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thesis entitled

DEVELOPMENT OF A SCALE TO MEASURE THE ATTITUDE
TOWARD CITIZEN PARTICIPATION IN COMMUNITY
MENTAL HEALTH CENTER BOARDS

presented by

i
Edward A. Oxer
\
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of the requirements for

Ph.D. degree in Counseling

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Date W \

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© Copyright by
EDWARD A. OXER
1979

DEVELOPMENT OF A SCALE TO MEASURE THE ATTITUDE
TOWARD CITIZEN PARTICIPATION IN COMMUNITY

MENTAL HEALTH CENTER BOARDS

BY

Edward A. Oxer

A DISSERTATION

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the Degree of

DOCTOR OF PHILOSOPHY

Department of Counseling, Personnel Services
and Educational Psychology

1979

ABSTRACT
DEVELOPMENT OF A SCALE TO MEASURE THE ATTITUDE

TOWARD CITIZEN PARTICIPATION IN COMMUNITY
MENTAL HEALTH CENTER BOARDS

BY

Edward A. Oxer

The concept of citizen participation has been a
central theme in American democracy and politics. Com-
munity institutions and agencies, as part of the fabric
of American democracy, have been influenced significantly
by the underlying philOSOphical base of community involve-
ment and local control.

Large State mental hospitals that were for many
communities the exclusive providers of inpatient mental
health services in the early 19503 with the impetus of a
strengthened mental health policy at the State and Federal
levels gave way to the "third revolution" in psychiatry;
that of community mental health.

Local communities were to be served by locally
operated, community-based mental health services, but the
problem of defining the community's boundaries and assuring
suitable citizen input, representative of the community,
was greater than anticipated by the planners. The contro-
versy soon became polarized around citizen participation

versus citizen control.

Edward A. Oxer

The purpose of this study was to develop an instru-
ment to measure the attitude toward citizen participation
in Community Mental Health Center boards. The importance
of this study is evident for any community mental health
center program that does not develop a suitable mechanism
for insuring adequate community involvement, so as to
relate itself to community needs, will soon be suffering
from a lack of community support, often with financial and
political consequences.

A series of 80 statements was developed from an
extensive review of the citizen participation in mental
health literature. Seven factors or subscales were
hypothesized and the 80 statements were scaled in the
Likert format. Seven experts in the field rated the 80
items and predicted directionality of the items, as well
as the factors into which the items fell. Items were
reviewed for content validity and criterion groups were
also suggested from an expanded list of groups concerned
with citizen participation in community mental health. A
total of 45 items and six factors received sufficient
support from the experts to be included in a pilot of the
scale. The 45-item scale was administered to a pilot
group of 50 with a lS-item semantic differential scale
and a five-item control over decision making scale
included as criterion measures. The final stage of instru-

ment development involved construct validation in which

Edward A. Oxer

several groups such as community mental health services
board members, community mental health center staff and
clients completed the scale in terms of their View of
citizen participation.

Strong correlations were expected between the cumu-
lative scores for each group and the criterion measures,
as well as certain of the demographic characteristics.
Significant differences were expected among groups, which
should indicate that the scale has the ability to dis-
criminate between those in favor of a strong citizen role
in CMHC decision-making and those who are not.

A reasonably reliable 30-item scale was developed
which has the ability to differentiate between groups with
varying views of citizen participation. Several weak
relationships were found between demographic characteris-
tics and the scale which suggested that those who were
older, more educated and at a higher income level support
a strong citizen role in decision-making. Other data
suggest that those in favor of citizen participation see
community leaders and potential consumers rather than
clients and mental health professionals as being able to
play a strong role in CMHC decision making. Minorities
and community mental health board members were in favor of
a strong citizen role. Clients and parents of clients
were found to be aligned with professionals in non-support

of a strong role for citizens in CMHC decision making.

To
My Wife, Tina
and

My Sons, Adam and Jeremy

ii

ACKNOWLEDGMENTS

This research as well as my doctoral studies would
not have been possible without the enduring love and
encouragement of my wife, Tina. Her constructive criticism
and discussion of the ideas contained herein were invalu-
able as an incentive toward eventually reaching my goal.
To my two sons, Adam and Jeremy, I express my appreciation
for their understanding and patience throughout the years
of work involved in my graduate studies.

To my parents, I wish to express my appreciation
for emphasizing the importance of education and learning.
The support and understanding of my wife's parents through-
out the period of my doctoral studies was of great
assistance.

I wish to express my sincere appreciation to my
dissertation chairman, Dr. James R. Engelkes, who cheer-
fully accepted the responsibility for this portion of my
doctoral studies and whose guidance and support was
invaluable. I would also like to thank my program chair-
man, Dr. John E. Jordan for his encouragement throughout
the years of my doctoral work.

In addition, I would like to express my gratitude
to the other members of my committee as follows:

iii

Dr. Herbert M. Burks, for his careful review of the
materials associated with the study; Dr. Norbert B. Enzer,
who has been of assistance by serving on this committee as
well as helping to find solutions to the day-to-day prob-
lems of managing a community mental health center; and

Dr. Lawrence A. Messe for his research expertise and
friendly support.

I would also like to thank the following friends
and colleagues: Dr. Judith Taylor, whom I met while
studying for my comprehensive examinations and who has
provided much invaluable consultation on research,
computer programming and data analysis; Dr. Romaldus
Kriauciunas, for his review of the research at various
stages of development. Dr. Duane Gibson, Chairman of
the Ingham Community Mental Health Center Advisory
Council for his guidance on matters pertaining to citizen
participation.

I wish to especially thank Thomas M. Ennis,
Executive Director, and Dr. Gilbert DeRath, Clinical
Director of the Community Mental Health Board of Clinton,
Eaton, and Ingham Counties, Lansing, Michigan for provid-
ing the sanction to complete this study.

Lastly, the clients, staff, board members, and
many-others too numerous to mention must be thanked for
their interest in citizen participation and their

willingness to "get involved."

iv

TABLE OF CONTENTS

LIST OF TABLES . . . . . . .

Chapter

I.

II.

III.

Iv.

INTRODUCTION . . . . . .

Introductory Statement . .
Need for the Study . . .
Statement of Purpose . . .
Questions to be Addressed by
Definition of Terms . . .
Summary . . . . . . .

THEORY AND SUPPORTIVE RESEARCH

Introductory Statement . .

History of Mental Health Care . .
The Ideology of Citizen Participation
Citizen Participation in CMHC' s .

Attitude Measures of Citizen
Participation . . . .
Summary . . . . . . .

DESIGN AND METHODOLOGY . . .

Introductory Statement
Procedure . . . .
Sample Selection .
Research Hypotheses
Statistical Analysis
Summary . . . .

RESULTS . . . . . . . .

Introductory Statement . .
Results of Analyses . . .
smary O I O O O

Page

vii

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11

ll
11
20
30

4O
45

47

47
47
61
68
71
72

74
74

74
89

Chapter Page

V. DISCUSSION 0 O O O O O O O O O O 88
Introductory Statement . . . . . . 93
Results of the Instrument Development . 94

Results Related to Differences Between
Criterion Groups on the Citizen
Participation Scale (CPS) . . . . 95

Results Related to the Relationship
Between Demographic Characteristics
and the Citizen Participation Scale

(CPS) . . . . . . . . . . . 99
Limitations of the Research . . . . 101
Implications for Future Research . . . 103
Conclusions . . . . . . . . . . 106

APPENDICES

A. Mailing to Judges: Four Tasks for Initial
Stages of Scale Development . . . . 109

B. Pilot: Instructions, 45-Item Scale,

Semantic Differential, Control over

Decision-Making Scale, and Demographic

Items . O O O O I O O O O O O 124
C. Letter to Federally Funded CMHCs . . . 137
D. Mailed Questionnaire . . . . . . . 141

E. Followup Reminder Post Card . . . . . 147

F. Letters of Approval . . . . . . . 149

BIBLIOGRAPHY . . . . . . . . . . . . 152

vi

Table

3.1

3.2

LIST OF TABLES

Distribution of 80 Declarative Statements
into Seven A Priori Factors as Predicted
by Author 0 O O O O O O O O O 0

Distribution of Judges by Organizational
Affiliation O O O O O I I O O 0

Two Levels of Agreement among Judges on the
Seven A Priori Factors . . . . . .

Comparison of the Number of Items in Each
A Priori Factor as Predicted by Author,
Agreed Upon by Judges, and Finally
Included in Pilot . . . . . . . .

Response Rate by Group Samples as of
April 17, 1979 . . . . . . . . .

Non-Respondents Rate of Return . . . .
One-Way ANOVA--Citizen Participation Scale
(CPS) Total Score by Non-respondents

versus Respondents . . . . . . . .

Reliability Analysis, Cronbach Alpha by
Number of Scale Items . . . . . . .

Means, Standard Deviations and Item-Total
Correlation Coefficients for the Thirty
Item Citizen Participation in CMHC
Boards Scale (CPS) . . . . . . . .

One-Way ANOVA--CPS Total Score by Income .

One-Way ANOVA--CPS Total Score by Age . .

One-Way ANOVA--CPS Total Score by Sex . .

One-Way ANOVA--CPS Total Score by Education

vii

Page

50

52

57

57

64

65

66

68

69
76
77
79

80

Table

Page

One-Way ANOVA--CPS Total Score by Marital
Status 0 O O O O O O O O O O O 81

One-Way ANOVA--CPS Total Score by Board
Chairperson versus Board Members . . . 33

One-Way ANOVA--CPS Total Score by Elected
Official versus Non-elected Officials who
are Board Members . . . . . . . . 34

One-Way ANOVA--CPS Total Score by
Professionals versus Non-professionals . 35

One-Way ANOVA--CPS Total Score Board Members
versus Non-board Members . . . . . . 86

One-Way ANOVA--CPS Total Score by Consumers
versus Non-consumers . . . . . . . 87

One-Way ANOVA--CPS Total Score by Race . . 88

One-Way ANOVA--CPS Total Score by Criterion
Groups . . . . . . . . . . . . 90

t-Tests of Contrasts of Mean Scores for
Criterion Groups on CPS . . . . . . 91

viii

CHAPTER I

INTRODUCTION

Introductory Statement

 

Government must be kept open. If we

intend to rebuild confidence in the

government process itself, policy must

be shaped through the participation of

Congress and the American people.
Jimmy Carter

(Community Services
Administration, 1978)

The concept of citizen participation has been
central to American democracy and politics. Community
institutions and agencies, as part of the fabric of
American democracy, have been influenced significantly
by the underlying philOSOphical base of community involve-
ment and local control.

Large state mental hospitals that were for many
communities the exclusive providers of inpatient mental
health services in the early 19508 gave way, with the
impetus of a strengthened mental health policy at the
federal and state levels, to the "third revolution" in
psychiatry: community mental health. State governments
that operated the mental hospitals responded to legisla-
tive forces, as well as to citizen groups calling for a

l

substantial portion of the mental health budget to be used
in operating and contracting for community services such
as outpatient clinics, day treatment, halfway houses, 24-
hour emergency services, inpatient services, and preven-
tion programs. The Federal government's initial role in
this was via the Community Mental Health Center's Act

(PL 88-164 of 1963) which funded state planning grants to
the designated state mental health authority. Service
districts, or catchment areas, ranging in size from 75,000
to 200,000 population were called for as a way of locating
services in close proximity to local "communities." But
the problem of defining the local community's boundaries
and assuring suitable citizen input, as well as its effec-
tiveness, was greater than anticipated by the National
Institute of Mental Health (NIMH) plannners. The contro-
versy soon became polarized around citizen participation
versus citizen control. Who are the true representatives
of the residents of the community? How should the
"community" be defined? Connery (1968) pointed out that
the Federal insistence on a population limit for community
mental health centers was unrealistic. "The guiding
principle should not be size but that the governmental
unit sponsoring it be a viable one in terms of an adequate
tax base and leadership supply. The unit must have a

present political reality" (Connery, 1968, p. 507).

The NIMH Community Mental Health Center (CMHC)
concept addressed the issue of community involvement
without specific regard to the local political realities
across the United States. The Federal Proqram of
Community Mental Health Centers (CMHCs) is based on the
premise that in order for a CMHC to be successful, it
must be responsive to the viewpoints and problems of local
communities. For this reason, the following mandate was
included in the Community Mental Health Centers' Amend-
ments of 1975, Public Law 94-63, Section 201(c)(1)(A):

The governing body of a community mental health
center shall:

(i) be composed, when practicable, of
individuals who reside in the center's
catchment area and who, as a group,
represent the residents of that area
taking into consideration their
employment, age, sex, and place of
residence, and other demographic
characteristics of the area, . . .
(NIMH, 1978, p. v).

Need for the Study

 

While much has been written on the ideological
mandate for citizen participation in all forms of social
and community services, little information is found in
the literature that quantitatively measures the outcomes.
One is left with the feeling that inquiry into this issue
in a more systematic way may be akin to heresy; but,
nevertheless, the need is present to try to investigate

methodically the effectiveness of citizen participation.

The importance of evaluating the effectiveness of

citizen participation is underscored by Hunt (1973b):

. . . in order for citizen groups to function

effectively over the long haul, it is important

to evaluate their activity and their effect on

the planning and delivery of health services.

Without adequate evaluative research, it will be

impossible to know whether the experiment has

been a success or whether changes are necessary

to produce a more positive outcome (p. 31).
Any community mental health program that does not develop
an effective mechanism for insuring adequate community
involvement so as to relate itself to community needs
will soon suffer from a lack of community support, often

with financial or political consequences.

Statement of Purpose

 

The purpose of this study was to expand upon the
research of Au Yeung (1973) and the Health Policy Advisory
Center (Health PAC) of New York's study, "The Evaluation
of Community Involvement in Community Mental Health
Centers" (1972). In conjunction with this study, entitled
Citizen Participation in a Community Mental Health Center,
Au Yeung developed two scales, "Participants' Views of
Citizen Participation in a CMHC" and "Participants' Per-
ceived Influence on the CMHC," with 10 and five items,
respectively. No reliability or validity data are
reported for these scales. Further research in the area
of refined measurement of the variables related to citizen

participation is a logical next step and was the focus of

 

 

this study. A case study approach was used by Health PAC
in surveying citizen participation in six community mental
health centers in various parts of the United States.

This study, while complete as descriptive research, made

no effort to measure any of the variables or the effective-
ness of the process of citizen participation in CMHC
boards. As noted above, this has been the case in the
field of citizen participation, which is usually described
in ideological terms with little quantifiable data to
support the concept.

Health PAC defines community involvement as
participation in policy-making by direct service con-
sumers, mental health professionals, and other community
members, i.e., providers and non-providers of mental
health services. Mechanisms of community involvement
include boards or advisory groups, volunteers working in
community mental health programs, employment of catchment
area residents (mostly para-professionals in designated
poverty areas), patient committees and advocates, and
consultation and education services. The purposes of
these mechanisms of community involvement are:

1. To educate and inform the community

(direct service consumer group) about
center services and how to use them.

2. To educate and inform center staff and

administration about the perception of

community needs, in particular mental
health needs.

3. To engage the community as much as possible

in the center's planning (operation) and
evaluation.

It was also suggested in this study that community
involvement contributes to the general level of mental
health in the community through citizen participation in
the self-determination of this community institution.

In summary, the purpose of this study was to
develop an instrument to measure the variable: attitude
toward citizen participation in CMHC boards.

Questions to be Addressed
by This Study

 

 

The mechanism of community involvement that was
of interest in this study was the CMHC board. Much con-
troversy has revolved around the issue of the community
mental health center's board and its role with respect to
the program. This controversy gave rise to many research
questions. Should a board be simply informed of decisions
made by the staff after they are made or should the board
have a policy-making role with substantial fiscal and
programmatic authority? What is the impact of the level
of participation on the effectiveness of the CMHC board
as a mechanism of community involvement? What are the
attitudes toward a particular model of decision-making or
influence over the decision-making process? What is the
role and function of citizen participation in community

mental health? How should members be selected and by

whom appointed? How should the nature of representation
be determined? What is the need for citizen participation?
What are the characteristics of effective citizen partici-
pants?

The independent variables of the Health PAC study
were the activity levels of community involvement as
reflected in the quantity and quality of participation.
The quantity of participation includes such considerations
as number of participants, frequency of meetings, and
amount of time spent; the quality of involvement dealt
with representativeness, depth of participation, and the
accuracy with which the mental health needs of the com-
munity are reflected. A second possible independent
variable of interest is the attitude toward citizen par-
ticipation.

The Health PAC study (1972) indicated that the
effectiveness of the CMHC Board may be seen in terms of
increased communication and understanding between the
center's staff and community members. It suggested that
there was a concurrence on service mission and that there
was a positive correlation between community perception
of need and the center's staff judgment. Other matters
raised in conjunction with assessing the effectiveness of
mechanisms for community involvement included resolution
of conflicts, accountability across the staff-community

boundary, communication of expectations, definitive roles,

and the general viability of the program in terms of

community support.

Definition of Terms

 

A common understanding of the key terms used in
this study is provided by the following definitions:

1. Community Mental Health Center (CMHC). In

 

keeping with PL 94-63 of 1975, a Federally-funded CMHC
consists of 12 services: inpatient, outpatient, day
treatment, emergency service, consultation and education,
transitional services, court screening, follow-up for
state hospital patients, children's services, services
for the elderly, and alcohol and drug abuse services.
Each center serves a catchment area of 75,000 to 200,000
population and must have a governing/advisory board that
is representative of the area served.

2. CMHC Board. The policy-making body of a

 

community mental health center which must be composed of
citizens who are representative of the catchment area.
This group may be a governing or advisory board. The
governing board provides the stronger form of citizen
participation.

3. Consumer Board Members. Individuals who have

 

actually used or have the potential to use the services
of the community mental health center and can represent
consumer interests. Also included are those who are

members of the immediate family of the consumers.

4. Provider Board Members. Individuals who earn

 

their living from the delivery of health care services
including mental health services. Specific professions
would include psychiatry, psychology, social work, and
nursing.

5. Citizen Participation. A process whereby

 

service users (actual and potential consumers), service
providers, and at-large community representatives (com-
munity leaders) are involved in the policy-making aspects
of the CMHC.

6. Community Leaders. Board members who are key

 

business, professional, and elected community leaders who
regularly serve on community boards and are active in
civic affairs, and represent the middle class and more
affluent members of the community.

7. Community Control. A process whereby repre-

 

sentatives of mostly low income and ethnic/racial minor-
ities attain representation and eventually policy-making
control over the CMHC. This has been achieved after much
controversy that has often had an ultimately destructive

effect on the program.

Summary

In order to achieve any of the evaluation tasks
on the effectiveness of citizen participation in CMHC
boards mentioned above, it was necessary to be able to

measure and quantify the independent and dependent

10

variables of interest. The purpose of this study was to
develop an instrument to measure the variable: attitude
toward citizen participation in CMHC boards.

Ultimately, it was expected that through the
development of this scale, a means will be found to
measure one of the major constructs in a field that
abounds with ideological fervor but has little in the way
of documentation and quantification. Through the develop-
ment of this instrument, more information and knowledge
will be acquired regarding the area of citizen participa-
tion, a process which is far from adequately understood.
The need to study this area was evident as a community
mental health center that does not develop a suitable
mechanism for insuring adequate community involvement and
citizen participation, so as to be responsive to community
needs, will soon be suffering from a lack of community

support, often with financial and political consequences.

CHAPTER II

THEORY AND SUPPORTIVE RESEARCH

Introductory Statement

 

In accord with the purpose of this study, which
is to develop an instrument to measure the attitude toward
citizen participation in CMHC boards, four areas of
relevant research literature were surveyed. These were
the history of mental health care, the ideology of citizen
participation, citizen participation in CMHC boards, and

attitude measures of citizen participation.

History of Mental Health Care

 

A familiarity with the ideology associated with
mental health and illness was important to understand the
development of mental health care. However, before one
could discuss community mental health, the most recent
mental health ideology to come into focus on the American
scene, it was necessary to trace briefly the history of
American psychiatry over the last 200 years.

A frame of reference was suggested for this by
Golann and Eisdorfer (1972) who, in assessing the changes
in the field, noted the universality of three related

social-clinical processes:

11

12

1. Classification. Some acts or behavior
patterns are distinguished from others and
certain concepts may be grouped together
under a single term such as neurosis.

 

2. Explanation. A belief system or theory is
developed to account for the occurrence of
certain acts of patterns of action.

 

3. Intervention or Regulation. A system of
institutions, persons, or practices is built
and sanctioned to cope with certain acts of
behavior. For each phase of mental health
ideology. there has existed a system of
classification or preferred theory of causa-
tion and a sanctioned form of response
(Golann & Eisdorfer, 1972, p. 3).

 

Two volumes (Zilboorg, 1941; Deutsch, 1949) surveyed in
great detail the history of mental health care from the
era of primative medical psychology through the period of
the Greeks and Romans to colonial America. The following
is a brief summary and review of the history which fits
into the present system of mental health care. A central
theme that runs through all modern mental health care is
that of concern for the welfare of the individual and the
preservation and enhancement of such institutions as the
family, community, and society in general.

