FACET ANALYSES 0F ATTITUDE - BEHAWORS OF MENTAL PATIENTS TOWARD MENTAL ELLNESS IN A COMMUNITY MENTAL HEAL?“ CENTER Dissertation for the Degree of P21. D. MICHGAN STATE UNEVERSHY BAHMAN DADGOSTAR 1974 TH‘FQ‘HE ” This is to certify that “1% A thesis entitled ' 2 'ALYSlS 0F ATTITUDE-BEHAVIORS OF MENTAL ' Tl-ENTS TOWARD MENTAL ILLNESS IN A 7. COMMUNITY MENTAL HEALTH CENTER presented by BAHMAN DADGOSTAR has been accepted towards fulfillment of the requirements for Ph.D. degeenIDepartment of Counseling, Personnel Services, and Educational Psychology 1974 John E. Jordan ,- Major professor _ , g. E.- F1 "tics—1‘ .4- { I 1 1 ABSTRACT FACET ANALYSIS OF ATTITUDE-BEHAVIORS OF MENTAL PATIENTS TOWARD MENTAL ILLNESS IN A COMMUNITY MENTAL HEALTH CENTER By Bahman Dadgostar Problem and Purpose Very little attention has been paid to the attitudes of people with emotional problems (the "mentally ill") toward emotional problems ("mental illness"), or to what these people consider emotional problems to be. What does a person who has been labeled as "mentally ill" call himself or herself, and what is the possible impact of the "mentally ill" on one another? Are they helpful or harmful to each other? These and other questions need to be answered. The concept of mental health and mental illness has been interpreted by different cultures and by different schools of thought. Throughout history mentally ill people have been mis- treated. The attitudes of people with emotional or mental problems toward mental (emotional) problems is an extremely important subject from the point of view of (a) social structures or social systems, from the point of view of (b) the conceptualization of mental health Bahman Dadgostar and mental illness, and of (c) the development of treatment programs for mental health professionals and for others who work in the area, i.e., for the development of training and educational programs. The major purpose of the present research was to investigate the attitudes of patients who had been referred to the Community Mental Health Center of the Ingham Medical Hospital,1 and to assess the predictive validity of a set of hypotheses related to the atti- tudes of this group of patients before they receive any type of psychotherapy and after receiving treatment. Methodology The Attitude-Behavior Scale-Mental Illness (Emotional Problems)2-ABS-MI/EM0 was administered to a group of patients who came to the Community Mental Health Center of the Ingham Medical Center in order to receive psychotherapy. The Attitude-Behavior Scale construction was guided by Guttman's facet theory of attitude structure and his definition of attitude as a "delimited totality of behavior with respect to something" (Guttman, 1950). According to the original theory of Guttman (l959), attitude was considered to be comprised of three facets and related elements, in such a way as to produce four levels of attitude-behavior. These four levels of 1The name was changed to Ingham Medical Center while this research was being conducted. 2The terms mental illness and emotional problems are used in this study interchangably, as they refer to the same concept. Some people prefer to use the term mental illness while others prefer to use emotional problems. It depends on the model being used, i.e., the medical model uses the term mental illness, whereas the non-medical model uses the terms emotional problems or problems of living. Bahman Dadgostar attitude-behavior represent a paradigm for interaction between or among groups. These four levels are: Stereotype, Normative Behavior, Hypothetical Behavior, and Personal Action. Guttman's theory was expanded into five facets and six levels by Jordan. These six levels contain the four which were identified by Guttman plus two additional levels: Moral Evaluation and Actual Feeling. The present study employed three levels (Normative, Moral Evaluation, and Feeling) of the six levels of Jordan's adaptation. A 38-item scale was used and each item was carried across the three attitude levels of Guttman-Jordan's paradigm. In addition the scales containing demographic questions were also used. The present investigation was based on a quasi-experimental research methodology using pre and post-test design. Results The results were obtained through the use of data analysis procedures which measured the affects of the following variables: psychotherapy, age, and education. Although the data did not indicate significant differences between pre-test and post-test results with regard to these three variables, it provided clues in the design of future investigations in the area of mental health and mental illness. FACET ANALYSIS OF ATTITUDE-BEHAVIORS OF MENTAL PATIENTS TOWARD MENTAL ILLNESS IN A COMMUNITY MENTAL HEALTH CENTER By Bahman Dadgostar 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 1974 ACKNOWLEDGMENTS I am indebted to many people for their support, assistance and interest. Foremost I am indebted to Dr. John E. Jordan who, as Chairman of my Doctoral Committee, guided me in the procedures of this investigation, from the initial stages through its completion. I would like to express my appreciation to Dr. James Costar, Dr. Alex Cade, Dr. Thomas Gunnings, and Dr. Pedro Ojeda for their interest, support, and suggestions. I am grateful to Dr. Rom Kriauciunas, Chief Clinical Psycholo- gist, and the rest of the staff of the Community Mental Health Center of the Ingham Medical Center. ' I am very much indebted to the patients of the Community Mental Health Center for their cooperation. Completion of this research would not have been possible without their assistance. Finally I am grateful to my wife and daughter for their unfailing encouragement and for their many sacrifices during this 0 time. ii TABLE OF CONTENTS LIST OF TABLES . LIST OF FIGURES Chapter I. II. III. IV. INTRODUCTION . Definitions of Mental Health and Mental Illness Nature of the Problem Statement of the Problem .‘ REVIEW OF THE LITERATURE. Facet Theory Attitude Research Quantitative vs. Qualitative . Four- Level Theory Six- Level Adaptation Application of Facet Theory in Related Studies : METHODOLOGY, PROCEDURE, INSTRUMENTATION DESIGN AND HYPOTHESES . . . . . . . . . Experimental Design . Criteria for Evaluation and Experimental Design. Randomization . . . Quasi- Experimental Design . . Generalization, Explanation, and Prediction . Pre- Test vs. Post- test . . Attitude Behavior Scale and Facet Theory. Rationale . . . Procedures of Administration . Population and Sample Instrumentation . The Personal Information Questionnaire Hypotheses of the Study . Level of Significance RESULTS Hypothesis I . Hypothesis II . iii Page vi Chapter Hypothesis III . Summary and Implications Limitations of the Study V. SUMMARY, DISCUSSION, IMPLICATIONS, AND RECOMMENDATIONS . . . . . . . Summary . Discussion . Implications . Areas Needing Further Investigation APPENDICES A. CONSENT FORM . B. ATTITUDE BEHAVIOR SCALE - ABS-EMO . BIBLIOGRAPHY iv Page 66 69 77 79 92 Table 10. LIST OF TABLES Basic Facets Used to Determine Component Structure of an Attitude Universe The Four Combinations and Descriptive Names Used in Guttman's Four Level Facet Theory . Basic Facets Used to Determine Joint Struction of an Attitude Universe Comparison of Guttman and Jordan Facet Designations Joint Level or Attitude Level, Profile Composition and Labels for Descriptive Names for Six Levels of Attitude-Behavior Sample Sizes, Means and Standard Deviations for the Variables of the ABS-EMO Study . Sample Sizes, Means and Standard Deviations for the Female Group on the Variables of the ABS-EMO Study Sample Sizes, Means and Standard Deviations for the Male Group on the Variables of the ABS-EMO Study Sample Sizes, Means and Standard Deviations for the AGe Group 20-24 on the Variables of the ABS-EMO Study . . . . . Sample Sizes, Means and Standard Deviations for the Age Group 25 and Over on the Variables of the ABS- EMO Study . . Page 29 29 29 36 37 60 61 62 63 64 LIST OF FIGURES Figure Page l. Five-Facet Six Level System of Attitude-Behavior Verbalizations: Levels, Facet Profiles, and Definitional Statement for Twelve Combinations . . . 