.2. Thus the change in attitudes over 15 years was very small (although it was statistically significant due to large sample sizes). Attitudes and demographic variables The correlations between demographic variables and attitudes are shown in Table 2. As in previous research, age and education correlated most strongly with attitudes. In the lower part of the table closeness to or knowledge of mental illness is measured. There are a few

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124 Tames 1 The public response (1~ _ 514) to attitude questions: How I would get along vs. how ’other people’ would get along with mental hospital ex-patients (means and standard deviations and percentages of positive answers*)

probability of two positive classes. the following: I = completely agree, 2 = partly agree, 3 = cannot decide, 4=partly disagree, 5=completely disagree. A half of the items were stated in negative form, but all items were transformed so that small numbers are positive and high numbers negative. All differences between means of ‘I’ and ’other people’ are statistically significant (p > .01) *The percentages indicate

The original Likert scale

a

was

statistically significant correlations, but they are very low. The number of mental health professionals is very small among the health-related workers (the last variable in the table). (We have also studied mental health workers and their attitudes are generally very positive.) Table 2 also shows three other variables. Ratings of other people’s attitudes or attitudeloaded information questions did not correlate significantly with demographic variables. Familiarity with mental health related information correlated as expected: personal and work experiences and higher education seemed to increase knowledge about these matters.

The correlations between age and education and attitudes are shown in Table 2 and 1 and 2. The correlations are not very high but were as predicted. The attitudes of younger and more educated respondents were more positive than those of older and less educated respondents. The relationship did not seem to be linear, because there were very small differences over a certain level of education (secondary school) and under a certain age (45 years in the current study).

Figures

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Figure

1. The

means

of age-groups in Lehtinen & V~is~nen’s attitude scale at 1970 and 1985

Figure 2. The means of educational

groups in Lehtinen V9is*nen’s attitude scale at 1970 and 1985

In the youngest age groups (15-24 and 25-34) education did not have any effect on attitudes. The means of the lowest educated were exactly the same as that of the highest educated. In the oldest groups (over 55) there was a statistically significant difference (p < .02) between low and high education groups. The comparison of the attitudes of old and young people is difficult, because their mental health related concepts are very different. When old, less educated (over 55 and only primary school) are compared with young, well-educated (under 35 and at least college education), they agree more often than the latter group that: A seriously mentally ill person can be recognised by his or her appearance; A layman cannot help mentally ill persons; The good appearance of a mental patient leaving hospital does not mean that he is well; -

-

-

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A sudden attack of mental illness does not get better without treatment; A strong person can solve his or her problems; and A professional has to take care of the treatment of the mentally ill. (These differences are all statistically significant (p < .01).)

-

-

-

6Th®~~ other people’ Table 1 shows both subjects’ own attitudes and the subjects’ report of ’other people’s’ attitudes. The contrast is striking. In effect people reported &dquo;I am very tolerant but those others are very intolerant.&dquo; Some of the differences are almost unbelievable. Practically all (85%) of ’us’ would hire an ex-patient, but only a few (10%) of ’them’. There were two interesting exceptions. Respondents reported that a similar proportion of ’other people’ would agree with ‘I’ that &dquo;the mentally ill should be treated more than presently in the community&dquo;. And they could fall in love with an ex-patient about as often as ‘I’ could. The first is a piece of good news for community mental health, but the latter may have a quite different meaning. Why is it so difficult to be a close friend with an expatient for ’them’, although ’they’ can fall in love with an ex-patient more easily? Perhaps subjects perceived the common man as being so boorish that it can very well be understood that they are stupid enough to lose their senses and fall in love with the mental

patients! DISCUSSION

Changes in attitudes The attitude changes during the 15 year period were small. The stability of attitudes was great. The average of 1985 was somewhat higher than that of 1970, because there had been a generational change. However, the level of attitudes seems to have been stabilised in the generations born after the Second World War. The major attitude change - if there was any at all took place earlier, possibly in the 1950s and 1960s. This may not be good news for public mental health work. It is a truism in discussions of practically any problem, be it mental health, delinquency or tra~c, that ’the attitudes should be made more positive’. Behaviour can only be changed if the attitudes are changed first. This hope seems to be unfounded. Firstly, attitudes are difficult to change, although not impossible (see eg. Ball-Rokeach et al. 1984), and secondly, attitudes are generally not good predictors of behaviour (Fazio, 1989; Ajzen, 1989). On the other hand, there have been some positive developments in many western countries during the 1970s and 1980s. The legal rights of the mentally ill have improved and, as in all deviant groups, their personal rights are now better recognised. It is possible that this development will later also be seen in attitudes. and education How should the correlation between attitudes and age and education be interpreted? Lehtinen and Vdisdnen (1977) summarise Johannsen (1959) as follows: &dquo;This result would be associated with the more noticeable appreciation of community services displayed by younger and better-educated persons who thus would also reveal