Prior to the emergence of humanitarian care, the
mentally ill or disordered were considered holy or
possessed by demons. Many cultures invoked gods or
demons to explain behavior, while care in the form of
exorcism of the mentally ill was expected from a medicine
man or religious figure of the culture. Various forms of

exorcism have been described throughout history, ranging

13

in degree and severity, and based upon a theory of how the
evil may have entered the body of the afflicted. Examples
of this include such procedures as trepanation, or boring
a hole in the skull of the possessed individual to allow
evil spirits to leave and good spirits to enter, thereby
reducing or replacing the cause of the mental symptoms
(Freedman, Kaplan & Saddock, 1975, p. 10), and the burning
of witches at the stake as the "ultimate" cure in 17th
Century Salem, Massachusetts for the suffering of dis-
ordered thought and behavior (Freedman, Kaplan and Saddock,
1975, p. 46). Less severe but equally dramatic were the
reports of Shamanism, or the inspirational activities of
the tribal medicine men. "Frequently, the patient's
liberation from the evil spirit was expressed concretely
through the explusion of an object such as a stone,

insect or from the mouth of the Shaman" (Freedman, Kaplan
& Saddock, 1975, p. 11). Vincenzo Chiarugi in Italy,
William Tuke in England, Phillippe Pinel in France, and
Benjamin Rush in America are generally credited with the
curbing of harsh and objectionable practices with respect
to the care of the mentally ill. Pinel is best known for
his liberation of the mentally ill at Salpetriere in 1795.
The work of these men led to the development of the concept

of moral treatment in the early 18003.

14

Ruth B. Caplan (1969) discussed moral treatment
and the concepts which provided its philosophical and
scientific base.

The essence of moral treatment was the belief
that because of the great malleability of the
brain surface, because of its susceptibility to
environmental stimuli, pathological conditions
could be erased or modified by corrective
experience. Therefore, insanity, whether the
result of direct or indirect injury or disease
or of overwrought emotions or strained intel-
lectual faculties, would be cured in almost
every case (Caplan, R. B., 1969, p. 9).
The mentally ill were, therefore, seen as sick rather than
guilty of an act which was deserving of punishment. They
were to be treated like those suffering from physical
illnesses rather than locked in poorhouses or jails.

Physicians who were involved in moral treatment
were personally involved in the care of their patients in
small institutions where caring, hOpeful attendants pro-
vided kind and respectful treatment. Dorothea Dix became
concerned that this type of treatment was not available
to the majority of those who needed it but only to the
mentally ill of the more affluent families. By petition-
ing state legislatures throughout the United States, she
is credited with the founding or enlarging of more than
30 state hospitals during the period of 1840 to 1880. It
was this expansion of services, coupled with immigration
in the latter part of the 18803 and the consequent

increase of poor "foreigners" attempting to adjust to the

American way of life, that caused increased numbers of

15

patients to be admitted to the state hospitals, thereby
causing an overload upon available resources which, con-
sequently, brought a decline in the quality of care which
led to a prevalent custodial ideology. Grob (1966)
indicated that other factors contributed to the decline
of care in state institutions, such as the professionali-
zation of psychiatry and the increased reliance upon
psychiatry as a scientific discipline based on a somatic
model of treatment. At the same time that psychiatrists
were becoming more scientifically oriented by virtue of
their identification with and training in medicine, they
were having a harder time being associated with main-
stream "acute care" medicine of the general hospital.
The large state institution located in a rural environ-
ment with minimal hospital facilities contributed to this.
Mechanic (1969) concluded that

the trend toward professionalization isolated

psychiatrists from the more humanitarian and

compassionate ideologies existing in the society

and replaced these with a barren, alleged objec-

tivity which offered little help or hope (Mechanic,

1969, p. 54).

The emphasis on humanitarian care and its decline,
often referred to as the first revolution in psychiatry
(Goldenberg, 1973, p. 295), led to the second revolution,
which directed attention to the inner psychological life
of man emphasizing developmental stages and the role of

the unconscious. Concerns in classification changed from

categorization of symptoms to elaboration of mechanisms

16

of defense. Golann and Eisdorfer (1972) discussed prob-

lems with the psychoanalytic approach:
The variations on the psychoanalytic theme pro-
liferated but all shared the difficulty that
patients were those who could afford such treat-
ment and had the verbal capacity and adaptability
to deal with a variety of feelings and memories
not usually at the level of awareness of the
patient when he requests help; this, of course,
leads to a variety of alternative styles of
verbal interaction with patients but effective
psychotherapy was not available to large numbers
of individuals because of financial or logistical
constraints, unfamiliarity of socially advantaged
mental health professionals with practical living
problems faced by disadvantaged clients and the
impracticality for disadvantaged clients of a
method requiring long periods of retrospective
analysis (Golann & Eisdorfer, 1972, p. 6).

Prior to World War II, 3000 psychiatrists prac-
ticed in the United States. The outbreak of war brought
about a concern for conducting an appropriate psychiatric
medical screening of all those inducted into the military.
A proposal from the profession of psychiatry to screen
all inductees was implemented but failed in effectiveness
due to the limitations in manpower. Large numbers of
American males were rejected from military services for
psychiatric reasons. This experience, as well as the
experience of mental health professionals in the war zone,
once again pointed to the need for stronger public mental
health programs of prevention, as well as treatment.

Following the war, concern for the mental health
needs of the country was reflected in the high rejection

rate of selective services, as well as the need to care

17

for those in the Veterans' Administration system who had
been disabled in the war. This provided the impetus for
Congress to passthe Mental Health Act of 1946 which led
to the establishment of the National Institute of Mental
Health (NIMH) in 1949. The intent of this program was to
combine a public health approach with mental health. The
NIMH budgets reflect the increased involvement of the
Federal government in mental health from 1950 with a
budget of less than $9,000,000 to $68,000,000 in 1960,
$338,000,000 in 1967 (Mechanic, 1969, p. 57), and
$503,000,000 in 1978.

In 1955 the Mental Health Study Act authorized
the Joint Commission on Mental Illness and Health to
conduct

an objective, thorough and nationwide analysis
and evaluation of the human and economic problems
of mental illness and of the resources, methods
and practices currently utilized in diagnosing,
treating and caring for and rehabilitation of
the mentally ill, both within and outside insti-
tutions as may lead to the development of compre-
hensive and realistic recommendations for such
better utilization of those resources (PL 84-182
as reproduced in Joint Commission on Mental
Illness and Health, 1961, p. 303).

In 1961 the Joint Commission published its report

entitled Action for Mental Health, which called for

l. A tripling of mental health expenditures in
ten years.

2. A new and better recruitment and training
prOgram for mental health professionals.

18

3. Expansion of treatment programs for acutely
ill patients in all facilities, including
community mental health centers, general
hospitals and mental hospitals.

4. Establishment of one mental health center
for every 50,000 persons in the population.

5. Conversion of large state hospitals to

smaller regional intensive treatment centers

with no more than 1,000 beds.

6. New programs for chronic patients such as
aftercare and rehabilitation services

(Mechanic, 1969, p. 60).

The following year a cabinet-level committee
reviewed the Joint Commission's recommendations and, on
February 5, 1963, President Kennedy sent to Congress his
message on Mental Illness and Mental Retardation. The
President called for "governments at every level--Federal,
State and Local, private foundations and individual
citizens [to] face up to their responsibilities in this
area" (Kennedy, 1963). A bold new approach was needed
"to use Federal resources to stimulate State, Local and
private action" (Kennedy, 1963). The President's message
also cited the need for broadly conceived community mental
health centers, rather than clinics, that would work
toward the elimination of state hospitals. Federal pro-
grams for the construction and staffing of community
mental health centers, which were to include the five
essential services of inpatient, outpatient, partial

hospitalization, emergency services, and consultation and

education, followed. The overall goal of the community

19

mental health centers program was the establishment of
2000 centers. As of April, 1978, the total number of
centers funded was 649 and future growth was uncertain.
The emphasis in the CMHC's upon early diagnosis and pre-
vention, based upon understanding of social and community
factors, has been referred to as the "third revolution"
in mental health, or the community mental health movement.
Gerald Caplan (1969) reflected on the history of
American psychiatry and states,

I now realize that traditional American psychiatry
has been community and population-oriented from
its beginning and that, with all its undeniable
assets, the individual patient orientation of
academic and psychoanalytic psychiatrists of the
last twenty to thirty years has been to some
extent a withdrawal to a professionally controlled
haven from the difficulties of grappling with the
demands made upon us by the society that sponsors
our Operations. Community psychiatry is not
merely a bright new idea developed by some of us
in the 19603 as a reaction to our awareness of

the shortcomings of the individual approach but

is a return to an orientation that was our basic
mandate from society when our profession was
established and within the framework of which it
has been developed (Caplan, G., 1969, p. 320).

Caplan continued by discussing the importance of

confrontation between psychiatrist and the public:

If we organize or participate in programs that

are administered or financed by public bodies,

particularly state or local governments, we must

be prepared to accept the political framework

within which support is given (Caplan, G., 1969,

p. 322).
He outlined five principal purposes to be served by this

interaction:

20

1. To communicate with legislators or others who
distribute community resources . . . in order
to persuade them to allot to us an appropriate
share of such resources in competition with
representatives of other groups and resources.

2. To influence social policy planning.

3. To monitor salient need to which mental health
services should be addressed and to find out
how to utilize non-psychiatric resources in
the community to extend the impact of mental
health professionals.

4. To elicit feedback from the recipient popula-
tion to those providing the mental health
services.

5. To obtain sanction for our activities (Caplan,
G., 1969, pp. 340-344).

Finally, Caplan commented that the most important
aspect<xfthe professional-public confrontation was "the
ever present danger of retiring into our own professional
group and reducing or interrupting communication with the
public and its leaders when they criticize or attack us
or when they say things we do not like to hear" (Caplan,
1969, p. 345).

The Ideology of Citizen
Participation

 

 

Citizen participation has been a much written
about topic. The idea of citizen participation has taken
on ideological proportions as a result of its roots in
American history, as well as the resurgence of community
involvement during the mid-19603 in the community action

programs associated with the "War on Poverty." Spiegel

21

and Mittenthal (1968) in their bibliographic review of
the citizen's participation literature entitled, "The
Many Faces of Citizen Participation" cited several reasons
for the elusive nature of the concept. They stated that
although there is some information available on the topic,
there is not enough to be able to draw reasonable conclu-
sions. An additional factor that clouded the situation
was bias:

. . . A scientific approach to citizen participa-

tion is extraordinarily difficult, suffused as it

is with nominative judgment, value laden precon-

ceptions, lack of objective criteria and standards

of measurement, and a host of differentiated per-

spectives from which anyone can draw just about

whatever meanings his predilections desire

(Spiegel & Mittenthal, 1968, p. 4).
Given the above cautions, an attempt will be made in the
following pages to sort through the citizen participation
literature first as it relates to the general concept and

then to the specific areas of community mental health.

John Rehfuss, in his book Public Administration as a

 

Political Process, indicated that

the program dealing with Community Action Programs
(CAP) was unusual in that it attempted to alleviate
poverty by directly involving the poor in designing
and operating programs for their own benefit. To
the extent that it attempted to make poor and
powerless persons a separate political force oper-
ating at the local level, it was a revolutionary
idea designed to federally finance opposition to
local political leaders in city hall (Rehfuss,
1973, p. 14).

"Maximum feasible participation" was the language

of the "War on Poverty." By this, it was expected that

22

the poor of communities, both urban and rural, across
the United States would become involved in the governance
of programs that affected their everyday lives. Sargent
Shriver (1965) justified the requirement for maximum
feasible participation of the poor by stating

It is desirable for the same reason that a busi-

ness concern tries to find what the consumer

thinks of his product. You would not be in

business twenty minutes if you did not run

consumer surveys. . . . We are trying to find

out what the poor people really think about

what all the rest of us are doing theoretically

for their benefit (Shriver, 1965, p. l).
Shriver's suggestion was well taken, given the "non-
market" aspect of many community programs. The non-
market aspect of a program represents a basic difference
which must be reckoned with by designing alternative
mechanisms of ascertaining the satisfaction or non-
satisfaction of the consumers of that service.

Kramer (1969), in his article entitled "Prelude:

Four Modes of Resident Participation," described the
Community Action Programs that developed out of the
Economic Opportunity Act of 1964. Because this legisla-
tion was written in the same period as the Community
Mental Health Center legislation, the commonality of the
two documents with respect to citizen input is apparent.
The four modes of participation were as follows:

1. CAP Policnyaking. The poor were cast in

the role of policy-makers as voting members
of the governing board of directors. In

this capacity, the representatives of the

 

23

poor were regarded by CEO as essential
members of a tripartite coalition, along
with the major governmental and voluntary
welfare agencies, and the leadership of
important elements in the community such
as labor, business, religious and minority
groups (Kramer, 1969, p. 6).

2. Program Development. Resident participation
took place on the neighborhood level and was
linked to the first through elected repre-
sentatives to the CAP's board of directors
from the target area. The core process was
one of program development; here the poor
were initially received primarily as con-
sumers who could give useful advice and
suggestions to those responsible for the
planning and delivery of social services
(Kramer, 1969, p. 11).

 

3. Social Action. The third type of resident
participation was the most radical and contro-
versial of all and for many persons the possi-
bility of increasing the power of the poor
was either the most objectionable or the most
encouraging feature of the CAP (Kramer, 1969,
p. 13).

 

4. Employment. The fourth and perhaps the least
controversial way in which the poor could
participate was through employment as aides
or in other non-professional roles, some of
which were defined as "new careers" in educa-
tional, health, welfare, legal and correc-
tional agencies. Employment was originally
regarded as the primary, perhaps sole form of
resident participation (Kramer, 1969, p. 18).

 

Lane (1962) pointed out that political participa-
tion is not the central mode of need satisfaction for
most Americans. Political scientists such as Milbrath
(1965) have been interested in the degree of intensity
of the participation and define participation in politics
in terms of apathetics who are not active in the political

process, spectators who view it as a spectator sport, and

24

finally, gladiators who maintain a high level of involve-
ment in political activities. Milbrath concluded that
most Americans play a passive role in relation to partici-
pation in party politics. Hofstetter (1972) defined
participation as "the conscious involvement of peOple in
the collective pursuit of a goal" (Hofstetter, 1972, p.
225). He also stated that those who are more politically
active feel more politically effective, have a higher
sense of obligation to participate, are less alienated
from politics, manifest less hostility, are less misan-
thropic, have greater ego strength, and show more
partisanship than those who are apathetic. These quali-
ties increase as they become more active and upon close
examination seem to be closely related to at least a
limited definition of improved mental health. In addi-
tion, those who are most politically active maintain
democratic values of tolerance, public responsibility,
and adherence to the rules of the game more than the less
active do. This has been emphasized in the citizen
participation literature as a particularly important
feature of involving citizens in the governance of com-
munity institutions.

Milbrath discussed the decisions of an individual
to act in a particular way with respect to a political
issue as "a function of the interaction between the

particular pattern of predisposition possessed by the

25

organism at a given point in time" (Milbrath, 1965,
p. 73). Predisposition can be categorized into:

(a) Physiological and psychological needs.

(b) Beliefs.

(c) Attitudes.

Beliefs and attitudes can be viewed as a function of a
learning mechanism called reinforcement. Political atti-
tudes are cognitions about and positive or negative feel-
ings toward political objects. These political objects
can be broadened to encompass attitudes toward a mental
health agency and the predisposition to become involved
in the decision-making process of such an organization.
Measuring the attitude of an individual (board members,
mental health staff, community agency representative,
consumers) toward citizen involvement in the decision-
making process of a mental health agency may be seen as

a predictor of how that individual will behave with
respect to the attitude object (citizen participation
ideology).

Lane (1962) stated that any ideology supports or
weakens the institution of democracy. The concept of
citizen participation in mental health services has taken
on the proportion of an ideology and may be characterized
according to Lane's concept of an "ideology." Lane
stated that the term "political ideology" means a body

of concepts with the following characteristics:

26

They deal with the questions: Who will be
the rulers? How will the rulers be selected?
By what principles will they govern?

They constitute an agreement that is intended
to persuade and to counter opposing views.

They integrally affect some of the major
values of life.

They embrace a program of defense or reform
or abolition of important social institutions.

They are, in part, rationalizations of group
interests but not necessarily the interest of
all the group espousing them.

They are normative, ethical, moral in tone
and content.

They are (inevitably) torn from their context
in a broader belief system and share structural
and stylistic properties of that system (Lane,
1962, p. 14).

Most ideologies have these qualities:

1.

They are a group of beliefs that individuals
borrow; most people acquire an ideology by
identifying (or disidentifying) with a
social group.

They have a body of sacred documents (con-
stitutions, bills of rights, manifestos,
declarations) and heroes (founding fathers,
seers and sages, originators and great
interpreters (Lane, 1962, p. 15).

All ideologies, like all other beliefs, imply an

empirical theory of cause and effect in the world and a

theory on the nature of man.

Democratic values heavily support participation

in group decision-making. Gibb, Platts, and Miller

(1951), in a study entitled Dynamics of Participative

 

27

Groups, enumerated the characteristics of a democratic

society which supported participative action:

1.

2.

A belief in the dignity and worth of the
human personality.

A belief in the equality of the rights and
worth of all men.

The right of all men to participate in the
decisions vital to the group.

A confidence in the capacity of man to work
out his goals and solve his problems.

The availability of all knowledge or data
relevant to the decision-making process
(Gibb, Platts & Miller, 1951, p. 77).

Cahn and Cahn (1971), in reviewing the concept of

masimum feasible participation associated with the Office

of Economic Opportunity (OEO) community action programs

of the late 19603, listed the values of citizen partici-

pation which they believed fell into three broad

categories:

1.

A means of mobilizing unutilized resources,
a source of productivity and labor not other-
wise tapped.

A source of knowledge--both corrective and
creative, a means of securing feedback
regarding policy and programs and also a
source of new incentive and innovative
approaches.

An end in itself--an affirmation of democracy
and the elimination of alienation and with-
drawal, of destructiveness, hostility and
lack of faith in relying on people (Cahn &
Cahn, 1971).

Mogulof (1974) examined the different patterns

and purposes of citizen participation in Federal programs,

28

and discussed the shifting view of citizen participation
in Federal programs. The initial problem was defined as
a need "to increase program effectiveness, to redistribute
power, to build an effective political constituency for
new programs . . . whereas, it is now a question of . . .
group rights and power vis-a-vis the larger community"
(Moguluf, 1974, p. 68). Federal policy in 1974 was still
addressed to the older definitions of citizen participa-
tion with little agreement about what direction policy
and practice would take. Mogulof, in demonstrating the
lack of agreement as to the purpose of citizen participa-
tion, listed eight varied purposes which he researched
in OEO publications:

1. Decentralizing governmental authority.

2. Engineering the consent of the governed.

3. Insuring equal protection to individuals
and groups through a watchdog citizenry.

4. Curing alienation and other social diseases
of our time by a form of therapy.

5. Employing residents so as to "humanize"
service.

6. Creating cadres of antirioters.

7. Building a constituency for the program.

8. Redistributing power (Mogulof, 1974, p. 69).
Mogulof concluded that

Citizen participation policy at the Federal level

is erratic, piecemeal, misunderstood and possibly

not really cared about. This patchwork of Federal
attitudes and practices, however, may have had

29

greater utility in contributing to Federal and
local experimentation with regard to participa-
tion, in the decade of the 19603 . . . to con-
tinue the "benign anarchy" of citizen participa-
tion policy in the 19703 would be the denial of
the utility of these experimental years (Mogulof,
1974, p. 76).

A recent publication by the Community Services

Administration (1978) entitled Citizen Participation

 

reflected an effort on the part of the Federal government
to respond to why the citizen participation requirements
vary from program to program. The authors took the view
that there is a rationale for the varied citizen partici-
pation requirements in Federal programs "because the
programs are different and the goal of citizen participa-
tion is significantly different from program to program
and because the general philosophy reflected in legisla-
tion and policy has changed over a period of time"
(Community Services Administration, 1978, p. 13). In
fact, this publication was primarily devoted to summariz-
ing citizen participation requirements in programs as
varied as the Departments of Agriculture, Commerce,
Justice, and Health, Education and Welfare.

Warner (1965), in his discussion of the problems
of participation, indicated that to succeed organizations
must have membership participation. Yet, getting the
quality and quantity of participation they want turned

out to be one of their most difficult and persistent

30

problems. Participation is a problem for several differ-
ent reasons:

1. Participation is essential to some degree
but rates of participation tend to be low.

2. Participation is seen as a symbol of
organizational success.

3. Society places value on democratic partici-
pation with the concurrent idea that low
participation threatens the democratic
operation of the organization (Warner,

1965, p. 128).
Warner divides the factors that influence participation
into three categories:

1. The attributes of the participants.

2. The environments, both physical and social.

3. The organization itself, its structure and
procedures (Warner, 1965, p. 130).

Of interest to this study were the attributes of the
participants, which included such variables as age, sex,
marital status, educational level, occupational status,
and income. More difficult variables reflective of
participant characteristics were motivation, attitudes,
beliefs, values, health, etc. The area of participant

attitudes was the focus in this study.