33 2. A Mapping Sentence of the Joint, Lateral, and Response Mode Struction Facets Used to Structure the Attitude-Behavior Scale-Mental Retardation . . . . . 34 vi CHAPTER I INTRODUCTION The mental health movement is generally viewed as being con- cerned with the welfare and care of the mentally ill and the mentally handicapped. Organizations, state authorities, and professionals generally feel that the public should know more about mental health. This view has been particularly supported by different specialists in the field of medicine. The movement toward more emphasis on mental health programs is founded on two basic aspects: (a) mental illness and emotional problems, together with physical disease which effect the minds of individuals, produce limitations in emotional growth and compatibility with other human beings, and (b) mental and emotional problems not only affect the individual himself but also affect his close associates such as spouse and children as well as society in general. From an historical point of view, the mentally ill have been viewed differently in many countries throughout history. Throughout history the mentally ill have been considered deviant and have aroused fear, revulsion, and disgust. Mentally ill subjects have been accused of devil possession. Therefore, disturbed people suffered from rejec- tion, neglect, and even ill-treatment; psychotic people with possible psychophysiological and psychochemical disorders were even punished for their "misbehavior." The mentally ill have not been mistreated in all cultures. In some cultures some types of emotional problems, such as schizophrenia were viewed as a spiritual aspect. For example, in the Moslem world the "afflicted of Allah" have been traditionally given Special considera- tion. There were hospitals in early times (12 A.D.) which were founded in Cairo and Baghdad. In the Hindu culture psychotic hallucinations were regarded as communication from the spirit world, the early Hindu societies showed remarkable tolerance for people with emotional prob- lems and bizarre behavior. In Christianity and Islam the belief of demon possession reached its height during the long preoccupation with witchcraft that coincided with the Reformation and Counter-Reformation. One of the most interesting historical views is the attitude of ancient Jews toward mental patients. In the Hebrew ancient texts, one will see positive and accepting statements regarding attitudes toward mental illness. There is very little evidence in the Hebrew texts for an ostrasizing and intolerant attitude toward the mentally ill. The mentally ill was not ridiculed as being blessed in his illness, a state of affairs which would have justified abandoning the ill, leaving him untreated and suffering in order to preserve his blessedness or to retain him as a source of fun. In the old Persian Zoroastrian culture (400 B.C.), mental problems were regarded as any natural disorder which man might possess, therefore psychotherapy as a science and practice was used as a major aspect in the practice of medicine. The interesting point is the varied techniques and systems of psychotherapy which are used in different cultures and countries. In some cultures emphasis is placed on the biological basis of mental disorder, therefore they use both mental and physical methods with psychotherapy which are used in modern psychiatry and neurology. Definitions of Mental Health and Mental Illness Statements are often made such as "You are healthy," "I am sick," "He is disturbed." Who is normal, who is abnormal? Mental illness has been one of the major individual and social problems of society. Many professions and organizations as well as millions of people have discussed mental health and mental illness. There are various ways of looking at the terms "mental illness" and "mental health." When there is a problem, i.e., not the usual normative situation, it is called "illness," which is viewed as the opposite of health. Increasingly, doubts are being expressed as to whether this is the right way of looking at it. Mental illness covers a wide range of phenomena, but is it all related to mental health? Does the loss of mental health end up with mental illness? Does recovery from mental illness mean the person is mentally healthy? These are the main questions which occupy the minds of specialists as they consider the use of the terms "mental illness" and "mental health." There is evidence that the dichotomy, mental health and mental illness, creates considerable confusion and contradiction when the behavior of human beings is observed in view of health and illness. Mental health investigators, both experimentalists and theoreticians, are of the opinion that there should be universally accepted defini- tions, of mental illness and mental health; distinguishing one from the other. The recent progress in the understanding and treatment of mental illness has been partly due to the opinion that mental illness is not an isolated phenomenon, but represents primarily a quantitative deviation from normality. It has been beneficial to de-emphasize the polarity of the terms mental illness and mental health and to stress possible differences between "states" of mental illness and mental health. The criteria of adequacy must be broken into at least two main components: (a) the individual's statements and expression of his/her own self, regarding his/her feelings and emotional experiences. For example, "I am happy," "I am feeling very well" and (b) social or public expectations, i.e., following standard social behavior. Who is mentally healthy and who is not? When reference is made to a person as "mentally healthy" it does not mean that he does not have any problems. He may experience occasional depression and anxiety, but he is usually able to provide his own recovery. Mentally healthy persons are rarely seen by those who study mental illness. A mentally ill individual, does not recover on his own. On the contrary, he is often unable to use help offered to him, he may also be resistent or in many cases will refuse to seek help. In summary, mental health and mental illness are often seen as opposite poles of the same continuum. This polarization has resulted in confusion and contradictions. The causes of mental illness may be biological (physiological, chemical, genetic, etc.) or psychological (developmental, family, early environmental factors, etc.). Since the general public associates many negative connotations with the term "mental illness": many specialists in the field suggest utilizing the terms "emotional problems" or "problems of living (Szazz, 1968). Many studies have shown (Whitman, 1970) that both patients and "normals" (i.e., persons in open society) see environmental problems and personality or behavioral disorders as the main causes of mental ill- ness. However, while normal persons emphasized hereditary and organic factors to a greater degree, patients indicated interpersonal and behavioral difficulties more frequently. Patients ideas of etiological factors seem to be drawn from those prevailin§5iq the larger culture. Research studies have reported comparisons between cultures and their different definitions of mental illness. One of the best studies (Sydiaha, Lafave, and Roatmen, 1969) was done by a group of Canadian psychiatrists. In their investigation they sampled French and non- French within each of two communities. Lack of specific knowledge of mental illness tended to be associated with the minority elements in each community. Minority groups-tended to have higher incidence rates of psychiatric disorders. Religious factors appeared not to be associated with incidence of mental illness. Stumme (1970) conducted a study to ascertain "what is meant by mental illness." The study reported that the common lay attitude toward the mentally ill indicates a general prejudice against the mental patient who is described as an uncontrolled, unpredictable, dangerous, violent, irresponsible person or an impulsive criminal. The result of this study revealed that the term "mentally ill" is not synonymous with all types of mental disorder but in the eyes of the public is regarded as the most extreme deviation in behavior. The study also reported that the term "mentally ill" is usually associated with patients in mental or state hospitals rather than with a particular set of symptoms. Since the definitions and conceptions of mental health is a very confusing subject, investigators try to formulate operational statements instead of defining mental health or mental illness. Klein (1960) suggests that the search for a definition of mental health be abandoned, at least temporarily, in favor of a differentiated approach to the problems of human adjustment and maladjustment. It has been suggested that the current concepts of mental health and mental illness are primarily concerned with the long standing emotional or psycho- logical conditions of individuals for which the term "soundness" is proposed. The immediate state of "well" or "ill-being" of the individual at any particular time is proposed as suitable for more intensive study, both because of its possible effect on the soundness level in some instances, and because it should be considered in and of itself as a period of acute illness or malfunctioning and worthy of note in p0pulation studies. The susceptibility of the individual to environmental stresses may be considered as a general factor which may be a study for the future regarding the possible implications of child rearing and educational practices. Perhaps by following this more differentiated approach to mental health and mental illness we may find conflicting doctrines of today much less contradictory. Nature of the Problem The importance of research in the area of attitudes is a primary focus in much of social-psychological research. One of the major problems which exists regarding attitudinal research is how to measure attitudes. In general there are three main purposes for measuring attitudes: (a) to measure the nature and structure of attitudes and test hypotheses regarding the conditions under which different attitudes are created, (b) to study changes in attitudes, as this is considered to be the main focus of attitude research, and (c) to apply the findings of attitude research to the planning of new sources of services for the community. Namely, in order to service a community, one needs to know existing attitudes of that particular community. There are many variables which are predictors of attitudes such as: sex, demographic information, education, religion, social, psychological, economic, socio-economic, and contact (amount and quality). One of the major benefits of knowing existing attitudes in the field of mental health is the matter of prevention. An ounce of prevention may cost a pound of cure. Primary prevention has been a key element in the ideology of the community mental movement over the past ten years (Shulberg and Baker, 1969). Many scholars in the field of community mental health have placed strong emphasis on the importance of adopting a public health approach to the widespread prevalence of mental illness and have emphasized the necessity for preventive intervention (Caplan, 1964, 1970). Unfor- tunately the prevention emphasis has not always been accepted and the public did not try to get involved in it due to the idea that the major purpose of the mental hygiene movement was the curbing of the growth of illness. This rejection of the public health model grew after disillusionment and failure of the earlier mental hygiene move- ment in curbing the growth of mental illness. The prevention approach gained acceptance when consultation education was accepted as one of the essential services of community mental health centers. Since 1963 there have been considerable writings and research devoted to con- sultation education as a primary method of prevention (N.I.M.H.). Despite such efforts, however, according to reports of the National Institute of Mental Health (N.I.M.H., 1971a, 1971b), mental health agencies know the importance of primary preventive but they continue to devote their major resources to the treatment, diagnosis, and rehabilitation, and neglect to emphasize the importance of inter- vention. Many investigators have pointed out the barriers to primary prevention. One barrier of primary prevention is the resistance of people because they feel that nothing canbe done short of a major overhaul of society (Bower, 1961, 1965). Bower has suggested that society will usually resist specific strategies as an invasion of privacy, therefore they are cautious about primary prevention. Bower also indicates that preventative efforts have a lower professional status than treatment, diagnosis, and rehabilitation. Snoke (1969) also stated that public health in general has a lower status when com- pared with the "curative program." Another important barrier of primary preventicns, as indicated by Rieff (1967), is the lack of trained specialists to carry out primary prevention activities. This idea has been emphasized by other investigators who indicate that the lack of trained specialists is because people are more inclined to be trained in the area of treatment and rehabilitation rather than primary prevention due to its lower status importance. Broskowski and Khajavi (1973) and Broskowski and Baker (1974) identify other barriers such as the fact that primary prevention is explained in a medical illness model rather than by an emotional and social psychological model. The idea of medical vs. non-medical models has been discussed by many psychiatrists and psychologists. Szasz (1961) soundly criticizes the medical model in discussing mental problems and mental illness. He even refuses to use the term mental illness, rather using the term: "problems of living." The medical model obscures the "value goals" of psychotherapy and the social goals of social psychiatry and social psychology. The ultimate goal of psychotherapy is individual self-knowledge and self mastery that fits within the constraints of society but does not become closed to changing the society. Expressing these goals in the language of medicine confuses the public about the nature of the human problem called mental illness. It obscures the relationship of these problems to the nature of the social order and it forces the public to rely on experts rather than on its own store of human wisdom. Therefore psychiatry is under attacks to abandon its medical disguise since it has been labeling people with psychophysiological and psycho- biological problems as mentally ill rather than also seeing the social system as a primary factor in a particular set of "human problems." 