American Journal of Community Psychology, VoL 6, No. 3, 1978

Social Activism and Psychiatrists in Community Mental Health Centers I Morton O. Wagenfeld and Stanley S. Robin Western Michigan University

A sample o f psychiatrists (n -- 72) working in 20 community mental health centers (CMHCs) representative o f the organizational and catchment area characteristics o f operating Centers were queried as part o f a larger study (n = 595) o f community mental health worker roles. It was found that psychiatrists were like other staff in perceived organizational expectations o f social activism but were significantly lower in perceived personal/professional role activism and role discrepancy. Unlike other staff, psychiatrists' levels o f activism and discrepancy were unaffected by personal characteristics or organizational and catchment area characteristics of the CMHCs. It was concluded that the psychiatrists' unwillingness to assume any but the most modest community activist stances may hinder the development o f the CMHC movement.

The establishment of the Community Mental Health Center (CMHC) as an innovation in mental health delivery services marked the coalescence of several trends in the treatment and prevention of mental illness. Among others, were the ideas that an inequity existed in the allocation of mental health resources, that the etiology of mental illness had a major social component, that the treatment and prevention o f mental illness should be addressed through the alteration of those social conditions seen as pathogenic; that the participation of those affected by these social conditions was desirable and therapeutic and that the community mental health center staff had a legitimate part in involvements or perhaps even a mandate to become involved in social change activities that constituted mental health efforts. The rationale for community mental health centers 1Version of a paper presented at the Annual Meeting of the American Sociological Association, New York, August 1976. The data presented here are part of a larger study, Emerging Roles of Community Mental Health Workers, supported by grant MH18958, from the National Institute of Mental Health. 253 0091-0562/78/0600-0253505.00/0 © 1978 Plenum Publishing Corporation

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was explicitly articulated by Caplan (1964), Dumont (1968), and Bellak (1964), among others. A succinct summary of these positions is provided by Baker and Schulberg (1967) who noted that community mental health was comprised of five conceptual areas: Population Focus, Primary Prevention, Social Treatment Goals, Continuity of Care, and Total Community Involvement. Psychiatrists were in the forefront of the development of this rationale, but the psychiatric community was not in full accord. Proponents hailed it as the "Third-Psychiatric Revolution" (Bellak, 1964), while detractors characterized it as an unwarranted "psychiatric bandwagon" (Burrows, 1969). Even psychiatric supporters have differed about the extent and nature of community mental health worker (CMHW) social involvement; some see it involving intensive and systematic consultation with those in the established social structures (Caplan, 1964), others maintaining its essence demanded the organization of indigenous groups traditionally excluded from meaningful participation in the existing social structures (Peck, Kaplan, & Roman, 1966). Even though the CMHCs were conceived in controversy, large sums of money and professional time and energy have been invested in their construction, staffing, and maintenance. Since the investment of resources has been considerable, and new roles about which marked controversy exists had to be created, investigation of the roles as defined by psychiatrists and others in CMHCs seems necessary. Indeed, the paucity of investigation into the question "What do CMHWs believe they should be doing?" as a means of assessing the reality of community mental health is difficult to understand. This research addresses the perceptions of CMHC staff - particularly psychiatrists - of their role as social activists, for many, the sine qua n o n of the CMHC as a mental health delivery system. Role is conceived as those behaviors (norms) expected of individuals occupying a specified social position in a defined social structure (Gross, Mason, & McEachern, 1958; Linton, 1936). The social structure investigated is the CMHC; the position is that of the CMHW, with analytic emphasis upon psychiatrists; and the expectations tapped are those of CMHWs as the most salient definers of their own roles. There are a variety of ways to describe or measure role (Biddle & Thomas, 1966; Jackson, 1972). In this research, social activism as a component of the CMHW role is analyzed. 8ocial activism in the role of CMHWs is seen in two ways. First is the perception of the role by the worker as a set of expectations sanctioned by the worker's CMHC (CMCH role activism). Second is the worker's definition of the role, independent of organizational influence (personal/professional role activism). Finally, the difference between the two, role discrepancy, is calculated as a measure of role structure (Goode, 1960). Since psychiatrists have provided the theoretical leadership and occupy the highest professional status within the CMHC, our first concern is to determine the extent of social activism seen in the CMHW role as defined by psy-