Citizen Participation in CMHC's

 

Much work has been done to understand the issue
of citizen participation in the CMHC services. The issue

has frequently become that of citizen participation versus

 

31

consumer control. Roman and Schmais (1972) pointed out
that:
The dominant characteristic of citizen participa-
tion in the health and welfare fields, until the
advent of federally sponsored programs emphasizing
involvement of the poor, has been middle and upper
middle-class membership on advisory boards, health
councils, trustee committees and governing com—
mittees (Roman & Schmais, 1972), p. 67).
Only recently has traditional board composition and board
member role been questioned with respect to representa-
tiveness, selection and appointment of membership and
participant characteristics ultimately leading to
questions of which interest controls the decision-making
process. Holton, New and Hessler (1973) describe three
models for citizen involvement in CHMC's. A study done
at Tufts University concluded that the CMHC's surveyed
defined citizen involvement in the traditional middle-
class pattern of housewives, businessmen, lawyers, and
ministers whose main role was to raise funds and not
raise serious questions about the professional directions
of the agency. This is the model of the elitist board.
The second is an advisory model with a majority of low-
income and minority group consumers and community resi-
dents as representatives. This model has largely been
rejected in poverty area CMHC's, in lieu of governing
board functions, where playing an advisory role is seen

as a symbol of the general powerlessness of the community.

The third model is that of consumer control in which a

32

governing board is composed of a cross-section of catch-
ment area residents and, in its purest form, is set up

as a community corporation to administer the CMHC. This
model seems to be relevant particularly in poverty areas
where there is a potential conflict between the perception
of mental health needs by middle-class mental health pro-
fessionals and residents of the area. The board, it is
hoped, serves as an effective mechanism for mediating
perceptions, indentifying needs, and developing a program
which is relevant to all parts of the catchment area,
including the low—income, disadvantaged, and minority
group community residents. If this is accomplished, com-
munity support for the program is the outcome.

Kupst, Reidda, and McGee (1975) studied 18
community-based community mental health centers in urban
settings, attempting to compare their developments, func-
tions and powers. Four groups were surveyed:

1. Citizen board members.

2. Board Chairpersons.

3. Center staff.

4. Center directors.

The groups generally agreed that the primary function of
a Community Mental Health Center Board was to see that

needs were met. Other functions considered were program
and policy advice, keeping the center visible, and direct

involvement of the community in assessing needs. With

33

respect to degree of involvement, board members saw

their role as advisory, staff favored co-decision or
advisory, directors favored co-decision, and Chairpersons
wanted more board control. There were differing percep-
tions between staff and board members regarding reasons
for joining boards, with staff feeling that joining was
related to a need for prestige and status and board mem-
bers to a desire to serve the community.

McGee and Wexler (1972), in discussing the
political considerations of community-based mental health
services, indicated that "mental health professionals must
recognize the importance of local political figures in the
development of . . . programs in an urban area and move
toward a spirit of openness and cooperation" (McGee &
Wexler, 1972, p. 303). They stated that

it is sobering to recognize that political
figures may listen more carefully to community
residents than to mental health professionals.
. . . The mental health professionals frequently
come from outside the community. . . . Community
residents come from the community and represent
votes (McGee & Wexler, 1972, p. 308).
The political and professional considerations cannot be
separated in the development of community mental health
programs. McGee and Wexler point out the necessity for
strong working relationships between professional and

community residents, citing three tasks for community

residents:

 

34

1. To work closely with local political
representatives to keep them informed of
the mental health needs in their community.

2. To provide increased awareness to both
political representatives and health
officials.

3. To act as advisors and evaluators in
relation to such things as plans, avail-
ability and effectiveness of community-
based services in an urban setting (McGee
& Wexler, 1972, p. 309).

Kenny and Ehrenreich (1974) assembled a particu-
larly detailed description of the situation in 1968 which
led to a confrontation between Columbia University and
the New York City Community Mental Health Board (CMHB)
and the Washington Heights Community.

The Washington Heights controversy may have made

more of an impact on CMHB and Columbia than they

were willing to admit. The recognition that

there was, somewhere out there, a "community"

. . . structured, vocal, and capable of raising

the same kind of community . . . control demands

that were paralyzing the New York City school

system at that time caused a profound rethinking

of community mental health by both CMHB and

Columbia. For both, the Washington Heights

confrontation has been their first sustained

encounter with any kind of organized consumer

constituency (Kenny & Ehrenriech, 1974, p. 168).
The authors pointed out that it is their feeling that
frontal attacks on establishment institutions such as
Columbia University will be the major weakness of the
community mental health movement. No group actually wins
or loses and, in support of this, the authors point out

that in Washington Heights "the symbolic victory of the

35

control has yet to be translated into tangible services"
(Kenny & Ehrenreich, 1974, p. 170).

Dudley (1975) described a more orderly process
for involving citizen participants in CMHC programs in a
large urban area. While the State of Pennsylvania, in
its Mental Health/Mental Retardation Act of 1966, only
allowed for a 13-member advisory board at the county level,
the City of Philadelphia developed a set of regulations
for citizen participation which the author proposed "may
serve as a model for the other county mental health/mental
retardation offices that are developed or intending to
develop community participation regulations" (Dudley,
1975, p. 417).

The history of community control has been a mixed
one emanating from the early 19603 and the experience of
several Federal programs in housing, poverty, and health.
Moynihan (1969) discussed the apparent contradiction of
community control.

Complete community control usually meaning black
control of all community affecting institutions
becomes the demand of more militant whites. On
the surface, a reasonable enough position, in
reality, took the form of denying the legitimacy
of those institutions of electoral representation
that had developed over the years--indeed, the
centuries--and which normally did provide com-
munity control. Plebiscitory democracy: the
people-in-council became the seeming non-
negotiable demand of many . . . . This quickly
enough becomes government . . . by process of

private nullification which has never been
especially good news for democracy. It would

36

be absurd to blame the community action programs
for the legitimization of something called "com-
munity control" in opposition to the established
system of electoral representation. The assump-
tion that established systems were not meeting
the needs of pe0ple was certainly much encouraged
by the community action movement (Moynihan, 1969,
p. 78).

Weissman's discussion of community control (1970)
provided further clarification of Moynihan's point:

Much of the rhetoric of those who advocate com-
munity control is strikingly similar to the
rhetoric of what has been described . . . as the
ideal "community organization process." This
process is essentially a rational problem solving
process in which there is complete and open sharing
of all information and facts, full discussion and
ultimate decision-making on the part of everyone

in the community. Indeed this process is the ideal
democratic procedure taught in any high school
civics course (Weissman, 1970), p. 168).

Hersch (1972) pointed out additional problems
with community control, such as the emergence of local
leaders who are not representative of the community,
power on the community heard not necessarily wielded for
the sake of rational program development, and the intense
anger that can be directed at professionals which has an
"anticolonialist" quality about it. Hersch believed the
problems are not limited to low-income boards but are more
pronounced when they do occur. He encouraged mental
health professionals not to romanticize working in these
settings but to examine all aspects of the situation

which would lead to a realistic sharing of power between

professionals and community residents.

37

Others, such as Meyers, Dorwart, Hutcheson and
Decker (1974), have conceptualized the problem of citizen
participation in terms which are broader than the issue
of community control or representativeness. In their
study, board accomplishment was seen as the central con-
cern with a concomitant interest in being able to quantify
how well boards achieve their goals and objectives. Four
separate types of accomplishments were identified:
. Service creation or improvements.
Mobilization of outside resources.
Local autonomy.

Coordination (Meyers, Grisell, Gollin,
Papernow, Hutcheson & Serlin, 1972, p. 319).

hWNI"

These four typologies are considered to be independent of
one another and "represent four very different strategies
that an area board can follow in pursuing its goals and
legislative mandate. This information should prove
valuable to area boards in more clearly defining their
roles and in planning future activities" (Meyers et al.,
1972, p. 320).

Another strategy cited in the literature for the
purpose of lending order to the CMHC planning process was
described by Krauss and Phillips (1974). This article
described the work of two architects who developed a
planning aid kit (PAK) to facilitate the community-based
design of CMHC services. Included in the PAK are guide-
lines for planning group composition to include mental

health professionals and paraprofessionals and

38

representatives of the catchment area to be served. The
planning process is structured around ten meetings and

ten workshops in which mental health services and facili-
ties are designed, using an environmental design approach
based on understanding how a proposed environment is to

be used before detailing its physical appearance. This
technique, while supportive of an orderly planning process
for CMHC programs, seems to lend itself best to communi-
ties that are not involved in a destructive form of con-
troversy over who will ultimately control community mental
health services.

Bertelson and Harris (1973) reviewed the accom-
plishments of the District V CMHC in San Francisco,
California, in their organizing efforts with the citizens
of the catchment area. The strengths and weaknesses of
the process were reviewed in this article which essentially
described the community organization process for the CMHC
in the context of a predominantly middle-class neighbor-
hood. This study identified the most salient contribution
that can be expected from citizen participation as follows:

Board members gain familiarity with and confidence
in the CMHC philosophy, but they also retain a
critical viewpoint. They ask challenging questions
such as: Do institutions return patients to the
community too quickly, and does the portion of

time allotted to consultation pay off? (Bertelson
& Harris, 1973, p. 556).

 

39

Rabiner (1972) described the initial stages of

the organization of a community advisory committee in a
department of psychiatry that had applied for a Federal
CMHC staffing grant. The unusual feature of this particu-
lar process seemed to be the real commitment of the
department of psychiatry to involve lay representatives
in the delivery of mental health services. This article
cited an excellent example of coalition building (com-
munity and department members traveling to Washington to
support the grant application) that is possible when power
is shared. Unfortunately, the article ended abruptly
with a discussion of how heavily involved the community
would be in the financial management of the center because
the article was written just prior to the award of a
Federal grant of two million dollars. The position was
taken, however, that training for CMHC board members
would make a significant difference in their ability to
play a meaningful and active role:

Rather than assume that our board members are

unable to become involved in the center's

finances, we take the position that they require

training in finance and management. Certainly

their commitment to the mental health center

has been well documented. In our Opinion,

business knowledge can be supplied to them more

readily than a commitment to the community can

be supplied to some who, although well versed

in business affairs, lives in another world
(Rabiner, 1972, p. 121).

40

Golann and Eisdorfer (1972) indicated that

the major issue of the 1960's has been the
achievement of increased flexibility and compre-
hensiveness of mental health services. The major
issue of the 1970's will be that of community con-
trol over the mental health field, a process to
date that has been initiated largely by profes-
sionals and taken over by the urban poor (Golann

& Eisdorfer, 1972, p. 14).

Attitude Measures of Citizen
Participation

 

 

A search of the literature (Shaw & Wright, 1967;
Comrey, Baker & Glaser, 1973; Bonjean, Hill & McLemore,
1967; Miller, 1970; Chun, Cobb & French, 1975; Lake, Miles
& Earle, 1973; Robinson & Shaver, 1969) with respect to
attitude measures revealed that there are no scales avail-
able that purport to measure the attitude toward citizen
participation on CMHC boards.

Robinson, Rusk and Head (1968) reported a collec-
tion of scales relating to liberalism and conservatism
of political attitudes, community-based political atti-
tudes, and political participation. All of these scales
deal with broad political issues rather than the political
process inherent in a CMHC board.

Scales in Au Yeung (1973) entitled "Participants'
Views of Citizen Participation in a CMHC" and "Partici-
pants' Perceived Influence on the CMHC" report no reli-

ability or validity data for the 10- and five-item scales,

41

respectively. Both scales were constructed in the
(Likert) summated rating format.

Other related scales, such as the Baker-Schulberg
Community Mental Health Ideology Scale (Baker & Schulberg,
1967) and the Gottesfeld Community Mental Health Critical
Issues Test (Gottesfeld, 1972), contain individual items
of general relevance to citizen participation in community
mental health, but only as they relate to community mental
health as an overall concept. Other studies reviewed,
such as Decker (1974), examined the roles of citizen
participation in Massachusetts Mental Health Advisory
Councils but do not report attitudinal ratings or make
any attempt to construct an instrument other than a survey-
type questionnaire.

From this point in the literature, efforts at
develOping measures of citizen participation in community
mental health services become more diffuse; the literature
shifts back to a descriptive and ideological approach.

Based upon the inadequacy of the scales cited
above, that is a broad rather than specific focus on
citizen participation, the most minimal psychometric data
and finally what amounted to an intuitive approach to
attitude measurement, it was decided to explore in depth
through a systematic empirical effort the question of

attitude toward citizen participation in a CMHC board.

42

In spite of the inadequacies, some effort was made to
incorporate some items in the scale for this study.

The technique of scale construction known as the
method of summated ratings is drawn from the work of
Likert (1932) in which, as part of a larger investigation
begun in 1929 by Gardner Murphy, a different method of
attitude scaling was develOped which represented a radical
departure from the work of Thurstone and the method of
equal-appearing intervals. Likert asked if it was pos-
sible to construct equally reliable attitudinal measures
by using simpler scaling techniques that did not involve
the laborious procedures of having judges sort items into
categories. Likert also felt that a simpler scale perhaps
did not have to make "unnecessary assumptions" (Likert,
1932, p. 35). He was careful to point out that he was
raising these questions in the spirit of academic inquiry.

It is feared that someone will mistakenly inter-
pret this article as an attack on Thurston's
methods. I, therefore, wish to emphasize in the
strongest terms that I am simply endeavoring to
call attention to certain problems of method and
that I am very far from convinced that the present
data closes the question (Likert, 1932, p. 6).
Likert defined an attitude as "a tendency toward a
particular response in a particular situation" (Likert,
1932, p. 4).

Many varied definitions of attitude were found

in the literature, which emphasized the cognitive,

43

affective, conative, or evaluative aspects of the con-
struct. Other definitions of attitude are:

An enduring learned predisposition to behave in

a consistent way toward a given class of objects

(English & English, 1958, p. 50).

A mental state of readiness, organized through

experience, exerting a directive or dynamic

influence upon the individual's response to

all objects and situations with which it is

related (Allport, 1954, p. 45).
Jordon (1971) pointed out that: "two basic views permeate
the literature on attitude research: one defining atti-
tude as a 'predisposition to behavior' and the second
emphasizing attitude as 'behavior'" (Jordan, 1971, p. 8).
A behavioral definition of attitude is provided by
Guttman (1950) who defined attitude as the "delimited
totality of behavior with respect to something" (Guttman,
1950, p. 48). Thurstone (1946) defined attitude in terms
of feeling as "the degree of positive or negative affect
associated with some psychological object" (Thurstone,
1946, p. 43).

The way in which an attitude is defined will
naturally have a direct relationship to the way in which
the attitudinal measurement is designed. For the purpose
of this study, Shaw and Wright's (1967) definition of
attitude was used:

A set of affective reactions toward the attitude
object, derived from concepts or beliefs that the
individual has concerning the object, and pre-
disposing the individual to behave in a certain

manner toward the attitude object (Shaw & Wright,
1967, p. 13).

44

Likert made several recommendations in the
selection of items for scale construction:

1. It is essential that all statements be state-
ments of desired behavior and not statements
of fact. Present rather than past behavior
is measured in that way. The term "should"
is a way of stating the proposition so that
it involves desired behavior.

2. Each statement should be clear, concise and
straight forward, using the simplest possible
vocabulary. No double negatives should be
used or other wording that would be confusing.
Avoid every kind of ambiguity.

3. In general, it would seem desirable to have
each statement so worded that the modal
reaction to it is approximately in the middle
of the possible responses.

4. About half the statements should give a
"strongly approve" and half should be "strongly
disapprove" distributed randomly throughout the
attitude scale (Likert, 1932, pp. 44-46).
Likert, Roslow and Murphy (1934) indicated that

the summated rating method of scoring, which does not
involve the use of a judging group, was found to be
"consistently more reliable than the original method of
scoring. The scores obtained by the two methods correlate
highly, indicating that they are measuring essentially the
same thing" (Likert, Roslow & Murphy, 1934, p. 237).
Tittle and Hill (1967) conducted a study in
which they used several well known methods of attitude
scale construction and compared their abilities to pre-
dict voting behavior among college students. The Likert

Scale was superior among the scale types, yielding a mean

45

correlation coefficient of .54 with the objective indices
of voting behavior.

The Likert Scale was found to be the best pre-

dictor and to exhibit greatest reliability,

while the Thurstone Scale is the poorest pre-

dictor and the least reliable. The findings,

with respect to the range of reliability, are

similar to those reported in other studies

using Likert's and Thurstone's procedures. In

addition, the available evidence suggests that

in cases where the two types of scales are of

equal length one can expect the Likert Scale

to exhibit higher reliability (Tittle & Hill,

1967, p. 211).

The second scaling technique used in this study

was the semantic differential (Snider & Osgood, 1969).
The semantic differential was used to obtain a concurrent
measure of validity by using 19 pairs of bipolar adjec-
tives describing citizen participation in CMHC boards to
which the subject responded. Three factors were assessed
with the semantic differential technique: an evaluative
factor, a potency factor, and an action factor. Reli-
ability has been reported by Osgood, Succi and Tannenbaum
(1957) ranging from .83 to .91. Validity measures have
been reported by correlating the semantic differential

with the other scales, such as the Thurstone, with a range

of .74 to .82 (Osgood et al., 1957).

Summary
This literature review has verified a number of
ideas that are of significance for this study. Mental

health care has evolved to its present level based on

46

commonly held assumptions as to the causes of mental
illness. The literature review has traced this from a
belief in evil spirits and deficit in moral character to
the presently held theories of biOpsychosocial causation
of mental illness. Citizen participation in American
government (participatory democracy) has had a long
history but during the 19603 took on a particular ideo-
logical fervor when associated with local control of
community services. The community mental health movement
represented an intersection of these forces with specific
applications being made to the boards of community mental
health centers as a social experiment in the delivery of
mental health care. The review of the literature indi-
cated that much work had been done in tailoring mental
health services to local needs. As the 19703 draw to a
close, accountability and cost effectiveness of community
mental health center programs has become a main concern.
The effectiveness of citizen participation in CMHC boards
has been cited as an area for study, but in order to do
this an evaluation technology is required. The literature
review has verified that there is little instrumentation
available to measure the impact of citizen participation.
The methodology chapter that follows describes an effort
to develop instrumentation that should be useful for
further evaluative studies of the impact of citizen

participation in CMHC boards.

CHAPTER III

DESIGN AND METHODOLOGY

Introductory Statement

 

The purpose of this study was to develop an
instrument to measure the variable: attitude toward
citizen participation in Community Mental Health Center
(CMHC) boards. This chapter will present the processes
used in developing the scale from the original 80 items
composed of statements found in the review of literature
to its final 30-item version. The methods used to test
the reliability and validity of the scale are described

as part of the process of developing the instrument.

Procedure

 

A pool of items based on 80 declarative statements
was developed based upon an extensive review of the litera-
ture of citizen participation in CMHC boards. Many of the
statements were taken directly from articles and books
reviewed reflecting an author's belief in a particular
aspect of the citizen role.

Following the development of the pool of items it

was postulated by the author that seven a priori factors

47

48

or subscales could be distinguished as comprising parts

of the overall scale under development:

CDM - Control Over the Decision-Making Process:

 

What different models of decision-making exist among CMHC
boards? On a continuum, they range from full policy-
making control to token or non-existent input. Which
model reflects an appropriate degree of influence over

the CMHC's decision-making process?

RCB - Role of CMHC Board: Should the role of the
board be well defined? Does this help the members perform
a more useful function? What are the appropriate functions
of the board? How does the board decide what tasks it

should perform?

SAM - Selection and Appointment of Members: How
are board members selected? What is the appropriate means

of selection? How should board members be appointed?

RB - Representativeness of Board: Who should be
represented on the board? What should the scope of member-
ship be in order to have a board which reflects the catch-
ment area population? What should be the relative propor-
tion of professionals, consumers, and community leaders

represented on the board?

49

ICP - Impact of Citizen Participation: What

 

effect does citizen participation have upon the community
and the mental health program with which it is associated?

Does citizen participation make a difference?

NCP - Need for Citizen Participation: Can

 

relevant community mental health services be provided
without citizen participation? Who says citizen partici-

pation is necessary?

PC - Participant Characteristics: How energetic
and active should participants be who are members of
CMHC boards? Are the best members those who are already
active in other agency boards? How knowledgeable should

participants be about mental health issues?

A review of the declarative statements indicated
the following distribution based on the seven a prior
factors cited above. In each case the item was reviewed
and a decision was made based on the content of the item
as to the category into which the item fell. The results
are presented in Table 3.1.

The next stage in developing this scale involved
seeking the opinion of judges who were considered
familiar with and knowledgeable about the concept of
citizen participation in CMHC boards. A total of 16

judges were selected who had background in the area and

50

TABLE 3.1.--Distribution of 80 Declarative Statements
into Seven A Priori Factors as Predicted by

 

 

Investigator.

Number of

Statements

Factor in Factor
CDM - Control over decision-making 12
RCB - Role of the CMHC Board 17
SAM - Selection and appointment of members 6
RB - Representatives of Board 15
ICP - Impact of Citizen Participation 12
NCP - Need for Citizen Participation 7
PC - Participant Characteristics .11
TOTAL 80

 

were deemed appropriate to participate in this phase of
the study. The first group of these judges was asso-
ciated with the National Institute of Mental Health (NIMH)
citizen participation program which has been an important
source of information. Their expertise in the area under
study is well recognized, as they are the source for the
development of policy relating to citizen participation
and governance of federally funded CMHC programs. The
three staff members of the program who were contacted

readily agreed to participate.