10 The deviant person is determined by social labeling rather than by objective and behavioral criteria. Szasz (1961) suggests that the phenomenon which is called mental illness be removed from the category of illnesses and be regarded as an expression of man's struggle with the problem of how he should live and how he interacts or relates with others and himself. Statement of the Problem Of the studies related to the present study, Maierle (1967) and Whitman (1970) relate directly to the use of the Guttman-Jordan (1968) theory used in this research. The general prupose of the present study was to investigate attitudes of mental patients or people with different degrees of emotional problems who have never been to apy_ type of psychotherapy before, toward mental illness. The specific delimited purpose of the study was to test attitudes toward emotional problems, before and after psychotherapy, of subjects with no previous experience with psychotherapy. The subjects of the present study were clients of the Ingham Medical Center, Community Mental Health Center. As detailed in the chapter on results in this study, a need exists for additional attitude research designed to promote knowledge of both substantive and methodological aspects. The patients attitudes were measured by a "set" of Guttman- Jordan facet theory derived scales: Attitude-Behavior Scale: Emotional Problems/Mental Illness-ABS-EMO or ABS-MI. ll The specific purposes of the present study were: l. Ascertain attitudes toward "mental illness," of people with emotional problems when they first come to the Community Mental Health Center and after they are treated at the Center. In other words, to measure value orienta- tions and attitudes toward mental illness of non- institutionalized mentally ill or people with emotional problems. To assess predictive validity of the following hypothe- sized determinants of attitudes toward mental illness; demographic, valuational, and contact. To use the Guttman-Jordan facet theory scaling approach on a population of patients who have never had psycho- therapy, before and after treatment. To test the Guttman facet theory hypothesis that, according to the principle of contiguity, the matrix of correlations will approximate a simplex (Guttman, 1959, 1966; Jordan, 1968, 1971). To develop plans to replicate the study in Iran regarding the attitudes of mentally ill or people with emotional problems toward mental illness. Ascertain relationships among varieties of attitude- behaviors, before and after psychotherapy, and relation- ships between designated predictor variables regarding attitudes toward mental illness (e.g., sex, education, religion, age). 12 7. Provide evaluation data for the out-patient program of the Ingham Medical Center, Community Mental Health Center, which could be feedback as a basis of decisions regarding future program plans. The knowledge attained through the above mentioned purposes may ultimately permit greater understanding and prediction of the kinds of attitudes, experiences, and situations which promote negative or positive behavior of people toward mental illness. In addition to the applied knowledge gained there are other potential benefits regard- ing the structure and measurement of attitudes. CHAPTER II REVIEW OF THE LITERATURE In numerous studies on hospitalized patients, mental and non- mental patients, it was found that mental patients are no better informed about mental illness or mental health than other people. Their attitudes toward mental illness were found to be as negative as other people (Givannoni and Ullman, 1963). In another study conducted by Crumpton and Wine (1965) it was concluded that differences exist between schizophrenic and non-mental patients in their conceptions of normality and mental illness. The differences could not be ascertained with certainty, but there were some points of argument which can be followed in this study. The Psychiatry Digest (May, 1965) reported that non-mental patients say the mental patient is sick; the schi20phrenic says that the mental patient is not sick, he is immoral. The non-mental patient thinks that the mental patient is dangerous, but the schizo- phrenic considers him safe. Non-mental patients say a man can be neurotic or show some neurotic behavior due to pressures of life, or, social-psychological situations, but a schizophrenic person does not know what "normal" (free from mental illness) is, and probably con- siders himself "normal." 13 l4 Perhaps the most systematic series of studies of pepular con- cepts of mental health and mental illness and the effects of the mass media in communicating information about mental health and mental illness have been those of Nunnally and his associates (1961). Nunnally investigated both information, i.e., knowledge of the facts held by the general public, and public attitudes or feelings, where no question of truth or falsity was involved. He found that the average man is not grossly misinformed, but rather he is uninformed about many issues. This, Nunnally stresses, is an important dis- tinction since it is easier to supply new information than to change well established opinions. On the other hand, public attitudes are relatively negative toward persons with mental health problems, with those suffering from psychotic disorders being held in lower esteem than those with neurotic disorders. While the younger and more educated have more information than the older and less educated, there is little dif- ference in their attitudes toward the mentally ill. By contrast the public holds moderately high positive attitudes toward mental health professionals, though it places a higher evaluation on those who treat physical disorders. Nunnally and his associates found that the general practitioner tends to be the "gate keeper" for the mentally ill, and that 77 percent say they treat about half of the mental patients they see. The general practitioners also tend to have a negative attitude toward the mentally ill and a moderately favorable attitude toward mental treatment specialists, hospitals, and mental institutions. Again, the younger and better informed 15 physicians tend to have more favorable attitudes and are more prone to treat mental problems than refer these patients to specialists. This may be explained in part by their questioning of psychi- atric treatment, though they express high regard for Psychiatrists as professionals. A major aspect of the Nunnally study is its report on the process of information transmission and attitude change. In the study of public interest about mental health topics they found that mental health topics compete well with other subjects in the mass media, but in general the