Relationship of ethnicity to conceptions of mental illness and attitude toward seeking psychological help

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Relationship of ethnicity to conceptions of mental illness and attitude toward seeking psychological help
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Thesis (Ph. D.)--University of Florida, 1984.
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Includes bibliographical references (leaves 112-120).
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by Lena E. Hall.
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Vita.

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RELATIONSHIP OF ETHNICITY TO CONCEPTIONS
OF MENTAL ILLNESS AND ATTITUDE TOWARD
SEEKING PSYCHOLOGICAL HELP



BY



LENA E. HALL


A DISSERTATION PRESENTED TO THE GRADUATE COUNCIL
OF THE UNIVERSITY OF FLORIDA IN
PARTIAL FiJLFILL:-1E,' OF THE REQUIRE:1E:iTS
FOR THE DEGREE OF DOCTOR OF PHILOSOPHY


UNIVERSITY OF FLORIDA


1984






























Copyright 1984

by

Lena E. Hall





























In memory of my father and mother who were always

very proud of me.














ACKNOWLEDGEMENTS


My sincere and deepest appreciation is extended to Dr.

Harry Grater, chairman of my doctoral committee, for his

encouragement and support. His confidence in me helped me

to be self-confident. I would also like to acknowledge the

continued support of Dr. Richard Scott. His helpful sugges-

tions and assistance with the statistical analyses are grate-

fully appreciated. I also wish to express appreciation to

Dr. Carolyn Tucker for providing me with a much needed female

role model, and for her encouragement and support over the

past five years. I would like to thank Dr. Franz Epting for

his support, encouragement, and helpful suggestions; and Dr.

Hernan Vera for his confidence in me, and his willingness

to support me.

Special thanks go to my sisters who encouraged me to

continue with my work; Armando for his support over the years;

and Orlando, my son, who is still too young to know what this

is all about, but who kept happy and healthy, allowing me to

work.














TABLE OF CONTENTS



ACKNOWLEDGEMENTS .....................................

LIST OF TABLES .......................................

ABSTRACT .............................................

CHAPTER

1 INTRODUCTION ................................

Purpose of the Study ........................

Hypothesis I ..............................

Hypothesis II .............................

Hypothesis III ............................

Rationale ...................................

Organization of the Study ...................

2 A REVIEW OF THE RELATED LITERATURE ..........

Mental Health/Illness--Some Definitions .....

Popular Conceptions and Attitudes
Concerning Mental Illness .................

Demographic Correlates of Public
Attitude and Information Concerning
Mental Illness ............................

Changing Ideas of Mental Illness
and Its Treatment .........................

Relationship of Knowledge and Attitude
Toward Mental Illness .....................

Cross-Cultural Attitudes and Conceptions
Concerning Mental Illness .................

Utilization of Mental Health
Facilities by Blacks ......................
V


Page

iv

viii

ix



1

3

3

4

4

4

5-

6

6


9



20


25


29


35


44








Demographic Characteristics ................ 53

Type of Service .............................. 54

Type of Personnel Seen ................. .. 54

Contact With Facilities .................. 55

Summary of the Literature .......... ......... 60

3 RESEARCH I'ETHODOLOGY ................. ........ 62

Overview ........................................ 62

Hypotheses ..................................... 63

Hypothesis I ................................. 63

Hypothesis II .................... ........... 63

Hypothesis III .............................. 63

Data Collection Procedures and
Selection of Subjects ..................... 63

Instruments .................................... 64

Fischer and Turner Pro-Con
Attitude Scale ...................... ...... 64

Nunnally's Conception of Mental
Illness Questionnaire ...................... 66

Vignettes ................................... 67

Demographic Information Questionnaire ...... 68

4 RESULTS ................. ........................ 69

Description of the Sample .................... 69

Results Related to the Hypotheses ............ 74

Hypothesis I .................................... 74

Hypothesis II ....................... .......... 74

Hypothesis III .............................. 4

Summary of the Results ........ ................ 83








5 DISCUSSION .........................

Review .............................

Attitude Toward Seeking
Psychological Help .............

Conception of Mental Illness .....

Vignettes ........................

Therapy ..........................

Relationship of Attitude to
Conception .....................

Implications .......................

Limitations and Methodological
Assumptions ......................

Conclusions ........................

Author's Reflections on the Study ..


APPENDICES

A

B

C

D

E


F


REFERENCES


EXPLANATION TO PARTICIPANTS .........

INFORMED CONSENT ....................

INSTRUCTIONS ........................

DEMOGRAPHIC INFORMATION QUESTIONNAIRE

DISTRIBUTION OF SUBJECTS BY
RACE AND SELECTED VARIABLES .......

REGRESSION ANALYSIS OF
CONCEPTION COMPONENTS .............


BIOGRAPHICAL SKETCH ........................


vii


100

101

103

104


106


108


........ 112














LIST OF TABLES


Table Page

1 Distribution of Subjects by Race,
Sex, and Age ................................. 71

2 Distribution of Subjects by Race,
Marital Status, and Highest Education ........ 72

3 Distribution of Subjects by Race,
Religion, and Income ......................... 73

4 Regression Analysis of Attitude Scores ......... 75

5 Regression Analysis of Conception Scores ....... 77

6 Descriptive Statistics for Conception
Component Scores for Whites and Blacks ....... 78

7 Regression Analysis of Race in
Conception Components ......... ........... .... 80

8 Regression Analyses of Responses
to Vignettes ........................... ........ 81

9 Descriptive Statistics for Vignette
Scores for Whites and Blacks ................ 83

10 Regression Analysis of
Therapy Scores ................................ 85

11-A Regression Analysis of Attitude Scores
with Conception Scores for Whites ............ 86

11-B Regression Analysis of Attitude Scores
with Conception Scores for Blacks ............ 87

12 Regression Analysis of Conception
Scores with Vignette Scores for
Whites and Blacks ............................ 89


vii i








Abstract of Dissertation Presented to the Graduate Council
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy

RELATIONSHIP OF ETHNICITY TO CONCEPTIONS
OF MENTAL ILLNESS AND ATTITUDE TOWARD
SEEKING PSYCHOLOGICAL HELP

By

Lena E. Hall

April 1984

Chairman: Harry Grater
Major Department: Psychology

The purpose of this study was to investigate the rela-

tionship of ethnicity to conceptions of mental illness and

help-seeking attitudes among school teachers, and to examine

the relationship of help-seeking attitude to conceptions of

mental illness. It was hypothesized that conceptions of

mental illness, and attitude toward seeking psychological

help are related to ethnicity and not to other demographic

variables. It was also hypothesized that there is a rela-

tionship between attitude to seek help and conceptions of

mental illness.

Four instruments were presented to 513 school teachers

employed by the Alachua County School Board in Florida.

These were the Nunnally Conception of Mental Illness Ques-

tionnaire, the Fischer and Turner Pro-Con Attitude Scale,

ten vignettes that investigated opinions on certain counseling

issues, and a Demographic Information Questionnaire.

The sample consisted of 321 whites and 192 blacks. The

responses they gave to the items were analyzed by hierarchial

multiple regression analyses. The demographic variables
ix







that were considered relevant in these analyses were race,

sex, age, marital status, highest education obtained, reli-

gion, and income.

The results showed that blacks and whites had similar

attitude toward seeking psychological help; therefore, help-

seeking attitude was not related to ethnicity. There were,

however, differences in conceptions of mental illness in

seven of the ten components of the conception scale, with

blacks' conceptions being more stereotypic and whites' closer

to those of mental health professionals. Analysis of the

responses on the vignettes also showed that blacks and whites

responded differently, with blacks responding more liberally

to mix-race, cross-cultural dyads in counseling. They, how-

ever, scored lower than whites on items that investigated the

efficacy of psychological treatment for certain problems.

The results indicated the possibility of cultural dif-

ferences in conceptions of mental illness. These results

might have important implications in the underutilization of

mental health facilities by blacks as well as in the strat-

egies employed in psychological interventions.













CHAPTER 1

INTRODUCTION

The function of counseling is essentially to establish

a temporary means oriented coalition with the client against

the problem. Unless such a coalition can be established, the

problem will continue to control the client and isolate the

counselor (Pederson, 1977). The effectiveness of counseling

is increased when the couneslors involved in these coalitions

have an understanding of the dynamics at work. Differences

in value perspectives of age, sex, lifestyle, socioeconomic

status, all interact to affect the counseling process (Bellis,

Redlich, & Hollingshead, 1955; Hollingshead & Redlich, 1958;

Lorion, 1973).

In addition to the above investigations, research has

focused on popular conceptions of mental illness (Nunnally,

1961; Rabkin, 1974), as well as attitudes toward mental ill-

ness and treatment (Crocetti & Lemkau, 1963; Edgerton, 1969;

Fischer & Cohen, 1972). Investigations such as these are

enabling mental health professionals to get a better under-

standing of the clients that they are trying to help. These

investigations have also shown that public conceptions and

attitude toward seeking psychological help vary according to

the educational level, age, income, sex of individuals (Gurin,

Veroff, & Feld, 1960; Nunnally, 1961).
1







A few researchers have investigated cultural conceptions

of mental Illness (Karno & Edgerton, 1969; Sue, Wagner, Davis,

Margullus, & Lew, 1976; Townsend, 1978), but very little

is known about the ways in which blacks' conceptions of

mental illness and attitudes toward seeking psychological

help differ from those of their white counterparts here in

the United States. However, the underutilization of mental

health facilities by blacks has become a growing concern

among mental health professionals, and the attitudes toward

white mental health professionals and the use of mental

health facilities have been widely researched (Davis & Swartz,

1972; Miller, 1980; Tucker, 1979).

The fact that little is known about blacks' conception

of mental illness is surprising based on the fact that black

people have become oneof the most widely researched minority

groups in counseling literature (Smith, 1977); but much of

this research has not led to a better understanding of how

to counsel them. Many mental health professionals have con-

cluded that racial or ethnic factors may act as impediment

to counseling (Atneave, 1972; Carkhuff & Pierce, 1967; Ruiz

& Padilla, 1977; Sue, 1975; Vontress, 1971). These barriers

to effective counseling often lead to alienation or inability

to establish rapport with the culturally different (Sue &

Kirk, 1975). Third World clients underutilize mental health

services (Sue & Kirk, 1975; Yamamoto, James, & Palley, 1968)

or prematurely terminate after an initial contact. Sue and

Kirk (1975) stated that there seems to be unanimous agreement







among professionals that many Third World clients find the

values of counseling to be inconsistent with their life ex-

periences. Could underutilization of mental health facilities

by blacks be related to their attitude toward seeking psycho-

logical help and conceptions of mental illness? Are these

attitudes and conceptions different from those of their

white counterparts?

Purpose of the Study

The purpose of this study was to determine black and

white school teachers' attitudes toward seeking psychological

help and conceptions of mental illness. Specifically, this

study was designed to provide answers to the following ques-

tions.

1. What is the relationship between help-seeking atti-

tude and ethnicity of school teachers?

2. What is the relationship between conceptions of

mental illness and ethnicity of school teachers?

3. Is there a relationship between conceptions of

mental illness and help-seeking attitudes among school

teachers?

From the above research questions, the following hypoth-

eses were formulated.

Hypothesis I

Help-seeking attitudes are related to ethnicity and not

to other demographic variables.








Hypothesis II

Conceptions of mental illness are related to ethnicity

and not to other demographic variables.

Hypothesis III

Attitudes toward seeking psychological help are related

to conceptions of mental illness.

Rationale

The functions of teachers as socializing and educating

agents in our society have earmarked them as target popula-

tions when knowledge is to be accumulated pertaining to as-

pects of life that will affect personal growth and development.

Conceptions of mental illness and attitudes toward seeking

psychological help are pertinent to such growth and develop-

ment, and hence pertinent to teachers. Mental health pro-

fessionals have long been aware of this and have concentrated

their research efforts in this area (Rabkin & Suchoski, 1967;

Yamamoto & Dizney, 1967).