51

A group of five judges was selected from the Urban
Research Center, University of Wisconsin-Milwaukee. This
institute had developed a questionnaire which was sent in
January 1978 to all federally funded CMHCs under a con-
tract from NIMH's citizen participation program. Because
of their expertise and association with NIMH, five staff
members were contacted who had worked on developing a
scale to measure citizen participation and they also
agreed to participate.

Additionally, it was felt that a group of judges
should be selected locally from academic departments on
the Michigan State University campus who had revealed
their expertise in citizen participation either by
scholarly work or by actual participation in CMHC boards.
A group was selected, based on the personal knowledge of
the author and recommendations of faculty members on
campus. The distribution of judges is presented in
Table 3.2.

Following the selection of the judges but prior
to obtaining their responses, review of the 80 declarative
statements was completed involving dissertation committee
members and one close associate. An effort was made to
collapse the a priori factors into fewer than seven cate-
gories, but this proved to make differentiation more
difficult. Retaining the original seven a priori factors

was preferable and prevented considerable overlapping.

52

TABLE 3.2.--Distribution of Judges by Organizational
Affiliation.

 

Organizational Affiliation Number of Judges

 

National

Urban Research Center -
University of Wisconsin-Milwaukee 3

Citizen Participation Program -
National Institute of Mental Health 5

Local

School of Social Work -
Michigan State University 3

Department of Psychiatry -
Michigan State University 2

Department of Community Health Sciences -
Michigan State University 2

Department of Sociology -
Michigan State University

*‘ l
m H

TOTAL

 

Drafts of the semantic differential scale and demographic
variables (Appendix A) were developed in conjunction with
the pool of items all of which were reviewed by the
dissertation committee members prior to being mailed to
the judges.

The 80 declarative statements were arranged ran-
domly and scaled using a Likert format. A change was made

involving a shift in the location of the response field to

53

break the response set. A seven-point scale agree/

disagree continuum (seven being the highest) to ascertain

the degree of concurrence with the particular declarative

statement under consideration was used. Detailed instruc-

tions were developed outlining the four tasks required of

the judges for the initial stages of the scale development.

The four tasks that the judges were accomplished were to

1.

Predict the Directionality of Items.

Judges were asked to respond to scale items
indicating in their opinion how someone who
was strongly identified (i.e., in high
agreement) with citizen participation
would respond.

Estimate the Validity of Content of Scale
Items. Judges were asked to suggest differ-
ent language, new scale items for areas that
might have been overlooked and changes in
wording, as well as other comments that
would help clarify scale items and, hence,
the issue under examination.

Validate the Seven A Priori Factors Defined
Above. Judges were asked to rate each
scale item in terms of the categories in
which they believe it falls. A provision
was made to allow for scale items that were
not classifiable, as well as those which
overlapped up to two categories.

Predict Two High- and Two Low-Scoripg
Criterion Groupy. For the purpose of
validating criteria, judges were asked to
select groups that, in their opinion, were
most divergent in their view of citizen
participation in CMHC boards from a list of
29 possibilities:

 

. High-income CMHC board members
Middle-income CMHC board members
Low-income CMHC board members

. Members of a CMHC policy board

. Members of CMHC advisory board

raccoons

54

F. Consumer members of a CMHC board
G. Provider members of a CMHC board
H. Professional staff of a CMHC
I. CMHC directors
J. State hospital staff
K. State hospital directors
L. Department of mental health officials
M. NIMH officials
N. County commissioners
0. County government staff
P. Social agency staff
Q. Social agency directors
R. University faculty
S. High-income consumers of CMHC services
T. Middle-income consumers of CMHC services
U. Low-income consumers of CMHC services
V. High-satisfaction consumers
W. Low-satisfaction consumers
X. Family members of consumers
Y. County community mental health
board members
Z. County community mental health
board Chairpersons
AA. CMHC board Chairpersons
BB. County directors
CC. Minority-group consumers of CMHC
services

Scales were then mailed to the judges. Returns
from the local (Michigan State University) judges were
received in seven out of eight scales sent. All seven of
the scales were able to be used since they were completely
filled out according to instructions. Of the eight scales
sent to the national (NIMH and Urban Research Center--
University of Wisconsin) experts, six were returned and
only two of the six were in a form that could be completely
used. Three judges who returned unusable scales were not
able to respond fully to the request because they were too
busy. Since an insufficient amount of information had

been returned by the national judges to warrant inclusion

55

in the study, the only use made of their returns was to
predict two high- and two low-scoring criterion groups
(task 4). On this task, the input of 13 returns from six
national and seven local judges was used.

The results of the scales returned by the judges
were reviewed according to each task completed and yielded

the following results for each task:

1. Predict the Direction of Items: The national
judges were excluded from the first three tasks because
data were incomplete. As seven local judges responded,

a positive or negative direction was always discernible
due to the odd number of respondents. A Cronbach Alpha
for inter-rater and inter-item reliability was calculated
on all seven ratesr and all 80 items, respectively. This
produced an inter-rater Cronbach Alpha of .91 and an
inter-item Cronbach Alpha of .83 for 72 items. Eight
items had zero variance and were excluded from the
analysis. The two reliability coefficients were well

within acceptable limits for the scales.

2. Estimate Validity of Content of Scale Items:
Many remarks and comments made by judges were incorporated
into a redraft of the scale. Some suggested changes
that were implemented included eliminating jargon, clari-

fying undefined items, eliminating redundant or

56

repetitive items, and revising the writing to be at a

reading level comprehensible to most subjects.

3. Validate the Seven A Priori Factors. The

 

criterion for agreement among judges was set at two
different levels to act as a coarse and fine screen to
decide whether an item would be retained in a particular
factor. The 71 percent or more and 57 percent levels
were combined to capture a larger number of items. The
first level required agreement among at least five out
of seven judges while the second level required four out
of seven of the judges to be retained. Hence, for an
item to be considered valid with respect to falling into
a given factor, there had to be four or more, or at least
57 percent agreement among judges. The results are pre-
sented in Table 3.3. One a priori factor (the need for
citizen participation) was dropped due to insufficient
agreement among the judges, leaving a total of six.

A total of 53 items met the criterion, causing 27
items to be dropped because of insufficient agreement
among judges as to the factor which was represented. A
comparison of the number of items in each a priori factor
as predicted by the author, agreed upon by the judges,
and included in the pilot is presented in Table 3.4.
Eight additional items were dropped because of duplica-

tion and zero variance, leaving a total of 45.

57

TABLE 3.3.--Two Levels of Agreement among Judges on the
Seven A Priori Factors.

 

Percent Agreement and Factors

 

 

Percent CDM RB RCB SNM ICP NCP PC Total

71+ 7 8 4 4 l3 1 5 42

57 .1 _4_ _1 .1 .2. __0_ __2_ 11.
TOTAL 8 12 5 5 15 l 7 53

 

TABLE 3.4.--Comparison of the Number of Items in Each A
Priori Factor as Predicted by Author, Agreed
upon by Judges, and Finally Included in Pilot.

 

Conditions and Factors

 

C114 RB RCB SAM ICP M1? PC Total

 

Predictedby

Auflrm 12 15 17 6 l2 7 ll 80
AgreedUpon

by.fifibes 8 12 5 5 15 l 7 53
lhchmkfl.h1

Pilot 5 12 5 5 12 0 6 45

 

58

4. Predict Two High- and Low-Scoring Criterion

 

Groups: For a group to be included as being potentially
in agreement or disagreement, at least two judges had to
concur. Other groups on the list selected by either one
or no judges were excluded. Groups were ranked based
upon the number of judges who agreed. In all, 12 groups
were considered as possibilities for sampling based on

agreement among the judges.

Dr. Byron Van Roekel of the Michigan State
University Reading Clinic was consulted and the method of
establishing reading level as suggested by Robert Gunning
(1952) was used. This method, referred to as the Fog
Index, involved estimating the reading level based upon
the average sentence length and the percentage of hard
words (three or more syllables) per one hundred words.
All scale items and instructions were adjusted for a read-
ing level of grades 9 to 10. This reading level was
recommended by Dr. Van Roekel based upon the idea that
driver's exams administered to the public were of a
similar level of reading difficulty. This was necessary
because several criterion groups such as clients would
have this as their average reading level.

In addition to adjusting the reading level, the
demographic items were revised from the original proposal

and an additional criterion measure was devised based upon

59

a conceptual framework suggested by Hunt (1973a). This
measure asked the subject to identify the degree of con-
trol over the decision-making process from low to high
for three board member groups: health care professional
members, community leaders, and consumer members.

The total package of instructions, 45 scale items,
the semantic differential, the control over decision-
making scale, and the demographic items were then
assembled and prepared as a pilot (Appendix B) which was
administered to 20 professional staff of the Elizabeth
Zepf Center (CMHC), Toledo, Ohio, and the South CMHC,
Kettering, Ohio. A total of 20 scales was distributed
and 19 were returned.

Following a review of this part of the pilot, four
of the semantic differential (adjective pairs) items were
removed due to the difficulty (three or more syllables)
of the words involved. The remaining 15 adjective pairs
of the semantic differential were included in the next
draft of the questionnaire. The control over decision-
making scale was modified to assess the subject's view of
this with respect to potential consumers of the Center as
differentiated from actual consumers (clients) and the
overall decision-making role of the Center's board. In
addition to the three member groups mentioned previously
(health care professionals, community leaders, consumers)

the latter was divided into two groups and the total board

60

added, making a total of five groups in the revised
version of the control over decision-making scale.

This version Of the questionnaire was prepared as
a preliminary step to using optical scan sheets. Generally,
the response was favorable by subjects who completed it
but it was difficult to score because of the manner in
which the items were arranged. It was anticipated that
by using optical scan sheets the process Of responding to
the questionnaire would be facilitated. The process of
reworking the questionnaire on Optical scan sheets was
followed by a further pilot using Oasis Fellowship members
(a Lansing area mental health consumer advocacy group) and
MSU graduate students in social work at the Ingham Com-
munity Mental Health Center (Lansing, Michigan). A total
of 30 questionnaires was distributed in this phase of the
pilot and 27 were returned. A total of 46 subjects was
used in the analysis of the pilot data.

An analysis of the pilot data revealed a Cronbach
Alpha of .79 for 33 items and a correlation coefficient
Of .53 (N = 34, p < .001) between the Citizen Participa-
tion in CMHC Board's Scale (CPS) and the Semantic Differ-
ential. As both statistics were at acceptable levels and
there appeared to be no major changes needed in the scale,

the decision was made to proceed with the major samples.

61

Sample Selection

One Of the tasks that judges were asked to com-
plete was to predict two high- and two low-scoring cri-
terion groups. Twelve groups received sufficient support
from the judges to be considered as possibilities for
sampling. Groups considered for sampling were examined
with respect to the judge' ratings and as to whether or
not it was feasible to actually obtain a sample, consider-
ing the numbers of subjects available and the amount of
time and cost involved. The decision was made to draw
samples from four groups: county community mental health
services board members, community mental health center
governing/advisory board members, and staff and clients
of a community mental health center.

The county community mental health services board
members' sample of 100 was selected randomly from a list
Of approximatley 700 members of the 55-county community
mental health services boards in Michigan Obtained from
the State's Department of Mental Health. The Community
Mental Health Center's Governing/Advisory Board members'
sample was selected from the federally funded CMHC's in
Michigan which currently receive federal funds and are in
compliance with the CMHC Amendments of 1975. A letter
was sent requesting board member lists and encouraging
participation in the research (Appendix C). From this

group Of nine centers, three boards were unwilling to

62

participate either because of an overwhelming burden of
responsibilities based on the Center's problems or on the
general burden Of board members' responsibility. The
remaining six centers made their board member lists avail-
able which totaled 109 members in all and they all
received questionnaires. Both samples of 100 and 109,
respectively, met the guidelines for size of population
and percent of population samples suggested in Engelkes,
Livingston and Vandergoot (1975) and developed by Greever,
Minton and Tseng (1974). Questionnaires (Appendix D)
were mailed to both sample groups with stamped, self-
addressed envelopes with instructions for completion and
return. A followup reminder post card was mailed 12 days
after the initial mailing (Appendix E).

Samples were also drawn from staff and clients of
Ingham CMHC (N = 100 each). These samples were limited
in their generalizability as they were drawn from only one
program in Michigan and in a non-random manner. Michigan
Department Of Mental Health reviewed the questionnaire for
approval on research with human subjects (Appendix F).
All client subjects were assured that participation was
voluntary, strictly confidential, and in no way was it a
prerequisite to their receiving services.

A fifth and final sample was drawn at the National
Council Of Community Mental Health Centers Annual meeting

in Washington, D.C. held during February 22-24, 1979.

63

This sample consisted of community mental health center
board members and staff attending the conference from all
parts Of the United States. Questionnaires were completed
by those people who volunteered. A total of 50 question-
naires was distributed. Table 3.5 indicates the level Of
return for the five sample groups as of April 17, 1979.

A return rate Of 55.6% was Obtained in this
study. This response rate was considerably better than
that which was reported by Nachmais and Nachmais (1976):

The main problem with mail questionnaires is that
of obtaining an adequate response rate. The
typical response rate . . . for a mail survey is
between 20 and 40 percent . . . . The researcher
who uses a mail questionnaire is almost always
faced with the problem of how to estimate the
effect the nonrespondents may have on his or her
findings (pp. 107, 108).

In order tO ascertain whether there was anything
in the content of the questionnaire which caused subjects
not to respond, a sample Of 10 percent of the subjects
who did not respond was contacted. For the County Com-
munity Mental Health Board members, five non-respondents
were contacted; for the Community Mental Health Center's
board members sample, four members were contacted. Com-
ments included not being members of the Mental Health
Board any longer (a 1978 board member list was used and
membership had changed in 1979) and not feeling that the

questionnaire applied to them, being too busy, having

been ill, not receiving the questionnaire, and being out

64

TABLE 3.5.--Response Rate by Group Samples as Of
April 17, 1979.

 

 

Number Number

Group Distributed Returned Percent
Pilot (OASIS Fellowship,
Ingham CMHC Students
and Staff Of Two CMHC's
in Ohio 50 46 92.0
National Council of
CMHC Meeting 50 28 56.0
County CMH Services
Board Members 100 50 50.0
CMHC Advisory/Governing
Board Members 109 63 57.8
Ingham CMHC Staff 100 66 66.0
Ingham CMHC Clients 100 30 30.0

TOTAL 509 283 55.6

 

Of town. All non-respondents reported that there was
nothing specific to the questionnaire that had caused
them not to respond.

Following telephone contact with thexxxrrespondent
County and CMHC board members, a second questionnaire was
sent requesting that it be completed and returned in 10
days. Table 3.6 depicts the results of this mailing to
non-respondents. Although non-respondents and respondents

appeared to be similar from the narrative remark3¢mfllected

65

TABLE 3.6.--Non-Respondents' Rate Of Return.

 

 

Number Number
Group Distributed Returned Percent
County CMH Services
Board Members 5 5 100
CMHC Advisory/Governing
Board Members ‘4 2 50
TOTAL 9 7 77.77

 

in telephone contact, a one-way ANOVA indicated that the
mean Of the non-respondents was higher than the mean of
the respondents (p < .01). This would suggest that non-
respondents had a more favorable attitude toward citizen
participation in CMHC boards. This was counter to what
might be expected since it is generally thought that non-
respondents harbor negative Opinions. The small numbers
involved in the sampling Of non-respondents would raise
questions as to the validity of any conclusions based
upon these data. Table 3.7 is a summary Of these findings.
As the staff sample return rate was over 60 per-
cent, non-respondents were not sampled. With reference
to clients, it was not possible to contact non-respondents
because questionnaires were given only to clients that
agreed to complete them, and it would be redundant to

contact clients regarding their participation. There was

66

TABLE 3.7.--One-Way ANOVA--Citizen Participation Scale
(CPS) Total Score by Non-Respondents versus
Respondents.

 

Standard Standard

 

Group Number Mean Deviation Error
Non-Respondents 7 151.79 14.05 5.31
Respondents 270 134.52 17.46 1.06

TOTAL 277 134.96 17.57 1.06

 

Analysis of Variance

 

Sum Of Mean F F
Source DF Squares Squares Ratio Prob.

 

Between Groups 1 2033.47 2033.47 6.72 .01

Within Groups 275 83185.80 302.49

 

TOTAL 276 85219.28

 

concern that clients not be pursued if they chose not to
respond. Staff members who had experience in distributing
the questionnaire to the clients stated that the length
and complicated nature of the questionnaire was responsible
for clients Opting not to complete the task, rather than
anything related to the content.

Reliability analysis was conducted on the data
following the completion of the sampling procedure. A

total of 290 cases were used in the analysis producing a

67

Cronbach Alpha Of .66 for 45 items (N = 277, p :<.0001).
Reliability coefficients were not sufficient to claim
internal consistency for the six a priori factors. As
scale reliability could be increased by dropping several
items that were not contributing sufficiently to total
scale reliability, a second run was completed, dropping
four items with weak item total correlations and raising
the Cronbach Alpha to .72 on 41 items (N = 277, p <.0001).
A Cronbach Alpha of .83 (N = 252, p < .0001) was computed
for the 15 semantic differential items. A factor analysis
was performed for eight factors which did not produce a
confirmation Of the a priori factors. Pearson correlation
coefficient for the reduced total scale (41) items and the
semantic differential was .54 (N = 247, p <:.0001). NO
strong relationships were found between the 41-item scale
and the control over decision-making items (second set Of
criteria variables).

The reliability analysis was continued by dropping
scale items that were weak (< .10 item-total r), and each
time the reliability improved. Once the scale dropped
below 27 items, the reliability began to decline rather
than improve and it was decided that from a practical as
well as statistical standpoint, 30 items would constitute
a scale of Optimal length. All further analysis was then
conducted on the 30-item scale, Citizen Participation in

CMHC boards scale (CPS). Tables 3.8 and 3.9 summarize the

68

TABLE 3.8.--Reliability Analysis, Cronbach Alpha by
Number of Scale Items on CPS.

 

 

Number of Scale Items Cronbach Alpha
45 .66
41 .71
38 .74
35 .76
30 .78
27 .79
23 .78

 

data for the reliability analysis and item analysis for

the scale.

Research Hypotheses

 

Based upon the research questions proposed in
Chapter I the following hypotheses were investigated in
this study:

1. There will be a negative relationship
between a favorable attitude toward
citizen participation in CMHC boards
and income.

2. There will be a negative relationship
between a positive attitude toward
citizen participation in CMHC boards
and age.

69

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71

3. There will be a positive relationship
between a favorable attitude toward
citizen participation in CMHC boards
and being male.

4. There will be a positive relationship
between a favorable attitude toward
citizen participation in CMHC boards
and education.

5. There will be a positive relationship
between being married and favorable

attitude

toward citizen participation

in CMHC boards.

6. There will be a positive relationship
between a favorable attitude toward
citizen participation in CMHC boards
and level Of community activity.

7. There will be a differentiation between
group means at the p < .05 level of
significance with regard to citizen
participation in CMHC boards.

Statistical Analysis

 

A variety Of

analyses were used in this study.

The computer programs used for these analyses were all

part of the Statistical Package for the Social Sciences

(1975) and the analyses were computed on the CDC 6500

computer at Michigan
variance was used to
between the means of
further analysis was
nificant differences

were established and

State University. Analysis Of

test for significant differences

the groups that were sampled. Where
required so as to find specific sig-
between paired group means, contrasts

evaluated with t-tests. Pearson

product moment correlations were used to examine

72

relationships between variables. In order to further
examine the data, one-way analysis of variance was used.
Reliability analyses were conducted using the Cronbach
Alpha. The Cronbach Alpha is ". . . the mean of all
split-half coefficients resulting from different split-
tings Of a test . . . [Cronbach Alpha] is therefore an
estimate of the correlation between two random samples of
items from a universe Of items . . ." (Cronbach, 1951,

p. 132).

Summary

In this chapter the procedures for developing the
30-item Likert scale were described in detail. Based upon
the review Of the literature, 80 declarative statements
were scaled in an agree-disagree format and six a priori
factors were validated by experts in the field of citizen
participation in CMHC boards. In addition, the experts
predicted high- and low-scoring criterion groups, item
directionality and reviewed the content validity of the
scale. The reading level Of the scale was adjusted for
9th - 10th grade. Demographic items and two criterion
measures (semantic differential and a control over
decision making scale) were developed prior to piloting.
Piloting of the scales was accomplished on graduate social
work students at the Ingham CMHC, Oasis Fellowship, Inc.

(a consumer advocacy group) and staff Of two CMHC's in

73

Ohio. A reliability of .79 and a validity of .53 were
considered sufficient to continue with the major study.
Major samples included those in attendance at the
National Council Of CMHC's meeting February 1978, in
Washington, D.C., randomly selected County Community
Mental health board members, and CMHC board members,
staff, and clients Of the Ingham CMHC. An overall return
rate Of 55.6% was reported for a total Of 509 question-
naires sent. Non—respondents were surveyed and differed
from respondents at the .01 level of significance. The
30-item scale had a reliability Of .78 and concurrent
validity Of .52 with the semantic differential. Weak

relationships were found for the second criterion measure.