public interest is centered on the immediate personal aspects of mental health problems (e.g., what causes them? how can one recognize them?), with rather low interest in broader problems relating to mental heatlh (e.g., the cost of mental illness to the community). Nunnally's research thus made a significant contribution to the understanding of variables which influence the transmittal of mental health information. It seems also by inference to throw further light on the "closed ranks" phenomenon experienced by Cummings (1957) when he attempted to study mental health education. Briefly, Nunnally investigated the opinions and attitudes that normal subjects held concerning mental health and mental illness. He con- cluded that the information held by the public is not really "bad" in the sense of being misinformed, but that the attitudes held by the public are fairly negative. A subject which has attracted the attention of many profes- sionals in the area of psychotherapy is the influence of attitudinal factors on treatment. One of the better studies was done by Brady, 16 Zeller and Reznikoff (1955). The general favorableness of the patient's attitudes toward psychiatric hospitals, psychiatrists, and psychiatric treatment was investigated. A favorable attitude toward mental illness, which seemed to be somewhat independent of background factors such as age, occupation, sex, etc., was found to be signifi- cantly related to successful outcomes of treatment. A favorable response to treatment was associated with the tendency to perceive, at the start of treatment, the psychotherapeutic stiuation as a neutral rather than a distinctly pleasurable experience. This study indicated that background factors such as age and previous treatment or psychotherapy bear some relationship to patients' attitudes. Gunther and Brilliant (1964) studied the attitudes of psychiatric patients toward mental illness to determine if attitudes were related to degrees of psychopathology. Another purpose of their study was to assess the effects of demographic variables such as sex, age, and education on attitudes toward mental illness. The results of their study indicate that successful treatment was not related to sex or admission status. However, they were related to age, education, and marital status. The data indicated that the older, married, and less educated patients were more custodial in their orientation toward mental illness than the younger, unmarried, and more educated patients. Further, a significant relationship was found between degree of psychopathology and attitudes toward mental illness, the more emotionally disturbed patients usually expressed a more humanitarian ideology. There are many investigations such as those of Rosenthals (1955) and Manis, Houts, and Blake (1963) which l7 relate attitude change to progress in treatment. Those patients who improved in psychotherapy (as rated by external observers) tended to adopt the value systems of their therapists concerning sex, aggres- sion, and authority; patients who did not improve became less like their therapists. These studies point to the importance of the therapeutic relationship and "modeling" to treatment outcomes. Crumption, Weinstein, Acker, and Annis (1967) conducted a study to ascertain how patients and normals view the mental patient. Their data indicated that normals view mental illness as a sickness or a dangerous state while patients' views are colored by moral terms. This study has been supported by other studies such as Crumpton and Wine (1965); Giovannoni and Ulman (1963); Manis, Houts, and Blake (1963); and Nunnally (1961). In summary, these studies indicate that the mental patient is described in unfavorable terms such as excit- able, foolish, unsuccessful, unusual, slow, active, weak, lazy, cruel, and ugly. Ratings of the "mental patient" were somewhat more likely to resemble ratings of "sick person" and "dangerous person" when made by normals, and more likely to resemble ratings of "criminal" and "sinner" when made by patients. Jones, Kahn, and McDonald (1963) studied the views of psychiatric patients toward mental illness, hospitalization, and treatment. The type of questions which were asked were grouped into areas of attitudes in the following scheme: (a) conceptions of ill- ness, (b) stigma of hospitalization or illness, (c) conceptions of hospitalization and treatment, and (d) attitudes toward hospital activities and treatment. The study indicated that patients show 18 considerable understanding of mental illness. Perhaps recent edu- cational campaigns about mental illness have had widespread accept- ance and effect on the public. The results of the study by Jones, Kahn, and McDonald (1963) suggest that the methods developed in the study are promising procedures for describing patients‘ views and for comparing patients' attitudes toward hospital goals. Finally, it has been demonstrated that, under certain circum- stances, what a person reportedly says about himself significantly influences the interpretation of his behavior by another, even though' the behavior does not justify that interpretation. It has also been postulated that the type of contact a person has with mental prob- lems affects his attitudes. Farina and Ring (1963), in their study about the influence of perceived mental illness on interpersonal relations, stated that if contact has been prolonged and intimate, it is reasonable to suppose that one's interpretation of another's behavior would be based less on stereotypes and more on the behavior itself. But during the initial phases of an interpersonal interaction one's interpretation of another's behavior tends to be based on stereotypes, and therefore, precisely because of these distortions in perception, further interpretation of the kind necessary to eradi- cate such stereotypes is not likely to occur. These statements have been the subject of arguments by many specialists in the area of attitude research. The mental illness paradigm, as a model for understanding and controlling deviant conduct, has not been widely accepted by the public. The central objective of the mental health movement has been 19 to influence the general public to regard mental illness with the same non-rejecting valuations as somatic illness. The reports of many researchers have shown that the public tends to project negative (rejection) valuations on persons diagnosed as mentally ill. 0n the other hand, the public tends to be more tolerant of deviant conduct when it is not described with mental illness labels. In other studies, attitudes toward mental illness are con- sidered to be an element in the environment. Human beings appear to be capable of evaluating behavior patterns differently at different times and in different situations. Many people have expressed, at least verbally, sentiments of understanding and tolerance for the mentally ill. Some social- psychological studies have reported that the public is presenting evidence of an emerging ability to distinguish between social devia- tion, i.e., behavior determined by socio-cultural factors, and mental illness. To the extent that this is true, the sociology of deviant behavior would no longer apply to the universe of mental illness as it has in the past (Lemkau and Crocetti, 1962). A survey was conducted in Baltimore, Maryland (Lemkau and Cro- cetti, 1962) using a randomly selected sample of the