Age

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responsibility for those mentally ill.Older persons who, rule, have a scantier education, tend to appreciate puritan values and personal performances, and thus want to stay away from mental disturbances, and feel less responsible for the social problems caused by psychic disorders.&dquo; (p. 295). Dohrenwend and Chin-Shong (1957 p.432) also seem to agree that &dquo;lower-status groups are predisposed to greater intolerance of the kinds of deviance that both they and greater social compassion and as a

groups define as serious mental illness.&dquo; They also point out that the definition of mental illness is narrower in lower-status groups. There are conceptual differences between age and education groups. Mental illness is for older people a narrow concept. Being mentally ill is a very serious matter. Only when problems cannot be taken care of in the family or community is the condition called mental illness. This group of people with an apparently hopeless problem is very small as compared to those who are recognised as mentally ill among younger generations. We should in fact talk about generations or cultural milieu rather than age. Attitudes may mellow somewhat with age. Although ’conservative’ attitudes may increase, ’nurturance’ may do so as well (Eichhorn et al. 1981). On average, attitudes are very stable in the longitudinal data. Thus the age and education differences are really differences of cultures. Those born before the Second World War can adopt the concepts of the later culture, if they pursue their education longer. This means that they are more open to new concepts and ideas. Data presented in Figure 1 suggest that the turning point in attitudes was soon after the Second World War. After that point there has been no change in attitudes between generations. If we are interpreting the figures correctly, both of these variables will lose their effect in the next decades. We are losing two of our most stable ’explanatory’ variables (age and education) in attitude data. A new cultural change is, of course, possible, but the trend is clear: nine years of education is enough to stabilise the attitudes at a fairly high level. The attitudes at the M.A. level are not any more positive (see Figure

higher-status

2). Attitudes of ’other people’ The results of respondents’ reports of ’other people’s’ attitudes are alarming. Why are we so much more tolerant (and better) than those others? Various interpretations are possible. Maybe this is a glaring example of projection. We see in others what we deny in ourselves. Or ’other people’ are just too distant, too alien to us. It is a concept as unspecific as ’mental patient’. Plausibly the self-data may be grossly inflated, reflecting social norms of tolerance. A self-serving bias is common in ratings of personal characteristics. The picture of’other people’s’ attitudes seems to be very harsh. One reason might be, as Rabkin (1984) stated, that mental health professionals have given too pessimistic descriptions about the behaviour of the general public. There is in reality a lot of tolerance and sympathy towards the mentally ill in the family and the community, too. If there is fear and rejection, much of it is natural under stressful circumstances.

Meaning and function of attitudes Greenwald (1989) rightly questions the importance of attitudes. Studies of attitudes have been numerous, but the results have been unsatisfying. There is no denying that attitudes

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do predict behaviour to a certain degree (see Ajzen, 1989; Fazio, 1989), but what behaviour could be predicted from the attitudes identified in this study? Attitude and behaviour should be observed at comparable levels of specificity, as suggested by Fishbein and Ajzen (1975). As an example, we can take the behaviour towards the new psychiatric homes. Why are middle-class and even upper-class people often strongly opposed to these homes (Segal et al. 1980)? Each behavioural situation is extremely complex and depends on cultural, situational, personal and interactional factors. In analysing the opposition towards psychiatric half-way homes, two concepts, personal security and personal interests, can be used. The more secure the person feels, the less prejudiced his or her reaction is and the less he has to lose, the easier he or she finds it to give time and sympathy. If a person is economically, physically or mentally in a poor position, it is more probable that he is afraid of deviant behaviour or people. His life is more easily threatened. Personal interests can be seen in the situations where highly educated people oppose new homes for deviant people. They are afraid of losing their peace or money. Similarly, unemployed people may be afraid that their jobs are given to the mentally ill or other deviant individuals. The most positive combination is thus one of high personal security and no risk to personal interests. Helpful and supportive behaviour is then possible. The combination of low security and personal danger is not necessarily the most negative, although negative reactions are common in that situation. When a secure person feels threatened he has the ability to use power to defend himself. He takes action to correct his position. In a similar situation a less secure person might be passive, although furious. Secondly, we cannot know what is the relation of a prototype of a ’mentally ill person’ to a ’mental patient coming into my neighbourhood’. The first is very abstract and the latter quite specific. In one case of opposition the latter was defined as ’crazy alcoholics who attract prostitutes and other homeless vagrants into the neighbourhood’. It is no wonder, then, if attitudes do not predict behaviour. However, although attitudes do not predict behaviour well, they may serve as protective or instigating factors. If the attitudes are very negative they ’allow’ one to do very negative things and, similarly, if the attitudes are very positive, they hinder one from doing terrible things. The data not reported here show that being a member of a mental health profession elevates the attitudes by 10 points on our 20-100 scale. Also, workers of the Lutheran church have high positive values on this scale. Both of these results have something to do with values. These two groups may not always behave in accordance with their attitudes, but participating in actions against half-way homes would be very difficult for them.