Another aspect is the day-to-day judgments teachers are

expected to make concerning mental health/illness of their

students, and the comcomitant nonreferral or referral to

guidance counselors and other mental health service providers.

It is, therefore, of paramount importance to mental health

professionals that teachers' views of mental illness and

attitude toward seeking help parallel their own, and to

correct whatever differences that exist through appropriate

mental health education programs. One of the primary pur-

poses of this study was to obtain base-line data on these

issues.




5

Organization of the Study

The remainder of this study is organized into four chap-

ters and appendices. A review of the literature related to

conception of mental illness and demographic correlates of

public attitude and information concerning mental illness is

presented in Chapter 2. Chapter 3 contains a description of

the methods and procedures employed. A summary of the results

is presented in Chapter 4. Discussion and implications are

presented in Chapter 5.













CHAPTER 2

A REVIEW OF THE RELATED LITERATURE

The review of the literature related to the investiga-

tion is divided into several broad areas: (a) some defini-

tions of mental health and mental illness, (b) popular con-

ceptions and attitudes concerning mental illness, (c)

demographic correlates of conceptions and attitudes concerning

mental illness, (d) changing ideas of mental illness and its

treatment, (e) relationship of knowledge and attitude toward

mental illness, (f) cross-cultural attitude toward and con-

ceptions of mental illness, and (g) utilization of mental

health facilities by blacks.

Mental Health/Illness--Some Definitions

A definition of mental health has been studiously avoided

by all its proponents. Thorpe (1950) stated that the reason

for this is that mental health may have different meanings

or implications at different times but can be described in

terms of negative or positive factors. From the negative

point of view, mental health has reference to the absence

of symptoms of maladjustment, be they mild or severe. Such

symptoms range along a continuum from feelings of guilt or

inferiority through psychosomatic disorders and the psycho-

neuroses, to the organic and functional psychoses. The men-

tally healthy individual is free from such maladjustments.
6







On the positive side, mental health means satisfactory ad-

justment and adaptation by the requirement of group life.

Such adjustments can be described in terms of degree. A

broad aspect of such adjustment is that of adjustment of in-

dividuals to themselves and the world at large with a maximum

of effectiveness, satisfaction, cheerfulness, and socially

considerate behavior, and the ability to face and accept the

realities of life. An even higher degree, according to

Thorpe, is the experiencing by the individual of the greatest

success which his abilities make possible, with a maximum

sense of well-being on his own part, and the highest possible

benefit to society.

Dannenmaier (1978) stated more cautiously that mental

health appears to be a state of affairs primarily within the

individual, which permits an optimal exercise of his talents

and a steady movement toward an optimal satisfaction of his

needs. He further stated that in some cases, society decides

that an individual's mental health is bad, without that in-

dividual's full agreement. The problem of mental health is

therefore multidimensional. The major sources of problems

being either within the person and/or between the person and

the society in which he lives.

Gladstone (1978) posited adaptability as the goal and

measure of mental health. Behavior that may have been de-

fined as adaptable in America fifty years ago may not hold

true today, He further stated that a time period creates

different modes of adaptability, but in general, adaptability

implies the ability to love, work, play in a balanced measure.







Gladstone sees mental illness as the converse of men-

tal health. For him, the notion of mental illness involves

restricted patterns of adaptation ending ultimately in the

inability to adapt at all, or in death.

Gallagher (1980), unlike Gladstone, did not see mental

health and mental illness as minor opposites of each other

but believes this approach is used because it is manageable.

He had posited that it is the cultural variation of what is

normal that makes the opposite approach unmanageable. He

believes that there is no psychologically meaningful and

operationally useful description of what is commonly under-

stood to constitute mental health. He claims that absence

of mental disorder, correct perception of reality, adjust-

ment to one's environment, and intrapsychic equilibrium are

the themes he comes across most frequently in attempts to

delineate mental illness.

Miles (1981) asserted that the question of who is men-

tally ill has proved an exasperatingly difficult question

to answer and that there is no consensus of opinion on the

subject in spite of the voluminous literature. A somewhat

plausible suggestion to solve this definition problem was

proposed by Crocetti, Spiro, and Siass (1971). This was the

suggestion to adopt a multiple model of mental illness. They

pointed out that it is ironic that at a time when virtually

all data point to the need for multiple models to understand

the varieties of mental illness, pleas are being advanced

for regression to an oversimplified unitary model of social







deviancy. They contend that such oversimplification runs

counter to the mounting data from such diverse sources as

anthropology and existential epistemology, psychophysiology

and behavioral psychology, sociology and neurochemistry, and

psychoanalysis and phenomenology.

As Miles (1981) pointed out, the debate about the con-

cept and nature of mental illness, conducted by medical and

social scientists, is remote from the daily practice of pro-

fessionals, and even more so from the everyday lives of lay-

men. He claimed that despite the lack of accepted definitions,

lay people make frequent use of the term mental illness, or

one of its many substitutes (such as "crazy," "mental," or

"mad") and have their own ideas as to what these mean.

Popular Conceptions and
Attitudes Concerning Mental Illness

Scott (1958), in his review of the research definitions

of mental illness, concluded that underlying the diversities

in definitions one can discern basic differences of view-

point concerning how the phenomena should be conceptualized.

Disagreements, he claims, can be abstracted by the following

four points of contention: (a) does mental illness refer to

a unitary concept or to an artificial grouping of basically

different specific disorders, (b) is mental illness an acute

or chronic state of the organism, (c) is maladjustment (or

deviance from social norms) an essential concomitant of

mental illness, (d) should mental illness be explicitly de-

fined according to the values other than social conformity?

He conjectured that the resolution of disagreements would







depend in part on the outcome of future empirical research

but adds that "at least some of the divergence inheres in

the theoretical formulation of the problem, and is more a

matter of conceptual predilection of empirical fact" (Scott,

1958, p. 39).

Over the past forty years, mental health professionals

have become increasingly interested in not only professional

conception of mental illness, but those of the public as

well. Definition of mental illness made by the lay public

is crucial with regard to who is treated and comprehension

of medical care programs requires an understanding of how

such definitions are made. Persons recognized and treated

may not be those most in need of treatment by psychiatric

criteria because the physician trained in the treatment of

the mentally ill applies different criteria to behavior than

does the layman (Mechanic, 1962).

One of the earliest researches into the investigation

of information concerning mental illness was by Ramsey and

Seipp (1947). Interviews were conducted by the researchers

and five graduate assistants. All questions were presented

orally to 345 respondents. In this investigation, data were

collected concerning opinions, attitudes, and information on

various aspects of nervous and mental illnesses. The respond-

ents consisted of a fairly representative group taken from

the population of Trenton, New Jersey. The answers given by

the respondents as to the cause of insanity were primarily

stated in terms of naturalistic rather than mystical or







supernatural concepts. However, some of the naturalistic

explanations were contrary to known facts or at least ques-

tionable in light of present-day knowledge. Explanations

of the causes of mental illness usually were based upon psy-

chogenic concepts. The researchers reported that only very

few individuals gave evidence of being able to differentiate

between the major and minor forms of mental illness. Symp-

tomatologies of mental diseases and environmental forces sur-

rounding the individual frequently were considered to be

causes of insanity.

One series of the questions sampled attitudes and opin-

ions concerning mental health. The first of the questions,

as reported by the researcher, pertained to the association

of sin and insanity. Seventy-four percent of the people in-

terviewed did not believe that insanity came as God's punish-

ment for some sin or wrongdoing, but 20% of the respondents

still adhered to this belief. Regarding the role that in-

heritance plays in insanity, it was found that 20% of the

respondents felt that insanity was completely due to heredity,

whereas 32% thought heredity bore no relationship to insanity

at all.

Of the questions concerning attitudes toward the prog-

nosis of mental illness and the type of treatment people

would recommend, 91% of the respondents felt that something

could be done for individuals who were exhibiting "very

strange and odd behavior." The researchers reported that

most of the respondents recommended some sort of professional







care, but about 25% did suggest some type of home care and

treatment.

Another of the early researches into the investigation

of conception of mental illness by the public was by Star

(1955), who asked a sample of 3,500 respondents about six

case abstracts of mentally ill persons (a paranoid schizo-

phrenic, an alcoholic, a depressed neurotic, a simple schizo-

phrenic). Of the sample, 17% said that none of these imagi-

nary persons was mentally ill, and another 28% limited their

concept of mental illness to the paranoid schizophrenic--the

only description where violence was a predominant feature of

the behavior.

Cummings and Cummings (1957) developed a mental health

education program within the Blackfoot Community (Prairres

Province in Canada). According to the researchers, the

citizens there had achieved little awareness of their own

attitude toward mental health and mental illness. The re-

searchers ascertained attitudes and beliefs of the local

population prior to the program and at the conclusion of

their educational efforts.

The Cummings' not only experienced a strong resistance

on the community's part to change their attitudes, but there

was also a pervasive "normalizing" theme. This consisted of

a tendency of the respondents to dismiss described psycho-

logical symptoms with comments such as "it's just a quirk"

or "it takes all sorts to make a world." They reported

that some respondents denied the seriousness of even the








bizarre behavior of the paranoid schizophrenic. This denial,

they claim, is one of the crucial differences between lay

and professional judgments of psychological symptoms.

By the 1960's, the exploration of public information

and attitude began to mushroom as a possible consequence of

the previous researches (Cummings & Cummings, 1957; Joint

Commission on Mental Health, 1961; Star, 1955). The Joint

Commission on Mental Health (1961) reported that there was

a major lack of recognition of mental illness as illness,

and a predominant tendency toward rejection of both the men-

tal patients and those who treat them.

The Lemkau and Crocetti (1962) study did not find evi-

dence to support the concept that there was a tendency on the

part of the public to "deny" mental illness, but found some

evidence of what the Joint Commission described as "pervasive

defeatism" concerning the mentally ill.

Nunnally (1961) reported a wide range of studies which

not only assessed public and professional information on

mental illness but also researched public attitude toward

the mentally ill, putlic attitude toward experts and treat-

ment, as well as studies on information transmission and

attitude change.

The instrument developed by Nunnally to measure con-

ception of mental illness has been used by several other

researchers. From the data that Nunnally collected, he

reported that there is a dislike and fear of the mentally

ill and that there is an overall tendency to degrade







mental health concepts, that the stigma is pervasive and not

easily changed by schooling and other cultural influences.

Nunnally claimed that whereas the information held by

the public is not really "bad" in the sense that the public

is grossly misinformed; the attitudes held by the public are

as bad as is generally expected. He also claimed that one

of the most important findings was that there was a strong

"negative halo" associated with the mentally ill and that

such unselectively negative attitude may in part be due to

a failure to observe and learn mental health phenomenon in

daily life.

When Nunnally researched the public's attitude toward

mental health professionals, using semantic differential

scales, he found that in the case of the comparison between

doctor and psychiatrist, for example, the psychiatrist was

rated less favorably on every scale, and on 14 of the 19

scales used, this difference was significant beyond the .01

level by t-test. When psychologist was compared to doctor,

the average absolute difference (showing the doctor as more

generally favorable) was significant beyond the .01 level 16

out of 19 times. In general, nurse was rated more favorably

than psychiatrist. On 14 of the 19 scales, the differences

were significant at the .01 level of confidence by t-test.

The study investigating attitude toward treatment

methods and institutions showed that hospital was rated as

much more valuable, safe, predictable, and understandable

than mental hospital. The results for treatment techniques







were similar with physical treatment looked at more favorably

than mental treatment. The mean differences between the at-

titudes toward the two types of institutions were much more

pronounced than were the mean differences between the atti-

tudes toward mental and physical health professions.

Studies such as those by Crumpton and Wine (1965) in-

vestigated conceptions of normality and mental illness held

by normal and schizophrenic adults. The researcher pointed

out that the results made it clear that there are differences

between normals and schizophrenics in their conceptions of

normality and mental illness. They stated, though, that

they could not determine with complete certainty what the

differences were but saw them as intriguing leads. According

to the results, the normals said the mental patient was sick;

the schizophrenics said the mental patient was not sick,

he was immoral. The normal thought the patient was danger-

ous, but the schizophrenic considered him safe. The normal

said a man can be neurotic and still be normal; the schizo-

phrenic did not know what it took to be normal.