population in order to study public information and attitudes toward mental illness. The results differed substantially from those attained in similar studies using identical or similar questions and comparable methodology. The most striking contrast was that the majority of respondents of the present study identified each of the following three descriptions of behavior as indicative of mental illness: (a) that of a simple 20 schizophrenic, (b) of a paranoid, and (c) of an alcoholic (these descriptive stories have been used in previous studies, in which the only one recognized as mentally ill my a majority of the respondents was the aggressive paranoid). Thus, the present study showed no tendency on the part of the public to deny mental illness. The study also showed no tendency toward attitudes of pessimism or defeatism in the face of intensified mental illness, and there was no tendency for the respondents to isolate or reject the mentally ill. The results of this investigation seem to indicate that attitudes toward mental illness are changing. Although it has been argued that the increased ability of the public to identify mental illness may lead to greater acceptance of the mentally ill, it is also sug- gested (Phillips, 1967) that the opposite may be true. To explore this position a pilot study was done in a small New England community (Lemkau, 1968). Data were collected from interviews with a random sample of 86 adults. It was found that the ability to correctly identify behavior as mental illness is associated with rejection, not with acceptance. In another study (Bohr and Hunt, 1967) a factor analytic analysis of the opinion of psychiatric patients about mental illness was conducted. The factorial structure of staff members' opinions about mental illness, as described in an earlier study, was compared with that of hospitalized psychiatric pateints. Most of the patients were blue-collar workers with little education.‘ Differences were found between the cognitive organization of mental illness attitudes by 21 staff members and by patients. The primary factor among the staff members was authoritarianism, whereas the first factor among the patients was denial, thus reflecting (a) their discovery of the severity of mental illness, (b) a non-psychological attitude toward life, and (c) a positive orientation toward social mobility and work. The results of this study suggest that hospitalized blue-collar patients, in contrast with mental health professionals, hold negative attitudes toward mental illness that are typical of the public in general and specifically of the lower strata of society. Therefore, it was concluded that a close relationship existed between social systems, general social-psychological attitudes and mental health ideology (Bohr and Hunt, 1967). Several studies have examined relationships between different strata of society and social status. Dohren, Wend, and Chin-Shong (1967) studied the attitudes of community leaders toward psychological disorder in contrast to attitudes held by an ethnic cross-section in an urban area. Results indicated that the general public is more likely now than in the 1950's to use the label "mentally ill" when describing deviant behavior, thus bringing the public view more in line with that of mental health professionals. Differences between psychiatrists (mental health professionals) and the general public emerged in judgments about the seriousness of problems. The general public does not judge seriousness on the basis of severity of psycho- pathology, as do psychiatrists or other mental health professionals such as psychologists, counselors or social workers, but on the basis 22 of the magnitude of overt threat to others. Concern about socio- pathic forms of deviance was inversely related to social class. This appearance of greater tolerance in low-status groups seems to be a consequence of their generally more accepting orientation toward deviance, in contrast with high-status groups which seem to be less conducive to accepting deviance and less receptivity to humanistic attitudes toward mental health. One of the major interests of scholars is the mental health of a community and the attitudes of that community toward mental illness. Perhaps the most underestimated problem facing our society today is that of the treatment of emotionally disturbed people. Unen- lightened attitudes toward mental illness, rising suicide rates, and alcohol and drug addiction all point to an unwillingness and perhaps an inability to cope with the stresses of modern society. The mani- festations of a disturbed society, as with a disturbed individual, are best treated early in the development of the disturbance. Therefore, it is urgent that more attention be paid to the emotional welfare of the young portion of society. By such procedures one can hope to provide future society with a better adjusted adult population. To accomplish this the stigma of mental illness must be removed and people must get involved in helping other people (Henley, 1968). In one study (Freeman, 1961) attitudes toward mental illness among relatives of former patients was investigated (the patients were mostly schizophrenic). A conclusion of this study was that "enlightened" attitudes toward mental illness were found to be positively correlated with level of formal education and verbal ability, and negatively 23 correlated with age. This study suggests that enlightened attitudes toward mental illness can be parsimoniously accounted for on the basis of differential verbal skills rather than on the basis of differences in "style of life." This study also reported that the relative's attitudes were not related to the diagnosis of the patient's illness nor to the duration of hospitalization. The patients' past hospital behavior seemed to influence the attitudes of family members, regard- less of their education level or age. Attitudes of patients' relatives seemed to be rooted in a set of diverse elements that include socializa- tion as well as situational variables. The results of another study (Ellsworth, 1965) lend support to defining attitude as an underlying disposition which enters into the determination of a variety of behaviors toward an objective class of objects, including statements of belief and feelings about the object as well as one's actions with respect to it (Cook and Selltiz, 1964). A measure of one's responses to an attitude questionnaire does not represent a complete measure of one's underlying attitude. Studies which report that student nurses change significantly in their attitudes as a result of psychiatric affiliation (Giford and Ullman, 1961, and Hicks and Spaner, 1962) are basically reporting a change in the manner in which the student nurses responded to a set of attitude statements toward mental illness. One cannot assume that a basic or underlying attitude change has indeed taken place unless one also knows the extent to which there has been a parallel change in the relationship between the student nurse and the hospitalized patient. 