CHAPTER IV

RESULTS

Introductory Statement

The purpose of this study was to develop an
instrument to measure the variable: attitude toward
citizen participation in Community Mental Health Center
(CMHC) boards. In this chapter the results of the study
will be presented as they relate to the development of
the Citizen Participation Scale (CPS). This analysis
will focus on differences and relationships among vari-
ables. Because a large number of subjects participated
in the study, considerations of practical versus statisti-
cal significance must be kept in mind.

Each hypothesis is restated from Chapter III,
with the statistical analysis immediately following. For
testing each of the hypotheses, the citizen participation
scale (CPS) of 30 items was used. The question numbers

refer to the scale in Appendix D.

Results Of Analyses
Hypothesis 1:
There will be a negative relationship
between a favorable attitude toward

citizen participation in the CMHC
Mental Health Boards and income.

74

75

The data for Hypothesis 1 related variable CPS to
the gross annual income (Question 7). The Pearson corre-
lation for these variables was .11 (N = 271, p < .04)
which indicated non-support of the hypothesis. In addi-
tion, a one-way ANOVA was done to detect differences among
the six income groups. The data did not support the
possibility that there were differences in the means among

the income groups (Table 4.1).

Hypothesis 2:

 

There will be a negative relationship

between a positive attitude toward

citizen participation in CMHC boards

and age.

The data for Hypothesis 2 related the variable

CPS to age (Question 4). The Pearson correlation coeffi-
cient for these variables was .14 (N = 276, p < .07) which
indicated weak relationship and non-support Of the
hypothesis. Additionally, a one-way ANOVA was done which

indicated that the differences among the means Of the

various age groupings was not significant (Table 4.2).

Hypothesis 3:

 

There will be a positive relationship
between a favorable attitude toward
citizen participation in CMHC boards
and being male.
The data for Hypothesis 3 related the variable
CPS to sex (Question 5). The Pearson correlation for

these variables was -.04 (N = 265, p <=.28) which

76

TABLE 4.l.--One-Way Anova--CPS Total Score by Income.*

 

 

 

 

 

 

Standard Standard
Group Number Mean. Deviation Error
3 4,999 or under 15 131.63 16.23 4.19
$ 5,000 - $ 9,999 20 130.88 16.85 3.77
$10,000 - $14,999 38 134.26 13.76 2.23
$15,000 - $19,999 34 132.72 25.03 4.29
$20,000 - $29,999 82 134.35 16.97 1.87
$30,000 and over _§2_ 137.78 16.56 £483
TOTAL 271 134.77 17.60 1.07
Analysis of Variance
Sum Of Mean F F
Source DF' Squares Squares Ratio Prob.
Between
Groups 5 1360.94 272.19 .88 .50
Within
Groups 2g; 82287.93 310.52
TOTAL 270 83648.87
*NOTE: In subsequent tables variable N sizes will be

noted due to differential response rates to
various items.

77

TABLE 4.2.--One-Way ANOVA--CPS Total Score by Age.

 

 

 

 

 

 

Group Standard Standard
(yrs) Number Mean Deviation Error
19-24 16 126.06 12.83 3.21
25-29 40 136.55 17.47 2.76
30-34 39 134.23 16.56 2.65
35-39 44 130.20 18.00 2.87
40.44 27 132.63 21.21 4.08
45-49 26 137.15 20.38 4.00
50-54 35 137.51 17.43 2.95
55-65 35 139.00 14.29 2.42
66 and over _£4 139.61 9.31 2:39

TOTAL 276 134.86 17.53 1.06

Analysis of Variance
Sum Of Mean F‘ F

Source DF Squares Squares Ratio Prob.
Between
Groups 8 3754.72 469.34 1.55 .14
Within
Groups 2&1 80783.93 302.56

TOTAL 275 84538.65

 

 

78

indicated no relationship and non-support Of the
hypothesis. Additional analysis Of the differences
among groups means was non-significant when using a one-

way ANOVA (Table 4.3).

Hypothesis 4:

 

There will be a positive relationship

between a favorable attitude toward

citizen participation in CMHC boards

and education.

The data for Hypothesis 4 related the variable

CPS to education (Question 6). The Pearson correlation
coefficients for these variables were .01 (N = 274,
p < .001) which indicated a statistically significant
relationship and support of the hypothesis. Additional
analysis Of the means of the educational groupings indi-

cated significant differences at the .005 level (Table

4.4).

Hypothesis 5:

 

There will be a positive relationship

between being married and a favorable

attitude toward citizen participation

in CMHC boards.

The data for Hypothesis 5 related the variable

CPS to marital status (Question 5). The Pearson correla-
tion coefficient for these variables were .09 (N = 265,
p < .07) which indicated no relationship and non-support

for the hypothesis. One-way ANOVA for the means indi-

cated no significant differences (Table 4.5).

79

TABLE 4.3.--One-Way ANOVA--CPS Total Score by Sex.

 

 

 

 

 

 

 

Standard Standard
Group Number Mean Deviation Error
Male 121 135.75 16.83 1.53
Female 144 134.53 17.55 1.46
TOTAL 265 135.09 17.21 1.06
Analysis of Variance
Sum Of Mean F F
DF Squares Squares Ratio Prob.
Between
Groups 1 97.33 97.33 .33 .57
Within
Groups 263 78056.67 296.79
TOTAL 264 78154.00

 

80

TABLE 4.4.--One-Way ANOVA--CPS Total Score by Education.

 

Standard Standard

 

 

 

 

 

Group Count Mean Deviation Error
Some
High School 5 121.70 10.40 4.65
High School
Graduate 24 124.42 16.78 3.43
Technical
School 5 121.20 19.71 8.81
Some College 44 136.03 12.81 1.93
College Grad. 48 136.92 18.19 2.63
Graduate or
Professional
School 148 134.91 18.25 1.50

TOTAL 274 134.91 17.66 1.07

Analysis of Variance
Sum of Mean F F
DF Squares Squares Ratio Prob.

Between
Groups 5 5098.97 1019.79 3.41 .005
Within
Groups 268 80046.76 298.68

TOTAL 273 85145.73

 

81

TABLE 4.5.--One-Way ANOVA--CPS Total Score by Marital

 

 

 

 

 

 

Status.
Standard Standard
Number Mean Deviation Error
Married 183 136.52 15.60 1.15
Single 35 130.59 21.78 3.68
Widowed 8 132.63 11.72 .14
Separated-
Divorced 39 132.92 20.18 .23
TOTAL 265 135.09 17.21 .06
Analysis of Variance
Sum of Mean F F
Source DF Squares Squares Ratio Prob.
Between
Groups 3 1314.17 438.06 1.49 .22
Within
Groups 26 76839.84 294.41

TOTAL

 

264 78154.01

 

82

Hypothesis 6:

 

There will be a positive relationship

between a favorable attitude toward

citizen participation in CMHC boards

and level of community activity.

The data for Hypothesis 6 related the variable
CPS to hours spent in community activities such as
participation in boards and volunteer work (Question 14).
The Pearson correlation coefficient for these variables
were -.05 (N = 277, p < .19) which indicated no relation-
ship and non-support for the hypothesis.
Further questions were explored related to the

demographic variables such as whether the instrument
could differentiate between board Chairpersons and board
members, board members who were elected officials and
non-elected official board members, professionals and
non-professionals, board members and non-board members,
consumers and non-consumers, and minority and non-minority
subjects. One-way ANOVA was performed on each of these
groups and significance at the .05 level was found between
the means Of the board members and non-board members and

minority and non-minority subjects. The data are pre-

sented in Tables 4.6 through 4.11.

Hypothesis 7:

 

There will be a differentiation between
group means at p < .05 level Of signifi-
cance with regard to citizen participation
in CMHC boards.

TABLE 4.6.--One-Way ANOVA--CPS Total Score by Board

83

Chairperson versus Board Members.

 

 

 

 

 

 

Standard Standard
Number Mean Deviation Error
Community Mental
Health Board
Chairman 17 141.53 13.45 3.26
Community Mental
Health Board
Members 98 141.02 17.81 1.80
TOTAL 115 141.09 17.19 1.60
Analysis of Variance
Sum of Mean
Source DF Squares Squares Ratio Prob.
Between
Groups 1 3.83 3.83 .01 .91
Within
Groups 113 33678.96 298.04
TOTAL 114 33682.79

 

84

TABLE 4.7.--One-Way ANOVA--CPS Total Score by Elected
Officials versus Non-elected Officials Who
are Board Members.

 

Standard Standard
Group Number Mean Deviation Error

 

Board Members
Who are
Elected Officials 31 138.95 18.67 3.35

Board Members
Who are Not
Elected Officials 86 141.53 16.63 1.79

 

TOTAL 117 140.85 17.15 1.59

 

Analysis of Variance

 

 

Sum of Mean F F
D]? Squares Squares Ratio Prob .
Between
Groups 1 152.06 152.06 .51 .47
Within
Groups 115 33971.07 295.40

TOTAL 116 34123.13

 

85

TABLE 4.8.--One-Way ANOVA--CPS Total Score by
Professionals versus Non-professionals.

 

Standard Standard

 

 

Group Number Mean Deviation Error

Professionals 117 133.84 17.44 1.61

Non-

professionals 16_ 135.78 17.67 Tng
TOTAL 227 134.96 17.57 1.06

 

Analysis of Variance

 

 

Sum of Mean F F
Source DF Squares Squares Ratio Prob.
Between
Groups 1 252.55 252.55 .82 .37
Within
Groups 275 84966.72 308.97

 

TOTAL 276 85219.27

 

86

TABLE 4.9.--One-Way ANOVA--CPS Total Score Board Members
versus Non-board Members

 

Stamdard Standard
Group Number Mean Deviation Error

 

Board Members 117 140.85 17.15 1.59

Non-board
Members 160 130.65 16.65 1.32

 

TOTAL 277 134.96 17.57 1.06

 

Analysis of Variance

 

 

Sum of Mean F F
Source DF Squares Squares Ratio Prob.
Between
Groups 1 7031.74 7031.74 24.73 .001
Within
Groups 275 78187.53 264.32

 

TOTAL 276 85219.27

 

87

TABLE 4.10.--One-Way ANOVA--CPS Total Score by Consumers
versus Non-consumers.

 

Standard Standard

 

Group Number Mean Deviation Error
Consumer 116 133.06 17.49 1.62
Non-consumer 158 136.34 11113_ 1111

TOTAL 274 134.95 17.66 1.07

 

Analysis of Variance

 

 

Sum of Mean F F
Source DF Squares Squares Ratio Prob.
Between
Groups 1 721.65 721.65 2.32 .13
Within
Groups 272 84464.53 310.53

TOTAL 273 85186.18

 

88

TABLE 4.11.--One-Way ANOVA--CPS Total Score by Race.

 

 

 

 

 

 

Standard Standard
Group Number Mean Deviation Error
White 248 134.05 17.29 1.10
Non-white 29 142.69 18.39 3.41
TOTAL 227 134.96 17.57 1.05
Analysis of Variance
Sum of Mean F F
Source DF Squares Squares Ratio Prob.
Between
Groups 1 1936.05 1936.05 6.39 .01
Within
Groups 275 83283.22 302.85
TOTAL 276 85219.27

 

89

This analysis was undertaken to explore the
question of significance between the groups that took the
scale. A confirmation of this would indicate that the
instrument has the ability to discriminate among various
groups along a continuum of those favorable toward citizen
participation in CMHC boards. Confirmation of this pat-
tern would indicate the instrument's basic construct
validity. An eight-cell one-way ANOVA was performed to
test for significance and, in addition, contrasts were
formulated for the 28 pairs of group means. Significance
was reported at the p < .001 level for an N of 276 for
all eight groups. The paired contrasts for the different
groups revealed 14 differences p < .01. The matrix
reflects a pattern that is consistent in most respects

to that which would be expected (Tables 4.12 and 4.13).

Summary

The results of the study were presented in this
chapter. The findings were reported in two categories;
the first related to the development of the scale and the
second described the relationships between the scale and
various demographic variables.

A 30-item Likert scale was developed with a reli-
ability of Cronbach Alpha of .78. The concurrent
validity of the scale with the 15-item semantic differ-

ential was found to be .52 (N = 247, p < .001). The

90

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92

concurrent validity of the scale with five other criteria
variables indicated weak, statistically significant rela-
tionships between the scale and a high level of control
over decision making for community leaders, potential
consumers, and for the entire board as opposed to clients
and mental health professionals. The construct validity
of the instrument was supported as the ordering of group
means was as expected, with board members being most in
favor of a strong citizen role while staff was less
favorable.

A weak, statistically significant relationship
was found between a favorable attitude toward citizen
participation and a high level of education. The data
suggest also that those who are older and who have a
higher level of income would also support a strong
citizen role. Minorities and board members scored sig-
nificantly higher on the scale, indicating their attitude
of being in favor of a high level of citizen participa-
tion. Clients and parents of clients, while supported
by "liberal" professionals to take an active role in the
governance of CMHC services, seem almost as Opposed to

the idea as the professionals.

CHAPTER V

DISCUSSION

Introductory Statement

This research was conducted to evaluate several

questions related to citizen participation in Community

Mental Health Center (CMHC) boards. The primary

questions of this study were as follows:

1.

Can an instrument be developed to measure
the attitude toward citizen participation
in CMHC matters by varying constituencies?

Is the attitude toward citizen participa-
tion in CMHC boards held by groups such
as clients, staff, and board members
significantly different?

How do the variables of age, sex, income,
education, and level of community
activity relate to the attitude toward
citizen participation in CMHC boards?

These questions produced research findings which will be

discussed separately in the following sections of this

chapter.

The first two sections focus on instrument

development and related issues, while the third section

elaborates upon the scale and various demographic

characteristics. Limitations of the research, implica—

tions for future research, and conclusions are then pre-

sented in the final sections.

93

94

Results of the Instrument Development

A 30-item Likert scale was developed which had a
reliability of Cronbach Alpha ~ .78. The reliability was
within acceptable limits for attitude scales, which is
typically .75 (Mehrens & Lehmann, 1969, p. 257). A
moderate level of relationship (.52) with one of the two
criterion measures, namely, the semantic differential was
found and a statistically significant and weak relation-
ship was found between the citizen participation scale
(CPS) and the five-item control over decision-making
scale. The construct validity of the instrument was
verified in a review of the contrasts between the means
of the criterion groups. Significant differences were
found among the groups which will be discussed in more
detail in the next section. The factor analysis that was
completed for the scale did not support the six a priori
factors (control over the decision-making process, role
of CMHC board, selection and appointment of members,
representativeness of board, impact of citizen participa-
tion, and participant characteristics) validated by the
judges in the early phase of the research.

The validity for attitude measures is usually
quite low. Values in the range of .5 to .6 are not
unusual (Tittle & Hill, 1967; Mehrens & Lehmann, 1969,

p. 258). Of the two measures of concurrent validity, the

value produced by the semantic differential, an instrument

95

with adequate research support, was superior to the five-
item control over decision-making scale. The data sup—
ported the characteristics of reliability and validity
associated with a typical Likert Scale. Since these
scales depend on the self-reporting of the subject where
it is possible to hide one's true attitudes, caution
should be exercised when interpreting these scores. How-
ever, for research purposes these scales represent the
"state of the art" and are the best that are available.

The factor analysis did not support the six a
priori factors. A possible explanation for this was that
the area of study is highly complex and that the scale
items developed did not lend themselves to simple cate-
gorization. The scale was consequently treated as a
single variable.

Results Related to Differences Between

Criterion Groups on the Citizen
Participation Scale (CPS)

 

 

 

A one-way ANOVA was conducted to demonstrate the
scale's construct validity on the eight groups indicating
a high level of significance (p < .001) between the means
of the consumer, staff, and board member groups. In
order to determine where the statistical significance was
specifically, 28 paired comparisons were established
among the eight groups. Differences were found (p < .001)

between clients of the Ingham CMHC and CMHC board members

96

in Wayne County. Other significant differences were
found reflecting a trend in the data to indicate that
those board members most associated with the governance
of the CMHC are most in favor of citizen participation,
while those whom the organization most affects--c1ients,
clients' parents (consumer advocates), and staff--were
less in favor of a strong citizen role.

One would expect governing board members of
CMHC's in Wayne County to be highly in favor of a strong
role for citizens in the governance of the center. The
CMHC's in Wayne County are private non-profit corporations
which can appoint their own board members from a variety
of neighborhood organizations. As such the centers pro-
vide a model which is "grass roots" oriented and closely
related to the model of governance proposed in federal
CMHC legislation. As pointed out in the review of litera-
ture, federal programs in the 19608 often directed support
to the local level of "fight city hall," thereby stimu-
lating local citizen participation. Interestingly, the
Wayne County governing board members were significantly
higher-scoring than all other groups tested.

An inconsistency in the data was reflected in the
lack of similarity between the means of the Wayne County
governing board member group and that of the National
Council of CMHCs. Since the National Council of CMHCs is

comprised of federally funded centers, it was expected

97

that they would View citizen participation quite similarly
to the Wayne County group. Since the National Council of
CMHCs group was composed of both staff and board members
(split about evenly), the influence of the staff which
tended to score lower on the scale (Ohio and Ingham CMHC
staff), may account for the somewhat lower than expected
group mean.

A review of the data for Oasis Fellowship, clients
and CMHC staff revealed some interesting observations.
Oasis Fellowship consisted of clients' parents who were
attempting to become consumer advocates. Consumerism has
been with us in force for the last several years. Indi-
viduals such as Ralph Nader who were associated with the
beginnings of the movement through his work on safety in
the automobile industry, have expanded their interest to
the area of health and mental health care (Chu & Trotter,
1974). If one were to generalize Nader's premise that
mental health services ought to be influenced strongly by
actual consumers (clients), and potential consumers who
are most closely affected by or most likely to be affected
by mental health services, then a strong citizen role in
the determination of how those services were to be offered
would be expected. Interestingly, when this thought was
tested, the data did not support it. While the concept
of citizen/consumer participation is most heavily'supporux1

by the board members themselves as Opposed to the

98

professional staff, the clients and Oasis Fellowship were
more closely aligned with the professionals than the
citizen board members. This finding adds support to what
was personally experienced.

It was paradoxical that groups which would be
most affected by the services, clients and their family
members, were the least in favor of their having a strong
voice in defining CMHC directions. At the same time,
clients and their families are often most critical of the
quality and quantity of the mental health services which
they use. Perhaps it is characteristic of this particu-
lar handicapping condition that those most affected by
it are least able to take political action to foster
change in the services available. If one would exclude
the clients themselves from this group because of their
limited ability to function in this area, then the
families should be most available as advocates on the
client's behalf. This has been observed with parents
of the mentally retarded for many years but has only
recently become a factor with groups representing the
psychiatrically impaired. Several years ago the author
would have hypothesized that parents and clients would
have scored even lower on the CPS scale than they did.
Perhaps the fact that they did score higher than expected
is reflective of a change. It is anticipated that in the

future they will play as active a role as the present

99

board members and will, in fact, be vying for seats on
mental health boards which will enable them to accomplish
their goal.
Other conclusions can be drawn from the data.

The data supported the idea that governing board members
would score higher than advisory board members. This
indicated that those board members actually involved in
policy-making supported a stronger role for citizens in
that policy-making as opposed to board members in an
advisory role who often questioned their impact on the
CMHC. County board members and CMHC governing board
members were significantly different, as would be
expected, since CMHC governing board members are generally
comprised of people who are not political appointments.

Results Related to the Relationship

Between Demographic Characteristics

and the Citizen Participation Scale
(CPS)

 

 

 

Of the demographic correlates studied (age,
marital status, sex, level of education, income and com-
munity activity) only education was at all suggestive of
being related to CPS. The relationship was weak (.21)
which accounted for only four percent of the common
variance among variables. The correlation, which was
statistically significant but at such a low level of

relationship, had little practical value.

100

In terms of the differences among groups, statis-
tical significance was found in three instances: whether
or not the subjects attended college, whether or not they
were members of a minority group, and whether or not they
were board members. Those who had some college or had
completed college, were members of a minority group, and
were board members tended to score significantly higher
on the CPS.

The results of this part of the study supported
the conclusions cited in the preceding section. As
expected, the Wayne County CMHC governing board members
were highly supportive of a strong role for citizen
participation. It was clear that the subjects who scored
higher in the study came from this group, scoring on the
average at least 10 points higher than any other group.

A plausible explanation for the results related to demo-
graphic characteristics could be that minority board
members in Wayne County played an active role in community
affairs in a county which has a significant population of
minority group members. Those who served on boards

tended to be upwardly mobile and more highly educated.
This was an interesting contradiction in terms since

there appeared to be a tendency not to identify with

one's immediate past while at the same time being expected
to represent the interests of actual and potential con-

sumers of publicly supported CMHC services. The data,

101

then, supported the notion that board members who were
somewhat more educated and members of minority groups
were the most likely to receive a high score on the CPS.
Those who were most involved as CMHC governing board
members were apparently the strongest supporters of
citizen participation in CMHC boards, a result which is

obvious and not surprising.