Another study (Crumpton, Weinstein, Acker, & Annis,

1967) investigated how patients and normals see the mental

patient. They reported that the image of mental patient,

as seen by both patients and normals was "unflattering."

However, they found that patients were more charitable toward

the concept of "mental patient" than were the normals.

Again, the notion that normals view mental illness in terms








of sickness and danger, while patients' views were more in

moral terms, were reflected in this study.

As exemplified by the last two studies cited (Crumpton

et al., 1967; Crumpton & Wine, 1965), research on public

information and attitude in the late sixties began to be

directed at specific populations, and with this new approach,

teachers also became a focus of interest to researchers

(Rabkin & Suchoski, 1967; Yamamoto & Dizney, 1967).

The role of education in improving information and at-

titude was recognized by the Joint Commission on Mental

Health (1961). Rabkin and Suchoski asserted that if there

is to be any success in bringing about any basic alteration

in information of, and attitude toward mental illness, then

the schools must play a prominent part in the campaign.

They further asserted that the child not only learns from

the direct tuition of the teacher but incorporates as well

his attitudes and conceptualizations about the world. This

is as true for the grade child as it is for the college

student. They claim, therefore, that if teachers are to be

entrusted with the responsibility for disseminating this

information, it is important that it is known what infor-

mation and attitude they possess.

In this investigation, 107 teachers taking summer courses

at the University of Washington served as subjects. Infor-

mation about mental illness was measured by the questionnaire

developed by Nunnally (1961). This was a forty item ques-

tionnaire consisting of a series of statements concerning








mental health problems. All subjects were asked to indicate

the extent of their agreement or disagreement with such

statements as

1. Will power alone will not cure mental disorders.

2. Psychiatrists try to show the mental patient where

his ideas are incorrect.

3. Mental health is largely a matter of trying hard

to control emotions.

The 40 items were factor analyzed into ten components of

four questions each, representing the following concept

clus ters.

1. Look and act different--the mentally ill are ob-

viously aberrant in manner and appearance.

2. Will power--people who are mentally ill are not

utilizing will power and trying to get better.

3. Sex distinction--women are more likely to develop

mental disorders than men.

4. Avoidance of morbid thoughts--positive thinking

is the key to mental health.

5. Guidance and support--mental health is maintained

by relying on strong persons in the environment.

6. Hopelessness--little can be done to cure mental

disorders.

7. Immediate external environment versus personality

dynamics--immediate environment pressure versus personal his-

tory is seen as the prime etiological agent in mental disorder.







8. Nonseriousness--emotional difficulties are really

trivial matters.

9. Age function--older people are more prone to emo-

tional disorders.

10. Organic causes--a mental disorder is caused by

organic factors and nervous system disease.

The second set of data consisted of a measure of atti-

tudes toward, and connotative meaning of, mental health con-

cepts. The Semantic Differential measuring instrument by

Osgoode, Suci, and Tannenbaum (1957) was used.

The researchers found that, on the whole, teachers are

reasonably well informed concerning mental health problems.

Their responses were compared to data from an Illinois study

representing the responses of a sample group of the general

public and a sample of psychiatric experts. Except for

components 9 and 10, their responses fell to the more "cor-

rect" side of the public's responses. The differences

between teachers and experts were relatively small.

However, the researchers reported that when it came to

the more affective components of their response (the atti-

tudinal aspects), teachers unfortunately presented a pic-

ture similar to that of the general public. Mental patients

were "viewed with.distrust, and generally devalued, were

seen as strange and incomprehensible, as well as unsafe"

(Rabkin & Suchoski, 1967, p. 40).

The overall findings, however, when the literature was

reviewed by Crocetti et al. (1971), was that (a) the "man








in the street" had bought the mental health story and be-

lieved to the point of consensus that the mentally ill re-

quire medical care as do those who suffer from any somatic

illness and that he was optimistic about their prognosis;

(b) the man in the street was perfectly able to identify,

other than the most "exaggerated deviations" as mental ill-

ness, and did identify the simple schizophrenic, the alco-

holic, and the juvenile character disorder, and others. An

"exemplar of the public" did not place a sizeable social

distance between himself and the labelled "mentally ill."

Contradicting this conclusion, Miles' (19811 report,

based on his reviews, was that the concepts of "mental ill-

ness" and "mental patient" have an unfavorable public image.

This, he claimed, had been the evidence of numerous surveys

designed to elicit public opinions and attitudes. He pointed

out that studies have consistently shown that people evaluate

mental illness negatively, reject and discriminate against

mental patients, and base their views on traditional stereo-

types. He claimed that the public opinion surveys elicited

public responses of fear and rejection, far exceeding the

intensity responses evoked by physical illness.

It is interesting that Crocetti et al. (1971) were op-

timistic about the public opinions and attitudes toward men-

tal illness and felt that the public was well informed

and was truly sensitive to the needs of the mental patient,

while Miles had the opposite reaction. Miles pointed out,

though, that the differing research results are not quite







as contradictory as they appear. He referred to the Elinson,

Padilla, and Perkins (1967) study where three-quarters of

the respondents agreed that unlike physical illness, mental

illness tends to repel people, yet only 16% admitted to being

repelled themselves, the rest indicating that only others

reacted in this way. Miles felt that people might have been

responding to the medical view of mental illness which to

them is "progressive" and "modern" and hence expected of

them. Rootman and Lafave (1969) had also cautioned that

attitudes expressed during an interview may not reflect

actual behavior toward the mentally ill.

Demographic Correlates of Public
Attitude and Information Concerning Mental Illness

As the stigma of the label "mental illness" became widely

acknowledged and documented (Rabkin, 1972), researchers be-

gan investigating demographic correlates of conceptions of

mental illness, and attitude toward it. Ramsey and Seipp

(1947) administered a public opinion questionnaire in the

field of mental health to 345 individuals in Trenton, New

Jersey. The population interviewed was fairly representa-

tive according to six background variables of sex, age, race,

religion, educational level, and occupational class.

When the responses to the questions were analyzed ac-

cording to these background factors, the differences revealed

that the higher the educational level

(1) the more optimistic the report given concerning

the outcome of mental disorders;







(2) the greater the tendency to recommend professional

treatment in place of home care;

(3) the more frequently there occurred the qualified

response that insanity might be inherited;

(4) the less frequent the association of sin with

insanity;

(5) the less the belief in the deleterious effects of

associating with the insane; and

(6) the less frequent the response that poor living

conditions were a cause of insanity.

The researchers reported that somewhat similar results

were found for men, younger age groups, Protestants, and

white respondents; and less so for women, older age groups,

Roman Catholics, and black respondents. Blacks more fre-

quently associated sin and heredity with causes of insanity.

In Hollingshead and Redlich's (1958) New Haven Commu-

nity Study, they found that persons in the higher classes

held more favorable attitudes toward psychiatrists than

those in the lower classes. This inference was supported

by the responses of a stratified sample of 517 persons, to

questions about their willingness to turn to psychiatrists

for help in emotional difficulties. Seven out of eight of

the upper class respondents had a fair grasp of the psychia-

trist's function; practically all knew he was a medical

doctor. Among the lower class, the researchers reported

that less than one person in sixteen knew that a psychiatrist

was a doctor, and even fewer had more than a vague idea of

a psychiatrist's function in society.







Nunnally (1960) pointed out that the favorableness of

initial attitudes toward mental illness concepts is unre-

lated or only weakly related to prominent dimensions of in-

dividual differences such as age, sex, education, intelli-

gence test scores, and some measures of personality. However,

he pointed out that the correctness of initial information

about mental illness/health phenomena corresponds strongly

to general sophistication; sophistication being represented

by years of formal schooling and intelligence scores.

These results were comparable to those of Rabkin and

Suchoski (1967) who investigated mental health views of

school teachers and found that teachers, when compared to

the public, were better informed about mental illness. Their

attitudes, however, were similar to those of the public.

Freeman and Kassebaum (1960), through zero-order corre-

lations and factor analysis of their data on opinions about

mental illness, found that the opinions regarding the etiology

and prevention of mental illness were only slightly, if at

all, related to the level of formal education; and they were

only weakly correlated to knowledge of the technical vocab-

ulary.

Clark and Binks (1966), in their analysis, found evi-

dence to support their hypothesis that the younger, more

educated, hold more liberal views about mental illness than

the older and less educated.

Fischer and Cohen (1972) categorized subjects by social

class, educational level, religion, and major in their







investigation of attitude toward seeking psychological help.

They used a large sample of high school and college students

to test two hypotheses regarding the expected relationship

between help-seeking attitude and socioeconomic class.

The first hypothesis was that subjects from upper class

families hold more favorable attitudes than subjects from

lower class families, particularly among high school and

beginning college students (i.e., before education has had

an effect). The second hypothesis was that orientations

to professional help become more positive as education

increases (and, therefore, the discrepancies between people

of different class origins diminish with advanced educa-

tion).

Contrary to the researchers' expectations, they found

that social class background had no evident connection to

subjects' help-seeking attitude. They found, though, that

educational level differences were highly significant.

Attitudes of college juniors and seniors were more favor-

able than college freshmen and sophomores, and college fresh-

men and sophomores had more positive attitudes than high

school students. They found that the effects noted for edu-

cation were independent of subject's age, so that positive

association between education and attitude scores held even

within fixed age groups. The obverse relationship (i.e.,

a correlation between age and attitude with education con-

stant) did not obtain.








In the case of religion, the researchers reported that

Jewish subjects tended to express more favorable attitudes

than Catholics or Protestants. This more positive attitude

of the Jews was present at every socioeconomic level.

In terms of scholastic majors, psychology majors were

more positive in their help-seeking attitudes than humanities,

hard science, or applied program majors.

Fischer and Cohen (1972), in explaining the "surprise"

result as far as "lower class" subjects go, pointed out that

the "lower class" persons who participated in the study were

atypical representatives of lower class subculture, since

many of them, as college or nursing students, were headed

to higher societal positions. This, they further pointed

out, make it obvious that help-seeking attitudes of working

class people are by no means negative or immutable.

This significance of educational level to positive at-

titude toward seeking psychological help was not surprising

to these researchers who made reference to the 1960 study

by Gurin, Veroff, and Feld (Americans View Their Mental

Health). This report showed that sex, age, and education

are consistently related to self-referral measure. Women,

young persons, and the more educated have sought psychologi-

cal help more than any other group. According to the report,

the more educated were the largest self-referred group to

psychiatrists, as well as to other help sources such as

ministers, or nonpsychiatric physicians.








Dohrenwend and Chin-Song (1967) researched social status

and attitude toward psychological disorder in relationship

to the issue of tolerance of deviance. From their data,

they concluded that the appearance of greater tolerance of

deviant behavior in low status groups is an artifact of

viewing their attitudes within a high status frame of refer-

ence. They reported that when both lower and upper status

groups define a pattern of behavior as seriously deviant,

lower status groups are less tolerant. Also, the relatively

tolerant policy of upper status groups appeared to be a con-

sequence of their generally more liberal orientation rather

than comprehension of the nature of psychopathology in

psychiatric terms.

Changing Ideas of Mental
Illness and Its Treatment

Research investigating changes in ideas concerning men-

tal illness and its treatment has parallelled researches

on popular conceptions and attitudes. The findings of such

investigations have been contradictory and complex. In a

study of attitudes toward mental illness in Louisville,

Woodward (1951) surveyed a cross-section sample of 3,971

Louisville residents and came to the conclusion that the

people (at least in Louisville) were moving toward "a hu-

manitarian and scientific point of view of mental illness

and have come quite a long way in that direction" (p. 444).