24 The relationship between the attitude of a staff member toward mental illness and his rated effectiveness in a hospital setting is dependent upon several factors. In a study by Taomey, Reznikoff, Brady, and Shuman (1961) no relationship was found between verbally expressed attitudes and success in psychiatric affiliation. The final conclusion about the relationship between expressed attitudes and effectiveness in patient rehabilitation will undoubtedly depend on what attitudes are being measured, the kind of demands of the treatment situation itself, and the kind of patient being treated. Facet Theory Attitude Research Throughout history behavioral scientists have employed differ- ent techniques to measure and categorize human feelings, thoughts, beliefs, and action; which can all be viewed as different aspects of behavior. The techniques and methods of measurement are classified into three general areas: (a) observations of individual and group behavior which are concerned with viewing, analysis, and description of behavior, (b) self-report via which the subject reports to the investigator his thoughts, feelings, actions, and beliefs, and (c) the use of an external methodological procedure, such as a scale, to measure human behavior. Self-report is especially useful in the fields of psychology, psychoanalysis, and in the Gestalt approach. A combination of the last two techniques was used in Jordan's attitude- behavior research program and the series of scales devised from it (Hamersma, Paige, and Jordan, 1973; Bray and Jordan, 1973; Jordan, 1970; POUIOSs 1970; Matthews, 1975; Gottlieb, 1973; Whitman, 1970; 25 Down, 1974; Smith, 1973, 1974; Bray, 1974a, 1974b). The Attitude- Behavior Scale is a self-report instrument which measures an indi- vidual's self reported feelings, thinking, and actual behavior. This chapter comprises a summary of both Guttman's original formulation and the subsequent adaptations and developments proposed by Jordan. Quantitative vs. Qualitative One of the main problems of research, particularly in the field of behavioral studies and social sciences, is the goal of adequately quantifying the qualitative. In the area of attitude-behavior it is extremely difficult to measure those aspects of human behavior which are qualitative rather than quantitative. The research literature contains two main definitions of attitude. The first definition denotes attitudes as a "predisposition to behavior," and the second approach defines attitudes as "behavior" itself. Guttman (1950, p. 51) defined attitudes as a “delimited totality of behavior with respect to something." Jordan (1971) states that attitude and behavior cannot be separated from each other. An attitude must be considered as a whole or a totality. There are many other investigators who have defined attitude. In the early part of the 20th century social scientists started propounding definitions of attitudes, most of which emphasized the cognitive and motor aspects of attitudes. The three classical definitions of attitude during this period, which have been cited by Allport (1954, p. 45) are the following: (a) Attitude is the specific mental disposition toward an incoming (or arising) experience, whereby that experience is 26 modified, or a condition of readiness for a certain type of activity (Warren, 1934); (b) An attitude is a mental disposition of the human individual to act for or against a definite object (Drola, 1933); Finally, Allport himself defined attitude in psychophysiological and bio-social terms as (c) A mental or neural state of readiness, organized through experience, exerting a directive or dynamic influence upon the individual's response to all objects and situations with which , 7. 1";4- Lr’ it is related (Allport, 1935). =f”[ The Guttman-Jordan theory considers attitude as a whole or a totality, a universe, composed of interdependent parts in which the parts themselves are subdivided and rearranged in specified diverse ways to represent the totality. It is this unique concept of totality and its ordered components as applied to "attitude-behavior" that enable scientists to quantify qualitative data. Facet theory is therefore a type of "set" theory. All the possible combinations of the diverse elements in a set are called the "set product" or "Cartesian product" (Elizur, 1970). In facet analysis, the combination of the elements across a total set, i.e., a profile, may be viewed as a multivariate instrument which has many variables, aspects, qualities, or facets. Two basic principles arise from the discussion of set theory. The first is the "rationale" which is imposed upon the selection and specification of the basic sets which are called facets. And the second is the method of "ordering" the variables selected for study in the attitude-behavior universe. Guttman (1954) divided factor analysis into two basic types: (a) the method of "common factors," which is the approach used by 27 Spearmen, Thurstone, and others, and (b) the method of "order-factors" which Guttman considers his own approach. Guttman does not make a complete differentiation between these two methods of research, but as mentioned before, he considers factor analytic techniques as the predecessor of facet theory. Guttman's approach to research methodology is primarily motivated by psychological, sociological or social psycho- logical considerations, rather than those of factor analysis which are basically mathematical in nature. In the Guttman-Jordan type attitude-behavior scales two major aspects are considered: (a) the domajn_of the behavior which may be cognitive, affective, or instrumental, and (b) a common range, which is ordered from very positive to very negative towards that object. From the above statement, Guttman develops the "First General Law of Atti- tude" which states that, “If any two items are selected from the universe of attitude items toward a given object, and if the population observed is not selected artificially, then the p0pulation regressions between these two items will be monotone and with positive or Zero Sign" (Gratch, 1973). The value of research is based on the validity and reliability which is imputed to the techniques and instruments of the study. These are the two elements which are specifically considered in facet theory. Since the major goal of Guttman-Jordan's attitude facet theory is to quantify qualitative data, facet theory purports to construct an instru- ment which can measure attitude-behavior or the qualitative aspects of behavior. The strength of the Guttman-Jordan porpositions are: (a) its logical and empirical relevance, and (b) the precision of its 28 "ordering principle" which introduces the concept of semantic structure as a procedure to quantify qualitative data (Foa and Turner, 1970). Four-Level Theory_ If one accepts Guttman's definition (1950, p. 51) of attitude as "a delimited totality of behavior with respect to something," then both verbal reactions andovert behavior can be regarded as attitude. If the attitude responses are properly categorized then the individual responses can be analyzed in an ordered arrangement. Ordered elements within semantic factors are one of the ways which facilitate measure- ment. In a reanalysis and review of the research by Bastide and Van den Berghe (1957), Guttman (1959) isolated three "necessary" semantic factors which may be involved in an attitude response and which can be combined according to definite procedures to determine the element structure of eight important profiles. In Guttman's approach one element from each facet of Table 1 must be represented in any attitude statement. The multiplication of these 2 x 2 x 2 facet combinations produce an attitude universe of eight semantic profiles: (1) a1 b1 c], (2) a1 b1 c2, (3) a1 b2 c2, . . . (8) a2 b2 c2. Guttman's three semantic factors were: (a) the Subject's behavior which consists of belief and overt action, (b) the Referent: group or self, and (c) the Referent's intergroup behavior (comparative or interaction). Each of the above facets contained two elements: one weak and one strong element in each of the three facets. Guttman proposed the "mapping sentence" as a procedure to develop a faceted 29 TABLE l.