Limitations of the Research

 

Caution must be exercised when generalizing the
results of this study. The County Community Mental
Health board members, CMHC board members, and advisory
board member samples were selected randomly from the
population of board members in Michigan. The results of
the study with respect to these samples could be con-
sidered valid for Michigan but probably not for board
members on a national level due to the many differences
between CMHC programs in various states.

Sample sizes for clients, staff, and Oasis Fellow-
ship were quite small and not randomly selected due to
financial limitations. Clients and staff were selected
from only one CMHC in Michigan and in the case of the
clients, a very low return rate was prevalent. Non-
respondent clients could not be sampled because of con-
cerns about client confidentiality and a general desire

on the part of the clients' therapists not to pursue the

 

102

completion of the scale if it were not returned
immediately.

Oasis Fellowship, a group of parents of young
adults who are mentally ill and who were currently
involved in some level of consumer advocacy, were unique
to the Lansing area. Due to financial limitations, no
effort was made to find and sample other similar groups
in Michigan. It was not clear whether any other groups
of this type have been organized in other parts of the
state. If so, they do not communicate with each other
and consequently have no knowledge of each other's
activities.

The samples of staff in the two Ohio CMHCs and
those at the National Council of CMHCs meeting were not
selected randomly. Subjects in both groups were selected
because they were available as volunteers, and results
related to these groups should be interpreted with
caution. Non-respondents sampled following the cut-off
date for the main samples of county community mental
health board members and CMHC governing and advisory
board members scored significantly higher than the
respondents. Telephone interviews were conducted in
addition to mailing a second questionnaire and the inter-
views indicated a positive attitude toward citizen par-
ticipation in CMHC boards and completing the task. The

fact that non-respondents scored higher than respondents

103

indicated a favorable attitude toward citizen participa-
tion and validated the reasons (i.e., being too busy,
not receiving the questionnaire) given by non-respondents
rather than the reason being the content of the question-
naire. Here, too, caution should be exercised in the

interpretation due to the very small sample involved.

Implications for Future Research

 

This study raised many questions in addition to
the immediate ones it set out to answer. By developing
an instrument it was expected that efforts to evaluate,
measure, and, in some way, quantify the concept of citizen
participation in CMHC boards would be achieved. Many
possibilities remain for expanding this research.

As mentioned above, some of the samples were not
randomly selected due to the financial limitations of
the study. Additional data could be gathered that would
allow greater generalization to CMHC clients and staff.
Other groups could be sampled, such as staff in state
hospitals, board members from CMHCs in other states, the
general public, and those who train mental health pro-
fessionals at various universities. Differences among
mental health professionals could be explored. Generally,
a broadening as well as a careful selection of additional
norm groups could add another dimension to the area of

research initiated in this study. Demographic

104

characteristics of the various groups could be explored

in more detail. Relationship to other variables for which
scales are already in existence could be explored relative
to the CPS.

One of the original purposes of this study was to
create an instrument which could measure one of the inde-
pendent variables that affect the effectiveness of a CMHC
board. With a suitable criterion measure, it would be
possible to assess the impact of the attitude of board
members on the actual level of accomplishment or effective-
ness of a CMHC board.

As a predictive measure, the CPS could be used as
a means of determining where a potential board member
stood in terms of his/her attitude toward citizen partici-
pation. It is possible that the nominating committee of a
CMHC board would want to use this information in making a
decision about whether or not to offer an appointment to
the board. Use of the CPS could address the concern that
the CMHC board have a balanced composition with respect
to being supportive of citizen/consumer interest. Since
boards of CMHCs are to be representative of the community,
use of the CPS may promote some assurance that a broad
range of attitudes might be represented.

The CPS could be used as a measure of results

(outcome) to assess the impact of board member training

105

programs upon attitude toward citizen participation in
CMHC boards. Recently articles have appeared (e.g.,
Howell, 1979) presenting a model of training to develop
board members and make them effective. The CPS could be
used as a pretest and posttest for measuring the effect
of thetraining program on board member attitude toward
citizen participation in CMHC boards. Training packages
producing no measurable results could be eliminated or
modified, saving time and limited financial resources.

A final question raised by this research relates
to the effect of citizen participation or consumer control
on the delivery of mental health services. Two authors
(Tischler, 1971, and Bolman, 1972) cite their rather dif-
ferent experiences in this area. For Tischler (1971) a
shift from informal citizen participation to more formal
community control caused a reordering of program priori-
ties (i.e., emphasizing children's services) and modifica-
tions in staff task characterized by four basic patterns:
(1) fear and disorganization; (2) retrenchment and denial;
(3) romance and surrender: and (4) collaborative engage-
ment. "All but the last [pattern] tended to compromise
the staff's capacity to perform their assigned roles and
therefore had an adverse effect upon the delivery of
service" (p. 505). Bolman (1972) cites examples from
clinical practice which illustrate the issues raised as a

result of community control of mental health centers. The

106

examples are characterized by consumer dissatisfaction,
institutional inability to respond and black-white con-
flict. A concerted effort on the part of professionals
to work closely with citizen/consumer groups is urged by
Bolman to overcome these obstacles to the effective
delivery of mental health services. Further research
into the coordination of effort between the CMHC staff
and board members for increased program effectiveness is
urgently needed and hopefully the research presented
herein can be a base upon which further investigation

may be built.

Conclusions

 

The purpose of this research was to develop a
means of measuring the attitude toward and effectiveness
of citizen participation in CMHC boards. This study has
produced the following findings related to this goal:

1. A reasonably reliable and valid instrument
was produced which could measure the
attitude under investigation.

2. Generally those in favor of citizen
participation saw community leaders and
potential consumers rather than actual
consumers (clients) and mental health
professionals as being able to play a
strong role in CMHC decision-making.

3. Correlations between demographic variables
and the citizen participation scale sug-
gest that those who are more educated
support a strong citizen role in decision-
making.

107

4. Minorities and board members were found
to be in favor of a strong citizen role.

5. The construct validity of the scale was
supported, showing governing board
members being most in favor of a strong
citizen role and mental health profes-
sionals least in favor.

6. Clients and parents of clients unexpectedly
were aligned with the professionals in not
supporting a strong citizen/consumer role
in mental health decision-making.

Citizen participation has permeated many areas of
American life and is closely associated with the basic
tenets of democracy. While citizen participation in com-
munity mental health services is a recent idea, it is
based upon many years of participatory democracy in
American institutions such as public schools. This study
sought to clarify the concept, measure attitudes, and
contribute toward accomplishing a quantifiable means of
evaluating its effectiveness. The results of this study
have supported the idea that much clarification was and
still is needed. It is hoped that this research has also
contributed to the ability to evaluate the effectiveness
of citizen participation, the acid test as to whether

efforts to improve community agencies' responsiveness

actually produces the intended results.

APPENDICES

108

APPENDIX A

MAILING TO JUDGES: FOUR TASKS FOR

INITIAL STAGES OF SCALE DEVELOPMENT

109

Dear

Thank you for agreeing to be a judge for the development of this scale.

I believe, as I'm sure you do, that citizen participation in the delivery
of community mental health services is an important area that requires
much study and research in order to increase the understanding and,
hence, the effectiveness of this endeavor.

I would like to draw on your expertise in the area and have you review
the enclosed first draft of this scale in terms of four tasks that need
to be accomplished.

These are as follows:

1) Predict two high and two low scoring criterion groups.

2) Predict the directionality of the scale items.

3) Estimate the content validity of the scale items.

4) Validate the seven factors of the scale.

Also enclosed is the scale entitled, "A Scale to Measure Attitudes Toward
Citizen Participation in Community Mental Health Center Boards" and more

detailed instructions as to how to proceed with the above-mentioned tasks.

Your time and assistance with these tasks is appreciated. The results of
the study will be forwarded to you at a later date.

If you have any questions, please contact me.

Sincerely,
Edward A. Oxer

EAO/mg

Enclosures

110

111

TASK N0. 1

PREDICT TWO HIGH AND TWO LOU SCORING CRITERION GROUPS

Below is a list of possible groups to which this scale could be administered
for the purpose of validation. From this list of criterion groups, please
select the two groups that would be most identified with citizen participation
in community mental health center boards (i.e., those that would score high on
the attached attitude scale). Next, please select the two groups that would be
least identified or in greatest disagreement with citizen participation in com-
munity mental health boards.

 

 

 

1. Two groups most in agreement
2.

1. Two groups least in agreement
2.

 

A. elite (high income) CMHC board members

3. middle income CMHC board members

C. low income CMHC board members

D. members of a CMHC policy board

3. members of CMHC advisory board

F. consumer members of a CMHC board

G. provider members of a CMHC board

H. professional staff of a CMHC

I. CMHC directors

J. state hospital staff

K. state hospital directors

L. department of mental health officials

M. NIMH officials

N. county commissioners

0. county government staff

P. social agency staff

Q. social agency directors

R. university faculty

5. high income consumers of CMHC services

T. middle income consumers of CMHC services
U. low income consumers of CMHC services

V. high satisfaction consumers

V. low satisfaction consumers

X. family members of consumers

Y. county (Community mental health board) meubers
2. county (Community mental health board) chairpersons
AA. CMHC board chairpersons

33. county directors

CC. minority group consumers of CMHC services

112

TASK NO. 2
PREDICT DIRECTIONALITY 0? ITEMS -

respond to each of the eighty scale items as per the instructions on the
scale indicating, in your opinion, how an individual who was strongly
identified (i.e., in high agreement) with citizen participation in CMHC
boards would respond.

TASK NO. 3
ESTIMATE CONTENT VALIDITY OF SCALE ITEMS --

suggest different language, new scale items for areas that might have been
overlooked, changes in wording, as well as other comments that would help
clarify scale items and, hence, the issue under examination.

TASK N0. 4
VALIDATE THE SEVEN FACTORS OF THE SCALE --
categorize each statement in terms of the factors listed below:

CDM - Control over the decision-making_process. What different models
of decision-making exist among community mental health center boards?
On a continuum, they range from full policy-making control to token or
non-existent input. Which model reflects an appropriate degree of in-
fluence over the CMHC's decision-making process?

RCB - Role of community mental health center's board. Should the role
of the board be well defined? Does this help the members perform a more
useful function? what are the appropriate functions of the board? How
does the board decide what tasks it should perform?

SAM - Selection and appointment of members. How are board members
selected? What is the appropriate means of selection? How should
board members be appointed?

ggi- Representative of board. "he should be represented on the board?
What should the scope of membership be in order to have a board which
reflects the catchment area population? What should be the relative pro-
portion of professionals, consumers and elite coununity members represented
on the board?

ICP - Impact of citizen participation. What effect does citizen parti-
cipation have upon the community and the mental health program with
which it is associated? Does citizen participation make a difference?

113

NCP - Need for Citizen Participation. Can relevant community
mental health services be provided without citizen participation?
Who says citizen participation is necessary?

PC - Participant Characteristics. How energetic and active
should participants be who are members of CMHC boards? Are the best
members those who are already active in other agency boards? How
knowledgeable should participants be about mental health issues?

Please respond to each scale item in terms of the category in which you be-
lieve it falls and circle the corresponding initials representing the factor.

Please refer to the examples below for an illustration of how you might indi-
cate your answers:
EXAMPLE 1.

Citizens involved in CMHC boards should not become involved in advocacy
in behalf of center clients.

AAA AA A D DD DDD CDM RCB RB SAM ICP NCP PC

An individual who wished to categorize this item as related to the role
of the CMHC board would circle "RCB."

There may be some items that can't be classified. Please indicate this
by placing an "x" to the left of "CDM" in the designated space.
EXAMPLE 2.

Citizen participation in CMHC boards should be the same as consumer con-
trol of community mental health services.

AAA AA A D DD DDD CDM RCB RB SAM ICP NCP PC

An individual who felt that this item overlapped more than one category
with the major factor being control of decision-making would circle
"CDM" as the strongest factor and underline no more than two additional
factors such as role of community mental health center board "RCB,"
and/or participant characteristics "PC."

Please proceed to complete Tasks 2, 3 and 4 directly on the attached scale.

114

A SCALE TO MEASURE ATTITUDES TOWARD CITIZEN PARTICIPATION IN

COMMUNITY MENTAL HEALTH CENTER BOARDS

A number of writers in the field of citizen participation have expressed the
feeling that it is the right of all citizens to participate in decision-making
matters which affect their lives. Until recently, only the affluent or elite
members of our society have had that right. Citizen participation then, is

a broad term referring to any citizen of the country expressing their opinion
whether consumer or provider of mental health services by participation in a
political process. There are many forms of citizen participation or com—
munity involvement. The purpose of this research is to determine which form
is most appropriate to which community.

Citizen participation means different things to different people. For some,
it is the same as consumer control and implies full policy-making control
over the major issues affecting the community mental health center programs
by those who actually use the services. This seems to be particularly true
in communities where the poor or racial and ethnic minorities do not have a
"real voice" in the policy determination of many community institutions that
affect their lives.

For others, (i.e., the more affluent members of the community) citizen parti-
cipation means citizen support for community mental health center programs,
but in the form of raising funds and matter-of-fact approval of the "profes-
sional issues" brought by the staff of the center. Board members often defer
to professional judgement and opinion in the majority of cases and show little
interest in advocacy in behalf of clients of the program.

Some mental health services, particularly those that are privately operated
may be completely governed by professional interests. Although this is less
the style with public or private non-profit community mental health centers,
many centers do have professional advisory boards mandated by the Community
Mental Health Center Amendments of 1975.

This scale seeks to have you express your opinion on the issue of citizen
participation. The information you provide will be valuable in helping us
to better understand the issue of citizen participation.

Please read each of the statements carefully and for each one indicate to
what extent you personally agree or disagree with it. You should do this by
circling one of the six choices that best represents your feeling about the
statement. You will note that the choices permit you to express an opinion
that ranges from strong agreement to strong disagreement.

Circle AAA, if you strongly agree
Circle AA, if you moderately agree
Circle A, if you slightly agree
Circle D, if you slightly disagree
Circle DD, if you moderately disagree
Circle DDD, if you strongly disagree

115

Please refer to the two examples below for an illustration of how you might
indicate your answers:

EXAMPLE 1.

Citizen participation in CMHC boards should be the same as consumer control
of community mental health services.

AAA AA A D DD DDD

An individual who wished to indicate agreement, but only slight agreement with
this statement, would circle the choice "A."

EXAMPLE 2.

Citizens involved in CMHC boards should not become involved in advocacy in
behalf of center clients.

AAA AA A D DD DDD

An individual who wished to indicate a moderate degree of disagreement with
this statement would circle the choice "DD."

Make sure that you circle a symbol for each statement. Leave none of the

items blank and make only one circle for each item. In some cases, you may
feel that you do not know how to judge a statement. When this occurs, please
make the best estimate you can. You should not spend more than a few seconds
on each item. If it seems difficult to make up your mind, make the best judge-
ment you can and go on to the next item.

Please proceed to the first item.

116

A SCALE TO MEASURE ATTITUDES TOWARD CITIZEN PARTICIPATION IN

COMMUNITY MENTAL HEALTH CENTER BOARDS

Citizen representatives should vote on decisions affecting the community
mental health center, but their decisions should be able to be reversed
by the center's administration.

AAA AA A D DD DDD CDM RCB RB SAM ICP NCP PC

Community residents who have actually used the services of the center
should be represented on the center board.

AAA AA A D DD DDD CDM RCB RB SAM ICP NCP PC

Citizen representatives involved in community mental health center boards
should be consulted about policy decisions before they are made.

AAA AA A D DD DDD CDM RCB RB SAM ICP NCP PC
In order to participate in making decisions in a community mental health

center board, citizens should have extensive knowledge of community mental
health service delivery systems.

AAA AA A D DD DDD CDM RCB RB SAM ICP NCP PC

Citizen representatives should advise in determining the community mental
health center's budget.

AAA AA A D DD DDD CDM RCB RB SAM ICP NCP PC
Citizen representatives should be elected to the community mental health
center's board by the residents of the catchment area rather than be
appointed by governmental officials.

AAA AA A D DD DDD CDM RCB RB SAM ICP NCP PC

Citizen participation should involve consumers in making policy decisions
for the community mental health center.

AAA AA A D DD DDD CDM RCB RB SAM ICP NCP PC

A most important area for citizens to be involved is program planning and
evaluation of community mental health center services.

AAA AA A D DD DDD CDM RCB RB SAM ICP NCP PC
New community mental health center programs should not be initiated by
citizen meubers of community mental health center boards as they are not

capable of designing programs of this type.

AAA AA A D DD DDD CDM RCB RB SAM ICP NCP PC

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

117

Citizen representatives of community mental health center boards who
do not regularly attend meetings should be asked to give up their
membership.

AAA AA A D DD DDD CDM RCB RB SAM ICP NCP PC

Citizen participation would be most effective when the board has less
than fifteen members.

AAA AA A D DD DDD CDM RCB RB SAM ICP NCP PC

Citizen representatives should be involved in the hiring and firing of
the community mental health center's director.

AAA AA A D DD DDD CDM RCB RB SAM ICP NCP PC
Accomplishments of the community mental health center board should be an
important factor in evaluating the effectiveness of citizen participation
in community mental health services.

AAA AA A D DD DDD CDM RCB RB SAM ICP NCP PC

Citizen members of community mental health center boards should be selected
for their energy level and leadership abilities.

AAA AA A D DD DDD CDM RCB RB SAM ICP NCP PC

Citizen representatives to community mental health center boards should
represent a cross-section of all elements of the catchment area.

AAA AA A D DD DDD CDM RCB RB SAM ICP NCP PC

Upper middle class members of the community should serve on community
mental health center boards to assist in fund raising activities.

AAA AA, A D DD DDD CDM RCB RB SAM ICP NCP PC

Providers of mental health services should be in the majority on community
mental health center boards.

AAA AA A D DD DDD CDM RCB RB SAM ICP NCP PC

Citizen participation should be an important part of the planning process
for community mental health centers.

AAA AA A D DD DDD CDM RCB RB SAM ICP NCP PC

Citizen representatives should serve on community mental health center's
policy making boards instead of advisory boards.

AAA AA A D DD DDD CDM RCB RB SAM ICP NCP PC

 

 

20.

21.

22.

23.

24.

25.

26.

27.

28.

29.

118

Citizen representatives should advise in evaluation of the community
mental health center's service delivery system.

AAA AA A D DD DDD CDM RCB RB SAM ICP NCP PC

Citizen representatives of the community should be involved in the day-
to-day operation of the community mental health center.

AAA AA A D DD DDD CDM RCB RB SAM ICP NCP PC

Local business and industry should be represented on community mental
health center boards.

AAA AA A D DD DDD CDM RCB RB SAM ICP NCP PC
Citizen boards would be a useful addition to the mental health system.
AAA AA A D DD DDD CDM RC3 RB SAM ICP NCP PC

Appointments to all community mental health center boards should be
approved by the State mental health authority.

AAA AA A D DD DDD CDM RCB RB SAM ICP NCP PC
Citizen participation in community mental health center boards would be
most effective if the catchment area is a politically viable area such as
a county or other governmental unit.

AAA AA A D DD DDD CDM RCB RB SAM ICP NCP PC

Consumers should be in the majority on community mental health center
boards.

AAA AA A D DD DDD CDM RCB RB SAM ICP NCP _PC

Citizen participation should be most effective when the board meets at
least once per month.

AAA AA A D DD DDD CDM RCB RB SAM ICP NCP PC

Citizen participation should involve community residents in identifying
mental health problems that need to be acted on.

AAA AA A D DD DDD CDM RCB RB SAM ICP NCP PC

Citizen participation should be most effective when the board is appointed
by a governmental body.

AAA AA A D DD DDD CDM RCB RB SAM ICP NCP PC

Citizen representatives should be involved in the setting of community
mental health center program priorities.

AAA AA A D DD DDD CDM RCB RE SAM ICP NCP PC

31.

32.

33.

34.

35.

36.

37.

38.

39.

40.

119

If local citizens are involved in policy making and decisions, mental
health professionals are not likely to be attracted to community mental
health centers.

AAA AA A D DD DDD CDM RCB RB SAM ICP NCP PC

Citizen participation in a private non-profit corporation which adminis-
ters all community mental health center services in the catchment area
would be the most effective form of citizen participation.

AAA AA A D DD DDD CDM RCB RE SAM ICP NCP PC

Every community mental health center should have consumer/patient repre-
sentation on the board of the program.

AAA AA A D DD DDD CDM RCB RE SAM ICP NCP PC

Every community mental health center should have formally associated with
it a local citizen's board assigned significant responsibilities.

AAA AA A D DD DDD CDM RCB RB SAM ICP NCP PC

Citizen representatives should share in making final decisions with
those who hold the ultimate power in the community mental health center.

AAA AA A D DD DDD CDM RCB RB SAM ICP NCP PC

Citizen representatives on advisory boards should have direct input to
the governing board rather than through center staff.

AAA AA A D DD DDD CDM RCB RB SAM ICP NCP PC

Appointments to community mental health center boards should be made
primarily by other community agencies.

AAA AA A D DD DDD CDM RCB R3 SAM ICP NCP PC

Citizen participation in the planning and operation of community mental
health center programs have not produced sufficient payoff to make it
worth our while.

AAA AA A D DD DDD CDM RCB RE SAM ICP NCP PC

Citizen participation should involve residents in implementing community
mental health center programs.