According to Woodward, the old ideas that the mentally ill

were

bad and dangerous and hence to be punished
(on the one hand) or were ludicrous and







silly, and hence to be laughed at (on the
other hand) seem to be to a considerable
extent superseded by the feeling that men-
tal illness is a sickness that should
evoke sympathetic understanding, and that
requires some form of professional treat-
ment. (Woodward, 1951, p. 444)

The researcher said she found that the sense of stigma

associated with mental illness was passing. She reported

that about half of the respondents said they would not hesi-

tate to tell friends and acquaintances about a family member

who was mentally ill, "just as if he had heart trouble or

asthma." However, she found a gross failure to recognize

serious mental symptoms, at least when they were described

in words. Woodward hypothesized that it might have been

different if the people described were observed.

Woodward also reported a considerable loss of faith in

repressive and punitive techniques, especially in dealing

with juveniles, and there was no strong negative reaction

to the psychiatrist, who she claimed was coming to be re-

garded as the logical person to handle identifiable cases

of mental disorder. She reported that the psychiatrist was

also seen as a useful resource in dealing with less serious

personality problems, although some stigma was attached to

his patients.

Lemkau and Crocetti (19621, like Woodward, had positive

response to their attitude studies ten years later, and re-

futed the widely accepted picture of the social response

to mental illness as "essentially rejective and punitive."

The researchers claimed that their study, carried out in







Baltimore, was to explore the readiness of a population to

accept a program to provide home care for psychiatric pa-

tients. They referred to previous studies that showed a

tendency to "isolate and reject the mentally ill," but they

found that the most common reasons for advocating hospital-

ization was that respondents felt that a change of environ-

ment would be best for both family and patient. This was

coupled with the feeling that the families concerned had

something to do with the patient's illness, and that the

patient might benefit from being away from them.

The findings of Lemkau and Crocetti were confirmed by

Dohrenwend and Chin-Song (1967), but Rootman and Lafave (1969)

argued that Lemkau and Crocetti had based their conclusion

mainly on a comparison of results they obtained in a 1960

Baltimore study with those obtained by Cummings and Cummings

(1957) when they investigated the attitudes toward mental

illness of a small Canadian town named Blackfoot. Rootman

and Lafave also pointed out that Lemkau and Crocetti them-

selves had raised the possibility that there was something

special and different about the Baltimore population that

rendered comparability with other populations impossible.

Rootman and Lafave felt that comparison of Blackfoot

to another comparable Canadian community--Saltwater--would

result in more relevant conclusions concerning attitude

change. This comparison of Blackfoot to Saltwater (Rootman

& Lafave, 1969) showed that not only did the residents of

Saltwater possess more knowledge about mental illness

but they also placed less social distance between themselves







and the mentally ill. Rootman and Lafave, however, pointed

out that it is quite possible, though unlikely, that urban

populations (e.g., Baltimore) have not changed at all in

their attitudes and knowledge, that they may always have

been more sophisticated about mental illness than rural popu-

lations with gradual enlightenment among rural populations

an accelerating phenomenon.

Ten years later, Baltimore was researched again. Cro-

cetti et al. (1971) wanted to find out if the attitudinal

distance toward mental illness had changed over the years

or had remained the same. The prior study of Lemkau and

Crocetti (1962) had employed a probability sample of the en-

tire population of Baltimore and had given them Star's (1955)

original standard descriptions of a withdrawn schizophrenic

girl, an alcoholic man, and a paranoid man. These persons

were not identified as mentally ill. Respondents were asked,

"do you think X should see a doctor or not?" For the schizo-

phrenic girl, 93% had answered yes. For the paranoid, 96%

had answered yes. For the alcoholic, 85% had answered yes.

The study of Crocetti et al. (1971) employed a probabil-

ity sample of 1,076 from a group of 4,827. Respondents were

asked, "do you think people who are mentally ill require a

doctor's care just as much as people who have any other sort

of illness?" The researchers reported that more than 99% of

the respondents answered yes. Other questions dealt with the

optimism or pessimism about the outcome of treatment, as








well as questions dealing with attitude toward ex-patients,

employing social distance statements such as, "could you

imagine yourself falling in love with someone who had been

mentally ill?" Using two random samples, a decade apart,

and using different question formats, the researchers found

evidence that for at least a decade, the public had accepted

mental illness as illness. They also looked to the medical

profession for treatment of this illness and were optimistic

about the outcome of such treatment. The researchers claimed

there was no evidence in their study of extreme rejection

of the mentally ill by blue collar workers.

In summarizing research on public attitude, Miles (1981)

remarked that a general conclusion of the many studies must

be that people in Western societies appear to be moving to-

ward greater acceptance of mental disturbance as another

illness and toward a lessening of the traditional fear, dis-

like, and mistrust it implies; but he emphasized that there

exists today a large proportion of the lay people who con-

tinue to hold the traditional notions.

Relationship of Knowledge and
Attitude Toward Mental Illness

Some researchers in this area viewed knowledge as syn-

onymous with education; others confined the term to men-

tal illness information. Even when knowledge is used to

include both concepts, research in this area is limited,

but directional.

Hollingshead and Redlich (1958) reported that Class

I and Class II (the most educated of the population)







respondents in the community he studied, had (with the excep-

tion of a few) little knowledge of the principles of dynamic

psychiatry before they entered treatment. Even those whose

knowledge they rated as fair

usually knew little more than that psy-
chiatry deals with mental illness and
that the psychiatrists heal-their pa-
tients, not only with drugs and surgery,
but also by "mental methods." (Hollings-
head & Redlich, 1958, p. 339)

The researchers, however, point out that they were unable

to tell just how these "mental methods" work and how emo-

ticnal stresses and problems are related to emotional and

physical problems even after months of psychotherapy.

The educated, though, have consistently been shown to

have the most positive attitude toward seeking psychological

help (Fischer & Cohen, 1972; Gurin, Veroff, & Feld, 1960;

Hollingshead & Redlich, 1958).

Freeman and Kassebaum (1960) found no correlation be-

tween formal education and opinions of the etiology and pre-

vention of mental illness. They, however, sanctioned a

rash conclusion based on this one analysis that knowledge

has little influence on opinions and attitudes toward men-

tal illness. They did, however, caution practitioners asso-

ciated with mental hygiene and health education programs,

in thinking that giving people the facts alters their opin-

ions. They believe that basic research is required into

the question of the "frames of reference by which persons

integrate factual information and personal opinion" (Freeman

& Kassebaum, 1960, p. 47). Such, they claim, would enable







health educators to develop more realistic community mental

health programs.

Freeman and Kassebaum cited Shirley Star (1957), who

said then that she thought that the primary reason for the

failure of mental health education was readily apparent; it

was that mental health education had primarily devoted it-

self to attempting to implant its psychiatrically oriented

conclusions into the thinking of people, starting from dif-

ferent premises; these conclusions being mental illness

facts without anything about the roots of human personality

and behavior.

Rabkin and Suchoski (1967) found that teachers, when

compared to the general public, had more "correct" informa-

tion on mental illness but had similar negative attitudes

toward it--again attesting to the irrelevance of informa-

tion to attitude. This was in agreement with Nunnally's

(1961) summary comment that whereas correctness of informa-

tion correlated to demographic variables such as age and

education, correlations between attitudes and such demo-

graphic variables are very small. Old people and young

people, and people with little formal schooling all tend to

regard the mentally ill as relatively dangerous, dirty, un-

predictable, and worthless (p. 51).

Phillips (1967) referred to both the studies of Lemkau

and Crocetti (1962) and Dohrenwend and Chin-Song (1967)

which inferred that the increasing ability of the public

to identify mental illness represented a step forward in







public attitude toward the mentally ill. Phillips was not

clear why this should be so but thought that if the public

increasingly considered mentally ill people to be mentally

ill rather than difficult, ill-mannered, bad tempered, or

socially deviant, that would in some way help them to become

more supportive of those persons.

In an earlier paper, Phillips (1966) had suggested that

the increased ability to identify mental illness may have

consequences opposite to that cited above, i.e., the person

whose behavior is correctly identified as mental illness

may as a result be stigmatized and may derive less under-

standing and support from those around him. To test this

hypothesis, Phillips asked a random sample from New Hamp-

shire to respond to three descriptions of mental illness

developed originally by Star (1955) and then asked them to

respond to a social distance scale which consisted of items

such as

1. Would you discourage your children from marrying

someone like this?

2. If you had a room to rent in your home, would you

be willing to rent it to someone like this?

After the respondents answered the social distance scale

questions about each case, they were asked whether the per-

son had some kind of mental illness or not.

The researcher found that the ability to correctly iden-

tify those behaviors as mental illness was not associated

with acceptance but rather with rejection. He admitted that







the association between identification and rejection did not

provide a causal relationship but pointed to two possibil-

ities.

(1) It might have been that respondents strongly re-

jected those mentally ill individuals on the basis of their

objectionable behavior, and then when asked whether or not

they considered them mentally ill, responded affirmatively

to support their earlier negative evaluation.

(2) Because respondents had already identified those

descriptions of mentally ill people (i.e., when first en-

countering the descriptions, and prior to answering the so-

cial distance scale questions), they rejected them strongly

based on this identification.

Phillips finally concluded that these findings did not

support the conclusions of Dohrenwend and Chin-Song, nor

those of Lemkau and Crocetti that the ability to identify

mental illness represents a step forward in public attitude

toward the mentally ill.

Altrocchi and Eisodorfer (1961), after investigating

the proposition that attitude change may occur as a func-

tion of increased information, reported that the results

of their study did not support this proposition. They used

didactic instruction about mental illness and obtained atti-

tudinal reactions to abstract concepts like "insane man"

through semantic differential scores.

This lack of relationship between knowledge and atti-

tude was also exemplified when a French and a non-French







Canadian town were compared (Lafave, Rootman, Sydha, & Duck-

worth, 1967). It was found that the more "enlightened"

and 'sophisticated" community manifested less tolerant be-

havior toward the mentally ill. Over one-third of the adult

population of the community signed a petition to reject the

establishment in the community of a halfway house for for-

mer residents of the town who had been hospitalized in the

state mental hospital.

The researchers reported that in contrast, the residents

of the "unenlightened" and "unsophisticated" town had been

most cooperative in the establishment and operation of three

foster homes for patients, some of whom had never been resi-

dents of the community.

Yamamoto et al. (1967), in their study of college stu-

dent teachers, had them indicate their mental health atti-

tudes in response to case descriptions on a questionnaire.

The main hypothesis was that among subjects of roughly similar

socioeducational level, rejection of the mentally ill, ex-

pressed in terms of social tolerance, and suggested help-

source, is a function of (a) type of described case, (b)

sex of described case, and (c) sex of respondent.

These researchers, granting weakness to the use of ques-

tionnaire case descriptions to approximate actual behavior,

found little to indicate any influence of training and educa-

tion upon the mental health attitudes of teachers.

Dixon (1967) compared attitude change after completion

of psychology courses. He found some favorable attitude







changes but subsequent interviews with the instructors led

him to believe that the instructor's attitude had greater

effect on the students' attitude than did the content of

the text used. This is more in agreement with other reports

that imparting information about mental illness does not,

by itself, alter attitudes of the general public (Rabkin,

1972).

Cross-Cultural Attitudes and
Conceptions Concerning Mental Illness

The clinical approach to mental illness supports the

notion that except for superficial variation in content,

psychiatric disorders are viewed as fundamentally the same

(Townsend, 1978). Based on this approach, Kiev (1969) sug-

gested that the difficulties inherent in cross-cultural study

of mental illness can be overcome by intensive studies of

a single culture.

The sociocultural approach to mental illness is sup-

ported by those who contend that behavior disorders vary

cross-culturally because they are molded by the particular

stresses and strains of a given society. There is also the

belief that virtually no act is inherently abnormal; cul-

tural context and more define what is normal or abnormal

(Benedict, 1934).

Gallagher (1980) espoused a similar view. He stated

that there is an important relationship between mental ill-

ness and the wider social forces commonly known as culture.

From his perspective, culture influences the very way men-

tal illness is defined; the same behavior can be considered








healthy or normal in one culture and ill or abnormal in

another.