--Basic Facets Used to Determine Component Structure of an Attitude Universe. (A) (B) (c) Subjects Behavior Referent Referent's Intergroup Behavior a1 belief b1 subjectls group c1 comparative a2 overt action b2 subject himself c2 interaction TABLE 2.--The Four Combinations and Descriptive Names Used in Guttman's Four Level Facet Theory. Level Profile Descriptive Name 1 a1 b1 c1 Stereotype 2 a1 b1 c2 Normative 3 a1 b2 c2 Hypothetical Inter- action 4 az b2 c2 Personal Interaction TABLE 3.--Basic Facets Used to Determine Joint Struction of an Attitude Universe. —.--- ..— ————_ -..—_-. -..——o Actor's Domain of Referent Referent . Actor Intergroup Actor's Behav1or Behavior Behavior a1 others b1 belief c1 others d1 comparison e1 symbolic a self b action c self d interaction e opera- 2 2 2 2 2 tional (I) (overt action) (mine/my) 3O semantic definition of a particular attitude research problem. Guttman provided logical reasons for considering four permutations of strong-weak elements from the Bastide and van der Berghe research. Elements can be ordered within the facets and the facets can be ordered with respect to each other. An ordered analysis of the semantic factors could then be established which will yield N + 1 types of attitude levels. Each succeeding level contains one more "strong" element than the preceeding one. Guttman (1966) hypothesized that if the items are organized in accordance with the four levels, then the levels closest to each other are similar to each other, and are more highly correlated with each other than levels which are more distant from each other. According to Guttman, then the responses to Level 1 should be more similar and more highly correlated with the items and questions of Level 2. Guttman refers to this statement as the "principle of contiguity." By this he means that items that are closer semantically should also be closer statistically. By the principle of contiguity Guttman devises the "simplex" notion. A simplex is a matrix of level-by-level correlations in which the order of the correlations is specified. This simplex hypothesis has been supported by Guttman's own research (1961) and other investigators (Foa, 1958, 1963; and Jordan, 1968, 1971). Guttman's facet proposal is to construct a scale by semantic procedures in order to predict the order of that structure from empirical data. In comparing facet theory with factor analysis one will find that facet theory and Guttman's methodology is the reverse 31 of what factor analysis does. Factor analysis tries to interpret the mathematical outcomes in a descriptive scheme, making correlational statements between what are called factors. Facet theory specifies the factors or "facets" before the data are gathered. Then the hypothesis is tested empirically in order to determine the relation- ship between the hypothesized semantic structure and the obtained statistical structure. Six-Level Adaptation It has been felt by some investigators (Jordan, 1968) that the Guttman attitude facets needed to be extended. Jordan (1968) expanded Guttman's attitude facets to include five facets and six levels. Table 3 contains the facets and elements developed by Jordan. Table 3 indicates the five/two-element/facets which produce 32 possible combinations of elements or profiles (Maierle, 1969). The joint struction of Table 3 is actually defined as the ordered sets of the five facets; low subscript lfs to high subscript gfs for all five facets. Namely, low indicatesa:cognitive-other-passive orientation while high indicates an affective-self—action orientation (Jordan, 1968, 1971). Table 5 contains the six profiles that were chosen as psycho- logically relevant, potentially capable of instrumentation, and pos- sessing a specific relationship between themselVes: a simplex one. In Table 5 joint struction refers to the combinations of facets A through E. Table 5 illustrates the order of the attitude levels; namely 1 < 2 < 3 4 < 5 < 6 or Social Stereotpye < Societal 32 Norm < Personal Moral Evaluation < Personal Hypothetical Action < Personal Feeling < Personal Action. Each of these profiles is a "deliminated totality of behavior." Guttman indicates that an order: jgg_by facets also implies an ordering within each facet. In this case the ordering of l < 2 < 3 < 4 < 5 < 6 implies also the following ordering: a1 < c2, b1 < b2, c1 < c2, d1 < d2, . . . x1 < x2. Attitude content is called "lateral" struction. The lateral struction deals with the content of the items and is very much related to the specific situation or attitude object. Figure 1 has been adopted from Harrelson (1970) in order to illustrate a mapping sentence and five additional facets which show the item content or lateral struction. This table also illustrates the relationship between joint struction or lateral struction on the ABS-MR (Attitude-Behavior Scale- Mental Retardation). The six facets of Table 3 are defined by Jordan (1968, 1971) as follows: Facet A - the referent "other" is weaker than "self"--I in being less personal. Facet B - "belief" is weaker than "action" in being passive rather than being active. 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PmUVLoooomoa oo ”moowczomp No mewmx on» mw> m_m»pmc< xopaewmu .mopomem> we ocwcums Loo uxop momo .memFaoLa Pacowp02m ”m_mum Low>msmm1mu=owup< 1 o2m1mmm1poupcou .oam .o_ .o. o—. oo. up.m Np oo. No.m NP m1_ xou1pumu=oo .oEm .mp Fmo. um. um._ no.~ NF om._ oN.N NP m1p pomucoo .02m .op moo. No. ~_. om.o Np mm. n~.o NP m1p .>Po>:H .mmLuom .m_ oo.F oo. oo. oo.m ~_ me. No.e NP m1F .mcoammL1cowpu< .NF ooo. oo. NP._ mw.m NP om. mm.~ NF m1p mam: pom .PF omo. _m. Fm._ No.~ NF om._ no.~ NF m1_ moF=L1.owFom .o_ mooo. No. Pm.P Fo.m Np mu. No.m NP m1~ mocmpLanw1.oP_mm .m 1 em. mm.~ NF em. mm.N N, m-_ coemwpmm .m 1 ea. mo.p ~_ oo._ oo.~ NP m1p magnum _moPLmz .L moooo.V No. . om. mo.m Np oo. No.m NP m1p .uEu1cowuuuzum .o 1 oo. oo._ NP oo. oo._ NF m1, mo< .m 1 mm. Ne._ NP mm. Ne.P NP N1. xmm .e om. mm. mm.o mw.o~. NP mN.m m~.op N_ om1m Food .m mm. em. ou.e mm.op NP Pm.m ~_.m_ ~_ em-o FmLoz .N No. oo. Pm.o oo.mp NP mm.o No.op NF um1o ELoz ._ a L om cam: 2 am cum: 2 mocmm umpnuer> pm~p1omoa use mLa ANLV ANLV mLoum .._.o n. 9.5 L umm._.1umon_ Hmwh1mLa .xu35m Boom-mm< as» L0 ommpoo_Lo> mop :o um1om a30Lo oo< moo Low mcowpuw>mo uLmucmum ucm mcomz .monm quEmm11.o mom_eowLeoeoeo1 .aeae sew: epewmmee =emea= em L_1ULLLaeeo ._1=wewLo. N Nco "meewezuou No mewex on» ew> mwmxwee< xopeswmu .mmweewLe> we ocwcems Lew uxmu memo .mse—eeLe PecewueEm "eweem Lew>ezem1eueuwup< n o2m1mm1-eeeeeoe .oeN .e_ Ne. N_. mL. ep.m eL me. em.N e_ m-_ aow-eeee=oe .oEe .mL Nee. Le. . em.P em.N e_ em.w eN.N eL m1_ eeeecee .eEe .e_ Le. Ne. me. mN.e me we. _m.e e, m-_ .>_e>:w .meLeme .mp meeee. Le. ee. oe.e e, em. mL.e e_ m1, .mcoemmL1=owee< .N. eeee. _L. em.P Lm.N e. NN.P eL.N e_ m1L mam; eem .__ e_. Nm. em. ee.m mp m_.F em.m e_ m1L me_=L-.ew~ee .e_ Neee. eL. mm. 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