AAA AA A D DD DDD CDM RCB RB SAM ICP NCP PC

Citizen representatives involved in community mental health center boards
should have prior experience with other social agency boards.

AAA AA A D DD DDD CDM RCB RE SAM ICP NCP PC

41.

62.

43.

44.

45.

46.

47.

48.

49.

50.

120

An active volunteer program in the community mental health center would
be a more effective mechanism for involving citizens in community mental
health center services than having them serve on a board.

AAA AA A D DD DDD CDM RCB RB SAM ICP NCP PC

Greater citizen participation should help the community mental health
center to offer better services to residents of the catchment area.

AAA AA A D DD DDD CDM RCB RB SAM ICP NCP PC

Citizen representatives involved in community mental health center boards
should have delegated power to make decisions.

AAA AA A D DD DDD CDM RCB RB SAM ICP NCP PC

Citizens who are most active in other social agency boards would make the
most effective members of community mental health center boards.

AAA AA A D DD DDD CDM RCB RB SAM ICP NCP PC
It should be more effective to have the families of community mental
health center patients represented on the board than the patients theme
selves.

AAA AA A D DD DDD CDM RCB RB SAM ICP NCP PC

Citizen participation would be most effective if the boards on which they
serve have substantial authority and responsibility.

AAA AA A D DD DDD CDM RCB RB SAM ICP NCP PC

Low income persons are not sophisticated enough to participate in policy
making in community mental health center boards.

AAA AA A D DD DDD CDM RCB RB SAM ICP NCP PC

Citizen participation in community mental health center boards would have
an impact on changing staff attitudes.

AAA AA A D DD DDD CDM RCB RB SAM ICP NCP PC

Citizen representation in community mental health center boards should
be consulted about decisions before they are made.

AAA AA A D DD DDD CDM RCB RB SAM ICP NCP PC

Greater citizen participation would hinder the working relationship be—
tween the community mental health center and other social agencies.

AAA AA A D DD DDD CDM RCB RB SAM ICP NCP PC

51.

52.

53.

54.

SS.

56.

S7.

58.

59.

60.

121

An annual service plan should be prepared by the community mental health
center board in conjunction with the residents of the catchment area.

AAA AA A D DD DDD CDM RCB RB SAM ICP NCP PC

Greater citizen participation in community mental health center boards
would hamper staff efficiency.

AAA AA A D DD DDD CDM RCB RE SAM ICP NCP PC

Citizen representatives involved in a community mental health center
board would find the experience a rewarding and gratifying one.

AAA AA A D DD DDD CDM RCB RB SAM ICP NCP PC

Fund raising should be an important activity for citizens participating
in community mental health center boards.

AAA AA A D DD DDD CDM RCB RB SAM ICP NCP PC
Citizens would be reluctant to serve on boards of community mental health

centers because they don't have the knowledge to make an effective con-
tribution.

AAA AA A D DD DDD CDM RCB RB SAM ICP NCP PC

Citizen participants should speak for the group which they represent
rather than for themselves.

AAA AA A D DD DDD CDM RCB RB SAM ICP NCP PC

Providers and non-providers of health services should be represented in
equal proportion on community mental health center boards.

AAA AA A D DD DDD CDM RCB RB SAM ICP NCP PC
An effective group of community representatives serving on the community
mental health center board would help to increase the utilization rates
of center services.

AAA AA A D DD DDD CDM RCB RB SAM ICP NCP PC

Citizen participation in community mental health center boards would be
a way of training community residents in democratic values.

AAA AA A. D DD DDD CDM RCB RB SAM ICP NCP PC

Citizen participation in a community mental health center board would be
most effective if their role is clearly defined.

AAA AA A D DD DDD CDM RCB RE SAM ICP NCP PC

61.

62.

63.

64.

65.

66.

67.

68.

69.

70.

122

Citizen representatives involved in community mental health center
boards should have full control over policy decisions that they make.

AAA AA A D DD DDD CDM RCB RB SAM ICP NCP PC

Community mental health center boards should sponsor forums to inform the
community about problems of providing services to the area.

AAA AA A D DD DDD CDM RCB RB SAM ICP NCP PC

Citizen representatives involved in community mental health center boards
should receive financial remuneration for their effort.

AAA AA A D DD DDD CDM RCB RB SAM ICP NCP PC

Citizen participation should be a necessary part of community mental
health planning.

AAA AA A D DD DDD CDM RCB RB SAM ICP NCP PC

Efforts to involve local citizens in community mental health center plan-
ning and decision-making will prove to be undemocratic in that a few
citizens will participate and those that do will do so for personal
ambition or to advance special interests.

AAA AA A D DD DDD CDM RCB RB SAM ICP NCP PC

Citizen representation in the local mental health association is an effec-
tive means of involving community residents in community mental health
programs.

AAA AA A D DD DDD CDM RCB RB SAM ICP NCP PC

Citizens who serve on community mental health center boards should be in
agreement with community mental health ideology.

AAA AA A D DD DDD CDM RCB RB SAM ICP NCP PC

Citizen representatives should be involved in community mental health
center boards primarily as a means of educating the public about mental
health services.

AAA AA A D DD DDD CDM RCB RB SAM ICP NCP PC

Staff of the community mental health center should not be involved in the
appointment of citizen representatives to the center.

AAA AA A D DD DDD CDM RCB RB SAM ICP NCP PC

Low income community residents should be involved in community mental
health center boards in order to provide therapy to the community as a
whole.

AAA AA A D DD DDD CDM RCB RB SAM ICP NCP PC

71.

72.

73.

74.

75.

76.

77.

78.

79.

123

Employing community residents as paraprofessionals in the community
mental center would be a more effective means of citizen participation
than having citizens serve on a community mental health center board.

AAA AA A D DD DDD CDM RCB RB SAM ICP NCP PC

Militant social action groups should be permitted to participate in the
planning of community mental health center services.

AAA AA A D DD DDD CDM RCB RB SAM ICP NCP PC

Citizen representatives should have a constituency to which they are
clearly accountable.

AAA AA A D DD DDD CDM RCB RB SAM ICP NCP PC

Attending meetings regularly should be an important part of citizen
participation in community mental health center boards.

AAA AA A D DD DDD CDM RCB RB SAM ICP NCP PC
Community representatives should have a complete orientation and train-
ing program so that they can participate effectively in the decision
making of the community mental health center.

AAA AA A D DD DDD CDM RCB RB SAM ICP NCP PC

Efforts to involve citizens in mental health programs have not produced
sufficient payoff to make them worthwhile.

AAA AA A D DD DDD CDM RCB RB SAM ICP NCP PC

Consumers of services should be involved in community mental health cen-
ter decision-making in order to control the cost of mental health care.

AAA AA A D DD DDD CDM RCB RB SAM ICP NCP PC

Greater citizen participation would bring greater public support to the
community mental health center.

AAA AA A D DD DDD CDM RCB RB SAM ICP NCP PC
Greater citizen participation in community mental health center boards
would insure greater representation of the wishes of residents of the

catchment area.

AAA AA A D DD DDD CDM RCB RB SAM ICP NCP PC

Local political leaders should be on the governing board of the community
mental health center.

AAA AA A D DD DDD CDM RCB RB SAM ICP NCP PC

APPENDIX B

PILOT: INSTRUCTIONS, 45-ITEM SCALE,
SEMANTIC DIFFERENTIAL, CONTROL OVER
DECISION-MAKING SCALE, AND
DEMOGRAPHIC ITEMS

124

 

CITIZEN PARTICIPATION
IN
COMMUNITY MENTAL HEALTH CENTER (CMHC) BOARDS SCALE

It is the right of all people to take part in the every day issues which
touch their lives. Citizen participation in mental health is the idea
that any citizen can be involved in deciding how mental health services
should be run, whether a user of mental health service or a mental health
professional, by taking part as a CMHC board member. There are many ways
for citizens to participate. The purpose of this study is to find out
what you think of citizens taking part in the board of a CMHC.

For a community mental health center (CMHC) to get Federal funds, it must
provide a wide range of services.

The CMHC must also have a board that can speak for the mental health needs
of the people of the service area.

This scale seeks to have you express your ideas on the issue of citizen
participation. The information you give will be valuable in helping us
to better understand the issue of citizen participation.

Please read each of the statements carefully and for each one indicate to
what extent you agree or disagree with it. You should do this by circling
one of the six choices that best states your ideas about the statement.

You will note that the choices permit you to express an opinion that ranges
from strong agreement to strong disagreement.

Circle AAA, if you strongly agree
Circle AA, if you moderately agree
Circle A, if you slightly agree
Circle D, if you slightly disagree
Circle DD, if you moderately disagree
Circle DDD, if you strongly disagree

Please refer to the two examples below for an illustration of how you might
indicate your answers:
EXAMPLE 1 .

Citizen participation in CMHC boards should be the same as consumer control
of community mental health services.

AAA AA A D DD DDD

An individual who wished to indicate agreement, but only slight agreement
with this statement, would circle the choice "A."

125

126

EXAMPLE 2.

Citizens involved in CMHC boards should not become involved in advocacy
in behalf of center clients.

AAA AA A D DD DDD

An individual who wished to indicate a moderate degree of disagreement with
this statement would circle the choice "DD."

Make sure that you circle a symbol for each statement. Leave none of the
items blank and make only one circle for each item. In some cases, you
may feel that you do not know how to judge a statement. When this occurs,
please make the best estimate you can. You should not spend more than a
few seconds on each item. If it seems difficult to make up your mind,
make the best judgement you can and go on to the next item.

10.

127

CITIZEN PARTICIPATION IN CMHC BOARDS
Citizen board members should vote on issues affecting the Cmc but
their choices should be able to be changed by the center's director.
AAA AA A D DD DDD

People who have used the center should be represented on the CMHC
board.

AAA AA A D DD DDD

In order to take part in voting on the CMHC board, citizens should have
knowledge of mental health services.

AAA AA A D DD DDD

Citizen board members should be elected to the CMHC board by local
people rather than be appointed by the county or city.

AAA AA A D DD DDD

Citizen members of CMHC boards who do not attend meetings should be
asked to resign (leave).

AAA AA A D DD DDD

Citizen members of the board should be involved in the hiring and fir-
ing of the CMHC director.

AAA AA A D DD DDD

What the CMHC board has done (achieved) should be a factor in looking
at the results of citizens taking part in CMHC boards.

AAA AA A D DD DDD

Citizen members of CMHC boards should be selected for their drive and
because they are leaders.

AAA AA A D DD DDD

Citizen members of the CMHC board should represent a sample of all
parts of the service area.

AAA AA A D DD DDD
CMHC boards should be made up of mostly mental health professionals.

AAA AA A D DD DDD

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

128

Citizen board members should serve on CMHC governing boards instead
of advisory boards.

AAA AA A D DD DDD

Citizen board members should be involved in the day-to-day workings
of the CMHC.

AAA AA A D DD DDD
Local businessmen should be asked to be members of CMHC boards.
AAA AA A D DD DDD

Those named to CMHC boards should be approved by the State Mental
Health Department.

AAA AA A D DD DDD

Citizens taking part in CMHC boards would bring the best results if
the service area of the center is the same as the county.

AAA AA A D DD DDD

People who have used the services should be in the major group on
CMHC boards.

AAA AA A D DD DDD

Citizen board members would have the most effect when they are
appointed by the county.

AAA AA A D DD DDD

If local people are involved in policy making, mental health pro-
fessionals are not likely to want to work in CMHC's.

AAA AA A D DD DDD
Citizen board members serving on a private non-profit corporation
which runs all CMHC services in the service area would be the most
effective form of citizen input.

AAA AA A D DD DDD

Every CMHC should have clients serving on the board.

AAA AA A D DD DDD

21.

22.

23.

24.

25.

26.

27.

28.

29.

31.

129

Citizen board members should share in policy making with those who
hold the power in the CMHC.

AAA AA A D DD DDD
Those named to CMHC boards should be chosen by other agencies.
AAA AA A D DD DDD

Citizens sharing in the planning and running of CMHC's have not pro-
duced enough payoff to make it worthwhile.

AAA AA A D DD DDD

Citizen board members of the CMHC should have had experience on other
social agency boards.

AAA AA A D DD DDD

A volunteer program would have more effect on involving citizens
in the CMHC than having them serve on the board.

AAA AA A D DD DDD

Citizen board members should have the power to make decisions such as
approving the CMHC budget.

AAA AA A D DD DDD

Those who are active on the civic boards should make the most effec-
tive members of the CMHC boards.

AAA AA A D DD DDD

It should be more effective to have the families of CMHC clients on the
board than the clients themselves.

AAA AA A D DD DDD

Citizens taking part in CMHC boards would have an impact on changing
how staff treats clients.

AAA AA A D DD DDD

Greater citizen input would hinder the work between the CMHC and
other social agencies.

AAA AA A D DD DDD
Greater citizen input in CMHC boards would reduce staff efficiency.

AAA AA A D DD DDD

 

32.

33.

34.

35.

36.

37.

38.

39.

40.

41.

42.

130

Fund raising should be an important job for citizens taking part in
CMHC boards.

AAA AA A D DD DDD

Citizen board members should speak for the group which they represent
rather than for themselves.

AAA AA A D DD DDD

People who speak for clients and people who speak for mental health
professionals should serve in equal numbers on CMHC boards.

AAA AA A D DD DDD

Those who are good at speaking for the community should serve on the
board to help to increase the use of the center.

AAA AA A D DD DDD

Having citizens take part in CMHC boards would be a way of training
local people in democratic values.

AAA AA A D DD DDD

Citizens taking part in CMHC boards would be most effective in their
role is clearly defined.

AAA AA A D DD DDD

CMHC boards should sponsor forums to inform the public about problems
of servicing the area.

AAA AA A D DD DDD

Citizens who serve on CMHC boards should agree with community mental
health ideas.

AAA AA A D DD DDD

Staff of the CMHC should not be involved in the naming of citizens to
the board.

AAA AA A D DD DDD

Militant social action groups should be allowed to take part in the
planning of CMHC services.

AAA AA A D DD DDD

Citizen board members should have local groups to which they are
accountable.

AAA AA A D DD DDD

131

43. Greater citizen input would bring greater public support for the CMHC.
AAA AA A D DD DDD

44. Local political leaders should be on the board of the CMHC.
AAA AA A D DD DDD

45. Citizen members of CMHC boards should be asked about policies before
they are made.

AAA AA A D DD DDD

132

INSTRUCTIONS: Rate the following concept with respect to the
adjectives listed below. Circle the number that indicates
the degree to which one or the other of the terms describes
the concept:

Citizen participation in Community Mental Health Boards?

Good 2 3 4 S 6 7 Bad
Ineffective 2 3 4 5 6 7 Effective
Irrelevant 2 3 4 5 6 7 Relevant
Timely 2 3 4 5 6 7 Untimely
New 2 3 4 5 6 7 Old
Regressive 2 3 4 5 6 7 Progressive
Wise 2 3 4 5 6 7 Foolish
Simple 2 3 4 5 6 7 Complex
Wrong 2 3 4 5 6 7 Right
Sophisticated 2 3 4 5 6 7 Naive
Narrow 2 3 4 5 6 7 Broad

Rash 2 3 4 5 6 7 Considered
Realistic 2 3 4 5 6 7 Unrealistic
Needed 2 3 4 5 6 7 Unneeded
Strong 2 3 4 5 6 7 Weak
Unimportant 2 3 4 5 6 7 Important
Sterile 2 3 4 5 6 7 Fertile
Conflicting Z 3 4 5 6 7 Cooperative
Active 2 3 4 5 6 7 Passive

133

CITIZEN PARTICIPATION IN CMHC BOARDS

INSTRUCTIONS: Rate the concept of Citizen Participation
in CMHC boards for each board member group. Please
rate all three groups in terms of whether they should
have high or low control:

 

Board Member Degree of Control Over
Group Decision Making Process
Low High
Health Care Professionals 1 2 3 4 5 6 7

(Provider Members)
Those who claim their
living from health care

Low High
Elite Members I 2 3 4 5 6 7

(Business, professional
and community leaders
interested in mental
health).

Low High
Consumer (Client) Menbers l 2 3 4 5 6 7

Family members and/or
those who have used the
CMHC services.

134

Please indicate your age:

1) Less than 18 4) 30-34 7) 45-49 10) 60-64
2) 19-24 5) 35—39 B) 50-54 ll) 65-69
3) 25-29 6) 40-44 9) 55-59 12) 70 and Over
Sex: 1) .____Male 2) ___ Female
Marital Status: l) ___ Married 3) ____Single
2) ___ Widowed 4) ___.Separated or
Divorced
Education: l) Grade School 5) Some College
2) Some High School 6) College Graduate
3) High School 7) Graduate or
Professional
Specify:

 

Please indicate your Gross Family Income:

1) $4,999 or Under 4) $15,000-$l9,999
2) $5,000-59,999 5) 520,000-529,999
3) $10,000-$14,999

Number in Your Family: l) l, 2) 2. 3) 3. 4) 4, 5) 5, 6) 6,
(Circle one)
7) 7, B) 8, 9) 9, 10) More than 9.

Number of Years in Community: 1) _____Less than 1 Year
2) _____l-5 Years
3) _ 6-lO Years
4) _____ll-ZO Years
5) ____ 2l-30 Years

6) More than 30

 

10.

ll.

12.

l3.

14.

IS.

I6.

17.

18.

19.

135

Please indicate your Racial/Ethnic Background:
l) ____Black 2) ____Hhite
3)____ Chicano 4) ___ Other; Specify

 

Occupation: l) ___ Professional 4) ____Clerical/Office 7) ___ Farming
2) ___ Skilled Trades 5) ____Business/Sales 8) Other
3)____ Self-employed 6) ____Managerial Specify:

Do you currently hold elected office:
1) ____County Commissioner 3) ___ State
2) ___ City/Township 4) ____Other Specify:
Have you previously held elected office?
-l) ____County Commissioner 3) ____State
2) ____City/Township 4) ___ Other Specify:

Are you employed in health care? 1) Yes 2) No

What is your position? Specify:

 

If yes, how long? 1) Less than l year 4) 6-l0 years
2) l-3 years 5) ll-ZO years

Have you used mental health services? l) Yes 2) No

If yes, please indicate kind: 1) CMHC 3) Other
2) Private Specify:

 

How long did you use services? 1) Less than 1 month 4) l-3 years
2) 2-6 months 5) 3-5 years
3) 7-l2 months 6) 5 or more years

Do you belong to an organized group of
people who have used mental health services? l) Yes 2) No

If yes, Specify:

 

20.

21.

22.

23.

24.

25.

26.

27.

28.

136

Are you a CMH Board Member: 1) Yes 2) No

If yes, please indicate type: I) PA-ZSB Board
2 CMHC Governing Board
3) CMHC Advisory Board

Are you a Consumer or Provider Member? 1) Consumer 2) Provider
How long have you been a board member?
1) Less than 1 year 3) 3-5 years

2) l-Z years 4) More than 5 years

Are you currently the Chairperson of the Board? I) Yes 2) No

Have you previously been the Chairperson? l) Yes 2) No
Are you active in other community boards? 1) Yes 2) No
Are you active in other civic activities? I) Yes 2) No

Are you a member of the Mental Health
Association in Michigan? l) Yes 2) No

APPENDIX C

LETTER TO FEDERALLY FUNDED CHMCS

137

January 15, 1979

Dear

Enclosed is an abstract of my doctoral research on "Citizen
Participation in Community Mental Health Center Boards."

Citizen participation has been an area of interest through-out
my nine year association with the Ingham Community Mental
Health Center especially in the past three years as Center
Director. with the advent of P.L. 94-63 and a renewed interest
in meaningful citizen participation, I have been especially
interested in an expanded knowledge base in the area. The core
of my proposal involves the development of a means of measuring
attitudes related to Citizen Participation in Community Mental
Health Center Boards.

One of the groups that I would like to sample in order to validate
the scale is board members of federally-funded Community Mental
Health Centers in Michigan. Your cooperation and the participation
of your board of directors in this study will be helpful in pro-
moting effective citizen participation in federally-funded centers
in Michigan. I plan to make the results available to all partici-
pating groups as soon as possible after the completion of the study.

I have been in touch with Dr. Paris Finner, Program Development
Specialist of the Detroit-Wayne Community Mental Services Board
and she has provided a list of Community Mental Health Centers
in Wayne County. I would greatly appreciate it if you could
provide a list of your board members names and addresses so that
I might contact them regarding their participation in the study.
The study involves completing a questionaire that would require
about thirty minutes of their time.

I would be glad to answer any further questions you might have
regarding this project. Your support is greatly appreciated.

Sincerely,

(1" (.1/ ’62
Edward A. Oxer, A.C.S.W.
Director

Ingham CMHC

138

139

A B S T R A C T

DEVELOPMENT OF A SCALE
T0
MEASURE ATTITUDES TOWARD CITIZEN PARTICIPATION IN CMHC BOARDS

by Edward A. Oxer
Statement of the Problem

The concept of citizen participation has been a central theme in
American democracy and politics. Community institutions and agencies,
as part of the fabric of American democracy, have naturally been
influenced significantly by the underlying philosophical base of
community involvement and local control.

Large State mental hospitals that were for many communities the
exclusive providers of (inpatient) mental health services in the
early 1950's with the impetus of a strengthened mental health policy
at the State and Federal levels gave way to the "third revolution"
in psychiatry; that of community mental health.