In Scheff's (1960) analysis of mental disorders as

social roles, he stated that both before and after public

labeling, the popular conceptions of mental illness which

have been learned and culturally reinforced since child-

hood govern the expectation of the rule-breaker and those

around him and force his behavior into increasing conformity

with popular conceptions. The theory thus proposes that a

culture's conception of mental illness largely determines

the process of defining someone as mentally ill. This

definition process acts as a self-fulfilling prophesy, that

is, through inadvertent reinforcement from the social en-

vironment, the deviant's symptomology ultimately comes to

resemble the popular stereotypes. In this process, the

stereotypes function as "guidelines for action," both for

the deviant and for the laymen and professionals who react

to him.

Relating Scheff's theory to this cross-cultural varia-

tion, Townsend (1978) proposed that one would make the

following predictions.

Proposition I. Two different cultures with different

conceptions of mental disorders will show differences in

professional conceptions which correspond to differences

in the two cultures' popular conceptions.

Proposition II. Mental patients' views of mental dis-

orders will show differences which correspond to differences

in popular conceptions.








Proposition III. Differences in symptom formation in

these two cultures will correspond to differences in popu-

lar conceptions.

Germany and America were chosen for the study because

their cultural similarities, according to the researcher,

would limit the number of variables and thus make comparisons

more useful and because previous studies had suggested that

conceptions of mental illness differed significantly in the

two countries (Nunnally, 1961).

Nunnally's sixty-item questionnaire (1961, pp. 259-

264) was utilized to assess conceptions of mental illness in

Germany and America. This instrument was chosen because the

researcher thought that it would facilitate comparison with

Nunnally's data and because the questionnaire items had been

derived from a broad spectrum of popular and professional

conceptions and then subjected to a considerable array of

validation procedures.

Townsend used students and mental hospital staff and

patients to test his hypotheses. The results showed that

mental health professionals in Germany and America resembled

their lay compatriots in their conceptions of mental dis-

order more than they resemble each other. Americans, in con-

trast to Germans, tended to endorse the notions that mental

disorders are environmentally induced and can be influenced

by an individual's personal effort and will power. Americans

differed significantly from Germans ( p < .001) in response

to the question, "how can you recognize a mentally ill







person?" More Americans cited stereotyped, bizarre physical

characteristics as "diagnostic criteria." In contrast, the

Germans more frequently favored "internal" criteria; that

is, they tended to cite disturbances of mental functions,

cognition, and judgement as characterizing mental illness.

Mental patients' conception in Germany and America

generally parallelled the conceptions held by professionals

and students in their own country.

Two studies compared Anglo-Americans' and Mexican-

Americans' perception of mental illness. Edgerton and Karno's

(1971) investigation was an effort to determine whether the

under-representation of Mexican-Americans in both private

and public psychiatric facilities throughout the southwestern

states could be related to differences in their perceptions

of, or attitude toward mental illness. The research method

was by survey interview in which were included eight vi-

gnettes representing a variety of diagnostic categories.

Three tentative and general conclusions were drawn by the

researchers.

1. The underutilization of psychiatric facilities by

Mexican-Americans (at least those who reside in east Los

Angeles) could not be accounted for by the fact that they

share a cultural tradition which caused them to perceive

and define mental illness in a significantly different way

than do Anglos.

2. It did not seem that the under-representation in

psychiatric facilities reflected a lesser incidence of








mental illness -than that found in other ethnic populations

in this country.

3. The under-representation in psychiatric treatment

facilities is to be accounted for by a complex of social and

cultural factors. These factors have very different weightings

in their relative influence. Some of the heavily weighted

factors include a formidable language barrier, the signifi-

cant mental health role of the very active family physician,

the self-esteem reducing nature of agency-client contacts

experienced by Mexican-Americans, and the marked lack of

mental health facilities in the Mexican-American community

itself.

Factors of moderate weighting are such considerations

as open border across which return significant numbers of

Mexican-Americans seeking relief of emotional stress, and

the perceived threat of "repatriation" attached to a variety

of institutions and agencies of the dominant society. Les-

ser weight is attributed to factors such as "folk-medicine,"

"folk psychotherapy," and "Mexican culture."

Parra (1980) also did a comparative study of Mexican

and Anglo-Americans' perception of and attitude toward men-

tal illness. Five short vignettes characterizing people

were employed to tap respondents' perception of mental ill-

ness. Among the questions, the most important, as assessed

by the researcher, was whether they would classify the case

in question as mental illness.







Attitude toward mental illness was measured by a social

distance scale, tapping high to low tolerance of the mentally

ill. The study revealed that a substantial difference ex-

isted between Chicanos and Anglos with regard to perceptions

of mental illness and attitude toward the mentally ill.

When relationship of demographic variables to percep-

tion of and attitude toward mental illness among Mexican-

Americans were analyzed in Edgerton and Karno's investigation,

age, sex, religion, education, occupation, and number of

years in the United States barely approached statistical

significance.

Parra's study, on the other hand, showed age and per-

ception of mental illness to be significantly related. The

younger Chicano tended to view mental illness within a nar-

rower framework than the older. The older Chicano, in turn,

was not much different from the Anglo. Among Anglos, age

made no difference. Education played a primary role in dif-

ferentiating Chicano perception of mental illness. The young

and the less educated were most likely to perceive fewer

behaviors as mental disorder.

With regard to attitude, Parra found that the young

Chicanos tended to be the most tolerant toward the mentally

ill. The older Chicanos, in contrast, tended to be the

least tolerant.

One study (Sue, Wagner, Davis, Margullus, & Lew, 1976)

investigated conception of mental illness among Asian and

Caucasian American students. The purpose of the study was








to investigate ethnic differences in beliefs and conceptions

of mental illness. Nunnally's (1961) questionnaire was used.

The researchers felt that this questionnaire would indicate

differences related to Asian subcultural values or minority

group status. Subjects were also asked for number of credits

taken in psychology courses; the prior enrollment in an ab-

normal psychology course; the level of educational attainment

achieved by their father, their mother, and themselves; their

ethnicity; age; sex; and marital status.

Through the use of partial correlation, the researchers

examined ethnic differences in belief toward mental illness,

after all the other background factors (educational level,

parents' education, age, sex, etc.) were controlled. The

partial correlations yielded six significant relationships.

Asian-Americans were more likely than Caucasian students to

believe that too much sex can cause personality problems;

a mentally healthy person does not become overly angry at

minor insults; in order to be well adjusted, people should

openly talk to others about all of their problems and se-

crets; children who are well adjusted should not talk back

to their parents; it is better for children if their father

rather than their mother makes most of the big decisions;

and families are better off psychologically if the mother

rather than the father is closer to the children. There was

a tendency for subjects to disagree, but with the Caucasian

students disagreeing more strongly than the Asian-American

students.







A controversial scale used in clinical diagnosis is the

MMPI (Minnesota Multiphasic Personality Inventory). Several

studies have reported distinctive differences in the MMPI's

of blacks and whites. Most of these studies, though, have

concentrated on establishing personality differences (Harri-

son & Kass, 1967; Jones, 1978). Gynther (1972), in his re-

view of the literature on the use of MMPI on blacks and whites,

wondered if this was not a "prescription for discrimination."

He pointed out that differences in social-desirability

ratings of items and a disproportionate representation of

black-favored items on the key scales partially accounted

for those findings. He believed that education, residence,

and cultural separation had some influence on the degree of

difference found.

Coie, Constanzo, and Cox (1976), fully cognizant of the

previous use of MMPI on black and white respondents and re-

sulting controversies, explored behavioral determinants of

mental illness by comparing two community subcultures. A

stratified sample (race, sex, and social class) of 469 lay-

men from two North Carolina communities responded to a 190-

item MMPI-based questionnaire with the degree of mental ill-

ness concern evoked by each item.

According to the researchers, the results reflected

systematic race and social class differences in the behav-

ioral bases. Black subjects expressed greater mental ill-

ness concern than white subjects on the clusters which in-

dexed social introversion, suspicion and mistrust,







disruptive thoughts, and personal inadequacy. Whites scored

higher than blacks on the drug and alcohol abuse cluster and

on the thought disorder cluster.

Lower class respondents showed greater mental health

concerns than either middle or upper class respondents on

the clusters which indexed social introversion, suspicion

and mistrust, and personal inadequacy. Both lower and mid-

dle class subjects scored higher than upper class respond-

ents on the resentment and aggression cluster. Middle class

subjects showed greater concern than upper or lower class

respondents on items reflecting drug and alcohol abuse.

Both upper and middle class subjects showed significantly

greater concern on the thought disorder and destructive tend-

ency clusters than the lower class respondents.

Gynther (1972) had suggested that the most satisfactory

results from the use of the MMPI would be those obtained

from an MMPI normed on blacks. If this concern is a valid

one, then the results of Coie et al. (1976) would have to

be deemed tentative.

Ring and Schein (1970) examined the attitude toward

mental illness and the use of caretakers in a black commu-

nity called Cobbs Creek, in west Philadelphia. The researchers

reported that from the sample of 388 households, the general

trend in attitude responses was in the direction of accep-

tance and understanding. They claimed that respondents

agreed strongly with items representative of an enlightened

mental health viewpoint and disagreed strongly with







factually inaccurate, prejudicial, and negative statements.

Respondents expressed willingness to associate with ex-

patients as fellow workers, club members, and neighbors;

but some reluctance was displayed to accepting an ex-patient

as a roomer and to having an ex-patient marry a member of

the respondent's family.

Only a negligible number of respondents favored consul-

tation with a nonmedical caretaker if faced with a mental

or emotional problem. Nearly 90% reported an intention to

utilize medical personnel in such a case.

Utilization of Mental
Health Facilities by Blacks

Results of Ring and Schein (1969), reported in the sec-

tion above, appeared to be the exception rather than the

rule when the utilization of mental health facilities by

blacks is examined.

Tucker (1979) pointed out that mental health clinicians,

psychiatrists, and psychologists consistently report a very

small black clientele. This researcher felt that a deterring

factor to seeking counseling is the blacks' attitude toward

white mental health professionals, whom they do not perceive

as being capable of helping them solve their problems. In

her investigation, she explored the attitudes of blacks to-

ward seeking professional counseling, and attitudes toward

black and white psychiatrists and psychologists as possible

factors in underutilization as well as to identify changes

needed to increase utilization.








Tucker found that, in general, blacks made little or

no use of mental health facilities. Only 8% of the blacks,

compared to 40% of the whites sampled had made use of these

facilities. Of the 8% of the blacks who had used these

clinics, only 2.5% reported liking the people there. Apart

from negative evaluation of the facilities and service pro-

viders, Tucker suggested several other factors that contri-

buted to underutilization. These included lack of informa-

tion concerning the existence of these facilities, the kind

of service offered, and simply not having felt the need for

such services.

Regarding the perceptions that blacks have of psychia-

trists and psychologists, Tucker reported that respondents

in the lowest income group (14%) viewed these providers'

roles as that of "dealing with crazy people," but the major-

ity did not share this view and felt that all kinds of people

would be helped with various kinds of emotional problems.

An interesting finding by Tucker was that 90% of blacks

interviewed believed that whites had more need for psychia-

trists and psychologists and that blacks are stronger and

more tolerant of hardships due to their history of oppression.

One pervasive factor brought out by the results of this

study was the awareness of the feeling of discomfort if

others knew they were seeing a psychiatrist or psychologist;

yet 62% would not stigmatize others who were clients. This,

as the researcher pointed out, was an unawareness or unwil-

lingness to acknowledge the negative feelings they have

toward seeking help from a psychiatrist or psychologist.







Another consistent result across all socioeconomic

levels was the attitude of blacks toward seeking help from

white therapists. The researcher reported that 66% of the

respondents said they would prefer a black therapist, while

12% of this 66% stated that they would not even talk to a

white therapist.