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255

chiatrists on the staffs of CMHCs. These measures of role activism and discrepancy are then compared to that found in the role definition of CMHW as defined by the others on the staffs of CMHCs. This will provide an indication of the agreement of psychiatrists with their colleagues in CMHCs relative to the expected professional behaviors germane to the stated purposes of community mental health. Having noted the disagreement within psychiatry about community mental health we will determine the extent to which this disagreement is reflected among psychiatrists employed by CMHCs. Investigated first is role activism and discrepancy by the age of the psychiatrist. Role definition may differ among those who have established their professional role with and those who were socialized professionally without the influence of the CMH movement. Next, role definition may be affected by the psychiatrists' experiences at the CMHC. In this context, role activism and discrepancy is seen as possibly" affected by the psychiatrists' duration of employment at the center and proportion of time spent in direct and indirect services. Put most simply, what one does may affect what he expects to do and considers legitimate to do. Also associated with differences in role activism and discrepancy may be the sort of center psychiatrists see themselves as functioning in, e.g. those psychiatrists who view their centers as more similar to a social service agency. Common sense would dictate that personal belief in CMH as an ideology would be associated with social activism defined as part of the worker's role. This reasonable expectation, however, has not been supported by prior research on CMHC workers in general (Robin & Wagenfeld, Note 1) and will be tested here specifically for psychiatrists. Finally, it seems reasonable that the nature of the center itself and the center catchment area would influence the psychiatrist's role definition and discrepancy. Organizational complexity, the locus of center control, and the auspices comprised the organizational variables. Catchment area characteristics were conceptualized as poverty or nonpoverty, ethnicity of indigenous population, and geographic complexity.

METHODS

The research was conducted in a nationwide sample of 20 NIMH-supported CMHCs selected to represent the major catchment area and organizational characteristics of operating centers. The variables used for center sample selection and also as the final set of independent variables were characteristics of the catchment area: socioeconomic status (measured by federal designation as either "Poverty" or "Non-Poverty" [Federal Register, 1971]), ethnicity (defined as percent white), and geographic complexity (defined as inner city, urban, urban. mixed, rural-mixed, and rural). The center organizational variables used were:

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organizational complexity (measured by the number of affiliate agencies comprising the center), auspices of the center (defined as the type of applicant applying for the NIMH grant and designated as Public/Governmental, Agency/ Board, University Medical School and Hospital), and accountability (defined in terms of proximity of governing body to the center: local control, distantregional or state body, or mixed). Data on these organizational and catchment area characteristics were obtained from NIMH. Data were collected from questionnaires sent to all staff at the 20 centers. Returns of 55.8% were checked against type of center and discipline of respondent and no bias was found. 2 Role activism was measured through the CMHW Role Inventory consisting of a series of highly specific vignettes developed from a content analysis of the CMH literature. The role inventory was designed to approximate the behavioral level as closely as possible and comprises nine areas of community life. Role activism is measured by selection of preferred responses to the vignettes, which represent a range of activism from exclusion of the vignette situation as a legitimate part of the role to responses endorsing behavior that is a direct, contestant behavior pursued outside of the established institutional structures of the community. CMHC staff responded to the role inventory from the perspective of their center (CMHC activism) and their own personal/ professional r o l e definition (personal/professional activism). High scores are indicative of strong activism. The difference between the two scores is the respondent's role discrepancy and indicative of role conflict. Perception of center organization was measured by asking respondents to place their center on a 10-point continuum with medical facility at point 1, social service facility at point 10, and an equal mixture of the two at point 5. Community mental ideology was measured by the Baker-Schulberg Community Mental Ideology Scale (Baker & Schulberg, 1967) of 38 items scored on a 7-point scale. This scale is highly reliable and valid. All other measures in the study were obtained from the self-reporting of the respondents.

FINDINGS

As seen in Table I, there are far higher levels of role activism in the personal/ professional definition of the role than in the CMHC definition. The distribution of activism scores indicates that the activism attributed to the role by psychiatrists for the CMHC role definition is similar to that of the rest of CMHC staffs. The personal/professional distribution, however, shows the psychiatrists 2For example, psychiatrists comprised 11.1% of the returns and 12.6% of the staffs of the 20 centers. Further, comparing our respondents with the membership of the American Psychiatric Association and the American Psychoanalytic Association on endorsement of the ideology of community mental health revealed no significant differences.