REFERENCES

AJZEN, I. (1989) Attitude structure and behavior. In Attitude Structure and Function (eds. A.R. Pratkanis, S.J. Brecler & A.G. Greenwald). Hillsdale, N.J.:Lawrence Erlbaum. BALL-ROKEACH, S.J., ROKEACH, M. & GRUBE, J.W. (1984) The Great American Values Test.

Influencing Behavior and Belief through Television. New York: The Free Press. CUMMING, J. & CUMMING, E. (1957) Closed Ranks. An Experiment in Mental Health Education.

Cambridge,

Mass.: Harvard

University Press.

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I. (1974) Contemporary Attitudes toward Mental Illness. Pittsburgh: of Pittsburgh Press. DOHRENWEND, B.P. & CHIN-SONG, E. (1967) Social status and attitudes toward psychological disorder: the problem of tolerance and deviance. American Sociological Review, 32, 417-433. EICHORN, D.H., CLAUSEN, J.A., HAAN, N., HONZIK, M.P. & MUSSEN, P.H. (1981) Present and Past in Middle Life. New York: Academic Press. FARINA, A. (1981) Are women nicer people than men? Sex and the stigma of mental disorders. Clinical

CROCETTI, G., SPIRO, H. & SIASSI,

University

223-243. Psychology Review, 1, FAZIO, R.H. (1989) On the power and functionality of attitudes: the role of attitude accessibility. In Attitude Structure and Function (eds. A.R. Pratkanis, S.J. Brecler & A.G. Greenwald). Hillsdale, N.J.: Lawrence Erlbaum. M. & AJZEN, I. (1975) Belief, Attitude, Intention and Behavior: An Introduction to Theory and Research. Reading, Mass.: Addison-Wesley. GREENWALD, A.G. (1989) Why are attitudes important? In Attitude Structure and Function (eds. A.R. Pratkanis, S.J. Brecler & A.G. Greenwald). Hillsdale, N.J.:Lawrence Erlbaum. JOHANNSEN, N.J. (1969) Attitudes toward mental patients. A review of empirical research. Mental Hygiene,

FISHBEIN,

53, 218-228. LAINE, A. & LEHTINEN, V. (1973) Attitudes toward mental illness and their relationship to social structure and hospital bed utilization in two Finnish rural communities. Social Psychiatry, 8, 117-123. LEHTINEN, V. & VÄISÄNEN, E. (1977) Social-demographic aspects in the attitudes towards mental illness in a Finnish population. Acta Psychiatrica Scandinavica, 55, 287-298. LEHTINEN, V. & VÄISÄNEN, E. (1978) Attitudes towards mental illness and utilization of psychiatric treatment. Social Psychiatry, 13, 63-68. PAGE, S. (1977) Effects of the mental illness label in attempts to obtain accommodation. Canadian Journal of Behavioral Science, 9, 85-90. RABKIN, J. (1974) Public attitudes toward mental illness: a review of the literature. Schizophrenia Bulletin, 10, 9-33.

RABKIN, J. (1984) Community attitudes and local facilities.

In The Chronic Mental Patient Five Years Later

(ed. J.A. Talbott). Orlando: Grune & Stratton. SEGAL, S.P., BAUMOHL, J. & MOYLES, E.W. (1980) Neighbourhood types and community reaction to the mentally ill: a paradox of intensity. Journal of Health and Social Behavior, 21, 345-359. WEBBER, A. & ORCUTT, J.D. (1984) Employers’ reactions to racial and psychiatric stigmata: a field experiment. Deviant Behavior, 5, 327-336. WEINSTEIN, R.M. (1983) Labeling and attitudes of mental patients. Journal of Health and Social Behavior, 24, 70-84.

Markku Ojanen, PhD, Associate Professor, SF-33101 Tampere, Finland.

Department of Psychology, University of Tampere, P.O.

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Box 607,

Attitudes towards mental patients.

A study of attitudes towards mental patients was made using a questionnaire developed by Lehtinen and Väisänen. Five hundred and fourteen persons from...
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