Tucker pointed out implications for increasing the

utilization of mental health services by blacks. These were

the need for better publication in the black communities of

the locations, fee rates, and kinds of available services

of nearby mental health clinics; need to establish the fact

that seeking psychological help is neither degrading nor a

sign of weakness; the need for the importance of mental

health and signs of unhealthy behavior to be taught in

schools; and the need for more visible black mental health

professionals.

Kenneth Davis and Jacqueline Swartz (1972) pointed out

that the patterns of underutilization of college mental

health services are similar to those of community services,

in that both are underused by black people who are seen

mainly at crisis points. They claimed that for many black

people, going for mental health services is a ready admis-

sion of being crazy. This is in agreement with Tucker's

(1979) finding. For black males, the suggestion that they

are not coping effectively with their lives touches highly

sensitive areas of identity and masculinity. For black

females, the concern of femininity does not seem to be as








much of an issue, as anxiety over not being able to deal

adequately with problems, handle crises, and arrive at

appropriate solutions.

Davis and Swartz also pointed out that most black people

do not come into contact with psychiatric clinics unless

overtly disruptive, psychotic, or arrested. Psychiatry is

often viewed as a punitive profession and is frequently

associated with social or medical agencies, and identified

with invasions of privacy and no regard for confidentiality.

Then there are the clinics themselves with cumbersome intake

procedures and derogatory prerequisites. They further stated

that if treatment is initiated, the therapist will most likely

be white and will probably be viewed as an alien person who

is unable to understand the personal and sociological pres-

sures that are obvious and inescapable to a black person.

The white person will be thought of as part of the white

power structure--an authority figure whose orientation and

training will most probably mean a long, tedious analytical

process. Tucker's (1979) study brought out the preference

by blacks for black therapists who they thought would better

understand them.

In a study on ethnic groups' perception of mental health

service providers, Schneider, Laury, and Hughes (1980) pro-

vided an example of an effort to pinpoint factors influencing

the utilization of mental health facilities by minorities.

This study assessed male and female Chicanos, blacks, and Anglo

college students' perception of one hundred characteristics







of six service provider groups and the likelihood that sub-

jects would discuss problem areas with them.

The analysis revealed that blacks and Chicanos were

more likely than Anglos to take personal problems to pro-

fessionals. Students preferred to consult psychiatrists and

clinical psychologists for the same types of problems more

than counseling psychologists, who in turn were preferred

more than college counselors, high school counselors, and

advisors. For educational-vocational concerns, students

generally expressed a stronger probability of consulting pro-

viders other than psychiatrists and clinical psychologists.

The five characteristics that most consistently dis-

criminated the providers were analytic, curious, intellec-

tual, knowledgeable, and persistent.

Webster and Fretz (1978) reported no difference between

sexes or among ethnic groups in comparing college students'

preferences for help-giving sources. Schneider et al.'s

study revealed that both sex and ethnic status, in addition

to the specific service provider, influence community college

students' preferences. Schneider et al. believed that the

discrepant findings between the two studies might be explained

by the fact that their study was restricted to professional

providers, whereas Webster and Fretz's list of help sources

included specific helpers as well as generic help agencies.

Schneider et al. also explained that the fact that Chi-

canos and blacks reported they they were more likely than

Anglos to discuss personal problems with professional groups







may be due to the fact that Anglos, being more familiar with

mental health professionals, know that they can hurt as well

as help. Another possibility they offered was that minorities

experience more difficulties and/or are more concerned about

their difficulties; or that Chicanos and black students would

simply have been motivated to breach personal problems with

providers since minorities are disposed to "gaming" or tell-

ing an interviewer what he/she wants to hear (Harrison, 1975).

Schneider et al., however, acknowledged several limita-

tions of the study, one being that the subjects were commu-

nity college students in the southwest, and that results

found in multiracial research to some extent reflect the pat-

tern of race relations that exist at that particular time

and in that particular part of the country.

Studies on factors influencing lower class black pa-

tients remaining in therapy have been done by several re-

searchers. One such was Anthony Vail (1976). He studied

the problem of early termination in an inner city community

mental health clinic. His hypothesis concerned similarities

between patients and therapists that would foster ongoing

relationships, and also black patients' attitude toward

whites and how relatable their therapists appeared to them.

Sex was found to be the only significant variable in the

effect of patient-therapist similarity on continuation in

therapy. Attitude toward whites had no effect on continua-

tion, nor did therapist characteristics and patient-therapist

similarity of views of treatment. Vail concluded that, based








on the result of this study, it seems as if negative atti-

tudes on the part of blacks may not always be directed against

the white professionals but against the white establishment

and their facilities; but Tucker (1979) believes attention

needs to be given to the attitudes of blacks toward white

professionals. Sue et al. (1974) pointed out that blacks

and the poor themselves may fail to utilize mental health

facilities due to negative attitude toward the facilities

as well as to factors such as difficulty in obtaining trans-

portation, release time from work, etc.; and they may begin

therapy and prematurely terminate for any of these reasons.

In the studies so far cited, the analyses have been

on clients who actually started therapy, and the assessment

of therapist variables and client perception of and attitude

toward service providers. There have also been studies that

have researched the need for mental health care as an effort

to understand underutilization. One such was by the North

Central Florida Community Mental Health Center (Miller, 1980).

Respondents from the black community in Gainesville, Florida,

were interviewed in an effort to assess their need, and re-

source utilization in their community. When asked to whom

they would refer a friend or family member experiencing a

"nervous breakdown," 30% of the respondents said they would

refer them to a doctor, 16.7% would recommend the community

mental health center, 12.8% suggested the emergency room,

12% did not know who they would recommend, and 10% would

suggest a family member, friend, or neighbor. Only 3.7%








said they would recommend the Crisis Center. The Crisis

Center was, however, the referral of choice for 20.1% in

answer to the question, "if a friend or family member came

to you and said they felt life was not worth going on with,

who would you urge them to see?"

In an effort to assess the reasons for underutilization

of the Alachua County Crisis Center by Gainesville's black

community, the researchers found that 52% of the respondents

in their study had heard of the Crisis Center, and of those,

only 14% had used it. The reason given by those who had

heard about it but had not used it was that they had no need

of its services. So one of the reasons for underutilization

was that 48% of respondents did not know of the Crisis Cen-

ter's existence. They found that those who had used it were,

on the average, younger with more education and income and

were more likely to be employed.

Other areas researched have been the inequities in the

delivery of services to blacks and the poor. These ineq-

uities, according to Sue et al. (1974), may occur at several

levels: (a) blacks or poor clients may be denied treatment

because of discriminatory institutional policies or because

of the cost of treatment, (b) they may be admitted to mental

health facilities but receive inferior forms of treatment com-

pared to other clients, (c) traditional forms of therapy may

be applied equally to all clients but be inappropriately ap-

plied without due consideration to cultural background or life-

style of these clients, and (d) blacks and the poor themselves







may fail to utilize mental health facilities due to negative

attitudes toward them.

In this particular study by Sue et al., they examined

the services received by black clients in the community men-

tal health care system. They found a high utilization of

services relative to the proportion of blacks residing in

the area studied. There was no evidence that blacks, com-

pared to whites, received inexpensive or inferior types of

treatment. In fact, they reported that blacks were slightly

more likely than whites to engage in individual therapy, an

expensive mode of treatment. However, the problem was that

black clients, more often than whites, were seen by parapro-

fessional staff at the intake session and during therapy.

The results persisted even when racial differences in demo-

graphic characteristics were eliminated.

The researchers found that although the magnitude between

the type of staff and the variables examined were small, race

had the strongest relationship with black clients having a

more difficult time than whites in receiving psychiatrists,

psychologists, and social workers. They were concerned about

whether staff assignment was another form of discrimination

whereby black clients are shuffled to staff members who are

relatively poorly paid, ineffective, or inexperienced. They,

however, did voice the opinion that they doubted that the

facilities had any formal policies that discriminate, and

that the extent of the informal discrimination was perhaps

a factor in the therapists' preference.







Sue et al. (1974) were particularly disturbed by the

finding that over half of the black clients failed to return

for therapy after the first session. The precise explanation

for the high dropout rate could not be determined. They

added that, if as indicated by previous studies that black

clients are usually seen by white therapists, and such ra-

cial differences often impede the development of trust and

rapport, then the early termination was understandable.

Sue (1977), in a later research, found that Asian-

Americans, Chicano, and native Americans who tended to re-

ceive treatment equal to that of white clients, also had poor

outcome as measured by premature termination rates. He ad-

mitted that minority groups do show considerable differences

in utilization patterns so that generalizations based upon

a nonwhite category may be inappropriate.

Some black and white differences in utilization were

analyzed by Sue, McKinney, Allen, and Hall (1974). This

was based on 13,450 clients seen at seventeen community men-

tal health facilities. Information was obtained on clients'

demographic background, diagnostic assessment, type of treat-

ment received, type of personnel rendering treatment, and

number of contacts. The analysis compared 959 blacks with

10% or 1,190 randomly selected whites.

Demographic Characteristics

In the case of blacks, males were more likely to seek

treatment than females, while the opposite was true for

whites. The sex difference between blacks and whites was







significant (X2 = 24.50, df = 1, < .001). Income, education,

and age were examined by a 2 (race) x 2 (sex) analysis of

variance. Blacks had a lower income than whites with sex,

and race x sex interaction being nonsignificant. With re-

spect to education, blacks were lower than whites, and males

were lower than females. The race x sex interaction was not

significant. The main effects of race and of sex were sig-

nificant for age, with whites and females, respectively,

being older. Among females, blacks were less likely to be

married than unmarried when compared to whites. Thus, ac-

cording to the results, blacks represented a quite different

type of clients than whites from the outset.

Type of Service

Although over 90% of all clients received inpatient or

outpatient programs, the researchers reported that there

was a tendency for blacks to be assigned less frequently for

outpatient than inpatient programs in comparison to white

clients, even after the effects of all demographic variables

were partialed out. They reported that there was no evi-

dence of blacks receiving inexpensive or less preferred ser-

vices since no differences emerged in individual psycho-

therapy, which had been used as an indicator of discrimina-

tion against blacks.

Type of Personnel Seen

Consistent differences were found in the type of per-

sonnel performing the intake and rendering treatment to

black and white clients. Blacks were more often seen at







intake by paraprofessionals (including other personnel) and

less often by professional specialists (psychiatrists, psy-

chologists, and social workers). This was so even after the

effects of other demographic variables were partialed out.

Contact With Facilities

In this study, the researchers analyzed for race and

other factors of clients who returned or failed to return

after the initial session, as well as for the actual number

of contacts (not including the initial session). When

examination was made of clients who failed to return after

the initial contact with the facilities, a striking racial

difference was found. Fifty-two point one percent of the

black clients dropped out of therapy as compared with 29.8%

of the whites, a difference that was significant (X2 = 110.

29, df = 1, p < .001). After the researchers eliminated the

influences of other demographic variables and service, blacks

were still more likely than whites to discontinue after the

initial session.

The researchers wondered if blacks had been less severely

disturbed than whites and therefore saw little need to con-

tinue in therapy. They, however, dismissed this as not being

likely since blacks (13.8%) were no more likely than whites

(12.7%) to receive a diagnosis of psychoses.

One of the limitations to generalization of the finding

(as pointed out by the researchers themselves) was the con-

finement of the study to one geographic area--the greater

Seattle (King County) area.







Another study done in a different geographic area was

that comparing minority students seen by a black psycho-

therapist (Lester Alston) with a randomly selected group of

white students during the academic year 1969-1970. The pur-

pose of the study was to determine if there were differences

between the minority and nonminority students seen by the

therapist in their utilization of the psychiatric unit of

the Health Service. Did minority students come to the Health

Service via the same routes as nonminority students? Did

they differ in stated reasons for coming as judged by their

presenting problems? Was their utilization of the service,

such as number of visits and returns, similar to that of

other students?

The researcher found that 75% of the nonminority students

were self-referred compared to 44% of the minority students.