Local communities were to be served by locally operated, community-
based mental health services, but the problem of defining the com-
munitys' boundaries and assuring suitable citizen input, representative
of the community, was greater than that anticipated by the planners.
The controversy soon became polarized around citizen participation
versus citizen control. Professional and consumer groups squared off
over who would control the nature of the mental health services pro-
vided. How should the "community" be defined and who were the
"representatives" if the community became the central issues.

Statement of Purpose

The purpose of the study is to expand upon the research done by the
Health Policy Advisory Center (Health PAC) entitled, "Evaluation

of Community Involvement in CMHC's" (1972). This will be done by
developing an instrument to measure the attitude toward citizen
participation in CMHC boards, and thereby attempting to establish a
method of measuring the attitude toward the most salient variable of

the Health PAC study. Ultimately, it is hoped that, via the develop-
ment of this scale, a means will be found to measure one of the major
constructs in a field that abounds with ideological fervor but little

in the way of documentation and quantification. Through the develop-
ment of this instrument, more information and knowledge will be acquired
regarding the area of citizen participation, a process which is far from
adequately understood. The importance of this study is evident for any

140

community mental health center program that does not develop a
suitable mechanism for insuring adequate community involvement, so
as to relate itself to community needs, will soon be suffering from
a lack of community support often with financial and political con-
sequences.

Methodology

A series of eighty statements were developed from an extensive review
of the citizen participation in mental health literature. Seven
factors or subscales were hypothesized and the eighty statements were
scaled in the Likert format. Seven experts in the field rated the
eighty items and predicted directionality of the items, as well as
into which factor the items fell. Items were reviewed for content
validity and criterion groups were also selected from an expanded
list of groups concerned with citizen participation in community
mental health. A total of forty-five items and six factors received
sufficient support from the experts to be included in a pilot of the
scale. In addition to the forty-five items, a semantic differential,
an additional criterion measure relating to board member control of
the decision-making process and demographic items were also piloted
on staff of a CMH system. The final stage of the instrument develop-
ment involves the criterion validation in which several groups such
as Michigan CMHC board members, CMH services board members, Mental
Health Association board members, state hospital directors and con-
sumers of mental health services complete the scale in terms of their
view of citizen participation.

Significant correlations are expected between the cumulative scores
for each group and the criterion measures, as well as certain of the
demographic characteristics. Significant differences are expected
between groups, indicating that the scale has the ability to discrimi-
nate between those heavily in agreement with those who favor a strong
citizen role in CMHC decision-making and those who do not.

APPENDIX D

MAILED QUESTIONNAIRE

141

142

Community Mental Health Board

Clinton 0 Eaton o Ingham
INGHAM COMMUNITY MENTAL HEALTH CENTER

THOMAS M sums. i 0. March 16 , 19 79 tone or omcroes
uscuvm omcvon NOLAN OWEN
CW!" new!“ wt Aim CHAIRMAN
0".qu .C IAVI‘ m 0 Nu" y Mllm"

CLO-‘0‘ .“CVOO
LAURIE DOWN! S

we“ Hum-w
MAI'O CAIIA
SAM Ktwrzu
Dear Participant: uww uooow
NIlEN IOMSCK PH 0
MAlCARE T Tumcsuo

The enclosed questionnaire is concerned with citizen participation :“WDWWHGI
in community mental health center boards and is part of a state- fififlxzfifif

wide study that I am conducting in conjunction with my doctoral

program at Michigan State University. This study has been approved

by the Michigan Department of Mental Health and will provide a basis

for assessing attitudes toward citizen participation in community mental
health center boards in Michigan.

The results of this study will provide information that will be useful in
the selection of community mental health board members, as well as assess-
ing the impact of board member training.

Participation in this study is strictly voluntary and the results will be
handled in an anonymous and confidential manner.

I am particularly interested in obtaining your response because your
experience with community mental health will contribute significantly to
an expanded knowledge base in this increasingly important area.

The enclosed questionnaire has been pretested by people with background
similar to yours and it has been revised in order to make it possible to
obtain all necessary data while requiring a minimum of your time. The
average time required for completing the questionnaire is about thirty
minutes.

It would be appreciated if you could complete the questionnaire prior to
March 26. Please return the questionnaire directly to me or via my mailbox.
Other phases of this study cannot be carried out until analysis of this
questionnaire data is complete.

I would welcome any comments that you might have concerning any aspects
of citizen participation in community mental health center boards not
covered in this questionnaire. I would be pleased to send you a summary
of the questionnaire results if you so desire.

Thank you for your cooperation.
V uly yours,

Edward A. Oxer, Director
Ingham Community Mental
Health Center

“7 W. GREENLAWN lANSlNG. MICHIGAN “910 PHONE (517') 374-0000

 

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143

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1 I

1
Please indicate your age:
(0) Less than l9 (4) 35-39 (B) 55-65
(1) l9-26 (5) 40-66 (9) 66 6 Over
(2) 25-29 (6) 65-69
(3) 30-34 (7) SO-Sb
Sex and Marital status
(1) Halo. married (5) Halo. widowed
(2) female. married (6) Pamela. widowed
(3) Male. single (7) halo. separated or divorced
(6) female. single (8) Female. separated or divorced
Education:
(l) Grade School (3) Some College
(2) Some High School (6) College Graduate
(3) High School Grad. (7) Graduate or Professional School

(6) Technical School

flags irsidicsts your Cross Annual Family Income:

6,999 or Under (6) 515.000 - $l9.°9’
(2) $5.000 - $9,999 (5) 520.000 - 529.3};
(3) “0.000 -Slb.999 (6) 530.000 and ova:

Please indicate whether your co-unity is mostly:
(1) Urban (3) Suburban
(2) Rural (6) Hired

Please indicate your Racial/Ethnic background:
(l) Black (3) Chicano
(2) “hits (4) Other Minority

Occupation (select only one that best reflects your

work);
(0) Professional (4) Business/Salas (B) Housewife
(1) Skilled Trades (5) Hana srial (9) Retired
(2) Self-employed (6) Farm n
(3) Clerical/Office (7) Unskil ad
Do you currently or have you previously held elected office?
( ) County Co-issionsr (4) Other
8; guy/Township (3) Not hold elected office
COCO

l) Clinical Staff - G010 (Commmity Mental Health Center)

2) Administrative Staff - CMHC (Co-nity Mental Health Center)
3) Clinical Staff - State Hospital

’0) Administrative Staff - Stats hospital

5) Other Health Care

6) lot onloyad in health or mental health care

serve on a CMHC Board?

(I) PA-ZSB Board (County Cmity hntal Health Services Board)
(2) PA-ZSB Board Chairperson

(1) WC Governing Board member

I?) was Governing Board chairperson

(6)

(7)

2
5

CHIC Advisory Board “or
out Advisory Board chairperson
lot a MC Board msdsr

Are you active in co-lnity affairs? Please indicate the order of

hours spent {or month in cm“ boards. church activities. etc.
(1) or sea (5) -l6 (7) lot active
(2) -b (3) l‘l-ZA
(3) 5-0 (6) 25 or more

you used Mental Health services personally as a client?
) CHIC (Co-mity lIsmtal Health Center)

) Private

) No use of mental health services

Cl“ md private

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{KWWZKXX‘Q‘OC 3...... m: "
Hark ll). if you completely agree Mar: 23;. i: you slightlyldigsgrse -
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IEXXXXXXXXXXXXXXXQ Mark (1). if you mdcratcly agree Marl: (7). if you strongly disagree -
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\— v’vv v QUOOV 16 . Citizen board members should vote on issues affecting the MIC but theit -
choices should be able to be changed by the csntss's director. -
A .. , A
' 0030:3000 l7 . People who have used the center should be represented on the 001C board. -
-
DCOCC'C'OCOC lb. in order to take part in voting on the OOH: board. citizens should have -
Knowledge of mental health services. -
QOOCCCOOOC l9 . Citizen board nembsrs should be elected to the CMHC board by local people -
rather than be appointed by the comty or city. -
33 C’ 300003 3 20 Citizen members of 000C boards who do not attend meetings should be asked -
to resign. -
‘,"\’\/T\f\fi.f\rv—~l’ .
u 000 v #3009 21 . Citizen members of the board should be involved in the hiring and firing "'
of the com director. -
DOOC'OOGOOC 21. m: the CHHC board has eccoqlished should be a factor in looking at the -
results of citizens taking part in OIIC boards. -
A - f“ ,
302x JQCOUOO 23 Citizen mothers of cmc boards should be selected for their drive and "'
because they are leaders. -
3000006000 26. Citizen members of the CMHC board should represent a sale of all parts -
of the area served by the program. -
0000000060 2!. cat boards should be made up of-mostly esntal health professionals. -
-
303 3300000 26. itizen board were should serve on (30!: governing boards instead of - 1
advisory boards. -- ‘
3 C 3 :2 3C 3 000 27. Citizen board m‘ers should be involved in the day-to-day workings of - |
the WC. -
QOOCCDCOOOC 2B. local businessmen should be asked to be odors of CMHC boards. -
-
3C; 3C3: .3030 29. Those nusd to a” boerds should be approved by the State Mental Health -
Department. -
0") ’1‘" ". ’M“ 1" 30. Citizens tahin part in out boards would bring the best results if the -
DVV 0V V V V V V service area o the center is the a- as the county. -
A _ . .., .
DUCOQOOOQC Jl. :opie who have used the services should be in the major group on GOIC -
er s. -
3 QCC‘CCOOOQ 32. Citizen board “yrs would have the soot effect when they are appointed -
by the cemty. .
:C 3330-0030 33. if citizen board lee-bers are involved in policy making. mental health -
professionals are not likely to want to work in Chin‘s. -
3303;230:3000 34.. Every once should hove persons serving on the board who have used an. -
services. -
30 00000000 35. Citizen board members should share in policy making with those who hold "'
the power in the m. -
3000300000 36. Those M to ORG boards should be chosen by other agencies. -
-
2000000003 37. Citizens sharing in the planning and naming of CHIC's have not produced -
§ enough payoff to make it worthsthile. -
3000606000 38. Citisen beard msdsrs of the 0m should have had experience on other -
7- social agency boards. -
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l 2 3

Storm; toy:

.‘lork (l). 1.! you couplotoly ogroo Hort (S). 1! you slightly dlsogroo
Mark (2). L! you stromzly agroo Mark (6). it you oodorstoly dunno
Fork (J). 1.! you mdorotoly ogroo .‘lork (7), 1.! you strongly dlsogrso
Hort (ls). 1.! you sllghtly ogroo Hort (8). it you toqlstoly dlssuso

39. A voluntoor progrn would howo Ioro offoct on lnwolVlh. eltlsns lh tho

thou hovm; thou sorwo on tho hoord.

#0. Cltuon hootd ooohors should hovo tho powor to ooho docisloos such so
opprovlh; tho 00K: hud‘ot.

'61. Thoso who oro sctlvo a would: he: do szd osho tho oost ofloctlvo
oo-hors of tho Who

‘2. It would ho ooro oftoctlvo to hows tho (alllss ot CHIC cllsnts on tho
hoord thoo tho clloots thousolvos.

63. Cltlsoos toklo; port to cxuc boords would hows on 'npoot on chohglo; how
stott troots cllohts.

66. Grootor cltlzoo lhput would hlhdor tho work hotwooo tho once and othor
soclol sgooclos.

k3. Grootor cltlsou luput to our: hoords would roduco Itl‘h ottlcloocy.

56. fund rolslo; should ho so Mortont job (or tltloohs tohlo. port lo C30“:
booxds.

’07. Cltlsoo hoord o-bors should spook tor tho group whlth thoy roprosoht
rothor thou tor thousolvos.

‘3. Pooplo who spook for ollonts sod pooplo who spook for oontsl hoolth
protosslohols should sorvo lo oquol omoors on mac hoot do.

‘9. Thoso who oro good st spookln, (or tho co-uolty should sorvo on tho boord
to holp to lootssso tho on tho contor.

50. loving cltlsoos tsko port to 08¢ bosrds would ho s wsy o! trololn; locol
pooplo Ln doncrotlo voluos.

51. Cltlsons tok port to CHIC hoords would ho oost otloctlwo l: tholr rolo
ls closrly do! d.

:2. ml: hoords should sponsor form to tutor. tho puhllo shout prohlsos o!
sorwlclog tho sroo.

SJ. Cltlzono who sorwo on out: hosrds should soroo wtth oo-oulty osotol
hooth ldoos.

Sb. Stott at tho Ole should not ho lovolvod lo tho onto; o2 cltlsohs to tho
boord.

55. Hilltoht soolsl sctloh grows should ho sllowod to toho port lo tho
plonolh; u! can: sorvl too.

56. Cltlzon boord oolbors should hovo lotsl groups to whloh thoy oro
scoouotohlo.

51. Grootor cltltoo Shout would bring grootor puhllc support for tho out.

SI. hood polltltol losdors should ho on tho hoord o! tho me.

59. Cltuoh oodors o! Gil: hoords should ho sshod shout polltlos holoro thsy
ors oodo.

60. Cltlsou hoord odors COMM on s prlwoto hon-profit corporotlon whlch

run oll once sorvlcos to tho sorvloo sroo uould ho tho oost ottottlvo
(on o! cltlooo lnput.

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INSTRUCTIONS :

146

Hork tho author L. tho :chlo on tho loft sldo

Judgo tho followlng ldoo by uslng tho sdjoctlvos

llstod holow.

of tho pogo thst shows tho

dogroo to whlch too or tho othor of tho words doscrlbos tho ldoo. Io ours-to
Iorh your answer on tho clrclus on tho lot: “do of tho pogo.
Cltlzon t‘srtlclpstl-m ln CHHC Ioords ls;
6 s s3 s3
vw‘I‘ #6 "s“ “to. .~¢o" ’9‘,

61. Good l 2 3 e. 3 6 7 Iod
62. lhofloctlwo l 2 3 6 5 6 7 lilootlwo
63 . lrro lovont l 2 3 6 5 6 7 6o lovout
66. “fl-sly l 1 3 6 5 6 7 Uhtlloly
65. low 1 2 3 6 S 6 7 Old
66 . logrosslvo l 2 .3 6 3 6 7 Progross two
67. “loo 1 2 3 6 S 6 7 Foolish
66. Sllplo l 2 3 6 5 6 7 Conplor
69. wrong 1 2 3 6 S 6 7 light
70. lorrow l 2 3 .6 3 6 7 Irood
7l. hoodod l 2 3 6 3 6 7 Uhhoodod
72. Strong 1 2 3 6 5 6 7 Hook
73. lhhportout l 2 3 6 3 6 7 Imrtoht
76. Confllctlng l 2 3 6 5 6 7 Cooporstlvo
73. Mtlvo l 2 . 3 6 S 6 7 Pooslvo
lh‘S‘l‘lUC‘l'lOlS: Judgo tho ldoo of Cltlooo 'Psrticlpotloh in CMHC hoords for

ooch hoord oonhor group. Plooso osrk tho must to tho circlo on tho loft
oido of the pogo thot shows whothor you think thoy should hovo high or low
control. 3o ours to oorh your ohswors in tho clrclos on tho lo£t oldo of
tho pogo.

Dogroo of Control (Ivor
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APPENDIX E

FOLLOWUP REMINDER POST CARD

147

March, 1979

Dear Participant:

I recently mailed a questionaire to you regarding
citizen participation in community mental health
center boards. I would like to thank those who
have reSponded for your participation, as the
success of this important study is highly de-
pendent upon your individual contribution.

If you had intended to reSpond but have not had

the time to complete the questionaire, I would
appreciate your doing so at your earliest convenience.

Director 740%]

Ingham Community Mental Health Center

Sincerely,

148

APPENDIX F

LETTERS OF APPROVAL

149

9: J ,3"
i" '3': 5 sure or mcmom
:.-,__;,.. DEPARTMENT OF MENTAL HEALTH

I A l AN N HIGAN 2‘
WILLIAM G. MlLUKEN. Gavovnor LEW S C 55 BUILD "6' L S! G “.0 609

v.A.51’EHMAN. MO"
Actmg Onocto:

 

March 7, l979

Edward A. Oxer, A.C.S.H.
Director

Community Mental Health Board
300 N. Hashington Square
Community Services Center
Suite 40l

Lansing, MI 48933

Dear Mr. Oxer:

We have reviewed your proposed dissertation research, "Development of a Scale
to Measure the Attitude Toward Citizen Participation in Community Health
Boards". We understand that this research involves a client sample who will
participate on a voluntary basis. Confidentiality will be maintained and
there will be no risk to clients. You have the approval of the Department

to proceed with this research, providing that the following is assured:

(1) Approval from the Clinton-Eaton-Ingham Community Mental Health
Board. ‘

(2) The questionnaire should have a cover letter indicating that
responses are anonymous and confidential, that completing the
survey is voluntary. and does not affect services received as a
client of the agency.

You might also consider indicating to patients and subjects what use may be
made of the data, that the purpose of this questionnaire is for your dissertation
research, and whether or not results will be sent back to participants.

Please direct the materials requested and/or any questions to Carol T. Mowbray,
Ph.D. (5l7-373-2746).

Departmental Administrative Procedures are that you provide the Department and
the CMH Board with a report of the results of your research. We look forward
to being informed of the findings of this interesting study.

Sincerely,

V.A. Stehman, M.D.

CC: Thomas Ennis, Director,
CEI BOARD

*} 3 303 :fiarrell
WC 'G'A‘N VAS.:CTM:g

It" .

'o' PM“)?!

150

 

To:
From:

151

COMMUNI" MENTAL HEAIJH BOARD
CUNTON-EAION-INGHAM I? E c E I v E D

MEMO MAR121979

INGHAM CMH".

Ed Oxer, A,C.S.W., Director Dots: March 7, 1979

Ingham CMHC
Gilbert W. DeRath, Ph.DM

Director of Clinical Services
Research Proposal

Ed,

I have reviewed your proposal for the "Development of 3 Scale
to Measure Attitudes Toward Citizen Participation in Community
Mental Health Center Boards." I approve of implementation of the
research within our programs. I assume that you will develop an

informed consent format for use with CMH clients.

Attached is the DH}! policy on Approval of Research Policies,

for your information.

Atch

jlz

(lniornol uso only)

BIBLIOGRAPHY

152

B IBLIOGRAPHY

Allport, G. w. The historical background of modern
social psychology. In G. Lindzey (Ed.), Handbook
of social psychology (Vol. 1). Cambridge, Mass.:
Addison-Wesley, 1954.

 

Au Yeung, B. A study of citizen participation in a com-
munity mental health center. Unpublished doctoral
dissertation, University of Pittsburgh, 1973.

 

Baker, F., & Schulberg, H. C. The development of the
community mental health ideology scale. Com-
munity Mental Health Journal, 1967, 3, 216-225.

 

Bertelson, K., & Harris, M. R. Citizen participation in
the development of a community mental health
center. Hospital and Community Psychiatry, 1973,
553—561.

Bolman, W. M. Community control of the community mental
health center: II. case examples. American
Journal of Psychiatry, 1972, 129(2), 181-186.

Bonjean, C. M., Hill, R. J., & McLemore, S. D.
Sociological measurement; an inventory of scales
and indices. San Francisco: Chandler, 1967.

 

Cohn, E., & Cahn, J. C. Maximum feasible participation:
A general overview. In E. S. Cahn & B. A.
Passett (Eds.), Citizen participation: Effecting
ggmmunity change. New York: Praeger Publishers,
1971.

 

Caplan, G. Implications for community psychiatry:
Personal reflections. In R. B. Caplan (Ed.),
Psychiatry and the community in nineteenth
century America. New York: Basic Books, 1969.

Caplan, R. B. Psychiatry and the community in nineteenth
century America. New York: Basic Books, 1969.

Chu, F. D., & Trotter, S. The madness establishment.
New York: Grossman, 1974.

 

153

154

Chun, K., Cobb, S., & French, J. R. P. Measures for
psychological assessment. Ann Arbor, Mich.:
Survey Research Center, Institute for Social
Research, 1975.

 

Community Services Administration. Citizen participation.
San Jose, Calif.: Rapido Press, 1978.

Comrey, A. L., Backer, T. B., & Glaser, E. W. A source-
book for mental health measures. Los Angeles:
Human Interaction Research Institute, 1973.

 

 

Connery, R. H. (Ed.). The politics of mental health:
Organizing community mental health in metro—
pplitan areas. New York: Columbia University
Press, 1968.

 

Cronbach, L. J., & Meehl, P. E. Coefficient Alpha and
the internal structure of tests. In W. A.
Mehrens & R. L. Ebel (Eds.), Educational measure-
ment. Chicago: Rand McNally, 1967.

Decker, D. K. Citizen participation in community mental
health: Massachusetts area board members'
evaluation for participation. Dissertation
Abstracts International, 1974, 74-25813.

Deutsch, A. The mentally ill in America. New York:
Columbia University Press, 1949.

Dudley, J. R. Citizens' boards for Philadelphia community
mental health centers. Community Mental Health
Journal, 1975, ll, 410-417.

 

Engelkes, J. R., Livingston, R., & Vandergoot, D. (Eds.).
Guidelines for conducting follow-up studies to
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