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Table I. Distribution of Role Activism Scores, Personal/Professional Activism Scores for Community Mental Health Workers and Psychiatrists in CMHCsa Personal/professional role activism

CMHC role activism Role activism scores 30 or below 31-40 41-50 51-60 61-70 71-80 Over 80 Total

n

%

Cumulative %

107 (16) 218 (29) 165 (25) 31 (2) 2 (0) 0 (0) 0 (0) 523 (72)

20.5 (22.4) 41.7 (39.3) 31.5 (34.5) 5.9 (2.8) 0.3 (0) 0 (0) 0 (0) 99.9 (99.0)

20.5 (22.4) 62.2 (61.7) 93.7 (96.2) 99,6 (99.0) 99.9 (99.0) 99.9 (99.0) 99.9 (99.0) 99.9 (99.0)

n

%

31 5.9 (12) (16.7) 112 21.4 (21) (29.2) 252 48.2 (33) (45.8) 112 21.4 (7) (9.7) 13 2.5 (0) (0) 2 0.4 (0) (0) 1 0.2 (0) (0) 523 100.0 (72) (101.4)

Cumulative % 5.9 (16.7) 27.3 (45.9) 75.5 (91.7) 96.9 (101.4) 99.4 (101.4) 99.8 (101.4) 100.0 (101.4) 100.0 (101.4)

aThe scores and percentages for psychiatrists are presented in parentheses. Scores and percentages for community mental health workers exclude data for psychiatrists.

as defining the role with considerably less social activism than the rest o f the staff. In an absolute sense, the level of activism in role, particularly in the personal/professional definition, is high. The highest possible score of 90 would indicate a level o f activism that would be unyieldingly opposed to social change through any established community structures, while 18 would avoid social activism of any sort. Large proportions of b o t h psychiatrists and others opt for moderate levels o f activism (41-50 range), but only nonpsychiatrists in any appreciable numbers (about 25%) see a stronger activism as part o f the personal/ professional worker role. Table II, which shows the distribution o f role discrepancy, indicates that most o f the discrepancy comes about from greater activism being specified in the personal/professional role definition than in the CMHC definition (the negative values). The absolute value o f role discrepancy is small. A score of 72 would indicate m a x i m u m discrepancy on each vignette. The largest frequency o f scores, however, are found in the - 1 to - 5 range. N o t e w o r t h y is the fact that 42% o f the psychiatrists, as opposed to 26% o f the rest of the center staff, define the role with no discrepancy. There is also a tendency for psychiatrists to have somewhat less discrepancy (have lower scores) than the rest o f the staff.

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Wagenfeld and Robin Table II. Distribution of Role Discrepancy Scores for Community Mental Health Workers and Psychiatrists in CMHCsa Role discrepancy scores

n

%

Cumulative%

Over 15 10-14 5-9 1-4 0 -1 to -5 - 6 to -10 -11 to -15 -16 to - 2 0 -21 to -25 -26 to -30 Over -30

1 (0) 1 (0) 6 (2) 70 (5) 137 (30) 161 (29) 99 (5) 34 (0) 10 (0) 3 (0) 0 (0) 1 (0)

0.2 (0) 0.2 (0) 1.1 (2.8) 13.4 (6.9) 26.2 (41.7) 30.1 (40.3) 18.9 (6.9) 6.5 (0) 1.9 (0) 0.6 (0) 0 (0) 0.2 (0),

0.2 (0) 0.4 (0) 1.5 (2.8) 14.9 (9.7) 41.1 (51.4) 71.2 (91.7) 90.1 (98.6) 96.6 (98.6) 98.5 (98.6) 99.1 (98.6) 99.1 (98.6) 99.3 (98.6)

Total

523 (72)

99.3 (98.6)