Nearly half the minority students seen were referred by

counselors, administrative officials, or faculty; while just

11% of the nonminority students were. A large percentage

of minority male students were staff-referred while none of

the white men and just four of the white women were staff-

referred.

Minority students (41%) exceeded nonminority students

(21%) in percentages citing situational and cultural fac-

tors as primary factors in their difficulty. A larger num-

ber of nonminority students presented themselves initially

on the basis of symptomatology despite the fact that there

was no appreciable difference between the groups in the







number referred by physicians and nurses from the Medical

Service.

In reviewing the issue for further utilization of the

service, the researcher found that more minority students

seen, returned for service at a later point than nonminority

students, although the difference was not significant. What

was interesting was that minority students who initially

presented themselves by identifying a behavior problem of

recurrent or repeated nature were somewhat more likely to

return than nonminority students who focused on situational

and cultural factors in their initial presentations.

The researcher felt that the difference between samples

in those returning probably reflected an interaction at some

level between the therapist and the client, with the minority

students feeling more comfortable in returning (although

they all did not) than the nonminority students.

Another interesting speculation of the researcher was

the fact that minority students would not focus on neurotic

symptoms initially, but it seemed must cope with ambiva-

lences and resistances about seeing a "shrink" over and be-

yond those experienced by the average nonminority student.

That such a large number of minority students presented

initially in situational or cultural terms, raised the ques-

tion, the researcher felt, of whether after presenting his/

her distress as fortuitous and transient (situational) or

inevitable and unsolvable (cultural) was subsequently able

to engage the problem at levels of insight and understanding







necessary to derive some therapeutic benefits from the con-

tacts.

None of the minority students who presented "cultural"

factors in the initial presentations were self-referred.

The researcher found that even this initial cultural pres-

entation did not seriously limit the range of materials

these students offered the therapist. This tendency, he

felt, of minority students to emphasize situational and cul-

tural factors in initial presentations was interpreted as

an attempt to cope with ambivalence, but did not seem to be

a barrier to more insightful discussion of their problems.

A study highlighting some of the complexities involved

in interpreting utilization studies is exemplified by re-

search by Goodman and Siegel (1978). This research investi-

gated differences in white/nonwhite community mental health

center service utilization patterns.

The researchers routinely collected computerized data

which were used to study the process of service delivery in

terms of admission patterns, type, and quantity of services

rendered, and status at termination for whites and nonwhites

in two community mental health centers with substantial non-

white populations. A total of 2,946 clients were studied.

Social area analysis techniques were employed to control

for socioeconomic status, ethnicity, and lifestyle variables;

and an epidemiological model was used to analyze admission

and service delivery rate differences.





59

The researchers found that nonwhite admission rates

were at least twice as great as white rates. Service deliv-

ery rates to the population at large were considerably

greater for nonwhites than for whites. Delivery of direct

services within the centers differed for whites and nonwhites,

but no consistent trends emerged when types and amounts of

services rendered were analyzed, controlling for sex, eth-

nicity, age, diagnosis, and social area. Disruption of case

indices was greater for nonwhites than for whites.

Comer (1973), in summarizing the problem of utilization

of mental health facilities by blacks, discussed various

facets involving the mental health needs of blacks. He

pointed out that many blacks are reluctant to see white

therapists, but that qualified black therapists are in short

supply. Blacks, however, he continued, suffer the full range

of mental illnesses and need the full range of mental health

services. Tucker (1979) shared this concern, stating the

need for more visible black mental health clinic workers.

This visibility and availability, whether or not they are

more effective in working with black clients, are conducive,

she feels, to blacks' at least coming to clinics and therapy

offices so that black and white mental health professionals

will have a chance to counsel them.

Tucker (1979), in her investigation of blacks' defini-

tions of mental health as a factor in their underutilization

of mental health services, found that many blacks accept a

wider range of behaviors as being mentally healthy than







whites, who have established the standard of mental health.

She found that 51% of her interviewees gave definitions "in

harmony with the idea of mental illness" in her assessment

of personal definitions of mental health, while 21% responded

in the direction of mental health. Tucker remarked that

since she had no comparable data from whites, it was not

conclusive that blacks have a unique conceptualization of

mental health.

Summary of the Literature

Over the past several years, mental health researchers

have investigated conceptions of mental illness and atti-

tude toward the mentally ill and their treatment. Their

investigations ranged from popular conceptions of respondents

from different geographic areas throughout the country to

more specific populations such as mental patients, mental

health professionals, students, and teachers.

The general finding was that knowledge about mental

illness has increased over the years. The results on at-

titudes have been somewhat conflicting with some researchers

claiming that attitude toward mental illness has become more

positive while others report that negative stereotypes still

exist to a large extent.

When the relationship between knowledge and attitude

was investigated, the over-riding finding was that knowledge

about mental illness bore little, if any, relationship to

attitude toward mental illness and its treatment. There was

the expressed need for further research on the "frames of








reference by which persons integrate factual information and

personal opinion" (Freeman & Kassebaum, 1960, p. 47).

However, when demographic variables were investigated

in relationship to attitudes, those in the higher socio-

economic strata, the more educated, the younger, and females

tended to have more positive attitudes toward mental illness,

the mentally ill, and toward seeking psychological help.

Studies, researching blacks' attitudes and opinions con-

cerning mental health providers, mental health facilities,

and attitude toward being mentally ill, have all been at-

tempts to understand factors responsible for their under-

utilization of mental health facilities.

Although a few studies have been aimed specifically at

understanding other minorities' conceptions of mental ill-

ness, there has been no detectable study reported on blacks'

conceptions of mental illness on a comparative basis with

whites. The same holds true for a comparative study of

blacks' and whites' attitudes toward seeking psychological

help. There is a need for such a study in order to better

understand underutilization of mental health facilities

by blacks.













CHAPTER 3

RESEARCH METHODOLOGY

0 ve r view

The purpose of this study was (1) to determine the re-

lationship of ethnicity to attitude toward seeking psycho-

logical help, (2) to determine the relationship of ethnicity

to conceptions of mental illness, and (3) to determine if a

relationship existed between attitude toward seeking psycho-

logical help and conception of mental illness. The study

included a sample of 321 white and 192 black school teachers

employed by the Alachua County School Board in Florida.

Conceptions of mental illness and attitude toward

seeking psychological help and the relationship between at-

titude and conception were investigated through a descrip-

tive research design. All subjects were administered a

Demographic Information Questionnaire, the Nunnally Concep-

tion of Mental Illness Questionnaire, the Fischer and Turner

Pro-Con Attitude Scale, and vignettes on counseling problems

and issues.

The remainder of this chapter will be concerned with

(1) hypotheses, (2) data collection procedure, (3) selection

of subjects, and (4) the instruments used.







Hypotheses

Hypothesis I

Help-seeking attitudes are related to ethnicity and not

to other demographic factors.

Hypothesis II

Conceptions of mental illness are related to ethnicity

and not to other demographic factors.

Hypothesis III

Attitudes toward seeking psychological help are related

to conceptions of mental illness.

Data Collection Procedures
and Selection of Subjects

Six hundred and sixty-nine school teachers employed by

the Alachua County School Board of Florida were randomly

selected from the 1983 Directory containing 1,300 full-time

employed teachers. Of those selected, 269 were black and

400 were white. Each was sent by mail a packet containing

(1) Explanation (Appendix A), (2) Informed Consent (Appendix

B), (3) Instructions (Appendix C), (4) Demographic Informa-

tion Questionnaire (Appendix D), (5) Nunnally Conception of

Mental Illness Questionnaire, (6) Fischer and Turner Pro-

Con Attitude Scale, and (7) vignettes. An addressed stamped

envelope was also included in each packet.

It was expected that the teachers would require approx-

imately 30 minutes to complete all the instruments in the

packet. Participation in the study was on a voluntary

basis, and this was stated in the explanation to the teachers.

Incentive to participate was the offer to have participants








who desired this to be informed of the results at the com-

pletion of the study. Ninety percent of the respondents

requested this information.

It was expected that there would be a return rate of

50% of the entire sample. There was a return of 76.9%; with

80% for whites (321) and 71% for blacks (192). The final

sample was 513 from the original 669 selected.

Instruments

The instruments used in this research were the Fischer

and Turner Pro-Con Attitude Scale, the Nunnally Conception

of Mental Illness Questionnaire, vignette case examples,

and a Demographic Information Questionnaire.

Fischer and Turner Pro-Con Attitude Scale

This scale was developed by Edward Fischer and John

Turner of the Psychology Department of Connecticut Valley

Hospital, Middletown, Connecticut (1970). The scale con-

sists of sixteen randomly selected items of the original 29.

Attitude statements, according to Fischer and Turner, were

written in collaboration with several clinical psychologists

who were familiar with numerous mental health settings in-

cluding state and federal hospitals, clinics, and private

practice and school situations. They felt that the items

selected sampled many aspects of the general orientation

toward seeking professional help for psychological problems.

Judges rated each item as to its relevance to the hypothet-

ical attitude domain and according to whether it reflected

a positive or negative attitude. Judges consisted of a







panel of fourteen clinical and counseling psychologists and

psychiatric ts.

The instrument utilizes a five point Likert format with

responses ranging from one (strongly disagree) to five

(strongly agree). Negative items were reversed for scoring.

A high score indicated a positive attitude toward seeking

psychological help.

The internal reliability of the scale (Tyron's 1957

method) computed for the standardization sample of n = 212

was reported by Fischer and Turner to be .86. The reliability

estimate was .83 computed on a later sample of 406 subjects.

Five groups of students were given the scale twice at varying

intervals to establish test-retest reliabilities. The at-

titude scores remained stable over time: r = .86 (n = 26),

r = .89 (n = 47), r = .82 (n = 31), r = .73 (n = 19), r =

.84 (n = 20).

None of the items correlated greater than .25 with so-

cial desirability scores neither in anonymous nor identifi-

able conditions. Factor analyses revealed four dimensions.

Factor I identifies a recognition of personal need for psy-

chotherapeutic support. The subject scoring low on this

subscale sees little necessity for professional help for

emotional problems, believing that psychological conflicts

resolve themselves. The high scorer is in favor of seeking

help for his emotional stress. Factor II includes items

which assess the subjects' opinions about the threat of stig-

matization as a result of psychiatric treatment. The high







scorer expresses freedom from such concerns. Factor III

refers to items in which subjects display interpersonal

openness with a willingness to reveal themselves to appro-

priate professionals. Factor IV involves confidence in

mental health professionals.

In addition to the sixteen items (four from each dimen-

sion), a seventeenth item--developed by the researcher--

was included. This asked subjects whether they had in the

past used psychological services.

Nunnally's Conception of Mental Illness Questionnaire

The conception of mental illness questionnaire was de-

veloped by Jim Nunnally in 1960. The construction of the

instrument involved initially over 3,000 opinion statements

by members of the public, by experts, and in the mass media.

Samples of expert opinions were gathered from mental hy-

giene books, professional publications, and over 200 public

information pamphlets, as well as from personal interviews,

magazines, etc. The more than 3,000 statements were related

to causes, symptoms, prognosis, treatment incidence, and

social significance of mental health problems. By reduction

of duplicates, the questionnaire was reduced to 60 items

which include the following ten components.

1. The mentally ill are characterized by identifiable

actions and appearances.

2. Will power is the basis of one's personal adjust-

ment.

3. Women are more prone to mental illness than are


men.







4. If one can avoid morbid thoughts, he/she can avoid

mental illness.

5. If one can obtain support and guidance from stronger

persons, he/she can avoid mental illness.

6. One who is mentally ill is in a hopeless condition.

7. Mental disorders are caused by immediate environ-

mental pressures.

8. Emotional difficulties are not matters of great

concern.

9. Older people are more susceptible to mental ill-

ness.

10. Mental illness is attributable to organic factors.

The scale used in this research consisted of 20 of the

original 60 items. Two items were randomly chosen from

each factor, e.g., Factor I: "The insane laugh more than

normal people." Factor II: "Will power alone will not cure

mental disorders."

The instrument utilizes a five point Likert format with

responses ranging from one (strongly disagree) to five

(strongly agree). Subjects are asked to choose one of the

five categories as a response to the items. The higher the

individual score, the greater the misconceptions about men-

tal illness. Nunnally's scale has been widely used in

assessing mental health conceptions (Sue et al., 1976; Town-

send, 1978).

Vignettes

Ten vignettes based on concepts derived from counseling

literature, cross-cultural counseling, and research on







utilization of mental health facilities were developed by

the researcher. These investigated the subjects' opinions

concerning the following issues.

1. Culture of the therapist versus culture of the

client.

2. Private practice versus community mental health

service.

3. Problem types and the efficacy of seeking treat-

ment.

4. Race of the therapist versus race of the client.

5. Socioeconomic difference between client and thera-

pist.

Each of the ten items had five response alternatives:

strongly agree, agree, neutral, disagree, strongly disagree.

Each item was given a score from one to five, with five

representing the most liberal views on the five issues in-

vestigated.

Demographic Information Questionnaire

This questionnaire was administered to subjects in order

to obtain the following information: race, age, sex, mari-

tal status, income, religion, highest education obtained,

subject being taught by teacher, place of birth, and where

educated. The first seven named variables were an integral

part of the analyses.













CHAPTER 4

RESULTS

This study was designed to investigate whether concep-

tion of mental illness and attitude toward seeking psycho-

logical help were related to ethnicity and not to other

demographic variables. This study was also designed to

examine the relationship of conception of mental illness to

help-seeking attitude, and if race was a significant factor

among subjects who had received psychological help in the

past. The population studied consisted of black and white

school teachers employed by the Alachua County School Board

in Florida. The demographic variables considered most rele-

vant with respect to the study were (1) sex, (2) age, (3)

marital status, (4) highest education obtained, (5) religion,

r6) income, and (7) race. This chapter will be divided into

two sections; (1) description of the sample and (2) results

related to the hypotheses.

Description of the Sample

The sample consisted of 513 school teachers employed by

the Alachua County School Board in Florida. Of these, 62.57%

were white and 37.43% were black. There were 23.19% males

and 76.81% females. Subjects in the 20-39 age group com-

prised 59.44% of the total sample: those in the 40-59 age

group comprised 37.44%, while 31.12% were in the over 60
69







age group. Distribution of these subjects by race are shown

in Table 1. Single subjects comprised 15.40% of the total

sample, with 64.72% married, 18.13% divorced, and 1.75%

widowed. A breakdown by highest education obtained by the

subjects revealed 2.14% with less than a bachelor's degree,

40.16% with a bachelor's degree, 20.07% with master of arts

degree, 28.0 % with master in education degree, and 1.56%

with a doctorate degree. Distribution of these subjects by

race are shown in Table 2.

Breakdown into religion revealed that 63.16% were

Protestants, 11.89% were Catholics, 2.92% were Jewish, and

43% belonged to none of the above religions. Income ranged

from $8,000 to over $16,000 with 1.5% receiving between

$8,000 and $10,000, 2.73% receiving between $10,000 and

$12,000, 13.65% receiving between $12,000 and $14,000, and

62.96% receiving over $16,000. Table 3 shows the distribu-

tion of these subjects by race.

Teachers were primarily employed at the elementary, mid-

dle, or high school levels with 48.73% at the elementary

level, 19.11% at the middle school level, 28.46% at the high

school level, and 3.70% not affiliated with any of the above

levels. Both blacks (77.6%) and whites (76.3%) were involved

in teaching subjects other than Social Science, Humanities,

Hard Science, and Biology. These other courses included

Music, Physical Education, and Mathematics.

A larger proportion of the white sample (67%) were born

in a non-Florida state compared to blacks who had only 23%

















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compared to 31% of the whites. Appendix E gives additional

information on the distribution of subjects by race and

selected variables.

Results Related to the Hypotheses

Hypothesis I

It was hypothesized that help-seeking attitudes, as

measured by the Fischer and Turner Attitude Scale are re-

lated to ethnicity and not to other demographic variables.

The other demographic variables considered were sex, age,

marital status, highest education obtained, religion, and

income. A hierarchical multiple regression analysis was

executed on the attitude scores. The controlled variables

were entered first and race entered last. The relevant test

was the increase in the variance explained by race over and

above that explained by the previous entered variables. The

results are reported in Table 4. For the entire group, the

mean score on the attitude instrument was 56.516. Blacks had

a mean of 56.159 and whites had a mean of 56.730. The hier-

archical multiple regression analyses indicated that race was

not a significant factor in help-seeking attitude. Thus,

the hypothesis that ethnicity is related to help-seeking

attitude is rejected.

Hypothesis II

It was hypothesized that conception of mental illness is

related to ethnicity and not to other demographic variables.












































































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As a first test of this hypothesis, the Nunnally Conception

of Mental Illness Questionnaire was administered to respond-

ents. The demographic variables considered were sex, age,

marital status, highest education obtained, religion, and

income. A hierarchical multiple regression analysis of the

conception scores was employed. The controlled variables

were entered first and race was entered last. The increase

in the variance explained by race over and above that ex-

plained by the previous entered variables is the test of

significance of race. The results are reported in Table 5.

The mean score for the entire sample was 47.734, while the

blacks had a mean of 49.370 and the whites had a mean of

46.754. Scores for blacks ranged from 36 to 62. Scores

for whites ranged from 32 to 57. Lower scores depicted less

stereotypic conceptions of mental illness, with conceptions

closer to those of professionals in the field of mental

health. The hierarchical multiple regression indicated that

race was a significant variable in conceptions of mental

illness.

In order to determine which of the ten components of

the conception scale was race significant, each component

was separately analyzed by hierarchical multiple regression

with the same demographic variables of sex, age, marital

status, highest education obtained, religion, and income

entered first and race entered last. The mean scores and

standard deviation for the component scores for each com-

ponent for blacks and whites are depicted in Table 6.

















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Table 6

Descriptive Statistics for Conception
Component Scores for Whites and Blacks

Whites (n = 321)

Standard
Components Mean Deviation

Look and act different 4.3917 1.2010
Will power 6.0725 1.0273
Sex distinction 5.6613 0.9608
Avoidance of morbid thoughts 5.0621 0.2601
Guidance and support 5.0893 1.2580
Hopelessness 7.2157 1.4032
External versus personality 5.7399 1.2341
Nonseriousness 1.5029 0.6519
Age function 6.1840 0.9880
Organic causes 4.8979 0.9924


Blacks (n = 192)

Standard
Components Mean Deviation

Look and act different 5.1432 1.4763
Will power 6.4184 1.1767
Sex distinction 5.9466 1.1429
Avoidance of morbid thoughts 5.8946 1.1538
Guidance and support 5.9650 1.3280
Hopelessness 7.0921 1.7235
External versus personality 5.9148 1.3666
Nonseriousness 1.6822 0.6616
Age function 6.0721 0.9174
Organic causes 5.1365 1.0384








Table 7 shows the effect of race after controlling for the

other demographic variables in the hierarchical multiple

regression analysis. The increase in variance explained by

race over the controlled variables was significant in the

following components: (1) look and act different, (2) will

power, (3) sex distinction, (4) avoidance of morbid thoughts,

(5) guidance and support, (6) nonseriousness, and (7) organic

cause. A more detailed description of the component analysis

is offered in Appendix F.

A second test of the second hypothesis was the analysis

of subjects' response to ten vignette items that explored

their opinions on the following issues: (1) culture of the

therapist versus culture of the client, (2) private prac-

tice versus community mental health service, (3) problem

types and the efficacy of seeking treatment, (4) race of the

therapist versus race of the client, (5) socioeconomic dif-

ferences between client and therapist. Hierarchical multiple

regression was used to determine if race was a significant

variable in the responses. Other demographic variables con-

trolled for were sex, age, marital status, highest education

obtained, religion, and income. These were entered first.

Then, race was entered last. The relevant test was the in-

crease in the variance explained by race over and above that

explained by the previously entered variables. The results

are depicted in Table 8. Race was significant in the fol-

lowing components: (1) child problem--whether or not parents

having problems disciplining their child should seek counseling,
















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(2) race difference of client and therapist--if therapist of

one race can truly understand a client of another race, and

(3) socioeconomic difference of client and therapist--if a

therapist of a middle socioeconomic status can relate to

and understand the problems of a lower socioeconomic status

client. The scores were also analyzed for the mean and

standard deviation on each item for each group (Table 9).

Blacks were more liberal (gained higher scores) than whites

on items that dealt with mixed race and cross-cultural coun-

seling. However, blacks scored lower than whites on the

items that dealt with the efficacy of psychological treatment

for the sex problem and the child problem presented.

It was assumed that conceptions of mental illness that

parallel those of mental health professionals should result

in the utilization of mental health facilities. To test

this, a third measure of conception of mental illness in

relation to ethnicity was therefore the analysis of the

responses subjects gave to whether or not they had received

therapy in the past. The responses to such a question re-

vealed that 27.41% of the white subjects and 14.58% of the

blacks had received psychological counseling in the past.

The demographic variables controlled for in a hierarchical

multiple regression were age, sex, marital status, highest

education obtained, religion, and income. These controlled

variables were entered first. Race was entered last. The

relevant test was the increase in variance explained by race

over and above that explained by the previously entered

















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variables. Race was significant in having sought therapy

in the past (Table 10).

Hypothesis III

It was hypothesized that attitudes toward seeking psy-

chological help are related to conceptions of mental ill-

ness for both whites and blacks. The first test of this

hypothesis was the employment of a hierarchical multiple

regression analysis on the attitude scores controlling for

the following variables: age, sex, marital status, highest

education obtained, religion, and income. These variables

were entered first, then conception scores were entered

last. The relevant test was the increase in the variance

explained by conception over and above the previously en-

tered variables. Conception was significant variable at

the p > .01 level of significance. This was the case for

both whites and blacks (Tables 11-A and 11-B). A negative

regression coefficient for both blacks and whites indicated

that there was a significant negative correlation between

attitude and conception. As attitude scores increased (de-

noting positive attitudes toward seeking therapy), concep-

tion scores decreased (denoting less stereotypic, and more

professionally oriented conceptions of mental illness).

Conception scores were also analyzed in relation to the

scores on the vignette items and the therapy items in order

to ascertain the significance of conception to the responses

given by blacks and whites. For those who had, or had not

been in therapy, conception was not a significant variable














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among both whites and blacks. Conception was, however, dif-

ferentially significant for whites and blacks on the vi-

gnette items. Results are shown in Table 12.

Summary of the Results

The findings demonstrated that

1. When race was considered along with other demo-

graphic variables, race was not a significant factor in at-

titude toward seeking psychological help as measured by the

Fischer and Turner Pro-Con Attitude Scale.

2. When race was considered along with other demo-

graphic variables, race was a significant variable in con-

ception of mental illness as measured by the Nunnally Con-

ception of Mental Illness Questionnaire.

3. Race was significant in the differences in responses

to the ten vignettes which investigated opinions on the ef-

ficacy of problems deserving psychological treatment, views

on cross-cultural and cross-racial dyads in counseling and

preference for certain counseling setting. Blacks scored

higher (more liberal) on items that dealt with issues such

as mixed race, and cross-cultural dyads, but scored lower

than whites on items that dealt with the efficacy of prob-

lems deserving psychological intervention.

4. There was a significant relationship of conception

of mental illness to attitude toward seeking psychological

help even when other demographic variables were considered.

This was true for both whites and blacks. Multiple regres-

sion coefficient depicted a significant negative correlation





89





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signifying that as attitude became more positive (higher

scores), conception became less stereotypic (lower scores).

5. When race was considered along with other demo-

graphic variables, race was a significant variable in having

received therapy in the past.

6. Conception of mental illness was significantly re-

lated to responses on the vignette items for both whites

and blacks, but moreso for whites.

7. Conception of mental illness was not significantly

related to whether or not these teachers had received therapy.

This was true for both blacks and whites.