99.3 (98.6)

aThe scores and percentages for psychiatrists are presented in parentheses. Scores and percentages for other community mental health staff exclude data for psychiatrists. A positive score indicates that the respondent's personal/professional activism in lower than his organization's, while a negative score is indicative of the opposite state of affairs: i.e., greater personal than organizational activism. Becoming more specific, we can compare psychiatrists with the other major occupational groups in the CMHC. These data are summarized in Table III, in which the CMHC activism, personal/professional activism, and role discrepancy are compared by major disciplinary affffliation. It can be seen that psychiatrists do not define the role differently from the CMHC perspective, but do define it with significantly less activism than the others from a personal/professional perspective. Further analysis shows that psychiatrists define Table III. Role Activism and Discrepancy by CMHC Worker Discipline

CMHC role activism Discipline Psychiatrists (72) Psychologists (96) Social workers (140) Nurses (95) Paraprofessionals (95) F ratio Probability

SD

37.47 7.78 37.78 7.98 36.80 8.67 38.01 7.70 37.40 9.96 1.08 < .37

Personal/ professional role activism X

SD

Role discrepancy X

SD

40.32 8 . 4 6 -1.11 3.00 44.35 8 . 2 8 -3.09 4.33 45.46 9 . 4 5 -3.95 5.92 42.78 8 . 5 3 -2.10 3.98 44.95 9.27 -3.60 5.08 3.58 3.09 < .0007 < .002

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Social Activism and Psychiatrists

Table IV. Role Activism and Discrepancy of CMHC Psychiatrists by Age Personal/ professional role activism

CMHC role activism Age of psychiatrist 25-34 (20) 35-44 (32) 45-54 (14) 55 or older (6) F ratio Probability

X

SD

34.65 9.49 37.69 7.64 40.21 5.49 39.33 4.46 1.62 < . 19

,,~

SD

39.80 10.15 40.38 8.81 40.57 6.43 41.17 5.85 0.05 < .99

Role discrepancy ,,Y

-2.30 -0.84 -0.71 -1.00

SD

3.10 3.00 2.92 2.19 1.74 < . 17

the role with significantly less organizational activism than all discplines except the paraprofessionals. Psychiatrists also display significantly tess role discrepancy than all other disciplinary groups. We now turn our attention to the differences among psychiatrists in role activism and discrepancy. As indicated in Table IV and V there are no significant differences among psychiatrists by age or number o f years at the center. Time of socialization and socialization within the center seem to have no effect upon the way psychiatrists define CMHW roles. While time at CMHC per se does not relate significantly to our several measures o f role, the organization does exert s o m e influence. In Tables VI and VII we can see the role definition and discrepancy of psychiatrists by the time spent in direct and indirect services. With one exception, psychiatrists do not vary in their role definition. Table VI indicates significantly less role discrepancy among psychiatrists who spend less than 10% o f their time in indirect services. The mean o f .29 for these psychiatrists indicates an almost perfect agreement between their perception of the role activism as expected in the center and their own personal/professional perspectives. Put another way, greater involvement in the community through indirect services is associated Table V. Role Activism and Discrepancy of CMHC Psychiatrists by Number of Years at CMHC

CMHC role activism Years at center Less than 1 year (20) 1-4 years (37) 5 or more years (15) F ratio Probability

X

SD

35.15 9.10 38.32 6.62 38.47 8.44 1.24 < .29

Personal/ professional role activism .X

SD

38.90 41.43 39.47

9.33 8.02 8.54 ,67 < .51

Role discrepancy X

-i.55 --1.14 -0.47

SD

2.48 3.23 3.14 .55 < .58

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Wagenfeld and Robin Table VI. Role Activism and Discrepancy of CMHC Psychiatrists by Percent of Time Spent in Direct and Indirect Servicea

Percent of time direct services

CMHC role activism

X

SD

Personal/ professional role activism

Role discrepancy

.~

X

SD 2.89 3.03

SD

25% (23) > 25% (49) Students t Probability

38.61 8.28 36.94 7.57 0.85 < .40

42.70 10.02 39.20 7.48 1.65 < •10

-1.82 -0.77

Percent of time Indirect services ~< 10% (27) > 10% (45) Students t Probability

35.44 2.76 35.82 3.06 0.52 < .60

39.41 7.60 40.87 8.98 0.%1 < .48

-0.29 -1.60

1.39 < . 10

2.66 3.12 1.81 < .05

air should be noted that percent of time in direct and indirect activities were not simply the inverse of one another: our respondents had other duties. This is supported by a correlation of -.57 between amount of time in direct and indirect services. with greater role discrepancy. Perception of the organizational character o f the CMHC (Table VII) does not appear to relate to the perception of role or role discrepancy. The association o f community mental health ideology and role activism, in spite o f the logical relationship, is modest for CMHC psychiatrists. CMHC role activism is correlated .35 and personal/professional activism .39 with ideology. These relationships - while statistically significant - indicate that only 13% o f the CMHC role activism and 15% o f the personal/professional activism are predictable from the psychiatrist's ideology.

Table VII. Role Activism and Discrepancy of CMHC Psychiatrists by Perception of CMHC Orientation

CMHC role activism CMHC orientation Center mainly as social service agency (~< 5) Center mainly as medical facility (> 5) Students t Probability

Personal/ professional role activism

Role discrepancy

X

SD

X

SD

X

SD

38.33

6.99

40.47

8.71

-1.00

2.87

40.21 8.39 0.12 < .90

-1.19

3.13 0.26 < .79

3 6 . 8 6 8.32 0.79 < .43

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Table VIII. Role Activism and Discrepancy of CMHC Psychiatrists by Center Organizational Characteristics

Center organizational characteristics Auspices Public/governmental (35) Agency/board (12) University (9) Hospital (16) F ratio Probability Locus of accountability Distant (30) Local (18) Mixed (24) F ratio Probability Number of center components 1 (27) 2 - 3 (t0) 4 - 6 (28) 7+ (7) F ratio Probability

CMHC role activism X

SD

Personal/ professional role activism .~"

SD

Role discrepancy .,Y

SD

34.29 8.12 39.25 3.67 42.67 6.06 40.19 7.57 4.82 < .004

37.63 8.11 39.25 5.26 47.11 9.27 43.19 8.35 4.32 < .008

-1.37 -.08 -1.56 -1.19

3.11 3.09 3.13 2.69 0.78 < .51

35.83 8.17 38.28 7.25 38.92 7.60 1.18 < . 31

38.23 7.63 41.00 7.75 42.42 9.62 1.74 < . 18

-.90 -1.11 -1.38

3.70 1.53 2.96 0.16 < .85

36.59 9.35 38.40 5.18 38.75 6.87 34.43 7.81 0.76 < .52

40.30 7.66 35.90 7.25 42.61 9.10 37.57 8.73 1.90 < . 14

-1.52 1.50 -1.53 1.57

2.49 4.20 2.83 2.07 3.19 < .03

Finally, turning to the independent variables o f CMHC organization and catchment area characteristics, we f'md that t h e y do make systematic differences in the ways psychiatrists define the CMHW role. In Tables VIII and IX we note the significant differences o f role definition b y center auspices, catchment area, geographic complexity, SES, and ethnicity. For b o t h CMHC and personal/ professional activism psychiatrists in centers with university auspices define the role with greatest activism. 3 Hospital and agency/board follow in degree of activism, with public/governmental auspices showing the least activism. High role discrepancy is noted for psychiatrists in urban settings and very low discrepancy is noted for those in rural settings. A positive role discrepancy (the role defined more actively from the CMHC perspective) is uniquely found in rural-mixed centers. Surprisingly, role activism of b o t h kinds is found to a greater extent in nonpoverty catchment areas than in poverty areas. Significantly higher levels of CMHC role activism are found in catchment areas with higher proportions o f Whites. In b o t h cases psychiatrists define the role o f CMHW with greater activism in circumstances where activism is easier to obtain and, from an ideological perspective, less needed.

s The small n for some of these categories suggests caution in interpretation.

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Table IX. Role Activism and Discrepancy of CMHC Psychiatrists by Catchment Area Characteristics of the CMHC

Catchment area characteristics Geographic Complexity Inner city and urban (32) Urban-mixed (25) Rural-mixed-rural (15) Socioeconomic Status Poverty (42) Non-poverty (30) Ethnicity 80-100% White (29) 40-79% White (43)

CMHC role activism .~

Personal/ professional role activism

SD

X

SD

Role discrepancy .~

SD

36.78 8.72 37.92 7.81 38.20 5.65 F=.23 p

Social activism and psychiatrists in community mental health centers.

American Journal of Community Psychology, VoL 6, No. 3, 1978 Social Activism and Psychiatrists in Community Mental Health Centers I Morton O. Wagenfe...
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